Changing Conceptions of Public Health

The Surgeons General have attained their preeminent public role as guardians of the nation's health by themselves becoming public figures, wearing the conspicuous uniform of a Public Health Service officer, organizing conferences, giving interviews, and delivering speeches across the country. Surgeon General C. Everett Koop alone gave about 800 speeches during his tenure, from 1981 and 1989. Above all other means, since the 1960s the Surgeon General has communicated through detailed scientific reports, beginning with the seminal 1964 Report on Smoking and Health, the first to receive widespread media and public attention. Before 1964, under the direction of the Surgeon General, Public Health Service officers published reports on a range of specific aspects of public health. Most, such as Charles Wardell Stiles's 1910 manual on The Sanitary Privy: Its Purpose and Construction, were directed to PHS field officers to aid them in their work in health care, epidemiology, and sanitation. Others were pathbreaking scientific studies of fundamental issues in medicine and health care, notably Leslie Lumsden's 1912 report on The Causation and Prevention of Typhoid Fever, and the 1959 report of the National Advisory Committee on Radiation on Control of Radiation Hazards in the United States. However, despite their importance, these reports received little attention outside of public health circles.

The 1964 report on the health hazards of smoking marked the beginning of a series of authoritative scientific statements by the Surgeon General. These reports have commanded public attention and have helped shape the debate on the responsibility of government, physicians, and individual citizens for the nation's health. Over the years the reports have addressed an increasing range of health issues. The Public Health Cigarette Smoking Act of 1969 requires that the Surgeon General produce an annual report reviewing the latest scientific findings on the effects of smoking on health. As a result, more than half of all reports published under the auspices of the Surgeon General during the past 40 years have dealt with this issue. Other reports, such as those on maternal and child health, address areas of health and welfare policy in which the federal government has been involved since the early part of the twentieth century. Still other reports, most notably those on Acquired Immune Deficiency Syndrome (AIDS), were a response to a rapidly developing pandemic. Reports, workshops, and conferences have reflected larger health trends, such as a growing awareness of the importance of nutrition and physical exercise, first discussed in the Surgeon General's report of 1979. Finally, several reports have addressed issues previously considered either to lie within the domain of private medicine and of the individual relationship between physician and patient, such as mental health, or to lie outside of medicine altogether, such as suicide, violence, and pornography. The reports have tried to frame these issues in terms of their implications for public health, properly within the purview of the Surgeon General.

Together, the reports of the past four decades have expanded the very meaning of public health. They show that the definition of public health is not fixed but has changed over time, and changed the practice of medicine, as well, to include areas such as human behavior and mental health. That fact has broad implications for our understanding of health and risk, personal pleasure and social norms, science and moral standards, and individual freedoms and public policy.