KOOP, CHARLES EVERETT

Dr. Charles Everett Koop, surgeon general under President ronald reagan, boldly led the United States on controversial health issues such as smoking, abortion, infanticide, and acquired immune deficiency syndrome (AIDS). Koop was a driven, dedicated public servant, committed to doing what he felt was best for the health of the American people. He aggressively confronted pressing health issues while dodging Washington, D.C.'s, political machinery. During his eight-year tenure, Koop increased the influence and authority of his post with the public health service. With a passion for medicine and a sincere interest in promoting the public's health, Koop was affectionately regarded as "America's family doctor."

Koop was born October 14, 1916, in Brooklyn, the only surviving child of John Everett Koop and Helen Apel Koop. As a young pupil, he excelled academically and socially, participating in football, baseball, basketball, and wrestling. One month before his 17th birthday, Koop entered Dartmouth College. The Dartmouth coaches quickly recognized Koop's talent at football and awarded him the coveted position of quarterback. However, after a severe concussion damaged his vision and threatened the surgical career that he had envisioned as a young man, Koop quit the team. He immersed himself in pre-med studies, majoring in zoology. Having lost his football scholarship, Koop took a series of odd jobs to finance his way through college.

"I think it ironic that at a time when socialist regimes are collapsing all around the world and American disenchantment with politics and government seems at an all-time high, so many Americans clamor for the government to take over the health-care mess."
—C. Everett Koop

Koop entered medical school at Cornell University in the fall of 1937. In 1938, he married Elizabeth ("Betty") Flanagan, with whom he eventually raised four children. When the United States entered world war ii, and many physicians were called to duty, Koop performed many surgeries that, under normal circumstances, would have been assigned to more senior physicians.

For his next phase of training, Koop and his family moved to Philadelphia. There, he took an internship at Pennsylvania Hospital, followed by a residency at University of Pennsylvania Hospital. After residency, in 1946, Koop became surgeon-in-chief of Children's Hospital of Philadelphia. He was 29 years old.

During his 32 years at Children's Hospital, Koop helped establish pediatric surgery as a medical specialty. At the time he took the job, many surgeons were reluctant to operate on infants and small children because of the risks associated with sedating them. Koop devised anesthetic techniques for his young patients and worked tirelessly to perfect surgical procedures and post-operative care for children. Along with being a skilled surgeon, he was a compassionate doctor. He was sensitive to the parents of sick and dying children, and helped to create support groups to meet their needs.

Koop's work with pre-term and malformed babies at Children's Hospital influenced his strong positions against abortion, infanticide, and euthanasia. While at Children's Hospital, Koop wrote The Right to Live, the Right to Die (1980), a best-seller that outlined the relationship among those three practices. He quickly became a spokesman on these issues and committed a great deal of his time to trying to rouse the American conscience. Later, after he was nominated to be surgeon general, Koop was surprised to learn that his Republican supporters valued him more for his stance against abortion than for his impressive medical career.

In 1980, with retirement just one year away, Koop was asked whether he would consider the surgeon general's post in Reagan's new administration. The surgeon general is an officer in the United States Public Health Service Commissioned Corps, a uniformed, mobile health unit. Under the leadership of the secretary of health and human services, the surgeon general administers health policies and supervises personnel in the field. During his time in office, Koop broadened the surgeon general's role from low-profile administrator to high-profile leader.

Koop's surgeon general's reports and frequent testimony influenced the passage of numerous health-related mandates. He became a household name as he gently, yet firmly, informed the American public about the most preventable threats to their health. Regardless of the political consequences, Koop believed that he was obligated to provide accurate information to the public.

Koop launched an antismoking campaign with the 1982 Surgeon General's Report on Smoking and Health. In that document, he clearly stated the relationship between cancer deaths and smoking. In the years that followed, Koop produced reports that linked smoking to cardiovascular disease and to chronic obstructive lung disease.

In an antitobacco campaign, Koop targeted smokeless tobacco products, such as chewing tobacco and snuff, citing their connections to various cancers. His actions spurred the passage of the Comprehensive Smokeless Tobacco Health Education Act of 1986, 15 U.S.C.A. §§ 4401 et seq., a mandate to educate the public

about this health threat. At Koop's urging, Congress legislated warning labels for smokeless tobacco products.

