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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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Remembering US Surgeon General C. Everett Koop and a Legacy of Leadership

Last Monday, former US Surgeon General C. Everett Koop, MD, ScD, died at the age of 96 years. But even though it’s been nearly 25 years since he completed his term as Surgeon General, his name remains virtually synonymous with the role.

Dr Koop transformed his office into a powerful platform for educating the public and reshaping the national dialogue on major public health challenges, from tobacco use to HIV/AIDS. At a time in which we are undertaking the largest overhaul of the health care system in our nation’s history, Koop’s passing provides an opportunity to reflect on the man and his accomplishments as well as the position of Surgeon General, a medical and public health leadership role that apparently has, sadly, all but vanished.

Former US Surgeon General C. Everett Koop, MD, ScD, who died at the age of 96 years, transformed his office into a powerful platform for educating the public and reshaping the national dialogue on major public health challenges, from tobacco use to HIV/AIDS.

On June 10, 2007, Koop, along with 2 other US Surgeons General—David Satcher, MD, PhD, of the Clinton Administration and Richard Carmona, MD, MPH, of the second Bush Administration—testified before the House Committee on Oversight and Government Reform on the increasing political interference that impeded the work of the office in which they had served. Although the committee chairman, Rep Henry Waxman (D, Calif), had joined other public health advocates in opposing President Ronald Reagan’s nomination of Koop in 1981, Waxman came to deeply admire Koop for his willingness to place science above ideology and the public’s interests above political ones. Koop, a distinguished pediatric surgeon, had little formal public health training, but he deeply believed that it was his duty as a physician to advocate for the health of the community and nation at large.

Koop’s commitment to these principles and belief in the important role that the US Surgeon General should play as a public health leader is evident in the following excerpts from his testimony:

I served from November 16, 1981 through October 1989; my confirmation process took 9 months because the appointment of the Surgeon General by the president and his/her confirmation by the Senate is really political.

I have observed many things that hinder the Surgeon General’s ability to serve our population.

The Surgeon General should be independent and free to assume the responsibility to advise our country and its citizens on how they can prevent disease and promote good health. He or she should be the health educator of Americans, par excellence. At the same time, the Surgeon General should play an important role in directing public health and health care in this country.

The personalities and qualifications of two individuals have much to do with the success of the Office of the Surgeon General:

First, the President. Mr. Reagan was pressed to fire me every day. Most of his cabinet opposed my description of HIV transmission, and some believed that those who had AIDS deserved what they got. But Mr. Reagan was a loyal man. If he had not been the kind of person he was, I would not be here today.

Second, the Secretary of Health and Human Services (HHS). I served under four. The last was Otis Bowen. When I was writing the report on AIDS—and the later mailer that was sent to every household in America—he was a constant ally. We maintained strict secrecy. If we had followed protocol and had every word scrutinized by the Secretary’s secretariat, these reports would not have seen the light of day.

The Secretary of HHS can use the talents of the Surgeon General—or ignore them.

Dr. David Satcher, a man uniquely suited to be the Surgeon General, did not fare as well as I did. Who should have kept the nation up-to-date during the attempted anthrax poisonings in 2001? The Surgeon General, with a six-year history of directing the Centers for Disease Control, or a former governor and political appointee [Tommy Thompson]?

Dr. Richard Carmona was treated with even less respect. Why wasn’t Dr. Carmona given a more prominent role in responding to Hurricane Katrina, given his background in trauma care and emergency health services?

The Surgeon General must be independent, impartial, and nonpartisan, to say nothing about competent, innovative, and able to teach. If I had been impeded for political reasons, as some of my successors were, there may never have been the publication of eight reports to Congress on smoking and health, the introduction of “no smoking” policies in most indoor places, the wide dissemination of information on drunk driving, an expansion of the Social Security Act to provide enhanced community-based care for special-needs children, and the publication of the first federal report on nutrition.

The Surgeon General must be free to serve the American people without political interference. He or she must also receive the necessary support and resources to do the job. Health is a huge task. It needs the leadership of a health-trained individual unencumbered by [additional] responsibilities. The Surgeon General has a unique role to play.

How can we insure that this happens?

First, the Surgeon General should not be a political appointment.

Second, the Office of Surgeon General must have secure staffing and funding to do its work. Lack of financial independence means that the Surgeon General must seek the permission and support of others to prepare a report, hold a press conference or attend a town meeting.

The combination of Koop’s courageous leadership as Surgeon General and an administration’s surprising restraint from interfering was a powerful but rare phenomenon. Although the Surgeon General is still widely perceived as “the doctor of our nation and an ombudsman for the public’s health,” the problems and potential solutions outlined by Koop have yet to be addressed. Surgeons General under recent administrations, Democratic and Republican alike, have languished without political or budgetary independence.

This is a missed opportunity for the public. And it is a missed opportunity for physicians, medical students, and those seeking careers in medicine to benefit from the kind of inspiring physician leadership in public health that Koop so effectively demonstrated.

America’s medical leaders, as health care services expert Robert H. Brook, MD, ScD, observed, too often focus their energies on self-interests associated with their practice and professional organizations rather than raise their sights toward the health of society. As Dr Koop once remarked,

We have to be more than a passive resource in this movement toward a healthier America…. We have an obligation to be active partners in these matters of disease prevention, of health maintenance and health promotion, playing a hand-in-hand role with those seeking to ward off disease and disability.

Although Dr Koop is now gone, we have his legacy and his words as a reminder of what is possible when physicians pursue the challenges and accept the responsibilities of being public health leaders.

About the authors:
Asa Tapley, MSc, is a student in the School of Medicine at University of California, San Francisco (UCSF). His interests include research on methods of improving tuberculosis detection and health care policy focused on improving health and well-being in poor and marginalized communities.
Andrew Bindman, MD, is Professor of Medicine, Health Policy, Epidemiology and Biostatistics at University of California, San Francisco (UCSF). He is the founder and Director of the University of California Medicaid Research Institute, a multicampus research program that supports the translation of research into policy.