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Who Should Ascend To The Office Of Surgeon General?

President-elect Obama’s nomination of CNN medical correspondent, Sanjay Gupta, for the Office of Surgeon General of the United States has ignited a firestorm of debate across the Internet. Some argue that he is not qualified for the position, others say that his charisma would be a boon to public health communications, though the lay majority appear to have mixed feelings.

It is highly irregular for a Surgeon General nominee to be announced before the Secretary of Health and Human Services is confirmed. This faux pas in itself may speak to an irresistible opportunity for self-promotion, or that the Senate confirmation hearing is not the independent review event that we assume it is.

At age 39, Gupta has long aspired to become the Surgeon General, as sources close to him report that he has been saying (since age 33) that “it’s the next logical step in his career development.”

But before we draw conclusions about who’s right for the job, we need to understand what the job entails.

I asked Dr. Richard Carmona, 17th Surgeon General of the United States, to explain the roles and responsibilities of the office. A summary of our conversation follows:

Dr. Val: What is the primary role of the Surgeon General?

Dr. Carmona: It’s the Surgeon General’s responsibility to protect, promote, and advance the health, safety and security of the United States. The office of the Surgeon General dates back to 1798, when President Adams passed a law to create the Marine Hospital Service. The lead physician of the service became known as the Surgeon General. The Marine Hospital Service eventually became the US Public Health Service, and the roles and responsibilities of the Surgeon General broadened to include immigration, disaster preparedness (in the case of nuclear and biological warfare), national safety, health prevention, and many complex public health issues that face our nation and the world.

Dr. Val: What sort of experience is appropriate for a candidate of the office of Surgeon General?

Dr. Carmona: A successful candidate for the office of Surgeon General should have deep and broad public health experience, especially as a public health or uniformed military officer.  The Surgeon General is given the rank of Admiral, and as such he or she will interface with other Admirals and Generals, and Army and Navy Surgeon Generals, most of whom are career officers with decades of experience in military matters. The Surgeon General must have the wisdom and experience to take on the position of an Admiral and represent our country internationally.

Dr. Val: What does the Surgeon General do on a daily basis?

Dr. Carmona: The Surgeon General is the commander of the US Public Health Service Commissioned Corps, which consists of thousands of officers in hundreds of locations around the world working anonymously to keep our nation and our world safe. The Surgeon General interfaces on a daily basis with the NIH, CDC, SAMHSA, HRSA, and all of the federally related health agencies as well as global health organizations like the World Health Organization, Pan American Health Association, and the American Public Health Association. The Surgeon General provides in-depth analysis of health policy for every cabinet minister, including the Interior, Commerce, and Homeland Security. It’s a very visible, credible, and iconic position.

Dr. Val: What’s the selection process for the office of Surgeon General?

Dr. Carmona: The Surgeon General is nominated by the President of the United States after much due diligence, and under the recommendation of his staff. The candidate is then introduced to the United States Senate. Then the Senate, if they so choose, extends the candidate the privilege of appearing before them for a Senate confirmation hearing. During the hearing they review the candidate’s credentials and ask him or her questions about anything and everything related to the public health of this nation and the world. You’re essentially put in a hot seat, and rightfully so because the Surgeon General is America’s face of public health to the world.

Dr. Val: What should Americans expect of their Surgeon General?

Dr. Carmona: The Surgeon General of the United States needs to remain a non-partisan physician. He or she should always communicate the honest, scientific truth to the American public so that they can make informed decisions about improving their health. Often, that scientific information is not the same as the policy that the President or Congress come out with, because policy is a very complicated process.

The Surgeon General has the largest medical practice in the nation (300 million), and when he or she issues reports, they actually change behavior in our country and the world. The Surgeon General is the true, honest broker of the best science for the people, offered in an a-political fashion. He or she is a patient advocate at the very highest level of government, and is expected to address the most complex health problems that face our nation. There is no more important or influential office that an American physician can hold.

***

There is no doubt that Sanjay Gupta is a slick communicator. But there is so much more to the office of Surgeon General than relaying talking points to the American public. That may be why Americans are confused about what the Surgeon General does – most of them work hard to influence policy  and spend the majority of their time coordinating very high level public health initiatives on a national and international scale. Their primary role is not to be a talking head – but a strong, independent, pro-science voice of reason to both educated and less educated healthcare decision-makers. One must have conviction and spine to do the job. We don’t need a communicator to be the Surgeon General but a Surgeon General who can communicate.

The fact that the American public hasn’t been as aware of the work of the more recent Surgeons General may be a testament to their selflessness. If they were more interested in getting in front of a camera, than having those difficult private conversations about stem cell research (and such matters) with people who have the power to enable or disable funding for entire programs, then I guess we’d be more familiar with their work.

The office of Surgeon General is the most influential public health position that a  physician can be offered. He or she is ultimately responsible for upholding science based medicine at the highest level of government, and must be willing to openly disagree with policies that are inconsistent with its standards. I don’t know if Sanjay Gupta will tow the line on science, but his previous lack of clarity on vaccine safety is certainly reason for pause. What do you think?

Posted in: Politics and Regulation, Public Health, Science and the Media

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50 thoughts on “Who Should Ascend To The Office Of Surgeon General?

  1. mageriane says:

    These are all very good points. But do we even know what the current Surgeon General thinks about, say, stem cells? Has anyone in the public even HEARD of the current Surgeon General in the last 8 years?

