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Interview with Dr. Edmund Pellegrino
Date:  August 2, 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. Edmund Pellegrino, John Carroll
Professor of Medicine and Medical Ethics at Georgetown
University.  Dr. Pellegrino served on the National Advisory
Council to the Surgeon General, which developed the 1967 Report
on Regional Medical Programs to the President and the Congress.
     It's good to have you here with us, Dr. Pellegrino.  

Pellegrino:  Thank you.

Rehm:  Tell me, first, your own understanding of the RMPs, what
they were, what they were designed to do.

Pellegrino:  My understanding at the time that I served on the
council was that the RMPs had a specific focus growing out of the
previous report of the DeBakey Committee which had to do with
heart disease, cancer, and stroke.  The central idea, it seemed
to me, was to close the gap between the discovery of new
knowledge and information in those three diseases and bring them
to the community, to bring the new knowledge into service as soon
as possible.  To do that, the idea behind the legislation and the
committee's suggestions to the Congress was that you would
develop regional networks in which medical schools would develop
cooperative arrangements with hospitals, other community
agencies, to close that gap.  Everything seemed to focus on the
closure of that gap.  
     Secondary to that, and ancillary, in a sense, assisting it,
were a variety of different objectives such as manpower,
development, training, and continuing medical education, and so
on.  But the focus was categorical on three diseases, closing
that gap between research and service, and doing so through a
cooperative arrangement in which medical schools and communities
came closer together.

Rehm:  Tell me about the thinking on the advisory panel.  Was
there a sense that this kind of gap which you talk about had
become to create problems for the delivery of medical care?

Pellegrino:  I think we were at the time, in the mid-sixties,
when we were just beginning to enter this era we're in now, the
unprecedented era of medical progress and expansion which I don't
think has been parallel to any--I know hasn't been parallel to
anywhere in history, I think the public interest in how do we get
the immediate benefit of what's happening in these research
institutes.  Also I think the public was becoming aware of the
fact that they were making public expenditures for research, and
saying, "Well, where is it?  We've put our money into research. 
What's the payoff?"  I think that pressure was there, and the
administration and the president at that time, I think, were
responding to that.  
     You have to recall that the chairman of the committee that
gave birth to the idea was Michael DeBakey, who was distinguished
and still is a distinguished cardiovascular surgeon.  So all of
these things came together and focused on this particular kind of
program.

Rehm:  What about the regions themselves?  Were they strictly
geographical?  Was there some of the manner in which they were
created?

Pellegrino:  The regions were created with a geographic idea in
mind, yes, but they also credit the idea of being in some
collaboration with the medical school, so they had a relationship
to university medical centers, the idea being that somehow that
was another hope of those days, to somehow bring the tremendous
resources of university medical centers--I at the time was
director of one of those--to bear on the communities in which
they resided.

Rehm:  What about the cooperation, or lack thereof, within the
communities themselves with these Regional Medical Programs as
they came into existence?

Pellegrino:  Of course, if you're talking now about the actual
experience as opposed to the expectations--

Rehm:  Yes.

Pellegrino:  Of course, there's always a gap there.  I think that
varied throughout different parts of the country, and it was
determined by, for one thing, how community oriented the medical
school and medical center was.  That then, as it is now, is
variable.  The state universities generally had a greater
interest, for obvious reasons, in their community, so they tended
to reach out.  The more private institutions didn't have that
kind of an impetus.  So it would vary with the kind of medical
center.  The part of the country in which they were located
tended to be in the rural areas or in the South or in the West. 
My experience was in the South at that time.  There was more
interest in cooperative arrangements than there was, let us say,
in the larger cities of the Northeast, although that also had its
exceptions.

Rehm:  You made reference to the difference between expectations
and actual reality.  What was the difference there?

Pellegrino:  There were many differences if you look at the whole
history of the Regional Medical Programs.  I think, first of all,
you started out with an expectation that this would be focused on
three diseases, as we talked about: heart disease, cancer, and
stroke.  The actuality was, as time went on with the change, the
unfortunately frequent changes in mission and direction from
above to the council, the staff and so on, it was hard to know
what the gap was between A and B or A and D and A and C.  The
mission was always fuzzy.  But it did move from this categorical
orientation into something more general.  Other things were
thrown in, then, as part of the mission, such as primary health
care, such as manpower development and training.  The things
which were secondary, at least as I saw it, when we first started
out, became primary.
     So it was very hard to measure what it was you were doing,
and I think this was one of the many reasons for the death of the
program.

Rehm:  Was the mission, as seen by the National Advisory Council
that worked on these, clear in and of itself?  Was it in the
translation to the Regional Medical Programs that it became
confused?  Or was the mission itself confused from the outset?

