26 him, in your judgment. DR. KOOP: In my judgment, we are not very well prepared at all. And the things that I've seen by people -- not necessarily medical people, but people on inside of government, who have been prompted to speak in the last few months of the Iragi war, they confirm everything that I fear about the lack of preparedness of the country for biochemical response. INTERVIEWER: On the Surgeon Generalship, others have come to town with, I'm sure, ambitions for the job and have not succeeded as well as you did --and as you bring your own persona and your own level of charisma and energy to the job, but how much is it the person and how much is it the political circumstances they work within? DR. KOOP: Well, I don’t think you can say it's either one to the exclusion of the other. There have been a lot of people who have discussed my performance as Surgeon General with me, and if they were people that I recognized as having experience in government I have asked them, "Why do you think I was successful?" And I would say the consensus of those 27 people has been something like this. That in Washington, you will find people who are remarkable diagnosticians of the problem, others who have wonderful therapy to change a situation, and a third group of people who do it. And I've been told that I have all three of those characteristics, and my work style is to diagnose, plan the treatment, and then do it myself. INTERVIEWER: In doing what you did, you arguably changed constituencies in terms of your support virtually a hundred percent, or -- and several times. How did that come about? Did you change? Did they change? Was it the time? DR. KOOP: I think there's no doubt about the fact that the people behind Mr. Reagan -- and in all the things I say about Mr. Reagan's administration, I separate Reagan the man from Reagan's advisers, because I found Ronald Reagan to be a straightforward person. If it hadn't been for the real conspiracy to keep me from the president about AIDS, I think that Reagan and I would have gotten along very, very well. And I think he would have seen the concerns that I had early on, and would have avoided for himself and his administration a 28 lot of the criticism that he had. I tried to blunt the criticism that Reagan had by saying, "The president doesn't usually assume the public air waves to talk about the health problems of the nation. That's why I'm here. And no one could have tried harder to give you an absolutely clear understanding of what we face with the problems we do face in health, especially with smoking and AIDS." And -- you had another question there. INTERVIEWER: Yeah, weli the question about the constituency. DR. KOOP: Yeah, my constituency. I think the people who advised Mr. Reagan saw me as an ultra- conservative who would do their bidding and who would fit very nicely into their preconceived notion of the way things would go. Of course, they didn't know about AIDS. INTERVIEWER: This was when they appointed you or they nominated you. DR. KOOP: That's right. And I was nominated by the president on Valentine's Day, 1981, but I had been discussing this with people who were searching for 29 Mr. Reagan's cabinet and so forth, from the day he was nominated by the Republican Convention. So this went on all during the fall, between Election Day and Valentine's Day. I think one of the problems with Washington in general is that people are labeled, first of all by the press; secondly, they're labeled by the supporters or the detractors of prospective members of the government; and those are three separate assessments of an individual, and none of them are necessarily true. And so I came with a label that I really didn't fit. I mean, my reaction to smoking, my reaction to big tobacco, was not the reaction of a Republican to big business. It was fury at the deception of an industry masquerading as a legitimate business, but really exuding evil in the attraction of children, especially, to an addictive drug that ruined their lives and killed them early. And so when I began to say things that I felt had to be said, there was never anybody who stopped me. Now, I don't understand the anatomy of what I just said completely. The advice that Reagan got from 30 his close advisers was to dump me and to get rid of me as soon as he could. He never did that. He never reprimanded me for anything that my critics criticized me for. When I left office, in 1989, one of the surprises I had at the celebration of the end of my term in California was a very long and highly complimentary video of Ronald Reagan talking to me, of course on the screen. One of my happiest possessions, because although it's absolutely true he never criticized me and never called me to stop me doing anything, but on the other hand he never said, "Good for you!" And so I didn't really know, until he had gone back to California, what he really thought about my performance, but I think he thought it was satisfactory. INTERVIEWER: Well, it sort of was a social conservative, the "Right to Life" groups, that touted you as their candidate. DR. KOOP: They touted me as