    Pendulums swing, and perhaps it’s time to swing this way for a while? At least with Dr. Gupta, we will all know what he thinks about vaccines or whatever, and we’ll be able to have that public debate.

  2. David Gorski says:

    The Surgeon General position has been vacant since 2006, which is why you probably haven’t heard of who’s Surgeon General. In the interim after Dr. Carmona left, there have been two Acting Surgeon Generals, because the Bush Administration never replaced him. That’s hardly the stability necessary for a Surgeon General to connect with the American public. The current Acting Surgeon General is Dr. Steven Galson, who’s been a caretaker since 2007.

    One reason why the Bush Administration didn’t replace Dr. Carmona is because he “didn’t go along” with its political objectives and complained about being muzzled when it came to speaking out about embryonic stem cell research, emergency contraception, and abstinence-only education, areas where the Administration’s political stance conflicted with scientific and medical opinion. The administration also tried to water down his report on the health dangers of secondhand smoke. The Bush Administration is well known for its political interference in science and health issues; it probably wanted to neuter the Office of the Surgeon General by simply not naming a replacement. Acting Surgeon Generals are caretakers and not likely to start any new initiatives or issue any new controversial reports that might conflict with the administration’s politics.

  3. MedsVsTherapy says:

    From the little that I know, Gupta is really into pharmaceutical treatments, including being ‘for’ Gardasil, and failing to respect the growing evidence of problems with the widely prescribed SSRIs – problems including very challenging withdrawal from SSRIs for some, and problems of increased impulsivity, including aggression and suicidality for some. If any of you are not familiar with either of these two issues, then just google a couple key words and start reading.
    Gupta jumped out, surgeon-general style, to promote gardasil, without letting us know that he was on the payroll. Simlpy google “sanjay gupta gardasil merck”. There is a fair amount of info on the web about his role in “AccentHealth,” a seemingly independent journalistic endeavor by CNN to cover health stories, for the common good, surgeon general style. AccentHealth, unlike other various endeavors such as professional organizations, CME providers, faculty disclosure policies, conference speaking engagements, etc., journal pubs, etc., does not have a strict, transparent COI policy. In short, my opinion, with a fair handful of evidence, is that Gupta has serious conflicts of interest that would compromise the tremendous potential that the fed govt has at this very momnet to promote EVIDENCE-BASED public health. In the past decade, AHRQ has developed amazing programs and resources toward promoting and sharing the evidence base, and promoting principles of quality performance, in many prevention and treatment issues. These are almost too numerous to list, but browse AHRQ for an idea. Are all of these “good”? Probably not – they may end up promoting P4P and changing CME recommendations to reduce influence from Big Pharma, and in general medical doctors are ‘against’ both of those quality efforts. Either way: In my opinion, I believe I have seen some of this AHRQ focus get slanted toward the agenda of Big Pharma, so there is risk. whether I am right or just paranoid, I believe we simply need a SG whose CV and bank accounts are not already riddled with these types of conflicts. On top of that, he simply is not a public health person. As far as I can tell, he does not have a Public Health degree, which would be nice, since there are many physicians around who actually do have public health experience plus an actual degree indicating formal study.

  4. weing says:

    MedsVsTherapy,
    And being ‘for’ Gardasil is bad because……?

  5. HCN says:

    weing said “And being ‘for’ Gardasil is bad because……?”

    Because bad girls who have sex outside of marriage should be punished with cancer. Oh, and they should also be punished if they marry some guy who has already contracted HPV before the wedding.

  6. HCN says:

    (is there such thing as a “sarcasm” tag?)

  7. weing says:

    HCN,
    Not that I know of. But I get it.

  8. overshoot says:

    (is there such thing as a “sarcasm” tag?)

    <sarcasm>

    </sarcasm>

  9. MOI says:

    From what I’ve heard and read, Gardasil was rushed through the FDA approval process and the vaccine was not tested for possible side effects when administered w/ other vaccines. Also the spin that only girls should get it was troubling to many parents. Not that that has anything to do with the science but if you piss off the parents who are responsible for vaccinating their children, you are hurting your cause. I, for one, am glad that it will be another 10 years before my daughter gets it. I’m happy that they found a vaccine for it, but the hoopla over the problems has me weary and grateful that my child is only 2.
    I do not have anything to compare these numbers to, but from a layman’s perspective, it a little worrisome. see link below: http://www.medicalnewstoday.com/articles/63586.php

  10. Harriet Hall says:

    At least Gupta is science-based. The previous SG, Carmona, is now the CEO of Canyon Ranch Health, an integrative health facility that offers such things as therapeutic touch. He wrote the foreword to his colleague Gary Schwartz’s ridiculous book about energy healing, which I reviewed for Skeptical Inquirer. See http://www.csicop.org/si/2008-02/hall.html. Schwartz works for Carmona as the Canyon Ranch Director of Development of Energy Healing.

    Carmona says, “Where the science supports these integrative concepts of energy medicine, let’s use them. Where there is not enough science, let the studies begin and continue.”

    I say, “if there is no convincing science or plausible mechanism to support them, let’s stop wasting our time chasing moonbeams”? All of energy medicine hinges on one basic claim: that people can detect subtle human energy fields. If Schwartz is wrong about that, the rest of the claims for so-called “energy medicine” fizzle away.

