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Interview with Dr. Merlin DuVal 
Date:  July 23, 1991
Location:  National Library of Medicine
           Bethesda, Maryland
Interviewer:  Donald A.B. Lindberg, M.D.
Transcriber:  Techni-type Transcriptions/DDR


Lindberg:  I am the Director of the National Library of Medicine. 
It is my privilege to interview Dr. Merlin K. DuVal today in
connection with our series on the history of Regional Medical
Programs in the United States.  
     Monty, you were connected with RMP in Arizona and then
subsequently, of course, served as Assistant Secretary of HEW
during 1970-71, wasn't it, under Secretary Richardson?

DuVal:  1971 to '73.

Lindberg:  And [Caspar] Weinberger.  So you saw RMP both from the
ground and from above, from the air.  What is your general
impression of the accomplishments of that program?

DuVal:  There were many accomplishments from that program. 
Probably some of them are very concrete and specific and would
only be recognizable geographically in the fields where they
occurred.  But I've always felt that the single most important
outcome of Regional Medical Programs was that it created the
framework by which people were brought together at the community
level to talk about the distribution of health services and about
the distribution of knowledge and information, particularly at
the beginning, with respect to cancer, heart disease, and stroke,
that normally would not sit around a table.  I've always felt
that as a convening force, we've never had anything quite the
equivalent, certainly up to that time.  
     To a lesser extent, Comprehensive Health Planning has done
some of that since then, but Regional Medical Programs, I
thought, was the key to that.  There are, of course, some
concrete examples of things that have come out of this: much more
information through continuing medical education is being focused
on today as a result of RMPs; the creation of HMOs in the United
States due to Vernon Wilson's imagination, using the renewed
authority of the Regional Medical Programs in the early 1970s to
start the first HMOs in the United States; the establishment of
medical centers themselves, like the Drew Medical Center in Los
Angeles, totally ascribable to the Regional Medical Programs.

Lindberg:  You mention continuing medical education.  That's one
of the early foci of RMP, certainly.  I sense, in reading the
history of those developments, that the program was occasionally
accused of lack of focus, of change of focus.  Could you say
anything about that?

DuVal:  Yes, I think that's a very accurate observation.  As a
matter of fact, that may be, as much as anything else, the reason
for its ultimate demise.  Federal focus was not clear in terms of
Regional Medical Programs.  Keep in mind--and you will learn this
much more crisply from others than from me--that early on the
concept of Regional Medical Programs was to move patients through
a system, and that move then shifted as a result of congressional
action after the original DeBakey Commission report was issued,
to move information through the system.  As a consequence, we
moved from actually moving patients to moving information so that
you could ultimately close the gap between literally the
laboratory bench and the patient who needed information.

Lindberg:  That was the other focus, the closing the gap between
what's learned in the laboratory and what's practiced at the
bedside.  I recall that being said many times.  How is it that
the dynamic change between a focus on heart disease, cancer, and
stroke as categorical disease elements and more on health care
delivery in the general, and then a shift back?

DuVal:  I think that the answer I would give to that is that it
was traceable to the fact that the original concept of Regional
Medical Programs after the Congress has at least grasped the
significance of the DeBakey report was to move in a direction of
getting, as you said, the gap closed between the laboratory bench
and the bedside, which was originally categorical.  
     Then it was associated, of course, when it was created and
established in Washington, originally at the NIH [National
Institutes of Health] and then later HSMHA [Health Services and
Mental Health Administration], it was associated with other
chronic diseases.  As a consequence, it began to spread in its
focus and become more diffuse.  The Congress was not sure that a
federal purpose was being served by the original RMPs as they
first described it, so they began to change it.  This was
characterized even further by changes in the administration's
concept of what RMPs really ought to do.  As a consequence, it
became more and more amorphous over time.  I think, as I've
already implied, this was partly responsible for its own demise,
because it was construed by many as no longer serving what you
would call a clear federal purpose.

