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THE SURGEON GENERAL’S VITAL MISSION:

CHALLENGES FOR THE FUTURE

HEARING

BEFORE THE

COMMITTEE ON OVERSIGHT

AND GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

JULY 10, 2007

Serial No. 110–38

Printed for the use of the Committee on Oversight and Government Reform

(

Available via the World Wide Web: http://www.gpoaccess.gov/congress/index.html

http://www.house.gov/reform

(II)

COMMITTEE ON OVERSISGHT AND GOVERNMENT REFORM

HENRY A. WAXMAN, California, Chairman

TOM LANTOS, California

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

BRIAN HIGGINS, New York

JOHN A. YARMUTH, Kentucky

BRUCE L. BRALEY, Iowa

ELEANOR HOLMES NORTON, District of

Columbia

BETTY MCCOLLUM, Minnesota

JIM COOPER, Tennessee

CHRIS VAN HOLLEN, Maryland

PAUL W. HODES, New Hampshire

CHRISTOPHER S. MURPHY, Connecticut

JOHN P. SARBANES, Maryland

PETER WELCH, Vermont

TOM DAVIS, Virginia

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

JOHN J. DUNCAN, JR., Tennessee

MICHAEL R. TURNER, Ohio

DARRELL E. ISSA, California

KENNY MARCHANT, Texas

LYNN A. WESTMORELAND, Georgia

PATRICK T. MCHENRY, North Carolina

VIRGINIA FOXX, North Carolina

BRIAN P. BILBRAY, California

BILL SALI, Idaho

JIM JORDAN, Ohio

PHIL SCHILIRO, Chief of Staff

PHIL BARNETT, Staff Director

EARLEY GREEN, Chief Clerk

DAVID MARIN, Minority Staff Director

(III)

C O N T E N T S

Page

Hearing held on July 10, 2007 ............................................................................... 1

Statement of:

Koop, C. Everett, M.D., Sc.D., 13th Surgeon General, 1981–1989; David

Satcher, M.D., Ph.D., 16th Surgeon General, 1998–2001; and Richard

Carmona, M.D, M.P.H, F.A.C.S., 17th Surgeon General, 2002–2006 ...... 16

Carmona, Richard ..................................................................................... 34

Koop, C. Everett ........................................................................................ 16

Satcher, David ........................................................................................... 26

Letters, statements, etc., submitted for the record by:

Carmona, Richard, M.D, M.P.H, F.A.C.S., 17th Surgeon General, 2002–

2006, prepared statement of ........................................................................ 37

Davis, Hon. Tom, a Representative in Congress from the State of Virginia, prepared statement of ........................................................................ 12

Koop, C. Everett, M.D., Sc.D., 13th Surgeon General, 1981–1989, prepared statement of ........................................................................................ 19

Satcher, David, M.D., Ph.D., 16th Surgeon General, 1998–2001, prepared

statement of ................................................................................................... 29

Waxman, Chairman Henry A., a Representative in Congress from the

State of California, prepared statement of ................................................. 4

(1)

THE SURGEON GENERAL’S VITAL MISSION:

CHALLENGES FOR THE FUTURE

TUESDAY, JULY 10, 2007

HOUSE OF REPRESENTATIVES,

COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM,

Washington, DC.

The committee met, pursuant to notice, at 10 a.m., in room 2154,

Rayburn House Office Building, Hon. Henry A. Waxman (chairman

of the committee) presiding.

Present: Representatives Waxman, Watson, Yarmuth, Norton,

Sarbanes, Davis of Virginia, and Issa.

Staff present: Phil Barnett, staff director and chief counsel;

Karen Nelson, health policy director; Karen Lightfoot, communications director and senior policy advisor; Andy Schneider, chief

health counsel; Naomi Seiler, counsel; Steve Cha, professional staff

member; Earley Green, chief clerk; Teresa Coufal, deputy clerk;

Caren Auchman, press assistant; Zhongrui ‘‘JR’’ Deng, chief information officer; Kerry Gutknecht, staff assistant; Art Kellermann,

fellow; David Marin, minority staff director; Keith Ausbrook, minority general counsel; A. Brooke Bennett, minority counsel; Susie

Schulte, minority senior professional staff member; Patrick Lyden,

minority parliamentarian and member services coordinator; and

Benjamin Chance, minority clerk.

Chairman WAXMAN. The meeting of the committee will come to

order.

Two months ago this committee began a series of hearings on

how to make government effective again. These hearings ask why

Federal agencies that were once admired as the finest in the world,

like the Food and Drug Administration, are failing to meet the

public’s expectations. And they seek to understand how we can restore these troubled agencies to models of excellence that will help

our Nation meet the challenges ahead.

Today’s hearing will examine the Office of the Surgeon General

in the Department of Health and Human Services. The Surgeon

General is the doctor to the Nation, a uniquely trusted figure who

brings the best available science on matters of public health directly to the American people. This position is unique among government agencies not only in the United States, but among health

agencies worldwide.

The ability of the Surgeon General to improve the health of the

Nation is vividly illustrated by the impact of the landmark 1964 report Smoking and Health. For the first time the American people

had a credible science-based report from the government that

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spelled out the relationship, the causal relationship, between smoking and lung cancer.

Over the years the Office of the Surgeon General has produced

highly influential reports and calls to action on topics ranging from

AIDS prevention to obesity to mental health. Like the 1964 smoking report, the Surgeon General’s work has shaped the Nation’s understanding of public health. But what we will learn today is that

this essential part of our government is in crisis. Political interference is compromising the independence of the Office of the Surgeon General. On key public health issues, the Surgeon General

has been muzzled. The Surgeon General’s greatest resource, his or

her ability to speak honestly and credibly to the Nation about public health, is in grave jeopardy.

Dr. Richard Carmona, the most recent Surgeon General, will tell

us that on issue after issue, he was blocked from speaking out and

prevented from using the best medical science to educate the American people. In his words, ‘‘the job of the Surgeon General is to be

the doctor of a Nation, not the doctor of a political party.’’ Yet Dr.

Carmona will tell us that he was astounded by the degree of partisanship and political manipulation he experienced. And he will

describe how, ‘‘anything that doesn’t fit into the political appointee’s ideological, theological or political agenda is ignored,

marginalized or simply buried.’’

Politics and science will always intersect in government, and Dr.

Carmona is not the only Surgeon General to face political interference. Dr. C. Everett Koop was the Surgeon General during the

Reagan administration and was told not to speak out on the subject

of AIDS, which was regarded as a gay disease. He courageously resisted this pressure. Dr. David Satcher served as Surgeon General

under President Clinton. He, too, faced political interference. His

efforts to release a report on the benefits of needle exchange programs were blocked, an action that President Clinton called a mistake. And when he wanted to release a report promoting the use

of condoms and other responsible sexual behaviors, he was told to

submit his report for publication in a medical journal rather than

release it as another Surgeon General’s report.

But as we will hear this morning, political interference with the

work of the Surgeon General appears to have reached a new level

in this administration. We will hear how reports were blocked,

speeches were censored and travel restricted. We will also hear

how the Surgeon General had to resist repeated efforts to enlist his

office to advance partisan political agendas. The public expects that

a Surgeon General will be immune from political pressure and be

allowed to express his or her professional views based on the best

available science, but when the science-based views of the Surgeon

General, like Dr. Carmona, are marginalized and ignored, that essential independence is lost.

The oversight should serve two purposes. It should expose problems in how our government operates, and it should point the way

to a reform. Today we will learn how political interference is undermining the Office of the Surgeon General, but we will also hear the

recommendations of Drs. Koop, Satcher and Carmona for restoring

the independence and the effectiveness of the Office of the Surgeon

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General. We need to pay as much attention to their prescription for

reform as we do their diagnosis for ills.

The position of Surgeon General is a revered post in our government. Fixing what is wrong and making the office work again

should be a bipartisan priority. In 2 days the Senate Committee on

Health, Education, Labor and Pensions will take up the nomination

of Dr. James Holsinger, Jr., to the position of Surgeon General. Today’s hearing does not concern this nomination of Dr. Holsinger’s

credentials, but I am hopeful that today’s testimony will be of value

to Congress and the American people as we consider the challenges

facing the next Surgeon General, whoever he or she may be.

[The prepared statement of Chairman Henry A. Waxman follows:]

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Chairman WAXMAN. We are fortunate to have a distinguished

panel of three former Surgeon Generals with us today, and I look

forward to their testimony. But before we hear from them, I will

recognize the ranking member of the committee Mr. Davis.

Mr. DAVIS OF VIRGINIA. Thank you, Chairman Waxman, for convening this hearing on a common issue. The Surgeon General,

often referred to as the Nation’s doctor, has played a pivotal role

over the years in educating Americans on important health matters. From our most visible health advocate, we have learned about

the dangers of using tobacco, the health effects of secondhand

smoke, underaged drinking and the lethal pathway of HIV/AIDS.

Many of the issues highlighted by Surgeon Generals have never

been addressed openly before. Some were considered taboo. But the

medical and moral authority of the Surgeon General’s voice broke

through those barriers and stipulated a central public discourse

and concrete actions to improve public health.

Operations of the Surgeon General’s office are not a new topic of

discussion for this committee. We held a hearing in 2003 to consider the proposal to make the U.S. Public Health Service Commissioned Corps a more readily deployable force in the Federal medical response to national disasters. As head of the committee, the

Corps of the Surgeon General leads a cadre of highly trained and

mobile health professionals who can respond to the Nation’s acute

and chronic health needs. Surgeon Generals Koop and Carmona

both testified at that hearing, and we welcome their insights again

today as we discuss more broadly the role of the future of the office

that they both held.

The committee also examined the Commissioned Corps’ deployment to the gulf coast after Hurricane Katrina. The Surgeon General’s Office was notified there was problem after landfall and that

their assistance would be necessary. Those offices provided muchneeded care to evacuees and provided a critical complement to the

Federal Government’s overall medical response. In the wake of that

historic storm, more than 1,000 Commissioned Corps officers were

deployed in that region. That effort was led by former Surgeon

General Carmona.

With the rich history and vital function, the Surgeon General

and I look forward to continuing our discussion today on how to enhance the role of that office as our Nation confronts the next generation of public health threats. We need to discuss the importance

of keeping the Surgeon General independent and free to communicate directly to the American people on disease prevention and

health promotion.

As we all know, our doctors sometimes have to deliver bad news.

Likewise, the Nation’s doctor is often called upon to make findings

that might be controversial or politically inconvenient to the administration of the day, Republican or Democratic. But waiting or

sugarcoating hard truths only allows public health problems to fester and grow worse. The voice of the Surgeon General can be a

powerful antidote to societal health and should not be muted or filtered through layers of needless bureaucratic or political approvals.

The physicians on this distinguished panel of witnesses have already made invaluable contributions to American public health. We

are grateful for the experience, the expertise and the insights they

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bring to today’s discussion of the Surgeon General’s vital role in

protecting and improving the Nation’s well-being. Thank you.

Chairman WAXMAN. Thank you, Mr. Davis.

[The prepared statement of Hon. Tom Davis follows:]

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Chairman WAXMAN. Ms. Norton, do you wish to make a statement?

Ms. NORTON. Thank you very much, Mr. Chairman. Just a very

brief statement.

First, a statement of gratitude that you are holding a hearing.

The reason I express such gratitude is because the Surgeon General very often speaks on health to the American people and can

have a remarkable effect simply by writing a report. So the lack

of such reports in recent years, when one man can almost singlehandedly, by speaking out, get people to think about smoking and

to have a material effect, not by going to the doctor, not by being

approached, just by issuing a report, when you have that kind of

power, it is important to use it.