  11. weing says:

    MOI,
    How was it rushed through the FDA approval process? Could you be more specific?

  12. Zetetic says:

    A little sidelight here – A national news story I saw yesterday said administration of Gardisil will soon be recommended for teen males too. It’s about time!

  13. David Gorski says:

    At least Gupta is science-based.

    I’m not so sure about that. He’s shown a depressing tendency to “tell both sides” and present woo as though it had some legitimacy. For example, he was right at the heart of the credulous media coverages of the Raelians’ Clonaid fiasco in 2002:

    http://scienceblogs.com/intersection/2009/01/sanjay_gupta_for_surgeon_gener.php

    He was also distressingly clueless about antivaccinationists, as brought out by his coverage of the Hannah Poling case:

    http://scienceblogs.com/purepedantry/2009/01/sanjay_gupta_is_a_possible_sur.php

    http://scienceblogs.com/insolence/2008/03/dr_sanjay_gupta_getting_clueless_over_th.php

    He’s also said things like:

    Though he described himself as a “Western-trained medical doctor,” Gupta allowed for the possibility of alternative medicine’s promise, saying “acupuncture may be difficult to prove, but these things are still used in big hospitals in China.”

    Meanwhile, Jeff Wagg at JREF has published a post about Dr. Gupta’s promotion of facilitated communication for autism:

    http://www.randi.org/site/index.php/swift-blog/379-sanjay-gupta-unfit.html

    So, forgive me if I’m a bit skeptical of just how science-based Dr. Gupta is.

    Although I’m less annoyed by this, his attack on Michael Moore was also notable not because he was wrong about Moore’s movie Sicko. Certainly there was much to criticize. It’s rather just how rotten a job Dr. Gupta did countering Moore’s claims. Unfortunately, Gupta missed the big picture and reduced his argments to, in essence, nitpicking Moore’s facts, which is a no-win game when dealing with Michael Moore. Indeed, it’s an exercise that plays to Moore’s strengths rather than to his weaknesses. Moore, of course, is a propagandist, and he’s a skillful one. He’s very good at cherrypicking verifiable facts, and, then, when he’s criticized, at loudly proclaiming that his facts are correct, the implication being that his argument must therefore also be correct. However, it’s not the facts he uses per se that make him deceptive at times, it’s how he uses them to weave a deceptive tale, a skill which is the sine qua non of a master propagandist. Someone who is going to be a public spokesperson can’t afford to fall for that trap when addressing critics of the administration, as Dr. Gupta did to his embarrassment.

  14. MOI says:

    “How was it rushed through the FDA approval process? Could you be more specific?” – weingon

    Nope, LOL. Now that I look more throughouly, the information is all second hand (opinion). I’d be more than happy to be wrong on this. Basically just rumors that the trials were rushed.

  15. Joe says:

    @ Harriet, Canyon Ranch!!?? “You will never find a more wretched hive of scum and villainy.” The medical director of the local installation is flogging his book on how to live to 150. All you have to do is follow his diet that impinges on the immune system. What would they be- sesquicentenarians? I don’t think he has any examples.

    @David, is it possible Carmona resigned merely to follow a more lucrative career? Anyone associated with Canyon Ranch cannot be too obsessed with facts.

  16. HCN says:

    MOI, if you do not want to rely on second hand opinions, you should do a search at http://www.pubmed.gov for tests on the HPV vaccine. You will see it was tested for several years in several countries. You will also find the opinion pieces, but those are obvious.

    My daughter is 14, and even though she is very intelligent, she is also a teenager. Hormones make even the smartest teenager do stupid things*. She survived her Gardacil series quite well, as well as getting Tdap last year, and the influenza vaccine last fall.

    * She still thinks boys are stupid creatures, even the young man who baked her a cake and gave it to her on Halloween!

  17. HCN says:

    Oh, MOI… I did finally click on the Medical News report you gave, the group quoted is NVIC. Many of us call it the “National Vaccine MIS-information Center”.

    If you look at their website you will see outdated and cherry picked information. Its founder is Barbara Loe Fisher, who you can read about in Arthur Allen’s book “Vaccine!”.

    Plus, that website has a special bonus, a clicky tab to find a lawyer. On their board is a rather infamous lawyer, Cliff Shoemaker. He has provided quite a bit of entertainment in his attempts to suppress the freedom of speech rights of a blogger. Check out what happened (and you really have to go look at all the pages on the case, they are classic!):
    http://neurodiversity.com/weblog/article/164/

  18. MOI says:

    @ HCN
    Thank you for the link!

    I can only hope that my daughter has that same attitude. But if she’s like her mother, all hope is sure to be in vein.

    If I could vent for a moment…Some of the negatives reactions to this vaccine were unreal. I had to wonder whether some of these proverbial ostriches would be so self righteous if an AIDS vaccine came out. The point to getting this vaccine at the age that is recommended is because you want to inoculate the child before she engages in the behavior that puts her at risk for getting the virus. Seriously, duh people.

  19. MOI says:

    Oh my! Thanks for information!

  20. overshoot says:

    She still thinks boys are stupid creatures, even the young man who baked her a cake and gave it to her on Halloween!

    Alas, she may be right. A boy who bakes girls cakes as presents is probably not paying attention to the pragmatic methods demonstrated to work.

