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Interview with Dr. Vernon E. Wilson
Date:  July 24, 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 now to interview Dr. Vernon E. Wilson in
connection with NLM's series on the history of Regional Medical
Programs in the United States.  
     Dr. Wilson, thanks so much for being with us.  You were
connected with RMP in many ways, but two obvious ways.  One, you
were coordinator of the program, the head of the program at the
University of Missouri in Columbia, and then subsequently, of
course, you came to Washington as the top man, head
administrator, at Health Services and Mental Health
Administration.  So you saw it locally and you saw it nationally. 
Just to start out with us, what did RMP mean?  What was its
importance?  

Wilson:  Obviously my initial impressions came from the
University of Missouri, and it came at a time when NIH [National
Institutes of Health] was in a flush of money, too. 
Investigators wouldn't agree that there was more than they
needed, but there was an ample supply.  There was nothing that
would deal with the distribution of health care, and my initial
impression of RMP was that here was a tool that would help us
take the technical work, which you and others were doing in the
school, and make it work in the health care system.  I guess I
still have that same impression.  

Lindberg:  Do you think such a program would still be a useful
item?

Wilson:  You're speaking to a converted disciple, so I'm not
about to say anything about the content of the program.  It is
clear that by this device, some other device, or one not yet
discovered, there is a lot of technology which can be used to the
advantage of patients, as well as a number of the university
disciplines that is currently not used.  Your work in the
Grateful Med at the National Library kind of reminds me of some
of the work that was done early in RMP.  The task that it set out
to do still needs to be done.  Part of it has been accomplished;
part of it has not.

Lindberg:  Certainly about every year we at NIH are told by the
Congress, one way or another, to make greater efforts to be sure
that the gains through research are made available in the
communities, that the information is distributed, disseminated. 
It seems to me that that was very central to the mission of RMP
as it was interpreted, at least there. 

Wilson:  And if you go back in the testimony--and I've gone
almost back to the beginning of the large appropriations at NIH--
that refrain has been there from the start, but the response to
it is very difficult to find in the medical profession a group of
people who will scientifically work at applicational, or the
function like they'll work at the content of medicine. 
Preventive medicine, of course, is the classic example.  Family
practice is also in that group, and RMP fell in the same
category.

Lindberg:  I was amazed to discover that discovery, while it's
difficult, is actually pretty inexpensive compared with the
dissemination of that discovery and making it available to large
numbers of people.

Wilson:  It takes two different sets of mind.  There is a
scarcity on university campuses and in professional groups of
individuals who are satisfied to synthesize.  There was a loyal
group in the Public Health Service who tried very hard to work at
preventive medicine, and every school has its token department of
preventive medicine, but there are very few people that have
dealt well with the problem of preventive medicine.  It, like
RMP, is a function rather than a body of knowledge.  The
university faculties are very comfortable with the boyd of
knowledge.  You can learn more and more abut it.  But when you go
to the synthesizing of that into a system, then we still have a
lot to learn.

Lindberg:  NIH now has much more in the way of community action
in cancer control, and I suppose you'd say application, than it
did in those days.

Wilson:  Yes.

Lindberg:  But at one point, Regional Medical Programs was housed
in NIH and then was moved, one way or another, to a building
called Parklawn, not too far from here, and an agency called
Health Services and Mental Health Administration, which you came
to head.  How did that move take place?  

Wilson:  Obviously I came after the decision had been made, so
what I can tell you is my impression of what happened.  RMP, from
the start, had some problems.  Number one, Dr. [Michael] DeBakey,
in a very fine way, put together a pattern of regional medical
complexes.  Unfortunately, that was antithetical to what
organized medicine wished, and just about as antithetical to the
AAMC [Association of American Medical Colleges], who don't get
mentioned very often, but who are very active.
     In the second place, RMP came at a time when there was
rigorous competition for funds, and the investigators who were a
fair-sized component of the medical faculty felt that this was an
intrusive factor in their ability to get money.  The
bureaucrats--and I was a bureaucrat subsequently--were looking
for places to curb expenditures, and very often unmentioned goes
Medicare.  If you look at health expenditures, the great portion
of them were in Medicare/Medicaid.  So the bureaucrats were
saying, "What can we find that we can cut?"  When I was there, 15
percent of the health budget in HEW was uncontrollable.  It was
an entitled program.  So they looked very closely for something
which they could cut. 
     Those three things made it a stranger to NIH, who did not
want to lose their--I'm being a little cruel, but essentially
they felt that it would be better if this program, which was a
function, not a discipline, and which had these other attributes,
be lodged someplace else.

