Sl

wanted it to go.

The thing that was frustrating is that there
were lawyers, lawyers, lawyers, lawyers. And there was
nobody from public health. And when they sat around the
table and discussed things, it was lawyers there
discussing with other lawyers in reference to their
clients; their clients were the tobacco companies, their
clients were other people in society, their clients were
the attorneys-general who got their own lawyers from
outside their offices, and we had just one person
representing our side. Now, he is a very zealous and a
very efficient guy, Matt Myers, who now runs the
campaign for Tobacco-Free Kids. But I do think if he
had said --

INTERVIEWER: "Our side" in this case? You
said Matt Myers was representing our side.

DR. KOOP: He was the person that was opposed
to smoking and opposed to the tobacco industry's
influence on children, advertising and everything else.

INTERVIEWER: But that was different than the
attorneys-general?

DR. KOOP: He had a passion that was closer
52

to --

INTERVIEWER: He was a pure advocate.

DR. KOOP: He was a pure advocate, but I think
he should have protected himself by saying, "I want
seven people from public health on this committee to be
my advisers and to work with me." And a lot of us tried
to talk with him, and I was talking to both sides, back
and forth, all the time, and the settlement itself was a
tremendous thing, huge amount of money, over 25 years,
but it were the things that happened apart from that
that made me leave Washington and move up here.

And when Trent Lott behaved the way he did and
said that this subject will not come up again as long as
I am president of the Senate, and when we took a vote in
the Senate and won, and we discarded the vote. It just
seemed to be such highhanded --

INTERVIEWER: He discarded the vote? Explain
more, because I'm not familiar with this.

DR. KOOP: I don't understand it either. But
the Senate vote was in favor of tobacco -- well, let me
interrupt and say that an ad hoc committee of Senators

and Congressmen asked me if I would be co-chair of a
53

committee, and David Kessler would be my other co-chair,
and that we would prepare, with the help of anybody we
wanted to get, the gold standard for tobacco
legislation, to control tobacco in the United States.
And I think it's one of the better things that we did,
and we presented that gold standard. And essentially,
that gold standard was sort of what we were voting on,
although it wasn't in the words that we used, and my
recollection is that we had six more votes than we
needed, and essentially won that battle, and then Trent
Lott said that he was withdrawing the, what I would
think would be a completed act, he was withdrawing it
from the Senate and --

This was an interesting time, because we had
some stalwarts from both sides of the aisle in both
Houses of Congress who were really hopeful -- Ted
Kennedy being one of them -- that we would finally come
to something that would pin the ears of the tobacco
industry back where they belonged. And when all those
things happened, in a matter of a couple of days, I
said, "If working as hard as I can with a very efficient

volunteer group helping me, and with the reputation that
54

I have in Washington about tobacco and about integrity,

if working two years like this, it comes to nothing more

than we have seen, there's no point in my staying here."
So I left and came here.

INTERVIEWER: And this would have been
legislation that would have been far more regulatory and
far more --

DR. KOOP: Yeah.

INTERVIEWER: -- and would have controlled the
tobacco industry and tobacco sales and advertising?

DR. KOOP: But you remember -- yeah, but you
remember, it was a little more complicated than that,
because there actually was a court case that came up in
the south that we lost, in trying to assure the role of
the FDA in the regulation of tobacco. So it wasn't as
open and shut as I like to think it was. It's a funny
way to say it, but there were so many things going on at
the same time, that I think even legislators were
confused.

INTERVIEWER: And the settlement was a
separate track.

DR. KOOP: Separate, indeed.
55

INTERVIEWER: And when that came down and was
finally legislated and accepted, were you satisfied with
that? Were you satisfied --

DR. KOOP: No, I was not satisfied with it
because although the sum of money was exorbitant and I
think fitting and proper, the thing that bothered me was
that there were so many little things that were just
ignored, and when the questions came up about them, the
answers were all, "Well, we understood that that was to
be this way," you know. They pretty well ran roughshod
over things that weren't settled by individual articles
in the law.

INTERVIEWER: The size of the settlement. Do
you recall what that was?

DR. KOOP: The what?

INTERVIEWER: The size of the settlement?

DR. KOOP: 270 billion, I think.

INTERVIEWER: Over 25 years? And since that
time there has, of course, been highly variable use of
the money on a state-by-state basis. Your thoughts
about that?

