Los Angeles Times Interview : Joycelyn Elders : Talking About the Health of America While Surgeon General--and After

When the Senate blocked the nomination of Nashville obstetrician Dr. Henry W. Foster Jr. for surgeon general last month, by failing to override a promised filibuster, it fulfilled the predictions of many conservatives. Shortly after the nomination was announced in Febru ary, Gary Bauer of the Family Research Council made this pronoucement: “We will count on the new U.S. Congress that was elected with the votes of millions of pro-family Americans not to repeat the mistake that was made when Dr. Joycelyn Elders was inflicted on our children.” Bauer called Foster “Elders Lite” and many of Foster’s other opponents were no doubt galvanized by controversial public statements made by Elders, the previous surgeon general, during her 15-month tenure as the nation’s top doctor.

Surgeon General Elders said drugs should perhaps be legalized. She campaigned for widespread condom distribution and sex education in the schools, as ways to combat the spread of HIV. She attacked the religious right directly, referring to them as “the un-Christian religious right” and saying, “We’ve got to be strong to take on those people who are selling our children out in the name of religion.” And in December of 1994, Elders lost her job after public remarks about masturbation. She told an AIDS forum she thought it was “natural and safe” and that “perhaps those facts should be taught in schools.” President Bill Clinton quickly asked for her resignation, and Elders returned home to her native Arkansas.

The oldest of eight children, Elders grew up in rural Arkansas. She saw her first doctor at age 15, when she won a scholarship to Philander Smith College in Little Rock. She graduated at 18, then served in the U.S. Army. The G.I. Bill helped her get through medical school at the University of Arkansas, where she eventually became a full professor, also earning a master of science degree in biochemistry. In 1987, Arkansas Gov. Clinton appointed her director of the Arkansas Department of Health.

Elders, who is married and has two grown sons, returned to the University of Arkansas Medical School upon leaving Washington last December. She is currently practicing pediatric endocrinology, keeping a schedule that finds her rising each morning at 3. She retains her sharp opinions, but seems happy to be working again as a hands-on physician, no longer the lightning rod for controversy that she became during her term as surgeon general.

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Question: What are your feelings about Dr. Henry Foster’s nomination as surgeon general, and that he never got an up-or-down vote in the Senate?

Answer: I am very disappointed that it turned out as it did. I feel he should have had an opportunity to have his appointment voted upon by the full Senate, and I think he would have won that vote. I think he had 51 senators there that would have supported him. The fact that our system allows the kind of political maneuvering such that people can take other people out using those kinds of tactics is disarming and disappointing to me.

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Q: What’s your opinion on the real reason his nomination was squelched?

A: I feel it was a way for the Republican-controlled Senate to show their power and flex their muscles. Also, I think they simply sold out to the religious right. Those were the people who were really pounding--they used the abortion issue as their trump card. Dr. Foster was simply caught in between, in this battle of the Titans. The presidential candidates were battling it out, and he was just the fall guy--if you will.

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Q: What are Dr. Foster’s feelings after having been rejected by the Senate?

A: I have spoken to him, and I think he feels that he was given a chance, and had an opportunity to explain himself to the American people, and he was satisfied with his explanation. I feel he’s now positive and upbeat, and says it’s not everyone who even gets an opportunity to be considered. And so he’s going on with his life.

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Q: Given what happened to Dr. Foster, and what happened to you, I would suspect physicians might not welcome a call offering a nomination for surgeon general.

A: I think the really good candidates probably would not welcome that call. I think anyone who had plans to really try to do something, and achieve some real change as surgeon general, would probably now have serious doubts. On the other hand, the President might be able to get a very good person who could tackle the job head-on, and try to do it. But it has become so politicized that it’s a job where regardless of what you do, you’re wrong. There’s the right, the left and the middle. If you shoot for the middle, you haven’t quite done enough; and if you’re doing what the left wants, the right’s mad, and vice versa.

It is by its very nature a controversial position, and the problem is, this is a position where you really have to take scientific fact and use it to try to make changes to improve the health of America. Now, wouldn’t you think that shouldn’t be controversial? But it always has been.

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Q: How could the job be depoliticized? Is it possible to shelter the surgeon general from the storms of politics?

A: That is supposed to be exactly how the job is set up. The surgeon general’s job is a four-year statutory appointment. Technically, he or she does not serve at the will of the President. I had a four-year statutory appointment. But you don’t want be the surgeon general if the President doesn’t want you to be the surgeon general. At least I didn’t.

But, technically, it is supposed to be sort of an apolitical job. We’re talking about the health of the American people. It doesn’t matter whether you are Republican or Democrat, you both get sick. But it’s gotten embroiled in the political debate, I just don’t know of a way that it can be removed from partisan politics.

