The Activist Surgeon General : It Used to Be a Figurehead Position. Then C. Everett Koop Came Along.

His nomination nearly six years ago was one of President Reagan’s most bitterly contested. His opponents called him a right-wing, religious, anti-abortion zealot with no public health experience. Attacking him incessantly, they charged that he would use his public office to preach his own conservative social agenda--hardly appropriate behavior for the surgeon general of the United States. Editorial writers around the country urged the White House to “dump Koop.”

His prior activism came back to haunt him: the 1978 pro-life film in which he appeared in a desert, surrounded by dolls who symbolized all the babies not born because of abortion; his description of amniocentesis, a test to detect fetal abnormalities, as “a search-and-destroy mission”; his labeling of homosexuality and single parenthood as “anti-family.”

His detractors in Congress, led by Los Angeles Democrat Henry A. Waxman, chairman of the House Energy and Commerce subcommittee on health, held up his confirmation for nearly a year. During that time he would come home every night, discouraged, to the cramped apartment he and his wife had rented in Washington once it became apparent that the process was going to drag on indefinitely. He would show her that day’s scathing editorials and suggest they abandon the battle.

“I can’t take any more--I don’t know what we’re doing here,” he would say. “Let’s go home to Philadelphia.” And she would reply: “Let me remind you--you’re unemployed in Philadelphia. Let’s stick it out.” Betty, his wife of 48 years, says today: “I thought he could never live with himself if he gave up.”

It would be out of character for Charles Everett Koop ever to abandon anything he has set out to accomplish. Koop is an imposing 6-foot-1, 206-pound figure with a booming voice, an intimidating demeanor and the same kind of neatly trimmed, square-cut beard favored by his Dutch ancestors. He is the first surgeon general in years to actively encourage the wearing of uniforms at the Public Health Service, an act he has described as “a real morale booster.” And on Wednesdays, which he has dubbed “uniform day,” he looks like a captain ready to put out to sea, resplendent in his gold buttons, braids and ribbons.

Today, well into his second four-year term as the nation’s surgeon general, he has surprised almost everyone. A Presbyterian with strong moral convictions, he continues to speak out against abortion and in favor of protecting the rights of handicapped children. And he has made enemies as the chief defender of the Reagan Administration’s controversial “Baby Doe” regulations, which brought the federal government directly into cases involving the treatment of deformed newborns.

Despite earlier concerns, however, he has not used his public platform to wage a campaign against abortion. “I don’t have any authority to change the law,” he says. “I haven’t changed my position--I’ve always been hard-line on abortion--but I have extraordinary compassion for those who have to make those decisions. I’m just glad I’m not an obstetrician.”

And, by launching a tireless crusade against cigarettes, Koop has become the most activist surgeon general on this issue in history and one the tobacco lobby has grown to fear and resent. He travels the country to promote his idea of a smoke-free society by the year 2000, speaking endlessly on the health dangers of cigarettes and smokeless tobacco. Declaring tobacco public-health enemy No. 1, he has become an adamant fighter for the rights of nonsmokers and an eloquent spokesman for the plight of the cigarette-addicted. “There’s nothing tougher than to give up smoking,” he says.

Most recently, he has taken on a new assignment. The White House has asked him to write a report to the public on AIDS, the invariably fatal disease that cripples the immune system and leaves the afflicted individual helpless against cancers, neurological disorders and ravaging infections. Reagan hopes that a report bearing the surgeon general’s name will calm public fears over the disease and prove to be a watershed event in public thinking about AIDS, much as the first report on smoking by an earlier surgeon general has defined that issue since the 1960s.

Finally, even Koop’s detractors have begun to recognize that his intense feelings on abortion were not lifted verbatim from a right-wing primer. Rather, Koop seems to have developed them--and his views on handicapped children--over more than three decades as a pioneer in children’s surgery at Children’s Hospital in Philadelphia.

“I feared he was going to politicize the office and use it to promote his religious, right-wing positions,” Waxman says. “I was wrong. So far, he’s done an outstanding job in trying to prevent diseases, in highlighting the need to stop smoking and in putting a greater emphasis on the public health. We’ve had our disagreements--Baby Doe, for example--but, by and large, he’s done a conscientious job and has worked diligently to enhance the public health of the American people.”