DR. KOOP: Only one state has used the money
56

for its intended purpose completely, and that's
Mississippi. And that's because Michael Moore was one
of the major protagonists in the group of attorneys-
general who were bringing the suit. But --

INTERVIEWER: And that purpose was tobacco
reduction?

DR. KOOP: There were two major issues. One
was to prevent children from starting to smoke, and the
other was to make treatment available and worthwhile for
adults. So (inaudible) still a problem.

INTERVIEWER: But other than that, states have
used it in a variety of ways?

DR. KOOP: Well, it came at a difficult time
when, because of an awful lot of problems in the
economic world, practically ever state in the union was
running a deficit budget. And they saw this as sort of
having won the lottery. And nobody had any qualms about
taking that money and using it to fill potholes or fix
bridges or pay schoolteachers or maternal and child
health, or -- very, very little of the money went to
health, even if it was tobacco health.

And states like California and Massachusetts,
57

which had the best programs for their own citizens, the
money that was available was in such short supply that
they lost a lot of their people, a lot of their
programs. New Hampshire, exactly the same way.
Everything up here was jeopardized. I knew 24 people
that were very active in the state, working with us here
periodically, and they all were without funds all of a
sudden because the money was not used for its intended
purpose.

INTERVIEWER: What will happen to tobacco in
America? What's your prognostication? Will we better
the situation now in terms of percent of the population?

Well, it's down, it's 20-some-odd --

DR. KOOP: Five.

INTERVIEWER: Twenty-five percent?

DR. KOOP: I think -- I don't think you can
talk about the United States separately. The United
States is 9 percent of the global economics of tobacco.

And to make that payment of $200-and-some billion, and
other things that have happened, and no one knows what's
going to happen with the huge suit that's been brought

by the government against the tobacco industry, but
58

that's a lot bigger than the settlement is, if they were
to win that, and it means that there's going to have to
be some very innovative financing, and I don’t see the
one thing that could be a deterrent, and that is a
global public health effort to fight big tobacco.

INTERVIEWER: It's not there.

DR. KOOP: It's not there. And the thing is,
you can't expect Zimbabwe to fight it by itself, or the
Philippines to fight it by itself. The American Cancer
Society has done as much as anybody, by bringing over to
this country selected individuals from developing
nations to teach them how we have handled the politics
of big tobacco, and to teach them the ways that we have
used our political muscle, the way we've used public
education, the way we've used gimmicks here and there.
And it just -- it's a nice effort, and it's well thought
out and very well-meaning, but it's just too little
recognize size of the problem.

INTERVIEWER: So I gather from that you think
that the United States' efforts over reduction will
remain where they are, but a great deal of the

commercial and promotional effort's been moved globally?
59

And will remain so?

DR. KOOP: I think so. And you know, again it
fits into -- it's a politically bad time to worry about
tobacco, when you try to get the attention of a
concerned citizen who is worrying about the war in Iraq,
the economics at home, and people dying tobacco deaths
in Indonesia, you know what takes third place. And I
don't know any way to overcome that.

Everybody talks about the shrinking globe and
the fact that our problems are everybody else's
problems, and there's no such thing as a disease which
is somebody else's problem alone, and yet we're not
doing the things that should come from that
understanding and working together to try to fight
what's happening.

When you think about the fact that 500 million
people now alive and well on this planet will be dead by
2025, you know, I can't take that number in. I tried to
work it out. That's the same number of deaths as if you
had all the Vietnam War deaths every day for 25 years.
It's the same as if the Bhopal incident in India

recurred every four hours for 25 years. It's the
60

Titanic sinking every 47 minutes for 25 years. If you
wanted to build a Vietnam-type memorial to these people
that were going to die by 2025, you'd use the same kind
of set-up. It would start in Washington and go westward
over six countries, and end in Kansas City. A pretty
big monument.

INTERVIEWER: Well, I think that puts tobacco
in perspective.

Would you like to take a break and --

DR. KOOP: I'll walk about a bit.

(Recording interruption.)

