The Doctor’s In: Interview with Richard Carmona

Dr. Richard Carmona served as seventeenth Surgeon General of the United States from 2002 to 2006. He was the Democratic nominee for the 2012 U.S. Senate race in Arizona and currently serves as president of Canyon Ranch Institute, a nonprofit charity that promotes public health. Dr. Carmona is also a distinguished professor at the University of Arizona’s College of Public Health and a combat-decorated Special Forces Vietnam veteran. He has served for over twenty years with the Pima County Sheriff’s Department in Tucson, Arizona and is a nationally recognized SWAT expert.

The Politic: I know that you’ve worked as a health-care administrator, a trauma surgeon, a SWAT team leader and Surgeon General, among other jobs.  Which of these have you found to be the most rewarding?

It’s really hard to say. I mean, I had the best job in the world, even when I was an ocean lifeguard. What they all had in common was public service, and I think that’s really what I’ve enjoyed the most. It was being able to make a difference in people’s lives, whether that was as a lifeguard, a soldier, [or as] Surgeon General of the United States, where you really have the biggest practice in the world—you’re the doctor for the nation. So I think the commonality that draws me to all of these jobs is that I really enjoy the responsibility and the opportunity and the privilege of service to others. I struggle myself to decide what the best job was, but they all gave me a better understanding of the complexities of our society.

The Politic: Do you think scientists and doctors are underrepresented in Congress, and if so, how do you think we can encourage more of them to run for elected office?

It’s a tough one, because most of my colleagues in the sciences have no desire to be in public office. When you deal with science, you deal with facts: there’s a scientific method, a hypothesis, and a rigorous way we prove or disprove a theory. Politics is more [about] spin and ideology. [Science and politics] can coexist, but my friends in science would rather not put up with [politics]. I think we need to make sure that our elected officials are engaged in fruitful scientific discussion. One of the challenges of being an elected official, especially if you’re a physician or a physicist or a nurse, is that when you’re immersed in that political milieu it’s all about politics. Science becomes marginalized at times, and depending on which party wants what, they can manipulate science for their own needs. It’s very frustrating, so I think that you don’t necessarily have to be an elected official as a doctor or scientist. I think our elected officials should work to ensure that they have good relationships with the scientific community and understand the science behind any issue, [as well as] the ramifications in the short and long term of any decision they make relating to science.

The Politic: Do you think that more scientists should speak out against misinformation that politicians might be espousing?

I think that we in the scientific community have an obligation to be informed on these topics and issues, such as genetics, national preparedness for counterterrorism measures, and the obesity epidemic. Science directs us in a certain direction, and it’s our responsibility as scientists to inform Congress what the best science is so that they can make their decision. I’m not implying that the decision should be made absent of politics, but it certainly shouldn’t be made without first judiciously studying the science. When you look at what Congress does on policy and legislation on a daily basis, very little involves science, directly or indirectly.

The Politic: You’ve had a long career in medicine and law enforcement. Why did you decide to run for U.S. Senate last year?

Actually, it was not something I was aspiring to do. What happened was I started getting calls from friends and colleagues at both the local and the national level that said, “Why don’t you run? We need a candidate.” I just rejected it for months. I said, “I’m not a politician,” but everybody kept calling and saying, “We really need people like you to step up.” Part of it was guilt, but when I thought about it after a few months, it was like, “Okay, so if everybody refuses to run like me, then who runs?” You would end up with a Congress filled up with people who are not the best people in those positions. So I thought, “You know what, if I’m willing to complain about the dysfunction, I should be willing to step up and to try to bring some sanity and reality to some of these discussions.” So I did it as a civic duty, really, and to be honest with you, I did it begrudgingly. I served my country and community for many years in other capacities, but I thought, “You know what, it’s a responsibility all citizens should relish, and when called upon, we should give it very careful thought.”

I’ve done very well — I come from a very poor family, I was a high-school dropout, my parents were immigrants. In one generation, I went from being a poor, homeless high-school dropout to Surgeon General of the United States, so I really shouldn’t have any complaints. And because of that, I recognized that democracy is wonderful. But it’s also painfully inefficient. Unless we get people in there [who are] willing to try to stand up and provide good information and not be ideologically driven, [who are there] not as a career change but willing to serve for a period and go home, our democracy is doomed. So that’s why I did it. 

The Politic: What did you enjoy the most and the least about running for Senate?

What I enjoyed the most was just sitting with diverse groups of people and listening to their issues, trying to see the world through their eyes and the issues that were important to them. I enjoyed sitting with large groups and small groups and answering questions — it was the essence of democracy. What I hated was the politics. People recruit you because you are independent, because you’re critical, because you’re going to stand up to the issues — and then they want you to fit into a mold. They hand you books and say, “Here are the answers to your questions, here’s what you need to do, here’s what you need to say.” You see the ugliness of politics. You spend most of your time raising money to buy negative ads about your opponent.