their candidate, and you know, one of the interesting things to me about government that most people don't know, I gave a tremendous number of talks in the old Executive Office Building, usually up in the Entreaty(?) Room, to groups 31 of constituents that really admired Ronald Reagan, and that he sometimes invited to the White House. And I'd get a call in the morning that the president's entertaining some people this afternoon, he's going to speak to them from 1:00 to 1:05, could you take over until 2:00 o'clock? And so it would be on all sorts of things that had nothing to do with my job, really, and I had one big collection of talking points. And I used them many, many times, but never gave them a title, because the title shifted all the time. And so my staff, to file it someplace had to give it a name, so they called it, "A Really Good Sermon." (Laughter) And I gave that really good sermon for Ronald Reagan many, many times, and -~ INTERVIEWER: Did it have a political or social agenda, or --? DR. KOOP: It was his political social agenda. Really. It was his pro-life position, it was a conservative view of life in general, but never cramping my style. And no, it's -- I worked much more closely with Mr. Clinton than I did with Mr. Reagan. Strange 32 circumstance, but he would never have let me get away with the things Mr. Reagan did. And I had a secret way of communicating with the president. You must remember that the people who were most opposed to the things I did and said, like Gary Bauer, had made it almost impossible for me to communicate with the president. But I had a way of slipping a note to him at the end of each day, if I wished to -- INTERVIEWER: "Him," being the president? DR. KOOP: The president. And -- INTERVIEWER: Through a back channel? Through someone? DR. KOOP: One of the routines of the day for Mr. Reagan was before he left the Oval Office and went up to his private quarters, is that the director of the mail service would drop by with about ten to twelve letters that she thought were the pulse of the nation that day in the letters that came to the president. And he'd dutifully sign them, but he added a little note to each one, "So sorry to hear about your husband's osteoarthritis," and that sort of stuff. 33 Well, sometimes between two of those would be a note from me. And -- INTERVIEWER: And then she saw to it he got them? DR. KOOP: He got it. And I'll give you one example. INTERVIEWER: But she was your contact? Or she was your -- DR. KOOP: She was my contact. And Mr. Reagan was very, very upset about the fact that there were children who were born with no bile ducts in the liver and who faced certain death, and the only possible chance for survival was a liver transplant. And so I did three Surgeon General's workshops on transplantation. I founded, for the people who used it, the American Council on Transplantation; got some funds from the public health service to pay for the legal fees to set that up and so forth and so on. But the -- where was I going with this? INTERVIEWER: You were talking about Reagan's interest in liver -- DR. KOOP: Oh. So he went on television one 34 afternoon, sat in his -- you know, he spoke on radio every Saturday afternoon. And his whole program was a plea to the American people, "There must be somebody out there who has someone who just died in the family or might die between now and the time tomorrow comes. We need a liver for this little girl." And he was, I heard from my White House contacts, crushed that nobody came through with a liver. As far as he knew. And so the little note that I put in his mail was, "Don't be upset about no liver for your patient. We actually had 40 livers offered to us. None of them were suitable, but the most important thing which, Mr. President, you do not know, is that no liver transplanter in this country is willing to put this little girl at the top of his list, which is the only way her parents will deal with a medical professional." And he called me about -- he flew to California that week, called me about five times, because he didn't know about the change in time, but anyway, and we had a great talk about liver transplant on the telephone. But those were the kind of opportunities I 35 used, and I think he appreciated the fact that I protected him and informed him about things like that. Which I would much rather prefer to do eyeball-to- eyeball, but his minions would not permit that. INTERVIEWER: Tell me about your relationship with the Clintons and how you moved, in your own political persona, in your latter Surgeon General years and post-Surgeon General years, to what, in simplistic political terms, would be from having been a conservative Republican to at least a moderate to liberal Democrat. DR. KOOP: I didn't ever really change my point of view, but what happened is my constituents felt that I did, ox understood where I stood in the first place. That was what most of them didn't know. Mr. Clinton had campaigned on a platform that had to do with health care reform. And I was speaking as often as I could to the American public about health care reform, and I