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Interview with Dr. Robert Q. Marston
Date:  September 23, 1991
Interviewer:  Dr. Donald Lindberg
Location:  National Library of Medicine
           Bethesda, Maryland
Transcriber:  Techni-type Transcriptions/DDR



Lindberg:  I am Donald Lindberg.  I am Director of the National
Library of Medicine.  It's my privilege today to interview Dr.
Robert Marston, who is now President Emeritus of the University
of Florida.  This is part of National Library of Medicine's
series of studies of Regional Medical Program in the United
States.  
     Bob, thanks so much for being with us.  You were, of course,
the first Director of the Regional Medical Programs when RMP was
at NIH [National Institutes of Health].  That was in 1966, I
guess.

Marston:  Yes.  February of 1966.

Lindberg:  You remember almost the day.

Marston:  Well, yes, I do remember the day.  A bad snowstorm. 
[Laughter]  I had not anticipated it.

Lindberg:  You are very well remembered at NIH for many things,
but just to remind our audience, you returned to NIH in '68, I
guess, to be the director.  

Marston:  I came in '66 to be the associate director and head of
the Division of Regional Medical Programs and then was made
Director of NIH in 1968 and was here for five years in that
capacity.

Lindberg:  You did a wonderful job, as all of us here remember. 
Today we're focusing on RMP.  You got it started here at NIH and
then it moved.  So obviously I'm going to ask you to give us a
little insight into why it was here to begin with and why it
moved and whether that was good or bad.  Would you like to tackle
that one?

Marston:  The legislation that was passed in 1965 included
Medicare, Medicaid, Comprehensive Health Planning, Regional
Medical Programs.  It was a lot that occurred, and there were
discussions about where to put Regional Medical Programs.  On the
one hand, by its very name, it could have fitted very well in the
rest of the Public Health Service.  On the other hand, health
manpower was being put in NIH at that time, and there was a
strong sense that the science base of medicine was very closely
allied with academic medicine in this country.  Since one of the
major targets of Regional Medical Programs were the medical
schools, I think ultimately Luther Terry, who was then the
surgeon general, and apparently a very dramatic evening
discussion at NIH about the location of RMP, the decision was
made to put it at NIH.  

Lindberg:  So that was really a PHS decision, not a piece of
legislation.

Marston:  No, it was not in the legislation, although I think
without question Mike DeBakey and others favored NIH, and it
surely made it more appealing to me.  I had been at NIH earlier,
in the early fifties, and had chaired one of the sections.

Lindberg:  You were here as a scientist.

Marston:  I was here as a scientist from '51 to '53, and then
also had chaired one of the committees for a number of years.  It
made it easier for me to recruit people, to tell the truth, out
of academia, who knew NIH.

Lindberg:  At the time you came here, you were Dean of the School
of Medicine at Mississippi.

Marston:  That's right.  Yes.  

Lindberg:  Pretty good connections.  Then RMP was moved.  Could
you say how that happened and whether that was good, bad, or
indifferent?  Of course, you moved to head the program.

Marston:  I guess this would have been in the--gosh, when was the
reorganization when John Gardner was still secretary and then
under Wilbur Cohen?  There was a reorganization in the Public
Health Service, NIH.  I was asked to head the Health Services and
Mental Health Administration (HSMHA) at that time.  Manpower was
moved out of NIH later, but at that time Regional Medical
Programs was moved over under what was called HSMHA at that time. 
There was some debate, but as I recall, that was a decision that
was made before Gardner asked me to come.

Lindberg:  Do you think it mattered?

Marston:  I don't know.  We'll get into what the larger dynamics
of Regional Medical Programs was tied with the Great Society
programs later on.  I doubt if the simple shift to that location
changed markedly the nature of the program.  

Lindberg:  What do you think were some of the best
accomplishments of RMP, if you look back on it?

Marston:  First of all, the very attempt to rationalize the
organization delivery of health services around the major killers
of the country--heart disease, cancer, and stroke--the
involvement on a cooperative basis of the AMA [American Medical
Association], which was very, very critical of the program to
begin with, and yet became a key player in working with us, the
medical schools, a lot of young deans.

Lindberg:  You feel they ultimately helped you?

Marston:  Oh, yes.  And the hospitals.  The basic theme of
bringing together medical schools, practicing physicians, and
hospitals into what were called at that time cooperative
arrangements worked very well in the rural areas.  There was much
more trouble in the complex urban settings.

Lindberg:  Still is.

Marston:  Still is, yes.  But I think it also interested people. 
There were a series of people who came to Washington, in part
because of their involvement in RMP, and became key members, some
assistant secretaries, others who had not thought about a career
in Washington.  It was an exciting time with a lot of ferment.
     One of the other things it did for me was to bring me in
contact with some of the programs elsewhere in the world.  I had
been in England as a Rhodes Scholar in 1948, when their health
service went into effect.  I had followed it somewhat, but we
talked a lot to people in Sweden and England and elsewhere in the
world.  I think there was an increased awareness of the
possibility of looking rationally at the organization and
delivery of health services.

