What should the Surgeon General do?

March 4, 2009

sanjay.jpgCommentary by Zackary Berger MD PhD, PGY-3, Health Care Policy Section Editor  

The name of neurosurgeon and health journalist Sanjay Gupta was leaked in early January as Barack Obama’s choice for Surgeon General. His selection has caused controversy, and the formal nomination seems to have been delayed by the search for a Secretary of Health and Human Services after the withdrawal of Tom Daschle. While we’re waiting for Gupta to be confirmed, we can ask: what exactly is the Surgeon General supposed to do, and in this administration whose watchword is change, can the office be more useful?

Nowadays, the Surgeon General is the head of the United States Public Health Service. The PHS’s main current function is to provide a cadre of medical professionals who can respond to emergencies at short notice, but it’s not the rapid-response group that first comes to mind. That’s the Epidemic Intelligence Service officers of the Centers for Disease Control, also part of the Department of Health and Human Services but under a Director who reports to the HHS Secretary.

The Surgeon General is best known as an advocate for public health. In 1964, Luther Terry published a well-known report linking tobacco smoking to lung cancer. Epidemiological evidence was already present on that front; what remained was for medical practitioners to become aware of it and integrate it into patient care. Similarly, C. Everett Koop made his name as an advocate for HIV/AIDS education. It was not that the virus or the disease was a mystery, but that its importance was not sufficiently recognized by the public heatlh establishment.

In other words, the Surgeon General’s advocacy lies in disseminating important facts and urgencies in public health to the lay and professional public. He or she is a filter. Some have argued that Gupta has advocated the wrong things on TV, publicizing screening strategies that aren’t evidence-based. But my question is a simpler one: who exactly should the Surgeon General speak to, and in whose name?

Nowadays there’s no shortage of health information available to the general public, much of it (for example, CDC.gov) published by the federal government. Many of us know patients who say that they are confused by the multiple health recommendations available to them. Thus one possible role of the Surgeon General in the Internet age is to serve as the central clearinghouse for reliable health information designed to motivate improved behaviors by the general public. He should be the National Health Educator.

And the source of this reliable health information? Enter Obama’s health care reform. The recently passed stimulus package included language which creates a Federal Coordinating Council for Comparative Effectiveness Research.

The main role of comparative effectiveness research (CER) – and any federal coordinating body – is to identify the tests and interventions which work. But as a happy side effect, we can also identify the information which the Federal government should make known to physicians and patients. The Surgeon General can be the public voice of that effort. Assuming Gupta is appointed, he could use his popularity and expertise as a media figure to help the public distinguish between well-founded and unfounded health advice. Since he is also an accomplished physician, he could also coordinate an effort to disseminate the results of CER among healthcare professionals.

If Obama is willing to rework the office of the Surgeon General (in the vein of his other avowals to change Washington), Gupta’s mark on the office could go beyond raising awareness about the health crisis du jour. He could be associated with a fundamental improvement to our haphazard and inconsistent system of health information. Patients would know where to go, doctors would know where to find their bearings in a forest of sometimes-conflicting guidelines, and care might be the better for it.