What should the US Surgeon General be like?
As Donald Trump prepares to assume the presidency, media outlets are aflutter with his nominees for Cabinet positions, and office seekers are glued to telephones calling for Executive Branch jobs. Amidst the tumult, President-elect Trump should soon consider another job that must be filled. It is less powerful than many cabinet positions, but often high profile. It deals not with bombs or buildings but with health and humanity. With Ebola just behind us, and who-knows-what disease disaster just ahead of us, this job is crucial. Donald Trump must select the next Surgeon General (SG) of the United States.
C. Everett Koop (1916-2013, SG 1982-1989) had recently retired as the Surgeon General when I graduated from the Loma Linda University School of Medicine in 1991. He was our commencement speaker, and his words shaped my thoughts as a young doctor. This article will review the job of Surgeon General, and consider some attributes that have made recent Surgeons General successful. Many have served as acting Surgeon General since the post tends to be low on Presidential appointment priority lists, but we will only consider the appointed office holders here.
The Surgeon General is “America’s Doctor”
Americans expect their Surgeon General (SG) to be their top doctor. Whether dealing with health care reform or influenza epidemics, the SG must speak with authority, clarity, and honesty. He* must be an expert in medicine. Koop was such a man. As a pediatric surgeon, he was the surgeon-in-chief at the Children’s Hospital in Philadelphia (CHOP), establishing the nation’s first neonatal surgical intensive care unit there. He did groundbreaking work in many areas of infant surgery, such as the separation of conjoined twins. Aged 65 and with a grandfatherly look when he took office in 1982, Koop was one of the few Surgeons General who became a household name.
Since preventive medicine and primary care are the foundation of any health care system, the SG must have a comprehensive understanding of both, preferably being a specialist in these areas. Of six appointed Surgeons General since Koop, the following four have been primary care specialists: Jocelyn Elders (pediatrics), David Satcher (family medicine), Regina Benjamin (family medicine), and Vivek Murthy (internal medicine). The Surgeon General should be familiar with subspecialty care as well, from allergy to urology, to best represent this large and influential community.
The next Surgeon General should have experience in all health care settings, including inpatient, outpatient, and community care. Having lived and practiced in many areas of the US would enable him to understand regional differences in needs and resources. The SG should have practiced in academia, from medical schools to residencies, and published in his field. All recent Surgeons General have shared this variety of experience.
One of the biggest problems worldwide is health disparities between groups. While some people can get the most effective treatments and medications, some can’t get even the most rudimentary. These inequities are fundamentally unfair, and put everyone at risk. For example, people in poverty with active tuberculosis who cannot afford and therefore don’t take their antibiotics will infect others. David Satcher (1941- , SG 1998-2001) released the influential report “Tobacco Use Among U.S. Racial/Ethnic Minority Groups” and did other important work to reduce health disparities during and after his tenure.
Other important health problems loom. Americans are aging, getting fatter, and exercising less. As American medicine is learning more about behavioral health and mild traumatic brain injury, we are discovering how harmful and prevalent they are. The problem of substance abuse is growing. America’s next Surgeon General will face these vexing issues, and must have ideas of how to combat them. Antonia Novello (1944-, SG 1990-1993), launched the “Healthy Children Ready to Learn Initiative,” and Regina Benjamin (1956, SG 2009-2013) issued “The Surgeon General’s Vision for a Healthy and Fit Nation” to address such problems.
No one can appeal to all Americans, but the next Surgeon General must be willing and able to engage people of different ethnicities, religions, and backgrounds. He must speak at churches, community centers, schools, and other religious venues; anywhere he is invited to spread messages of health and fitness. The SG must work with community leaders to devise and implement programs that will resonate in their community. He must work with local, regional, state, and Federal governments, with businesses, and with other organizations, to provide resources for the right interventions. Koop was probably the best example of the engaged and engaging surgeon general.
The Surgeon General must be what he wants others to become
A good SG will encourage a healthy body weight and physical fitness, and so he must have a healthy body weight and be physically fit. A good SG will be moderate in alcohol use and will not use tobacco products. Americans need to see their Surgeon General running, cycling, lifting weights, stretching, engaging in sports, eating right, and doing the things the things that he is asking them to do. Regina Benjamin faced intense criticism for warning people about being overweight and yet having extra pounds herself. Health and fitness should be a genuine part of the SG’s life, not something invented for the camera. Vivek Murthy is an avid walker.
The Surgeon General is the leader of the Commissioned Corps of the Public Health Service
The Commissioned Corps (CC) of the Public Health Service (PHS) has over 6,800 officers, including physicians, veterinarians, nurses, engineers, scientists, and a host of other health care professionals. These men and women improve the health and well-being of Americans from Alaska to Florida, and even overseas. The CC is a uniformed service, just like the Army, Navy, Air Force, and Marine Corps. Antonia Novello, the first woman and first Hispanic to serve as surgeon general, was a uniformed member of the Public Health Service for years before her appointment. The next SG should have experience in the PHS or at least in the uniformed environment. Richard Carmona (1949-, SG 2002-2006) is an Army veteran, having served as a Special Forces medic in Vietnam.
The US Public Health Service falls under the Department of Health and Human Services (DHHS) and so the ideal candidate for Surgeon General would have experience working in, or at least with, DHHS. Knowing the people, the places, and having an existing social network would better allow him or her to “hit the ground running.”
The Surgeon General is a de facto leader in medicine and health care worldwide
America leads the world in many areas, and medicine is no exception. The United States took a leading role in the eradication of smallpox and in the fight against Ebola. As the face of American medicine, the Surgeon General will interact with other health care leaders to advance health around the globe.
The Surgeon General is a representative of the President and must be confirmed by the Senate
As a political appointee, the SG is the face of the President on health care and medical matters. Presidents want to appeal to everyone in the nation, but in reality they are elected by a segment of the population. The SG must appeal to as broad a constituency as possible, but must especially appeal to the groups that elected the President. Koop was well aligned with Reagan’s priorities, and well aligned with Reagan’s working class and religious base. Donald Trump has a similar base. Carmona, less successful than Koop, opposed some of George W. Bush’s priorities, and those of his base. Jocelyn Elders (1933-, SG 1993-1994) was removed by President William Clinton for making controversial remarks.
In addition to appealing to the voters, the Surgeon General must pass Senate confirmation. He must have credentials that make him a plausible candidate, and not have any disqualifying history or associations. The confirmation process will be grueling. Murthy was outspoken against gun violence, and his confirmation as SG was opposed by the National Rifle Association. After a strenuous fight, and with a Democratic majority of 54-45 in the Senate, Murthy was confirmed 51-43.
Nonetheless, the next SG must have the courage of his convictions; “with firmness in the right, as God gives us to see the right.” No one who wants to be Surgeon General more than he wants the truth deserves to be Surgeon General.
C. Everett Koop’s legacy lives on in the hearts and minds of physicians, like me, who finished medical school in the 1980s and early 1990s. To many, he was an American icon. Perusing a list of prior Surgeons General of the United States, I was struck by how often in recent decades no SG was appointed and how often acting SGs served. As qualified as these acting Surgeons General have been, the failure to appoint a Surgeon General of the United States is a big mistake. Medicine and health care are getting more and not less important in America and across the globe. President-Elect Donald Trump should appoint a Surgeon General of the United States. If he finds someone with the skills, experience, and priorities comparable to the best of recent SGs, he will pick well.
*I have used the pronoun “he” rather than “she”, “he or she”, “their”, or some other combination for the sake of readability. Both men and women have successfully served as Surgeon General. No offense is intended.