GovernmentExecutive.com

Ezra Klein is pretty excited about the prospects of CNN's Dr. Sanjay Gupta as our next Surgeon General. I have no particular quibble with Ezra's theory that Gupta will be an advocate for health care reform, and that his appointment represents a reconceptualization of the position. Both of those things are probably true. But I think it's a mistake to minimize "the guy who writes warnings for cigarette labels" part of the job, or to suggest that the 1964 Surgeon General's report was just one in a line of public health PR initiatives. Rather, tobacco in particular provides an instructive lesson on how the Surgeon General can operate.

Before I explain why, I have to admit to being a bit of a Surgeon General groupie. One of my first real reporting experiences came at a terrific presentation by former Food and Drug Administration Commissioner David Kessler when I was in high school. Kessler was basically leading a master class on tobacco regulation, assigning various audience members roles to play (your loyal blogger got a minor part as a Philip Morris lobbyist). In attendance was former Surgeon General Julius Richmond, who I buttonholed after the event to ask if I could interview him for my National History Day paper. For a fifteen-year-old high school newspaper editor, it was pretty exciting to come home after school one day, and mid-snack pick up the phone to find a Surgeon General on the other end of the line. But for the project, I also read Richard Kluger's Ashes to Ashes: America's Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris, which along with Kessler's A Question of Intent, provide an important lens into another one of the Surgeon General's roles: building consensus within the medical community.

The story of the 1964 Surgeon General's report on smoking and health really ought to be made into a movie sometime, if corporate insider flicks are in fact on the way back. It's an amazing story, and Kluger does a terrific job of capturing it, and demonstrating how hard it was to get the report exactly right. Luther Terry, the surgeon general, was a tobacco picker as a child, and his father's doctor's son, the congressman Lister Hill, chaired a health subcommittee when Terry became surgeon general. Terry was slow to get started on evaluating tobacco, and his efforts really only got under way when President Kennedy got asked at a May 23, 1962 press conference what the administration intended to do on smoking and health.

The task was incredibly challenging. The consensus was that the report could rock the stock market, and it obviously had major public health implications. In order to succeed, then, the Committee had to get their findings right, and to produce a document of almost incontestable strength and unanimity. Kluger explains one of the things Terry did right:

Although disparaged as a political appointee, selected to head the 33,000-member U.S. Public Health Service from outside the ranks of the commissioned officers' corps at the heart of the PHS, Terry brought an innate decency and reassuring bedside manner of the old-time family physician to the task of administering fourteen government hospitals and some 200 federal institutes and programs. He had the competent administrator's essential knack of picking able assistants--in this case, his Assistant Surgeon General, James Hundley, a more severe and brighter man than himself, to serve as chief liaison with the advisory committee on smoking, and as scientific coordinator for the corps, Dr. Peter Van Vechten Hamill.

Hamill in particular had a hellish job. He had to sort through the nominees to pick a panel that would represent the government, the medical community, and cigarette manufacturers. Then he had to help sequester them under armed guard, get everyone involved in the report security clearances, fire anyone who leaked anything immediately, keep committee members from quitting over scientific disagreements or refusing to endorse language they thought was too mild, and, in one of the more entertaining rules governing the committee, make sure anyone who smoked before the Committee started meeting kept smoking to avoid roiling the markets.

Even though Terry wasn't the direct administrator of the Committee, at the end of the day, he had to stand alone with the results. There is no indication that Terry was a public relations whiz, but the report he released laid a rock-solid scientific foundation for his claims, and the report was met with universal acclimation and acceptance by the press. Without the 1964 report, future Surgeons General wouldn't have been able to press the case against smoking. They also gave Terry legitimacy: he was the only person the Health, Education and Welfare Department allowed to testify in Congress in favor of warning labels on cigarettes. C. Everett Koop did much the same with his report on AIDS twenty-two years later: he did a year of interviews and research, and published his report without letting the White House see a draft, giving him an independent foundation from which to advocate for public education about AIDS and condom use.

Those major achievements might have been easier to promote if Terry or Koop was a telegenic, trusted presence. But they wouldn't have been possible without brilliant staff work, deep research, intelligent delegation, and a commitment to establishing an unshakable scientific consensus. Developing that kind of consensus around health issues continues to be important: it gives all kinds of doctors and advocates ground on which to stand. Gupta probably won't need that if his main role is going to be as a health policy adviser to Obama and as an advocate for health care reform: that requires a political consensus, rather than a medical and scientific one.

But if that ends up being Gupta's core mission as Surgeon General, that leaves vacant the role of a consensus-builder. Perhaps he can delegate and do both, although if he's deeply embroiled in a partisan fight over health-care reform, it might end up being somewhat harder for Gupta to be the universally trusted voice of a next major public health issue, particularly if that issue is itself--as AIDS and smoking were--entangled with politics and in need of an independent voice to cut through the fray. Koop was involved in anti-abortion work before he was Surgeon General, but not simultaneously. Terry was a career public health officer. It may be kind of dry to establish definitively that smoking causes emphysema or that condom use can stop the transmission of AIDS, but establishing those facts is a key first step to explaining them and convincing people of them.