Medical Examiner

Koop’s Crusade

The surgeon general made public health a divine commandment.

C. Everett Koop, former surgeon general of the United States speaks at the closing ceremonies of the World Conference on Tobacco or Health in Chicago, August 11, 2000.
As surgeon general, C. Everett Koop’s approach to AIDS education put medicine ahead of politics

Photo by Reuters

When C. Everett Koop accepted his post as the U.S. surgeon general in 1982, few thought he would become one of the most outspoken advocates of sex education in public schools. Koop was an emerging leader within the Christian pro-life movement, and his conservative credentials caught the attention of Ronald Reagan’s team, who approached him about serving as surgeon general even before the 1980 election. Koop’s appointment reflected Reagan’s appreciation for the conservative evangelicals who voted him into office.

Koop would eventually defy expectations from both the left and the right through his bold approach to addressing AIDS, including his call for frank talk and comprehensive sex education. He has been remembered this week for the distance he created between himself and his former allies on the Christian Right. But far from leaving his religious friends behind, Koop drew upon his role as a Christian and as surgeon general to pull conservative religious groups into the fold of AIDS education, calling upon religious groups to take an active role in defining sexual morality and public health, an effort that reverberates today.

For the first five years of the epidemic, Koop monitored CDC reports from the sidelines. Despite his position as “America’s Doctor,” as he recounts in his memoir, Koop was “completely cut off from AIDS.” In those early years, religious conservatives William Bennett, who was the secretary of education, and his undersecretary Gary Bauer served as the White House’s key spokesmen on AIDS. As Jennifer Brier notes in her recent history of AIDS, they worked together to formulate a strategy that emphasized “morality, local control, and a strong executive branch” and marginalized approaches that supported behavior that they deemed immoral. In an internal memo for the Department of Education, Bauer emphasized that “heterosexual sex within marriage is what most Americans, our laws and our traditions consider the proper focus of human sexuality.”

By the summer of 1985, almost 16,000 cases of AIDS had been reported in the U.S. alone. But there were virtually no treatments at the time—the “AIDS cocktail” was still a decade away. Following an unusual visit to the Department of Health and Human Services, Reagan finally declared AIDS a top priority and asked the surgeon general to prepare a report. After months of research, Koop released the Surgeon General’s Report on Acquired Immune Deficiency Syndrome on Oct. 22, 1986. The 36-page document urged Americans to fight the epidemic as a unified group, rather than condemning certain populations disproportionately affected by the disease. In saying this, Koop attempted to shift the rhetoric of AIDS beyond its association with homosexuality and drug use. As he noted, “We’re fighting a disease, not people.” Koop’s report went further than what most observers had anticipated from the evangelical doctor, calling for comprehensive safe-sex education “at the lowest grade possible.”

Media coverage was generally quite positive, but it quickly honed in on Koop’s call for sex education. The Los Angeles Times declared: “Koop Urges AIDS Sex Course in Grade School.” Phyllis Schlafly, founder of the conservative Eagle Forum, denounced the AIDS report for looking “like it was edited by the Gay Task Force” and accused Koop of advocating that third-graders learn the rules of “safe sodomy.” Airing his frustration to reporters, Koop retorted, “I’m not surgeon general to make Phyllis Schlafly happy. I’m surgeon general to save lives.” 

But Koop’s message on AIDS did not end there. Under his leadership, the Public Health Office produced a trimmed-down version of the AIDS report as part of a massive national education campaign. In 1988, 107 million copies of the pamphlet, Understanding AIDS, were mailed to every household in the United States. The national mailer described how the disease was—and how it was not—contracted. It outlined the types of behaviors that people needn’t fear engaging in, such as casual contact, kissing, or donating blood, and it dismissed the rumor that AIDS could be spread by mosquitoes. And it specified, explicitly, the behaviors that put one at risk, including needle sharing, anal sex “with or without a condom,” oral and vaginal intercourse without protection, and sex with multiple partners. The brochure even included a section called “What Is All This Talk about Condoms?”

Koop’s approach to AIDS education put medicine ahead of politics, and it drew criticism from leaders within the Christian Right. But it would be a mistake to read his prescription for HIV prevention simply as unbiased medical advice, unfettered by religious and sexual politics. As Paula Treichler has noted, while Understanding AIDS presented much-needed facts about the disease, it also reproduced a visual hierarchy of moral blame. Photographs in the pamphlet represented the epidemic’s “innocent victims,” focusing on women and children, rather than the populations most affected and most at risk. Gay men reading Understanding AIDS would be hard-pressed to see themselves in the pamphlet (unless, perhaps, the photo of a construction worker was meant to conjure images of the Village People).

