Surgeon General Vivek Murthy pulls beets out of a planter in the Freemont High School Garden in Los Angeles in 2015.
Photo by Mark Boster, courtesy Los Angeles Times/Getty Images
“My hope is that the surgeon general that ultimately is nominated and confirmed by the Senate understands what public health is about and is able to take on those bipartisan challenges.”
— Boris Lushniak
For more than 150 years, the U.S. surgeon general has shaped the national conversation on health — from sounding the alarm on syphilis in the 1930s, to releasing a landmark report on the dangers of smoking in the 1960s to drawing attention to the AIDS crisis in the 1980s.
But today, that voice is missing. The role has remained vacant under the Trump administration.
Public health leaders warn that without a qualified professional who brings both scientific credibility and a willingness to withstand political pressure, the role's influence and the public's trust in it could continue to erode.
“The surgeon general has been a very strong apolitical voice for advancing the health of the public,” APHA CEO Georges Benjamin, MD, told The Nation's Health. “In a federal system where the chief health official may not be a medical professional, having an expert voice that can speak in a non-political, nonpartisan manner around the health of the public is very important.”
Often referred to as the nation's top doctor, the surgeon general is tasked with communicating the best available scientific information to improve health and reduce the risk of illness and injury. The surgeon general also serves as vice admiral of the U.S. Public Health Service Commissioned Corps, which includes more than 6,000 uniformed public health professionals.
By law, the surgeon general is appointed from the USPHS Commissioned Corps, but there is no minimum service requirement before nomination. In recent decades, nominees have often been commissioned at the time of their appointment rather than rising through the ranks.
“It's a political appointee who, for the most part, is put overnight into uniform and then made the commanding officer of the Public Health Service Commissioned Corps,” former Acting Surgeon General Boris Lushniak, MD, MPH, told The Nation's Health.
Although the surgeon general is expected to serve as an independent, apolitical voice, the appointment has become increasingly politicized over time, according to Lushniak, who is now dean of the University of Maryland School of Public Health.
Unlike other uniformed services, which emphasize advancement through a merit-based system, the surgeon general is selected by the president and typically reflects an administration's priorities. That dynamic, public health leaders say, can complicate their ability to operate independently.
While the surgeon general does not set policy, they often release reports and advisories through their office and speak out publicly on public health issues. The position carries significant influence, serving as a key adviser on public health, medical and scientific issues to the president and the U.S. health secretary, according to former Surgeon General Richard Carmona, MD, MPH, who is now chief of health innovation at Canyon Ranch and a laureate professor in public health at the University of Arizona.
Dissenting opinions are essential to reaching sound scientific conclusions, Carmona said.
“Democracy is not looking for one answer,” he told The Nation's Health. “I want the best answer after I speak to everybody.”
Surgeon General Jerome Adams speaks with healthcare workers at a COVID-19 testing site in Miami in July 2020.
Photo by Joe Raedle, courtesy Getty Images
Before political pressures intensified, surgeons general had greater independence to confront some of the nation's most complex and controversial public health challenges. At times, that leadership drew criticism when it conflicted with an administration's priorities.
In the 1980s, under the Reagan administration, Surgeon General C. Everett Koop used the office's platform to advance the national conversation on HIV at a time when stigma and misinformation were widespread. While political advisers pushed for the president to remove Koop, the office was able to operate with a degree of independence that allowed him to prioritize public health.
“Surgeon General Koop, during the HIV epidemic, became a symbol of good sense, responsible action and credible science...using his leadership in order to sway politicians to make the best decisions in protecting the nation's health,” Ayman El-Mohandes, MBBCh, MD, MPH, dean of the City University of New York's Graduate School of Public Health and Health Policy, told The Nation's Health.
Concerns about political interference in the role are not new. In 2007, Carmona, Koop and former Surgeon General David Satcher, MD, PhD, testified before the House Committee on Oversight and Government Reform about increasing political pressure that they said impeded their work while in office.
Without a surgeon general who can operate independently and communicate without political constraint, public health risks being sidelined, they argued.
Those concerns have taken on new urgency under the Trump administration, which has a tendency to base its health decisions and messaging on politics instead of science. The administration has also shown intolerance for dissenting opinions.
In September, Susan Monarez, PhD, former director of the Centers for Disease Control and Prevention, was fired after she reportedly refused to comply with a request to dismiss top CDC officials and pre-approve vaccine recommendations ahead of an advisory board meeting.
The administration has so far failed to secure a nominee who aligns with its agenda. President Trump has tapped news contributors and media influencers with little to no background in public health or medicine, with two nominees withdrawing from consideration. The most recent nominee, Nicole Saphier, MD, is a radiologist and former Fox News contributor. As of press time, she had not garnered sufficient support to move through confirmation, leaving the post open.
“My hope is that the surgeon general that ultimately is nominated and confirmed by the Senate understands what public health is about and is able to take on those bipartisan challenges and be able to speak the truth,” Lushniak said.
Whomever ultimately fills the surgeon general role will face a uniquely difficult landscape. In addition to navigating a deeply polarized political environment, the next surgeon general will need to combat health misinformation while working to rebuild trust in public health institutions, which has eroded under the Trump administration. An April poll from KFF, released in May, found that fewer than half of Americans are confident federal health agencies can act independently without outside interference.
Rebuilding that trust will require not only strong communication skills but also a visible commitment to public service and scientific integrity, experts say. To restore credibility, the next surgeon general should come from the USPHS Commissioned Corps and be prepared to respond to public health crises, according to Steven Solomon, MD, president of the Commissioned Officers Foundation for the Advancement of Public Health.
“If you bring people up through the ranks and they have a...history of service, that's one small step of beginning to rebuild trust,” Solomon told The Nation's Health.
In an administration that many times has prioritized ideology over science, there may still be opportunities for the surgeon general to advance issues that draw bipartisan support. Lushniak pointed to areas such as chronic disease prevention and responses to international health threats as potential points of consensus.
For more on the Office of the Surgeon General, visit www.surgeongeneral.gov. Hear more from public health leaders on what they expect from the next surgeon general in the June episode of The Nation's Health Podcast at bit.ly/aphapodcast.
- Copyright The Nation’s Health, American Public Health Association
