Can Surgeon General Pick Balance Politics With Public Health?

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Analysis Law and Policy

Can Surgeon General Pick Balance Politics With Public Health?

Martha Kempner

Maybe, maybe not. But the history of the nation's top physician faring badly in ideological battles doesn't bode well.

On Tuesday, a U.S. Senate committee held a hearing for the Trump administration’s surgeon general candidate before the full Senate vote on the nomination, expected to happen today. Dr. Jerome Adams, the man who could become the nation’s doctor, is currently Indiana’s health commissioner, a position he was appointed to in 2014 by then-governor and now Vice President Mike Pence.

Trained as an anesthesiologist, Adams is best known for his work on the opioid epidemic. He has advocated for laws restricting the number of pills physicians can prescribe and increasing access to the overdose antidote, naloxone. He is also credited with having convinced Pence to institute a needle exchange program to fight an emerging HIV epidemic in the state. Colleagues say he’s a true public-health advocate, but his views on many issues are unknown and it’s unclear how often he will stand up to an administration likely to take positions that counter best public-health practices.

We know of at least one instance in which Adams allowed a conservative, anti-science agenda to influence his department’s work in Indiana. In September 2015, the Indiana State Department of Health (ISDH) began sending letters to parents reminding them of the importance of vaccinating their children against the human papillomavirus (HPV). The parents had been identified through the state’s immunization records as those who had not yet started the three-shot series recommended by the Centers for Disease Control and Prevention (CDC) as part of routine vaccinations for 11- and 12-year-olds.

The original letter explained that “HPV vaccines help protect boys and girls against various cancers that affect 27,000 men and women annually.” It pointed out that, in addition to the CDC, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians all suggest that every child 11 years and older get the vaccine. And it informed parents of ways that they could get the vaccine for their children even if they did not have insurance. It did not talk about HPV as a sexually transmitted infection.

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One of the parents who received the letter was Micah Clark, head of the conservative American Family Association of Indiana. Clark’s 14-year-old daughter had not yet received the shots. Clark sent an email to his supporters, criticizing ISDH’s vaccine promotion efforts as being part of a “nanny state” and taking away his parental rights. He explained in the email that he’s not anti-vaccine and his daughter was vaccinated against mumps and polio. But he felt vaccinating her against a sexually transmitted disease is “something with completely different moral connotations and risk/benefit considerations.”

His email criticized ISDH’s letter for not emphasizing that HPV is a sexually transmitted disease and for saying that cervical cancer could damage fertility and prevent young people from starting their own families. He argued that since the average age of onset of cervical cancer is 48, most people who get it would have already had the children they wanted.

Clark also noted: “While the ISDH letter expressed many health concerns, it didn’t say that HPV causes anal cancer in gay men at a rate astronomically higher than heterosexuals. Why is that?” His email went on to include numerous myths and misconceptions about the HPV vaccine, such as suggesting it is ineffective and potentially dangerous.

It should be clear to anyone who has followed the debate over the HPV vaccine, as Rewire has been doing for years, why the ISDH letter was not written with Clark’s preferred language. This life-saving vaccine is already working to reduce the rate of HPV. A 2016 study concluded that within six years of the vaccine’s introduction, HPV rates were down 64 percent among teen girls and 34 percent among women in their 20s. In fact, experts estimate that widespread use could prevent 90 percent of cases of cervical, vulvar, vaginal, and anal cancer. Cervical cancer alone kills about 4,100 U.S. women annually.

Yet too often, the conversation gets mired in the fact that HPV is spread through sexual activity, and parents (and politicians) stop focusing on preventing cancer and start worrying about whether young people should be having sex in the first place. Given this discourse, it’s not surprising that the rate of HPV vaccination lags behind all other vaccines.

ISDH’s original letter was clearly aiming to correct this. It read, “Please allow this letter serve as a reminder to contact your health care provider and make an appointment to start the series.” But after Clark’s email went out, Pence began being questioned about the letter. He told the Fort Wayne Journal Gazette: “We certainly want to respect the prerogatives of parents. The role of the state department of health in making information available to families is longstanding. We’ll look into it and make sure it’s clarified.”

A few days later, a new letter was sent out with a very different focus and tone. Instead of starting with cancer risk, the letter stated, “HPV is the most common sexually transmitted infection and is spread through skin-to-skin sexual contact.” It downplayed the potential seriousness of the virus and associated conditions by noting “most HPV infections cause no symptoms and go away on their own.” (This fact was one of Clark’s suggestions.) And it replaced language on how many cancer cases could be prevented with something more generic: “Infection with the virus can lead to cervical cancer in women. It can also cause other genital cancers in men and women, as well as genital warts.”

It is unclear what role Adams himself played in this controversy. We do not know, for example, whether he argued vehemently for the original letter or swiftly agreed to modify it. We only know that the original letter upset Pence’s far-right allies in Indiana and that a second letter was written, all while Adams was heading the IDHS.

