Interview with Dr. Richard Camona US Surgeon General in December 2004

Integrative Medicine for Anti-Aging e-Journal
Age Management for Physicians & Healthcare Practitioners

Vice Admiral Richard H. Carmona, M.D., M.P.H., F.A.C.S., was sworn in as the 17th Surgeon General of the United States Public Health Service on August 5, 2002

Born and raised in New York City, Dr. Carmona dropped out of high school and enlisted in the U.S. Army in 1967. While enlisted, he received his Army General Equivalency Diploma, joined the Army's Special Forces, ultimately becoming a combat-decorated Vietnam Veteran, and began his career in medicine.

After leaving active duty, Dr. Carmona attended Bronx Community College of the City University of New York, where he earned his Associate of Arts degree. He later attended and graduated from the University of California at San Francisco, with a Bachelor of Science degree (1977) and a Medical degree (1979). At the University of California Medical School, Dr. Carmona was awarded the prestigious “gold-headed cane” as the top graduate. He has also earned a Masters of Public Health from the University of Arizona (1998).

Dr. Carmona has worked in various positions in the medical field including paramedic, registered nurse, and physician. Dr. Carmona completed a surgical residency at the University of California at San Francisco, and a National Institutes of Health-sponsored Fellowship in trauma, burns, and critical care. Dr. Carmona is a Fellow of the American College of Surgeons and is also certified in Correctional Health Care and in Quality Assurance.

Prior to being named Surgeon General, Dr. Carmona was the Chairman of the State of Arizona Southern Regional Emergency Medical System, a Professor of Surgery, Public Health, and Family and Community Medicine at the University of Arizona, and the Pima County Sheriff's Department Surgeon and Deputy Sheriff.

Dr. Carmona has also held progressive positions of responsibility as Chief Medical Officer, Hospital Chief Executive Officer, Public Health Officer, and finally Chief Executive Officer of the Pima County Health Care System. He has also served as a Medical Director of Police and Fire Departments and is a fully-qualified peace officer with expertise in special operations and emergency preparedness, including “weapons of mass destruction.”

Dr. Carmona has published extensively and received numerous awards, decorations, and local and national recognition for his achievements. A strong supporter of community service, he has served on community and national boards and provided leadership to many diverse organizations.

Just prior to this interview, Dr. Carmona had returned to his office after personally delivering copies of an Interagency Report by the Drug Importation Policy Task Force, which he chairs at the request of the President.

Dr. Coles: When we first met and I heard you give your keynote address at the Anaheim Convention Center this past summer, you presented your personal seven-point Agenda for the Office of the Surgeon General.

The first point was to establish a policy for health and disease prevention for all Americans. Secondly, you wanted to establish a plan for preparing for potential healthcare emergencies and crises. Thirdly, you wanted to eliminate the disparity in the distribution of healthcare by race or ethnicity in order to ensure that American Orientals, Latinos, and Blacks would get equal treatment along with Whites. Fourthly, to improve the literacy of Americans regarding health, as I recall, you made a special effort to create a number of reports directly targeting the American public (many in Spanish) and not just technical reports for demographers, epidemiologists, or physicians. Fifth, you’ve focused on dentistry (the health of the gums and mouth). Sixth, on Osteoporosis and bone health. And then finally, the last point was mitigating the continuing use of tobacco by many Americans.

So these are all topics that you’re very familiar with, and I’ll have you speak to these issues in terms of where you are in your personal Agenda, what you’re proud of, in terms of your accomplishments so far, and to see where you’re hoping to go from here, now that we’re essentially in the middle of your four-year term which overlaps that of the Administration.

Dr. Carmona: First, let me clarify a couple of issues, and then we’ll get into the Agenda itself. First of all, although we’re going to talk about disease prevention and health promotion as well as various issues that have led to healthcare disparity, the cornerstone or common currency of all of those endeavors is health literacy. Although you’ve listed it as the fourth component, it really is the key tool for me to be successful. If I can’t engage the American public and our peers about the issues before us, make the best science available, and deliver it in a culturally-competent manner, to very diverse communities, then I’ll simply be “spinning my wheels” and we won‘t make much gain. So, recognizing that we are largely a health-literate society, and being very sensitive to that, as I deliver our message that all of these areas are very important.

