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Interview with Dr. William H. McBeaath
Date:  September 5, 1991
Interviewer:  Diane Rehm  
Location:  National Library of Medicine
           Bethesda, Maryland
Transcriber:  Techni-type Transcriptions/DDR



Rehm:  I'm Diane Rehm at the National Library of Medicine in
Bethesda, Maryland.  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. William McBeaath,
Executive Director of the American Public Health Association. 
Dr. McBeaath served as the Program Coordinator for the Ohio
Valley Regional Medical Program from 1966 until 1973.
     Welcome, Dr. McBeaath.  It's good to have you here.

McBeaath:  Thank you, Diane.

Rehm:  Talk a little bit about the intellectual and political
origins of the RMPs.

McBeaath:  The RMPs grew out of that great health ferment of the
Great Society in the 1960s, and those of us who lived through
that can remember a lot of exciting times for those of us in the
health area.  I tend to associate the origins of RMP an awful lot
with Dr. [Michael] DeBakey, the great Texan.  I did part of my
training in Houston at Dr. DeBakey's facility, so maybe that's
one reason for the bias.  
     I think the affinity between President Johnson and his
desire for new adventures and new initiatives in the area of
health and his friendship with Dr. DeBakey led to this
President's Commission on Heart Disease, Cancer and Stroke. 
There was a lot of renewed interest upon society trying to deal
with some of its pressing problems, and certainly among them were
heart disease, cancer, and stroke.  So I think the DeBakey
Commission and President Johnson's desire for new social
initiatives in the area of human services were the basic
underlying political implications for that.  

Rehm:  In general, what were the RMPs designed to do?

McBeaath:  Oh, that's a very, very difficult question, because I
think it has so many different answers from the perspective of
different folks.  The DeBakey Commission foresaw regional medical
complexes that would have coordinated arrangements between
medical centers, university health science centers, and regional
centers of excellence for patient care.  I think that for many,
they saw in that an opportunity for the medical schools' interest
in the discovery of new knowledge and the dissemination of new
knowledge, and they saw a real opportunity for the schools,
particularly medical schools, to expand their operations in that
area.  
     There were others who had maybe a more peripheral health
system kind of interest.  They thought they might become one of
those regional centers of excellence.  Competition and tensions
that are felt between geographic areas that are in close
proximity, but each like to think of themselves as regional
centers of excellence, was a natural attraction for people to
think that the Regional Medical Programs might feed that.
     There were others who felt that surely it would be very
directly addressed to heart disease, cancer, and stroke.  After
all, those were the big problems of morbidity and mortality that
were addressed in the title.  People who had been in the
voluntary health agencies, like the Heart Association or the
Cancer Society, saw that, and there were others.  Some people
thought it would be continuing education.  Others thought it
would bring new innovations in care that were not now existing.

Rehm:  So everybody had their own expectations, without
necessarily having agreed to one particular direction.

McBeaath:  I think one very characteristic element of the program
throughout its history was that it maintained maybe even almost
the fatal flaw of the desire for flexibility that would permit
almost anybody to choose from certainly a limited range of
objectives, but if they were a categoricalist, if they were a
medical center-advantaged person, if they wanted to develop
peripheral secondary centers of excellence, these and other
objectives for quick for them to be able to latch onto within the
flexibility that RMP had.

Rehm:  So, as you imply, one the one hand that could be a true
advantage for those who had their own visions.  On the other
hand, a disadvantage for someone who couldn't really get hold of
what it was.  

McBeaath:  Yes, but I think there were probably relatively few of
those of us who were involved in the RMP movement itself who
couldn't get hold.  There were an awful lot of things that were
encouraged and even a broader range of things that were
permitted.  I think who couldn't get hold was the Congress and
some of those who required for national support and leadership
and continuance of this.  There just isn't any regional medical
disease that anybody ever dies of, and increasingly, members of
Congress, I think, have a hard time in coming to grips with
something as abstract--maybe appropriately so--but, nonetheless,
as abstract as regionalization or regional cooperative
arrangements.  The idea that there will be advances in science
that can be immediately applied that would see an effect very
quickly, if there were people who had that expectation, they were
very unrealistic.  In the halls of Congress and some other areas,
there may have been too great an expectation for immediate
results of that kind.  

