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Warning: the Surgeon General may be good for your health.


In 199 C. Everett Koop, an anti-abortionactivist who believes so passionately in "the sanctity of life" that a colleague once said "he would ventilate an amoeba," faced an excruciating choice. A set of Siamese twins had been brought into Philadelphia's Children's Hospital, where Koop was chief of surgery. The twins were joined at the chest, sharing one-and-a-half hearts, which could support only one child. The choice was between doing nothing and having two deaths, or through surgical separation, killing one so the other might live.

Koop waited 11 days as the girls' parents, froma deeply religious Orthodox Jewish family, discussed the issue with rabbinical scholars for hours each day before making a decision. For Koop the decision was easy. "It took me about ten minutes after I knew all the facts to make up my mind about what should be done," Koop recalls. He recommended surgery. When it came time to tie off the carotid artery feeding the brain of the infant who would die, Koop, zealous defender of infants and the unborn, did the job himself.

A decade later, Koop, now surgeon general ofthe U.S. Public Health Service, made another remarkable medical decision. Last October 23, he released his now-famous report on AIDS. Some had feared that the intensely religious koop might use the occasion to moralize about the disease's wicked causes. Even the most knowledgeable outside observers had expected the kind of vague and euphemistic warnings about AIDS that Health and Human Services (HHS), under its conservative management, had been offering. Instead, Koop was compassionate and extremely frank. "It is time to put self-defeating attitudes aside," Koop announced at the news conference that day, "and recognize that we are fighting a disease, not people." Without embarrassment, he advocated the use of condoms. He denounced ideas, popular among many of his conservative friends, about quarantining AIDS victims. Most shocking of all, he called for an intensive program of sex education, beginning "at the lowest grade possible."

Conservatives were furious. They had supportedKoop for surgeon general in 1981 over the fierce opposition of liberals, believing that his strong conservative views would guarantee a politically correct public health policy. Now they felt betrayed. The Washington Times called for him to shape up or resign. Reagan administration officials in the Department of Education protested elements of Koop's call for sex education. "The very people who supported me in my tough times of '81," Koop says, "arethe people who don't seem to understand what I'm trying to say."

Today it is the liberals who appreciate whatKoop has to say. Somehow, the integrity of the man--his willingness to make the medically correct decision, not the politically correct one--had eluded them in 1981. Back then, he seemed a right-wing crank, an intolerant right-to-lifer whose reactionary views on abortion, homosexuality, and religion made him incapable of serving the larger public interest. Now, Senator Ted Kennedy, who led the Senate opposition to Koop's appointtment, applauds Koop's activities on AIDS and his vigorous campaign against both smoking and cigarette companies. And Rep. Henry Waxman, Koop's most bitter enemy on Capitol Hill in 1981, is now his biggest fan. "I just have the very highest regard for Dr. Koop," says Waxman. "He's a man of tremendous integrity. He's done everything a surgeon general should do, and more, to protect the health of the public."

House arrest

Koop came to Washington in 1981 with thereputation of being one of the finest pediatric surgeons in the world, but it was as an anti-abortion crusader that he was best known. He had sat on the boards of three national right-to-life groups and was one of the movement's major theorists. In a series of books and articles he wrote in the seventies, Koop propounded the theory that society's tolerance of abortion leads directly to tolerance of infanticide and euthanasia, first of congenitally deformed infants and the consenting terminally ill, then of babies with the wrong skin color or the elderly who have become too much of a drain on the pension fund.

In the late seventies, Koop toured the countrywith a lavish multimedia show he co-wrote, narrated, and starred in. The show's centerpiece was the film series, "What Ever Happened to the Human Race?" Shot on 50 locations in five countries at a cost of $1 million, the film is particularly famous for a scene in which a thousand black and white dolls lie scattered on the salt wastes of the Dead Sea, a gruesome representation of the six million abortions said to have been performed in the U.S. since the 1973 Supreme Court ruling legalized the practice.

To the right-to-life movement, Koop was a heroand a chip they wanted cahsed in when Ronald Reagan took office in 1981. In February of that year the administration slipped him into HHS as deputy assistant secretary of health, a job that doesn't require Senate confirmation, with the idea of bumping him up to surgeon general as soon as possible.

