Interview: Antonia Novello
Former Surgeon General of the United States

When did you know that you wanted to become a doctor?

Antonia Novello: All my life.

I was one of those children who were sick when they were born. So, all my life, I spent two weeks every summer in the hospital. So, the people that I learned to relate to since I was little were doctors and nurses, always assuming that they were there doing things in my mind. I always felt I was going to be a doctor. I didn't know when, but I knew that was the only thing that I really had role models on a constant basis.

What was your illness as a child?

Antonia Novello: I was born with an inability to move the intestines because there were no nerve cells. It's called congenital megacolon. I was born without the cells that make you think you have to go to the bathroom.

I was one of those kids that got lost in the system of health, either because you're poor or either because your parents are not doctors, so you cannot ask the right questions. I was one of those. I was supposed to have surgery when I was eight, and I didn't have surgery until I was 18. So, when you get lost in the track of medicine, then you want to be somebody that will solve the problems for others. And I think that motivation was there all my life, all my life.

And then, when I was 18 and I entered college, all of a sudden, I thought, I want this to be over. I told my mother, "I want this over," because I would be skinny one month and I would be fat the other month. You cannot look normal in the minds of an adolescent because your belly would get big and people would probably have, even the possibility in their minds, that there was something in there that was not what it was. So, it was over at 18, but it could have been over at eight. That really taught me that if you feel you're sick, you must have somebody who follows up with you. Otherwise, you can get lost. In my case, it was not fatal, but it was too long to go with the disease that I had when it could have been solved. First, at birth it was missed, then at eight.

Tell me about your childhood, the conditions under which you grew up as a kid.

Antonia Novello: I was one of those middle class kids who had a pushy mother. She was the principal of the junior high school. Plus, on top of that, every time a teacher was absent, Mommy would come and substitute for the class. So there was never a day off. Most important, Mommy was my teacher of mathematics and science, at which she was very good. That was very hard. Since I was little, it taught me I can't fail. One, because she would not allow me to, and second, because she would whop me in the middle of the class.

Then she became the principal of the high school, so she followed my whole career. She always pre-selected the teachers that were going to be in charge of my education. If I was going to ninth grade, the best math teacher would be in ninth grade that year. She would say, "Education is the reason by which we exist, and I will make sure that the best teaches you, because public school is a good system." She made sure of that. All my life I almost felt that my grades were not mine, that my grades were a product of my mother making sure that I was educated by the best.

I always remembered coming down a stairway once when I got an "A" in Spanish 12 by a teacher who never had given an "A" to anyone. And, as I came down through the steps running to tell my peers, which were five, they were talking without them knowing that I was listening, and they said, "I bet you that Tonia is going to have an 'A' because (her mother) Miss Flores talked to Mr. Hernandez." That really put it into the perspective. That was junior year. It only motivated me to be better. So, what I did is I studied so hard from there on that I took the entry examination to college in my junior year rather than my senior year, with the hope that, if I failed, I still had one year to catch up. And, to my surprise, I was the highest grade in the school.

It helped my ego. It hurt my relationships with my peers because they already felt that I was separate. But, at that moment in my junior year, it said "Your mother did not make your grades. You made your grades." It established once and for all, I may be the principal's daughter, but I am my own person and I'm not dumb, and I can show it. It was quite a turning point in my life.

I remember a little Peanuts cartoon that said, "There's no greater burden than great potential." You must have felt a lot of pressure as a kid.

Antonia Novello: Do you know what else I learned? To be accepted by my peers with all these things against me, I felt that I had to be the comedian. To this day, I don't think I would have survived 18 years of my disease if I had not learned to laugh at myself. I was the humorous kid in school. I was the funny one. I was the actress. I had to be accepted, so I did every single thing. If it had to be done, I was the one who did everything. I was president of every club.

I have always found that the element of surprise wins the biggest battles. If people assumed that I was funny, then they would be my friends. Friendship is one thing and intelligence is another one. At the entrance examination test, that was the time to show that I was intelligent.

I graduated from high school when I was 15. I turned 16 in August. I didn't have surgery until I was 18. There were complications of the surgery that stayed with me until I was 20, when I entered medical school. During those years, between age 16, when I was in college, and my twenties, in medical school, I learned to laugh at myself because, with all the complications of the surgery, it was very hard to act like there was nothing wrong.

