Author: Mike Magee
The ghost of Christmas past, in the form of Surgeon General C. Everett Koop, returns this season to torment a man named RFK Jr. who refused to fully share life-saving vaccines with children. In this encounter, the ghostly Coop recalls a time 37 years ago when citizens came together to celebrate the separation of scientific fact from life-saving fiction.
Since 1988, the United States, like the rest of the world, has officially recognized and celebrated World AIDS Day on December 1 each year until 2025. At the direction of President Trump, the State Department, with support from HHS, refuses to accept an inconvenient truth: the Republican Party's early record on HIV/AIDS. Let’s look back at the truth-telling surgeon generals of Christmas past and remember the story that was told.
On June 5, 1981, the CDC reported six cases of Pneumocystis carinii in California men associated with a strange immunodeficiency disease. PhD. Michael Gottlieb and Joel Weisman, infectious disease experts who regularly provide care to gay people in Los Angeles, alerted the CDC. Debate raged within the organization over how best to report the new disease among gay men.
The CDC's tool of choice is a weekly report called the Morbidity and Mortality Weekly Report, or MMWR. In order not to offend, we decided to publish the new findings on page two instead of page one, without any mention of homosexuality in the title. Almost no one noticed.
On April 13, 1982, nine months after the initial alarm, Senator Henry Waxman held the first congressional hearing on the growing epidemic. The CDC confirmed that tens of thousands of people may have been infected. On September 24, 1982, the disease was first labeled AIDS—acquired immunodeficiency syndrome.
The focus of the new Surgeon General, C. Everett Koop, and the vast majority of the nation's public health leaders at the time was not on emerging infectious diseases but on the nation's burden of chronic disease, particularly cardiovascular disease and cancer caused by the postwar surge in tobacco use. He has speculated that the power of his position lies in communication and advocacy.
A month after being sworn in, he appeared on a panel to deliver a typically bland Surgeon General's latest report on tobacco. He wasn't planning to play a major role. When Cupp made what everyone considered a brief, inconsequential remark, he promptly dismantled the tobacco association, a lobbying organization. To the print reporters in the audience, his speech was clear, concise, and quotable. For a broadcast journalist, he was a dream come true—tall, upright, with a Mennonite beard, wearing a dark suit and tie, exuding a combination of supreme confidence and legitimacy mixed with a “don't mess with me” swagger.
As Coop later said, after that, “I started being viewed as an authority. From that point on, the media was on my side…I made snowballs and they threw them.” Another thing Coop noticed early on was that the Reagan administration didn't shut him down. That's surprising because Cupp's main backer in the yearlong confirmation fight, in which the American Medical Association opposed his appointment, was conservative Sen. Jesse Helms of North Carolina.
Adding to Jesse's anger, R.J. Reynold's CEO, Edward Horrigan, complained directly to Regan about Koop's “increasingly shrill sermons. Cigarette consumption in the United States plummeted. By 1987, 40 states had laws banning smoking in public places; 33 states had enacted bans on public transportation; and 17 states had eliminated smoking in the workplace.
Reagan still didn't stop him. Now, everyone from public schools, medical groups, women's associations to private businesses wants him. Beginning in late 1982, he arrived in full regalia, the splendid Public Health Service, lieutenant general uniform with ribbons and epaulettes. His assistant, also in uniform, always carried a bag of distributed buttons that read: “The Surgeon General personally asked me to quit smoking.”
But the department is AWOL when it comes to today's most pressing public health challenge: HIV/AIDS. Koop was actively ostracized by senior government officials. Not surprisingly, the situation quickly deteriorated. Everyone is feeling the heat, including the CDC, which defunded AIDS education after being accused by conservatives of promoting sodomy.
As more and more people died—now not just gays but straights, hemophiliacs, drug addicts, newborns of infected mothers—Reagan's silence became deafening. To relieve the pressure, in 1986, the president finally freed Koop's hand and instructed him to coordinate a report on AIDS for the American public.
In October 1986, Reagan first coined the term AIDS. By that time, more than 16,000 Americans had died. Within his administration, Reagan had earlier spoken out to the likes of Education Secretary Bill Bennett, who discouraged AIDS information in schools, and domestic policy adviser and Christian evangelist Gary Ball. Bauer, Koop said, was “my nemesis in Washington because he kept me away from the president. He kept me away from the Cabinet, and he built a wall of animosity between me and most of the people around Reagan because he believed that anyone who had AIDS should die of AIDS. That was God's punishment for them.” “
On May 31, 1987, at the urging of his wife Nancy and their friend and actress Elizabeth Taylor, Reagan gave his first major speech on the subject at an American Foundation for AIDS Research event. It's six years too late. 21,000 Americans have died and another 36,000 have been diagnosed with the disease.
His previous inaction cannot be attributed to ignorance or lack of exposure. Cupp has done his best to keep the president informed. But the door to the White House remains open to the Christian conservative elite. As promised, policies are being pushed to reassert traditional Judeo-Christian values. Meanwhile, an epidemic rages, which some believe is “the hand of God at work.” However, there is one unknown. Now calling himself “the nation's doctor,” Kupp has evolved.