The surgeon general's post carries littlestatutory authority. Koop would be largely held on a leash by his superior, the cautious, conservative assistant secretary of health, Dr. Edward N. Brandt Jr. The sharp-eyed in Washington saw this as an early sign of the new administration's strategy of placating the far right while steering a more moderate course on social issues. But Democrats, already panicked over the prospect of Kesse Helms loose in a Republican-controlled Senate and an anti-abortion president in the White House, were not relieved. The surgeon general's office carried the weight of medical authority, and they feared C. Everett Koop would use that position to lead a crusade against abortion.

The new Republican Senate, everyone knew,would almost surely support Koop's nomination. A small problem, however, stood in the way. Being a few months past his 64th birthday, Koop was technically several months too old for the job. Jesse Helms tried to remove this potential snag with an amendment changing the age restriction, which he attached to legislation on credit cards already approved by the House. The Senate approved the change after Helms misinformed them that the House had no objections. His Senate approved that the House had no objections. His effort to bypass the House backfired, however, when Speaker Tip O'Neill, angry at the slight and sensing a prime opportunity to embarrass the administration, used an obscure parliamentary rule to send the credit card bill to the House health subcommittee, chaired by liberal pro-choicer Rep. Henry Waxaman.

Republicans on the subcommittee tried to limitthe discussion to the age issue; Waxman and the Democrats, however, proceeded to conduct a de facto confirmation hearing. Koop, with strong advice from his superiors, refused to testify, on the grounds that the House was usurping a Senate responsibility. So Koop's writings and past statements were allowed to speak for him. At a right-to-life seminar in 1979, for example, Koop had referred to the "women's lib movement" and the "gay pride movement" as propelling "anti-family trends," comments women's and gay rights group pointed to as evidence Koop would discriminate against them and decimate abortion-related medical programs. In an article used by Waxman to show Koop's intolerance, the surgeon had written, "Sadly, most mainline denominations have made pro-abortion statements illustrating their superficial theology, lack of morality, and insensitivity to the eventual reward for their own depravity."

The document that spurred liberals to nicknamethe surgeon "Dr. Kook" was a 1979 commencement address in which Koop pretended it was 1999. "Secular Humanism" had become the official state anti-religion; "Doctrine Squads" snooped on people and hauled them off to be punished for "speaking of the Lord"; rampant infanticide had resulted in a generation of young people who were "perfect speciments-no defects, no eyeglasses...[and] a preponderance of boys"; talk of "death with dignity" and "living wills" in the seventies had been "the thin wedge" that cracked open American morality and led to compulsory euthanasia for the old and infirm; something called the "Rockhead Foundation" supported the culturing of "100,000 homosexual and lesbian test-tube babies to give the gay movement more political clout."

It's easy to see why liberals regarded Koop asa mean-spirited nut. That was not their only line of attack, though. Just as important, they claimed, was his lack of "significant" public health experience. The American Public Health Association (APHA) testified that there was an important difference between providing preventive health care for large populations, the role of public health professionals, and treating sick individuals, which is the role of most of the rest of medicine, surgeons included.

The New York Times, along with a dozen othermajor liberal newspapers, and an army of powerful liberal groups--from Big Labor to the National Organization of Women--joined the opposition. Wavering legislators would have been foolish to cross the picket line. It was eight months before Koop, eventually allowed to testify, could win Senate confirmation. "He does not have a public health background. He's dogmatically denounced those who disagree with him, and his intemperate views make me wonder about his, and this administrationhs, judgment," Rep. Waxman said, summing up the liberal consensus. "Dr. frightens me."

An academic bully

One afternoon in November 1986, SurgoenGeneral Koop woke up from a nap in a friend's house in San Antonio to find himself "essentially quadriplegic." He tested his hands; they wouldn't move. With some effort, he rolled himself to the edge of the bed. He struggled to his feet. He tried to walk, he recalls, but "it felt like I had cement boots on." He knew what was happening. He had been expecting it for years.

A large man--six feet one, 206 pounds--hehad hung his head over the tiny bodies of some 100,000 patients in the course of his 35 years as a pediatric surgeon. Shoulders scrunched, elbows in, sometimes for hours, his large hands working through miniature incisions (repairing a newborn's esophagus, Koop says, is like "sewing together two pieces of spaghetti at the bottom of an ice cream cone"), he had subjected to vertebra in his neck, already fractured in a college ski jumping accident, to "about 12 pounds of constant traction." Over the years, bone spurs had shrunk the hole through which the spinal cord, and its attendant artery, pass. During his nap, his head had slipped off a small rubber orthopedic pillow, twisting his neck and pinching off the artery.