    My own “research” suggests that adult memory-editing seriously distorts our notions of what we found desirable in our younger years.

    As for the “rushed approval” opinion, do bear in mind that to an antivaccinationist, anything short of tracking at least two generations from cradle to grave is a conspiracy to ignore the “long-term consequences.” I wish I were joking, but I’ve been in exchanges where the antivac crowd made exactly that argument.

  21. snfraser says:

    This article documents some of the Gupta/Moore encounter:

    http://www.fair.org/index.php?page=3135

    Gupta does appear to levy some unfair attacks on single payer health care. Given Gupta’s record as described by Gorski above, one wonders if Gupta will inform his health delivery plans with evidence or if he will tow the private insurance line.

  22. Nyx says:

    Is Dr. Gupta science based in his thinking? I have questions.

    On one hand the “Position Statement on Human Aging” by S. Jay Olshansky, Ph.D. , Leonard Hayflick, Ph.D. , Bruce A. Carnes, Ph.D. and published in Scientific American Magazine, May 2002 and the Journal of Gerontology: Biological Sciences, Aug. 2002, says this in the concluding remarks: ” Our language on this matter must be unambiguous: there are no lifestyle changes, surgical procedures, vitamins, antioxidants, hormones or techniques of genetic engineering available today that have been demonstrated to influence the processes of human aging.”

    You can also find the paper here: http://www.quackwatch.org/01QuackeryRelatedTopics/antiagingpp.html

    On the other hand, Dr. Gupta published a book titled “Chasing Life: New Discoveries in the Search for Immortality to Help You Age Less Today.” I have not read Dr. Gupta’s book. I will have to before I critique it. But neither the title and the review from Amazon.com are scientifically inspiring. This is an excerpt from that review: “While stem cell injections, nanotechnology, cryonics and other possible therapies are on the horizon, Gupta tells readers that extending life today is as easy as eating less, moving more and exercising the brain.” The review goes on to list some of the living examples of Dr. Gupta’s advice, anecdotes in other words, but does not have any reference to clinical trials.

    And an excerpt from his book was posted here: http://www.cnn.com/2007/HEALTH/04/13/chasing.lessons/index.html

    From that excerpt: “I’ve also become aware of how attitude can have a profound effect on our health and longevity. A positive outlook means a healthier body, more often than not. A sense of worth, of family, of joy — all these can have profound and positive effects on your physical well-being. ”

    I’ll not deny a positive makes my life more enjoyable. Feeling good is far better than feeling bad. But I will not claim that I will live longer for it.

  23. wertys says:

    This guy looks seriously underqualified compared to his predecessors…

  24. Ex-drone says:

    He’s shown a depressing tendency to “tell both sides” and present woo as though it had some legitimacy.

    Agreed. The example I remember is a clip he did on 25 June 2008 (no longer available on CNN site) about healing prayer. He dithered in his report stating that findings were split about the effectiveness of healing prayer across many studies. Of course, he failed to indicate (or understand) that the better designed studies did not support the claim. I got the feeling at the time that the report was written by his staff and that his opinion was “Don’t know. Don’t care. What’s the harm. Best not piss off the faith-based viewers.” I have no way to corroborate that impression though.

  25. Fifi says:

    Really? He fell for the Raelians? They have a UFO theme park for reality’s sake!(Well, it’s currently for sale so apparently it’s hard times for Rael…) Bah, their whole reason for existence is so that wrinkly old men and women can get access to sleeping with teenagers (they were involved in the rave scene in Quebec, that’s partly where their technofetishism comes from).

  26. MedsVsTherapy says:

    Gardasil: the public controversy can be seen as similar to the public controversy over sex ed: conservative parents don’t want this to be forced upon their kids. Sure, that public controversy exists. There is also another public controversy. You have to get past the anti-Christian, natural-science-is-my-faith knee-jerk reflex to detect this other controversy. The other controversy is this: Merck developed a marketing strategy far beyond the usual strategy of gaming the peer-review system, the CME system, the off-label RX system, and the FDA approval process system. Merck conducted a campaign to get each and every governor to make drastic efforts to get Gardasil-for-teen-girls as a policy mandate at the state level. Familiar with manipulating systems while maintaining a straight face, Merck worked to figure out HOW to achieve this policy mandate WITHOUT state legislature process, if at all possible. This is what happened in Texas: Gov Perry mandated one day that all teen girls would get this shot. Now, put down the copy of God Delusion that your domestic partner just gave you for Winter Solstice, and think about this: As we debate and discuss the science and health cred of Sanjay Gupta, a neurosurgeon, Rick Perry is so far from being qualified to judge anything like this that it is shocking to imagine this cotton farmer declaring, by fiat, a totally brand new vaccine in this current vaccine-unfriendly climate. Here in Texas, we do not have resources equivalent to the U.S. Preventive Services Task Force to coolly evaluate the risks and benefits, per a decently defined set of criteria for judging evidence, of each prevention measure that gets proposed. What Rick had was a team of Pharma marketing reps telling him how good Gardasil is. PLUS: we do not know what else Perry, or any other governors, were given or promised in exchange for mandating that their product be granted automatic annual sales in the millions. This is shocking, especially considering how challenging it is currently for a confused, concerned parent to get M then M then R, rather than MMR, just to be on the safe side. There is not yet any state mandate, as far as I know, declaring that this option be available to those patients who ask for it, yet as far as vaccines go, that is about th hottest topic out there right now. While this marketing plan did not succeed in Texas, it was pursued in each and every state, and Merck was successful in some of the states. NOW: look out: there is a new, emerging model for pharma development: develop a vaccination, and get it to be mandated state by state. A few months ago, I received a conference announcement covering this emerging field. A How-To manual, in short. There have been other Pharma-sponsored efforts to get us ALL to take some patented medication, such as the Texas Medication Algorithm Project, or Bush’s Mental Health Freedom Commission (Bush senior was on the board of what company? Lilly? You don’t say!). So, you can see this issue as just more than Christian right-wing home-schooler fear/paranoia/oppression, or as Pharma exploiting yet another public avenue for their patents. One blogger hypothesized that Merck actually was planning on the home-schooler crowd to raise objections, since that would quickly and easily galvanize support from the anti-Christian pro-’natural world’ medical crowd. Put a few key words in Google and read up if you are not familiar with any of these stories.