Rehm:  You were Director of the Ohio Valley RMP.  How did that
program, as it emerged, differ from the recommendations of the
DeBakey report? 

McBeaath:  I'm not sure I can characterize it to the DeBakey
report, but I can certainly characterize how it differed from the
mainstream of Regional Medical Programs that emerged, and I think
that's implicit, probably.  It was one of the few--maybe eight or
ten--that organized on what it perceived to be functional service
areas.  It tried to reflect patient service patterns and service
delivery patterns.  It included a portion, for example, of four
states; it did not include all of any of them.  There were maybe
a dozen such programs that did that, but they were certainly in
the minority.  Most of those that were organized in that way were
built on the assumption that they wanted to encourage the
development and to emphasize particularly the regional
cooperative arrangements, more so than any specific content of
the program.  
     It was the type of program that tended to think that these
regional networks could be developed slowly over a period of
years, that they would involve multiple levels of the health care
system, such as the University Health Science Center, the
regional hospital, the local community health centers, and that
there would be an interdependence develop among these units as
they developed programs together and sought to jointly benefit
from them and to provide support to them and in an interdependent
kind of way exercise a joint control over the regional
operations.
     I think most of the programs were really quite different. 
They operated on the assumption that they were going to very
quickly bring new innovations in technology and in health
services to more peripheral areas, or they were going to make
major assaults upon the heart disease, cancer, and stroke
problem.  Many of them--in fact, I guess most of us--eventually
focused on continuing education, which ended up being an activity
that, although present from the first, received more emphasis
later on.  

Rehm:  Can you talk a little bit about why the RMPs were
transferred from the National Institutes of Health (NIH) to the
Health Services and Mental Health Administration (HSMHA) in 1968? 
Do you recall that and why that transition came about?

McBeaath:  My recollections are that, again, that decade was a
time when reorganization of HEW and particularly the health
component was an exciting activity undertaken, as I recall, by
Dr. Phil Lee, who was Assistant Secretary of Health early on.  I
would imagine that if you view that kind of a context and
environment of a lot of health services agencies' reorganization,
it wasn't surprising that RMP would be one of those subject for
reassignment.  
     If I were to speculate on a more personal level about what I
think was there, I think that from the first, RMP was seen as a
medical school program.  The schools were looked to early on to
be the initiating stimulus within their regions to try to start
these programs.  I think that was true almost everyplace across
the country.  The schools have the majority of their
relationships with the federal health establishment through NIH,
and the genesis of the program first being administratively sited
in NIH, I think, was a natural.  But the breadth of the program
and the diversity of emphases that began to emerge in those first
couple of years may well have had some influence upon the fact
that it was reassigned.  One could say it's because NIH was less
interested in it and thought that it was not going to develop
along the lines that they had thought.  But it could have well
been more subtle.  

Rehm:  I just wonder what impact that kind of transition had on
the program, whether there was an improvement, whether there was
a sharpening of focus, sharpening of goal-setting.  

McBeaath:  My recollection is that the changes in organizational
siting of the program and the changes in the directors of the
program, I don't recall now how closely they paralleled each
other, but it seems to me there was some parallel in them.  In
the period of time I was with Regional Medical Programs, there
were four different directors for the program.  I think it
probably was sited in three different agencies.  But I think
that's bound to have some effect upon the ability of any one
leader or group of leaders to stabilize the foundation of the
program, to give clear direction and impetus to its goals and
objectives.  So while I wouldn't view a move from one particular
agency to another as particularly sinister, I would just think
any move from one agency to another would have some of those
kinds of disruptures that might make it difficult, particularly
with coming to focus on what the programs were supposed to do.

Rehm:  Dr. McBeaath, talk specifically, if you would, about your
own experience with the Ohio Valley RMP.  How did you come to be
the director of that program?

