U.S. Surgeon General Richard Carmona Offers a Vision of What We Must Do to Improve the Well-Being of America’s Children
By Bill Lindsay
Meet the Surgeon General
Read about the path that General Richard Carmona followed to the Surgeon General's office
As the nation’s chief health educator, Surgeon General Richard Carmona has his work cut out for him. There’s the obesity epidemic, childhood mental health issues, asthma and allergies, diabetes, sexually transmitted diseases among teens, and the perennial childhood injury hazards of cars, pools, bikes, guns and toxins in the home … the list goes on.
On the other hand, American children are doing pretty well in many areas of health these days, Carmona says during a recent interview in his Rockville, Md., office. “Immunization rates are not bad. Teen pregnancy seems to be leveling off or going down. Smoking is not where we want it, but at least it’s not increasing.”
The Surgeon General is both realistic and optimistic about improving public health in America. He’s adamant about the need to increase the public’s health literacy and he knows that solving many of the nation’s current health problems requires societal change – not something that comes quickly. Yet, that doesn’t temper his enthusiasm when he talks about improving public health, especially for kids.
“We know what we need to do,” he says with the no-bull demeanor of an ex-military man. “We just have to do it.”
In January, Carmona declared 2005 the “Year of the Healthy Child” to give priority to ensuring a healthier body, mind and spirit for American kids.
As Carmona sees it, the Surgeon General’s role is to identify gaps in our health systems and to develop a “more comprehensive approach” to filling those gaps. When it comes to ensuring children’s well-being, he says, efforts need to begin even before conception.
“When we looked at what causes the morbidity and mortality in children, we said, ‘We’ve got to get to them as babies,’” Carmona says. “But even that is too late, because if you just look at birth defects, there are about 150,000 birth defects every year in the United States. And about 80 percent of those are preventable with good prenatal care.”
So the Surgeon General has targeted health messages to young mothers and fathers. “It’s a huge responsibility you take on when you decide to have a child, in order to bring a healthy baby into the world. That doesn’t just happen automatically.”
He has been campaigning to get all women of childbearing age to take vitamins and folic acid – “because you just never know,” he says, noting that half of all pregnancies in the United States are unplanned. “That’s the second issue,” he adds. “Let’s think a little bit more about planning pregnancies to make sure we are in the proper emotional and financial state to have a child.”
Once a child is born, the focus must be on good, consistent postnatal and pediatric care, he says. This way, any problems can be identified and dealt with early on. And, of course, there’s no substitute for proper nutrition and physical activity, which are at the root of the health concern now on everyone’s mind: the nation’s obesity problem.
Failures in Food and Fitness
America’s weight problem – like many of the health issues we face today – is the result of cultural change over the last 50 or 60 years, Carmona says. He points to:
• the rise in single-parent families and latch-key kids who have more autonomy;
• the demise of the traditional family dinner hour with home-cooked meals and the increased reliance on fast food; as well as
• the availability of many more snacks that taste good, but are laden with fat, sugar and salt.
Meanwhile, he adds, many schools have eliminated physical activity from their curriculum due to increased academic pressure and budget cuts. And then, to generate desperately needed funds, many have installed vending machines filled with unhealthy snacks.
Even school lunches themselves sometimes leave a lot to be desired, the Surgeon General says. “I’ve gone through some school lunch lines that are tremendous – just really healthy food, healthy choices. And then I’ve gone through others that are dismal.”
What many people don’t realize, he explains, is that federal nutrition guidelines only apply to schools that are part of a Head Start program or a federally subsidized school lunch program. “The fact of the matter is, it’s the local school board that decides what the kids eat,” he says.
Nevertheless, these circumstances don’t make the issue of overweight children any less serious.
“Approximately two out of three Americans are overweight or obese,” Carmona says. About 9 million of them are children.
“We’re seeing unprecedented rates of Type 2 diabetes associated with that obesity,” he notes. “We’re starting to see reports of children with hypertension, who have obesity and have diabetes. So we’re taking middle-aged disease and bringing it down to childhood.”
