Public Health and Medical Humanities History Corner Charles Everett Koop : the “ Family Doctor of America ”


Charles Everett Koop was a great Surgeon General, probably the most influential in the history of the United States of America. He never missed courage in his life and often he had used it to tackle professional and personal tough problems. 
In his public activity, he faced controversial health problems of American people as smoking, abortion and the first occurrence of the epidemic Acquired Immune Deficiency Syndrome (AIDS). Koop was a rigorous man. The lodestar that guided Koop in his work, as a public servant was to do the best for health of Americans. In his prestigious and difficult role, he faced the pressing problems of health of millions of people trying to avoid political influence. During his mandate of eight years, Koop increased the influence and authority of his role. His appearance and behaviour were unmistakable: Lincolnesque beard and uniform, conduct hard and pure, exclusively oriented to the health of citizens, over the personal conveniences, political pressure and lobbying. An exemplary man, who for his passion for medicine and his sincere interest in promoting public health, was affectionately considered the "Family Doctor of America". 



AN EARLY VOCATION
Behind a great man there is often a happy childhood and much love, like the case of Charles Everett Koop.He was born in Brooklyn, October 14, 1916, the only child of a banker and a business manager, Charles grew-up in a house in South Brooklyn surrounded by his family.His father was an assistant vicepresident in one of the largest banks in the country, and increased his culture by regular attendance at the New York Public Library where he fed his love for Shakespeare [1].Koop had always been defined as a "extravagant" and he didn't experience discomfort in public elementary and secondary schools in neighbourhoods frequented mainly by Italians, Poles, and Jews.He was of Jewish and Dutch origin and this ethnic mix was probably related to his deep and continuing intellectual curiosity.He had also a great passion for sport and he loved spending time with his family, which was very close.This excellent relationship with his family was the basis of generous character and ideals of solidarity and compassion that always inspired him.
Koop was only six years old when he said he wanted to become a surgeon and his family took him seriously.His mother Helen played an important role in his very early orientation toward medicine and surgery because she exercised during surgeries in-house in their neighbourhood with the administration of anaesthesia, a role often left to the laity.In fact, three decades later, the first innovation introduced by Koop as a paediatric surgeon was the development of a device that prevented overdose of anaesthesia to children [1].
As a child, instruments used by doctors and the kindness, gentleness and friendliness of the family physician and orthopaedist fascinated Koop."The idea of using my mind, then my hands, to heal someone simply fascinated me" he remembered [1].
When he was 14, he followed surgery in the gallery of operating theatre at Columbia University College of Medicine, with a student friend.
When he was 16, Koop worked as a volunteer during the summer at Mather Memorial Hospital and St. Charles Hospital for Crippled Children.In 1933, a month before his 17 th birthday, he came in Dartmouth College.He was a model student, excellent in academic studies and in sports.Successfully he played baseball, basketball and wrestling, but especially football.The coaches immediately found out his talent and his determination and gave him the role of quarterback and this allowed him to get a scholarship.However, during a hard match, he had a serious eye injury that damaged his sight and threatened his future career as a surgeon.So he left football and devoted himself to studies.Losing his scholarship, Koop engaged in odd jobs to finance his studies.Dartmouth College gave him not only the title of the study, in fact, there he met his wife Elizabeth "Betty" Flanaghan, his "chick" as he liked to call her.
Koop returned to New York City in 1937 to attend Cornell University Medical College.A year later, Charles and Betty were married.Betty, daughter of a physician, was the main breadwinner of the couple until Koop graduated in medicine in 1941, working as a secretary in the hospital.They had four children, Allen, Norman, David and Betsy, born in 1944, 1945, 1947and in 1951, respectively.In the summer of 1941 Koop began an internship at the Pennsylvania Hospital in Philadelphia.In the "City of Brotherly Love" he lived for the next 40 years and there he became surgeon.The request of surgeons created by World War II and Koop's natural inclination to that activity led his superiors to allow him to complete his surgical training in half of the nine-year period.Koop spent days and days in the hospital."My happiest hours were those in the operating room," he said."I love the surgery because I have a constant respect for the human body, respect for the ways in which its anatomical details allow it to function" [1].