Rehm:  I think the mission itself was probably not confused at
the outset in the minds of those who recommended it.  It
certainly was changed so often that it was hard to say, you know,
what, in fact, they were trying to do.

Rehm:  Who was doing the changing?

Pellegrino:  The changing was coming at all levels.  First of
all, you had throughout the life of the program a change in
presidents.  When one president has a program, that doesn't
always translate to another president.  I'm not being critical of
anyone.  So it got a push in one administration and other
administrations didn't have the same commitment.
     Then we had changes in the Secretary of (then) HEW, and each
secretary was of a different style and a different notion of what
this thing ought to be, and that trickled down to us through the
directors of the programs.  That created confusion.  
     Then I think the idea of a cooperative network was something
that people really couldn't grasp.  

Rehm:  You're talking about the doctors themselves now.

Pellegrino:  I'm talking about the doctors, I'm talking about the
hospitals, I'm talking about medical schools.  I think none of
the American health care apparatus have had much experience with
regional cooperative networks, although for forty years there has
been talk about cooperation at a regional basis.  Regionalization
was one of the things people talked about.

Rehm:  Is that because each group wanted to do things its own way
and did not like the idea of somehow having to blend its own
ideas?

Pellegrino:  Yes, that's always part of it when it comes to
cooperation.  How much do I give up for the benefit I gave by our
working together?  That's a perfectly human response, and I
wouldn't point a finger at anybody on that.  I think also there
was a fear on the part of the private practitioners that this was
the foot in the door to a federalized, "socialized" health care
program.  They were a little bit leery.  There was the leeriness
about the medical center, of course.  Academia and the practicing
profession have always had what I might say was a balanced
tension between them, a little fearful of each other, although
cooperative when they had to be.  Then I think the whole notion
in our individualistic American way of looking at things, of
giving up some of your serenity, which is necessary in
cooperation.  All of those things, I think, were operative.

Rehm:  The one thing you haven't mentioned, which I wondered
about as I read through the material, is whether the mission was
clearly defined as education or care.

Pellegrino:  No, it wasn't.  As a matter of fact, we were not
supposed to provide care.  There would be no dollars for care. 
That was clear at the beginning in the legislation.  What was not
clear was how you linked up this new knowledge, presumably, and
how you brought it to bear on care.  That was supposed to be
through this communicative, cooperative networks.  Now, I am not
suggesting that there was not cooperation in quite a few of these
programs, but the point that you started with, it was difficult. 
There were problems and there were gaps, understandably.  

Rehm:  Was that, for you, the greatest accomplishment of the
RMPs, that somehow there was a certain amount of cooperation, a
certain amount of industry that brought to bear knowledge,
understanding of the kinds of problems you were working on?

Pellegrino:  Oh, I think unquestionably the one real contribution
that was made was that for the first time medical schools,
practicing physicians, medical societies, hospitals, planning
agencies, were talking together.  This federal impetus of money
to do so--let's face that fact, but it's a reality--I think
achieved something that had not existed in America before.  I
think that was a very valuable thing.  It was sketchy, but it was
beginning to develop, I think, in a way that might have led
somewhere had not all of these things at the upper levels
occurred, the funding which varied enormously, the changes in
policy, the changes in administration, etc.

Rehm:  How were those funding decisions made?  If those funding
decisions varied tremendously, who decided how much a certain
region got and whether a certain region was somehow "successful"
or otherwise?

Pellegrino:  First of all, I don't think the funding problem was
between regions.  The funding problem was from the administration
through the Office of Management and Budget at that time, called
the OMB.  

Rehm:  So you're saying they were not competing with one another
for funds.

Pellegrino:  What I'm saying is that the directors and
administrators of the program, and the council, were never sure
how much money was going to be available at a particular time and
what would be held back.  In the history of the program several
times it was held back, etc., etc.  There had to be a suit about
it, as you know, and so on.  So I think that's one level.
     The question of who decided between programs, that was the
National Advisory Council, would look at the applications after
they had been reviewed at peer review.  They would come to us and
we would try to weigh one against the other--not against the
other, but competitively, to see which ones had the programs that
seemed to fit most with what we at that particular moment thought
were the gains and the missions of the program.
     So, you see, all of these things are interlocking.  If
you're not sure about mission, then the criteria for judging who,
in fact, satisfies the mission become confused.  Now, it isn't as
confused as it seems to be from what I'm saying.  I'm pointing
out that there were these gaps, and it takes time to get over
that, and it takes firm direction and takes stable leadership. 
That we didn't have.

