The rise and fall of the nation's doctor

![Figure][1] In lectures to medical and public health professionals, I often ask audiences if they can identify the current U.S. surgeon general. Typically, few know the answer (the current acting surgeon general is Rear Admiral Boris Lushniak). If the surgeon general is the trusted voice on health—the “nation's doctor”—how can he be unknown to a room full of physicians and other medical professionals? ![Figure][1] PHOTO: FEVERPITCHED/[ISTOCKPHOTO.COM][2] Journalist Mike Stobbe provides answers in Surgeon General's Warning , which describes the rise and fall of this presidentially appointed official over the past century and a half. He traces the origins of the office and its continually changing duties and describes the men and women who have held the office. The book is organized into four eras: Rise, 1871–1948; Decline, 1949–1980; Struggle, 1981–2001 ; and Plummet, 2002 to Present , which weave together stories of personality, power, and politics. Throughout the history of the office, power and politics have been closely linked. Early surgeons general sought to enlarge their reach, but ultimately, politics shifted the authority for public health elsewhere within the growing federal health bureaucracy. Today, the surgeon general has some responsibilities for the Commissioned Corps, a group of health professionals within the Public Health Service, but no others, and the office has no direct budget. Politics continue nonetheless. The current nominee for the position of surgeon general, Vivek Murthy, is a young physician who has already made a name for himself on the political scene as the founder of Doctors for Obama, now Doctors for America, a nonprofit that has advocated in support of both the president and the Affordable Care Act. He stands to be the youngest physician to be appointed to the role, but final confirmation hearings have been delayed following comments he made concerning guns as a public health issue (he thinks they are). Of the 18 surgeons general, many were colorful personalities, as nicely captured by Stobbe. Some readers will remember surgeon general Everett Koop, appointed by President Reagan, who unexpectedly became a vigorous public health advocate and spokesperson to the nation after being appointed largely because of his views against abortion. He is still regarded as a model for his credibility, communication skills, and use of the “bully pulpit”—a role not yet stripped away—while he held the office. Antonia Novello, appointed by George H. W. Bush, was the first woman to hold the office of surgeon general. A controversial figure while in office, she was later indicted on charges related to abuses of her position as commissioner of health for the State of New York. Readers may also remember Joycelyn Elders, appointed by President Clinton and dismissed within a year for her frank discussion of masturbation. Surgeon general Richard Carmona, appointed by George W. Bush, was a former medic and Green Beret with a colorful history as a feisty trauma surgeon and leader of the Pima County SWAT team. Since leaving, he has unsuccessfully run for the Senate and joined the board of a company that manufactures electronic cigarettes. Stobbe gives equal weight to the early surgeons general as well, including John Woodworth, the first to hold the position, which was then known as the supervising surgeon of the Marine Hospital Service; John Hamilton, who created the Commissioned Corps, which still operates today; and Walter Wyman, under whose leadership the position saw a substantial expansion in responsibilities. He devotes an entire chapter to Thomas Parran, who held office from 1936 to 1948 and campaigned vigorously against sexually transmitted diseases. While he was involved with the establishment of the World Health Organization, Parran's legacy was tarnished by his role in the Tuskegee Syphilis Study and another set of experiments in Guatemala in which nearly 1300 soldiers, prisoners, and mental health patients were deliberately exposed to syphilis and other sexually transmitted diseases without their consent. Since 1964, the surgeon general has been tightly linked to tobacco control, having prepared a number of authoritative reports on smoking and health. The first report ([ 1 ][3]), released by Luther Terry in 1964, stands as a landmark model of systematic review, evidence synthesis, and causal inference, reaching the then momentous conclusion that smoking causes lung cancer. Subsequent reports on secondhand smoke and addiction ([ 2 ][4], [ 3 ][5]) have had wide policy effects. Now, as Stobbe notes, the office is largely vestigial, gaining attention only with the release of a report. When this occurs, the surgeon general briefly holds a national stage and is granted the opportunity to communicate to the nation on public health issues. But otherwise, the bully pulpit has effectively been taken away from the office. Although Stobbe tells the history of the office, he only partially details the public health context that is the backdrop. The historical sweep of the office spans from an era when a few infectious diseases dominated the public health sphere to today, where factors including chronic, noncommunicable diseases; antibiotic resistance; and the politicization of public health issues such as vaccination have significantly increased the breadth and complexity of this arena. Given the complicated nature of today's health challenges, does it really make sense to have one national voice on health? Stobbe thinks not and proposes eliminating the office altogether. Alternatively, I believe that the status of the office could be rebuilt and the bully pulpit restored. Only then might health professionals and the public once again know and trust the surgeon general. 1. [↵][6] Public Health Service, Smoking and Health: Report of the Advisory Committee to the Surgeon General (Public Health Service, Washington, DC, 1964). 2. [↵][7] Office on Smoking and Health, The Health Consequences of Involuntary Smoking: A Report of the Surgeon General (Public Health Service, Washington, DC, 1986). 3. [↵][8] Office on Smoking and Health, The Health Consequences of Smoking: Nicotine Addiction: A Report of the Surgeon General (Public Health Service, Washington, DC, 1988). [1]: pending:yes [2]: http://ISTOCKPHOTO.COM [3]: #ref-1 [4]: #ref-2 [5]: #ref-3 [6]: #xref-ref-1-1 "View reference 1 in text" [7]: #xref-ref-2-1 "View reference 2 in text" [8]: #xref-ref-3-1 "View reference 3 in text"