Now, there had been a report on obesity. There needs to be another one, because we now have not only a childhood obesity epidemic before our very eyes that no amount of healthcare will solve

when these children get to be adults, but we have a remarkable

trend where in every age group, in every income group, in every

race, people are fat. And we see these fat people in our own constituencies, and we have nothing authoritative that speaks to

them.

And if I may say one more thing, Mr. Chairman. There is an

HIV/AIDS epidemic that has settled in the African American community, and shame on the Surgeon Generals of the United States

for not pointing out that 50 percent of the cases today are African

American, and we are 12 percent of the population. How could that

happen? Stereotyping this disease, as the chairman said, initially

as a gay disease can be controversial, and it was certainly wrong,

but imagine allowing it to travel over into another community and

not one word.

Finally, in the District of Columbia, everybody should be tested

in the United States to wipe away the stigma, to wipe away the

superstition and the homophobia. If the Surgeon General is to recoup his major role in American history not by telling us what to

do, but by speaking authoritatively to the American people, then he

must begin by speaking to us about the issues we can do something

about, and I have named two of them. Obesity and HIV/AIDS are

both preventable. One word from the Surgeon General can do more

than a multitude of hearings, as important as they are, from Congress.

Thank you, Mr. Chairman.

Chairman WAXMAN. Thank you, Ms. Norton.

Mr. Issa.

Mr. ISSA. Thank you, Mr. Chairman. I’ll put my entire opening

statement in for the record, but I would just like to thank our distinguished panel for being here today.

I, like the chairman, would like to take full advantage of the

independence of our Surgeon Generals. I believe that today we are

going to have an opportunity to delve into a number of areas. The

area that I would like to spend the most time on is one that is near

and dear to the chairman, and that is private health care, why

does it cost so much; public health care, why does it not meet the

expectations of the American people; and can we mend it, either

one of them, or do we need to end them? So I am going to very

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much take advantage of sort of the independence, and particularly

in Dr. Koop’s case, the independence that comes from some time

out of some of the public limelight.

I very much thank the chairman for holding this hearing and

would hope that this is a unique opportunity to ask the questions

that are very hard to ask in a normal hearing where we either

have the pharmaceutical industry or advocate industry or some

group that has a financial bent, if you will, in answering the questions.

Mr. Chairman, I’ll hold the rest of my questions, and I thank you

for holding this hearing today.

Chairman WAXMAN. Thank you, Mr. Issa.

Mr. Sarbanes, do you want to make any opening statement before we begin?

Mr. SARBANES. No, Mr. Chairman, just thank you for holding the

hearing and looking forward to openings.

Chairman WAXMAN. Thank you.

We do have three very distinguished former Surgeon Generals,

individuals who have served our country with honor and distinction

during four Presidential administrations. Dr. C. Everett Koop

served as our 13th Surgeon General from 1981 to 1989. A pediatric

surgeon by training, he is widely credited for making the Office of

the Surgeon General a scientific and principled force in American

life. More than any of his predecessors, Dr. Koop made the office

a bully pulpit for public health. His standing in the eyes of the

American public allowed him to tackle many sensitive and politically controversial issues, most notably the AIDS epidemic, which

emerged as a major threat to public health. During his tenure as

Surgeon General he spoke also forcefully and repeatedly about the

health consequences of smoking. And I am very pleased to welcome

Dr. Koop back with us today.

Dr. Koop, as you well know, I was initially very skeptical about

your nomination when President Reagan put it forward. I was

wrong, and I have come to know you as a professional dedicated

to the public good and public health. You had the courage to speak

truth to power and the good sense to distinguish public health from

politics. And I learned to admire you and to enjoy working with you

over the years on tobacco and HIV and children’s health. And I

look forward from hearing your testimony today. But I wanted to

pay a special tribute to you through the years that we have worked

together.

Our second witness, Dr. David Satcher, served as the 16th Surgeon General from 1998 to 2001. A family physician with additional training in public health, Dr. Satcher served for 6 years as

Director for the Centers for Disease Control and Prevention. During his tenure as Surgeon General, Dr. Satcher issued a number

of important reports, most notably his 1999 Surgeon General’s Report on Mental Health, which did much to remove the stigma from

mental illness, and his 2001 Surgeon General’s Call to Action to

Promote Sexual Health and Responsible Sexual Behavior. He also

released influential reports on oral health, youth violence and the

prevention of tobacco use by young people.

Dr. Satcher, we are very pleased to have you with us here, and

I enjoyed the time that we worked together as well.

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Our third witness, Dr. Richard H. Carmona, served as the 17th

Surgeon General from 2002 to 2006. A combat-decorated veteran of

the Special Forces, Dr. Carmona brought a varied background in

health care to the position. At different points in his career, he was

a paramedic, registered nurse, trauma surgeon and health care administrator. Although some criticize him for maintaining a low profile as Surgeon General, he released a number of important reports

and calls to action during his tenure. These included the Surgeon

General’s Call to Action to improve the health and wellness of persons with disabilities issued in 2004, and his landmark Surgeon

General’s Report on the Health Consequences of Involuntary Exposure to Tobacco Smoke, released shortly toward the end of his term

of service.

And, Dr. Carmona, I am delighted that you are here as well.

It is the practice of this committee to do this for all witnesses.

We do ask you to be sworn in, and I would like to ask you if you

would raise your right hands. Stand and raise your right hands, if

you are able to do that.

[Witnesses sworn.]

Chairman WAXMAN. The record will indicate that each of the witnesses answered in the affirmative.

I am going to call on Dr. Koop first, then call on Mr. Satcher and

then Dr. Carmona.

Dr. Koop, there is a button on the base of the mic.

STATEMENTS OF C. EVERETT KOOP, M.D., Sc.D., 13TH SURGEON GENERAL, 1981–1989; DAVID SATCHER, M.D., Ph.D.,

16TH SURGEON GENERAL, 1998–2001; AND RICHARD

CARMONA, M.D, M.P.H, F.A.C.S., 17TH SURGEON GENERAL,

2002–2006

STATEMENT OF C. EVERETT KOOP

Dr. KOOP. Mr. Chairman, members of the committee, I am C.

Everett Koop, Surgeon General for 7 years when Ronald Reagan

was President and 1 year with George Bush, Sr. My remarks come

from the vantage point of 26 years of close observation of the office

and of its mission.

I strongly believe that the Surgeon General must be independent

and free to advise the Nation on how it can prevent disease and

promote good health. He or she should be the health educator for

Americans par excellence. At the same time the Surgeon General

should be an important cog in the machinery that directs public

health in the United States, and I acted in these capacities. In addition to working within the United States, I served for 8 years as

our Nation’s representative to the World Health Organization. The

consensus of the representatives of other nations for my role was

something like this: What a wonderfully appropriate position. I

wish we had such an office and such a person.

The personalities of two individuals have much to do with the

success of the Surgeon General; first, the President of the United

States. Mr. Reagan was pressed to fire me every day, largely because of my work on AIDS, but he would not interfere. If he had

not been the kind of person he was, I would not be here today.

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Second, the Secretary of HHS. On a day-to-day basis, the Secretary is the most influential person in determining the effectiveness of the Surgeon General. I served under four. The last one was

Dr. Otis Bowen, a three-time Governor of Indiana, a medical doctor, and a fine gentleman. When I was writing the Surgeon General’s Report on AIDS and the later mailing sent to every household in America, he was a constantly supportive gentleman. It was

Otis Bowen who insisted that I sign the documents in question myself. I asked Otis Bowen to keep the contents of these two reports

close to his chest. I promised to do the same. In addition to the two

of us, only two staffers were privy to the contents. We maintained

strict secrecy from the day we began to write until we presented

the finished product, 17 drafts later, and released them to the

press. If we had followed the protocol and every word was scrutinized, these reports, because of their nature and plain speaking, I

am sure would not have seen the light of day.

The Secretary of Health and Human Services can use the talents

of the Surgeon General or ignore them. In that regard, my successors were less fortunate than I. Over the years since I left office,

I have observed a worrisome trend of less than ideal treatment of

the Surgeon General, including undermining his authority at times

when his role and function seemed abundantly clear.

If I had been impeded in my duties as some of my successors

were, here are some of the things that would never have happened.

Eight reports to Congress on smoking and health might not have

been published. The knowledge of the addiction of tobacco because

of its nicotine content might have been suppressed. We might have

still have smoking on airplanes. Changes in Title V of the Social

Security Act entitling special needs children to comprehensive,

family centered, community-based care might not have happened,

either. Assurance during the Tylenol scare would have been missing, leading to panic and possible market upheaval. Revision of the

health care agreements with the People’s Republic of China, the

Soviet Union and Kuwait might not have occurred. The only Federal Government report on nutrition might not have been published, and many, many more that time does not permit to tell.

Clearly the Surgeon General must be free to serve the American

people without political interference. It is also vital that future

Surgeon Generals have the necessary support and resources to do

their job. How can we ensure that this happens? First I believe

that the Surgeon General should not be a political appointment. In

my opinion, the Surgeon General should be named by the President

from a panel selected by the Promotions Committee of the Commissioned Corps of the U.S. Public Health Service. This was once the

protocol, and it served our country well for nearly 100 years. It remains today the protocol used to appoint the Surgeons General of

the Army, Navy and the Air Force.

Second, the Surgeon General must have secure funding to do his

work. The security of a 4-year appointment doesn’t mean much if

you can be easily denied the resources you need to do your job.

Therefore, I recommend that Congress annually appropriate funding on a line-item basis to the Office of the Surgeon General.

In closing, I may say, Mr. Chairman, as you already mentioned,

you were from the beginning one of my severest critics. You became

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one of my trusted supporters, and I thank you for that and the excellent job, sir, that you have done in improving the health of the

American people. Please continue to exercise oversight of the Office

of the Surgeon General and the Commissioned Corps of the Public

Health Service so that they can continue to do their vital work.

Thank you, sir.

Chairman WAXMAN. Thank you very much, Dr. Koop.

[The prepared statement of Dr. Koop follows:]

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Chairman WAXMAN. Dr. Satcher.

STATEMENT OF DAVID SATCHER

Dr. SATCHER. Thank you, Chairman Waxman and members of

the committee, for holding this hearing and for your attention to

the importance of the Office of the Surgeon General. I had the opportunity to serve for almost 9 years in government, 5 years as Director of the Center for Disease Control and Prevention, and 4

years as Surgeon General, 3 of which I also served as Assistant

Secretary for Health. Also I had the opportunity to represent the

United States as a delegate to the World Health Assembly for 9

years and to interact with colleagues from throughout the world,

and I share the experience of what Surgeon General Koop had in

terms of their admiration for the unique role which the Surgeon

General plays in the health of the American people.

It is my opinion that we critically maintain a role of the Surgeon

General. The Surgeon General is responsible for communicating directly with the American people based on the best available

science, not politics, not religion, not even personal opinion. The

Surgeon General does this, as you have heard, through speeches,

writings, press conferences and especially the Surgeon General’s reports. These Surgeon General reports are vetted with the relevant

scientists at the CDC and other appropriate agencies.

During my 4-year tenure as Surgeon General, I had the opportunity to release reports on mental health, suicide prevention,

youth violence, smoking and health, oral health, overweight and

obesity, and the Surgeon General’s Call for Action for Responsible

Sexual Behavior. The reports on mental health, oral health, suicide

prevention, youth violence and sexual health were the first from

the Office of the Surgeon General. The overweight and obesity report was also the first to follow a report on nutrition that had been

done in the 1980’s.

The Surgeon General’s Office has evolved over the years since

1873 with changes in level and magnitude of responsibility. Today

the Surgeon General oversees the Commissioned Corps—health

professionals who are on call 24 hours a day, 7 days a week to respond to emergencies.

