Opinion
VIEWPOINT
Nathaniel P. Morris, AB Harvard Medical School, Boston, Massachusetts.
Corresponding Author: Nathaniel P. Morris, AB, Harvard Medical School, 25 Shattuck St, Boston, MA 02115 (nathaniel [email protected] .edu). jamainternalmedicine.com
A To-Do List for the Next US Surgeon General The surgeon general of the United States is a troubled position, largely forgotten by the public. In July 2013, Regina Benjamin, MD, resigned from the post, cutting her 4-year term short by 4 months. Several of her predecessors have publicly testified that political censorship and paltry resources weakened the office. Nonetheless, Dr Benjamin has been criticized for further diminishing the office through the obscurity of her term. Despite promoting preventive medicine, smoking cessation, and other worthy causes, Dr Benjamin was largely unknown to the public. Between November 3, 2009, when her term started, and July 16, 2013, when it ended, there were fewer than 20 unique mentions of her name in the New York Times, as determined by an online search of the newspaper’s archives. As of early November 2013, there was only an interim surgeon general. In the past, the position, which requires senate confirmation of the president’s nomination, has gone unfilled for years at a time. After President Clinton forced Jocelyn Elders, MD, to resign in 1994 for making controversial statements about sex education, the senate did not confirm a replacement until 1998. The Bush administration never officially replaced Richard Carmona, MD, after he completed his term in 2006. Executing the duties of the surgeon general—to “advance the health of the nation through educating the public” and to “articulate scientifically based health policy analysis”1—has thus become increasingly difficult. In 2007, Dr Carmona testified to Congress 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.”2 The resources dedicated to the job are miniscule—the annual budget of the office hovers around $1 million, and the staff numbers less than a few dozen. But the United States needs an activist surgeon general who addresses pressing national issues with scientific evidence and brings public health into our daily conversation.3 We have a Secretary of Health and Human Services, yet the duties of this administrative position are very broad, and a physician has not held the post for over 20 years. It is vital to have an independent and credible surgeon general, as the nation’s first physician, whom we can trust specifically on matters of medicine and public health. Our health care system is in crisis, with $2.7 trillion in annual health expenditures and almost 50 million Americans without health insurance. More than 70 million baby boomers will soon pass age 65 years, effectively doubling the size of elderly population. And the burdens of obesity and chronic disease are immense, to name just some of the reasons for our fragile state of public health. How can the Office of the surgeon general be revitalized to address the health challenges of today? Even
with minimal budget and staff, the next surgeon general could lay the groundwork for a revival by pursuing 4 initiatives.
Educate the Public About Health Insurance and the Affordable Care Act Health care in the United States is exceedingly complex, and the 906-page Affordable Care Act in many ways compounds this problem. Although our medical system will work only if Americans can efficiently navigate it, we generally lack the knowledge to do so. In a 2013 study, only 14% of people between the ages of 24 and 64 years with private insurance understood the basic concepts of coinsurance, copayments, deductibles, and out-of-pocket maximums.4 A recent Gallup poll showed that 19% of the public—and 43% of the uninsured—did not know that the Affordable Care Act will require them to have health insurance or to pay a fine.5 In August 2013, a Kaiser Health Tracking Poll found that nearly half of those surveyed were unsure if the Affordable Care Act was actually law.6 These startling statistics show that educational efforts by the Obama administration and the Department of Health and Human Services have been inadequate. The surgeon general, however, could play a unique role in raising awareness. A well-respected public face to explain the intricacies of our health care system would be far superior to the political speeches and bureaucratic directories that we so often encounter. The next appointee might make a national tour, provide interviews to major news outlets, and issue a “Surgeon General’s Everyday Guide to Getting Health Care in America.”
Focus Antiobesity Efforts on Systemic Causes, Not Personal Responsibility Notions of will power and personal responsibility dominate public approaches to our obesity crisis. Antiobesity campaigns use stigmatizing language,7 and recent reports from the surgeon general implore Americans to exercise, eat nutritious food, and turn off the television.8 Yet the American Medical Association recently classified obesity as a disease, and health experts now recognize that structural changes are necessary if antiobesity efforts are to succeed.9 The next surgeon general should champion this important shift in perspective and take on systemic causes of obesity, such as government subsidies for junk food ingredients and the advertising of fast foods to children. He or she should advocate legislation that changes communities through better urban design, greater availability of healthy food options, and targeted food tax policies. Americans need incentives to engage in healthier behaviors, not a scolding for making the unhealthy choices encouraged by present conditions. JAMA Internal Medicine February 2014 Volume 174, Number 2
Copyright 2014 American Medical Association. All rights reserved.
