Antonia Novello : U.S. Surgeon General Moniters Nation’s Public Health

Early in the Bush Administration, Dr. Antonia Novello, 47, succeeded C. Everett Koop as U.S. Surgeon General. Born in Puerto Rico, educated there and at Johns Hopkins University, Novello practiced in Virginia as a pediatrician, then spent a decade as a staff physician and administrator at the National Institutes of Health before being selected for the Surgeon General’s post. Her husband, Joe, is a child psychologist. She is one of the few Latino women ever to hold high federal office.

Koop was an unusual Surgeon General in that he actually was a surgeon; Novello, like most others in the post, has her advanced training in public health. The Surgeon General has no jurisdiction over surgery--the job’s primary responsibility is to issue warnings about health threats. Holders of the post also supervise the Public Health Service, an organization that details doctors to various federal health projects.

Where Koop was fiery and theatrical, Novello is soft-spoken. Her speech, delivered in a light Spanish accent, is laden with the terminology of public-health studies, words like data and cohort. Novello has retained Koop’s practice of wearing the slightly comic-opera uniforms of the Public Health Service, apparel that had fallen out of favor with previous surgeons general. These can give her the appearance of a Gilbert-and-Sullivan character, but as Koop discovered, help get the Surgeon General’s picture on the evening news, media organizations ever hungering for interesting visuals.

Question: The Northeast and central United States now have a measles epidemic. Measles is supposed to be ancient history. What’s happened?

Answer: In 1980, there were fewer than 1,500 cases of measles in the United States. In 1991, we had at least 9,400 cases. Other diseases for which there exist widely available vaccines are re-emerging. Even some cases of polio have been reported. Parents are not getting their children vaccinated on proper schedules.

Some people are skipping the shots because of complacency, others because of cost. In 1980, the drugs to vaccinate one child for polio, measles and DTP (diphtheria, tetanus and whooping cough) cost $6.69. By 1984, it went up to $11.54. Now the cost is $96. That’s for vaccine alone, not counting the $15 or so per shot that the physician charges. For the private paying patient, a basic course of childhood vaccines may now cost $300 out of pocket.

Q: Haven’t some people become afraid of vaccines?

A: To my amazement, many parents today know much more about the potential complications from inoculation than about basic benefits. Last year, there were two confirmed cases of brain damage caused by reaction to the DTP shot. Thousands of lives were saved by this same substance. Somewhere along the way the media has focused so much attention on those rare cases where a child is harmed by inoculation, to the point that people have forgotten that vaccines stop terrible diseases. Encephalitis and pneumonia are now rampant in some parts of the country. To be worried about the million-to-one chance of a bad reaction to one of these vaccines, when the underlying diseases are far more likely, is not common sense.

Q: Why has vaccination declined so much among the poor, who usually don’t have to pay for shots?

A: Most public-health clinics are open 8 to 5, not in the evenings. A working mother has trouble getting two hours off to take her child in for a shot. When the mothers do come in, they bring all five children with them, because they can’t afford child care. But most public health clinics lose that wonderful opportunity to vaccinate all five on the spot--they only vaccinate the one child who has the appointment, telling the mother she must bring the others back later. Also, the poor get much of their medical care in hospital emergency rooms, and emergency-room personnel are too harried to check for vaccinations.

Q: Vaccination is perhaps the most cost-effective medical therapy, since it prevents disease. Yet many insurers that pay unlimited thousands for high-tech intervention won’t pay $20 for a flu shot. Why?

A: Prevention as a goal is simply not understood by our health system.

Q: You’ve said domestic violence, mainly against women, is a public-health issue.

A: Every five years, domestic violence claims as many lives as were lost in the Vietnam War--about 58,000. Domestic violence not only happens to the poor, it happens in all socioeconomic classes. Yet the medical community pretends it isn’t there. There was an analysis done on the emergency-room records of 170 victims of domestic violence. The data showed that, despite black-and-blue marks and other telltale signs of abuse, only 5% of the records made any notation of possible domestic violence.

Q: Doctors are now generally alert to the physical signs of child abuse.

A: Yes. If they see an abused child, they know who to call to have the child taken from the home to safety. And they know that the law will protect someone who reports child abuse. But if they see an abused wife, they feel that reporting it may open a Pandora’s box. Doctors don’t know which social-services agencies to call. They fear getting mixed up in legal cases. They tend to accept it if the woman says she received her injuries from “a fall” or some other obviously untrue explanation.

Q: How can that be changed?

A: The American Medical Assn. has recently taken some responsive steps. They asked that medical schools incorporate into their curriculum instruction on domestic violence as a health issue. And many residency programs are beginning to include protocols on how to recognize the symptoms.

Q: You’ve spoken often of the health effects of underage drinking. Since teen-agers have always found ways to sneak beers, why do you think it’s worse today?

