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Interview with Dr. Arthur E. Rikli
Date:  July 25, 1991
Location:  National Library of Medicine
           Bethesda, Maryland
Interviewer:  Storm Whaley 
Transcriber:  Techni-type Transcriptions/DDR



Whaley:  Since we've been friends for many years, I don't know
how I can call you other than Buck, so I hope you don't mind.

Rikli:  I hope I can say Storm, too.

Whaley:  Very good.  Would you give us your professional
background, your career?  I think it is relevant to the Regional
Medical Program story.

Rikli:  Storm, I think that I was probably in Regional Medical
Programs before the president signed the bill on October 5, 1965. 
I served as a regional medical consultant in the field of chronic
disease for the Public Health Service and then I came to
Washington, became Chief of the National Heart Disease Control
Program, and while serving as the Assistant Director of the Hill-
Burton Program, Dr. Vernon Wilson called and asked if I'd be
interested in joining the staff of the University of Missouri
College of Medicine.
     Then on February 1, 1968, I accepted that appointment and my
primary responsibility then was to serve as the coordinator for
the Missouri Regional Medical Program.  At the end of that
program, I continued to serve as the Coordinator of the Missouri
Kidney Program.  The Missouri Kidney Program was created by the
Missouri Regional Medical Program, and today it is funded at over
$4 million a year.  
     That's a thumbnail sketch, Storm.

Whaley:  That's very interesting, Buck.  You were here in
Washington at the time the Regional Medical Program was
conceived.

Rikli:  Yes.

Whaley:  What can you tell us of the intellectual and political
ferment that led to it?

Rikli:  Probably the United States spends more money on
biomedical research than any other country in the world, and
President Johnson, with his great foresight, felt that some of
these products of research should be made available to all the
people in the country, those people in rural areas, minority
groups, and all the individuals who were not in ready contact
with medical centers.  As a result, he called upon the very
distinguished Dr. Michael DeBakey to head up the Heart, Stroke,
and Cancer Commission.  As a result of that commission, the
Regional Medical Programs [was established].  Incidentally, the
Regional Library Programs were also established.

Whaley:  In your role in the Public Health Service, you were in
regional programs, you said, even before RMP began.

Rikli:  That's true.  That's true, Storm.

Whaley:  What were they?

Rikli:  Strange as it may seem, they were heart, stroke, and
cancer.  I started out in tuberculosis and then we also had
diabetes and kidney diseases, so that the Public Health Service,
of course, has been interested in the major killing diseases, so
to speak, for its entire career, since it started, actually.

Whaley:  When you went to Missouri, did you start the program
there?

Rikli:  No, I was fortunate that Dr. [Donald A.B.] Lindberg and
Dr. Vernon Wilson had made a national study of how computers
might be used in the doctor's office or assisting in the medical
profession in taking care of patients.  As a result of their
program, I was called on to really deliver their baby, so to
speak, and so I served as the coordinator after Vernon had
started the program.  I was there February 1, 1968.

Whaley:  Were there other programs in the Missouri area?  Wasn't
there one in St. Louis?

Rikli:  Yes.  Actually, the country was divided into fifty-seven
different Regional Medical Programs and they were not necessarily
divided up along state lines.  However, the majority did end up
along state lines.  We tried very hard to have the state of
Missouri be the Regional Medical Program, but St. Louis chose to
become Bi-state Regional Medical Program.  So it was part of
Missouri and part of Illinois, an excellent program.  Bill
Stoneman was the coordinator of that program.

Whaley:  Was there something at Kansas City?

Rikli:  Yes.  Kansas City was part of the Missouri program, and
Gray Diamond was there where the new medical school was
established, and the Missouri Regional Medical Program was of
assistance to them in getting the Missouri Medical School in
Kansas City off the ground.  

Whaley:  Medical schools were essential to the development of a
region for a Regional Medical Program, is that true?

Rikli:  Each Regional Medical Program required a medical school
to be associated with it, and I've forgotten the basic
population, but I think it was somewhere around 2 or 3 million
people.  

Whaley:  So the University of Missouri Columbia was the base of
the Missouri Regional Medical Program.

Rikli:  That's correct.  Dean Mayer actually followed Dr. Wilson
as the dean of the school of medicine there in Columbia, and that
was the cooperative effort between the school and the providers
and consumers of health care throughout the entire state, was the
basis for establishment of Regional Medical Programs in Columbia,
Missouri.  