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177
Opinion Viewpoint
Release a Report on the Safety of Vaccines Some immunizations have genuine adverse effects, but the widespread safety concerns surrounding vaccines must be put to rest. In 2011, a National Public Radio/Thomson Reuters poll found that 21% of Americans believed that vaccines played a role in the development of autism,10 though scientific reviews have repeatedly found no evidence for this claim. Since then, overall vaccination rates in the United States have remained high, but disturbing trends persist. A congressional hearing in 2012 devolved into legislators berating scientists on the subject. Various states have passed legislation to stem the tide of parents requesting exemptions for their children from immunization requirements. Vaccine refusals have led to outbreaks of preventable diseases, such as measles in New York City and Texas. The surgeon general should not regularly dignify superstition with the attention of his or her office. Nonetheless, these fears have spread to the point of perpetuating falsified science and endangering public health. A definitive report from the surgeon general would make a strong statement against this quackery and give physicians an effective tool to use in educating patients and parents.
Prepare an Annual “State of American Health” Report and Testimony for Congress Since the passage of the Humphrey-Hawkins Act of 1978, the Chairman of the Federal Reserve has been required to deliver semian-
Conclusions The surgeon general’s word is the most powerful instrument of this position—it is the foundation on which these recommendations stand. However, the current constraints on the office make adequate engagement of most public health challenges impossible. The Obama administration can change nothing and relegate the next surgeon general to the obscurity of past appointees, or it can revitalize the position, provide the post with a bully pulpit, and underscore public health as a fundamental priority of the federal government. A surgeon general who carries out these high-profile and readily accessible suggestions would be a first step toward this transformation, a new beginning for a brighter and healthier American future.
3. Morris NP. A strong leader needed for top US doctor. Boston Globe; June 24, 2013:A11.
ARTICLE INFORMATION Published Online: November 25, 2013. doi:10.1001/jamainternmed.2013.12376. Conflict of Interest Disclosures: None reported. Additional Contributions: The author thanks former US Surgeon General Richard Carmona, MD, and former acting US Surgeon General Steven Galson, MD, for discussions during the preparation of this article. REFERENCES 1. Office of the US Surgeon General. Duties of the Surgeon General. http://www.surgeongeneral.gov /about/duties/. Accessed September 23, 2013. 2. Carmona RH. The surgeon general’s vital mission: challenges for the future. http://www.gpo.gov/fdsys/pkg /CHRG-110hhrg40151/html /CHRG-110hhrg40151.htm. Accessed October 14, 2013.
178
nual reports and testimony on the state of monetary policy to Congress. These reports greatly influence financial markets and decision making at the highest levels of government. The surgeon general, often called America’s doctor, deserves a similar platform from which to shape public perceptions and policy on national health issues.11 Ideally, the surgeon general would independently prepare this report, consulting as needed with other federal health officials, but without the need for clearance from the Department of Health and Human Services and the White House. Such independence is necessary if the surgeon general’s report is to be credible and thus play an important role in the national conversation about how to improve Americans’ health.
4. Loewenstein G, Friedman JY, McGill B, et al. Consumers’ misunderstanding of health insurance. J Health Econ. 2013;32(5):850-862. 5. Jones JM. In US, 43% of uninsured unaware they must get coverage: awareness higher, at 81%, among all Americans. http://www.gallup.com/poll /163280/uninsured-unaware-coverage.aspx?utm _source=email-a-friend&utm_medium=email&utm _campaign=sh-aring&utm_content=titlelink. Accessed October 14, 2013. 6. Henry J. Kaiser Family Foundation. Kaiser Health Tracking Poll: August 2013. http://kff.org/health -reform/poll-finding/kaiser-health-tracking-poll -august-2013/. Accessed October 14, 2013. 7. Puhl R, Luedicke J, Peterson JL. Public reactions to obesity-related health campaigns: a randomized controlled trial. Am J Prev Med. 2013;45(1):36-48.
8. US Department of Health and Human Services. The Surgeon General's Vision for a Healthy and Fit Nation. Rockville, MD: US Dept of Health and Human Services, Office of the Surgeon General; 2010. 9. Institute of Medicine. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington, DC: The National Academies Press; 2012. 10. NPR-Thomson Reuters. NPR-Thomson Reuters Health Poll: August 1-16, 2011. http://blog .thomsonreuters.com/index.php/thomson-reuters -npr-health-poll-vaccines/. Accessed October 22, 2013. 11. Carmona R. The trauma of politics: a surgeon general’s perspective. J Trauma Acute Care Surg. 2012;73(2):314-318.