What has not changed about the Surgeon General’s Office is its

direct responsibility for communicating with the American people

based on the best available science, and its responsibility for responding to public health emergencies that threaten the health of

the American people—regardless of where those emergencies occur.

There have always been challenges to the role of the Surgeon

General. Sometimes these challenges are based on the political nature of issues or the religious implications of issues. However, the

Surgeon General’s Office has a remarkable record of credibility and

trust in communicating with the American people based on the

best available science.

The Surgeon General’s Office would benefit tremendously from

being more independent, with well-defined resources for carrying

out the duties of that office. It is clear that the American people

value the Office of the Surgeon General, and that the global community has tremendous respect and appreciation for the office.

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After I released the Surgeon General’s Report on Mental Health

in the United States, I had an opportunity to present that report

to Director Gro Brundtland of the World Health Organization in

May 2000. That resulted in the World Health Organization later

issuing a world mental health report which all the ministers of

health around the world valued very highly. During my tenure I

was able to release some very valuable reports with lasting impact.

However, certain areas of health, especially areas that are politically sensitive, such as drugs and sex, despite their great significance in dealing with issues such as HIV/AIDS, were often hampered by politics and/or religious implication.

I have, in my written report to you, described my experience with

the needle exchange program. As the Director of the CDC, I

oversaw the funding of research programs evaluating the impact of

needle exchange programs in reducing the spread of HIV/AIDS and

showing that there was no increase in drug use. I submitted that

report to the Department. Soon after I became Surgeon General,

we planned to have a press conference to release that report to the

American people, and we were hoping it would lead to Federal

funding for the needle exchange program. I think because of the

political environment and the almost certain defeat of the needle

exchange program with Congress, the White House made a decision the day before the press conference not to support it. That left

me in a very difficult position as both Assistant Secretary for

Health and Surgeon General. As Assistant Secretary For Health,

I was expected to support the position of the White House and the

Department. But as Surgeon General, my responsibility was to

speak to the American people based on the best available public

health science.

I did the latter. I went throughout the country speaking about

the value of needle exchange programs. Many localities funded

those programs, and, as you know, the Congress has not yet supported the funding of needle exchange programs. But it is an example of why it is so important the Surgeon General should be able

to speak on this or the best available science, and not politics and

not religion.

Later, I completed a report, the Surgeon General’s Call to Action

to Promote Sexual Health and Responsible Sexual Behavior. That

report was actually completed during the Clinton administration,

and, as you know, I served my last year in the new Bush administration. I was hampered from releasing that report during the Clinton administration, but also the new Bush administration. I was

able to finally release it, but without the support of the Department. It is the only report I released that was not signed off on by

the Secretary. I released that report in 2001 during my last year

as Surgeon General. The President and the Secretary did not support that report, and they did not support it because of obviously

both its political and religious implications.

I think it is OK for the White House or the Congress to disagree

with the Surgeon General on issues, because the American people

look to the Surgeon General for the best available science. I don’t

think it is OK for the White House or the Congress to dictate the

messages of the Surgeon General, and that is our concern, that the

Surgeon General’s Office be independent enough to speak directly

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to the American people based on the best available science. So I

join Surgeon General Koop in asking that Congress take those

steps to make this office independent enough to communicate directly with the American people based on the best available public

health science, and that it be adequately funded by an independent

source of funding for Congress so that it can carry out those responsibilities.

I’ll end my comments with one story. When I released the Surgeon General’s Report on Mental Health, I received letters from

people all over the country expressing their appreciation because

they had members in their families who suffered from mental illness, and there had been so much stigma surrounding it until they

just felt embarrassed to even talk about it. One young man wrote

that when he was 8 years old, his mother died, and he didn’t learn

until he was 20 that she had committed suicide. And he explained

how he heard people whispering about her death, but nobody would

talk about the condition that led to it. She had suffered from severe

depression. And, again, he thanked the Office of the Surgeon General for bringing mental health out of the closet, helping to remove

the stigma.

We have much more to do, but I hope that we will be able to rely

upon the Office of the Surgeon General to provide that kind of

leadership. Thank you.

Chairman WAXMAN. Thank you very much, Dr. Satcher.

[The prepared statement of Dr. Satcher follows:]

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Chairman WAXMAN. Dr. Carmona.

STATEMENT OF RICHARD CARMONA

Dr. CARMONA. Good morning, Mr. Chairman, distinguished members of the committee. My name is Richard Carmona. I am the

17th Surgeon General of the United States, and I am profoundly

grateful for your invitation to me and my Surgeon General colleagues to testify before you today. I want to thank you for your

interest and commitment to these very important national public

health issues.

I had the privilege of working with many of you during the 4

years I served as U.S. Surgeon General, and I stand ready to continue to partner with you to improve the health and well-being of

our great Nation and the world. Being nominated and confirmed as

Surgeon General is still a surreal event for me. I will never forget

the extraordinary privilege that the President of the United States

and the Senate extended to me allowing me to serve my country

once again in uniform.

As grateful as I am to my country for the opportunities that I

have been afforded, that sense of appreciation will never allow me

to become complacent in my commitment to continue to improve

the health, safety and security of our Nation and the world. As

members of a very small and unique fraternity of Surgeons General

of the United States, we all believe that once a Surgeon General,

always a Surgeon General.

I came to Washington, DC, having served as a U.S. Army Special

Forces medic and weapons specialist, a registered nurse, police officer, SWAT team leader, trauma surgeon and CEO of a public

health and hospital system and a university professor. I also came

to the Office of the Surgeon General knowing what it feels like to

be a poor Hispanic child growing up in New York City, a high

school dropout whose family often had to stand in line at public

hospitals waiting for health care and not knowing how we would

pay for the doctor’s bill, and sometimes not even knowing where

our next meal would come from.

I came to our Nation’s Capital wanting to serve all people and

prepared to carry on what I believed was a tradition of implementing nonpartisan, evidence-based solutions to public health challenges. My fellow U.S. Surgeons General warned me that partisan

political agendas often undermine the public health and well-being

of the Nation.

During my first year as Surgeon General, I was still quite politically naive in the ways of the Beltway. As I witnessed partisanship

and political manipulation, I was astounded, but also unsure of

what I was witnessing for I had no reference point. I asked myself

whether this was just happening to me as a new Surgeon General,

or whether this was a norm for all Surgeons General.

I turned to my fellow Surgeons General, the men and women

who came before me and made tremendous positive contributions

to the science and practice of public health, who had saved and improved millions of lives through their work and dedication. They

became my mentors. They said that they had all been challenged

and had to fight political battles in order to do their job as the doctor of the Nation. But each agreed that never had they seen WashVerDate 11-MAY-2000 13:35 Apr 24, 2008 Jkt 000000 PO 00000 Frm 00038 Fmt 6633 Sfmt 6633 C:\DOCS\40151.TXT HGOVREF1 PsN: HGOVREF1
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ington, DC, so partisan or a new Surgeon General so politically

challenged and marginalized as during my tenure. They told me

that although most Americans believe that the Surgeon General

has the ability to impact the course of public health as the Nation’s

doctor, the reality is that the Nation’s doctor has been marginalized

and relegated to a position with no independent budget and with

supervisors who are political appointees with partisan agendas.

Anything that doesn’t fit into the political appointee’s ideological,

theological or political agenda is often ignored, marginalized or

simply buried.

The problem with this approach is that in public health, as in a

democracy, there is nothing worse than ignoring science or

marginalizing the voice of science for reasons driven by changing

political winds. The job of the Surgeon General is to be the doctor

of the Nation, not the doctor of a political party.

The good news is that there is a straightforward remedy to the

problem of partisan politics undermining the health and well-being

of our Nation. That solution is to empower the Office of the Surgeon General and the U.S. Public Health Service Commissioned

Corps. This would not be a radical new approach. It would simply

be reinstating the roles and responsibilities of the Office of the Surgeon General that had been slowly eroded since politicians decided

in the late 1960’s that the Office of the Surgeon General should be

disempowered and its authorities placed within the offices of the

Department of Health and Human Services political appointees.

Historically the Surgeons General had occupied increasingly embattled positions where each has had to fight to scientifically address the contemporary health issues of the Nation and the world

within an increasingly partisan agenda that is often devoid of open

discussion of scientific evidence or data. To address these problems

we must empower, fund and support the Office of the Surgeon General and U.S. Public Health Service Commissioned Corps to serve

the people and the world and not a political party. The Commissioned Corps delivers arguably the best evidence-based health care

in the world. With unparalleled passion and dignity, they are a

precious resource that can be used much more efficiently and effectively to serve the public health needs of our Nation and the world.

Require a uniformed, physically fit professional Commissioned

Corps with continuity of operations between administrations and

Surgeons General, as is the basic protocol among all of our fellow

uniformed services.

End the practice of the political discretionary awarding of a fourstar admiral rank to HHS Assistant Secretary for Health, who may

be a civilian political appointee with no uniformed service experience.

Ensure that all future Surgeons General are nominated by the

President of the United States from the ranks of career U.S. Public

Health Service Commissioned Corps officers based on merit and

without political, ideological or theological filters. This is just as

the U.S. Army, Navy and Air Force Surgeon Generals are selected

and how the U.S. Surgeon General was selected, until the position

became increasingly politicized.

In addition, we should consider going back to the nonpolitical

U.S. Public Health Service Commissioned Corps officers ascending

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the ranks based on merit in order to command our Public Health

Service agencies again, just as our sister uniformed services do and

have done for centuries.

In closing, I hope that you will hear me and my fellow Surgeon

Generals today and make the decisions and changes that only you

can make so that future Surgeon Generals do not have to struggle

against impossible odds to ensure that public health is free of political manipulation. I hope that you will agree with us that the citizens of the United States deserve a Surgeon General as a doctor

of our Nation and leader of the U.S. Public Health Service Commissioned Corps, who is empowered and supported by the U.S. Government to address our national and global health issues transparently, openly and apolitically, with the best science, in order to

improve the health, safety and security of our Nation and the

world.

Thank you, Mr. Chairman.

Chairman WAXMAN. Thank you very much, Dr. Carmona.

[The prepared statement of Dr. Carmona follows:]

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Chairman WAXMAN. We are now going to proceed to questions.

I will have 10 minutes, Mr. Davis will have 10 minutes, then we

will go to 5-minute rounds.

Dr. Carmona, that is a very strong statement. It appears that

both Dr. Koop and Dr. Satcher both had the ability to be the Surgeon General, to use science, to use the position as a bully pulpit,

interfered with. But it seems to me what you are saying is that

even though you consulted with them, the experience you had was

even worse, and it is now a new magnitude of involvement and interference. Is that the message I should get?

Dr. CARMONA. Mr. Chairman, I believe that’s correct. As I said

in my statement, my first year of being somewhat politically naive,

and as much education as I had, nothing can prepare you for what

you finally come to witness in Washington. And being devoid of a

reference point, I sought their good counsel to say, what’s going on

here, did you have these problems? And it was Surgeon General

Koop who pointed out, and still does today, he said to me, Richard,

we all have fought these battles, as have our predecessors going

back over a century, but we have never seen it as partisan, as malicious, as vindictive, as mean-spirited as it is today, and you clearly have it worse than any of us had.

Chairman WAXMAN. But you tried to fill the role and did a responsible job of trying to provide accurate science-based information. But you indicate that at times you were marginalized or simply had your reports or ideas buried.

You came in as Surgeon General in 2002, and at that time there

was a great national debate about the role of stem cells in medical

research. I understand you thought the Surgeon General could play

a constructive role in explaining this issue, just the science of it,

to the American public. Could you tell us what you tried to do, and

what the result was?

Dr. CARMONA. Yes, Mr. Chairman, I would be happy to.