With that in mind, we also need to recognize the reality of working in a huge, complex bureaucracy. I believe that every U.S. Surgeon General preceding me said that they themselves all went through this same process. In other words, you come to Washington with your slide show or your PowerPoint presentations, with plenty of knowledge and a lot of experience, and you have the passion of the first-year intern who wants to stamp-out disease, famine, and pestilence all in one year. Then, you bump into the reality of the “Beltway” and how extraordinarily difficult it is to move any agenda forward, because there are so many stake holders, and then you really learn about public and health policy and how it’s formed with its various constituencies, lobbyists, and so on. So, these are the things that have not tempered my enthusiasm as much as they have bred reality into my approach to finding an incremental change necessary for public-health policy. And, I now have an understanding that most things don’t come with sweeping change here at this level; they only come with incremental change.

And, as it relates to health promotion and disease prevention, largely being a treatment-oriented society, how do we shift that culture and everything from how we reward our healthcare providers to how we actually practice on an individual basis, and accept responsibility for some of our own health needs? We are presently on a “path to failure.” We are not going to be able to sustain the deep economic burden that will be upon us if we don’t break that cycle; the legacy we leave our children will be unsustainable. So, we must embrace prevention first. Later, there will be many other programs that we must deal with.

For example, if you look at Nos. 5, 6, and 7, they’re—all of them—representative of preventive strategies, such as people stopping smoking. And we’ve been very active with my testifying on the Hill, with more Congressmen being curious about their constituencies, about how to eliminate tobacco use at all levels; we find that about 400,000 Americans are still dying of smoking-related diseases. And what I’ve tried to do is to pick up where some of my predecessors left off in this area—[Dr. C. Everett] Koop with smoking, with AIDS, [my immediate predecessor, Dr. David] Satcher with his concern for the problem of obesity, and some other issues. And then, I had to make sure that there was continuity among us, and next “carrying the ball forward,” so as to identify emerging gaps in our public health where I could make a unique contribution. Of course, one gap that I saw was the oral-health issue, which is exemplified by our Oral Health Report. And osteoporosis/bone health is another newly defined problem. My task is to shed light on that problem, using my “bully pulpit” to get information out and working with various stake-holder organizations to assure bone health. And the issue of tobacco speaks for itself. So, that’s just an example of part of what my Office does.

The other part, of course, concerns the personal responsibility that people need to feel for the whole business of physical activity, a healthy diet, reducing risks in one’s life, whatever that risk may be. This really can, in the aggregate, decrease disease risk for all of us significantly and lower the cost of health care, while at the same time increasing the quality of our lives.

Preparedness

Now let’s go on to the next issue of preparedness. And this is new as it relates to weapons of mass destruction, terrorism—and a whole list of other hazards, such as emerging infections, like flu, SARS, Mad Cow Disease [Bovine Spongiform Encephalitis], Monkey Pox, Hanta Virus, and on and on. Of course, we also deal with hurricanes, tornadoes, and floods—these are the more common natural disasters that occur on a day-to-day, year-to-year basis in our country. Now, we have these new threats thrust upon us, and we need to educate the public as to develop resilience and capacitance for dealing with these issues much as we did in the 1950’s with Civil Defense, air-raid sirens, etc., at the time of the Cold War. It goes to training our “first responders” and our soldiers and sailors and Marines as to how to deal with this “new world order.” A lot of that falls onto prevention as well, but preparedness really is an area onto itself, and my office is doing a great deal on this topic that ranges from basic science, as it relates to developing more robust surveillance systems for infectious disease, early warning systems for pathogens or chemicals that might be used to hurt us, various types of treatments and trustworthy antidotes; other threats that we know of; training police officers, paramedics, fireman, soldiers, sailors; and the newest methodologies for dealing with terrorist threats and weapons of mass destruction. So, that kind of covers both of these components of my Agenda globally.

