Dr. C. Everett Koop Reflects on Working Toward Peace
From
the time I was six years old I knew that I wanted to be
a surgeon, and even as a young boy I trained my hands for
future surgical maneuvers by cutting pictures out of magazines
using both my right and left hands. But I also spent hours
with my first chemistry set, at first just making colorful
solutions, then conducting what may have been some rather
sophisticated experiments for a twelve-year-old. As a teenager
I combined my interest in chemistry with my budding interest
in surgery by performing simple operations on some of the
many stray cats that prowled my Brooklyn, New York, neighborhood.
Using the ether that I supplied, my mother would anesthetize
the cats while I removed an unnecessary organ, such as one
ovary. We were a good team, and I never lost a feline patient!
After my mother's death in 1974 at age eighty-six, I found
among her treasured papers an essay that I had written as
a high school senior. Its concluding paragraph summed up
my hopes for careers in both science and medicine:
Now at sixteen I picture myself a surgeon-nothing would
give me a bigger thrill and would please me more than to
operate on a human being from an altruistic viewpoint of
relieving his ills, or from the scientific viewpoint of
giving to science some information unknown to it.
That was the joint dedication to science and medicine that
shaped my forty-year career as one of the United States'
first pediatric surgeons. In the late 1940s and 1950s I,
and a handful of other surgeons, were pioneers in this new
field of surgery, often being forced to invent new operations
as we encountered congenital abnormalities in newborns that
had never before been corrected surgically. Although we
were serving primarily as doctors attempting to bring healing
and comfort to our tiny patients and their worried families,
we were, at the same time,
scientists pushing the surgical frontier into the unknown,
all the while documenting our hard-won surgical successes.
By performing thousands of new and then routine operations,
through surgical research, published articles, and innovations
in science, pediatric surgery eventually became an established
surgical specialty. In those operations that were particularly
difficult to perform on newborns, in the brief forty-year
span of my surgical career I witnessed a mortality rate
of 95 percent become a survival rate of 95 percent, thanks
to the progress made in pediatric surgery.
In addition I learned that for all of its reliance on science,
medicine is also an art. I learned that pediatric surgery
requires a gentle touch, not just on the fragile tissue
of an infant's body, but also on the fragile emotions of
patients and their families. I learned that to do full justice
to my interests in science, surgery, and research, I had
to apply myself not merely to curing, but also to caring.
My stress on the human dimension of science remained important
as I left my surgical career to become the United States
Surgeon General. As surgeon general I always seemed to be
issuing a "Surgeon General's Warning" about one
thing after another that threatened the health of the American
people: cigarettes, smokeless tobacco, AIDS, Reye's syndrome,
violence, and a host of others. In each case I had to be
certain that the science behind the health warning was impeccable
and able to withstand the critics who sought to dismiss
the warnings. But I also needed to ensure that the science
made sense on a personal level. I had to listen to the American
people as well as to talk (sternly) to them. Also, I wanted
to be certain that my message reached the most vulnerable,
often those high-risk groups living in poverty on the fringes
of this affluent and sometimes overconfident society.
Now, in my present career as national lecturer, author,
and advocate for the health of the American people, I find
myself once again motivated by the concerns of both science
and medicine. As I did when
surgeon general, I strive to advise people about what they
can do to promote health and avoid disease. In this ongoing
endeavor I base my message on the best science, as, for
instance, in my effort to communicate the dangers of hepatitis
C. But I have also discovered that relying on the best science
is not enough, because it can be pushed aside by politics
and economics, or, to put it another way, by greed. . .
.
One can observe similar trends in the world of health care
delivery. At the end of the twentieth century the scientific
research community has done wonders to fulfill medicine's
historic goals of prolonging life and alleviating suffering.
Almost every day we read about a new scientific breakthrough
that provides a cure for this, relief for that, and new
hope for millions of people suffering from a variety of
diseases. But we know that scientific progress is not enough.
We have seen that the dictates of economics, that "dismal
science," limit the benefits of medical science.
I practiced surgery in the so-called golden age of medicine,
a time when it seemed that each day medical science could
do more for patients, and more and more Americans gained
access to the health insurance that would provide needed
health care. But now, as daily an increasing number of Americans
lose their health insurance (the United States has close
to fifty million uninsured citizens), and as most of those
who are insured are covered through economically driven
managed care plans, those who need health care the most
are often the ones who get it the least.
Physicians' unhappiness with a system that diluted their
focus on patients with cost issues made them the initial
advocates of managed care. The managers and physicians in
these early health maintenance organizations (HMOs) were
unexpectedly surprised to find that maintaining their patients'
health provided the added benefit of containing health care
costs. This had been accomplished by shifting the focus
to preventive care, to a standardization of practice that
resulted in better outcomes, and by elimination of unnecessary
tests and procedures. Now, in all too many cases, that added
benefit has become the primary purpose of managed health
care companies, as Wall Street investors have determined
that hospital companies and health care companies should
be treated like any other business, as an opportunity for
investors to make money. Profit, not health, is the prime
objective of this kind of managed care.
I am concerned about the intrusion into medical education
by these investor-controlled health care companies: Some
have even bought medical schools, and at least one has subsequently
filed for bankruptcy. I do not want the education of our
next generation of physicians to be held hostage to bottom-line
oriented managers who buy and sell hospitals, medical practices,
and medical schools as though they were pork futures. Americans
are only slowly realizing how many medical decisions have
been taken out of the control of physicians and other health
care personnel and placed on the desks of accountants and
businessmen. Every American should be concerned about the
unwillingness of managed care companies to do their fair
share in supporting medical education and medical research,
especially clinical research.
I do not intend my remarks to be a diatribe against managed
care. This is still very much a fluid situation, and it
may work out in such a way that HMO patients will be delighted
to deal with relaxed doctors free to make clinical decisions
in a financially neutral environment. However, it could
also develop so that patients find themselves shuttled about
from gatekeeper to nurse, denied costly specialists and
unable to penetrate the bureaucratic maze of a health care
company that cares more about profits than patients. . .
.
I believe that it may take a decade or so to find a new
equilibrium involving HMOs, medical innovations, patient
concerns, and physician-directed decision making, an equilibrium
that will deliver what is medically necessary, not what
is merely profitable. I am hopeful, but not certain, that
what is in the best interest of the patient will begin to
prevail over what is in the best interest of the health
care company investors. This attitude must support medical
research as well as medical care. The issues of managed
care, patient rights, physician professionalism, medical
research, and health care in America need to be lifted from
the bottom line to our highest aspirations.
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