On December 17, 1984, a young hemophiliac from Kokomo, Indiana, who underwent a partial lung resection for severe pneumonia and was diagnosed with HIV/AIDS, was a critical turning point for the pediatric surgeon-turned-surgeon. His name is Ryan White. He was 14 years old at the time. He became infected while receiving an infusion of the blood derivative Factor VIII for hemophilia. When he was allowed to return to school, 50 of the school's teachers and more than a third of the parents of students signed a petition calling for him to be banned.
It was clear to Coop that his continued inaction was unacceptable. This occurs when scientific fact and fiction are deliberately misrepresented. Without his leadership and provision of proper health education, ignorance and prejudice would prevail.
In April 1985, Ryan White re-entered school (after the state's health commissioner and the New England Journal of Medicine emphasized that the child's disease could not be spread through casual contact). Five years after his death, legislation would open up much-needed federal funding in his name to care for those affected by the disease.
At this point, President Reagan felt the pressure and finally directed Koop to write a report, and he was ready to respond. He interviewed AIDS activists, representatives of medical and hospital associations, Christian fundamentalists, and politicians from both parties. Few people knew exactly what he was doing. One exception is his colleague Tony Fauci, a personal physician at the NIH and an infectious disease expert who leads the NIH's AIDS research efforts.
Fauci has a troubled history with AIDS activists. This goes back to the serious mistake he made on May 6, 1983. On the same day, the Journal of the American Medical Association issued a press release, quoting Fauci extensively, titled “Evidence suggests household contact may transmit AIDS.” In the article, the NIH scientist said, “We are currently witnessing the evolution of a new disease process of unknown etiology, with a mortality rate of at least 50 percent and possibly as high as 75 to 100 percent, and with the number of people affected doubling every six months… If daily close contact can transmit the disease, then AIDS takes on a whole new dimension.”
The announcement unsurprisingly caused a wave of public hysteria. The religious right emerged. “We express our deepest sympathies to the victims of AIDS, but I am troubled that the government is not spending more to protect the public from the gay plague,” said the executive vice president of the Moral Majority.
Fauci has since been more cautious, taking good advice from Cupp on public information technology. Meanwhile, Cupp learned everything he knew about the virus, its behavior and spread from Fauci and planned to share it with the public in the future. Fauci was also the first to actively include AIDS activists on government scientific advisory boards in efforts to combat the disease. Initially the target of their anger and frustration, Fauci subsequently won praise and admiration from leaders in the AIDS activist community as more and more people died in front of an apparently selfless government and a hysterical public.
Cupp consulted with Fauci on a daily basis as he worked on the draft in secret. Fauci later noted, “With the spread of HIV, he would come home from hearings downtown. When he would come home, he would have to go by my office. Around 7:30 at night, he would knock on my door. He would say that this AIDS thing is very disturbing and I want to give the right impression to the public. How clear he thought we as the federal government needed to be about it — oral sex, anal sex, commercial sex. He went out of his way to shock a lot of people when it came out because of the clarity of it.”
The report drew immediate criticism from the conservative right, but that was nothing compared to the outrage nineteen months later.
In the period after the initial report was released, Cupp quietly hired the public relations firm Ogilvy & Mather to ensure his messaging, language and imagery were correct. Then, after raising enough funds from various government agencies, he produced an 8-page pamphlet called “Understanding AIDS” for mail distribution to support the massive mailing costs of delivering 107 million copies of the publication to every household in the United States.
His message is a call to action. His dramatic image was accompanied by the headline: “Message from the Surgeon General.” Understanding AIDS is not an innocent read. It's candid and factual, covering anal and vaginal sex, injection drug transmission, and which condoms to use in the first place. It promotes sex education starting in elementary school and punctures the current message of today's most popular Christian televangelist with comments like: “Who you are has nothing to do with whether you are at risk for HIV. It's what you do that matters.”
The large print runs of 1988 required government printing presses to work 24 hours a day for weeks on end. Thirty-eight boxcars were used to transport the mail. The mail-in approval bypassed the normal process. When the eight-page pamphlet started arriving, the phones rang in the Senate offices of conservatives like Jesse Helms. Televangelists Jerry Falwell and Pat Robertson and their followers were outraged. Trying to stop it is futile. Mass mailing has been completed. There is no turning back.
His ghostly presence should disturb Robert F. Kennedy Jr.'s sleep these days. As Jacob Marley told his ghost, “I wear chains forged in my lifetime.” For now at least, eternal torment seems to be Kennedy's reward.
Not so for C. Everett Koop. Whether personally religious or politically motivated, his actions were motivated by a deep commitment to scientific integrity. When criticized, Kupp took no prisoners. His answer: “I am the nation's doctor, not its priest.”
Mike Magee, MD, is a medical historian and regular contributor to THCB. He is the author of “Code Blue: Inside the American Medical-Industrial Complex.” (Grove/2020).
