Ihad first heard about the pioneering surgeon operating out of the Children’s Hospital of Philadelphia (CHOP) during my years as a medical resident at The New York Hospital. Impressionable young physicians such as I was at the time frequently took particular notice of the careers of famous physicians who might serve as role models, even from a distance. And Dr. C. Everett Koop was truly a legend in his own time. He had been the surgeon in chief of CHOP from 1948 through 1981. When I was in training during the late 1960s and early 1970s, Dr. Koop was at the peak of his career. He invented surgical procedures for the correction of congenital abnormalities that were previously considered hopeless. Among these was the correction of esophageal atresia, which is a lack of connection of the esophagus to the stomach, a fatal condition. In addition, he developed new procedures for the treatment of hydrocephalus, a condition where normal fluid (called cerebrospinal fluid) accumulates around the brain because of an obstruction to the free flow of the fluid. He also revolutionized the surgical repair of pediatric inguinal hernias and the correction of undescended testicles. In essence, he more than anyone created the discipline of pediatric surgery. He gained true international fame in 1974 by surgically separating twin girls who were born joined together at the trunk and pelvis, saving the lives of both of them. He felt strongly that society had an obligation to respect the sanctity of life, and in his profession this extended to doing whatever is possible and reasonable to save the life of a child with certain abnormalities for which he had developed these revolutionary surgical procedures. It would have been a great honor for me as a medical student or physician in training to just meet Dr. Koop and perhaps shake his hand. I never imagined that this would happen.
Dr. Koop’s reputation as a defender of the right to life including his concerns about abortion had caught the attention of President-elect Ronald Reagan in late 1980. Reagan nominated Koop for surgeon general in 1981, and this triggered a series of hostile congressional hearings, public debates, and media commentaries that put Dr. Koop under a degree of stress that even his most difficult surgical procedures did not elicit.
Ever since I had returned to the NIH from my final year of clinical training, I was considered the “house physician” for many NIH staff and their families and assorted Washington VIPs. One day I received a call from the NIH director, Dr. Donald Fredrickson, telling me that Dr. Koop was “not feeling well” and that HHS would like one of the NIH physicians to see him.
At 8:30 one morning, I went to the nurses’ station on the 11 East ward of the NIH Clinical Center, where I had been working for the past nine years, and waited for Dr. Koop to arrive. Out of the elevator and down the hall came this imposing man—tall (six feet, two inches) and ramrod straight, sporting his trademark Captain Ahab beard, and with a concerned expression on his face. We shook hands, and I led him into the treatment room to take a history and perform a complete physical examination.
Dr. Koop explained his symptoms to me: insomnia, a feeling of jumpiness, irritability, intermittent flushed sensation, occasional headaches, and lightheadedness. His physical examination was completely normal. I drew blood for a number of tests and arranged to see him again after the results of the blood work came back. Before I let him go, I asked, even though I already knew the answer, if anything was bothering him or causing him stress. He brushed off the possibility. I strongly suspected that his symptoms were all being caused by the fact that due to his pro-life stance he was getting trashed on a regular basis by the liberal media and that Senator Ted Kennedy, one of the most respected members of the Senate, was dead set against his nomination as surgeon general. Still, I had to rule out any physical cause. When the blood work, electrocardiogram, chest X-ray, and other laboratory tests came back as unremarkable, I was convinced that we were dealing with a reversible constellation of signs and symptoms. But reversibility is easier said than done. I first had to convince him that he was physically fine and that we could work this out. Because he was an accomplished surgeon, I told him that the bad news was that this was not a surgically correctable problem. However, the good news was that it was fixable. “I have a name for your condition, Dr. Koop. The welcome-to-Washington traumatic stress syndrome.” He thought this was hilarious, and we shared the first of what would be a series of hearty laughs together over the next thirty years. I told him I planned to gradually diminish and ultimately discontinue some of the medications that various physicians had put him on over the past year because I did not think that he needed them. He agreed only under the condition that I not attempt to discontinue his beloved daily predinner dry martini. He also insisted that I stop calling him Dr. Koop. “My friends call me Chick,” he said. I agreed and my friendship with the medical icon began.
