Chief medical officers: the need for public health at the heart of governmentBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f688 (Published 05 February 2013) Cite this as: BMJ 2013;346:f688
- Gabriel Scally, director, WHO Collaborating Centre for Healthy Urban Environments, University of the West of England
As the global economic crisis continues to have detrimental effects on health and health services around the world, there has never been a greater need for powerful advocates for public health at the heart of government. The need for an articulate and authoritative voice that can tell elected politicians the potential health consequences of their actions and inactions has been recognised in many democracies since the pinnacle of the sanitary revolution of the 19th century.
Many countries around the world have such a post designated in their governmental structures to provide expert advice on current and potential hazards to public health. There is, however, enormous variation in how this national role is positioned. In the countries of the European Union it ranges from a top level office occupied by a public health physician to a post at a lower level of government, or even separate from it, and occupied by an administrator rather than a physician.1
Perhaps the two most prominent posts globally are the surgeon general of the United States and the chief medical officer (CMO) of England, which incorporates the role of chief medical adviser to the UK government. These two posts show the advantages and hazards of having a medical voice so close to the heart of government.
There has been a surgeon general in the US since 1871. He or she is an officer in the US Public Health Service, and the holder is appointed by, and serves at, the pleasure of the president. Although lacking substantial power, the post has traditionally had a high profile and carries a public expectation of championing public health goals and aspirations.
The close connection with the political process can lead to conflict if the surgeon general’s views meet with the disapproval of the president. Bill Clinton sacked Joycelyn Elders, the 15th surgeon general, after a series of controversial statements on sexual health.2 Even more tellingly, at a hearing of a House of Representatives committee in 2007, three former surgeons general gave testimony of a culture of political interference in their role.3 Richard Carmona, who served President George W Bush, experienced the most extreme professional repression, he told the House Committee on Oversight and Government Reform in 2007. He was regularly told what he should or should not say and had his reports censored and suppressed. He was even instructed not to prepare reports on mental health, emergency preparedness, and global health.
The history of the CMO in England stretches back to 1855, when John Simon was appointed medical officer to the Board of Health in response to the threat of cholera.4 Simon used his considerable political skills to establish his freedom of speech and his access to ministers and the machinery of government. Despite being the driving force behind many pieces of public health legislation that laid the foundations of the improvement in population mortality, even Simon was eventually marginalised and resigned.5 The post, however, has remained: it is a high level civil service post, and now has its 16th holder. Sir Liam Donaldson, the 15th CMO, broke new ground as a senior civil servant by making public his disagreement with the government on the subject of control of environmental tobacco smoke, and by surviving in office with even greater influence. His robust approach to protecting the public’s health won the day. He combined this independence of view with helping the government develop important policies on health and healthcare.
Historically, the best CMOs have been willing to speak publicly without fear or favour but often also did so behind closed doors, where tough arguments with recalcitrant or ideologically dogged ministers needed to be won. This strength often garnered respect, sometimes, ironically, from politicians who received praise for taking the firm public health action on which they were reluctant to embark (smoke-free legislation in England is a good example of this).6 Perhaps though, strength and fearlessness are not to the taste of all political administrations. Donaldson’s successor was appointed on a short term contract to a post diluted by being combined with the role of director general of research and development (a demanding portfolio in its own right with extensive international commitments) and is one of the few English CMOs to have no public health background.
Even more curious is the UK government’s decision to appoint a medical scientist to the post of chief scientific adviser. This seems a recipe for conflict, misunderstanding, and confusion, particularly in giving advice to the public on aspects of health risk and also in the handling of emergencies, where both CMO and chief scientific adviser sit around the COBRA table to guide ministers’ decisions. In the past, distinguished non-medical scientists have held the latter post and complemented very well the CMO’s role and responsibilities. It remains to be seen whether the nation can have two doctors, especially if they disagree in public, say, on vaccination policy.
The challenges set by landmark reports on social determinants of health in the UK and globally should presage a broadening in health thinking that is, in its way, equivalent to the sanitarian movement that shifted the focus from care to prevention in the 19th century.7 8 For this reorientation to succeed even partially requires outspoken public advocacy at local, national, and international level. The role of CMO at national level as an empowered advocate of population health should be promoted by the World Health Organization as an essential component of good health governance for the 21st century.
Towards the end of Bertold Brecht’s play Life of Galileo, Galileo says: “Unhappy is the land that needs a hero.”9 The state of global health is such as to indicate clearly that we are in desperate need of passionate public health heroes at the heart of national governments around the world.
Cite this as: BMJ 2013;346:f688
Competing interests: The author was a candidate for the chief medical officer of England in 2011.
Provenance and peer review: Not commissioned; not externally peer reviewed.