Thursday, July 25, 2024

As public health becomes political, state surgeons general play delicate role • Stateline

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When Louisiana Republican state Rep. Brach Myers stood on the House floor this past April to advocate for his bill to create a state surgeon general position, the questions were sparse, and the debate lasted only a few minutes.

Democratic Rep. Matthew Willard asked whether the new role “could create chaos or maybe even division” in the state health department. Republican Rep. Nicholas Muscarello sought assurances that the new position wouldn’t add to the state bureaucracy. “Help me feel good about this,” Muscarello said. “This is not growing government, right?”

The House approved the bill, which was strongly backed by Republican Gov. Jeff Landry, with zero opposition. In May, Landry signed the measure into law and Louisiana joined Arkansas, California, Florida, Michigan and Pennsylvania in having an official state surgeon general or similar position.

Under the measure Landry signed, the surgeon general must be licensed to practice medicine in Louisiana and will be employed by the state health department. The person filling the role will be “the state’s leading advocate for wellness and disease prevention” and “shall serve as the state health officer,” the law states. Technically, the surgeon general and the secretary of the Louisiana Department of Health will be co-leaders of the department, with the secretary serving as “CEO,” Landry said at a news conference, the Louisiana Illuminator reported. The governor will resolve any disputes between them.

That language, and the lack of legislative opposition, suggests that the role will be noncontroversial. But pandemic-era mask mandates and vaccination requirements have politicized public health like never before. Childhood vaccinations, once generally embraced as a public good, are being challenged in multiple states, including Louisiana. And Landry’s choice for the job, Dr. Ralph Abraham, is a former three-term Republican congressman (he served in the U.S. House from 2015-2021) and GOP gubernatorial candidate who recently endorsed a state law classifying abortion drugs as controlled substances.

Elsewhere, Florida’s surgeon general has made headlines by helping Republican Gov. Ron DeSantis defy the medical consensus on COVID-19 vaccines, even appearing with him on the presidential campaign trail.

That model has raised questions about what the Louisiana surgeon general might do.

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Myers told Stateline that his legislation wasn’t about injecting politics into public health.

“I know our surgeon general, and I know the integrity of that man,” Myers said. “What I’m worried about is where we are in terms of health care outcomes and access.

“It’s very important to me that the legislature always has the ability to come back and amend a bill like this, if we find ourselves in a place where that position is being used as a political football,” he said.

But Abraham, who has practiced family medicine for more than 30 years — after being a veterinarian for a decade — and who had been serving as the secretary of health, hasn’t shied away from politics. He co-chaired Landry’s transition committee after Landry was elected governor in October 2023. And he joined the bill-signing ceremony in May when Landry made Louisiana the first state to classify the medication abortion drugs mifepristone and misoprostol as controlled substances. The classification adds restrictions for prescribers and the possibility of legal penalties for providers and patients. Because abortion is almost completely banned in the state, the hurdles would be faced primarily by patients who need the drugs to manage miscarriages.

Abraham’s participation in that ceremony, while serving as secretary of health, raised some eyebrows among Louisiana health care providers.

Dr. Jennifer Avegno, director of the New Orleans Health Department, noted that the state health department was officially neutral on the abortion medication bill, and that “hundreds of health professionals statewide expressed serious concerns” about it.

“Certainly, the governor has a right to reorganize departments however he sees fit. New offices come and go,” Avegno told Stateline. “But the health department being neutral, I think, was significant. I can’t speak to why they were neutral, but it does indicate that they did not want the issue to become politicized.”

Victoria Coy, executive director for the Louisiana Coalition for Reproductive Freedom, an abortion rights group, said she hopes Abraham “turns over a new leaf” in his new role as surgeon general.

She noted that Louisiana has one of the nation’s highest maternal mortality rates and argued that the policies that Abraham and Landry have supported will only make it worse.

Stateline reached out to Louisiana’s health department for a response, but officials did not respond to multiple requests for comment or an interview with Abraham.

Significant turnover

On most health indicators, Louisiana consistently ranks among the bottom half of states. Abraham argues that as state surgeon general he can help improve the state’s health outcomes.

“I’ve watched the surgeon general of Florida, Dr. [Joseph] Ladapo, the surgeon general of California, Dr. [Diana] Ramos. They are doing phenomenal work in their states,” Abraham told Louisiana legislators at an April hearing, where he sat beside Landry as the two testified in favor of the surgeon general bill.

“So, this is somewhat of a modernization tool. What we’ve done in the past, again, is not working very well. And we need to do better.”

