Surgeons General in the Shadow of Dr. Koop

The NY Times has just published a fairly fluffy Q and A with Surgeon General Dr. Regina Benjamin. She’s an accomplished physician and leader, but she’s in a virtually meaningless job. The governmental parallel to Paris Hilton and other second-rate celebrities who are “famous for being famous” are Surgeons General, who are “respected for being respected”. Many people will assert that the Surgeon General job is terribly important but then be unable to explain why.

In reality, the Surgeon General is a low-ranking official whose office does not even appear on the main Department of Health and Human Services organizational chart. The SG is not “the nation’s top doctor”, s/he is not even close to being the top doctor in the building where s/he works. The Assistant Secretary of Health position, which is usually filled by a physician, dwarfs the power of the SG in every respect.

When I point this out to public health advocates, they usually become indignant and huff “But Dr. Koop…”. Dr. Koop was and is flat out a remarkable person (and a newlywed at 93!) but he would have been a great public health leader whether he took the SG job or not. And in any event, he came into office three decades ago. Challenge even a political junkie to come up with another important or even memorable SG since and they will usually say “Well, that one who said schools should teach masturbation” and, if they are total political junkies, will also remember “that one who had civil servants do her shopping for her”.

When I heard that Sanjay Gupta was being considered for SG, I thought that made sense, as the job’s only important public function is communicating health information and he is masterful at that. But then again — why become an SG to do that? Someone like Gupta has more freedom and more ability to reach people (and no political constraints and a higher salary) on CNN. He doesn’t need the SG post to do that and society doesn’t need an SG post to get that.

A small but useful reform for this job would be to remove the need for Senate confirmation, which it does not warrant. Make the job a career capstone for a long-term public health corps member who knows the bureaucracy and can make the trains run on time. And let them wear a business suit — everyone since Koop looks like they are about to offer us peanuts, Diet Coke and an inflight pillow.

Author: Keith Humphreys

Keith Humphreys is the Esther Ting Memorial Professor of Psychiatry at Stanford University and an Honorary Professor of Psychiatry at Kings College London. His research, teaching and writing have focused on addictive disorders, self-help organizations (e.g., breast cancer support groups, Alcoholics Anonymous), evaluation research methods, and public policy related to health care, mental illness, veterans, drugs, crime and correctional systems. Professor Humphreys' over 300 scholarly articles, monographs and books have been cited over thirteen thousand times by scientific colleagues. He is a regular contributor to Washington Post and has also written for the New York Times, Wall Street Journal, Washington Monthly, San Francisco Chronicle, The Guardian (UK), The Telegraph (UK), Times Higher Education (UK), Crossbow (UK) and other media outlets.

6 thoughts on “Surgeons General in the Shadow of Dr. Koop”

  1. If you look at that org chart again and look at all of those divisions that have asterisks. "*Designates a component of the US Public Health Service." The surgeon general is the head of the PHS. Of course, not all of those agencies are wholly PHS. PHS is a distributed organization.

  2. Matt: Why do you think that the distributed nature of PHS makes the SG a highly important job?

  3. "A small but useful reform for this job would be to remove the need for Senate confirmation, which it does not warrant."

    Quite. I've pointed out before that unlike the powerless Surgeon-General, the National Health IT Coordinator – a line job running an expensive, sensitive and mission-critical programme – does not need Senate confirmation, because that's the way GW Bush Jnr originally set it up. Without, at the time, significant power and money.

    Time to shrink the confirmation list from 2000 to 100: cabinet officers, SCOTUS and Federal Appeal judges, Fed board members, the half-dozen really important ambassadorships, and what else?

  4. The Public Health Service today is a real personnel system linked to an obsolescent organization chart. The personnel system is a "uniformed service" that started as the Marine Hospital system, and grew under the "PHS Act" to include the Communicable Disease Center, NIH, the FDA, etc. These agencies were originally staffed and directed by officers of the PHS, then by a mixture of civil servants and PHS officers. About 50 years ago the PHS was politicized by creating the ASH to run the PHS agencies and turning the Surgeon General into an oft-vacant staff position. The agencies under the ASH are still referred to as PHS agencies because overhauling the PHS Act is too complicated.

    You're asking to put them back as they were before. But the Senate confirmation comes because "regular" PHS officers, like any officers of the "Uniformed Services", are commissioned officers of the United States, and have to be confirmed by the Senate, and the SG has to be regularly appointed.

  5. Don't forget the one whose brother-in-law was Father Guido Sarducci. Bill Donahue's outrage would probably be enough to keep her from being confirmed today.

  6. I'm inclined to think that the confirmation requirement for Commissioned Officers is a wise one; I certainly think it ought to be retained for Flag/Star rank officers.

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