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Interview with Dr. Charles Flagle
Date:  September 12, 1991
Interviewer:  Dr. Donald Lindberg
Location:  National Library of Medicine
           Bethesda, Maryland
Transcriber:  Techni-type Transcriptions/DDR



Lindberg:  I'm Donald Lindberg.  I'm Director of the National
Library of Medicine.  It's my privilege today to interview Dr.
Charles Flagle in connection with NLM's project to study the
history of Regional Medical Programs and its legislation in the
United States.  
     Charlie, you are now professor emeritus of operations
research at Johns Hopkins University, but back in the good old
RMP days, you were special assistant in the Office of the Surgeon
General under Dr. Stewart, is that right?

Flagle:  That's correct.  

Lindberg:  Was that a pleasant experience?

Flagle:  Well, it certainly was.  Yes.  So much so that I find
myself coming back and forth to Bethesda and Rockville to this
day.

Lindberg:  Well, we're delighted.  What did you see of the early
formation of the Regional Medical Programs, from the vantage
point of the surgeon general?  

Flagle:  They had been established for several years by the time
I arrived to be Special Assistant for Applied Health Technology. 
In that role, I met a number of times with staff from RMP, with
Dr. [Robert Q.] Marston, who was director at the time.  The
particular concern that I was addressing was what the federal
government's role should be in the support of technological
developments for the health services, a problem in economics, the
problem in appropriate role of government, and within that, a
problem within just which agency should do what.  
     Simultaneously, I was there to help the surgeon general's
office establish the National Center for Health Services Research
(NCHSR) and Development, as it was to be called in the beginning. 
There was a problem which undoubtedly will be discussed by some
of the people here about how the money that was available should
be allocated between pure research and technological development. 
Lots of money and could chew up the budget very fast.

Lindberg:  Was there a kind of competition between NCHSR and RMP? 
I didn't realize that.  

Flagle:  Not between the center and RMP, but the center was
certainly attached to that part of the health services to which
programs such as Comprehensive Health Planning belonged.  By the
participants, it was seen that there was a competition between
Comprehensive Health Planning and the Regional Medical Programs,
although I was not aware of anything like that where health
services research was concerned.

Lindberg:  Ultimately the administration took the position that
CHP would really do what RMP started out to do.  

Flagle:  So maybe the collision was averted in that way.

Lindberg:  How about the event of the surgeon general moving his
office over to the Parklawn Building?  Was that a momentous
event?

Flagle:  It wasn't the Parklawn Building; it was Building 31
right here.

Lindberg:  Oh, was it?

Flagle:  Yes.  

Lindberg:  Right in the middle of NIH [National Institutes of
Health], then.

Flagle:  Yes, right in the middle.  I had an office there, I
believe on the second floor of Building 31.  That's how I managed
to get here without getting lost, Don.  
     The hope was to establish closer ties between the surgeon
general's office, which was quite large at the time, with very
broad responsibilities, and the National Institutes of Health,
which was at the time generously funded, and working with an
agenda pretty much developed itself.  I speak now as the person
coming on the scene for a one-year leave of absence to be a
special assistant.  

Lindberg:  So the move had to do with kind of corralling NIH and
Dr. [James] Shannon, perhaps?

Flagle:  Well, the word "corral" is your word, but in some way
establishing closer ties.  

Lindberg:  I see.  Did that succeed, that strategy?  RMP did move
from NIH elsewhere.  Is that connected with this operation?

Flagle:  Sure.  There were other things happening at the same
time.  There were, and had been, efforts to really curtail the
traditional Public Health Service and to move the authority of
the surgeon general into the assistant secretary for health and
scientific affairs.  That, in fact, took place in March of '67. 
All this happened almost minutes after I arrived on the scene,
and I assure you I had nothing to do with it, other than just to
observe it and really to help make the resulting organizations
useful.  The resulting organization was the Health Services and
Mental Health Administration (HSMHA).  If you ask where the
continuity is, as I recall, Bill Marston, the director of the
erstwhile Regional Medical Programs in NIH, simply moved to
direct the whole program.  Perhaps there was, then, a
consolidation of efforts and later on--that is, in 1968--the
authority was centralized in the office of the assistant
secretary.  

Lindberg:  Charlie, did you get a chance to visit any of the
Regional Medical Program sites and activities out of town?

Flagle:  I think I visited yours in Missouri.

Lindberg:  Then it probably would be unfair to ask you what was
the best that you saw.  [Laughter]  We'll have to hedge that
question.  