It’s a very dysfunctional system. I think that we desperately need campaign finance reform. I fully believe that the government should fund certain positions at a certain amount and [designate] how many dollars are allowed. This way, candidates have to compete on substantive issues and debate in the old-fashioned way, rather than relying on special interest groups and people giving them huge sums of money so they can extinguish their competitors through negative ads. To me, that’s not the essence of democracy. So that was the negative part: when you see how the system really works, the money that has to be raised, and where that money is spent. How is that beneficial to an informed citizenry? You’re shouting at each other and making accusations that you know really aren’t true. It’s really embarrassing. When you’re a public figure, of course, you can be accused of anything, and the best you can say is, “That’s not true.” [Your opponents] can accuse you of treason and child molestation, and the best you can do is say, “No, that’s not true.” But the more they get you on the defensive, the more you’re losing. That’s the way the system works.

The Politic: How do you feel about President Obama’s record on immigration? Are you optimistic about the prospects of comprehensive immigration reform?

I think the president’s heart is in in the right place. I was disappointed during his first term that he was not more aggressive on immigration reform. There are economic opportunities and workforce issues too — if you live along the Southwest border, farmers rely on guest workers and day workers. I think that we missed an opportunity early on. The president chose a different agenda, and immigration was marginalized. I don’t walk in [Obama’s] shoes, so I’m not going to second-guess him. But personally, I was disappointed, being Hispanic and living near the Southwest border, that he didn’t push it harder.

Now, am I optimistic about the prospects? I am. But it’s going to be painful, as we’ve seen in the discussions. If you look at many of the people who are now professing to be reasonable, they were the unreasonable people before November 6. They were Republicans and they were extreme and they wanted to deport everybody, and so on. Now we see new waves of people saying, we really need to relook at this. Why is that? I think people are coming to the realization that the fastest growing group of folks in our country is Hispanic. We are still minorities, but we’re rapidly approaching majority status. If you want to get elected, people [understand that], especially in some areas of the country, you have to embrace people of color: African American, Native American, Hispanic, and so on. So I think that the demographics are ultimately going to force the shift. We’re still going to have the Extreme Right who want a very Anglo society and are discriminatory, but I think over time, because of the shifting demographics, we’ll see younger people getting open and more embracing of diversity. I think the problem will eventually go away because of the changing demographics, but it will take a long time.

The Politic: Do you think gun violence should be addressed as a public health issue? Do you agree with President Obama’s decision to lift the ban on CDC gun-violence research?

Yes, I do think gun violence is a public issue. As a trauma surgeon, as Surgeon General, as a professor at the university, I’ve always stressed it as a public health issue. If we look at it scientifically and not through the bias of either party, most of the handgun deaths every year are due to suicide. When you actually take out the passionate political pleas of either side and ask, “What can we do?” there are things we can do. Background checks are a first start — being able to identify people who you don’t want to have weapons, making sure that people have the appropriate training and understand the liability of holding a weapon. For instance, many suicides [result when] people impulsively grab an [unsecured] weapon that’s in their homes when they’re despondent and kill themselves. Gun violence is definitely a public health issue. There are reforms — if we look at the science — that don’t violate anybody’s Second Amendment rights but make it safer for the collective society, and that’s what I’m in favor of.

As far as the CDC gun violence research, I absolutely think it is reprehensible that we allowed the gun lobby to buy its way into legislation that would block research. Why would you ever block scientific research that would give you a definitive answer or at least a general pathway forward on any issue? As a scientist, I think the more we can do research, the more we’re able to truly delineate what the causal factors are of any problem, whether it’s gun violence or diabetes or obesity. That’s what we should be doing, because that’s what benefits the people.

The Politic: Living in Arizona, which is a very pro-gun state, do you think anything can be done to enact safer gun laws?

I think it’s going to be tougher, with its culture. The problem is that the issue has been framed as good guys versus bad guys. Most gun owners have no problem with registration and background checks. But when it’s an all-or-nothing issue, many people argue that  it’s just the first step to taking our guns — these are people arguing from extreme political positions that are biased. I’ve been a soldier and a police officer. I’ve had weapons myself and still do; they were tools for my job. But I recognize the need to keep society safe. There’s a fine line.

I think that [passing safer gun legislation] will be tougher in a state like Arizona. Our governor [Jan Brewer] wanted to support guns on campus and felt that armed college students would make things safer. Many faculty [members] said they would resign from their university. Why would you want college students armed on a regular basis? It just doesn’t make any sense. Universities should be gun-free zones. Our governor also rescinded the education requirement for concealed carry. In the past, you had to take a 12-to-16 hour course where you would learn about gun safety and liability issues. Now in our state, almost anybody can buy a gun and carry it concealed, without even knowing how to load it or shoot it. Those are the challenges we have here, but I think that reasonable people still need to pursue reasonable safety alternatives. I’m in favor of [the policy that] anyone who owns a weapon should take a certified course. Why would we sell weapons to people who we don’t even know can handle them? I think a basic safety course that demonstrates that you’re able to use a weapon safely is in the best interest of society.

