Interview with C. Everett Koop, MD,
The U.S. Surgeon General

In his State of the Union address,
President Ronald Reagan announced
a swap: The federal government
would take over the administration
of Medicaid, and the states would he
asked to take on welfare programs,
including Aid to Families with De-
pendent Children and food stamps.
How is the President's proposal for
federalizing Medicaid affecting your
job?

We are under duress now to leave
Washington only for very important
public health business and to turn
our efforts to how the switcharound
will affect the federal government's
Medicaid regulatory process. We
are just beginning to scratch the
surface.

Before the State of the Union
message, we were in the midst of
trying to bring about some regulato-
ry relief in Medicaid. What we have
done was to shift gears, not upward
but downward, to go more slowly
and look at Medicaid more broadly.

Some states have very liberal
benefits, and some are stingy. Some
Medicaid prototypes must be out
there, but whether we can afford
them is another question. Federaliz-
ing Medicaid can be affordable. The
plan is good; it goes along with
everything else President Reagan
has tried to do, and I think the pub-
lic is still in favor of his trying to do
it, that is, to give the welfare pro-
grams back to the states.

Health care may need to change in
other directions, too. How will pub-
lic officials face the resulting chal-
lenges?

Finding innovative ways of taking
care of old problems is one chal-
lenge. Prevention, which is being
emphasized by Secretary Richard S.
Schweiker and the Department of
Health and Human Services (HHS),
is the other side. Disease can be
more economically prevented than
treated. You will be seeing a
major prevention initiative from
this department in the months
ahead. One major thrust will be

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a change in life style, something
that is easy to advertise. For exam-
ple, we can encourage grade-school
children to take home to their par-
ents fundamental information about
prevention-information about
blood pressure screening, smoking,
exercise, nutrition. The kids can
work toward a Public Health Ser-
vice (PHS) award by teaching their
family these basics of prevention.

The problem with disease preven-
tion and health promotion is that
they are something people are not
used to dealing with. To the public
they are nebulous and hard to mea-
sure, and results are hard to see.
We will concentrate on a circum-
scribed program that can be under-
stood and accomplished.

Many private-sector hospitals have
begun to define their mission broad-
ly to include community health/well-
ness. What do you think of this
trend?

Teaching hospitals and community
hospitals are becoming the commu-
nity's educational resources. It
seems reasonable to add a little
more to every inpatient charge in
order to accomplish the educational
program that in the long term will
reduce society's health care costs.

You have been quoted as saying that
as Surgeon General you want to im-
prove care for disabled persons.
What measures do you propose?

Harold O'Flaherty, former chair-
man of the Interagency Committee
for the International Year of Dis-
abled Persons (1981), who is blind,
will join me soon. Together we will
establish a road map of all govern-
ment and private-sector services for
the disabled. Our purpose is to di-
agnose and eliminate duplication
and overlap. Providers could then
maintain the same level of services
despite a diminishing budget. The
bottom line is my desire to establish
with the President and HHS a
Magna Carta for the disabled-
minimum benefits they could look

forward to wherever they live and
whatever their problems might be.

The Surgeon General's office will
disseminate facts so that those who
need information will find it. For
example, when a child is born with
a visible congenital anomaly, the
parents and the medical personnel
often do not know where to turn.
They should be able to ask the
proper government agency for the
names of public agencies that can
help them and, perhaps most im-
portant for the parents, for a list of
people who have lived through
something similar and have man-
aged.

And what can the Surgeon General's
office do for the nation's elderly?

The Surgeon General stands at the
narrow point of the hourglass be-
tween the aging and the public, ac-
quainting each with the other's
problems. 1 would like to develop
with the National Institute of Aging
and other agencies a philosophy on
aging so voters can make informed
decisions about the aging popula-
tion.

This country needs a philosophy,
a set of basic beliefs, about aging     .
upon which to base decisions. Now
people have a few facts and scary
statistics. They need to understand
that aging is a process that everyone
goes through, that it is a part of
their own future.

You pointed out that getting rid of
overlapping services for the disabled
will save money. Are you confident
that enough money will be available
to provide adequate health and wel-
fare services?

Voluntarism is going to be a main-
stay for delivery of services to peo-
ple in need. By voluntarism I mean
the system whereby the public ac-
cepts individual responsibility ahead
of self-interest or government
imposed duties in looking after its
fellow man.