I recognize that notwithstanding stem cell issues, the Nation suffers from health illiteracy. The literature is clear, about a third of

the Nation really doesn’t understand the science we have to deal

with every day, it doesn’t understand the relationship that their

behavior has to ultimate health outcomes. And I saw this debate

going around not only as a Surgeon General, but I witnessed it as

a professor, and I saw that much of the discussion was being

moved forward devoid of science.

And so I approached leadership to say the Surgeon General

should be leaning forward on this; we should be, in fact, in the debate on this issue so that we make sure the American public, and

our elected officials, our appointed officials are all knowledgeable

of the science.

Much of the discussion was being driven by theology, ideology,

and preconceived beliefs that were scientifically incorrect. So I

thought this is a perfect example of the Surgeon General being able

to step forward, educate the American public as well as elected appointed officials so that we can have, if you will, informed consent

on an issue to the American public to make better decisions.

I was blocked at every turn. I was told the decision had already

been made, stand down, don’t talk about it. That information was

removed from my speeches.

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Chairman WAXMAN. Who would remove a portion of your speech?

Dr. CARMONA. There were people who were actually assigned in

the Department to vet my speeches to speechwriters who were

helping me put together talking points and things like that. Unfortunately I was naive enough during my first year that I didn’t recognize this was happening. Many of the staff, in trying to protect

me, didn’t tell me the embattled problems and positions that they

were in in trying to help me bring the best science forward, but

constantly being vetted, and politically vetted, I should say, not scientifically vetted. And it was a while before I figured out that this

was happening behind the scenes.

Chairman WAXMAN. Did you have any of your other speeches vetted and censored?

Dr. CARMONA. Repeatedly.

Chairman WAXMAN. Repeatedly.

Dr. CARMONA. Yes.

Chairman WAXMAN. And were these scientists or physicians that

were doing it, or political people?

Dr. CARMONA. No. In fact, I welcome input from my colleagues

on science. I often called my NIH colleagues and CDC, my officers

in other departments, to say, what do you think about this, give

me the best science. And I would bring groups together to achieve

consensus on a scientific issue.

The vetting was done by political appointees who were specifically there to be able to spin, if you will, my words in such a way

that would be preferable to a political or ideologically preconceived

notion that had nothing to do with science.

Chairman WAXMAN. Were you allowed to speak freely to reporters?

Dr. CARMONA. No. I was often instructed what to say or what not

to say. I did the best I could to speak out on issues honestly. I

never lied, I never covered the truth. But it was a fine line that

I walked all the time, because often the particular issue already

had a preconceived political solution, and I had nothing to do with

it. And what I found in my first year was that I would see policy

moving forward, and I would scratch my head and think, shouldn’t

the Surgeon General have been involved in this discussion? Yet I

had nothing to do with it, but yet be expected to support these notions that were released to the press, through policy, legislation

and such. I had no input into them prospectively.

Chairman WAXMAN. The President made a decision on stopping

research using embryonic stem cells. He claimed he had a certain

number of lines of cells that were already in existence, and he

would allow that research to go forward. It may not have been the

decision you agreed with, but it was his decision. What do you

think your role should be after the President decides for the administration what that administration’s policy would be?

Dr. CARMONA. Well, Mr. Chairman, I think clearly the President

of the United States, as the senior elected official, has the authority to do what he sees fit, as does Congress as the elected officials

representing our citizens. However, I think as part of the due diligence the Surgeon General should be at the table representing our

colleagues in science as it relates to the issue.

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Make no mistake, I think I speak with my fellow Surgeon Generals on this as well, we recognize that ultimately the authority

rests with those elected officials. The danger is when the science

is not heard, when the policy, when ideas are promulgated forward

in front of the American public devoid of scientific discussion,

where the Surgeon General is marginalized; that is the danger.

Chairman WAXMAN. Were you going to advance a particular

point of view on research, or were you going to simply discuss the

science and what it would mean if embryonic stem cells or any

other stem cells were used?

Dr. CARMONA. Mr. Chairman, I think the Surgeon General walks

a fine line. Certainly if asked by senior officials to discuss an opinion as to what an appropriate course of action should be, I think

that is a perfectly good role for the Surgeon General, but also recognizing that it is ultimately the elected official and officials who

have the authority to make the final decision. So that had I been

asked, my discussion would have been more about the science of

stem cells devoid of the political ideological banter that was going

on so that the American public could understand, if you will, the

risks, the benefits, and the costs of going in a certain direction and

understand the science of stem cells. Because that, I felt, was devoid within these discussions that were mostly being driven politically, ideologically or theologically.

Chairman WAXMAN. Well, is this a unique issue? Did you have

experience with the administration, other political appointees in

the administration, interfering with other discussions on public

health?

Dr. CARMONA. Well, in speaking with some of my colleagues in

other departments, and not only in HHS, but in others, there were

those complaints from others.

Chairman WAXMAN. I am talking about you.

Dr. CARMONA. Only me specifically.

Chairman WAXMAN. A Plan B——

Dr. CARMONA. Yes, sir.

Chairman WAXMAN [continuing]. Emergency contraceptive drug,

comprehensive or abstinence-only sex education. Those are all matters the public needs to know more about in terms of just the basic

science. Were those issues that you tried to speak out about and

stopped from discussing as well?

Dr. CARMONA. Yes, sir, that is true. On many of those issues, I

felt at the end that the Surgeon General should be taking the lead

on discussions with the American public on what the science is behind those issues to help the public come to some conclusions as

to what course of action they might support, as well as our elected

and appointed officials, that they should be aware of the science.

Chairman WAXMAN. What was the interference? Did they tell you

you can’t talk about it, did they review your speeches, did they edit

speeches and remarks to the press, edit reports? What was the way

in which you were interfered?

Dr. CARMONA. All of the above, sir, all of the above. And, for instance, on abstinence education, when that came up, a lot of my

colleagues, my colleague Surgeon Generals, have said, this position

of the U.S. Surgeon General really has morphed into a global position. I would regularly speak with health ministers and leaders

48

from other countries who would call for information and would ask

us questions. And on the abstinence issue, right away I started getting a lot of calls from our colleagues in the United States and even

overseas who would say, well, how can you only support abstinence

only? That flies in the face of public health science. I said, I don’t.

I said, if you look at any one of my presentations, it was always

about a comprehensive approach to sexual education, largely based

on my predecessor David Satcher’s work, who had brought that information forward before I came. And I built on that platform.

However, there was already a policy in place that did not want to

hear the science, but wanted to just, if you will, ‘‘preach abstinence,’’ which I felt was scientifically incorrect.

Chairman WAXMAN. Well, I thank you for your comments and responses to these questions. I know many of my colleagues will have

further questions of you. But I do think that the Surgeon General

has to be independent if the Surgeon General is going to have any

credibility. And the credibility of that position is what is the key

to the success of the Surgeon Generals that we have had over the

years.

If my colleagues will just indulge me. I was in the Soviet Union,

and I was with some dissidents, and they were smoking cigarettes

like crazy. And I asked one of them, don’t you have any warnings

on your cigarette packs that tell you how dangerous it is? And I

was told by one of the dissidents, this is a warning put on by the

government. How can you believe anything the government tells

you? Well, if it is the government telling you that political point of

view, you start not believing anything the government has to say,

unless there is some credible, independent scientific statement

which supersedes the politics.

Dr. CARMONA. Mr. Chairman, may I just make a comment on

that to echo what my colleagues have said? After I got over my political naivite and I started traveling, I had the same experience

that Surgeon Generals Koop and Satcher had. As I met with my

colleagues in the World Health Organization, they looked at the

Surgeon General position as one of a beacon of hope, one that really represents the best of America as giving truthful information.

And I think one of the more perfect examples of that would be we

fought for years to get out that report on secondhand smoke. When

it finally got out, because of all the political manipulations and

marginalization, it slipped out. Within 2 weeks, I had calls from six

continents, hundreds of cities in our own country. I had small restaurateurs in Texas, in El Paso, calling and saying, we have the

information now, we are going smoke-free in all of my restaurants.

I had governments calling me saying, we have information now

from the U.S. Surgeon General that will help us make our city, our

country, smoke-free. The ramifications were rippling because of the

credibility that your Surgeon General of the United States had for

the health not only of the Nation, but of the world.

Chairman WAXMAN. Thank you very much, Dr. Carmona.

Mr. Davis.

Mr. DAVIS OF VIRGINIA. First of all, let me thank all of you for

your public service. This is a serious job that all three of you have

taken seriously. I have a great respect for the job that all of you

have done. I am not sure what the boundaries are for appointed

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political officials who sometimes have opinions different from the

elected administration. It is tough trying to define where you would

be a team player and where you feel strong enough to speak out

with your positions. I think you try to balance that every day. Even

as independently elected Members of Congress, we try to balance

those issues out.

So we are talking, I guess, in some of your practical experiences

trying to get a better understanding. My friend, Henry Waxman,

makes a good point that at the end of the day the job deserves

credibility with the American people. But we have politicians who

run the government, not scientists, for better or for worse.

But, you know, I happen, Mr. Carmona, to agree with you on

stem cells. I was a cosponsor of Federal funding of stem cells to

override the veto. But the administration is also entitled to make

their moral determination over where the boundaries should be,

notwithstanding what other scientific data is. And of course the

model of the staters is that the State will be a moral terce and enforce the laws, the morality. And, it is very difficult, I understand,

as part of an appointed team, to be part of that and get facts out,

and now you are free to say whatever you want.

Dr. Satcher, you went through something similar on your report

on sexual health and sexual behavior. Could you tell us a little bit

about that? I think in your testimony you alluded to that. But that

was also something you felt very strongly about and ran into some

problems with the administration.

Dr. SATCHER. First, let me respond to something you said which

I think is important. I think when the Surgeon General is speaking

only based on his or her opinion, without having the science behind

it, I think it deserves no more credibility than anything else. But

when the Surgeon General speaks on the basis of the best available

public health science, I think the American people deserve to hear

that independently.

And the Surgeon General does not make policy. You are right,

we don’t make policy. We were not elected to make policy. We were

appointed to communicate directly with the American people. That

should not be interfered with. I think that is our concern. I think

when the Surgeon General is not able to communicate, to write his

or her speeches and say what they want to say to the American

people, I think you have crossed the line significantly.

Mr. DAVIS OF VIRGINIA. Is that true, even when you are contradicting the policy of the administration?

Dr. SATCHER. I don’t think the Surgeon General necessarily

should speak about the policy, but the Surgeon General should

speak about the science. For me to not say that needle exchange

programs were able to decrease the severity of HIV/AIDS, and

there was no evidence of increased drug use, I think that would

have been unfaithful to the science. Congress would ask Secretary

Shalala for an updated report, and what she did was to ask me to

write a letter giving her the most recent information. When I did,

she would say, I just received this letter from the Surgeon General,

and this is what he said. But I think you are right, it has to be

based on the best available public health science, not personal

opinion.

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Mr. DAVIS OF VIRGINIA. Before you get to that, we just had a vote

last week on needle exchange programs in the District of Columbia.

My feeling was it is their own money, let them spend it the way

they want to. There is a ban on Federal funding for that. And the

reason for that is the policy—although you are saying that science

is very clear on that, I am not going to take issue with you on that

in terms of stopping the spread of HIV. The policy then becomes

if you are a citizen and you go into a hospital and you need a needle for IV, if you are on Medicare or you are a veteran, you pay

for it. But if you are using illegal drugs, the government pays for

it. And so there are contradictions policywise.

Dr. SATCHER. I think you make a very important point. You also

pay to treat people when they get AIDS. And you really pay dearly

and society pays dearly because people will infect, spread the disease to other people. So you have to make a decision. So the Surgeon General is trying to advise based on the best available

science.

