U.S. MEDICINE 3 Dr. C. Everett Koop Never planned on a `public Ige' -U.S. Medicine photos Dr. WilliamH. McBeath Nominee's `public health' work questionable By Suzanne viau be judged on the basis of a single issue," WASrirNfzroN-The controversy sur- the question of whether Dr. Koop has rounding the confirmation of Dr. Cha- accrued enough public health expe- rles Everett "Chick" Koop, 65, as U.S. rience to qualify for surgeon general surgeon general again appears to have took center stage. boiled down to a single issue-public The committee was expected to vote health service. this week on whether to approve his Despite assurances from prominent nomination. Senate liberals such as Howard M. Met- Another issue, which until then had zenbaum (D., Ohio) at Dr. Koop's dominated the controversy over Dr. Senate confirmation hearings that the Koop-namely, his vocal opposition to -nowned pediatric surgeon "would not abortion-was conspicuously avoided by the witnesses testifying at the hearing. Only the National Organization for Women, one of the two groups testify- ing against Dr. Koop's confirmation as surgeon general, chose specifically to take issue with his record of crusading against abortion, amniocentesis and birth control devices which. act after conception to preclude pregnancy. Yet, almost to the man, medical col- leagues of Dr. Koop expressed different feelings on abortion than his. Nevertheless, the witnesses assured the Senate Labor and Human Resour- ces Committee, chaired by antiabortion advocate Sen. Orrin G. Hatch (R., Utah), that Dr. Koop never .mixed his antiabortion feelings with business, although he is known for taking a com- passionate, personal interest in his patients and their families. "I can state with honesty that Dr. Koop never forced his opinions on me or or any staff in the hospital...that he did not let them (feelings) interfere with his professional duties," Richard D. Wood, chairman of the board of man- agers of Children's Hospital of Phila- delphia, where Dr. Koop spent more than thirty years practicing, said. Wood added, however, that having been associated with Planned Parent- hood for 30 years, he was opposed to Dr. Koop's position on abortion. Dr. John J. Downes, head of anesthe- siology at the hospital, said he has known Dr. `Koop for 20 years, and des- cribed him as a "medical diplomat" who has carried his pioneering concepts in neonatal intensive .care (he established the first neonate critical care unit in the U.S.) .throughout Europe (including Krakow, Poland, the home city of Pope John-Paul II) and Japan. Dr Koop also is noted for his cham- pioning of a wide range of causes from the outlawing of fluoroscopic shoe lit- ting machines for children to a hydra- tion project to control infant mortality from diarrhea in the Dominican Repub- lic. These efforts were an outgrowth of his clinical concern and experience in (Continued on page 14) 14 U.S. MEDICINE OCTOBER 15, 1981 .Koop Hearing Centers On Public Health Issue (Continued from page 3) those areas and highlighted his dedica- tion to public health, the witnesses said. But public health experience and treating the public are two different things, according to Dr. William H. McBeath, president of the American Public Health Association and the sole organized medicine representative at Dr. Koop's nomination for surgeon general is the first one the organization the hearing. has opposed in 109 years. u `Public health' defined as anything done in the interest of the public is not a very helpful definition of public health," Dr. McBeath said. The law now permits the designation of a surgeon general from outside the career PHS, but only with the specifica- tion that nominees possess "specialized training or significant experience in public health programs," he noted. Almost all the cases cited at the hear- ing of Dr. Koops' public health expe- rience "are not exampks of public health service at all, but examples of clinical service," he added. Better examples of public health ser- vice involve epidemiology studies and the tracking of disease outbreaks, such as the Centers for Disease Control's efforts to isolate the source of a recent Dr. Halfdan Mahler, director general typhoid outbreak in Texas, Dr. of the World Health Organization, in 1975 indicated that one of Dr. Koop's so-called public health efforts, the McBeath contended. hydration project in the Dominican Republic, was an example of the "inap- propriate transfer of Western technol- ogy to Third World countries," Dr. McBeath continued. Dr. McBeath said he does not oppose having Dr. Koop's clinical experience within the HHS. "I would second his nomination for the Nobel Prize-but that is not the issue here." But for surgeon general, he said, "I have some difficulty listening to your testimony that since he (Dr. Koop) is not a member of the `club' (APHA), he should not be surgeon general," Sen. Hatch angrily responded. "I think you should reconsider your position," he told Dr. McBeath. Asked by Sen. Hatch why he had not specifkally pursued public health as a medical career, Dr. Koop said he had chosen pediatrics as a "building block." "However, I am not a man of narrow vision," he added. When a public health problem became evident in the course of his clinical practice, he sought to correct it, Dr. Koop explained. "I had never planned to have a role in public life" when the Reagan adminis- tration tapped him for surgeon general, he continued. - U. S. Medicine photo Sen. Orrin Hatch APHA position unacceptable At the confirmation hearings, at least, sentiments appeared to be run- ning in favor of the father of four, Pres- byterian church elder and husband of 43 years. research and infant breast feeding at the hearing. This, despite the firm stand Dr. Koop took on such issues as contraception On abortion, however, he said little. Sen. Jennings Randolph (D., W. Va.), after stating that he was against federally