Lindberg:  And yet one of the advantages often cited was its
decentralized decision-making and the evocative nature of
bringing out the needs and the strengths at the community level.

DuVal:  No question about it.  While you're on that, let me
comment.  You may want to bring this up in a different context in
a moment, but it did two or three other things at that time, in
addition to bringing certain groups of people together around a
table that normally would not be brought together.  It was a way,
for instance, of creating a capability for subgranting, which the
only parallel in my immediate history, at least, was general
revenue sharing.  This was a concept in which the federal
government actually spent money and gave it to local groups and
permitted them to go ahead and distribute those monies to
petitioners, you see.  That was a relatively new concept twenty
or so years ago in the federal government.

Lindberg:  It did it quite well, didn't it?

DuVal:  It did it extraordinarily well, with a lot of goofs.  I
have every reason to believe that those who were more
knowledgeable than I could give you examples of that.  
     But I think there's another thing that it created at that
time, and did at that time, that also was rather special, and
that was it addressed the issue of what I would call meeting
watershed needs as opposed to political jurisdictions.  Regional
Medical Programs was allowed to look at the way patients and
information flowed in the real world.  If you looked, for
instance, at Kansas City, the question is, do you give it to
Kansas City, Missouri, or do you give it to Kansas City, Kansas? 
The issue is, that's not important, and you shouldn't be wasting
your time addressing that question.  The point is, there's a
metropolitan area there which is in two states.  So Regional
Medical Programs was created and permitted money to flow to
entities that were not geographic or political jurisdictions. 
They were watershed jurisdictions.  I thought that was an
incredible breakthrough for the federal government to take as a
step.

Lindberg:  It was.  I can recall hearing for the first time some
other cost-cutting ideas, like cost of illness, the concept that
we may acknowledge now, but we still don't know the cost of most
illnesses.

DuVal:  Right.  We don't.

Lindberg:  We know the per diems for a hospital in a local area.

DuVal:  The cost is what I'm saying.  

Lindberg:  Right.  You spoke about the program starting at NIH
and moving out of NIH.  Why did that happen?

DuVal:  I wasn't here when they made that relocation, but don't
forget at that time there was still a very--what would be the
right word?--a very puritan view as to what the NIH should do. 
The ultimate concern of Regional Medical Program was not just to
distribute information, but was also to set up model experiments
for patient care and so forth.  There were people who felt that
that probably was not a proper function, an appropriate function,
if you believe and accepted the pure concept of NIH.  So it was
easy to move it over to Health Services and Mental Health
Administration when that new organization was created.  

Lindberg:  So you are suggesting it was kind of evicted from NIH,
or they applauded its departure.

DuVal:  I don't know that it was evicted.  You'd have to ask
those who were here at that time.  I came to Washington in July
of 1971, and that decision had already taken place, so I was not
an actor.  At that time, I was, as you have already implied,
actively running the Regional Medical Program over in Arizona.

Lindberg:  How did that go?

DuVal:  Very well.

Lindberg:  Was that fun?

DuVal:  It was fun.  I happened to have a good friend who was the
governor at that time, and he called me one day and said, "We
have this new activity from the feds called Regional Medical
Programs.  Do you know much about it?"
     I said, "I know something of it, but not much."
     And he said, "Well, as I read it, it's got to involve a
research institute or a medical school, and you're the only one
in Arizona.  Would you mind accepting responsibility for this?"
     And I said, "Not at all."  And I recruited a wonderful and
respected more senior practicing physician from Phoenix, the
community where the medical school was not, persuaded him to come
down and mobilize the interests of the other physicians and so
forth in the state, to work with him to create Regional Medical
Programs, and they did, as I think is true in the other forty-
nine states and jurisdictions.  I think they did a very fine job
with what they did.  
     It was fun, yes.  I would be lying if I said it wasn't fun
to see that thing develop.

Lindberg:  I recall it being marvelous.

DuVal:  Yes.  

Lindberg:  One of the interesting questions was, what is a
region?  It turned out empirically mostly to be states.  Do you
think that's good?

