Paging America’s Doctor

C. Everett Koop, perhaps America’s most famous surgeon general, passed away on Monday, February 25. Obituaries in all of America’s major newspapers highlighted Koop’s numerous accomplishments, controversial public health initiatives, and most of all his political courage in standing up for convictions that were unpopular with the administration that appointed him. Regrettably, the same cannot be said of his successors. 

The Legacy of C. Everett Koop

Koop is perhaps best known for his fight against tobacco. Over his tenure as surgeon general, his office published eight reports on the effects of tobacco and smoking on human health. Despite the efforts of the powerful tobacco industry, he testified before Congress in favor of replacing rotating warning labels on tobacco products with a single, stark message: “Warning: The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health” – a message that remains unchanged to this day. Without regulatory authority, Koop relied on the power of media and publicity to carry his message. By the time he left office, smoking rates nationwide had declined over 10 percent.

Koop also put public health above conservative politics. For AIDS activists, Koop was the rare public figure who endorsed substantive public health action against AIDS in a time of crisis when little was known about what caused AIDS, let alone what could prevent or cure it. As Koop said, “If ever there was a disease made for a Surgeon General, it was AIDS.” In preparing a report on AIDS for the Reagan administration, Koop took care to frame the issue as one of public health, rather than of moral values. In the report, he controversially highlighted the need for distribution of condoms as a preventive health measure, and most controversially, sex education for schoolchildren as young as the third grade. He followed through by mailing pamphlets about AIDS to every household in America, empowering citizens with knowledge and awareness of the syndrome.

Koop’s advocacy for such measures would seem to be antithetical to his personal roots. Critics initially denounced Koop’s appointment to the post of surgeon general, saying that he was only chosen by Reagan because he was a staunch conservative. However, Koop proved to hold his own against political pressure. Encouraged by the Reagan administration to publish a report on the damaging psychological effects of abortion, Koop refused. When that “Koop Report” was subpoenaed by the Government Operations Committee, Koop testified publicly that he refused to publish the report because he felt that scientific evidence did not support the conclusion that abortion was psychologically damaging to women. Although an evangelical Christian who personally stood against abortion, Koop did not let his personal religious beliefs and conservative political views affect his responsibilities as surgeon general. He believed that abortion was an issue of personal moral values, not a public health issue requiring the intervention of the surgeon general.

Paging Dr. Benjamin

By the time Koop ended his tenure as surgeon general, he was a household name, known for the politically-challenging, high-profile health issues that he tackled. This raises the question: who is our surgeon general now, and why haven’t we heard of her?

Her name is Regina Benjamin. I only learned her name after a Google search. After reading her biography and some of her reports online, I feel I am no closer to knowing who she is or what she believes in than I was before. Publications released during her tenure have hardly been groundbreaking: “How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease“, “The Surgeon General’s Vision for a Healthy and Fit Nation“, “Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General”.

Of course, not every surgeon general encounters the “Next Big One” like C. Everett Koop did, and so one can perhaps excuse the unoriginal subjects of these reports. What is inexcusable is the blandness of the language and suggestions proposed within. Obesity, which now occurs in one in three American adults, is perhaps the major American public health concern of this decade, and campaigns like Michelle Obama’s “Let’s Move!” have attempted to address it. One would therefore expect ”The Surgeon General’s Vision for a Healthy and Fit Nation” to develop tough, substantive recommendations to reduce obesity. Instead, it is filled with inoffensive platitudes (“As a society, we have to begin to change our habits one healthy choice at a time”). When offering suggestions for changes, the report goes for easy pickings: creating a healthy home environment through a nutritious diet, reducing television time, and reducing stress.

It is naive to believe that our current obesity epidemic is caused by and can be solved by modifying personal behavior. The report encourages the public to reduce sugar consumption through fast foods, but does not mention the industries that introduced refined sugar into everything; it encourages schools to buy nutritious foods and install water fountains but does not mention the food industries that can afford to sell unhealthy foods cheaply because of subsidies. By refusing to assign blame to the industries that promote our unhealthy habits, the report indirectly condemns individuals for falling prey to them.

The scientific data pointing to refined sugars and added salts and excess fats as a proximal cause for obesity is growing day by day, and so is the evidence that the food industry is willfully responsible for this trend. So in a time when the fight against obesity needs a powerful spearhead, where is America’s Doctor, who has sworn to provide Americans “the best scientific information available on how to improve their health?”

The Future of America’s Doctor

I do not believe that Surgeon General Regina Benjamin really believes that individuals are solely to blame for obesity, or that individual behavioral modifications will be enough to combat the growing obesity epidemic. What I do believe is that the government pressure that C. Everett Koop faced during his tenure as surgeon general has not abated – and that it has, perhaps, actually increased.

In a Congressional hearing in 2007, three former surgeons general testified that administrations refused to let them speak on pertinent scientific issues and censored their speeches for political reasons. Former Surgeon General Richard Carmona was forbidden by the Bush administration to discuss issues including stem cells, emergency contraception, global health, mental health, or sex education, and was required to mention Bush’s name during his speeches and support Republican candidates. Former surgeons general including C. Everett Koop and David Satcher also testified that they were encouraged to withhold information from the public regarding certain scientifically-proven but politically-controversial interventions, such as needle exchange programs that were pioneered under Satcher’s tenure.

It is a basic tenet of medical ethics that doctors must place their patients first, and that they should minimize political and industrial influence on their commitment to their patients. Thus, it is deeply troubling those political and industrial influences are now stifling our doctor’s voice and leaving patients to tackle alone the conflicting messages about their health. We cannot let these influences continue to get in the way of real national discussion about medically-relevant topics. Our nation needs a leader to reassume the mantle that C. Everett Koop once wore, to be politically courageous and stand up to government and industrial influences in the name of our nation’s public health. It’s time to restore America’s faith in the prestige of the office of the Surgeon General; it’s time to make America’s Doctor once again a household name.

Dr. Benjamin, it’s time for some real talk.

Photo Credit: NIH

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