MAHA Split Over New Surgeon General

The collapse of Dr. Casey Means’ nomination this week has sent shockwaves through the “Make America Healthy Again” (MAHA) movement. While the tech world debates AI, healthcare is debating the “Saphier Pivot,” the Trump administration’s sudden shift from a radical MAHA outsider to a credentialed Fox News regular. With the Surgeon General’s office at a crossroads, we have to ask: is the role still a beacon of public health, or has it become the ultimate prize in the culture war?

John Driscoll, Chairman of UConn Health and David E. Williams, President of Health Business Group, diagnose the state of the Surgeon General's office, examining what the rapid pivot to Dr. Nicole Saphier reveals about the limits of MAHA's political power, and whether the nation's most visible public health platform can still move the needle in an era of historic distrust in federal health agencies.

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Transcript

David: 0:00

The collapse of Casey Means' nomination for surgeon general has sent shockwaves through the Make America Healthy Again movement. We're now trying to understand the sapphire pivot, the administration's sudden shift from a radical outsider to a more traditional Fox News regular. With the surgeon general's office at a crossroads, we have to ask, is this role still a beacon of public health, or is it just another casualty of the culture wars? Welcome to Care Talk, America's home for incisive debate about healthcare business and policy. I'm David Williams, president of Health Business Group.

John: 0:40

And I'm John Driscoll, the chair of the UConn Health System. David, it's good to see you again.

David: 0:45

You as well, John, and I, I thought, you know, we're gonna talk about the surgeon general. It's more fun than talking about a general surgeon, so yes, good to see you, John.

John: 0:53

I knew that, that canard would come in. For sure. But it's good that we're talking with the breaking news about, you know, the, the, we're, we, the administration has decided to nominate someone with an active medical license as the surgeon general. That's gotta be progress, right, Dave?

David: 1:10

It's something, John, and I think, you know, this is our chance to do a little bit of a diagnostic and remember, you know, go back to some of the greats and some of maybe the lowlights of the surgeon general's, uh, past and see, you know, like, whether this sort of nation's doctor is still a thing or not. I'm, I'm hoping the answer is yes, but I, I'm not there yet, John.

John: 1:29

So what happened to the Cassie Means, the telegenic Cassie Means, who was very consistent, in fact, you know, arguably she was one of the more articulate leaders of the Make America Healthy movement. What happened to her nomination?

David: 1:45

Yeah. Well, so I think you had, you know, Senator Cassidy, uh, who kinda let RFK Jr., kind of, who let RFK Jr. through, is now, had second thoughts. Nothing he can do about RFK, but he can do something about some of the others that are, that are coming. And I think there were a couple things. As you said, like, uh, no active medical license, that's one thing, and then unorthodox views on childhood vaccines. Now, because of things getting delayed, uh, she was actually pregnant, and when she gave birth, it w- they they actually scheduled a, they actually scheduled the hearing for her due date, and she gave birth, so that didn't happen. And now there's questions like, "Hey, you know, are you vaccinating your own child?" And she's like, "That's personal, and we can't talk about it." So I think it's basically- That means

John: 2:27

yes... David: yeah. We- well, I don't know. Yeah, I don't, I don't know what it means. But, uh, yeah, so- That generally translates into yes. Um, so th- Yeah ... well, that's interesting. And so what's the, the, now that the Senate has kind of woken up to this vaccine challenge, because we've now got some pretty serious outbreaks of measles, which is unique to this period, and largely Um, blamed in many way, in, to, by many people, not all, at the lower rate of vaccination within certain communities and certain geographies. You know, herd immunity only really kicks in at n- north of 90% vaccination, and some of these, these, these have gone well below that, and we've got some kids who are really suffering. So that's gotten people's attention. The anti-vax movement appears to be outvoted. It, certainly by, by popularity, by the pro-vaccination majorities. Uh, what does that mean for this nomination?

David: 3:29

Well, so they intro- they, they introduce somebody, John, who's a real gem, at least her, uh, name is Sapphire, and she's a doctor- Oh, man ... Nicole Sapphire.

John: 3:38

We're gonna- And- We're gonna go through t- but let's- I think- I mean, a real... I mean, a, a quite a substantial doctor- A real doctor you know? Right ... Memorial Sloan Kettering- So at Memorial Sloan Kettering. Yep. Yeah, Memorial Sloan Kettering radiologist. Yep. She's published a bunch. Yeah, she's- And as, in some ways, as important, she's a Fox News contributor.