DuVal:  No, not necessarily, and I spoke to that a few moments
ago.  One of the nice things about this was it permitted
jurisdictions to be, as it were, other than political, so it
wasn't necessarily confined to states.  You could combine
regions, Kansas City being an excellent example.  The Indian
reservation, if you happen to want to use it, is a very good
example, because in the Southwest, for instance, the Navajo
reservation, which is a population of 200,000 Navajos, is really
in four states--Colorado, New Mexico, Utah, and Arizona.  That,
for at least Comprehensive Health Planning purposes, it was most
important that that be addressed as a jurisdiction that was not
limited to one state.  

Lindberg:  Do you think that RMP, where it did good work and
succeeded, do you think that was more pronounced, perhaps, in the
rural areas than in the big cities?

DuVal:  I think I'd not be a good judge of that.  My suspicion is
that it probably had a higher visible impact in somewhat more
rural areas, but you can't overlook the fact that, for instance,
early on in Wisconsin they got into a program in which they made
available the equivalent of an 800 number, with an enormous bank
of tapes, in which every citizen in most rural areas could call
in to one central number which was in a metropolitan area and get
contemporary information about a particular medical problem.  

Lindberg:  I remember that very well.  It was in a pharmacy,
actually.

DuVal:  That's right.  It was in a pharmacy.  

Lindberg:  I used to call it every July Fourth just to make sure
it was still working.  [Laughter]

DuVal:  Good!  [Laughter]  But I think that's another example of
how cutting the line, so to speak, between rural and
metropolitan, where it turned out to have served the purposes
very well of persons in rural areas that might not have benefited
from other metropolitan services.  I like to think also it was a
way of playing into the hands, again, to my colleague Vern
Wilson, if you don't mind my mentioning his name, because he was
one of the first persons to bring to my attention what he called
the importance of the activated patient.  He and I were serving
in an earlier capacity at the National Association of State
Universities and Land Grant Colleges, in which we worked
together, actually, to see what steps could be taken to activate
a patient to become somewhat more nearly a partner in the medical
interchange that took place in a doctor's office.  Regional
Medical Programs gave that a substantial boost.  

Lindberg:  Absolutely.  You didn't intend for them to carry
placards out on the sidewalk the way they turned out to do, did
you?  [Laughter]

DuVal:  No.  [Laughter]

Lindberg:  What about the question you raised of the original
concept of the DeBakey report?  No doubt Dr. DeBakey and many
others, although I think it was done in about a year, and then a
kind of transformation to the legislation.  How did that all
happen?  

DuVal:  As I understand it, the original concept was--and I don't
know if this was in Mike DeBakey's mind itself, but it was sort
of a European concept, in the sense that if you wanted to
distribute medical services wisely and efficiently, you had
tertiary care centers that were the last court of appeal, and
then you had staged, as it were, areas where patients could be
treated closer to home, and that ultimately you should move
patients through that kind of a system to the tertiary care
institution as promptly as possible if that's what they needed. 
That became the principal thrust of the original DeBakey
Commission.
     I have reason to believe--but cannot confirm it personally--
that the American Medical Association probably did not want to
favor that particular expression through Regional Medical
Programs, and through their [influence] and the influence of
others on Congress, the original DeBakey proposition was
modified.  What came out of it was essentially the movement, as I
said a few moments ago, of information, instead of the movement
of patients.

Lindberg:  I understand also the prohibition to do building.

DuVal:  Yes.  Of course, construction authority did arrive a
little later in the history, but there was, nonetheless, a
constant reshaping and a revisiting of the purposes of this to
the point that there was genuine confusion in the field as to
what was the purpose and what was the expected outcome of
Regional Medical Programs.  
     I have often remembered--and this is kind of fun to recall
in a historical sense--one of yours and my earlier colleagues in
this business was a fellow named Ken Endicott, a great career
officer in the Public Health Service.  When asked this question
about what was the ultimate expected outcome of Regional Medical
Programs, Ken would often tell the story about the child who was
sitting in school drawing a picture, and the teacher came by,
looked over her shoulder and said, "What is that a picture of?" 
And she looked up and said, "That's a picture of God."  When the
teacher looked at her and said, "How do you know what God looks
like?" she looked up and said, "I'll know after the picture is
completed."  [Laughter]  And I think that's a bit characteristic
of the history of RMPs.  

