AIDS, Abortion, and 9/11: The Public Health Journey of Surgeon General Antonia Novello

Prior to the arrival of C. Everett Koop (1916-2013) as Surgeon General of the United States in 1982, the position was a relatively low profile affair held by career officers dedicated to the task of gathering data on matters related to public health and suggesting policies to address problems uncovered thereby. In 1964, Surgeon General Luther Terry published a report on the dangers of tobacco, and before him, in 1959, Leroy Burney released an important report on environmental health. This was solid, methodical, non-political work, and as such, it is all but forgotten today, along with the names of the Surgeon Generals who carried it out.

This changed with the appointment of Koop, who brought the office, for better and worse, into mainstream public consciousness during the 1980s through his media appearances (he was on an episode of The Golden Girls at one point), books, and controversial opinions about tobacco, abortion, sex education, and the AIDS crisis. His approach brought a prestige and visibility to the position which created in turn a politicization which it has never fully shaken, a fact which defined much of the career of Koop’s successor in the office, Antonia Novello (b. 1944). 

We celebrate Novello’s becoming Surgeon General in March of 1990 for its historic nature - she was both the first woman and first Hispanic individual to hold the position - but her reason for receiving the offer in the first place was tied less to its historical nature than to the political litmus test that had been developed by Bush’s advisors for Koop’s successor. Koop, though staunchly anti-abortion personally, had refused to toe the Reagan administration’s line when it came to using his position to generate false reports about the psychological damage that abortion caused women. When it came time for George H.W. Bush to select his Surgeon General, he wanted to make sure he had somebody who jibed with his own conservative views, i.e. that abortion should be illegal in all cases except for those involving the potential death of the mother or instances of rape or incest. A number of potential SGs had removed themselves from consideration because of an inability to reconcile themselves with that position, but it fit nicely with the personal philosophy of Novello, setting the stage for the pioneering moment that saw her, the first woman Surgeon General, sworn into the office by Sandra Day O’Connor, the first woman Supreme Court justice, in the White House.

What followed was a term in office that showed Novello to be a reasonable, data-driven, and gifted administrator who, if not the fulfillment of all that feminists of the era might have hoped from a woman SG, was at least not the nightmare that the Pro-Choice community feared from her status as a Catholic Republican nominee. Hers was a success rooted in personality traits forged during a youth marred by poor health and inconsistent medical care. Born Antonia Coello in Fajardo, Puerto Rico, in 1944, and raised by her determined mother, who served as one of the region’s key educators for over half a century, the course of her early years was set by a persistent medical condition known as congenital megacolon, in which there is an absence of the nerves controlling the relaxation of the colon, meaning in effect that feces cannot be passed out of the body, and back up in the intestines. 

For the first eighteen years of her life, Novello had to live with regular sessions that manually removed the feces from her colon, and with the discomfort that it brought as, week after week, her abdomen started bloating from the buildup within her. It was an embarrassing condition, but the first attempt to cure it made things, if anything, worse for Novello, when at the age of eighteen a heart surgeon decided that he had enough natural experience and ability to perform a surgery that would remove a length of her colon and reattach what was left to the rectum. Not only did the surgeon sever one of her fallopian tubes during the procedure, but the reattachment did not take, and for years thereafter Novello had to deal with constant fecal seepage requiring the wearing of diapers that produced an omnipresent and overpowering stench that kept all but the closest friends and colleagues from associating with her socially or professionally. 

She was brilliant and, thanks to her mother’s influence, deeply driven (she had, in fact, graduated high school at the age of 15), and the suffering she had experienced on account of her condition fueled her with a desire to make a contribution in the field of medicine, but how could she expect to really make something of herself in this field if, wherever she went, she brought with her a cloud of overpowering fecal scent? Help came at last in the form of the Mayo Clinic, where Dr. Markham Anderson approached her medical situation with care and compassion, ordering a fistulogram that uncovered the fact that Novello had been born with two vaginas and two uteri, a condition that had gone totally unnoticed until then. He performed the procedure that removed the secondary vagina and the fistula, and repaired the surgical error which had been making Novello’s life miserable for the previous three years. 

