PROJECT HOPE

Health Affairs

Interview with C. Everett Koop, M.D.

May 24, 2004

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PROCEEDINGS

         INTERVIEWER:  The date is the 24th of May,


2004.  We're in the office of Dr. C. Everett Koop, at

Dartmouth,  in Hanover,  New Hampshire.  Let me just take


a sound level here.  Would you tell me your name, and

spell it?

         DR. KOOP:   I am C.  Everett Koop, C, period,


E-v-e-r-e-t-t,  capital K-o-o-p.


          INTERVIEWER:  All right.   Good.   What I'd like

to do is start by talking about children's health, as I

mentioned,  since this is primarily a child health issue

of Health Affairs that we're going into.  And maybe talk

most specifically first about pediatric surgery which,

of course,  is where you got your start in medicine.

Just a word about how you've seen the development of

that as a discipline,  and how you feel about it looking


back on it.

         DR. KOOP:  Well,  I've always been delighted to

have been associated with pediatric surgery.   It was

really a passion of mine,  and I wish I could say that I

had thought years ago that there ought to be such a


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thing as pediatric surgery, but that's not the case.

But I did know that children did not get a fair shake in


surgery,  and when I had the opportunity to be part of a

new developing specialty, I seized it.

       One of the things that I think made that

experience so remarkable is that it was a new specialty.

I was associated with the founding of the two societies

that represent pediatric surgery.  One was the Surgical

Section of the Academy of Pediatrics, and the other was

the American Pediatric Surgical Association. In

addition to that, I had founded, with Stephen Gaines,

the Journal of Pediatric Surgery, and had the great

privilege of being the surgeon chief of the Children's

Hospital of Philadelphia from 1946 until I went to be


Mr.  Reagan's surgeon general in 1981.   So I entered on


the ground floor,  and what I like to say is true, and

that is pediatric surgery really replicated the growth

of general surgery in America, but whereas it took

general surgery about 200 years to evolve, pediatric

surgery started from scratch and achieved about as much

as a specialty in 35 years.

INTERVIEWER:  Where does it sit today?   Are


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you pleased with its developments, even after your


active role in it?

         DR. KOOP:  I am pleased with part of it, and

very frightened about another part.  The part that I'm

pleased with is that we have developed a group of young

surgeons who are not just clinical surgeons and people

who understand how to do good surgical procedures, but

their bench research is contributing to other fields of

surgery, as well,  and I think that's one of the ways

that a new specialty not only grows but retains the

respect of its competitive --

          INTERVIEWER:   Their  "venture search"?



          DR. KOOP:   Their what?



          INTERVIEWER:  Their -- oh, their "bench


research."

          DR. KOOP:   Bench research.


          INTERVIEWER:   Bench research.


         DR. KOOP:  Yes,  I'm sorry.  The thing that



worr ies me about the futu re of pediatric surgery, I give

you the bottom line first.   I don't think that the

surgical care of my great-grandchildren will be as good

as the surgical care was of my grandchildren.   And let


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me explain that to you.

       I remember a day when I was the only pediatric

surgeon south of Boston and east of the Mississippi.

When we started,  we were a very small group.   I was the


fifth person in America who called himself a child


surgeon;  "pediatric surgeon"  wasn't invented until


somewhat later.  But I was the first person in America

who did children's surgery exclusively.   And that was as


recently as 1946,  so you can see we are relatively


young.

       The specialty grew in numbers.   There was not,

in the beginning,  an international society of pediatric

surgery, but the British Association of Pediatric

Surgeons served in that capacity, and it was sort of the

mother organization of other national pediatric surgical


societies.

       What happened to pediatric surgery is part of

what happened to medicine itself.  It slowly evolved

from being a pure profession to being a professional

business,  and in business money is the bottom line, and

that means that hospitals, medical centers, and even

medical schools are competing against each other for


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supremacy,  and it got to the point, about 20 years ago,

when if a small hospital didn't have a pediatric

surgeon,  parents knew enough about pediatric surgery

that they wanted their child to be seen by someone who'd

had experience with their child's problem.   A reasonable

and sensible request.  That meant that small hospitals

with no pediatric surgeon had to send from their

institution,  elsewhere,  patients who were considered

high risk pediatric surgical patients.

       The resulting change in the business of

pediatric surgery was that more and more hospitals

advertised for a pediatric surgeon, the enticements were

great,  "We'll build you an ICU, we'll do this and do

that for you," and the best way I can describe it is

that when you have the number of pediatric surgeons

multiplying the way they were,  the gravy gets so thin


it's not nutritious.  And I am convinced, especially in

a specialty like pediatric surgery where the technical

prowess of the surgeon is very important to the initial

success of the patient's outcome,  I'm convinced that

nothing succeeds like experience on experience.   And


today,  there are so many pediatric surgeons that some of


them see very few of what we call "index cases," such

esophageal atresia,  diaphragmatic hernia, intestinal

obstruction of the newborn,  things of that particular


nature, which were real technical challenges as well as

physiologic challenges post-operatively, and there were

times in the Children's Hospital of Philadelphia when we

would have a dozen patients with esophageal atresia that

came through in a single month.   And in the last

20 years,  when I have occasionally made rounds in other

children's hospitals,  the first question that I ask is,

"How many esophageal atresias did you see last year?"

And I get the astonishing answer, "Was that the year we

had two,  or was that the year we had three?"


         INTERVIEWER:  How many pediatric surgeons are

there in the United States today?


         DR. KOOP:   I don't think I can answer that

question for you.


         INTERVIEWER:   But the numbers have

proliferated,


         DR. KOOP:  The numbers are great.  Somebody

told me that there are something like 800 certified

pediatric surgeons,  not all practicing in the United


States.  That includes Canada,  some from South America,

but that are certified by the American Board of Surgery

as pediatric surgeons.

      And with the esophageal statistics, for

example, my group and I did 272 esophageal atresias --

that's not right.  We did 472 esophageal atresias


between 1946 and 1981.  And the results speak for


themselves.  In my own personal practice, for the last

eight years that I was a surgeon, we didn't lose a

patient with esophageal atresia.   And our survival rate

for premature babies was 88 percent.   And I don't think

that you can achieve that for the tough anatomical and

physiologic challenges unless you have the experience

that warrants your ability to meet the unexpected and 'cc


take care of it.


         INTERVIEWER:  Both as a pediatric surgeon and

then in your role as Surgeon General, you had an

extraordinary opportunity to observe the health of

children or developments in the health care and health


of children.  How have you seen that over the last half


century,  and where do you feel we're headed?


         DR. KOOP:  Well,  children occupy a very


special place in medicine.  We always talk about the

children being our future,  and therefore they deserve

our best,  but I'm afraid we don't always deliver that

way, and I have to admit that the older I get, the more

I understand the relationship of poverty in a child and

poor outcomes in everything else.   And I think that I'm

not beating a socialist kind of drum here, but I think,

as we look to the future,  unless we take into account

what a severe role poverty plays in the future of

children,  we will never be able to attack its base




causes.


        Now,  we have accomplished a good many things.

One of the things I'm proudest of is that during my

tenure as Surgeon General,  working with Finch Hutchins

and Norma Cursett (phonetics) of the Bureau of Maternal

and Child Health, we were able to actually amend the

Social Security Act, Title V thereof, so that it became

the right of every special needs child in this country

to have coordinated, comprehensive, family-centered,

community-based care.   And that was a tremendous


advance,  because it said the child will have the support

of the family,  which is so essential to developing kids


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emotionally,  but it also said you won't have to travel

across the country to get it.

         INTERVIEWER:  What does that mean in terms of


clinical or social support?   What did that mean?   What

did kids get as a benefit of that they weren't before?

          DR. KOOP:  What they get is the ability to --

let me explain it with somebody like Katie Beckett, that

is known to many people.   Katie Beckett was a child who

was respirator-dependent and lived in Iowa, but she was

hospitalized as a Medicaid patient 30 miles from her

family,  and that was a great burden for the family to

provide the emotional support that they needed.   And



Mrs.  Beckett wondered why,  when we had gotten children

out of hospitals into their home, on a respirator, at

ever so much cheaper rates per week than the hospital

could do it,  why that wasn't possible.

        And out of that came the Katie Beckett

Waivers,  and that meant that Katie Beckett was

transferred from a hospital to her home.   That meant

that it was community-based and not at a distant place.

She had the emotional support of her family, so it

became family-centered.  It was comprehensive in that


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all of the necessary specialists and those who provided

social support were part of the team, and --

it.

INTERVIEWER:  And Medicaid continued to cover

          DR.  KOOP:  Medicaid continued to cover it, but

it was ever so much cheaper for them to do it at home.

And it's interesting that just the day before we're

speaking now,  I noticed in the newspaper, warning that

there would be tampering with the Katie Beckett Waiver

System.  So after all these years, we may have to fight

that battle again.

         INTERVIEWER:   It's K-a-t-i-e?


         DR. KOOP:   Yeah.


         INTERVIEWER:   B-e-c-k-e-t-t?


         DR. KOOP:  Right.


         INTERVIEWER:   There is social criticism or

political or policy criticism from time to time about

the income transfer between youth and the elderly, with

Medicare in particular commanding such a huge portion of

our public budget,  and relatively less going to

children.  Is that a concern you subscribe to in terms

of public policy?


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         DR. KOOP:  It's a concern that I have, because

all the time that I was a pediatric surgeon,  I was aware

of the fact that our chief competitor was really not in

the pediatric field at all,  it was geriatrics.  And just



as --

of?

INTERVIEWER:   " Ch ief competitor" in the sense

         DR. KOOP:   Demand for services and the fact

that people were living longer, living better, and you

can't do either of those things without spending more


money.  And so I would say that it can be summarized by

saying pediatric social and medical interests were vying

with geriatric social and medical interests for an

ever-increasing slice of a shrinking pie.   And that

doesn't make for good social service, it doesn't make

for good family support, and it doesn't make for good

medical outcomes.

     But I would say that on balance, except for a

few major things that stick out like sore thumbs,

children do get a better shake.  They certainly do,

surgically.  One of the changes --


         INTERVIEWER:  Than they did previously?


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         DR. KOOP:  Than the did previously.   I think

one of the changes that should be noted is pediatric

surgery started in a strange way, and the people who

called themselves pediatric surgeons in the early days

were really surgeons of the skin and all of its

contents.   I mean,  I used to do subdural hematomas, and


I'd work in the neck.  I avoided the eye and the ear,

but the rest of it was my domain.   And it didn't mean

that I kept out of the chest or the belly or the pelvis

or the extremities,  and for a surgeon who loves surgery

the way I did,  that was a wonderful system.

      But if one looked at the development of

general surgery in America after World War II, the great

spurt in surgery, what I call "the golden era of

surgeryll  in America,  came about because of

specialization.  The war made specialization easy, and

made it almost necessary.

          INTERVIEWER:  "Easy"  in the sense?


         DR. KOOP:  Well,  if you were in military

situation and you suddenly had a huge bunch of burns,

you've got to develop a kind of specialist that can take

care of big burns.  And the same is true with trauma,


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and then people began to say, "Well, look, I've had so

much experience in the chest, why do you abdominal

surgeons keep stepping in my territory," and on it goes.

      The long and short of that is that with the

burgeoning of surgical specialties, I don't think

there's any doubt about the fact that patients got

better care and their outcomes were better.  Largely on

the basis of the fact that I mentioned before about

pediatric surgery,  study after study shows that the best

outcomes are in the places that have the most

experience.  And surgeons did not like to see the log of

general surgery cut into any more splinters, and one of

the reasons that pediatric surgery faltered a little bit

in getting it started in American surgical circles was

that it was seen as not only the competition of another

specialty, but here were a group of people who came

along and said,  "We can do what you do better at a

certain age," and that made the competition even more

telling.  It wasn't just technical skills, it was

understanding the physiology of a newborn and a small


child.

INTERVIEWER:  What do you think of the


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prospects for child health as you look at the situation

now,  and look to the future?  Is the aging of the

population going to continue to create competition that

kids won't be able to keep up with?