Surgeons were able to repair the damage. Exceptfor a numb patch on his hand, he is back to normal. The career that caused this disability began in the forties when there were only five other pediatric surgical specialists in the country and the notion of anesthetizing and operating on children was considered wildly risky. For 33 years he ruled over the Children's Hospital of Philadelphia as surgeon-in-chief. He and the staff he recruited had pioneered surgical procedures for congenitally deformed infants. In 1962 they had built the country's first neonatal surgical intensive care unit.

Despite APHA's contention that he had no"significant" public health experience, Koop had worked much of his professional career as a volunteer consultant and organizer of Third World health efforts. For 20 years he had sat on the board of a private medical relief agency, MAP International, that distributed medicines and sanitary and water supplies to 83 countries. He created an organization that sent hundreds of third-year medical students to bush hospitals in remote parts of the world. He helped build a medical school in Ghana, fight a dysentery epidemic in the Dominican Republic, and bring primary medical care to the Tarascan Indians of southwestern Mexico. (None of this impressed APHA).

Most of Koop's associates tolerated the arrogancethat came with Koop's compassion. They greatly admired him, but his bellicose style led to incidents of cruel insensitivity. He once encountered a woman at a party holding an infant. "Thanks for not having an abortion," Koop told the woman. The child was not hers, and she had had an abotion. Robert Kettrick, senior anesthesiologist at Children's, who assisted Koop hundreds of times in the operating room, says this arrogance results in part from "too many years in the university." His rhetorical combativeness is typical of academics, explains Kettrick, "but in Chick Koop's case, it came with a desire to then demonstrate his mastery of the subject and the dominance of his logic. He like to play academic bully, as if to say, 'I'm right, I've studied the issue, I know the standard retorts and where all the weak spots are in your arguements, and I'm going to eat you up.'"

As a surgeon, Koop's skills were universallyrespected. Indeed, at times during his career, Koop has been accused of saving too many lives, including those of children with birth defects, on whom other surgeons couldn't--or, for the sake of the children, wouldn't--operate. "I believe there are times nature has made a mistake and nature should be allowed to correct that mistake," says Dr. Audrey Evans, head oncologistt at Philadelphia's Children's Hospital. "There are some children born with such severe defects that they will never be useful citizens in society," she explains. To Koop, to allow such "quality of life" concerns into the medical decision process not only defies the word of God but is--like abortion--a first step onto the slippery slope of the kind of utilitarian ethics that led to Nazi death camps.

It would be hard to exaggerate the strength ofKoop's conviction on these matters. It arose in part from his work. "[N]o family has ever come up to me and said: 'Why did you work so hard to save the life of my child?'" Koop wrote. "And no grown child has ever come back to aske me why, either." But it is also a matter of religious faith. For more than 30 years Koop had been a member of Philadelphia's conservative, evangelical 10th Presbyterian Church.

But those who worked with him say his insistenceon preserving life when possible was always tempered with reason. "Chick Koop didn't try to extend a life at any cost," says Kettrick. "He knew when to give up. I never had the agonizing deaths with his patients that I did with patients of some other surgeons. I never saw him pushing life at any cost or for any cause."

For the first few years of his tenure, Koop gavelittle reason for his critics to think they'd been wrong. He raised some eyebrows by donning the uniform of the Public Health Service, the first surgeon general to do so regularly in years. True, only a few months after his confirmation, Koop came out with his first surgeon general's report on smoking, which The New York times described as "one of the strongest indictments of cigarettes since the landmark federal report on smoking 18 years ago." But a surgeon general warning that cigarette smoking is harmful to your health was not exactly breaking new ground.

Then, in 1982, there was the troubling BabyDoe case, which hinted that Koop's right-to-life dogmatism would guide his thinking as surgeon general. Though doctors could do nothing about the newborn infant's Downs Syndrom and its inevitable mental retardation, they could correct life-threatening problems such as an underdeveloped esophagus. On the advice of one physician, and over the objections of two others, the parents decided to forgo treatment. The nursing staff rebelled. Pro-life groups protested. Several families offered to adopt the child. An Indiana judge ruled in favor of the parents' right to take their physician's advice. Seven days after its birth, the child died.

The Baby Doe case made the front page ofnewspapers across the country. Influential members of pro-life groups leaned on their White House contacts. Soon, HHS issued regulations that set up toll-free hotlines for reporting Baby Doe-type cases to HHS, created federal "Baby Does squads" to investigte tips, and threatened to hold hospitals receiving federal funds in violation of civil rights laws if they withheld treatment from handicapped newborns.

