The Surgeon General Dr. C. Everett Koop A conversation with the doctor about smoking on the job, taking better care of yourself and the changing health care industry by George Ewing G Od'S law and "health facts" keep the Surgeon General of the1 Jnited States on a clear and optimistic course as the na- tion's highest medical officer. An evangelical Christian, outspoken anti-abortionist and author of the call for "a smokeless society by the year 2000," Charles Everett Koop, M.D., Sc.D. was nominated for the post by President Reagan "for the most cynical reasons.. .not for his medical accomplishments, but his political compatability," opined a 1981 Nav York 75~s editorial. Opposition later included the 114-year old American Public Health Association, which had never before objected to a presi- dent's choice to fill the public health post. Confirmed in 1981 on the strength of his medical accom- plishments, Dr. Koop appears to have lived up to his promise not to use the office as a pulpit from which to sell ideology. "I'm not allowed to lobby," he explains, wryly. "Aside from a number of specific tasks mandated by public law," he continues, "my position is one of educator, overseer and public com- municator. I preach the virtues of health promotion and disease pm- vention as a philosophy to whomever I can reach: be it chil- dren, the elderly, the handicapped, or others. "Meanwhile, Congress works on problems, such as prospective pay- ments and putting caps on expendi- tures of Medicaid and Medicare, while regulatory agencies, such as the Health Cam Financing Admin- istration, establish systems such as DRGs (Diagnostically Related Groups) to cut down the costs of medical care." Dr. Koop is the nation's first full- time surgeon general since 1972, when responsibilities for the post were assumed by the assistant sec- retary of health. He is one of the country's most distinguished Chris- tian writers and author of two pow- erful books that discuss abortion, euthanasia and mercy-killing (`"The Right To Live, The Right To Die" [Living Books, 1976) and, with Francis A. Schaeffer, "Whatever Happened To The Human Race" [Crossway Books, 19791). Born in 1916, C. Everett Koop grew up in the Flatbush section of Brooklyn, New York. As an adoles- cent he "learned what it feels like to be a patient.*' A fractured cervi- cal vertebra sustained during a ski- ing accident and a brain hem- morhage during a football scrim- mage kept him bedridden for more than a year An excellent student, he entered Dartmouth in 1933 at the age of 16 and earned a B.A. degree. From there, he went on to Cornell Medi- cal College, graduating with an M.D. in 1941 and began his in- ternship at Pennsylvania Hospital. It was there that he became in- terested in the field of pediatrics, to which he would devote the rest of his career. After graduate training at the University of Pennsylvania School of Medicine and Boston's Chil- dren's Hospital, Dr. Koop was awarded a doctor of science degree from the Gmduate School of Medicine of the University of Pennsylvania id- 1947. sub- sequently, he was appointed sur- geon-in-chief of Children's Hospi- tal in Philadelphia in 1948 - be- coming one of very few physicians who specialized in pediatric surgery. 14 C~~FORATE MONTHLY JANUARY 1986 In February 1982. the Surgeon General made his controversial call for a smokeless society by the year 2000, calling the risks associated with smoking "the most important public health issue of our time." He pressed for legislation strengthening cigarette warning labels-an effort that was successful with last year's addition of three new labels (for a total of four) that: warn women smokers of potential complications during pregnancy; point out ties be- tween smoking and a variety of can- cers: and state that cigarette smoke contains carbon monoxide (see box). "Smoking is bad for everybody," Dr. Koop says. "While it is true that some people smoke all their lives and live a long life, you never know that until they have lived a long life [Ed- italics are speakers emphasis]. They might fool you, though. and die at the age of 45 of a coronary," he points out. "The 1985 Surgeon General's Re- port to Congress, which I presented last month, focused on the question of smoking at the work site. There are some fascinating things that are now becoming well known: smokers are more expensive as employees The Surgeon General Has Determined.. . "A person who is going to quit smoking must have, first of all. a self-rewarding goal. He has to be- lieve that going through the effort to quit an addictive drug. nice tine, is going to be worth it. "Once you've decided to quit, the most effective way to do so is the best way for you. Most people find that quitting `cold turkey' is best. In addition, having another person in on the effort is very helpful. Trying to quit while your husband. wife, father or friend