PROJECT HOPE

Health Affairs

Interview with C. Everett Koop, M.D.

May 24, 2004

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PROCEEDINGS

INTERVIEWER: The date is the 24th of May,
2004. We're in the office of Dr. C. Everett Koop, at
Dartmouth, in Hanover, New Hampshire. Let me just take
a sound level here. Would you tell me your name, and
spell it?

DR. KOOP: I am C. Everett Koop, C, period,
E-v-e-r-e-t-t, capital K-o-o-p.

INTERVIEWER: All right. Good. What I'd like
to do is start by talking about children's health, as I
mentioned, since this is primarily a child health issue
of Health Affairs that we're going into. And maybe talk
most specifically first about pediatric surgery which,
of course, is where you got your start in medicine.
Just a word about how you've seen the development of
that as a discipline, and how you feel about it looking
back on it.

DR. KOOP: Well, I've always been delighted to
have been associated with pediatric surgery. It was
really a passion of mine, and I wish I could say that I

had thought years ago that there ought to be such a
thing as pediatric surgery, but that's not the case.
But I did know that children did not get a fair shake in
surgery, and when I had the opportunity to be part of a
new developing specialty, I seized it.
One of the things that I think made that

experience so remarkable is that it was a new specialty.

I was associated with the founding of the two societies
that represent pediatric surgery. One was the Surgical
Section of the Academy of Pediatrics, and the other was
the American Pediatric Surgical Association. In
addition to that, I had founded, with Stephen Gaines,
the Journal of Pediatric Surgery, and had the great
privilege of being the surgeon chief of the Children's
Hospital of Philadelphia from 1946 until I went to be
Mr. Reagan's surgeon general in 1981. So I entered on
the ground floor, and what I like to say is true, and
that is pediatric surgery really replicated the growth
of general surgery in America, but whereas it took
general surgery about 200 years to evolve, pediatric
surgery started from scratch and achieved about as much
as a specialty in 35 years.

INTERVIEWER: Where does it sit today? Are
you pleased with its developments, even after your
active role in it?

DR. KOOP: I am pleased with part of it, and
very frightened about another part. The part that I'm
pleased with is that we have developed a group of young
surgeons who are not just clinical surgeons and people
who understand how to do good surgical procedures, but
their bench research is contributing to other fields of
surgery, as well, and I think that's one of the ways
that a new specialty not only grows but retains the
respect of its competitive --

INTERVIEWER: Their "venture search"?

DR. KOOP: Their what?

INTERVIEWER: Their -- oh, their “bench
researcn."

DR. KOOP: Bench research.

INTERVIEWER: Bench research.

DR. KOOP: Yes, I'm sorry. The thing that
worries me about the future of pediatric surgery, I give
you the bottom line first. I don't think that the
surgical care of my great~grandchildren will be as good

as the surgical care was of my grandchildren. And let
me explain that to you.

I remember a day when I was the only pediatric
surgeon south of Boston and east of the Mississippi.
When we started, we were a very small group. I was the
fifth person in America who called himself a child
surgeon; "pediatric surgeon" wasn't invented until
somewhat later. But I was the first person in America
who did children's surgery exclusively. And that was as
recently as 1946, so you can see we are relatively
young.

The specialty grew in numbers. There was not,
in the beginning, an international society of pediatric
surgery, but the British Association of Pediatric
Surgeons served in that capacity, and it was sort of the
mother organization of other national pediatric surgical
societies.

What happened to pediatric surgery is part of
what happened to medicine itself. It slowly evolved
from being a pure profession to being a professional
business, and in business money is the bottom line, and
that means that hospitals, medical centers, and even

medical schools are competing against each other for
supremacy, and it got to the point, about 20 years ago,
when if a small hospital didn't have a pediatric
surgeon, parents knew enough about pediatric surgery
that they wanted their child to be seen by someone who'd
had experience with their child's problem. A reasonable
and sensible request. That meant that small hospitals
with no pediatric surgeon had to send from their
institution, elsewhere, patients who were considered
high risk pediatric surgical patients.

