The words on the cigarette package read:
"Warning: The Surgeon General Has Determined That Cigarette Smoking Is Dangerous To Your Health."
But for four years there has been no surgeon general of the United States.
For eight years before that - since the Department of Health, Education and Welfare gained a politically appointed assistant secretary for health - the surgeon general had not been the nation's top health officer.
Both situations are expected to change shortly, with a new kind of double appointment: the naming of Dr. Julius Richmond, well-known Boston specialist in children's mental health, as both assistant secretary for health and surgeon general.
Why is more, in the words of HEW Secretary Joseph A. Califano Jr., Richmond could emerge as "the government's top health officer" in a way that far surpasses the role of other recent assistant secretaries for health. All have found themselves vying for control of health with many other HEW officials.
But Richmond said last week that Califano has given him the main responsibility for achieving one of President Carter's dearest goals - comprehensive national health insurance covering every American from cradle to grave.
"Mr. Califano has put health insurance development under me," Richmond said. "It will be operationally my responsibility."
And what he and Califano have basically agreed, Richmond added, is "that I'm the chief health officer."
This agreement came after two prominent doctors turned down the assistant secretaryship, and a third - Dr. Christopher Fordham of the University of North Carolina - walked out on Califano April 20 after spending a month as assistant secretary-designate and finding he had little power.
The agreement also follows what has been a rocky reception so far on Capitol Hill for HEW health proposals.
"The reception so far for their health programs has not been good," Jerome Brazda, editior of the McGraw-Hill Washington Report of Medicine & Health and one of the capital's keenest health observers said last week.
In an effort to solve this problem, Califano also decided to name William Fullerton, onetime House Ways and Means Committee staffer under then-powerful Wilbur Mills, as both his special assistant for health insurance, and Richmond's deputy assistant secretary.
Fullerton has decided not to take that job, Brazda's newsletter reported yesterday. It said Fullerton was upset because Califano "pulled back" on his job description, making it clear he had to report to Richmond.
Fullerton denied this. Other sources said the main problem was that he feld he needed a large staff collecting all HEW expertise in health economics, including a health staff under Hendry Aaron, assistant secretary for planning, and economist Karen Davis, who left the Brookings Institution to develop Califano's proposal to contain health tests.
Califano saw Fullerton more as a coordinator. Fullerton argued he couldn't have responsibility without authority.
If backed by Califano, it could now be Richmond who emerges with that kind of authority. He is a gentle, softspoken man with a velvet glove, his friends say. But inside the velvet glove is a steel hand.
Most health observers feel the country has too long lacked a top doctor on issues from health insurance to health care, one who commanded the public ear in a way that most famous of modern surgeons general. Dr. Thomas Parran, commanded public attention from 1936 to 1943.
Parran thundered against "syphilis," "gonorrhea" and "venereal disease" when there was a taboo against those words in speech or print. He forced newspapers and radio stations to join a frank "anti-VD" crusade and crusaded for health in many other ways.
Parran's successor, Dr. Leonard Scheele, held office from the Democratic Truman administration well into the Republican Eisenhower administration and made the crucial decisions that led to use of the Salk polio vaccine.
Next, Dr. LeRoy Burney moved the country from the Salk to the Sabin oral polio vaccine. Then Dr. Luther Terry launched the epoch-making surgeon general's study of smoking and health, and persuaded Congress to order the cigarette pack warning.
Gradually, however, surgeons general were becoming mere subordinates to shifting political powers. By 1973, when the last one, Dr. Jesse Steinfeld, resigned, the job had become mainly one on paper, with nominal supervision over the Public Health Service. An acting surgeon general has since played that role.
Last year the country saw the swine flu vaccine fiasco - a declaration that an epidemic might be imminent, a hectic effort to get drug makers to make a vaccine, a late start on shots that might have been costly if swine flu had appeared, then, instead of seine flu, a rash of Guillain-Barre paralysis caused by the vaccine.
What the country needs now in health is a strong and sure hand, many people say.
Califano said in an interview he has done much in health already, such as unifying Medicare and Medicaid, which "were buried" before, under a new Health Care Financing Administration headed by Robert Derzon, a respected California hospital director.
Califano said he has named "a spectacular group of health," including Dr. Donald Fredrickson to remain head of the National Institutes of Health, Dr. Donald Kennedy to head the Food and Drug Administration and Dr. William Foege to head the Center for Disease Control.
"I think Julie" - Richmond - "can sit on top of all these things, and he's capable of doing it and thinking about all of it," Califano maintained.
Richmond himself promised to try to improve the delivery of health sevices, especially to the elderly and deprived. He said he wants to emphasize prevention, child health services and, as surgeon general, enlarge, and strengthen both the Public Health Service's commissioned corps and its National Health Service Corps and move them into under-served areas like inner cities and rural slums.
At 60, he has had a life of trying to better the lot of the needy. He was first director of Project Headstart, the federal program to educate disadvantaged youngsters in the 1960s. He heads preventive and social medicine in both the Harvard medical school and Harvard school of public health, another double job.
Washington health observers, who have seen a long parade of disppointed assistant secretaries and surgeons general, think Richmond is in a strong position in HEW. They feel sure Califano does not want more trouble in getting or keeping health officials.
Beyond that, they will wait and see.