A hundred years ago, the church
provided all the social services peo-

HOSPITAL PROGRESS, MARCH 1982


C. Everett Koop, MD, was sworn
in as U.S. Surgeon General January
21, ten months after his nomination
by the Reagan administration. In
Senate hearings during October and
November 1981, opponents of his
nomination alleged that he lacked
public health experience and quar-
reled with his forceful opposition to
abortion; Dr. Koop and his sup-
porters pointed out his public health
initiatives for children and his work
in 33 foreign countries. He received
the French Legion of Honor and
the Dominican Republic's highest
award.

Before becoming deputy assistant
secretary for health in February
1981, Dr. Koop was surgeon-in-

chief, Children's Hospital of Phila-
delphia. He successfully separated
Siamese twins in 1977, developed
safer anesthesia for infants, and
founded The Journal of Pediatric
Surgery.

In his February 2 interview with
HOSPITAL PROGRESS, Dr.
Koop discusses his reasons for
wanting to be the U.S. Surgeon
General, his conviction that people
will increasingly volunteer to work
together toward improving health
care, the Public Health Service
Commissioned Corps's role, health
promotion, and the Reagan admin-
istration's plans for improved health
care for the disabled, the elderly,
and children.

ple have now come to expect and
demand from government. The new
voluntarism is a return to what the
church knew very well how to do a
long time ago and to a responsibili-
ty the church accepted.

In the Senate hearing about your
confirmation last November Senator
Orrin G. Hatch, R-UT, quoted your
description of your conversation
with Secretary Schweiker the day
you arrived in Washington: "I went
and told him that I felt that I had
said all that I should say and written
all that I should write about the
abortion issue. It was not my intent
to use any post that I might have in
the government as a pulpit for an
ideology. I thought that was im-
proper." Does that mean that you
are not trying to influence policies
that would restrict abortion?

There really is nothing in the Sur-
geon General's job that affects
abortion policy; if there were, I
would probably excuse myself from
that decision-making process be-
cause of my promise to Secretary
Schweiker. That does not in any
way alter my basic understanding of
the sanctity of human life, nor does
it impinge on my being an advocate
for other kinds of life, such as chil-
dren, the elderly, and disabled
people.

Abortion was only one small
piece of my film "Whatever Hap-
pened to the Human Race?" My
concern about protection of the
newly born, who some think have a
low quality of life, was my real
entree into the whole prolife move-
ment. That led to the next group of

HOSPITAL PROGRESS, MARCH 1982

people who are likely to be disen-
franchised: the elderly.

The trend of lessened concern for
the helpless is likely to continue.
The thing that will push us is eco-
nomics. I hate to say that, but it is
true. The question is, Who makes
the rules?

How would adoption of the Hatch
Human Life Amendment affect pub-
lic health?

Abortion would be not a federal
problem but one for states and ter-
ritories. You would find, as in the
years before the 1973 Supreme
Court decision, wide variations
among the states-from those with
a free and easy attitude to those
that would prohibit it.

Would you describe the PHS Com-
missioned Corps, of which the Sur-
geon General is head?

The PHS Commissioned Corps is
the nation's only rapid deployment
health group. Its members respond
to emergencies around the country
and throughout the world, such as
the outbreak of Legionnaires' dis-
ease, Love Canal, or Three Mile Is-
land.

The 7,000 officers are in PHS
agencies throughout the country,
and some are on detail to specific
projects. They are scattered about
in order to maintain their expertise
so that if something happened to-
morrow, we wouldn't be without
the necessary manpower and exper-
tise to respond.

A misconception is that the Com-
missioned Corps consists of physi-

cians only. It also has nurses,
veterinarians, entomologists, civil
engineers, mechanical engineers,
sanitary engineers-anybody who
could be needed in a public health
emergency.

How do the recommendations of the
presidential ethics commission affect
PHS grants?

No direct cogwheel converts an ad-
visory commission's decision into
practice. But undoubtedly the com-
mission's moral suasion is felt in a
relatively short time in decisions
about the ethics of research, for ex-
ample, questions about the protec-
tion of subjects, or about clinical re-
search involving a child who does
not benefit from the effort. Guide-    .
lines are built in to the PHS grant-
ing mechanisms; PHS does not
make grants to institutions that do
not comply with ethical guidelines.

A group known as the federal
chiefs-the Surgeons General of the
Army, Navy, Air Force, PHS, and
the Veterans Administration's chief
medical officer-interfaces with the
Federal Emergency Management
Agency.

Why did you want to be Surgeon
General?

I wanted to join this administration
in a health capacity because I saw a
time of change. The public has seen
that change, too, in the manner in
which the President has gone about
his tasks. If. for little cost per capi-
ta, we can prevent disease and pro-
mote health, I have to say that I
think that is worthwhile.         *

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