The resulting change in the business of
pediatric surgery was that more and more hospitals
advertised for a pediatric surgeon, the enticements were
great, "We'll build you an ICU, we'll do this and do
that for you," and the best way I can describe it is
that when you have the number of pediatric surgeons
multiplying the way they were, the gravy gets so thin
it's not nutritious. And I am convinced, especially in
a specialty like pediatric surgery where the technical
prowess of the surgeon is very important to the initial
success of the patient's outcome, I'm convinced that
nothing succeeds like experience on experience. And

today, there are so many pediatric surgeons that some of
them see very few of what we call "index cases," such
esophageal atresia, diaphragmatic hernia, intestinal
obstruction of the newborn, things of that particular
nature, which were real technical challenges as well as
physiologic challenges post-operatively, and there were
times in the Children's Hospital of Philadelphia when we
would have a dozen patients with esophageal atresia that
came through in a single month. And in the last
20 years, when I have occasionally made rounds in other
children's hospitals, the first question that I ask is,
"How many esophageal atresias did you see last year?"
And I get the astonishing answer, "Was that the year we
had two, or was that the year we had three?"

INTERVIEWER: How many pediatric surgeons are
there in the United States today?

DR. KOOP: I don't think I can answer that
question for you.

INTERVIEWER: But the numbers have
proliferated.

DR. KOOP: The numbers are great. Somebody
told me that there are something like 800 certified

pediatric surgeons, not all practicing in the United
States. That includes Canada, some from South America,
but that are certified by the American Board of Surgery
as pediatric surgeons.

And with the esophageal statistics, for
example, my group and I did 272 esophageal atresias --
that's not right. We did 472 esophageal atresias
between 1946 and 1981. And the results speak for
themselves. In my own personal practice, for the last
eight years that I was a surgeon, we didn't lose a
patient with esophageal atresia. And our survival rate
for premature babies was 88 percent. And I don’t think
that you can achieve that for the tough anatomical and
physiologic challenges unless you have the experience
that warrants your ability to meet the unexpected and to
take care of it.

INTERVIEWER: Both as a pediatric surgeon and
then in your role as Surgeon General, you had an
extraordinary opportunity to observe the health of
children or developments in the health care and health
of children. How have you seen that over the last half
century, and where do you feel we're headed?

DR. KOOP: Well, children occupy a very
special place in medicine. We always talk about the
children being our future, and therefore they deserve
our best, but I'm afraid we don't always deliver that
way, and I have to admit that the older I get, the more
I understand the relationship of poverty in a child and
poor outcomes in everything else. And I think that I'm
not beating a socialist kind of drum here, but I think,
as we look to the future, unless we take into account
what a severe role poverty plays in the future of
children, we will never be able to attack its base
causes.

Now, we have accomplished a good many things.
One of the things I'm proudest of is that during my
tenure as Surgeon General, working with Finch Hutchins
and Norma Cursett (phonetics) of the Bureau of Maternal
and Child Health, we were able to actually amend the
Social Security Act, Title V thereof, so that it became
the right of every special needs child in this country
to have coordinated, comprehensive, family-centered,
community-based care. And that was a tremendous
advance, because it said the child will have the support

of the family, which is so essential to developing kids
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emotionally, but it also said you won't have to travel
across the country to get it.

INTERVIEWER: What does that mean in terms of
clinical or social support? What did that mean? What
did kids get as a benefit of that they weren't before?

DR. KOOP: What they get is the ability to --
let me explain it with somebody like Katie Beckett, that
is known to many people. Katie Beckett was a child who
was respirator-dependent and lived in Iowa, but she was
hospitalized as a Medicaid patient 30 miles from her
family, and that was a great burden for the family to
provide the emotional support that they needed. And
Mrs. Beckett wondered why, when we had gotten children
out of hospitals into their home, on a respirator, at
ever so much cheaper rates per week than the hospital
could do it, why that wasn't possible.

And out of that came the Katie Beckett
Waivers, and that meant that Katie Beckett was
transferred from a hospital to her home. That meant
that it was community-based and not at a distant place.

She had the emotional support of her family, so it

became family-centered. It was comprehensive in that
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all of the necessary specialists and those who provided
social support were part of the team, and --

INTERVIEWER: And Medicaid continued to cover
it.

DR. KOOP: Medicaid continued to cover it, but
it was ever so much cheaper for them to do it at home.
And it's interesting that just the day before we're
speaking now, I noticed in the newspaper, warning that
there would be tampering with the Katie Beckett Waiver
System. So after all these years, we may have to fight
that battle again.