INTERVIEWER: I'd like to pick up with looking
at public health in America. We can talk global later,
but talking United States in particular. Post-9/11? I
mean, that certainly was a seminal event for the nation,
but also for public health. It's not clear to me
whether it started public health on a new route and, of
course, 9/11 is overlaid with anthrax and events of that
period. Do you -- I mean, how do you feel about the
direction of public health? Do you think it's gotten
new life? Or do you think it's been diverted into wacky

bioterror concerns?
61

DR. KOOP: I think that public health in the
United States began to slip in the Clinton
administration, and I think that we began to lose some
of the people in the commission corps that I thought
were real stalwarts and people who understood the
permanence of such a group and what its contribution
could be to the nation. And since that time, everything
that I have seen or been able to understand that was
happening to the public health service of the United
States in that group, and especially to the commission
corps, has been downhill.

And I actually got to the point where I
stopped going to meetings of the commission officers
that were social events and I sometimes could attend,
just because I'd come home so depressed by everybody's
cornering me and telling me how awful things were and
how they were going downhill and getting worse. And I
think that a lot of little things -- there were some
changes in pay for -- of the uniformed services, but
they weren't passed on to the public health service, and
at every turn it seemed that something was happening

that wasn't good, and then when I was asked to testify
62

about the public health service and about the commission
corps before Shays' committee, I really felt that the
public health service and the commission corps were
being exposed to scrutiny from people who really didn't
understand much about either, and when you got finished
hearing all the complaints it sounded like things just
couldn't be very good in the future.

INTERVIEWER: This Representative Shays --
Chris Shays?

DR. KOOP: Chris Shays.

INTERVIEWER: Of Connecticut.

DR. KOOP: Bioterrorism didn't start with
9/11, and we've had ample discussions about bioterrorism
in the confines of the public health service and in the
commission corps, and it seems to me that we never took
very much of an effort to do anything about it, and yet
I believe that the public health service, as it was
constituted when I was there, and the commission corps
particularly, was very well suited to running a program
that would be as good as you would expect.

You can't prevent terrorism, and so your

effort has to be on ready response. And rapid
63

deployment of your resources to prevent things from
going from bad to worse. And I don't see that.

And I think the manner in which the anthrax,
for example, was handled was five cases -- suppose it
had been 50? Suppose it had been 5,000? Suppose it had
been 50,000? I mean, what would we have done? I think
we wouldn't be over the panic yet.

And I don't know enough about the new
department except that it's the biggest we have to have
in government --

INTERVIEWER: Homeland Security?

DR. KOOP: Homeland Security, to know how well
that's going to go. I think Governor Ridge was given a
very tough assignment, because, I mean, people such as
you and I know that Washington and your ability to
function there depends an awful lot on old-boy networks
and people you know and can call on in time of need, and
Ridge came into Washington with a huge task to perform,
and no connections at all. And I think that with that
in mind, he has done an admirable job with what he had
to face. But as far as being able to show me or anybody

else, "This is what we would do if somebody blew up this
64

bridge and attacked us at the same time," and so and so
forth, and that's what worries me.

INTERVIEWER: In the real 9/11 and the
post-9/11 period there was a lot of money put into the
system in and around public health, including very
specific and rather wooden items, like vaccine
procurement. I don't mean that disrespectfully, but
"wooden" in the sense you've bought that, that's just a
flat purchase starter pile. Do you get any sense that
this new money, new attention, has invigorated American
public health in general public health
service, or not?

DR. KOOP: If you ask me a yes or no question,
I'd say not. And I realize that in organizations such
as the size of which we're talking, a lot of things can
be good that are going on that you don't hear about, but
you hear about the bad things. And I don’t want to
badmouth the official representatives of public health
in this country. But I do have the feeling that the
people who know the most, those who are responsible --
not medically, but line officers for the defense of this

country -- are as concerned as I am about the lack of
preparedness, and that worries me. It worries me

65

at the

level of communication. And it seems to me that the

public health service, going back to the NIMNIS
(phonetic) days, has had --
INTERVIEWER: "NIMNIS"?
DR. KOOP: You must know what --
INTERVIEWER: Shame on me.

DR. KOOP: It's the thing that -- about

1986

or so, the military made a decision that they would not

try to have a chain of health command like they had in

the Korean War, with MASH units and base hospitals and

up, but that the transportation was sufficiently good

for the entire globe that we'd have the hospitals

here,

use the benching(?) system, and transport our wounded to

there. And there were a lot of people who had --
health service who had obligations to NIMNIS, and
were people who would be called up immediately if
were a military conflict and so on. And the only
I raise it is that the thing that always appealed
about NIMNIS, it was a system that was working in

of peace, in a civilian authority, but it was

public
some

there
reason
to me

a time

transferable to a military need just by saying, "Hey,
66

we're using you."