had some good ideas about it, and I received a sort of relatively secret message from the president by word of mouth -- INTERVIEWER: This being now President 36 Clinton? DR. KOOP: Clinton, that he would like me to be the salesperson for his health plan. INTERVIEWER: So during the campaign or prior to that, you had not worked with him. DR. KOOP: I had talked with him nine different times during the campaign about health care reform. INTERVIEWER: He had sought you out, or --? DR. KOOP: He had sought me out, and thereafter I would call him or he would call me, and we had a good understanding about our differences of opinion and what I thought were important things and what I thought could be accomplished and what I thought couldn't be accomplished. And that was interrupted by - - he had a medical student from Harvard who was advising him, down in Little Rock -- INTERVIEWER: Atua Gwandi (phonetic) ? DR. KOOP: Atua Gwandi. And Atua Gwandi told me that I would no longer have the opportunity to talk to the president, and any message I had I would give to him and he would give to the president. And I never 37 passed any word to the president through Atua Gwandi, but -- INTERVIEWER: He's become a pretty good surgeon. DR. KOOP: Yeah, so I've heard. INTERVIEWER: Yeah. He's an excellent writer, too. DR. KOOP: Yeah. INTERVIEWER: Yeah. But that was a little presumptuous, I have to agree. DR. KOOP: I thought at the time, yeah, even for a Harvard medical student. (Laughter) So I said that I could not support any program as a sales person unless I knew what it was all about, and I had to confess that some of the things that I had read in the press were disturbing to me. So the president sent for me, and we had our first meeting, and he said -- he was very gracious. He said -- INTERVIEWER: This is in Washington or this is in Little Rock? DR. KOOP: Washington. It was in the Oval 38 Office. He said, "I know you can't be my salesperson," and he said, "I realize that we have differences on opinion about some things and what I'd like to reform,” he said, "but what I'd like to ask you, would you be willing to be the moderator of a conversation between the medical profession and me and/or the First Lady?" I said I could not possibly turn that down. And so that gave me the opportunity to travel with Hillary and I truly believe -- something you can't disprove but neither can I prove it --but I truly believe if she and I could have done what we did for a whole year, instead of for three months, we could have come up with a compromise with the medical profession and we might have avoided the horrible transition to managed care. We just didn't have time to get it done. INTERVIEWER: "Horrible," in that you would have been able to craft or develop legislation that would have been passed, that would have been a reform? DR. KOOP: The thing that impressed me about this dialogue that I had been asked to moderate was how flexible both parties were. I would go to a meeting with medical profession, anywhere from 40 to 400 people, 393 with the First Lady. We'd stand on opposite sides of a platform, behind lecterns. And there was no bitterness. There was no accusation of carrying too much baggage with you and that sort of stuff. But she understood their point of view, and when she didn't I explained it to her then or later, and vice versa. And I don't remember leaving a single one of those things, those dialogues, when she didn't have a broader view of the medical profession and when they didn't have a more accepting view of her. INTERVIEWER: She credits you in her book as selling health care reform with her in a very effective way. DR. KOOP: Yeah. Well, she -- INTERVIEWER: She doesn't limit it to the medical profession. DR. KOOP: No. INTERVIEWER: You talked to other audiences, as well? DR. KOOP: Well, the medical -- I think in the medical profession you have all the people who worry about insurance, health care and administration of 40 hospitals and the sale of goods and pharmaceuticals, and that sort of stuff. So they're all -- INTERVIEWER: And your coverage went everywhere, I'm sure. DR. KOOP: Yeah. But she -- INTERVIEWER: So you spent three months on the road -- DR. KOOP: Yeah. INTERVIEWER: -- on and off, with her? DR. KOOP: Uh-huh. And we would come home from someplace, Atlanta, and I'd sit with her and her chief assistant in the plane, and we'd just outline -- I'd say, "This is what you learned today. This is what you found is going to be hard to push the medical profession on," and so forth. And we'd get back to the White House late in the day, and her devoted staff would be waiting, at 12:00 midnight or 1:00 o'clock, and she'd say, "You do this, and you do this, and you do that," and they'd get report back to me in three or four days and say, "We were able to accomplish this, this and that, but we can't do this." And it was a heady time, because I felt that 41 we were -- I never came away from any of those meetings saying, "They don't understand each other." Because they did understand each other. And I would be elated sometimes at the concessions the medical people would make once