Dr. C. Everett Koop, who was widely regarded as the most influential surgeon general in American history and played a crucial role in changing public attitudes about smoking, died on Monday at his home in Hanover, N.H. He was 96.
His death was confirmed by Susan A. Wills, an assistant at the Geisel School of Medicine at Dartmouth College, which has an institute named after Dr. Koop.
Dr. Koop had never served in public office when President Ronald Reagan appointed him surgeon general of the United States in 1981. By the time he stepped down in 1989, he had become a household name, a rare distinction for a public health administrator.
Dr. Koop issued emphatic warnings about the dangers of smoking, he almost single-handedly pushed the government into taking a more aggressive stand against AIDS, and despite his moral opposition to abortion, he refused to use his office as a pulpit from which to preach against it.
These stands led many liberals who had opposed his nomination to praise him, and many conservatives who had supported his appointment to vilify him. Conservative politicians representing tobacco-growing states were among his harshest critics, and many Americans, for moral or religious reasons, were upset by his public programs to fight AIDS and felt betrayed by his relative silence on abortion.
As much as anyone, it was Dr. Koop who took the lead in trying to wean Americans off smoking, and he did so in imposing fashion. At a sturdy 6-foot-1, with his bushy gray biblical beard, Dr. Koop would appear before television cameras in the gold-braided dark-blue uniform of a vice admiral — the surgeon general’s official uniform, which he revived — and sternly warn of the terrible consequences of smoking.
“Smoking kills 300,000 Americans a year,” he said in one talk. “Smokers are 10 times more likely to develop lung cancer than nonsmokers, two times more likely to develop heart disease. Smoking a pack a day takes six years off a person’s life.”
When Dr. Koop took office, 33 percent of Americans smoked; when he left, the percentage had dropped to 26. By 1987, 40 states had restricted smoking in public places, 33 had prohibited it on public conveyances and 17 had banned it in offices and other work sites. More than 800 local antismoking ordinances had been passed, and the federal government had restricted smoking in 6,800 federal buildings. Antismoking campaigns by private groups like the American Lung Association and the American Heart Association had accelerated.
Dr. Koop also played a major role in educating Americans about AIDS. Though he believed that the nation had been slow in facing the crisis, he extolled its efforts once it did, particularly in identifying H.I.V., the virus that causes the disease, and in developing a blood test to detect it.
Where he failed, in his own view, was to interest either Reagan or his successor as president, George Bush, in making health care available to more Americans.
Dr. Koop was completing a successful career as a pioneer in pediatric surgery when he was nominated for surgeon general, having caught the attention of conservatives with a series of seminars, films and books in collaboration with the theologian Francis Schaeffer that expressed anti-abortion views.
At his confirmation hearings, Senate liberals mounted a fierce fight against him. Senator Edward M. Kennedy, Democrat of Massachusetts, said Dr. Koop, in denying a right to abortion, adhered to a “cruel, outdated and patronizing stereotype of women.” Women’s rights organizations, public health groups, medical associations and others lobbied against his appointment. An editorial in The New York Times called him “Dr. Unqualified.”
But after months of testimony and delay, he was confirmed by a vote of 68 to 24, garnering more support than many had expected. Some senators who had been hesitant to support him said he had convinced them of his integrity.
Dr. Koop himself said he had taken a principled approach to the nomination. As he and his wife, Elizabeth, had driven to Washington for the confirmation hearings, he recalled telling her, “If I ever have to say anything I don’t believe or feel shouldn’t be said, we’ll go home.”
An Only Child in Brooklyn
Charles Everett Koop was born on Oct. 14, 1916, in Brooklyn, and grew up in a three-story brick house in South Brooklyn surrounded by relatives; his paternal grandparents lived on the third floor, and his maternal grandparents as well as uncles, aunts and cousins lived on the same street. He was the only child of John Everett Koop, a banker and descendant of 17th-century Dutch settlers of New York, and the former Helen Apel.
