A Challenge to the Acting Surgeon General

by james s. hirsch

He sees no patients. He doesn’t submit insurance claims. And he doesn’t run any clinic or hospital. But the U.S. Surgeon General is the most important doctor in America.

Sometimes called “America’s top doc,” the surgeon general is appointed by the president, and his or her job is to promote the health of the nation through education and to advise the president on health care policy. Some surgeon generals have been controversial while others quite influential: Dr. C. Everett Koop, who held the post from 1982 to 1989, used the bully pulpit to help change the country’s policies on tobacco and AIDs.

With diabetes now making a legitimate claim as the country’s number one public health threat – by the government’s own estimate, one in three Americans born in this century will develop the disease – we would hope that the surgeon general would make diabetes a national priority. But that’s not the case. The surgeon general identifies five “public health priorities:” disease prevention, eliminating health disparities, public health preparedness, improving health literacy, and organ donation.

All of these intersect diabetes but do not focus full attention on the disease itself and do not send any clarion call to action.

a diabetic patient in high places

Which might be a little odd, because since August of last year, the acting surgeon general has been Rear Admiral Kenneth P. Moritsugu, who was diagnosed with diabetes seven years ago at age 55. Prior to his current appointment, he had been deputy surgeon general since 1998 (in 2002, he briefly served as acting surgeon general).

In many ways, Dr. Moritsugu is an inspiration, showing that diabetes has not impaired his ability to work at the highest levels of government. He has also had to overcome stunning personal tragedies that make his professional accomplishments stand out even more.

He was recently the keynote speaker at the “Friends for Life Conference” in Orlando for the Children with Diabetes organization. Standing in his white gold-braided navy uniform, his chest bedecked with ribbons, he slipped his Animas insulin pump out of his pocket to show the children that he was one of them. “I am also a patient,” he said, stressing that everyone – including himself – needs to better understand “health literacy.”

But does Dr. Moritsugu’s employer – the federal government – understand the scope of the diabetes epidemic? Consider the government’s spending for medical research for diabetes: between 1980 and 2006, the NIH budget for the disease increased by 240 percent, to $1.1 billion, but its total expenditures grew by 261 percent. So the percentage given to diabetes slightly declined even as the number of diabetics had doubled. (Even more sobering: the NIH in 2004 spent $68 for each diabetic, compared to $16,936 for each patient with the West Nile virus.)

blame it on congress

In an interview with me, Dr. Moritsugu blamed the funding shortfall on Congress. “We can only administer those programs for which we have authority,” he said, “and we can only distribute those funds which have been legislatively appropriated to us . . . As a patient, I see that the federal government is doing a good job with the funding that it has.”

If anything, Dr. Moritsugu said, diabetic patients should look less to the federal government for help and more to themselves. “From my experience of 36, 37 years as a career officer in public health services, I have seen programs come and go, and the biggest mistake is if everything is leveraged on federal funding, as opposed to a partnership on the federal level, the state level, the community level, private organizations, and foundations. From that perspective, it is less us who have the power to affect the federal component of funding for research than you, meaning the constituency who actually has better access to the ears of those who make the appropriations.”

My first reaction to those words was: ugh, what a cop out. Yes, I can write a letter to my congressman, but I don’t have the megaphone that a president has, or a senator, or an acting surgeon general. Why are none of them doing what President Franklin Roosevelt did for polio – make its defeat a real priority? Dr. Moritsugu said the emphasis by the surgeon general’s office on “disease prevention” is very much tied to diabetes. (The Web site identifies diabetes, along with heart disease and many forms of cancer, as examples of “preventable chronic diseases” that kill 70 percent of Americans each year.) “The first priority is prevention,” he said. “I think overweight and obesity will put this smack dab in the middle of the radar screen.” He describes the complications of weight gain and obesity – heart disease, kidney failure, etc. – as “the domino effect.”

connecting the dots

Prevention is a laudable strategy to curb the type 2 epidemic, but is diabetes per se just another “domino”? Of course not, it’s the entire game board, and Dr. Moritsugu said that he understands the vast challenge before us: changing lifestyles, improving health care delivery, and increasing biomedical research. He calls the challenge “connecting the dots.”

“Many of us want to do good things for the health of America, but what we do is not really integrated into an overall strategy,” he said. “We need to look at overweight and obesity and diabetes as not simply a health issue but a dietary issue – that’s the Department of Agriculture. It’s a Housing and Urban Development issue. It’s a Transportation issue. It’s an Education issue. It’s a Commerce issue. You say, ‘Eat well,’ but in some of our communities there is no supermarket within a reasonable distance, so we have to bring commerce into the neighborhood and we have to help people help themselves do the right thing . . . This is a long way of saying, ‘Connect the dots.’”

But Dr. Moritsugu’s integrated strategy begs the larger question – Who will connect the dots? Who will unite these disparate entities, across all levels of government and all walks of life, to fight a common foe?

looking for a leader

Perhaps the best qualified person in America is Dr. Moritsugu himself. While he lacks the charisma of a Colin Powell, the resources of a Bill Gates, or the power of the president, he has a remarkable personal story – of triumph and heartbreak – that commands attention. Born in Honolulu of Japanese descent, he has both a medical degree and a master’s degree in public health. He entered the Public Health Service in 1968 and has held numerous positions, including medical director of federal prisons, and has won a slew of honors, including the “Surgeon General’s Medallion.” (I don’t know what that is, but it sounds impressive.) Resume aside, what distinguishes Dr. Moritsugu is family tragedy: he lost his wife in an auto accident in 1992, and then his daughter was killed four years later, at age 22, in a separate car accident. Dr. Moritsugu has used these tragedies to promote organ donation. Both his wife and his daughter were donors, and he found comfort in knowing their organs saved others. (A retired policeman received his wife’s heart.) Organ donation stands as one of the health priorities of the surgeon general’s office.

Dr. Moritsugu, who has remarried and has two daughters, will return to his position as deputy surgeon general once the current nominee is approved. Asked about the leadership vacuum in diabetes, Dr. Moritsugu told me: “Waiting is passive, instead of what I know is part of the fabric of America, which is that people come together and raise their voices and say, ‘Hey, pay attention to that issue, and here is the science, and here is the evidence, and here is the emotion.’”

but what role should you play?

He paused before answering, then looked me in the eye. “I have engaged in the challenge,” he said. “I have engaged in the challenge with the Office of the Secretary (for Health and Human Services). I have engaged in the challenge with our former surgeon general, and there is another nominee, and I have engaged him.”

But how many people in America know about Kenneth Moritsugu – about his life story, about his experiences, and about his commitment to diabetes? “Basically, I’m holding myself out to the department and saying, ‘Use me. I am the one who has the disease. It is very personal as well professional.’” With a glint in his eye, he thanked me for pressing the issue.

“I hear your challenge,” he said, “and I am willing to rise to it.”