In my junior year in college, I had one of the biggest surgeries to correct the complications of the eighteenth birthday surgery. And some other kid would have said, "I'm sick. I'm going to take music appreciation, art." I took that semester -- as a denial -- calculus, trigonometry, quantitative chemistry, everything that made me believe that I was not sick. But the part was, that in those six months, I had to wear Pampers to go to college and no one ever knew because I was not about to show it. And I continued to laugh at this little incidental in my life while I was showing that my brain was still okay. So that taught me one thing which I think sometimes is useful and sometimes is not. I have this inability to feel for the ones who use disease to not do what they are supposed to do. Because, believe me, if I did it, then anyone can, because there will be the plugging of the microscope, the plugging of the heating pad and the every five minutes going to the bathroom because I had to, until I had my last surgery.

The point is, you can be sick and get to the top, absolutely. People will always help you. The other point is: don't get disappointed because sickness puts you down. I went through a system of care that was not very keen, in a diseased state that makes you realize that there are good people and bad people in medicine, with a mother who said, "I'm not going to let your disease be used for you not to succeed." All those three prepared me for the job that God eventually made me have. When I speak, some people say, "Oh, great speech." I say, "Well, I learned it in the school of life." Life has taught me is how to say it in a way that is understood without self pity, but with a lot of impact because I have been there. I absolutely have been there.

Who or what inspired you to believe in yourself this way?

Antonia Novello: My mother was key. My father had died. My mother remarried, but she always felt "These are my children, and therefore they are my responsibility." I still have the same stepfather, but my mother is the center. To this day, she is still the principal of the same school. She is 72 years old and still has a keen mind. Even when I was a kid, Mommy was a teachers with two years of college that became four years of college, that then became two master's degrees. So I always saw somebody studying.

I remember the time I said, "Mommy, I have to take my board of pediatrics exam. Do you think it's necessary since I work for the government?" And she said, "Absolutely." I said, "Why?" She said, "Because someday their absence will be used not to give you the job that you deserve. So be prepared, even if you never use it."

She was always very keen in education without pushing. I finished college and entered medical school in '65. The only time that they could do the corrective surgery was in that first semester of my first year of medical school. So, I had to leave to get the surgery done at the Mayo Clinic in October, come back in December and reintegrate myself with the new class of '66. It was getting very hard in my first year of medical school because that semester was interrupted.

I told Mommy, "I'm quitting. It's getting hard to plug the microscope and plug the heating pad." She said, "I'll go with you and we quit together." At that moment, I said, "Oh, no. I'm not quitting." If Mommy would have been the one who said, "No you won't," I would have. But, she always felt, "You must be very sick to want to quit now. You want it? We go."

Something else I learned at that time is that sometimes people want you to do things for them rather than for you. A teacher of mine at that time wanted me to have the most drastic operation that a human being could have at the age of 20. Without any explanation whatsoever, she said, "I want you to have a colostomy." I said, "For how long?" She said, "For life." I would have had a bag attached to my body all my life, with a potential smell every time I had to change the bag. There are many devices now that attach better to the body, and take the smell away. But, at that time, 1966, we were just beginning to think of these things. When you're 20 and you are not the ugliest thing that anyone has seen, to believe that forever I had to have another secret... it was not the best thing that could have happened to me. I said, "I'm 20 and you want to do a colostomy for life. Don't take it lightly. It's my body. It's my life. Give me some hope." She didn't. She said she had also been a sick medical student and look at her now.

(My teacher) called my mother and despite of the fact that I was 20, she called my mother to tell her, "I want her to have surgery." And, my mother said, "She's 20. She can speak for herself. Do you want it?" I said, "Mommy, if I have to have that surgery without any explanation or no limitation, I think I'd rather die." And, Mommy said, "It is your body and you will take care of it they way you want to." And that was the end of it. But, it was painful because people make decisions for you in your benefit without asking you what is good for you.

My mother said, "It's your body. It's your decision." I said, "No. If I was like this for 18 years, I can be like this for life." Once again, my mother helped me make the decision. In that sense, she was really my greatest role model.