still smokes is tough. There are also things like group therapy. hypnosis, classes, counseling. and nicotine chewing gum: if it works, do it. "Having your doctor in on the effort is even better. He's going to say. `look, if you don't stop, you may die!' 73ar.s an incentive." tf P, smoke-free. ian non-smokers. It behooves com- anies to make their work sites "Some haven't gone that far and only restrict smoking to certain areas. When a company makes their work site smoke-free, though, it has at least three advantages: first, the cost of health insurance drops; sec- ond, fire insurance rates drop; and three, the cost of maintenance (of a company's work site) goes down." Citing an example, he explains, "In Seattle, a company that had their maintenance done on contract went smoke-free. After three months. the contractor came to the management and said, `we're cutting your costs by 25 percent. Since nobody smokes here, we can do the job in 75 percent of the time'." He lists some of the other findings in the 1985 report. ticking them off on his fingers. "A smoker at the work site has twice the rate of mortality during his working years as a non- smoker, so he's a pension problem. He uses 50 percent more hospital days as a non-smoker. "A smoker has mote absenteeism; he spends 8 percent of his time finding a cigarette, ashtray, lighter. etc; and he has three out of four (work-related) accidents. Everything (a smoker) does." he intones, "is a disaster to his employer." Sitting up suddenly, Dr. Koop asks, "What has been the reaction of unions to efforts on the part of man- agement to go smoke-free? The unions are espousing th came. "Everybody thought that they, would fight it, but, unions are bring- ing it up in their contract negotia- tions, saying, `if you go smoke-free. we know you will save on this. that. etc., and that means you'll have a bigger profit - therefore. we'd like some of that profit for employee be- nefits. ' "More and more corpomte groups are becoming aware of mo things: one. disease prevention and two. health promotion. No matter what else they do, when they cut donn they attack the number one health problem in the country. `Are you interested in doing some- thing about what we've been telling you since 1964?" he asks, referring to the original surgeon general's re- port linking health risks to cigarette smoking. Almost shrugging his shoulders, he answers his 0N.n ques- tion, "let's have a smoke-free socien by- the year 2000." To smokers who have heard the warnings, read the dangers and still light up, he adds, philosophically. CORFORATEMONTHLY JANARY 1986 IF "Liie is mom than just accumulating Surgeon General Reports on a shelf." He wants to see the infoxma- tion available put to use: harnessed by smokers to make appmpriate choices that take into account these `health facts. ' "A lot of corporations don't realize it yet, but we ate moving towards major change. In the first quarter of 1985, the National Center for Health Statistics points out, we fell below 30 percent of the population (who smoke) for the first time in history; down from 55 percent in 1964. `That's a tremendous change. Locai Unions And Smoking.. . Local unions have begun to ad- dress the issue of smoking in the wokplace. Pat Gillespie, busi- ness manager of the Building and Construction Ilades Council in Philadelphia (60,000 members) says unions are espousing the cause, but not for financial reasons, mther for the benefit of their membeds health. "I think most unions believe thestatisticsonsmok.ingandwe may very well include `smoke- fit& issues in our spring Cons talks." Wmdell W. Young, III, pmsi- dent of Philadelphia-based united Fbod and Commemial Workers (24,ooO members) says his or- ganization has actively supported segregated smoking and non- smoking for many years. "About four months ago," he says, "we started to look at smok- ing-related deaths and injuries. w will try to xecoup these losses, for the employee and the health Fund, thmugh litigation.*' `W is no question," Mr. Young concludes, "that smoking will have an impact on our (con- Tact) negotiations." "Smoking has become mom and more a bluecollar habit. Mom and mote white collar and professional workers have given up smoking. You are beginning to see stratification by class; economic concerns by employ- ers; and appreciation of those con- cerns by unions." He stmsses, "It's nor government policy to achieve a smoke-free soci- ety by the year 2tXl0, but it is do- able. Them! will never be a ban against smoking in this country, nor will there be so many local oldi- nances that the= is no smdcing all over the country. Eventually, though, people will not smoke in the pres- ence of those who don't." T tuning to what is to many people this country's most important public health concern since out- breaks of polio in the 1950s and measles in the 196Os, Dr. Koop is leading a campaign by the federal govemment to educate people about AIDS, acquired immune deficiency Syndrome. "`Up until the present time," he notes, "public education aboutAIDShasbeenhandledbythe Centers for Disease Control.