Lindberg:  So the graft was rejected by the host.

Wilson:  That's exactly my interpretation of it.  

Lindberg:  I guess I didn't say, for our audience, that Regional
Medical Programs fell within the domain of Health Services and
Mental Health, so that, again, you saw it nationally as the boss. 
In all of the things that you saw, whether locally or site visits
or applicants, what was the best you saw in Regional Medical
Programs?

Wilson:  I was a prejudiced observer.  I think the Alabama
program, the Utah program, the Missouri program, and the
Washington program, as far as I was concerned, contained the
elements that I thought RMP was addressing.  Each of them had a
different program.  Missouri, as you know almost better than I,
really addressed the issue of finding a way to get the individual
who is at some distance from the medical center.  Jack Bass
[phonetic], of course, was the classic, but by no means the only,
give him the resources that he needed without him coming in.  The
Missouri program in Springfield, of course, with Glen Turner in
cardiovascular demonstration, took care of heart patients.  That
was another.  I won't go through the litany of them.  
     Utah dealt with getting that information to a four-state
area, and very successfully they dealt with that.  They did what
Missouri and Alabama did so well, they formed a telephone bank
and people could call in for information.  They also actively
distributed.  
     Washington (and I will stop with that, as it's a little
repetitive) took on Alaska with Washington, and that was yet a
different problem.  Alaska had no medical resources in condensed
form, and Washington is a very good school.  
     Each of them, I think, demonstrated how you can improve
heart, stroke, kidney care at a distance with central resources
and maintain quality.

Lindberg:  So really those are all innovative approaches.

Wilson:  All of them.  All of this had been present technically;
none of it had been demonstrated in use.  

Lindberg:  Do you think if RMP had lasted for ten or fifteen
years that the programs all would have had certain of those
elements, that there would have been a similarity, that the best
of each would have been adopted by all?

Wilson:  There's no doubt about it.  The measurement system was
applied to it at the same time the death sentence had been
pronounced.  In the legislative process at the time they were
asking for the 1972 budget, the president had already decided
that the program really should be cut out, not programmatically,
although there was a lot of programmatic verbiage in the
testimony.  That's part of the political process.  That was a
logical thing.  Nevertheless, they had decided this was the only
one of the few programs that they could get hold of and cut out,
so they just cut it out, regardless of its productivity.  

Lindberg:  Do you think that had to do with coming from a
previous administration?

Wilson:  No.  It had to do with the newness of Medicare.  See,
Medicare had just been passed--what, two years before this came
on?  And Bob Ball was sitting in his lofty chambers trying to
figure out what he would do with Medicare because it was growing
so rapidly, and although he knew the entitlement, he didn't know
the scope of the demand.  I watched Richardson and Bob Ball
struggle over and over the budget.  Bob was kind of the gorilla
who came to lunch.  He sat anyplace he wanted to because he took
all the money.  

Lindberg:  What was the difference in the point of view, if you
knew RMP in a local level and then you came nationally to see the
much larger range of activities?

Wilson:  It was much more comfortable locally.  [Laughter] 
Locally, of course, we were so busy, as you will recall, putting
together what we hoped were creative packages to present to the
National Council.  One thing I have not mentioned, and would be
derelict if I did not, the matter of trust between the medical
center faculty and the university faculty and between that set
and the practicing physician in the community was a very complex
and difficult affair.  We were very busy, thank you, trying to
get this group marshalled so that they didn't permit, but
actively endorsed, the program.  
     We didn't address it nationally.  That was Bob [Robert Q.]
Marston's problem.  That is probably a monocular view, but
locally that was really our attitude.  When I came in here, I saw
it in reverse with RMP as one of seventeen programs, and I saw it
in competition with Medicare and Medicaid and also saw it in
competition with the national funding.  I knew before it expired
that it must expire, not because of its merit, but because of the
competition.

Lindberg:  But it competed with things that were apples and
oranges.

Wilson:  That's right.  

