Quick, name any US surgeon general who's served in the past 25 years. If you can, it's probably C Everett Koop, the pediatric surgeon who revolutionised the national conversation on health under Ronald Reagan and George Bush. Barack Obama apparently has done his predecessors one better by picking CNN's chief medical correspondent Dr Sanjay Gupta, who comes with a built-in audience, as his nominee to be surgeon general.
Choosing a doctor that some consider little more than a TV personality has raised a few eyebrows. Being named one of People Magazine's Sexiest Men Alive (and including that gem in your CNN biography) probably doesn't help. His leading critic, House Judiciary Chairman John Conyers, a Michigan Democrat, says Gupta "lacks the requisite experience needed to oversee the federal agency that provides crucial healthcare assistance to some of the poorest and most underserved communities in America."
However, his fellow Michigander isn't a lightweight. In addition to producing health and wellness documentaries and leading efforts like CNN's anti-obesity initiative Fit Nation, Gupta, a neurosurgeon, works and teaches at the Emory University School of Medicine in Atlanta, Georgia. He is also the associate chief of neurosurgery at Grady Memorial Hospital. In 2003, he served as an embedded correspondent in a Navy medical unit in Iraq and Kuwait.
The surgeon general oversees more than 7000 members of the Commissioned Corps of the US Public Health Service, which tackles public health concerns, conducts research and handles health emergencies. (Directing healthcare policy and reform is the unenviable chore entrusted to Tom Daschle, the secretary of health and human services nominee.)
But today few look to the surgeon general to serve solely as an administrator. He or she derives true clout from the bully pulpit. Over the past several decades, the task of promoting health improvement strategies and illness and injury prevention has fallen to the nation's "chief health educator".
Critics who downplay this role fail to consider the nation's conflicted body politic. While many Americans are health-obsessed, they are also doctor-phobic. Unfortunately, some people will give Oprah and her team of health experts their undivided attention, but avoid their family physician (if they can afford one) or the local health clinic.
Gupta's telegenicity means that when the surgeon general talks, people will listen. When the Commissioned Officers Association (which represents a segment of the health service's members) expressed disappointment that presidents continue to nominate surgeon generals from outside its ranks, the group also held out an olive branch. "If Dr Gupta is, in fact, nominated and confirmed as the 18th surgeon general, our hope is that he will emerge as the next Dr Koop."
Koop was easily one of the country's most effective and controversial surgeon generals. Consider the crusade against smoking. In the mid-1960s, surgeon general Luther Terry issued the first major report linking smoking and lung cancer, which led to warnings like "cigarette smoke contains carbon monoxide" on cigarette packs and cartons. Koop took up the battle, documenting the relationship between smoking cancer and heart and lung diseases, nicotine's addictive properties and the effects of secondhand smoke.
He also stood up to the politicisation of medicine during the Reagan years. At the height of early hysteria over Aids, he opposed mandatory testing, sent literature about the disease to every home in the country (the largest mailing in American history, marking the first time the federal government had provided such information) and called for expanded sex education in schools. Koop also fought (unsuccessfully) against having his name on a report that sought to document the adverse long-term effects on a woman's psychological well-being.
Social conservatives made his life difficult. That he was an evangelical Christian who personally opposed abortion, but refused to compromise his professional integrity to march in lockstep with them, made his outspokenness even more extraordinary – and galling to his detractors. "Mr. Reagan was pressed to fire me every day," Koop told a congressional committee (pdf) in 2007. To his credit, Reagan didn't cave.
But blinding opponents with science doesn't always work for presidents. Joycelyn Elders, the first African-American surgeon general, earned the everlasting enmity of the religious right for her remarks to a 1994 United Nations World Aids Day audience. Asked if teaching masturbation in schools would help cut down on risky sexual behaviours by young people, she replied: "With regard to masturbation, I think that is something that is a part of human sexuality and a part of something that perhaps should be taught." For this and an expanding list of other heresies, Bill Clinton fired her less than halfway into her four-year term.
Along with obesity, several other major public health issues merit renewed attention that Gupta could bring to them, including the Aids epidemic, the ongoing mental and physical problems faced by New Orleans residents, particularly children and the medical issues faced by the newest group of veterans.
But Gupta's already watching his back. Why is Conyers – who doesn't have a vote in the Senate-only confirmation process – trying to take him down? Some speculate that Conyers' friendship with filmmaker Michael Moore, who tangled with Gupta over Sicko, Moore's 2007 indictment of the healthcare system, might be fueling this unexpected gambit (along with Conyers's own preference for another homestate candidate).
However, short of scandal, the Senate is unlikely to raise its collective blood pressure by taking on Obama's prospective pick. There are minefields aplenty for a surgeon general who wants to make an impact on health issues in a culturally conservative country. If Gutpa is willing to channel his inner Koop, one hopes that the president-elect is ready to channel his inner Reagan.