Lindberg:  So you're not so easily persuaded by people who tell
us to follow an English model?

Marston:  Well, no.  I don't think at any time.  There were two
or three early fears about Regional Medical Programs--first, that
it was simply a way to pump research dollars into heart, cancer,
and stroke at the expense of other needed dollars.  Second, that
it was a plan to have the federal government take over the
organization delivery of health services.

Lindberg:  Socialized medicine.

Marston:  Socialized medicine was one of the key ones.  So there
was a lot of suspicion at the beginning.  I think the single most
rewarding part was the ability to get people together from
diverse backgrounds and to talk seriously about health problems
in the country.

Lindberg:  Apparently there was a bit of a sea change between the
heart, cancer, stroke report and the legislation, and part of
that was to reduce its content of alerting the AMA.  Is that
right?

Marston:  Well, one of my personal contacts and one of the
reasons I came here was Carlton Chapman, who was then in Texas,
had been President of the American Heart Association.  He had
personally, and with the support of the American Heart
Association, essentially gone through line by line.  I remember
sitting down in his home and going over the original bill and
what he had said, and Carlton encouraged me strongly to consider
coming here, and I encouraged him strongly to become a dean,
which he did at Dartmouth, so that was one of the tradeoffs.  So
I think the American Heart Association played a key role in the
legislation that finally emerged.

Lindberg:  That's very interesting.  Would he be the right person
to ask about that?

Marston:  Oh, yes.  He was very, very deeply involved in it and,
as I say, had a great influence on me and convinced me that it
was a worthwhile thing to do.

Lindberg:  I've heard that Ed Dempsey is a person who staffed up
the commission and later did a good bit of writing of the
legislation.  Is that accurate?

Marston:  Yes, and he was very active on the first council and a
great person, a great supporter of the program.

Lindberg:  I've heard that.  Regrettably, he died before NLM got
going with the study, so we missed the chance to talk with him.

Marston:  I remember one meeting, the first meeting of the
council, in which we were to make some awards.  Ed [Dempsey] and
Mike [Debakey] and a couple of others from the council and I sat
and essentially said, "What are we going to do?  We've got this
range of applications."  We ended up by approving some and not
approving others, because that's the way it fell out, and that's
what we should have done.  

Lindberg:  Bob, are there accomplishments that RMP did or that
you observed as you traveled around the country that personally
you're proud of?

Marston:  I think it's hard to judge.  You go around the country
and everybody likes the National Library of Medicine because it's
good, but also because you're the director.  I hear of strong
support of everything from cardiologists who felt that their
ability to set up these telephone communications--this is a long
time ago--to be able to interpret EKGs.  Practitioners in
Florida, where I've been now for a number of years, felt very
strongly that RMP was important for that state.  I hear a lot of
disappointment about the fact that it didn't continue.  You can
hear the same thing in Missouri, of course, where there was a
great deal of enthusiasm.  Washington-Alaska was a unique part of
the health problems of the nation, and I suspect you still use
that satellite that pumps medical knowledge into that area.  
     So, yes, there are things that occurred, but I think the
spirit of cooperation, not uniform, but was very strong and
people appreciated that.  The ability to recruit people into the
program was amazing.

Lindberg:  People have spoken about the convener function,
getting the right players around the table.  

Marston:  Yes.

Lindberg:  Well, why did it all end?

Marston:  Well, I think, first of all, there was ambiguity in
both the legislation and the program itself.  You've talked, I
gather, to Irv [Irving] Lewis.  Irv Lewis was in the Bureau of
the Budget at that time and had responsibility for Regional
Medical Programs in NIH and a number of other programs.  I spent
a lot of time with Irv, finally recruiting him to be my deputy.

Lindberg:  Did you?

Marston:  At HSMHA.  He became convinced of the importance of it,
but it was only because he spent hours and hours and hours
looking at it.  There was not a clear distinction between
Comprehensive Health Planning and Regional Medical Programs.  The
state planning agencies tended to look on Comprehensive Health
Planning as being their focus, whereas the medical schools and
hospitals tended to be only--

Marston:  That seemed like a very clear distinction.  One was
good, one was useless.  [Laughter]

Marston:  [Laughter]  But then, I think, the basic thing is the
guns and butter problem, the fact that at the time Regional
Medical Programs started, the world was open.  We were Johnson's
dream of redoing the American society on a different level, and
although Regional Medical Programs did not fit into the social
Great Society programs in the sense that others did.  I think it
was caught up in that change.

Lindberg:  I think he was a supporter of them, though, for sure.

Marston:  Oh, yes.

