<DOC>
[110th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:40151.wais]
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
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COMMITTEE ON OVERSISGHT AND GOVERNMENT REFORM
HENRY A. WAXMAN, California, Chairman
TOM LANTOS, California TOM DAVIS, Virginia
EDOLPHUS TOWNS, New York DAN BURTON, Indiana
PAUL E. KANJORSKI, Pennsylvania CHRISTOPHER SHAYS, Connecticut
CAROLYN B. MALONEY, New York JOHN M. McHUGH, New York
ELIJAH E. CUMMINGS, Maryland JOHN L. MICA, Florida
DENNIS J. KUCINICH, Ohio MARK E. SOUDER, Indiana
DANNY K. DAVIS, Illinois TODD RUSSELL PLATTS, Pennsylvania
JOHN F. TIERNEY, Massachusetts CHRIS CANNON, Utah
WM. LACY CLAY, Missouri JOHN J. DUNCAN, Jr., Tennessee
DIANE E. WATSON, California MICHAEL R. TURNER, Ohio
STEPHEN F. LYNCH, Massachusetts DARRELL E. ISSA, California
BRIAN HIGGINS, New York KENNY MARCHANT, Texas
JOHN A. YARMUTH, Kentucky LYNN A. WESTMORELAND, Georgia
BRUCE L. BRALEY, Iowa PATRICK T. McHENRY, North Carolina
ELEANOR HOLMES NORTON, District of VIRGINIA FOXX, North Carolina
Columbia BRIAN P. BILBRAY, California
BETTY McCOLLUM, Minnesota BILL SALI, Idaho
JIM COOPER, Tennessee JIM JORDAN, Ohio
CHRIS VAN HOLLEN, Maryland
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont
Phil Schiliro, Chief of Staff
Phil Barnett, Staff Director
Earley Green, Chief Clerk
David Marin, Minority Staff Director
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
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 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 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 much-needed 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 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 single-handedly, 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 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.
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.
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 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.
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 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 Washington, 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 four-star 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 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.
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.
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 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 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.
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 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.
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 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?
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.
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 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
mandatory 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, 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 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 report 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.
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.
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 that I looked at the model of a U.S. Public Health
Service Commission 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 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 American 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 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----
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.
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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