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Historian and ethicist Nigel Cameron discusses his article, “How DrKoop.com rose and fell: the untold story behind the Surgeon General’s startup.” The conversation chronicles the dramatic history of the iconic dot-com era company, from its modest beginnings as a personal medical record system to its meteoric rise as the world’s top health site. Nigel explains how the company’s core strategy was to leverage the unparalleled credibility of former Surgeon General C. Everett Koop, leading to a wildly successful IPO that raised over $84 million. The discussion then details the company’s rapid collapse, focusing on the ethical blunders, like blurring the line between advertising and information, that eroded public trust. This episode serves as a cautionary tale about brand credibility, startup hubris, and the ultimate indignity Dr. Koop faced when his name and brand were sold in a fire sale after accumulating over $200 million in losses.

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Kevin Pho: Welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Nigel Cameron. He is a historian and ethicist. He is the author of the book, Dr. Koop: The Many Lives of the Surgeon General. We are going to talk about an excerpt from that book today on KevinMD, “How Dr. Koop.com Rose and Fell: The Untold Story Behind a Surgeon General Startup.” Nigel, welcome back to the show.

Nigel Cameron: Great to be here, Kevin.

Kevin Pho: What is this particular excerpt about?

Nigel Cameron: Koop stepped down as Surgeon General in 1989, but he was not done. He was just getting moving and he had all kinds of projects, and one of them, which could have been the biggest of all, was to set up the top health care site on the internet, working with a bunch of other guys who were more business-minded than he was. Briefly, it was incredible. And then, it was a bad time to be doing this. This was the late 1990s, 2000 .com boom and .com bust, and he was riding that wave.

Kevin Pho: So we are talking about the late 1990s and early 2000s, and there were not very many health sites on the web. So maybe he was a little bit ahead of his time. Dr. Koop.com and having a site with reliable health care information back then was something that was pioneering.

Nigel Cameron: It was, and in fact, the original project that these business guys put to him and he got involved with was much more modest. It was about enabling people to have their own medical records on their own home computers because the internet was pretty young then; there was not a lot of bandwidth and so on. So originally the company, founded, I do not know, in the mid-1990s, was called Personal Medical Records, Inc. And it was so you could have your records on your PC, which of course we know is difficult enough anyway, but that was what they were trying to do.

Then they came up with this web-based strategy and they cleverly decided to use the brand, Dr. Koop.com. I think it was *The Wall Street Journal* that said that their basic play was to use the name of the feisty Dr. Koop to give the whole thing credibility and make it stand out from other nascent websites. Pretty good idea.

Kevin Pho: So what happened? Because I remember this was around the time that I was in residency in the early 2000s, and I think even I heard of Dr. Koop.com. So how big did it initially get?

Nigel Cameron: They got big. They had an IPO and they raised, I think, $80 or $90 million in the marketplace. At one point, Koop’s share was worth well over $100 million nominally. And it seemed to be going very well. Bear Stearns did the IPO. They were known for being a pretty much out-there, gung-ho merchant bank, but they did it and it floated fine.

And they began doing deals with AOL and with other players in the web marketplace. There were criticisms of what the managers did. A guy called Donald Hackett, whom I have spoken to, was very helpful with my book. He was candid about this. They had business challenges because this was a very novel thing. But what they had was this incredible, best-known and most-trusted doctor in the English-speaking world chairing the board and using his actual name for the product.

And so they really had a lot going for them, but it did not actually go very well. And whereas a lot of companies were going up and down in the .com boom and .com bust, there were some special factors here that can be a bit embarrassing.

Kevin Pho: So at its heyday, at the height of its popularity, what exactly was Dr. Koop.com? If you went to that website, what exactly were you getting?

Nigel Cameron: It had a ton of stuff. They had very early discussion groups; there were all sorts of things where you could ask people questions. They would have 20 reasons why you should not drink and drive. But it was also a lot of interactive stuff going on. The things that got embarrassing were, they had, for example, a list of, I do not know, maybe the 10 top hospitals in the U.S. And someone discovered that these were hospitals that were paying, I do not know, $10,000 or $15,000 to advertise. At that time, there was very little agreement about how you deal with editorial versus advertising on commercial websites. This was pretty early days. It was a bit of a Wild West, and when that criticism came, Koop responded very interestingly.