Whaley:  Do you remember some of the programs other than the ones
you've mentioned as continuing out of that program?

Rikli:  Certainly some of the most dramatic things are those that
were computer-related programs.  We started out with one of very
special interest to me, and that was the computerization of
electrocardiograms and then one that Dr. Lindberg actually
started, called Consider.  This was a differential diagnostic
system that used computers as a means of identifying the cause of
disease in an individual.  The program preceded what today is
called an Expert System or probably artificial intelligence.  So
that was really a pioneering effort in that area.  
     Another project which was of great interest was one called
APHAS.  APHAS stands for--let me see if I can remember what it
stands for--the Automated Physicians History Acquisition System. 
How about that?

Whaley:  Good job!

Rikli:  That wasn't easy.  Dr. Simmons was the project director
for APHAS, and the key to that was taking pictures and trying to
break through the language barrier by using pictures of someone
who had a headache or stomachache or identifying where on their
body that particular pain might be located, and then the patient
would see these pictures and would be able to give a history to
the doctor without the doctor having to spend his time and also
overcoming the language barrier, a very innovative effort.
     The one that I'm particularly interested in today as kind of
the predecessor, I think, of the Grateful Med and Lonesome Doc
Program of the National Library of Medicine was called the Stroke
Fact Bank.  What they did there was store current medical
literature on microfiche.  We were able to retrieve from that
Mosler 410, I think it was, the big machine that had all this
information in it, in about fifteen seconds, any single page in
current medical literature.  This was available to the doctors
over the telephone, and we could actually send them hardcopy of
those documents if they wanted it.

Whaley:  Did you have any community programs away from Columbia,
out in the state?

Rikli:  Oh, yes.  We had many programs out in the community.  One
of the most influential ones was Springfield, Missouri, of
course, where Glen Turner was the project director.  He was
particularly interested in cardiovascular disease and he came up
with the concept of what's known as the Springfield Wall.  That's
where he took all this equipment that had been stored all around
the patient's bed and put it in the wall with plug-in.  So it was
one of the early efforts to put the instrumentation for the
cardiovascular patient into the wall.  Springfield is one of our
programs.  

Whaley:  What was the reaction of the established medical
community in Missouri to Regional Medical Programs?

Rikli:  I think that as far as Missouri was concerned, we had
extremely good relationships with the medical society, and
probably Dr. Vernon Wilson was instrumental in bringing that
about, not only in Missouri, but he played a prominent role in
bringing the medical group across the country into the Regional
Medical Program.  They were very skeptical of it initially and
put some rather strong restrictions on what we could and could
not do, but we had good cooperation from the medical society in
the state of Missouri.  

Whaley:  If I recall, each Regional Medical Program had to have a
council or a board or a committee that was advisory, at least, to
the director of the program.  Did you have one?  And what was its
composition?

Rikli:  We started out with Mr. Nate Stark [phonetic], who was
with the Hallmark Company, as our first chairman of our RAG, I
think we called it, Regional Advisory Group.  Our group, I think,
was made up of about twenty different people, both consumers and
producers of health care services. It was a pleasure for me to
work with them.  Following Dr. Nate Stark--I keep calling him Dr.
Nate Stark.  He may be a doctor of law.  I think his profession
was law.  He was followed by Wyeth Hamlin, Dr. Hamlin, and then
Bob Frank, who was the president of Barnes Hospital served as
chairman of our Regional Advisory Group.  
     Missouri was a little bit different than some of the other
groups.  We also had a liaison group that backed up the Regional
Advisory Group on which all of the voluntary and other related
groups were represented.  So we had our Regional Advisory Group
and the liaison group.  

Whaley:  If I recall, the grant applications for Regional Medical
Programs were quite complicated and relatively large, even for
present time.  Do you recall much about your budget and
applications?

Rikli:  Certainly a lot of time was required in writing up our
regional applications for grants.  At one point I believe that
the Missouri Regional Medical Program had an appropriation of $5
million for the year.  The grant proposals took a lot of time and
for good reason.  The different communities across the United
States certainly had all different ideas as to how to solve the
medical care problems of their people.  As a result, there was
great variation in the composition of our grant applications.  I
think this caused a problem for the national administrators who
had to come up wit a mission statement that reflected all of the
different desires of the providers and consumers of health care
services across the country.  As a result, it was rumored that
the national Regional Medical Program was a program in search of
a mission.  I thought that was a very unfair criticism of those
of us who were trying to do our best to satisfy the local needs.

