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Interview with Dr. Paul Sanazaro
Date:  July 31, 1991
Location:  National Library of Medicine
           Bethesda, Maryland
Interviewer:  Diane Rehm
Transcriber:  Techni-type Transcriptions/DDR



Rehm:  The interview you are about to see is one of a series
designed to record and document the history of Regional Medical
Programs.  My guest today is Dr. Paul Sanazaro, Emeritus Clinical
Professor of Medicine at the University of California at San
Francisco.  Dr. Sanazaro was a Consultant to the Division of
Regional Medical Programs in its early days, then he worked for
the Department of Health, Education, and Welfare in the area of
health services research from 1968 to 1973.  
     Welcome, Dr. Sanazaro.  It's good to have you here.

Sanazaro:  Thank you.

Rehm:  Talk a little about what the RMPs were.  What was the
thinking behind them?  How did they come into being?

Sanazaro:  That's a tangled tale.  It goes back to the late
fifties.  Mary Lasker at that time was a strong advocate of
clinical research.  She had a great deal to do with the funding
of the National Institutes of Health.  Late in the fifties, she
became particularly focused on heart disease and cancer as very
important conditions.  She happened to be a close friend of the
Kennedys, and she suggested to President Kennedy at that time
that he look into this, but he was occupied by things like the
Bay of Pigs and so forth, and nothing much came of that.  
     But after Kennedy's assassination, President Johnson was
also interested in these issues, and he took up this theme and
appointed Michael DeBakey, who is also from Texas and Houston, as
chairman of this [President's] Commission on Heart Disease,
Cancer, and Stroke (now), because the senior Kennedy had had a
stroke.  That commission completed its work in a very short time,
less than a year, and basically what they recommended was two
things.  One is that they increase the amount of support for
research in heart disease and cancer in order to prevent them,
and at the same time that deliberate efforts be made to bring the
benefits of this research to the people.  DeBakey's idea was that
we have centers of excellence.  They were called regional
complexes.  They were intended to be actual buildings, hospitals,
specialty centers, through which would flow the results of
research and in the form of improved diagnosis and treatment of
patients.  So originally the proposal was for regional medical
services, regional medical complexes.
     Two bills were introduced with that in mind, one in the
Senate, one in the House, and in the course of the summer,
various groups from organized medicine made it be known that they
could not possibly approve the creation of regional medical
complexes if this meant disturbing existing relationships.

Rehm:  Oh, I see.  They didn't want anything new to interfere
with that which was already in place.

Sanazaro:  Well, they didn't object to anything new; they
objected to interference.  So the law specifically states that
whatever was done should not interfere with existing patterns of
financing, of care, and so forth.  As a result of that, what came
out was not regional medical centers, not regional medical
complexes, not regional medical services, but Regional Medical
Programs, where there was to be local initiative, local planning,
local direction, and under no circumstances was there to be
federal direction.

Rehm:  How soon were you involved in the process?

Sanazaro:  It was after the bill was finally enacted, RMP 89-239,
and 89th Congress.  Dr. [Robert Q.] Marston was appointed the
director of the program, and he convened a group of us to talk
about what all this meant.  We convened there.  We were known as
the Pooks [phonetic] Hill Mob because we stayed at the Pooks Hill
Hotel.

Rehm:  Did you think it was a good idea?  Did you think it had
real potential for doing what it was setting out to do?

Sanazaro:  Yes and no.  The basic idea, of course, is a permanent
good idea, that there's no point in doing all this research
unless the benefits come down to the people, and to pick priority
conditions like heart disease and cancer, that's also a good
idea.  The problem was that RMP, the legislation, was one of over
thirty bills in the health area.  So as someone said, health
legislation had been bottled up for over thirty years in the
Congress, and when the door opened for Medicare, everything came
through, whether it made sense or not.  Remember that after the
assassination, there was a mood of self-recrimination, and I
think the Congress was in an idealistic mood and wanted to do
what was good and what was right.

Rehm:  That's fascinating that you feel that somehow the
development of the RMPs came directly out of that assassination
experience.