         DR. KOOP:  I think it depends, in the long


run,         about advocacy.  There are people who

have always been child advocates, and they've done a

tremendous job to advance the understanding of the

public to garner public and private funds, and to, in

general, move pediatrics along.   But children are not

able to have their own lobby, and I think there's no

doubt about the fact that the geriatric lobby -- and

that's not a specific group of people, it's just a

tremendous variety of people who have interest in the

aging population because that's where their business

interests lie --

         INTERVIEWER:  And the aging population is not

quiet group themselves.

       DR. KOOP: No, they're not quite, and they


vote.  And I think that one of the major reasons why

groups of people like handicapped children have never

made the same kind of progress that elderly population


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has in gaining services that they need, is that they

don't have the ability to fight for themselves.   And

when you're fighting for yourself, I think you're

fighting a different battle than when you're fighting

for a class of people, like children, that you have sort

of a nebulous connection to.

      The one thing that I think stands out as -- I

said like a sore thumb a minute ago -- and that is that

the pediatric world did not recognize the fact that

obesity, which is becoming a national problem, was also

affecting children.  And they didn't seem to understand

that fat bouncing babies became fat children, and fat

children became fat adolescents,  and fat adolescents

became fat adults.  And we now have a problem that is

going to be very difficult to reverse, and it has very
serious implications about diseases in the long run and

in later years that are associated with obesity, like

Type 2 diabetes, breast cancer, colorectal cancer; that

sort of thing.

         INTERVIEWER:  So this,  in terms of the

vigilance within the child health community, that's an

area that perhaps might have been attended to better?


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         DR. KOOP:   I think it could have been attended

to better if, for example,  I'd had another four years as

Surgeon General,  even though people weren't talking much

about obesity in 1989,  I would have made that one of the

pillars of a next term.

       The government were very slow, I think, to

recognize what was happening with obesity and

overweight,  and you may recall that in the private

sector I founded,  with the aid of Hillary Clinton and

the White House, a thing called "Shape Up America."

Which was designed for the private sector working with

private entrepreneurs to provide a way for people to

become educated and aware of the dangers of obesity.

          INTERVIEWER:  Let's switch to your years as

Surgeon General.  As you look back on those eight years,

what sort of reflections do you have about the job,

about the experience,  and about the outcome?


          DR.  KOOP:  Well,  no one ever tells you what


the job description is of Surgeon General.   And I think

it's entirely possible,  the way that job was organized

when I arrived in Washington,  to almost make it what you


will.  And I found that at the end'of Mr. Reagan's first


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term,  as his early appointees began to leave government

and go back to the private sector, that there were many

vacuums in the government,  a lot of them in public


health and HHS.  And waiting for somebody else to fill

those vacuums,  I stepped in and tried to do those jobs.

I think it was appreciated by people who were

leaderless,  but it provided the opportunity to get

several major things done.

       One is,  I don't think there ever has been --

had never before that been the same type of assault, not

just on the problems of smoking and the health

consequences thereof, but on the nefarious activities of

tobacco industry and their deceitful processes, which

were designed to obfuscate the public's understanding of

what the government was trying to teach them.   And

fortunately(?),  the momentum of that work has never

really subsided.   And I think we -- I have a terrible

prospect of global expansion of smoking by the tobacco

industry with the University of Cambridge statisticians

predicting that by 2025 there will be an additional

500 million deaths of people now alive on this planet,

due to smoking causes alone.


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       But the other thing that was a huge problem

during my tenure was AIDS.   And as I have made it

abundantly clear in my writings about the subject, no

one ever asked me to be the spokesperson of the

government for AIDS,  but it's a job that I assumed

because nobody else was doing it and because, frankly,

the people who advised Mr.  Reagan were doing such a poor

job of it.  And I think the people -- and when I say

"the people,"  I mean the public -- appreciated honest

answers about a difficult disease to understand, and I

think that both AIDS and smoking are the two huge

problems that our global society faces in reference to


health in the future.  The problems have expanded, and

they will not go away.

       Smoking is a lot different than AIDS.  Smoking

involves an addictive substance,  and that changes the

whole aspect of the growth and development of an

industry that has to replace those it kills, with new

recruits on a constant basis,  and the various

settlements that the tobacco company has fallen heir to

make it necessary for them to find new and outrageous


sources of income.  And they can pay the huge bill that


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they established with this attorneys-general of the

several states only because they had plans afoot even

then to smother the rest of the world where men smoke

but women didn't,  and to turn their financial returns in

such a way that they could pay what they had indebted

themselves to do.

         INTERVIEWER:   Yet to these -- I do want to

pursue the tobacco theme,  but staying on the PHS for a

moment and staying on AIDS, you described to me

previously the vacuum that existed and how back of the

hand or how informal your invitation to step up to the

AIDS issue and develop the first AIDS report had been.

Run that by me again,  I mean how that happened, because

I think that's an important part of history.

         DR. KOOP:  Well,  for reasons that were never

made clear to me,  when AIDS was established as a disease

and we knew we had an epidemic on our hands, I was told

that AIDS did not come under my purview and that that

would be handled by other people in the department, and

I was reminded of that any time I made a public

appearance or went on television or gave a lecture, that

I was not to get into the subject of AIDS.


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       And yet,  when that day came that I just

mentioned a moment ago,  when the original Reagan

appointees began to go home to their points of origin,

there were fewer and fewer people who really knew what

was going on with AIDS,  and it was easy to step in and

by that time I had secured, I think, a sufficient

confidence in the people of America that they could

expect me to handle the situation with integrity, that

the efforts that had been made to silence me before sort

of disappeared.  And I did become the spokesperson, and

one of the things that aided and abetted that was that

we changed secretaries of HHS,  from Margaret Heckler to


Otis Bowen.

      Otis Bowen was a remarkable gentleman and a

physician,  a man with tremendous political experience,

had been the governor several times of Indiana, and we

struck it off as medical and political colleagues right

from the start.  And he made it very clear to me that it

was not his intent at any time to step on my toes or get

in my way,  because he was very pleased with what I was

doing,  and he gave me every support that I could have.

      The next thing that came along that was


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fortuitous was that President Reagan asked me to write a

report for the American people on acquired immuno-

deficiency syndrome.   And I don't think I've worked

harder in my life on anything, and we published that,

and except for treatment modalities, everything about

the epidemiology of that disease and so on that was


stated then is still true.

          INTERVIEWER:  And that report you got through

with very little clearance,  as I recall you and perhaps

Secretary Bowen?

         DR. KOOP:  Secretary Bowen and I were the only

people in HHS,  except for two people appointed by me to

be my associates,  that knew what was going on.   And I

had agreed with Otis Bowen that if we passed this

through the usual channels,  of one being the Secretariat

of the HHS,  it would never have seen the light of day,

because there were too many people, especially those

surrounding the president at that time, who felt that

who had AIDS after all,  weren't they prostitutes,

homosexuals and drug abusers and, after all, didn't they

deserve what they had?

And the thing that I published had as its


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theme,  along those lines,  we were fighting a disease,

and not the people who had it.   And I think that was a

turning point --

(End of Tape 1, Side A)

         INTERVIEWER:  This is Dr. Koop, Side 2.


          DR. KOOP:  I do think that -- I forgot what I

was saying.

         INTERVIEWER:  I'm sorry.  The question was the

clearance process and who -- and your position --

         DR. KOOP:   Yes.  I did think that the major

mistake that was made by government and the public was

to treat AIDS as a political disease and not as a public


health disease.   I think we would not be in the terrible

global situation we are right now if we had treated this

the way we would have treated typhoid fever. Or

syphilis.  Or gonorrhea.  And instead,  we had special

rules about privacy and special thoughts about

protecting people,  and as a result now we have a

pandemic that is out of control in Asia and in Africa,


and so --

         INTERVIEWER:  So you think if we'd been more

incisive and more traditional in our infectious disease


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approach,  the epidemic would have been better contained?


         DR. KOOP:  I think the epidemic would have

been far better contained if we had treated it according

to public health principles as an infectious disease


that was containable.   I mean,  the thing that stands out

about AIDS more than anything else is its

preventability.  And as long as you had no way of

knowing who contacts were and no way of understanding

the reasons for testing and not testing, we just were in

a quagmire for years.

         INTERVIEWER - A word on be
                            .           ing the Surgeon


General.  The metaphor,  the cliche is, "bully pulpit."

And you certainly used it as a bully pulpit.  But beyond

that, how did you feel about your prosecution of the job

and what would you say about it as a position in

general?

         DR. KOOP:  Well,  I have tried to intimate that

it is a job that you can make into really what you'd


like to make it.

       INTERVIEWER: Or, I presume, not?  Should you


not have the vision --

DR. KOOP:  If you decided to sit and read the


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New York Times,  that would be also acceptable.  Nobody

would say, "Hey,  do your job a little better."

      I think the present situation, which I don't

know whether you want to get into or not, but --

         INTERVIEWER:   Sure.


         DR. KOOP:  But we have a Surgeon General now

whose qualifications seem to be perfectly satisfactory

for the job at hand,  but you don't hear much about him

because he doesn't have the freedom that I was afforded

by the Department of HHS; in this case, being strongly

overshadowed by the White House.   And so I describe


Dr.  Carmona as being a capable Surgeon General who is

unfortunately wearing a straitjacket.

      And I think that in this era where most people

are a little concerned and some people greatly concerned

about our preparedness for a possible biochemical

terrorist attack,  that this is a magnificent time for a

Surgeon General with a bully pulpit to educate the

people of the country, and, by moral suasion, to improve

the preparedness of the public health service to deal

with the problem.

INTERVIEWER:  But that isn't being afforded



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him,  in your judgment.


         DR. KOOP:  In my judgment,  we are not very

well prepared at all.  And the things that I've seen by

people -- not necessarily medical people, but people on

inside of government,  who have been prompted to speak in

the last few months of the Iraqi war, they confirm

everything that I fear about the lack of preparedness of

the country for biochemical response.

         INTERVIEWER:  On the Surgeon Generalship,

others have come to town with, I'm sure, ambitions for

the job and have not succeeded as well as you did --and

as you bring your own persona and your own level of

charisma and energy to the job, but how much is it the

person and how much is it the political circumstances

they work within?

         DR. KOOP:  Well,  I don't think you can say

it's either one to the exclusion of the other.   There

have been a lot of people who have discussed my

performance as Surgeon General with me, and if they were

people that I recognized as having experience in

government I have asked them,  "Why do you think I was


successful?"  And I would say the consensus of those


27

people has been something like this.   That in

Washington, you will find people who are remarkable

diagnosticians of the problem, others who have wonderful

therapy to change a situation, and a third group of

people who do it.   And I've been told that I have all

three of those characteristics,  and my work style is to

diagnose,  plan the treatment,  and then do it myself.


         INTERVIEWER:  In doing what you did, you

arguably changed constituencies in terms of your support

virtually a hundred percent, or -- and several times.

How did that come about?  Did you change?  Did they

change?  Was it the time?


         DR. KOOP:   I think there's no doubt about the

fact that the people behind Mr. Reagan -- and in all the

things I say about Mr.  Reagan's administration, I

separate Reagan the man from Reagan's advisers, because

I found Ronald Reagan to be a straightforward person.

If it hadn't been for the real conspiracy to keep me

from the president about AIDS,  I think that Reagan and I

would have gotten along very, very well.   And I think he

would have seen the concerns that I had early on, and

would have avoided for himself and his administration a


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lot of the criticism that he had.

      I tried to blunt the criticism that Reagan had

by saying,  "The president doesn't usually assume the

public air waves to talk about the health problems of


the nation.  That's why I'm here.   And no one could have

tried harder to give you an absolutely clear

understanding of what we face with the problems we do

face in health,  especially with smoking and AIDS."

      And -- you had another question there.


         INTERVIEWER:  Yeah,  well the question about

the constituency.

