Blog: The Battles of C. Everett Koop

C. Everett Koop, who served as Surgeon General in the Reagan administration, died this week at the age of 96. His legacy is an unexpected story of public service triumphing over ideology.

A devout Christian and lifelong Republican, Koop held strong views on abortion and homosexuality early in his life which endeared him to fellow conservatives. After being appointed Surgeon General, Koop’s views were leavened through his experience responding to the AIDS crisis and protecting the public from attempts within the White House to subvert medical science to advance its ideological agenda.

Prior to serving as Surgeon General, Koop served for 35 years as Surgeon-in-Chief at Children’s Hospital of Philadelphia. He gained international repute by building the nation’s first neonatal ICU, pioneering surgical procedures for separating conjoined twins, correcting a wide range of congenital birth defects, drastically reducing infant-surgery mortality rates, and developing infant anesthetic. Many of the surgical procedures developed by Koop to save children’s lives are textbook cases for medical students today.

Throughout the 1970s Koop saw a contradiction between society’s struggle to protect the lives of struggling newborns while simultaneously allowing unfettered access to abortion. A lay Presbyterian, Koop wrote two books decrying abortion and teamed up with evangelical leader Francis Schaeffer in 1976 to produce the video series Whatever Happened to the Human Race? The series took an uncompromising stance, equating abortion with infanticide and compared women seeking abortion to German soldiers in Nazi death camps.

At one point in the series, Koop surveyed thousands of naked dolls placed across the Dead Sea and intoned: “I am standing on the site of Sodom, the place of evil and death.”

His ideological positions were unapologetic, and seemingly inflexible. He dismissed amniocentesis as a “search and destroy mission” because it was done to detect the presence of birth defects in a fetus—presumably to help mothers decide whether to terminate their pregnancies, and characterized homosexuals, childless couples, and single parents as “anti-family.” He co-founded the pro-life political organization Christian Action Council and made abortion a central topic for conservatives and evangelicals throughout the nation.

By the time Ronald Reagan was elected in 1980, Koop’s prestigious medical record and conservative credentials made him a natural candidate for Surgeon General. After a protracted confirmation battle in which he promised nervous Democrats that he would not use his position as Surgeon General as a pulpit on which to oppose abortion, C. Everett Koop was confirmed by the Senate.

But he did use his new role as a pulpit—against an unlikely target.

The new Surgeon General’s first act was the publication of his Report on Smoking and Health. The report minced no words in explaining that smoking caused cancer and heart disease, and was more dangerous than asbestos and coal dust. Koop compared nicotine addiction to heroin and cocaine, and attributed 30% of all cancer deaths in the United States to smoking. He argued for mandatory warning labels on tobacco products, a ban on cigarette vending machines, and increased regulation of tobacco.

Big Tobacco struck back, deriding his findings and accusing him of embarking upon a personal crusade. Brennan Moran of the Tobacco Institute argued that “claims that cigarettes are addictive contradicts common sense.” This was not what the Republican administration had expected from its new appointee. The GOP traditionally shielded Big Tobacco from scrutiny, and Republican Senator Jesse Helms immediately called for an official investigation into the Surgeon General.

Koop gave as good as he got. When Republican Senator Bob Dole dismissed his warnings about nicotine addiction as evidence that he had been brainwashed by the liberal media, Koop fired back that the Senator’s comments “either exposed his abysmal lack of knowledge of nicotine addiction or his blind support of the tobacco industry." When North Carolina’s Democratic Senator, Terry Sanford, warned that “in comparing tobacco -- a legitimate and legal substance -- to insidious narcotics such as heroin and cocaine, he has directed 'friendly fire' at American farmers and businessmen," Koop remained firm.

“I haven’t mistaken the enemy,” he responded. “My enemy kills 350,000 people a year.”

Koop published additional reports detailing the deadly effects of smoking, and called for a smoke-free society by the year 2000. His role in educating consumers, creating mandatory warning labels, and banning cigarette vending machines caused smoking rates to decline from one-third to one-quarter of the population by the time he resigned his post in 1989. Koop’s crusade to protect the American people laid the groundwork for the epic battles against Big Tobacco which took place the following decade during the Clinton administration.

While Koop was studying the research on smoking, a new disease was beginning to spread in America. The first confirmed cases of AIDS were discovered in the U.S. in 1981. Evangelicals like the Reverend Jerry Falwell who had helped send Reagan to the White House wasted no time explaining the new disease, explaining that “AIDS is the wrath of God upon homosexuals.”

