[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]




 
     THE SURGEON GENERAL'S VITAL MISSION: CHALLENGES FOR THE FUTURE

=======================================================================

                                HEARING

                               before the

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 10, 2007

                               __________

                           Serial No. 110-38

                               __________

Printed for the use of the Committee on Oversight and Government Reform


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             COMMITTEE ON OVERSISGHT AND GOVERNMENT REFORM

                 HENRY A. WAXMAN, California, Chairman
TOM LANTOS, California               TOM DAVIS, Virginia
EDOLPHUS TOWNS, New York             DAN BURTON, Indiana
PAUL E. KANJORSKI, Pennsylvania      CHRISTOPHER SHAYS, Connecticut
CAROLYN B. MALONEY, New York         JOHN M. McHUGH, New York
ELIJAH E. CUMMINGS, Maryland         JOHN L. MICA, Florida
DENNIS J. KUCINICH, Ohio             MARK E. SOUDER, Indiana
DANNY K. DAVIS, Illinois             TODD RUSSELL PLATTS, Pennsylvania
JOHN F. TIERNEY, Massachusetts       CHRIS CANNON, Utah
WM. LACY CLAY, Missouri              JOHN J. DUNCAN, Jr., Tennessee
DIANE E. WATSON, California          MICHAEL R. TURNER, Ohio
STEPHEN F. LYNCH, Massachusetts      DARRELL E. ISSA, California
BRIAN HIGGINS, New York              KENNY MARCHANT, Texas
JOHN A. YARMUTH, Kentucky            LYNN A. WESTMORELAND, Georgia
BRUCE L. BRALEY, Iowa                PATRICK T. McHENRY, North Carolina
ELEANOR HOLMES NORTON, District of   VIRGINIA FOXX, North Carolina
    Columbia                         BRIAN P. BILBRAY, California
BETTY McCOLLUM, Minnesota            BILL SALI, Idaho
JIM COOPER, Tennessee                JIM JORDAN, Ohio
CHRIS VAN HOLLEN, Maryland
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont

                     Phil Schiliro, Chief of Staff
                      Phil Barnett, Staff Director
                       Earley Green, Chief Clerk
                  David Marin, Minority Staff Director


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on July 10, 2007....................................     1
Statement of:
    Koop, C. Everett, M.D., Sc.D., 13th Surgeon General, 1981-
      1989; David Satcher, M.D., Ph.D., 16th Surgeon General, 
      1998-2001; and Richard Carmona, M.D, M.P.H, F.A.C.S., 17th 
      Surgeon General, 2002-2006.................................    16
        Carmona, Richard.........................................    34
        Koop, C. Everett.........................................    16
        Satcher, David...........................................    26
Letters, statements, etc., submitted for the record by:
    Carmona, Richard, M.D, M.P.H, F.A.C.S., 17th Surgeon General, 
      2002-2006, prepared statement of...........................    37
    Davis, Hon. Tom, a Representative in Congress from the State 
      of Virginia, prepared statement of.........................    12
    Koop, C. Everett, M.D., Sc.D., 13th Surgeon General, 1981-
      1989, prepared statement of................................    19
    Satcher, David, M.D., Ph.D., 16th Surgeon General, 1998-2001, 
      prepared statement of......................................    29
    Waxman, Chairman Henry A., a Representative in Congress from 
      the State of California, prepared statement of.............     4


     THE SURGEON GENERAL'S VITAL MISSION: CHALLENGES FOR THE FUTURE

                              ----------                              


                         TUESDAY, JULY 10, 2007

                          House of Representatives,
              Committee on Oversight and Government Reform,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10 a.m., in room 
2154, Rayburn House Office Building, Hon. Henry A. Waxman 
(chairman of the committee) presiding.
    Present: Representatives Waxman, Watson, Yarmuth, Norton, 
Sarbanes, Davis of Virginia, and Issa.
    Staff present: Phil Barnett, staff director and chief 
counsel; Karen Nelson, health policy director; Karen Lightfoot, 
communications director and senior policy advisor; Andy 
Schneider, chief health counsel; Naomi Seiler, counsel; Steve 
Cha, professional staff member; Earley Green, chief clerk; 
Teresa Coufal, deputy clerk; Caren Auchman, press assistant; 
Zhongrui ``JR'' Deng, chief information officer; Kerry 
Gutknecht, staff assistant; Art Kellermann, fellow; David 
Marin, minority staff director; Keith Ausbrook, minority 
general counsel; A. Brooke Bennett, minority counsel; Susie 
Schulte, minority senior professional staff member; Patrick 
Lyden, minority parliamentarian and member services 
coordinator; and Benjamin Chance, minority clerk.
    Chairman Waxman. The meeting of the committee will come to 
order.
    Two months ago this committee began a series of hearings on 
how to make government effective again. These hearings ask why 
Federal agencies that were once admired as the finest in the 
world, like the Food and Drug Administration, are failing to 
meet the public's expectations. And they seek to understand how 
we can restore these troubled agencies to models of excellence 
that will help our Nation meet the challenges ahead.
    Today's hearing will examine the Office of the Surgeon 
General in the Department of Health and Human Services. The 
Surgeon General is the doctor to the Nation, a uniquely trusted 
figure who brings the best available science on matters of 
public health directly to the American people. This position is 
unique among government agencies not only in the United States, 
but among health agencies worldwide.
    The ability of the Surgeon General to improve the health of 
the Nation is vividly illustrated by the impact of the landmark 
1964 report Smoking and Health. For the first time the American 
people had a credible science-based report from the government 
that spelled out the relationship, the causal relationship, 
between smoking and lung cancer.
    Over the years the Office of the Surgeon General has 
produced highly influential reports and calls to action on 
topics ranging from AIDS prevention to obesity to mental 
health. Like the 1964 smoking report, the Surgeon General's 
work has shaped the Nation's understanding of public health. 
But what we will learn today is that this essential part of our 
government is in crisis. Political interference is compromising 
the independence of the Office of the Surgeon General. On key 
public health issues, the Surgeon General has been muzzled. The 
Surgeon General's greatest resource, his or her ability to 
speak honestly and credibly to the Nation about public health, 
is in grave jeopardy.
    Dr. Richard Carmona, the most recent Surgeon General, will 
tell us that on issue after issue, he was blocked from speaking 
out and prevented from using the best medical science to 
educate the American people. In his words, ``the job of the 
Surgeon General is to be the doctor of a Nation, not the doctor 
of a political party.'' Yet Dr. Carmona will tell us that he 
was astounded by the degree of partisanship and political 
manipulation he experienced. And he will describe how, 
``anything that doesn't fit into the political appointee's 
ideological, theological or political agenda is ignored, 
marginalized or simply buried.''
    Politics and science will always intersect in government, 
and Dr. Carmona is not the only Surgeon General to face 
political interference. Dr. C. Everett Koop was the Surgeon 
General during the Reagan administration and was told not to 
speak out on the subject of AIDS, which was regarded as a gay 
disease. He courageously resisted this pressure. Dr. David 
Satcher served as Surgeon General under President Clinton. He, 
too, faced political interference. His efforts to release a 
report on the benefits of needle exchange programs were 
blocked, an action that President Clinton called a mistake. And 
when he wanted to release a report promoting the use of condoms 
and other responsible sexual behaviors, he was told to submit 
his report for publication in a medical journal rather than 
release it as another Surgeon General's report.
    But as we will hear this morning, political interference 
with the work of the Surgeon General appears to have reached a 
new level in this administration. We will hear how reports were 
blocked, speeches were censored and travel restricted. We will 
also hear how the Surgeon General had to resist repeated 
efforts to enlist his office to advance partisan political 
agendas. The public expects that a Surgeon General will be 
immune from political pressure and be allowed to express his or 
her professional views based on the best available science, but 
when the science-based views of the Surgeon General, like Dr. 
Carmona, are marginalized and ignored, that essential 
independence is lost.
    The oversight should serve two purposes. It should expose 
problems in how our government operates, and it should point 
the way to a reform. Today we will learn how political 
interference is undermining the Office of the Surgeon General, 
but we will also hear the recommendations of Drs. Koop, Satcher 
and Carmona for restoring the independence and the 
effectiveness of the Office of the Surgeon General. We need to 
pay as much attention to their prescription for reform as we do 
their diagnosis for ills.
    The position of Surgeon General is a revered post in our 
government. Fixing what is wrong and making the office work 
again should be a bipartisan priority. In 2 days the Senate 
Committee on Health, Education, Labor and Pensions will take up 
the nomination of Dr. James Holsinger, Jr., to the position of 
Surgeon General. Today's hearing does not concern this 
nomination of Dr. Holsinger's credentials, but I am hopeful 
that today's testimony will be of value to Congress and the 
American people as we consider the challenges facing the next 
Surgeon General, whoever he or she may be.
    [The prepared statement of Chairman Henry A. Waxman 
follows:]

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    Chairman Waxman. We are fortunate to have a distinguished 
panel of three former Surgeon Generals with us today, and I 
look forward to their testimony. But before we hear from them, 
I will recognize the ranking member of the committee Mr. Davis.
    Mr. Davis of Virginia. Thank you, Chairman Waxman, for 
convening this hearing on a common issue. The Surgeon General, 
often referred to as the Nation's doctor, has played a pivotal 
role over the years in educating Americans on important health 
matters. From our most visible health advocate, we have learned 
about the dangers of using tobacco, the health effects of 
secondhand smoke, underaged drinking and the lethal pathway of 
HIV/AIDS.
    Many of the issues highlighted by Surgeon Generals have 
never been addressed openly before. Some were considered taboo. 
But the medical and moral authority of the Surgeon General's 
voice broke through those barriers and stipulated a central 
public discourse and concrete actions to improve public health.
    Operations of the Surgeon General's office are not a new 
topic of discussion for this committee. We held a hearing in 
2003 to consider the proposal to make the U.S. Public Health 
Service Commissioned Corps a more readily deployable force in 
the Federal medical response to national disasters. As head of 
the committee, the Corps of the Surgeon General leads a cadre 
of highly trained and mobile health professionals who can 
respond to the Nation's acute and chronic health needs. Surgeon 
Generals Koop and Carmona both testified at that hearing, and 
we welcome their insights again today as we discuss more 
broadly the role of the future of the office that they both 
held.
    The committee also examined the Commissioned Corps' 
deployment to the gulf coast after Hurricane Katrina. The 
Surgeon General's Office was notified there was problem after 
landfall and that their assistance would be necessary. Those 
offices provided much-needed care to evacuees and provided a 
critical complement to the Federal Government's overall medical 
response. In the wake of that historic storm, more than 1,000 
Commissioned Corps officers were deployed in that region. That 
effort was led by former Surgeon General Carmona.
    With the rich history and vital function, the Surgeon 
General and I look forward to continuing our discussion today 
on how to enhance the role of that office as our Nation 
confronts the next generation of public health threats. We need 
to discuss the importance of keeping the Surgeon General 
independent and free to communicate directly to the American 
people on disease prevention and health promotion.
    As we all know, our doctors sometimes have to deliver bad 
news. Likewise, the Nation's doctor is often called upon to 
make findings that might be controversial or politically 
inconvenient to the administration of the day, Republican or 
Democratic. But waiting or sugarcoating hard truths only allows 
public health problems to fester and grow worse. The voice of 
the Surgeon General can be a powerful antidote to societal 
health and should not be muted or filtered through layers of 
needless bureaucratic or political approvals.
    The physicians on this distinguished panel of witnesses 
have already made invaluable contributions to American public 
health. We are grateful for the experience, the expertise and 
the insights they bring to today's discussion of the Surgeon 
General's vital role in protecting and improving the Nation's 
well-being. Thank you.
    Chairman Waxman. Thank you, Mr. Davis.
    [The prepared statement of Hon. Tom Davis follows:]