         DR. KOOP:  Yeah, my constituency.   I think the

people who advised Mr.  Reagan saw me as an ultra-

conservative who would do their bidding and who would

fit very nicely into their preconceived notion of the

way things would go.  Of course,  they didn't know about


AIDS.

         INTERVIEWER:  This was when they appointed you

or they nominated you.

         DR. KOOP:  That's right.   And I was nominated

by the president on Valentine's Day, 1981, but I had

been discussing this with people who were searching for


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Mr.  Reagan's cabinet and so forth, from the day he was

nominated by the Republican Convention.   So this went on

all during the fall,  between Election Day and

Valentine's Day.

       I think one of the problems with Washington in

general is that people are labeled, first of all by the

press;  secondly,  they're labeled by the supporters or

the detractors of prospective members of the government;

and those are three separate assessments of an

individual,  and none of them are necessarily true.   And

so I came with a label that I really didn't fit. I

mean,  my reaction to smoking, my reaction to big

tobacco,  was not the reaction of a Republican to big


business.  It was fury at the deception of an industry

masquerading as a legitimate business, but really

exuding evil in the attraction of children, especially,

to an addictive drug that ruined their lives and killed

them early.  And so when I began to say things that I

felt had to be said,  there was never anybody who stopped



me.

        Now,  I don't understand the anatomy of what I

just said completely.  The advice that Reagan got from


30

his close advisers was to dump me and to get rid of me


as soon as he could.   He never did that.   He never

reprimanded me for anything that my critics criticized


me for.  When I left office, in 1989, one of the

surprises I had at the celebration of the end of my term

in California was a very long and highly complimentary

video of Ronald Reagan talking to me, of course on the

screen.  One of my happiest possessions, because

although it's absolutely true he never criticized me and

never called me to stop me doing anything, but on the

other hand he never said,  "Good for you!"   And so I

didn't really know,  until he had gone back to

California, what he really thought about my performance,

but I think he thought it was satisfactory.

         INTERVIEWER:  Well,  it sort of was a social

conservative, the "Right to Life" groups,  that touted

you as their candidate.

         DR. KOOP:  They touted me as their candidate,

and you know,  one of the interesting things to me about

government that most people don't know, I gave a

tremendous number of talks in the old Executive Office

Building, usually up in the Entreaty(?) Room, to groups


31

of constituents that really admired Ronald Reagan, and

that he sometimes invited to the White House.   And I'd

get a call in the morning that the president's

entertaining some people this afternoon, he's going to

speak to them from 1:00 to 1:05, could you take over


until 2:00 o'clock?  And so it would be on all sorts of

things that had nothing to do with my job, really, and I

had one big collection of talking points.   And I used

them many,  many times,  but never gave them a title,


because the title shifted all the time.  And so my

staff,  to file it someplace had to give it a name, so

they called it,  "A Really Good Sermon."

       (Laughter)

       And I gave that really good sermon for Ronald

Reagan many, many times, and --

         INTERVIEWER:  Did it have a political or

social agenda, or --?

         DR. KOOP:  It was his political social agenda.

Really.  It was his pro-life position, it was a

conservative view of life in general, but never cramping

my style.  And no, it's -- I worked much more closely


with Mr.  Clinton than I did with Mr. Reagan.  Strange


32

circumstance, but he would never have let me get away

with the things Mr. Reagan did.

      And I had a secret way of communicating with

the president.  You must remember that the people who

were most opposed to the things I did and said, like

Gary Bauer,  had made it almost impossible for me to

communicate with the president.  But I had a way of

slipping a note to him at the end of each day, if I


wished to --

         INTERVIEWER:  "Him, " being the president?


          DR. KOOP:  The president.   And --


         INTERVIEWER:  Through a back channel?  Through


someone?

         DR. KOOP:  One of the routines of the day for


Mr.  Reagan was before he left the Oval Office and went

up to his private quarters,  is that the director of the

mail service would drop by with about ten to twelve

letters that she thought were the pulse of the nation

that day in the letters that came to the president.   And

he'd dutifully sign them,  but he added a little note to


each one,  "So sorry to hear about your husband's


osteoarthritis,"  and that sort of stuff.


33

       Well,  sometimes between two of those would be


a note from me.   And --


         INTERVIEWER:  And then she saw to it he got


them?

DR. KOOP:  He got it.  And I'll give you one

example.

         INTERVIEWER:  But she was your contact? Or

she was your --

          DR. KOOP:  She was my contact.  And Mr. Reagan


was very,  very upset about the fact that there were

children who were born with no bile ducts in the liver

and who faced certain death, and the only possible

chance for survival was a liver transplant.   And so I

did three Surgeon General's workshops on

transplantation.  I founded,  for the people who used it,

the American Council on Transplantation; got some funds

from the public health service to pay for the legal fees

to set that up and so forth and so on.

But the -- where was I going with this?

          INTERVIEWER:  You were talking about Reagan's


interest in liver --

DR. KOOP: Oh.   So he went on television one


34

afternoon, sat in his -- you know, he spoke on radio

every Saturday afternoon.  And his whole program was a

plea to the American people,  "There must be somebody out

there who has someone who just died in the family or

might die between now and the time tomorrow comes. We

need a liver for this little girl."

       And he was,  I heard from my White House


contacts, crushed that nobody came through with a liver.


As far as he knew.  And so the little note that I put

in his mail was,  "Don't be upset about no liver for your

patient.  We actually had 40 livers offered to us.   None


of them were suitable, but the most important thing

which, Mr. President, you do not know, is that no liver

transplanter in this country is willing to put this

little girl at the top of his list, which is the only

way her parents will deal with a medical professional."

       And he called me about -- he flew to

California that week,  called me about five times,

because he didn't know about the change in time, but

anyway,  and we had a great talk about liver transplant

on the telephone.

But those were the kind of opportunities I


35

used,  and I think he appreciated the fact that I

protected him and informed him about things like that.

Which I would much rather prefer to do eyeball-to-

eyeball,  but his minions would not permit that.


         INTERVIEWER:  Tell me about your relationship

with the Clintons and how you moved, in your own

political persona,  in your latter Surgeon General years

and post-Surgeon General years, to what, in simplistic

political terms,  would be from having been a

conservative Republican to at least a moderate to


liberal Democrat.

         DR. KOOP:  I didn't ever really change my

point of view, but what happened is my constituents felt

that I did,  or understood where I stood in the first

place.   That was what most of them didn't know.


          Mr.  Clinton had campaigned on a platform that

had to do with health care reform.  And I was speaking

as often as I could to the American public about health

care reform,  and I had some good ideas about it, and I

received a sort of relatively secret message from the

president by word of mouth --

INTERVIEWER:  This being now President


36

Clinton?

         DR. KOOP:  Clinton,  that he would like me to

be the salesperson for his health plan.


         INTERVIEWER:  So during the campaign or prior

to that,  you had not worked with him.


         DR. KOOP:   I had talked with him nine

different times during the campaign about health care


reform.

         INTERVIEWER:  He had sought you out, or --?


         DR. KOOP:  He had sought me out, and

thereafter I would call him or he would call me, and we

had a good understanding about our differences of

opinion and what I thought were important things and

what I thought could be accomplished and what I thought

couldn't be accomplished.  And that was interrupted by -

- he had a medical student from Harvard who was advising

him, down in Little Rock --

         INTERVIEWER:  Atua Gwandi (phonetic)?


         DR. KOOP:   Atua Gwandi.   And Atua Gwandi told

me that I would no longer have the opportunity to talk

to the president,  and any message I had I would give to

him and he would give to the president.   And I never


37

passed any word to the president through Atua Gwandi,


but --

         INTERVIEWER:  He's become a pretty good


surgeon.

DR. KOOP:  Yeah,  so I've heard.


INTERVIEWER:   Yeah.  He's an excellent writer,

too.

         DR. KOOP:   Yeah.


         INTERVIEWER:   Yeah.   But that was a little


presumptuous,  I have to agree.


         DR. KOOP:  I thought at the time, yeah, even


for a Harvard medical student.

(Laughter)

      So I said that I could not support any program

as a sales person unless I knew what it was all about,

and I had to confess that some of the things that I had

read in the press were disturbing to me.   So the

president sent for me,  and we had our first meeting, and

he said -- he was very gracious.   He said --


         INTERVIEWER:  This is in Washington or this is


in Little Rock?

DR. KOOP:  Washington.   It was in the Oval


38

Office.  He said,  "I know you can't be my salesperson,"

and he said,  "I realize that we have differences on

opinion about some things and what I'd like to reform,"

he said,  "but what I'd like to ask you, would you be

willing to be the moderator of a conversation between

the medical profession and me and/or the First Lady?"

      I said I could not possibly turn that down.

And so that gave me the opportunity to travel with

Hillary and I truly believe -- something you can't

disprove but neither can I prove it --but I truly

believe if she and I could have done what we did for a

whole year,  instead of for three months, we could have

come up with a compromise with the medical profession

and we might have avoided the horrible transition to

managed care.  We just didn't have time to get it done.


         INTERVIEWER:  "Horrible," in that you would

have been able to craft or develop legislation that

would have been passed,  that would have been a reform?


         DR. KOOP:  The thing that impressed me about

this dialogue that I had been asked to moderate was how

flexible both parties were.  I would go to a meeting

with medical profession,  anywhere from 40 to 400 people,


39

with the First Lady.  We'd stand on opposite sides of a

platform, behind lecterns.   And there was no bitterness.

There was no accusation of carrying too much baggage

with you and that sort of stuff.   But she understood

their point of view,  and when she didn't I explained it

to her then or later, and vice versa.   And I don't

remember leaving a single one of those things, those

dialogues,  when she didn't have a broader view of the

medical profession and when they didn't have a more

accepting view of her.

         INTERVIEWER:  She credits you in her book as

selling health care reform with her in a very effective

way.

         DR. KOOP:   Yeah.  Well, she --


         INTERVIEWER:   She doesn't limit it to the

medical profession.

DR. KOOP: No.

         INTERVIEWER:  You talked to other audiences,


as well?

         DR. KOOP:  Well,  the medical -- I think in the

medical profession you have all the people who worry

about insurance,  health care and administration of


40

hospitals and the sale of goods and pharmaceuticals, and


that sort of stuff.  So they're all --


         INTERVIEWER:  And your coverage went

everywhere, I'm sure.

DR. KOOP:   Yeah.   But she --


INTERVIEWER:  So you spent three months on the

road --

         DR. KOOP:   Yeah.


         INTERVIEWER:  -- on and off, with her?


         DR. KOOP:   Uh-huh.   And we would come home

from someplace, Atlanta,  and I'd sit with her and her

chief assistant in the plane, and we'd just outline --

I'd say,  "This is what you learned today.   This is what

you found is going to be hard to push the medical

profession on," and so forth.  And we'd get back to the

White House late in the day, and her devoted staff would

be waiting,  at 12:OO midnight or 1:00 o'clock, and she'd


say,  "You do this,  and you do this, and you do that,"

and they'd get report back to me in three or four days

and say,  "We were able to accomplish this, this and

that,  but we can't do this."

      And it was a heady time, because I felt that


41

we were -- I never came away from any of those meetings

saying,  "They don't understand each other."   Because

they did understand each other.   And I would be elated

sometimes at the concessions the medical people would

make once they heard her say it.  Very charming person,

one to one,  with a doctor.  And no sign, ever, of any


arrogance,  "I've got a reform plan and you're going to

take it," you know.  And it was really great to see.

And I do think we could have done it.

         INTERVIEWER:  As you look back on health care

reform and your work with the Clintons, what do you


conclude?  What might have -- was it doomed, ultimately?


         DR. KOOP:  Toward the end of those days, I was

sort of acting as a courier between the Senate and the

White House, and it demonstrated to me the one thing

about politics that is, I guess, insurmountable. I'd

spend all day talking to three Senators, and I'd get

them to join the eleven that were already agreeing with

what we wanted to do, but in getting those three I lost


five others.

And the person that was trying to shepherd

this -- you remember that it got so complicated that the


42

House threw up its hands and went home.  They didn't

even bother to continue to discuss health care reform.