Sanazaro:  Well, all that legislation came.  President Johnson
had been a Special Assistant to Franklin Roosevelt in 1935 and
was there to see how quickly Roosevelt lost his clout with
Congress after the election.  Roosevelt had a landslide election,
but within two years he was powerless.  Johnson knew that if he
was going to do anything, he had to do it in his first two years,
so he put all of the health measures together, the OEO programs,
the Civil Rights Act, and all the rest of it.  It all went
through in a rush.  As a result, there were fiefdom problems,
see, and the biggest one, of course, was comprehensive health
planning and RMP.  But the basic idea was sound.  
     The unsoundness was created by the change in legislative
language.  There was to be no federal direction.  The only
federal direction was that there were to be regions agreed upon
locally, they were to be funded centrally, but the allocation of
funds was based upon what had been locally decided.

Rehm:  And all decisions, then, would be locally made.

Sanazaro:  That's right.

Rehm:  Not just those regarding money, but exactly how each
program would be carried out.

Sanazaro:  The central function here in Washington, Bethesda, the
National Advisory Council, was simply to look at the merit of the
proposals, the likelihood of success, not whether they were
germane to the program or not, because obviously it's a very
broad mandate.  
     So because it was local initiative, because it was so broad,
because health care is a bottomless pit, the money that was
available for RMP is a little bit like thinking you're going to
irrigate the Sahara Desert with a garden hose.  That's about it. 
So the money, while it seemed like a large amount, was pitifully
inadequate to do anything significant across the country, much
less even in one area.

Rehm:  Did the fact that there was so little federal direction
create greater problems for the RMPs because the initiative was
left primarily to those local groups?

Sanazaro:  I'm not sure it created problems.  It contributed to
the fact that RMP ended up not producing much in the way of a
tangible product.  I don't know why there was even the
unwillingness to give technical assistance.  For example, I
worked with Stan [Stanley W.] Olson during the years that he was
here.  He became the director of the RMP after Bob Marston.  Stan
always said, "You know, we need better evaluation.  The RMPs
simply aren't evaluating what they're doing, and we're not being
able to go up on the Hill and tell Congress, 'Look at this great
stuff we're doing.'"  But yet he never offered any technical
assistance.  His people never offered any.  I think that might
have made a difference. It might have given some better focus to
how to show something, and that, of course, is why the whole
program collapsed in the early seventies.  They were unable to
show anything real, tangible.

Rehm:  I want to get to that more in detail, Dr. Sanazaro. 
First, though, when the RMPs were created, you were serving as
Director of the Division of Education for the Association of
American Medical Colleges.  How did that organization, the AAMC,
and the nation's medical schools react to the creation of the
RMPs?

Sanazaro:  Again, the language and the guidelines that were
published specifically mentioned medical schools, medical
centers, as the logical basis for carrying out the grand scheme. 
In other words, tertiary-level care for the target diseases at
these centers of excellence, and then flowing out through
cooperative, voluntary, cooperative agreements, to clinics, to
community hospitals, to practitioners' offices and so forth.  So
medical schools had a keen interest in this.  Also, medical
schools knew how to apply for federal money, they had had
experience through all the research and demonstrations programs,
and it was natural for them to take a leadership role.  But that
leadership role was very often self-centered, obviously, and so
the AAMC was not directly involved in that sense.  They supported
the legislation as a national organization of medical schools,
but not because they saw this as a great, new mission for medical
education.  
     I was involved not as a representative of the AAMC, because
I became Chairman of the Health Services Research Study Section
and we'd been studying the organization, delivery, financing,
quality of health care in this country and abroad.  Dr. Marston
asked me to sit on the group, with that background, and that was
my perspective.  But I was sitting alongside of practitioners,
hospital administrators, medical school faculty, each of whom saw
this new whatever it was going to be in their own way.

Rehm:  Yes.

Sanazaro:  You see?  So there was no unanimity of perspective. 
The goals were very broadly stated.  What was mainly stated were
the limitations, what it should not do.

Rehm:  What did that mean as far as cooperation among those
various groups?  Or the lack thereof.

Sanazaro:  Well, no.  Those that knew how to cooperate,
cooperated.  Those that were already cooperating found out how to
cooperate better.  This was probably the main objection to
continuing the RMP program.  It really didn't bring about major
change, you see.  They could never point to a body of people with
target diseases that were better off as a result of it.  So the
cooperative arrangements were very narrowly focused.  They were
around training programs, setting up specialty units, setting up
computer systems, communication systems, television networks,
continuing medical education programs, and many people wondered,
"Where is the care part?"