*' The Surgeon General will appear in a number of public service mes- sages that explain the disease. In addition, a nationwide effort to dis- tribute free information in pamphlet form through neighborhood organi- rations and supermarkets has been put into place. Having identified enough about AlDS to draw pdminq conclu- sions and make specific mcommen- dations to the public-at-large, the federal government wants to stem the spmad of quasi-panic that has infected many communities. Large metmpolitan ateas seem more af- ,fected by hysteria, while smaller communities are less pemrbed and, ovemll, mono cautious in their ap pmach to AIDS-patient regulations. In a recent report on the prolifera- tion of AIDS-related legislation at all levels of government, The Phila- oWphi0 hquin~ cited four develop ments around the country that illus- trate various leactions. o ??????????? ???? ?????o????? ??? ????? ???o? ?o????o?? ??? peqle with AIDS whose work in- whes handling food. They are al- lowed to work asj&d handI& only under certain proscrith?d con& o ???????? ????? ??? ?o??o ?????? ???? ???* empowered to close homosexuole~~,suchas lx&houses. where the risk of spreading the tiease is high. `colim&bec~thejirststatei?l the nation to require &at names and odfresses of those jnurd to ha~AlDSbetumedo~rtosme he&h oJpciak o Cal~~mia Rep&-can, (US Repre- 16 CORPORATE MONTHLY JANUARY 1986 sentat&) William E. Danmmyer has intr&ed$ve bit% in Congress rhatwoukiresp&vely:makeita jknyjbr an individual- a high- risk group to &ma12 bk9od;prohibit anyonewishAiDSjknnworkingas a he& care proJmioml in bwitu- tions that receivef&raljiuu&; deny fun& to cities that do not close bad&owes fieque~ by homosex- uah; keep children with AIDSfiom atmdingpuMicsc~;andauow hedthcareww-kerstowearspecial protkxtiw cbhing aroundAlDSpa- tiem without inte*encefiom hos- Wm. One of the most poignant fears among those tmncend with civil liberties is that AIDS-related laws may stigmatize othelwise healthy people who have test umlts showing the plrsellce of the virus, when in fact many of these people do not have AIDS. On the other hand, raising the ecmlomic and social `penalties' for those with AIDS could effect the- nqorting of the disease - driving it undergmund. l%arful of being os- tracized or held without their con- sent, some AID!3 victims may sim- ply not teport their conditim to health officials or their doctor. Dr. Koop, although identified with conservative policies on the whole, does not believe the govem- ment should ttgulate AIDS policy. "The federal government should not impose regulations over the whole country, unless there is something that affects, for example, the (do nated) blood supply, and that's al- lleady been done. "`W know mole about AIDS than we do about whooping cough. But, we don't know the essential things: `How do we stop it?`, `How is it cud?`, and `How can it be pm- vented with a vaccine?"' Aside from what is known to date (see box), the Surgeon General couusels `lifestyle' changes. "If an individual wants to avoid getting AIDS, all they have to do is maintain sexual relations with one partner. that in itself dramatically limits expome. As long as the other parhler~~~..W~they~ in a pretty safe situation," he ex- plains. `That is a health fact" (see box). He continues, `As a health offi- cial, one has to be very canzful to state the facts. For example, while it can be said that a normally behaved student who is infected with AIDS is no risk to his or her classmates, we can say that (the victim's) class- mares are a risk to the student in- fected with AIDS." `An outbreak of chickenpox in a classroom with an AIDS infected student ," he stresses, leaning for- ward, "means that studeru might die. Too many people get confused be- tween what ate `health statements' and what I call, `sequels to health statements'. For example, some say, `I think every kid has a right to an education, therefore, he should go to school. ' That's not a health state- ment." He cautions that decisions over the medical and social treat- ment of AIDS patients should be based on fact, not fear. T he health industry is propelled by economics, says the surgeon general, speaking of concerns over vast and sometimes troubling changes in medical treatment, their costs and payment. "Fit of all, it is clear we cannot afford the curative and repairative medicine and surgery that is so popular with the American people," he explains. "Instead, we have to turn to something that is not only better as a principle, but is affordable. That is - the prevention of disease. "Portunately, the prevention of disease is largely up to personal choice," he continues. "You and I can