Warning: The Surgeon General May Be Good for Your Health
Glastris, Paul
WARNING: THE SURGEON GENERAL MAY BE GOOD FOR YOUR HEALTH by Paul Glastris Six years ago, C. Everett Koop was loved by conservatives and vilified by liberals. Now it's the other way...
...Tobacco promotion, he said, "increases the total universe of users and increases consumption by those who already use it...
...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 has turned that warning into a personal crusade...
...In a conversation with Margaret Heckler, then secretary of HHS, 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...
...Last March, for instance, Koop lost a battle with Defense Secretary Caspar Weinberger...
...Antismoking groups, like pro-life groups before them, value Koop's knack for drawing the attention of both the public and the press...
...That was not their only line of attack, though...
...The nursing staff rebelled...
...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 general...
...True, only a few months after his confirmation, Koop came out with his first 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 warning that cigarette smoking is harmful to your health was not exactly breaking new ground...
...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...
...William Mayer, to eliminate the discount...
...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...
...with all the bad publicity, Regan relented...
...He and the staff he recruited had pioneered surgical procedures for congenitally deformed infants...
...It would be hard to exaggerate the strength of Koop's conviction on these matters...
...And no grown child has ever come back to ask me why, either...
...To the right-to-life movement, Koop was a hero and a chip they wanted cashed in when Ronald Reagan took office in 1981...
...he attacks smokeless tobacco...
...She was very reasonable...
...He struggled to his feet...
...Though doctors could do nothing about the newborn infant's Downs Syndrom and its inevitable mental retardation, they could correct life-threatening problems such as an underdeveloped esophagus...
...I never had the agonizing deaths with his patients that I did with patients of some other surgeons...
...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 antiabortion crusader that he was best known...
...He's done everything a surgeon general should do, and more, to protect the health of the public...
...To Koop, to allow such "quality of life" concerns into the medical decision process not only defies the word of God but is—like abortion—a first step onto the slippery slope of the kind of utilitarian ethics that led to Nazi death camps...
...When it came time to tie off the carotid artery feeding the brain of the infant who would die, Koop, zealous Paul Glastris is an editor of The Washington Monthly...
...Now it's the other way around...
...The New York Times, along with a dozen other major liberal newspapers, and an army of powerful liberal groups—from Big Labor to the National Organization of Women—joined the opposition...
...But by the summer of 1984 Congress, inspired and guided in part by Koop's compromise, passed overwhelmingly an amendment to the Child Abuse Act, defining refusal to treat handicapped newborns as child abuse...
...Pro-life groups protested...
...Being a few months past his 64th birthday, Koop was technically several months too old for the job...
...Koop," says Waxman...
...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...
...Past surgeon generals have warned of the dangers of smoking...
...Another reason was money: the administration had budgeted none for AIDS education until fiscal 1984, and then only a paltry $1.4 million...
...It was Koop who formally requested copies of the child's medical records, the denial of which led to a major legal battle...
...Kook" was a 1979 commencement address in which Koop pretended it was 1999...
...During his nap, his head had slipped off a small rubber orthopedic pillow, twisting his neck and pinching off the artery...
...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 going to beat you up...
...rampant infanticide had resulted in a generation of young people who were "perfect specimens—no defects, no eyeglasses...
...The show's centerpiece was the film series, "What Ever Happened to the Human Race...
...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...
...He had sat on the boards of three national right-tolife groups and was one of the movement's major theorists...
...The Justice official said the adminstration didn't favor a bill sponsored by Rep...
...It took me about ten minutes after I knew all the facts to make up my mind about what should be done," Koop recalls...
...The style he'd employed as the pro-life movement's most effective propagandist served him here...
...People don't often light up in front of the man...
...In May 1984, he began a public relations campaign, calling for "a smokeless society by the year 2000" 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...
...There are some children born with such severe defects that they will never be useful citizens in society," she explains...
...and] a preponderance of boys...
...In fact, cheap smokes during World War II were the chief cause of the great rise in the number of smokers in the late forties and fifties...
...The military groups had protested that cuts in cigarette discounts would provide a dangerous precedent for cuts in other benefits...
...Observers sensed a diversion: the administration was simultaneously offering budget cuts for AIDS research...
...The surgeon general's post carries little statutory authority...
...The Justice official told the committee that the adminstration had "very serious concerns" about banning tobacco advertising and that it was "not convinced that the case has been made that cigarette advertising leads to increased consumption ." Koop politely disagreed...
...But it is also a matter of religious faith...
...Although Koop was consulted in the drafting of those regulations, and defended them publicly, 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...
...But it was also Koop, uncomfortable with the administration's interventionist approach, who forged a compromise...