Koop, known to his friends as Chick, speaks of those early days without anger. Still, he says, “I was unfairly maligned. I know a lot of it is theater. But there is one remarkable advantage to what happened: I had to prove myself everywhere I went. And the benefit has been that the people I had to prove myself to believe in me now. I have credibility.”

Recently, Koop encountered Waxman at a luncheon sponsored by an anti-smoking group at Washington’s posh F Street Club. Koop spoke first. “It’s hard to believe I have so much respect for somebody I once disliked so much,” he said. The diminutive Waxman looked up at his old adversary. “The feeling is mutual,” he replied.

A lovely, almost ethereal black-and-white photograph hangs above Koop’s desk in his office at the Department of Health and Human Services and on a living room wall in his home on the campus of the National Institutes of Health in suburban Bethesda, Md.

It is of his son David, one of his four children, who was a 20-year-old junior at Dartmouth College when he died in 1968 in a rock avalanche while climbing in the White Mountains of New Hampshire. He is standing on the top of a mountain, wearing cutoff jeans, a T-shirt and a backpack. He is staring away from the camera at some unknown but almost certainly spectacular sight. His head appears to be touching the clouds.

Even before his son’s death, Koop, a pediatric surgeon, had developed a reputation for his sensitivity in helping families cope with the grief of losing a child. He had spent his career dealing with dying children--other people’s children. In early 1968, he realized that four members of his staff who had become specialists in each of four pediatric problems “had each had a child born to his wife with that very same problem.”

He asked himself: “What am I famous for?”

With horror, the answer came: “Dying children.”

A premonition, which he shared with no one, began to gnaw at him. “I was convinced I was going to lose one of my children,” he says.

After David was killed, “nobody in the family was ever the same,” Betty Koop says. “It was a terrible blow, a very devastating experience to lose a child--especially a child in good health. But all our children grew from it, spiritually and emotionally. We told ourselves that God doesn’t make mistakes--it was part of his plan for our family.”

She pauses. “I told my husband it would better enable him to deal with parents. It would give him more insight into their grief and their loss. When he would say, ‘I know how you feel,’ they would believe it.”

But instead, the loss of his son--which he calls the most profound event in his life--drew him into the grief of his young patients’ parents, and his professional detachment disintegrated. He says it took him a long time to get it back.

Ten weeks after the accident, Koop and his wife found their son’s Bible opened to the second-to-last verse of Jude, the final passage David had read before he died: “And now unto him who is able to keep you from falling. . . .” Years later, the Koops wrote a short book about their son’s death, called “Sometimes Mountains Move.” It detailed how their religious faith enabled them to endure the tragedy. “Many people have told us how much it has helped them,” Betty Koop says.

The Koops’ surviving children are Allen, 42, a history professor at Colby-Sawyer College in New Hampshire; Norman, 40, a Presbyterian minister in New Jersey, and Elizabeth Thompson, 35, known as Betsy, a homemaker in Georgia. They also have seven grandchildren.

Koop met his wife, Elizabeth, now 68, at the Dartmouth Winter Carnival in 1936, where he was a student. She had come from Vassar College for the weekend. “She was the date of somebody else--and I swiped her,” he says.

Betty Koop--”I call her Liz; nobody else does”--tells a different but no less appealing version of the story.

“That’s when we met, but we didn’t see each other again until the following May,” she says. “He invited me up for the spring parties. By the end of the weekend, we were engaged--but we waited two years before we got married.”

Koop was reared in Brooklyn, N.Y., the only child of a banker. “My life as a kid was fascinating,” he says. “I learned a lot from both (my grandfathers). We used to wander through the cemetery on Sundays, and they would use the tombstones to teach me the history of Brooklyn. One of my grandfathers took me to Nova Scotia. He took it upon himself to entertain the lighthouse keepers. He was practically a citizen of Yarmouth, Nova Scotia. He’d sing hymns and play his concertina.”

He pauses. “Those kinds of things don’t happen anymore,” he says. “Kids don’t seem to have time for their grandparents anymore.”