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Q: As you mentioned, the surgeon general should make decisions based on scientific fact. But when medicine collides with politics, doesn’t science often lose out?

A: In the past, that has happened, and we pay very dearly when science loses. In science, if something is correct, it is considered fact, and there is only one right way. In politics, when we are talking about things that don’t directly have an effect on the health of individuals, then there is plenty of room for debate and discussion. But the surgeon general is talking about using scientific data to make decisions about how to improve the health of America. In those cases, prolonged debate means people suffer, and perhaps even die.

Let me give you an example. We had a small burden of disease with HIV. Because we didn’t listen to former Surgeon General C. Everett Koop, we now have a very heavy burden of disease.

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Q: Dr. Koop brought the office of surgeon general to a new level of public awareness, and he campaigned for widespread use of condoms to combat the spread of HIV. And though he’s considered a conservative, if you had to compare your philosophies about public health, there might not a lot of difference.

A: They are probably very similar. I had a lot of respect for Dr. Koop. He was very courageous in taking on difficult issues. I tried to do the same. You know, if I had made my major issue something like the need to immunize children, nobody would probably even know who I was. Remember, Dr. Koop’s confirmation process took nine months, and then he was talking about AIDS and the need to use condoms, and he did not get along well with President Reagan. So it’s not an office that is a stranger to controversy.

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Q: Do you think the fact that you are a woman and an African American made you less able to withstand criticism for taking on issues like condom distribution and sex education?

A: On the contrary. I think being a black female enhanced my ability to bring up and discuss difficult issues. First of all, had a white man or woman talked about some of the issues I brought up--the links between poverty, education and pregnancy, for instance--they would have been attacked by the minority community. Because of my gender and race, and the fact that I grew up in a poor family, people knew that I understood many of these problems and I was not out there just talking about something I’d heard about or read about. They knew that I knew.

Of the many things you’ve heard people say about me, you’ve never heard anyone say I lied about the issues. Black people, poor people and women--they all knew that I knew what I was talking about.

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Q: There is a move among Republicans to simply abolish the post of surgeon general. What difference would it make in the life of the average American?

A: It would probably not make a great deal of difference tomorrow. But 10 years from now, the difference would be huge. That’s because there would be no one whose job was to talk about the health of America and who had a mission and responsibility to see that health was a major part of the national agenda. And, you know, when nobody is responsible for the job, it usually doesn’t get done.

Abolishing the job of surgeon general sends a loud message. It says we don’t care about the collective health of America. It says, “I’ll take care of my own health, you take care of yours, and we’ll let the rest of them die.”

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Q: Medicine is often a powerful tool for social change. Do you think there are forces in the government that see the entire public-health system as a political enemy?

A: There are many people who feel that everyone should pull themselves up by their bootstraps, and I believe there are people who see the Public Health Service as an instrument of social change--not the kind of change they want. Perhaps this is one reason why we in America spend so little on public health, when compared with every other industrialized country. Instead of focusing on keeping people well, we focus on taking care of people when they get sick. We’ve got the best sick-care system in the world.

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Q: What are the public-health issues of paramount concern to you right now?

A: There is the classic “3 Ps” definition of public health: poverty, population and pollution. People who live in poverty are more likely to have unplanned pregnancies, to contract HIV, have more low-birth-weight babies and are more likely to be malnourished. They’re also more likely to live in areas impacted by air and water pollution, so that poverty itself can almost be seen as a disease.

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Q: Your approach toward the spread of HIV and other sexually transmitted diseases has been a pragmatic one--you believe young people will have sex no matter what, so it’s best to arm them with education, and condoms. That infuriates the religious right, which says teaching abstinence is the best course.

A: How are they going to make that happen? They’ve been trying that for a thousand years. Heaven knows every mother, every preacher, every teacher would love for young people to practice abstinence--but there is all kinds of evidence to the contrary. We have more than a million teen-agers getting pregnant every year--unplanned pregnancies. We have a rapidly spreading HIV-disease epidemic, other sexually transmitted diseases.

So, rather than just standing out there and hollering “Abstinence! Abstinence! Abstinence!” we have to teach our children to be responsible. Other countries do it. They aren’t out there trying to legislate morals. They’re out there trying to prevent their young people from having unplanned, unwanted pregnancies and from getting sexually transmitted disease. The sexual activities of teen-agers in the Netherlands, Japan and many other countries are no different than those of our teens--yet, American teens are eight to nine times more likely to have an unwanted pregnancy or a sexually transmitted disease.

There are other areas of great concern. Our adolescents have become vectors in an epidemic of violence--they take it from the home and into the streets.

We need to teach our young people nonviolent ways to resolve conflicts. We know that it works. But the response is always, “We don’t have enough money.” But we have plenty of money to put people in jail. It just makes no sense.