Everett Koop : The Former Surgeon General Examines the Nation’s Health

Everett Koop was probably the most influential and outspoken U.S. surgeon general in the history of the job. Unlike his predecessors, who were figureheads for the most part, Koop used his eight years as the nation’s top doctor to voice his opinions on the country’s most pressing public-health problems--often to the chagrin of the Ronald Reagan Administration.

At the same time, Koop, an imposing figure with his 6’1” frame, his stern demeanor, booming preacher’s voice and the same sort of neatly trimmed, square-cut beard favored by his Dutch ancestors, shocked and delighted his early critics, who initially feared he would apply his politically conservative and religious views to health issues.

Instead, Koop used his public platform to launch a relentless campaign against smoking, to defend the rights of deformed newborns and, in a landmark report to the public, to call for early childhood sex education and the use of condoms in the fight against the AIDS epidemic. Moreover, he condemned AIDS-related discrimination, calling for compassion for those suffering from the deadly disease.

An avowed foe of abortion, he nevertheless has approached the issue differently from other anti-abortionists. He opposes reversing Roe vs. Wade--the Supreme Court decision guaranteeing a woman’s right to abortion--and instead believes society should focus on reducing the need for abortion by emphasizing more contraception education.

Conservatives attacked him for abandoning his constituency. Liberals applauded his transformation. But Koop scoffed at both, insisting that he remains the same person he has always been--but politics and personal views have no place in public-health policy.

A native of Brooklyn, N.Y., Koop decided early on--he believes it was at the age of 5 or 6--to become a doctor. He was graduated from Dartmouth College and Cornell University Medical School. Before becoming surgeon general, he spent three decades as a pediatric surgeon in Philadelphia, where he established an international reputation for his innovative surgical techniques.

Since leaving government, the 75-year-old Koop has written his autobiography, “Koop: The Memoirs of America’s Family Doctor,” hosted a five-part television series, become an activist for children by leading the national Safe Kids Campaign to protect youngsters from accidental injuries and has traveled the country, speaking out on the health issues he feels are important.

Question: What’s life been like for you since you left the government?

Answer: The last couple of years of my life have been extraordinarily interesting. I almost think each successive career surpasses the one before it. I’ve been crisscrossing the country lecturing, attending meetings, talking to people, assessing where we are in health care and where we ought to go. I’m extraordinarily interested in health-care reform.

Q: What is the state of health of our nation’s health-care system and can we cure it?

A: Our health-care system is in crisis, bordering on chaos. Unfortunately, most Americans believe members of Congress could fix it tomorrow--they can’t. The changes that are needed are so complex that it will take us a decade to get from here to there.

Q: What do we have to do?

A: We need to do four things. We have to do something to cut down on administrative costs, since paperwork is 24 cents of every health-care dollar. If we cut that in half, we would have $100 billion to apply to the other things that need fixing.

We have to alleviate the need for malpractice and the need for doctors to practice defensively. We should substitute binding arbitration for lawsuits and, as part of that, a no-fault compensation fund that could come from the present insurance system. That would take care of the mal-occurrences that happen despite a doctor’s best efforts: If I have a coronary while you’re taking out my gallbladder, that’s an act of God--the doctor should not be sued.

We need to provide health insurance for every American to cover the basic needs plus catastrophes, funded in a variety of ways. This could include the $100 billion saved from unnecessary paperwork, and other things could enable you to begin the application of outcomes research, improved doctor-patient relationships with the increased use of patients in decision-making. That could get rid of 25% of medically unnecessary procedures, which could give you another $200 billion.

Q: Where do you start?

A: There are seven players in the health-care game, and all have an idea of what should be done--and all distrust each other. They include the government, doctors and other health-care workers, hospitals, third-party payers, lawyers, the medical/pharmacological-industrial complex and consumers.

It’s like football players in the middle of a losing game. They’re all shouting at the same time. But only the coach can call the next play.

The problem is that the United States has no coach. The only coach that can call the plays is the President. The President needs to call all the players together and say: “I am giving you the following charge: In order to achieve a goal, and for each of you to make a profit in the long term, you have to be sacrificial in the short term. We have to fix the system and the public will be holding you accountable.” It’s known as policy by embarrassment--and it works.

Q: Part of the problem, then, is there hasn’t been any real leadership on this issue?

A: Yes. The succession of Democratic presidential hopefuls will be making extravagant promises to garner votes. Eventually, out of that, will come a platform on health; therefore, there has to be a response from this Administration. There will at least be a debate.

Q: How do you feel about the Bush Administration’s overall performance in the health area?

A: I have been disappointed that there hasn’t been a greater health initiative during the last three years--especially since there are so many Americans willing to move forward on such issues as AIDS, smoking, drunken driving, violence. I think a definite momentum about those issues was built during the Reagan Administration--and it has faltered.

Q: You were eloquent and outspoken on AIDS during your years as surgeon general, but many of your recommendations--and those of two major AIDS commissions--have been ignored by the last two Administrations. Are we losing the battle?

A: It seems to me that the federal government is capable of a better education program than what I see being delivered to the public. My interpretation is that they have found barriers that have been erected by the White House and by powerful people in Congress to be insurmountable. I don’t think we’ve lost the battle by any means, but we have been deterred by its ambitious pursuit--but remember, we are dealing with behavioral issues that are difficult to change.

Q: What impact did Magic Johnson’s disclosure have?

A: I have been waiting for five years for two people to arise in our society--”Granny Doe,” who will bring to light the horrors of elder abuse, and the other one is a Magic Johnson. A lot depends on what Magic Johnson wants to say and how his handlers will guide him. The most important contribution he could make is to remind Americans that AIDS is a sexually transmitted disease, and that you can get it from regular heterosexual intercourse.

Q: You’ve had little to say about abortion since you’ve left government. Why?

A: I’m not talking to either side of the abortion issue until they sit down and talk to each other. I think we’ve had 18 years of rhetoric, with very few people changing sides. The time has come to get rid of abortion--which I am convinced both sides would at least like to see reduced--by attacking the cause of abortion, which is unwanted pregnancy. And that can only come about by the understanding of contraception--and a commitment to it.

Q: How do you feel about the “gag rule?” Should pregnant women be told that abortion is one of their options?

A: I can’t understand why nobody has ever gotten up in public and said: “No one that I have ever met is able to give unbiased advice and counsel to a woman who is pregnant and doesn’t wish to be.” Further, I don’t understand why somebody hasn’t proposed that all pregnant women be counseled by representatives of both sides of the issue.

Q: What are the most important health messages that you would like to deliver to all Americans?

A: Stop smoking. Don’t drink if you have a problem with it. And for those who don’t have a problem, drink only in controlled moderation. The best thing that could happen in that area is an absolute commitment to the designated driver.

Exercise and diet appropriate to one’s age. You need your doctor to check your blood pressure once a year, and your cholesterol every five years--if it’s normal--and find a way to avoid stress, and you can do it. All of those things can be done by an individual who chooses to take charge of his or her health.

There are some special things I’d like to say for children, starting with the moment of conception: Mothers should get good prenatal care and a safe delivery. And children should receive appropriate immunization and screening. Then, prevent injuries--which is the chief cause of death of youngsters.

Q: How is your own health?

A: In my 76th year, my health is great. I continue to run circles around my colleagues, and I’m grateful for the energy and stamina I have.