Lindberg:  You know, I read one interesting statement about its
partial recapitulation in history that said that 18,600-odd
persons were volunteer members of RMP review boards of one sort
or another.  That's an amazing number.

DuVal:  Yes, it is amazing.  I have no knowledge of whether that
figure is correct.  I assume that it is, but I'm not the least
bit surprised.  

Lindberg:  That's activating a lot of community interest.

DuVal:  You get it is, but it also, I think, lends a little
support to my earlier observation that it brought those kind of
people together around a table who would normally not be there. 
And I'm talking about blood bankers, I'm talking about lawyers,
I'm talking about physicians, I'm talking about hospital
representatives, researchers, communication experts, and so
forth, people who normally would not have a reason to sit down
that late in an afternoon and go over these problems.  I think
that was a great contribution.  

Lindberg:  I do, too.  We've touched, however briefly, on a few
positive aspects of the program.  Ultimately it died or was
killed or, anyway, ceased to exist.  Can you shed any light for
us on the circumstances?

DuVal:  Yes, I can.  Because it first surfaced as a very serious
concern to all of us by the fall of 1972, by which time, as you
know, we were taking our first cut at the preparation of the
fiscal 1974 budget for the then president, frankly, the
conversations that went on through our corridors at that time
were responsive to the signals from the administration that they
wanted to start cutting back some of the health programs. 
Regional Medical Programs were, in some regards, very difficult
to defend from inside the federal establishment.  Again, they did
not have a crisp federal purpose and there were a lot of people
who said, "This is not something we should be pursuing.  We're
not getting what we think we should back from this."
     Incidentally, I might add, I found that paradoxical,
because, if anything, it was both the administration and the
Congress' own confusion about what they wanted out of it that was
responsible for that.  There were others who held the view that
since continuing medical education, for instance, was a
substantial part of the spinoff from Regional Medical Programs,
there was no reason to be spending public tax dollars to
subsidize the education of one of the wealthiest professions in
the United States, namely the medical.

Lindberg:  Yes, I recall that discussion.

DuVal:  You bet.  There were others.  There were some who
thought, again, about the issue of accountability.  Can you hold
a region that is not a political jurisdiction appropriately
accountable?  There were those who held the concern about whether
it was prudent and wise to give money to a regional group of
people who had no other standing, as it were, and were then
authorized to give those tax dollars away to other enterprises in
the community.  There were enough of those kind of reservations
that the weight of those itself, I think, were responsible for
killing it by, as I recall it, '74 or '75.  It did get a one-year
reprieve after we prepared the first fiscal 1974 budget in 1972.

Lindberg:  Was there any element of it being a program from a
previous political administration?

DuVal:  I don't think so.  At least if it was, I was not
sensitive to that.  But don't forget the political administration
at that time was the same.  President Nixon was the one who asked
us, through the OMB [Office of Management and Budget], to
reconsider whether or not RMPs should be kept alive.  But he had
been reelected, so he was preparing the fiscal '74 budget.  It is
true that Cap Weinberger came over, as you know, from being the
Director of the Office of Management and Budget to being the
Secretary of HHS, so he was put in that situation where following
his then nickname, "Cap the Knife," he was in a position to
actively move on his own recommendation.

Lindberg:  I recall the nickname very well.  So you don't think
it was viewed as an LBJ [Lyndon Baines Johnson] program, then?

DuVal:  I think it was considered an LBJ program, but I have to
believe personally that enough time had gone by that that was no
longer an issue.  I think it was probably addressed on its own
merits and was not killed for reasons related to the fact that it
was, so to speak, a vestige or had its heritage in the Johnson
years.