Betty Koop describes her husband (who rises at 5 a.m., first to pray and then to attack his paper work) as a workaholic, and she worries about what he will do when his term as surgeon general ends--though “I know he’ll find something,” she says. “He sets tremendous goals and standards. It’s hard for him to take time off and relax. He used to make jewelry. He brought it all to Washington, but he never even opened the cartons.

“He’ll be 70 in October, but he doesn’t look it or act it. He always says, ‘It takes an old man like me to keep the schedule you young men set.’ ”

She says that despite the impression he gives as gruff and preacher-like, “he is a very kind person who extends himself to people constantly,” and his son, Allen, says, “Dad has always been an advocate for some group of people who needed someone.”

But his wife teases him: “I tell him, ‘You frighten people.’ ” Koop, amused and perplexed by the austere image he seems to convey, insists, “I really am a human being.”

He decided to become a doctor at the age of 5. “I saw a movie about a surgeon,” he says. “When I saw what he could do--remaking lives--I never wavered from it. I’ve been dedicated to it ever since. And I loved it. Every minute of it.”

His debut as a surgeon came unexpectedly. He was a premed student at Dartmouth and had landed a summer job at a Long Island hospital, where the chief of surgery became his mentor. One day, as Koop stood in the operating room watching the chief surgeon getting ready to amputate a leg, he was startled when the doctor said to him:

“Koop--why don’t you do it?”

Without hesitation, the 19-year-old Koop took over. The operation was a success.

“Surgery is filled with so much,” Koop says. “It’s a very different life from that of other people. You have so many decisions to make per hour. You get used to operating on a tightrope. When you lose a patient or the result is imperfect, it’s a very discouraging thing. In the beginning, you win few and lose many. In the end, you win many and lose few.”

He estimates that he has treated 100,000 children during his career. In 1948, when he became surgeon-in-chief at Children’s Hospital in Philadelphia, he was one of only six pediatric surgeons in the country. Surgeons were reluctant in those days to operate on children. “There was no basic science,” he says. “It all had to be worked out.” It was considered too dangerous to put an infant under anesthesia. Doctors often insisted that surgery be delayed until children were older. If a youngster had a hernia, for example, the child would have to wear a truss until he was at least 5--and then the surgery would be performed.

“Children didn’t get a fair shake in surgery, and I saw this as one of the great inequities in medicine,” he said several years ago. “Children had as much wrong then as they do now. And yet we were so ill-equipped to take care of them.”

Determined to change this, he directed his energies toward building the finest surgical staff possible--and he is credited with creating a first-rate pediatric surgery department at Children’s. He brought in specialists. The first to be added was a neurosurgeon who was needed to treat the large numbers of babies born with spina bifida, or open spine, and hydrocephalus, or increased spinal fluid in the head. These two conditions would, years later, figure prominently in the publicized Baby Doe battles of the Reagan Administration.

“He was the forefather of pediatric surgery,” says Dr. Louise Schnaufer, associate professor of pediatric surgery at the University of Pennsylvania School of Medicine, of which Children’s Hospital is a part.

Schnaufer, one of Koop’s early residents in 1957, calls him “one of the best surgeons I’ve ever seen and one of the most dedicated to training young people to become pediatric surgeons.” She laughs. “Of course, he is very, very imposing. He can scare a young resident to death. But any professor is like that to a young resident.”

“My lifelong ambition,” Koops says, “was to have the most competent group of pediatric surgeons in the country under one roof. It took me 33 years to do it.”

In 1962, he established the first surgical newborn intensive-care unit in the country. “Before that, newborns were operated on and put back in the ward--with no monitors,” Schnaufer says. “People just looked in on them periodically. It’s amazing that no one thought of it before 1962.” A second breakthrough he promoted, she says, was the use of intravenous nutrition.

There were many firsts over those years, though not all of them had happy endings. In 1957, he successfully separated a set of Siamese twins, but one sister died from a cardiac defect when she was 9. The other one reached adulthood, married and is still in touch with him.

