Bully-Pulpit Role Makes Surgeon General Center of Controversy

ONCE, the surgeon general had an entire medical army at his command.

Now, Henry Foster seeks Senate confirmation to a post that has direct command of a staff of about five persons.

Yet with enough on-camera charisma and media savvy, surgeons general can use their platform to make a strong impact on public behavior, according to public-health experts.

The symbolic, head national doctor role is part of why Dr. Foster's confirmation appears to be in jeopardy in the Senate. Like most physicians in his speciality, he has performed abortions, and anti-abortion activists do not want to honor that practice with the surgeon general's uniform.

The single greatest credit of past surgeons general so far is the cultural shift against smoking. Their work, from Luther Terry in the 1960s to C. Everett Koop in the 1980s, clearly ''has had an enormous impact,'' says Alfred Sommer, dean of the Johns Hopkins School of Hygiene and Public Health in Baltimore.

Until 1968, the surgeon general had an administrative job, running most of the nation's nonmilitary government health programs. Its roots reach back to the Marine Hospital Service in 1798. When the National Institutes of Health and the Centers for Disease Control were founded in 1937, they were under the command of the surgeon general and his health officers.

NOW, the general who wears what looks like a Navy uniform has a function more like a spokesman in chief for public health. The surgeon general is still charged with recruiting and retaining the 6,300 health officers of the commissioned corps, but they are deployed under other commands, from the Bureau of Prisons to the Coast Guard.

Whether a surgeon general succeeds in converting his office into a bully pulpit ''really depends on whether the president thinks it's important or not,'' says William Stewart, the last surgeon general to hold broad administrative duties before they were taken over by the Secretary of Health, Education, and Welfare in 1968.

Dr. Stewart was the first surgeon general to stamp his health-hazard warning on cigarette packs. But the groundwork was laid by Luther Terry in 1964.

President Kennedy had skipped the usual promotion from the ranks of the public-health officer corps in bringing Dr. Terry in from the outside, with his strong scientific credentials. Terry quickly turned his role into that of a scientific consensus-builder. His most significant consensus -- reached in an ironically smoke-filled room in 1964 -- was that the best studies indicated smoking was dangerous.

He then drafted legislation, passed by Congress, to require health-warning labels on cigarettes.

The strong self-assurance and charisma of Dr. Koop, a conservative Presbyterian with an Amish beard, gave the antismoking drive a new surge during the Reagan years. Koop touted the dangers of ''passive'' or second-hand smoke and promoted the goal of a smoke-free society.

Among the better educated, smoking has dropped dramatically, although the change among blue-collar families is far less notable, says Dr. Sommer.

Koop's conservative, anti-abortion credentials also gave him the credibility to bring awareness of AIDS into the social mainstream, along with the promotion of condom use.

Henry Foster, if confirmed, plans to make his chief thrust a battle against teen pregnancy, through self-esteem and sexual abstinence. The value of surgeons general, according to doctors concerned with public health, is that they promote prevention of health and social problems rather than their repair.

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