What was her reaction when you were named Surgeon General of the United States?

Antonia Novello: As a matter of fact, my mother did not come to my hearing because she was afraid that if I answered one question wrong and I was not selected, she was going to have a heart attack. So she stayed home and watched it on C-SPAN.

How about you? How did you react when you first heard about it?

Antonia Novello: I almost died of shock because life has made us believe that you must be a politician to succeed in government life. Life has made you believe that you have to have connections, that you must be at the right place at the right time and have the right friends. None of those things happened to me. This is why, when the call came, I thought it was a joke and I almost didn't answer it. It was the Assistant Secretary of Health who said, "You have been suggested to us as a possible chief of one agency of the public health," which had never been a woman.

When the call came, I said, "But I am not interested. I'm not looking for a job." He said, "Well, the Secretary of Health will call you, and you have an appointment on Monday." Grudgingly, I went and I thought I knew the agency, so I took the budget, the people who work in it, the mission, and I read it over the weekend because, I was going to tell him no. But the thing that I learned, too -- even when you say no, be prepared for them to want you because you're good.

When I went to the interview and the Secretary of Health said, "Do you know why you're here?," I assumed I did. I said, "More or less." He said, "Well, I want to offer you the job of the Surgeon General of the United States." I remember I should have been very, very dainty and very, very proper to say, "Really?" but I didn't. I was in such a state of shock that I said, "What?!" And then, I realized, "My God, this is the biggest interview of my life and I blew it on my expression."

Dr. Everett Koop had been my boss for eight years and I knew exactly what this job was. When I had an interview with Dr. Koop, I was impressed with the job. And you mean to tell me that me, Toni Novello, the little kid from Puerto Rico who has been in the National Institutes of Health all her life has been picked? Then I got upset.

I said: Are you calling me to be the Surgeon General because I can do the job or because I'm Puerto Rican and I'm female? "I will not be your quota. Where did you find me, now, after twelve years doing my same job? Why?" And, I remembered, the Secretary at that time was African American. And he said, "I have read your curriculum and I can see that you can do it. I don't need quotas, because I am myself a minority." That's when I said, "Okay. Let's keep going on the interview."

Even at that moment, I could have blown it. I was not about to forfeit all the things that I had done for a job that would count me as a number in a minority group rather than somebody who happens to be minority that can do the job.

What is it about you that made you stand out as a candidate for this job?

Antonia Novello: I think that one has to be realistic. The time was right for a woman and the time was right for a minority. But I also believe that they needed someone who knew AIDS, and at that time, I had just finished a report on AIDS. I truly believe that they needed someone who could show the American dream, all of those things together. I think the time was right for someone who was kind of conservative, but with common sense. I think I was selected for all those things together. It was a package deal. Then, I had to prove that it can be done. Again, the element of surprise.

When the President did the whole swearing in, I remember I said, "Mr. President, thank you very much for bringing West Side Story to the West Wing." I thought that said it all, because when you're Puerto Rican, when you're a minority kid, when you're a kid from an island this little, you can't dream that the American dream is going to include you. And, most importantly, when the stereotype of being a Hispanic, and specifically of Puerto Rican descent, it's not intended for you to succeed. I had to do it better. I had to do it better.

Something else I always tell the kids:

"When the time comes to be the best, do it. But, when the time comes to step down from being the best, do it better, because when you are a small group, they expect you to come down fighting." And, again, element of surprise -- come down with dignity and don't let anyone confuse dignity with weakness because people will remember more that minute of dignity than those three and a half years of good work, because on your shoulders are all of those that want to be you and they want you to do good for them. And boy, is it hard not to fight, but it's harder to do what is right.

Why am I making more speeches now than when I was Surgeon General? Why do I keep being invited by commencements galore? For that minute of dignity, backed up by the three and-a-half years of knowledge, and more importantly, because people want you to do good.