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    Chairman Waxman. Ms. Norton, do you wish to make a 
statement?
    Ms. Norton. Thank you very much, Mr. Chairman. Just a very 
brief statement.
    First, a statement of gratitude that you are holding a 
hearing. The reason I express such gratitude is because the 
Surgeon General very often speaks on health to the American 
people and can have a remarkable effect simply by writing a 
report. So the lack of such reports in recent years, when one 
man can almost single-handedly, by speaking out, get people to 
think about smoking and to have a material effect, not by going 
to the doctor, not by being approached, just by issuing a 
report, when you have that kind of power, it is important to 
use it.
    Now, there had been a report on obesity. There needs to be 
another one, because we now have not only a childhood obesity 
epidemic before our very eyes that no amount of healthcare will 
solve when these children get to be adults, but we have a 
remarkable trend where in every age group, in every income 
group, in every race, people are fat. And we see these fat 
people in our own constituencies, and we have nothing 
authoritative that speaks to them.
    And if I may say one more thing, Mr. Chairman. There is an 
HIV/AIDS epidemic that has settled in the African American 
community, and shame on the Surgeon Generals of the United 
States for not pointing out that 50 percent of the cases today 
are African American, and we are 12 percent of the population. 
How could that happen? Stereotyping this disease, as the 
chairman said, initially as a gay disease can be controversial, 
and it was certainly wrong, but imagine allowing it to travel 
over into another community and not one word.
    Finally, in the District of Columbia, everybody should be 
tested in the United States to wipe away the stigma, to wipe 
away the superstition and the homophobia. If the Surgeon 
General is to recoup his major role in American history not by 
telling us what to do, but by speaking authoritatively to the 
American people, then he must begin by speaking to us about the 
issues we can do something about, and I have named two of them. 
Obesity and HIV/AIDS are both preventable. One word from the 
Surgeon General can do more than a multitude of hearings, as 
important as they are, from Congress.
    Thank you, Mr. Chairman.
    Chairman Waxman. Thank you, Ms. Norton.
    Mr. Issa.
    Mr. Issa. Thank you, Mr. Chairman. I'll put my entire 
opening statement in for the record, but I would just like to 
thank our distinguished panel for being here today.
    I, like the chairman, would like to take full advantage of 
the independence of our Surgeon Generals. I believe that today 
we are going to have an opportunity to delve into a number of 
areas. The area that I would like to spend the most time on is 
one that is near and dear to the chairman, and that is private 
health care, why does it cost so much; public health care, why 
does it not meet the expectations of the American people; and 
can we mend it, either one of them, or do we need to end them? 
So I am going to very much take advantage of sort of the 
independence, and particularly in Dr. Koop's case, the 
independence that comes from some time out of some of the 
public limelight.
    I very much thank the chairman for holding this hearing and 
would hope that this is a unique opportunity to ask the 
questions that are very hard to ask in a normal hearing where 
we either have the pharmaceutical industry or advocate industry 
or some group that has a financial bent, if you will, in 
answering the questions.
    Mr. Chairman, I'll hold the rest of my questions, and I 
thank you for holding this hearing today.
    Chairman Waxman. Thank you, Mr. Issa.
    Mr. Sarbanes, do you want to make any opening statement 
before we begin?
    Mr. Sarbanes. No, Mr. Chairman, just thank you for holding 
the hearing and looking forward to openings.
    Chairman Waxman. Thank you.
    We do have three very distinguished former Surgeon 
Generals, individuals who have served our country with honor 
and distinction during four Presidential administrations. Dr. 
C. Everett Koop served as our 13th Surgeon General from 1981 to 
1989. A pediatric surgeon by training, he is widely credited 
for making the Office of the Surgeon General a scientific and 
principled force in American life. More than any of his 
predecessors, Dr. Koop made the office a bully pulpit for 
public health. His standing in the eyes of the American public 
allowed him to tackle many sensitive and politically 
controversial issues, most notably the AIDS epidemic, which 
emerged as a major threat to public health. During his tenure 
as Surgeon General he spoke also forcefully and repeatedly 
about the health consequences of smoking. And I am very pleased 
to welcome Dr. Koop back with us today.
    Dr. Koop, as you well know, I was initially very skeptical 
about your nomination when President Reagan put it forward. I 
was wrong, and I have come to know you as a professional 
dedicated to the public good and public health. You had the 
courage to speak truth to power and the good sense to 
distinguish public health from politics. And I learned to 
admire you and to enjoy working with you over the years on 
tobacco and HIV and children's health. And I look forward from 
hearing your testimony today. But I wanted to pay a special 
tribute to you through the years that we have worked together.
    Our second witness, Dr. David Satcher, served as the 16th 
Surgeon General from 1998 to 2001. A family physician with 
additional training in public health, Dr. Satcher served for 6 
years as Director for the Centers for Disease Control and 
Prevention. During his tenure as Surgeon General, Dr. Satcher 
issued a number of important reports, most notably his 1999 
Surgeon General's Report on Mental Health, which did much to 
remove the stigma from mental illness, and his 2001 Surgeon 
General's Call to Action to Promote Sexual Health and 
Responsible Sexual Behavior. He also released influential 
reports on oral health, youth violence and the prevention of 
tobacco use by young people.
    Dr. Satcher, we are very pleased to have you with us here, 
and I enjoyed the time that we worked together as well.
    Our third witness, Dr. Richard H. Carmona, served as the 
17th Surgeon General from 2002 to 2006. A combat-decorated 
veteran of the Special Forces, Dr. Carmona brought a varied 
background in health care to the position. At different points 
in his career, he was a paramedic, registered nurse, trauma 
surgeon and health care administrator. Although some criticize 
him for maintaining a low profile as Surgeon General, he 
released a number of important reports and calls to action 
during his tenure. These included the Surgeon General's Call to 
Action to improve the health and wellness of persons with 
disabilities issued in 2004, and his landmark Surgeon General's 
Report on the Health Consequences of Involuntary Exposure to 
Tobacco Smoke, released shortly toward the end of his term of 
service.
    And, Dr. Carmona, I am delighted that you are here as well.
    It is the practice of this committee to do this for all 
witnesses. We do ask you to be sworn in, and I would like to 
ask you if you would raise your right hands. Stand and raise 
your right hands, if you are able to do that.
    [Witnesses sworn.]
    Chairman Waxman. The record will indicate that each of the 
witnesses answered in the affirmative.
    I am going to call on Dr. Koop first, then call on Mr. 
Satcher and then Dr. Carmona.
    Dr. Koop, there is a button on the base of the mic.

   STATEMENTS OF C. EVERETT KOOP, M.D., Sc.D., 13TH SURGEON 
 GENERAL, 1981-1989; DAVID SATCHER, M.D., Ph.D., 16TH SURGEON 
GENERAL, 1998-2001; AND RICHARD CARMONA, M.D, M.P.H, F.A.C.S., 
                17TH SURGEON GENERAL, 2002-2006

                  STATEMENT OF C. EVERETT KOOP

    Dr. Koop. Mr. Chairman, members of the committee, I am C. 
Everett Koop, Surgeon General for 7 years when Ronald Reagan 
was President and 1 year with George Bush, Sr. My remarks come 
from the vantage point of 26 years of close observation of the 
office and of its mission.
    I strongly believe that the Surgeon General must be 
independent and free to advise the Nation on how it can prevent 
disease and promote good health. He or she should be the health 
educator for Americans par excellence. At the same time the 
Surgeon General should be an important cog in the machinery 
that directs public health in the United States, and I acted in 
these capacities. In addition to working within the United 
States, I served for 8 years as our Nation's representative to 
the World Health Organization. The consensus of the 
representatives of other nations for my role was something like 
this: What a wonderfully appropriate position. I wish we had 
such an office and such a person.
    The personalities of two individuals have much to do with 
the success of the Surgeon General; first, the President of the 
United States. Mr. Reagan was pressed to fire me every day, 
largely because of my work on AIDS, but he would not interfere. 
If he had not been the kind of person he was, I would not be 
here today.
    Second, the Secretary of HHS. On a day-to-day basis, the 
Secretary is the most influential person in determining the 
effectiveness of the Surgeon General. I served under four. The 
last one was Dr. Otis Bowen, a three-time Governor of Indiana, 
a medical doctor, and a fine gentleman. When I was writing the 
Surgeon General's Report on AIDS and the later mailing sent to 
every household in America, he was a constantly supportive 
gentleman. It was Otis Bowen who insisted that I sign the 
documents in question myself. I asked Otis Bowen to keep the 
contents of these two reports close to his chest. I promised to 
do the same. In addition to the two of us, only two staffers 
were privy to the contents. We maintained strict secrecy from 
the day we began to write until we presented the finished 
product, 17 drafts later, and released them to the press. If we 
had followed the protocol and every word was scrutinized, these 
reports, because of their nature and plain speaking, I am sure 
would not have seen the light of day.
    The Secretary of Health and Human Services can use the 
talents of the Surgeon General or ignore them. In that regard, 
my successors were less fortunate than I. Over the years since 
I left office, I have observed a worrisome trend of less than 
ideal treatment of the Surgeon General, including undermining 
his authority at times when his role and function seemed 
abundantly clear.
    If I had been impeded in my duties as some of my successors 
were, here are some of the things that would never have 
happened. Eight reports to Congress on smoking and health might 
not have been published. The knowledge of the addiction of 
tobacco because of its nicotine content might have been 
suppressed. We might have still have smoking on airplanes. 
Changes in Title V of the Social Security Act entitling special 
needs children to comprehensive, family centered, community-
based care might not have happened, either. Assurance during 
the Tylenol scare would have been missing, leading to panic and 
possible market upheaval. Revision of the health care 
agreements with the People's Republic of China, the Soviet 
Union and Kuwait might not have occurred. The only Federal 
Government report on nutrition might not have been published, 
and many, many more that time does not permit to tell.
    Clearly the Surgeon General must be free to serve the 
American people without political interference. It is also 
vital that future Surgeon Generals have the necessary support 
and resources to do their job. How can we ensure that this 
happens? First I believe that the Surgeon General should not be 
a political appointment. In my opinion, the Surgeon General 
should be named by the President from a panel selected by the 
Promotions Committee of the Commissioned Corps of the U.S. 
Public Health Service. This was once the protocol, and it 
served our country well for nearly 100 years. It remains today 
the protocol used to appoint the Surgeons General of the Army, 
Navy and the Air Force.
    Second, the Surgeon General must have secure funding to do 
his work. The security of a 4-year appointment doesn't mean 
much if you can be easily denied the resources you need to do 
your job. Therefore, I recommend that Congress annually 
appropriate funding on a line-item basis to the Office of the 
Surgeon General.
    In closing, I may say, Mr. Chairman, as you already 
mentioned, you were from the beginning one of my severest 
critics. You became one of my trusted supporters, and I thank 
you for that and the excellent job, sir, that you have done in 
improving the health of the American people. Please continue to 
exercise oversight of the Office of the Surgeon General and the 
Commissioned Corps of the Public Health Service so that they 
can continue to do their vital work. Thank you, sir.
    Chairman Waxman. Thank you very much, Dr. Koop.
    [The prepared statement of Dr. Koop follows:]

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    Chairman Waxman. Dr. Satcher.

