THE SURGEON GENERAL AND THE BULLY PULPIT Michael Stobbe A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Public Health in the Department of Health Policy and Administration, School of Public Health Chapel Hill 2008 Approved by: Ned Brooks Jonathan Oberlander Tom Ricketts Karl Stark Bryan Weiner ABSTRACT MIKE STOBBE: The Surgeon General and the Bully Pulpit (Under the direction of Ned Brooks) This project looks at the role of the U.S. Surgeon General in influencing public opinion and public health policy. I examined historical changes in the administrative powers of the Surgeon General, to explain what factors affect how a Surgeon General utilizes the office’s “bully pulpit,” and assess changes in the political environment and in who oversees the Surgeon General that may affect the Surgeon General’s future ability to influence public opinion and health. This research involved collecting and analyzing the opinions of journalists and key informants such as current and former government health officials. I also studied public documents, transcripts of earlier interviews and other materials. ii TABLE OF CONTENTS LIST OF TABLES.................................................................................................................v Chapter 1. INTRODUCTION ...............................................................................................1 Background/Overview .........................................................................................1 Research Hypothesis............................................................................................5 Project Components.............................................................................................5 Literature Review.................................................................................................6 Endnotes...............................................................................................................21 2. METHODS ..........................................................................................................23 Study Design and Data Sources...........................................................................23 Data Management and Analysis ..........................................................................29 IRB and Confidentiality Issues ............................................................................29 Endnotes...............................................................................................................32 3. HISTORY AND CASE STUDIES......................................................................33 How the Surgeon General Gained Power and a Bully Pulpit ..............................33 How the Surgeon General Lost Power, but not His Pulpit ..................................47 Jesse Steinfeld......................................................................................................55 Julius Richmond...................................................................................................67 C. Everett Koop ...................................................................................................80 iii Antonia Novello...................................................................................................99 Joycelyn Elders ....................................................................................................109 David Satcher.......................................................................................................121 Richard Carmona .................................................................................................135 Endnotes...............................................................................................................150 4. ANALYSIS AND DISCUSSION........................................................................177 Survey of Journalists............................................................................................177 Themes.................................................................................................................192 Endnotes...............................................................................................................213 5. PROPOSAL.........................................................................................................216 Discussion............................................................................................................216 A Bill....................................................................................................................226 Endnotes...............................................................................................................229 6. APPENDICES .....................................................................................................231 Consent form for key informants.........................................................................231 Guiding questions for key informants..................................................................234 Fact sheet for key informants...............................................................................236 Salutation and questions for survey participants .................................................239 House bill, “Surgeon General Independence Act” ..............................................243 Senate bill, “Surgeon General Integrity Restoration Act”...................................246 The 1998 bill, “Office of the Surgeon General Sunset Act”................................248 7. REFERENCES ..................................................................................................................253 iv LIST OF TABLES Table 1. Newsworthiness results, larger survey response set ..................................................186 2. Credibility results, larger survey response set ...........................................................186 3. Newsworthiness results, megaphone group respondents...........................................187 4. Credibility results, megaphone groups respondents ..................................................187 v CHAPTER 1 INTRODUCTION This project looks at the role of the U.S. Surgeon General in influencing public opinion and public health policy. I examined historical changes in the administrative powers of the Surgeon General, to explain what factors affect how a Surgeon General utilizes the office’s “bully pulpit,” and assess changes in the political environment and in who oversees the Surgeon General that may affect the Surgeon General’s future ability to influence public opinion and health. This research involved collecting and analyzing the opinions of journalists and key informants such as current and former government health officials. I also studied public documents, transcripts of earlier interviews and other materials. BACKGROUND/OVERVIEW U.S. President Theodore Roosevelt once told a friend; “Most of us enjoy preaching, and I’ve got such a bully pulpit.” He was referring to the White House as being a splendid (or “bully”) platform from which to persuade the public. More properly defined, a bully pulpit is a public office of sufficiently high rank that it provides the office holder with an opportunity to speak out and be heard on any matter. The U.S. presidency is a bully pulpit, but there are similar offices in the world of public health. The U.S. Secretary of Health and Human Services has a bully pulpit, to a certain degree, as does the Director of the Centers for Disease Control and Prevention. The U.S. Surgeon General does also. But there’s a difference between the Surgeon General and these other offices, which is highlighted by another Roosevelt quote; “Speak softly and carry a big stick.” The saying is an advisory to leaders to have the resources to enforce their will beyond persuasion. President Bush, the chief executive of the nation, has such ability. U.S. Health and Human Services Secretary Mike Leavitt, who heads one of the largest divisions of the executive branch, commands significant resources as well. CDC Director Julie Gerberding has power, too, overseeing an agency with nearly 9,000 employees and a budget of $8 billion. [1] When Bush, Leavitt and Gerberding speak, their words are backed not only by the prestige of an office but also by their control over significant public health resources. That’s also true of leaders in the business world, in the military and other leadership realms. In those settings, great leaders demonstrate the ability to communicate a mission to their followers and persuade them to accomplish a goal. But though skill at utilizing a bully pulpit is important, it is not absolutely necessary in those settings. The Surgeon General is in a different position. The office of the U.S. Surgeon General was created in 1870 to oversee the Marine Hospital Service, a national hospital system for sailors that is the ancestor of the U.S. Public Health Service. In 1889, the Surgeon General gained the additional responsibility of running the Commissioned Corps, a personnel system of doctors and other professionals that from the beginning was organized along military lines. [2] Commissioned Corps members staffed the hospital service and subsequent federal public health agencies that were created. As the National Institutes of Health, the Food and Drug Administration and the Centers for Disease Control and Prevention came into existence, the Surgeon General was placed in charge