Rehm:  Talk about your own personal involvement with the program,
what it meant to you and how you began to put it into operation.

Pellegrino:  My personal involvement was as a responsible member
of the National Advisory Council.  That's one of many councils on
which I served at the national advisory level.  I felt that my
role there was to be what the councils are supposed to be--
advisors to the administrators of the program.  We don't run the
program, but we do have an advisory capacity on policy and then
specifically on grant applications and reviews.  That's a very,
very important job that we all take very seriously.  I think it's
one of the wonderful things about American medicine on the
national scene is the peer review system. 
     The second thing was I was very interested in it personally,
because at the time I was the director of a new Health Sciences
Center and very interested, myself, in involving that center in
the community.  I was at the State University of New York.  I was
the founding director of the Health Sciences Center at Stony
Brook.  So I was personally interested in seeing how, in fact, we
could achieve this ideal of university and community cooperation. 

     A third personal interest was I served locally as an advisor
to the Regional Medical Program's Comprehensive Programs, and as
the director of the Center, I, of course, had the responsibility
on the local scene for carrying out this cooperative notion and
trying to play out the role of the medical school, which was
central.

Rehm:  Do you recall any specific experiences, Dr. Pellegrino,
where you thought, "This is right.  This is exactly why this
program was put into place, and I'm so glad it's here and
working"?

Pellegrino:  I remember a number of those, and I think I saw them
around the country.  I wouldn't single one out over another.  I
think it would be an invidious comparison, really, to say.  But
in my view, wherever I saw and whenever I saw people talking
together who had never talked together before, people developing
programs together who had never done it before, in other words,
this cooperative notion, I was pleased to see that.  I wouldn't
single one out over another; that would be, as I say, an
invidious comparison at this date.

Rehm:  You have made several references to the notion that
everything changed as time went on and sometimes those changes
were detrimental to the forward movement of the whole operation. 
Can you talk about some of those specific changes and how they
may have perhaps confused the mission, confused the people who
were working on the program?

Pellegrino:  I think the most serious changes, from the point of
view of the program--by the way, they were all, I'm sure, well
intentioned, and any one of those changes by itself would have
been a worthwhile goal, but you can't keep saying to someone,
"Look, we have to go this way.  It's nice to go that way.  But
it's nice to go that way, too," and so on.  It was kind of the
anxiety of possibilities that grabbed people.  [Chuckles]  
     But specifically I have already mentioned to you the shift
from the categorical to, let us say, the non-categorical, losing
the connection with heart disease, cancer, and stroke.  That
might have been good or bad.  I'm not arguing that point.  That
required a reorientation.  
     Then to go from the transfer of knowledge from research
institutions to service institutions to something more general,
primary care for accessibility and availability of care, or
concern for the poor and for minority health care and so on, all
worthwhile in themselves, but you cannot do everything all at
once.  It's the story of an inability to arrive at a goal and to
pursue that goal to the exclusion of all others.  

Rehm:  How did the RMPs relate to other programs designed to
integrate health care such as the Comprehensive Health Plan?

Pellegrino:  I think that's one of the problems was that the
Comprehensive Health Care Program was generated out of another
agenda.  That was the public health approach.  The public health
people, the state commissioners of health and so on, were very
active in pushing for comprehensive health planning.  They were
concerned that the Regional Medical Programs was too much
oriented to curative medicine.  So you had, again, two agendas,
both having planning in their names, in their designations, in
their missions.  So that created duplication of effort which Mr.
[Caspar] Weinberger pointed out when he became Secretary of HEW,
in his budget-cutting proclivities, and not inappropriately. 
There was an overlap here of functions, and trying to put those
together, from my point of view at the local level (and I was
active in both because I thought both were worthwhile) was
sometimes a real problem.

Rehm:  When did you begin to see that the end was perhaps coming?

Pellegrino:  I don't want to claim prophetic capabilities and
powers.  I was concerned after about the first year or two.

Rehm:  Really?  That soon?

Pellegrino:  Because of the changing mission.  We could never get
it clearly articulated in our own minds.  I wouldn't say that I
wasn't also somewhat confused at times by the input of data that
we got and so on.

Rehm:  Were there others equally as concerned as you?

Pellegrino:  Oh, I think so, yes.  

Rehm:  It seems to me that so many people feel that this was such
a worthwhile program in terms of intent, and yet it ran into so
many difficulties, some outwardly imposed, some of its own
creation.

Pellegrino:  That's correct.  I think what you saw was an
experiment in human behavior that was a little bit before its
time.  I think the idea behind it was a good one.  We weren't
ready for it.  I think it's going to have to be reinvented.