According to the Department of Health and Human Services, 5,000 letters a week were being received by conservative citizens who argued against federal research into the new disease—let those who practice a perverse lifestyle pay the price for their immorality. Nor were such views limited to external actors. White House Communications Director Patrick Buchanan argued that AIDS was “nature’s revenge on gay men.” Koop observed that "Gary Bauer [Reagan's chief advisor on domestic policy] ...believed that anybody who had AIDS ought to die from it. That was God's punishment for them." President Reagan seemed to share such views: despite an alarming increase in the number of AIDS-related fatalities, The Washington Post wrote that “almost nobody in the Reagan administration would even utter the word 'AIDS’.”

During his first five years as the nation’s leading health figure, C. Everett Koop was not allowed to acknowledge the AIDS crisis. Journalists were instructed by the White House that the new Surgeon General was not to be asked questions about AIDS, and that the subject would not be addressed. Koop knew that the gag rule came from staffers inside the White House mirroring widespread conservative opinion. He later explained that “because transmission of AIDS was understood to be primarily in the homosexual population and in those who abused intravenous drugs. [The president’s advisers] took the stand, 'They are only getting what they justly deserve.'"

The official silence surrounding AIDS gave rise to public fears: could one contract the deadly disease through casual contact in schools and other public places? Such fears were stoked by those like Senate candidate and future Republican presidential hopeful Mike Huckabee, who decried homosexuality as sinful and called for mandatory testing and quarantining of those afflicted with “the plague” into camps to protect the general public.

Faced with mounting public opposition, the gag rule was finally lifted in 1986—12,000 positive diagnoses and 6,000 deaths later. The White House instructed its Surgeon General to produce a report about AIDS. Koop wasted no time in meeting with numerous organizations, including gays and lesbians, religious conservatives, African-Americans, top health experts, and AIDS patients. As he reached his conclusions, he worried that conservatives in the White House would run his final report through an ideological purity filter, stripping it of recommendations which did not fit within its narrow worldview. He carefully produced over 17 drafts before reaching his final version. Koop devised a clever scheme to outwit ideological watchdogs: he distributed numbered copies of his final report to the internal review team, then collected them back at the end of the meeting instead of allowing attendees to retain copies for deeper analysis—ostensibly to prevent the report from getting leaked.

The gambit worked. Koop’s final report was presented to the public with his recommendations intact. Conservatives were appalled by its frank discussion of sexual practices, including anal and oral sex, its lack of moral judgment against homosexuality, Koop’s call for increased condom use, and his recommendation of sex education in elementary schools. Religious right founder Paul Weyrich and conservative firebrand Phyllis Schlafly called for a boycott of a Washington dinner held in Koop’s honor, arguing “His report on AIDS issued last November reads as though it were edited by the National Gay Task Force. Dr. Koop's proposals for stopping AIDS represent the homosexuals' views, not those of the profamily movement." Conservative Digest claimed that Koop was “proposing instruction in buggery for schoolchildren as young as the third grade,” and National Review accused him of “criminal negligence” for advocating the use of condoms.

Undaunted, Koop next oversaw the largest mailing in history by sending a simplified version of the report to every household in America—the first time the government had distributed information about sex to the public. In his landmark account of the history of the epidemic, And the Band Played On, journalist Randy Shilts credited Koop’s report for dramatically improving public understanding of AIDS and quelling fear and paranoia about those who carried the disease.

Evangelical leaders like James Dobson and Gene Antonio were not to be silenced so easily. They harshly criticized Koop and continued to spread misinformation. They suggested that—contrary to the Surgeon General’s report –the disease could indeed be contracted by kissing, mosquito bites, and toilet seats. The goal was to incite widespread fear of gays and lesbians as being carriers of “the new plague.” Koop lambasted such efforts, arguing: “The Christian activity in reference to AIDS of both D. James Kennedy and Jim Dobson is reprehensible. The first time that Kennedy ever made a statement about AIDS, I saw it on television. It was so terrible, so homophobic… I just cannot believe the poor scholarship of so many Christians."

He fought efforts to discriminate against victims of AIDS in public spaces, including workplaces and schools, and attacked the notion of forced testing and quarantine as being unconstitutional. Looking back at the period after the Reagan gag rule had been lifted, Koop reflected, “AIDS took over my life.”

The issue which would follow Koop throughout his tenure as Surgeon General was the same issue which had nearly derailed his confirmation: abortion. Conservatives expected the man whose writings had helped make abortion a front-burner issue through his earlier advocacy would naturally use his role as Surgeon General to lead the charge in rolling back Roe v Wade. But in this, the right discovered another unpleasant surprise. While Koop made no secret of his staunch pro-life views, he studiously avoided the subject in his appointed role. He reasoned that abortion was a moral issue which could not be solved by medicine or science. As he had previously told evangelical audiences after the furor caused by the publication of his AIDS report, "I'm the surgeon general, not the chaplain general."