...He denounced ideas, popular among many of his conservative friends, about quarantining AIDS victims...
...when they do, he sternly hands them a button that reads, "The surgeon general personally asked me to quit smoking" He has called tobacco companies "sleazy" and labeled as "flat-footed lies" their claims that science can't say with certainty that tobacco causes cancer...
...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't—operate...
...In his reports, he warns of smoking's ruinous effects on the heart...
...We're not just fighting for this baby," Koop proclaimed on "Face the Nation!' "We're fighting for the principle of this country that every life is individually and uniquely sacred ." The Justice Department wanted to make the Baby Jane Doe case a test of the principles underlying its regulations...
...Military personnel have long enjoyed a discount on cigarette purchases...
...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 infants 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...
...Weinberger overruled Mayer, bowing to pressures from tobacco state legislators, the tobacco industry, and associations of present and former military personnel...
...He's a man of tremendous integrity...
...The assistant secretary during the first Reagan term, Dr...
...The document that spurred liberals to nickname the surgeon "Dr...
...Without embarrassment, he advocated the use of condoms...
...He listened very carefully, didn't ask too many questions, didn't say too much," recalls Gary MacDonald, executive director of the AIDS Action Council...
...The twins were joined at the chest, sharing one-and-a-half hearts, which could support only one child...
...Republicans on the subcommittee tried to limit the discussion to the age issue...
...Even the most knowledgeable outside observers had expected the kind of vague and euphemistic warnings about AIDS that Health and Human Services (HHS), under its conservative management, had been offering...
...As a surgeon, Koop's skills were universally respected...
...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...
...Koop frightens me...
...With his steely gaze, Dutchman's beard, summer white uniform and powerful Brooklyn voice, he is an imposing speaker...
...N]o family has ever come up to me and said: 'Why did you work so hard to save the life of my child?' "Koop wrote...
...Shoulders scrunched, elbows in, sometimes for hours, his large hands working through miniature incisions (repairing 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 college 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...
...Robert Kettrick, senior anesthesiologist at Children's, who assisted Koop hundreds of times in the operating room, says this arrogance results in part from "too many years in the university...
...I never saw him pushing life at any cost or for any cause!' For the first few years of his tenure, Koop gave little reason for his critics to think they'd been wrong...
...Koop would testify, but with a Justice Department representative at his elbow to make sure the adminstration's line was properly aired...
...Now, Senator Ted 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...
...When White House Chief of Staff Donald Regan was told that Koop planned to endorse the ban, he barred him from testifying...
...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 "essentially quadriplegic?' He tested his hands...
...We certainly feel he's been very positive...
...The choice was between doing nothing and having two deaths, or, through surgical separation, killing one so the other might live...
...he calls smoking "an addiction...
...Mike Synar banning tobacco ads...
...In an article used by Waxman to show Koop's intolerance, the surgeon had written, "Sadly, most mainline denominations have made pro-abortion statements illustrating their superficial theology, lack of morality, and insensitivity to the eventual reward for their own depravity...
...He created an organization that sent hundreds of third-year medical students to bush hospitals in remote parts of the world...
...As to the wisdom of APHA's past opposition, McCarter replies, "that's all behind us...
...He recommended surgery...
...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...
...Koop had been working behind the scenes with the Defense Department's assistant secretary for health affairs, Dr...
...Today it is the liberals who appreciate what Koop has to say...
...I was stunned," says MacDonald...
...Fair warning For a long time there was one issue about which Koop could not speak his mind—AIDS...
...So Koop's writings and past statements were allowed to speak for him...
...At a right-to-life seminar in 1979, for example, Koop had referred to the "women's lib movement" and the "gay pride movement" as propelling "antifamily trends," comments women's and gay rights groups pointed to as evidence Koop would discriminate against them and decimate abortionrelated medical programs...
...A large man—six feet one, 206 pounds—he had hung his head over the tiny bodies of some 100,000 patients in the course of his 35 years as a pediatric surgeon...
...His rhetorical combativeness is typical of academics, explains Kettrick, "but in Chick Koop's case, it came with a desire to then demonstrate his mastery of the subject and the dominance of his logic...
...Most of Koop's associates tolerated the arrogance that came with Koop's compassion...
...Several families offered to adopt the child...
...Brandt, said Koop was not to talk about the disease...
...The Washington Times called for him to shape up or resign...
...In spending this money, federal public health officials were told to be extremely circumspect, which led to vague and misleading public warnings 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...
...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...
...It was eight months before Koop, eventually allowed to testify, could win Senate confirmation...
...Some had feared that the intensely religious Koop might use the occasion to moralize about the disease's wicked causes...
...Doctrine Squads" snooped on people and hauled them off to be punished for "speaking of the Lord...