And it was the Senator from Maine -- what's his name?

         INTERVIEWER:  Mitchell,  George Mitchell.


          DR. KOOP:  George Mitchell was trying to act

for the Clintons in getting this stuff through Congress,

and it just -- we'd gain three and we'd lose four; we'd

gain five,  and we'd lose six;  we'd gain six and we'd

lose two;  and we just never got to the point we could

pass it.

      But see what -- I think we were watching

history in the making,  because I think essentially what

medical politics said at the failure of the Clinton

plan, is "The pundits have always told us if we let

market forces run health care, we'd have lower costs and

higher quality,  and let's give it a try."   And I don't

know anything that works that way.  You get lower cost,

and you don't get higher quality; it's usually the other

way around.

      And even at this late date, my feeling is that

if we'd had a better chance to educate the medical

profession and the public -- and we were doing a good


43

job,  but you can't do it all in three months.   If we

could have spent a year doing that, and had postponed

health care, say,  until maybe the third year of his

first term,  I really think we could have avoided managed



care.  And we would have had a better health care plan

than we lived through with managed care.


         INTERVIEWER:  And that what we have now,

you're saying.

          DR. KOOP:  Oh, yeah,  I don't even know what to


call it now.

         INTERVIEWER:   We'll come back to that. Is

Hillary going to be president?

          DR. KOOP:  You're not going to put this in the


Journal.

         INTERVIEWER:  I won't if you don't want.


        DR. KOOP: No,  uh -- I think Hillary would

like to be president.   I think that there are a lot of

barriers in the way.  I think if Giuliani runs against

her for the Senate, for example, and she loses, which is

a likely thing to happen,  then I think it's all over.


        But I think that it will take several more

years of history to fully assess the importance of the


44

Clintons to the things that are going on right now in

the Democratic party.  Because I -- you've got to ask

yourself about Howard Dean's meteoric rise and meteoric

fall, how'd that come about?  Not for publication,

please,  but I don't think it would have suited the

Clintons to have another leader in the Democratic party.

         INTERVIEWER:   As Howard Dean.


         DR. KOOP:  And he was on the way to being


that.   I mean,  you know, up here,  which you didn't have

a chance to see, this place was pulsing for Dean. It

was really -- it was like when Reagan came to

Washington.  People who weren't even interested in

politics were thinking, "This is pretty good."


         INTERVIEWER:  Do you think she would be a good

president from her executive ability, her vision and

wisdom?

         DR. KOOP:  She's one of the most talented

people I've ever worked with, and I think she has all

the necessary things to do the right thing.   I think

whenever you talk about what will a politician do, you

just don't know because politics is so important.


         INTERVIEWER:   Yeah.  Do you want to take a


45

break?

       DR. KOOP: No, I'm okay.  Well, maybe I -- no,

I changed my mind.   I'm fine. I'm         my legs so

they don't clot anyway.

         INTERVIEWER:  Okay, good.  Let's go back and

pick up on tobacco.  And you certainly got your feet and

more of your anatomy wet with tobacco, as Surgeon

General,  but then there was the battles after that and


there was the ultimate tobacco settlement.   Tell me a


bit about that,  and how you feel about the settlement


and the aftermath of settlement.

          DR. KOOP:  Well,  I think the first thing that

should be said about tobacco at any time, but especially

right now in history,  is that tobacco is always a good

news/bad news story.  Tobacco at this moment is, at



once,  one of our greatest triumphs and one of our

greatest defeats.  It's a horrible defeat, after all the

effort we've made,  to know we have 49 million nicotine


addicts in America.  On the other hand, we have fewer

than half the number of people smoking than we had in


1964.

INTERVIEWER:  Percent-wise in the population?


46

         DR. KOOP:   Yeah.   Yeah.  So we are, you know,

we've done very well,  but it hasn't been good enough.


And I think that efforts at tobacco control have been

rather magnificently done,  and I think in the past

decade we've seen all the things fall in place that make

it possible to control tobacco, and the reason I say


that is that --

(End of Tape 1, Side B.)

          INTERVIEWER:  Koop,  Tape 2, Side 1.   You were

saying about tobacco just in the last week?

         DR. KOOP:  Just last week, both the House and

the Senate gave approval to that, which should lead to

the regulation of tobacco by the FDA, and then the thing

that I think will make it happen is that Phillip Morris

supported it.  And so when you have the House, the

Senate and Phillip Morris, you've got a majority, as far


as that is concerned.

      I think one of the things that differed in my

approach to the tobacco problem was that I did what my

predecessors had done,  and I talked about the health

effects of smoking.  And we did that very well through

the Surgeon General's reports,  and we had things nailed


47

down,  chapter and verse.  I think that the two major

things that I accomplished along those lines was making

clear the dangers of passive smoking, because what that


did was to turn nonsmokers from neutral folks into

activists against smoking.   And I think the most

important thing that I accomplished in the Surgeon

General's role with the Congress was the 1988 report on


addiction.

          INTERVIEWER:  When was passive smoke?   That


was earlier?

         DR. KOOP:  It was earlier, yeah.


         INTERVIEWER:  But during -- there was a report

on passive smoking?

         DR. KOOP:   Yeah.  I think there five public --


         INTERVIEWER:   But the addiction one was '88?


          DR. KOOP:   '88.   And I consider that to be

progress in the following way.  If I had gone to a

meeting any place in this country or Canada, say in

1987, where I was in a room full of smokers and I asked,

"How many of you are addicted to nicotine?" you might

have seen one or two hands gone up.   You ask that same

audience today,  and you get 80 percent of the people


48

saying,  "I'm addicted."  And I think that is a huge

change.  It's a sea change in the way people think about

themselves, and if you think of yourselves as somebody

who has a tough habit to break, "But I can do it

tomorrow," it's an entirely different problem than if


You say,  "I am truly addicted to an addictive drug."

And I think that the ground rules change, and it's, in a

sense, harder to sell a cure, but it's also, for some

people,  easier to sell a cure.

      The other thing that I did a little

differently than my predecessors was to attack the

tobacco industry.  And I -- see,  I came on the tobacco


scene as an anti-smoker.   I came on the tobacco scene

with very little political understanding of what went on

behind the scenes.  And I was absolutely infuriated that

when we would make -- spend a whole year getting a

report together and present it, and two weeks after that

the tobacco industry would spend tearing down the

science and saying it wasn't true, and so forth and so



on.  And I decided not to take that as just things that

happen to the Surgeon General's report, but to continue

to hammer away until the next time something happened


49

that they were a deceitful group of people.

And I used to talk about the fact that

although it couldn't be used in a court of law, that I

had many communications from tobacco industry workers

telling me about the nefarious things that were going on

in their company,  but everything was protected by

attorney/client privilege.  Which was a pretty clever

maneuver on the part of tobacco, that any research was

never reported to management without being reported to

legal counsel first.  So everything became

attorney/client privilege.

       And that was the biggest, the biggest aspect

and the biggest sea change in the tobacco settlement,

was the tremendous efforts of Skip Humphrey, the

attorney general of Minnesota, Hubert Humphrey's son, in

getting the courts to remove that attorney/client

privilege because it was not necessary and it was

spuriously obtained.  And now,  not only do we have

repositories here and in England of all of the

documents,  something like 30 million pages, but they're

catalogued,  and there still is a treasure trove we

haven't turned up,  of the things that were deceitfully,


50

knowingly and deceitfully said by the tobacco industry

that's perjury.

      And one of the things that I find very

difficult to understand is why there isn't more outrage

on the part of the public on the way the tobacco

companies duped them,  to the point that their mothers

and fathers died of tobacco, and their kids are hooked,

and they are too.  I think they would be furious.


         INTERVIEWER:   Yeah.  The run-up to the

ultimate settlement was a fairly rough and tumble

period,  as I recall.


         DR. KOOP:  It was a rough and tumble period.

I've got to be very careful what I say, because I don't

want it to be the wrong way.   I think that the tobacco

industry sort of rigged it the way they wanted to. I

had two secret meetings with people from the tobacco

industry,  with great secrecy,  in places I didn't usually

frequent,  go in the back door,  go up the backstairs,


this sort of stuff.  Really seeing if, I would say, I

could be bought,  but seeing whether in my position of

righteousness about tobacco,  I couldn't say things that

would be favorable to the settlement, the way they



51

wanted it to go.

      The thing that was frustrating is that there

were lawyers, lawyers, lawyers, lawyers.   And there was

nobody from public health.  And when they sat around the

table and discussed things, it was lawyers there

discussing with other lawyers in reference to their

clients; their clients were the tobacco companies, their

clients were other people in society, their clients were

the attorneys-general who got their own lawyers from

outside their offices,  and we had just one person

representing our side.   Now,  he is a very zealous and a

very efficient guy, Matt Myers, who now runs the

campaign for Tobacco-Free Kids.   But I do think if he


had said --

         INTERVIEWER:   "Our side"  in this case?   You

said Matt Myers was representing our side.

         DR. KOOP:  He was the person that was opposed

to smoking and opposed to the tobacco industry's

influence on children,  advertising and everything else.


         INTERVIEWER:   But that was different than the


attorneys-general?

DR. KOOP:  He had a passion that was closer


52

to --

         INTERVIEWER:  He was a pure advocate.


          DR. KOOP:  He was a pure advocate, but I think

he should have protected himself by saying, "I want

seven people from public health on this committee to be

my advisers and to work with me."   And a lot of us tried

to talk with him,  and I was talking to both sides, back

and forth,  all the time,  and the settlement itself was a

tremendous thing,  huge amount of money, over 25 years,

but it were the things that happened apart from that

that made me leave Washington and move up here.

      And when Trent Lott behaved the way he did and

said that this subject will not come up again as long as

I am president of the Senate, and when we took a vote in

the Senate and won,  and we discarded the vote.  It just

seemed to be such highhanded --

         INTERVIEWER:   He discarded the vote?  Explain


more,  because I'm not familiar with this.


         DR. KOOP:   I don't understand it either.   But

the Senate vote was in favor of tobacco -- well, let me

interrupt and say that an ad hoc committee of Senators

and Congressmen asked me if I would be co-chair of a


53

committee, and David Kessler would be my other co-chair,

and that we would prepare, with the help of anybody we

wanted to get,  the gold standard for tobacco

legislation,  to control tobacco in the United States.

And I think it's one of the better things that we did,

and we presented that gold standard.  And essentially,

that gold standard was sort of what we were voting on,

although it wasn't in the words that we used, and my

recollection is that we had six more votes than we

needed,  and essentially won that battle, and then Trent

Lott said that he was withdrawing the, what I would

think would be a completed act, he was withdrawing it

from the Senate and -- .

      This was an interesting time, because we had

some stalwarts from both sides of the aisle in both

Houses of Congress who were really hopeful -- Ted

Kennedy being one of them -- that we would finally come

to something that would pin the ears of the tobacco

industry back where they belonged.   And when all those

things happened,  in a matter of a couple of days, I

said,  "If working as hard as I can with a very efficient

volunteer group helping me,  and with the reputation that


54

I have in Washington about tobacco and about integrity,

if working two years like this,  it comes to nothing more

than we have seen,  there's no point in my staying here."


So I left and came here.

         INTERVIEWER:   And this would have been

legislation that would have been far more regulatory and


far more --

          DR. KOOP:   Yeah.


          INTERVIEWER:   -- and would have controlled the

tobacco industry and tobacco sales and advertising?


         DR. KOOP:  But you remember -- yeah, but you

remember,  it was a little more complicated than that,

because there actually was a court case that came up in

the south that we lost,  in trying to assure the role of

the FDA in the regulation of tobacco.   So it wasn't as


open and shut as I like to think it was.  It's a funny

way to say it,  but there were so many things going on at

the same time,  that I think even legislators were


confused.

         INTERVIEWER:   And the settlement was a


separate track.

DR. KOOP:  Separate, indeed.


