At the end of 1981, C. Everett Koop, MD, was appointed the

Ge

new surgeon general of the United States. His duties include direct-
ing the U.S. Public Health Service and serving as the deputy assistant
secretary for health in the Department of Health and Human Serv-
ices. As America’s highest-ranking physician, Dr. Koop, a pediatri-

cian, shares his views on his new role and

responsibilities with

PRIVATE PRACTICE in this exclusive interview.

 

Q: What is the role of a surgeon
general? Is he an adviser? If so, how, and
on what level does he advise? ;

Dr. Koop: Up until 1966,
the surgeon general was without any
question the primary health officer of
the land and had great credibility in
Congress and with the public. Then
there was a period when the surgeon
general’s position was somewhat de-
meaned and the functions of that of-
fice were carried out in an office of
the deputy surgeon general.

When Julius Richmond, MD,
came on board at the beginning of
the Carter administration, the
surgeon general and the assistant
secretary of health were the same in-
dividuals—they wore different hats
for different parts of their job. With
this administration, the positions of
assistant secretary for health and
surgeon general have once again
been separated. So, this is the first

38 PRIVATE PRACTICE

time now, since before 1966, that the
surgeon general acted in the capacity
in which I will act.

I guess you could say that my
role is ‘‘adviser.’’ By statute, I do
have an advisory capacity to the
Department of Health and Human
Services, But I think the way the
position develops, I am more or less
the spokesman, in as apolitical a way
as possible, for public health in this
country. I am here to give on-line in-
formation to the public about things
that would improve their health and
things that would prevent disease.
Now, that might be in such things as
the surgeon: general’s Report on
Smoking or it might be something
that comes up tomorrow as an
emergency in reference to a Three
Mile Island catastrophe, or a Love
Canal, or a Mount St. Helens’ erup-
tion or something like that. But,
perhaps more importantly, the
surgeon general has a very important

The Surgeon
neral
Has Determined...

 

role in representing government to
medical societies and representing
the concerns of those societies to
government.

Q: In that regard, I gather you
work with and try to have some sort of com-
munication with groups like the AMA or
American Association of Physicians and
Surgeons?

Dr. Koop: Yes, the surgeon
general of the Public Health Service
has a seat in the House of Delegates

of the AMA. So, he does have a
voice there through that position. J
welcome dialogue with the various
societies in the country to listen to
their concerns and to interpret for
them some of the things they are
uncertain about the government's
actions in health.

Q: Since I am sitting in front of a
uniformed individual, one of the obvious
questions is: “What are you doing wearing
@ uniform?”’

Dr. Koop: There is in the
Public Health Service a commis-
sioned corps of approximately 7,000
officers consisting of not only physi-
clans but nurses, veterinarians,
sanitary engineers, civil engineers,
physiotherapists, dietitians, etc. We
are a uniformed, but unarmed, serv-
ice of the United States. The Public
Health Service had a commissioned
corps before there was a medical
corps in the Army or the Navy.
Therefore, our uniforms were taken
from what was then the Merchant
Marines uniform. When _ the
Medical Corps of the Navy was
established, we then conformed to
the standards of the Navy uniform;
and the only thing different about the
uniform I wear and that of a vice ad-
mural of the Navy is the different in-
signia above the braid on the arms
and the buttons on my cap and the
shield on my visor.

Q: Is the surgeon general also an
advocate on certain issues, certain positions?

Dr. Koop: Yes, he’s an ad-
vocate for certain groups of people.
In my present role, I am acting as
advocate for children. ’m acting as
an advocate for the disabled. I’m act-
ing as an advocate for those who are
aging because I think these are three
groups at risk in our country who at
all times need an advocate. And in
the tremendous overlap and duplica-
tion of services for these groups of
people in government, I do try to act
as ‘‘advocate.”’

Q: In what way does the surgeon
general have the power to enforce certain
decisions?

Dr. Koop: The surgeon
general has no power. His position is
advisory, and that is implicit in issu-

~
APRIL 1982 39
42 PRIVATE PRACTICE

ing a warning. We can’t say to peo-
ple, ‘“Don’t smoke!”’ But we can tell
people that smoking is injurious to
their health.

Q: In that regard, should not the
government—the surgeon general—say,
“Smoking is dangerous to your health,’
present the information and leave tt to the
public to decide? Rather than as in the past,
for example, under the Carter Administra-
tion when Secretary Califano seemed to be
going on a crusade. There were commercials
being planned for television and it seemed to
be either a vendetta or sort of a moral cam-

paign?