...And Rep...
...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...
...Thanks for not having an abortion," Koop told the woman...
...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 violation of civil rights laws if they withheld treatment from handicapped newborns...
...A small problem, however, stood in the way...
...Shot on 50 locations in five countries 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 performed in the U.S...
...The new Republican Senate, everyone knew, would almost surely support Koop's nomination...
...For Koop the decision was easy...
...It just doesn't make sense to me," Koop said publicly of Weinberger's decision...
...He helped build a medical school in Ghana, fight a dysentery epidemic in the Dominican Republic, and bring primary medical care to the Tarascan Indians of southwestern Mexico...
...He's dogmatically denounced those who disagree with him, and his intemperate views make me wonder about his, and this administration's, judgment," Rep...
...A set of Siamese twins had been brought into Philadelphia's Children's Hospital, where Koop was chief of surgery...
...Now they felt betrayed...
...A court later struck them down...
...Behind the scenes he really was manipulating and moving the administration to the decentralized, non-federal approach," says Jennison...
...They greatly admired him, but his bellicose style led to incidents of cruel insensitivity...
...Jesse Helms tried to remove this potential snag with an amendment changing the age restriction, which he attached to legislation on credit cards already approved by the House...
...Dr...
...they wouldn't move...
...Henry Waxman, Koop's most bitter enemy on Capitol Hill in 1981, is now his biggest fan...
...Waxman and the Democrats, however, proceeded to conduct a de facto confirmation hearing...
...He had been expecting it for years...
...Public Health Service, made another remarkable medical decision...
...In 1962 they had built the country's first neonatal surgical intensive care unit...
...He tried to walk, he recalls, but "it felt like I had cement boots on" He knew what was happening...
...Last October 23, he released his now-famous report on AIDS...
...In the late seventies, Koop toured the country with a lavish multimedia show he co-wrote, narrated, and starred in...
...He knew when to give up...
...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...
...The AAP, which adamantly opposed the existing "Baby Doe" regulations, suggested a compromise that appealed to Koop's Republican sensibilities: hospitals would set up their own "infant care committees" to review Baby Doe-like cases...
...We were getting 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...
...Conservatives were furious...
...Audrey Evans, head oncologist at Philadelphia's Children's Hospital...
...he warns of the dangers to nonsmokers of "passive smoking" and cites smoking as the number one hazard in the workplace...
...This allowed Washington to withhold federal money to states that lacked procedures for guaranteeing the medical rights of disabled infants...
...At these meetings, the rival group produced a "Statement of Principles for the Treatment of Disabled Infants," which in essence required physicians to treat infants with handicaps unless such treatment only prolonged the dying process...
...The sharp-eyed in Washington saw this as an early sign of the new administration's strategy of placating the far right while steering a more moderate course on social issues...
...Just as important, they claimed, was his lack of "significant" public health experience...
...I was amazed" "Many people—especially our youth," Koop announced at the report's October unveiling, "are not receiving information that is vital to their future health and well-being because of our reticence in dealing with the subjects of sex, sexual practices, and homosexuality...
...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...
...Jesse Helms, who had been Koop's strongest Senate supporter, called for his resignation...
...He does not have a public health background...
...They had supported Koop for surgeon general in 1981 over the fierce opposition of liberals, believing that his strong conservative views would guarantee a politically correct public health policy...
...None of this impressed APHA...
...Back then, he seemed a right-wing crank, an intolerant right-to-lifer whose reactionary views on abortion, homosexuality, and religion made him incapable of serving the larger public interest...
...On the advice of one physician, and over the objections of two others, the parents decided to forgo treatment...
...Said Koop, "As a person, I endorse the bill" It was a great victory for the bill's sponsors...
...Except for a numb patch on his hand, he is back to normal...
...Wavering legislators would have been foolish to cross the picket line...
...Whatever their motives, Koop's friends in the White House had fair warning, Koop recalls...
...A man of his political reputation, exercising the kind of moral leadership that the Public Health Service had not done to date...
...But some in the administration have tried...
...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...
...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...
...Research assistance by Alex Friend...
...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...
...Almost since the disease was first identified, gay groups, outside health experts, and scientists in the HHS bureaucracy argued to top officials that public education was the only weapon against a disease with no known cure...
...I just have the very highest regard for Dr...
...A decade later, Koop, now surgeon general of the U.S...
...But those who worked with him say his insistence on preserving life when possible was always tempered with reason...
...For 33 years he ruled over the Children's Hospital of Philadelphia as surgeon-in-chief...
...Reagan administration officials in the Department of Education protested elements of Koop's call for sex eduction...