David: 3:53

Fox News. Now, John, what is the name of her book?

John: The title is Now the Movement: 3:56

Make America Healthy Again, which i- honestly, Dave, stepping back to your point about the long arc of the general surgeon who's the surgeon general, uh, that's the, that is actually the mission of the surgeon general, to be the public face here. I mean, you kn- you, you've met a lot of these surgeon generals, Dave. G- the, the, probably the most interesting one in our, the recent past is the, the, the one who looks a little bit like an, uh, he's chasing Ahab, you know, the old, with the, with the, with the, uh, uh, Surgeon General C. Everett Koop, who, who was appointed during the Reagan administration and looked like he was just pulled off of a whaling boat in the late 19th century.

David: 4:45

John, let's, let's actually go back in, in history and talk about that, and then, then I'm gonna have you go back one further and talk about- Ooh ... tobacco. But so, uh, C. Everett Koop, and, and the C I think was for Charles, but he, he went by Chick, if you knew him well, which I didn't, but I heard him called that. So he was a conservative evangelical, and he was appointed under the Reagan administration, and, you know, everybody figured he was just gonna be, just kinda sit there and just, and, and, and do not that much. So he, first of all, he refused to write an, uh, a report about abortion against it that the White House wanted, and then, uh, he issued-

John: 5:20

Which was, which was the primary reason. They just assumed because he was a- Yeah ... conservative evangelical doctor that he would be a sop or a, or a rep- good representative of the pro-life, anti-abortion movement. That was a shocker

David: 5:37

They didn't even think twice about it, just assumed it. But then even bigger, I believe, is, is when AIDS came up. Okay, so in 1986, he issued a report, and he mailed it out to 107 million households that had explicit information about condom use. And, you know, that was-

John: 5:54

And let's, let's, let's give the context there that HIV/AIDS had emerged in a novel way and started to grow virally through sexual contact. It was in many w- it was everything... It was seen as everything as blasphemous and anti-Christian by some of the conservative anti-gay, uh, advocates of the time. It was confusing and scary to many, coming at a time when sexual license had sort of was, had sort of taken off fr- after the '60s. And it was s- it, it had plague-like impacts in certain parts of the, certain parts of the community where there were a number of people who, uh, you know, had... were, were struck with this disease. And, and people were really confused about it. And, and it was a time of considerable prudishness as well about c- about communicating sexual contact in the public square. I mean, this is... It's hard to imagine how conservative that period was in the, in the, uh, in, uh, the early '80s. Um, President Nixon, uh, uh, uh, Reagan was elected in 1980. And just how, how, how fearful and novel and uncertain the country was about HIV/AIDS

David: 7:21

John, I was present, uh, for the awarding of the first C. Everett Koop for Health Leadership Award in, in 2010. Uh, you exaggerate. This is the one guy that I've actually met, uh, Surgeon General. And, you know, one of the things that I learned there, I'd, I'd known about that mailing, but it turns out that they actually didn't have the budget to mail it out, and he arranged something with NIH in order to be able to get the funds to, to do it. And in the introduction, uh, the person that was presenting said,"You know, everyone says, 'Oh, he's so unpredictable and surprising.'" But actually what he said was that he, he was the least surprising because if you were insightful enough to figure out what the correct approach was to a problem under trying circumstances, well, it was very predictable because, uh, Dr. Koop would actually ... He would figure out what was the correct thing to do, correct, honorable, and appropriate thing to do for the health of the nation and the world, and that's his legacy, so he would do it. So it wasn't like a shocker- When you said that- ... or like a turnaround... John: David, who, who, who, You gonna share that with us? Was it you? So it wa- uh, I was present, but it was actually, uh, Dr. Tony Fauci who, uh, had worked alongside, uh, Dr. Koop in the, uh, in the, in the AIDS battle,

John: 8:27

so. And, and just 107 million, I mean, just to give people context, that's probably trying to mail it out to every household in America. All households. I mean-