Dr. Koop: I don’t think it
was a vendetta. I think if the Public
Health Service and the surgeon
general feel strongly about an issue
which affects the health of the public,
they have the obligation to at least
communicate it to the best of their
ability. And I think that’s what the
campaigns that you were concerned

about [attempted to do]. I think this —

is a fitting and proper role for
government because in a sense if you
just say, ‘Don’t smoke,’’ you
haven’t given the people who smoke
the reasons why you are concerned.
‘That’s why each of the recent reports
on smoking and health has focused
on a different aspect of the
deleterious results of smoking on
health—not just cancer of the lung.

Q: To what extent does the surgeon
general and the U.S. Public Health Service
have an international role? Do they interact
with the U.N.? With the World Health
Organization [WHO]? Stmilar interna-
tional bodies?

Dr. Koop: We interact inter-
nationally in several ways. First of

all, we [the United States] are
members of the World Health
Organization. Edward Brandt,
[MD], the assistant secretary for
health, is a member [during his
tenure] of the Executive Committee
of the World Health Organization.
He and I both were delegates last
May to the World Health Assembly
in Geneva and will be again this
year. Therefore, we are committed
to the general goals of the World
Health Organization, such as
clean water supply for all by 1990
and any other initiatives of WHO
that do not conflict in any way with
the laws of our own land.

In addition, the United States
has about 35 bilateral health
agreements which may or may not
be part of broader science and
technology agreements with a
number of foreign countries. With
European countries, most of our ef-
forts are in the field of research;
rather sophisticated research at that.
With the lesser developed countries,
our cooperative agreements are to
bring our expertise to those countries
through the various public health
agencies so that the health of the
public in those countries will be
elevated.

Q: Would you say that the position
of surgeon general and the Publu Health
Service provide a policy-making role to the
president in this regard?

Dr. Koop: No, the Office of
the Assistant Secretary of Health at
the present time has a division which
is called the Office of International
Health and functions at this par-
ticular time by internal arrangement
with Dr. Brandt and me. We have
sort of divided up the countries. He
has a concern about some; I have a
concern about others. Some, we
have a mutual concern about.

Q: Earlier this year, the Reagan
administration took a position regarding a
decision by the World Health Organization
concerning advertising and sale of infant
Jormulas [food formulas] in underdeveloped
countries, [The whole conflict between
breast feeding and bottle feeding, etc.] The
United States voted against that decision.
Have there been repercussions since then?
What has been the attitude of the World
Health Organization toward the U.S. ?

Dr. Koop: First of all, let me
make it clear that the Public Health
Service is committed to the benefits
of breast feeding for children all over
the world and for the best possible
nutrition for young infants and older
children, The infant formula code as
proposed by WHO had non-health
matters involved that made it im-
possible for this country to sign.
Since the signing of the code, we
have two task forces at work in the
Public Health Service. One of those
is under my direction, and we are
preparing two documents. One is a
mandated reply to WHO, which is
our response to the code. ‘The second
is a statement of understanding of
what is best for infant and young-
child feeding. The other task force is
looking into the scientific claims in
reference to breast feeding versus
supplementary feeding. I think out of
this will come some very interesting
information that will be useful to this
country in planning our own nutri-
tional strategies in days ahead.

Q: Would you give us an idea
what is the adminsstration’s view regarding
catastrophic health insurance? What you’re

studying? What your plans are? What role
private enterprise—private medical

coverage—should be?

Dr. Koop: I don’t think I can
answer your question fully because
what comes out in the way of in-
surance alterations will be done by
the legislative branch. I can tell you I
have a commitment to some kind of
catastrophic health insurance as does
the secretary because we both have
seen what happens to a family hit by
a medical catastrophe. Fortunately
it’s a very small percentage of in-
sured people in this country who are
so hit; and, therefore, it seems logical
to me to spread the cost of that kind
of catastrophe over a much larger
group of people who are purchasing

insurance.

Q: What is the role of the Public
Flealth Serowce in immunization in this
country?

Dr. Koop: First of all, we are
in a position of doing experimental
work on vaccines, in our various
agencies. Some do the experimental
work to produce it—others are in the
business of approving it. This ad-
ministration and this Public Health
Service are totally committed to im-
munization. I think one of the
proudest things we can claim is our
role in the elimination of smallpox
from the world. Secondly, if you’ve
watched what’s been happening to
measles in this country, there has
been domestically almost a repetition
of smallpox. There are little out-
breaks of measles here and there but
for four weeks in December and
November of last year only 1 percent
of the counties in the U.S. reported
measles; for the last 48 weeks of 1981

only 10 percent. So, immunization
has top priority with us—not only
here but as one of the things we’re
very much interested in for interna-
tional health.