And we have a group up here that's working on
some of the problems with terrorism, that's an official
DARPA thing, and then there's another group of us that
have published five papers on terrorism so far, all
asking the same thing: that in this day and age,
terrorism is going to best be fought in cyberspace
because we have a communications system, and if we're
going to use our heads we want a system when we finish
using it for the military, we can use it for civilians,
and it works just as well.

And whatever we have should be able to handle
the Oklahoma bombing of a government building or a
tornado or hurricane or a flooding, as well as it could
handle anthrax in Trenton or with the post office. And
that's what we've been trying to focus our attention on
is a system that is not either military or civilian, but
it can serve both at any time by a switch of the --.

And I know that's not answering your question,
because it's very hard to get your hand on what's going
on, and I would be hard put to make you a list of the

things that ought to be changed right now.
67

INTERVIEWER: Yeah. I don't have a sense
that, say, the profession of public health has received
a bump up in public esteem. I don't have a sense that
more physicians are choosing public health or public
health careers. I don't have a sense -- I know actually
I'm not as well read on this, that might be admitted,
but post-9/11 CDC published an evaluation of state
health capabilities, connectivity being a big one, that
was just an embarrassment.

DR. KOOP: Right.

INTERVIEWER: I mean --

DR. KOOP: Well, that's what I mean about it's
got to be fought in cyberspace. The number of local
first responders that don't even have a computer and
can't go on the Internet, can't send e-mail -- it's
astonishing, really.

And the other thing that you mentioned, I
don't find people dedicated to public health as much as
I find them feeling they ought to have a little
background because it's good on their resume. I mean, a
lot of students come through here and ask me if they

shouldn't go someplace where they can take an MBA -- I
68

mean, a --

INTERVIEWER: MPH.

DR. KOOP: -- MPH along the time they're
getting their medical degree.

I always say, "Yeah, it's a great idea."

And I have actually turned a couple of people
toward public health alone and forget the medical school
business, because I think we need the kind of people
that go into medicine to go into public health.

The other big shock to me was that I was with
one of a group of six people who, about six years ago
now, decided that the spread of public health from
medicine was not to the benefit of either profession,
and there were things that we could do together, we
could fight together for principles, we could fight
together for money, we could fight together for research
budgets, and we could work in each other's labs and
bring that together, and you know the old joke they tell
about Baltimore, that the widest street in Baltimore is
Wolf Street, because public health's on one side and the
medical school's on the other.

But old joking aside, that group of six grew
69

to a group of 70, grew to a group of 240, who wanted to
see public health integrated. We even got so far in the
planning as to think if Dartmouth couldn't be a virtual
school of public health for all the medical schools in
New York and New England who didn't have a school of
public health associate with a university where they
were. And Roy Shores (phonetic) was very prominent in
this, Stan Reiser -- do you know Reiser? He's got an
interesting title, he's Professor of Humanities, the
Department of Medicine, at Baylor in Houston.

And we had a meeting of the 240 invited
guests, and I gave a keynote, Reiser gave a keynote,
Bozher (phonetic) gave a keynote, and we went away from
that meeting with the feeling, at last places like the
Providence Rhode Island Department of Public Health is
talking to people in Connecticut about how they can work
together on problems, and terrorism wasn't even a big
thought at the moment. And it is dead. It is totally
dead.

And you call anybody who was part of the
planning committee or something, say, "When is the next

meeting?" they want to know, "What meeting?" And I
70

think we muffed a tremendous opportunity to bring
medicine and public health together, and to stress our
ways that we could cooperate. And, you know, somebody
asked me one time, "If you could do something about
public health and medicine, what would it be?"

And I gave an answer off the top of my head
which, in retrospect, isn't too bad. I said, "The first
thing I would like the people in (inaudible) in medicine
to realize is that there are more doctors than medical
doctors, and that they shouldn't look down their noses
at people who spend their years getting a doctor in
public health."

And the person who asked me the question,
"Well, what about the other side?"

