INTERVIEW: Richard Carmona, MD

Steve Osborn

Dr. Richard Carmona, who served as Surgeon General of the United States from 2002 to 2006, has a longstanding connection to Northern California. After serving as a Special Forces medic during the Vietnam War, he attended medical school at UC San Francisco, where he received the gold-headed cane as the top graduate of 1979. He stayed at UCSF to complete a residency in general and vascular surgery and then became director of Arizona’s first regional trauma care system.

 

During his wide-ranging career, Dr. Carmona has served as professor of surgery and public health at the University of Arizona; as deputy sheriff for Pima County, Arizona; and as vice chairman of Canyon Ranch, a health and wellness company. While he was Surgeon General, he issued a definitive report about the dangers of second-hand smoke.

 

The following interview with Dr. Carmona was conducted by phone on Jan. 24, 2012.

Q: When you were Surgeon General, were there any instances when politicians tried to interfere with your decisions?

A: There were numerous instances over time, and they were actually delineated in congressional testimony in July 2007. Former Surgeon General Koop, former Surgeon General Satcher and myself all went before a congressional committee looking into these issues. All three of us told the same stories about various administrations trying to manipulate, marginalize or forget the scientific truth for political expediency. This has been going on for some time--all Surgeons General have had this problem.

Q: Did you learn how to approach things differently or change the way you presented scientific proposals?

A: You have to stand firm as to what the science is on the issue. As the Surgeon General, your job is to take the best science available and render the scientifically best practice opinion. It is sort of a give and take, and you learn how to stay centered and focused on the best science, and let everybody else do the politics.

For instance, when David Satcher was Surgeon General, he wanted to move the needle exchange program forward, but there was a lot of opposition from the Republican Party based on erroneous information. Yet he knew that needle exchange would reduce disease transmission, HIV, hepatitis, and so on. He stuck to his guns and released his report. It became a very controversial issue politically but not scientifically.

When Everett Koop was Surgeon General in the early 1980s, we were not sure what this disease was that was killing young men with fevers and lymphadenopathy. Scientists found that it was an HIV virus that was ultimately called AIDS, and Koop spoke to the scientists and got the word out to the American public. But when he did that, he was admonished by certain conservative political elements for speaking about these issues in a public forum, about sex and homosexuality and so on. At the time, certain elected officials were telling the public that this was God’s way of punishing homosexuals. Surgeon General Koop had to stand up and say that’s not true. This is an infectious disease that we can prevent.

So you see a theme that goes from Surgeon General to Surgeon General. No matter which side of the aisle you are on, there is an attempt at manipulation. This is why the position of Surgeon General should be independent and should be independently funded. The Surgeon General should be mandated to speak out regularly on the scientific evidence, not the political evidence, on any issue that will affect the health, safety or security of America.

Q: Do you think science should always take precedence, or are there instances when political considerations might be more important than the scientific evidence?

A: I think first and foremost science should always be part of the discussion. I recognize the realities of politics and also that some issues are quite complicated, and that ideology and theology get involved on some of the issues. But science should always be at the table as a guiding factor. The question that needs to be asked all the time is, What is best for the American public?

Science should be a major driving force in how things are done, but there are political realities. How much money is available, and what are the downsides of any policy decision? Could this be positively or negatively disruptive? I don’t want to just take science out of context and say ignore all the other things, but it needs to be at the table as a driver for the final decision. You can take these political considerations into account, but always with the thought of what is best for the American citizen, the American public in general.

Q: In a recent instance of politics vs. science, Health and Human Services Secretary Kathleen Sebelius nixed over-the-counter sales of the morning-after pill. Do you think those sales should have been allowed?

A: Let me preface my answer. Not being Surgeon General any more, and not having been involved with her decision, I only know what was in the media and a couple of discussions that I had with friends. Nonetheless, this is an issue I did deal with when I was Surgeon General, when the initial launch of the Plan B morning-after pill was delayed. It was not delayed because of science--it was delayed because of political considerations. It was just an inopportune time, and people didn’t want to fight the parties and so on and so forth.

At that time, it was clear to me after talking to the scientists that there was enough science to go ahead and deal with this issue. However, politically everybody wanted to stay away from it because it was such a volatile issue. I think that was a poor decision, especially when we are dealing with unwanted pregnancies and the parties are fighting over pro-choice and pro-life, and here is a scientific method that will decrease the amount of unwanted pregnancies and hence the need for abortion.

