Friday, October 19, 2012

Dr. Carmona's Condition By Dr. Henry I. Miller

If intelligence and integrity have long been in short supply among politicians, there has been no shortage of spoofs of them. “Suppose you were an idiot and suppose you were a member of Congress. But I repeat myself,” quipped Mark Twain. Humorist Will Rogers addressed the consequences of these deficiencies: “When Congress makes a joke it’s a law, and when they make a law, it’s a joke.”

By those standards, Dr. Richard Carmona, the Democratic candidate for the U.S. Senate from Arizona, would fit right in. I followed his career when he served as U.S. surgeon general during 2002-2006, and it was nothing to write home about – or on which to run for political office.

The Washington political game has two modes: claiming undeserved credit, and shifting blame for your own shortcomings to others. Carmona proved adept at the latter during July 2007 testimony before the House Oversight and Government Reform Committee chaired by Representative Henry A. Waxman (D-Calif.). The subject of the hearing was how to strengthen the office of the surgeon general. Dr. C. Everett Koop, surgeon general in the Reagan administration, and Dr. David Satcher, surgeon general during the Clinton administration, also testified. Both of them complained about political pressure and interference during their respective tenures, but as discussed below, their responses were more courageous – and more respectful of the mission of the office — than Carmona’s.

The position of surgeon general is unusual: Although it carries an exalted title, it lacks virtually any budget or staff or programs of its own. Most of what the incumbent achieves is the result of moral suasion – and in the case of some incumbents, courage.

Dr. Satcher testified at the hearing that the Clinton administration tried to interfere with his issuing a report demonstrating that needle-exchange programs were effective in reducing disease. He released the report anyway. Dr. Koop, perhaps the best known surgeon general in modern times, said he had been discouraged by senior officials in the Reagan administration from discussing the accelerating AIDS crisis. He ignored the pressure and became known as a champion of AIDS funding and research.

In contrast to these profiles in courage, Dr. Carmona went along to get along. He testified before the Waxman committee that he had allowed himself to be muzzled and subjected to “partisanship and political manipulation” by Bush Administration “political appointees” in his “chain of command,” whom he refused to name. (He, too, was a political appointee, by the way.) Apparently, it never occurred to Dr. Carmona that his alternatives included ignoring the demands of his political bosses and taking actions that were in the public interest, or simply resigning.

Dr. Carmona was virtually invisible during his entire tenure. Toward the end of his four-year stint as surgeon general, in an informal poll that I conducted, only five of 60 experts in public health and public policy could identify the current surgeon general, even when offered a multiple-choice format. Many thought the post had been abolished.

When I mentioned to former Surgeon General Koop that I was conducting an informal poll of how many physicians and public health experts could identify the current surgeon general, he quipped, “Have you found one?”

Dr. Carmona often got the science wrong. In 2003, he testified before the House Energy and Commerce Committee, “No matter what you may hear today or read in press reports later, I cannot conclude that the use of any tobacco product is a safer alternative to smoking.” That statement is manifestly untrue. It had been known for almost a decade that switching from smoking to smokeless tobacco is a life-saver.

Although tobacco is a public health scourge, all forms of it are not equally risky; smokeless tobacco causes neither lung cancer nor other pulmonary diseases; nor do its users experience an enhanced risk of heart attacks. Oral cancers are the only important adverse health effect of smokeless tobacco, and they are relatively infrequent (about half as great as in smokers).

While he was surgeon general, Dr. Carmona gave a lecture (which I attended) to an audience of scholars at Stanford University’s Hoover Institution. Thirty-five of his forty minutes were devoted to self-serving autobiography; the remaining five minutes offered no specifics but merely a promise to “implement the public health policies of the president.” That isn’t what policy wonks came to hear.

Dr. Carmona said on PBS’s The News Hour that the office of the U.S. surgeon general is regarded as “a shining example of a great America.” Certainly not on his watch.

Perhaps the most revealing insight into Dr. Carmona’s tell-all congressional testimony is that after enduring the alleged muzzling, political interference, marginalization and manipulation for four years, he asked to continue in the job. He was turned down.

Arizona and the U.S. Senate deserve better than Dr. Carmona.

Henry Miller, a physician and molecular biologist, is the Robert Wesson Fellow in Scientific Philosophy and Public Policy at Stanford University’s Hoover Institution. He was an official at the NIH and FDA from 1977 to 1994.

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