The Politic: As Surgeon General, you released an influential report on secondhand smoking. Do you think more places in the country should adopt vigorous anti-smoking measures like New York City has under Mayor Michael Bloomberg?

Well, I think we should continue to [discourage smoking], but we’ve already done really well. If you look at what happened in the first couple of years after that report came out, half of the states in the United States enacted some type of smoke-free legislation. Almost every place you go in the United States now, you’ll see that schools are smoke-free and hospitals are smoke-free. We understand that secondhand smoke kills. I think we should continue to encroach upon the smoker, because smokers’ expressing their rights violates all of our rights when we breathe in stuff that is carcinogenic and causes cardiovascular disease and such. We’re making progress, but we should continue to [encourage] progress not only in the United States, but globally. In the United States, about one in five people still smoke, and about one and three people in the military smoke. That’s still way too high, and it results in almost half a million people dying every year and millions more with chronic diseases like emphysema, asthma, bronchitis, and cancers.

The Politic: Marijuana has been the subject of much public debate recently, with Washington and Colorado trying to safely legalize marijuana and an increasing number of states legalizing medical marijuana, including Arizona. As a former Surgeon General, how do you stand on the issue?

Great question — it’s something that I’ve had to deal with as Surgeon General and afterward. I look at the marijuana issue in two separate buckets, if you will. If as a society, we want to make marijuana legal, because some people perceive it will decrease the crime rate and stop some of the drug wars — I’m not going to debate those issues with you. As Surgeon General, I always said, “We’re in a democracy and you have a right to vote.” But it’s my obligation to tell you the potential deleterious effects of smoking marijuana, short-term and long-term. There’s a health risk. If everybody starts smoking marijuana, what disease burden and economic burden will it create, and who will pay for it? Again, as Surgeon General, I want to divorce myself from the politics — I want everyone to make an informed decision and take into account all of the science and ramifications [behind] their decision. However, that is just for societal use; it has nothing to do with medicine.

Now let’s go to legalizing [medical] marijuana, which is a very controversial area. For years, people have said we should legalize it. A lot of companies started looking at this, and some companies then took out the active ingredient —tetrahydrocannabinol —and said, “Why don’t we just make a pill?” For some people, that sufficed, but other people wanted to smoke it. There is a group of people who feel that marijuana is being pushed for medicinal uses as a backdoor for general use, and other people who feel it’s legitimate. When you look at the science, and you believe that [marijuana will help relieve] glaucoma or AIDS, then why wouldn’t a THC pill work? That’s part of the debate. If you are going to use marijuana as a [medicinal] drug, then you ought to treat it as one.

In the state of Arizona, I think we failed, because we approved it before it was looked at. If you’re a physician and you decide you’re going to dispense marijuana, how much marijuana do you prescribe? How long should [patients] use it for? And then how do you account for the variability in potency? They are some strains of marijuana that are much more potent than others. So there are a lot of questions that weren’t answered. Any drug that we offer in the United States has to go through an FDA regulatory process so that the patient has informed consent. If you take this drug, here are the risks and the benefits, and here is the proper dosage. We didn’t do that for marijuana, and yet some states went ahead and made it a drug, circumventing the very process that’s in place to protect our citizens. So that’s how I feel. If [the people] want to use it as a drug, and they believe it has medicinal purposes, then I think it should go through the same process that all drug go through to ensure basic safety.

The Politic: Do you have any advice for college students interested in public service?

Sure. It depends on what your interests are, but there are so many things that you can do in public service, whether it’s in policy or administration or medicine. It takes you a while to figure out what it is that you really enjoy in life. Once you figure that out, I think you should go where your heart is, because the last thing you want is to be one of the many who have a job because they need to generate a paycheck but really don’t enjoy what they’re doing. I think all of us should do some public service at some time. I’m actually a believer that young people should do some type of public service for a couple of years, such as working in a community clinic or volunteering for the Peace Corps. Do something that broadens your life’s horizons and learn about other cultures. It makes you a better person as you age and gives you a better understanding of people in general, no matter what you get into. I think that public service is really rewarding when you’re able to contribute value to the lives of others.

I enjoy it personally and I’ve done it on a lot of different levels, whether as a paramedic or as Surgeon General, where you have the biggest practice in the world, and your job description is to promote, protect, and advance the health, safety and security of the nation. It was a daunting responsibility, but it’s such an empowering feeling when you do something that can make a difference, like when I released the secondhand smoking report. It changed the world, and it’s reducing morbidity and mortality in our country and the whole world. It’s making the country a healthier place and reducing the amount of preventable disease. So that is public service.

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