Disparity of Healthcare Delivery

Next, the disparity of healthcare delivery is a very important issue, one that is near and dear to my heart, as you know, having lived in my youth without ready access to doctors, not going to the dentist in a timely fashion, or not getting any preventive care, and then understanding some of those indignities like having to go to a county hospital or a city hospital. Having to have a parent struggling to decide, whether they should go on welfare. By the way, my own mother declined to go on welfare. All of those questions are linked with disparity.

We know that people generally have access to healthcare, but paradoxically, even when they have such access, their outcomes in many outcome categories are still poor. So we see obesity, and diabetes, hypertension, and stroke, disproportionately represented in certain minority populations. And sadly enough, these populations, which need to get good science, in a culturally-competent manner, to empower them to take action to reduce morbidity and mortality and to increase their health and wellness, are the populations that are farthest away from health literacy. Often, it’s these very populations that have the biggest literacy gap, and therefore this adds to the problem of health disparity.

So, we are moving ahead in a number of areas with basic science up at NIH. We have about $4 million in funding that’s related to health-disparity research to help us delineate not just the epidemiology but the pathophysiology and the incremental contributors to healthcare disparity. Along with the CDC, we have many political programs that are addressing healthcare disparities—from dealing with children in grade school, to high school and college-level adults, and even senior citizens. Many of these programs are tailored to a particular geographic area or the particular ethnicity that we are dealing with in these populations.

A Legacy of Change

So, in addressing our top three priorities—prevention, preparedness, and disparity—I think there is measurable change, although it’s incremental. So what we are actually doing in all of these areas is a process of cultural change, and that takes time, since people need to be empowered and to fully understand that they need to do something different.

So there’s a side of me that’s happy with some of this “incremental” progress that we’ve made, as there truly has been some positive evidence based on measurable outcomes that have improved. However, I’m never going to be complacent in this job, since the extent of the need is overwhelming. The needs seem to be infinite, while resources are obviously finite. And, that’s my challenge on a daily basis—how to stretch every possible dollar and every possible program for those who need them—in the hopes that when I leave, like my predecessors, I will leave a legacy of positive change for my successors, so they can continue this responsibility towards the American public.

Resources

Dr. Coles: All right. Now in your remarks earlier on, you used some very strong language when you said, “We are currently on a path to failure,” and that we needed to “reassess our methods for rewarding healthcare providers,” and how “people must be educated to take greater individual responsibility with regard to their weight, not smoking, and so on.” But I think one of the contributions that this interview could make toward your Agenda is in alerting the doctors who are reading this, as to how they could obtain copies of some of the reports that your office has prepared for their own patients.

Also, I believe that we need to have more general publicity for your Office… Look, I read three newspapers a day and maybe 200 journals a month—and I very rarely see on CNN or in other media any references to your reports, except maybe on the same day that a new report is issued, like the one you just completed on Osteoporosis. So, is there a Website or a special “1-800” toll-free number that we should be calling to have access to the full range of the reports your office is targeting for the public?

Dr. Carmona: My answer to both of these questions is “Yes.” A more general Website is http://www.hhs.gov, and this will link to every program we’ve got regarding health and the Federal government, including a special section on age-related diseases. But the Surgeon General also has a Website, http://www.surgeongeneral.gov, and you can use it to link to all of my reports—all the speeches that I’ve given, which generally average 300 a year, on a wide range of topics, along with a list of my presentations. There’s a lot of information there on specific reports, and there are “1-800” toll-free telephone numbers one can call, so anybody could order them by phone or by simply filling out a standard form on the Website itself. For example, I recall that the Bone Health and Osteoporosis Report, which was issued last October 14^th, has a 1-866-718-BONE (2663) toll-free number.

Dr. Coles: So, because this interview will be published electronically, we will definitely insert a link—a so-called URL on the Internet—to the hhs.gov Website and to the surgeongeneral.gov website, so that the doctors among our readers will conveniently be able to “click through” and find out exactly what these resources are.

Dr. Carmona: Absolutely, I would appreciate it. Thank you so much, and happy holidays.

This interview was conducted by phone on December 21, 2004.