Koop examined the effects of smoking on nonsmokers in his 1986 report Health Consequences of Passive Smoking. Legislators across the nation responded to his report by creating laws to restrict smoking and to reduce the risk of passive smoking to nonsmokers. By 1987, smoking was banned in all federal buildings, and regulated in restaurants, hospitals, and other public places in over 40 states. In 1988, Koop commissioned studies on smoke in airplanes. Congress reacted to the results of these studies by banning smoking on all flights lasting less than six hours.

Koop publicized the addictive nature of tobacco in his 1988 surgeon general's report. This report forced tobacco officials to agree to more specific surgeon general's labels on cigarettes. However, Koop lost the fight for labels that would have identified nicotine as an addictive substance.

Although Koop was known for his antiabortion stance, he did little on this issue during his time as surgeon general. He viewed abortion as a moral issue, not a political one, and he strongly disagreed with those who wanted to ban contraceptives and abortion. In response to Koop's position on contraception and sex education, many conservatives who at first had supported him turned against him.

Koop faced a dilemma when President Reagan asked him to study the psychological effects of abortion on women. In Koop's opinion, it was a poor strategy to quibble about the effects of abortion on the mother when the effects on the fetus were conclusive. In addition, because both sides of the abortion controversy produced biased studies, the available research was useless. In the end, Koop could not gather evidence to assert conclusively or to refute damaging psychological effects of abortion on the mother. He never completed the report.

In 1982, the Baby Doe case alarmed the nation. Baby Doe was born with Down's syndrome, which results in mental retardation and other physical problems, as well esophageal atresia, an obstruction in the food passageway. The Down's syndrome was not correctable but was compatible with life; the esophageal atresia was incompatible with life but was correctable. On the advice of their obstetrician, the parents chose to forgo treatment, and the baby died.

Koop believed that the child was denied treatment because he was retarded, not because the surgery was risky. Koop himself had performed this kind of surgery successfully many times. Judging this to be a case of child abuse and infanticide, Koop commented publicly that it is imperative to choose life, even when the quality of that life is not perfect.

In 1983, the nation grappled with similar difficult circumstances surrounding the Baby Jane Doe case. Baby Jane Doe was born with spina bifida (a defect in the lower back), an abnormally small head, and hydroencephaly (a condition that causes fluid to collect in the brain). At issue was the baby's right to medical treatment to increase her quality of life, despite her physical handicaps. Koop believed that without medical treatment, Baby Jane Doe's spine would become infected, that the infection would spread to her brain, and that she would become severely retarded. He therefore advocated medical treatment for that condition.

Koop's efforts to educate Congress and the public about the medical injustices affecting handicapped children led to the Baby Doe Amendment (42 U.S.C.A. §§ 5101, 5102, 5103). On October 9, 1984, the amendment extended the laws defining child abuse to include the withholding of fluids, food, and medically indicated treatment from disabled children.

While in office, Koop became embroiled in the politics of educating the public about a growing health threat, AIDS. The Reagan administration prohibited Koop from speaking on the topic for nearly five years. This constraint distressed Koop, who believed that it was the surgeon general's duty to inform the public about all health issues. Despite the Reagan administration's silence on the issue, on October 22, 1986, Koop released The Surgeon General's Report on Acquired Immune Deficiency Syndrome. In it, he clearly stated the facts about the transmission of the disease and identified preventive measures and high-risk behaviors.

Koop was adamant that all U.S. citizens obtain the information that they needed in order to stop the spread of AIDS. In May 1988, he sent the mailer Understanding AIDS: A Message from the Surgeon General to every household in the United States.