Lindberg:  With the school lunch programs and Indian Health
Service.  An amazing assortment of programs packaged in one
agency.

Wilson:  Yes.  Anyone who looks at RMP and tries to find a
logical reason programmatically for its demise is going to be
frustrated, because there was no logical reason.  You can go
through the testimony and it denies itself as you read the
testimony.  It was simply a shortage of funds, pure and simple. 
That I can understand.

Lindberg:  That's one of the mysteries that we're trying to
penetrate in this little historical study.  As you know, in the
end we'd like to have assembled enough testimony and interview
and documentation so that the field becomes the proper study of
historians who probably can give a more dispassionate view
downstream than we.  RMP has its admirers, still.

Wilson:  It has a whole group of admirers.  I'm one.  I think it
must learn a bit more about politics and the political machinery
before it attempts to be reincarnated.  In its present form it
cannot survive, I think.

Lindberg:  I was a little disappointed when I read the published
testimony, as I'd never done that before, at the justifications
and the presentation evaluations and so forth.  At least in
modern terms, it has an almost amateurish flavor.

Wilson:  Yes.  I just read part of those, as you well know.  The
evaluation processes were designed to do a job; they were not
designed to evaluate programs.  I may meet some of those people
and they may challenge it, but I'm convinced of that, because
even their award system did not match the evaluation system.

Lindberg:  Yes.  I was very much younger in those days; I suppose
everyone was.  I didn't have as high a regard for evaluation as a
process as I now do, because I now know how hard it really is to
do, and how useful when done right.  
     What do you think are, in the end, the lessons that we can
learn?  The country still has many of the same problems.  A lot
of progress has occurred, but there's talk of new legislation,
new plans for national health care schemes.  What can we learn
from this experience?

Wilson:  National health insurance, of course, has been imminent
now for about two decades and it's still imminent.  I expect it's
going to stay imminent for another decade or two.  Eventually the
mix of the United States population is such that we're getting a
wider diversity of races and we're urbanizing.  The rural
contingent who bore quite a bit of weight in the legislature up
until very recently have about lost their voice.  They have now
become a lobby, an agricultural lobby, but they're not a voting
public.  
     If I were to guess what will have to be done, I think that
Mike DeBakey was absolutely correct in his initial instinct to
establish complexes, but I think they will have to come after the
national health insurance is invoked.  That, in turn, is not yet
mature from a political sense.  If you look at the testimony and
read it, there still isn't agreement across the board sufficient
that a sound program can be founded.  One guy's prediction.  If I
were to guess now, ten years ago I would have guessed ten years. 
But I would say another ten to fifteen years the House will have
changed enough and the Senate will change its patterns, and it
will probably come in that order, and I think some Regional
Medical Program-type activity then will become perforce a
necessary part of the system.

Lindberg:  One of the things that we used to speak about a good
bit then was this gap between the laboratory, discoveries, and
what's available at the bedside.

Wilson:  Still there.

Lindberg:  To some extent that's still there.  But we also spoke
about improved access.  You were just talking about that.  For
what populations?  Well, for minorities, for central city, and
for rural.  Those are precisely the same population groups at
whom we are to this day aiming outreach programs.

Wilson:  That's right.

Lindberg:  Can you remember any of the things RMP might have
done, or did do, that facilitated access for health care to those
groups?

Wilson:  We thought we were pointed directly at it, although the
work was terminated before it could reach fruition.  Take the
automated patient history acquisition.  That deals with the rural
group and was beginning to deal with the illiterate patient.  As
you will recall, we were beginning to use the screen--or you and
Jack Bass were beginning to use the screen and diagnosis and
pointing and back up from the language obligation for diagnosis. 
It is clear, absolutely clear, that physicians must change their
pattern.  Any physician who is trying to carry around in his head
all of the knowledge that's needed for even a discipline anymore
is just destined for an end.  Regional Medical Programs, of
course, was trying to deal with it, and your Grateful Med at the
present time surprises me, and I'm very grateful for Grateful
Med, because it's doing what the Regional Medical Program was
trying to do, and that is to take to the rural or to any audience
the information you had.  
     Let me put in one more plug and quit.  I said then, and I've
said many times in between, that there is one great unemployed
person in the medical group, and that's the patient.  

Lindberg:  Yes.