Mr. DAVIS OF VIRGINIA. No, I understand. But I think there are

some contradictions. The argument is with the health side. I know

we will talk in a little bit about this sexual health and responsible

sexual behavior. You wanted to get this out, and you felt this was

important to get out to the public.

Dr. SATCHER. Well, it started off by informing the American people about the magnitude of the public health problems surrounding

sexual health; HIV/AIDS, the growing of STDs, including the reemergence of syphilis and others. So it really talked about the magnitude of—it also talked about sexual violence. In fact, 22 percent

of women report having been assaulted sexually sometime during

their life and about 4 percent of men. So it really put the data out

there about the magnitude of the sexual health problem. This area,

while we are not willing to talk about it, is wreaking all kinds of

havoc in families and individuals. Many people who have been infected with AIDS end up infected because they were abused sexually as children. So there are a lot of things in the report about

that.

I think the most sensitive issues—let us go back to three which

I think got the report in trouble. We did talk about sexual orientation. We said that based on the science, sexual orientation is determined in adolescence, and there was no scientific evidence that it

could be changed. So that was a very sensitive issue about sexual

orientation. We said that regardless of how we felt about people

and their sexual orientation, they deserve to be respected; not just

tolerated, but respected as people.

We talk about comprehensive versus abstinence-only sexual

health education, and we looked at all of the studies that had been

done. And we said, based on the studies available to us, there was

no evidence that abstinence-only sexual health education was effective—now, this was 2001—and that, in fact, a comprehensive approach to sexual health education was the most reasonable approach based on all of the available science.

And then we talked about sexual health education. We recommended that children be educated about their sexuality beginning at home. Parents are the first to provide sexual health education. It needs to be age appropriate. But it also needs to be in

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schools. I mean, what should happen should be—regardless of the

age of the children, they should learn about their sexuality and

how to protect themselves and make the right decisions about it

based on the best available science. So those were the three things.

Mr. DAVIS OF VIRGINIA. When this came up originally though the

White House was undergoing some political problems; is that right.

Dr. SATCHER. Well, I think it is fair to say even though the support had been vetted by the CDC and NIH, it had gone to all of

those scientists, I think it was the political environment that carried the day——

Mr. DAVIS OF VIRGINIA. In the Lewinsky scandal?

Dr. SATCHER. Exactly. There was a political environment that

carried the day, but I think it is critical when it comes to a Surgeon

General’s report, the Surgeon General should be independent in his

ability to release them. In the Bush administration, I think as Secretary Thompson certainly pointed out to me, you know, the politics of sex in Washington, you know that even—he made it very

clear that support was important, but also made it very clear that

politically it would be very difficult. So I finally——

Mr. DAVIS OF VIRGINIA. Ms. Elders took a lot of heat also, didn’t

she, on those issues?

Dr. SATCHER. Oh, Jocelyn Elders was fired because of the things

she said.

Mr. DAVIS OF VIRGINIA. She took a lot of heat.

Dr. SATCHER. I want to make it very clear that Dr. Elders’ firing

was not about a report——

Mr. DAVIS OF VIRGINIA. It was about her speaking out.

Dr. SATCHER. It was about her speaking out about issues of sexuality. So the report was finally released in the Bush administration, and then they made it very clear to me that I was on my own.

I think of course you probably are not aware of some of the

things that have happened since. Last year after bringing together

a group of people who met for 18 months, some of the most conservative groups in the country, some of the most liberal, some of

the most moderate, including Medical and Educational Association,

we released a report that all of those people were able to agree on

after having met together for a year and a half, but a very important report. I would not have been able to do that if I had not received foundation funding after I left government to continue this

effort.

So as Surgeon General Carmona says, we never stop being Surgeon General. I mean once you are Surgeon General, as far as we

are concerned, you are always responsible.

Mr. DAVIS OF VIRGINIA. They still call you General, right?

Dr. SATCHER. Exactly.

Mr. DAVIS OF VIRGINIA. I will have to say, Dr. Koop, I really respect the work that you did talking about smoking. The effects of

secondhand smoke has had a huge effect on policymakers on both

sides of the aisle.

So I yield back.

Chairman WAXMAN. Thank you, Mr. Davis.

Ms. Norton.

Ms. NORTON. Thank you, Mr. Chairman. I would like to thank

all three of you, Dr. Koop, Dr. Carmona, Dr. Satcher.

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Dr. KOOP. Can’t quite hear you, ma’am.

Ms. NORTON. I would like to thank all three of you for the courage and the independence you asserted with considerable courage,

the three of you have had your courage tested, and it is impressive

to see how you have responded. I do thank you, Dr. Satcher, for

being way ahead of your time during the Clinton administration

who for all of its progressive stance, would not in fact support needle exchanges, despite knowing full well what the consequences

were.

Dr. Carmona, I must say one would have to congratulate the

President on his appointment of you a year or so following 9/11.

Here he reaches out and he finds an especially qualified Surgeon

General because you had been in the Special Forces, you were a

trauma surgeon, you were an expert in emergency medical services,

there is a laundry list of challenges.

I want to ask you about that work particularly, since I represent

the District of Columbia and because I served on the Homeland Security Committee, because this is where the anthrax attacks took

place, right here at Congress as a matter of fact, where we lost two

postal workers and you know the rest.

We have had a hearing in this committee, an astounding hearing

recently, on how hospital emergency services, particularly emergency rooms, are now being stretched to the breaking point. As I

understand it, you did use your background in emergency services

and sought permission to prepare a report on emergency preparedness; is that so?

Dr. CARMONA. Yes, ma’am, that is correct.

Ms. NORTON. That was before a report was written, sir?

Dr. CARMONA. Well, I can give you a general timeline, Ma’am.

What happened was I came in shortly after 9/11 and the anthrax

challenges to our Nation, and as I looked at the gaps in our system

and where I could assist, especially after being appointed by the

President and confirmed by Senate, given that there was a great

deal of fanfare about my background and that I was selected because I had this background in emergency management and preparedness pretty much my whole life and being quite serious in

this area.

I said, well, there are a couple of issues I see before us. One, we

are a nation that on a good day has inadequate mental health care.

One in five people can’t get mental health care on a daily basis in

the good times. Now we have war, we have 9/11, we have an anthrax attack, we have people feeling very uncertain about their futures. What are we doing to shore up our mental health issues,

why is that important?

When you look at what terrorism does, we often do very well at

preparing for the physical wounds, but the psychological wounds

are lifelong and lasting and can devastate a population. So I

thought we need to move forward on an emergency preparedness

report, as well as a report on preparedness that would bring our

Nation forward so that all citizens would understand the threats

and challenges before us and what their individual responsibility

is. Just like we had civil defense in the 50’s, we were talking about

the new civil defense of the new world, the new world order. So I

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moved forward with those ideas and tried to move those reports

out. Unfortunately, then never got out———

Ms. NORTON. Just a moment, this is almost a neutral sounding

request, emergency preparedness, mental health, where did you

take your requests for permission and what reason was given to

you for denying permission?

Dr. CARMONA. Let me tell you, I will go—each of them were

slightly different, so I will start with the mental health one. I had

made a commitment to my mental health colleagues nationally as

well that we needed to move to mental health as an agenda item.

As you know, my colleague, David Satcher, first identified some

of the issues, and as I took the baton from him, I knew I needed

to continue moving in the direction based on some of the information he had already generated, mental health was one. Mental

health preparedness was extraordinarily important because of——

Ms. NORTON. I am trying to find out, you don’t go to the President and say I want to do a mental health and emergency preparedness. Who do you go to?

Dr. CARMONA. Yes, ma’am. What I did was independently I

looked at the science, and the first call I made was to my colleagues at the National Institutes of Health to say, guys, let’s have

a meeting, I walk to talk to you about the mental health needs of

the country, specifically as it relates to the new threats and challenges of mental health preparedness as a working title.

I got the best scientists in the world together. We had the discussion, everybody agreed that this was a huge void in our society,

and we needed to move this forward. I generated the evidence base

to move such a report to the American public. I went to other agencies, I brought in one of our sister agencies who had a political appointee who basically went to HHS, went to the White House, and

complained vehemently that this was not my responsibility, that he

was in charge of mental health.

In fact, I was admonished by this gentleman because he said, you

don’t get it. He said, you don’t write anything unless we approve

it and that this information——

Ms. NORTON. On the mental health report, not only were you refused, you were admonished. Before my time is up——

Dr. CARMONA. Yes.

Ms. NORTON. Would you tell me about the report on emergency

preparedness?

Dr. CARMONA. Emergency preparedness, from what I have seen

and based on a report I brought my colleagues in to achieve consensus, I mean government and people who have national reputations, credibility, nonpartisan to achieve consensus, everybody had

agreed it was absolutely essential to move forward.

I then ran it up the flag pole and went to the domestic policy

council at the White House, spoke to HHS officials, I was given lots

of different reasons. This might scare the people, you should think

about it. The new Department of Homeland Security will be responsible and why would the Surgeon General do this? I was given

lots of reasons, from the cost to everything else, not to move this

forward.

Ms. NORTON. Who at the White House was responsible that told

you that the emergency preparedness should not move forward?

54

Dr. CARMONA. I was speaking to the Domestic Policy Council just

then. I mean if you want those names in the future, I would be

happy to do it. Since some of these people still work in the government, I ask that we do this through private communication or a

closed hearing because I don’t want to put anyone in jeopardy.

Ms. NORTON. I respect this request, but this is a public hearing,

it is going to become public in any case, because we believe in

transparency, and I leave it up to the chairman as to how to handle

that.

Dr. CARMONA. Thank you.

Chairman WAXMAN. We will take it under advisement and hear

from Mr. Issa.

Mr. ISSA. Thank you, Mr. Chairman. Dr. Carmona, I feel that

perhaps what you are telling us here today is that we need to cut

by 75 percent the number of political appointees we authorize the

President to make so that a few people have more things to do

than have turf battles. We will take that under advisement.

Dr. Koop, during your administration how large was your budget

and how large was your direct report staff, the people you could

count on directly that were allocated to you?

Dr. KOOP. I had no budget. As far as my staff was concerned I

had the privilege and ability to call upon 6,000 members of the

Commission Corps, all of whom occupy special niches and very special kind of training, and this is one the gems of our government

because I don’t know any place where there are that many experts

that can be called upon by the government in reference to health

as we have here.

Mr. ISSA. General Koop, if I hear you directly, what you are saying is because you were appointed by the President uniquely, not

because you have been brought up through a system, you felt it appropriate enough that you could call on just about anybody and

they would return your calls.

Dr. KOOP. In general.

Mr. ISSA. So this position is to a great extent what you make of

it, isn’t it?

Dr. KOOP. Well, I tried to point out that who the President is,

and who the Secretary of HHS is, makes a real difference. The

third person that makes a difference is the Surgeon General himself. I was accused of not being a team player. I was denied a position I wanted very much by senior George Bush. I felt after 8 years

as Surgeon General I could hit the ground running as Secretary of

HHS, but I was considered not to be a team player and therefore

not suitable to do this.

I would like to step a little bit wider than your question and

please tell you what I hear going on here. I would think you committee members would think these three Surgeon Generals have a

touch of paranoia. It sounds like——

Mr. ISSA. That is common in Washington.

Dr. KOOP. Yeah, but the thing is, I thought of writing a book one

time, the title of which would have been ‘‘They and Them,’’ because

I don’t know who all these people are who interfere with the Surgeon General. I really don’t know who they are, we call them ‘‘they’’

and we call them ‘‘them,’’ but I never know who they are, but they

do step in.

