The Surgeon General
Dr. C. Everett Koop

A conversation with the doctor about smoking
on the job, taking better care of yourself
and the changing health care industry

od’s law and “health facts”

keep the Surgeon General of

the United States on a clear
and optimistic course as the na-
tion’s highest medical officer. An
evangelical Christian, outspoken
anti-abortionist and author of the
call for “a smokeless society by the
year 2000,” Charles Everett Koop,
M.D., Sc.D. was nominated for
the post by President Reagan “for
the most cynical reasons...not for
his medical accomplishments, but
his political compatability,” opined
a 1981 New York Times editorial.

Opposition later included the
114-year old American Public
Health Association, which had
never before objected to a presi-
dent’s choice to fill the public
health post. Confirmed in 1981 on
the strength of his medical accom-
plishments, Dr. Koop appears to
have lived up to his promise not to
use the office as a pulpit from
which to sell ideology. “I’m not
allowed to lobby,” he explains,
wryly.

“Aside from a number of specific
tasks mandated by public law,” he
continues, “my position is one of
educator, overseer and public com-
municator. I preach the virtues of
health promotion and disease pre-
vention as a philosophy to
whomever I can reach: be it chil-
dren, the elderly, the handicapped,
or others.

“Meanwhile, Congress works on
problems, such as prospective pay-
ments and putting caps on expendi-
tures of Medicaid and Medicare,
while regulatory agencies, such as

14. CORPORATE MONTHLY JANUARY 1986.

by George Ewing

Dressed in the uniform of the Surgeon
General, Dr. Koop visits a suburban
cemetery in New Jersey.

the Health Care Financing Admin-
istration, establish systems such as
DRGs_ (Diagnostically Related
Groups) to cut down the costs of

~ medical care.”

Dr. Koop is the nation’s first full-
time surgeon general since 1972,
when responsibilities for the post
were assumed by the assistant sec-
retary of health. He is one of the
country’s most distinguished Chris-

tian writers and author of two pow-
erful books that discuss abortion,
euthanasia and mercy-killing (“The
Right To Live, The Right To Die”
[Living Books, 1976] and, with
Francis A. Schaeffer, “Whatever
Happened To The Human Race”
[Crossway Books, 1979]).

Born in 1916, C. Everett Koop
grew up in the Flatbush section of
Brooklyn, New York. As an adoles-
cent he “learned what it feels like
to be a patient.” A fractured cervi-
cal vertebra sustained during a ski-
ing accident and a brain hem-
morhage during a football scrim-
mage kept him bedridden for more
than a year.

An excellent student, he entered
Dartmouth in 1933 at the age of 16
and earned a B.A. degree. From
there, he went on to Cornell Medi-
cal College, graduating with an
M.D. in 1941 and began his in-
ternship at Pennsylvania Hospital.
It was there that he became in-
terested in the field of pediatrics,
to which he would devote the rest
of his career.

After graduate training at the
University of Pennsylvania School
of Medicine and Boston’s Chil-
dren’s Hospital, Dr. Koop was
awarded a doctor of science degree
from the Graduate School of
Medicine of the University of
Pennsylvania in” 1947. Sub-
sequently, he was appointed sur-
geon-in-chief of Children’s Hospi-
tal in Philadelphia in 1948 — be-
coming one of very few physicians
who specialized in pediatric
surgery.
In February 1982, the Surgeon
General made his controversial call
for a smokeless society by the year
2000, calling the risks associated
with smoking “the most important
public health issue of our time.’’ He
pressed for legislation strengthening
cigarette warning labels~an_ effort
that was successful with last year’s
addition of three new labels (for a
total of four) that: warm women
smokers of potential complications
during pregnancy; point out ties be-
tween smoking and a variety of can-
cers, and state that cigarette smoke
contains carbon monoxide (see box).