Lindberg:  Certainly in the oversight testimony that kind of
finished it off, which we have written records of, it appeared
that the administration clearly made up their mind that that was
the end of the program, and that message was conveyed by Dr. Zap
[phonetic], who was assistant secretary.  It didn't appear that
the protestations of the RMP directors had much impact on the
decision.

DuVal:  That's correct.  Of course, the way that unfolded, from
the viewpoint of timing, it's very possible that the explanation
there is the fact that the administration took that position
straight up and early on before, so to speak, those who had a
vested interest in it were able to mobilize.  And after that
incident, the determination, so to speak, even within a year or
so was fast enough that those in the field probably weren't able
to mount an adequate campaign.

Lindberg:  No.  Well, I think you and I are both used to the idea
of testifying for the president's budget and for the
administration's position.  That's natural.

DuVal:  And you do that because that's the signal that's being
called by the Office of Management and Budget and the president.

Lindberg:  Yes.  There were statements, however, in that hearing
that leave one shaking his head a bit.  One was the suggestion
that Comprehensive Health Planning, CHP and CHPB, would fill the
gap, would do the things that RMP was doing.  Is there any
likelihood that that might have happened?  

DuVal:  That's a compound question.  Let me answer that this way. 
You are, fortunately, as I understand it, going to interview
again my colleague Vern Wilson on this, because this is a very,
very important issue.  It would be a little difficult for me to
tie a string between the two entities, but in approximately 1970
(and I'm subject to correction here; it may have been 1971,
certainly flowed into 1971), Vern called together a group of, as
I recall it, about five people.  This is Nathan Stark and Joe
English and John Hoagness [phonetic] and myself.  There was a
fifth.  
     He asked us specifically to spend as much time as we needed
to look at an issue from his vantage point, to wit, what is the
best way for the person who is the administrator of the Health
Services and Mental Health Administration to blend, so to speak,
the somewhat overlapping purposes of three legislative
authorities.  One was the residual at that time of the original
1965 Comprehensive Health Planning Act.  The second was Regional
Medical Programs.  Third was the National Health Research
Services.  
     We did work together for, as I recall it, about eighteen
months, and published a report for Vernon, in which we suggested
that the three programs could be collapsed into a health planning
system.  In fact, I personally was the one who, in effect,
suggested that we consider creating, instead of RMPs, what were
later called health systems agencies. 
     So there is some truth to the allocation that there is a
time between them, but whether the flow was quite as direct as
I'm implying in my comments, I really can't give testimony to.

Lindberg:  As you probably know, we want to assemble enough
material to place this whole domain of RMP in the area of the
historians, so we'll be sure to get hold of a copy of that
report.

DuVal:  You should.  As a matter of fact, in anticipation that
this was coming up, I thought I would try to get back and see if
I couldn't dig out my copy.  I am sorry to say that it is
somewhere now in microfiche form in the office of the dean of the
College of Medicine at the University of Arizona, and I am no
longer connected there.  I may have to go down there and see if I
can find it.  It's very possible, also, that it's in the office
of the administrator here, or one of the other four of the five
people that I mentioned may have a copy.  

Lindberg:  Do you think it would be worthwhile to make a true
historical study of this topic?

DuVal:  I think that's a matter of priority based on your time
and resources.  I do think that this is, in its own way, a
watershed event.  It's a watershed event because it brought a
type of early partnership into the providing elements of
America's health care system and the federal government.  Until
that time, they did not have that kind of relationship.  NIH
might have been, so to speak, the only microcosm of that effort. 
But under Regional Medical Programs, and then to some
considerable extent also under Comprehensive Health Planning,
that partnership was created.  It got a little bit of additional
amplification at almost the same time, a little later than RMPs
through the so-called PSROs, a movement.  But the AMA and
organized medicine at that time made, in my judgment, one of the
most important contemporary tactical mistakes they made by not
embracing that legislation.  Had they given PSROs an opportunity
to work, I think we would not have had today's PRO movement and
the intensive heavy hand of third-party payers literally into the
examining room.  But that's another subject.

