A Public Servant for the Public's Health

September 1989

An Interview with Surgeon General C. Everett Koop

Washington—[Dr. C. Everett Koop has just stepped down as the nation's top public health official. On March 3, he spoke at length with Public Justice Report correspondent Joan Orgon who interviewed him for the Family Radio Network's program called Viewpoints. Excerpts from the interview follow.]

Joan Orgon: When you took this office, what kind of vision did you have or what kind of strategy did you map out for your successive years?

Dr. Koop: Surgeons General don't usually have a strategy. They respond to the times. My case was different, and I did develop a strategy. The reason it was different was that I had been for the previous ten years the most outspoken physician in America against abortion. I had been a well-loved physician in Philadelphia. When I got to Washington, I could not believe the antagonism I ran into here, the venom, the people that were trying to shoot me down all because of my anti-abortion position. They said other things. They said I was incompetent and couldn't do public health, but it was my abortion position.

So my confirmation hearings, instead of taking three weeks or so took more than nine months. And during that time, I had to establish my credibility with all kinds of people in Washington, and I did. So that in that nine-month period I developed friends and an agenda. My agenda simply was to espouse the cause of the disenfranchisedthe elderly, mothers and children, handicapped kids and their families, baby Doe, those who've needed organs for transplantation, and so on. And that's why I've been a different kind of Surgeon General. By the time I was sworn in, there was nobody around who realized I was new. So, no one ever said, "Here's your job." And from that time on, I just did what I wanted to do.

Orgon: It seems that Americans, with their wealth and many, many resources, should be more healthy overall. Is this the case? How do we compare to other nations around the world?

Koop: Well, it's hard because they all have different problems. We have one major problem in this country and that is that all of our people don't have equal access to health care. We have perhaps as high as 37 million people who are what we used to call the working poor. They're not poor enough to be on welfare; they don't qualify for medicaid; they're not old enough for medicare; they work for small companies that can't afford to buy expensive insurance. And so they don't get the care they need, and that is really intolerable in a nation as affluent as this one.

Orgon: What did you find most challenging in this job?

Koop: I guess most challenging is to walk the straight and narrow path which you have to do as a public servant where you are the Surgeon General to all the people, and you have to do things that might grate a little bit on your own personal sense of values. AIDS was a perfect example of that. Everybody has commended me for my stand on AIDS and the way I have handled the problems of discrimination and so on. But I have always said in spite of that that one of the big problems about

AIDS is that most people get it by doing things that most people do not do or don't approve of other people doing. And so I've had criticism from people that I didn't bash homosexuals, but that's not my job. Or that I talked about such unseemly things as condoms for teenagers who were going to be promiscuous. But as Surgeon General I don't have the luxury of choosing the people that are my clientele. And when it comes to things like recommending condoms to young people, I hate to do that, but I never do it without first going through the advantages of abstinence, the advantages of mutually faithful monogamy and then, as a poor third, I get into the things that people criticize me for.

Orgon: Is some of this criticism coming from the Christian community?

Koop: I think most of the criticism comes from the Christian community, and I think that's the hardest thing to take. These I consider to be my own people, but I have to acknowledge I don't admire their scholarship, I don't admire their understanding, and for people who are supposed to understand faith and trust more than other people, I don't admire their faith and trust in me. I have not changed one iota. But I don't think the average Christian, whether he is in the pew or in the pulpit, realizes you can still maintain your integrity and you can still be honest and you can still take your own ethical and moral stand, but as a public servant, you are not in the position of preaching that to other people.

Orgon: Where do you have leeway or how do you integrate your faith and your responsibilities as a surgeon general? Where do those two things meet?

Koop: I don't think that's hard to answer. I have always talked to medical students and young people who are concerned about combining one's faith and practice, and you do the job you're given to the very best of your ability. In other words you avoid mediocrity to the Nth degree. Now I don't think that just because you're in Christian work that makes you a better Christian. I think sometimes the practice of surgery is just as sacred as preaching. In this particular job, I know who I am, and I know what my relationship is to the Lord. And for these eight years I'm serving the Lord by being the Surgeon General of the United States and doing that job to the best of my ability and above criticism. It's unpleasant that the people who criticize me are Christian, but I guess that goes with the territory.