...WARNING: THE SURGEON GENERAL MAY BE GOOD FOR YOUR HEALTH by Paul Glastris Six years ago, C. Everett Koop was loved by conservatives and vilified by liberals...
...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...
...defender of infants and the unborn, did the job himself...
...talk of "death with dignity" and "living wills" in the seventies had been "the thin wedge" that cracked open American morality and led to compulsory euthanasia for the old and infirm...
...Influential members of pro-life groups leaned on their White House contacts...
...In February of that year the administration slipped him into HHS as deputy assistant secretary of health, a job that doesn't require Senate confirmation, with the idea of bumping him up to surgeon general as soon as possible...
...His effort to bypass the House backfired, however, when Speaker Tip O'Neill, angry at the slight and sensing a prime opportunity to embarrass the administration, used an obscure parliamentary rule to send the credit card bill to the House health subcommittee, chaired by liberal pro-choicer Rep...
...Koop, with strong advice from his superiors, refused to testify, on the grounds that the House was usurping a Senate responsibility...
...Despite APHA's contention that he had no "significant" public health experience, Koop had worked much of his professional career as a volunteer consultant and organizer of Third World health efforts...
...But those officials resisted the idea, in part to avoid the kind of controversy over sex education currently swirling around Koop...
...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...
...It does this, and does it very effectively...
...It's not going to be political...
...I believe there are times nature has made a mistake and nature should be allowed to correct that mistake," says Dr...
...Koop took on other administration officials last summer...
...It arose in part from his work...
...He once encountered a woman at a party holding an infant...
...He and I were flat out adversaries on this thing," recalls Dr...
...The American Public Health Association (APHA) testified that there was an important difference between providing preventive health care for large populations, the role of public health professionals, and treating sick individuals, which is the role of most of the rest of medicine, surgeons included...
...The Baby Doe case made the front page of newspapers across the country...
...It doesn't seem to share Koop's extreme distaste for tobacco and the tobacco industry...
...The career that caused this disability began in the forties when there were only five other pediatric surgical specialists in the country and the notion of anesthetizing and operating on children was considered wildly risky...
...He raised some eyebrows by donning the uniform of the Public Health Service, the first surgeon general to do so regularly in years...
...The child was not hers, and she had had an abortion...
...To the Reagan administration, however, Koop's antismoking crusade has been a headache...
...Edward N. Brandt Jr...
...Secular Humanism" had become the official state anti-religion...
...And I'm not going to clear it with anybody before delivering it to the White House:' For months, Koop invited experts and representatives of AIDS-affected groups into his office...
...The surgeon general's duties and responsibilities are delegated by the assistant secretary of health...
...His courage on AIDS and smoking is to be commended," says Katherine McCarter, the American Public Health Association's associate executive director...
...The Senate approved the change after Helms misinformed them that the House had no objections...
...Waxman and Regan exchanged a series of angry letters...
...Instead, Koop was compassionate and extremely frank...
...Surgeons were able to repair the damage...
...For more than 30 years Koop had been a member of Philadelphia's conservative, evangelical 10th Presbyterian Church...
...I told them, I'm going to do a health report...
...With Koop running around the country passing out buttons, that's been a hard promise to keep...
...An Indiana judge ruled in favor of the parents' right to take their physician's advice...
...Seven days after its birth, the child died...
...Chick Koop didn't try to extend a life at any cost," says Kettrick...
...I said if I'm going to take the flack why can't I write the regulations...
...As Public Health Service personnel leaked memos to Capitol Hill staff members on the need for public education efforts, Congress appropriated nearly $10 million in 1985 and $30 million in 1986...
...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...
...Henry Waxman...
...The Baby Jane Doe case showed a diplomatic side of Koop that liberals hadn't noticed in 1981...
...He was the one who could speak from a medical viewpoint...
...Waxman said, summing up the liberal consensus...
...We really don't like to dwell on that...
...He had agreed to testify at Henry Waxman's health subcommittee, which was discussing a ban on all tobacco advertising...
...something called the "Rockhead Foundation" supported the culturing of "100,000 homosexual and lesbian test-tube babies to give the gay movement more political clout ." It's easy to see why liberals regarded Koop as a mean-spirited nut...
...Somehow, the integrity of the man—his willingness to make the medically correct decision, not the politically correct one— had eluded them in 1981...
...With some effort, he rolled himself to the edge of the bed...
...since the 1973 Supreme Court ruling legalized the practice...
...Quite the opposite, in fact...
...Koop would be largely held on a leash by his superior, the cautious, conservative assistant secretary of health, Dr...
...Most shocking of all, he called for an intensive program of sex education, beginning "at the lowest grade possible...
...Though Koop clearly represented the administration, he played the role of moderator, and was willing to listen...
Vol. 19 • March 1987 • No. 2
