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Interview

INTERVIEW

Reagan, Clinton, Tobacco, And Children: An Interview With C. Everett Koop

Abstract

 
At eighty-seven years of age, former Surgeon General C. Everett Koop has an extraordinary perspective on health and medicine in America. He reflects on child health from his thirty-five years as a pediatric surgeon; AIDS from his position as Surgeon General at the outset of the epidemic; Presidents Reagan and Clinton, with whom he worked extensively; and smoking from his long battle first in government and then later as public antagonist to what he sees as the duplicitous and deceptive "killer" industry: tobacco.

Top Status Of U.S. Child... The Surgeon Generalship Working For Ronald Reagan Working With The Clintons The Tobacco Wars Medicine In America International Health Service... Outreach At Home Reflections On A Career... Editor's Notes

C. Everett Koop: 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, and, I have to admit, the older I get, the more I understand the relationship of poverty in a child and poor outcomes in everything else. I’m not beating a socialist kind of drum here. I think as we look to the future, unless we take into account what a severe role poverty plays in the lives of many children, we will never be able to achieve good child health in the United States.

Mullan: There is concern raised from time to time about the relative support we afford youth versus the elderly, with Medicare in particular commanding a huge portion of our public budget and relatively less going to children. Is that a concern you subscribe to?

Koop: It’s a concern 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. People were living longer and living better, and you can’t do either of those things without spending more money. Pediatric social and medical interests were vying with geriatric social and medical interests for their slices of the shrinking public 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.

Mullan: What do you think of the prospects for child health as you look to the future?

Koop: I think it depends. In the long run, child health is about advocacy. Children don’t vote. They can’t lobby, unlike, say, the geriatric community. I think that is one of the major reasons why groups such as handicapped children have never made the same kind of progress that the elderly population has. One of the keys to the future of child health is advocacy for children and their causes.

From a clinical perspective, the problem of the future is obesity. I think that the pediatric world as well as the general population let obesity sneak up on them. No one seemed to understand that bouncing babies became fat children, and fat children became fat adults. And we now have a problem that is going to be very difficult to reverse that has very serious implications for our health as a nation. It starts as a child health challenge.

The Surgeon Generalship

Top Status Of U.S. Child... The Surgeon Generalship Working For Ronald Reagan Working With The Clintons The Tobacco Wars Medicine In America International Health Service... Outreach At Home Reflections On A Career... Editor's Notes

 
Mullan: You served eight years as Surgeon General. You began that time as an embattled nominee thought to be the candidate of the right-to-life movement. You ended your tenure as one of the most powerful public health advocates of the twentieth century, often said to be the second most recognized face in the nation’s capital. What are your reflections on those years?

Koop: Well, no one ever tells you what the job description is of Surgeon General. The job has enormous potential, but if you decided to sit and read the New York Times, nobody would say, "Hey, do your job a little better." I was nominated by President Reagan on Valentine’s Day 1981. I think that 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. One of the problems with Washington in general is that people are labeled—by the press, by politicians, and by the public—and these labels are not necessarily true. I came with a label that really didn’t fit.

When I was nominated, AIDS wasn’t on the scene. No one ever asked me to become the government’s spokesperson on AIDS, but I assumed the job because nobody else was doing it and because, frankly, the people who advised Mr. Reagan were doing such a poor job of it. The public appreciated honest answers about a difficult disease. The other major theme of my time as Surgeon General was tobacco. AIDS and smoking were the two huge health problems that our global society faced. These problems have expanded since then, and they will not go away.

Mullan: Yet AIDS wasn’t really in your portfolio during the first Reagan term. No one seemed to take much leadership at first. What happened?

Koop: I was told early on that AIDS would be handled by other people in the Department of Health and Human Services. Not much happened. When Otis Bowen became HHS Secretary in 1985, that all changed. Bowen was a gentleman, a physician, and a man with tremendous political experience. Then President Reagan asked me to write a report on AIDS for the American people. I don’t think I’ve worked harder in my life on anything. Secretary Bowen and I were the only people in HHS, except for two people appointed by me, who knew what was going on. No one else cleared it. We published it and distributed tens of millions of copies. Had it not been for Secretary Bowen, it would never have seen the light of day. There were too many people in the administration, especially those surrounding the president, who felt that AIDS was a disease of prostitutes, homosexuals, and drug abusers, and, after all, didn’t they deserve what they got? Our strategy was that we were fighting a disease and not the people who had it. I think that was a turning point for the Surgeon Generalship.

