Democrats seek to shield top health official from political pressure

In response to complaints that political interference often prevents the nation's top public health official from dispensing unvarnished medical opinions, two powerful Democratic lawmakers want to make the position of surgeon general more independent by giving the president less of a free hand in selecting nominees.

Sen. Edward Kennedy, chairman of the Senate Health, Education, Labor, and Pensions Committee, and Rep. Henry Waxman, chairman of the House Oversight and Government Reform Committee, introduced their measures in the wake of testimony last month by former Surgeons General Richard Carmona, David Satcher, and Everett Koop that the position is becoming too politicized.

Carmona, who served from 2002 to 2006, accused top Bush administration officials of censoring his speeches and preventing him from speaking out on embryonic-stem-cell research, sex education, and emergency contraception. "Anything that doesn't fit into the political appointees' ideological, theological, or political agenda is ignored, marginalized, or simply buried," he said.

Satcher, a Clinton appointee who served from 1998 to 2002, and Koop, a Reagan appointee who held the post from 1982 to 1989, joined Carmona before Waxman's committee on July 10, but testified of less severe meddling during the Reagan, Bush I, and Clinton administrations.

Waxman, D-Calif., told the three, "The position of surgeon general is a revered post in our government. Fixing what's wrong and making the office work again should be a bipartisan priority."

At a Senate hearing on the same subject two days later, Chairman Kennedy, D-Mass., declared, "The Office of the Surgeon General has become a morass of shameful political manipulation and distortion of science."

Carmona, Satcher, and Koop contend that the best way to strengthen the surgeon general's hand is to make the nomination process less political and to give the office an independent budget and staff.

With a budget of $19 million and a staff of 115 employees, the Surgeon General's Office has the responsibility of spotlighting important health concerns by issuing statements that promote public health education, analyze health policy, and identify research priorities for health professionals. The surgeon general also advises the president and the secretary of Health and Human Services, and directs the 6,000-member Commissioned Corps of the Public Health Service.

Although most surgeons general have served quietly, Luther Terry, who was appointed by President Kennedy, publicized the dangers of smoking, and Koop increased AIDS awareness despite the insistence of Reagan administration officials that he ignore the epidemic. The activism of Terry and Koop demonstrated that a surgeon general can play an important role in shaping public health policy and in increasing the public's understanding of various health threats.

But all too often, say Waxman, Kennedy, and the former surgeons general, "the nation's doctor" is pressured by HHS and the White House to tailor health care messages to an administration's political agenda.

Waxman and Kennedy based their legislation on the notion that the best way to safeguard the surgeon general's objectivity is to begin by making the selection process less overtly political. As of now, the president is free to nominate anyone to be surgeon general. If confirmed by the Senate, the appointee serves a four-year term. But until the late 1960s, surgeons general were required to come from the Commissioned Corps of the Public Health Service.

Under Kennedy's proposal, the Institute of Medicine, which was created by the National Academy of Sciences, would present HHS and the White House with a list of 10 public health experts. The president would then choose the next surgeon general from that pool.

John Parascandola, a retired historian of the Public Health Service who is now an independent consultant, says that the Kennedy approach might indeed "depoliticize the appointment," but he doubts that the measure could make it through Congress. "I suspect [it] might be resisted by politicians of whatever party," Parascandola said, explaining that lawmakers probably would be unwilling to diminish the president's appointment powers.

But Waxman's bill would also do that. Waxman proposes having the Public Health Service come up with a list of six possible surgeons general, three of whom would have to come from the upper ranks of the Commissioned Corps. The HHS secretary would be required to forward those names to the president, who would then choose among them. Under both the Waxman and Kennedy bills, the president's selection would still need to win Senate confirmation.

But narrowing the president's appointment options isn't enough to ensure the surgeon general's independence, critics of the current system say. Kennedy and Waxman agree, saying that the surgeon general should be able to hire his or her own staff and submit budgetary requests directly to the president without having to go through HHS. Kennedy also recommends forbidding the executive branch to censor the surgeon general's health reports.

Under Waxman's bill, a surgeon general's report or call to action (a report that outlines steps that need to be taken to address an urgent health problem) could be blocked only by the HHS secretary, who would then have 10 days to notify Congress of that decision and its rationale. Waxman would also change the chain of command so that the surgeon general would report directly to the secretary, instead of the assistant secretary, and his bill would make it harder for a president to get rid of a surgeon general because of ideological differences.

In 1994, after 15 months as surgeon general, Joycelyn Elders resigned at President Clinton's request after making controversial statements about masturbation and sex education and being criticized as too liberal. With the Elders example still fresh in observers' minds, Waxman says that fear of losing the job could lead surgeons general to be inappropriately circumspect when the time comes to deliver hard-hitting health care messages.

The Bush administration is predictably cool to the Waxman and Kennedy proposals. "We are reviewing the legislation, and we believe that the Office of the Surgeon General functions very well," says White House spokeswoman Emily Lawrimore.

Meanwhile, Rep. Tom Davis of Virginia, the ranking Republican on Waxman's committee, has said that the surgeon general's views "should not be muted or filtered through layers of needless bureaucratic or political approvals." Davis spokesman Brian McNicoll says, however, that "political interests are always going to be a part" of the position, and he is noncommittal about whether Davis will support Waxman's legislation.

"We [Republicans] here would take a look at it," McNicoll said. Craig Orfield, spokesman for Sen. Michael Enzi of Wyoming, the ranking Republican on Kennedy's panel, calls complaints that surgeon generals are subjected to too much political pressure a "refrain from an old song."

According to Parascandola, "There's no question that the position has become more political ... but this is a process that has been going on for years." As early as 1869, he says, political and logistical concerns prompted reformation of what started in 1798 as a health care system for merchant seamen.

Just a dozen years ago, shortly after Elders's resignation, overhaul legislation was introduced -- by conservative Republicans. Then-Rep. Robert Dornan, R-Calif., and Rep. Henry Bonilla, R-Texas, introduced measures in 1995 that effectively would have eliminated the position of surgeon general.

Dornan said, "The Surgeon General's Office has become a largely symbolic position that has been abused in recent years to advance offensive propaganda.... The responsibilities of the surgeon general can easily be absorbed by the assistant secretary of health." Bonilla called the surgeon general "a glorified spokesperson who plays no role in shaping health policy. Congress should eliminate the [job] and save taxpayers close to a million dollars a year."

Michael Tanner, director of health and welfare studies at the Cato Institute, says that the Republicans who wanted to get rid of the position in 1995 and the Democrats who want the surgeon general to be less under the thumb of the White House are missing the point.

"The surgeon general has no real nonpolitical purpose," Tanner said. "This is a political appointee put in a position that is primarily designed to espouse political policies." Because the position is inherently political but is expected to produce health care advisories that are objective and scientific, he says, there will always be critics pushing for pointless reforms.

"This is a silly debate -- and one we're doomed to every couple of years," Tanner says.