55

         INTERVIEWER:   And when that came down and was

finally legislated and accepted,  were you satisfied with


that?  Were you satisfied --

       DR. KOOP: No,  I was not satisfied with it

because although the sum of money was exorbitant and I

think fitting and proper,  the thing that bothered me was

that there were so many little things that were just

ignored,  and when the questions came up about them, the

answers were all, "Well,  we understood that that was to

be this way," you know.  They pretty well ran roughshod

over things that weren't settled by individual articles


in the law.

         INTERVIEWER:   The size of the settlement. Do

you recall what that was?

         DR. KOOP:   The what?


         INTERVIEWER:   The size of the settlement?


         DR. KOOP:  270 billion, I think.


         INTERVIEWER:  Over 25 years?  And since that

time there has, of course,  been highly variable use of

the money on a state-by-state basis.  Your thoughts


about that?

DR. KOOP:  Only one state has used the money


56

for its intended purpose completely, and that's

Mississippi.  And that's because Michael Moore was one

of the major protagonists in the group of attorneys-

general who were bringing the suit.   But --


         INTERVIEWER:  And that purpose was tobacco


reduction?

         DR. KOOP:  There were two major issues.   One

was to prevent children from starting to smoke, and the

other was to make treatment available and worthwhile for

adults.  So (inaudible) still a problem.


         INTERVIEWER:  But other than that, states have

used it in a variety of ways?

         DR. KOOP:  Well,  it came at a difficult time

when, because of an awful lot of problems in the

economic world,  practically ever state in the union was

running a deficit budget.  And they saw this as sort of

having won the lottery.  And nobody had any qualms about

taking that money and using it to fill potholes or fix

bridges or pay schoolteachers or maternal and child

health, or -- very, very little of the money went to

health, even if it was tobacco health.

And states like California and Massachusetts,


57

which had the best programs for their own citizens, the

money that was available was in such short supply that

they lost a lot of their people, a lot of their


programs.  New Hampshire,  exactly the same way.

Everything up here was jeopardized.  I knew 24 people

that were very active in the state, working with us here

periodically,  and they all were without funds all of a

sudden because the money was not used for its intended

purpose.

         INTERVIEWER:  What will happen to tobacco in


America?  What's your prognostication?   Will we better

the situation now in terms of percent of the population?

Well,  it's down,  it's 20-some-odd --


         DR. KOOP:   Five.


         INTERVIEWER:  Twenty-five percent?


          DR. KOOP:  I think -- I don't think you can

talk about the United States separately.   The United

States is 9 percent of the global economics of tobacco.

And to make that payment of $200-and-some billion, and

other things that have happened, and no one knows what's

going to happen with the huge suit that's been brought

by the government against the tobacco industry, but


58

that's a lot bigger than the settlement is, if they were

to win that,  and it means that there's going to have to

be some very innovative financing, and I don't see the

one thing that could be a deterrent, and that is a

global public health effort to fight big tobacco.

         INTERVIEWER:   It's not there.


         DR. KOOP:   It's not there.  And the thing is,

you can't expect Zimbabwe to fight it by itself, or the

Philippines to fight it by itself.   The American Cancer

Society has done as much as anybody, by bringing over to

this country selected individuals from developing

nations to teach them how we have handled the politics

of big tobacco,  and to teach them the ways that we have

used our political muscle,  the way we've used public

education,  the way we've used gimmicks here and there.

And it just -- it's a nice effort, and it's well thought

out and very well-meaning,  but it's just too little

recognize         size of the problem.


         INTERVIEWER:  So I gather from that you think


that the United States'  efforts over reduction will

remain where they are,  but a great deal of the

commercial and promotional effort's been moved globally?


59

And will remain so?

         DR. KOOP:   I think so.  And you know, again it

fits into -- it's a politically bad time to worry about

tobacco,  when you try to get the attention of a

concerned citizen who is worrying about the war in Iraq,

the economics at home,  and people dying tobacco deaths

in Indonesia,  you know what takes third place.   And I

don't know any way to overcome that.

       Everybody talks about the shrinking globe and

the fact that our problems are everybody else's

problems,  and there's no such thing as a disease which

is somebody else's problem alone, and yet we're not

doing the things that should come from that

understanding and working together to try to fight

what's happening.

       When you think about the fact that 500 million

people now alive and well on this planet will be dead by

2025, you know,  I can't take that number in.   I tried to


work it out.  That's the same number of deaths as if you

had all the Vietnam War deaths every day for 25 years.

It's the same as if the Bhopal incident in India

recurred every four hours for 25 years.   It's the


60

Titanic sinking every 47 minutes for 25 years.  If you

wanted to build a Vietnam-type memorial to these people

that were going to die by 2025, you'd use the same kind

of set-up.  It would start in Washington and go westward

over six countries,  and end in Kansas City.  A pretty

big monument.

         INTERVIEWER:  Well,  I think that puts tobacco

in perspective.

Would you like to take a break and --


DR. KOOP:   I'll walk about a bit.

(Recording interruption.)

         INTERVIEWER:  I'd like to pick up with looking

at public health in America.  We can talk global later,

but talking United States in particular.   Post-9/11? I


mean,  that certainly was a seminal event for the nation,

but also for public health.   It's not clear to me

whether it started public health on a new route and, of


course,  9/11 is overlaid with anthrax and events of that

period.  Do you  -- I mean,  how do you feel about the

direction of public health?  Do you think it's gotten


new life?  Or do you think it's been diverted into wacky

bioterror concerns?


61

         DR. KOOP:  I think that public health in the

United States began to slip in the Clinton

administration,  and I think that we began to lose some

of the people in the commission corps that I thought

were real stalwarts and people who understood the

permanence of such a group and what its contribution

could be to the nation.  And since that time, everything

that I have seen or been able to understand that was

happening to the public health service of the United

States in that group,  and especially to the commission


corps,  has been downhill.

      And I actually got to the point where I

stopped going to meetings of the commission officers

that were social events and I sometimes could attend,

just because I'd come home so depressed by everybody's

cornering me and telling me how awful things were and

how they were going downhill and getting worse.   And I

think that a lot of little things -- there were some

changes in pay for -- of the uniformed services, but

they weren't passed on to the public health service, and

at every turn it seemed that something was happening

that wasn't good,  and then when I was asked to testify


62

about the public health service and about the commission

corps before Shays' committee, I really felt that the

public health service and the commission corps were

being exposed to scrutiny from people who really didn't

understand much about either,  and when you got finished

hearing all the complaints it sounded like things just

couldn't be very good in the future.

         INTERVIEWER:  This Representative Shays --

Chris Shays?

         DR. KOOP:  Chris Shays.


         INTERVIEWER:   Of Connecticut.


         DR. KOOP:  Bioterrorism didn't start with

9/11, and we've had ample discussions about bioterrorism

in the confines of the public health service and in the

commission corps,  and it seems to me that we never took

very much of an effort to do anything about it, and yet

I believe that the public health service, as it was

constituted when I was there,  and the commission corps

particularly, was very well suited to running a program

that would be as good as you would expect.

      You can't prevent terrorism, and so your

effort has to be on ready response.  And rapid


63

deployment of your resources to prevent things from

going from bad to worse.   And I don't see that.

      And I think the manner in which the anthrax,

for example, was handled was five cases -- suppose it


had been 50?  Suppose it had been 5,000?  Suppose it had

been 50,000?  I mean,  what would we have done?   I think

we wouldn't be over the panic yet.

      And I don't know enough about the new

department except that it's the biggest we have to have

in government --

         INTERVIEWER:  Homeland Security?


         DR. KOOP:  Homeland Security, to know how well

that's going to go.  I think Governor Ridge was given a

very tough assignment, because, I mean, people such as

you and I know that Washington and your ability to

function there depends an awful lot on old-boy networks

and people you know and can call on in time of need, and

Ridge came into Washington with a huge task to perform,

and no connections at all.   And I think that with that

in mind, he has done an admirable job with what he had


to face.  But as far as being able to show me or anybody

else,  "This is what we would do if somebody blew up this


64

bridge and attacked us at the same time," and so and so

forth,  and that's what worries me.


         INTERVIEWER:   In the real 9/11 and the

post-g/11 period there was a lot of money put into the

system in and around public health, including very

specific and rather wooden items,  like vaccine


procurement.  I don't mean that disrespectfully, but


"wooden" in the sense you've bought that, that's just a

flat purchase starter pile.  Do you get any sense that

this new money, new attention,  has invigorated American

public health in general         public health

service, or not?

         DR. KOOP:  If you ask me a yes or no question,

I'd say not.  And I realize that in organizations such

as the size of which we're talking, a lot of things can

be good that are going on that you don't hear about, but

you hear about the bad things.   And I don't want to

badmouth the official representatives of public health

in this country.  But I do have the feeling that the

people who know the most,  those who are responsible --

not medically,  but line officers for the defense of this


country  -- are as concerned as I am about the lack of


65

preparedness,  and that worries me.   It worries me at the


level of communication.  And it seems to me that the

public health service,  going back to the NIMNIS

(phonetic) days, has had --

         INTERVIEWER:   "NIMNIS"?


         DR. KOOP:   You must know what --


         INTERVIEWER:   Shame on me.


         DR. KOOP:  It's the thing that -- about 1986


or so, the military made a decision that they would not

try to have a chain of health command like they had in

the Korean War, with MASH units and base hospitals and

up, but that the transportation was sufficiently good

for the entire globe that we'd have the hospitals here,

use the benching(?) system,  and transport our wounded to

there.  And there were a lot of people who had -- public

health service who had obligations to NIMNIS, and some

were people who would be called up immediately if there

were a military conflict and so on.  And the only reason

I raise it is that the thing that always appealed to me

about NIMNIS, it was a system that was working in a time

of peace,  in a civilian authority, but it was

transferable to a military need just by saying, "Hey,


66

we're using you."

      And we have a group up here that's working on

some of the problems with terrorism, that's an official

DARPA thing,  and then there's another group of us that

have published five papers on terrorism so far, all

asking the same thing:  that in this day and age,

terrorism is going to best be fought in cyberspace

because we have a communications system, and if we're

going to use our heads we want a system when we finish

using it for the military,  we can use it for civilians,

and it works just as well.

And whatever we have should be able to handle

the Oklahoma bombing of a government building or a

tornado or hurricane or a flooding, as well as it could

handle anthrax in Trenton or with the post office.   And

that's what we've been trying to focus our attention on

is a system that is not either military or civilian, but

it can serve both at any time by a switch of the --.

      And I know that's not answering your question,

because it's very hard to get your hand on what's going


on,  and I would be hard put to make you a list of the

things that ought to be changed right now.


67

         INTERVIEWER:   Yeah.   I don't have a sense

that, say,  the profession of public health has received

a bump up in public esteem.   I don't have a sense that

more physicians are choosing public health or public


health careers.  I don't have a sense -- I know actually

I'm not as well read on this, that might be admitted,

but post-g/11 CDC published an evaluation of state

health capabilities,  connectivity being a big one, that

was just an embarrassment.

         DR. KOOP:  Right.


         INTERVIEWER:   I mean --


         DR. KOOP:  Well,  that's what I mean about it's

got to be fought in cyberspace.   The number of local

first responders that don't even have a computer and

can't go on the Internet, can't send e-mail -- it's

astonishing, really.

      And the other thing that you mentioned, I

don't find people dedicated to public health as much as

I find them feeling they ought to have a little

background because it's good on their resume.   I mean, a

lot of students come through here and ask me if they

shouldn't go someplace where they can take an MBA -- I


68

mean, a --

         INTERVIEWER:   MPH.


         DR. KOOP:  -- MPH along the time they're

getting their medical degree.

      I always say, "Yeah, it's a great idea."

      And I have actually turned a couple of people

toward public health alone and forget the medical school

business, because I think we need the kind of people

that go into medicine to go into public health.