Rehm:  What do you mean, we weren't ready for it?  Was the fact
that the organizations weren't sufficiently in place, they didn't
have a complete understanding?  What do you mean, we weren't
ready?

Pellegrino:  I think we weren't ready for it as a profession, as
a community.  We weren't ready for this kind of cooperative
effort.  This was a kind of new things on the American health
care scene.  I think if we had had a clear direction of where we
wanted to go and had agreed upon it and had given it time, it
would have worked.  But if you add to the fact that we were
unused to it, there had been very little precedent for it, plus
all of these changes, you just had a formula that spelled
failure, unfortunately.

Rehm:  Are you suggesting that had there been more careful
planning, a longer planning process before undertaking the actual
carrying-out of these programs, that it might have had a better
chance?

Pellegrino:  Possibly, but let me say by preface I've done a lot
of planning in my time, I've started five new organizations, and
I know something about it. I don't think, however, that a longer
planning period is really the answer.  The answer as I see it
was, again, to have a clear and firm objective that you would
articulate.  People are easily confused.  When they have multiple
agendas going on all at once, they need to have someone and some
group to say, "This is what we're going to do.  Let's agree on
it.  Let's do it."  And not keep shifting.  It's like having your
hands on the tiller in a sailboat and going back and forth, back
and forth.  And you know what happens when the wind hits those
sails.  

Rehm:  Tell me how your own experience with the RMPs has perhaps
affected your growth as a medical specialist, your understanding
not only of how bureaucracies succeed or fail, but also in terms
of your own understanding of the best way to reach people.  

Pellegrino:  I think that certainly what I've learned from this
is something I think I knew before also, but I think it was
really again brought home to me, is, once again, the importance,
when you're dealing with groups, of a clear understanding at the
beginning and acceptance by the group of a clear goal.  Second,
the importance of a limited number of goals.  Third, the
importance of stability in pursuing those goals and not changing
them all the time.  And fourth, it seems to me, is to give it the
time.  People need time to develop these relationships,
especially when they are, as we talked about it earlier, a little
suspicious of each other, the question of, "Are they going to
swallow us?  Are they really bringing us now into a federal
program?"  As you know, about that time Medicare/Medicaid had
just come in, and a lot of doctors were worried about
socialization of medicine, universalizing health care, etc.,
etc., etc.  So I think those are the lessons that I've learned
and lessons that I have used in my own organizational life over
and over again.

Rehm:  It occurs to me that if such a program were reinstituted
today, that not only might that kind of planning be at the ready,
but that there would also be a lobbying organization designed to
help people better understand what's going on, there would be a
group, perhaps, within the medical profession itself designed to
help educate people about exactly what these programs are likely
to do, or supposed to do.  Would that kind of 1990 PR approach
have made a difference?

Pellegrino:  No, I think that's a standard delusion.  I think the
PR approach would be a failure.  You don't do good things that
way.  My view would be to do those simple things that I
mentioned.  People understand this notion if they're given time
to work with it.  No, I don't think the PR notion--and god knows
the last thing it would want to be is a lobby.  [Laughter]  If
there's any desecration of the political and moral scene in this
country, it's lobbying.  

Rehm:  At the same time, lobbying does somehow turn sort of
vaguely unsuccessful programs into things that are palatable.

Pellegrino:  But it also produces programs which are absolutely
worthless.

Rehm:  Yes.

Pellegrino:  Because people cave into the pressure.  So at least
if you ask my opinion, no, I think that the PR approach is not
one that would make for a genuine lasting--we had PR with the
Regional Medical Programs.  It had the push of Dr. DeBakey's
name, it had the push of the administration.  President Johnson
was firmly behind it.  It fit into the goals of his
administration.  But that wasn't the answer.  The answer was, I
think, what all too often happens in federal programs, the
instability, the lack of permanent commitment.  As I say, you
look at the rotation of secretaries of HEW, directors of the
programs, etc., etc., etc., the vagaries of the budget, which are
understandable, of course, all of those things, I think, spell
the death knell.  And PR isn't going to solve those.  

Rehm:  How could the RMPs be adapted for use today?