JAMA Internal Medicine February 2014 Volume 174, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Birmingham User on 06/04/2015
jamainternalmedicine.com
VIEWPOINT
Nathaniel P. Morris, AB Harvard Medical School, Boston, Massachusetts.
Corresponding Author: Nathaniel P. Morris, AB, Harvard Medical School, 25 Shattuck St, Boston, MA 02115 (nathaniel [email protected] .edu). jamainternalmedicine.com
A To-Do List for the Next US Surgeon General The surgeon general of the United States is a troubled position, largely forgotten by the public. In July 2013, Regina Benjamin, MD, resigned from the post, cutting her 4-year term short by 4 months. Several of her predecessors have publicly testified that political censorship and paltry resources weakened the office. Nonetheless, Dr Benjamin has been criticized for further diminishing the office through the obscurity of her term. Despite promoting preventive medicine, smoking cessation, and other worthy causes, Dr Benjamin was largely unknown to the public. Between November 3, 2009, when her term started, and July 16, 2013, when it ended, there were fewer than 20 unique mentions of her name in the New York Times, as determined by an online search of the newspaper’s archives. As of early November 2013, there was only an interim surgeon general. In the past, the position, which requires senate confirmation of the president’s nomination, has gone unfilled for years at a time. After President Clinton forced Jocelyn Elders, MD, to resign in 1994 for making controversial statements about sex education, the senate did not confirm a replacement until 1998. The Bush administration never officially replaced Richard Carmona, MD, after he completed his term in 2006. Executing the duties of the surgeon general—to “advance the health of the nation through educating the public” and to “articulate scientifically based health policy analysis”1—has thus become increasingly difficult. In 2007, Dr Carmona testified to Congress 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.”2 The resources dedicated to the job are miniscule—the annual budget of the office hovers around $1 million, and the staff numbers less than a few dozen. But the United States needs an activist surgeon general who addresses pressing national issues with scientific evidence and brings public health into our daily conversation.3 We have a Secretary of Health and Human Services, yet the duties of this administrative position are very broad, and a physician has not held the post for over 20 years. It is vital to have an independent and credible surgeon general, as the nation’s first physician, whom we can trust specifically on matters of medicine and public health. Our health care system is in crisis, with $2.7 trillion in annual health expenditures and almost 50 million Americans without health insurance. More than 70 million baby boomers will soon pass age 65 years, effectively doubling the size of elderly population. And the burdens of obesity and chronic disease are immense, to name just some of the reasons for our fragile state of public health. How can the Office of the surgeon general be revitalized to address the health challenges of today? Even
with minimal budget and staff, the next surgeon general could lay the groundwork for a revival by pursuing 4 initiatives.
Educate the Public About Health Insurance and the Affordable Care Act Health care in the United States is exceedingly complex, and the 906-page Affordable Care Act in many ways compounds this problem. Although our medical system will work only if Americans can efficiently navigate it, we generally lack the knowledge to do so. In a 2013 study, only 14% of people between the ages of 24 and 64 years with private insurance understood the basic concepts of coinsurance, copayments, deductibles, and out-of-pocket maximums.4 A recent Gallup poll showed that 19% of the public—and 43% of the uninsured—did not know that the Affordable Care Act will require them to have health insurance or to pay a fine.5 In August 2013, a Kaiser Health Tracking Poll found that nearly half of those surveyed were unsure if the Affordable Care Act was actually law.6 These startling statistics show that educational efforts by the Obama administration and the Department of Health and Human Services have been inadequate. The surgeon general, however, could play a unique role in raising awareness. A well-respected public face to explain the intricacies of our health care system would be far superior to the political speeches and bureaucratic directories that we so often encounter. The next appointee might make a national tour, provide interviews to major news outlets, and issue a “Surgeon General’s Everyday Guide to Getting Health Care in America.”
Focus Antiobesity Efforts on Systemic Causes, Not Personal Responsibility Notions of will power and personal responsibility dominate public approaches to our obesity crisis. Antiobesity campaigns use stigmatizing language,7 and recent reports from the surgeon general implore Americans to exercise, eat nutritious food, and turn off the television.8 Yet the American Medical Association recently classified obesity as a disease, and health experts now recognize that structural changes are necessary if antiobesity efforts are to succeed.9 The next surgeon general should champion this important shift in perspective and take on systemic causes of obesity, such as government subsidies for junk food ingredients and the advertising of fast foods to children. He or she should advocate legislation that changes communities through better urban design, greater availability of healthy food options, and targeted food tax policies. Americans need incentives to engage in healthier behaviors, not a scolding for making the unhealthy choices encouraged by present conditions. JAMA Internal Medicine February 2014 Volume 174, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Birmingham User on 06/04/2015
177
Opinion Viewpoint
Release a Report on the Safety of Vaccines Some immunizations have genuine adverse effects, but the widespread safety concerns surrounding vaccines must be put to rest. In 2011, a National Public Radio/Thomson Reuters poll found that 21% of Americans believed that vaccines played a role in the development of autism,10 though scientific reviews have repeatedly found no evidence for this claim. Since then, overall vaccination rates in the United States have remained high, but disturbing trends persist. A congressional hearing in 2012 devolved into legislators berating scientists on the subject. Various states have passed legislation to stem the tide of parents requesting exemptions for their children from immunization requirements. Vaccine refusals have led to outbreaks of preventable diseases, such as measles in New York City and Texas. The surgeon general should not regularly dignify superstition with the attention of his or her office. Nonetheless, these fears have spread to the point of perpetuating falsified science and endangering public health. A definitive report from the surgeon general would make a strong statement against this quackery and give physicians an effective tool to use in educating patients and parents.