Although Koop was consulted in the draftingof those regulations, and defended them publicly, his major invilvement didn't begin until after the birth in 1983 of an infant that had spina bifida and other complications and was dubbed "Baby Jane Doe." "We're not just fighting for this baby," Koop proclaimed on "Face the Nation." "We're fighting for the principle of this country that every life is individually and uniquely sacred." The Justice Department wanted to make the Baby Jane Doe case a test of the principles underlying its regulations. It was Koop who formally requested copies of the child's medical records, the denial of which led to a major legal battle.

But it was also Koop, uncomfortable with theadministration's interventionist approach, who forges a compromise. In a conversation with Margaret Heckler, then secretary of HHS, about Baby Doe, Koop says he told her, "Now, I have been taking all the flack for two years, and I have had no role that could help me deflect some of that stuff. I said if I'm going to take the flack why can't I write the regulations? She was very reasonable. She said go ahead and do it."

Over the past several months, Koop had beenmeeting with some of the fiercest rivals involved in the issue: the American Academy of Pediatrics (AAP), along with pediatric hospital, pro-life, and disability rights groups. The AAP, which adamantly opposed the existing "Baby Doe" regulations, suggested a compromise that appealed to Koop's Republican sensibilities: hospitals would set up their own "infant care committees" to review Baby Doe-like cases. At these meetings, the rival group produced a "Statement of Principles for the Treatment of Disabled Infants," which in essence required physicians to treat infants with handicaps unless such treatment only prolonged the dying process. Though Koop clearly represented the administration, he played the role of moderator, and was willing to listen. "He and I were flat out adversaries on this thing," recalls Dr. M. Harry Jennison, then executive director of AAP, "but overtime I've came to respect him for his intellectual honesty."

Koop wrote regulations that incorporated thegroup's guidelines. A court later struck them down. But by the summer of 1984 Congress, inspired andguided in part by Koop's compromise, passed overwhelmingly an amendment to the Child Abuse Act, defining refusal to treat handicapped newborns as child abuse. This allowed Washington to withhold federal money to states that lacked procedures for guaranteeing the medical rights of disabled infants.

The Baby Jane Doe case showed a diplomaticside of Koop that liberals hadn't noticed in 1981. "Behind the scenes he really was manipulating and moving the administration to the decentralized, non-federal approach," says Jenison. "He was the one who could speak from a medical viewpoint. That had a lot of weight."

Smoke out

Liberals would also learn to apreciate Koop'szealous side, at least when he applied it against smoking. Past surgeon generals have warned of the dangers of smoking; Koop has turned that warning into a pesonal crusade. In his reports, he warns of smoking's ruinous effects on the heart; he calls smoking "an addiction"; he attacks smokeless tobacco; he warns of the dangers to nonsmokers of "passive smoking" and cites smoking as the number one hazard in the workplace. In May 1984, he began a public relations campaign, calling for "a smokeless society by the year 2000." In countless press conferences and speeches, Koop has argued that by the end of the century our attitudes should evolve to the point that no smoker will light up in the presence of a nonsmoker without permission. Jesse Helms, who had been Koop's strongest Senate supporter, called for his resignation.

The style he'd employed as the pro-life movement'smost effective propagandist served him here. With his steely gaze, Dutchman's beard, summer white uniform and powerful Brooklyn voice, he is an imposing speaker. People don't often light up in front of the man; when they do, he sternly hands them a button that reads, "The surgeon general personally asked me to quit smoking." He has called tobacco companies "sleazy" and labeled as "flat-footed lies" their claims that science can't say with certainty that tobacco causes cancer. Antismoking groups, like pro-life groups before them, value Koop's knack for drawing the attention of both the public and the press.

To the Reagan administration, however, Koop'santismoking crusade has been a headache. It doesn't seem to share Koop's extreme distaste for tobacco and the tobacco industry. Quite the opposite, in fact. In a 1980 campaign appearance the president promised to "end what has become an increasingly antagonistic relationship between the federal government and the tobacco industry. I can guarantee that my own cabinet members will be far too busy with substantive matters to waste their time proselytizing against the dangers of cigarette smoking."

