On June 27, 2006, U.S. surgeon general Richard H. Carmona, who made prevention and health promotion the major goals of his term in office, issued a report warning about the hazards of secondhand smoke. At a press conference he stated that “science has proven that there is no risk-free level of exposure to secondhand smoke. Let me say that again: there is no safe level of exposure to secondhand smoke.”
One month later, when his four-year term expired, he quietly left Washington, D.C., without fanfare or formal acknowledgement from the White House. Many in the U.S. Public Health Service (USPHS) were unaware of his departure until an open letter to the USPHS Commissioned Corps appeared online. Although few recent surgeons general have served two terms (the only one since 1956, C. Everett Koop, served from 1981 to 1989), there has been speculation that the secondhand smoke report sealed Carmona's fate as a one-term surgeon general in an administration charged with being overly friendly to the tobacco industry.
Jerry Farrell, the civilian executive director of the Commissioned Officers Association of the USPHS, said it plainly in a recent interview: the report was probably “the nail in the coffin” for Carmona. “The corps was devastated by his departure,” Farrell said. “He was a straight speaker who wanted to protect the integrity of the office.” Farrell speculated that Carmona did not stay on because he would not have been able to speak “unfettered.”
Politics and public health. When I asked Carmona what he considered his greatest success in Washington to be, he said, “Surviving my term.” The most challenging aspect of the job, he said, “was how politically astute you have to be. Colleagues would ask me, ‘Why not hold a press conference on the capitol steps and tell the truth?’ I could have done that. If a surgeon general calls a press conference, the press will certainly come and report on what you say,” he said. “But if you launch all your rockets, it's probably the last press conference you'll have, so you work quietly within the system.”
Carmona's deputy, Kenneth Moritsugu, postponed his retirement for a year to become acting surgeon general. Though a lame duck, he has been active, issuing a call to reduce underage drinking and announcing an initiative to encourage Americans to know their family health history. Good advice? Sure. Likely to offend any major administration supporters? No.
Almost daily, there are reminders of the difficulties the U.S. public health system faces: the rise of drug-resistant bacteria; the growing rates of type 2 diabetes, heart disease, obesity, and cancer; the critical shortages of health care workers; the disparities along racial, ethnic, and class lines in accessing care; and the government's ineptitude in the face of natural disasters. Filling the post of surgeon general might seem a logical priority, but according to assistant secretary for health John O. Agwunobi, Moritsugu continues to address the priorities President Bush asked Carmona to address, and the public health is in good hands. The White House did not respond to telephone or e-mail inquiries for this article.
Assistant surgeon general and chief nurse officer Carol Romano told AJN that Carmona was supportive of nursing, as is Agwunobi. “He has extended an open invitation to bring concerns to his office,” she said, noting that “while there's no lapse in policy or direction, we feel strongly about the value of the position of the surgeon general, and we'd like to see it filled.”
Meanwhile, Carmona's legacy is not yet clear. But as he wrote in his departure letter, “If a mother decided to quit smoking to improve her child's health … then yes, it was all worth it.”
Maureen Shawn Kennedy, MA, RN, news director
Cost versus care: data show that health loses out. Patients who benefited from initial lifesaving care may lose those gains in the long term because of financial constraints or inadequate health insurance, according to a study reported in the March issue of Pediatric Transplantation. While one-year graft survival rates in adolescent renal transplantation patients have improved (from 72% in 1988 to 95% in 1998 for kidneys from deceased donors and from 88% to 96% for kidneys from living donors), after five years, graft survival rates for 11-to-17-year-olds were only 60% and 72%, respectively. Nonadherence to immunosuppressive regimens is known to be a common cause of organ rejection, and the authors suggest that as much as 50% of nonadherence may be due to the inability to afford immunosuppressive medications, which can cost up to $14,000 per year.
This cost can be particularly onerous for pediatric patients because of their potential for longer survival and the greater likelihood of adolescents to have inadequate insurance as they move into adulthood. Many insurers impose lifetime maximum amounts on drug coverage, and Medicare coverage ends 36 to 44 months after transplantation or when the child reaches adulthood, unless she or he qualifies for disability. The annual cost of maintenance care for a transplant recipient is $13,749; a patient whose transplant fails returns to Medicare coverage for dialysis, which will cost $137,930 during the first year.