  27. MedVsTherapy,
    (A) The MMR is safe. Tell your friends.

    (B) It is good to scrutinize the pharmaceutical companies, always. But their methods and motives for ensuring a broad uptake of Gardasil has nothing to do with whether or not Gardasil is a great preventive vaccine.

    Personally, I plan to see my son gets it in seven years. I understand there have been good results in boys. The higher percent of the population that is immunized vs. HPV, the lower the risk of cervical cancers. There is absolutely nothing wrong with that.

  28. Chris says:

    MedVsTherapy posting can be summarized in his quote: “One blogger hypothesized”

    “Hypothesized” does mean anything of any worth.

    A couple of suggestions for you:

    1) Please use paragraphs. It makes it easier to read.

    2) This is “Science Based Medicine” blog, so instead of giving us speculations, opinions and guess (hypotheses) try to find some actual science to support your points.

    Especially with silly things you say like ” This is shocking, especially considering how challenging it is currently for a confused, concerned parent to get M then M then R, rather than MMR, just to be on the safe side.”

    No, getting the seperate vaccines increases the risk of allergic reaction and is NOT safer. There is absolutely no real scientific evidence that the MMR is worse than getting the three components separately (plus it has been around since 1971!!!).
    Did you miss that memo?

  29. Chris says:

    Aargh!!! The meaning of a sentence completely changed with a missing word! I meant to say:

    “Hypothesized” does NOT mean anything of any worth.”

  30. MedsVsTherapy says:

    In recent years, I have had MMR done with both of my children. I have no problem with MMR together or separately. I was painting the picture that, currently, parents in general are not sure what to make of the vaccine issues, and one reasonable solution is to take MMR separately if it makes the parent feel better. I understand that it does not reduce the likelihood of autism to take them separately, because neither M, nor M, nor R cause autism. Other parents are not sure – especially since the general parent population hears conflicting medical evidence evidence almost daily (today’s headline: antipsychotics double risk of death when used in pts with Alzheimer’s – along with getting MMR for my kids, I have also had dosc prescribe antipsychotics for never-psychotic elderly in my family). I see no problem with a physician agreeing to give MMR each separately to accomodate the wishes of the parent. Nonetheless, physicians are very hesitant to make this accomodation.

    Some of my post was supposed to be humorous – I truly have no data to support the idea that ANYONE received any book, for or against deism, for Christmas. I can’t back that up with any science.

    Merck has been conducting a coordinated campaign to get Gardasil mandated in 50 states: for the simplest way to give you the tip of the iceberg, look through data at this link
    http://www.sourcewatch.org/index.php?title=Gardasil

    I understand that some physicians may not like to see criticism of pharmaceutical companies. Nonetheless, almost daily, info comes out indicating that the pharmaceutical companies can be devious in their marketing strategies.

    Rather than by executive fiat, how might preventive services be more optimally evaluated? First of all, amybe run it past the state legislature, like every other law. Also, as I mentioned, the U.S. Prev Svc Task Force has a pretty good system for evaluating a public health recommendation before jumping to invoke the idea as mandated policy. This is covered in their ‘guide to clincal preventive services’ publication. Just check it out of the library. For the younger set, it is probably out there in PDA and .mobi format. This is the strategy adopted by the U.S. Preventive Services Task Force. It was adopted because it seemed reasonable. The 2005 criteria were not scientifically tested against the established, 2002 criteria, so I really can’t provide scientific evidence for the superiority of 2005 versus 2002. Go figure. BTW: the RTC gets a little tarnish on its gold-standard status from 1998 to 2002 to 2005. Another story for another day.

    So, that is some data, whether scientific or not, answering the question about why, other than through narrow-minded religious idealism, everyday people might be hesitant to adopt the recently developed Rotavirus vaccination (oh, sorry, scratch that) the new-and-improved even-more-recently developed Rotavirus vaccination. Oh, wait, I meant the thoroughly safe Gardasil. (Note: humor, intended to illustrate the possibility that a recently approved vaccine could be less than benign.)

    Whether Merck planned a predictable religious-right outcry as an impetus to solidify the general health care community in favor of Gardasil, I do not know. I presented that as speculation, and I have no RCT reference to support that hypothesis. And, it was an add-on to my main point, not the heart of my note.