David: 8:35

Yeah,

John: 8:35

yeah ... it, it's, it, it was a remarkable thing. And I think that the promise of the surgeon general is you truly become the voice of how to keep and maintain and, and, and improve the health of America. You're really the public face. And C. Everett Koop had this wonderful dramatic presence, and for a generation he represented probably the, the clearest and the lou- the most, the loudest public voice on healthcare, and in some ways laid the track for a very, to f- to take a role that in many ways is an also ran, you know I mean, this, the, the surgeon general I believe was originally established... It's g- it's got a, a great history to it. That's why the surgeon general actually wears a uniform and has a uniformed team, or has the up- has the choice to wear a uniform. And I believe it was tied to the initial public health initiatives in the United States, which were tied to, um, uh, testing and managing ship-borne illness that was part of the international trade going back a couple of hundred years. That's where, that's where we started with we needed docs to manage the risk of viral diseases coming from outside the United States to the US. So it was really defensive initially and, and, and C. Everett Koop really made, turned it into a job that was offensive. How do we really make, how, improve the health of all Americans?

David: 10:09

So John, there'd been a big gap, but back in the early '60s, uh, Luther Terry was the surgeon general, and he issued the 1964 Smoking and Health report. So Koop wasn't the first one to do something. Do you wanna talk more about what happened back then, the surgeon general's report? That was a big, big deal.

John: 10:27

And, and at the time, again, it's hard for folks to contextualize this with casual smoking still being a thing and everybody recognizing that it's a major health hazard. At the time, you know, cigarette smoking was v- sh- very common, and, and in, and in the public s- And you'd see it in every restaurant and, and in... There were ashtrays on airplanes. I mean, it was a very... It's extraordinary to think back of how common, uh, smoking used to be.

David: 10:54

So the, this report came out in 1964, and it's considered to be perhaps the most consequential public health document in American history, and it was actually, uh, he brought it out despite big pressure not to do it. Um, he actually released it on a Saturday in order to reduce the stock market panic. But it shows you the potential, and where we are in terms of smoking and where we are in terms of HIV/AIDS have a lot to do, uh, with these surgeon generals. Now, you had mentioned that the, the prudishness of the Reagan era, and that's right, but it's interesting that if you look at some others, uh, surgeon generals that came later, it's not as though, okay, that we just set the bar, and now we can go even further. So Joycelyn Elders was probably the, one of the least successful surgeon generals, and she was actually fired by President because she was suggesting schools should discuss masturbation as a safe sex alternative, and she had some other things that were kinda out there, needle exchanges, drug decriminalization, universal coverage, which was sort of ahead of its time. You might be able to talk about some of those things now. But she didn't have everything that Dr.

John: 11:57

Koop had. Well, one of the things we should get right is her name, which was Joycelyn Elders. Okay. And, and a lot of those ideas were then embraced by local public health departments. And while she gets a bad rap for, um, the m- the, the bringing up, uh, a s- a, a, a, a reportedly common sexual practice among most Americans- Yeah um, she was blunt and clear and very focused on the public square. So this, this can be... You're, I think you're either a nobody or you're somebody who makes waves. She made probably too many waves in this job.

David: 12:31

Yeah All right, so now let's talk about, uh, w- we could talk about, you know, some of the other historical ones. I wasn't gonna go all the way back to, uh, Adam and Eve as you- I went, I went- ... as you went

John: 12:40

to- I went back to whaling.

David: 12:41

Yeah. Yeah. Back in the day. All right. But it- So let's talk-

John: 12:44

But it, but it, the point of this, of I think the, the historical lesson that you're foisting upon us, Dave, is that this can be a job that can change the arc of health. That's what the secretary has, Secretary Kennedy has talked about. The White House every now and then, um, you know, will just skip over the Tylenol and the vaccine stuff. And, and, and, and th- so I think I, I've got... I'm kind of optimistic about the surgeon general nominee. Why do you... What, what... You look like a skeptic, Dave. What, what is there to be skeptical about here?