Koop avoided the issue until Reagan, under pressure from conservatives upset with his inaction on restricting abortion, asked Koop to produce a report detailing the negative impact of abortion on women’s health. White House advisor and future conservative spear-carrier Dinesh D’Souza convinced Reagan that "The findings would be so devastating that they would reverse Roe v. Wade." Perceiving the request stemmed from politics rather than any actual concern about improving the lives of women, Koop repeatedly delayed starting the project, until Reagan finally ordered his Surgeon General get started.

As with his AIDS report, Koop personally interviewed numerous sources during his research, including doctors, advocates, religious groups, women directly affected by abortion, and the Centers for Disease Control. He concluded that insufficient scientific research existed to produce the report Reagan wanted. Koop wrote to the White House explaining the situation, and hoped the matter would be dropped: “the available scientific evidence about the psychological sequelae of abortion simply cannot support either the preconceived notions of those pro-life or those pro-choice.”

The man whose earlier public advocacy had helped make the fight against abortion a rallying cry for conservatives was now denounced as a traitor to the cause. National Review described him as “one of the major disappointments of the Reagan Administration.” Reagan staffer and future Republican presidential candidate Gary Bauer denounced Koop’s letter as “a cop-out” for not pursuing a staunchly anti-abortion agenda. Howard Phillips, Chairman of the Conservative Caucus, suggested that “If he couldn't act on what he believed to be correct, he should have resigned. He has revealed himself to be a man who prized the public spotlight rather than his conscience." For his part, Koop remained morally opposed to abortion, homosexuality, and promiscuous sex, but he saw a distinction between his private religious opinions and his duty to safeguard the health of the American people.

After George H.W. Bush was inaugurated as President, Koop was passed over for the head of Health and Human Services. His chief aid was dismissed. Numerous slights occurred to send the message that he was not welcome in the new administration: his access to the executive dining room unaccountably ended, he was not invited to retreats for senior staff members, and his phone calls were not returned. In 1989, Koop announced his retirement from the role of Surgeon General. The man who had been described by Congressman Henry Waxman as “scary” and “intolerant” during his 1981 confirmation battle now stated: "He's a man of tremendous integrity. He's done everything a Surgeon General can do, and more." Waxman’s praise was echoed by the American Medical Association, Planned Parenthood, and the National Gay and Lesbian Task Force. One group that had vociferously opposed his nomination seven years earlier, The American Public Health Association, now presented him with its highest award.

***

C. Everett Koop was a man of strong personal and religious convictions. A Presbyterian and lifelong Republican, he disapproved of homosexuality, sex outside of marriage, promiscuity, and abortion. But he saw himself as the chief protector of public health and safety, not an ideological warrior. “I separate ideology, religion and other things from my sworn duty as a health officer in this country,” he explained in 1988. A year earlier, he had told an evangelical group: “I am the surgeon general of the heterosexuals and the homosexuals, of the young and the old, of the moral and the immoral."

Koop was deeply disturbed by the ease with which conservatives were willing to allow ideology to trump the findings of science and empirical research. When National Review claimed that Koop had exercised “criminal negligence” in recommended condom use as a means of reducing the spread of AIDS, he retorted that the journal was “letting politics and ideology supersede science.”

The situation has not improved.

The Republican war on science accelerated during the administration of George W. Bush. In 2002, Surgeon General Dr. Richard Carmona accused the George W. Bush administration of muzzling him on issues like stem cell research. He told a Congressional committee:

Anything that doesn't fit into the political appointees' ideological, theological or political agenda is ignored, marginalized or simply buried. The problem with this approach is that in public health, as in a democracy, there is nothing worse than ignoring science, or marginalizing the voice of science for reasons driven by changing political winds.

In words that could have been pronounced by C. Everett Koop twenty years earlier, Carmona testified that “the job of Surgeon General is to be the doctor of the nation, not the doctor of a political party."

Today, conservative hostility toward science is costing Republicans elections. Republican Senate candidate Todd Akin took fire last year for suggesting that women’s bodies are able to physiologically prevent pregnancies during “legitimate rape”—a sentiment shortly followed by Republican Senate candidate Richard Mourdock, who affirmed that even if rape did result in pregnancy, it was “something that God intends to happen.”

Both candidates lost to their Democratic challengers.