  31. HCN says:

    MedVsTherapy trying to be “humorous” said “So, that is some data, whether scientific or not, answering the question about why, other than through narrow-minded religious idealism, everyday people might be hesitant to adopt the recently developed Rotavirus vaccination (oh, sorry, scratch that) the new-and-improved even-more-recently developed Rotavirus vaccination.”

    A bout with rotavirus when he was about 14 months old put my kid in the hospital. Explain to me very carefully why the science is inadequate in the new version with results like, and what in the bloody blue blazes it has to do with religion!:
    http://cmr.asm.org/cgi/content/full/21/1/198?view=long&pmid=18202442 (note there is more than one kind of rotavirus vaccine, not including the old Rotashield)…. “RotaTeq was tested in a large phase III trial in 11 countries, with subjects from the United States and Finland accounting for more than 80% of all enrolled subjects (85). The trial included more than 70,000 children and was designed primarily to evaluate vaccine safety with respect to intussusception but also to evaluate the immunogenicity and efficacy of the vaccine with respect to the severity of illness and the number of hospitalizations or emergency department visits for rotavirus gastroenteritis….
    In these trials, the efficacy of RotaTeq against rotavirus gastroenteritis of any severity after completion of a three-dose regimen was 74%, and that against severe rotavirus gastroenteritis was 98%. RotaTeq also proved to be strongly efficacious in preventing rotavirus gastroenteritis of any severity caused by the predominant G1 serotype (75% efficacy) and the G2 serotype (63% efficacy). ….
    ….
    “RotaTeq reduced the incidence of office visits by 86%, emergency department visits by 94%, and hospitalizations for rotavirus gastroenteritis by 96%. ”

    You might try actually attempting to look for the science, instead of relying on guesses and opinion.

    (I used the “review” button for the “rotateq” search results in Pubmed to find that paper, and there are several others… including one published in 2009 on the first page for the search term “rotavirus” from New Zealand, titled “Rotavirus Vaccine RIX4414 (Rotarixtrade mark): A Review of its Use in the Prevention of Rotavirus Gastroenteritis.”, notice that is NOT RotaTeq).

  32. storkdok says:

    This is from one of my throw away journals Ob.Gyn. News:

    Volume 43, Issue 22, Page 1 (15 November 2008)

    SHARON WORCESTER (Southeast Bureau)

    ATLANTA—Postlicensure safety monitoring by three national vaccine safety systems indicates that, in the more than 2 years since the human papillomavirus vaccine Gardasil was licensed, serious adverse events have been rare and have not been specifically linked with the product.

    More than 20 million doses of Gardasil, manufactured by Merck & Co., had been distributed and are under passive surveillance, and more than 375,000 doses are under active surveillance as of Aug. 31, Centers for Disease Control and Prevention officials reported at the fall meeting of the CDC’s Advisory Committee on Immunization Practices.

    Of the more than 10,300 adverse events reported thus far to the Vaccine Adverse Event Reporting System (VAERS), 94% have been nonserious. Most of the adverse event reports to VAERS were consistent with prelicensure trial data.

    Among the adverse events reported are syncope, dizziness, nausea, Guillain Barré syndrome, venous thromboembolism, and death, according to Dr. Angela Calugar of the CDC.

    About 51 reports, 3 of which were serious, have been made per 100,000 doses given. About half of all reports are in those aged 11–18 years, and 25% are in those aged 19–26 years, Dr. Calugar said, noting that this likely reflects the proportion of patients in these age groups who are receiving HPV vaccine.

    Serious adverse events—including syncope, venous thromboembolism (VTE), and Guillain Barré syndrome—occurred mostly in individuals with other contributing factors.

    For example, of 18 reports of VTE, 14 were in patients who also used hormonal contraceptives, which are known to increase VTE risk, she noted.

    As for the 17 deaths reported in association with HPV vaccination, no clusters based on patient age, timing of vaccination, or other factors were identified that might hint at a causal relationship, she said.

    Furthermore, the Clinical Immunization Safety Assessment (CISA) Network—a collaboration of six U.S. academic centers that conduct research on adverse events associated with immunizations—has found insufficient evidence to support a causal relationship between HPV vaccination and the reported serious adverse events, reported Dr. Barbara Slade, who also is with the CDC.

    Likewise, findings of the Vaccine Safety Datalink project—which was established in 1990 to improve the evaluation of vaccine safety through active surveillance and epidemiologic studies—showed that among more than 375,000 doses administered and monitored, no statistically significant risk for any prespecified adverse event (Guillain Barré syndrome, seizures, syncope, anaphylaxis, other allergic reactions, appendicitis, stroke, and VTE) occurred after vaccination in either youth (ages 9–18 years) or adults (ages 19–26 years), Julianne Gee of the CDC reported.

    The Vaccine Safety Datalink Project used rapid cycle analysis—a study method that compares actual vs. expected adverse events to provide a more timely analysis of vaccine safety than traditional study methods allow—to test hypotheses suggested by VAERS reports and prelicensure trials.

    Monitoring by this system, as well as by VAERS and CISA, will continue, the officials said.

  33. SC says:

    It is good to scrutinize the pharmaceutical companies, always. But their methods and motives for ensuring a broad uptake of Gardasil has nothing to do with whether or not Gardasil is a great preventive vaccine.