When AIDS first attracted attention, it was labeled a homosexual disease because it was transmitted predominantly through sexual contact among gay males. Koop lost the support of staunch conservatives because he refused to use his position to publicly condemn homosexual behavior. Koop's focus was to educate and to save lives. Although he advocated abstinence as the best method for preventing the transmission of AIDS, he also urged the use of condoms by those who continued to engage in risky sexual behavior. Koop spoke against proposals such as mandatory testing and the detention of HIV-positive homosexuals. He challenged those who opposed the use of tax dollars to fund AIDS research. His reasoned approach to the AIDS epidemic helped to calm the hysteria of the public.

Shortly after george h.w. bush became president, Koop expressed interest in the position of secretary of Health and Human Services. Bush chose Dr. Louis W. Sullivan for that job.

Koop resigned from his position as surgeon general at the end of his second term. He wanted new challenges and looked forward to educating the public without the interference of Washington politics. Ironically, Koop's popularity had undergone a complete reversal during his term in office office: Koop had entered his post on the shoulders of conservative Christians, and he was leaving it as a hero of the liberal press and public.

Even in retirement, Koop continues to fulfill his role as public-health educator. He established the Koop Foundation, and the C. Everett Koop Institute at Dartmouth. The Koop Foundation is a private, nonprofit organization dedicated to fitness, education, and research initiatives to promote the health of U.S. citizens. The Koop Institute actively works for reform in medical education and the delivery of medical care. To that end, the institute provides a health-information network to help doctors address challenging medical cases. Still writing, speaking, and consulting on health issues, the diligent Koop continues to champion the cause of better and more accessible health care.

Koop has received numerous awards for his many lifetime achievements. In 1995, President bill clinton awarded Koop the Presidential Medal of Freedom, the nation's highest civilian award.

further readings

Koop, C. Everett. 2002. Critical Issues in Global Health Care. San Francisco: Jossey-Bass.

——. 1991. Koop: The Memoirs of America's Family Doctor. New York: Random House.

The Koop Institute site. Available online at <www.dartmouth.edu/dms/koop> (accessed November 21, 2003).

cross-references

Acquired Immune Deficiency Syndrome; Health Care Law; Surgeon General; Tobacco.

C. Everett Koop

C. Everett Koop (born 1916), one of America's most outspoken surgeons general, served two terms in the 1980s. Koop's appointment angered liberals. However, the conservative Christian doctor later alienated social conservatives by refusing to compromise his common-sense approach to health issues for the sake of politics.

Brooklyn, NY-born Koop graduated from Dartmouth College in 1937 and earned his M.D. degree from Cornell Medical College in 1941. Following an internship, he pursued postgraduate training at the University of Pennsylvania School of Medicine, Boston Children's Hospital, and the Graduate School of Medicine at the University of Pennsylvania, from which he earned a doctor of science degree in medicine in 1947.

Koop became a professor of pediatric surgery at the University of Pennsylvania's School of Medicine in 1959 and professor of pediatrics in 1971. Koop also was surgeon-in-chief of Children's Hospital of Philadelphia from 1948 until he left academia in 1981. At the hospital, Koop gained renown for success in repairing birth defects, including the separation of conjoined twins. He also was editor-in-chief of the Journal of Pediatric Surgery from 1964 to 1976.

Koop was appointed Deputy Assistant Secretary for Health of the U.S. Public Health Service under the Reagan administration in March 1981 and was sworn in as surgeon general November 17, 1981. He held the post for two terms, serving under presidents Ronald Reagan and George Bush, until resigning October 1, 1989. In that time, Koop's willingness to speak out-and speak out boldly-on public health issues earned him much media attention and the enmity of a number of former allies.

Refused to Compromise on Health Matters

Koop saw fit to wear the traditional braided uniform of the surgeon general, a decision some derided, calling him an admiral without any ships. While traveling, the uniform once caused him to be mistaken for an airline crew member. A more significant departure from the style of previous surgeons general was Koop's decision to ignore advice he had been given upon arriving in Washington. That advice was, "Keep your head down and your mouth shut, " he wrote in Koop: The Memoirs of America's Family Doctor. While the uniform confused some, the man wearing it left no doubt where he stood on numerous public health issues.