Over the next four years as the number of cases of AIDS increased at a sharp rate, Chick Koop was not actively engaged with AIDS and spent the bulk of his time on other issues such as the crusade against tobacco use. But starting in early 1986, I saw a distinct evolution in his growing appreciation of the devastating effect HIV/AIDS was having and of the potential role he, as surgeon general, could play in the nation’s response to the epidemic. A peculiarity of the HHS allocation of housing for high-ranking employees played some role in this evolution. Although the office of the surgeon general is located in the main headquarters of HHS in the Hubert H. Humphrey Building at 200 Independence Avenue, S.W., in Washington, D.C., the living quarters of the surgeon general were at that time on the NIH campus in Bethesda, Maryland. The house in which Koop and his wife, Betty, lived was about a hundred yards from my office in the Claude Denson Pepper Building (Building 31). Upon entering the NIH campus, Chick had to walk directly past my building to get to his house. Starting in 1986 he began regularly stopping off for visits in the evening, usually around 7:30 after all my staff had already left for the day. He would arrive resplendent in his Public Health Service uniform, which is almost indistinguishable from the uniform of a U.S. Navy officer. The sleeves of his jacket displayed the thick bands of a vice admiral. He knocked softly and led off with the same introduction each time: “You work too hard; take a few minutes and relax with me.” I put aside the manuscript I was working on in preparation for submission to a medical journal, and the few minutes inevitably turned into an hour as he probed me about every aspect of the scientific, medical, epidemiological, and policy issues of HIV/AIDS. It was clear that he wanted to learn everything he could about the disease. He referred to those sessions as his “nighttime tutorials.” But it was not long until he became a true expert in his own right. During his evening visits, he described with passion and enthusiasm the visits he had begun making to AIDS clinics throughout the country and his interactions with patients, their families, and various constituency groups. He was about to enter the arena of AIDS in a big way.
In 1986, the Reagan administration asked Dr. Koop to prepare a report on AIDS. The Surgeon General’s Report on Acquired Immune Deficiency Syndrome, released at a press conference on October 22, 1986, was a masterpiece of clarity, candor, evidence-based statements, and critically useful information. Chick dispensed with the niceties and talked about the epidemic in real-world terms. His descriptions of the risks of transmission by anal intercourse among gay men and his advocacy for the use of condoms to prevent transmission of HIV caused quite a stir among certain religious leaders and social conservatives. Chick was not deterred. To the contrary, he was concerned that such a daunting, technical report might not be widely read, particularly by the general public, who would most benefit from the information. Chick wanted to mail a pamphlet containing frank information about HIV infection and AIDS to every household in the United States. But because the Office of the Surgeon General was mostly thought of as a bully pulpit position and had a relative paucity of financial resources, his budget was too small to pull the project off.
Here is where we hatched what he jokingly called “the Brooklyn Scheme.” Like me, Chick Koop was born and raised in Brooklyn. He grew up in Flatbush, originally populated by children and grandchildren of Dutch and German immigrants. It was just a few neighborhoods away from Bensonhurst. Chick’s scheme was one Brooklyn boy helping another to enable the pamphlet to be produced and mailed in a timely fashion. It was early 1988, and NIAID now had a substantial budget of $740 million. It was not unusual for one component of a government agency to transfer a small amount of money to another component for services rendered through what is referred to as an interagency transfer. Because my institute was the leading government agency performing and supporting AIDS research, the pamphlet, which might help prevent HIV infection, was in the interest of NIAID. When the first mailing went out, Chick called me up and with a mischievous laugh said, “I guess we Brooklyn boys pulled it off!”
The pamphlet had a profound effect on the country’s awareness of the seriousness of the AIDS epidemic and the risks of infection. It remains one of the most influential public health publications ever distributed by the U.S. government. It was both highly effective and controversial. This latter fact was illustrated by a syndicated cartoon that appeared in a number of newspapers showing a working mother leaving her home and telling her children as she walks out the door, “If anything comes in the mail from the Surgeon General, don’t open it!”
Chick Koop remained a force on issues related to public health for many years following his tenure as surgeon general. Our friendship endured, and Chick and I both were invited back to our medical school alma mater, Cornell University Medical College, in May 1992. I was to receive the Alumni Award of Distinction, and Chick was to deliver the commencement address. He decided that we should rent a limousine and take a tour of our childhood landmarks in Brooklyn. We visited his elementary school, the Flatbush School, and mine, Our Lady of Guadalupe; the sports fields where he played football and I played baseball; and other neighborhood hangouts. We finished the day by driving to Coney Island to reprise one of the great treats of our childhood, a hot dog at Nathan’s Famous. As we stood on line waiting to be served, a small crowd gathered around us and began staring at Chick. Soon you could hear people saying, “Hey, isn’t that the surgeon general guy? That must be him, look at that crazy beard. What is he doing here?”
He heard the remark, started to laugh, and said, “What do you think I am doing here? I’m a Brooklyn guy, and this is Nathan’s.”