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Abraham said at the hearing that part of the reason why the state is failing is because the Louisiana Department of Health is “either inefficient or not proficient in certain areas,” as “the department is big.”

One problem, for Louisiana and nearly every other state, has been tremendous turnover in the public health ranks. Guiding the country through a once-in-a-century health emergency ratcheted up the pressure in an already difficult job — even before fierce opposition to mask mandates and vaccination requirements curdled into physical threats against health officials themselves.

Nearly half of state and local public health employees left their jobs between 2017 and 2021, according to data from a 2023 study published in Health Affairs. With those departures, health departments lost “invaluable experience and institutional knowledge,” the report stated.

Dr. Scott Rivkees, who served as Florida’s surgeon general and health secretary from 2019 to 2021, said that turnover, combined with an increasing public skepticism toward science, has opened the door to health care leaders with different agendas.

Rivkees said that during his tenure, DeSantis developed an increasingly anti-vaccine and anti-mask stance. With Ladapo as surgeon general, Rivkees said, the position has moved further into politics and away from science and health.

“There’s no question that Gov. DeSantis went for somebody that became more aligned with his views on COVID-19 vaccines,” said Rivkees, who is now a professor at the Brown University School of Public Health. Rivkees said DeSantis, who was getting ready to run for president at the time, “decided to really take a very staunch anti-vaccine stance, which was very different from what had happened before. I remember when I interviewed with him for this position, we actually talked about vaccines and their importance.”

Ladapo, who succeeded Rivkees in 2021, has come under fire for his views against mask-wearing during the pandemic, his rhetoric against the federal Centers for Disease Control and Prevention, and his anti-vaccination stance. The CDC even wrote a letter to Ladapo in March 2023 “to correct the associated misinterpretations and misinformation” he had been spreading about vaccines.

Rivkees said the role of surgeon general varies by state, but that generally the mission is to advise the governor and other elected officials on health issues so they can enact health policies that align with “scientific facts and grounded scientific information.”

“But we are able to see the influence of politics on public health,” he said, particularly when it comes to issues such as childhood vaccinations. “Coming out of this pandemic, where the country has really been divided.”

The Louisiana Department of Public Health website on immunizations, which includes Abraham’s name and title at the top, encourages childhood vaccinations and offers tips for doctors on how to deal with hesitant parents. But as attorney general under his Democratic predecessor, Landry challenged COVID-19 vaccine and mask mandates in court and sent a departmentwide email to state justice department employees suggesting strategies for avoiding school mask mandates.

“Louisiana law offers broad and robust protections for students’ and parents’ religious and philosophical objections to certain state public health policies. I support your religious liberties and right to conscientiously object,” Landry wrote.

Different duties

So far, Rivkees said, Florida is an outlier in having a top doctor who is out of step with mainstream ideas on public health and safety. But surgeons general in other states also help carry out the governor’s agenda.

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In California, the state’s second-ever surgeon general, Dr. Diana Ramos, an OB-GYN, has prioritized reproductive health, contraception and abortion access — views squarely in the medical mainstream but also ones that are aligned with those of Democratic Gov. Gavin Newsom, who appointed her in 2022. She also has championed mental health initiatives, another Newsom priority.

Michigan was the first state to create a surgeon general’s position, in 2003. The first person to hold that post, Dr. Kimberlydawn Wisdom, told Stateline her job was to rebuild the state’s health infrastructure by advocating at the legislature and securing grants. In contrast, she said, the role of the secretary of health was to focus on “day-to-day” issues, such as sanitation and sexually transmitted diseases.

“The [surgeon general position] was created during a challenging time, both politically and economically,” said Wisdom, now a senior vice president at Henry Ford Health in Detroit. “In Michigan there had been years of budget cuts to health initiatives under the previous administration, which did not give the appropriate focus to the broad economic and social value of promoting public health objectives and had significantly eroded the state’s public health infrastructure.”

Dr. Kay Chandler, who has been the surgeon general in Arkansas since April 2023, said her role is to be a “voice to the state and to citizens on public health issues.” Chandler, an OB-GYN, distinguished her role from that of physicians who work in the state health department, who are supposed to implement policy rather than shape it, she said.

She emphasized that a surgeon general must ground her guidelines and recommendations in hard data.

“I do think that oftentimes people come into a position [and] they have their underlying ideas,” Chandler told Stateline. “So, I think it’s important to always temper that with what the data is showing. And I think we need to make sure that people do trust us to do that.”

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