In 1945 he covered an important role for a 29-year-old: surgeon-in-chief at Children's Hospital of Philadelphia.An honour and a recognition of his surgical cH arles eV erett Koo P e 9 0 4 6 -3 skills, but also a difficult challenge because paediatric surgery was not still recognized like a medical specialty and therefore, as most of the doctors of that time, he had received a very little training in paediatrics.Koop felt attracted to that field because it promised to perform a wide range of interventions on patients, as children, particularly vulnerable and poorly served by specialized surgeons.So he made an internship for one year with the founders of paediatric surgery in the United States, William E. Ladd and Robert E. Gross, in Children's Hospital Boston.In 1946 he returned to Philadelphia and contributed to identify paediatric surgery as a field well defined, despite resistance of some paediatricians and general surgeons [1].The bodies of the children, Koop argued, are not miniaturized adult ones, but are anatomically and physiologically different and therefore they require special surgical procedures.
This approach allowed Koop to enhance greatly the paediatric surgery, especially in newborns.Until then many surgeons were reluctant to operate infants and young children because of risks related to anaesthesia.Koop, mindful of the mother's experiences, devised techniques of anaesthesia for his young patients and worked tirelessly to improve surgical procedures and postoperative paediatric care.
Koop, in fact, made innovations in the most common operation on children, the correction of hernia, through a shorter incision and stitching without crossing the skin, making it, thus, less painful and disfiguring.He also developed the first technique to correct esophageal atresia.During his career he saved about 500 of these young patients, who were previously destined to die.In 1977, for the first time in the history of medicine, he separated Siamese twins joined at the heart and saving the life of one of them, gaining international attention.Koop created the first surgical neonatal intensive care unit in USA in 1956.
The effect of that period on Koop's ideals was great.He reviewed, in a Christian light, the ethical implications of medical procedures developing a relationship of empathy with bereaved parents, saving newborns with life-threatening birth defects, spending nights at the bedside of the sick and dying children.
The work with pre-term babies and malformed children greatly favoured his strong position against abortion and euthanasia.Koop began to expose publicly his fears and he expressed his view in "The right to live, the right to die", published in 1976, and in "What has happened to the human race?", a multimedia project carried out in collaboration with the renowned theologian Francis Schaeffer in 1978, including five films together with lectures and seminars.
On these issues, he quickly became a true spokesman and spent much time and energy trying to mobilize the conscience of Americans.He acquired a great appreciation in Republican circles so much that, after his appointment as surgeon general, he said that he was surprised to note that his Republican supporters evaluated him more for his stance against abortion than for his exceptional surgical career.
Koop underwent a spiritual awakening in 1948 after his entry in the Tenth Presbyterian Church in Philadelphia.In his autobiography, "The Memoirs of America's Family Doctor", published in 1991, [1] he wrote: "As a person whose training and experience put full faith in science, I came to see an even higher truth.From then on, I saw a coexistence between science and God".
In a terrible moment of his life, when his son David died in an accident in 1968, he took comfort and strength in faith.His character, his experiences and the rediscovery of religion after the recent tragedy were all elements that gave a particular strength to his reaction to the decision of the Supreme Court of the United States that legalized abortion in 1973.Koop became an anti-abortion activists through speeches, publications and films and got the confidence of President Ronald Reagan, nominating U.S. Surgeon General in March 1981.It was not a quiet decision: controversy and congressional speeches have been cH arles eV erett Koo P e 9 0 4 6 -4 for eight months.Opponents and supporters harshly argued if, for his position on abortion and his devotion to the treatment of individual patients, Koop was sufficiently qualified to engage the health needs of the nation.Reagan finally confirmed him as U.S. Surgeon General in November 1981.
The Surgeon General was an official in the U.S. Public Health Service Commissioned Corps that administered general health policies and supervised the staff.Koop's love for the people in particular for the weakest and most defenceless one induced him to accept the role.During his mandate, Koop expanded the role of the Surgeon General from simple administrator to highprofile leader.After a career of 35 years as paediatric surgeon, Koop was able to transform this federal office with a minimal budget and a staff of public health professionals demoralized by the closure of hospitals and PHS and for the cutback staff in the early 1980s, into the most authoritative platform to educate the nation in health promotion, disease prevention and emerging threats for health.
His Reports were precious to inform firmly but without harshness, almost affectionately, the Americans about the most preventable threats for their health.He knew he should be strict and sincere despite political hostilities and lobbying.But he also knew that in his role he was morally obliged to provide accurate and correct information to the people.