55

You notice that I went to the extent in my prepared remarks of

telling you how Otis Bowen and I kept the report on AIDS essentially secret. The reason for that is there is such a thing called a

Secretariat of the HHS Department and if you were to—thank

you—if you were to submit the report such as I wrote on AIDS,

which is very plain speaking, it wouldn’t have been out of there yet

in those 12 years. And I don’t know who ‘‘they’’ were. I don’t think

you could find out who they were, but they and them are the people that my colleagues are talking about, and it is not paranoia.

If I could go back to what Dr. Carmona was saying about the

stem cells or take the thing that is in the papers this morning

about insurance for children’s health, the science, of the need of

children in this country for health plans because of the poverty

level at which they live; that science is absolutely irrefutable. Anybody who knows anything about children thinks it is a marvelous

idea. No matter how you have to pay for it, our children deserve

that.

And then today, the newspapers carry word that the President

has decided he would not support that. Well, what is the Surgeon

General’s role in that particular picture? Here is what I think it

should be. I don’t think he should have made a statement about

whether he is going to support it or not, until he had met with the

people in government who know the most about children health

needs and about their poverty status, and that would include the

Surgeon General. And it is not asking the Surgeon General to

make policy, but asking that the Surgeon General from a big bunch

of expertise and the contacts that you said, everybody would call

on the phone, answers you, they do, they support the Surgeon General, then, at least the White House or the people who make decisions about what bills are going to go through and what are not

have the advantage of that kind of expertise. And ‘‘they’’ and

‘‘them’’ are sort of overridden in the process. And then all the way

down the chain, until that bill comes before Congress and is voted

upon or is turned down by the President or is vetoed.

The Surgeon General should be, as I call it, a cog in the machinery that decides about the health and the well-being of the American people. It is part of what he knows, it is part of what he does

best, and it is not changing policy. But——

Mr. ISSA. Thank you.

Dr. KOOP. Hmm?

Mr. ISSA. I apologize. I love the answer and I would like to get

one more question in. I promise, I know the chairman’s indulgence

has to be limited to hear a lot of other people.

In my opening statement I said that I wanted to take advantage

of the opportunity of the three of you here to deal with one thing

I haven’t seen come out of your offices over your time, and that is

an overall statement on why America spends per capita 50 percent

more in health, public and private, insurance and noninsurance,

emergency room and nonemergency room and in fact we don’t have

the highest life expectancy, we don’t have the lowest infant mortality, we don’t have a people who are nearly as satisfied or feel comfortable sleeping that they are not going to have their homes taken

away because of the high cost of an emergency event. Can you—

I know there is a limited amount of time for what you all can look

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at during your tenures, but why is it that is not something that we

would hear Surgeon Generals talking about, taking on, if you will,

about the large amount of health care costs that ultimately make

America be first in cost and nowhere close to first in performance?

Dr. KOOP. I don’t want to sound disrespectful, but you are not

reading the right stuff and you are not listening to the right people

because I have been talking about that since I was a Surgeon General. And on the Internet right now, I have 970 lectures on the profiles and science Web site of the National Library of Medicine,

about half of which address all of the questions you have asked. It

is a huge problem and it has taken us years to get into this mess,

and it is going to take us years to get out of this mess unless some

big surprise comes along or a catastrophe, and either one of those

could very well be in the offing. I could go on and talk to you about

these individual things, but it would take hours.

Dr. SATCHER. I understand your question. I spoke about and continue to speak about this issue and published about it extensively.

But, your point is interesting, because the Surgeon General is not

a policymaker. When President Truman introduced the national

health insurance, they wanted Surgeon General Shiley, I believe,

to debate it on TV, and he refused. He said, this was not an appropriate role for the Surgeon General. Once the Surgeon General gets

involved in policymaking, I think you are interfering with the role

of Congress and the President.

But, I do think it is important for the Surgeon General, as Dr.

Koop said, to make sure the people understand what is happening

in the health care system, the fact that it is inefficient, and I participated in the WHO report showing the inefficiency of our health

system. And when the program was first passed, we had done a lot

of background work in terms of the plight of children in this country. Ultimately when it comes to introducing policy and discussing

policy, beyond the science—behind it I think we are limited.

Chairman WAXMAN. Well, we have other Members who have

questions. We will have to allow those to stand as a response to

a question. I know we could use at least another five hearings.

Mr. Sarbanes.

Mr. SARBANES. Thank you, Mr. Chairman.

I wanted to get a better sense of the political interference issue

that Carmona, that you have referred to and we have had some

questions about already, because we have had other testimony in

this committee recently with regard to other agencies where there

appears to be this kind of political interference. In particular, we

had two hearings about how the General Services Administration,

very high level people, and including, it appears to us, the head of

GSA, Lurita Doan, was involved in meetings that were really political meetings that were arranged by the White House and others to

advance the fortunes of Republican candidates. I am trying to get

a sense of whether that sort of activity exists in other places, and

I would like to get any input from you.

So the question is were there any meetings that you were asked

to participate in, or other sources of political activities that you

would characterize as political and, if so, what were they?

Dr. CARMONA. I recall during my tenure that from time to time

we would receive invitations, sometimes they were called mandaVerDate 11-MAY-2000 13:35 Apr 24, 2008 Jkt 000000 PO 00000 Frm 00060 Fmt 6633 Sfmt 6633 C:\DOCS\40151.TXT HGOVREF1 PsN: HGOVREF1
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tory meetings of, ‘‘political appointees.’’ This was sometimes at

HHS, sometimes they were at EOB, every once in a while someplace else at some type of an event. I went to a couple of those initially, but I recall early on that I recognized that these were really

more political pep rallies, high-level political appointees within government who were, all, trying to rally the troops.

Mr. SARBANES. Who was housing these, where were the invitations to these meetings——

Dr. CARMONA. Sometimes they were e-mails or just memos in

your mail to political appointees. There would be a brown bag

lunch at this location, and maybe a senior political official officiating. I went to a couple of those, as I said, and I found most of the

time that the discussions were about political issues of which the

Surgeon General really had nothing to do with. So I stopped going

to them, to be honest with you, because I was not really feeling I

was representing the office well in that.

There were times when I was invited to political events to speak

and I felt that this was an ethical violation. I am an Admiral and

shouldn’t be at a political event supporting any political party because I am in uniform, and so I took a pretty firm line with my

colleagues that our job is not to engage in political rhetoric supporting any party or any candidate. The Surgeon General’s job is

apolitical. And as soon as you start attending meetings like that,

start supporting political policies, candidates, you become less effective as a Surgeon General, you are looked at as being partisan.

It has never happened. I think the beauty of what you see here.

You have three Surgeon Generals who have served in the most liberal and most conservative administrations, and yet we are all telling you the same thing about what needs to be done, the partisanship and the problems we have all experienced.

Mr. SARBANES. The few meetings that you did attend, who were

some of the senior officials that were presiding at those meetings?

Dr. CARMONA. As a matter of common courtesy, I have spoken to

the staff and said I am happy to provide you with the information

but I am very sensitive to the fact that one, some of these people

are still working; two, retribution does occur in government; three,

I don’t want this to become a ‘‘he said, she said’’ issue.

The three of us are up here because there are systematic infrastructure problems. The name game and finger pointing goes back

and forth all the time. We feel, really need, we need to get above

that. This is about fixing an infrastructure.

Mr. SARBANES. The description of the Surgeon General as America’s doctor I think is a very admirable one. To carry an analogy,

if I go to my doctor and the doctor comes in the room and has a

report in front of him from the lab and they want to tell me the

contents of that report but somebody’s muzzling them so that I am

not getting the real story, I am going to be outraged. And America

ought to be outraged that when it goes to its doctor, the Surgeon

General, he is not able to give them the truth about the health status of the nation.

Dr. CARMONA. Mr. Sarbanes—yes.

Mr. SARBANES. I am curious whether ideology is driving the suppression of science, or is it politics? Because if it is ideology, as

troubling as that could be, someone could have the attitude well,

58

we elected this President, he has a certain belief system and that

flows down through the demands of government. And I say that

would be troubling but one can understand it at a certain level.

But much of what I describe is that it is politics. It is almost as

if there is a perrenial campaign underway that at no point somebody decided that now that we are elected, we have to actually govern. Instead we sacrifice the health of children, the health of HIV

victims, etc., we are willing to sacrifice all of that for political ends.

I am out of time. If you could touch on the relative weight in this

suppression campaign, as I will call it, of ideology versus politics

or political agenda.

Dr. CARMONA. Thanks for your question. I believe it is all of the

above. In my opinion, there is a political driver, there is preconceived political agendas already there that fly in the face of

good science and they don’t want these three Surgeons General

here to speak out on the science because it will complicate their life

in trying to move a certain agenda.

There are also ideological and theological agendas—abortions,

Plan B, stem cells—that drive a particular theological construct

that leads somebody to a policy, yet the science hasn’t been heard.

As Surgeon General Satcher said, what we are hearing here is

that we should never, ever—our citizens should be outraged—that

three Surgeon Generals were marginalized and had to fight to get

the information out to them. I used to use that analogy with people. I said when you go to a doctor, do you pick your doctor based

on what political party that he belongs to? They say no. You don’t

want Republican or Democratic information; you want real scientific information, and that is our job to bring it forward. I would

say it was all of those are barriers that we faced.

Mr. SARBANES. Thank you.

Chairman WAXMAN. Thank you, Mr. Sarbanes.

Dr. Carmona, we heard that the Office of Political Affairs, or

Public Affairs, headed by Karl Rove, gave the political briefing. We

heard about this Office of Public Affairs headed by Karl Rove giving the briefings, staff of the office giving the briefing?

Dr. CARMONA. There were communications from his office and

his staff during my tenure, and at times staff from those offices

were giving briefings.

Chairman WAXMAN. Ms. Watson.

Ms. WATSON. I just have to make this statement. This is probably the finest collection of integrity and scientific knowledge sitting in front of us that I have heard since I have been on this committee, and I want to thank you three gentleman.

I also want to thank the Chair, who I served with in the California Legislature, and I remember him standing alone, here in Congress, with the executives of tobacco companies having them raise

their hands and asking them the key question whether they

thought that tobacco was harmful to one’s health and could cause

cancer. And he stayed on that issue until finally the world is recognizing his work.

But Dr. Koop, you were the Surgeon General when I was

chairing Health and Human Services in the California Senate. I

admired you for speaking out about AIDS, and I thought wow,

what a risk you were taking under that current administration at

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that time, but you stood strong and because of that I worked on

needle exchange. It took me 8 years. I was taken on by the clergy

and everyone else because they thought I was promoting drug use.

Dr. Satcher, thank you for the years that we worked together

and you produced the report on the diversity in health care, and

we still use that today in trying to improve the health care delivery

system in the State of California. I hope as a result of this hearing

we can start addressing the real needs of public health.

Dr. Carmona, I admire you, I look at the three of you. You represent the fabric of the United States, each ethic group and the

majority group, and I thank you for your service.

We will quickly, as you are trying to present to this country and

the world the global report on health care, the emergence of avian

flu, SARS and the extremely drug resistant TB, and you have illustrated why public health threats respect no international borders.

And it should never get political. Health is not a political issue. We

have to understand that. And I don’t care if you are sitting on this

side or you are sitting on that side.

And in trying to get that word out that in your report on public

health, some way it was stymied, I respect the fact you are not

going to point fingers, but do you know where the report is today?

And Mr. Chairman, we need to obtain this report and in some

way we need to make it public so that the general public and those

who watch everything we do here in the United States can change

behavior. We talk about Homeland Security, this is not about the

land, it is about the people who live on the land. When attorney

Speaker left the United States to get married and was carrying a

virus that we thought could contaminate the rest of the world, it

got top publicity across all networks, in the newspapers and so on.

And we need to know threats to our health.

To you, Dr. Carmona, I just want to say how proud we are of the

work you did under adverse circumstances, and can you comment

about that report, where it is and, Mr. Chairman I hope we can obtain it.