affect the way we smoke, drink, exercise, eat, and the kinds of stress we have. if we take care of these five things, and check our blood pressure, we've covered almost ev- erything ." According to Dr. Koop, the best community health care centers today act in the role that he does, as "dis- ease prevention and health promo tion educator; by teaching people to monitor their own lives. In many hospitals today, the walls are covered with educational material. That is the teal, grassroots response to what we are trying to do." Answering concerns that changes in medical care have tossed some to the mercy of a sometimes callous public health bureaucracy, he cau- tions, "There am a lot of rough edges that have to be smoothed out, and they will be, by either regulation or legislation. These policies have been in effect for only two years. To judge their consequences now would be premature." Will concerns be addressed? `The government is not immune to sug- AIDS is a serious conditio~`twowe& as eases. Investigations have discovered the vims that causes Ams. It b citlre&, by several names, but preiiminarv nzqlts show that infected v remainingoodheal~othersrnay develop illness varying iu severity from mild to extremely serious. Most individu& infect& wit& AIDShWem,syrnptomsanrifed well. !ibne clever' `m which may in&de tittcdness, feveg loss of appetite and weight, dianhea, night sweats and swollen glandj (lymph nodt+usuaBy in the neck, armpit, or gmin. Anyone with symptoms like t&e for morrz *- 20 CORPORATEMONTHLY JANUARY 1986 gestion. Neither is it trying to en- force the unenforceable, or impose a burden that is inequitable. `The government is desperately trying not to go bankrupt over health care. There will be a response if there are inequities. It won't be as fast as the physicians in some hospi- tals want it, but it will come." Wtth medical treatment costs in- creasing and more specialized ser- vices being offered by traditional, community hospitals , there are con- cerns that the availability of health care will depend on the patient's abil- ity to pay for it. Dr. Koop is hopeful and counsels patience. "There are a lot of things that the insurance indus- try has to acomplish. They are look- ing at (the subject of cost versus availability) very carefully." With more data about smoking, drinking, and other lifestyle ques- tions that affect an individual's health, there have been efforts made by some insurance companies to identity `high risk' and `low risk'- clients. Should they both be charged the same price? Dr. Koop says, "No. And I see (the insurance industry) coming to that conclusion, too. Should a smoker pay the same pre- mium as a non-smoker?" he asks, "Should a drinker pay the same as a nondrinker? "One of the ways the insurance industry is experiencing economic change is with smokers," he adds. "For example, Minnesota's Blue Cross offered to all customers who were non-smokers what essentially amounted to a 16 percent reduction in their premiums." He taps his fingers, emphasizing the point, `That group of non-smokers was their most profitable group because they didn't use the health cam sys- tem. (Philadelphia-based) CIGNA, which has very large holdings in HMO's, found the same kind of profitability when it offered a simi- lar, two-level premium to their cus- tomers." Philadelphia Blue Cross, according to a spokesman, has no plans to offer a two level premium for smokers and non-smokers. C harles Everett Koop's surgical career was marked by a number of innovations and achievements that still stand as records in the field of pediatrics. Many of the surgical pro- cedures in use, at the time of his appointment to Philadelphia's Chil- d&s I-Iospital, resulted in mortality rates of near 95 percent. Pre- and postoperative improve- ments he put into place significantly reduced this late, including the development of surgical techniques that allowed the correction of birth defects that up to then. were consi- dem-l unconectable. "It was almost like we vme begining to invent the wheel ; he explains. "Every- thing...was brand new. It was an exciting time." In addition to new surgical and postoperative tteatments, he found- ed the nation's first neonatal inten- sive surgical care unit, as well as a totalcare pediatric facility, at Phila- delphia's Children's Hospital. Describing the origins of the term, `Xoopian Method," used by his col- leagues, Dr. Koop explains, "When ImtimdfiompracticeinBhiladel- phia, about 500 of my surgical col- leagues, from hem and 28 countries almad, put on a tremendous, three- day farewell for me. One of my residents gave a talk on what he calkd the Koopian Method. "It's not even a good word, as far 8s I am concerned," he admits, chuckl- ing. what he was trying to say dkcted the way I approach pmb- lems in the surgical cam of children. For example, if a child has twelve things wrong with him, don't