Koop later complained that his position on sex education was commonly misrepresented in the press. “Often I would spend several minutes of a speech extolling abstinence and monogamy (for social and moral reasons as well as health reasons)” Koop explained in his memoir: “And then at the end I would say that those foolish enough not to practice abstinence or mutually faithful monogamy should, for their protection and their partner’s protection, use a latex condom.” “Usually the press would repeat only the last phrase,” he objected: “That annoyed me.”

Koop in fact never doubted that AIDS was connected to questions of sexual morality and that religious groups should play a formative role in shaping AIDS education. “Knowing what Christians believe,” Koop explained, “I felt I was in a unique position to understand their point of view.” He aspired to draw his religious supporters into his AIDS campaign:

I saw a unique opportunity for these groups to join together to produce a morally based sex education program that would conform to their moral standards and also serve to protect a generation of youngsters from AIDS. I hoped that we could work together after the release of the report to unite morality and science.

Koop embarked on a lecture tour, and his first stop was Liberty University, where he was invited by Jerry Falwell, founder of the Moral Majority. The surgeon general described Falwell in a later reflection on his visit as “one of the most understanding and far sighted members of the religious community in reference to AIDS.”

Speaking to his Liberty University audience, Koop first advocated monogamy, which “may sound like a morality lesson,” he explained, “but it also happens to be good science. In containing the epidemic of AIDS, science and morality advance hand-in-hand toward the same goal.” Koop’s second message advised caution for single people, describing as “fool-hardy” all those “who will not be abstinent or will not achieve a faithful monogamous relationship and, therefore, will expose themselves and others to the AIDS virus.” His reluctant advice to such foolhardy people was the following: “Don’t have sex with someone who could carry the virus of AIDS … a person who, for example, practices high-risk behavior. That includes homosexuals, intravenous drug users, prostitutes, and other persons who have many different sex partners.” Finally, Koop continued, if you do have sex with such a person, “a decision that could have serious health consequences—then, if you’re a man, at least use a condom from start to finish. If you’re a woman, make sure your partner uses a condom.”

Over the past few years, I have assigned Understanding AIDS and Koop’s lectures in courses on the history of American Christianity and religion and medicine. Following Koop’s advice about using a condom from start to finish, I like to pose the question: When, exactly, does sex start? How should lesbians regard these suggestions? What kinds of assumptions are built into this advice? This isn’t meant to be a damning critique of Koop’s message. But slowly, students begin to see how difficult, if not impossible, it is to describe HIV prevention in a way that fully escapes politics. As AIDS activists contended at the time, sex is political. 

Koop clearly favored abstinence and monogamy not simply as scientific measures to prevent the spread of AIDS, but as moral lessons. In pointing this out, I don’t simply intend a criticism of Koop’s moral approach to sex education. Koop proves an interesting figure in the history of American religion and public health not only because his AIDS message drew criticism from the far right, but also because he struggled to maintain ties with conservative Christians. He represents a pivotal, and often pivoting, figure both in the history of the Christian Right and in the development of AIDS education, including later programs that have emphasized abstinence training. He offers an important contrast to the loudest and most vitriolic leaders within the Christian Right, who regarded AIDS as no less that God’s wrath for sexual immorality. As he often said, he was the surgeon general for everyone, not just for Christians.

But it would be shortsighted to assume that placing medicine before politics translated into a public health program free from moral claims. Koop’s focus in HIV prevention on abstinence, monogamy, and, as a last choice, using condoms reversed the priorities of a number of public health leaders, who started with the assumption, from a pragmatic standpoint, that people would engage in sex and so needed to be equipped with the proper education and prevention tools. Koop’s emphasis has since been picked up, and often extended, by other American evangelicals, such as Kay and Rick Warren. In the past decade, their HIV & AIDS Initiative at Saddleback Church has led the way for many American Christian to become involved in AIDS relief work, often focusing on sub-Saharan Africa. Perhaps one of Koop’s most lasting legacies, then, was to render public health no less than a divine commandment in itself, and thus the proper domain of religious attention as well.