The American dream continues because every time that I speak, somebody believes that they can be me. Little kid, little island, a good pushy mother we all have, almost a mother that took care of you alone. Twenty-five percent of our population do that, single mothers taking care of their kids. But, more important, not rich, not poor -- normal American citizen making it to the top without political connections. Now the kids want to be somebody. And when they look at the Surgeon General of 1990, it's feasibly possible that they can be me. Not for what I have accomplished, but because of the life that I lived that is equal to so many out there. And I'm someone that they can touch and say, "Hey, she did it. Absolutely. I can too."

What does the American Dream mean to you?

Antonia Novello: To make it by making sure that you have all the things that are American -- education, good communication, empathy for people. For women, I truly believe a little mixture of both feminism and femininity, utilizing it to the best of your ability. But most importantly, credibility, dignity, fortitude and character. Take a stand. But, more importantly, believe that it's there for you if you work at it. I always tell kids four things. The first one is:

If you do not know where you're going, you are already there. The second thing is the world owes you nothing. To believe that the world will get you everything you want because you're a good kid and you studied is like believing that a bull is not going to hit you because you're a vegetarian. So, you must be able to do good. The third one is take a stand and believe in something. And those were the words of Goethe. Goethe said, "The hottest space in hell will be saved for those that during the time of conflict decided to stay neutral." So take a stand. But the most important one is number four, which is what has been said many times by some members of the academy. Service is the rent you pay for living, and that service is what sets you apart. Service to God, to the country, to the community, and to yourself. But most importantly, service. So, when you do all those four, absolutely the American dream will be found, and you will be part of it.

What book or books have meant a lot to you?

Antonia Novello: One is Love in the Time of Cholera.. Every Latin is a romanticist, but especially when it has something that you gain from it. I love autobiographies. All I Really Need to Know I Learned in Kindergarten. If you look into that book, you absolutely have the values which are best for you. Stand in line, wait your turn, wash your hands, say thank you. You would not believe how much those little things help you in your life when you put them into action.

And again, the element of surprise, I love anything that has to do with patriotism. I think that's very important when you're a woman, because I don't believe honor is gender-specific. I love this business of uniforms and medals and awards. Colin Powell gave me the Legion of Merit Medal when I was the Surgeon General. That is a uniform service medal that is not usually given to the public health service, but he gave it to me.

What do you think have been the most exciting moments of your career?

Antonia Novello: There are so many. When I was Surgeon General and everybody in my little town was so happy for me. You know one of the things that makes it great? To this day, when I go to Puerto Rico and I walk down the street, grandmothers stop and hug me, they kiss me, they thank me, and they say, "I want my granddaughter to be like you." Not all of us are born to be role models and God knows I never intended to be one. But, when you are in a position like the Surgeon General, and through your actions, one human being can be good or feel that they can offer something and be noticed for their actions, then you absolutely have done something worthwhile. People still feel that I represented them well and their kids should be like me. If that ever becomes a reality in the long term, then I all the chicken dinners, all the moments of despair, and all the stress were worthwhile. Somebody benefited because I existed.

What made this office so exciting for you?

Antonia Novello: One of the things about the Surgeon General's office that is unique, is that you have nothing but the pulpit. Therefore, you must always be well informed, and motivated to get the message out. But the beauty is that what you say has an impact. Therefore, you must be credible. I believe that the American public is tired of being told you must do this, you must do that. I think the time has come to tell them what is there and let them do the best that they can with the information at hand. But in the quest of preventing, let's not be preachy, because human nature has a way of turning off. I always felt that it was better to tell them what was at stake and tell them what the alternatives were, and just watch them make the choice. But never tell them "I know better than you," because when you do that, eventually you will lose the power.

So, the Surgeon General has this wonderful pulpit. Once you're well informed, you can decide what to tell, and then watch them grow. You have no underlying power, no authority except moral authority. And, boy does that make it harder, because you must be very, very sure of what you say and compound it with your knowledge. People quote you, and therefore you end up sleeping with tons of books and tons of data.

There's one thing I always find very interesting: this world is biotechnology-oriented. Somewhere along the way, we are forgetting that we must be there for the people behind the numbers and not so much for the numbers alone. How can we make the kids be better when we forget that the statistic is a face? Give them options. Give them hope. For every door you close, you must open a window. Otherwise, you're telling people what they already did wrong rather than saying it's never too late. You must also ask them to take a little responsibility, and meet you halfway, but no preaching. People are tired of being told what to do without giving them options. You have to do both. That was part of my job. What's wrong? What can you do? How can I help? Let's meet in the middle and do it with credibility and empathy, a lot of empathy.