Rehm:  But as I understand it, care was not necessarily a part of
the initial thrust.  It was supposed to have been far more
primarily education.

Sanazaro:  You're right, and the reason is that that was the
least controversial function in all of RMP.  Everyone could agree
that education improves the care of patients.  It doesn't
interfere with any existing relationships.  But, unfortunately,
they didn't examine the fundamental premise, that continuing
education is a very inefficient way to improve practice.  It
really is very ineffective.  So all the money that was spent in
that provided some benefit by improving technology, the
techniques of medical education.  The use of television, for
example, came into its own as a media for continuing education
under RMP.  But that didn't improve care.  So you rarely saw
direct services there.  
     So the cooperative arrangements were institutional
agreements, where there was money traded for training, for
setting up a special facility, but nothing emerged that compared
with the original idea of centers of excellence, satellite
distributing points, reaching out into the community where
populations would be benefited by the results of research.  That
never emerged anyplace.

Rehm:  And why do you feel it didn't, Dr. Sanazaro?  What were
the stumbling blocks there?  Was it a lack of clear direction on
the part of the federal government?  Was it a failure to work out
the channels by which the kind of work that you're talking about
could actually come about?

Sanazaro:  It's an easy question to ask.

Rehm:  A difficult one to answer.

Sanazaro:  It's complicated.  If you think about it, what you're
talking about is the regionalization of services in a natural
trade area, medical trade area.  Britain has that, Sweden has
that, but they have that because they've been doing that for over
100 years.  Now, in this country we have individualism, we have
pluralism, and we pride ourselves on that.  There is no place
where you have a large region, that truly has regionalized
services.  Now, as a result of RMP, I will say, many years later,
you do have regionalized trauma centers. The one at Maryland is a
classic national example, one in San Francisco.  You do have
regionalized perinatal services.  You're now having much talk
about regionalizing open heart surgery.

Rehm:  You seem to be suggesting, Dr. Sanazaro, that it was an
idea too early for its time.

Sanazaro:  Exactly.  Exactly.  The fallacious assumption was that
there were enough people in this country at that time who knew
how to analyze what needed to be done in order to bring this
about.  In fact, there were very few people.  One of the very few
people was Dick Weinerman [phonetic], professor of epidemiology 
at Yale, and his original plans for the RMP would have come
closest to actualizing what the intent had been originally. 
Unfortunately, he was killed tragically in a plane crash in
Israel, so the Connecticut RMP went the way of all RMPs, with
little bits and pieces here and there, but no grand scheme.

Rehm:  Considering the fact that I'm sure you and others saw the
difficulties as the program moved along, was there an effort to
revise, revamp programs as the program progressed?

Sanazaro:  The only revision was made by the administration in
1970 when to the categorical programs they added primary care,
again because of the lack of evidence that it was doing anything
for initial diagnosis and treatment, and they added care for the
poor.  This simply compounded the difficulty that already existed
with clearly defined categorical diseases, heart disease, cancer,
stroke.  
     But in terms of program administration, no, there was no
redirection, because, again, the message is very clear from
organized medicine that this must be based on local initiative
and it must not disrupt existing patterns.  So what's the
difference between improving and changing?  RMP was not supposed
to change anything, but it was okay to improve some things.

Rehm:  Are you suggesting that perhaps organized medicine was in
some way an impediment to the forward movement of the program and
the effectiveness of the program?

Sanazaro:  Let's say it's a matter of record that at the time of
the legislation, before it was enacted, the organized medicine,
the President of the American Medical Association notified
President Johnson that if the regional medical complexes were to
be enacted into legislation, organized medicine would not support
the passage of Medicare.  Medicare clearly was a higher priority
than RMP, and President Johnson, I mentioned, had been in
Washington in 1935.  Medicare was part of the original Social
Security legislation of 1935.  Many attempts were made to
subsequently pass it, always defeated because of the opposition
of the AMA.  AMA, once again, threatened to lobby against
Medicare, so Johnson acceded and allowed the intent of RMP to be
changed.

