As America's doctor, The US Surgeon General provides Americans with the best scientific information available on how to improve their health and reduce the risk of illness and injury. As a scientist interested in translating evidence to improve the public's health, spending a year as a fellow in the Office of the US Surgeon General has been the opportunity of a lifetime.
I applied for the Health and Aging Policy Fellows program this year because I wanted to participate in this unique moment in health policymaking, in which the implementation of the Affordable Care Act paved the way for an expanded emphasis on improving population health. Historically, health policy has really focused on health care policy. Issues such as expanding health care access, reducing health care costs, and improving health care quality are incredibly important, but they often are not tied directly to improving population health.
A large body of evidence suggests that the air we breathe, the education we receive, and the homes we live in affect our health as much as the medical care we receive. Because these social determinants influence our health and our ability to manage our health care needs, they determine how likely we are to end up in the doctor's office or hospital in the first place. In fact, investing in behavioral and environmental prevention strategies is more effective at saving lives and saving money than expanding health insurance coverage or increasing quality of care alone.Footnote 1
But if many of the factors that are most important to promote health and reduce health care costs lie beyond the health care system, how do we address this wide range of issues? As an Assistant Professor of Epidemiology and Public Health at the University of Maryland School of Medicine, I have contributed to the scientific evidence base showing that the social determinants of health are important predictors of poor health and disability in old age. In applying for the Health and Aging Policy Fellowship, I wanted an opportunity to participate in the cross-sectoral policymaking needed to improve population health.
The Affordable Care Act laid the groundwork for these efforts in a number of ways, including the Community Transformation Grants funded under the Public Health and Prevention Fund, the emphasis on Population Health as part of the work of the Center for Medicare and Medicaid Innovation, and the creation of a National Prevention, Health Promotion, and Public Health Council (hereafter, the National Prevention Council) to be chaired by the US Surgeon General. By designating the US Surgeon General as the Chair of this new, 17-department effort, the Affordable Care Act dramatically expanded the role of the Office of the Surgeon General as a leader in public health.
The Office of the Surgeon General
The US Surgeon General is probably most familiar to Congress and the American public in their primary role as America's doctor, providing scientific information to improve the public's health. This role emerged over the course of the second half of the twentieth century, most notably when Surgeon General Luther Terry dramatically raised the profile of the office with the release of the first tobacco report in 1964. The report had an immediate impact on public attitudes and policy, leading to large increases in the number of Americans who believed that smoking caused cancer and to legislation requiring a health warning on cigarette packaging.Footnote 2 Tobacco education has continued to be a major emphasis of US Surgeons General, most recently with the 2012 release of Preventing Tobacco Use among Youth and Young Adults: A Report of the Surgeon General, the 31st Surgeon General's report on tobacco.
The role of the Surgeon General in communicating science to the public extends beyond tobacco. Surgeon General C. Everett Koop reached out to the public directly with a 1988 mailing called “Understanding AIDS” which was sent to all 107 million households in the United States and remains the largest public health mailing ever done. Reports by the Surgeon General have addressed topics as varied as osteoporosis, mental health, youth violence, and oral health. A major role of the office continues to be acting as an authoritative voice on science, medicine, and public health, speaking and writing for diverse audiences including both clinicians and the public.
The Surgeon General also has important administrative functions within the Office of the Assistant Secretary for Health in the Department of Health and Human Services. The Surgeon General directs the operations of the US Public Health Service Commissioned Corps, an elite team of more than 6,500 full-time, well-trained, highly qualified public health professionals dedicated to delivering the nation's public health promotion and disease prevention programs and advancing public health science. Additionally, the Surgeon General oversees the Division of the Civilian Medical Reserve Corps. The Medical Reserve Corps (MRC) is a national network of more than 900 communities and more than 200,000 volunteers committed to improving the health, safety, and resilience of their communities. MRC volunteers include medical and public health professionals, as well as non-medical volunteers who are interested in strengthening the public health infrastructure and improving the preparedness and response capabilities of their local jurisdictions.