In 1974, he separated a second set of Siamese twins in an operation that captured worldwide attention--neither twin had lingering physical problems. Tragically, two years later, one of the sisters choked to death. A sorrowful Koop delivered the eulogy at her funeral.

In 1977, he separated Siamese twins who were born with only one healthy heart--one heart that could not sustain two lives. One baby girl had an essentially normal four-chambered heart that was fused to the stunted two-chambered heart of her sister. “One child had to be destroyed to save the other,” he says.

He adds, his expression grim: “The nurses couldn’t believe it. Here was pro-life Koop about to kill a child.”

The twins’ grandfathers, both Orthodox rabbis, would not agree to surgery until they had conducted a Talmudic argument. The debate lasted 11 days, with each rabbi taking a different position every evening. Finally, they consented to the operation. “I’m glad I had that time to get ready,” Koop says. “I needed it to prepare emotionally.” But it was almost too late. “They were already in heart failure when I began the surgery.”

“He was very patient (with the delay),” Schnaufer recalls. “He knew this was a unique situation because he could be legally responsible for the death. He could have been indicted for killing a child. He got legal counsel and legal permission. He does everything so thoroughly. He knew they had to go through this. He didn’t pressure them. The stronger one was designated to survive--the other one was more or less a parasite.”

Koop himself clamped off the carotid artery that was feeding blood to the baby with the deformed heart. Death was instantaneous.

But, Koop says quietly, “The other one lived 47 days and died of hepatitis, probably contracted from a blood transfusion. That was a real low point for me.”

After he devoting his life to rehabilitating children, those close to him say, it is simply inconceivable to him that anyone could end an unborn life or deny any child a chance to be saved.

“There are certain babies who should be allowed to die, and most of us recognize this,” Schnaufer says. “But one of Dr. Koop’s greatest contributions was developing techniques that saved many infants with physical problems incompatible with life. Until the 1940s, many of these things went uncorrected because no one knew how to correct them. He and several others created the techniques that cured these children.

“All of this came together over the years,” she says. “He salvaged so many handicapped babies, most of whom later turned out to be blessings in the lives of their families. It became more and more of a driving force in his whole life.”

Koop explains it this way: “When you do a piece of surgery on a newborn who weighs only 2 1/2 pounds and you know you’ve given him a life expectancy of more than 70 years, that’s a feeling of incredible high.”

Traditionally, the surgeon general has merely been a figurehead. He has had few responsibilities other than to issue an annual report on smoking, which began in 1964 with the first major health indictment against cigarettes. Unlike other Administration officials, the surgeon general, who earns $85,000 a year, is not supposed to be a politician or a dealmaker. He is not expected to set policy or lobby for votes. If he chooses, he can simply remain behind the scenes and write his annual smoking reports.

Not Koop. “If there is anything the surgeon general is supposed to do, it’s to warn people of things that are a threat to their health,” he says.

And that is exactly what he has done. He has aggressively embraced the smoking issue--so much so that in July he defied the White House by supporting a total ban on the advertising of all tobacco products. Koop--although an Administration team player--was reportedly pressured by the White House to withhold his views. Yet, he still felt compelled to tell Waxman’s subcommittee that he favored a bill to end the tobacco industry’s $2-billion-a-year promotional efforts: “As a person, I endorse the bill.”

Koop has delivered many speeches unabashedly condemning the health dangers of cigarettes. “Smoking is guilty of being the leading preventable cause of disease and death in this country,” he declared recently in Glen Ellyn, Ill. “That’s not just the verdict of science. It’s also the verdict of your government, which has taken its cue from the scientific record.”

In November, he plans to issue the surgeon general’s annual report on smoking; this one will deal with the effects of “passive” smoke on the nonsmoker. “We are going to nail down (the effects of ) passive smoking,” he says, adding, “It’s bad, believe me.”

Koop, who has never smoked cigarettes and gave up his pipe 10 years ago, calls his idea for a smoke-free society by the year 2000 “a pet of mine.” Knowing that an outright ban won’t work, he says his concept means “that smokers will not smoke in the presence of nonsmokers without their permission.” He predicts that nonsmokers will enthusiastically support it.