Prepare an Annual “State of American Health” Report and Testimony for Congress Since the passage of the Humphrey-Hawkins Act of 1978, the Chairman of the Federal Reserve has been required to deliver semian-
Conclusions The surgeon general’s word is the most powerful instrument of this position—it is the foundation on which these recommendations stand. However, the current constraints on the office make adequate engagement of most public health challenges impossible. The Obama administration can change nothing and relegate the next surgeon general to the obscurity of past appointees, or it can revitalize the position, provide the post with a bully pulpit, and underscore public health as a fundamental priority of the federal government. A surgeon general who carries out these high-profile and readily accessible suggestions would be a first step toward this transformation, a new beginning for a brighter and healthier American future.
3. Morris NP. A strong leader needed for top US doctor. Boston Globe; June 24, 2013:A11.
ARTICLE INFORMATION Published Online: November 25, 2013. doi:10.1001/jamainternmed.2013.12376. Conflict of Interest Disclosures: None reported. Additional Contributions: The author thanks former US Surgeon General Richard Carmona, MD, and former acting US Surgeon General Steven Galson, MD, for discussions during the preparation of this article. REFERENCES 1. Office of the US Surgeon General. Duties of the Surgeon General. http://www.surgeongeneral.gov /about/duties/. Accessed September 23, 2013. 2. Carmona RH. The surgeon general’s vital mission: challenges for the future. http://www.gpo.gov/fdsys/pkg /CHRG-110hhrg40151/html /CHRG-110hhrg40151.htm. Accessed October 14, 2013.
178
nual reports and testimony on the state of monetary policy to Congress. These reports greatly influence financial markets and decision making at the highest levels of government. The surgeon general, often called America’s doctor, deserves a similar platform from which to shape public perceptions and policy on national health issues.11 Ideally, the surgeon general would independently prepare this report, consulting as needed with other federal health officials, but without the need for clearance from the Department of Health and Human Services and the White House. Such independence is necessary if the surgeon general’s report is to be credible and thus play an important role in the national conversation about how to improve Americans’ health.
4. Loewenstein G, Friedman JY, McGill B, et al. Consumers’ misunderstanding of health insurance. J Health Econ. 2013;32(5):850-862. 5. Jones JM. In US, 43% of uninsured unaware they must get coverage: awareness higher, at 81%, among all Americans. http://www.gallup.com/poll /163280/uninsured-unaware-coverage.aspx?utm _source=email-a-friend&utm_medium=email&utm _campaign=sh-aring&utm_content=titlelink. Accessed October 14, 2013. 6. Henry J. Kaiser Family Foundation. Kaiser Health Tracking Poll: August 2013. http://kff.org/health -reform/poll-finding/kaiser-health-tracking-poll -august-2013/. Accessed October 14, 2013. 7. Puhl R, Luedicke J, Peterson JL. Public reactions to obesity-related health campaigns: a randomized controlled trial. Am J Prev Med. 2013;45(1):36-48.
8. US Department of Health and Human Services. The Surgeon General's Vision for a Healthy and Fit Nation. Rockville, MD: US Dept of Health and Human Services, Office of the Surgeon General; 2010. 9. Institute of Medicine. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington, DC: The National Academies Press; 2012. 10. NPR-Thomson Reuters. NPR-Thomson Reuters Health Poll: August 1-16, 2011. http://blog .thomsonreuters.com/index.php/thomson-reuters -npr-health-poll-vaccines/. Accessed October 22, 2013. 11. Carmona R. The trauma of politics: a surgeon general’s perspective. J Trauma Acute Care Surg. 2012;73(2):314-318.
JAMA Internal Medicine February 2014 Volume 174, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Birmingham User on 06/04/2015
jamainternalmedicine.com