they heard her say it. Very charming person, one to one, with a doctor. And no sign, ever, of any arrogance, "I've got a reform plan and you're going to take it," you know. And it was really great to see. And I do think we could have done it. INTERVIEWER: As you look back on health care reform and your work with the Clintons, what do you conclude? What might have -- was it doomed, ultimately? DR. KOOP: Toward the end of those days, I was sort of acting as a courier between the Senate and the White House, and it demonstrated to me the one thing about politics that is, I guess, insurmountable. I'd spend all day talking to three Senators, and I'd get them to join the eleven that were already agreeing with what we wanted to do, but in getting those three I lost five others. And the person that was trying to shepherd this -- you remember that it got so complicated that the 42 House threw up its hands and went home. They didn't even bother to continue to discuss health care reform. And it was the Senator from Maine -- what's his name? INTERVIEWER: Mitchell, George Mitchell. DR. KOOP: George Mitchell was trying to act for the Clintons in getting this stuff through Congress, and it just -- we'd gain three and we'd lose four; we'd gain five, and we'd lose six; we'd gain six and we'd lose two; and we just never got to the point we could pass it. But see what -- I think we were watching history in the making, because I think essentially what medical politics said at the failure of the Clinton plan, is "The pundits have always told us if we let market forces run health care, we'd have lower costs and higher quality, and let's give it a try." And I don’t know anything that works that way. You get lower cost, and you don't get higher quality; it's usually the other way around. And even at this late date, my feeling is that if we'd had a better chance to educate the medical profession and the public -- and we were doing a good 43 job, but you can't do it all in three months. If we could have spent a year doing that, and had postponed health care, say, until maybe the third year of his first term, I really think we could have avoided managed care. And we would have had a better health care plan than we lived through with managed care. INTERVIEWER: And that what we have now, you're saying. DR. KOOP: Oh, yeah, I don't even know what to call it now. INTERVIEWER: We'll come back to that. Is Hillary going to be president? DR. KOOP: You're not going to put this in the Journal. INTERVIEWER: I won't if you don't want. DR. KOOP: No, uh -- I think Hillary would like to be president. I think that there are a lot of barriers in the way. I think if Giuliani runs against her for the Senate, for example, and she loses, which is a likely thing to happen, then I think it's all over. But I think that it will take several more years of history to fully assess the importance of the 44 Clintons to the things that are going on right now in the Democratic party. Because I -- you've got to ask yourself about Howard Dean's meteoric rise and meteoric fall, how'd that come about? Not for publication, please, but I don't think it would have suited the Clintons to have another leader in the Democratic party. INTERVIEWER: As Howard Dean. DR. KOOP: And he was on the way to being that. I mean, you know, up here, which you didn't have a chance to see, this place was pulsing for Dean. It was really -- it was like when Reagan came to Washington. People who weren't even interested in politics were thinking, "This is pretty good." INTERVIEWER: Do you think she would be a good president from her executive ability, her vision and wisdom? DR. KOOP: She's one of the most talented people I've ever worked with, and I think she has all the necessary things to do the right thing. I think whenever you talk about what will a politician do, you just don't know because politics is so important. INTERVIEWER: Yeah. Do you want to take a 45 break? DR. KOOP: No, I'm okay. Well, maybe I -- no, I changed my mind. I'm fine. I'm my legs so they don't clot anyway. INTERVIEWER: Okay, good. Let's go back and pick up on tobacco. And you certainly got your feet and more of your anatomy wet with tobacco, as Surgeon General, but then there was the battles after that and there was the ultimate tobacco settlement. Tell me a bit about that, and how you feel about the settlement and the aftermath of settlement. DR. KOOP: Well, I think the first thing that should be said about tobacco at any time, but especially right now in history, is that tobacco is always a good news/bad news story. Tobacco at this moment is, at once, one of our greatest triumphs and one of our greatest defeats. It's a horrible defeat, after all the effort we've made, to know we have 49 million nicotine addicts in America. On the other hand, we have fewer than half the number of people smoking than we had in 1964. INTERVIEWER: Percent-wise in the population? 