                   STATEMENT OF DAVID SATCHER

    Dr. Satcher. Thank you, Chairman Waxman and members of the 
committee, for holding this hearing and for your attention to 
the importance of the Office of the Surgeon General. I had the 
opportunity to serve for almost 9 years in government, 5 years 
as Director of the Center for Disease Control and Prevention, 
and 4 years as Surgeon General, 3 of which I also served as 
Assistant Secretary for Health. Also I had the opportunity to 
represent the United States as a delegate to the World Health 
Assembly for 9 years and to interact with colleagues from 
throughout the world, and I share the experience of what 
Surgeon General Koop had in terms of their admiration for the 
unique role which the Surgeon General plays in the health of 
the American people.
    It is my opinion that we critically maintain a role of the 
Surgeon General. The Surgeon General is responsible for 
communicating directly with the American people based on the 
best available science, not politics, not religion, not even 
personal opinion. The Surgeon General does this, as you have 
heard, through speeches, writings, press conferences and 
especially the Surgeon General's reports. These Surgeon General 
reports are vetted with the relevant scientists at the CDC and 
other appropriate agencies.
    During my 4-year tenure as Surgeon General, I had the 
opportunity to release reports on mental health, suicide 
prevention, youth violence, smoking and health, oral health, 
overweight and obesity, and the Surgeon General's Call for 
Action for Responsible Sexual Behavior. The reports on mental 
health, oral health, suicide prevention, youth violence and 
sexual health were the first from the Office of the Surgeon 
General. The overweight and obesity report was also the first 
to follow a report on nutrition that had been done in the 
1980's.
    The Surgeon General's Office has evolved over the years 
since 1873 with changes in level and magnitude of 
responsibility. Today the Surgeon General oversees the 
Commissioned Corps--health professionals who are on call 24 
hours a day, 7 days a week to respond to emergencies.
    What has not changed about the Surgeon General's Office is 
its direct responsibility for communicating with the American 
people based on the best available science, and its 
responsibility for responding to public health emergencies that 
threaten the health of the American people--regardless of where 
those emergencies occur.
    There have always been challenges to the role of the 
Surgeon General. Sometimes these challenges are based on the 
political nature of issues or the religious implications of 
issues. However, the Surgeon General's Office has a remarkable 
record of credibility and trust in communicating with the 
American people based on the best available science.
    The Surgeon General's Office would benefit tremendously 
from being more independent, with well-defined resources for 
carrying out the duties of that office. It is clear that the 
American people value the Office of the Surgeon General, and 
that the global community has tremendous respect and 
appreciation for the office.
    After I released the Surgeon General's Report on Mental 
Health in the United States, I had an opportunity to present 
that report to Director Gro Brundtland of the World Health 
Organization in May 2000. That resulted in the World Health 
Organization later issuing a world mental health report which 
all the ministers of health around the world valued very 
highly. During my tenure I was able to release some very 
valuable reports with lasting impact. However, certain areas of 
health, especially areas that are politically sensitive, such 
as drugs and sex, despite their great significance in dealing 
with issues such as HIV/AIDS, were often hampered by politics 
and/or religious implication.
    I have, in my written report to you, described my 
experience with the needle exchange program. As the Director of 
the CDC, I oversaw the funding of research programs evaluating 
the impact of needle exchange programs in reducing the spread 
of HIV/AIDS and showing that there was no increase in drug use. 
I submitted that report to the Department. Soon after I became 
Surgeon General, we planned to have a press conference to 
release that report to the American people, and we were hoping 
it would lead to Federal funding for the needle exchange 
program. I think because of the political environment and the 
almost certain defeat of the needle exchange program with 
Congress, the White House made a decision the day before the 
press conference not to support it. That left me in a very 
difficult position as both Assistant Secretary for Health and 
Surgeon General. As Assistant Secretary For Health, I was 
expected to support the position of the White House and the 
Department. But as Surgeon General, my responsibility was to 
speak to the American people based on the best available public 
health science.
    I did the latter. I went throughout the country speaking 
about the value of needle exchange programs. Many localities 
funded those programs, and, as you know, the Congress has not 
yet supported the funding of needle exchange programs. But it 
is an example of why it is so important the Surgeon General 
should be able to speak on this or the best available science, 
and not politics and not religion.
    Later, I completed a report, the Surgeon General's Call to 
Action to Promote Sexual Health and Responsible Sexual 
Behavior. That report was actually completed during the Clinton 
administration, and, as you know, I served my last year in the 
new Bush administration. I was hampered from releasing that 
report during the Clinton administration, but also the new Bush 
administration. I was able to finally release it, but without 
the support of the Department. It is the only report I released 
that was not signed off on by the Secretary. I released that 
report in 2001 during my last year as Surgeon General. The 
President and the Secretary did not support that report, and 
they did not support it because of obviously both its political 
and religious implications.
    I think it is OK for the White House or the Congress to 
disagree with the Surgeon General on issues, because the 
American people look to the Surgeon General for the best 
available science. I don't think it is OK for the White House 
or the Congress to dictate the messages of the Surgeon General, 
and that is our concern, that the Surgeon General's Office be 
independent enough to speak directly to the American people 
based on the best available science. So I join Surgeon General 
Koop in asking that Congress take those steps to make this 
office independent enough to communicate directly with the 
American people based on the best available public health 
science, and that it be adequately funded by an independent 
source of funding for Congress so that it can carry out those 
responsibilities.
    I'll end my comments with one story. When I released the 
Surgeon General's Report on Mental Health, I received letters 
from people all over the country expressing their appreciation 
because they had members in their families who suffered from 
mental illness, and there had been so much stigma surrounding 
it until they just felt embarrassed to even talk about it. One 
young man wrote that when he was 8 years old, his mother died, 
and he didn't learn until he was 20 that she had committed 
suicide. And he explained how he heard people whispering about 
her death, but nobody would talk about the condition that led 
to it. She had suffered from severe depression. And, again, he 
thanked the Office of the Surgeon General for bringing mental 
health out of the closet, helping to remove the stigma.
    We have much more to do, but I hope that we will be able to 
rely upon the Office of the Surgeon General to provide that 
kind of leadership. Thank you.
    Chairman Waxman. Thank you very much, Dr. Satcher.
    [The prepared statement of Dr. Satcher follows:]

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    Chairman Waxman. Dr. Carmona.

                  STATEMENT OF RICHARD CARMONA

    Dr. Carmona. Good morning, Mr. Chairman, distinguished 
members of the committee. My name is Richard Carmona. I am the 
17th Surgeon General of the United States, and I am profoundly 
grateful for your invitation to me and my Surgeon General 
colleagues to testify before you today. I want to thank you for 
your interest and commitment to these very important national 
public health issues.
    I had the privilege of working with many of you during the 
4 years I served as U.S. Surgeon General, and I stand ready to 
continue to partner with you to improve the health and well-
being of our great Nation and the world. Being nominated and 
confirmed as Surgeon General is still a surreal event for me. I 
will never forget the extraordinary privilege that the 
President of the United States and the Senate extended to me 
allowing me to serve my country once again in uniform.
    As grateful as I am to my country for the opportunities 
that I have been afforded, that sense of appreciation will 
never allow me to become complacent in my commitment to 
continue to improve the health, safety and security of our 
Nation and the world. As members of a very small and unique 
fraternity of Surgeons General of the United States, we all 
believe that once a Surgeon General, always a Surgeon General.
    I came to Washington, DC, having served as a U.S. Army 
Special Forces medic and weapons specialist, a registered 
nurse, police officer, SWAT team leader, trauma surgeon and CEO 
of a public health and hospital system and a university 
professor. I also came to the Office of the Surgeon General 
knowing what it feels like to be a poor Hispanic child growing 
up in New York City, a high school dropout whose family often 
had to stand in line at public hospitals waiting for health 
care and not knowing how we would pay for the doctor's bill, 
and sometimes not even knowing where our next meal would come 
from.
    I came to our Nation's Capital wanting to serve all people 
and prepared to carry on what I believed was a tradition of 
implementing nonpartisan, evidence-based solutions to public 
health challenges. My fellow U.S. Surgeons General warned me 
that partisan political agendas often undermine the public 
health and well-being of the Nation.
    During my first year as Surgeon General, I was still quite 
politically naive in the ways of the Beltway. As I witnessed 
partisanship and political manipulation, I was astounded, but 
also unsure of what I was witnessing for I had no reference 
point. I asked myself whether this was just happening to me as 
a new Surgeon General, or whether this was a norm for all 
Surgeons General.
    I turned to my fellow Surgeons General, the men and women 
who came before me and made tremendous positive contributions 
to the science and practice of public health, who had saved and 
improved millions of lives through their work and dedication. 
They became my mentors. They said that they had all been 
challenged and had to fight political battles in order to do 
their job as the doctor of the Nation. But each agreed that 
never had they seen Washington, DC, so partisan or a new 
Surgeon General so politically challenged and marginalized as 
during my tenure. They told me that although most Americans 
believe that the Surgeon General has the ability to impact the 
course of public health as the Nation's doctor, the reality is 
that the Nation's doctor has been marginalized and relegated to 
a position with no independent budget and with supervisors who 
are political appointees with partisan agendas. Anything that 
doesn't fit into the political appointee's ideological, 
theological or political agenda is often ignored, marginalized 
or simply buried.
    The problem with this approach is that in public health, as 
in a democracy, there is nothing worse than ignoring science or 
marginalizing the voice of science for reasons driven by 
changing political winds. The job of the Surgeon General is to 
be the doctor of the Nation, not the doctor of a political 
party.
    The good news is that there is a straightforward remedy to 
the problem of partisan politics undermining the health and 
well-being of our Nation. That solution is to empower the 
Office of the Surgeon General and the U.S. Public Health 
Service Commissioned Corps. This would not be a radical new 
approach. It would simply be reinstating the roles and 
responsibilities of the Office of the Surgeon General that had 
been slowly eroded since politicians decided in the late 1960's 
that the Office of the Surgeon General should be disempowered 
and its authorities placed within the offices of the Department 
of Health and Human Services political appointees.
    Historically the Surgeons General had occupied increasingly 
embattled positions where each has had to fight to 
scientifically address the contemporary health issues of the 
Nation and the world within an increasingly partisan agenda 
that is often devoid of open discussion of scientific evidence 
or data. To address these problems we must empower, fund and 
support the Office of the Surgeon General and U.S. Public 
Health Service Commissioned Corps to serve the people and the 
world and not a political party. The Commissioned Corps 
delivers arguably the best evidence-based health care in the 
world. With unparalleled passion and dignity, they are a 
precious resource that can be used much more efficiently and 
effectively to serve the public health needs of our Nation and 
the world.
    Require a uniformed, physically fit professional 
Commissioned Corps with continuity of operations between 
administrations and Surgeons General, as is the basic protocol 
among all of our fellow uniformed services.
    End the practice of the political discretionary awarding of 
a four-star admiral rank to HHS Assistant Secretary for Health, 
who may be a civilian political appointee with no uniformed 
service experience.
    Ensure that all future Surgeons General are nominated by 
the President of the United States from the ranks of career 
U.S. Public Health Service Commissioned Corps officers based on 
merit and without political, ideological or theological 
filters. This is just as the U.S. Army, Navy and Air Force 
Surgeon Generals are selected and how the U.S. Surgeon General 
was selected, until the position became increasingly 
politicized.
    In addition, we should consider going back to the 
nonpolitical U.S. Public Health Service Commissioned Corps 
officers ascending the ranks based on merit in order to command 
our Public Health Service agencies again, just as our sister 
uniformed services do and have done for centuries.
    In closing, I hope that you will hear me and my fellow 
Surgeon Generals today and make the decisions and changes that 
only you can make so that future Surgeon Generals do not have 
to struggle against impossible odds to ensure that public 
health is free of political manipulation. I hope that you will 
agree with us that the citizens of the United States deserve a 
Surgeon General as a doctor of our Nation and leader of the 
U.S. Public Health Service Commissioned Corps, who is empowered 
and supported by the U.S. Government to address our national 
and global health issues transparently, openly and 
apolitically, with the best science, in order to improve the 
health, safety and security of our Nation and the world.
    Thank you, Mr. Chairman.
    Chairman Waxman. Thank you very much, Dr. Carmona.
    [The prepared statement of Dr. Carmona follows:]