David: 13:18

No, I think it's fine to be skeptical. I would like to be optimistic. So let's talk about, let's take the optimistic path. So there are some real issues to talk about right now. Oh, yeah. So I think that there... A lot of people, in fact, one of the reasons that RFK has some popularity is that with all the craziness, there are some things that kinda resonate, and people know things aren't exactly right. And, you know, what's... Some of the things on the Make America Healthy Again agenda, like seed oils, pesticides- Well, but, but before- ... ultra-processed foods... John: you get there, I, I think the most Healthy Again movement that I think everyone agrees with, it's a bipartisan and sort of a gut sense in most Americans, that, uh, us, uh, we're, we're most of, of, of, of the diseases we have, the chronic diseases, metabolic syndrome, heart disease, liver disease, diabetes, that, that lifestyle and food supply and environmental toxins are in some ways directly related, that we have the ability effectively to reverse and change the arc of chronic disease in America, which is the majority of the burden of healthcare costs that are a tax on every Americans. That chronic disease, if we could deal with the food, lifestyle, and environmental issues, we could potentially really make America much healthier. And I think, I think there is broad bipart- You may... Your choices might differ within it, the, the ways to get there. But that is something that I think the president and this surgeon general actually... I mean, she invented the phrase, Dave. Did you realize that? Yeah, after you told me about it. But, you know- The thing is this, John, so it's one thing to say can, can the surgeon general go and be America's doctor and, and, and say these, these sort of things? Well, you have some other people in politics, starting with RFK Jr. himself, you know, who are spouting off a bunch of things. It's hard for one person to break through. And then some of the items that you're talking about, which you say have bipartisan support, let's talk about, you know, improving the environment. Well, what else is going on with this administration and this Congress in terms of the environment? You know, we're talking about rolling back EPA standards. We're talking about essentially, you know, banning electric vehicles to the extent possible, c- canceling wind projects. So it's not as though it's just like, oh, someone can come with some clarity. It's that a, like a lot of the actual policy, the real policy is aligned against what somebody might say that would be enlightened.

John: 15:46

Yeah, and I'll, I'll get the name wrong, but the, the current, uh, argument about gly- glyphosate phosphate, y- you know, the where, where there's a, a real belief that a, uh, a pesticide that is in common use may actually be a major environmental toxin, and that, that has been a, uh, certainly an agenda item for the Make America Healthy movement, and it appears to have been stopped dead by the Department of Agriculture and the White House. Uh, there are other, uh, I'm sure, examples of that, but they have had some successes, David, at, uh, at getting, getting some of the dye out of, out of, out of food and kids' candy. And, and I think it's changed the agenda around food, but I'm, I'm cautiously optimistic that if we could... I mean, a lot of, um, you know, the, the, the, the, the current nominee, uh, has been very clear that lifestyle and, uh, environment really does drive a lot of our chronic illness burden, and she may be able to navigate this. She's also not a big fan of big government and certain mandates, and she's not a fan of the, uh, Affordable Care Act. Uh, but she has been pretty consistent about that burden of chronic disease, and I think there, there is a, there may be a w- path to reset, Maha, around the things we agree on to make progress.

David: 17:08

Okay. Well, that sounds like you're, you're, you're optimistic but within a little bit of a narrow lane. So why is she, why is Safar being called, like, a tool of the pharma industry? Like, what, why-- Where does that come from?

John: 17:19

Oh, I, I, I think anyone-- I mean, the, the benefit of, uh, uh, Casey Means is that she consciously lived outside and made the, the, uh, the reason why she didn't have a, um, a practicing medical license is she choose...'Cause she was a very talented student and a, and a very promising, with a very promising career. She went to Stanford Medical School. But she consciously said, "Look, this medical establishment and the royal, the, the, the infrastructure that exists is not something that's supporting, that's doing anything other than, than dealing with the symptoms versus the cause of chronic disease." And she did a, she's, she's been a real advocate against that. You know, the, the current nominee, much, you know, much more, more of a conventional clinical background. One of the... She's one of the best cancer facilities in the world at Memorial Sloan Kettering. She's got a, a storied career. She's a published author. Um, and she's a practicing doc. And I think it may be easier to move the establishment from inside than, than, than from the outside. The problem is that the folks who are, are most con-comfortable criticizing the current healthcare, food, big company, big government, you know, toxic combination, who are the advocates against that and wanna make America healthy and who are skeptical of all the insiders are gonna be really skeptical of an insider, and she's perceived, even though her criticisms are similar to theirs of the system, as an insider. I think it's ca- I think it's tribal. I don't think it's, it's based on content. I think it's based on, you know, discomfort.

David: 18:57

So maybe the thing to do would've been not to have RFK Jr. as the head of HHS, and maybe you would've had, uh, Means as the surgeon general, and it could've worked out. But that's not, that's not where we are. So let's talk about this whole role of the surgeon general because I think we are, uh, John, believe it or not, agreeing a bit. I, I see the potential of somebody who actually has a bully pulpit as their main tool as opposed to running a big, you know, part of the, of the executive branch as being a potential way to move things and to unify them. But we see that the, the trust in the federal agencies is at a real low. So CDC, FDA, NIH, they all, um, have lost the trust. And so the surgeon general, where does that fit in? I mean, is there a possibility? Is it just, "Let's get... That's just, like, one more thing that we don't like"? Or is there a potential to actually have the surgeon general stand out in that environment?