He was thinking strategically, and he said, let’s get together all the other websites doing this kind of stuff, and let’s come up with some terms of reference, with some protocols. And they came up with a statement called Hi-Ethics, which is health care internet ethics, saying that they would specify, this is advertising, this is editorial. But by then, the word about this little scandalous association had gone out, and the press were jumping on him because this guy was so well thought of. He was a superb target for a journalist with a pen who really wanted to have some fun.

The other real issue with the website was that they discovered he was getting a commission on everything sold through the site, and they were selling various medical apparatus and so on and so forth. Now, that does not seem unreasonable, but it was not declared.

And so with these twin particular criticisms, Koop had this incredible image. The more incredible your image, the higher they fly, the further they fall. And so I think it was a Boston paper that had this list of winners and losers at the end of every year. And for Koop they said he has lost his chance of sainthood because of this criticism.

Another problem with the whole thing was he tried to do everything. I think at one point a journalist said he was in his office—or one of his offices; at one point he had five offices in five states. This guy was in his eighties, and there were 35 nodes on an organization chart on the wall.

So the day the IPO launched and they pulled in his $87 million or whatever it was, Koop was not hunkered down in the offices in, I think, Austin, Texas with the guys for three or four days. No. He was going to other meetings on other projects. He had this plan for a medical museum on the Mall that was the evening of that day and so on.

And so the people around the company did not see very much of him. And this was a big strategic mistake on his part. But on the other hand, the market was going up and down, so I think he did some things for which he really could be blamed. It is in my book. I do not think he could be blamed too much, but it was a fiasco.

And the tragedy is, you go now to Dr. Koop.com. It is still there. Because when the company went belly up in 2001, they had a fire sale. When you are bankrupt, they lost over $200 million. What could they sell? They sold the site and the name of the site and the mailing list for, I think it was, $183,000. Koop apparently never thought of buying it. He must have really, really wished he had. He probably thought it was worth a lot more money than that.

So you can go on there now: Dr. Koop.com. This is a sort of wormhole into life in the 1990s, still there. And on the site, they sell vitamins and all kinds of that sort of stuff. At the bottom of every single page, it says, “Dr. Koop.com has no relation to Dr. C. Everett Koop, former Surgeon General,” which is a brand on the guy’s neck forever. Because of course, it does have a relationship to him. That is why it is there. There is a legal nicety, in a sense, that just made the whole thing so much worse.

Kevin Pho: So during the heyday of Dr. Koop.com, it sounded like Koop had a big hand in terms of the day-to-day operations, strategic direction, and editorial control. How involved was he?

Nigel Cameron: I think his involvement was somewhat episodic. Somebody who worked on their team said that every month or two, he would fly in, and he’d have security guys with him. And when he flew into their offices, they would have these top-end security guys screening the office with all these devices in case there were bugs and cameras and this and that. So it was a huge to-do because nobody wanted his secrets and all that sort of stuff to get out there. And I do not think he was ever on top of the project. He chaired the board. One of his good friends and long-term colleagues, Admiral Edward Martin, who was his chief of staff at one point, refused to join the board. He was asked to join the board and refused to do it. He said these guys, they are not quite the guys you want to work with. That may be unfair, but let’s just say they were not the top people in the world doing this kind of thing. They were entrepreneurs. Don Hackett had a good reputation working in on IT stuff.

Koop was never on top of the project, and he made a very odd comment when the whole thing began to fall apart. He told an interviewer, “If I could do it again, I would not let them use my name.”

Now, Koop was a brilliant man, and he was a friend of mine, but he was a very naive man in some ways. It plainly had never occurred to him that the whole point of the site was, as *The Wall Street Journal* put it, the feisty name of Dr. Koop because he had this great street cred, and without his name, they would not have done the project. But he regretted it, and lots of bad publicity and blame and so on.

And toward the end, he was depressed in his final years, for more personal reasons, but this took a hit, and he really had the sense that his sterling reputation was being damaged in this process. But for a few months, it was a top medical site on the web.

Kevin Pho: Do you feel that he had regret, and if he had to do it all over again, he would not have?

Nigel Cameron: I think if he had to do it again, he might have listened to some of his friends and colleagues, like Admiral Martin, and worked out how to improve the project, how to make it less risky, and how to risk his name less flagrantly. I think he would have been persuaded that he needed to use his name because that was what distinguished this site from various other sites that were getting going.

And it might have succeeded. In fact, one of the obituaries, there were various obituaries in *Fortune* and other publications, and one of the obituaries basically said, “Well, this really could have worked.”