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    Chairman Waxman. We are now going to proceed to questions. 
I will have 10 minutes, Mr. Davis will have 10 minutes, then we 
will go to 5-minute rounds.
    Dr. Carmona, that is a very strong statement. It appears 
that both Dr. Koop and Dr. Satcher both had the ability to be 
the Surgeon General, to use science, to use the position as a 
bully pulpit, interfered with. But it seems to me what you are 
saying is that even though you consulted with them, the 
experience you had was even worse, and it is now a new 
magnitude of involvement and interference. Is that the message 
I should get?
    Dr. Carmona. Mr. Chairman, I believe that's correct. As I 
said in my statement, my first year of being somewhat 
politically naive, and as much education as I had, nothing can 
prepare you for what you finally come to witness in Washington. 
And being devoid of a reference point, I sought their good 
counsel to say, what's going on here, did you have these 
problems? And it was Surgeon General Koop who pointed out, and 
still does today, he said to me, Richard, we all have fought 
these battles, as have our predecessors going back over a 
century, but we have never seen it as partisan, as malicious, 
as vindictive, as mean-spirited as it is today, and you clearly 
have it worse than any of us had.
    Chairman Waxman. But you tried to fill the role and did a 
responsible job of trying to provide accurate science-based 
information. But you indicate that at times you were 
marginalized or simply had your reports or ideas buried.
    You came in as Surgeon General in 2002, and at that time 
there was a great national debate about the role of stem cells 
in medical research. I understand you thought the Surgeon 
General could play a constructive role in explaining this 
issue, just the science of it, to the American public. Could 
you tell us what you tried to do, and what the result was?
    Dr. Carmona. Yes, Mr. Chairman, I would be happy to.
    I recognize that notwithstanding stem cell issues, the 
Nation suffers from health illiteracy. The literature is clear, 
about a third of the Nation really doesn't understand the 
science we have to deal with every day, it doesn't understand 
the relationship that their behavior has to ultimate health 
outcomes. And I saw this debate going around not only as a 
Surgeon General, but I witnessed it as a professor, and I saw 
that much of the discussion was being moved forward devoid of 
science.
    And so I approached leadership to say the Surgeon General 
should be leaning forward on this; we should be, in fact, in 
the debate on this issue so that we make sure the American 
public, and our elected officials, our appointed officials are 
all knowledgeable of the science.
    Much of the discussion was being driven by theology, 
ideology, and preconceived beliefs that were scientifically 
incorrect. So I thought this is a perfect example of the 
Surgeon General being able to step forward, educate the 
American public as well as elected appointed officials so that 
we can have, if you will, informed consent on an issue to the 
American public to make better decisions.
    I was blocked at every turn. I was told the decision had 
already been made, stand down, don't talk about it. That 
information was removed from my speeches.
    Chairman Waxman. Who would remove a portion of your speech?
    Dr. Carmona. There were people who were actually assigned 
in the Department to vet my speeches to speechwriters who were 
helping me put together talking points and things like that. 
Unfortunately I was naive enough during my first year that I 
didn't recognize this was happening. Many of the staff, in 
trying to protect me, didn't tell me the embattled problems and 
positions that they were in in trying to help me bring the best 
science forward, but constantly being vetted, and politically 
vetted, I should say, not scientifically vetted. And it was a 
while before I figured out that this was happening behind the 
scenes.
    Chairman Waxman. Did you have any of your other speeches 
vetted and censored?
    Dr. Carmona. Repeatedly.
    Chairman Waxman. Repeatedly.
    Dr. Carmona. Yes.
    Chairman Waxman. And were these scientists or physicians 
that were doing it, or political people?
    Dr. Carmona. No. In fact, I welcome input from my 
colleagues on science. I often called my NIH colleagues and 
CDC, my officers in other departments, to say, what do you 
think about this, give me the best science. And I would bring 
groups together to achieve consensus on a scientific issue.
    The vetting was done by political appointees who were 
specifically there to be able to spin, if you will, my words in 
such a way that would be preferable to a political or 
ideologically preconceived notion that had nothing to do with 
science.
    Chairman Waxman. Were you allowed to speak freely to 
reporters?
    Dr. Carmona. No. I was often instructed what to say or what 
not to say. I did the best I could to speak out on issues 
honestly. I never lied, I never covered the truth. But it was a 
fine line that I walked all the time, because often the 
particular issue already had a preconceived political solution, 
and I had nothing to do with it. And what I found in my first 
year was that I would see policy moving forward, and I would 
scratch my head and think, shouldn't the Surgeon General have 
been involved in this discussion? Yet I had nothing to do with 
it, but yet be expected to support these notions that were 
released to the press, through policy, legislation and such. I 
had no input into them prospectively.
    Chairman Waxman. The President made a decision on stopping 
research using embryonic stem cells. He claimed he had a 
certain number of lines of cells that were already in 
existence, and he would allow that research to go forward. It 
may not have been the decision you agreed with, but it was his 
decision. What do you think your role should be after the 
President decides for the administration what that 
administration's policy would be?
    Dr. Carmona. Well, Mr. Chairman, I think clearly the 
President of the United States, as the senior elected official, 
has the authority to do what he sees fit, as does Congress as 
the elected officials representing our citizens. However, I 
think as part of the due diligence the Surgeon General should 
be at the table representing our colleagues in science as it 
relates to the issue.
    Make no mistake, I think I speak with my fellow Surgeon 
Generals on this as well, we recognize that ultimately the 
authority rests with those elected officials. The danger is 
when the science is not heard, when the policy, when ideas are 
promulgated forward in front of the American public devoid of 
scientific discussion, where the Surgeon General is 
marginalized; that is the danger.
    Chairman Waxman. Were you going to advance a particular 
point of view on research, or were you going to simply discuss 
the science and what it would mean if embryonic stem cells or 
any other stem cells were used?
    Dr. Carmona. Mr. Chairman, I think the Surgeon General 
walks a fine line. Certainly if asked by senior officials to 
discuss an opinion as to what an appropriate course of action 
should be, I think that is a perfectly good role for the 
Surgeon General, but also recognizing that it is ultimately the 
elected official and officials who have the authority to make 
the final decision. So that had I been asked, my discussion 
would have been more about the science of stem cells devoid of 
the political ideological banter that was going on so that the 
American public could understand, if you will, the risks, the 
benefits, and the costs of going in a certain direction and 
understand the science of stem cells. Because that, I felt, was 
devoid within these discussions that were mostly being driven 
politically, ideologically or theologically.
    Chairman Waxman. Well, is this a unique issue? Did you have 
experience with the administration, other political appointees 
in the administration, interfering with other discussions on 
public health?
    Dr. Carmona. Well, in speaking with some of my colleagues 
in other departments, and not only in HHS, but in others, there 
were those complaints from others.
    Chairman Waxman. I am talking about you.
    Dr. Carmona. Only me specifically.
    Chairman Waxman. A Plan B----
    Dr. Carmona. Yes, sir.
    Chairman Waxman [continuing]. Emergency contraceptive drug, 
comprehensive or abstinence-only sex education. Those are all 
matters the public needs to know more about in terms of just 
the basic science. Were those issues that you tried to speak 
out about and stopped from discussing as well?
    Dr. Carmona. Yes, sir, that is true. On many of those 
issues, I felt at the end that the Surgeon General should be 
taking the lead on discussions with the American public on what 
the science is behind those issues to help the public come to 
some conclusions as to what course of action they might 
support, as well as our elected and appointed officials, that 
they should be aware of the science.
    Chairman Waxman. What was the interference? Did they tell 
you you can't talk about it, did they review your speeches, did 
they edit speeches and remarks to the press, edit reports? What 
was the way in which you were interfered?
    Dr. Carmona. All of the above, sir, all of the above. And, 
for instance, on abstinence education, when that came up, a lot 
of my colleagues, my colleague Surgeon Generals, have said, 
this position of the U.S. Surgeon General really has morphed 
into a global position. I would regularly speak with health 
ministers and leaders from other countries who would call for 
information and would ask us questions. And on the abstinence 
issue, right away I started getting a lot of calls from our 
colleagues in the United States and even overseas who would 
say, well, how can you only support abstinence only? That flies 
in the face of public health science. I said, I don't. I said, 
if you look at any one of my presentations, it was always about 
a comprehensive approach to sexual education, largely based on 
my predecessor David Satcher's work, who had brought that 
information forward before I came. And I built on that 
platform. However, there was already a policy in place that did 
not want to hear the science, but wanted to just, if you will, 
``preach abstinence,'' which I felt was scientifically 
incorrect.
    Chairman Waxman. Well, I thank you for your comments and 
responses to these questions. I know many of my colleagues will 
have further questions of you. But I do think that the Surgeon 
General has to be independent if the Surgeon General is going 
to have any credibility. And the credibility of that position 
is what is the key to the success of the Surgeon Generals that 
we have had over the years.
    If my colleagues will just indulge me. I was in the Soviet 
Union, and I was with some dissidents, and they were smoking 
cigarettes like crazy. And I asked one of them, don't you have 
any warnings on your cigarette packs that tell you how 
dangerous it is? And I was told by one of the dissidents, this 
is a warning put on by the government. How can you believe 
anything the government tells you? Well, if it is the 
government telling you that political point of view, you start 
not believing anything the government has to say, unless there 
is some credible, independent scientific statement which 
supersedes the politics.
    Dr. Carmona. Mr. Chairman, may I just make a comment on 
that to echo what my colleagues have said? After I got over my 
political naivite and I started traveling, I had the same 
experience that Surgeon Generals Koop and Satcher had. As I met 
with my colleagues in the World Health Organization, they 
looked at the Surgeon General position as one of a beacon of 
hope, one that really represents the best of America as giving 
truthful information. And I think one of the more perfect 
examples of that would be we fought for years to get out that 
report on secondhand smoke. When it finally got out, because of 
all the political manipulations and marginalization, it slipped 
out. Within 2 weeks, I had calls from six continents, hundreds 
of cities in our own country. I had small restaurateurs in 
Texas, in El Paso, calling and saying, we have the information 
now, we are going smoke-free in all of my restaurants. I had 
governments calling me saying, we have information now from the 
U.S. Surgeon General that will help us make our city, our 
country, smoke-free. The ramifications were rippling because of 
the credibility that your Surgeon General of the United States 
had for the health not only of the Nation, but of the world.
    Chairman Waxman. Thank you very much, Dr. Carmona.
    Mr. Davis.
    Mr. Davis of Virginia. First of all, let me thank all of 
you for your public service. This is a serious job that all 
three of you have taken seriously. I have a great respect for 
the job that all of you have done. I am not sure what the 
boundaries are for appointed political officials who sometimes 
have opinions different from the elected administration. It is 
tough trying to define where you would be a team player and 
where you feel strong enough to speak out with your positions. 
I think you try to balance that every day. Even as 
independently elected Members of Congress, we try to balance 
those issues out.
    So we are talking, I guess, in some of your practical 
experiences trying to get a better understanding. My friend, 
Henry Waxman, makes a good point that at the end of the day the 
job deserves credibility with the American people. But we have 
politicians who run the government, not scientists, for better 
or for worse.
    But, you know, I happen, Mr. Carmona, to agree with you on 
stem cells. I was a cosponsor of Federal funding of stem cells 
to override the veto. But the administration is also entitled 
to make their moral determination over where the boundaries 
should be, notwithstanding what other scientific data is. And 
of course the model of the staters is that the State will be a 
moral terce and enforce the laws, the morality. And, it is very 
difficult, I understand, as part of an appointed team, to be 
part of that and get facts out, and now you are free to say 
whatever you want.
    Dr. Satcher, you went through something similar on your 
report on sexual health and sexual behavior. Could you tell us 
a little bit about that? I think in your testimony you alluded 
to that. But that was also something you felt very strongly 
about and ran into some problems with the administration.
    Dr. Satcher. First, let me respond to something you said 
which I think is important. I think when the Surgeon General is 
speaking only based on his or her opinion, without having the 
science behind it, I think it deserves no more credibility than 
anything else. But when the Surgeon General speaks on the basis 
of the best available public health science, I think the 
American people deserve to hear that independently.
    And the Surgeon General does not make policy. You are 
right, we don't make policy. We were not elected to make 
policy. We were appointed to communicate directly with the 
American people. That should not be interfered with. I think 
that is our concern. I think when the Surgeon General is not 
able to communicate, to write his or her speeches and say what 
they want to say to the American people, I think you have 