Flagle:  I saw a lot of the Maryland program.  We haven't
mentioned this, but in my other life, namely the years
surrounding that year in the surgeon general's office, I was on
the advisory group of the Maryland Regional Medical Program.  The
principal role there was to do scientific merit review of the
proposals that came into the programs.

Lindberg:  Jumping ahead a little bit, do you know of any
residual effect, good or bad, of Regional Medical Programs, say,
in this area?

Flagle:  You mean the area where I was working at the time?

Lindberg:  Yes.

Flagle:  Yes, indeed.  For one thing, since the Regional Medical
Programs operated through the medical teaching centers rather
than through the state authorities, it brought the University of
Maryland and Johns Hopkins together not only in the review
processes, but, as it turned out, in what became the Maryland
program on high blood pressure control, which was funded in 1978. 
So that's some years later, to bring about the coordination of
hypertension control services.  There was strong cooperation
between the University of Maryland and Johns Hopkins, and there
was also a great involvement of such things as the media, the
heart associations.  I would call it an unprecedented--I was
about to say conglomeration, but it really wasn't that.  It was a
well-orchestrated program and it resulted in the creation of the
Maryland High Blood Pressure Commission, which is still in
existence and still operating for purposes of implementing some
of the results of that five-year study of coordination.   
     I think it's interesting to note that the funding of that
effort came from the National Heart, Lung, and Blood Institute
(NHLBI), which was, in effect, the heir to the Regional Medical
Programs, at least in the cardiovascular disease area.  So what
had begun in NIH returned there.  Meanwhile, there were, of
course, other interesting developments that took place in the
activities surrounding the National Center for Health Services
Research, which is now succeeded by the Agency for Health Care
Policy and Research, which also--and I think this is what
probably caught our attention in the first place--doing many of
the things that the Regional Medical Programs were expected to
do.

Lindberg:  Sure.  Was there any direct connection, actually,
between the funding of this NHLBI and of community outreach
efforts and RMP?  How were they related in years?  The NHLBI
programs followed, but did they follow the demise of RMP?

Flagle:  Yes, they followed the demise of RMP, but they followed
by several years.  Those programs had the character that the
Regional Medical Programs were expected to have.  The ones I was
involved in were either community-based statewide or in
occupational health settings or in community health services.  So
this was, I think, traditionally an unusual role for NIH, and yet
the mood for it, the nature of it, the concept of it, was created
by the Regional Medical Programs, which, as you recall, were
categorically based.  It started out as the President's
Commission on Heart Disease, Cancer and Stroke.  
     Once in the hands of the regions, I'm not sure how your
experience was, but certainly ours in the state of Maryland was
that there was much branching out in the direction of the
formation of organizational relationships and regionalizations in
the sense of linking the medical teaching centers to the
activities in the counties.

Lindberg:  Getting all the interested parties around the same
table.

Flagle:  Right.  If you recall, in the [Dr. Michael] DeBakey
report, one of those recommendations was to do just that.  But
it's my recollection that the Maryland program emphasized that
aspect, that is, the non-categorical development of coordinated,
or vertically integrated, organizations, and not so much the
concentration on specific disease categories.

Lindberg:  The emphasis changed from categorical to more general
and then back, I guess, toward the end toward more categorical
once again, and the addition, of course, of emergency medical
programs and other things, kidney dialysis.  

Flagle:  That's right.  That was introduced as the fourth major
problem area.  We most certainly did have projects.  I site-
visited projects in kidney dialysis.

Lindberg:  They're still going, probably.  Did you find an
emphasis or a centering on the theme of narrowing the gap between
the laboratory and the bedside, what's known and what's
practiced?  Was that part of your experience with RMP?  Or was it
talked about in those terms in the surgeon general's office, I
guess, more importantly?

Flagle:  It certainly was.  I'm trying to find specific examples
of that, and I have a feeling that because of my particular
interest, which had to do with organization management planning,
that things that I dealt with were those things that were
organizational in nature.  So I'll leave it to someone else,
hopefully someone who was closely associated with that program
full time.

Lindberg:  Of course, the idea that one can reduce blood pressure
and that, having reduced it, one can half the stroke rate, that
is a very powerful piece of information and the implementation of
it, as well, was a major effort.

Flagle:  It's interesting.  Now I'm really straying from the
Regional Medical Program, but I think this is indicative of the
town-versus-gown problem, the traditional interests of NIH in
centering on disease categories and the Public Health Service,
other parts of it, looking at things non-categorically.  