Whaley:  In response to that criticism, how would you evaluate
what Regional Medical Programs nationally accomplished?

Rikli:   I think that a significant point is that Regional
Medical Program was not just a talking program; we didn't just
talk to the providers and the consumers of health care services. 
We were actively engaged in providing them technical assistance
and financial assistance so that they could actually produce and
realize their plans to carry out better health services to meet
the heart, stroke, cancer, and kidney patients in their local
areas.  

Whaley:  You mentioned earlier the business of the relationship
with the medical community.  Do you think Regional Medical
Programs had a role to play in the amalgamation, if you call it
that, of the medical faculties into the practice communities?

Rikli:  I'm glad you asked that, Storm, because I think that's
one of the major benefits of Regional Medical Programs that has
not been realized.  I think the Regional Medical Programs really
built an active bridge between the medical school and the
providers of health care, not only in their immediate area, but
out in the rural areas, as well.  So the Regional Medical Program
still has that benefit in most of the communities and regions
where they were set up originally.

Whaley:  You mentioned earlier some of the lasting monuments, one
might say, to the Regional Medical Programs in Missouri.  Maybe
if you'd give those once again and how they started and what
they're doing now.  

Rikli:  Probably the most important was the improvement in
communication facilities.  Back about that time, twenty-five
years ago, we had programs called Telemed, for example, which
linked together many of the hospitals in the state of Missouri
with the university, and we were able to not only give lectures
over that Telemed out to the communities, but also they could ask
questions of the professors who made these presentations.  Of
course, that's common practice today, and also on television.
     Then one of our more exciting projects was called the
Automated Physician's Assistant.  Here in Salem, Missouri, Dr.
Billy Jack Bass, a country physician, was able to line up in his
office an automated history-taking system and other data
acquisition devices to relieve him of the tedious task of
collecting this information.  As a result of this dual method in
his office, which either the patient could accept the automated
system or the manual system, and interestingly enough, many
patients preferred the automated system, so that I think that
patients are less afraid of computers than are many physicians. 
This project was a very controversial, but most fascinating
project, that we had in the program, and it certainly was
bringing modern medicine out to the rural areas in Missouri.

Whaley:  What would you say, Buck, was your favorite of all the
activities of RMP in Missouri?

Rikli:  I can't pass up the computerized electrocardiogram,
because that was of interest to me before I came to Missouri, and
certainly computerization of medical activities is one of the
most fascinating things, but I think it was a special privilege
for me to have an opportunity to take the innovative ideas of Dr.
Lindberg and Dr. Wilson and the providers and consumers of health
care services in the state of Missouri and try to really bring
that to the people out in the rural areas, so that that was just
a great challenge.  Incidentally, I think we did a pretty good
job.  [Laughter]

Whaley:  What was your relationship with directors of RMPs in
adjoining states or adjoining areas?

Rikli:  There was a regular meeting of the coordinators of
Regional Medical Programs, and we found that an exchange of
information with each other was very useful in going back and
trying to solve some of the problems that each of us saw in our
communities.  As I mentioned, Bill Stoneman was in Kansas City
and Bob Brown was in Kansas, and those were the ones that we
worked most closely with.  

Whaley:  We are talking about the history of Regional Medical
Programs, and it's a little odd to be talking about history
because it means that it's a thing of the past, in a sense.  Why
do you think that happened?

Rikli:  I think that you're asking the critical question.  Why
were Regional Medical Programs terminated?  The national
administrators saw fit to say that they didn't think the Regional
Medical Programs were worth the $500 billion that had been spent
on Regional Medical Programs.  Well, I think they incorporated in
their answer part of the truth, and that is the pursuit of money
or the demand for money by other programs really was responsible
for the termination of Regional Medical Programs.  
     It was at this time that the administration was able to get
many of its favorite programs passed that they had wanted,
Medicare and Medicaid, and others, the National Health Services
and Resource Development Act.  They wanted to put this money that
was in Regional Medical Programs to other use, and, of course,
the change in administration from President Johnson, who was the
originator of the program, to President Nixon, who had different
priorities for use of those funds, probably explains why the
demand for dollars was the reason for the termination of the
national Regional Medical Program.

Whaley:  How did the program end in Missouri?  What were the
steps that led to its dissolution?