But the Surgeon General is critical of the “blame game” response to this epidemic. “Nobody is to blame,” he says. “Just after I came on as Surgeon General we started to see the first lawsuits against the fast-food industry. And we said, ‘This is crazy! This is a matter of decision and choice.’ Do we not accept any responsibility for what we do? Do we always blame somebody else?”
Rather than taking a confrontational approach with the food industry, Carmona and other public health officials sought the industry’s help in addressing the problem. They met with leaders of the Food Manufacturers’ Association, McDonald’s, Coca-Cola, Kraft and others.
“These people are moms and dads and grandmas and grandpas, too,” he points out in praising the industry response.
He cites McDonald’s elimination of “super-size” portions and the addition of nutritional information on menus and the inclusion of more healthful food choices at many restaurants. “Now you see kids’ meals with a fruit option and a juice option,” he says.
“There’s no question that there’s more room for improvement. But it has taken us a half a century to get here,” Carmona says. “We can’t expect to change this overnight. We have corporations that are geared to make food a certain way. It has taken them years to get there with the machinery and the people. Now they have to retool. They have to figure out how to preserve things differently, take the trans fat out, not use so much salt. They still want shelf life – how do they do that? So this is going to take some time.”
Getting Kids Moving
Beyond dietary habits, America’s weight problem is exacerbated by the simultaneous decrease in physical activity among children. Whether it’s because parents think it’s unsafe for their children to run around the neighborhood, because kids are spending too much time parked in front of a video screen, or because recess and phys-ed classes have been eliminated from the school day, the bottom line is that many children today are not getting enough exercise.
Parents need to encourage their kids to be physically active and be good role models themselves, Carmona says.
As for school districts that blame increased academic pressure for cuts in phys ed or recess, that’s “a lame excuse,” the Surgeon General says bluntly. “Educational outcomes have to be measured, but to say ‘it’s either/or,’ that doesn’t make sense. Physical education is very important. It needs to be included in the curriculum. How each school district decides to divide that time is up to them.”
And in response to schools that eliminate phys ed as a cost-cutting measure, he adds, “You may save some money today, but you’ve traded it for an unhealthy future.”
A System For Sounder Minds
Next to obesity, the hot topic on the minds of many is the state of America’s mental health system. In 2001, then Surgeon General David Satcher declared it a “crisis.” Carmona is no less alarmist today.
“People say to me, ‘Surgeon General, you need to fix the mental health system,’” he says. “My response is that there’s nothing to fix. We don’t have a system!”
As many as 10 percent of U.S. children and adolescents have some type of emotional disorder, Carmona says. The problem is that for about one in five people with mental health issues, their needs go unmet.
While he acknowledges “isolated areas of excellence,” the Surgeon General laments the lack of an overall health system that would allow a patient with a mental health problem to see a health professional suited to his or her needs and to have adequate follow-up care – whether it’s psychotherapy or drug therapy.
“As a society, we have marginalized mental health,” he says. “Nobody wants to admit to a mental health problem. It’s like alcoholism was 30 or 40 years ago: ‘Oh, that’s taboo. Don’t talk about it.’ We cannot marginalize mental health any longer. We have to accept the fact that we have people who are burdened with mental illness. We have to step up and figure out a system that will accommodate them.”
“There are many mental health advocacy groups that are pushing for this,” he adds. “I’m in total agreement with them that we have to push harder. There needs to be parity. Public health should automatically include mental health. We should not have to say, ‘Oh, by the way, let’s have some mental health, too!’ It can’t be an afterthought.”
Health Literacy and Cultural Change
In talking about public health in America today, the Surgeon General repeatedly refers to the “good scientific knowledge” we have at our fingertips and the need to make choices based on that, rather than myth or popular perception.
“It’s all part of health literacy, and we are largely a health illiterate society,” he says. “We’re driven by headlines. We’re driven by anecdote and not by science most of the time.”
As an example, he points to the current culture of parental anxiety over children becoming victims of abduction or violence, when it’s bicycle accidents, car accidents, pool drownings and encounters with household hazards – “attractive nuisances” as he often calls them – that pose the most significant risks.