crossed the line significantly.
    Mr. Davis of Virginia. Is that true, even when you are 
contradicting the policy of the administration?
    Dr. Satcher. I don't think the Surgeon General necessarily 
should speak about the policy, but the Surgeon General should 
speak about the science. For me to not say that needle exchange 
programs were able to decrease the severity of HIV/AIDS, and 
there was no evidence of increased drug use, I think that would 
have been unfaithful to the science. Congress would ask 
Secretary Shalala for an updated report, and what she did was 
to ask me to write a letter giving her the most recent 
information. When I did, she would say, I just received this 
letter from the Surgeon General, and this is what he said. But 
I think you are right, it has to be based on the best available 
public health science, not personal opinion.
    Mr. Davis of Virginia. Before you get to that, we just had 
a vote last week on needle exchange programs in the District of 
Columbia. My feeling was it is their own money, let them spend 
it the way they want to. There is a ban on Federal funding for 
that. And the reason for that is the policy--although you are 
saying that science is very clear on that, I am not going to 
take issue with you on that in terms of stopping the spread of 
HIV. The policy then becomes if you are a citizen and you go 
into a hospital and you need a needle for IV, if you are on 
Medicare or you are a veteran, you pay for it. But if you are 
using illegal drugs, the government pays for it. And so there 
are contradictions policywise.
    Dr. Satcher. I think you make a very important point. You 
also pay to treat people when they get AIDS. And you really pay 
dearly and society pays dearly because people will infect, 
spread the disease to other people. So you have to make a 
decision. So the Surgeon General is trying to advise based on 
the best available science.
    Mr. Davis of Virginia. No, I understand. But I think there 
are some contradictions. The argument is with the health side. 
I know we will talk in a little bit about this sexual health 
and responsible sexual behavior. You wanted to get this out, 
and you felt this was important to get out to the public.
    Dr. Satcher. Well, it started off by informing the American 
people about the magnitude of the public health problems 
surrounding sexual health; HIV/AIDS, the growing of STDs, 
including the reemergence of syphilis and others. So it really 
talked about the magnitude of--it also talked about sexual 
violence. In fact, 22 percent of women report having been 
assaulted sexually sometime during their life and about 4 
percent of men. So it really put the data out there about the 
magnitude of the sexual health problem. This area, while we are 
not willing to talk about it, is wreaking all kinds of havoc in 
families and individuals. Many people who have been infected 
with AIDS end up infected because they were abused sexually as 
children. So there are a lot of things in the report about 
that.
    I think the most sensitive issues--let us go back to three 
which I think got the report in trouble. We did talk about 
sexual orientation. We said that based on the science, sexual 
orientation is determined in adolescence, and there was no 
scientific evidence that it could be changed. So that was a 
very sensitive issue about sexual orientation. We said that 
regardless of how we felt about people and their sexual 
orientation, they deserve to be respected; not just tolerated, 
but respected as people.
    We talk about comprehensive versus abstinence-only sexual 
health education, and we looked at all of the studies that had 
been done. And we said, based on the studies available to us, 
there was no evidence that abstinence-only sexual health 
education was effective--now, this was 2001--and that, in fact, 
a comprehensive approach to sexual health education was the 
most reasonable approach based on all of the available science.
    And then we talked about sexual health education. We 
recommended that children be educated about their sexuality 
beginning at home. Parents are the first to provide sexual 
health education. It needs to be age appropriate. But it also 
needs to be in schools. I mean, what should happen should be--
regardless of the age of the children, they should learn about 
their sexuality and how to protect themselves and make the 
right decisions about it based on the best available science. 
So those were the three things.
    Mr. Davis of Virginia. When this came up originally though 
the White House was undergoing some political problems; is that 
right.
    Dr. Satcher. Well, I think it is fair to say even though 
the support had been vetted by the CDC and NIH, it had gone to 
all of those scientists, I think it was the political 
environment that carried the day----
    Mr. Davis of Virginia. In the Lewinsky scandal?
    Dr. Satcher. Exactly. There was a political environment 
that carried the day, but I think it is critical when it comes 
to a Surgeon General's report, the Surgeon General should be 
independent in his ability to release them. In the Bush 
administration, I think as Secretary Thompson certainly pointed 
out to me, you know, the politics of sex in Washington, you 
know that even--he made it very clear that support was 
important, but also made it very clear that politically it 
would be very difficult. So I finally----
    Mr. Davis of Virginia. Ms. Elders took a lot of heat also, 
didn't she, on those issues?
    Dr. Satcher. Oh, Jocelyn Elders was fired because of the 
things she said.
    Mr. Davis of Virginia. She took a lot of heat.
    Dr. Satcher. I want to make it very clear that Dr. Elders' 
firing was not about a report----
    Mr. Davis of Virginia. It was about her speaking out.
    Dr. Satcher. It was about her speaking out about issues of 
sexuality. So the report was finally released in the Bush 
administration, and then they made it very clear to me that I 
was on my own.
    I think of course you probably are not aware of some of the 
things that have happened since. Last year after bringing 
together a group of people who met for 18 months, some of the 
most conservative groups in the country, some of the most 
liberal, some of the most moderate, including Medical and 
Educational Association, we released a report that all of those 
people were able to agree on after having met together for a 
year and a half, but a very important report. I would not have 
been able to do that if I had not received foundation funding 
after I left government to continue this effort.
    So as Surgeon General Carmona says, we never stop being 
Surgeon General. I mean once you are Surgeon General, as far as 
we are concerned, you are always responsible.
    Mr. Davis of Virginia. They still call you General, right?
    Dr. Satcher. Exactly.
    Mr. Davis of Virginia. I will have to say, Dr. Koop, I 
really respect the work that you did talking about smoking. The 
effects of secondhand smoke has had a huge effect on 
policymakers on both sides of the aisle.
    So I yield back.
    Chairman Waxman. Thank you, Mr. Davis.
    Ms. Norton.
    Ms. Norton. Thank you, Mr. Chairman. I would like to thank 
all three of you, Dr. Koop, Dr. Carmona, Dr. Satcher.
    Dr. Koop. Can't quite hear you, ma'am.
    Ms. Norton. I would like to thank all three of you for the 
courage and the independence you asserted with considerable 
courage, the three of you have had your courage tested, and it 
is impressive to see how you have responded. I do thank you, 
Dr. Satcher, for being way ahead of your time during the 
Clinton administration who for all of its progressive stance, 
would not in fact support needle exchanges, despite knowing 
full well what the consequences were.
    Dr. Carmona, I must say one would have to congratulate the 
President on his appointment of you a year or so following 9/
11. Here he reaches out and he finds an especially qualified 
Surgeon General because you had been in the Special Forces, you 
were a trauma surgeon, you were an expert in emergency medical 
services, there is a laundry list of challenges.
    I want to ask you about that work particularly, since I 
represent the District of Columbia and because I served on the 
Homeland Security Committee, because this is where the anthrax 
attacks took place, right here at Congress as a matter of fact, 
where we lost two postal workers and you know the rest.
    We have had a hearing in this committee, an astounding 
hearing recently, on how hospital emergency services, 
particularly emergency rooms, are now being stretched to the 
breaking point. As I understand it, you did use your background 
in emergency services and sought permission to prepare a report 
on emergency preparedness; is that so?
    Dr. Carmona. Yes, ma'am, that is correct.
    Ms. Norton. That was before a report was written, sir?
    Dr. Carmona. Well, I can give you a general timeline, 
Ma'am. What happened was I came in shortly after 9/11 and the 
anthrax challenges to our Nation, and as I looked at the gaps 
in our system and where I could assist, especially after being 
appointed by the President and confirmed by Senate, given that 
there was a great deal of fanfare about my background and that 
I was selected because I had this background in emergency 
management and preparedness pretty much my whole life and being 
quite serious in this area.
    I said, well, there are a couple of issues I see before us. 
One, we are a nation that on a good day has inadequate mental 
health care. One in five people can't get mental health care on 
a daily basis in the good times. Now we have war, we have 9/11, 
we have an anthrax attack, we have people feeling very 
uncertain about their futures. What are we doing to shore up 
our mental health issues, why is that important?
    When you look at what terrorism does, we often do very well 
at preparing for the physical wounds, but the psychological 
wounds are lifelong and lasting and can devastate a population. 
So I thought we need to move forward on an emergency 
preparedness report, as well as a report on preparedness that 
would bring our Nation forward so that all citizens would 
understand the threats and challenges before us and what their 
individual responsibility is. Just like we had civil defense in 
the 50's, we were talking about the new civil defense of the 
new world, the new world order. So I moved forward with those 
ideas and tried to move those reports out. Unfortunately, then 
never got out------
    Ms. Norton. Just a moment, this is almost a neutral 
sounding request, emergency preparedness, mental health, where 
did you take your requests for permission and what reason was 
given to you for denying permission?
    Dr. Carmona. Let me tell you, I will go--each of them were 
slightly different, so I will start with the mental health one. 
I had made a commitment to my mental health colleagues 
nationally as well that we needed to move to mental health as 
an agenda item.
    As you know, my colleague, David Satcher, first identified 
some of the issues, and as I took the baton from him, I knew I 
needed to continue moving in the direction based on some of the 
information he had already generated, mental health was one. 
Mental health preparedness was extraordinarily important 
because of----
    Ms. Norton. I am trying to find out, you don't go to the 
President and say I want to do a mental health and emergency 
preparedness. Who do you go to?
    Dr. Carmona. Yes, ma'am. What I did was independently I 
looked at the science, and the first call I made was to my 
colleagues at the National Institutes of Health to say, guys, 
let's have a meeting, I walk to talk to you about the mental 
health needs of the country, specifically as it relates to the 
new threats and challenges of mental health preparedness as a 
working title.
    I got the best scientists in the world together. We had the 
discussion, everybody agreed that this was a huge void in our 
society, and we needed to move this forward. I generated the 
evidence base to move such a report to the American public. I 
went to other agencies, I brought in one of our sister agencies 
who had a political appointee who basically went to HHS, went 
to the White House, and complained vehemently that this was not 
my responsibility, that he was in charge of mental health.
    In fact, I was admonished by this gentleman because he 
said, you don't get it. He said, you don't write anything 
unless we approve it and that this information----
    Ms. Norton. On the mental health report, not only were you 
refused, you were admonished. Before my time is up----
    Dr. Carmona. Yes.
    Ms. Norton. Would you tell me about the report on emergency 
preparedness?
    Dr. Carmona. Emergency preparedness, from what I have seen 
and based on a report I brought my colleagues in to achieve 
consensus, I mean government and people who have national 
reputations, credibility, nonpartisan to achieve consensus, 
everybody had agreed it was absolutely essential to move 
forward.
    I then ran it up the flag pole and went to the domestic 
policy council at the White House, spoke to HHS officials, I 
was given lots of different reasons. This might scare the 
people, you should think about it. The new Department of 
Homeland Security will be responsible and why would the Surgeon 
General do this? I was given lots of reasons, from the cost to 
everything else, not to move this forward.
    Ms. Norton. Who at the White House was responsible that 
told you that the emergency preparedness should not move 
forward?
    Dr. Carmona. I was speaking to the Domestic Policy Council 
just then. I mean if you want those names in the future, I 
would be happy to do it. Since some of these people still work 
in the government, I ask that we do this through private 
communication or a closed hearing because I don't want to put 
anyone in jeopardy.
    Ms. Norton. I respect this request, but this is a public 
hearing, it is going to become public in any case, because we 
believe in transparency, and I leave it up to the chairman as 
to how to handle that.
    Dr. Carmona. Thank you.
    Chairman Waxman. We will take it under advisement and hear 
from Mr. Issa.
    Mr. Issa. Thank you, Mr. Chairman. Dr. Carmona, I feel that 
perhaps what you are telling us here today is that we need to 
cut by 75 percent the number of political appointees we 
authorize the President to make so that a few people have more 
things to do than have turf battles. We will take that under 
advisement.
    Dr. Koop, during your administration how large was your 
budget and how large was your direct report staff, the people 
you could count on directly that were allocated to you?
    Dr. Koop. I had no budget. As far as my staff was concerned 
I had the privilege and ability to call upon 6,000 members of 
the Commission Corps, all of whom occupy special niches and 
very special kind of training, and this is one the gems of our 
government because I don't know any place where there are that 
many experts that can be called upon by the government in 
reference to health as we have here.
    Mr. Issa. General Koop, if I hear you directly, what you 
are saying is because you were appointed by the President 
uniquely, not because you have been brought up through a 
system, you felt it appropriate enough that you could call on 
just about anybody and they would return your calls.
    Dr. Koop. In general.
    Mr. Issa. So this position is to a great extent what you 