Rikli:  It was certainly difficult to terminate the program
because we had a number of very wise and dedicated people working
in the program.  Gayle Adams was from the engineering school and
Gayle Banks was in charge of continuing education there in the
medical school.  John van Penin [phonetic] in the laboratory
played a prominent role, and also Gil Lodwick [phonetic] from the
radiology department.  So these people had really put their
hearts into the projects that helped make up the Regional Medical
Program.  As a result, they had to terminate.  However, what they
did was many of the things that they learned or had experienced
with Regional Medical Programs became part of their permanent
ongoing program, such as the kidney program which started out at
approximately $100,000 and today is funded at over $4 million a
year.

Whaley:  What have we learned, then, from this brief and shining
hour?

Rikli:  What have we learned?  Well, I think, number one, is that
it's very difficult for a program to carry out its mission if you
don't know if you're going to have dollars next year to carry it
out and if, at the same time, somebody is changing your mission
statement each year.  I think the national administrators had
difficulty coming up with uniform guidelines to try to solve all
of the local communities' health care problems.  So that one
thing is you've got to be sure you have money coming, and you
have to have a fixed mission statement if you want to perform
well as a national program.
     Next I think we might give some thought to the basic
premises on which Regional Medical Programs were established. 
Number one, the products of research.  We didn't have products of
research in heart, stroke, and cancer like we have in smallpox,
for example.  If Regional Medical Programs had markedly altered
the mortality rate from heart, stroke, and cancer, it would have
been difficult to terminate them.  
     Incidentally, the mortality rate for cardiovascular disease
has been reduced from--I believe it's around 250 per 100,000 to
approximately 150 per 100,000.  But the mortality rate for cancer
has been essentially unchanged between 1970 and 1988.  It
suggests that there was some difference in the nature of the
products of research for heart disease than for cancer.  
     As a result, I think that we have to wonder were the
products of research really of so much impact that we could
expect a marked change in the mortality and morbidity information
as far as heart, stroke, and cancer patients were concerned.  And
was there really a time delay in putting these products to work? 
Did the Regional Medical Programs really have the authority and
time to do the job that was assigned to them?  I think those are
some of the critical issues that we must remember when we start
to consider new delegation to solve the problems of the leading
killers in the United States.

Whaley:  Do you have any other thoughts you would like to add?

Rikli:  You've given me a chance to air most of my views, I
think, Storm.  I guess that my concern really rests more on the
products of research that we had.  We have dealt with the risk
factors in cardiovascular disease while I was serving as director
of the National Heart Disease Control Program.  We were trying to
put those products to work.  If you look at the mortality curve,
you will see that starting back about that time is when things
changed.
     One other point that we didn't get a chance to make is that
really the treatment of the acute coronary patient has changed
dramatically since Regional Medical Programs put on its original
demonstrations of moving the ambulances from the morticians'
office to the hospital, and then having the ambulances manned by
personnel who are adequately trained in taking care of living
people, if you get the point.  Of course, then along with the
trained people, communications between the ambulance and the
hospital, permitting them to run electrocardiograms over the
wires and getting information and directions actually from the
hospital to assist them in the care of the patient.  The
establishment of coronary care units in hospitals was another
great improvement.  
     So probably one of the major benefits from Regional Medical
Programs has been accelerating the application of the products of
research for cardiovascular disease patients.

Whaley:  Buck, thanks very much.

Rikli:  It's been a pleasure to be with you today, Storm.  Thank
you.

[End of interview]
                           Addendum to Interview

Q:  Just talk to Storm as you did before and sort of phrase it in
statement form so it will stand by itself.  

Rikli:  I think the outstanding activities of the Missouri
Regional Medical Program was the use of modern communications
equipment, modern technology, and transfer of medical knowledge. 
In addition to the use of computers in medicine, as we did in the
Stroke Fact Bank, the program Consider, the Automated Physician's
Assistant was the continuing education activities providing more
rapid transfer of technical information to the doctors and nurses
in hospitals.  We also were actively involved in bringing
together doctors and consumers in trying to solve their common
problems.  

Q:  Would this have happened without the Regional Medical
Program?

Rikli:  Many of these activities had been in the minds of doctors
and the university prior to Regional Medical Programs, but
Regional Medical Programs was the change agent which really made
it possible for these people to get together and solve some of
their common problems.

Q:  Stop tape.  That was the line I was looking for.  That should
do us.