Dr. Koop traced his interest in medicine to watching his family’s doctors at work as a child. To develop the manual dexterity of a surgeon, he practiced tying knots and cutting pictures out of magazines with each hand. At 14 he sneaked into an operating theater at Columbia University’s medical college. At home he operated on rabbits, rats and stray cats in the basement after his mother had administered anesthesia. By his account, not one of the animals died.
While attending high school at the private Flatbush School, he worked as a summer volunteer in hospitals near his family’s vacation home in Port Washington, on Long Island. He attended Dartmouth College and, after graduating, entered Cornell University Medical College in Manhattan and married Elizabeth Flanagan of New Britain, Conn., a Vassar student.
Dr. Koop completed his residency at the University of Pennsylvania Hospital, where he acquired a reputation for boldness. Afterward, his surgery professor, Dr. I. S. Ravdin, offered him a job as surgeon in chief of Children’s Hospital in Philadelphia, a rare offer for someone so young.
Dr. Koop held that position until the Reagan administration recruited him 35 years later. By then he had become renowned in medicine as an innovator in surgery on infants.
He and his colleagues performed thousands of operations to correct birth defects in premature babies or other newborns; 475 operations alone were on those with esophageal atresia, a condition, previously fatal, in which the esophagus and the stomach are not connected.
In one case, after cutting open the side of a baby’s chest to find an entire section of the esophagus missing, he built, on the spot, a new link out of tissue from the baby’s colon. It became standard procedure for repairing such a defect. He also did groundbreaking work in separating conjoined twins.
Faith and Principle
His experience in correcting birth defects compelled him to thrust himself into the middle of a controversy in the early 1980s over the rights of infants with congenital defects to receive medical care. In two cases involving infants, identified as Baby Doe and Baby Jane Doe, those who favored government intervention to save a disabled child were pitted against liberals, libertarians and medical groups who argued that parents had the right to withhold treatment from a child who was severely impaired.
Though courts sided with the parents, Dr. Koop spoke out against the parents’ decisions in both cases, saying that the medical and legal establishments had a duty to protect citizens against neglect and discrimination, no matter their age, and that a government’s authority to override the rights of parents had been established in truancy law and in child abuse and immunization laws. (Baby Doe died while the case was being appealed to the United States Supreme Court; Baby Jane Doe survived, though a delay in treatment was believed to have contributed to her severe retardation.)
Dr. Koop often said that his Presbyterian faith had helped him and his wife cope with the death of his 19-year-old son, David, who was killed in 1968 when a cliff gave way while he was climbing in New Hampshire. Dr. Koop and his wife wrote about the loss of a child in “Sometimes Mountains Move,” published in 1974.
Dr. Koop’s religion was also central to his opposition to abortion, which he considered a violation of divine principle. But once in public office, he said, he found it necessary to declare — to the disappointment of the White House — that evidence did not support the contention that abortions were essentially unsafe. In taking that position, he later said, he was being naïve. He had failed to realize that the Reagan administration expected him to oppose abortion zealously, he wrote in his 1991 autobiography, “Koop: The Memoirs of America’s Family Doctor.” And in an interview for this obituary in 1996, he said he had declined to speak out on abortion because he thought his job was to deal with factual health issues like the hazards of smoking, not to express opinions on moral issues.
Abortion presented little health hazard to women, he said, so it was a moral and religious matter, not a health issue.
Taking On Big Tobacco
Dr. Koop said he had begun campaigning against smoking after studying the research into its link to cancer, heart disease, stroke and other diseases. He was “dumbfounded,” he said, “and then plainly furious at the tobacco industry for attempting to obfuscate and trivialize this extraordinarily important public information.”
In taking on the tobacco lobby, he was also taking on powerful politicians from tobacco-growing states. After Dr. Koop accused the industry of directing advertising at children and threatening human lives, Gov. Jim Hunt of North Carolina, a Democrat, called for his impeachment, and Senator Jesse Helms, Republican of North Carolina, tried in vain to have Congress investigate him.
Dr. Koop came to believe that the Reagan administration itself offered only lukewarm support for the antismoking public-education campaign “A Smoke-Free Society by the Year 2000.” Feeling stymied, he said, he asked himself, “What if I called on America itself?” So he embarked on a national speaking tour in 1984, often wearing the uniform of his office. The uniform, he said, was intended to help restore his diminishing authority as the surgeon general and director of the Public Health Service.