McBeaath:  In late 1965, when medical schools across the country
were looking with some interest upon this emerging program, there
were eight medical schools in that mid-America region, from
Pittsburgh to Ohio State, to Cincinnati, to Indiana, to
Louisville.  I don't remember all of them.  But they all got
together to explore whether or not there was feasibility to do a
large program in that area of the country, in that region of the
country, that several of these schools would be involved in. 
They eventually decided that that would not work, that there was
too much diversity, that it was too large an area.  
     But three of those schools, the ones at Louisville,
Cincinnati, and Kentucky (in Lexington), decided that they would
try to go it together and they would try to develop a program
that was based upon their tripartite areas that formed a rather
natural Ohio Valley region.  
     In mid-1966, I was Director of Medical Care for the State
Department of Health in Kentucky, and I was asked to come and
work with them in the development of an application for a
program.  For a while I was on the staffs of all three of the
universities, but beginning in October of 1966, when the Regional
Medical Program was funded, I became the director of the program.

Rehm:  What are some of the experiences that stand out most in
your mind as you were director of that program?

McBeaath:  I think the very gratifying success that we felt we
had in the cooperative arrangements between these three
universities, first, and then these three areas, because there
was certainly not anything certain about the success of it. 
These were institutions with long and proud histories.  They have
what I view as the natural desires and pride in their own
institutional well being and some extent of competition, maybe
even jealousy, between each other at times.  But it just worked
extremely well.  
     It also worked well in that these three schools were
committed to turn the control of this program over to an
independent group that it's true they created, but they created
with a great deal of compromise on the part of everyone to be
assured that there was a very substantial regional advisory
group, it was called, because that's the name the RMPs gave them. 
But it was really a group of thirty-six to forty-five individuals
who took control of the program, acted like a board of directors,
and although they came from disparate interests and disparate
areas of the region and disparate occupational representations, I
think very quickly gave us all gratification that that type of
interorganizational, inter-area interest cooperation was going to
be easier to achieve than some had predicted.  

Rehm:  How did the RMPs relate to the other programs designed to
integrate health care?  For example, the Comprehensive Health
Planning programs.  How did RMP work with those?

McBeaath:  In the case of OV RMP, it worked extremely well.  We
were, as I've said, a region that included several states,
portions of several states, and many of these local areas that
would have been beginning to participate in the health planning
movement.  Certainly the situation was different, for example, in
Ohio.  Ohio is a state that has several major metropolitan areas
that have educational institutions and other social organizations
that are very important in the development of those activities. 
So that a statewide planning effort, for example, in Ohio, OV RMP
participated in that, but really rather more peripherally, as I
would imagine did the interests from Cleveland or from Toledo or
from Columbus.  
     In Kentucky, on the other hand, very much of the state was
included, and some of our staff had come from the health planning
activities in Kentucky.  
     Another aspect of Kentucky's agencies at that point in time
were that they had emerged, several of them, like the Medicaid
program and the programs of the Health Department, in a very
intimate cooperation with the University of Kentucky Medical
Center, which is another story.  
     It's worth saying this.  The University of Louisville and
the University of Cincinnati are among the oldest municipal
institutions in the country.  The University of Kentucky is a
very recent medical center.  The institution is old, but the
medical college is relatively new--or was at that time.  It had
been developed by people like Dr. William Willard, Dr. Curt
Dushel [phonetic], Dr. Robert Strauss, Mr. Bob Johnson, and
others, who had developed a medical center along the model of the
Agricultural Extension Service, and felt that one of the major
functions of a university health science center should be to
relate productively with the health resources of the region. 
Regional medical program at Ohio Valley reflected an awful lot of
those interests when it came into being.  So it kind of meshed
well with a lot of the planning that had gone on before.  

Rehm:  Dr. McBeaath, from everything you've said, the program
seemed to work well.  These was a considerable amount of
cooperation.  It seemed to be doing exactly what it was supposed
to be doing.  Talk a bit about why you believe the RMPs were
terminated.  

McBeaath:  First, I'm not sure that we were doing exactly what we
were supposed to be doing, because I think that even looking back
on it from all these years, I still have the feeling that it was
never really clear to all concerned what we were supposed to be
doing.

Rehm:  Talk for a moment about why that focus was so out of
focus.