Speaking of statistics, where do you see the AIDS crisis going in the next 25 or 50 years?

Antonia Novello: As long as we are denying it, we're going to be in really bad shape. I'm worried about everyone, but I am very worried about the adolescents and the women, because society is giving them mixed messages. When you're an adolescent and the disease takes ten years and you're 13, how can you feel that can happen to you? Then, you are denying that 54 percent of the adolescents of the country are sexually active by the time they're 18.

Adolescents have three things that are truly against them. The world is not consent-proof for the ones below 18. Your confidentiality is also at stake, because your insurance depends on your parents and your parents get the bill when you have your AIDS test. Another thing is that the system of care for the adolescent is nonexistent. It is very hard for a pediatrician to answer the questions of the day, because the child has grown and wants to do things we never thought they would. So, between your confidentiality and your consent and the way in which medicine takes care of adolescents, there are three things that are impinging on them.

The number for adolescent AIDS that people are paying attention to is only the number of cases between the ages of 13 and 19, which is less than 3,000 cases. But it can take ten years to incubate. Thirteen plus ten is 23 and 13 plus 14 is 24 and so on. Between the ages of 23 and 30, there are 48,000 cases of AIDS. If you subtract ten, they must gave gotten infected when they were adolescents.

So, in the presence of that, my other biggest worry is Spring break. All you need is one infected adolescent that is sexually active with partners that he or she does not know, without responsibility, in a milieu where they will not remember what happened ten years from now. If you can't remember what you ate last week, how can you remember what you did ten years ago? When we find them, and we do the test at their request, 54 percent of adolescents do not return for the test result. Where is the trust? Did they lose it from me or did they lose it from the system? In the presence of that, I worry about adolescents. When you prevent, you will do better. But the message of just giving you a condom for condom's sake, I don't find that is very good public health. If you are going to advocate for the condom, then give them the means to obtain it. Give them the instructions to use it, and give them the responsibility to which it is entitled. In the absence of that, you are just giving an instrument that happens to be of latex. That makes no impact on an adolescent who already feels invincible.

We have to be more and more respectful of adolescents without thinking that, because they are young, you cannot talk to them at the level of an adult. They are clamoring for respect, but also for true information. I spoke to a group of adolescents once in an AIDS symposium, and they taught me something. They said, "Dr. Novello, the epidemic has been here for twelve years, and we've lived. I'm only 16 and I've lived with it almost all my life. So, don't tell me anything about AIDS when all you're telling me is that I'm going to die. Please see it through my eyes rather than through yours. I have nothing to compare it with." We have to start dealing with them as people who need to know serious, accurate, straightforward information. They need all the attention. So, AIDS worries me for the women, for the children and for the adolescents. But it's not all lost, because every day we do something else that is going to at least delay death.

One last question. Regardless of what field someone chooses, be it medicine or art or paleontology, what personal characteristics are most important in your view for success?

Antonia Novello: I believe that fortitude is key. More than anything, be consistent. Go at it. Go at it. Go at it. There will be friends that will not want you to do your best. There will be life episodes that will obscure you. I would say, believe that you can, but plan. It will not fall in your lap. Plan. And once you've got it, be credible, be consistent and be responsible. It is absolutely crucial. And, when you have the opportunity and you're done, then you must bring somebody else up with you. Because when you're on top, and you forget that some others are just clamoring to join you, you will fall, and when you fall, you will be alone.

Be consistent. Be credible. Have fortitude. Have empathy for the ones who are not in your same position, but whatever you do, your credibility and your dignity will not be hampered. That's all you have left. You can do it, but you must make sure that you plan for it. It sounds ludicrous, but in the new era, everyone will come from a great university. The system will set you apart when you have done something that is different, and that is going to be community and people involvement. In the presence of those two, with all the things that you have from your family and from your upbringing, you will be successful. And when you succeed, don't forget the responsibility of making somebody else succeed with you.

Thank you, Dr. Novello.

You're welcome.