Wilson:  Until there is found a way to make that person an active
participant and contributor, it's going to be very difficult. 
Again, you know, given time, that will occur.  That's, of course,
one of our legacies from Regional Medical Program.

Lindberg:  Following up on that, I'd like to ask you about a
criticism that I read in the testimony.  A person said that RMP
was provider-dominated and comprehensive health planning, a
different program, was consumer-dominated.  Do you think that's
right?  What's the sense of that?  

Wilson:  No, no.  The AMC got in its licks as the programs were
distributed, and they still hadn't come to a dynamic balance.  It
is true that the implementers were largely professional people,
but that's where they were, and we had to train the participants. 
If you look at the advisory councils, there was plenty of public
representation on them, and if you go talk to those people at
this stage of the game, they're still enthusiastic.  It wasn't
only the people who got the money; it was the participants.

Lindberg:  As you know, currently the federal advisory law, the
committee law, requires consumers on the panels and they're often
the most valuable contributors, but it is a problem that once you
pull out of line a representative consumer, he or she is no
longer representative.  

Wilson:  That's right, a professional consumer.  But, you know,
there is no way to avoid that.

Lindberg:  No, I don't think so either.  Another question I'd
like to ask about the criticism that we see in retrospect was
historically the change in focus on RMP between something
categorically having to do with heart, cancer, stroke, and then
later kidney disease was added for you.  Then the alternative
mode, which was just a general focus on improved health care
delivery, health services research, what will you,
undifferentiated, systematic improvement, did it change?  And why
did it change?  Was it helpful to change?

Wilson:  No, it was not helpful to change.  That was part of the
static in the system as they geared up to eliminate the program. 
It was confusing to the coordinators.  I think that's literally
true.  They never understood.  As in Red Ward and other people's
papers, they couldn't understand it.  The politicians didn't
understand it, and the testimony is very clear that they're
asking questions about the previous incarnation and the program
people are trying to respond to the administrative direction.  I
think that was just the cacophony, kind of the throes as the
giant was sort of wandering off to die.  You know, the event was
determined just where and how it was going to occur.
     The suit at the end, you know, that's my only knowledge of a
suit of that kind in order to keep legislation in existence.  It
had the end results you should expect; it just prolonged the
agony, was all.

Lindberg:  The patient was on resuscitated measures for a while.

Wilson:  That's right.  But non compus mentis.  

Lindberg:  What do you think the world would have to learn from
RMP?  Does it resemble any system anywhere else in the world?

Wilson:  No, I think not.  You know, I've made the cruel comment,
but I think anybody who tries to learn from this is probably only
going to learn, other than the mechanical lessons, the transfer
of technology and the use of TV, that's easily transmittable, but
you're talking, I think, about the program, as a program.  I have
more respect for the democratic process now than I had before I
entered that fray.  I think the people in Congress are attempting
mightily to referee the contentions that come out of the public
and come in the form of requests, and they're very jealous of
that prerogative.  
     RMP did one of the unforgiveables: it tried to take over the
political process.  If we learned anything, we've got to learn to
leave the politics to those in the political arena and let the
professionals and the lay public do what they can do well, handle
the program end of it.  If there was a tactical error made that
was at least partially responsible for the failure of the
program, I think that was it.

Lindberg:  That's very interesting.

Wilson:  And it was epitomized then by that suit at the end. 
They got a little bit more money and the program lasted two or
three more years, but they had missed the point, and that was
they had defended the system which had to cooperate to do the job
that they were going to do.

Lindberg:  If you look comparatively, both the Dutch and the
Swedes expend a tremendously much greater effort than we do in
getting kind of a community consensus, an expression of community
desire and acceptance before they operate programs.  RMP got
closer to that than any medical setting I've ever seen in my
life.

Wilson:  Yes.  The Public Health Service has tried to do that and
tried very valiantly to do it, but they worked from the wrong
base.  I have never seen before or since the kind of
collaborative endeavor that evolved in the state of Missouri. 
Despite the accusations made in testimony, that was not along
political lines, geographically.  It didn't have to be a
politically geographic base.  It was people who were doing a job. 
They forgot the political lines and really went to work.  But we,
more than most of the groups, also stayed out of the political
scene.  We left the politics to the politicians.  I would hope,
if we do it again, that we might learn something.