In the recent ruling by Secretary Sebelius, she said there wasn’t enough science, but clearly the scientists who commented said there was more than enough science. The allegations here show that the system is broken, that we can’t make good decisions because we are worried about party political opposition on so many fronts.

Q: In another instance of politics vs. science, President Obama last year rejected a proposed rule from the EPA that would have reduced emissions of smog-causing chemicals. He argued that it would be too costly for industry to implement. What is your view of that decision, recognizing that you are not currently in the administration?

A:  Again, I don’t have all the facts on that. I have read what was in the media. My concern is that emissions can be harmful, asthma levels go up, we get pulmonary problems and so on, so what can we do to reduce that? If emissions are looked at as a partisan issue and people are fighting over this based on partisan lines, we fail to do what’s right for the public.

The fact of the matter is if we find scientific evidence that there are pollutants being created by any industry, it doesn’t make a difference what the industry is. The real issue is how do we start to change the way manufacturing is done or emissions are created, and that’s going to take a little bit of time. We don’t want to be disruptive where we are going to shut businesses down acutely when they are beneficial.

So again, not knowing what the President was faced with when he looked at all sides of this issue, I am giving you a general framework of how I would approach it if I was in a leadership position. I understand that you are telling me these emissions are bad. Where are they coming from? What do we need to do to cut them back? If industry then says okay, we are willing to work with you but it may take a little time because it is going to cost so much and we have to generate revenue, I think those are perfectly legitimate reasons to think about how to implement changes that will benefit the American public.

This is something we are going to be dealing with in perpetuity in any industry because as new science evolves there are better ways to do things that are more efficient, more effective and less toxic. We have to be willing to have those discussions in a nonpartisan way that benefits business but also benefits the American public.

Q: The war on tobacco has been a public health success story, but now we have an enormous obesity epidemic. Do you think that government should wage a similar war on soda pop and other junk foods to try to stem the obesity epidemic?

A: My sense is that government’s role should be to raise the level of health literacy to help people make better decisions, and to make sure that the poorest people up to the wealthiest have access to a good, balanced diet of healthy foods that are free of contaminants and organic when possible. I think it is not the right way to go to just admonish somebody for drinking soda pop or going to a fast-food restaurant, because where does it stop then? Are we going to have a government agency that is going to decide what is good to eat and what isn’t good, and what amounts?

I think the real issue here is to educate the American public and make sure that everyone has access to healthy foods. In doing so, I believe industry will change over time, because if the American public begins to demand healthy choices, industry will move in that direction.

I have a concern about waging a war on anything because where does it stop? Where does that money go that you bring in? We have taxed cigarettes very highly in many states, and one of the challenges with getting states to agree to reduce the amount of tobacco being sold, or in fact ban tobacco, is there is so much revenue being generated now, one that runs public functions and keeps cities moving and pays for public service, that nobody wants to deal with the issue. There really is an incentive not to do away with tobacco because now we have become dependent upon those revenues. So it’s not only the intended consequences of what we want to do, we have to look at the unintended consequences, and tobacco is a good example of what’s been good and what’s been bad.

My sense when I was Surgeon General was always to spend the time and effort with the American public, to raise the level of health literacy, to have them understand that you can find reasonably priced healthy foods in the right amounts, and to stay physically active. For the most part, that will begin to reduce the obesity epidemic without legislating the intent to decrease the obesity epidemic. I think legislation should always be a last resort.

Q: What changes do you think could be made to ensure a better balance between politics and medical science?

A: As I said before, I think the Surgeon General’s office should become independent. The Surgeon General should be chosen based on merit from the ranks of the U.S. Public Health Service. They should be career officers and have prerequisite core competency to do the job. Then the nomination should go to the President, and the President should decide just like with the other services.

Just like the President delivers a yearly State of the Union address, I think the Surgeon General should deliver a state of the nation’s health, global health, every year. That way it is clear to Congress and the American public what issues our nation is facing. Our elected officials will be more accountable if they are focused on the issues that were presented impartially and nonpartisanly by the Surgeon General.

We also have to do a lot more to make all these discussions transparent to the American public, whether it be tobacco, stem cells, abortion or pollution. The more we can make these discussions transparent and engage the public, the more likely it is that we will make nonpartisan, rational decisions that benefit citizens directly.