get overwbdrned by the fact that there am twelve things. Just treat each one of them individually and each - one as tumble, and you can solve the problem. "Secondly, you can't just treat a (young) patient, you have to treat the entire family. In addition, you have to garner all the support in the community thfit'll make (the tnxtt- ment) work." Dr. Koop has left the comfortable conditions of private practice, where he was the nation's sixth pediatric surgeon, for the hectic realm of pub- lic office. Is he satisfied with his new job? "`Yes. I had a marvelous career in pediatric surgery. I would never have imagined that changing cateers, at my age, would have pm- duced such excitement. This job changes every hour and it runs the gamut from health issues to financial considerations." Of course, he adds, `Working for the f&ml government takes a year or so to find your way around and another year to understand the pms- ence of an ovenvhelming buleau- cay (140,000 employees in the US Public Health Service and its afiili- tated agencies). By the third year you begin to be able to work with that bureaucracy to accomplish things. I am fortunate to have been confirmed for four mom years. `When I went into pediatric surgery, there were tremendous prob- lems which no one had tried to solve. If you are interested in the health of the people, you must iden- tify `the SolI spots'," he says. By his own definition (an ac- tivist), the Surgeon General has pros- cribed a path for the public to follow. It is his wish that we hear his calls for action and change our habits, lifestyle and attitudes on health cam. Dr. Koop believes in selfdetermina- tion when it comes to being healthy. W hilehehasmadeagenerally successfuI effort to sepmte religion from the responsibilities of being surgeon general, he is a man of rock solid principle. In a 1982 interview, published by the sanuriay Ewing Post, he said, "Everything I gl;;r$ I cons&r to be a grft The sax&y of life is uppermost in the mind of the Surgeon General. "I am not comfortable with [the way in which] abortion is available today," be explains. In his controver- sial book, What- Happened To The Human Race (with Francis A. Schaeffer), Dr. Koop puts his view on abortion into perspective. Stated in the context that aborting a pre- gnancy is a violation of the sanctity of life, he blames society's accep- tance of abortion on the popular shift away from Judeo-CXstian stan- dards. `When a Chrisdan consensus existed, itgawahisjhlaw.in- steadofthis,wenowliveun&ran a&my, or soctigicd law." Condemning the humanistic d&c- tion of modem Western society, he continues, ". . . 7?lelizwbefwmeswhat afavpec.+insomebmnch$gov- ernmentthinkwillpwtotethepre- sent soctigicd and econonlic good. in reality, the will and moml judge- mentsofthen&rityarenow~- encedbyorevenovemdedbythe opinionsofasmllgrotqofmenand lwmf?n. `Thismeamthatwmchangescan tX???lU&i?ltiWhOlt?W?ECtpt$WhUt stJoulvandwhatsholddnotbedone. Iblues cnn lx? altered mrni~ht and at ahost l4nbhwble speed. `The number of US abortions per- formed in 1984 for health reasons were few," he says. Simultaneously, over 6 million were completed on demand. Dr. Koop continues, `About 3 per- cent of abortions am done for health reasons, or what I call medical indi- cations (rape, incest, birth defects, or danger to the life of the mother). You can't condone abortion, unborn life, without spilling into `born' life." One of the ways we see changes in the valuation of human life is through the use of `living wills'. Patients draw up a legal document that ask doctors and family members not to prolong their life if pmgnoses show no hope for improvement. `We are going to face a push to ward euthanasia, although it may come disguised as something that sounds a little better, like `living will' legislation, `the right to die', `death with dignity', or so forth," he believes. `People are getting polarized about the end of life, just as they have gotten polarized about the beginning of life. `Wehavetodoabetterjobin- fotming the public about what the endoflifeisabout.Deathisapart of life and people die, of something, everyday. W have to get to where people no longer believe that if ev- erything is not being done to save a person, that (the health cam indus- try) has somehow failed. Them is a Iine between the extension of life prolonging death- "It has been pointed out that the last year of life is the most expen- sive. That shouldn't come as any surprise because you get sick and you die. "I believe people have the right to say, `I've had all that I want of this treatment; I know that I am dying and therefore I don't want that extra three days, or one week. ' A person's wishes should be honored in this matter." CM . , "The pasr is bus the beginning of a beginning and all that 13 an has been 13 but the twi@bt of the dawn. n -H. G. WlLs CORPORATE MONTHLY J&WARY 1986 21