Pellegrino:  I wish I could answer that question better than I
can.  Let me say at the outset I think they're going to have to
be reinvented, because regionalization of health care services is
something I think we really must have.  The reason it's going to
have difficulty is that everyone wants to do his own little thing
and every hospital wants its own MMR, MRI, what have you, and so
on, and everybody wants to do what they want to do without
interference.  But I think we've reached the point now where that
is no longer tolerable.  I think the economics of the situation
probably will push us further in the direction of cooperation. 
People cooperative beautifully when survival is the issue, and I
think we may be at that point now.  
     I think if we went back to something like the Regional
Medical Programs, the idea behind it, without the categorical
orientation of heart disease, cancer, and stroke, if we focused
it on developing a network through which we could pass a lot of
different things, but spend time first developing the network,
because that's the instrument, you see, and I think it would take
three or four or five years of just developing the network.
     The thing that ired a lot of people was the network required
paying the salaries of some kinds of substantial permanent staff. 
Certainly Mr. Weinberger, in his comments published on the
subject, was somewhat annoyed at that, I'm sure.  I can
understand that, but you do have to make a certain investment in
developing the apparatus.  Then I think we could use it for a
number of things.

Rehm:  There are so many people within the Bush administration
today concerned about rising health care costs.  In your opinion,
do you feel that the reinstitution, or reinvention, of Regional
Medical Programs might indeed serve to begin to pare back the
rising cost in medical care in this country?

Pellegrino:  It could do that by avoiding duplication, by
providing for greater efficiency of delivery, etc., and by its
cooperative effort.  It would require the things we talked about,
we don't have before.  But I would say that if you established
the network with the idea in mind of cost containment being the
prime end, you will defeat it once again.  

Rehm:  You don't seem to feel that Caspar Weinberger was wrong in
approaching the RMPs as he did, with a view first to cutting
back, then cutting off.

Pellegrino:  Well, I would say, no, I don't disagree with him,
although I thought it was a very, very painful thing to do.  But
I think that after six or seven years of operation, with the kind
of confusion that one could see looking at this objectively, I
think I probably would have made the same decision.

Rehm:  Really?

Pellegrino:  You've heard me say that I believe the idea is a
very good one, but it had become just so confused that you had to
ask yourself.  Either I'm willing to put money into this to get
it straightened out and clean house.  And there was no one at
fault, because the directions were coming from everywhere.  We've
got one director here taking care of us, as you and I talk, but
we had six or seven or eight.  So I think that Mr. Weinberger's
decision was probably not an unreasonable one, given the state of
affairs and the shifting mission and all the things I've talked
about.

Rehm:  But if you're dealing with Regional Medical Programs, you
are, it would seem to me, going to have individuals responding to
areas of the country that may be different from one another.

Pellegrino:  Yes.  That wasn't the problem.  No, no, no.  The
problem was not from the periphery; it was central.

Rehm:  And you feel that that central problem was so diffused--

Pellegrino:  That's correct.

Rehm:  --and coming to the regions in such a way that was totally
confused.

Pellegrino:  You see, it isn't the regions themselves, as I said. 
I want to go on the record of saying that many of the regions did
very good things with this program.  They carried out many of the
ideas, but there were so many goals and objectives.  It's
perfectly all right to have variety in the regions, but the
important thing that mustn't be missed is that the network that
brings it about was utterly confused at times, not knowing where
it was going.  So that when we looked at programs, we would have
such a variety, we didn't have solid criteria that we could use
to judge them, and it was a little bit unfair, as a matter of
fact, because, as you say, different parts of the country had
different requirements.

Rehm:  Different needs and different goals for themselves.

Pellegrino:  But if you have a network set up, you can deliver
what they need at the periphery.  But the point is, we were
trying to say, "No, it's got to be primary care," or, "No, it's
got to be this," "It's got to be that."  And it kept changing. 
So when you're out on the periphery, you're saying, "What do they
want?  How can I develop my grant so that I get support for what
I think I want to do?"  
     And there's an important lesson here, and that is that
whenever a grantee, whether it's a community or an individual,
fashions their grant proposal to get money and squeeze it under
your criteria, you usually end up with a bad program.  You do
much better when you support something that people develop, that
they really believe in.

Rehm:  That's come from your experience since then, as well as
out of that program?

Pellegrino:  No, that's come from my experience in various other
advisory councils, as a scientist, and as reviewing scientific
proposals, as well as public health and health care proposals.

Rehm:  Dr. Pellegrino, are there any other recollections you'd
like to share with us before we close?

Pellegrino:  No.  I think I've said more than I perhaps should
have said, but those are my feelings about the program.  I think
I would repeat [that] I think it was probably ahead of its time. 
I think the time will come again when we must reinvent it,
because I think regionalization is part of--by the way, that's
one of the other defects I would like to add.  It was not part of
a comprehensive program for national health care, which we
urgently need.  I think if it could be placed within that
context, then the mechanism of cooperative arrangements on a
regional basis would really have a tremendous use in improving
the health care of the American people, which was the aim in the
first place.

Rehm:  Dr. Pellegrino, thank you so much for being with us today.

Pellegrino:  Thank you.  It's a pleasure being with you.

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

[End of interview]