Q: Many doctors are concerned
about the degree of regulation in the medical
and health-care fulds. Is this an area of
concem the Reagan administration has re-
garding the amount of regulation that 1s in
medial care?

Dr. Koop: Well, let me
preface my remarks by saying I think
one of the strengths I bring to this job
is the fact that for 36 years as a
private practitioner I worked in the
marketplace as a recipient of the
problems the government produces
for the practice of medicine.
Therefore, I come into the govern-
ment very much in tune with Presi-
dent Reagan’s deregulatory efforts in
reference to health. I think that
regulations, in certain circumstances,
are necessary in order to protect the
public. But I certainly think we can
get rid of a tremendous amount of
regulatory apparatus; and I think as
we do, it then falls on the physicians
of America to regulate themselves, to
police themselves and to maintain
the integrity in the profession led by
the public.

Q: Would you care to comment on
any recommendation the department may
have with regard to increased competition in
the medical fueld?

Dr. Koop: Again, I think it’s
premature to say. We have just been
through our own studies. We’re in
the process of discussing these. There
are, as you know, a number of pro-

‘competition bills that have been pro-

APRIL 1982 43
posed by members of Congress. And
I think we really have to wait to see
how the debate begins to develop.

Q: Turing to another sulyect, your
hearings for confirmation as surgeon general
were probably somewhat controversial—at
least they aroused a lot of interest regarding
that position. Why do you think there was
so much attention brought to your
background and the office in which you were
confirmed?

Dr. Koop: It wasn’t that my
hearings were controversial. The
thing that was controversial was my
appointment. And the thing that
disturbed me was the inordinate
delay in letting me get to the
confirmatory process. There is no
doubt in my mind it was the active
role I have taken in trying to
elucidate some of my concerns about
bio-medical. ethics, particularly in
reference to abortion in the past
several years. That was the fun-
damental reason why I was opposed
by so many people. I think other ac-
cusations, such as an attitude toward
women that was outdated, etc., was
absolutely nothing but a
smokescreen to cover the other aspect
of people’s concerns.

The day I arrived in
Washington, I told the secretary I felt
I had said and written and done all I
needed to do in reference to abortion,
and it was not my intent to come to
Washington in order just to be a
speaker on the pro-life circuit. I
thought there were many oppor-
tunities here for health initiatives to
which I would like to turn my atten-
tion. And I have kept my word on
that since I’ve been here.

The other aspect of opposition
to me was I didn’t have any public-

44 PRIVATE PRACTICE

health experience. I think that was,
again, a smokescreen to cover my
anti-abortion statements in days
gone by. I think as was definitely
shown at the hearings, not only by
my own testimony but by that of ex-
perts in the public-health field, I was
not without public-health experience
or knowledge and had, over my
lifetime in pediatrics and surgery,
made a number of public-health in-
itiatives.

Q: President Reagan is concerned
about ‘‘volunteerism.’’ He’s made this a
part of his philosophy. Is this something
your office will be involved in?

Dr. Koop: I will be involved
in this to the extent of my ability to
do it, but it is nothing I can legislate.
It’s only something I can recom-
mend with all the moral suasion this
office carries with it. But if you look
at the history of health care in this
country, doctors have always been
very much in the forefront of the
voluntary effort because it is doctors
and patients, working together, who
have brought about the various foun-
dations in this country aimed at the
research into and the cure of specific
diseases. I think as doctors find there
are gaps now in the programs that
used to be paid for by the govern-
ment, they will see the effort to fill
that gap will have to come through
the voluntary sector. One thing I
would suggest to them is the tradition
of separation of church and ‘state in
this country is no reason not to turn
to the churches to provide this social
safety net. Because, after all, 100
years ago, it was only the church that
provided this. And they are well
equipped to do it.

Q: You mentioned one of the sub-
jects brought up during your confirmation
hearings was a concern by some regarding
your position on the abortion questions. You
appeared in a film and co-authored a book,
“Whatever Happened to the Human
Race?,’”? in which you expressed con-
cern about this, euthanasta and medical
experimentation on children. Obvious-
ly, you still have those concerns. How
do these concerns still fit in with your
responsthility and role as surgeon
general?

Dr. Koop: Nothing at all in
reference to decisions regarding
abortion comes across my desk. I
haven’t changed my attitude with
regard to abortion. The only thing
that is part of my job is to look at the
scientific accuracy of the reports that
come from this department concern-
ing abortion surveillance. I’m con-
cerned, not with an ideology when I
do that, but with scientific accuracy.