Working For Ronald Reagan

Top Status Of U.S. Child... The Surgeon Generalship Working For Ronald Reagan Working With The Clintons The Tobacco Wars Medicine In America International Health Service... Outreach At Home Reflections On A Career... Editor's Notes

 
Mullan: You surely were one of the enigmas of the Reagan presidency. You seemed to function with such effectiveness but often in ways that seemed at odds with the president’s political values. What was your relationship like with President Reagan?

Koop: 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 talking to 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 he would have avoided for himself and his administration a lot of the criticism that he received, before and since.

I tried to blunt that criticism by taking to the public airways to represent the president. I spoke out on tobacco as well as AIDS, and, frankly, my reaction to big tobacco was not the reaction of a Republican to big business. I was furious at the deception of an industry masquerading as a legitimate business while luring children to an addictive drug that ruined their lives and killed them early. When I said things that I felt had to be said, no one ever stopped me. I know that the advice that Reagan got from his close advisers was to dump me as soon as he could. But he never did. He never reprimanded me for anything that my critics criticized in me. When I left office in 1989, one of the surprises I received was a long and complimentary personal videotape from Mr. Reagan thanking me for my service. It is one of my happiest possessions, because he seemed to support my work so thoroughly.

I had a secret way of communicating with the president. The people who were most opposed to the things I did and said, like Gary Bauer [Reagan’s domestic policy adviser], had made it almost impossible for me to talk with the president. But I had a way of slipping a note to him at the end of each day, if I wished to. Mr. Reagan had a routine at the end of every workday. Before he left the Oval Office and went up to his private quarters, the director of the mail service would drop by with about a dozen letters to the president that she thought were the pulse of the nation. He would dutifully sign the responses and add a personal note to each one. Sometimes between two of those there would be a note from me. For example, Mr. Reagan was very concerned about children who faced certain death without a liver transplant. I sent him notes about the state of organ donations, and he would call me back to discuss transplantations.

Working With The Clintons

Top Status Of U.S. Child... The Surgeon Generalship Working For Ronald Reagan Working With The Clintons The Tobacco Wars Medicine In America International Health Service... Outreach At Home Reflections On A Career... Editor's Notes

 
Mullan: Although you served under President Reagan, you were an adviser to President Clinton, and you traveled extensively with Mrs. Clinton in support of health care reform. Tell me about your relationship with the Clintons. What was it like to move from the ranks of the conservative Republicans to the midst of the Democrats?

Koop: I actually worked much more closely with Mr. Clinton than I did with Mr. Reagan, but, strangely enough, Mr. Clinton would never have let me get away with the things Mr. Reagan did. Throughout my political life, I never really changed my point of view. Some of my constituents felt that I did, but they didn’t understand where I stood in the first place.

Mr. Clinton had campaigned on a platform of health care reform, and I received an inquiry from him early on as to whether I would be willing to be a salesperson for his plan. We met for the first time in the Oval Office. He said, "I realize that we have differences of opinion about some things, but I’d like to ask you to be the moderator of a dialogue between the medical profession and me or the First Lady." I said that I could not possibly turn that down. So that gave me the opportunity to travel around the country with Hillary meeting with medical groups. Wherever we went, we found interest and flexibility. I don’t remember leaving a single one of those meetings, those dialogues, when she didn’t have a broader view of the medical profession and when the doctors didn’t have a more accepting view of her.

Mullan: She credits you in her book [Living History, 2003] as selling health care reform with her in a very effective way.

Koop: We spent the better part of three months on the road together. We’d get back to the White House late at night, and her devoted staff would be waiting at midnight or 1 a.m. She’d say, "You do this and you do that," and they’d report back to us promptly. It was a heady time, because I felt that we were on the road to changing and improving the system.

Mullan: As you look back on health care reform and your work with the Clintons, what do you conclude? What might have been? Was reform doomed from the start?

Koop: Even at this late date, my feeling is that if we’d had more time, we could have prevailed. We would have had a better health care plan, and we wouldn’t have had to live through the managed care period. I think after the failure of the Clinton plan, the conventional wisdom said, "The pundits have always told us if we let market forces run health care, we’ll have lower costs and higher quality. Let’s give it a try." I don’t know anything that works that way. If you get lower cost, you don’t get higher quality; it’s usually the other way around.

The Tobacco Wars

Top Status Of U.S. Child... The Surgeon Generalship Working For Ronald Reagan Working With The Clintons The Tobacco Wars Medicine In America International Health Service... Outreach At Home Reflections On A Career... Editor's Notes

 
Mullan: You waged war against tobacco as Surgeon General and haven’t stopped since. What is it about tobacco that has made it such a mission for you?