The individual who emerged from the Mayo Clinic was changed in ways that she had hardly hoped for before, able to partake of regular society and live a life not ringed in on all sides by discomfort and rejection. She graduated medical school on May 29, 1970, two weeks after having married Joe Novello, who was stationed in Puerto Rico with the Navy. He encouraged her to specialize in pediatrics instead of the surgery she had initially been drawn towards, while he switched career paths from ophthalmology to psychiatry. New specialties in hand, the couple moved to Michigan, where Antonia pursued her internship at the University of Michigan Medical School because that institution was the best place for Joe to continue his education in psychiatry. She was placed initially at Wayne County hospital, where the other interns called her “Chiquita Banana” on account of her Puerto Rican accent, but her fierce determination to learn pediatrics and to spare nothing of herself in providing for patient care soon won the admiration of her colleagues and superiors, garnering her the Intern of the Year award.

The first years in a medical career are always the most trying, and Novello’s situation was not aided by Joe’s serial philandering or expectations that, no matter how hard or long she worked, responsibility for domestic maintenance and routine was to rest entirely on her shoulders, while he maintained complete financial control of their situation, all of her checks going directly to him, while she was not even permitted a credit card in her own name. The death of an aunt from kidney disease prompted her to choose nephrology as her pediatric specialty, which she pursued at Georgetown University from 1973 to 1976, but after splitting up with then moving back together with Joe, who did not discernibly change in the interim, she was feeling personally adrift and professionally rudderless.

Enter a man in a white uniform. He showed up every Wednesday to work at the pediatrics ward where Antonia was stationed, and she asked him about what he did. He said he was an employee of the Public Health Service, and after learning more about it, she decided it was exactly the sort of environment where she could thrive - an agency devoted to public medical service, but with the rigor and structure of the military. She applied for a position, but was very nearly turned down when she disclosed that she and her husband had been seeing a couple’s counselor. This disqualified her in the eyes of the PHS at the time, because it meant she had seen a psychologist for a personal issue, and was therefore unfit to serve. Characteristically, she fought the decision, arguing that this view of counseling as evidence of mental unbalance was arcane and unbecoming of an organization purportedly devoted to pursuing the best practices for public health.

The decision was overturned, and in 1979 she began her career with the PHS, forming a particularly close working relationship with Republican Senator Orrin Hatch (1934-2022). Today, those who remember Hatch at all remember him for the Hatch Amendment which attempted to overturn Roe v. Wade by changing the Constitution, and for the 1994 act that removed all regulation from the dietary supplement industry, creating a myriad of problems today as dangerous drugs bypass all regulation by calling themselves Dietary Supplements, but he was in fact something more than a reactionary crackpot, serving as chair of the Senate Committee on Health, Labor, and Education from 1981 to 1987. It was in this capacity that his work crossed Novello’s, as they lobbied for cigarette labeling that addressed the dangers of tobacco for women and children, and crafted the 1984 National Organ Transplant Act, which created a national organ registry and criminalized the private organ transplant industry. 

These years also saw Novello working on issues of AIDS research with the National Institute of Child Health and Human Development, focusing particularly on pediatric AIDS. Republicans’ reaction to the original outbreak of AIDS in the early 1980s had been widely criticized for its sluggishness in responding to a disease that befell a portion of society they held in contempt, but Novello was not possessed of their instinctual aversion to the gay community, and her work with AIDS activists throughout the 1980s and early 1990s was characterized by mutual respect. 

Novello’s work in pediatric AIDS and her productive working relationship with Senator Hatch, combined with her passing of the Bush administration’s abortion litmus test, put her on the path towards Surgeon General, a position she assumed on March 9, 1990. As a pediatrician, one of the major planks of Novello’s time in office was devoted to children’s health issues, including a campaign against the use of cartoon characters like Joe Camel in cigarette advertisements, the promotion of childhood immunization, and a campaign to move the fortified wine cooler drink Cisco (known colloquially as “liquid crack”) out of supermarkets’ easily accessible refrigerated sections and back behind the counter where adolescents couldn’t as easily obtain it, which was itself part of a larger campaign against underage drinking that spawned seven official SG reports.