KOOP AND SMOKING
"Smoking kills 300 000 Americans a year"."Smokers are 10 times more likely to develop lung cancer than non-smokers, are twice as likely to develop heart disease.Smoking a pack of cigarettes a day means losing six years of life".These thunderous warning, coming not by a researcher, just like Ernst Wynder [2], but by the Surgeon General, had a tremendous impact on the attitude of Americans to smoking.
When Charles Everett Koop took office, 33 percent of Americans were exposed to smoke.When he resigned, this percentage declined to 26. 40 states restricted smoking in public places, 33 prohibited on public transport and 17 banned in offices and other workplaces.More than 800 local anti-smoking ordinances were approved and the federal government limited smoking in 6 800 federal buildings [2].
To achieve these objectives, considering his Republican matrix, he took no interest in the controversy raised by tobacco industries and launched a campaign against smoking in the 1982 Surgeon General's Report on Smoking and Health.In this document, he stated clearly the relationship between cancer deaths and smoking.In the following years, Koop produced eight reports connecting smoking to cardiovascular disease and chronic obstructive pulmonary disease.In the crusade against smoking, that saved many lives in the U.S. and worldwide, he played a strategic role having been one of the first high-profile government officials to raise the warning of passive smoking.He observed that cigarettes are addictive as heroin or cocaine, and argued that written warning on cigarette packs could be an important deterrent to smoking.This goal was achieved and those labels are still unchanged today.He also accused smokeless tobacco products, such as chewing tobacco and snuff, citing their connections with various types of cancer.Koop also urged Congress to legislate on the warning labels for smokeless tobacco products.His actions were decisive for the approval of the Comprehensive Smokeless Tobacco Health Education Act of 1986, 15 USCA § § 4401 et seq., a milestone in education about tobacco damages.
Koop's role in the struggle against second-hand smoking was crucial.The Report of 1986 encouraged lawmakers to create laws to restrict smoking and reduce the risk of passive smoking to non-smokers.In 1987, smoking was cH arles eV erett Koo P e 9 0 4 6 -5 banned in all federal buildings and regulated in restaurants, hospitals and other public places in over 40 states.In 1988, Koop commissioned studies on smoking on the airplane.Also in this case the Congress welcomed Koop's suggestions banning smoking on all flights lasting for less than six hours.
Koop was particularly motivated to act after a thorough examination of the results of research on the links between tobacco and cancer, heart disease, stroke and other diseases.He was "stunned", he said, "and then very angry with the tobacco industry for trying to obfuscate and trivialize this extraordinarily important public information" [2].
The attack of the tobacco lobby against Koop took vehement tones when he accused the industry to target advertising on children, influencing the behaviour and threatening their lives.He attracted the anger of powerful politicians who were representing the interests of tobacco growers.Jim Hunt, the Governor of North Carolina, a Democrat, asked his impeachment and Jesse Helms, the Senator of North Carolina, a Republican, tried in vain to induce Congress to inquire into him [2].
In the midst of the storm, Koop took note that Reagan administration offered only a tepid support for the public campaign "a smoke-free society by 2000".So he decided to bypass the political obstacles addressing directly the nation, with the same determination when he was a quarterback, making a national tour in 1984 to speak directly to the people, often wearing the uniform of his office.The uniform, he observed, aimed at restore his authority as general surgeon and director of the Public Health Service, which risked to decline.

KOOP AND ABORTION
Although Koop was against abortion, he did little on this issue during the period as Surgeon General.Koop considered abortion a moral issue, not a political one, and he was strongly disagree with who wanted to ban contraceptives and abortion.In response to this position many Republicans, who at first supported him, turned against him.
In 1982 Koop faced the case of Baby Doe with moral rigor.Baby Doe was a child born with Down syndrome and esophageal atresia.Down syndrome was not correctable, but it was compatible with life, esophageal atresia was incompatible with life, but it was correctable.On advice of gynaecologist, parents chose to forgo treatment and the child died.
Koop considered that the treatment was denied to Baby Doe for mental problems associated with Down syndrome, and not because the intervention was risky.Koop himself performed this type of surgery successfully many times.Therefore he judged that this was a case of child abuse and infanticide and said publicly that it was essential to choose life even when the quality of that life was not perfect [3].
Koop produced the Baby Doe Amendment (42 USCA § § 5101, 5102, 5103) to guide Congressional legislation and inform the public about the injustices of handicapped children.On October 9, 1984, the amendment extended the laws defining child abuse to refusal of fluids, food, and medical treatment to children with disabilities.