Lindberg:  Charles, was the Public Health Service in favor of
RMP?  Were they trying to help it succeed?  Did they like the
idea?  

Flagle:  You say the Public Health Service.  Remember the NIH was
part of the Public Health Service.

Lindberg:  We sometimes forget that, yes.  How about the SG? 
What did he think?

Flagle:  I don't recall a specific expression from him, but
certainly within the traditional Public Health Service, the
people in RMP, yes, they felt that NIH was getting into their
business.  

Lindberg:  And that was good?  Was that good?

Flagle:  Well, they didn't exuberate over that development.  I
think they were concerned by it, and I think there was a wish on
the part of some sections within the Public Health Service to
bring Regional Medical Programs into some entity, which happened,
after all.  That's what happened.  

Lindberg:  That's interesting.  So they were trying to move it
out of NIH, then, is that right?  I saw it more as getting
ejected, but apparently there was a pull as well as a push.

Flagle:  I think there was a pull, yes.  In the aftermath of the
Russian coup, one doesn't like to attach too much to these
things.  I remember using the expression on one occasion--and
this had to do with health technology--seven or eight people
scattered around, who were all holding onto their piece of the
activity, that they should really think of each other as the
agents of each other's fulfillment, that it was an immense field. 
The idea that it could be cornered by one agency was not
productive.

Lindberg:  Right.  Again, jumping ahead to where we are, 1991,
there's a good bit of talk now about new health care legislation
and solutions to the countrywide problem.  What can one learn
from the RMP experience, in looking back now?  Can we have a
guidance to the new programs and how we should use them, how we
should formulate them?  

Flagle:  Yes, I think there were some positive aspects.  One can
learn lessons of what to do and what not to do.  

Lindberg:  I'm all ears.  

Flagle:  On the "to do" side, we did learn from the Regional
Medical Programs and we also learned from the successor programs
that the Heart Institute sponsored, that given the proper
stimulus, namely financial, that the lion will lie down with the
lamb, or vice versa.  [We learned] that you can create such a
thing as the Maryland High Blood Pressure Coordinating Council,
with representatives from really competing forces, people
competing ordinarily for the same grants programs, that you can
create a lasting organizational entity by doing that.  
     Let me go to the negative things for a minute before I
forget them.  I think you expect a thing to last, create it as
simply a reaction to a political force.  I somehow could not
escape the feeling that the Regional Medical Programs were
created because NIH was really under criticism from the Congress. 
"We've given you all this money.  We know that you have magic
solutions to problems.  Why aren't they reaching the man in the
street?"  I'm wondering whether others would bear out that
impression I had, that Regional Medical Program was not a
wholehearted thing, but a reaction to an external pressure.  
     If you want to do anything as difficult as, say, create a
vertically integrated coordinated health system, there better be
wholehearted support and interest behind it.

Lindberg:  Do we still have a few of those problems today?

Flagle:  Well, I see less of it today.  Could I go on to my other
negative? 

Lindberg:  Sure.

Flagle:  I had another negative.  This is not a negative in terms
of people and organization as it is in technology.  We didn't
have the ability at that time to tie disparate organizational
pieces together and manage them.  My belief is that the trend in
most major cities toward large health care systems, with tertiary
care hospitals, satellite hospitals, HMOs attached, is enabled by
computer technology, by communications technology, and it still
has a long way to go.  We haven't even gotten into the widespread
use of imaging, either in terms of publications or of X-rays.

Lindberg:  So is your thought that some of the organizational
matters that were attempted in RMP days couldn't be accomplished
because of lack of this technology at that time?

Flagle:  Yes.

Lindberg:  Is that right?

Flagle:  Yes.

Lindberg:  Do you think it's now available?

Flagle:  Yes.  

Lindberg:  Should one start RMPs all over again?

Flagle:  Here and there.

Lindberg:  Is this the time to strike again?

Flagle:  That's an excellent question.  The new agency, Health
Care Policy and Research, is certainly exploiting the
technologies to the extent that they can be, the development of
databases, numerical quantitative databases, and making them
available for research, which is really directed toward policy-
making.  The agency's own interagency agreement with NLM is
moving in the direction.  Thanks to piggy-backing on all of your
outreach programs, lots of new material is available to
practitioners.  The word "guideline" was present in the
predecessor agencies to AHCPR, for purposes of hospital design
and management.  We have hundreds of guidelines produced in the
old predecessor agencies, but they stayed away from anything to
do with medical practice.  I think it was only as a result of
Windberg's work and the coalitions that have formed since then
that essentially the same people are building on the same
organizations--the Office of Health Technology Assessment, the
National Center for Health Services Research.  We see this effort
to measure outcomes and effectiveness and to reach conclusions
about advisable forms of medical intervention, and to place them
in a form that reaches out in the sense that the Regional Medical
Programs hoped to reach out.  But it's interesting that the
agency has not associated itself with any particular form of
organization.

