Six years a o,
was loved %  C. Everett Koop
     y conservatives and vilified by liberals.
Now it's the other way around.

W ARNING:
THE SURGEON
   GENERAL
    IWiY BE

  GOOD FOR
YOUR HEALTH

by Paul Glastris

I n 1977 C. Everett Koop, an anti-abortion
  activist who believes so passionately in
  "the sanctity of life" that a colleague
   once said "he would ventilate an

amoeba," faced an excruciating choice A set of
Siamese twins had been brought into
Philadelphia's Children's Hospital, where Koop
was chief of surgery. The twins were joined at the
chest, sharing one-and-a-half hearts, which could
support only one child. The choice was between
doing nothing and having two deaths, or, through
surgical separation, killing one so the other might
live.
Koop waited 11 days as the girls' parents, from
a deeply religious Orthodox Jewish family,
discussed the issue with rabbinical scholars for
hours each day before making a decision. For
Koop the decision was easy. "It took me about
ten minutes after I knew all the facts to make up
my mind about what should be done," Koop
recalls. He recommended surgery. When it came
time to tie off the carotid artery feeding the brain
of the infant who would die, Koop, zealous

hd Gfastris is an editor of The Washington Monthly.
Research asdance by Alex Friend

THE WASHINGION MONTHLY/MARCH 1967

defender of infants and the unborn, did the job
himself.

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

13


ported Koop for surgeon general in 1981 over the
fierce opposition of liberals, believing that his
strong conservative views would guarantee a
politically eormct public health policy. Now they
felt betrayed. The Washington Times called for
him to shape up or resign. Beagan administra-
tion officials in the Department of Education
protested elements of Koop's call for sex educ-
tion. "The very people who supported me in my
tough times of `81," Koop says, "are the people
who don't seem to understand what I'm trying
to say."

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

House arrest

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

In the late seventies, Koop toured the country
with a lavish multimedia show he co-wrote, nar-
rated, and starred in. The show's centerpiece was
the film series, "What Ever Happened to the
Human Race?" Shot on 50 locations in five coun-
tries at a cost of $1 million, the film is particularly

famous for a scene in which a thousand black
and white dolls lie scattered on the salt wastes
of the Dead Sea, a gruesome representation of
the six million abortions said to have been per-
formed in the U.S. since the 1973 Supreme Court
ruling legalized the practice

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

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

The new Bepublican Senate, everyone knew,
would almost surely support Koop's nomination.
A small problem, however, stood in the way. Be-
ing a few months past his 64th birthday, Koop
was tdniadly sewral months too old for the job.
Jesse Hehns tried to remove this potential snag
with an amendment chaqing the age restriction,
which he attached to legislation on credit cards
aheady approved by the House The Senate ap-
provedthechangeafterHelmsmisinformedtlrem
that the House had no objections. His effort to
bypass the House backfired, however, when
Speaker Tip O'Neill, angry at the slight and sen-
sing a prime opportunity to embarrass the ad-
ministration, used an obscure parliamentary rule
to send the credit card bill to the House health
subcommi~ chaired by liberal proxhoicer Rep.
Henry Waxman.

Bepublicans on the subcommittee tried to limit
the discussion to the age issue; Waxman and the
Democrats, however, proceeded to conduct a de
facto confirmation hearing. Koop, with strong
advice from his superiors, refused to testify, on
the grounds that the House was usurping a
Senate responsibility. So Koop's writings and past
statements were allowed to $eak for him. At a

14

THE WHINGTON MONTHLY/MARCH 1987


right-to-life seminar in 1979, for cxampls Koop
had referred to the "women's lib movement" and
the "gay pride movement" as propelling "anti-
bmilytrendsp comments women's and gay rights
groups pointed to as evidence Koop would
. . .
dscmmnate against them and decimate abortion-
related medical programs. In an article used by
Mxman to show Koop's intolerang the surgeon
had written, "Sadly, most mainline denomina-
tions have made pro-abortion statements il-
lustrating their superficial theology, lack of
morality, and insensitivity to the eventual reward
for their own depravity.'