Media coverage is a big part of this, Carmona says. “When I was a child in the ’50s and ’60s, there were not Amber Alerts. There were not news blasts every hour when a child was missing for a few hours. Those are all good things, don’t get me wrong, when it’s legitimate,” he says. “But now every day there’s a newspaper story of an abducted child. So it starts to seem that it’s almost the norm. But when you look at the science, the incidence really hasn’t changed. No more children are abducted today than there were 20 years ago. No more homicides are committed against children.”
“We have the best science in the world,” he continues. “What’s lacking is moms’ and dads’ understanding of it.” With improved awareness about real risks and what makes for good health, Carmona says, we can finally begin to make the cultural changes needed for a healthier nation.
In his declaration of 2005 as the “Year of the Healthy Child,” the Surgeon General draws attention to the body, mind and spirit aspects of overall health and well-being. How does the spirit part fit in?
“Kids are fountains of passion and innovation,” he says. “Often, as they get older, you can harness that energy. You can put it to use in your community. A perfect example is Boy Scouts and Girl Scouts, who volunteer at nursing homes, clean up yards or help senior citizens with their shopping.”
Another example, he points out, is the Medical Reserve Corps, a component of the President’s Citizen Corps that the Surgeon General heads up.
“We have about 250 Medical Reserve Corps in the country, over 40,000 volunteers,” he explains. “Last year, at our national meeting, we asked, ‘Who are we leaving out?’ Well, the children!”
So Carmona began to look for ways to get kids involved. Having been an ocean lifeguard himself when he was young, one idea quickly came to mind. He hooked up with former colleagues who told him about a junior lifeguard program for adolescents and young teens called “Go-JG” (Go Junior Guard).
“So we let Go-JG in and we started looking at other youth groups to bring in,” he says. “Why shouldn’t kids be a part of the community’s assets to provide for unmet needs?”
“The kids love it,” he adds. “Everybody wants to belong and be a contributor. What better way is there to do that and to instill self-esteem and confidence in a child than to say, ‘You’re part of the team. You can help … You’re important!’?”
It’s this kind of innovative approach to community and our institutions that the Surgeon General believes is the course to a healthier childhood and, ultimately, a healthier America.
“Community is being redefined in everything we do – our organizational constructs for schools, for school boards, for the military, for emergency preparedness, for EMS systems,” he says. “Many of these systems served us well in a different time, but to face the challenges we have today, whether they’re educational or response to emergencies, we need new organizational constructs to use those assets and resources more effectively and efficiently.”
This won’t be easy, he admits. “Stepping back and letting go of the comfort of old approaches never is, but it’s a different world and there’s a better way.”
From Treatment to Prevention
On the path to this better way, Carmona explains, is the need to become a “prevention-oriented” society, rather than a “treatment-oriented” one in how we approach health.
America faces a disease burden that costs us about 15 percent of our gross national product, he says. This is “unsustainable as a legacy to our children, not only economically, but health-wise. We must take some very targeted interventions right now.”
“The good news,” he adds, “is that we’ve identified the variables that contribute to the disease burden in society. And most of what we’re seeing is preventable.”
“Our culture has to change so that we begin to embrace health, wellness and disease prevention more fervently than we’ve embraced treatments over the years.”
This too is bound to take time, the Surgeon General admits, but he points to recent progress. Insurance companies, which rarely paid for preventive health care in the past, now routinely cover many preventive screenings.
“We have to figure out ways to incentivize health and wellness and prevention, and create an industry around that, where that becomes the norm,” he says, rather than health failures and treatment being the norm.
Recent advances in technology and understanding of the human genome will pave the way for this, he believes. Whether it’s through customized pharmacology or health care tailored to a person’s genetic predisposition, science will be a valuable tool in making America a healthier society – if we become more literate in utilizing it, he says.
Ultimately, Carmona says, it’s up to community leaders and individual citizens to find “community-specific solutions” to our health challenges.
“We’ll provide the technical assistance. We’ll provide guidance. We’ll give you all the good scientific information,” he says. “But it’s all of you moms and pops [in business, on community boards and at home] who need to make decisions that say, ‘This is best for our kids.’”
More Health Matters
Learn more about the Surgeon General’s views on:
• The Future of Medical Care
Bill Lindsay is editor in chief of United Parenting Publications.