      The other big shock to me was that I was with

one of a group of six people who, about six years ago

now, decided that the spread of public health from

medicine was not to the benefit of either profession,

and there were things that we could do together, we

could fight together for principles, we could fight

together for money, we could fight together for research

budgets,  and we could work in each other's labs and

bring that together,  and you know the old joke they tell

about Baltimore,  that the widest street in Baltimore is

Wolf Street, because public health's on one side and the

medical school's on the other.

But old joking aside,  that group of six grew


69

to a group of 70,  grew to a group of 240, who wanted to

see public health integrated.  We even got so far in the

planning as to think if Dartmouth couldn't be a virtual

school of public health for all the medical schools in

New York and New England who didn't have a school of

public health associate with a university where they

were.  And Roy Shores (phonetic) was very prominent in

this,  Stan Reiser -- do you know Reiser?  He's got an

interesting title,  he's Professor of Humanities, the

Department of Medicine, at Baylor in Houston.

      And we had a meeting of the 240 invited

guests,  and I gave a keynote,  Reiser gave a keynote,

Bozher (phonetic) gave a keynote, and we went away from

that meeting with the feeling,  at last places like the

Providence Rhode Island Department of Public Health is

talking to people in Connecticut about how they can work

together on problems,  and terrorism wasn't even a big

thought at the moment.   And it is dead.  It is totally


dead.

      And you call anybody who was part of the

planning committee or something, say, "When is the next

meeting?"  they want to know, "What meeting?"   And I


70

think we muffed a tremendous opportunity to bring

medicine and public health together, and to stress our

ways that we could cooperate.  And,  you know, somebody

asked me one time,  "If you could do something about

public health and medicine, what would it be?"

      And I gave an answer off the top of my head

which,  in retrospect, isn't too bad.  I said,  "The first

thing I would like the people in (inaudible) in medicine


to realize is that there are more doctors than medical


doctors,  and that they shouldn't look down their noses

at people who spend their years getting a doctor in

public health."

      And the person who asked me the question,

"Well, what about the other side?"

I said, "Ben," I said, "I think that the

contribution that medicine has to make to public health

in this regard is that we've got to teach all those

people with MPHs that the numbers the computers spew out

all the time are real honest-to-goodness people with

blood, who are hurting,  and they're hurting because of

poverty or they're hurting because of disease or they're

hurting because of both of them, or they're hurting


71

because our systems don't jibe right where public health

interfaces with medicine."   And I think it's one of the

biggest challenges that we have for the future, and one

of the great missed opportunities, that we can't pull

together medicine and public health in such a way that

we help each other instead of be detrimental to each


other.

          DR. KOOP:  Well,  I think the major thing

that's happened to medicine, I alluded to in reference

to pediatric surgery,  it's all part of the same big ball

of wax,  and that is the gradual evolution from a pure

profess ion to a profession that rel ies on businessmen to


make it  work.


         Take the American Medical  Association.   There

         INTERVIEWER:   The status of medicine.   Had

health care reform attempted, and you've described

eloquently your role in trying to make that happen, and

then as you indicated,  we had a market solution that was

brought upon us, managed care, which is still with us in

various morphed forms.

      What do you see as the lot of medicine today,


and where is it headed?


72

was a day when the infrastructure of the AMA -- that is,

the people who worked out in Chicago in the AMA building

-- were retired physicians or sometimes impaired

physicians who couldn't do the job they did before. As

those men have died and retired,  they have been replaced

by MBAs.  They're not health-oriented, they're not

medicine-oriented;  they're business-oriented.   And that

is to the detriment of our profession.

      And the second thing that I find has changed

tremendously is the doctor/patient relationship.   And

that is, to me,  the most precious thing about the

practice of medicine.  Medicine's appeal is not its

independence financially or its ability to be your own

man and your own boss,  it's the fact that you

interdigitate or you cooperate with the public at the

interface between the patient and the doctor.   And the

thing that has changed that has been the things that

came in with managed care, and have stayed.   Even when

managed care seems to have disappeared, the bad things

about it stayed behind,  such as 14 minutes per patient

and that sort of stuff.

I ran a program with the help of John a couple


73

of years ago, called "Take Time to Talk."   And I went

around the country talking to doctors and to patients

about taking time to talk with each other, and about

what the benefits would be to both the profession and

.

       Secondly,  we are reaching this crisis in the

doctor/patient relationship just at a time when I would

have predicted just the opposite, with the use of the

Internet to provide information for patients, we have

the opportunity to have a much more knowledgeable set of

patients than their parents were.  And everybody knows,

I think,  that a physician loves to talk to an

intelligent patient,  and the opportunity now exists to

be able to,  instead of meeting a patient and starting

with a kindergarten and work him on up to college, he

can ask you to do that the night before.   Suppose

somebody calls up and says, "I'm having pain in my

chest, DOC,  and I get it mostly when I'm tense or trying

to be active at the same time, and I think I have an

angina."

       Well,  the doctor doesn't say, "Well, come on

in and I'll talk to you about it."  He says,  "I'll see


74

tomorrow morning, but before you come I want you to look

upon the Internet the following.  I want you to know

what angina is,  I want you to know what GERD is, I want

you to know the difference between those two, and when

we get here together,  instead of taking 20 minutes to

get to the point we are when you walk in the door

tomorrow we'll have it all behind us.   And I can talk

about angiograms,  you know what I'm talking about."

      And that is not working as well as I thought

it would.

      The other thing that I think is a tremendous

boon, and that is doctors and patients using e-mail for

types of communication.  We do it very well in this

institution because we were the first school in America

where everybody had to have a computer, and we had

something called "blitzmail."  And people don't use

telephones in this town.  They just don't use them.

They use fax machines.  They use e-mail.   Three kids

will occupy a room in a dormitory, they don't know each

other very well but they know each other best by e-mail,

in spite of the fact that they can reach out and touch

the guy they sent an e-mail.


75

       But the intimacy that has been lost between

doctor and patient can be partially regained by the

Internet,  and it can be an additional boon to a patient.


Mrs.  McCarthy comes in and has her time with the doctor

and it turns out to be 11 minutes and she's out in the

parking lot before she knows it, and she gets home and

says,  "I never asked him about so and so."


        So she sends him an e-mail.   And instead of

playing telephone tag for three days, he answers her,

but he has the opportunity, with no effort at all, to

lift her spirits and put her on a whole different level

of healing, by saying, "By the way,  I should have told


YOU,  I never saw you look better."  And it regains some

of that intimacy that even doctors say, "I've lost with

my patients."

      And one of the things that I look back on,

I've been in medicine now since 1934. I've been having

something to do with medical students          1934,


and what do I look back on now and see that we've lost?


We've lost role models.  Used to be that people my age


were not uncommon in medical schools.  They didn't want

to give up,  and they had an awful lot to tell students,



76

and a students had a lot to learn by just watching what

they did and the way they thought.  It's not so popular


any more.   And I think that if medicine continues on the

path that it seems to be taking about being a business,

we are heading ourselves into a future that I don't

think we're going to like as well as we liked the past.

       Do you remember when Mr. Clinton campaigned,

he was talking about 34 million people who were


uninsured or under-insured.  When he was talking about

his health care reform, as president, that had gone up


to 43 million.  And it's someplace above that now. I

think there's a day ahead of us when the critical mass

of people who are uninsured will be so heavy that they

can't stand it,  nor can we who are insured stand by and

see them deprived.  And I think when that day comes,

there will be a real sea change in the way we practice

medicine in this country, and that's when I see us

moving into a single-payer system that we will do at a

time when every other country that's used it has weighed

it in the balances and found it wanting.   It's kind of

the wrong time to go.   But I think it is almost


inevitable,  and it will happen because people say,


77

"Well, we've tried everything else."

       We really haven't tried anything else.   Both

the Democrats and the Republicans, ever since

Mr.  Clinton's health care plan failed, are afraid to

talk about a big plan.  If you look back on the history

since 1993,  there are no big plans that are discussed

about medicine and health,  and yet the problems are

bigger than they ever were before.   Talk about this

little thing down here,  we'll fix that and nobody will

notice it and they won't get mad at us, and then we'll

fix this little thing over here.  Well,  by the time you

fix the third thing,  the first one's broken down again,

and you know,  you're going around in a circle.

      And I think that there is a way out of our

troubles that nobody has ever tried and nobody talks

about,  and that is to have the care of patients managed

in a public/private partnership.  I think public/private

partnerships have a great advantage of a private sector

keeping down fraud, waste and abuse, and the public

sector being able,  by regulation and legislation, to set

the parameters within which they think medicine ought to


function.   But,  there's one thing missing.   And I think


78

that we could take a page from the book of the

economists and we need, in medicine, what the economists

have in the way of the Federal Reserve Board.   And --


          INTERVIEWER:  Let me just flip the tape over.

       (End Tape 2, Side A)

         INTERVIEWER:  Tape 2, Side 2.   The Federal


Reserve Board.

         DR. KOOP:  I think it's possible to have a

medical board that sits between the government and the

public/private partnership, that takes care of the


health of America.  And I am sure that there are enough

men left in medicine who don't have overpowering

financial connections to some clinic or some legal

enterprise,  I think there are enough people who are not

seeking personal aggrandizement, I think there are

enough people who are not trying to squeeze the last

dime out of medicine,  who would welcome the opportunity

to act in an advisory capacity, just like the Federal


Reserve Board does.  It has an understanding of

economics and that's why it can make its decisions.

This board would have an understanding of medicine,

where it's been,  where it could go, and can guide its


79

direction that way,  and can respond to the things that

happen in medicine that bother people.

        I mean,  if you talk to the average patient

today,  he doesn't have much to say about what a

wonderful experience he had.  It's all the problems he


had.  And when I talk to a stranger about my medical

problems, they say, "Wow!  If that's happening to you,

what do you think is happening to me?"   And it's a

really serious question to ask.

      And I think we need that kind of thinking and


not -- it seems to me that we're stymied in sort of a

quagmire of lack of innovative creativity as far as what


medicine could be.  If we look at the things that made

medicine great,  and we had a board and a private/public

partnership that tried to guarantee that those things

were sacred and sacrosanct,  and would never vary for

future generations of patients, I think we could restore


medicine to what it once was.

       One of the things that is of greatest concern

to me is that when I was a young man, no matter whether

it was in a Reader's Digest or Vanity Fair or Fortune

magazine,  any poll put the medical profession at the


80

very top of everyone's list for respect and awe.   Now


we're number 17.  And we should have nipped that in the

bud when we got to be number two and three.   But it's

pretty hard to come back from 17.

       But the pride that an individual has that he

is responsible for the way his profession is accepted, I

think is gone.  And when I talk about doing something in

medicine now,  with a medical reserve board and

public/private partnership,  then I think I could go back

and I would think about the medical student who hasn't

yet become a medical student.  But he is up to his neck,

trying to find a way to get in medical school.   He wants

this more than anything else in the world, and so he

spends four years in college worrying about that and

preparing himself intellectually to be that.  But nobody

in our profession says, "Welcome to the guild.   Let me

tell you some of the things you're going to love about


medicine."

      We could build into college students who are

heading for medical school a loyalty to the profession,

a disgust with people who abuse the profession, and we

could turn it around to be what it was in the days of


81

our parents,  when they really had tremendous respect for

doctors,  and doctors in turn respected them.   We don't


have that now.

         INTERVIEWER:   The amount of malaise and

complaint that you hear within the profession today is

quite profound.   I mean,  for a long time I wrote it off

as disgruntled people getting more press than others,

but the more I travel and talk, the more folks I hear

are unhappy.  And I'm sure you hear the same thing.

       Is this failed expectations?  Is this greed

not being satisfied?  Or is this that the ground really

has shifted,  and people who went in with reasonable and

noble expectations have been poorly dealt with by the

profession.  What do you think is going on?


         DR. KOOP:  Well,  I think the first thing

that's wrong is that a young person that goes into

medicine doesn't feel that the day he steps over the

line and joins the guild,  and he has responsibilities to

that profession and to himself and to his patients, and

there's a code of ethics and there's a code of behavior.

Doesn't realize that any more,  and that we have to get


back to.  I've already covered what I think the


82

governance should be in the way of a medical board and a

public/private partnership.