Generally lauded for her AIDS and pediatric public health work, Novello came under intent criticism for her stance on abortion, and no policy more so than the “gag rule” she instituted which denied federal funding to any programs, such as family planning, which discussed abortion with patients. This policy, along with similar legislation passed throughout the 1980s by the Republican Congress, served as a template for the Trump administration’s Global Gag Rule of 2017 which threatened to revoke hundreds of millions of dollars of global health funding for organizations which provided or even advocated for abortion services. The policy goes unmentioned in Novello’s memoirs, where the only real references to abortion are limited to outlining the reasons she had for closing down a clinic that did not meet health standards, and the relating of a speech during which her reasonableness impressed abortion activists who had turned out to protest. 

With the victory of Bill Clinton in the election of 1992, it was a foregone conclusion that Novello would be replaced as Surgeon General. Previously, however, it had been a rule of thumb that SGs would be allowed to serve out their four year term, even if these extended into a new presidency. That courtesy was not extended to Novello, who found herself removed from her position in 1993, to be succeeded by Joycelyn Elders, who only served for one and a third years before being drummed out in turn. 

Where does one go after having served as the Nation’s Physician? Koop’s post-SG career featured a revolving door of questionable business decisions that tarnished his legacy, but Novello showed a sure instinct for choosing positions that allowed her to continue working on important public health issues. Working for UNICEF, she participated in the global campaign to iodize salt which saw rapid adoption in both China and India, as well as in other programs to bring child’s health services to underdeveloped countries. 

1999 saw her appointed Commissioner of the New York State Department of Health, a position she held until 2006. She earned enemies throughout this time through her steadfast refusal to give special treatment to hospitals or organizations which were politically important, but which ran facilities that did not meet health standards. She dismissed surgeons who were shown to be negligent in their duties, and continued to underscore the importance of childhood vaccination. Her most dramatic moment in office, however, came with the attacks of September 11, 2001, when she spearheaded medical services for the population affected by the destruction of the Twin Towers, using her old SG contacts to bring in emergency services, particularly military nurses trained in burn treatment procedures.

Novello’s career as Commissioner ended on a series of frustrations, as members of her staff conspired to produce testimonies about mal-administration that ultimately led to Novello’s felony conviction in 2009. For her part, Novello has steadfastly denied any malicious wrong-doing, saying at most that she was guilty of signing documents handed to her by her staff too casually, and that the charges against her were primarily the result of hurt feelings engendered by her refusal to grant special favors to the politically well-connected.

Gathering of living Surgeon Generals organized by Novello.

Novello’s career did not end there, however. She was an active force during the relief efforts after Hurricane Maria hit Puerto Rico in 2017, and again after the earthquake of 2020. During the Covid-19 outbreak, she waded once more into the fray to do battle in the name of sane health policy as a steady voice of reason calmly advocating for masking protocols, public distancing, and the efficacy of vaccines. 

A hundred years hence, we will continue to remember the name of Antonia Novello as the first woman Surgeon General of what used to be the United States, because we are, as a civilization, mostly decent at remembering People Who Did Something First. But it is my hope that, in addition to the bare fact of having been the first to hold her office, those future generations will also remember what she did both in that office, and in the stretching years before and after it - bringing empathy and education to the fight against AIDS, reining in tobacco and alcohol companies in their attempts to hook children on their products, standardizing donor organ procedures, giving the world population reliable access to iodine sources, and using her knowledge of government to get resources to people who needed them most during moments of natural and man-made crisis. She did not overcome every prejudice of her era, but then again who does? She pushed past what limitations of tradition and upbringing she could, aided by her dedication to research and her fundamental sense of empathy, and achieved a truly global amount of good in the process, while creating an example that has stood for four decades now as a source of inspiration to Puerto Rican girls and women, allowing them to believe that though their land is still somehow not a state, they might nonetheless someday hold and serve with distinction in the highest offices of the nation. 

FURTHER READING:

As you can gather from the above, Novello’s memoirs, Duty Calls (2024) is an at times fascinating, at times frustrating, read. Her accounts of her youth, and the two decades of misery she endured at the hands of her medical condition and the botched first surgery to remedy it, are not only interesting from a medical perspective, but provide insights into small town life in 1950s Puerto Rico that one doesn’t often get to read about. Once the book moves to her more political years, there are frustrating omissions which we talked about, which then trigger suspicions that we are also not being told everything we should about the accusations brought by the Albany Five which brought her down in 2009. At the end of the day, it’s something that simply Needs to be read - both for its inherent historical value, and in the hope that it will encourage more women medical trailblazers to put their careers to paper, so, yeah, grab a copy!