Dr. CARMONA. Madam Congresswoman, thank you. That was a

report that was very near and dear to my heart. We spent over a

year working on this global health report; Surgeon General’s call

to action on global health. That is what we were doing. To do that,

I assembled the best minds in the world on health, NIH, CDC and

many other agencies and nongovernmental professors from around

the country who are preeminent in the field, to get the best science

to give to the public because we recognize our village is now global.

The threats and challenges we have do not respect the geopolitical

borders that we have. And we have to start thinking bigger, whether it is AIDS or SARS or any of the other challenges that people

read about.

We are very proud of this draft report. Unfortunately, when we

began the political vetting process, I was called in and admonished

for this report by a senior official that said you don’t get it. He said

to me, this report has to reflect American policy. And what he

meant was that they actually counted how many times that I did

not have the President’s name and other people’s names in the report. I said that is not my job. I said I will help you write a compendium report on policy for the U.S. Government. This is on a reVerDate 11-MAY-2000 13:35 Apr 24, 2008 Jkt 000000 PO 00000 Frm 00063 Fmt 6633 Sfmt 6633 C:\DOCS\40151.TXT HGOVREF1 PsN: HGOVREF1
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port the science of global health. We spoke of all the topics at

length. And it was blocked repeatedly from getting into the vetting

process because of a senior official telling me that this will be a political document or it will not be released. I said it can’t be a political document because I am the Surgeon General never releases political documents. I will release a scientific document that helps our

elected officials and citizens understand the complex world we live

in and what their responsibilities are.

I fought for my last year to try and get it out and couldn’t get

it past this initial vetting. They were clear, there was no nebulousness about it, this will be a political document or you will not release it, and I refused to release it. Because I would not put the

political rhetoric into that document that they wanted, because it

would tarnish the Office of the Surgeon General when our colleagues saw us to take a political stand, so I refused.

The document is still in draft form. My colleagues are encouraging me to still release it. I just entered into the private sector and

am looking at ways to do that, but there is a great deal of concern

and empowerment to me to move ahead with this report. It still

needs a little bit of work, mind you, it is still in a draft form, but

the essence of the report is there.

Ms. WATSON. Mr. Chairman, thank you for the time. Could we

obtain that report under the auspices of this committee?

Chairman WAXMAN. We will see if we can obtain that report

from Dr. Carmona.

Mr. Yarmuth.

Mr. YARMUTH. Thank you, Mr. Chairman. I thank the gentleman

for his testimony.

I might suggest I certainly respect everyone’s desire and I agree

with everyone’s desire for independence for the Surgeon General.

Since we learned over the last few weeks apparently Mr. Cheney

considers himself a separate branch of government, maybe we can

create our own independent branch for Surgeon Generals.

I do want to talk about accountability. I think all of us believe

that nobody in government, most of us do anyway, is unaccountable. What do you think the appropriate accountability system

should be for the Surgeon General’s position? I know the current

nominee, Dr. Holsinger, some 15 years ago wrote a paper suggesting that gays could be cured. I suspect that if a Surgeon General

took that position there would be those who would take issue with

that.

So where do you think the Surgeon General’s accountability

should be placed? Anyone can answer.

Dr. SATCHER. I would say that when it comes to reports or positions taken by the Surgeon General, the Surgeon General is accountable for the best available science. and that is why the reports

need to be vetted by the scientists, the appropriate scientists at

NIH and CDC.

I said before, if the Surgeon General is speaking based on his

own opinion without the science, then I don’t think the Surgeon

General deserves any more recognition for that than anybody else.

But I think when the Surgeon General speaks to the American people based on the best available public health science, he deserves

that recognition.

61

I issued this Surgeon General’s prescription in 1999. I actually

issued it at an international meeting of ministers of health from

189 countries. It is a prescription for the American people that

talks about physical activity on a regular basis, eating five servings

of fruits and vegetables, avoidance of toxins like tobacco, responsible sexual behavior, and daily participation in a relaxing act.

Every one of these statements were based on research done at

CDC and NIH. We could point to the literature as to why we knew

that regular physical activity could reduce cardiovascular disease

in adults by 50 percent; reduce the onset of type II diabetes by

more than 60 percent.

So as long as the Surgeon General is speaking on the best available science, then I think that is accountability—to the best available science.

Mr. YARMUTH. Dr. Carmona, we have heard a number of instances in which you and the other Surgeons General have been

prohibited from speaking out on things you thought were important. Are there instances in which you were actually asked to do

something you did not want to do in terms of pursuing a political

agenda on behalf of the White House?

Dr. CARMONA. There were times when I was invited to meetings

or had discussions where I guess people were testing the waters.

On abstinence, abstinence only, I remember that in all of my presentations, I never wavered, based on the best science that Surgeon

Koop had spoke about, that it was clear we needed a more comprehensive program of sexual education in the United States that

would include abstinence, but not be exclusively about abstinence.

People weren’t happy about that. I think they saw that I was going

to be true to the science and that was challenging.

When global warming came up, it was my first year. And I was

naive enough listening to the discussion at this office with senior

officials, where they were heralding global warming to be nothing

to be more than a liberal cause, and had no merit, and they were

kind of dismissing it. And I remember thinking oh, I understand

why they want me here, they want me to discuss the science, obviously they didn’t understand the science. I had this discussion for

half an hour and I was never invited back to the meeting.

There were a number of anecdotes like that over the years where

the water was tested and I was asked certain things at meeting,

things were put into my speeches. In fact, I had two speechwriters

quit because they were so intimidated and browbeaten by political

officials. We would play this game the day before a talk. I told the

staff, let them put in whatever they want, I will not say it anyway.

Eventually, the people left the employ there because they were

really in an embattled position, and people were trying to get to the

Surgeon General through them.

Mr. YARMUTH. Were you ever told to mention a President a certain number of times, were you promoting him specifically?

Dr. CARMONA. In fact, in my first year, clearly, I was told a number of times that the President’s name was not mentioned in a

speech. I was told it should be mentioned, at one point, at least

three times on every page. I said, I am not going to do that. I said

I will mention any politician when appropriate, if they are involved

in a scientific endeavor, but my job is not to sell politics.

62

The speechwriter will tell you they fought that battle every day,

I would tell them what I wanted in the speech, he provided it back

to me and it would be vetted, and I didn’t know this was happening

and they were being admonished for not putting certain politicians’

names in or political phrases in that I subsequently took out because I said this has nothing do with public health science and I

will not say those things.

Mr. YARMUTH. Thank you very much.

Chairman WAXMAN. Thank you, Mr. Yarmuth. For our second

round I want to recognize Representative Norton.

Ms. NORTON. I appreciate the opportunity to ask this question at

this time. This is based on Dr. Carmona’s testimony and my own

interest in the structure of government. I have been trying to rack

my brain to think of a way to have a truly independent Surgeon

General. I think it is very difficult to come up with a way in our

system of government. The only truly independent people I know

sit on the Supreme Court, and the President can’t get to them.

I noticed you took a stab at this, Dr. Carmona. You indicated

that what turns out to be quite something of a pretense, you don’t

use those words, of a four-star admiral maybe out to balance that.

It looks like you go back to kind of a militarized example. I understand where it came from, historically that the Corps could be militarized.

But you say on page 7 of your testimony I think in an attempt

to get independence, that the Surgeon General could be nominated

by the President from the ranks of career public health officers

based on merit, without political ideology or theological filters.

Then you say that just as the U.S. Army, they are selected that

way.

Again, let me indicate, I wonder if we should do that. What impresses us, we have very distinguished physicians. I don’t mean to

imply they don’t come out of the Public Health Service as well, but

if an eminent physician from practice or academia becomes Surgeon General, doesn’t that bring to the office such value added that

we wouldn’t want to exclude such eminent candidates for the office?

I would like your opinions on how to make it more independent

and whether or not going to a narrower group of physicians would

really serve the larger purposes of the Office of Surgeon General?

Dr. SATCHER. Let me speak before Dr. Carmona. This is one

issue we don’t totally agree, the idea of excluding a whole group

of people based on the fact they are not in the Commission Corps.

I like the process of a group getting nominated based in part on

service in Commission Corps, but saying you are not nominated if

you are not in the Commission Corps, then Surgeon General Koop

would never have been Surgeon General.

So I have some difficulty with that. I think ultimately the President should name a person and recognize, as you do with the Supreme Court justices, how that profession feels about that person’s

capabilities and qualifications, but I basically agree with the process being as Dr. Koop described it, but not necessarily with the limitations.

Dr. CARMONA. I think we all agree with the process. The reason

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sion Corps officers that would come up through the ranks, was if

you look just at these officers right here, these represent the finest

doctors, nurses, scientists in the world right here. When the Army,

Nave, Air Force promote a Surgeon General, they are professional

officers who come up through the ranks.

Ms. NORTON. They are not practicing medicine as Surgeon General, they have only themselves, their word, their eminence and, by

again casting no aspersion on this extraordinary corps, one wonders why the only way to accomplish this is to narrow the pool. Dr.

Koop, I would like your view on this as well?

Dr. CARMONA. Ma’am, may I finish?

Ms. NORTON. Yes.

Dr. CARMONA. We all agree on the process. The reason I am looking to stay within the Commission Corps is that you have professional uniformed officers, just like the Army, Navy and Air Force,

and I am open to the discussion. I brought forth an idea that says

I think this would work to depoliticize the process. These are professional uniformed officers. The President of the United States

nominates the Army, Navy and Air Force Surgeon Generals from

the ranks and then they are confirmed by the Senate.

Ms. NORTON. One wonders if that depoliticizes.

Dr. CARMONA. Well, granted——

Ms. NORTON. One wonders if the officer in Iraq are depoliticized,

whether the Supreme Court justices are depoliticized. So I understand, I am simply trying to say of the ways of doing it, would we

want to sacrifice something that is important, since this man

doesn’t do anything but speak, and whether he has credibility?

Dr. CARMONA. Thank you.

Dr. KOOP. Even if you have concerns about the manner in which

I outlined it, if you look at the people who were in the Commission

Corps at the time I was appointed, there were already 55 Assistant

Surgeon Generals. If you look at some of those people, they have

turned out to be the best public health voices we have had in the

country, in the private sector and some within government.

I don’t think, even though my plan would eliminate me as a candidate for Surgeon General, you would always get good people. But

there are is one other thing, if it were known, that you could enter

the Commission Corps of the U.S. Public Health Service with the

eventual possibility of working as a Surgeon General, you would attract better and better and better people to the Corps.

Chairman WAXMAN. Thank you very much.

Ms. Watson.

Ms. WATSON. Thank you so much. I am just going to throw out

these questions to the panel and after I do that, I would like Dr.

Satcher to talk about your oral health report, and I have a bill

right now in the process to remove the dental amalgams that have

mercury. And I see the mercury as the basis for poor dental health

and poor systemic health, so I would like you at the end to comment on that.

I would like to ask all three of you how can we improve the Surgeon General’s position, should we lengthen the term time that you

serve? How do we make you independent? And what about budget?

I think all of you have hit on it a bit in your presentations, but

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I would like you to outline what you would do to improve the position, starting with you, Dr. Koop, please. Dr. Koop.

Dr. KOOP. Well, I have outlined the manner in which the person

is chosen, I think that is essential, I have talked about independence, I have talked about being apolitical. And then I have also

suggested that the expertise of the Surgeon General be used in an

advisory capacity at every level of discussion of an issue that eventually will become a legislative problem and eventually acted upon

by the Congress of the United States. That is the way that I think

the Surgeon General can be in on what is being discussed. It keeps

them out of policymaking, but it gives the President and the White

House and it gives the Secretary of HHS and that Department the

benefit of his expertise.