A: Today, the problem is more rampant and more openly tolerated. High-school data show that 92% of teen-agers drank in the past year, and one-third tried alcohol in binges. One-fourth tried binge drinking by eighth grade. By the way, the data also show that kids in college drink more than kids who don’t go to college. When you’re a parent paying all that money to send your kids to college just to drink more, maybe it’s time to do something about it.

Q: By numbers, cigarette smoking dwarfs all other public-health issues combined--as many as 395,000 deaths per year from cigarettes, more than a thousand per day. This continues, though the public has been elaborately warned that cigarettes ruin the lungs and the heart.

A: I worry about smoking across-the-board, but I am now very much worried about women smoking, because the numbers show that young women are smoking more while young men smoke less. And young women are smoking Winstons and Marlboros (high tar and nicotine brands). Cancer of the lung has surpassed cancer of the breast as a women’s problem. Women tell me that part of liberation is behaving like men, including smoking like men. But is it really necessary to get men’s diseases in order to be liberated?

Q: What’s left to do from an anti-smoking standpoint?

A: Traditionally, it is said that smoking is a personal decision that only effects the smoker, whose rights should not be impinged. Understanding of passive inhalation is changing that premise. Consider the data on the Japanese wives who died of cancer of the lung when they never smoked themselves. (Their husbands smoked.) If people who smoke are harming someone other than themselves, the freedom-of-choice equation changes.

Q: Doesn’t your office already consider secondhand smoke a health threat?

A: The Environmental Protection Agency has concluded that, and we believe the EPA analysis. The estimate is 3,800 deaths per year from passive inhalation. For instance, in the cases where cancer of the lung occurs in children, one parent or the other is a smoker.

Q: About AIDS--the perception now is that the spread has leveled off. Has it?

A: Don’t, don’t believe that AIDS has leveled off. In the original target population of homosexual men, AIDS might be leveling, mainly because they have become serious about methods of prevention. But AIDS in homosexual men will be surpassed by AIDS among heterosexuals in some parts of the population. In New York and New Jersey, AIDS is now the first cause of death for women between the ages of 15 and 44. And remember, there is a new transmission means now--from women with HIV to their children as they are born. That was not an issue 10 years ago when the epidemic started, but is an issue now. The transmission rate from mothers with AIDS to infants is 30%, much higher than the transmission rate among homosexual adults.

Q: Young people seem to think of AIDS as a disease of the over-30 generation.

A: Complacency and lack of knowledge about AIDS is common among young homosexuals. If the young homosexual disregards the epidemic and has unprotected sex, the next generation will be at risk. Twenty-one percent of adolescent homosexual boys have a minimum of four sexual partners; 63% do not use condoms with their multiple partners. And the data clearly show that young people generally are having sex earlier than ever, at ages when they are least likely to understand about protected sex. What effect will that have on AIDS transmission? The people who are now developing symptoms in their 20s must have contracted the virus when they were aged 13 to 19.

Q: The Public Health Service is currently recommending to the White House that infection with HIV be dropped as a barrier to entry into the United States. In fact, the PHS recommends that visa applicants to the U.S. no longer be restricted for any deadly disease except tuberculosis. The White House is strongly resisting this idea. What’s your rationale?

A: AIDS is not infectious in the normal way. You get it only through sex, blood contact or IV drug use. From the public-health perspective, this is no reason to refuse someone entry into the U.S. AIDS never should have been used to deny visas in the first place. The Justice Department, Immigration and Naturalization Service and Department of Health and Human Services are all looking at our proposal, and there is no consensus yet.

Q: The General Accounting Office recently released a study that asserts standard methods for testing toxicity of most chemicals fail to take into account reproductive impact.

A: This is part of a broader issue of the medical Establishment’s relationship to women in testing. It’s amazing how often women’s concerns are excluded from testing. There were longitudinal aging studies that followed subjects for 20 years and came to all these wonderful conclusions about how to understand aging, except that there was not one woman in the cohort. There was a study involving the relationship between aspirin and cardiovascular risk--22,000 men, not one woman. We’re not only not testing adequately for possible reproductive effects on the fetus; we don’t even treat women as separate disease entities for their own sake. So if I’m the doctor and you’re a woman, how do I know how many aspirin to tell you to take? (Recent studies suggest women in risk groups for heart disease may benefit from one to six aspirin per week.) This is changing, but slowly.

Q: On the politics of breast cancer, do you accept the premise that the medical Establishment pays too little attention to this because it is a disease that men don’t get?

A: Till recently, women themselves did not realize how rampant this ailment is--one out of every nine women get it. I don’t judge the Establishment too harshly on this, when women themselves did not seem adequately concerned. Incidentally, it is possible for a man to develop breast cancer. Rare, but it happens.

Q: Suddenly I consider this a woefully underfunded health priority.

A: (Laughter)