Momentum is in his favor. More and more companies, motivated in part by the promise of huge savings in health-care costs and productivity, have established programs to help their employees give up smoking. Approximately 800 anti-smoking ordinances have been approved around the country. Legislation is pending in Congress to prohibit smoking in government buildings, and some federal agencies and the military have already established their own non-smoking policies. The National Academy of Sciences and the American Medical Assn. have called for a ban on smoking on all domestic airline flights. The federal excise tax on cigarettes has been doubled, and legislators are talking about increasing it further. Health warnings on cigarette packages have been enhanced, and warnings have been added to smokeless tobacco products.

“Do you know that they put on tobacco-spitting contests in the South and kids as young as 4 take part?” Koop says. “That’s gross.”

Still, Koop describes his relationship with Senate Agriculture Committee Chairman Jesse Helms (R-N.C.), who counts tobacco growers among his most important constituents, as “excellent.”

“We have never discussed smoking,” Koop says, chuckling. “In fact, he has defended me. Jesse Helms has said that I am a ‘reasonable physician’ and all ‘reasonable physicians know that smoking is dangerous to your health. Dr. Koop always separates the health issue from price supports.’ ”

Predictably, Koop has not endeared himself to the tobacco lobby, although industry officials coolly acknowledge his right to speak out. “That’s his prerogative in that particular office,” says Scott Stapf, a spokesman for the Tobacco Institute. “We disagree with him, but it’s not like we have dart boards up with his face on it.”

In the Baby Doe cases, Koop’s involvement drew criticism from both sides: He alienated not only physicians, who felt that the rule was an unwarranted government intrusion into the practice of medicine, but also the right-to-life movement, which felt he had not gone far enough. The original regulation set up “hot lines” in federally assisted hospitals for tipsters to report cases in which severely handicapped newborns were denied surgery or other forms of care. Later, Koop became even more involved, serving as the architect and mediator of a revised version that established voluntary hospital committees to review such decisions as they were being made. In June, the Supreme Court declared such federal efforts in Baby Doe cases unconstitutional.

But Koop, admittedly “disappointed” by the high court’s ruling, still believes that the controversy increased public consciousness and forced parents and hospitals to think more compassionately about such decisions. “It was an acrimonious debate, but a lot of good things happened,” he says. “We had a sharpening of ethics that we hadn’t had before. The only thing that matters, in the long run, is that children are protected.”

AT SUMMER’S END,KOOP refused all appointments and sat down to begin work on the AIDS report, expected later this fall.

Until now, he has been silent on the subject of AIDS. For the most part, AIDS policy and information has come from the office of the assistant secretary for health, his AIDS coordinator, officials at the federal Centers for Disease Control, and from the department’s medical and scientific research arms at the National Institutes of Health.

Koop’s current involvement comes on the orders of President Reagan, who believes that the public will trust the word of the surgeon general.

But some of the populations at risk for AIDS, remembering Koop’s past rhetoric, are nervous. “It doesn’t matter how I feel about homosexuality,” says Koop. “That’s not my job as a health officer. When I was a surgeon it didn’t matter if I was treating the gunshot victim or the perpetrator caught by the police--they were both people.”

Koop describes himself as “a listener and an observer” in gathering AIDS data. Indeed, Jeff Levi, executive director of the National Gay Task Force, and representatives from other gay rights groups and AIDS organizations met with Koop for several hours to discuss the report. They wanted, Levi says, to emphasize “the need for the government to do more education and prevention . . . and to understand the civil rights concerns of those affected.”

“We were certainly impressed with the level of attention and interest he showed, but he gave us no clue as to what his thinking was,” Levi says.

Koop says he has met with every group or individual with an interest in the AIDS report who has asked for his time. “I want everybody who has a stake in this to have an opportunity to tell me what it should have,” he says. And Koop, who intends to write this document himself, says that though it will break no new ground, he wants it to be the definitive report on AIDS.

“It will not be a policy statement,” he says. “It will be designed to let people have the facts--not to scare them, but not to let them have a sense of complacency either. When you finish reading a sentence, you won’t say, ‘Did they say it all? Did they leave something out?’ ”

And, he adds: “It will have the imprimatur of a name the public has come to rely upon.”