The document that spurred liberals to nick-
name the surgeon "Dr. Kook" was a 1979 com-
mencement address in which Koop pretended it
was 1999. "Secular Humanism" had become the
official state anti-religion; "Doctrine Squads"
snooped on people and hauled them off to be
punished for "speakii of the Lord"; rampant
infanticide had resulted in a generation of young
people who were "perfect specimens-no defects,
no eyeglasses. . . [and] a pmponderance of boys";
talk of "death with dignity" and "living wills"
in the seventies had been "the thin wedge!' that
cracked open American morality and led to com-
pulsory euthanasia for the old and infm;
something called the "Rockhead Foundation"
supported the culturing of "lCKl,O homosexual
and lesbian test-tube babies to give the gay move-
ment more political clout!'

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

The New York 7imes, along with a dozen other
major liberal newspapers, and an army of power-
ful liberal groups-from Big Labor to the Na-
tional Organization of Women-joined the op-
position. Wavering legislators would have been
foolish to cross the picket line It was eight
months before Koop eventually ahowed to testify,
could win Senate confirmation. "He does not
have a public health background. He's
dogmatically denounced those who d&agree with
him, and his intemperate views make me wonder
about his, and this administration's, judgment,"
Rep. Waxman said, summing up the liberal con-
sensus. "Dr. Koop frightens me."

An academic bully

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

A large man-six feet one, 2% pounds-he
hadhunghisheadoverthetinyhodiesofsome
100,000 patients in the course of his 35 years as
a pediatric surgeon. Shoulders scnmcw elbows
in, sometimes for hours, his large hands work-
ing through miniature incisions @pairing a
newborn's esophagus, Koop says, is like "sewing
together two pieces of spaghetti at the bottom
of an ice cream cone"), he had subjected a
vertebra in his neck, already fractured in a col-
lege ski jumping accident, to "about 12 pounds
of constant traction ? Over the years, bone spurs
had shrunk the hole through which the spinal
cord, and its attendant artery, pass. During his
nap, his head had slipped off a small rubber or-
thopedic pillow, twisting his neck and pinching
off the artery.

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

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

TilE WASHlNGlDN MONTHLY/MARCH 1987

15


API-IA.)

Most of Koop's associates tolerated the ar-
mgance that came with Koop? compassion. They
greatly admired him, but his bellicose style led
to incidents of cruel insensitivity. He once en-
countered a woman at a party holding an infant.
`Thanks for not having an abortion," Koop told
the woman. The child was not hers, and she had
had an abortion. Robert Kettrick, senior
anesthesiologist at Children's, who assisted Koop
hundmdsoftimesintheope&ngroom,saysthis
arrogance results in part from "too many years
in the university!' His rhetorical combativeness
is typical of academics, explains I&trick, "but
inChickKoop'scase,itcamewithadesiretothen
demonstrate his mastery of the subject and the
dominance of his logic He likes to play academic
bully, as if to say, `I'm right, I've studied the issue,
I know the standard retorts and where all the
weak spots are in your arguments, and I'm go-
ing to beat you up! "

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

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

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

iife at any cost or for any cause."

Forthefustfewyearsofhistenure,Koopgave
Iittle reason for his critics to think they'd been
wrong. He raised some eyebrows by donn(ng the
uniform of the Public Health Service, the fust
surgeon general to do so regularly in years. True,
only a few months after his confirmation, Koop
came out with his frrst surgeon general's report
on smoking, which The New York Times
described as "one of the strongest indictments of
cigarettes since the landmark federal report on
smoking 18 years ago." But a surgeon general
UarningthatdgaretteSIllOkitlgiSharmfUltOyOlU
health was not exactly breaking new ground.

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

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

Although Koop was consulted in the drafting

of those regulations, and defended them public-
ly, his major involvement didn't begin until after
the birth in 1983 of an infant that had spina
bifida and other complications and was dubbed
"Baby Jane Doe." "We're not just fuhting for
this baby," Koop proclaimed on "Face the Na-
tion." " We're fighting for the principle of this
country @at every life is individually and unique-
ly sacred." The Justice Department wanted to
make the Baby Jane Doe case a test of the prin-
ciples underlying its regulations. It was Koop who
formally requested copies of the child's medical
records, the denial of which led to a major legal
battle

But it was also Koop, uncom&table with the
administration's interventionist approach, who

16

THE WASHINGTON MONTHLYIMARCH lob


forged a compromise In a conversation with
Margaret Heckler, then secmmry of HI-IS, about
Baby Doe, Koop says he told her, "Now, I have
been taking all the flack for two years-and I have
had no role that could help me deflect some of
that stuff. I said if I'm going to take the flack
why can't I write the regulations? She was very
reasonable She said go ahead and do it ."