Koop: Smoking is a lot different from AIDS. Smoking involves an addictive substance that entraps people and then, years later, kills them. Over time, the nefarious activities of the tobacco industry and its deceitful processes were designed to dupe the public and obfuscate an understanding of what the government was trying to do in raising public awareness about smoking and health. The tobacco industry has to replace those it kills with new recruits on a constant basis. Additionally, the tobacco settlement to which the companies have fallen heir make it necessary for them to find new and outrageous sources of income. So now their strategy is to spread smoking around the world—especially to societies where men smoke but women do not. There are estimates that by 2025 there will be an additional 500 million deaths of people now alive on this planet due to smoking causes alone.

Mullan: The tobacco industry has been dealt some serious setbacks. Clean air legislation, secondhand smoke awareness, and the hazards of smokeless tobacco are on the table now. How do you feel about the results of your campaigns?

Koop: The first thing that should be said about tobacco is that it is always a good news/bad news story. Tobacco is 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 still have forty-nine million nicotine addicts in America. On the other hand, we have cut the rate of smoking in half since 1964. During my time as Surgeon General, we published a series of reports to Congress on smoking and health, the most important of which were on passive smoking [The Health Consequences of Involuntary Smoking, 1986] and nicotine addiction [The Health Consequences of Smoking—Nicotine Addiction, 1988]. The first turned nonsmokers from neutral folks into activists against smoking, and the second changed the definition of the problem. If I had asked a room full of smokers in 1987, "How many of you are addicted to nicotine?" you might have seen one or two hands go up. You ask that same audience today, and you get 80 percent of the people saying, "I’m addicted." That’s a sea-change in the way people think about smoking and themselves.

I came on the tobacco scene as an anti-smoker, but I arrived with very little political understanding of what went on behind the scenes. I was absolutely infuriated by the tobacco industry’s response to our reports: foot dragging, disingenuousness, and disinformation. They were a deceitful group of people. I decided not to take their behavior as business as usual but to hammer away until something happened.

Mullan: As a private citizen, you played a prominent role in the congressional tobacco wars of the 1990s and, with [Food and Drug Administration Commissioner] David Kessler, chaired a committee at the invitation of Congress on tobacco policy. That committee seemed to cement into public policy the view of tobacco as addictive and lead to the tobacco settlement of 1999. How do you feel about the settlement?

Koop: The purpose of the committee was to prepare a gold standard for legislation to control tobacco in the United States. We did that, but it was too much for the tobacco forces in Congress. My recollection is that we had six more votes than we needed to pass our recommendations as legislation, and then Trent Lott, in his capacity as Majority Leader and a diehard defender of big tobacco, pulled the bill off the floor to prevent a vote. We had stalwarts from both sides of the aisle in both houses of Congress who were fully behind us in the belief that we would finally pin the ears of the tobacco industry back where they belonged. Instead of the regulation that we had proposed, we got the settlement negotiated by lawyers, lawyers, and lawyers, with very little input from public health.

Mullan: And when the settlement was agreed on and passed into law, were you satisfied with it?

Koop: No. The $200-plus billion was fitting and proper, but there were many items missing related to the key strategies we recommended—preventing children from starting to smoke and making treatment available and worthwhile for adults. And the money has not been used well. Only one state has used the money for its intended purpose completely: Mississippi, home of Michael Moore, the leader of the attorneys general who brought the suit. States treat the tobacco money as if they had just won the lottery. Nobody seems to have qualms about using the money to fill potholes, fix bridges, or pay schoolteachers.

But I think for the future you can’t talk about the United States separately. The United States is 9 percent of the global economics of tobacco. Global tobacco promotion is where the companies are going. You can’t expect Zimbabwe or the Philippines to fight tobacco by themselves. The American Cancer Society has done as much as anybody, by bringing selected individuals from developing nations here to teach them how we have handled the politics of big tobacco and to show them how to use political muscle and public education to battle against tobacco. We must do more of this.

Medicine In America

Top Status Of U.S. Child... The Surgeon Generalship Working For Ronald Reagan Working With The Clintons The Tobacco Wars Medicine In America International Health Service... Outreach At Home Reflections On A Career... Editor's Notes

 
Mullan: You worked hard on health care reform—which did not happen. Managed care followed in what some described as a "market solution" to the problems of the system. Today a sizable percentage of the population remains without health insurance, medical costs are on the rise again, and malpractice premiums are at an all-time high. Doctors have had to practice in this uncertain and rapidly changing environment. What do you see as the lot of medicine today, and where is it headed?