Lindberg:  I've never seen a set-up that had more plenteous or
better community and consumer input than the Regional Medical
Program activity.

Wilson:  In Missouri, the governor turned to us for the
comprehensive health planning, and then when they came up with
the kidney program--and Buck Rickley [phonetic], I'm sure, will
give you much more on this--they turned that over to the Regional
Medical Program.  There was a real community trust--which is the
word.  Wyeth Hamlin [phonetic] in Hannibal, Hector Benois
[phonetic] in Kansas City, Glen Turner and Walt Tillman, Clark,
all of those people became warm not only to the university, but
to the task it was accomplishing.  

Lindberg:  In closing, I want to pay tribute to you.  I think you
did a marvelous job as the dean and as the coordinator of RMP,
and I'm sure you did in Washington, too.  It was every minute a
pleasure working with you.  Thanks for being with us.

Wilson:  Thank you, Don.

[End of interview]
                           Addendum to Interview

Q:  Could you feed that back to us one more time?  That was a
great line.  It had to do with in '72 when the plans were being
made and when the death sentence came down, it was inevitable,
etc.

Wilson:  If I remember correctly, this had to do with the fact
that they had announced that the program was going to be ended,
even while we were active in the business of requesting money.

Q:  That's right.  Okay?  Just look and talk to Dr. Lindberg. 
Tell Dr. Lindberg about the death sentence.

Wilson:  We were dealing in this stage with the decision to
discontinue the program, and Bob Ball and Eliot Richardson and
others were struggling with the entitlement programs.  HEW, in
turn, was struggling with its total budget and, of course, Nixon
was trying to make that fit into the national pattern.  They had
long ago come to the conclusion that only 15 percent of that
budget could be maneuvered, and in that 15 percent lay Regional
Medical Programs.  
     So when that became evident, then the decision-making came
back.  I think I used the comparisons of the wolves and the
caribou.  The weak ones came out.  In this case, RMP had no
political base really from which it could work.  It had too many
conflicting directives.  

Q:  Should we wipe a tear away?

Wilson:  Yes, wipe a tear away.

Q:  When you were administrator of HSHMA, you made a point in
there where you said you're sitting at there looking at its
competition, and you specifically said seventeen programs.  Could
you just give us a statement that the situation that RMP found
itself in, in your organization, that it was having to compete?

Wilson:  The budget of the Health Service and Mental Health
Administration varied during the time I was there, but ran from,
as I recall it, $1.9 billion to about $2.75 billion.  The amount
that went to RMPs, as in the record, varied, but it was always in
a matter of small number of millions of dollars.  There were
seventeen programs, all of them dealing in this money that was 15
percent of the budget.  That was all appropriated money. 
Therefore, RMP was competing in house with the other programs and
they invited me very deliberately to decide between the children. 
"Here's a limited amount of money and everybody's going to be a
little bit hungry.  Which ones are to be the hungriest?"  So that
RMP found itself in need of very strong leadership, and I found
myself in a position of being a very partisan person personally,
but not being able to use that to work in the program.  

Q:  The other interesting thing, tell us in a statement, as short
and concise as possible, your reaction to the suit that was filed 
after the walls came tumbling down.  

Wilson:  I learned about the suit in the reading of the
testimony, so I think Buck Rickley, who will be in a subsequent
meeting, can give you much more about that, what came out of the
coordinators' group.  I was happily the vice chancellor of the
Vanderbilt University at that stage of the game.  [Laughter]

Q:  The best unrehearsed spontaneous response we got yesterday
was, "Where were you when the famous telegram went out, and what
was your reaction?"  Just give us a statement about when Dr.
M_____'s telegram was sent out.

Wilson:  See, I was back at the University of Missouri.

Q:  You were gone by then.

Wilson:  I was called by Eliot Richardson in November in Puerto
Rico and told that he had been graduated to the Department of
Defense and, unfortunately, could not take anyone with him.  So I
simply said, "I'll exit the first of January."  Of course, that
telegram came after that.  
     Part of the business, we were dedicating a hospital, the
Public Health Service Hospital in Puerto Rico.  He had as much
feeling about it as I did.  They just told him he could not take
anybody with him over to Department of Defense.  It was that
simple.  It was a cruel time.