Q: One of the accusations brought
up in the hearings was your attitude toward
women—professionally, etc. Would you
care to comment?

Dr. Koop: Yes, I felt very
bad about that because it’s just the
absolute opposite of my life history as
a professional. It stemmed from a
commencement address I gave at a
finishing school for young ladies in a
Philadelphia suburb where I said,
among other things, that if a girl
wished to follow the traditional, role
of being a mother and a wife, she
should not be ashamed of that
because other people were going on
to careers that used to be exclusively
for men. But to be accused of having
stereotyped old-fashioned and cruel
attitudes toward women as I was ac-
cused of by Sen. Edward Kennedy is
absolutely incorrect. I have always
been a champion of women’s
rights—all one has to do to verify
that is to talk to the women I’ve
worked with for the past 35 years
professionally and academically. It is
true I have trained more women in
the specialty of pediatric surgery than
any other trainer of pediatric
surgeons in this country; and I began
to do it when training women in
surgery was not popular.

Q: Who's influenced you the most

in your career?

Dr. Koop: I would think
there’s no doubt about the fact that
in my formative years as a surgical
resident Jonathan E. Rhoads, [MD],
a long-time professor of surgery at
the University of Pennsylvania, was
my mentor and, therefore, had the
greatest effect upon me. But it’s hard
to point out someone specific. His
mentor was I. S. Ravdin, [MD], sol
have a lot of the background that
came from Ravdin’s teaching of
Rhoads. And the man that just
preceded me with Dr. Rhoads was
Harold Zintel, [MD], now vice
president of the American College of
Surgeons. We worked side-by-side
during the war—during very difficult
times. There is no doubt he had
tremendous influence upon my
understanding of surgical facts and
judgment.

Q: Do you see any change in this
regard for up-and-coming young physt-
cians? Or are thé “‘greats’’ you look upon
still influencing young doctors?

Dr. Koop: Oh, yes, I think
there’s no doubt about that. I think

I’ve had an effect upon those I’ve
trained. They come away with my
techniques, my judgment and my
philosophy. I guess as you get older
you tend to think the people you
knew earlier on were ‘‘characters’’
more than you find now—by that I
mean they had eccentricities that
were appreciated. I wouldn’t want to
say we are all being more or less con-
formed to the same mold, but it does
take years to develop these unique
characteristics and sometimes I think
they are very important in the
teaching of young professionals.

Q: Are there individuals who have
influenced your personal philosophy, your
attitudes and how you will administer this
office?

Dr. Koop: Not specifically to
administer this office. I would say the
non-medical person who had the
greatest influence on my life, prob-
ably, was a minister and Bible
teacher in Philadelphia, Donald
Grey Barnhouse. There’s no doubt
about the fact Francis Schaeffer, the
theologian and philosopher with
whom I worked on_ the
book, ‘‘Whatever Happened to the
Human Race?, ’’ had a tremendous
impact on me.

Q: When you finish as surgeon
general, what do you want to have ac-
complished?

Dr. Koop: I want to be
known as a person who was alert to
the opportunities that made
themselves available to a public
health officer. I want to be known as
a person who acted for the good of
the health of the public and did so
with the best justice available to him.

Cee ET ee nner ea ee eee eee eee een

Q: Coming to this offue, you
already had a reputation as a pediatric
surgeon. When history looks back at Dr.
Koop, what do you think you'll be
remembered for? ,

Dr. Koop: Speaking from
my former professional life, I think
I'll be remembered as a person who
saw the tremendous need for a
specialty in pediatric surgery and did
his best to develop the standards and
the credentialing process to give the
public the assurance the surgeons
who care for their children are able to
do so with the best of scientific infor-

mation.

Q: If you had some recommenda-
tions to the American medical community,
what would you wish them to be concerned
about or more aware of in the next few

years?

Dr. Koop: That’s a big ques-
tion! If I were talking to the current
practitioners of medicine, I would tell
them they have asked for deregula-
tion of government in their affairs
and they have asked for fewer
“handouts”? on the part of the
government. And now they are in a
position to appreciate what they’ve
asked for. That means the burden to
maintain the standards and to keep
the integrity of the profession what it
should be is going to be very much in
their own laps, where I think it
belongs. I have every confidence
when they have the obligation to
do it, they’ll perform it well. [Pp

 

Mr, Wiliams is a freelance writer in Arlingion, Va. A former
news commentator for KERA-TV im Dallas, he has had articles
published in The American Spectator, Human Events and

APRIL 1982 45