INTERVIEWER: It's K-a-t-i-e?

DR. KOOP: Yeah.

INTERVIEWER: B-e-c-k-e-t-t?

DR. KOOP: Right.

INTERVIEWER: There is social criticism or
political or policy criticism from time to time about
the income transfer between youth and the elderly, with
Medicare in particular commanding such a huge portion of
our public budget, and relatively less going to
children. Is that a concern you subscribe to in terms

of public policy?
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DR. KOOP: It's a concern that I have, because
all the time that I was a pediatric surgeon, I was aware

of the fact that our chief competitor was really not in

the pediatric field at all, it was geriatrics. And Just
as --

INTERVIEWER: "Chief competitor" in the sense
of?

DR. KOOP: Demand for services and the fact
that people were living longer, living better, and you
can't do either of those things without spending more
money. And so I would say that it can be summarized by
saying pediatric social and medical interests were vying
with geriatric social and medical interests for an
ever-increasing slice of a shrinking pie. And that
doesn't make for good social service, it doesn't make
for good family support, and it doesn't make for good
medical outcomes.

But I would say that on balance, except for a
few major things that stick out like sore thumbs,
children do get a better shake. They certainly do,
surgically. One of the changes --

INTERVIEWER: Than they did previously?
13

DR. KOOP: Than the did previously. I think
one of the changes that should be noted is pediatric
surgery started in a strange way, and the people who
called themselves pediatric surgeons in the early days
were really surgeons of the skin and all of its
contents. I mean, I used to do subdural hematomas, and
I'd work in the neck. I avoided the eye and the ear,
but the rest of it was my domain. And it didn't mean
that I kept out of the chest or the belly or the pelvis
or the extremities, and for a surgeon who loves surgery
the way I did, that was a wonderful system.

But if one looked at the development of
general surgery in America after World War II, the great
spurt in surgery, what I call "the golden era of
surgery" in America, came about because of
Specialization. The war made specialization easy, and
made it almost necessary.

INTERVIEWER: "Easy" in the sense?

DR. KOOP: Well, if you were in military
Situation and you suddenly had a huge bunch of burns,
you've got to develop a kind of specialist that can take

care of big burns. And the same is true with trauma,
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and then people began to say, "Well, look, I've had so
much experience in the chest, why do you abdominal
surgeons keep stepping in my territory," and on it goes.

The long and short of that is that with the
burgeoning of surgical specialties, I don't think
there's any doubt about the fact that patients got
better care and their outcomes were better. Largely on
the basis of the fact that I mentioned before about
pediatric surgery, study after study shows that the best
outcomes are in the places that have the most
experience. And surgeons did not like to see the log of
general surgery cut into any more splinters, and one of
the reasons that pediatric surgery faltered a little bit
in getting it started in American surgical circles was
that it was seen as not only the competition of another
specialty, but here were a group of people who came
along and said, "We can do what you do better at a
certain age," and that made the competition even more
telling. It wasn't just technical skills, it was
understanding the physiology of a newborn and a small
child.

INTERVIEWER: What do you think of the
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prospects for child health as you look at the situation
now, and look to the future? Is the aging of the
population going to continue to create competition that
kids won't be able to keep up with?

DR. KOOP: I think it depends, in the long
run, about advocacy. There are people who
have always been child advocates, and they've done a
tremendous job to advance the understanding of the
public to garner public and private funds, and to, in
general, move pediatrics along. But children are not
able to have their own lobby, and I think there's no
doubt about the fact that the geriatric lobby -- and
that's not a specific group of people, it's just a
tremendous variety of people who have interest in the
aging population because that's where their business
interests lie --

INTERVIEWER: And the aging population is not
quiet group themselves.

DR. KOOP: No, they're not quite, and they
vote. And I think that one of the major reasons why
groups of people like handicapped children have never

made the same kind of progress that elderly population
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has in gaining services that they need, is that they
don’t have the ability to fight for themselves. And
when you're fighting for yourself, I think you're
fighting a different battle than when you're fighting
for a class of people, like children, that you have sort
of a nebulous connection to.