And then I think we have to work on the

individual and his profession, and you can't get into

medicine very far without doing something about

malpractice.  And I mean,  the things that have happened

in the practice of medicine,  I mean,  they should have

been nipped in the bud in the beginning.   I mean, how

can a physician do his bet for a patient if, on the

first occasion when he sees that patient, his patient

brings a lawyer with him,  to be sure that everything is

done in such a way that they can s.ue at the right time

if it doesn't go right.

      And there is a way -- I practiced medicine --

actually practiced medicine after all my training was

finished,  from 1945 until 1981.   And I had all kinds of

problems.  I was in a brand-new specialty, and I did

things that nobody ever did before.  And I never got


sued.   Now,  why didn't I get sued?   Because I made the

patients'  parents allies with me against the problem

their child had,  and we fought it out together.   But

that takes an effort,  and it takes an understanding of


83

what makes people unhappy about their doctors.   But it's

a teachable thing.   I mean,  you can't teach some

virtues,  but you can teach the practicality of getting

on the right side of your patient so he doesn't sue you

when things go wrong.

         INTERVIEWER:  Is the changing demographics --


more women,  and the changing environment, where

professions in America perhaps are not what they once

were,  that leisure time has become a more important

phenomenon,  is that impacting the profession?


         DR. KOOP:  Yeah,  I think it is.   When I was


young,  we were looking for training jobs, we wanted to

know what their autopsy record is.  Now what people want

to know is how many nights you have off.   And how much


money you get paid,  and so forth and so on.   And so


there has been a shift in that.  Some of those things

are inevitable over the passage of time and the growth

in the complexity of the profession.

But I think we have to be more frank about our

problems,  and we have to address them as problems and


find solutions to them.  If some large international

corporation, like Sony,  were having relationship


84

problems between the people who worked for Sony and the

people who bought Sony products,  they would either have

to fix it or they'd be out of business.  And we've got

to take that attitude,  and that's why I say you have to

start in college,  you even could start in high school.

       You know,  if you study the guild system in

Britain, didn't matter whether you were a chimney sweep

or a butcher or you were a doorman, you were proud to be

that, and you wore a uniform that showed that you were,

and you knew what was expected of you and you knew what

was a line you didn't step over.  We don't raise people

to feel that way any more.

         INTERVIEWER:   Your theme about business and

medicine, theme since it impacts many of your diagnoses,

is there a way back from this?  I mean,  once upon a time

there was a belief that medicine was a profession

relatively untainted by business concerns.   You didn't

advertise,  for instance.  You allegedly saw the poor and

charged them what they could pay, or didn't charge.   You

taught for free or little recompense.   And those

traditions have largely fallen by the wayside.   And

business has roared into medicine.


85

       Is there a way back out of that?


         DR. KOOP:  There's not an easy way, and

there's not a quick way, I don't believe, out of that.

But it's going to take a generation to change it, but I

think that well-meaning in planning that generation and

keeping tabs on the way it works can bring it about.

But you know,  the attention span of people is very


short.  And to tell the people who are critical of

medicine,  "We can change it,  but it won't be until this

college student has gotten to the age of 40, when he's

practicing medicine,  and he's only 16 now," well, that's

a long time to wait.

      But I think if you don't change it, you're

going to lose it all.

         INTERVIEWER:   I mean,  I do see the ground

shifting in ways that it's hard to imagine it shifting

back, not only in medicine but around medicine.   I mean,

the first person whose story I tell in "Big Doctoring,"

which you probably heard,  I think I read a quote from

him,  Eugene McGregor,  who practices up here in a little

town -- or Lebanon, "All is life," was sort of the

classic old-model GP,  and he referred to younger doctors


86

who came and had practice and moved, as "gypsy doctors."

"We were gypsy doctors in my day."  Of course, he

practiced in one place for 40 years.   But it's kind of a

gypsy society,  at least compared to the rather more

staid society.  And I find it hard to envision, I mean,

the values that you describe make a lot of sense to me,

appeal to me,  but I don't see how teachable that is, I

guess is the question I'm asking.   I mean,  you can teach

a higher level of awareness, but the society is a

different society.

         DR. KOOP:  Well,  you can't teach a society not


to be mobile.  But you can teach a doctor, who is taking

care of a member of that mobile society, how to approach

the patient on a new arrangement.  Guy used to live in

Des Moines, Iowa,  his business changed and how he lives

in Brooklyn, New York,  and the culture is different and

the climate's different and the pay is different and

everything is different,  but here's a doctor who still

feels the same way toward him.   I think that's doable.


         INTERVIEWER:  And I must say, I see in young

people in medicine,  and clinically I work with medical

students and pediatric residents, there is an awful lot


87

of idealism in those folks, to be cultivated, cultured,


nurtured.  I mean, that's, to me, the most sustaining

thing,  the people who go into it are good people.


         DR. KOOP:  You're absolutely right.  The thing

that impresses me most about medical students today is

that you never hear them talk,  as you used to hear them

talk, about the accumulation of wealth.  They are not

ashamed to say,  "I'm going back to Bridgeport to

practice because that's where I was born and that's

where they need me."

      And the thing that proves to me that they mean

what they say is that the average student that comes to

this medical school has had two years minimum between

the time he left college and the time he went to medical


school.  And in that period of time, he has almost

always spent that time doing some beneficial service to

society.  And it's because he wanted to, not because he

wanted it on his resume so it would get him into medical


school.

         INTERVIEWER:  Tell me more about your view now

of specialism and generalism.   We talked about

specialism in surgery.  And I know the Koop Institute


88

has been a pusher of primary care ideas over time.   How

have you seen that play out,  and where do you see it

going in medicine,  in the division of labor.


         DR. KOOP:  Well, when I came to Dartmouth,

29 percent of medical practitioners were in primary



care.  And that got up almost to 45 or something --


         INTERVIEWER:  When you came to Dartmouth this


time around?

         DR. KOOP:   Yeah.   When I was 72.


         INTERVIEWER:   That would have been '94?   '5?


         DR. KOOP:  I'm 87 now,  you can figure it out.


         INTERVIEWER:  Well, when you left --


         DR. KOOP:  It was two years after I left the

government,  which was in '89.


         INTERVIEWER:  So 29 percent then.  And as high


as 49?

         DR. KOOP:  Got as high as about 45 percent in

some parts of the country,  and now it's drifting back

again because the same things that led people away from

primary care are at work in the whole business of


medicine.  The pay isn't as good, hours are worse, the

leisure time doesn't exist, and there is still, on the


89

part of specialists,  an unreasonable failure to

understand the real contribution of the primary care

doctor,  who has to know a little bit about such a huge


amount of stuff.  And there's nothing that makes me

madder than to see a professor of medicine humiliate a

medical student on grand rounds, because he says, "What

do you expect to do with your life?"

       He says,  "I'm going to join my father in the

family practice."

       It's as though he committed a sin and went

into prostitution.

         INTERVIEWER:  That does happen.


         DR. KOOP:   Yeah.  And,  you know, I am

surprised at the way it's happened.  I'm surprised that

-- I'm not surprised at the change in gender.   I think

women are kinder, gentler people, and I think they're

good for medicine.  And I think there's no reason why

they can't do specialties that people used to think were

only for men.  Surgery, for one.  A lot of very good

female surgeons around.

But I do see the pull in every way --

economics,  leisure time, prestige, importance, self-


90

esteem -- that goes with specialization, as compared to

primary care.  And the primary care doctor has to have

his feet on the ground.   He has to know himself well

enough to know that he's making a contribution that a

specialist can never make to medicine.   And he has to

know that that's what brings him satisfaction and not

envy.

         INTERVIEWER:   One scenario for the future is

that medicine will become increasingly the domain of

specialism.   And that nurses and others will inhabit the

realm of primary care as, to some extent, they've done

already.  Is that a plausible outcome or a plausible

possibility?  And if so,  would that be good or bad?


         DR. KOOP:  Well, with the caveat that all

people aren't the same,  I think that it makes good sense

to share the burden of primary care with people who can

handle certain things,  but I think it is a mistake to

say that because a nurse has taken two years of training

to be a nurse-practitioner, that that makes her

equivalent to a primary care doctor.   And I think that

is a tendency that you hear criticized by primary care

physicians,  and it's a tendency that nurse-practitioners


91

aid and abet by believing it.

         INTERVIEWER:  My concern is that if medicine

does not take a firm stand for primary care, beyond the


rhetoric -- that is,  structuring payment so there's some

pay equity,  structuring values so that primary care is

valued and supported in terms of research, in terms of

training,  we will have a profession that, because of the

inevitable lure of technology and money, will become

largely balkanized into specialties, with no base.

         DR. KOOP:  Right.


         INTERVIEWER:   And I think the nurses and

others will -- because primary care is necessary.

Society says it needs it.  Others will migrate in and

populate it,  but medicine will essentially have become

a domain of specialists,  which to me would be a great


loss.  But I think is a possible outcome.   I mean,

that's the doomsday outcome, from my perspective.  Hope


not.

       DR. KOOP: No,  I've spent a lot of my time in

the U.K.,  watching that  system work,  and there isn't

the same split that there is -- they have more primary


care doctors.  And they have fewer specialists.  They


92

should go together,  but they don't always.   And I think

that the differences in income are not as exaggerated as

they are in this country.

      And one of the things, while we're on that

subject, might be settled by having the federal medical

board that I was talking about a bit ago, but what's

disturbing to me is that the knowledge that a primary

care physician has is not appreciated and is not

compensated, but if he has a gadget that he can use on a

patient, he does a technical procedure, and he suddenly

can become a quote, "specialist," by buying the gadget.

      And I think that there are some other things

in medicine that we have talked about that are affecting


the future.  One of them is something that nobody talks

about much -- I do, all the time -- and that is the

great advances in medicine and surgery have made a lot

of acute diseases chronic.   We can't afford that. We

can't afford it as a society, and we can't afford it

financially.

      One of the other things that bothers me is if

you were to ask the question to a totally honest

audience,  unable to give you a false answer, why has it


93

taken us so long to do some of the things that we do?

For example,  as the treatment of the cancer program

becomes such big business that there are forces at work

that don't want to see cancer moved toward cure because

that would change the balance of economic power.  Very

difficult questions to ask, and even more difficult

questions to answer.

         INTERVIEWER:   I mean,  I've heard those charges

often from what I'll call the "Rodale Community." I

mean,  the kind of health food fringe.


         DR. KOOP:  Oh, yes.


         INTERVIEWER:   That --          cancer, but

about other -- about disease in general.  Do you think

there's credibility at all that there are physicians or

clinicians or clinical specialties that don't want to

see progress because it would be bad for business?

         DR. KOOP:   I think the more that our

profession becomes a business,  the more you'll see that

sort of thing.

      There was a certain purity that

professionalism delivered to medicine, and when it is

contaminated by greed. . . .  The average guy that went


94

into medicine,  even now,  he does it for entirely

different reasons than the average guy that goes into

business.  Has to make money, to be sure.   But that's


not the end-all and be-all.   And that is one of the

things that I most enthusiastic about in the future, is

that the medical student of today seems to have lost

that greedy outlook for the future that his predecessors

had 25 years ago.

         INTERVIEWER:  Speaking of idealism, global


health.  Where do you see the role for the United States

in global health?  Where have we been?   Where are we

going?  Is it something we have done well with or not?


         DR. KOOP:  Well,  global anything is kind of

frightening.

      When you treat a problem globally -- let me

start it a different way.

      The only thing that I am absolutely certain

that we have globalized is the spread of disease. We

have really done that very well.


         INTERVIEWER:   "We, " United States, or --

       DR. KOOP: We, all of us, because of

transportation, communication, and reliance on quick


95

treatments,  quick fixes,  rather than prevention. So

that that's a fact of life, I think, today.   And if we

have globalized disease, we certainly have the

obligation to globalize health.