46 DR. KOOP: Yeah. Yeah. So we are, you know, we've done very well, but it hasn't been good enough. And I think that efforts at tobacco control have been rather magnificently done, and I think in the past decade we've seen all the things fall in place that make it possible to control tobacco, and the reason I say that is that -- (End of Tape 1, Side B.) INTERVIEWER: Koop, Tape 2, Side 1. You were saying about tobacco just in the last week? DR. KOOP: Just last week, both the House and the Senate gave approval to that, which should lead to the regulation of tobacco by the FDA, and then the thing that I think will make it happen is that Phillip Morris supported it. And so when you have the House, the Senate and Phillip Morris, you've got a majority, as far as that is concerned. I think one of the things that differed in my approach to the tobacco problem was that I did what my predecessors had done, and I talked about the health effects of smoking. And we did that very well through the Surgeon General's reports, and we had things nailed 47 down, chapter and verse. I think that the two major things that I accomplished along those lines was making clear the dangers of passive smoking, because what that did was to turn nonsmokers from neutral folks into activists against smoking. And I think the most important thing that I accomplished in the Surgeon General's role with the Congress was the 1988 report on addiction. INTERVIEWER: When was passive smoke? That was earlier? DR. KOOP: It was earlier, yeah. INTERVIEWER: But during -- there was a report on passive smoking? DR. KOOP: Yeah. I think there five public -- INTERVIEWER: But the addiction one was '88? DR. KOOP: ‘88. And I consider that to be progress in the following way. If I had gone to a meeting any place in this country or Canada, say in 1987, where I was in a room full of smokers and I asked, "How many of you are addicted to nicotine?" you might have seen one or two hands gone up. You ask that same audience today, and you get 80 percent of the people 48 saying, "I'm addicted." And I think that is a huge change. It's a sea change in the way people think about themselves, and if you think of yourselves as somebody who has a tough habit to break, "But I can do it tomorrow," it's an entirely different problem than if you say, "I am truly addicted to an addictive drug." And I think that the ground rules change, and it's, ina sense, harder to sell a cure, but it's also, for some people, easier to sell a cure. The other thing that I did a little differently than my predecessors was to attack the tobacco industry. And I -- see, I came on the tobacco scene as an anti-smoker. I came on the tobacco scene with very little political understanding of what went on behind the scenes. And I was absolutely infuriated that when we would make -- spend a whole year getting a report together and present it, and two weeks after that the tobacco industry would spend tearing down the science and saying it wasn't true, and so forth and so on. And I decided not to take that as just things that happen to the Surgeon General's report, but to continue to hammer away until the next time something happened 49 that they were a deceitful group of people. And I used to talk about the fact that although it couldn't be used in a court of law, that I had many communications from tobacco industry workers telling me about the nefarious things that were going on in their company, but everything was protected by attorney/client privilege. Which was a pretty clever maneuver on the part of tobacco, that any research was never reported to management without being reported to legal counsel first. So everything became attorney/client privilege. And that was the biggest, the biggest aspect and the biggest sea change in the tobacco settlement, was the tremendous efforts of Skip Humphrey, the attorney general of Minnesota, Hubert Humphrey's son, in getting the courts to remove that attorney/client privilege because it was not necessary and it was spuriously obtained. And now, not only do we have repositories here and in England of all of the documents, something like 30 million pages, but they're catalogued, and there still is a treasure trove we haven't turned up, of the things that were deceitfully, 50 knowingly and deceitfully said by the tobacco industry that's perjury. And one of the things that I find very difficult to understand is why there isn't more outrage on the part of the public on the way the tobacco companies duped them, to the point that their mothers and fathers died of tobacco, and their kids are hooked, and they are too. I think they would be furious. INTERVIEWER: Yeah. The run-up to the ultimate settlement was a fairly rough and tumble period, as I recall. DR. KOOP: It was a rough and tumble period. I've got to be very careful what I say, because I don't want it to be the wrong way. I think that the tobacco industry sort of rigged it the way they wanted to. I had two secret meetings with people from the tobacco industry, with great secrecy, in places I didn't usually frequent, go in the back door, go up the backstairs, this sort of stuff. Really seeing if, I would say, I could be bought, but seeing whether in my position of righteousness about tobacco, I couldn't say things that would be favorable to the settlement, the way they