“Smoking is bad for everybody,”
Dr. Koop says. “While it is true that
some people smoke all their lives
and live a long life, you never know
that until they have lived a long life

 

[Ed.—

italics are speakers emphasis]. They
might fool you, though, and die at
the age of 45 of a coronary,” he
points out.

“The 1985 Surgeon General’s Re-
port to Congress, which I presented
Jast month, focused on the question
of smoking at the work site. There
are some fascinating things that are
now becoming well known: smokers
are more expensive as employees

 

The Surgeon General
Has Determined...

“A person who is going to quit
smoking must have, first of all, a
self-rewarding goal. He has to be-
lieve that going through the effort
to quit an addictive drug. nico-
tine, is going to be worth it.

“Once you've decided to quit,
the most effective way to do so is
the best way for you. Most people
find that quitting ‘cold turkey’ is
best. In addition, having another
person in on the effort is very
helpful. Trying to quit while your
husband, wife, father or friend
still smokes is tough. There are
also things like group therapy.
hypnosis, classes, counseling.
and nicotine chewing gum: if it
works, do it.

“Having your doctor in on the
effort is even better. He’s going to
say. ‘look, if you don’t stop, you
may die!’ That's an incentive.”

 

 

 

than non-smokers. It behooves com-
panies to make their work sites
smoke-free.

“Some haven't gone that far and
only restrict smoking to certain
areas. When a company makes their
work site smoke-free, though, it has
at least three advantages: first, the
cost of health insurance drops; sec-
ond, fire insurance rates drop; and
three, the cost of maintenance (of a
company’s work site) goes down.”

Citing an example, he explains,
“In Seattle, a company that had their
maintenance done on contract went
smoke-free. After three months, the
contractor came to the management
and said, ‘we're cutting your costs
by 25 percent. Since nobody smokes
here, we can do the job in 75 percent
of the time’.”

He lists some of the other findings
in the 1985 report, ticking them off
on his fingers. ‘A smoker at the work
site has twice the rate of mortality
during his working years as a non-
smoker, so he’s a pension problem.
He uses 50 percent more hospital
days as a non-smoker.

“A smoker has more absenteeism;
he spends 8 percent of his time
finding a cigarette, ashtray, lighter,
etc; and he has three out of four
(work-related) accidents. Everything
(a smoker) does,” he intones, “‘is a
disaster to his employer.”

CORPORATE MONTHLY

Sitting up suddenly, Dr. Koop
asks, “What has been the reaction of
unions to efforts on the part of man-
agement to go smoke-free? The
unions are espousing the cause.

“Everybody thought that they
would fight it, but, unions are bring-
ing it up in their contract negotia-
tions, saying, ‘if you go smoke-free.
we know you will save on this. that,
etc., and that means you']] have a
bigger profit — therefore. we'd like
some of that profit for employee be-
nefits.”

“More and more corporate groups
are becoming aware of two things:
one, disease prevention and two,
health promotion. No matter what
else they do, when they cut down
they attack the number one health
problem in the country.

 

“Are you interested in doing some-
thing about what we've been telling
you since 19647” he asks, referring
to the onginal surgeon general's re-
port linking health risks to cigarette
smoking. Almost shrugging _ his
shoulders, he answers his own ques-
tion, “let's have a smoke-free society
by the year 2000.”

To smokers who have heard the
warnings, read the dangers and still
light up, he adds, philosophically,

JANUARY 1986 15
 

16 CORPORATE MONTHLY JANUARY 1986

“Life is more than just accumulating
Surgeon General Reports on a
shelf.” He wants to see the informa-
tion available put to use: harnessed
by smokers to make appropriate
choices that take into account these
‘health facts.’

“A lot of corporations don’t realize
it yet, but we are moving towards
major change. In the first r of
1985, the National Center for Health
Statistics points out, we fell below
30 percent of the population (who
smoke) for the first time in history;
down from 55 percent in 1964.
That’s a tremendous change.

Local Unions
And Smoking...