Rehm:  The thrust of complaints about RMPs that I have read
suggest that they were trying to do too much.  Not only were they
not focused, but there was not a sufficient limitation to their
ambitions, that they were trying to get into both education and
delivery and health care.  So that made it less effective a
program than it might otherwise have been.

Sanazaro:  I mentioned the poor analogy of irrigating a large
area with a small hose.  When you talk about improving health
care, you're not talking about a simple process; you're talking
about an enormous array of interacting factors.  So when you say
"improve," and that improvement has to be approved locally, it's
natural that in some areas, say, someone says, "Let's do it
through education," someone would say, "Let's link up our
laboratories," someone says, "Let's put in telephone lines so
that doctors can call in," someone says, "Let's just check how
well we're diagnosing and treating patients." It's to be
expected, when you have fifty-five different programs, that
you're going to have an enormous variety of little bits and
pieces.  Unfortunately, you put them together and they don't make
a pretty mosaic that you can understand.  

Rehm:  Dr. Sanazaro, what was the most exciting element of your
own participation in the RMPs?

Sanazaro:  Oh, the initial enthusiasm and expectation that
through this vehicle it would be possible, for the first time in
the United States, to put together good basic epidemiological
information on what people needed for their diagnosis and
treatment, and then actually direct the efforts of RMP in accord
with those findings.  That's where the excitement came for me. 
You asked me.  I don't know what it was for other people.  
     But this is a political issue, and what I talked about, to
get such kind of information together would take several years. 
When you have a new program and other programs competing for that
limited budget, you can't wait three years before you make a
move.  So RMP had to move and, as someone said, show Congress
that they were spending the money as evidence that they were
doing something.  So that never eventuated.  
     I thought, to me, I don't know if it's exciting, but
important, the most important thing that RMP did was to put in
place, which is still in place, in the United States intensive
care units for heart disease patients, the coronary care units
and the training of personnel for that, and specialized equipment
for that.  That probably was its greatest technical contribution
to patient care, and that's very exciting that that happened.  It
came along at just the right time.  It did other things which
were important, but that probably had the greatest payoff in
terms of lives saved.

Rehm:  In your own opinion, why were the RMPs terminated?  Was it
a political decision?  Was it a rational medical decision in
terms of what the RMPs were actually delivering?

Sanazaro:  It was political with a big P and a small P.  The big
P was that by the early seventies, the cost of Medicare and
Medicaid were far beyond what anyone had even imagined, and so
Congress was in some consternation about that.  RMP had not
demonstrated it could produce anything that Congress could use to
justify its continuing the program.  That's the big P.  
     The small P is locally.  Remember we said that there were
cooperative arrangements among some people that knew how to
cooperate?  Well, that leaves 90 percent of the people who are
not cooperating and somewhat disaffected.  So there was no
groundswell of support.  In fact, what you heard was, "Well,
they're doing something over there.  The medical school is in
charge of this.  We're not getting any of that."  So that's the
small P.
     But it terminated really because in the mid-sixties you had
this flood of legislation, much of which was contradictory. 
Essentially all the programs that were enacted at that time are
gone, not just RMP.  Comprehensive health planning doesn't exist,
as such, anymore.  Community health planning doesn't exist, as
such, anymore.  The OEO doesn't exist, as such, anymore.  So in
this flood of legislation to make America a better place,
consistency and rationality was not the prime concern; it was
simply giving vent to the intent to redress what was seen as a
black commentary on our nature.

Rehm:  When it began to look as though the RMPs were going to be
dissolved, what was the reaction, once again, of organized
medicine?  Was there an effort at this point to do something to
try to hold on, or was there simply an acknowledgement that they
were going to go?

Sanazaro:  Yes, yes.  There was no effort to save them.  The
people that had invested their careers in that, of course, had a
vested interest in it, but by that time there were new problems
on the horizon and there simply wasn't a place for RMP.  But you
made the correct point: it anticipated the present.  In the
literature today, you are reading about regionalizing, highly
technical services that require large volume, highly skilled
personnel, and special support facilities.  So we will see
regionalization, but unfortunately maybe some twenty years after
RMP was on the scene.

Rehm:  And perhaps in different forms.

Sanazaro:  Different forms.