    And conversely, its specific qualities don’t say anything about appropriate processes for developing and implementing safe and effective public-health measures. There seem to be two separate issues here: the safety and efficacy of the HPV vaccine, and the process through which it comes to be utilized in public health. It is certainly possible to be concerned about mechanisms that allow for-profit corporations to exert a strong influence on this process in their own interest and to urge caution without suggesting that a specific vaccine itself is necessarily dangerous or inefficacious. So pointing to further research suggesting Gardasil’s safety and/or efficacy doesn’t say anything about the appropriateness of political actions aimed at making it not just available, affordable, or recommended, but mandatory.

    I would be interested in people’s responses to this piece:

    http://jama.ama-assn.org/cgi/content/full/297/17/1921

  34. weing says:

    “(Note: humor, intended to illustrate the possibility that a recently approved vaccine could be less than benign.)”

    It’s the same with drugs. If you are looking for a perfectly safe drug or vaccine, you will never fin them. They don’t exist. One strategy I follow is not to be the first nor the last doctor to start using a particular drug or vaccine.

    Personally, I bristle at the use of any mandates. The fact that a company makes a profit from a drug or vaccine says nothing about the safety or utility of that drug or vaccine.

  35. SC says:

    The fact that a company makes a profit from a drug or vaccine says nothing about the safety or utility of that drug or vaccine.

    Why do people keep saying this? Of course it doesn’t. But the profit motive does mean that the corporation will be very aggressive in ensuring that it is used as widely as possible as quickly as possible, trying to influence physicians and policymakers who are supposed to be beholden not to them but to their patients and/or the public interest. This in turn means that we, the public, should do everything possible to scrutinize and challenge conflicts of interest and undue influence on those people and institutions responsible for evaluating safety, prescribing, and making policy recommendations, and should make sure institutional safeguards are in place to protect the public (whether or not this is entirely possible in a system in which drug development is a for-profit business is another question, but the dangers can be minimized if they are appreciated).

  36. SC, I think your point is well-taken by everyone here. In fact, I don’t think anyone’s arguing with you. :)

  37. weing says:

    “But the profit motive does mean that the corporation will be very aggressive in ensuring that it is used as widely as possible as quickly as possible, trying to influence physicians and policymakers who are supposed to be beholden not to them but to their patients and/or the public interest.”

    Of course they will and we all know that. You would too if you were that corporation. That’s the beauty of capitalism. Do you have a non-profit business model of drug development?

    What would happen if a miracle drug came out that cured arthritis and paralysis but killed 1 out of every 1 million people that took it? Do you think that long term care facilities, wheelchair manufacturers, and the scooter store would be protecting the public interest by blocking access to this drug because of safety concerns?

  38. SC says:

    Of course they will and we all know that. You would too if you were that corporation. That’s the beauty of capitalism [!!!. Do you have a non-profit business model of drug development?

    Well, I’m an anarchist, and I have many ideas for the radical restructuring of science in general and of medicine and public health more specifically. It is empirical science that has brought us the great developments in these fields. As anarchist scientist Peter Kropotkin pointed out a century ago, capitalism, with its consolidation of corporate power and profit motive, has corrupted this process in any number of ways:

    - distorting priorities so as to emphasize drugs and treatments for the wealthy and ignore less profitable lines that might have enormous impact on public health, and putting life-saving treatments beyond the reach of poor people

    - promoting the destruction of public initiatives or systems in these areas by arguing for forcing SAPs on governments that require the dismantling of public programs in favor of “free markets”

    - interfering with the process of research into safety and efficacy in their favor (I find myself mentioning Jennifer Washburn’s University Inc. a lot lately)

    - corrupting the doctor-patient relationship by offering incentives to doctors that may not be in the best interest of their patients and, in the case of HMOs, destroying that relationship

    - corrupting the democratic process of policy-making with regard to public health

    - fighting for a weakening of human- and animal-subjects protections and interfering in other ways with ethical research guidelines that respect human rights

    - driving developments in other areas – industrial agriculture, unhealthy fast food, water pollution, etc. – that are extremely harmful to public health, while promoting individual, profitable “solutions” to public-health problems

    - diverting enormous resources to marketing and promotion which could be better used

    I don’t believe capitalist medicine’s going away anytime soon. That’s going to be a long struggle, though there are promising developments in science and healthcare to our south. In the meantime (in addition to supporting publicly-funded health care) I:

    - favor scrapping Bayh-Dole and support greater public investment in drug development;
    - support reforms like those promoted by organizations like the Institute on Medicine as a Profession at Columbia and educational efforts for medical professionals in these areas;
    - encourage greater scrutiny of the drug-development and use process in terms of ethics and conflicts of interest and the development of transparent and open institutional mechanisms to decide about drug policy based on the science;
    - support efforts for greater (global) democratic participation in the setting of priorities in medicine and public health, and especially those movements fighting huge health disparities and seeking greater access to existing treatments;
    - encourage nonprofit pharmaceutical companies, which do in fact exist and have real business models;
    - promote alternative visions of health care that see it as a fundamental human right covering many areas and a public responsibility.

    While some here may disagree with many or all of these, I simply can’t imagine that people find the Gardasil/governor story remotely acceptable. I recognize that my views aren’t shared by the vast majority of people in this country, but to present this as simply a matter of supporting or rejecting evidence-based medicine strikes me as extraordinarily naive. We shouldn’t let Merck define medical science any more than we should let Monsanto define agricultural science.