Local unions have begun to ad-
dress the issue of smoking in the
workplace. Pat Gillespie, busi-
ness manager of the Building and
Construction Trades Council in
Philadelphia (60,000 members)
says unions are espousing the
cause, but not for financial
reasons, rather for the benefit of
their members’s health.

“T think most unions believe
the statistics on smoking and we
may very well include ‘smoke-
free’ issues in our spring contracts
talks.”

Wendell W. Young, III, presi-
dent of Philadelphia-based United
Food and Commercial Workers
(24,000 members) says his or
ganization has actively supported
segregated smoking and non-
smoking for many years.

“About four months ago,” he
says, “we started to look at smok-
ing-related deaths and injuries.
We will try to recoup these losses,
for the employee and the health
fund, through litigation.”

“There is no question,” Mr.
Young concludes, “that smoking
-will have an impact on our (con-
tract) negotiations.”

 

 

 

 

“Smoking has become more and
more a blue-collar habit. More and
more white collar and professional
workers have given up smoking. You
are beginning to see stratification by
class; economic concerns by employ-
ers; and appreciation of those con-
cems by unions.”

He stresses, “It’s not government
policy to achieve a smoke-free soci-
ety by the year 2000, but it is do-

able. There will never be a ban
against smoking in this country, nor
will there be so many local ordi-
nances that there is no smoking all
over the country. Eventually, though,
people will not smoke in the pres-
ence of those who don't.”

uring to what is to many people
T this country’s most important
public health concem since out-
breaks of polio in the 1950s and
measles in the 1960s, Dr. Koop is
leading a campaign by the federal
government to educate people about
AIDS, acquired immune deficiency
syndrome. “Up until the present
time,” he notes, “public education
about AIDS has been handled by the
Centers for Disease Control.”

The Surgeon General will appear
in a number of public service mes-
sages that explain the disease. In
addition, a nationwide effort to dis-
tribute free information in pamphlet
form through neighborhood organi-
zations and supermarkets has been
put into place.

Having identified enough about
AIDS to draw preliminary conclu-
sions and make specific recommen-
dations to the public-at-large, the
federal government wants to stem
the spread of quasi-panic that has
infected many communities. Large
metropolitan areas seem more af-

fected by hysteria, while smaller

communities are less perturbed and,
overall, more cautious in their ap-
proach to AIDS-patient regulations.

In a recent report on the prolifera-
tion of AIDS-related legislation at
all levels of government, The Phila-
delphia Inquirer cited four develop-
ments around the country that illus-
trate various reactions.

© Massachusetts officials established
the first statewide guidelines for
people with AIDS whose work in-
volves handling food. They are al-
lowed to work as food handlers only
under certain proscribed condi-

° New “York state and local officials
have been empowered to close
homosexual establishments, such as
bathhouses, where the risk of
spreading the disease is high.

* Colorado became the first state in
the nation to require that names
and addresses of those found to
have AIDS be turned over to state
health

* California Republican, (US Repre-
Sentative) William E. Dannemeyer
has introduced five bills in Congress
that would respectively: make it a
felony for an individual from a high-
risk group to donate blood, prohibit
anyone with AIDS from working as
a health care professional in institu-
tions that receive federal funds; deny
funds to cities that do not close
bathhouses frequented by homosex-
uals; keep children with AIDS from
attending public schools; and allow
health care workers to wear special
protective clothing around AIDS pa-
tients without interference from hos-
pital officials.
One of the most poignant fears
among those concerned with civil
liberties is that AIDS-related laws
may stigmatize otherwise healthy
people who have test results showing
the presence of the virus, when in
fact many of these people do not
have AIDS.

On the other hand, raising the
economic and social ‘penalties’ for
those with AIDS could effect the.
Teporting of the disease — driving it
underground. Fearful of being os-
tracized or held without their con-
sent, some AIDS victims may sim-
ply not report their condition to
health officials or their doctor.