And had it not been for the .com boom and bust thing, had it been a year or two earlier, perhaps, or even a year or two later, or had there been some slightly different decisions taken, it could have worked and it still could have been the world’s top medical website.

And Koop was committed to PR before anything else, to medical communication, to information, to helping people, helping people with their health, to being a kind of eternal surgeon general outside of government and finding all sorts of ways to deliver health messages. And this, of course, would be the best of all. I wish he had dropped everything and done it rather than have the other 34 nodes and all these different projects he was involved in. He was far too committed.

It is a tragic situation, and I feel very sorry for him, the old guy, as he realized what was going on here. Because every time he went on the web, if you looked at Dr. Koop.com, it was still there as a kind of a haunting, a sort of shadow of what he wanted to do. And it was hawking medical vitamins and tobacco smoking cures. Some of the things actually were in line with what he was trying to do. But basically, it was a commercial operation that he had no control over, but bizarrely, for legal reasons on every page, you had to point out, reminding people who he was. So, it must have been a pretty nasty, nasty thing, and it is still there.

Kevin Pho: It almost sounds like a missed opportunity because this could have been an enduring memorial to what he believed in and who C. Everett Koop was as a person. I just think, as I said earlier, maybe he was just ahead of his time and he did not receive the proper business advice and did not have the right team around him to kind of steer him in the right direction. Because having a reputable website backed by the name of the Surgeon General in the early 2000s could have been quite pioneering for the time.

Nigel Cameron: I think it was a missed opportunity. I think done slightly differently, it could have been really very important. Because he was deeply committed to science, to integrity and honesty in science. And he would never do anything for a quick buck. He would not mind making money, but he was very serious in what he did. And it would have provided a site which could have been the go-to place for medical information.

Something else worth mentioning is that his interest really was in communicating medical information. Earlier on, there had been a disaster with Time Life because Time Life, an absolute top brand in communication, launched a series of videos which Koop had a key role in, and the whole thing failed. So you are thinking he might have learned that you did not just listen to the business guys and found some way to give more stability to this project and to focus more time on it. But he really had this deep commitment to information and to giving people free-of-charge health care information.

And on the site, they developed communities. There were actual discussions. This was pretty early on for chat and so on and so forth. And it was leading-edge. And the fact that the whole thing went down, the site lost $200 million. Koop made about a million dollars out of it. You can make what you will of that. I have discovered all this; it is all in the book.

And he persisted in his efforts to use technology. And what most people do not know is that during the Clinton-Gore administration, with Al Gore kind of inventing the internet and all that sort of humor, Koop was very much involved with Al Gore in developing projects to use the internet to link health care companies and practitioners and so on. He got two major grants in the Clinton administration, which got no publicity at all, to build infrastructure based on health care, what we now call bioinformatics, but that was not a term they were using back then. So it was not just this sort of top-level, “I’m a big guy.” He got quite seriously involved. And somebody who worked with him at Dartmouth College, which is where he was then based, who was a big guru on bioinformatics stuff, he said he really understood. He was not a technical guy, but he really understood the significance of these technologies in building communication.

And so I think if he had focused and brought together people to focus on the big one, Dr. Koop.com, maybe it would still be there.

Kevin Pho: We are talking to Nigel Cameron, author of the book, Dr. Koop: The Many Lives of the Surgeon General. We are talking about an excerpt from that book, “How Dr. Koop.com Rose and Fell: The Untold Story Behind the Surgeon General Startup.” Nigel, let’s end with some take-home messages that you would like to leave with the KevinMD audience.

Nigel Cameron: Well, one would be, Koop said there is nothing more important than information. Learning stuff about how to manage your health is the most important thing. And that, of course, remains true. And in his old age, he just kept repeating this message.

Another is that I think if we are looking for examples, not least in our current political climate, of integrity and somebody who could be criticized and was not a perfect individual but really had a fundamental commitment to being honest, to being truthful, to saying what he felt needed to be said, I think it is hard to find a better example. And so I have a great admiration for Koop. If you read the book, you will find out some of the problems with him. He had feet of clay like the rest of us do.

Looking back at his life and despite the final failure of this project, for a short time, for months, perhaps for a year or so, he was the world’s top health care communicator using the most advanced technology platform of the day in his eighties. That is an incredible thing, and I think we can be grateful for it. And you need to read the book to find out more about him.

Kevin Pho: Nigel, thank you again for sharing your perspective and insight. Thanks again for coming back on the show.

Nigel Cameron: Kevin, thanks so much. Take care.