Lindberg:  In just a couple of minutes, do you think that you
could tell us which health care problems have been solved and
which are still around with us?

Flagle:  In just a couple of minutes.  Thank you.  Which health
care problems?  Are you referring to categorical health care
problems, organizational ones?

Lindberg:  Either you wish.  The ones that were looked at by RMP. 
In other words, did any get solved or some of them go away for
other reasons?  Or are we still looking at the same set of
difficulties?

Flagle:  It's my impression, since most of my experience there
was with the Heart Institute and the RMP activities related to
it, that a tremendous amount of progress was made.  I know that
in the state of Maryland, in one aspect, we cut in half the
amount of undetected hypertension through the assistance to
screening programs and through the media encouraging that.  It
turned out that about half those cases could be brought under
control.  Well, if you doubled the number of cases found, you
increase the number of cases brought under control.   Speaking as
a man with three degrees in engineering, I think the medical
profession has made great strides in that area.
     The more subtle areas have to do with organization.  

Lindberg:  Certainly the medical interventions are shown to be
effective.  I guess it's a question of universal access to them
and the cost control.  Those were talked about, of course, in RMP
days, as well as now.  

Flagle:  The great terror at this point is the rate of increase
in cost, so certainly nothing has stopped the absolute rise.  The
question is whether you're getting more for the money.  Our
technologies are contributing to that cost.  There was one area
where I know there has been improvement, and that is the whole
business of managing outpatient care, panels of patients or the
patients who are part of the health maintenance organization.  We
have evidence of much better reaching of patients for appropriate
interventions of their automated records, databases.

Lindberg:  Do you?

Flagle:  Yes.  Boy, am I going out on a limb with this, but when
the lights go out here, you'll probably ask me what they are.  I
think it's time that some of that were documented.  I think
medical informatics has been an enabler of the coming into
existence of the very type of organizations that RMP had hoped to
create.  But paradoxically, they're coming about almost
spontaneously within the existing structure of hospitals and
community health services without obvious intervention by a
federal program.  

Lindberg:  I think your connecting the enabling capabilities of
this information technology to the organizational changes that
accompany these medical goals is a very interesting observation. 
Others haven't made that.  Are you a voice in the wilderness, or
do some other people believe that same way?

Flagle:  No, at the Agency for Health Care Policy and Research, I
work in the division called the Center for Research Dissemination
and Liaison, and its job is to develop, in detail, strategies for
dissemination of research results into whatever extent is
possible, prescriptive forms.  

Lindberg:  That's a wonderful undertaking.  Were such things done
in RMP times?  There was a focus then on information
dissemination.

Flagle:  There was.  In fact, I think I lost touch with RMP
because I was scooped up in the development of the National
Center for Health Services Research, which created a study
section, a whole program in health technology, and a health
systems technology study section, chaired first by Morris Colin
[phonetic].  So even though there weren't many examples at the
time, we were doing the best we could to see that these
prototypes were developed.  

Lindberg:  I think I've got the picture.  I think a lot of what
was foreseen then, as seen now, and some of the problems solved
and enough remaining to keep life interesting for us.  
     Charles, thanks so much for being with us.

[End of interview]
                           Addendum to Interview

Flagle:  A direct line of influence in Regional Medical Programs
in Maryland on the existence of the Maryland High Blood Pressure
today, it publishes a newsletter and is very active in the state. 
It was during the Regional Medical Program days that there was a
project that studied the feasibility of a statewide program of
hypertension control, made recommendations to create the
Governor's Commission, and it was with that very team that we put
together the five-year study that has now resulted in a permanent
Maryland Commission on High Blood Pressure Control.

Lindberg:  What's the effect of that commission?

Flagle:  The effect of it, I don't know the extent to which it is
now measured, but its role is to be an educational instrument and
to bring together the organizational entities that are concerned
with high blood pressure control, both screening and therapeutic
intervention.  So that's one example of the influence.  It
happens that it dealt with one of the original problems that the
DeBakey report addressed.

Lindberg:  Maybe even two of them--heart and stroke.

Flagle:  I think so, yes.  

[End of recording]