Lindberg:  Did they, in fact, give wholehearted support?  They
didn't give wholehearted support to the DeBakey report, but they
didn't give wholehearted support to RMP as it launched, did they?

DuVal:  No, they didn't, but a substantial proportion of American
medicine was wooed into RMP when it was understood basically what
it could do for them through continuing education, through the
flow of information, etc.  Many physicians in this country
benefited as a result of RMPs.  

Lindberg:  I understand that there's some thought about a
national health plan right now, in the next year or two.  Do you
think that this kind of [unclear] of RMP, that based on that
there's some lesson to be learned that you could pass along to
those making the plans now?

DuVal:  No, I don't.  I don't think that based on where we are in
this country--

Lindberg:  You won't be entrapped?  [Laughter]

DuVal:  Well, it's not a matter of being entrapped.  I'd be
delighted to do so, but I think that the issue today of health
care reform is such a wrenching experience for those who are
going to be in a position ultimately to make that decision, that
it will reach way beyond what RMPs did.  I think RMPs showed, as
I've already implied, that you can get people together at the
community level, you can get a working partnership together
between providers and the federal government, but I think to go
from there to the health care reform and national health plan
that you're talking about is quite a big jump, and I would say
RMP was simply one of the actors that's, so to speak, at the
table.  But it won't be an important one.  

Lindberg:  There are a couple of elements that might relate
there.  One is the question of how fast can you expect results. 
It only lived for five years.  Is that time enough for any major
reform to be measurable?

DuVal:  No, I think it is not.  One of the things that I think I
have learned as a result of increasing responsibilities as I've
gotten older, added to that the wonderful experience I had
serving as a federal officer for a short period of time, is that
the so-called acceptance time is much greater than you think it's
going to be.  The fact that you put a program in place does not
meant that you can measure it within the next two or three or
four years and see what success you've had.  I might add that RMP
is an example of that.  An even better one, frankly, is PSROs,
which were collapsed much too soon.
     I think you do learn that, that it takes a lot of time to
achieve acceptance.

Lindberg:  I also worry a little bit about the question when the
federal government comes around and knocks on the door for the
second, third, and fourth time, having been unfaithful on all the
previous co-ventures, how it will be received.

DuVal:  No question about that.  As you know, especially today,
there's an extremely high level of distrust out in the community,
that the federal government is not capable of maintaining a
reasonably steady posture.  That's true, incidentally, whether
it's the Boland Amendment having to do with support of the
contras or whether it's in an area that's a little more close to
you and me.  For instance, PSROs might be an excellent example, a
new contemporary example, as what they did to hospitals as a
consequence of introducing prospective pricing.  See, they made
certain commitments and promises and then turned around and
undercut the hospitals.  It's a very difficult environment to
achieve the kind of level of trust that you're talking about.

Lindberg:  One of the things that amazes me, in retrospect, is
the amount of technological change going on in medicine during
the brief period that RMPs existed.  It really wasn't designed to
be a technology transfer kind of remediating activity, but a lot
of changes occurred and, of course, subsequently even more.

DuVal:  Yes, I think that's true, but I don't think the impact of
that was negative on RMPs.  I trust that wasn't your implication.

Lindberg:  No, it was a great opportunity, actually.

DuVal:  It was a great opportunity.  RMPs did serve one purpose
with respect to new technology, and that was it kept contemporary
information in the field about the availability of that
technology, even if technology was not itself the subject of the
transfer.

Lindberg:  Right.  And I think it could have--well, I personally
think it could have grown into a proper logical planning means,
but that remains to be seen.

DuVal:  Well, unfortunately it had one flaw, and I think we
brought that out in the report that we wrote for Dr. Vernon
Wilson.  That was that when you get into community health
planning and give a large role to providers, there is a
disproportionate influence that providers bring to the table. 
They are enormously respected and well regarded as experts by the
others around the table.  When you get into such a thing as
planning with a residual of, say, RMPs, which was heavily
medically oriented, I think you would have had that flaw inborn.