Finally, as noted above, the visibility and responsibilities of the Office of the Surgeon General were increased through the Affordable Care Act, which names the Surgeon General as Chair of a new National Prevention Council, comprised of 17 heads of departments, agencies, and offices across the federal government. The council is charged with providing “coordination and leadership at the federal level, and among all executive departments and agencies, with respect to prevention, wellness and health promotion practices, the public health system, and integrative health care in the United States” as well as with developing a “strategy that incorporates the most effective and achievable means of improving the health status of Americans and reducing the incidence of preventable illness and disability.”Footnote 3 Reporting is mandated through January 2015, and all activities must take place within existing appropriations.
In June 2011, the National Prevention Council released the National Prevention Strategy, which identified strategic directions and priorities for prevention with the goal of increasing the number of Americans who are healthy at every stage of life. The Strategy recognizes the ways that Departments as varied as Housing and Urban Development, Agriculture, Transportation, and Justice can contribute to health through a range of health promoting policy goals, including healthy and safe community environments, injury and violence free living, and active living. Importantly, the Strategy identifies a vision in which multiple sectors work together to move the nation from a focus on sickness and disease to one based on prevention and wellness.
A Fellow's Perspective on the Office of the Surgeon General
I have had the incredible honor and pleasure of serving as a Fellow for the 18th US Surgeon General, Dr. Regina Benjamin. Because of the wonderful reputation of the Health and Aging Policy Fellows program and the American Political Science Association's Congressional Fellows Program, I had a wealth of placement opportunities, but two things persuaded me to take a fellowship in this office. The first was the incredible opportunity to be a part of the implementation of the National Prevention Strategy. The second was Dr. Benjamin herself. As I was debating my placement options, I spoke with a colleague who had worked with Dr. Benjamin on the Kaiser Commission on Medicaid and the Uninsured and described her by saying “She's the real deal. She gets it.” What she meant is that Dr. Benjamin understands the on-the-ground needs of patients, their families, their primary care providers, and their communities, a characteristic I have witnessed time and again since joining her office. Nowhere is this more evident than in Dr. Benjamin's own words, whether talking about the joy she finds in primary careFootnote 4 or describing how she dried health records in the 90-degree sun after her clinic was destroyed by Hurricane Katrina.Footnote 5
When I interviewed with Dr. Benjamin, I noted that the Office of the Surgeon General is a small office with a big mission, and asked her where the Prevention Strategy fell on her priority list. She replied, “It is my priority list” and went on to share the ways in which she herself had been touched by preventable diseases, noting that her brother died of HIV/AIDS, her father of stroke, and her mother of lung cancer. Her personal commitment to prevention comes across as she communicates with audiences across the country about the National Prevention Strategy. True to her word that the National Prevention Strategy was a top priority, she and her staff have worked to align all of the office's work to the Strategy. This is a natural fit, because it includes many areas – such as tobacco free living, healthy eating, breastfeeding, and medication adherence – that are clear priorities for the Surgeon General.
What has been truly exciting is the way that other National Prevention Council Departments have advanced the Strategy in their own work. The Office of the National Drug Control Policy recently released its 2012 National Drug Control Strategy, which recognizes drug prevention as part of overall health and specifically references the National Prevention Strategy. The Department of Defense has launched a major new obesity and nutrition campaign that is highly aligned with the National Prevention Strategy. As we prepare our 2012 Annual Status Report to Congress, I have been amazed and impressed by the commitment to population health and prevention across the National Prevention Council, and it has been tremendously exciting to see this health-in-all-policies approach in action at the federal level.
As a Fellow, I have gotten to see and be a part of the release of a Surgeon General's tobacco report, meetings with the White House Domestic Policy Council, and the launch of a new postage stamp about heart health. I have had the chance to be involved in work within our office to translate science into improving health in ways both large (the implementation of the National Prevention Strategy) and small (writing a Federal Register Notice on medication adherence). I could not possibly have asked for a better fellowship experience, and I will be forever grateful to the Atlantic Philanthropies, the American Political Science Association, and my colleagues at the Department of Health and Human Services for this experience – and I've only been here for four months. I can't wait to see what the next six months have in store.
I gratefully acknowledge support from the Atlantic Philan-thropies and the Health and Aging Policy Fellows Program. I would also like to thank my mentors in the Office of the US Surgeon General and in the Health and Aging Policy Fellows program: Mary Beth Bigley, Corinne Graffunder, Lesley Russell, Lynda Anderson, and Patrick Conway.
The views expressed in this article are those of the author and do not represent the official policy of the DHHS.