And as I think all of us have said either directly or indirectly,

the respect in which the Surgeon General is held by other people

that we have been talking about, our colleagues abroad and the

private sector in this country, there is almost nothing that a Surgeon General asks that he can’t get in the way of advice and help.

Ms. WATSON. Thank you so much.

Dr. Carmona.

Dr. CARMONA. Thank you. I would like to echo what Surgeon

General Koop has already said and wht is in my remarks about

independence. I think our government should not only fund and

empower and support, but I think the citizens should demand

transparency and honesty in all scientific communications because

this is the doctor of the Nation, and in fact, as you have heard from

the three of us, the rest of the world looks to the Surgeon General

for honest governmental, scientific communication, which is distinctly different from many of the other countries.

One thing I think is important to consider, politicians often publicly shy away from hot button, partisan, scientific issues. For

whatever reason, it really doesn’t really make a difference. I think

that we would all agree that allowing the Surgeon General to be

the lightning rod on these issues and move forward in a nonpartisan, apoiltical way, based on science, actually helps to insulate

politicians who don’t want to talk about abortions or stem cells or

Plan B, or something that tends to polarize people, left or right.

And I think the Surgeon General is driving something forward

the best science. I think the Surgeon General, driving some of

these discussions based on the best science, would actually help in

a nonpartisan way all political persons because they don’t have to

take the heat. It is the Surgeon General who said this.

Ultimately though, with a better informed public, we can improve health literacy for the public and elected officials, better policy moves forward less painfully for some politicians, because it is

the Surgeon General out there who is speaking as the doctor of the

Nation just as they would speak to you individually about very personal issues that could also be polarizing.

I think that is another added advantage, to add on to what Surgeon Koop said and what General Satcher is going to say. I think

the beauty of what we are saying here is that we speak as one.

Three Surgeon Generals serving over very liberal and conservative

administrations, all came to the same conclusion about the dignity

of the office. It’s about the importance of representing the AmerVerDate 11-MAY-2000 13:35 Apr 24, 2008 Jkt 000000 PO 00000 Frm 00068 Fmt 6633 Sfmt 6633 C:\DOCS\40151.TXT HGOVREF1 PsN: HGOVREF1
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ican people and not a political party. And we hope to make it easier

for those who walk in our footsteps in the future to better represent the American public.

Dr. SATCHER. I want to begin by briefly saying what I say to students all over this country, whether it is in commencement addresses, or in high school. I would trade nothing for the opportunity which I had to serve in government, I would trade nothing.

As Director of the CDC, as Surgeon General, as Assistant Secretary

for Health. I came from the cotton fields of Alabama. Neither of my

parents finished elementary school. The fact you can rise in this

country to the position of Surgeon General says a lot about the

strengths of our Nation.

I believe that the Surgeon General’s office is too important to

allow it to be politicized. I think the World Health Organization,

while I was serving, ranked the United States number 37 in the

world in terms of our health system. Despite the fact that we spend

twice as much money as the next country’s level of expenditures

and we have 45 million people uninsured, we still rank number 37.

The only area in which I think in the world who would rank us

No. 1 would be the Office of Surgeon General. When China got

ready to look at the issue of tobacco, the invited me as Surgeon

General to come and advise them, and that’s happened over and

over again. I believe it is important to maintain the integrity of the

Office of the Surgeon General. I would say two things, No. 1, the

budget, I believe Congress ought to insist that the Surgeon General’s office has its own budget—and I say this as one who was Assistant Secretary of Health and Surgeon General, so I reported to

myself as Surgeon General and if I hadn’t of course I wouldn’t have

any money. That is where I got the money, and that should not be

the case. The Surgeon General should be independent and have his

or her own budget and be able to speak independently to the American people.

You asked me about oral health. I will be very brief. I issued the

Surgeon General’s report of oral health in the year 2000. We tried

to do a few things. No. 1, we tried to point out the magnitude of

the oral health problem in this country. The fact that still 30 percent of people over 65 in this country are edentulous, that children

miss 57 million hours of school every year because of tooth decay,

while there may be 46 million Americans are uninsured for medical

care there are 108 million who don’t have dental insurance. We

talked about how oral health is a major part of overall part of

health and well-being and needs to be treated that way. Oral

health problems can be associated with cardiovascular disease and

diabetes. We tried to point all of that out based on the current research and we talked about the importance of fluoridation in water.

We didn’t talk about Mercury, and this is important point. We

didn’t feel that science at that point related to mercury and health

was adequate for the Surgeon General to take a position. We don’t

take positions on issues that are not clear. If they are not clear,

we say they are not clear. And that is why you did not see a

stronger statement in that report about mercury.

I must say of all the reports that I have issued, I am very

pleased with what happened with the results of that report. I think

the Johnson Foundation funded 19 dental schools to provide health

66

care to poor children, boys clubs and things like that. Many children are now getting dental care because of that report and what

has happened afterwards. That is a very important report, like so

many of the reports we have issued.

Chairman WAXMAN. Thank you very much, Ms. Watson.

Let me conclude the questioning. Dr. Carmona, you talked about

the areas where you had some interference, but one of the jobs of

the Surgeon General is to go out and talk to groups, communicate

at the local and State level, talk to different groups who are like

minded or suffering from diseases. Were you prevented from traveling to speak to groups that you thought you wanted to visit and

talk to?

Dr. CARMONA. Yes, that occurred several, many times actually

over the years, and it was because people were politically vetting

decisions I made to go before groups based on science and the

needs of the citizens, versus a political need. As Surgeon General

Satcher has mentioned, he might have had it a little easier—I was

Assistant Secretary for a while as well as Surgeon General, and we

both came to the same conclusions, it is hard to do both jobs, because the government expects you as Assistant Secretary to be a

politician and so you are constantly switching hats. This is very difficult to do. Dave and I both did the same thing. We said we are

doctors first, we are Surgeons General. I can’t do the political part,

which often doesn’t make politicians very happy. It gave David

more budget discretion, because he could control his own office.

There were a couple of issues, I can give you some examples. As

you know, I issued a Surgeon General’s call to action, the first on

the health of people with disabilities. I was looking at the GAP

analysis to see where I could add to the great body of evidence. I

saw the issue of disability in children’s health and we started to

have some discussions with Special Olympics and Best Buddies and

a number of organizations that deal with the health of the disabled

children. And the Special Olympics was coming up. I was asked if

I would come to Japan and give the opening keynote address and

discuss the health of disabled athletes which had been

marginalized. I thought this was a perfect forum globally. I was

told I couldn’t do it. There was no reason given other than it was

kind of expensive to go over there. But there were times I was

asked to speak to groups I wasn’t sure I should be at where budget

was not an issue.

Chairman WAXMAN. Give me an example of that.

Dr. CARMONA. Group, political gatherings, political gatherings

where they wanted to have the Surgeon General there to say some

things about programs that parties were moving forward and——

Chairman WAXMAN. Were these in districts of vulnerable Republicans?

Dr. CARMONA. Sometimes that was the case, yes, sometimes that

was the case to talk about a program or a particular issue for the

benefit of some elected official. Yes, that happened.

Chairman WAXMAN. You were told you couldn’t make a decision

to go speak to the Special Olympics but you were never given a

reason why you couldn’t, but then you were told there was money

to go and speak to somewhat politicalized——

67

Dr. CARMONA. The Special Olympics one was an egregious one.

Ultimately, another group, the Best Buddies program, which deals

with physical activities for intellectually disabled children. I

thought that was some place we should be speaking out on to prevent the marginalization and it addresses health disparities as

well. So I put in my paperwork to go to this meeting to give the

Keynote address and actually ride a bike with a disabled child, and

hoped to bring some light to this problem in our Nation. I was admonished for doing that.

The reason I was admonished for doing that. Unfortunately, I

was told that I would be helping a politically prominent family who

this is one of their endeavors, and why would I want to help those

people? And I said I don’t even know—I am not going it mention

names now. I remember responding, this is about sick kids. It has

nothing do with who is moving the project. So in effect I was told

I cannot travel, my travel orders were canceled. I took a weekend

vacation and paid for it myself because I was committed to the

group.

Chairman WAXMAN. At what level were you told you couldn’t go

to the Special Olympics?

Dr. CARMONA. These were highly appointed officials in the Department, yes, in the Department.

Chairman WAXMAN. You were told that they wanted you to act

as a surrogate to go and speak in districts where you could act on

behalf of the Republican cause; is that correct?

Dr. CARMONA. That happened at times, yes.

Chairman WAXMAN. There they didn’t have a problem with

money?

Dr. CARMONA. It didn’t seem so.

Chairman WAXMAN. Well, I just have to say, Dr. Carmona, I find

the political interference with you doing your job astonishing. It

was difficult enough for Dr. Koop and Dr. Satcher, but it really is

distressing that you had such much more interference in what you

were trying to do. You testified you were prevented from speaking

on stem cells, abstinence education, and Plan B emergency contraception; is that correct?

Dr. CARMONA. That is correct.

Chairman WAXMAN. You testified you were prohibited from preparing reports on mental health preparedness and emergency preparedness; is that correct?

Dr. CARMONA. And global health.

Chairman WAXMAN. You testified you couldn’t release the report

on global health.

Dr. CARMONA. Correct.

Chairman WAXMAN. You testified that your report on the dangers of secondhand smoke was delayed for years while you fought

efforts to weaken your science-based findings; is that correct?

Dr. CARMONA. That is correct, and I was not aware of it at the

time. I did not find out about the scientific assaults until later on,

because the staff was trying to protect me. It wasn’t until very late

in the game that I found out that they were fighting the rewording

of certain paragraphs and things like that, fighting their own battles, if you will, for scientific integrity.

68

Chairman WAXMAN. You testified that you were even directed to

attend White House political briefings about the best interests of

the Republican Party and its candidates, is that right?

Dr. CARMONA. Let me clarify. I can’t say there were White

House, but there were memos from senior political officials who

brought people together to discuss things. The couple I went to,

clearly they were discussing political issues and you know, elections getting people out. Pep rallies I would call them. Political pep

rallies.

Chairman WAXMAN. This wasn’t from the Department, it was beyond the Department?

Dr. CARMONA. Yes, yes. Sometimes the meetings took place at

the Department, sometimes they were off in other buildings.

Chairman WAXMAN. And people would come and talk about, give

a list of the key races for the Republicans?

Dr. CARMONA. You know, I can’t say key races, but certainly talking about getting our word out, political agendas, things like that,

which really the Surgeon General should have nothing to do with.

Because it undermines the credibility of the office. Because it undermines the integrity and dignity of the office. The Surgeon General is not involved in day-to-day politics. That is not our job.

Chairman WAXMAN. Did Karl Rove attend any of those meetings?

Dr. CARMONA. I can only remember one where I saw him. There

were other staffers up and down, at different levels of government

that would come and speak, at brown bag lunches, meetings, things

like that. Honestly, I didn’t pay too much attention. After the first

few, I recognized it was really something the Surgeon General

shouldn’t be at or involved in.

Chairman WAXMAN. And you didn’t take any grief and not go to

any future meetings, did you.

Dr. CARMONA. Not grief. In fact, I made sure I was busy during

those times.

Chairman WAXMAN. Well, I thank you for your being forthright

and talking to our committee and the American public about this

issue. I hope the testimony of you, Dr. Koop and Dr. Satcher will

help us clarify that this is an important position that we shouldn’t

allow to be marginalized. We shouldn’t allow the Surgeon General

to be politicized as the doctor to the Nation. That person needs to

have credibility, independence and to speak about science. I think

that is so important.

I thank you all very much for your testimony today. That concludes our hearing, and the committee stands adjourned.

[Whereupon, at 12:10 p.m., the committee was adjourned.]

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