Twilight of Surgeons General: Q&A with Mike Stobbe

While working on a doctorate in public health at the University of North Carolina  several years ago, AP reporter Mike Stobbe set out to learn my the post of US surgeon general had become “invisible.”

The result is his new book, “Surgeon General’s Warning: How Politics Cripple the Nation’s Doctor,” (University of California Press, 2014). It’s a fascinating history of the office and the behind-the-scenes politics. Stobbe graciously shared some insights with Global Health NOW. Thanks, Mike! —Dayna Kerecman Myers, GHN Associate Editor

Vivek Murthy’s nomination as surgeon general is currently held up because of opposition from the gun lobby. Has politics always influenced the SG’s selection and role so heavily?
Since the office was created in 1871, surgeons general have always had to curry favor with members of Congress and stay in the White House’s good graces.  The selection process has also long been political—for example, in the 1960s Luther Terry was picked because of his connections in Congress. But a lot of those machinations were behind-the-scenes. It's really been in the last 35 years or so that political battles over nominees became more public. There was a huge fight over the selection of C. Everett Koop in the early 1980s, and the approval of Joycelyn Elders, in the early 1990s, was another pitched battle. Even the more mild-mannered David Satcher took some heat before he was confirmed.

Which surgeons general really moved the needle in US public health?
It's hard to objectively measure the influence of an individual surgeon general, especially in the last 45 years -- since the position's administrative powers were stripped away. The job now is a spokesman and health educator. A surgeon general is high profile, perhaps, but just one player in the national world of public health. It’s hard to say they moved the needle more than anyone else. That said, Koop was a loud and constant opponent of cigarette smoking, and I believe it was more than coincidence that we saw an accelerated decline in adult smoking rates while he was in office. Two decades before him, Luther Terry released the tide-changing 1964 report on smoking and health. And many decades ago, there were surgeons general who saved countless lives against epidemics of cholera, plague, influenza and other deadly diseases.

How has the office of Surgeon General been weakened in recent years? Can it be fixed?
In terms of actual power, the office isn’t dramatically weaker now. But I believe it has lost more visibility and public influence for a number of reasons: Pronounced political meddling, the unwillingness of the last couple of surgeons general to try to push past their political constraints, and the ascension of the CDC director and other health officials as more prominent -- and competing -- voices. There are a number of ways, in theory, to fix this situation: Give the surgeon general a separate budget and greater independence; alter the selection process to give weight public health experience over political relationships; or extend the 4-year term to limit ties to any one presidential administration. However, as Washington powerbrokers show no interest in making such changes, I concluded that things will only get worse and perhaps it's time to end the position.

What surprised you most in your research?
It surprised me to see how pivotal politics and individual human failings were throughout the US Public Health Service history. As a journalist covering health and health policy, I know that people are people, and politics and petty concerns will always color the formation of public health policy. But before I really dug into this research, I thought there were entirely noble generations of public health leaders in earlier days. To be sure, there WERE many heroic figures in the 19th and early 20th centuries. But it was disheartening to learn about the ulterior motives, bad decisions, and other crap that went on back then, too.

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