make of it, isn't it?
    Dr. Koop. Well, I tried to point out that who the President 
is, and who the Secretary of HHS is, makes a real difference. 
The third person that makes a difference is the Surgeon General 
himself. I was accused of not being a team player. I was denied 
a position I wanted very much by senior George Bush. I felt 
after 8 years as Surgeon General I could hit the ground running 
as Secretary of HHS, but I was considered not to be a team 
player and therefore not suitable to do this.
    I would like to step a little bit wider than your question 
and please tell you what I hear going on here. I would think 
you committee members would think these three Surgeon Generals 
have a touch of paranoia. It sounds like----
    Mr. Issa. That is common in Washington.
    Dr. Koop. Yeah, but the thing is, I thought of writing a 
book one time, the title of which would have been ``They and 
Them,'' because I don't know who all these people are who 
interfere with the Surgeon General. I really don't know who 
they are, we call them ``they'' and we call them ``them,'' but 
I never know who they are, but they do step in.
    You notice that I went to the extent in my prepared remarks 
of telling you how Otis Bowen and I kept the report on AIDS 
essentially secret. The reason for that is there is such a 
thing called a Secretariat of the HHS Department and if you 
were to--thank you--if you were to submit the report such as I 
wrote on AIDS, which is very plain speaking, it wouldn't have 
been out of there yet in those 12 years. And I don't know who 
``they'' were. I don't think you could find out who they were, 
but they and them are the people that my colleagues are talking 
about, and it is not paranoia.
    If I could go back to what Dr. Carmona was saying about the 
stem cells or take the thing that is in the papers this morning 
about insurance for children's health, the science, of the need 
of children in this country for health plans because of the 
poverty level at which they live; that science is absolutely 
irrefutable. Anybody who knows anything about children thinks 
it is a marvelous idea. No matter how you have to pay for it, 
our children deserve that.
    And then today, the newspapers carry word that the 
President has decided he would not support that. Well, what is 
the Surgeon General's role in that particular picture? Here is 
what I think it should be. I don't think he should have made a 
statement about whether he is going to support it or not, until 
he had met with the people in government who know the most 
about children health needs and about their poverty status, and 
that would include the Surgeon General. And it is not asking 
the Surgeon General to make policy, but asking that the Surgeon 
General from a big bunch of expertise and the contacts that you 
said, everybody would call on the phone, answers you, they do, 
they support the Surgeon General, then, at least the White 
House or the people who make decisions about what bills are 
going to go through and what are not have the advantage of that 
kind of expertise. And ``they'' and ``them'' are sort of 
overridden in the process. And then all the way down the chain, 
until that bill comes before Congress and is voted upon or is 
turned down by the President or is vetoed.
    The Surgeon General should be, as I call it, a cog in the 
machinery that decides about the health and the well-being of 
the American people. It is part of what he knows, it is part of 
what he does best, and it is not changing policy. But----
    Mr. Issa. Thank you.
    Dr. Koop. Hmm?
    Mr. Issa. I apologize. I love the answer and I would like 
to get one more question in. I promise, I know the chairman's 
indulgence has to be limited to hear a lot of other people.
    In my opening statement I said that I wanted to take 
advantage of the opportunity of the three of you here to deal 
with one thing I haven't seen come out of your offices over 
your time, and that is an overall statement on why America 
spends per capita 50 percent more in health, public and 
private, insurance and noninsurance, emergency room and 
nonemergency room and in fact we don't have the highest life 
expectancy, we don't have the lowest infant mortality, we don't 
have a people who are nearly as satisfied or feel comfortable 
sleeping that they are not going to have their homes taken away 
because of the high cost of an emergency event. Can you--I know 
there is a limited amount of time for what you all can look at 
during your tenures, but why is it that is not something that 
we would hear Surgeon Generals talking about, taking on, if you 
will, about the large amount of health care costs that 
ultimately make America be first in cost and nowhere close to 
first in performance?
    Dr. Koop. I don't want to sound disrespectful, but you are 
not reading the right stuff and you are not listening to the 
right people because I have been talking about that since I was 
a Surgeon General. And on the Internet right now, I have 970 
lectures on the profiles and science Web site of the National 
Library of Medicine, about half of which address all of the 
questions you have asked. It is a huge problem and it has taken 
us years to get into this mess, and it is going to take us 
years to get out of this mess unless some big surprise comes 
along or a catastrophe, and either one of those could very well 
be in the offing. I could go on and talk to you about these 
individual things, but it would take hours.
    Dr. Satcher. I understand your question. I spoke about and 
continue to speak about this issue and published about it 
extensively. But, your point is interesting, because the 
Surgeon General is not a policymaker. When President Truman 
introduced the national health insurance, they wanted Surgeon 
General Shiley, I believe, to debate it on TV, and he refused. 
He said, this was not an appropriate role for the Surgeon 
General. Once the Surgeon General gets involved in 
policymaking, I think you are interfering with the role of 
Congress and the President.
    But, I do think it is important for the Surgeon General, as 
Dr. Koop said, to make sure the people understand what is 
happening in the health care system, the fact that it is 
inefficient, and I participated in the WHO report showing the 
inefficiency of our health system. And when the program was 
first passed, we had done a lot of background work in terms of 
the plight of children in this country. Ultimately when it 
comes to introducing policy and discussing policy, beyond the 
science--behind it I think we are limited.
    Chairman Waxman. Well, we have other Members who have 
questions. We will have to allow those to stand as a response 
to a question. I know we could use at least another five 
hearings.
    Mr. Sarbanes.
    Mr. Sarbanes. Thank you, Mr. Chairman.
    I wanted to get a better sense of the political 
interference issue that Carmona, that you have referred to and 
we have had some questions about already, because we have had 
other testimony in this committee recently with regard to other 
agencies where there appears to be this kind of political 
interference. In particular, we had two hearings about how the 
General Services Administration, very high level people, and 
including, it appears to us, the head of GSA, Lurita Doan, was 
involved in meetings that were really political meetings that 
were arranged by the White House and others to advance the 
fortunes of Republican candidates. I am trying to get a sense 
of whether that sort of activity exists in other places, and I 
would like to get any input from you.
    So the question is were there any meetings that you were 
asked to participate in, or other sources of political 
activities that you would characterize as political and, if so, 
what were they?
    Dr. Carmona. I recall during my tenure that from time to 
time we would receive invitations, sometimes they were called 
mandatory meetings of, ``political appointees.'' This was 
sometimes at HHS, sometimes they were at EOB, every once in a 
while someplace else at some type of an event. I went to a 
couple of those initially, but I recall early on that I 
recognized that these were really more political pep rallies, 
high-level political appointees within government who were, 
all, trying to rally the troops.
    Mr. Sarbanes. Who was housing these, where were the 
invitations to these meetings----
    Dr. Carmona. Sometimes they were e-mails or just memos in 
your mail to political appointees. There would be a brown bag 
lunch at this location, and maybe a senior political official 
officiating. I went to a couple of those, as I said, and I 
found most of the time that the discussions were about 
political issues of which the Surgeon General really had 
nothing to do with. So I stopped going to them, to be honest 
with you, because I was not really feeling I was representing 
the office well in that.
    There were times when I was invited to political events to 
speak and I felt that this was an ethical violation. I am an 
Admiral and shouldn't be at a political event supporting any 
political party because I am in uniform, and so I took a pretty 
firm line with my colleagues that our job is not to engage in 
political rhetoric supporting any party or any candidate. The 
Surgeon General's job is apolitical. And as soon as you start 
attending meetings like that, start supporting political 
policies, candidates, you become less effective as a Surgeon 
General, you are looked at as being partisan.
    It has never happened. I think the beauty of what you see 
here. You have three Surgeon Generals who have served in the 
most liberal and most conservative administrations, and yet we 
are all telling you the same thing about what needs to be done, 
the partisanship and the problems we have all experienced.
    Mr. Sarbanes. The few meetings that you did attend, who 
were some of the senior officials that were presiding at those 
meetings?
    Dr. Carmona. As a matter of common courtesy, I have spoken 
to the staff and said I am happy to provide you with the 
information but I am very sensitive to the fact that one, some 
of these people are still working; two, retribution does occur 
in government; three, I don't want this to become a ``he said, 
she said'' issue.
    The three of us are up here because there are systematic 
infrastructure problems. The name game and finger pointing goes 
back and forth all the time. We feel, really need, we need to 
get above that. This is about fixing an infrastructure.
    Mr. Sarbanes. The description of the Surgeon General as 
America's doctor I think is a very admirable one. To carry an 
analogy, if I go to my doctor and the doctor comes in the room 
and has a report in front of him from the lab and they want to 
tell me the contents of that report but somebody's muzzling 
them so that I am not getting the real story, I am going to be 
outraged. And America ought to be outraged that when it goes to 
its doctor, the Surgeon General, he is not able to give them 
the truth about the health status of the nation.
    Dr. Carmona. Mr. Sarbanes--yes.
    Mr. Sarbanes. I am curious whether ideology is driving the 
suppression of science, or is it politics? Because if it is 
ideology, as troubling as that could be, someone could have the 
attitude well, we elected this President, he has a certain 
belief system and that flows down through the demands of 
government. And I say that would be troubling but one can 
understand it at a certain level. But much of what I describe 
is that it is politics. It is almost as if there is a perrenial 
campaign underway that at no point somebody decided that now 
that we are elected, we have to actually govern. Instead we 
sacrifice the health of children, the health of HIV victims, 
etc., we are willing to sacrifice all of that for political 
ends.
    I am out of time. If you could touch on the relative weight 
in this suppression campaign, as I will call it, of ideology 
versus politics or political agenda.
    Dr. Carmona. Thanks for your question. I believe it is all 
of the above. In my opinion, there is a political driver, there 
is preconceived political agendas already there that fly in the 
face of good science and they don't want these three Surgeons 
General here to speak out on the science because it will 
complicate their life in trying to move a certain agenda.
    There are also ideological and theological agendas--
abortions, Plan B, stem cells--that drive a particular 
theological construct that leads somebody to a policy, yet the 
science hasn't been heard.
    As Surgeon General Satcher said, what we are hearing here 
is that we should never, ever--our citizens should be 
outraged--that three Surgeon Generals were marginalized and had 
to fight to get the information out to them. I used to use that 
analogy with people. I said when you go to a doctor, do you 
pick your doctor based on what political party that he belongs 
to? They say no. You don't want Republican or Democratic 
information; you want real scientific information, and that is 
our job to bring it forward. I would say it was all of those 
are barriers that we faced.
    Mr. Sarbanes. Thank you.
    Chairman Waxman. Thank you, Mr. Sarbanes.
    Dr. Carmona, we heard that the Office of Political Affairs, 
or Public Affairs, headed by Karl Rove, gave the political 
briefing. We heard about this Office of Public Affairs headed 
by Karl Rove giving the briefings, staff of the office giving 
the briefing?
    Dr. Carmona. There were communications from his office and 
his staff during my tenure, and at times staff from those 
offices were giving briefings.
    Chairman Waxman. Ms. Watson.
    Ms. Watson. I just have to make this statement. This is 
probably the finest collection of integrity and scientific 
knowledge sitting in front of us that I have heard since I have 
been on this committee, and I want to thank you three 
gentleman.
    I also want to thank the Chair, who I served with in the 
California Legislature, and I remember him standing alone, here 
in Congress, with the executives of tobacco companies having 
them raise their hands and asking them the key question whether 
they thought that tobacco was harmful to one's health and could 
cause cancer. And he stayed on that issue until finally the 
world is recognizing his work.
    But Dr. Koop, you were the Surgeon General when I was 
chairing Health and Human Services in the California Senate. I 
admired you for speaking out about AIDS, and I thought wow, 
what a risk you were taking under that current administration 
at that time, but you stood strong and because of that I worked 
on needle exchange. It took me 8 years. I was taken on by the 
clergy and everyone else because they thought I was promoting 
drug use.
    Dr. Satcher, thank you for the years that we worked 
together and you produced the report on the diversity in health 
care, and we still use that today in trying to improve the 
health care delivery system in the State of California. I hope 
as a result of this hearing we can start addressing the real 
needs of public health.
    Dr. Carmona, I admire you, I look at the three of you. You 
represent the fabric of the United States, each ethic group and 
the majority group, and I thank you for your service.
    We will quickly, as you are trying to present to this 
country and the world the global report on health care, the 
emergence of avian flu, SARS and the extremely drug resistant 
