Testimony Before Subcommittee on Health and the Environment of the Committee on Energy and Commerce
House of Representatives
April 3, 1981
Presented on Behalf of The American Public Health Association by
William H. McBeath, MD, MPH
Executive Director
American Public Health Association
1015 Fifteenth Street, NW
Washington, DC 20005
Chairman Waxman, and members of this distinguished Committee. My name is William H. McBeath. I am a public health physician currently serving as Executive Director of the American Public Health Association. I am authorized to appear before you today on behalf of that organization.
APHA is the oldest and largest professional public health society in the world, having begun in 1872, and now having over 50,000 national and affiliate members across the country. We are a science-based, action-oriented, multi-disciplinary organization with an envied tradition and significant potential as a force in the movement toward valid national health policy and effective public and private health programming at federal, state and local levels.
We truly appreciate this opportunity to present our views on this important subject.
The American Public Health Association firmly believes that the health interests of the nation are best served only when the United States Public Health Service is headed by a Surgeon General who is a clearly qualified, specially trained, broadly experienced community health professional of demonstrated expertise and recognized ability. Long-standing tradition and specific provisions of federal law have helped assure such leadership by requiring that the Surgeon General be appointed for fixed terms from the commissioned corps of USPHS professional officers.
The Congress now has before it for consideration a proposal to waive or nullify certain provisions of the Public Health Service Act which is supposedly intended to address only the technical point of maximum age for commissioned corps appointment. It is our sincere belief that this proposal is, in reality, a thinly veiled attempt to circumvent a significant barrier to the designation of an unqualified candidate as Surgeon General.
Accordingly, for the first time in over a century of collegial co-existence with the Public Health Service, we in the American Public Health Association are constrained to speak out against the appointment of a specific candidate being designated as Surgeon General. We oppose the confirmation of Dr. C. Everett Koop as Surgeon General, and any modification of federal law which would facilitate his appointment.
There is ample evidence that Dr. Koop is a distinguished pediatric surgeon. He is much honored, doubtless deservedly, as a practitioner and teacher in his chosen medical specialty. It is not our intention to cast the slightest shadow upon his reputation as a highly skilled physician, exceptionally gifted in the art and science of surgery for infants and children. However, we must insist that these admirable qualities alone are wholly inadequate to equip one for national professional public health leadership; and Dr. Koop is otherwise almost uniquely unqualified.
We believe one aspiring to such national public health leadership must be well supplied with an understanding of public health principles and a mastery of public health methods which together give an essential background for an effective approach to and solution of public health problems. Permit a brief elaboration to demonstrate this point, which is central to our position.
A recent national commission has defined "public health" as "the effort organized by society to protect, promote, and restore the people's health.  The programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole."
The importance of "public health" as a recognized discrete area of organized societal endeavor and of official governmental effort is reflected in the distinguished 180+ years history of the U.S. Public Health Service. Likewise,  each of the several states and territories today benefits from the essential activities of officially established public health agencies. In fact, every American community of any size can boast of local community health programs under governmental and voluntary auspices.
To staff this array of agencies and programs, this country has a core group of about 150,000 qualified professional and technical personnel with distinct public health competence who work exclusively in public health settings (as estimated in a recent report to the Congress by the Secretary of Health, Education, and Welfare).
In addition to this large core of professional public health workers, the report goes on to enumerate supporting personnel in public health agencies and programs, and others whose primary work requires the performance of significant public health functions. This total public health workforce is over a half million.
It would be an unwarranted affront to every American public health worker to name an unqualified Surgeon General.
Several occupational disciplines are included within this national cadre of professional community health workers. They include community health educators, environmental health scientists, epidemiologists, health services administrators, health planners, industrial hygienists, nutritionists, public health dentists, public health nurses, public health physicians, sanitarians, statisticians, and others. Each of these brings to the public health task the distinctive skills of a primary professional discipline: but in addition, each shares a distinctive and unique body of knowledge basic to the principles and practice of public health. This recognized graduate education and/or specialty training in public health is now available for all health professionals, and has been encouraged by years of Congressional support.  Surely any Surgeon General today should have benefited from such education and training!