The one thing that I think stands out as -- I
said like a sore thumb a minute ago -- and that is that
the pediatric world did not recognize the fact that
obesity, which is becoming a national problem, was also
affecting children. And they didn't seem to understand
that fat bouncing babies became fat children, and fat
children became fat adolescents, and fat adolescents
became fat adults. And we now have a problem that is
going to be very difficult to reverse, and it has very
serious implications about diseases in the long run and
in later years that are associated with obesity, like
Type 2 diabetes, breast cancer, colorectal cancer; that
sort of thing.

INTERVIEWER: So this, in terms of the
vigilance within the child health community, that's an

area that perhaps might have been attended to better?
17

DR. KOOP: I think it could have been attended
to better if, for example, I'd had another four years as
Surgeon General, even though people weren't talking much
about obesity in 1389, I would have made that one of the
pillars of a next term.

The government were very slow, I think, to
recognize what was happening with obesity and
overweight, and you may recall that in the private
sector I founded, with the aid of Hillary Clinton and
the White House, a thing called "Shape Up America."
Which was designed for the private sector working with
private entrepreneurs to provide a way for people to
become educated and aware of the dangers of obesity.

INTERVIEWER: Let's switch to your years as
Surgeon General. As you look back on those eight years,
what sort of reflections do you have about the job,
about the experience, and about the outcome?

DR. KOOP: Well, no one ever tells you what
the job description is of Surgeon General. And I think
it's entirely possible, the way that job was organized
when I arrived in Washington, to almost make it what you

will. And I found that at the end’ of Mr. Reagan's first
18

term, as his early appointees began to leave government
and go back to the private sector, that there were many
vacuums in the government, a lot of them in public
health and HHS. And waiting for somebody else to fill
those vacuums, I stepped in and tried to do those jobs.

I think it was appreciated by people who were
leaderless, but it provided the opportunity to get
several major things done.

One is, I don't think there ever has been --
had never before that been the same type of assault, not
just on the problems of smoking and the health
consequences thereof, but on the nefarious activities of
tobacco industry and their deceitful processes, which
were designed to obfuscate the public's understanding of
what the government was trying to teach them. And
fortunately(?), the momentum of that work has never
really subsided. And I think we -- I have a terrible
prospect of global expansion of smoking by the tobacco
industry with the University of Cambridge statisticians
predicting that by 2025 there will be an additional
500 million deaths of people now alive on this planet,

due to smoking causes alone.
19

But the other thing that was a huge problem
during my tenure was AIDS. And as I have made it
abundantly clear in my writings about the subject, no
one ever asked me to be the spokesperson of the
government for AIDS, but it's a job that I assumed
because nobody else was doing it and because, frankly,
the people who advised Mr. Reagan were doing such a poor
job of it. And I think the people -- and when I say
"the people," I mean the public -- appreciated honest
answers about a difficult disease to understand, and I
think that both AIDS and smoking are the two huge
problems that our global society faces in reference to
health in the future. The problems have expanded, and
they will not go away.

Smoking is a lot different than AIDS. Smoking
involves an addictive substance, and that changes the
whole aspect of the growth and development of an
industry that has to replace those it kills, with new
recruits on a constant basis, and the various
settlements that the tobacco company has fallen heir to
make it necessary for them to find new and outrageous

sources of income. And they can pay the huge bill that
20

they established with this attorneys-general of the
several states only because they had plans afoot even
then to smother the rest of the world where men smoke
but women didn't, and to turn their financial returns in
such a way that they could pay what they had indebted
themselves to do.

INTERVIEWER: Yet to these -- I do want to
pursue the tobacco theme, but staying on the PHS for a
moment and staying on AIDS, you described to me
previously the vacuum that existed and how back of the
hand or how informal your invitation to step up to the
AIDS issue and develop the first AIDS report had been.
Run that by me again, I mean how that happened, because
I think that's an important part of history.

DR. KOOP: Well, for reasons that were never
made clear to me, when AIDS was established as a disease
and we knew we had an epidemic on our hands, I was told
that AIDS did not come under my purview and that that
would be handled by other people in the department, and
I was reminded of that any time I made a public
appearance or went on television or gave a lecture, that

I was not to get into the subject of AIDS.
21

And yet, when that day came that I just
mentioned a moment ago, when the original Reagan
appointees began to go home to their points of origin,
there were fewer and fewer people who really knew what
was going on with AIDS, and it was easy to step in and
by that time I had secured, I think, a sufficient
confidence in the people of America that they could
expect me to handle the situation with integrity, that
the efforts that had been made to silence me before sort
of disappeared. And I did become the spokesperson, and
one of the things that aided and abetted that was that
we changed secretaries of HHS, from Margaret Heckler to
Otis Bowen.