In 1986, a surgeon general’s report expanded the alarm about smoking, stating that secondhand smoke had also been conclusively proved to cause cancer. Over the next year, federal, state and local governments and private businesses began to restrict smoking in public and quasi-public places like restaurants, airports and workplaces. (In 2004 he joined with three other former surgeons general to offer a plan to cut cigarette smoking in part with a $2-a-pack tax increase.)
AIDS had just been discovered when Dr. Koop was awaiting confirmation in 1981. But within weeks, with 108 cases reported in the United States and 43 deaths, “I knew we were in big trouble,” he said. He realized later, he said, that the Reagan administration had been slow to address the disease because the election had brought to power people who were antithetical to homosexuals, then thought to be its only victims.
As the epidemic worsened, reaching drug addicts infected with contaminated needles and hemophiliacs who had received a contaminated blood-clotting factor, Reagan, in 1986, asked Dr. Koop to prepare a special report. Dr. Koop proceeded cautiously, knowing the report would be unpopular with many in the administration, with conservatives in Congress and with church groups opposed to homosexuality. He wrote 17 drafts.
A Public Profile
With its release, he was attacked as advocating that third graders be taught about sodomy and that 8-year-olds be given condoms. What the report said was that the best protection against AIDS was abstinence and monogamy, but that for those who practiced neither, condoms were a necessary precaution.
White House aides tried to get him to delete the reference to condoms, but he refused to alter the report or make it more morally judgmental. He prevailed, and the government eventually printed more than 20 million copies of the report.
Dr. Koop later wrote that “political meddlers in the White House” had complicated his work on the disease, and that “at least a dozen times I pleaded with my critics in the White House to let me have a meeting with President Reagan” on AIDS in the mid-1980s. Too many people, he said, “placed conservative ideology far above saving human lives.”
He added: “Our first public health priority, to stop the further transmission of the AIDS virus, became needlessly mired in the homosexual politics of the early 1980s. We lost a great deal of precious time because of this, and I suspect we lost some lives as well.”
Dr. Koop had no success in pushing the Reagan administration to take action on delivering health care to Americans who could not afford it. He announced his resignation after Mr. Bush was elected president in 1988 and did not name him secretary of health and human services, as Dr. Koop had hoped.
Dr. Koop’s first wife died in 2007; he is survived by their three children, Allen, Norman and Elizabeth Thompson; eight grandchildren; and his second wife, Cora Hogue, whom he married in 2010.
In 1992 Dr. Koop founded the Koop Foundation in Hanover, N.H., to help strengthen humanitarian values among doctors. In 1995, nearing his 80th birthday, he became chief executive of a Time-Warner division, Time Life Medical, to produce videos for sale in pharmacies. Dr. Koop appeared in the videos, each tailored to patients with a newly diagnosed disease, to explain the ailment, alternative treatments and anticipated outcomes.
In 1997 he founded DrKoop.com, a popular medical information Web site whose critics said blurred the line between objective information and advertising and promotional content. The site was valued at more than $1 billion before it went bankrupt in the collapse of the Internet bubble.
Dr. Koop also came under criticism in 1999 when a panel of scientists he led investigated claims that certain chemicals used to make plastics more flexible — in hospital tubes and some children’s toys, for example — were dangerous. The panel determined that they were safe, a finding disputed by Health Care Without Harm, an international coalition of health workers, advocacy groups and environmentalists.
Dr. Koop maintained a public profile well into his later years. In January 2010, he appeared in an advertisement opposing the Democratic health care proposal then being negotiated in Congress, saying it threatened to ration health care for older people, an assertion that drew criticism as misleading.
When he stepped down as surgeon general, however, Dr. Koop had won over many of his original detractors.
“The skeptics and cynics, this page included, were wrong to fear that Surgeon General C. Everett Koop would use his office only as a pulpit for his anti-abortion views,” an editorial in The Times said in 1989, as he was leaving office. “Throughout he has put medical integrity above personal value judgments and has been, indeed, the nation’s First Doctor.”