Koop: I think the major thing that’s happened to medicine is the gradual evolution from a pure profession to a profession that relies on businessmen to make it work. Money is the bottom line. That means that hospitals, medical centers, and even medical schools are businesses competing against each other for supremacy. Take the American Medical Association. There was a day when the infrastructure of the AMA was mostly physicians. As those people have retired or died, they have been replaced by MBAs. They’re not health-oriented, they’re not medicine-oriented; they’re business-oriented. And that is to the detriment of our profession.

The second thing that I find has changed tremendously is the doctor/patient relationship. The business push, brief visits, and the wrong incentives have jeopardized this relationship. The intimacy that has been lost between doctor and patient can be partially regained by the Internet, and it can be an additional boon to a patient. With the Internet, we have the opportunity to have a set of patients who are much more knowledgeable than their parents were.

Mullan: What prospects do you see for a better system?

Koop: If medicine continues on the business path, we are heading to a future that we won’t like as well as we liked the past. I think there’s a day ahead of us when there will be a critical mass of people who are uninsured, and those of us who are insured won’t stand by complacently. That’s when I see us moving into a single-payer system. But we will be doing that at a time when countries with single-payer systems are abandoning them. We’ll do it nonetheless because people will feel we’ve tried everything else. We really haven’t tried anything else. Since Clinton failed, both the Democrats and the Republicans are afraid to talk about a big plan.

What I think would work for the United States is a public/private partnership in health that would be overseen by a kind of health Federal Reserve Board. This board would have an understanding of medicine—where it’s been, where it could go—and would be able to respond to the things that happen in medicine that trouble people. I am sure that there are enough people left in medicine who don’t have an overpowering financial connection to some business enterprise, who are not trying to squeeze the last dime out of medicine, who would welcome the opportunity to act in an advisory capacity, just like the Federal Reserve Board does.

Mullan: The amount of malaise and complaint within the profession today is profound. Is this failed expectations? Is this greed not being satisfied? Or is it that the ground really has shifted and people who chose medicine with reasonable expectations and a good attitude have been dealt with unfairly?

Koop: We’ve lost our role models. It used to be that people my age were not uncommon in medical schools. They didn’t want to give up; they had an awful lot to tell students; and students had a lot to learn by just watching what they did and the way they thought. Older physicians are largely gone from medical schools. A young person entering medicine today doesn’t feel that the day she joins the guild of medicine she has responsibilities to the profession and to patients as well as a code of ethics and a code of behavior. We don’t raise people to feel that way any more. When we looked for residencies in my day, we wanted to know what the autopsy record was for the hospital. Now young doctors want to know how many nights they have off and how much they will get paid. Some of these changes are inevitable due to changes in the society as a whole. But I think we have to be more frank about our problems, and we have to find solutions to them. If some large international corporation, like Sony, were having relationship problems between the people who worked for Sony and the people who bought Sony products, either they would have to fix it or they’d be out of business.

Mullan: Once upon a time, medicine as a profession was relatively untainted by business concerns. Advertising was forbidden. Most doctors saw poor patients and accepted what they could pay. Many physicians taught for free. Most of these practices have fallen by the wayside as business practices have roared into medicine. Is there a way back out of this?

Koop: There’s not an easy way or a quick way out of this predicament. It’s going to take a generation to change it, but if we don’t change it, we’re going to lose it all.

Mullan: It’s hard to imagine the ground shifting back. Recently I talked to a retired GP [general practitioner] who spent all of his practice years in the same town in New Hampshire where he was born. He talked deprecatingly of the "gypsy doctors" of today—meaning young physicians who change jobs often. I well understood his sentiment, but it is a different world today than it was when he entered practice in 1940.

Koop: Well, you can’t teach a society not to be mobile. But you can teach a doctor, who is taking care of a member of that mobile society, how to approach the patient on a new arrangement. I’m optimistic because of the values of medical students today. Community service is a big deal in medical education now. The thing that impresses me most about the students is that you never hear them talk, as you used to hear them talk, about the accumulation of wealth. They are not ashamed to say, "I’m going back to Bridgeport to practice because that’s where I was born and that’s where they need me."

Mullan: I know you have been concerned about the state of primary care in the country and the falling popularity of primary care careers among young physicians. What’s at issue here?

Koop: Primary care is at the heart of good medicine—on a personal level and on a system level. Yet we don’t support it well. The pay isn’t as good, hours are worse, leisure time doesn’t exist, and specialists still fail to understand the real contribution of the primary care doctor. There’s nothing that makes me madder than to see a professor of medicine humiliate a medical student because the student is interested in primary care. It happens all the time. "You’re too smart for that," or "you are throwing your life away," the professor will sneer. It’s as though the student were going into prostitution. The primary care doctor has to have his feet on the ground. He has to know himself well enough to know that he’s making a contribution to medicine that a specialist can never make. And he has to do it knowing that his work will bring him satisfaction and not envy.