Dr. Koop, although identified
with conservative policies on the
whole, does not believe the govern-
ment should regulate AIDS policy.
“The federal government should not
impose regulations over the whole
country, unless there is something
that affects, for example, the (do-
nated) blood supply, and that’s al-
ready been done.

“We know more about AIDS than
we do about whooping cough. But,
we don’t know the essential things:
“How do we stop it?’, ‘How is it
cured?’, and ‘How can it be pre-
vented with a vaccine?” Aside from
what is known to date (see box), the
Surgeon General counsels ‘lifestyle’
changes.

“If an individual wants to avoid
getting AIDS, all they have to do is
maintain sexual relations with one
partner, that in itself dramatically
limits exposure. As long as the other
partner does the same thing they are
in a pretty safe situation,” he ex-
plains. “That is a health fact” (see
box).

He continues, “As a health offi-
cial, one has to be very careful to
State the facts. For example, while it
can be said that a normally behaved
student who is infected with AIDS
is no risk to his or her classmates,
we can say that (the victim’s) class-
mates are a risk to the student in-
fected with AIDS.”

“An outbreak of chickenpox in a
classroom with an AIDS infected
student,” he stresses, leaning for-
ward, “means that student might die.
Too many people get confused be-
tween what are ‘health statements’
and what I call, ‘sequels to health
statements’. For example, some say,
‘I think every kid has a right to an
education, therefore, he should go to
school.’ That’s not a health state-
ment.” He cautions that decisions
over the medical and social treat-
ment of AIDS patients should be
based on fact, not fear.

TT” health industry is propelled
by economics, says the surgeon

general, speaking of concerns over
vast and sometimes troubling
changes in medical treatment, their
costs and payment. “First of all, it is
clear we cannot afford the curative
and repairative medicine and surgery
that is so popular with the American
people,” he explains. “Instead, we
have to tum to something that is not
only better as a principle, but is

affordable. That is — the prevention
of disease.

“Fortunately, the prevention of

disease is largely up to personal
choice,” he continues. “You and I
can affect the way we smoke, drink,
exercise, eat, and the kinds of stress
we have. If we take care of these
five things, and check our blood
pressure, we’ve covered almost ev-
erything.”
According to Dr. Koop, the best
community health care centers today
act in the role that he does, as “dis-
ease prevention and health promo-
tion educator; by teaching people to
monitor their own lives. In many
hospitals today, the walls are covered
with educational material. That is
the real, grassroots response to what
we are trying to do.”

Answering concerns that changes
in medical care have tossed some to
the mercy of a sometimes callous
public health bureaucracy, he cau-
tions, “There are a lot of rough edges
that have to be smoothed out, and
they will be, by either regulation or
legislation. These policies have been
in effect for only two years. To judge
their consequences now would be
premature.”

Will concerns be addressed? “The
government is not immune to sug-

 

 

cases.

by several names, but preliminary
results show that infected persons

remain in good health; others may.
from mild to extremely serious.

well. Some deve:
night sweats and swollen glands

armpit, or groin. Anyone with
symptoms like these for more than.

 

20 CORPORATE MONTHLY

as “opportunistic” infections or oy i

Investigations have discovered the _ ing
virus that causes AIDS. It is called»

develop illness varying in severity

Most individuals infected with .
AIDS have no symptoms and. feel -
which may include tiredness, fever, fi
loss of appetite and weight, diarrhea,

(lymph nodes)-usually in the neck,

    
   
  
   
  

‘More About AIDS’

AIDS is a serious condition — two weeks should see a doctor:
characterized by a defect in natural Casual contact with AIDS patients
immunization against disease. or persons who might be at risk for’
People who have AIDS are vulnera- the illness docs not place others ay
ble to serious illnesses which would risk for getting AIDS. ’. oS
not be a threat to anyone whose. - AIDS is spread by sexual conta
immune system was functioning nor- needle sharing, or less coi
mally. These illnesses are referred to through blood or its components

may also be transmitted from

self, However, there is. good
to believe that individuals can re

ments oF you phycicion Fhe) eS
Health Service AIDS eta pees,

JANUARY 1986

gestion. Neither is it trying to en-
force the unenforceable, or impose a
burden that is inequitable.