Koop took on the American tobacco industry, a bountiful source of campaign contributions for a number of congressional Republicans, when he called for a smoke-free society by 2000. Koop also pushed then-president Ronald Reagan to publicly address the AIDS crisis. In addition he weathered a storm of criticism over positions on abortion and contraception many conservatives said were in conflict with Koop's own beliefs. During the course of his tenure he was shunned by conservative former associates and embraced by liberal former detractors.

Koop became a Reagan nominee largely based on his anti-abortion activism. The devout evangelical Koop had delivered his pro-life message through a number of books, films and lectures nationwide. One film shows Koop surveying a sea of naked dolls, intended to symbolize aborted fetuses, and saying, "I am standing on the site of Sodom, the place of evil and death." Liberals challenged Koop's appointment, delaying Congressional confirmation for eight months. Once Koop took office, though, liberals and conservatives each would do a turnabout.

Shortly after becoming the nation's top doctor, Koop began speaking out against tobacco and pressed for legislation to strengthen warning labels on cigarette packs. He later called for smoke-free work environments. As a result, the ten-year period encompassing Koop's tenure is said to have seen the greatest decline in smoking by Americans ever.

Safe Sex Proponent

In an October 1986 report to the president, Koop argued sex education and condoms were the most effective way to combat the AIDS epidemic. In 1987, Koop was the lone administration dissenter from a plan calling for widespread AIDS testing. His rationale was that the prevailing stigma against people with AIDS made mandatory testing unfair and impractical. He argued that compulsory testing would force those potentially infected with AIDS or HIV, the virus that causes AIDS, further away from medical treatment and education that could prevent spread of the disease.

Conservatives found Koop's views on AIDS so unpalatable they attempted to sabotage a Washington testimonial dinner held in his honor in May 1987. Of the dinner's original sponsors, 11 boycotted the event, including then Republican presidential hopefuls Senator Robert Dole and Congressman Jack Kemp. As pickets demanding his ouster marched outside, Koop thanked those in attendance. "There has never been a time in my life when I wanted or appreciated such a show of friendship." According to a 1987 Time magazine report, Koop was discouraged by the loss of conservative supporters. "They don't listen to what I've said, but they criticize me about what somebody told them they think I've said."

One weapon in Koop's anti-AIDS arsenal was information. The surgeon general was responsible for developing an eight-page booklet on the disease and its communicability at a cost of $17 million. Understanding AIDS was mailed to 107 million households in 1988 following a year and a half of debate over what the pamphlet would and would not say. Social conservatives were angered by the pamphlet's content as it included information on condom use. The AIDS prevention effort had two sides: Prevent the spread of the disease, of course, but also prevent the spread of panic over the disease. "Trying to estimate your chances of catching the virus based on the latest magazine article or newspaper story is like playing Russian roulette, " Koop said at the time of the pamphlet's release.

Unexpected Abortion Report

Koop was routinely caught in the crossfire when medicine and politics clashed, as when President Reagan called upon the surgeon general to report on the psychological effects of abortions on women who have them. One might have guessed the outcome of a conservative president asking a conservative, staunchly anti-abortion doctor for such a document. All bets were off, however, when in early 1989 Koop wrote to the president saying data he had gathered were inconclusive; he could not determine whether women who had abortions suffered psychologically. Koop's response to President Reagan did not go unnoticed by either side of the abortion debate.

Writing in the liberal journal New Republic, John B. Judis commented at the time, "The antagonism generated by the report will only reinforce the reversal over the past eight years in Koop's constellation of friends and enemies. The New Right, which once championed him as a bearded Ahab who would slay the white whale of liberalism (and which helped him get his job), now denounces him as an instrument of immorality. Meanwhile, the liberals, feminists, and public health lobbyists who once called him 'Dr. Kook' sing his praises."

A commentator in the conservative National Review suggested that the thinking behind Koop's abortion letter was in conflict with principles underlying his stance on other public health issues. "Koop's tentative tone on [abortion] contrasts sharply with his own strong statements of yore that abortion does harm women, " according to a 1989 article in the magazine. "Nor is he averse to making stern moral, as opposed to merely medical, statements against smoking. On abortion, as on AIDS, he has learned to assume properly enlightened attitudes."

