C. Everett Koop

MANY PEOPLE RECOGNIZE C. Everett Koop, MD, as US surgeon general extraordinaire, a man who single-handedly led thousands to kick the cigarette habit and saw to it that an AIDS education brochure arrived in every American mailbox at a time when the disease was shrouded in misinformation. Others herald him for saving thousands of young lives as a pioneer of pediatric surgery. And most who work in and for public health recognize the changes Koop brought about and is still fighting for.

“I remember so many things that this wonderful man did,” Sen Orrin Hatch (R, Utah) said at Koop’s 90th birthday celebration in Washington, DC, in 2006. “He became one of the most popular people ever in the history of government. And we all love him to this very day.”1

Born in Brooklyn, NY, in 1916, Koop knew from an early age he wanted to work in medicine. He started his surgical training as a young boy by cutting pictures from a magazine with both his left and right hands to develop dexterity. As a teenager he snuck into the operating theaters at Columbia Presbyterian Medical Center to watch the surgeons and spent his first summer job in a hospital laboratory, performing urinalyses and blood counts and helping the resident pathologist with autopsies. His undergraduate studies at Dartmouth College (Hanover, NH) led to Cornell University Medical College (New York, NY) and, eventually, his work in establishing the nation’s first neonatal intensive care unit.2

“He was a real icon before he even became surgeon general,” said Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases and a longtime friend and colleague of Koop.

Koop considered retiring after a trailblazing career that resulted in surgical techniques still used today to save tiny newborns. Yet being tapped to serve as surgeon general at age 64 excited Koop, who as he approached his 91st birthday, credited his longevity to both genetics and working in a field he adores.

“I’ve never had a job where I didn’t like to get up in the morning and go to it, and that’s, I think, unusual,” he said from his office at the Koop Institute at Dartmouth. “I told that to a group of medical students a couple of years ago and they looked at me like I was out of my mind.”

Known for his powerful speaking voice and trademark beard that have led some to describe him as resembling an Old Testament prophet, Koop likely was such an effective surgeon general because he truly cared about the people he was working to protect. And he doesn’t mince words or tiptoe around what some might think of as political land mines.

“He’s a completely transparent, honest, tell-it-like-it-is kind of person,” said Fauci, once Koop’s personal physician and a confidant at the time the surgeon general was working on his controversial AIDS report. “He’s just not afraid of anybody.”

“This is a man who, above all else, is willing to communicate his convictions with courage when it’s the right thing to do,” said Timothy Johnson, MD, MPH, medical editor for ABC News and coauthor with Koop of Let’s Talk: An Honest Conversation on Critical Issues: Abortion, Euthanasia, AIDS, Health Care. “He’s always willing to dialogue and listen to the other side. I think that’s a great strength.”

Courage and faith helped Koop weather a confirmation process that stretched out for 9 months and included some “slings and arrows” that were often personally painful. His previous speeches and publications against abortion led some in the conservative Reagan administration to believe Koop would use the surgeon general’s post to rally against the procedure. Yet Koop insisted he had said all he wanted to say on the topic and didn’t believe the surgeon general had power to change the legality of abortion.2

Still, editorials ran, people spoke out, and it seemed everyone had an opinion about why Koop shouldn’t be the nation’s surgeon general. “I was ‘Dr Kook,’” Koop said with a pained expression, also recalling a newspaper editorial that ran under the headline, “Dr. Incompetent.” The American Public Health Association was one of many groups to oppose Koop’s confirmation on the grounds that his medical background did not qualify him to serve as surgeon general. Rep Henry Waxman (D, Calif) was an outspoken opponent.

“I was taken by surprise,” said Waxman, who now regularly turns to Koop for advice on health-related issues, including asking Koop to testify at a July 2007 hearing before the House Committee on Government Oversight and Reform on depoliticizing the surgeon general’s post. “I didn’t know what to expect from him. I thought he was more likely than not a right wing ideologue.”