Lindberg:  LBJ.

Marston:  No question about it.  I had clear access to the White
House.

Lindberg:  And did it occasionally come in handy?  

Marston:  Mike DeBakey was always there, so I met the president
several times and I knew he was interested in it.  But Mike was
the one who spoke to him more frequently, Mike and other members
of the council.  

Lindberg:  But then, of course, Mr. Nixon was distinctly not
interested, I gather.  Is that right?  Or was he ever really
aware of the program?

Marston:  I don't know.  I didn't hear a lot of--I was already
over at NIH at that time.  Remember, my first year as Director of
NIH was the $8 billion tradeoff on the guns and butter issue that
led to Secretary John Gardner's resignation.  

Lindberg:  You saw a lot of change, I know.

Marston:  It was a tight budget year, and I think that lots of
programs simply were not afforded.  The money was not present,
which may be the single key reason why Regional Medical Programs
didn't continue, because it was at a stage then when large
dollars had been anticipated and would have been needed.  

Lindberg:  Bob, if you would, I'd like to talk a moment more
about the Comprehensive Health Planning.  I didn't mean to
dismiss it casually.  I know that it must have had people
sincerely behind it and supporting it and expecting great things
of it, as well.  I'm told that Bill Stewart actually was in some
sense responsible for both programs, or at least took a personal
lead in Comprehensive.  Is that right?

Marston:  Yes, and he was very supportive.  I have great respect
for Bill, worked very closely with him.  Jim Cavanaugh was the
head of Comprehensive Health Planning at that time.  I know Bill,
through his background, was very interested in Comprehensive
Health Planning and probably is the single person who tried to
articulate the relationship between the two programs for people.

Lindberg:  As a matter of fact, in the final oversight
testimonies in '73, the administration took the position that all
of the things that RMP was supposed to be doing would be done by
other programs, and they leaned heavily on CHP.  It's hard to
understand it, in retrospect.  They may have believed that at the
time.  I don't know.  We're going to ask Dr. Zapp, who gave
testimony, about that and see if he can remember.  
     In the end, it ended.  Can you tell us, do you think there's
any lesson to be learned?  We still have some of the same
problems in this country and there's still talk about new
legislation to the national cures.  What can we learn from the
RMP experience?

Marston:  Comprehensive Health Planning really did not reach
fruition in terms of accomplishing what had been envisioned.  But
I think the control of the organization and delivery of health
service on the basis of financial incentives and financial
penalties has been very successful in a number of ways, but I
think it has serious limitations.  I think we are at a point now,
and quite frankly, Don, some of my friends have told me, who knew
that I was coming to talk to you, urged me to say that there is
again the need, I think, from some overall intellectual and
conceptual view of how best to organize and deliver health
services in the country, not in the corrosive fashions of any of
the models perhaps that we have in mind, but the ability to sit
down and try to decide what the goals are, what the relationship
among the players should be, and not simply from controlling it
from the reimbursement standpoint.  Whether that will occur or
not, I don't know.  
     I am chairing a commission, as you know, on medical
education.  The focus is on science.  We've arrived at the very
clear conclusion that the nature of the science that underlies
medicine has changed so dramatically since I was Director of NIH,
that we're able now to work from principles, which was not
possible in the past, integration is across disciplines, the rate
of change is so great that it has major implications for medical
education and for the practice of medicine in the future.  It's a
new world.  Whether you use the words "new paradigm" or not, it
is different and it is going to be more different in the future,
and we ought to look at forces of that type, as well as societal
forces that are different now than they were in the past, as we
think seriously about how the health needs of the population
should be served.

Lindberg:  That's a remarkable overview.  Bob, have there ever
been any regional models, any experiments, good or bad,
successful or unsuccessful in managed health care?  

Marston:  The Swedish one was built on the regionalization of
communities long before the medicine aspect of it was simply put
on the regional organization of that country.  

Lindberg:  In some respects, the country has regionalized. 
Medical care has regionalized in many respects along the RMP
model, even without RMP.  

Marston:  Yes.  

Lindberg:  I just returned from a visit to Bowman Gray School of
Medicine in Winston-Salem and Baptist Hospital Medical Center
Union, where we celebrated their fiftieth anniversary, but that
is clearly a regional center.  That's its strength.

Marston:  It's interesting, you coming back from North Carolina. 
The Markel [phonetic] program had a number of people who became
involved in RMP, and at one time the three deans of the three
medical schools in North Carolina were all Markel scholars and
all were very actively involved in the development of the
Regional Medical Program in that state.

Lindberg:  As you know, I had the pleasure of meeting you lo
these many years ago in the Markel Program.  I think it was a
marvelous thing, and I regret that it didn't continue.

Marston:  Yes.  