In an interview following delivery of his letter to President Reagan, Koop articulated his frustration with social conservatives and reiterated his philosophy on health policy. "What has given me so much trouble in this job from the right is that I separate ideology, religion and other things from my sworn duty as a health officer in this country."

When Koop resigned as surgeon general, he did not put the abortion debate behind him. Instead, as he did in a 1991 Good Housekeeping magazine article, he lamented the politicization of an issue that came to life as concern for the unborn and the health of women. "I wonder if they have forgotten what originally prompted the debate: the innocent unborn child, the agonized pregnant woman. Many opposed to abortion have been notoriously unhelpful to unwed pregnant women; they must be more forthcoming with their time and money to help pregnant women in hardship. And those who call themselves 'pro-choice' ought to make more of adoption as a clear choice."

Remained in Debate

Although no longer surgeon general, Koop retained a voice in the debate of public health issues during the administration of Democrat Bill Clinton. He did not keep quiet during the Clinton administration's aborted attempt to reform the health care and health insurance industries and lent his support to some Clinton initiatives.

Koop was not immune to controversy even during his early eighties. When President Clinton granted Koop a waiver in 1994 for burial at Arlington National Cemetery, congressional Republicans thought they smelled a conspiracy and suggested Koop was granted the waiver in exchange for his support of health care reform. Precedent did exist for granting a waiver to a surgeon general who had not served in the armed forces. President Reagan had approved an Arlington burial for Dr. Luther Terry, the surgeon general who first publicized the link between smoking and cancer. Koop later declined the waiver. "I do this without rancor and with an understanding of and respect for the special place that burial at Arlington has in the hearts of the American people, " a Koop statement at the time said.

In 1997, Koop co-chaired a task force on tobacco that recommended a hefty increase in the tax on cigarettes to discourage teenagers from smoking. Koop also was an opponent to granting tobacco companies immunity from further liability in conjunction with a government settlement with the industry over the cost of smoking-related illnesses. The prospect of revenue from a tobacco settlement being used to fight cancer and improve public health must have been gratifying to Koop. Indeed, a Koop remark reported by Reuters in 1998 suggested that the former surgeon general saw similarities between tobacco's reversal of fortune and his own during the 1980s. "The public is now fully aware that the tobacco industry has lied to them. This has enraged a number of Americans and has disgusted a number of people in Congress who were for years the best friends of tobacco."

Koop has written more than 200 articles and books on medicine and surgery, biomedical ethics and health policy. He is married to the former Elizabeth Flanagan and has three living children and seven grandchildren.

Further Reading

Bianchi, Anne, C. Everett Koop: The Health of the Nation, Millbrook Press, 1992.

Easterbrook, Greg, Surgeon Koop, W.W. Norton & Company, 1991.

Koop, C. Everett, M.D., Koop: The Memoirs of America's Family Doctor, Random House, 1991.

Koop, C. Everett, The Right to Live: The Right to Die, Life Cycle Books, 1981.

Koop, C. Everett, Whatever Happened to the Human Race, Crossway Books, 1983.

Koop, C. Everett, and Johnson, Timothy, Let's Talk: An Honest Conversation on Critical Issues: Abortion, AIDS, Euthanasia, Health Care, Zondervan, 1992.

Koop, C. Everett; Virgo, John M., editor, Exploring New Vistas in Health Care, International Health Economics, 1985.

Koop, Everett C.; Elizabeth Koop; and Koop, C. Everett, Sometimes Mountains Move, Zondervan, 1995.

Christian Century, January 26, 1994.

Good Housekeeping, September, 1991.

JAMA: The Journal of the American Medical Association, November 24, 1989.

Los Angeles Times, December 23, 1997.

National Review, February 10, 1989.

New Republic, February 1, 1988; January 23, 1989; October 23, 1989.

Playboy, May, 1989.

Time, June 8, 1987.

U.S. News & World Report, May 16, 1988; May 30, 1988.

Heinz Awards, 1995 Recipients,http://www.awards.heinz.org/koop.html (March 6, 1998).