TB, and you have illustrated why public health threats respect 
no international borders. And it should never get political. 
Health is not a political issue. We have to understand that. 
And I don't care if you are sitting on this side or you are 
sitting on that side.
    And in trying to get that word out that in your report on 
public health, some way it was stymied, I respect the fact you 
are not going to point fingers, but do you know where the 
report is today?
    And Mr. Chairman, we need to obtain this report and in some 
way we need to make it public so that the general public and 
those who watch everything we do here in the United States can 
change behavior. We talk about Homeland Security, this is not 
about the land, it is about the people who live on the land. 
When attorney Speaker left the United States to get married and 
was carrying a virus that we thought could contaminate the rest 
of the world, it got top publicity across all networks, in the 
newspapers and so on. And we need to know threats to our 
health.
    To you, Dr. Carmona, I just want to say how proud we are of 
the work you did under adverse circumstances, and can you 
comment about that report, where it is and, Mr. Chairman I hope 
we can obtain it.
    Dr. Carmona. Madam Congresswoman, thank you. That was a 
report that was very near and dear to my heart. We spent over a 
year working on this global health report; Surgeon General's 
call to action on global health. That is what we were doing. To 
do that, I assembled the best minds in the world on health, 
NIH, CDC and many other agencies and nongovernmental professors 
from around the country who are preeminent in the field, to get 
the best science to give to the public because we recognize our 
village is now global. The threats and challenges we have do 
not respect the geopolitical borders that we have. And we have 
to start thinking bigger, whether it is AIDS or SARS or any of 
the other challenges that people read about.
    We are very proud of this draft report. Unfortunately, when 
we began the political vetting process, I was called in and 
admonished for this report by a senior official that said you 
don't get it. He said to me, this report has to reflect 
American policy. And what he meant was that they actually 
counted how many times that I did not have the President's name 
and other people's names in the report. I said that is not my 
job. I said I will help you write a compendium report on policy 
for the U.S. Government. This is on a report the science of 
global health. We spoke of all the topics at length. And it was 
blocked repeatedly from getting into the vetting process 
because of a senior official telling me that this will be a 
political document or it will not be released. I said it can't 
be a political document because I am the Surgeon General never 
releases political documents. I will release a scientific 
document that helps our elected officials and citizens 
understand the complex world we live in and what their 
responsibilities are.
    I fought for my last year to try and get it out and 
couldn't get it past this initial vetting. They were clear, 
there was no nebulousness about it, this will be a political 
document or you will not release it, and I refused to release 
it. Because I would not put the political rhetoric into that 
document that they wanted, because it would tarnish the Office 
of the Surgeon General when our colleagues saw us to take a 
political stand, so I refused.
    The document is still in draft form. My colleagues are 
encouraging me to still release it. I just entered into the 
private sector and am looking at ways to do that, but there is 
a great deal of concern and empowerment to me to move ahead 
with this report. It still needs a little bit of work, mind 
you, it is still in a draft form, but the essence of the report 
is there.
    Ms. Watson. Mr. Chairman, thank you for the time. Could we 
obtain that report under the auspices of this committee?
    Chairman Waxman. We will see if we can obtain that report 
from Dr. Carmona.
    Mr. Yarmuth.
    Mr. Yarmuth. Thank you, Mr. Chairman. I thank the gentleman 
for his testimony.
    I might suggest I certainly respect everyone's desire and I 
agree with everyone's desire for independence for the Surgeon 
General. Since we learned over the last few weeks apparently 
Mr. Cheney considers himself a separate branch of government, 
maybe we can create our own independent branch for Surgeon 
Generals.
    I do want to talk about accountability. I think all of us 
believe that nobody in government, most of us do anyway, is 
unaccountable. What do you think the appropriate accountability 
system should be for the Surgeon General's position? I know the 
current nominee, Dr. Holsinger, some 15 years ago wrote a paper 
suggesting that gays could be cured. I suspect that if a 
Surgeon General took that position there would be those who 
would take issue with that.
    So where do you think the Surgeon General's accountability 
should be placed? Anyone can answer.
    Dr. Satcher. I would say that when it comes to reports or 
positions taken by the Surgeon General, the Surgeon General is 
accountable for the best available science. and that is why the 
reports need to be vetted by the scientists, the appropriate 
scientists at NIH and CDC.
    I said before, if the Surgeon General is speaking based on 
his own opinion without the science, then I don't think the 
Surgeon General deserves any more recognition for that than 
anybody else. But I think when the Surgeon General speaks to 
the American people based on the best available public health 
science, he deserves that recognition.
    I issued this Surgeon General's prescription in 1999. I 
actually issued it at an international meeting of ministers of 
health from 189 countries. It is a prescription for the 
American people that talks about physical activity on a regular 
basis, eating five servings of fruits and vegetables, avoidance 
of toxins like tobacco, responsible sexual behavior, and daily 
participation in a relaxing act.
    Every one of these statements were based on research done 
at CDC and NIH. We could point to the literature as to why we 
knew that regular physical activity could reduce cardiovascular 
disease in adults by 50 percent; reduce the onset of type II 
diabetes by more than 60 percent.
    So as long as the Surgeon General is speaking on the best 
available science, then I think that is accountability--to the 
best available science.
    Mr. Yarmuth. Dr. Carmona, we have heard a number of 
instances in which you and the other Surgeons General have been 
prohibited from speaking out on things you thought were 
important. Are there instances in which you were actually asked 
to do something you did not want to do in terms of pursuing a 
political agenda on behalf of the White House?
    Dr. Carmona. There were times when I was invited to 
meetings or had discussions where I guess people were testing 
the waters. On abstinence, abstinence only, I remember that in 
all of my presentations, I never wavered, based on the best 
science that Surgeon Koop had spoke about, that it was clear we 
needed a more comprehensive program of sexual education in the 
United States that would include abstinence, but not be 
exclusively about abstinence. People weren't happy about that. 
I think they saw that I was going to be true to the science and 
that was challenging.
    When global warming came up, it was my first year. And I 
was naive enough listening to the discussion at this office 
with senior officials, where they were heralding global warming 
to be nothing to be more than a liberal cause, and had no 
merit, and they were kind of dismissing it. And I remember 
thinking oh, I understand why they want me here, they want me 
to discuss the science, obviously they didn't understand the 
science. I had this discussion for half an hour and I was never 
invited back to the meeting.
    There were a number of anecdotes like that over the years 
where the water was tested and I was asked certain things at 
meeting, things were put into my speeches. In fact, I had two 
speechwriters quit because they were so intimidated and 
browbeaten by political officials. We would play this game the 
day before a talk. I told the staff, let them put in whatever 
they want, I will not say it anyway. Eventually, the people 
left the employ there because they were really in an embattled 
position, and people were trying to get to the Surgeon General 
through them.
    Mr. Yarmuth. Were you ever told to mention a President a 
certain number of times, were you promoting him specifically?
    Dr. Carmona. In fact, in my first year, clearly, I was told 
a number of times that the President's name was not mentioned 
in a speech. I was told it should be mentioned, at one point, 
at least three times on every page. I said, I am not going to 
do that. I said I will mention any politician when appropriate, 
if they are involved in a scientific endeavor, but my job is 
not to sell politics.
    The speechwriter will tell you they fought that battle 
every day, I would tell them what I wanted in the speech, he 
provided it back to me and it would be vetted, and I didn't 
know this was happening and they were being admonished for not 
putting certain politicians' names in or political phrases in 
that I subsequently took out because I said this has nothing do 
with public health science and I will not say those things.
    Mr. Yarmuth. Thank you very much.
    Chairman Waxman. Thank you, Mr. Yarmuth. For our second 
round I want to recognize Representative Norton.
    Ms. Norton. I appreciate the opportunity to ask this 
question at this time. This is based on Dr. Carmona's testimony 
and my own interest in the structure of government. I have been 
trying to rack my brain to think of a way to have a truly 
independent Surgeon General. I think it is very difficult to 
come up with a way in our system of government. The only truly 
independent people I know sit on the Supreme Court, and the 
President can't get to them.
    I noticed you took a stab at this, Dr. Carmona. You 
indicated that what turns out to be quite something of a 
pretense, you don't use those words, of a four-star admiral 
maybe out to balance that. It looks like you go back to kind of 
a militarized example. I understand where it came from, 
historically that the Corps could be militarized.
    But you say on page 7 of your testimony I think in an 
attempt to get independence, that the Surgeon General could be 
nominated by the President from the ranks of career public 
health officers based on merit, without political ideology or 
theological filters. Then you say that just as the U.S. Army, 
they are selected that way.
    Again, let me indicate, I wonder if we should do that. What 
impresses us, we have very distinguished physicians. I don't 
mean to imply they don't come out of the Public Health Service 
as well, but if an eminent physician from practice or academia 
becomes Surgeon General, doesn't that bring to the office such 
value added that we wouldn't want to exclude such eminent 
candidates for the office?
    I would like your opinions on how to make it more 
independent and whether or not going to a narrower group of 
physicians would really serve the larger purposes of the Office 
of Surgeon General?
    Dr. Satcher. Let me speak before Dr. Carmona. This is one 
issue we don't totally agree, the idea of excluding a whole 
group of people based on the fact they are not in the 
Commission Corps. I like the process of a group getting 
nominated based in part on service in Commission Corps, but 
saying you are not nominated if you are not in the Commission 
Corps, then Surgeon General Koop would never have been Surgeon 
General.
    So I have some difficulty with that. I think ultimately the 
President should name a person and recognize, as you do with 
the Supreme Court justices, how that profession feels about 
that person's capabilities and qualifications, but I basically 
agree with the process being as Dr. Koop described it, but not 
necessarily with the limitations.
    Dr. Carmona. I think we all agree with the process. The 
reason that I looked at the model of a U.S. Public Health 
Service Commission Corps officers that would come up through 
the ranks, was if you look just at these officers right here, 
these represent the finest doctors, nurses, scientists in the 
world right here. When the Army, Nave, Air Force promote a 
Surgeon General, they are professional officers who come up 
through the ranks.
    Ms. Norton. They are not practicing medicine as Surgeon 
General, they have only themselves, their word, their eminence 
and, by again casting no aspersion on this extraordinary corps, 
one wonders why the only way to accomplish this is to narrow 
the pool. Dr. Koop, I would like your view on this as well?
    Dr. Carmona. Ma'am, may I finish?
    Ms. Norton. Yes.
    Dr. Carmona. We all agree on the process. The reason I am 
looking to stay within the Commission Corps is that you have 
professional uniformed officers, just like the Army, Navy and 
Air Force, and I am open to the discussion. I brought forth an 
idea that says I think this would work to depoliticize the 
process. These are professional uniformed officers. The 
President of the United States nominates the Army, Navy and Air 
Force Surgeon Generals from the ranks and then they are 
confirmed by the Senate.
    Ms. Norton. One wonders if that depoliticizes.
    Dr. Carmona. Well, granted----
    Ms. Norton. One wonders if the officer in Iraq are 
depoliticized, whether the Supreme Court justices are 
depoliticized. So I understand, I am simply trying to say of 
the ways of doing it, would we want to sacrifice something that 
is important, since this man doesn't do anything but speak, and 
whether he has credibility?
    Dr. Carmona. Thank you.
    Dr. Koop. Even if you have concerns about the manner in 
which I outlined it, if you look at the people who were in the 
Commission Corps at the time I was appointed, there were 
already 55 Assistant Surgeon Generals. If you look at some of 
those people, they have turned out to be the best public health 
voices we have had in the country, in the private sector and 
some within government.
    I don't think, even though my plan would eliminate me as a 
candidate for Surgeon General, you would always get good 
people. But there are is one other thing, if it were known, 
that you could enter the Commission Corps of the U.S. Public 
Health Service with the eventual possibility of working as a 
Surgeon General, you would attract better and better and better 
people to the Corps.
    Chairman Waxman. Thank you very much.
    Ms. Watson.
    Ms. Watson. Thank you so much. I am just going to throw out 
these questions to the panel and after I do that, I would like 
Dr. Satcher to talk about your oral health report, and I have a 
bill right now in the process to remove the dental amalgams 
that have mercury. And I see the mercury as the basis for poor 
dental health and poor systemic health, so I would like you at 
the end to comment on that.
    I would like to ask all three of you how can we improve the 
Surgeon General's position, should we lengthen the term time 
that you serve? How do we make you independent? And what about 
budget? I think all of you have hit on it a bit in your 
presentations, but I would like you to outline what you would 
do to improve the position, starting with you, Dr. Koop, 