McBeaath:  Let me quickly say I think the things we were doing
were within that broad range that was permitted.  The language
that was within the act made enough allusions to regional
cooperative arrangements and to heart disease, cancer, and
stroke, and to the improvement of medical care that you could do
almost any of those.  
     I think that, in the first place, there probably was no
rigorous attention given to making a new program justify
precisely what it was supposed to do.  Those were days when we
enjoyed, those of us who were living through them and working in
health, were enjoying just an awful lot of new vistas of
opportunity to do things.  We felt that most of those things were
good.  We felt that they were showing results that were
beneficial to society.  But to target and to have to be very
specific about what each particular program element was supposed
to be doing was a little less rigorously adhered to, I think,
than would be certainly today or was maybe before that.

Rehm:  Do you think the mandate itself changed along the way, and
that that was part of the problem?

McBeaath:  I think certainly that the emphases and the priorities
that came out of the Washington leadership changed.  Sometimes
you got the impression it was changing with the administration. 
Sometimes you got the impression that it was changing with the
political climate and sometimes with the change of directors of
RMP.  But nonetheless, there was a good deal of floating crap
game kind of character to trying to know what was in right now
and what we were supposed to be following.  
     Yet, on the other hand, that's not a fair characterization. 
Maybe a fairer characterization is to say that throughout each of
those periods of so-called change, there was this constant
reaffirmation of the flexibility of RMPs and how they were so
able to respond to local initiative.  They were able to appeal to
regional differences and needs and demands.  
     A consequence of that, a corollary of that, is that it may
be so diffuse at the national level that it loses national
support.  I think that belatedly we began to see that.  There
came a time when efforts [were made] to convince not only the
administration, but the Congress, that, "This program is doing
good things in your community."  While you might be able to
convince a given member of Congress that we're doing this in your
community and it's a good thing, the focus nationally was so
diffuse that I think that was one of the programs with regard to
the program.  

Rehm:  You were one of the people who testified before the
Congress in defense of the program.  As I recall from reading
some of the transcript, Congressman Carter of Kentucky said to
you that he didn't see any specific results of the program in his
state.  

McBeaath:  In his region, anyway.  In his district, I think he
was referring to.  Well, I'm sure that the nature of the program
was such that any member of Congress may have had some particular
expectation.  Mr. Carter, a member of Congress, happened to be a
physician, so I'm sure he had expectations about something that
he would have liked to have seen in Eastern Kentucky, where he
was a member of Congress.  
     I don't think the problem was there to demonstrate at the
local level what had been accomplished, and I don't know what my
response was to Congressman Carter, but I would imagine I would
be able to point out to him at least a few things that had been
done in this area.

Rehm:  You did.  

McBeaath:  But the satisfaction of thinking that this was a major
program and that it seems to be doing different things in
different areas was hard to sell.  
     I think another thing that probably is fair to say, in
looking back on it, is that these days were times of great
expansion in health programming, and one could not have expected
all of these initiatives to have survived, and others of them
have not.  Health planning has since gone by the wayside.  The
nature of support for medical schools has changed dramatically. 
The grant programs to state health agencies have changed.  Those
were days in which there was expansion and flexibility in those
areas, as well, and there's been a re-targeting of that.  
     In fact, the pendulum swings from time to time, and we go
through a period when things are very targeted, project oriented,
and we'll go through a period where we go back to block grants
and states and localities are supposedly given greater
initiative.  Then this diffusion occurs.  There's usually in
Congress a rising, increasing concern about, "What do the home
folks know about this?" if it's all being done at state and local
level at their initiative.  

Rehm:  Were you in the minority, as far as the medical profession
was concerned, in your attempts to stand up for the RMPs?

McBeaath:  I don't think I would count myself among the medical
profession in that context.  I had a vested interest.  I was an
employee of RMPs as a director.

Rehm:  Of course.

McBeaath:  However, I believe in the Ohio Valley region and
elsewhere across the country there was a great deal of support
from organized medicine, from the practicing medical profession. 
I think, there again, there were a variety of expectations and
there are things about federal programs, certainly in the 1960s,
if you'll remember them, that were very threatening to organized
medicine and private practitioners.  Each of the laws that were
passed during that period had that great phrase "not to interfere
with the patterns of practice."  Yet here was a program that was
supposed to be changing those patterns of practice!  So I think
it would be natural for anyone in a hospital or in a medical
practice or in some other kind of a health care provision effort
to wonder whether or not this was going to change the nature of
the way they provided services in a way that might not be
compatible with their desires.