Waxman, American Public Health Association members, and many others soon discovered Koop was a doctor with sincere concern for people and a desire to apply a science-based, public health approach to threats such as tobacco and the emergence of AIDS. “After we worked together I was tremendously impressed by him,” Waxman said. “I was tremendously impressed by the way he took on tobacco and when the AIDS epidemic hit in the early ’80s how he approached it from a public health point of view and nothing else.”

Koop, also credited with revitalizing the Commissioned Corps of the US Public Health Service during his 1981 to 1989 tenure as surgeon general, donned the navy jacket and gold braid of the corps and quickly became the face of public health. He was prepared for the job, he said, because of a long career in pediatrics, which put him “closer to public health than if you are a surgeon.”

“I really did a lot to establish pediatric anesthesia, not only here but in many places around the world, and I had experience staffing a medical school in Ghana, working with the Rockefeller Foundation, so I had the benefit of that kind of prestige and money behind me and also working for the State Department,” Koop said. “I did a lot of things that I thought were public health, and that stood me in good stead for decisions I had to make. It wasn’t nearly the leap that some people think it was or that you might think it is, to go from being a surgeon of individual patients who had a surgical problem to 347 million people, which is what the population was when I went to Washington.”

Although the drawn-out confirmation process was “onerous” at the time, Koop said the months helped him prepare to lead the nation on public health issues. “What I was able to do at that time was to make friends, study the situation,” Koop recalled. “I’m probably the only, the first, surgeon general to step into the job with an agenda. I had seen, for nine months, things that I thought were really bad. So I had some priorities.”

Koop described some of those early priorities in his 1992 memoir, recalling that he wanted

to find ways to avoid overlap and duplication of services for handicapped children and their families, to provide computerized information banks to help physicians and nurses find proper care for defective newborns, and to enable their families to ferret out the resources that communities made available for their upbringing, education, and support.2^(p174)

Of his many notable accomplishments as surgeon general, Koop issued the Surgeon General’s Report on Smoking and Health in 1982. Former Surgeon General Luther Terry had laid the groundwork with his 1964 report, which led to warnings on cigarette packages. On the basis of scientific research, Koop’s 1982 report attributed 30% of all cancer deaths to smoking.

Koop’s series of reports on smoking “totally changed the landscape,” said Michael Fiore, MD, MPH, a current-day leader in tobacco control as founder and director of the University of Wisconsin Center for Tobacco Research and Intervention. For example, Koop’s 1986 report on environmental tobacco smoke let the public know that living with or working near a cigarette smoker put their own health at risk.3

“It no longer was a discussion of my individual rights. Rather, it was a public health discussion that no one has the right to put those sitting next to them at undue risk,” Fiore said. “As a society, we don’t tolerate that. He established environmental tobacco smoke as a killer, based on science.”

His 1988 report4 established unequivocally that nicotine is addictive and that tobacco use is not a habit but an addiction, a chronic disease that requires effective treatment. Koop handed out blue buttons that read, “The Surgeon General asked me personally to stop smoking” and then rewarded those who followed through with a red button that read “And I Did.”2 His influence extended across generations, evidenced when a person dressed in a Mr. Potato Head costume visited Koop’s office to share the news that the popular toy would no longer be packaged with a pipe as an accessory.

As the health dangers of smoking became known more widely, Koop saw US smoking rates decline but still worried as more young people and women picked up the habit. To this day Koop takes every opportunity to call for a smoke-free society, opening speeches with statistics on the nation’s number-one preventable cause of death. As surgeon general he would often open with these chilling lines: “A thousand people will stop smoking today. Their funerals will be held sometime in the next three or four days.”2^(p206)

A churchgoing man with conservative personal values, Koop found himself, at age 70 years, in the awkward but critically important position of educating the public about the emerging and devastating health threat of AIDS in 1985.2 Koop said he angered some by talking openly about a disease that was largely being transmitted through homosexual intercourse and intravenous drug use. He butted heads with lawmakers and White House staffers to make sure the truth about AIDS transmission was not muddied by conservative political views or antigay sentiments.