Lindberg:  Yes.  

DuVal:  This business of, "If you say so, Doctor, that's it,"
that's not the right way to do planning.

Lindberg:  And before those times I really wasn't familiar with
the whole concept of providers and consumers.  I'm reminded of a
doctor I met in those days who got sick.  He had a gall bladder
done or something like that, and after he lived through all that,
he said to one of these hospital administrator planning people,
"Well, now at least I know what it means to be a consumer of
health care."  And this planner said, "You're not a consumer. 
You're a sick provider."  [Laughter]

DuVal:  [Laughter]  Very good.  

Lindberg:  The distinction is never blurred.

DuVal:  It's never blurred.  It's tragic that we've let some of
these words creep into our vocabulary, but everybody is using
them and at least understand what you're talking about.  

Lindberg:  Thank you so much for joining us.

DuVal:  It's a pleasure to have been a participant.  Thanks, Don.

[Begin Tape 2, Side 1]

DuVal:  . . . United States and organized medicine, although the
concept of closing the gap literally between the laboratory
bench, in other words, what was new in this tertiary care level
and what the patients' needs were, was kept and retained.  When
Regional Medical Programs finally emerged from the Congress, the
gap was closed by moving the information instead of by moving the
patient.  

Lindberg:  Great.  What is closing the gap?

DuVal:  Closing the gap, in the sense that I would use it, would
be to take the extraordinary new research and the advancing
technology that characterized the years beginning in the sixties,
and get it out to the availability of physicians and patients
with the lowest possible loss of time.  That was the real key. 
Most people forget the era of the sixties were an incredibly
productive series of years in which literally there was a massive
transfusion of the supply side of the health care equation in
anticipation of Medicare and Medicaid and the new demand that
would arise.  Among the things that were there were neighborhood
health centers and family health centers and emergency medical
services, regional medical programs, so forth and so on.  But in
the meantime, there was a tremendous investment in new research
through the National Institutes of Health, and the products of
that research, Congress and the administration and the DeBakey
Commission felt should be made available to all physicians and
all patients in the United States in the promptest possible way.

Lindberg:  Let's look at the demise.  You started out talking
about in the fall of '72 and setting the budget.  Could you give
us a condensed version of how it all ended?

DuVal:  Yes.  In 1972 we got the first signals from the Office of
Management and Budget that they wanted to reconsider the total
amount of money that was being spent on discretionary health care
programs, and among those that were vulnerable were Regional
Medical Programs.  So we were asked to consider tailoring those
way back.  There was, of course, at that time this other concept
of forced carry forward of funds, which I think you already know
about, characteristic of that area where in order to reduce the
subsequent year's appropriation, as much carry forward as
possible was kept in the budget, so you would reduce the amount
you had to ask for from Congress the following year.  At that
time it seemed very propitious to the administration that we
should look at Regional Medical Programs in terms of whether they
should be perpetuated.  So for the first time, we recommended
that we move towards closing them out in the fall of 1972, in the
projected 1974 fiscal year budget.  

Lindberg:  Where were you on February 1, 1973 when the famous
telegram that John Zap sent out to all the poor folks around the
country?

DuVal:  I had left Washington in the middle of January 1973 to
return to my committed position at the University of Arizona and
was not a part of that.  

Lindberg:  So you weren't here.  

DuVal:  I was not here when it happened.

Lindberg:  You received it.

DuVal:  We all saw the telegram.  You have to remember at that
time John Zap was my deputy assistant secretary for legislation. 
I met John today in National Airport coming in.  

Lindberg:  He works for AMA, doesn't he?

DuVal:  Yes, he works for AMA.  

Lindberg:  Would you like to say something of the role of AMA in
this?

DuVal:  I did say organized medicine.  

Lindberg:  That's sufficient.

DuVal:  Which is a codeword for the AMA, and everybody in this
audience is not going to have a problem with that.  
[End of interview]