Rehm:  Dr. McBeaath, you've talked about what did not survive
from the Regional Medical Programs, but as Executive Director of
the American Public Health Association, can you talk just briefly
about what has survived and what elements of the RMPs are perhaps
incorporated into public health care today?

McBeaath:  It's interesting that you asked that question to me as
Director of the American Public Health Association.  As I look
upon it, the American Public Health Association had very little
involvement with RMP in its development and while it was going
on.  It was, like a lot of others, I guess, passively accepting
of it.  Perhaps the public health establishment in this country
saw in it no great potential benefit nor any great potential
threat.  In my experience with the Ohio Valley Regional Medical
Program, in trying to relate to official health agencies, which
is another group we tried to relate to, it was really an activity
that never produced a whole lot of fruit.  There were a lot of
friends and acquaintances of mine that were there, and we
obviously had some joint activities, but they really never became
strong actors in that whole scene.
     The American Public Health Association and the public health
establishment that I think it reflects, the public health
practitioners around the country, were probably a whole lot more
interested in the health planning development that was emerging. 
They saw that as having a great deal more threat or potential for
disruption of their happy arrangements in that it would exercise
control over grants and programs and at least surveillance of
them that they'd never had before.  I think that in the public
health establishment there was a rather acceptance, but a lack of
strong interest within the Regional Medical Programs.  It was
viewed as a medical school and a doctor and a hospital program. 
They certainly incorporated their interest to be sure that
epidemiological studies were accomplished and that needs were
assessed on the basis of good health planning.  There were many
areas where there was involvement of public health people, but,
by and large, they were peripheral to the core of Regional
Medical Programs.

Rehm:  What do you think we learned from the RMPs perhaps that
can be applied to health care today?  

McBeaath:  One of the things I learned is that when I'm out
speaking to groups or talking to students and they tell me a
federal program has never gone out of existence, I can tell them
that that's not the case.  [Laughter]
     I think that the lessons from RMP and from that period, I
think one of the lessons that I would have to say comes from it
for me, is that the inauguration of a major federal, national
program, federal, state, local program, just demands that there
be a great deal of agreement and consensus among important forces
about precisely what its purposes are, and support for it that
will be at least at a level of commitment and expect one to carry
through a few years.  
     But there are other things, as well.  You've got to ensure
that there will be a continuing economy and political environment
that will be supportive of those kind of initiatives by those
kinds of actors and players.  We lost that in RMP.  We did not
have the support and the interest and the commitment of the
Republican administration, which came along. Cap [Caspar]
Weinberger just didn't feel the same way about RMP as did
previous secretaries.  I'm sure there were other lessons that
were learned from it.  
     I think in a more practical, hands-on kind of level, we
learned an awful lot in my area about how to organize cooperative
ventures between various interests that I think do continue
today.  There is still a great deal of programmatic effort in the
Ohio Valley area that does revolve around both tertiary care
centers, regional hospitals.  An awful lot of it comes in the
area of health personnel development, health work force
development, which is a natural for schools and for practitioner
foci to be involved in.  
     There is still a good deal of those kinds of activities that
I think of as having been greatly stimulated and encouraged and
strengthened by Regional Medical Programs.  
     Some would say that in some of the programs that there was a
negative lesson learned about high technology hardware, the
coronary care units, the computerized radiation dosimetry, the
efforts to develop television networks for continuing education. 
Some of the lessons that we learned in those kinds of experiments
were that the hardware was leading us and that we weren't
prepared, at least at that point in time, to take full advantage
of those.  The nature of the expanse of high technology medicine
today, of course, is widely recognized as having not only
blessing, but some cost involved in it.

Rehm:  Dr. McBeaath, I want to thank you so much for being here
today.  Good to talk with you.

McBeaath:  Thank you, Diane.

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

[End of interview]