Lindberg:  North Carolina brings up another connection, though,
and that's libraries.  At the same time the heart, cancer, stroke
commission report recommended these RMPs, it also recommended
what became the Medical Library Assistance Act.  That has
continued, of course funded much more modestly, to be sure, and
perhaps with more specific expectations.  But that allowed NLM to
create the Regional Library Medical Network, now the National
Network of Libraries of Medicine.  Were you ever aware of any
connection during RMP days between libraries and RMPs?

Marston:  The answer is yes, but not to a great extent.  One of
the things that one can do in an organized system is this sort of
90 percent thing that the local and regional libraries did, not
trying to put in every library all of the information in the
world.

Lindberg:  Yes.  We still subscribe to that.  

Marston:  Yes.  Part of that was discussed in RMP, is what do you
need to take care of 90 percent or 50 percent or 70 percent of
the health needs, and then what do you do in terms of backup and
ultimately to get to the point that you could get--I don't know
what your goal is--99 percent.  You always resisted in the
library of meeting 100 percent of needs, I guess.

Lindberg:  Actually, about 82 percent of the interlibrary loans
are provided locally now, so that's a little bit different
number, but that's a happy number.

Marston:  Yes.

Lindberg:  Did AHEC, Area Health Education Centers, ever rise to
prominence in RMP considerations?

Marston:  I think that came mostly afterwards, as I recall.  

Lindberg:  I think of it because of the Carolinas.  They were
some of the better programs.  Some of the better of the AHECs, it
seems to me in retrospect, were ones that took a little bit of a
focus on libraries, which Carolina did.

Marston:  Yes.

Lindberg:  How about, in closing, probing this issue of the
assertions that the goals of RMP kept changing?  We know that it
was directed to heart, cancer, stroke to start out with, and
subsequently became more general.  Then specific programs like
Emergency Medical were added back in, kidney, and so forth.  How
did that play in the office of the director?  How did you think
about that?  Did you feel that the goals were changing?  

Marston:  Surely there was confusion, as we've said before. 
There's no question but the origin was to put a focus on the
dread disease by people who had supported NIH.  Then there was
the modification that occurred with the rewrite of the
legislation.  There was concern.  I remember the kidney people
came to me the first year and said, "Give us $200 million and
we'll take care of renal dialysis for all time."  [Laughter] 
That was before transplants.  
     I think this idea of cooperative arrangements is difficult
for a government such as ours, and it's uneven in terms of its
receptivity.  It does allow people to look at the elephant and
see what it is that they want to see.

Lindberg:  Multiplicity of views.  Sure.

Marston:  Multiplicity of views.  In a sense, our country is
built on that type of strength.  On the other side, it is a
weakness in terms of having sharply defined programs in which
everybody understands clearly.  It was a great experience for me,
I must say, and affected my career and got me interested in
things in medicine I would not have been interested previously.

Lindberg:  Me, too.  I was a foot soldier, so I didn't have the
overview, but I was an enthusiastic foot soldier.

Marston:  Gave up deans and everything else to come.  

Lindberg:  Yes.  Do you think that there's a way to combine this
liberality in which the local people determine the needs in
medical programs to combine that with a kind of national goal-
setting so that you can keep a program in focus?

Marston:  I think we do it.  We do it in a number of various--

Lindberg:  Block grants had roughly that in mind also.

Marston:  Yes, and the manpower grants that sort of refines had
that.  But, again, when the dollars are short, they're often the
first things that people cut, because they don't build up the
type of constituency that you have.  
     I think we have a complexity in the health care system now
that didn't exist in those days, I think the unmet needs in large
segments of our population now.

Lindberg:  Almost greater now than then.

Marston:  Oh, yes.  I think it is.  Well, it's hard to say,
because we didn't recognize some of those.

Lindberg:  We didn't have Medicare.

Marston:  Yes.  That was just beginning at that time.  The cost,
the percentage of the gross national product, is up at levels now
that brings the medical care increasingly each year into the
political arena as a major issue.  I think that the next time
around, that it will get attention, not just Regional Medical
Programs, but how we try to solve what is a major national
problem at present, access to adequate health care in a country
that has the best in many ways.

Lindberg:  It does.  Bob, thanks for your kindness to NLM and for
your attention to these public policy matters.  You're a great
man.

Marston:  I'm very pleased to be here.  The National Library of
Medicine is one of the gems, I guess, of NIH when I was here and
it is the best of its type in the world.

Lindberg:  Thank you. 

                          Addendum to Interview

Q:  Tell us how and why it was ending.  

Marston:  Regional Medical Programs was discontinued for a number
of reasons.  There was a change of administrations with a major
change in social policies.  The Vietnam War had raised the issue
of guns and butter, and funds suddenly became very restricted at
the federal level.  Then, finally, I think, Regional Medical
Programs, as a part of the Great Society programs, was caught up
in a rejection of such programs.  

[End of recording]