“The government is desperately
trying not to go bankrupt over health
care. There will be a response if
there are inequities. It won’t be as
fast as the physicians in some hospi-
tals want it, but it will come.”

With medical treatment costs in-
creasing and more specialized ser
vices being offered by traditional,
community hospitals , there are con-
cerns that the availability of health
care will depend on the patient’s abil-
ity to pay for it. Dr. Koop is hopeful
and counsels patience. “There are a
lot of things that the insurance indus-
try has to acomplish. They are look-
ing at (the subject of cost versus
availability) very carefully.”

With more data about smoking,
drinking, and other lifestyle ques-
tions that affect an individual's
health, there have been efforts made
by some insurance companies to
identify ‘high risk’ and ‘low risk’ -
clients. Should they both be charged
the same price? Dr. Koop says, “No.
And I see (the insurance industry)
coming to that conclusion, too.
Should a smoker pay the same pre-
mium as a non-smoker?” he asks,
“Should a drinker pay the same as a
non-drinker?

“One of the ways the insurance
industry is experiencing economic
change is with smokers,” he adds.
“For example, Minnesota's Blue
Cross offered to all customers who
were non-smokers what essentially
amounted to a 16 percent reduction
in their premiums.” He taps his
fingers, emphasizing the point,
“That group of non-smokers was
their most profitable group because
they didn’t use the health care sys-
tem. (Philadelphia-based) CIGNA,
which has very large holdings in
HMO’s, found the same kind of
profitability when it offered a simi-
lar, two-level premium to their cus-
tomers.” Philadelphia Blue Cross,
according to a spokesman, has no
plans to offer a two level premium
for smokers and non-smokers.

Cis Everett Koop’s surgical
career was marked by a number
of innovations and achievements that
still stand as records in the field of
pediatrics. Many of the surgical pro-
cedures in use, at the time of his
appointment to Philadelphia’s Chil-
dren’s Hospital, resulted in mortality
rates of near 95 percent.

Pre- and post-operative improve-
ments he put into place significantly
reduced this rate, including the
_ development of surgical techniques
that allowed the correction of birth
defects that up to then were consi-
dered uncorrectable. “It was almost
like we were begining to invent the
wheel,” he explains. “Every-
thing...was brand new. It was an
exciting time.”

In addition to new surgical and
post-operative treatments, he found-
ed the nation’s first neo-natal inten-
sive surgical care unit, as well as a
total-care pediatric facility, at Phila-
delphia’s Children’s Hospital.

Describing the origins of the term,

“Koopian Method,” used by his col-
leagues, Dr. Koop explains, “When
I retired from practice in Philadel-
phia, about 500 of my surgical col-
leagues, from here and 28 countries
abroad, put on a tremendous, three-
day farewell for me. One of my
residents gave a talk on what he
called the Koopian Method.
“It’s not even a good word, as far &s
I am concermed,” he admits, chuckl-
ing. “What he was trying to say
reflected the way I approach prob-
lems in the surgical care of children.
For example, if a child has twelve
things wrong with him, don’t get
overwhelmed by the fact that there
are twelve things. Just treat each
one of them individually and each
- one as curable, and you can solve
the problem.

“Secondly, you can’t just treat a
(young) patient, you have to treat
the entire family. In addition, you
have to garner all the support in the
community that’ll make (the treat-
ment) work.”

Dr. Koop has left the comfortable
conditions of private practice, where
he was the nation’s sixth pediatric
surgeon, for the hectic realm of pub-
lic office. Is he satisfied with his
new job? “Yes. I had a marvelous
career in pediatric surgery. I would
never have imagined that changing
careers, at my age, would have pro-
duced such excitement. This job
changes every hour and it runs the
gamut from health issues to financial
considerations.”