KOOP, CHARLES EVERETT 1916-

Surgeon general

The Nation's Family Doctor

C. Everett Koop always knew he would grow up to be a surgeon. As a teenager in Brooklyn, he pretended to be a medical student so he could sneak into hospitals and watch operations. Koop was a renowned pediatric surgeon, known for his successes in separating Siamese twins and in surgical procedures for dealing with formerly fatal birth defects. He played a major role in stopping the 1950s practice of X-raying children's feet in shoe stores, which exposed children to harmful radiation. In the fall of 1981 he became President Reagan's surgeon general of the United States, the nation's leading spokesman on public-health issues. As a passionate evangelical Christian and foe of abortion, he became during his confirmation hearings the target of those who felt his conservative perspective made him the wrong man for the post. But by the time he resigned his post in July 1989, Dr. C. Everett Koop stood out as a model of integrity and courage in public office. He confounded everyone's expectations as he put aside his own personal beliefs and Reagan-administration policy on medicine and health and acted in the best medical interests of the American people.

The Confirmation Controversy

When Koop was first named in February 1981 as deputy assistant secretary for health in the Department of Health and Human Services, it was widely believed he and Reagan agreed on issues such as abortion. Koop's surgeon general nomination created tremendous controversy, not so much over Koop himself as over the abortion issue. Even the American Public Health Association opposed him, as it had never done his predecessors, criticizing him for his lack of public-health experience. Massachusetts senator Edward M. Kennedy criticized Koop, charging that his concept of the role of women was based on "cruel, outdated, and patronizing stereotypes." When Koop was confirmed after an unprecedented nine-month battle, his new post was technically limited in scope, with no real authority, little staff, and almost no formal responsibilities. His chief duties included reporting on public-health issues and advising the White House on health policy. But Koop became one of the nation's most famous surgeon generals and a most influential and admired member of President Reagan's administration with his stance on many major public-health issues.

Smoking

Koop pledged that he would not use his position as "a pulpit for ideology," and pointed out that he did not always agree with the Reagan administration. He stirred up his first controversy in February 1982 with his strong stand against smoking, "the most important public-health issue of our time," linking it scientifically to some 30 percent of all cancer deaths. His "Smoke-Free Society" campaign during his tenure as surgeon general ruffled the Reagan administration and the strong tobacco lobby, but by the end of his term the percentage of U.S. smokers had dropped from one-third to one-quarter of the adult population, with much of that drop because of Koop's efforts.

AIDS

Although AIDS was a subject of national concern by the mid 1980s, the president remained silent on the subject. By 1986, as public pressure mounted, Reagan ordered his surgeon general to prepare a report. For the next two years Koop focused on the crisis: "I realized that if ever there was a disease made for a Surgeon General, it was AIDS." The country was panicked, and ill-founded rumors and incorrect information about the disease and its transmission were widespread. Once again, Koop stunned his president and his fellow citizens by his willingness to focus on the nation's health rather than the perspective of the administration. His report clarified the nature of the disease and told people how they could protect themselves. He spoke graphically and candidly about safe and unsafe sex practices. He used and publicized the taboo "C word"—condoms—and, disregarding Reagan-administration policy entirely, he argued for intensive sex education in the schools, beginning in the third grade. Over the strong objections of the White House, Congress approved a shortened version of Koop's report, which in May 1988 was sent to every American household.

Abortion

His public-awareness campaign was successful, but his stance was one of many that turned his conservative allies against him. Opposition mounted when Reagan asked him to write a report on the health effects of abortion on women. Koop was certain there would not be enough unbiased scientific evidence to support the White House's assumption that abortions damaged women's health. He delivered his opinion to newly elected George Bush in January 1989. Conservatives turned their backs on him, and Koop realized that the Bush White House wanted him gone. But after his July resignation, Koop found he had earned the liking and respect of the American people. He became a fixture on television, passing along important health information in news broadcasts and other media. The nation's family doctor had become the health conscience of America.

Sources:

Anne Bianchi, C. Everett Koop: The Health of the Nation (Brookfield, Conn.: Millbrook Press, 1992);

C. Everett Koop, Koop: The Memoirs of America's Family Doctor (New York: Random House, 1991).