Otis Bowen was a remarkable gentleman and a
physician, a man with tremendous political experience,
had been the governor several times of Indiana, and we
struck it off as medical and political colleagues right
from the start. And he made it very clear to me that it
was not his intent at any time to step on my toes or get
in my way, because he was very pleased with what I was
doing, and he gave me every support that I could have.

The next thing that came along that was
22

fortuitous was that President Reagan asked me to write a
report for the American people on acquired immuno-
deficiency syndrome. And I don’t think I've worked
harder in my life on anything, and we published that,
and except for treatment modalities, everything about
the epidemiology of that disease and so on that was
stated then is still true.

INTERVIEWER: And that report you got through
with very little clearance, as I recall you and perhaps
Secretary Bowen?

DR. KOOP: Secretary Bowen and I were the only
people in HHS, except for two people appointed by me to
be my associates, that knew what was going on. And I
had agreed with Otis Bowen that if we passed this
through the usual channels, of one being the Secretariat
of the HHS, it would never have seen the light of day,
because there were too many people, especially those
surrounding the president at that time, who felt that
who had AIDS after all, weren't they prostitutes,
homosexuals and drug abusers and, after all, didn't they
deserve what they had?

And the thing that I published had as its
23

theme, along those lines, we were fighting a disease,
and not the people who had it. And I think that was a
turning point --

(End of Tape 1, Side A)

INTERVIEWER: This is Dr. Koop, Side 2.

DR. KOOP: I do think that -- I forgot what I
was saying.

INTERVIEWER: I'm sorry. The question was the
clearance process and who -- and your position --

DR. KOOP: Yes. I did think that the major
mistake that was made by government and the public was
to treat AIDS as a political disease and not as a public
health disease. I think we would not be in the terrible
global situation we are right now if we had treated this
the way we would have treated typhoid fever. Or
syphilis. Or gonorrhea. And instead, we had special
rules about privacy and special thoughts about
protecting people, and as a result now we have a
pandemic that is out of control in Asia and in Africa,
and so --

INTERVIEWER: So you think if we'd been more

incisive and more traditional in our infectious disease
24

approach, the epidemic would have been better contained?

DR. KOOP: I think the epidemic would have
been far better contained if we had treated it according
to public health principles as an infectious disease
that was containable. I mean, the thing that stands out
about AIDS more than anything else is its
preventability. And as long as you had no way of
knowing who contacts were and no way of understanding
the reasons for testing and not testing, we just were in
a quagmire for years.

INTERVIEWER: A word on being the Surgeon
General. The metaphor, the cliché is, "bully pulpit."
And you certainly used it as a bully pulpit. But beyond
that, how did you feel about your prosecution of the job
and what would you say about it as a position in
general?

DR. KOOP: Well, I have tried to intimate that
it is a job that you can make into really what you'd
like to make it.

INTERVIEWER: Or, I presume, not? Should you
not have the vision --

DR. KOOP: If you decided to sit and read the
25

New York Times, that would be also acceptable. Nobody
would say, “Hey, do your job a little better."

I think the present situation, which I don't
know whether you want to get into or not, but --

INTERVIEWER: Sure.

DR. KOOP: But we have a Surgeon General now
whose qualifications seem to be perfectly satisfactory
for the job at hand, but you don't hear much about him
because he doesn't have the freedom that I was afforded
by the Department of HHS; in this case, being strongly
overshadowed by the White House. And so I describe
Dr. Carmona as being a capable Surgeon General who is
unfortunately wearing a straitjacket.

And I think that in this era where most people
are a little concerned and some people greatly concerned
about our preparedness for a possible biochemical
terrorist attack, that this is a magnificent time for a
Surgeon General with a bully pulpit to educate the
people of the country, and, by moral suasion, to improve
the preparedness of the public health service to deal
with the problem.

INTERVIEWER: But that isn't being afforded