With Koop running around the country passingout buttons, that's been a hard promise to keep. But some in the administration have tried. Last March, for instance, Koop lost a battle with Defense Secretary Caspar Weinberger. Military personnel have long enjoyed a discount on cigarette purchases. In fact, cheap smokes during World War II were the chief cause of the great rise in the number of smokers in the late forties and fifties. Koop had been working behind the scenes with the Defense Department's assistant secretary for health affairs, Dr. William Mayer, to eliminate the discount. Weinberger overruled Mayer, bowing to pressures from tobacco state legislators, the tobacco industry, and associations of present and former military personnel. The military groups had protested that cuts in cigarette discounts would provide a dangerous precedent for cuts in other benefits. "It just doesn't make sense to me," Koop said publicly of Weinberger's decision. "How could the removal of cigarettes be viewed as a reduction in benefits when the only benefits would be a lifetime of illness and early death?"

Koop took on other administration officialslast summer. He had agreed to testify at Henry Waxman's health subcommittee, which was discussing a ban on all tobacco advertising. When White House Chief of Staff Donald Regan was told that Koop planned to endorse the ban, he barred him from testifying. Waxman and Regan exchanged a series of angry letters; with all the bad publicity, Regan relented. Koop would testify, but with a Justice Department representative at his elbow to make sure the administration's line was properly aired. The Justice official told the committee that the administration had "very serious concerns" about banning tobacco advertising and that it was "not convinced that the case has been made that cigarette advertising leads to increased consumption." Koop politely disagreed. Tobacco promotion, he said, "increases the total universe of users and increases consumption by those who already use it. It does this, and does it very effectively." The Justice official said the administration didn't favor a bill sponsored by Rep. Mike Synar banning tobacco ads. Said Koop, "As a person, I endorse the bill." It was a great victory for the bill's sponsors.

Fair warning

For a long time there was one issue aboutwhich Koop could not speak his mind--AIDS. The surgeon general's duties and responsibilities are delegated by the assistant secretary of health. The assistant secretary during the first Reagan term, Dr.Brandt, said Koop was not to talk about the disease. Almost since the disease was first identified, gay groups, outside health experts, and scientists in the HHS bureaucracy argued to top officials that public education was the only weapon against a disease with no known cure. But those officials resited the idea, in part to avoid the kind of controversy over sex education currently swirling around Koop. "We were getting 5,000 letters a week saying don't do AIDS research because it's God's retribution," recalls a former HHS official who woked closely with Brandt. "It makes you think twice about crafting national messages that will speak to the needs of the risk groups but won't offend other groups." Another reason was money; the administration had budgeted none for AIDS education until fiscal 1984, and then only a paltry $1.4 million. As Public Health Service personnel leaked memos to Capitol Hill staff members on the need for public education efforts, Congress appropriated nearly $10 million in 1985 and $30 million in 1986. In spending this money, federal public health officials were told to be extremely circumspect, which led to vague and misleading public warnings such as "avoid exchanging bodily fluids." This euphemism policy extended to the education funds HHS funneled through state and local government health departments to private community and gay groups.

Finally, in October of last year, the president,whose remarks on the epidemic had amounted to a few cursory answers to reporters' questions, freed Koop's tongue by asking him to write a report. Observers sensed a diversion: the administration was simultaneously offering budget cuts for AIDS research. Whatever their motives, Koop's friend in the White House had fair warning, Koop recalls. "I told them, I'm going to do a health report. It's not going to be political. And I'm not going to clear it with anybody before delivering it to the White House."

For months, Koop invited experts and representativesof AIDS-affected groups into his office. "He listened very carefully, didn't ask too many questions, didn't say too much," recalls Gary MacDonald, executive director of the AIDS Action Council. "He gave me no sense of what he was thinking or what he planned to write in his report."

Few people anticipated what they would hear. "Iwas stunned," says MacDonald. "A man of his political reputation, exercising the kind of moral leadership that the Public Health Service had not done to date? I was amazed."

"Many people--especially our youth," Koopannounced at the report's October unveiling, "are not receiving information that is vital to their future health and well-being because of our reticence in dealing with the subjects of sex, sexual practices, and homosexuality. This silence must end." His report's frank discussion of the causes of AIDS transmission and ways to prevent its spread has given federal health officials the latitude to educate the public well. "We certainly feel he's been very positive. His courage on AIDS and smoking is to be commended," says Katherine McCarter, the American Public Health Association's associate executive director. As to the wisdom of APHA's past opposition, McCarter replies, "that's all behind us. We really don't like to dwell on that."
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Title Annotation:C. Everett Koop reports on AIDS
Author:Glastris, Paul
Publication:Washington Monthly
Date:Mar 1, 1987
Previous Article:Power of attorney.
Next Article:The door SDI won't shut.

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