Orgon: Clearly, Dr. Koop, one of the most pressing issues that you've had to deal with in your service here has been the whole issue of AIDS. Did you expect that or did you know the extent of this when you came into office?

Koop: No, I arrived here in March of 1981. The first five cases of AIDS came along in the summer of 1981. We didn't even know what to call it until the next year. But I recognized by September of 1981 that we had a big problem on our hands, especially when I recognized that it was the disease that was primarily at that time among homosexuals, that it was being transmitted primarily by sodomy, but, most importantly, that bisexual men were also transmitting it to women through heterosexual relationships. So I knew we had a big deal on our hands, and we do!

Orgon: Congress has appropriated hundreds of millions of dollars for educational and research programs to hit the war against AIDS, and your office has been very instrumental in a lot of these programs. Can you give us an assessment of where we are. Are we winning the war?

Koop: No, we're not winning the war. First of all, let's repeat what we have—a disease that is transmitted only by sexual contact or by the sharing of intravenous drug paraphernalia or is passed from a pregnant woman to her child. We used to have to worry about the safety of the blood supply for transfusions but that is now as safe as you can get it. So you can see that AIDS is something that will not ever be picked up by casual contact. You have to make a decision to do something, to do something in the way of an act that leads to the transmission of the virus. So we know where it comes from and where it does not come from.

It is unfortunately, as far as we know, 100 percent fatal. So far—we're talking now in March of 1989—there have been about 88,000 cases reported in this country. More than half of those have died. The other half almost certainly will. But there are about a million and a half people infected with the virus who are perfectly well so far, who are able to transmit the disease. Probably most of those don't even know that they're infected. So that's where the education campaign becomes so important because we have no cure and no vaccine and the only weapon we have is education and more education and more education.

Now, the people we've talked to don't all listen. But the homosexual community has listened, and we know by other sexually transmitted diseases they have, that when they heard the message, they dropped off remarkably. We know that in 1987 the actual new cases of AIDS among homosexuals and bisexual men dropped off for the first time.

But we know that in spite of the fact, let's say that in 1987 teenagers heard repeatedly the most explicit, clear messages on how to avoid sexually transmitted diseases (and of course AIDS is the most horrible of all of those sexually transmitted diseases), and yet pregnancy, syphilis, and gonorrhea increased in the 14-17 year-old age group at a steeper rate than they had done in the previous 16 years. That's very discouraging to a health officer. That means they have not listened, they're taking risks, they think they're immortal, and, if they're having that much disease, and if they're producing 1,200,000 babies every year out of wedlock while they're still teenagers, then if there's HIV out there you know they're going to pick it up. That is frightening to me.

Orgon: Is the educational campaign about AIDS hitting the Christian community? It seems to be divided. Many believe it's God's judgment and wrath against homosexuals. Others think this is just an evolution of our culture, and we need to reach out with compassion to people who are suffering with AIDS.

Koop: Well, I can say this—if any of your listeners believe this is God's judgment on homosexuals, then you have to wonder about why the babies born to mothers who are heterosexual are having the problem. But, let me say to your Christian listeners that if your Biblical understanding is that homosexual behavior is a sin, then I know that the same place you learned that has taught you that you have to have the ability to separate the sin from the sinner. And in this particular instance it means that no matter what you think about the behavior that produced the AIDS, you ought to have compassion and love for the person who has that disease.

And let me go further than that—AIDS is just like the leprosy of the middle of the last century. It's a marvelous opportunity and challenge for the Christian church. It's an opportunity for Christian service, it's an opportunity for Christian witness to the world, it's an opportunity for Christian missions because, even in Africa today, the hospitals that were once filled with leprosy patients in the times of David Livingston are filled with AIDS patients today.