Of course, he adds, “Working for
the federal government takes a year
or so to find your way around and
another year to understand the pres-

ence of an overwhelming bureau-
cracy (140,000 employees in the US
Public Health Service and its affili-
tated agencies). By the third year
you begin to be able to work with
that bureaucracy to accomplish
things. I am fortunate to have been
confirmed for four more years.

“When I went into pediatric
surgery, there were tremendous prob-
lems which no one had tried to
solve. If you are interested in the
health of the people, you must iden-
tify ‘the soft spots’,” he says.

By his own definition (an ac-
tivist), the Surgeon General has pros-
cribed a path for the public to follow.
It is his wish that we hear his calls
for action and change our habits,
lifestyle and attitudes on health care.
Dr. Koop believes in self-determina-
tion when it comes to being healthy.

WW Lite he has made a generally
successful effort to

religion from the responsibilities of
being surgeon general, he is a man
of rock solid principle. In a 1982
interview, published by the Saturday
Evening Post, he said, “Everything I
value or do I consider to be a gift
from God.”

The sanctity of life is uppermost
in the mind of the Surgeon General.
“T am not comfortable with [the way
in which] abortion is available
today,” he explains. In his controver-
sial book, Whatever Happened To The
Human Race (with Francis A.
Schaeffer), Dr. Koop puts his view
on abortion into perspective. Stated
in the context that aborting a pre-
gnancy is a violation of the sanctity
of life, he blames society’s accep-
tance of abortion on the popular shift
away from Judeo-Christian  stan-
dards.

“When a Christian consensus
existed, it gave a basis for law. In-
stead of this, we now live under an
arbitrary, or sociological law.”

Condemning the humanistic direc-
tion of modern Western society, he
continues, “...The law becomes what
a few people in some branch of gov-
ernment think will promote the pre-
sent sociological and economic good.
In reality, the will and moral judge-
ments of the majority are now influ-
enced by or even overruled by the
opinions of a small group of men and
women.

“This means that vast changes can
be made in the whole concept of what

CORPORATE MONTHLY

should and what should not be done.
Values can be altered overnight and
at almost unbelievable speed.

“The number of US abortions per-
formed in 1984 for health reasons
were few,” he says. Simultaneously,
over 6 million were completed on
demand.

Dr. Koop continues, “About 3 per-
cent of abortions are done for health
reasons, or what I call medical indi-
cations (rape, incest, birth defects,
or danger to the life of the mother).
You can’t condone abortion, unborn
life, without spilling into ‘bom’
life.”

One of the ways we see changes
in the valuation of human life is
through the use of ‘living wills’.
Patients draw up a legal document
that ask doctors and family members
not to prolong their life if prognoses
show no hope for improvement.

“We are going to face a push to-
ward euthanasia, although it may
come disguised as something that
sounds a little better, like ‘living
will’ legislation, ‘the right to die’,
‘death with dignity’, or so forth,” he
believes. “People are getting
polarized about the end of life, just
as they have gotten polarized about
the beginning of life.

“We have to do a better job in-
forming the public about what the
end of life is about. Death is a part
of life and people die, of something,
everyday. We have to get to where
people no longer believe that if ev-
erything is not being done to save a
person, that (the health care indus-
try) has somehow failed. There is a
line between the extension of life
and prolonging death.

“It has been pointed out that the
last year of life is the most expen-
sive. That shouldn’t come as any
surprise because you get sick and
you die.

“I believe people have the right to
say, ‘I’ve had all that I want of this
treatment; I know that I am dying
and therefore I don’t want that extra
three days, or one week.’ A person’s
wishes should be honored in this
matter.” cM

oF

“The past is but the beginning of a

beginning, and all that ts an has

been ts but the twilight of the dawn.”
—H. G. Wells

JANUARY 1986 21