The mother science of public health is epidemiology, i.e., the systematic, objective study of the natural history of disease within populations, and the factors that determine its spread. In addition to this analytic measurement science, the study of public health is based on other essential environmental sciences, social sciences, and management sciences. Examples of courses of study at the heart of public health are behavioral science, biostatistics, community dynamics, demography, educational change, environmental protection, human ecology, public administration, and social policy. Certainly any Surgeon General today should have more than fleeting exposure to such areas of study!
This particular combination of disciplines and sciences which comprise the public health rubric have also seen the development of specialized methods, procedures, and skills common to research and service in public health.  Epidemiologic investigations, health survey research, controlled field trials, health program planning and evaluation, environmental inventories, sanitary inspections, community development, legislative implementation, and regulatory enforcement are just a few tools uncommon in clinical fields related to public health. Preferably any Surgeon General today should have more than amateur status in such operational activities.
Why do we say that being a specialized medical clinician is not sufficient qualification for Surgeon General? Are not the biomedical and clinical sciences at the core of medical education and practice, also importantly related to public health? Of course they are.
But only the narrowest form of medical chauvinism would permit the view that any competent clinical physician is automatically equipped to direct organized community health endeavors.
Physicians are especially and exquisitely trained to deal with the pathology of disease in the individual, rather than the active promotion of health in population groups.
Medical science and technology is largely that of the treatment of a diseased patient not that of the prevention of ill health in aggregates.
Private medicine is focused on the care of patients and the cure of their individual ailments. Public health is concerned more with varied causes of disease and their control in the population and its enviroment.
The almost exclusive orientation for one-to-one, provider-patient relationships so advantageous for the clinician, can actually be a disadvantageous distortion for the community practitioner committed to the broader target of equitable programming for a total population.
Finally, clinicians (physicians, dentists, nurses, and others) who in the past have secondarily sought to serve successfully in the field of public health practice have learned the necessity, and demonstrated the validity, of proceeding to expanded and extended fields of expertise quite differentiated from and additional to the biomedical and clinical sciences.
Please note that in contrasting the patient care clinician and the community health practitioner, we attribute no inherent superiority to either. It is the significance of their differences we seek to emphasize, and the distinctive contribution each can best make to human well-being.
Frankly, we believe the qualifications defended here are appropriate for any of the nation's top health officials, including the Assistant Secretary for Health. But the qualifications are absolutely essential in the case of the Surgeon General of the U. S. Public Health Service.
The Surgeon General is the commanding officer of the PHS commissioned corps, and the chief executive of its civil service professionals. (Please recall that the USPHS is one of the statutory federal uniformed services. Can one readily imagine an armed forces Surgeon General being named from outside the medical corps of each respective service?).
The Surgeon General is also the senior official of the federal public health endeavor, and as such, a symbolic leader of the nation's community health movement -- a direct counterpart to professional colleagues serving as state health directors, county health commissioners, and city health officers across the nation. Can any but a public health professional recognized and respected by peers, rightly expect to be accepted as a leader in this national (and international) movement?
The Surgeon General is widely viewed now as the primary public spokesperson for the nation presenting authoritative positions of important matters of national public health policy. The scientific reports and official pronouncements issued over his imprimatur (e.g., smoking, nutrition, legionaire's disease, swine flu, prevention) must maintain worthiness of acceptance by the public and the health professions. Can the "SG" post retain this public trust and professional confidence if it becomes merely a hollow partronage perquisite handed out as an additional title to inflate the ego, increase the compensation, or add to the benefits of a partisan appointee?
Be assured that the range of political preference among qualified public health professionals covers a wide spectrum of beliefs and positions.  Conservatives and Republicans can readily be found among us. As an organization committed to open, democractic processes of self-government, our own internal public policy deliberations are usually peppered with a vital variety of opinion.
On one issue, however, we have consensus -- the Surgeon General should be qualified. As tradition has directed, and as existing law provides, the Surgeon General should be chosen from the ranks of qualified senior Public Health Service officers; or at least from the career professional staffs of other governmental and quasi-governmental public health agencies at federal, state, and local level.
Thank you.