please. Dr. Koop.
    Dr. Koop. Well, I have outlined the manner in which the 
person is chosen, I think that is essential, I have talked 
about independence, I have talked about being apolitical. And 
then I have also suggested that the expertise of the Surgeon 
General be used in an advisory capacity at every level of 
discussion of an issue that eventually will become a 
legislative problem and eventually acted upon by the Congress 
of the United States. That is the way that I think the Surgeon 
General can be in on what is being discussed. It keeps them out 
of policymaking, but it gives the President and the White House 
and it gives the Secretary of HHS and that Department the 
benefit of his expertise.
    And as I think all of us have said either directly or 
indirectly, the respect in which the Surgeon General is held by 
other people that we have been talking about, our colleagues 
abroad and the private sector in this country, there is almost 
nothing that a Surgeon General asks that he can't get in the 
way of advice and help.
    Ms. Watson. Thank you so much.
    Dr. Carmona.
    Dr. Carmona. Thank you. I would like to echo what Surgeon 
General Koop has already said and wht is in my remarks about 
independence. I think our government should not only fund and 
empower and support, but I think the citizens should demand 
transparency and honesty in all scientific communications 
because this is the doctor of the Nation, and in fact, as you 
have heard from the three of us, the rest of the world looks to 
the Surgeon General for honest governmental, scientific 
communication, which is distinctly different from many of the 
other countries.
    One thing I think is important to consider, politicians 
often publicly shy away from hot button, partisan, scientific 
issues. For whatever reason, it really doesn't really make a 
difference. I think that we would all agree that allowing the 
Surgeon General to be the lightning rod on these issues and 
move forward in a nonpartisan, apoiltical way, based on 
science, actually helps to insulate politicians who don't want 
to talk about abortions or stem cells or Plan B, or something 
that tends to polarize people, left or right.
    And I think the Surgeon General is driving something 
forward the best science. I think the Surgeon General, driving 
some of these discussions based on the best science, would 
actually help in a nonpartisan way all political persons 
because they don't have to take the heat. It is the Surgeon 
General who said this.
    Ultimately though, with a better informed public, we can 
improve health literacy for the public and elected officials, 
better policy moves forward less painfully for some 
politicians, because it is the Surgeon General out there who is 
speaking as the doctor of the Nation just as they would speak 
to you individually about very personal issues that could also 
be polarizing.
    I think that is another added advantage, to add on to what 
Surgeon Koop said and what General Satcher is going to say. I 
think the beauty of what we are saying here is that we speak as 
one. Three Surgeon Generals serving over very liberal and 
conservative administrations, all came to the same conclusion 
about the dignity of the office. It's about the importance of 
representing the American people and not a political party. And 
we hope to make it easier for those who walk in our footsteps 
in the future to better represent the American public.
    Dr. Satcher. I want to begin by briefly saying what I say 
to students all over this country, whether it is in 
commencement addresses, or in high school. I would trade 
nothing for the opportunity which I had to serve in government, 
I would trade nothing. As Director of the CDC, as Surgeon 
General, as Assistant Secretary for Health. I came from the 
cotton fields of Alabama. Neither of my parents finished 
elementary school. The fact you can rise in this country to the 
position of Surgeon General says a lot about the strengths of 
our Nation.
    I believe that the Surgeon General's office is too 
important to allow it to be politicized. I think the World 
Health Organization, while I was serving, ranked the United 
States number 37 in the world in terms of our health system. 
Despite the fact that we spend twice as much money as the next 
country's level of expenditures and we have 45 million people 
uninsured, we still rank number 37.
    The only area in which I think in the world who would rank 
us No. 1 would be the Office of Surgeon General. When China got 
ready to look at the issue of tobacco, the invited me as 
Surgeon General to come and advise them, and that's happened 
over and over again. I believe it is important to maintain the 
integrity of the Office of the Surgeon General. I would say two 
things, No. 1, the budget, I believe Congress ought to insist 
that the Surgeon General's office has its own budget--and I say 
this as one who was Assistant Secretary of Health and Surgeon 
General, so I reported to myself as Surgeon General and if I 
hadn't of course I wouldn't have any money. That is where I got 
the money, and that should not be the case. The Surgeon General 
should be independent and have his or her own budget and be 
able to speak independently to the American people.
    You asked me about oral health. I will be very brief. I 
issued the Surgeon General's report of oral health in the year 
2000. We tried to do a few things. No. 1, we tried to point out 
the magnitude of the oral health problem in this country. The 
fact that still 30 percent of people over 65 in this country 
are edentulous, that children miss 57 million hours of school 
every year because of tooth decay, while there may be 46 
million Americans are uninsured for medical care there are 108 
million who don't have dental insurance. We talked about how 
oral health is a major part of overall part of health and well-
being and needs to be treated that way. Oral health problems 
can be associated with cardiovascular disease and diabetes. We 
tried to point all of that out based on the current research 
and we talked about the importance of fluoridation in water.
    We didn't talk about Mercury, and this is important point. 
We didn't feel that science at that point related to mercury 
and health was adequate for the Surgeon General to take a 
position. We don't take positions on issues that are not clear. 
If they are not clear, we say they are not clear. And that is 
why you did not see a stronger statement in that report about 
mercury.
    I must say of all the reports that I have issued, I am very 
pleased with what happened with the results of that report. I 
think the Johnson Foundation funded 19 dental schools to 
provide health care to poor children, boys clubs and things 
like that. Many children are now getting dental care because of 
that report and what has happened afterwards. That is a very 
important report, like so many of the reports we have issued.
    Chairman Waxman. Thank you very much, Ms. Watson.
    Let me conclude the questioning. Dr. Carmona, you talked 
about the areas where you had some interference, but one of the 
jobs of the Surgeon General is to go out and talk to groups, 
communicate at the local and State level, talk to different 
groups who are like minded or suffering from diseases. Were you 
prevented from traveling to speak to groups that you thought 
you wanted to visit and talk to?
    Dr. Carmona. Yes, that occurred several, many times 
actually over the years, and it was because people were 
politically vetting decisions I made to go before groups based 
on science and the needs of the citizens, versus a political 
need. As Surgeon General Satcher has mentioned, he might have 
had it a little easier--I was Assistant Secretary for a while 
as well as Surgeon General, and we both came to the same 
conclusions, it is hard to do both jobs, because the government 
expects you as Assistant Secretary to be a politician and so 
you are constantly switching hats. This is very difficult to 
do. Dave and I both did the same thing. We said we are doctors 
first, we are Surgeons General. I can't do the political part, 
which often doesn't make politicians very happy. It gave David 
more budget discretion, because he could control his own 
office.
    There were a couple of issues, I can give you some 
examples. As you know, I issued a Surgeon General's call to 
action, the first on the health of people with disabilities. I 
was looking at the GAP analysis to see where I could add to the 
great body of evidence. I saw the issue of disability in 
children's health and we started to have some discussions with 
Special Olympics and Best Buddies and a number of organizations 
that deal with the health of the disabled children. And the 
Special Olympics was coming up. I was asked if I would come to 
Japan and give the opening keynote address and discuss the 
health of disabled athletes which had been marginalized. I 
thought this was a perfect forum globally. I was told I 
couldn't do it. There was no reason given other than it was 
kind of expensive to go over there. But there were times I was 
asked to speak to groups I wasn't sure I should be at where 
budget was not an issue.
    Chairman Waxman. Give me an example of that.
    Dr. Carmona. Group, political gatherings, political 
gatherings where they wanted to have the Surgeon General there 
to say some things about programs that parties were moving 
forward and----
    Chairman Waxman. Were these in districts of vulnerable 
Republicans?
    Dr. Carmona. Sometimes that was the case, yes, sometimes 
that was the case to talk about a program or a particular issue 
for the benefit of some elected official. Yes, that happened.
    Chairman Waxman. You were told you couldn't make a decision 
to go speak to the Special Olympics but you were never given a 
reason why you couldn't, but then you were told there was money 
to go and speak to somewhat politicalized----
    Dr. Carmona. The Special Olympics one was an egregious one. 
Ultimately, another group, the Best Buddies program, which 
deals with physical activities for intellectually disabled 
children. I thought that was some place we should be speaking 
out on to prevent the marginalization and it addresses health 
disparities as well. So I put in my paperwork to go to this 
meeting to give the Keynote address and actually ride a bike 
with a disabled child, and hoped to bring some light to this 
problem in our Nation. I was admonished for doing that.
    The reason I was admonished for doing that. Unfortunately, 
I was told that I would be helping a politically prominent 
family who this is one of their endeavors, and why would I want 
to help those people? And I said I don't even know--I am not 
going it mention names now. I remember responding, this is 
about sick kids. It has nothing do with who is moving the 
project. So in effect I was told I cannot travel, my travel 
orders were canceled. I took a weekend vacation and paid for it 
myself because I was committed to the group.
    Chairman Waxman. At what level were you told you couldn't 
go to the Special Olympics?
    Dr. Carmona. These were highly appointed officials in the 
Department, yes, in the Department.
    Chairman Waxman. You were told that they wanted you to act 
as a surrogate to go and speak in districts where you could act 
on behalf of the Republican cause; is that correct?
    Dr. Carmona. That happened at times, yes.
    Chairman Waxman. There they didn't have a problem with 
money?
    Dr. Carmona. It didn't seem so.
    Chairman Waxman. Well, I just have to say, Dr. Carmona, I 
find the political interference with you doing your job 
astonishing. It was difficult enough for Dr. Koop and Dr. 
Satcher, but it really is distressing that you had such much 
more interference in what you were trying to do. You testified 
you were prevented from speaking on stem cells, abstinence 
education, and Plan B emergency contraception; is that correct?
    Dr. Carmona. That is correct.
    Chairman Waxman. You testified you were prohibited from 
preparing reports on mental health preparedness and emergency 
preparedness; is that correct?
    Dr. Carmona. And global health.
    Chairman Waxman. You testified you couldn't release the 
report on global health.
    Dr. Carmona. Correct.
    Chairman Waxman. You testified that your report on the 
dangers of secondhand smoke was delayed for years while you 
fought efforts to weaken your science-based findings; is that 
correct?
    Dr. Carmona. That is correct, and I was not aware of it at 
the time. I did not find out about the scientific assaults 
until later on, because the staff was trying to protect me. It 
wasn't until very late in the game that I found out that they 
were fighting the rewording of certain paragraphs and things 
like that, fighting their own battles, if you will, for 
scientific integrity.
    Chairman Waxman. You testified that you were even directed 
to attend White House political briefings about the best 
interests of the Republican Party and its candidates, is that 
right?
    Dr. Carmona. Let me clarify. I can't say there were White 
House, but there were memos from senior political officials who 
brought people together to discuss things. The couple I went 
to, clearly they were discussing political issues and you know, 
elections getting people out. Pep rallies I would call them. 
Political pep rallies.
    Chairman Waxman. This wasn't from the Department, it was 
beyond the Department?
    Dr. Carmona. Yes, yes. Sometimes the meetings took place at 
the Department, sometimes they were off in other buildings.
    Chairman Waxman. And people would come and talk about, give 
a list of the key races for the Republicans?
    Dr. Carmona. You know, I can't say key races, but certainly 
talking about getting our word out, political agendas, things 
like that, which really the Surgeon General should have nothing 
to do with. Because it undermines the credibility of the 
office. Because it undermines the integrity and dignity of the 
office. The Surgeon General is not involved in day-to-day 
politics. That is not our job.
    Chairman Waxman. Did Karl Rove attend any of those 
meetings?
    Dr. Carmona. I can only remember one where I saw him. There 
were other staffers up and down, at different levels of 
government that would come and speak, at brown bag lunches, 
meetings, things like that. Honestly, I didn't pay too much 
attention. After the first few, I recognized it was really 
something the Surgeon General shouldn't be at or involved in.
    Chairman Waxman. And you didn't take any grief and not go 
to any future meetings, did you.
    Dr. Carmona. Not grief. In fact, I made sure I was busy 
during those times.
    Chairman Waxman. Well, I thank you for your being 
forthright and talking to our committee and the American public 
about this issue. I hope the testimony of you, Dr. Koop and Dr. 
Satcher will help us clarify that this is an important position 
that we shouldn't allow to be marginalized. We shouldn't allow 
the Surgeon General to be politicized as the doctor to the 
Nation. That person needs to have credibility, independence and 
to speak about science. I think that is so important.
    I thank you all very much for your testimony today. That 
concludes our hearing, and the committee stands adjourned.
    [Whereupon, at 12:10 p.m., the committee was adjourned.]

                                 
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