An unhealthy use of power

An unhealthy use of power
By Christopher Caldwell
Copyright The Financial Times Limited 2007
Published: July 14 2007 03:00 | Last updated: July 14 2007 03:00


"Gagged", "muzzled" and "censored" are some of the words used to describe what the Bush administration did to its former surgeon-general, Richard Carmona. On the eve of confirmation hearings for his successor, Dr Carmona told a congressional committee this week that Mr Bush's people tried to "water down" a report he wrote on second-hand smoke. They were uninterested in his views on stem cell research. They pressured him to sing the administration's praises. His allegations are probably all true. But there is a larger problem with the surgeon-general's job than its politicisation, which did not begin with the Bush administration.

The surgeon-general, who works for the Department of Health and Human Services, publicises health risks. He is often called "America's family doctor" but the metaphor is misleading. Few family doctors infuriate half their patients, as surgeons-general have tended to do. Some shape the public mood: C. Everett Koop played a role in demonising tobacco in the Reagan administration. Others fail: Joycelyn Elders was fired early in the Clinton administration after telling a United Nations conference that masturbation was "part of something that perhaps should be taught".

The same pattern is repeated again and again: a doctor of some professional distinction, vetted for pro-administration sympathies, gets confirmed and quickly becomes a political "maverick". The problem is simple: the surgeon-general is both a political post, with a good deal of clout, and a "caring" post, which puts it above criticism. Naturally, the temptation of power without accountability arises.

A big risk of déformation professionnelle has always confronted doctors. Their day-to-day interactions place them in the position of oracle or saviour. Those they deal with are at their weakest and most desperate. Hubris can result. When the New York Times revealed that Dr Koop had collected commissions on products recommended by his health website, Dr Koop replied that other people might be bought, but not he. "I am an icon," he said. Today, medicine's prestige has grown along with its power to heal. The border between health and social science has been eroded, as has the border between social science and politics. Doctors increasingly pronounce on matters outside medicine.

Even the Clinton appointee David Satcher, Dr Carmona's upright and accomplished predecessor, had a wildly exaggerated conception of his remit. For Dr Satcher, violence against homosexuals and gun violence were not just crime problems but health problems. Dr Carmona, an experienced bureaucratic infighter, took this occupational imperialism a step further. The surgeon-general's role, he said during his confirmation hearings, "has broadened significantly from that of traditional public health responsibilities to now include the expanded leadership role of addressing homeland defence and domestic preparedness". Really? Who passed that law? Who gave an appointee in Health and Human Services the authority to pronounce on defence policy?

A broader conception of the job is not the only thing that surgeons-general want. They want to pursue their agenda of "science" without "political interference". Dr Koop told a reporter recently: "There should be a law that says this person would be apolitical and when he is appointed, he will not be answerable to the president for what he says about health or anything else." This sounds noble, but it is not. It amounts to a demand to have one's cake and eat it, too - to shape politics while professing oneself neutral.

This is a misrepresentation. For it is not "science" that people obey when health policies get implemented. It is power. The science in the 1964 surgeon-general's report linking smoking to lung cancer stopped relatively few people from smoking. Smoking rates began to fall steeply only in the 1980s. What brought the change was legislation and judicial decrees. State power enforced the surrender of a certain amount of liberty in exchange for a certain amount of cleanliness, health and longevity. Policies on sex education, abortion and cloning are similarly matters of politics, not science. The surgeon-general is not at the intellectual pinnacle of the medical profession. He is at the political pinnacle of the medical profession. None of the surgeons-general in the past generation has been among the country's authoritative scientists. Their authority derives only from the administration they represent.

Dr Carmona is confused about this. "I could get no traction whatsoever to move this agenda forward," he complained at one point. But in a democracy, "traction" is a synonym for constitutional authority. The surgeon-general has little of that. It is the president who pursues the national agenda, not his appointees. Dr Carmona's observation that "anything that doesn't fit into the political appointee's ideological, theological or political agenda is ignored, marginalised or simply buried" is probably correct, but it is true of most issues in most administrations. The Bush administration "interfered" with Dr Carmona in the way the Truman administration interfered with General Douglas MacArthur's plans to use the army to wage freelance war on China in the 1950s: it impeded an individual's use of public power by asserting its duly constituted authority.

In a political struggle between the presidency and the surgeon-general, the presidency prevails. What was revealed in testimony last week was not the politicisation of the surgeon-general's office but its de-politicisation. Dr Carmona's superiors, by reasserting their control over health policy, made it more accountable. That does not mean they made it more competent. If it is competence you want, you have your vote for that.

The writer is a senior editor at The Weekly Standard