John: 19:52

You know, I think it's a very interesting question. You know, the The surgeon general has a choice to make a couple of things priorities and just pound on them. Sur- the ge- uh, General Vivek Murthy, who with v- who, who served under and, and Obama, really just focused on a number of things, but really loneliness. I mean, he was, he, uh, br- tried to bring up gun violence a couple of times and was, was, was, was brushed back by the Republican establishment and, and he really focused on this terrible, um, growth of loneliness in everything from teenagers, uh, to the elderly that's a through line, and that's more dangerous in many ways than alcohol and smoking. You know, the lack of soc- the, the decline of social contact in a time of more item- atomization of relationships, um, a- as people get older, and the, the isolation that a lot of teens and young, young, young people and their young li- younger people feel in their lives based on social media. I think if this now... If the nominee gets through, which I think she will, uh, because she does have, she... The kinds of things that, that, that, that, uh, got in the way of the prior nominee are, are not, do not exist here. I think it's gonna be really interesting to see how she navigates the vaccine question, because that is something that is unifies America, and the anti-vax movement is one of the more important sub-constituencies of the Maha movement. Um, but if she gets through, I think, you know, I think my advice to her is pick a couple of these themes where... And, and a little bit like the Vivek Murthy thing. Pick something where you can get bipartisan support, bring up some potential novel insights, and start to build a coalition. And perhaps it's around food, Dave. You know, maybe it's, um, maybe it's around some specific subset of lifestyle choices. Um, but the, uh... A- anytime you are trying to get America to change, you mentioned Luther Terry around smoking. We talked about, um, you know, sexual contact and different and sexual practices with C. Everett Koop and AIDS. Um, you know, you're, you're going to be into some tricky personal territory, um, but you have, uh, loneliness. You have the opportunity though to really make America healthier, if not healthy on an absolute scale, on a relative scale.

David: 22:17

Yeah. I, I think, uh, vaccination will be a difficult one, and it's easier to find something that hasn't been staked out or defined as well. So the way, you know, Vivek Murthy, as you mentioned, talking about loneliness, which was sort of mocked at the time, um, is, but now is more mainstream. So I don't know w- what she'll be able to pick. I think vaccination's gonna be hard because the lines are drawn. Maybe she can pick some aspect of it. I do think that, uh, food is a good area, and it's something more than just, hey, ultra-processed, uh, food. You know, it's gotta be-

John: 22:49

The other, the other, the other area that could be kinda interesting is mental health

David: 22:53

Yeah

John: 22:53

I mean, to expanding on Vivek Murphy, but she would never say that, but there's a lot of under, under-treatment of mental health issues as we've explored on, on Care Talk, and keeps showing up in the numbers, and is tied to higher medical expenses in general, and actually is something that there's bipartisan agreement around things like recovery and loneliness and, um, uh, schizophren- like pick your, uh, uh, suicide, um, um, the rise of, you know, just, you, it's, it's a through line of, a public health through line. There, you have to find that public health through line where you can talk about the problem and solutions and behavior change that could affect dramatically the arc of America's health, and then build, and then get a bi- a bipartisan solution, even if you're taking on some big institutions. That, that I think is, could make her... That, that's, that's the promise of the job. That's, that's the exciting part of the job. That's what C. Everett Koop and others were able to deliver.

David: 23:52

It's probably too early to pick AI and its impact on, on health, but I think some combination of that and social media, internet-based

John: 23:58

technology- Well, the danger is that AI may come, may push back. AI remembers its own constituency. I'd probably avoid that one.

David: 24:05

Yeah. It may, AI may appoint its own surgeon general, uh, by the next administration, and we'll have to watch out, uh, but we can interview it on Care Talk. In any case, John, that's it for another episode of Care Talk. We've been discussing the high-stakes battle for the surgeon general's office and whether the MAHA movement can actually change how America gets or stays healthy. I'm David Williams, president of Health Business Group.

John: 24:28

And I'm John Driscoll, the chair of the UConn Health System. If you like what you heard, you didn't, we'd love you to subscribe on your favorite service.