KOOP AND AIDS
During his mandate as Surgeon General, Koop faced the problem of educating the people about a growing threat to health: AIDS; showing, even in this case, his full independence from politicians.The Reagan administration forbade Koop to cH arles eV erett Koo P e 9 0 4 6 -6 talk about this theme for nearly five years.This restriction distressed Koop, who believed in the duty of the Surgeon General to inform the people about health problems.Despite the silence of Reagan administration on this issue, October 22, 1986 Koop intervened on the issue of Acquired Immune Deficiency Syndrome.His authoritative opinion was absolute essential.The epidemic was growing and Koop pointed out clearly the terms of the dramatic problem specifying measures for the prevention and described high-risk behaviours.
Koop was convinced that all U.S. citizens had the right to get the needed information to stop the spread of AIDS.So, in May 1988, he sent a message from the Surgeon General for each U.S. family.
Initially, AIDS was labelled to a "gay disease" because the first cases were transmitted mainly through sexual contact between men.For conservative politicians it was an opportunity to be exploited politically but they needed the help of Koop to condemn publicly the homosexuality.Koop refused political influence yet again.Koop, as Surgeon General, aimed to educate people to save lives, in the purest tradition of Public Health.He, therefore, argued that abstinence was the best way to prevent the transmission of AIDS, but urged the use of condoms in who continued to practice risky sexual behaviour.Koop also criticized some proposals such as mandatory testing and detention of HIVinfected gay.He challenged those who opposed the use of public money to finance research against AIDS.His approach against AIDS epidemic helped to calm the spreading hysteria of the public, losing the support of the most radical conservatives, reproached for putting put the value of conservative ideology above the value of saving lives.The New York Times reported Koop's opinion in this regard: "Our first priority for public health, to stop further transmission of the AIDS virus, has been unnecessarily bogged down in the politics of the early 1980s homosexuals.We have lost a great deal of valuable time because of this, and I suspect that we have lost some lives".
Charles Everett Koop paid dearly for his courage.When George W. Bush became President, he denied him the role of the Secretary of Health and Human Services, preferring Louis W. Sullivan.
Thus the curtain came down on the formidable public career of Charles Everett Koop, who resigned in October 1989, one month before the official end of his second term.He wanted new challenges and opportunities to educate the public without the interference of politics in Washington.Ironically, the popularity of Koop underwent a complete reversal during his tenure: he obtained his place through the support of conservative Christians and went as a hero of the liberal press and the public progressivist.
Even in retirement, Koop continued to fulfill his role as educator of public health.He founded the Koop Foundation and C. Everett Koop Institute at Dartmouth.The Koop Foundation was a private non-profit organization devoted to welfare, education, research and other initiatives to promote U.S. citizens health.The Koop Institute worked actively to reform medical education and to procure medical care.For the latter purpose, Koop continued to make his case of better and more accessible health care.He became president of the National Safe Kids Campaign, an organization committed to reducing accidents among children, which he founded as the last initiative by General Surgeon.In the 90s Koop continued to speak widely on health care reform and promoted the use of the Internet for the circulation of health information.

CONCLUSIONS
Charles Everett Koop was a great scientist and man, an evangelical Christian.He didn't impose his moral view to people and he didn't let his own cH arles eV erett Koo P e 9 0 4 6 -7 moral code to interfere in his public activity.These made him very popular.According to the Associated Press, "Koop was the only general surgeon to become a household name" [4].Despite his successful medical career, his most lasting legacy will be a public official who was able, as a public servant, to separate his personal beliefs from his duty.His personality and his consistency could be an example for all.
When he retired, The New York Times wrote: "The skeptics and cynics, including these pages, were wrong to fear that the Surgeon General C. Everett Koop would have used his office only as a pulpit for his anti-abortion opinions" [2].At the same time, the Washington Post noted that Koop, "used the pulpit to fight for the health of Americans" [5].He was estimated by Ronald Reagan not only as a paediatric surgeon but also for his pro-life position.However, once installed, Koop quickly understood and applied the concept of separation of Church and State and placed the service to citizens above his personal moral code.His only purpose was the health education of the nation to make it more healthy.
Koop could have become rich using his talents for himself, but he preferred to spend his life as a public servant, putting his expertise at the service of citizens.So it's hard to imagine a more deserving man for the acknowledgement that in 1995 President Clinton awarded him: the Presidential Medal of Freedom, the highest civilian award of the nation.This is a lesson that all politicians, in the world, should take to heart.