“It was clear the only weapon we had against AIDS was education, education, and more education,” Koop said.2^(p258) He bypassed the “normal clearance process” to produce an AIDS pamphlet, “Understanding AIDS: A Message From the Surgeon General,” sent to 107 million American households in 1988.

Former Surgeon General David Satcher, who served from 1998 to 2002, said the AIDS report was courageous and based on the best possible science. Satcher himself endured resistance in releasing the first surgeon general’s report on sexual health. “There are certain issues that cause you problems when you’re in that office,” Satcher said. “I think Dr Koop showed a lot of courage.”

Koop has said his work on smoking and AIDS stand out as top accomplishments, but he also takes pride in a change in federal law that entitles disabled children to “coordinated, comprehensive, family-centered community-based health care,” he said, an important step “because, sadly, children occupy a great deal of our rhetoric but not much of our action…. The sad thing is that if you are an elder or if you are middle aged or if you are a baby boomer just coming into maturity—that’s a good word—then you can be your own advocate or you can get a lobbyist,” Koop said. “But kids can’t get a lobbyist. Kids don’t have any money, and kids don’t have any organizations. And so they get the shorter end of every stick.”

Koop has the kind of tangible integrity that comes from living through both great accomplishments and almost unbearable tragedy. A loving father of 4, he and his wife lost their 20-year-old son David to a rock-climbing accident in 1968.5 Thinking they might help other grieving parents, they wrote Sometimes Mountains Move, about David and the family’s grief. When his wife died in early 2007 after a long illness, Koop took some time to mourn and said losing her made him feel like “a tent peg being hammered into the ground.” Yet a few months later, he was testifying on Capitol Hill about the need for the surgeon general’s position to be more politically independent. Later in the summer he traveled to Atlanta to speak on emergency preparedness. He is a professor of surgery, community and family medicine, and psychiatry at Dartmouth Medical School and is working to revitalize a dialogue between medicine and public health. He believes strongly in national health reform.6

Just before a group of public health luminaries headed to a dessert table to cap off Koop’s 90th birthday celebration in Washington, DC, the guest of honor gave an impassioned speech about the need for health care reform. Echoed in a December 2006 Journal editorial,6 Koop outlined 3 core principles for reform: the fundamental right of all people to have the highest standard of health care, that disparities are “absolutely unacceptable”1 and at odds with the right to health, and that public, private, and health-related agencies need to make disease prevention and health treatment a priority.

“I am still concerned that the present difference between the haves and have-nots will worsen,” Koop said.1 Reflecting on health care reform in summer 2007 as presidential candidates were hitting the campaign trail in full force, Koop said the question about health reform is not how it will happen, but when. Koop said,

My overarching opinion about health care reform is that it will be extraordinarily difficult to accomplish because the various groups of people that are now making good money on the health care system don’t want to change it. But it can be done, and it takes courage. I think it’s the kind of thing that may have to wait until the mass of uninsured people is so critical that they can’t stand it, or you and I who are insured can’t stand it, and I don’t know what that is, 65 million? You never can tell about those things because one of those things that always happens when you’re waiting for the expected is, the unexpected comes along.

Former Surgeon General Richard Carmona, who served from 2002 to 2006, said Koop brought the office “to a new standard” and was effective because he “stepped up and took risks and did the right thing.” Koop said his success can be attributed to a combination of factors.

“I look back on those days, and some things I accomplished because I was naïve. Some things I accomplished because I was furious and I wasn’t going to let that stand in my way,” Koop said with a smile. “Other things I accomplished by what I call moral suasion … and by that I mean having an explanation for what you want to do that transmits the passion you feel for it, the rightness of what you want to do and why it is good for the recipients to have somebody advocate for them because nobody else will.”

Those who know Koop well, including Johnson of ABC News, know that the man who hopes to be remembered as “the health conscience of the nation”2 will work as long as he’s able to improve the public’s health. “He studies. He knows what he’s talking about,” Johnson said from his office in New York. “He knows how to say things that will capture your attention.”

Figure 1.

C. Everett Koop, MD.