International Health Service Corps

Top Status Of U.S. Child... The Surgeon Generalship Working For Ronald Reagan Working With The Clintons The Tobacco Wars Medicine In America International Health Service... Outreach At Home Reflections On A Career... Editor's Notes

 
Mullan: Some contend that the U.S. contribution to the health of other countries isn’t what it might be. What do you see as our role in global health?

Koop: The only thing that I’m sure we have globalized is the spread of disease. By "us" I mean the world community—with transportation, communication, and our reliance on quick treatments and quick fixes rather than prevention. If we have globalized disease, we certainly have the obligation to globalize health. I think that the role of the United States in all global health problems is to share our knowledge and, where possible, to put in seed money to help. The fact that President Bush has included this in his plans is very good, I think. It’s also a good sign that some of the pharmaceutical houses have changed their pricing structure for places like Africa.

One of the things that I always wanted to do when I was Surgeon General—and I think should be done now—was to develop an International Health Service Corps, just the way we have the National Health Service Corps. The international model would be a little different, emphasizing training (rather than hands-on care) and transmitting know-how so that others can do these things on their own. I think that’s the real challenge of globalization of health care. We shouldn’t be exporting treatments; we should be exporting knowledge so that other countries can develop their own systems of care.

Mullan: Where do you see the recruits coming from for such an international corps?

Koop: I think there are reasons why it should work now better than ever. There is a lot of interest in global health among young physicians, whose idealism is high. There are also record numbers of older physicians leaving medicine early—many of whom would welcome an opportunity to contribute abroad. Think about how the Peace Corps came about: It took one man talking about it (John F. Kennedy); it took another man writing about it (Sargeant Shriver); and it took a lot of people who, once they went, became the advertisers for the program.

Outreach At Home

Top Status Of U.S. Child... The Surgeon Generalship Working For Ronald Reagan Working With The Clintons The Tobacco Wars Medicine In America International Health Service... Outreach At Home Reflections On A Career... Editor's Notes

 
Mullan: For a number of years you have been talking about a National Health Museum on the National Mall in Washington, D.C. Why do you see this as an important cause, and what would the role of such a museum be in American life?

Koop: When I was Surgeon General, I used to stand in my office on the top floor of the Humphrey Building and see all these kids on their school trips to Washington standing by one of the reflecting pools getting their pictures taken. It occurred to me over and over again that they could be stimulated to be almost anything in the world by what they saw in Washington—except something in medicine and health. There was no place to see it. A National Health Museum should be a place to celebrate our tremendous achievements in medicine, but it should not be just a curio shop. It should be a place to learn about personal health and prevention and get a glimpse of the future of the health sciences, but it should not be just a self-help center. Most important, this museum should be a center for education and inspiration about what is possible to accomplish in science and the healing arts. Its special mission would be the education of the next generation and the recruitment of young people to careers in health and medicine.

Reflections On A Career And A Life

Top Status Of U.S. Child... The Surgeon Generalship Working For Ronald Reagan Working With The Clintons The Tobacco Wars Medicine In America International Health Service... Outreach At Home Reflections On A Career... Editor's Notes

 
Mullan: A final question: As you look back on your career, what are your thoughts about it?

Koop: I’ve had a very, very interesting life, and I really feel that I was born at a good time, because I lived through what I think was the golden age of surgery, with tremendous technical advances. But in the midst of it, I was very much a part of the development of pediatric surgery, which was a special privilege. My time as Surgeon General was one of the happiest and I think most productive times of my life. And the fact that I’m eighty-seven and still active, still lecturing, and still teaching is...it’s enough to raise your eyebrows.

Editor's Notes

Top Status Of U.S. Child... The Surgeon Generalship Working For Ronald Reagan Working With The Clintons The Tobacco Wars Medicine In America International Health Service... Outreach At Home Reflections On A Career... Editor's Notes

 
After retiring as Surgeon General on 1 October 1989, C. Everett Koop has continued to be a force for public health and health education through his writings, electronic media, public appearances, and personal contacts, and as senior scholar of the C. Everett Koop Institute at Dartmouth University in Hanover, New Hampshire. Fitzhugh Mullan is the author of the book Plagues and Politics: The Story of the United States Public Health Service, a former Assistant Surgeon General, and a contributing editor of Health Affairs.

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