      And it seems to me that there was always a

huge barrier to the globalization of health, and that

was it would take so long and so much money to build the

infrastructure in,  say,  a developing country, that you

might lose sight of your goals before you ever achieved


them.  But two things have happened that have changed

that.

      One is the invention of the cell phone, and

the other is the Internet.

      And with the Internet and the cell phone, you

don't have to build that infrastructure any more

Because instead of having to go through all the stuff

that's down here that used to be called infrastructure,

now you can go from here to here, and here to there.

And therefore I have real hope for globalization, if it

doesn't destroy the little man in the process.   What I

mean by that is,  if you globalize everything, then

you're going to have Wal-Marts and K-Marts instead of


96

individual shopkeepers.  And I don't know how you're

going to manage the economic side of the change to

globalization if you deprive people of their livelihood.

So I think that that's something that has to be an

economic arm that has to be discussed whenever any of

these things are talked about that are global.

      I think that one of the things that I always

wanted to do when I was Surgeon General, was to have an

international health corps,  the way we had a national

health corps,  because I didn't mean to have people

leaving these shores and going and doing hands-on care

in underdeveloped countries, but I saw a corps of

capable trained people transmitting the know-how to

other people,  so that they could do it on their own.

And I think that's the real challenge of globalization

of health care,  is that you don't just import the

treatment but you import the understanding so that they

can develop their own system.

      And I think that's all the more important when

you try to recognize the cultural differences that we

have -- we have them in this country and we don't


          them.  It's a totally different cultural


97

challenge to talk against smoking in Utah and

California,  than it is in Kentucky or Virginia.  Totally


different.  We have the same people, we speak the same

language,  but it's totally different.   It's increased in

complexity when you're talking about a sub-Saharan

African country and something that's attached to India.

And that is going to be the hardest thing, I think, to

learn because you can't treat different cultures with

the same,  as I said,  the accoutrements of medicine. It

takes more than just the pill.

         INTERVIEWER:  Any likelihood of an

international health corps, or -- one more question.

Outside of the missionary community, it's argued, and

perhaps outside of the CDC with some of its targeted

efforts,  we haven't done a lot to promote, certainly at

a government level,  large numbers of teachers,

clinicians,  going abroad.  Any prospects that we'll be

doing that?

         DR. KOOP:   I think there are theoretical

reasons why it should work now better than any time that

I've been alive,  because you have more disgruntled

physicians leaving medicine because of the things we've


98

been talking about, than ever before.

         INTERVIEWER:  Who might be recruitable?


         DR. KOOP:  They're recruitable.  And you know,

the thing that I have seen,  you take somebody who's

never been off on an altruistic mission to help somebody

in another country,  the first time he does it it's like


a new world to him.  He just can't believe how great it


is.  And they go back.

       (Interruption)

      If you think about how the Peace Corps came

about,  that didn't take a lot.  It took one man talking

about it,  it took another man writing about it --

Kennedy,  Sargeant Shriver,  and it took a lot of people

who,  once they went,  they became the advertisers.   And I

think there's so much to be learned, so much to bring

satisfaction with some kind of a thing like an

international health service corps, that it would be

worth some major foundation really attempting to try it.

         INTERVIEWER:   Yeah.  Switching gears.   I want

to get at least something on the record about the


National Health Museum.  I know it's something you've

been involved with for a number of years, been one of


99

the leaders and thinkers about it.   What would the role

of a National Health Museum be in American life?

         DR. KOOP:  Well, what a National Health Museum

should not be is just a curio shop.   There is a real

place in education to have some illustrations from the

past about how things were successfully or

unsuccessfully managed,  but the challenge of a so-called

museum today is that it becomes a health education

center primarily to inspire the new generation about

what is possible to be accomplished.

      My reason in the beginning for being

interested in a museum in Washington that had to do with

health, was that I used to stand in my office up on the

top floor of the Humphrey Building and see all these

kids standing by one of the reflecting pools, getting

their pictures taken,  when they came on their senior

trip to Washington,  and I kept thinking about the

wonderful opportunities that they had, and then it

occurred to me that they could be stimulated to be

almost anything in the world by what they saw in

Washington,  except something in medicine and health.

Because there's no place to see it.


100

      And I think that still should be the major

educational effort to get young people to commit early

to a life of health and medicine and science that leads

to the betterment of the human condition, but there are

so many things that you can tack on to that to make it

interesting,  that I think it's a great idea.


         INTERVIEWER:   Good.   The Bushes.   We talked a

little bit about George Herbert Walker and a kind of

transition,  but you've seen the Bushes as presidents and

worked to some extent with them and their people.  Any


                                        lth

thoughts about either or bo

th, and their hea

policies?

DR. KOOP:   I don't think -- as far

as I know,

there's only one person in health that has the ear of

the president.  I don't think one person is enough.


         INTERVIEWER:  This being the current

president?  George W.


         DR. KOOP:   Yeah.  And that person is Tony

Boucher(?).  And great respect for Tony Boucher in many


ways,  but I think one person can't do it.

      The thing that I see different about this

administration from the other three that I was


101

associated with is that it is hard to get an answer to a

health question in the White House.   And I don't think

that this administration really thinks it needs any

guidance in the health field.   And I think that that's


wrong,  because nobody can guide in health except

somebody who is trained in health.

       And off the record,  this is a pretty hard

group to infiltrate.  Just twixt thee and me, I sat with

Barbara Bush for eight hours one day, and I filled her

in on a lot of things that I wanted her son to know.

And I said,  "I've met him socially and I've met him when

he was governor,  but I would like to talk to him about

his presidency because, one, I know where there are a

lot of minefields that he shouldn't step on, but also I

know that there are opportunities for him to make an

absolutely lasting contribution to the health of this


nation.   And I'd like to be able to talk to him about


it."

       She wrote it all down and she said, "Chick, I

will see that he gets this the first time I see him."

      And I know Barbara well enough to know that

she did,  but I never have been to see him.


102

        And I think the war on terrorism has taken a

lot of attention, but I think if there weren't a war on

terrorism,  it would still be about the same because I

don't think they have the capacity to understand what we


need to do.

         INTERVIEWER:  Being a senior statesman is a

role you played well.  Personally and business-wise, I

know it's been a tough role. Dr. Koop dot corn, in

particular.  If you were coming out of the surgeon

generalship into your senior statesman role on the

personal side, would you -- business side, would you

have done it differently?

         DR. KOOP:  With the hindsight I have --


         INTERVIEWER:  Time Life Books, too, I guess.


         DR. KOOP:  Something that is not known by the

public and I don't mind if they do know it, I think the

Time Life venture is one of the best things I ever did,

and I think that what remains and hasn't become

antiquated by the passage of time is still state-of-the-

art.

The reason that that company went bankrupt had

nothing to do with that company.   It had to do with the


103

fact that my plans were a threat to the tobacco

industry, and they went to Time Life, Time-Warner, and

said if I were permitted to go the direction I was

going, that they would cease to advertise in People,

Time, Life,  Sports Illustrated.   We were in business at

4:00 o'clock,  and bankrupt at 4:20.

      So that was an engineered thing by the greed

of tobacco companies.  I think I got caught up in

something that a lot smarter businessmen than I got

caught up in,  and that is the dot.com craze --


         INTERVIEWER:  Yes,  on that,  the Time Life


Books, which was supporting the videotapes and the --

what was the whole enterprise called?

DR. KOOP:  Well, we called it Time Life, Inc.,

and we had the privilege to do that as a franchise.

         INTERVIEWER:  Right,  but the health

information video program, did it have a --


         DR. KOOP:  Yeah, well,  that was called --


         INTERVIEWER:  Did it have your name on it

       DR. KOOP: No,  it didn't have my name on


No.  Media Information --


         INTERVIEWER:  There was a program of

?

it.


104

informational materials,  videotapes in particular --


         DR. KOOP:  There were 34 videotapes.   That was


Time --

         INTERVIEWER:   State-of-the-art commentaries on

different diseases for the layman.


          DR. KOOP:  Right.


         INTERVIEWER:  And the legs were cut out from

under it financially because the company went bankrupt?


         DR. KOOP:  They refused  -- Time and Life took

their franchise away from us because they were

threatened with no advertising by tobacco industry.


         INTERVIEWER:  Is that something you're willing


to --  if I include that in the new --


         DR. KOOP:  I've said it publicly before.


         INTERVIEWER:  Okay, good.  And drkoop.com.?


          DR. KOOP:  drkoop.com, we -- you know, the

first year we got every prize that you could get in the

world of the Internet for what we did with that thing.

We really kept the data up-to-date, so forth and so on.

But competition was just too tough.   There were too

many people in the business,  and I don't want to say

this,  but I'll tell you,  one of our competitors was


105

Med -

         INTERVIEWER:  MedScape?  Web,  M.D.?


         DR. KOOP:  Web, M.D.  And you know how they're


financed?  Any time they need any money, they just call

Bill Gates and he gives it to them.  Can't fight that.

And Web, M.D.,  has not been for the benefit of the

public since that time.   It's for the benefit of the

doctors saving money by having electronic ways of

handling their business.

       (Recording interruption)


         INTERVIEWER:  We were talking of drkoop.com.

Anything else -- I mean,  I know it was an awful episode

for you,  to sort of take the thing public and have as

much attention to it,  and then have it fail.


         DR. KOOP:   Yeah.


         INTERVIEWER:   Is that --


         DR. KOOP:  It was a very disappointing thing,

and fortunately I had lots of other interests, and so it

-- I seldom think about it now.   I'm not sure that if I

did it again and that I could weather the storm any


better.  Because it was just -- just thousands of health


sites failed.


106

         INTERVIEWER:   Yeah.   I mean,  certainly, with

your interest in communication and the explosion of the

Internet, the two seemed destined to work together, and

that they came together and then it didn't work is just

-- I mean,  a disappointment to you, a disappointment to



me.

        HIV and the world.  A problem.   You were there


when it started.  Where do you see it today?


          DR. KOOP:  Oh, HIV and the world is a


disaster.  There are countries with 38 to 40 percent HIV

positivity,  in sub-Saharan Africa.  The people that I

talk to who know what's going on in China say that the

future there is grim,  because there has been such a

population shift from central China to coastal China,

which is where the business opportunities are today,

that by being introduced in coastal China also

introduces a naYve population to the sexually oriented

population, and there is very little understanding about

the transmission of the disease by these country folks

who come in to town.  And so public health people in

China are looking forward to a disaster they don't know


how to handle.


107

      I think that the obligation of the United

States in all global health problems is to share our

knowledge and to share our know-how and, where possible,

to put in seed money,  and I think that the fact that


Mr.  Bush has included that in his plans is very good. I

think it's a good sign that some of the pharmaceutical

houses have changed their pricing structure for places


like Africa.  But when a country like South Africa still

refuses to believe that HIV is the cause of AIDS, we

have a very serious problem.

      And we do know, by the way Uganda has changed

its educational program and has changed its culture, to

some degree,  that AIDS is not an insurmountable problem


even in a culture like that.   So I think that it needs

organization,  there ought to be some kind of African-


Asian consortium that worries about this.

       Compared to the United States, the rest of the

world is in terrible shape.  The United States, because

it's an affluent country and because we know about

giving AZT to pregnant women and because we know about

fancy therapeutic cocktails,  it's possible now to be

diagnosed with AIDS and to live out your life expectancy


                                                  108




and die of something else.   But that's at the cost of

$20,000.00  a year per person.


         INTERVIEWER:  A final question.  As you look

back on your career, thoughts about it?


         DR. KOOP:  I've had a very,  very interesting

life, and I really feel that I was born at a good time,

because I lived through what I think is the golden age

of surgery,  tremendous technical advances, but in the

midst of it was very much a part of the development of

pediatric surgery,  which was a special privilege.

      My time as Surgeon General was one of the

happiest and I think most productive times of my life.

And the fact that I'm 87 and still active and still

lecturing and still teaching here, is -- it's enough to

raise your eyebrows.

       (Laughter)


         INTERVIEWER:  That's a good place to end.


         DR. KOOP:   Good.

       (End of proceedings as recorded.)