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

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

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

Smoke out

Liberals would also learn to appreciate Koop's
zealous side, at least when he applied it against
smoking. Past surgeon generals have warned of
the dangers of smoking; Koop has turned that
warning into a personal crusade In his reports,
he warns of smoking's ruinous effects on the
heart; he calls smoking "an addiction"; he attacks

smokeless tobacco; he warns of the dangers to
nonsmokers of "passive smoking" and cites
smoking as the number one hazard in the
workplace In May 1984, he began a public rela-
tions campaign, calling for "a smokeless society
by the year 2000 I In countless press conferences
and speeches, Koop has argued that by the end
of the century our attitudes should evolve to the
point that no smoker will light up in the presence
of a nonsmoker without permission. Jesse Helms,
who had been Koop's strongest Senate supporter,
called for his resignation.

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

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

With Koop running around the country pass-
ing out buttons, that's been a hard promise to
keep. But some in the administration have tried.
Last March, for instance, Koop lost a battle with
Defense Secretary Caspar Weinberger. Military
personnel have long enjoyed a discount on
cigarette purchases. In fact, cheap smokes dur-
ing World War II were the chief cause of the great
rise in the number of smokers in the late forties
and fifties. Koop had been working behind the
scenes with the Defense Department's assistant
secretary for health affairs, Dr. William Mayer,
to eliminate the discount. Wbinberger overruled
Mayer, bowing to pressures from tobacco state
kgislators, the tobacco industry, and associations
of present and former military personnel. The
military groups had protested that cuts in

16

THE WASHINGKIN MONTHLY/MARCH 1967


cigarette discounts would provide a dangerous
precedent for cuts in other benefits. "it just
doesn't make sense to me," Koop said publicly
of Ninberger's decision. "How could the
removal of cigarettes be viewed as a reduction in
benefits when the only benefits would be a
lifetime of illness and early death?"

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

Fair warning

For a long time there was one issue about
which Koop could not speak his mind-AIDS.
The surgeon general's duties and responsibilities
are delegated by the assistant secretary of health.
The assistant secretary during the first Reagan
term, Dr. Brandt, said Koop was not to talk about
the disease Almost since the disease was first
identified, gay groups, outside health cxper& and
scientists in the HHS bureaucracy argued to top
officials that public education was the only
weapon against a disease with no known cure.
But those officials resisted the idea, in part to
avoid the kind of controversy over sex education
currently swirling around Koop. `We were get-
ting 5,000 letters a week saying don't do AIDS
research because it's God's retribution," recalls
a former HHS official who worked closely with
Brandt. "It makes you think twice about crafting
national messages that will speak to the needs of
the risk groups but won't offend other groups."
Another reason was money: the administration

had budgeted none for AIDS education until
fisca) 1984, and then only a paltry Sl.4 million.
As Public Health Service personnel leaked
memos to Capitol Hill staff members on the need
for public education efforts, Congress ap-
propriated nearly SlO million in 1985 and S30
million in 1986. In spending this money, federal
public health officials were told to be extremely
circumspect, which led to vague and misleading
public wamings such as "avoid exchanging bodily
fluids !' This euphemism policy extended to the
education funds HHS funneled through state and
local government health departments to private
community and gay groups.

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

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

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

`Many people-especially our youth," Koop

a~ounced at the report's Gctober umeiling, %re
not receiving information that is vital to their
future health and well-being be-cause of our
reticence in dealing with the subjects of sex, sex-
ual practices, and homosexuality. This silence
must end." His report's frank discussion of the
causes of AIDS transmission and ways to prevent
its spread has given federal health officials the
latitude to educate the public well. "We certain-
ly feel he's been very positive His courage on
AIDS and smoking is to be commended," says
Katherine McCarter, the American Public Health
Association's associate aecutive director. As to
the wisdom of APHA's pas1 opposition,
McCarter replies, "that's all behind us. We real-
ly don't like to dwell on that ."

ME WASHINQIDN MONTHLWMARCH lS87

19