Global Health: Former Surgeons General Recount Political Pressure on the Job

By | October 25, 2018

It made an arresting tableau: four former surgeons general, aged 68 to 85, all in their blue admirals’ uniforms, together on stage like four grizzled Civil War veterans rehashing their biggest battles, and how they were treated afterward by the President and Congress.

But this was no re-enactment of Bull Run or Shiloh. It was an after-action report on America’s medical wars, and it took place this month on the stage of the New York Academy of Medicine.

“In this current climate of incivility, I think it’s important that medical students see models of integrity, compassion, camaraderie and wit,” said Dr. Judith A. Salerno, the academy’s president, who invited Dr. Antonia C. Novello, Dr. M. Joycelyn Elders, Dr. David Satcher and Dr. Richard Carmona to speak.

The underlying theme was how badly the country needs independent public health leadership and how often partisan politics obstruct that.

There were more than a few “I told you so” moments.

Since the late 1990s, retired surgeons general have become an informal club, appearing together every few years when someone asks them to speak out. They have discussed transplant medicine at a surgeons’ conference, cancer treatment at Lance Armstrong’s Livestrong Foundation, maternal care during Women’s Health Month, and so on.

The four at this meeting were in office from 1990 to 2006 during the administrations of George H.W. Bush, Bill Clinton and George W. Bush.

That was an era when — not unlike today — scientists felt they were under attack by the White House, Congressional conservatives and armies of industry lobbyists. Then, however, the fights were even more blatantly over medical issues rather than global warming.

The four described battles over AIDS, smoking, teenage pregnancy and drugs.

They lost most of them — but time usually proved them right.

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For example, in 1998, Dr. Satcher backed giving clean needles to drug users to stop H.I.V. and hepatitis. Conservatives accused him of encouraging drug use, and the Clinton White House publicly repudiated him. Now that the opioid epidemic has caused H.I.V. outbreaks even in rural America, clean-needle programs are common.

“If we had responded to the crack cocaine epidemic as we should have, we wouldn’t have had the opioid epidemic,” Dr. Satcher said.

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In 1992, Dr. Novello said, the first Bush White House ordered her to stop condemning Joe Camel cartoons for marketing cigarettes to children. Five years later, under increasing pressure, R.J. Reynolds Tobacco retired the character.

In 1994, from behind a desk bouquet of faux roses made of condom wrappers, Dr. Elders, the first black Surgeon General, called teen pregnancy “a form of slavery” for young black women and vigorously backed sex education, birth control, and wider use of the RU-486 abortion pill.

She also suggested legalizing drugs as a way to cut crime and jail crowding.

In response, she was pilloried.

Conservatives accused her of promoting premarital sex and drug addiction, black leftists accused her of promoting black genocide. Mr. Clinton first rebuked her and then later dismissed her over an offhand answer she gave at an AIDS conference. Asked if she thought teaching children about masturbation could reduce unsafe sex, she answered that it was part of human sexuality and “perhaps should be taught.” (She later explained that she meant children should be told it was normal, not be given how-to instructions.)

“I have no regrets,” Dr. Elders said at the academy. “If I had to do it all over again, I’d do it the same way. I thought I did it right the first time.”

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After she was forced out, Mr. Clinton admitted to an extramarital affair. Since those days, thanks largely to measures she backed, birthrates have plummeted among both black and white teenage girls. Marijuana is now legal in many states. And masturbation is more often an issue for adult men caught by the #MeToo movement.

After he left office, Dr. Carmona testified before Congress that the second Bush White House had prevented him from speaking out on many issues, including the dangers of secondhand smoke, embryonic stem cell research, climate change, emergency contraception and abstinence-only sex education.

Their complaints echo similar ones from other federal health officers. Privately, top officials at the Centers for Disease Control and Prevention in Atlanta have complained for years about demands that they clear public statements and even medical advice through the Department of Health and Human Services, which is considered by some to be heavily politicized.

The depth of that interference became public last year when the Washington Post revealed that H.H.S. had forbidden the C.D.C. to use certain words, including “fetus” and “transgender” in its budget requests.

The surgeons general described moments of equal absurdity.

In Dr. Carmona’s case, it involved Sesame Street.

A former police officer and Special Forces medic who grew up in Harlem, he was asked by the producers of the children’s show to make occasional appearances, sitting on a stoop in his uniform, chatting about health. (One tentative plotline called for him to talk Cookie Monster into trying broccoli.)

But the department, he said, decreed that the role had to go to H.H.S. Secretary Tommy G. Thompson. Sesame Street dropped the idea.

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In 1991, Dr. Novello said, when the basketball star Magic Johnson shocked the world by revealing that he had H.I.V., she was told that her role in the announcement had to be handed over to the H.H.S. secretary.

All four lamented that the surgeon general’s job has faded in stature. From 1871 to 1968, its holder was the nation’s chief medical officer and commanded the Public Health Service Corps, a uniformed rapid-reaction force for health crises.

But the office was subsumed under H.H.S. and its budget was cut. Nowadays, the director of the C.D.C., which was created in 1942, is usually the most visible health official, especially during epidemics.

The exception was Surgeon General C. Everett Koop, a renowned pediatric surgeon in office from 1982 to 1989. He was chosen by President Reagan because of his conservative political views and opposition to abortion, but he became famous for defying White House pressure.

He condemned nicotine as addictive and endorsed warnings on cigarette packs. At a time when many politicians said AIDS was divine punishment for homosexuality, he sent every American household a pamphlet explaining how it was transmitted. And he refused to issue a report saying that abortions harmed the mental health of women who had them.

In testimony before Congress in 2007, Dr. Koop — who died in 2013 — said efforts to suppress sound medicine appeared to be getting worse.

Even he had not faced as much pressure as Dr. Carmona did, he testified.

Dr. Carmona recalled that moment.

“Once you put on the uniform, there’s supposed to be no room for politics,” he said. “But we aren’t stupid — Washington is a combat zone. And you don’t always know where the shooting is coming from.”

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