  39. Fifi says:

    SC – “Well, I’m an anarchist, and I have many ideas for the radical restructuring of science in general and of medicine and public health more specifically. It is empirical science that has brought us the great developments in these fields. As anarchist scientist Peter Kropotkin pointed out a century ago, capitalism, with its consolidation of corporate power and profit motive, has corrupted this process in any number of ways:…”

    Dude, I am SO with you! No gods no masters ;-)

  40. Fifi says:

    And, yes, I see commercial concerns to be a huge problem in the practice of medicine as a capitalist, profit-driven pursuit. It may have been less of one when doctors had individual practices but the US medical business model is antithetical to the practice of good medicine since it puts profits before patients.

    Also, because the pharmaceutical companies are profit driven it means research into simple but not profitable (things one can’t own exclusively) solutions is squashed. So, big advances in “popular” and profitable areas (hence the increased funding of SCAM and involvement of drug companies in those areas) but no research into ones that aren’t but that may be more important. It does also mean that the research emphasizes pharmaceutical “cures” over prevention and so on.

  41. weing says:

    ‘- encourage nonprofit pharmaceutical companies, which do in fact exist and have real business models;”

    Be more specific please. How would you encourage the companies without giving them money to make a profit?

    You say you are an anarchist, but you want my dollars and to be funding drug development, etc. How is that being an anarchist?

  42. weing says:

    Anyway, we’re getting off topic. My pick for surgeon general would be Steve Novella or Dave Gorski.

  43. SC says:

    Dude, I am SO with you! No gods no masters

    w00t!

    Be more specific please. How would you encourage the companies without giving them money to make a profit?

    Good question, though kind of strange as a nonprofit is, by definition, not for profit. Anyway, here’s one:

    http://www.iowh.org/

    Here’s an article about it from a while back:

    http://www.nytimes.com/2006/07/31/health/31charity.html?_r=1

    While it’s still more of a charity (and still too tied to the industry), it looks like it has potential to become self-sufficient over time. People can support them by donating, by publicizing their efforts (as I’m doing now :)), by volunteering… I’ve been working in a related area relevant to public health (agriculture), but it’s the same sort of thing.

    You say you are an anarchist,

    That’s because I am. :)

    but you want my dollars and to be funding drug development, etc. How is that being an anarchist?

    I think you may be confusing anarchism – I am an anarchist-communist very much influenced by Kropotkin – with blithertarianism. The idea that human health is a right and a public responsibility is fundamental to my politics. Now, if you’re suggesting that it is inconsistent for an anarchist to support government programs, this is indeed somewhat more complicated. I love to see new grassroots funding initiatives (don’t know how MalariaEngage is doing these days…), but these are no substitute for public investment in areas where there is great suffering and urgency, and in my view the idea that government funding should be bypassed encourages among many people the notion that health is not fundamentally a public responsibility. I think a lot about what a more anarchist system of health funding (again, for all sorts of interventions) would look like – with merit still judged by scientists in the relevant fields but decentralized, driven by and responsive to real community needs and engaged with communities, transparent, etc. This would be a good direction to move, and while I don’t believe this would lead to any sort of “withering away” of the state, going in this direction would mediate against corporate influence.

  44. SC says:

    Anyway, we’re getting off topic. My pick for surgeon general would be Steve Novella or Dave Gorski.

    Gorski? That running dog reactionary old guard supporter of bourgeois ideology?!

    ;)

  45. weing says:

    What do you want? I’m a capitalist pig.
    Anyway, I’ll check out your references. For some reason, I still think of Bakunin whenever I think of anarchy.

  46. Jurjen S. says:

    I’m with weing; I think I’d rather see Novella, Gorski, or indeed Harriet Hall as Surgeon General. Assuming any of them would even want the job.

    That said, regarding Gupta’s vacillating about health issues and trying to inject “balance” into his reporting may simply be a result of pressure from his producers due to CNN’s organizational culture and notions of what constitutes “good journalism” in the US today. Maybe (maybe) if Gupta is relieved of corporate pressure and the need to appease sponsors and pressure groups, he’ll emerge as a more unequivocally science-based professional. I’d certainly like to see somebody on the Senate hearing committee give him a thorough grilling on this, though (although I’m not optimistic about that happening either).

    I do have to wonder why Dr. Jones considers it a “faux pas” (literally, a “mis-step”) to nominate a Surgeon General before nominating a Secretary of HHS. It’s unusual, certainly, but then again, a large part of Obama’s proclaimed modus operandi is not to stick to established procedure merely because “it’s just the way we do things.” Does it really matter that the prospective Secretary of HHS be known before the prospective Surgeon General? And if so, why?

  47. weing says:

    I thought Daschle was supposed to be the HHS Secretary.

  48. Chris says:

    Personally, I would like to see the job go a qualified candidate who is presently part of the uniformed Public Health Corps:
    http://www.usphs.gov/default.aspx

    It is one of the uniformed services, just like the Army, Navy, Air Force and Coast Guard. Hence the term Surgeon “General”.

    Kind of how I like diplomatic assignments to very important countries to be given to professional diplomats and not to political donors.

  49. Jurjen S. says:

    Daschle’s been nominated, but not yet confirmed by the Senate. I mis-parahprased what Dr. Jones had written, for which I apologize.

    So to rephrase the question: Why is a “faux pas” to nominate a Surgeon General before the Secretary of HHS has been confirmed?

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