Will Adams Put Health First?

On Tuesday, Adams faced questions during a confirmation hearing before the U.S. Senate Committee on Health, Education, Labor and Pensions. He promised to “lead with science …. but I also want to listen to what stakeholders and patients are saying.” 

Experts across the country have suggested that Adams will stand up for public health over ideology. Dr. Joshua Sharfstein, an associate dean at the Johns Hopkins Bloomberg School of Public Health, told the New York Times: “From everything I’ve seen, Dr. Adams is a very serious and capable physician and public health official. This is an opportunity to speak to the problems as they are and not as they are viewed through an ideological prism.” In the same article, Charles Rothenberg, president of the Medical Society of the State of New York, echoed the sentiment that “Dr. Adams has a proven track record to make public health a priority despite political hurdles.”

Indeed, Adams is credited with stemming an HIV epidemic in rural Indiana by convincing Pence to overcome his own negative opinions on needle exchange. A month into Adams’ tenure at IDHS, the first cases of HIV in rural Scott County were reported. Within a year, there were 181 cases in a town with fewer than 5,000 residents. The virus was being spread through needles used to inject prescription painkillers. At the time, the state banned needle exchange programs but, perhaps at the urging of Adams, Pence launched an emergency clean needle program.

While the needle exchange reversal is often pointed to as proof of Adams’ ability to stand up to political opposition, critics felt this change of heart on needle exchange came far too late.

Adams later wrote of the decision: “No matter how uncomfortable syringe service programs make us, they are proven to save lives, both by preventing the spread of diseases like HIV and hepatitis C, and by connecting people to treatment that can put them on a path to recovery.”

In Tuesday’s hearing, Adams spoke about a conversation he had with a local sheriff who was concerned about needle exchange “and the revolving door of his jail” for people arrested for drug offenses. 

The “biggest lesson” Adams gleaned from these community discussions and trying to address the HIV situation in Scott County was that “science and evidence is necessary, but it’s not always sufficient” to effect change. 

It’s Hard Being at the Top

Surgeons general wield little power except that of persuasion when they use their office to shine a light on issues they deem priorities. They tend to get the most attention when their positions differ with those of the administration that appointed them.

Dr. C. Everett Koop, for example, was the surgeon general under Ronald Reagan when he was asked to write a report about what anti-abortion opponents call post-abortion stress syndrome (and which public-health officials say is non-existent). Koop had been chosen for the role, in part, for his own personally conservative views on abortion. Yet, after going over the evidence, rather than write a report, he issued a letter saying there “was no unbiased, rigorous scientific research on the effects of abortion on women’s health that could serve as the basis for a Surgeon General’s report on the issue.” Anti-choice groups, however, later used Koop’s letter in challenging the U.S. Supreme Court’s Roe v. Wade decision, reported the New Scientist in 1989.

Koop also pushed the Reagan administration to respond to the emerging HIV and AIDS crisis, and he was ultimately responsible for a report that called for condom use, condom education, and sex education starting in third grade.

Dr. Joycelyn Elders, who served under Bill Clinton, sparked frequent controversy for her views on sex education. She spoke out in favor of making contraception available in school and criticized the Catholic Church for its anti-abortion stance. But it was backlash to comments she made at a conference on World AIDS Day 1994 that ultimately lead to her resignation. When asked about masturbation, she said: “I think that [masturbation] is something that is part of human sexuality, and it’s part of something that perhaps should be taught. But we’ve not even taught our children the very basics.” This was just too much for some opponents, and the Clinton administration, which was reeling from Newt Gingrich’s recent takeover of the U.S. House of Representatives, wanted no part of the controversy.

In 2007, Dr. Richard Carmona accused the George W. Bush White House of watering down or even suppressing important public health reports for political reasons. He was not asked back for a second term.

And our most recent Surgeon General, Dr. Vivek Murthy, made political enemies with his focus on preventing gun violence. The National Rifle Association actively opposed his nomination, and there is speculation that his strong anti-gun views are why he was asked to leave his post in April.

It remains to be seen what issues Adams will highlight if confirmed, though he mentioned the opioid crisis and engaging workplaces in improving the nation’s health during Tuesday’s hearing. Colleagues note he has been passionate about curbing tobacco use and reducing the infant mortality rate in Indiana. He has spoken in favor of Indiana’s Medicaid expansion program, but it’s unclear whether he likes all such programs (which are now on the GOP chopping block) or was fond of the conservative elements that Pence worked into his state’s program. Adams said of the program known as Healthy Indiana 2.0, “I’m convinced it’s going to give people access, it’s going to provide better health care, and it’s going to transition our citizens … to be able to work and better themselves as opposed to trapping them in an income-based entitlement program.”

And, of course, there’s no way to know whether he’ll be the voice of public health reason in an administration that has of yet seemed uninterested in science, health, or even facts.