In a move reminiscent of Reagan’s request for a report detailing the harmful effects to women from abortion, Republican Governor Sam Brownback has sharply restricted access to abortion in his home state of Kansas over the past two years. He argues that he has acted in part from a desire to protect women’s health-- despite the lack of evidence that their health was being harmed in the first place.

This willingness to promote bad science to advance a conservative agenda extends to those seeking the White House. Republican presidential candidate and Tea Party favorite Michele Bachmann argued in 2011 that the HPV vaccine, which protects women from a sexually-transmitted form of cancer, can lead to mental retardation. “There are very dangerous consequences,” she warned. The next day, Dr. O. Marion Burton, president of the American Academy of Pediatrics, issued the following statement:

The American Academy of Pediatrics would like to correct false statements made in the Republican presidential campaign that HPV vaccine is dangerous and can cause mental retardation. There is absolutely no scientific validity to this statement.

[…]

This is a life-saving vaccine that can protect girls from cervical cancer.

Bachmann’s misinformation about HPV bore similarities to the Reagan administration’s request that its Surgeon General prepare a report detailing the negative health effects of abortion on women. In both cases, the goal was to distort medical science to change women’s sexual behavior. Reagan hoped to reduce or eliminate abortion by detailing its supposedly dangerous effects on women. Bachmann hoped to reduce underage sexual activity among girls by suggesting that the HPV vaccine used to prevent a sexually-transmitted form of cancer might also lead to mental retardation.

When confronted with conservative attacks over his anti-smoking campaign, support for sex education in schools, advocacy for greater condom use, or his refusal to demonize homosexuals and abortion-seekers, Koop did not offer half-hearted defenses: he launched unapologetic counterattacks. He denounced evangelicals for rejecting the tenets of basic science, accused members of his party of being on the payroll of Big Tobacco, and refused to succumb to political pressure concerning women’s access to abortion. He greatly expanded the role of the Surgeon General, waging campaigns to reduce cigarette smoking, drunk driving, sexual abuse, and other preventable accidents—areas normally limited to law enforcement. This expansion of federal power was driven by a deeply-held belief that government officials had a responsibility to serve the people well. This meant following scientific data to their logical conclusions without regard to ideological frameworks.

"I am a public health officer,” he told The New York Times in 1988. “I can't deliver a public health message to just those people whose behavior the conservatives approve of."

Koop’s view is echoed today by other enlightened Republicans willing to challenge the party’s anti-scientific stance. New York Republican Mayor Michael Bloomberg has enacted prohibitions on large-sized sugary drinks to reduce obesity-related health problems like diabetes. He has also been a leading voice calling for sensible gun control measures which have proven effective in reducing firearm deaths and injuries. Republican presidential candidate Jon Huntsman tweeted during the 2011 Republican primaries: “I believe in evolution and trust scientists on global warming. Call me crazy”—a tweet heard ‘round the world, and one that presaged his eventual elimination from a contest in which only those willing to cast doubt on commonly-accepted scientific principles would survive. In 2011, Republican Governor Arnold Schwarzenegger sounded off in the pages of The Wall Street Journal that the Clean Air Act had saved hundreds of thousands of lives by removing deadly pollutants from the atmosphere. He slammed efforts by fellow Republicans in Congress to reverse the legislation:

This is not an abstract political fight. If these proposals are passed, more mercury, dioxins, carbon pollution and acid gases will end up in the air our kids breathe. More Americans will get sick, end up in the hospital, and die from respiratory illness. We would be turning our backs on the sound science and medical advice that has reduced air pollution from large industrial sources…

These courageous political stands come from the few remaining Republicans who are willing to do battle with the party’s right wing and the powerful business interests it protects. They are the political heirs of C. Everett Koop, and they take fire from their own party and the big business interests it protects in their determination to protect the public interest.

Koop’s legacy was the elevation of public duty over politics—the simple idea that government could be a force for good in people’s lives. He held uncompromising views about abortion and homosexuality, and his basic views never changed once he took office. But his direct experience working with gays and lesbians suffering with AIDS, and his research into why women sought abortion led him to promote compassionate responses which re-humanized those who suffered—often to the fury of his former standard-bearers. Gone were the rhetorical salvos comparing abortion-seekers to Nazi officers. The same empathy which led C. Everett Koop to save the lives of infants during his days at Children’s Hospital of Philadelphia now extended to protecting other populations which had historically received nothing but scorn from his party.

Reflecting back on his early days as Surgeon General, Koop said: "I had a chance to look at the health problems of the nation and wonder what I could do about them when I was finally let loose. I decided I would use the office to espouse the cause of the disenfranchised: handicapped children, the elderly, people in need of organ transplantation, women and children who were being battered and abused.”

He will be missed.