The debate over confirmation of Dr. Joycelyn Elders as surgeongeneral speaks volumes about the evolution of that office and its position in the contemporary health establishment. Only in recent times, shorn of most of its original administrative functions, has the office emerged as "First Doctor" to the nation and vocal advocate for health reform.
The surgeon general, usually a three-star commissioned officer in the U.S. Public Health Service, is the lineal descendant of the "Supervising Surgeon" of the "Marine Hospital Service." Established in the late 18th century, the MHS provided care to poor merchant seamen who were frequently foreign to the port in which they landed and thus lacked access to local health facilities which, in any case, were unfamiliar and ill-prepared to deal with their often exotic infectious diseases. These marine hospitals, and the officers that manned them, thus became experts in infectious diseases, the major cause of serious illness and death in the United States well into this century.
It was only a matter of logic and time before the service expanded its activities to include screening immigrants and other travelers that landed on our shores, running quarantine stations and issuing regulations for controlling infectious outbreaks. The nascent Public Health Service thus became the country's first line of defense against imported and indigenous epidemics such as smallpox, typhoid, cholera, plague and yellow fever. The "Supervising Surgeon General" organized and administered this growing corps of commissioned officers and civilians.
But the traditional responsibilities and powers of the surgeon general were undermined by the very success the service bred, by political interests and by the changing nature of threats to our health.
A succession of remarkable surgeons general turned this to advantage by refocusing the interests of society and the service. They challenged Victorian views of our culture and demonstrated the need for effective responses to the new health challenges that confronted us. Through their advocacy, integrity and sheer grit, they elevated their office above the level of partisan and special interest squabbles. They turned an administrative position into an effective and respected "bully pulpit."
While the threat of infectious epidemics were never eliminated (as the resurgence in drug-resistant tuberculosis and AIDS make clear), chronic diseases (cancer, heart disease, stroke) and unhealthy life styles that led to them (smoking, alcohol consumption, drug abuse, diet) became the dominant risks to health. The Public Health Service increasingly turned its attention to societally organized approaches for improving individual and collective health (that is, the public's health).
Major initiatives outgrew their origins and were spun off to new agencies established specifically for that purpose, reporting directly to the cabinet secretary in charge of health rather than to the surgeon general: The pioneering research of the Service's Hygienic Laboratory gave root to the National Institutes of Health; regulating wholesomeness and safety of foods and pharmaceuticals, to the Food and Drug Administration; ensuring the purity of the air we breathe and the water we drink to the Environmental Protection Agency. The position of the surgeon general as manager and line officer became increasingly untenable, particularly as the vast majority of the service's employees were civilians.
A major turning point came in 1961 with the appointment of Dr. Luther Terry as ninth surgeon general. This was the first time completion of the surgeon general's term of office coincided with a new administration. Passing over more senior, traditional officers, President John F. Kennedy tapped Dr. Terry, who had spent part of his early career at the Baltimore Marine Hospital and subsequently rose to deputy director of the National Heart Institute.
This single stroke made the surgeon general an agent of political policy; and in Dr. Terry, it set a precedent for individuals committed to translating research on non-infectious diseases into active and effective health initiatives. It was Dr. Terry who issued the landmark 1964 report, "Smoking and Health," which launched the aggressive health legislation and public education campaign ("The Surgeon General has determined that smoking is bad for your health") that transformed societal norms and reduced the major preventable cause of disease and premature death in the United States. The report also broke new methodological ground: It established criteria for deciding when a non-infectious agent was the cause of a disease.