I said, "Ben," I said, "I think that the
contribution that medicine has to make to public health
in this regard is that we've got to teach all those
people with MPHs that the numbers the computers spew out
all the time are real honest-to-goodness people with
blood, who are hurting, and they're hurting because of
poverty or they're hurting because of disease or they're

hurting because of both of them, or they're hurting
71

because our systems don't jibe right where public health
interfaces with medicine." And I think it's one of the
biggest challenges that we have for the future, and one
of the great missed opportunities, that we can't pull
together medicine and public health in such a way that
we help each other instead of be detrimental to each
other.

INTERVIEWER: The status of medicine. Had
health care reform attempted, and you've described
eloquently your role in trying to make that happen, and
then as you indicated, we had a market solution that was
brought upon us, managed care, which is still with us in
various morphed forms.

What do you see as the lot of medicine today,
and where is it headed?

DR. KOOP: Well, I think the major thing
that's happened to medicine, I alluded to in reference
to pediatric surgery, it's all part of the same big ball
of wax, and that is the gradual evolution from a pure
profession to a profession that relies on businessmen to
make it work.

Take the American Medical Association. There
72

was a day when the infrastructure of the AMA -- that is,
the people who worked out in Chicago in the AMA building
-- were retired physicians or sometimes impaired
physicians who couldn't do the job they did before. As
those men have died and retired, 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.

And the second thing that I find has changed
tremendously is the doctor/patient relationship. And
that is, to me, the most precious thing about the
practice of medicine. Medicine's appeal is not its
independence financially or its ability to be your own
man and your own boss, it's the fact that you
interdigitate or you cooperate with the public at the
interface between the patient and the doctor. And the
thing that has changed that has been the things that
came in with managed care, and have stayed. Even when
managed care seems to have disappeared, the bad things
about it stayed behind, such as 14 minutes per patient
and that sort of stuff.

I ran a program with the help of John a couple
73

of years ago, called "Take Time to Talk." And I went
around the country talking to doctors and to patients
about taking time to talk with each other, and about

what the benefits would be to both the profession and

Secondly, we are reaching this crisis in the
doctor/patient relationship just at a time when I would
have predicted just the opposite, with the use of the
Internet to provide information for patients, we have
the opportunity to have a much more knowledgeable set of
patients than their parents were. And everybody knows,
I think, that a physician loves to talk to an
intelligent patient, and the opportunity now exists to
be able to, instead of meeting a patient and starting
with a kindergarten and work him on up to college, he
can ask you to do that the night before. Suppose
somebody calls up and says, "I'm having pain in my
chest, Doc, and I get it mostly when I'm tense or trying
to be active at the same time, and I think I have an
angina."

Well, the doctor doesn't say, "Well, come on

in and I'll talk to you about it." He says, "I'll see
74

tomorrow morning, but before you come I want you to look
upon the Internet the following. I want you to know
what angina is, I want you to know what GERD is, I want
you to know the difference between those two, and when
we get here together, instead of taking 20 minutes to
get to the point we are when you walk in the door
tomorrow we'll have it all behind us. And I can talk
about angiograms, you know what I'm talking about."

And that is not working as well as I thought
it would.

The other thing that I think is a tremendous
boon, and that is doctors and patients using e-mail for
types of communication. We do it very well in this
institution because we were the first school in America
where everybody had to have a computer, and we had
something called "blitzmail." And people don't use
telephones in this town. They just don't use them.
They use fax machines. They use e-mail. Three kids
will occupy a room in a dormitory, they don't know each
other very well but they know each other best by e-mail,
in spite of the fact that they can reach out and touch

the guy they sent an e-mail.
75

But 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.

Mrs. McCarthy comes in and has her time with the doctor
and it turns out to be 11 minutes and she's out in the
parking lot before she knows it, and she gets home and
says, "I never asked him about so and so."

So she sends him an e-mail. And instead of
playing telephone tag for three days, he answers her,
but he has the opportunity, with no effort at all, to
lift her spirits and put her on a whole different level
of healing, by saying, "By the way, I should have told
you, I never saw you look better." And it regains some
of that intimacy that even doctors say, "I've lost with
my patients."

And one of the things that I look back on,
I've been in medicine now since 1934. I've been having
something to do with medical students 1934,
and what do I look back on now and see that we've lost?

We've lost role models. Used to be that people my age
were not uncommon in medical schools. They didn't want

to give up, and they had an awful lot to tell students,