Rehm:  As you speak, Dr. Sanazaro, I sense a certain sadness
about the RMPs, your feeling, perhaps, that they could have been
so much more effective, that they could have done so much more,
not only for the understanding of knowledge that was certainly
coming out, but also for the delivery of health care to the
populace.

Sanazaro:  Oh, yes.  No question.  One of the problems was the
lack of cooperation among the programs in the new agency that was
created.  Dr. Marston moved from NIH to this new agency, Health
Services and Mental Health Administration, and RMP moved over
there also.  There were other programs that could have worked
cooperatively.  I was the Director of the National Center for
Health Services R&D.  We had a limited amount of money.  RMP had
a limited amount of money.  Comprehensive Programs had a limited
amount of money.  There was Hospital Construction that had a
limited amount of money.  But if we cooperatively had set some
priorities in the regions that were well organized, had
leadership, had commitment, had good technical support, if we'd
had a few priorities and had worked through our own agencies
together, much more would have been achieved.  But bureaucracy is
bureaucracy, and there seem to be some impenetrable walls.  The
idea, everyone said, "Yes, that's good," but then nothing would
ever happen.  

Rehm:  How has your experience with the RMPs affected your own
understanding of how best to deliver health care and education to
the general public?

Sanazaro:  Education, you have to educate people and train them
to do what they're supposed to do, but there must be an
evaluation at the point of delivery of care to the patient in
order to determine whether the patients are getting the full
benefit.  Until and unless that is done, it doesn't matter what
you do with your resources.  RMP went broke trying to develop the
resources for improving care.  They made some nice contributions
in that, but they never got to evaluating whether or not patients
were getting the benefits then available of those services.  So
that, to me, has been most important since then.

Rehm:  And how has it affected your own forward movement in this
area?

Sanazaro:  I have spent now twenty-five years evaluating the
quality of medical care, developing techniques for evaluating the
quality of personal medical care, and worked with a number of
national organizations on that.  The tools are becoming more
practical, more readily available.  It's not just research
anymore.  But this is where the great advance in education will
be made.  Everyone has known from way back that you need to know
what a man is doing or not doing properly before you can help
him.  Don't fix what isn't broke.  So unless you know what that
individual is deficient in, in his knowledge, in his techniques,
you can't really help him.  So that's the next big step in
continuing medical education, and that's when really the benefits
of research will come to bear directly on patients.  Right now
they're sort of hung up here.  They don't all get to where they
should get to.

Rehm:  It sounds as though you're saying there are some real
lessons that we can learn, both from the limited activity and
success of the RMPs, as well as from its failure.  What would
those lessons be?

Sanazaro:  The common expression is "Don't build a spaceship on
the way to the moon."  Don't work on component parts before you
know what the final machine is supposed to do.  So RMP did bite
off much more than could be chewed by anyone and in only a few
areas did it make a lasting contribution.  So there has to be a
finite objective, there has to be clear understanding of how to
achieve that objective.  The technical know-how has to be there
off the shelf.  It has to be readily available, not known to a
few consultants who appear and then disappear.  

Rehm:  Is there anything else that you would like to say about
the RMPs before we close?

Sanazaro:  I think as a result of RMP much of the forward-looking
thinking that you're reading about today will bear fruit much
more quickly.  We will not have a debate for another twenty years
whether regionalization is good or not.  It set the stage for it. 
Now that we have truly highly complex procedures across an
enormous spectrum of diseases, the concept is more viable than
ever, and I think there are still some old hands around that
might bring it into fruition earlier than otherwise would be the
case.

Rehm:  It sounds as though you're one of those who could truly be
of benefit to that kind of thinking.

Sanazaro:  Conceptually.

Rehm:  Conceptually, but perhaps you would be reluctant to be
directly involved.  Is that what you're saying?

Sanazaro:  You need the experts and they need some technical
assistance in organization, regionalization.  But foremost in all
of this, remember it began with research and the people that
understand what you can do in diagnosis and treatment.  That's
where the action is.

Rehm:  Dr. Sanazaro, I want to thank you so much for being with
us today.

Sanazaro:  You're welcome.

Rehm:  From the National Library of Medicine, I'm Diane Rehm.

[End of interview]