funded abortions, but in favor protecting the right of women to choose to have an abortion, asked Dr. Koop his ; opinion on the subject. "It would be difficult to answer that question in just one word, but in view of the law of the land, I would have to agreed with you," Dr. Koop responded. APHA would prefer to have an addi- tional individual, someone with specific PHS work experience and "not an occa- sional exposure to public health work." Subsequently, when Sen. Hatch asked if, given Dr. Koop's antiabortion sentiments, he would in any way seek to use the position of surgeon general to alter fertility and population research policy, Dr. Koop responded that he had assured Health and Human Services secretary Richard S. Schweiker "I have said all I should say and written all I should write" on abortion. "I am not opposed to contraception. I am not opposed to family planning," Dr. Koop added. "I think we should have as much research as possible in these fields," he continued, because of the potential answers such research could provide ethical medical problems. Asked by Sen. Metzenbaum whether he considered unwanted pregnancies a public .health concern, Dr. Koop responded that such pregnancies "have to be a public health problem-but not solely a public healthYproblem." He told the committee, however, that he would have no responsibilities related to .family planning, and would be reporting directly to HHS assistant secretary for health Dr. Edward N. Brandt Jr. as surgeon general. Asked by Sen. Edward Kennedy (D., Mass.) where he stood on the issue of infant formula promotion abroad, Dr. Koop asserted that he was opposed to the United States' vote against a .World Health Organization code to impose sanctions against American infant for- mula manufacturers engaged in unethi- cal marketing practices in third world nations. Dr. Koop, who said he wasa delegate at the WHO meeting when the issue came up, added that he had advised against the U.S. position, but left the meeting before the U.S. vote was cast. -He acknowledged that the govem- ment's decision to oppose the code was based on "other reasons" presumably set forth by the State Department. As a physician, -"I think breast feed- ing is superior-far so," Dr. Koop said, adding, however, that infant formulas were preferable to .no infant nuitrition when mothers are incapable of lactating. Dr. Koop indicated he was no stranger to the sanitation and preven- tive health problems of developing countries, having served as vice- president of MAP (Medical Assistance Programs) International, a worldwide : relief organization with which the OCTOBER 15, 198 1 U.S. Agency for International Develop- ment has contracted for medical and consultation services. Dr. Koop stressed the health prob- lems of the aged and disabled would be his two domestic priorities as surgeon general. "Would you be a specific advocate of these constituencies?" Sen. Kennedy asked. "I'm not just willing but intend to be an advocate of those groups," Dr. Koop responded. Sen. Kennedy countered, however, that aged and disabled persons will be among those hardest hit by a pending medicaid cap and, cutbacks in supple- mental energy funds, food stamps and other social services. He charged that Dr. Koop was nominated because he is "politically compatible" with the Rea- gan administration. Dr. Koop added that he recognized these groups will be "heavily impacted,** but that new priorities would have to be set to al.low the aged and disabled to "make do with what they have" to improve their quality of life. "Do you support these cutbacks then?" Sen. Kennedy pressed. "1 think that's an unfair question,`* Dr. Koop responded. He contended that "One in five Americans by 1990 would be over 65 and I will be in that age group...1 assure you that does not mean you are over- the-hill." Dr. Koop said the life expectancy for his age group now is 12 years, "which means there's still the opportunity to practice preventive medicine." Many elderly are being placed in nursing homes at high costs, when with a little assistance they could continue to live at home, he added. Dr. Koop said he would support leg- islation to develop new types of health professionals for home health care for the elderly. With respect to nursing, he stressed that such skills should be maximized, but that there must remain a "captain of the ship," a physician in charge of supervision. Turning to other health profession- als, Dr. Koop said he was supporting policy proposals to streamline Public Health Service commissioned corps operations, now being considered by HHS. Those proposals include: basing re- tention and bonus pay on merit; finding new roles for the commissioned corps in the implementing of recently approved state block grants; and developing new areas of preventive care to be carried out by the corps. As surgeon general, Dr. Koop would by commander of the corps. Dr. Koop also told the committee "there has been no discussion between myself or secretary Schweiker or Dr. Brandt about the reorganization of the (assistant secretary for health) department." The Reagan administration at one time had considered creating an under . secretary for health position, pnsuma- bly to be filled by Dr. Brandt, leaving unclear what other positions in the health offtce would remain. Dr. Koop currently is holding the position of HHS deputy assistant secretary for health. With respect to the other priority he cited, the disabled, Dr. Koop said he would be working to better define dls- ability and to eliminate "a tremendous amount of duplication and overlapping in the provision of services for the dis- abled among the public and private sec- tors." More coordination of efforts is needed, he said. He estimated 1 in 7 persons in the U.S. is in some way disabled and that disability benefits, which now total 8 per cent of the gross national product, may reach 18 per cent of GNP by 1990.