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Interview with Herbert B. Pahl, Ph.D.
Date:  October 4, 1991
Interviewer:  Diane Rehm
Location:  Bethesda, Maryland  
Transcriber:  Techni-type Transcriptions/JMW



Rehm:  I am Diane Rehm at the National Library of Medicine in
Bethesda, Maryland.  The interview you are about to see is one of
the series designed to record and document the history of
Regional Medical Programs.  My guest today is Dr. Herbert Pahl. 
Dr. Pahl served as Deputy Director of Regional Medical Programs
from 1971 to 1973 and then as Director from 1973 to 1975.
     Welcome, Dr. Pahl.  It's good to have you here.

Pahl:  Thank you, Diane.  Very nice to be here.

Rehm:  We should tell you at the outset that you are not an M.D;
you are a Ph.D.

Pahl:  I have to admit to that.  [Chuckles]

Rehm:  And I'm interested that as a Ph.D. you became such an
integral part of the Regional Medical Programs.  Talk about your
own involvement with the programs.

Pahl:  Well, my involvement with the programs started in 1971 and
mainly concerned itself with all of the operational aspects from
Washington, interfacing with the programs in different regions. 
The program had been going on for a number of years and those who
look at the history of it see that each and every year brought
different problems.  After some three or four years, it was time
to perhaps codify some of the practices and to improve our
technical assistance to the regions because, by that time, we, in
Washington, were finding out what some of the regions were doing
that was very effective and perhaps could be translated to other
regions.  
     We tried to gather such materials together and then to write
policies and procedures and guidelines which would assist other
regions in perhaps carrying out some of the same or similar types
of activities in a more effective fashion.  
     So as the deputy director, under Dr. Margulies, who, by the
way, was a wonderful person, we instituted a series of steps
designed to help the regions improve their technical review of
applications, institute a dual-review process, that is have two
layers of review within the regions, just as we have at the
National Institutes of Health and, also, introduced into the
Regional Medical Program service early in its formation.  This
tended to improve the program markedly and, I think, advanced the
quality of some of the products that came into Washington for
review.  
     Eventually, the individual medical programs developed quite
strong staffs, in not only developing projects, but establishing
criteria for their evaluation and, thus, were able to improve
projects on the basis of information.

Rehm:  I'm going to take you back, even before you became
involved directly and that is, to your own understanding of what
precisely these RMPs were designed to do.  What was the political
thinking behind them?  What was the intellectual idea that
motivated these programs?

Pahl:  It's had a checkered history in the early years.  I'm sure
in the other interviews you've gone over much of the material by
those who were with it, perhaps, in earlier years than when I
joined.  My understanding--and the thing that attracted me, very
honestly--was that the RMPs were to decide for themselves what
needs they had in the region to improve health care for all the
citizens.  In other words, it was something like a town hall.  It
was the citizens deciding for themselves.  Something in Tennessee
would be different than it would be in Wisconsin.  
Secondly, the idea was for the people in the regions to work
together closely, be they at the state or local government levels
or private foundations, private health agencies, medical
associations, nurses' associations, medical schools, research
institutes and so forth.  The idea was to get people to work
together to communicate effectively and then to take the
additional step.  That is to try to develop plans, workable
plans, as they would see it, for meeting some of these needs and
make application to the Regional Medical Program service for
money to carry out these plans.  So it was transferring money
directly to local groups, not to the governor's office, not to
the mayor's office, but to the citizens that had, together,
formed themselves into a Regional Medical Program made up of
people from all different walks of life and to send the money
directly and, hopefully, with minimal guidance from Washington,
and let them try to meet their own needs as best they saw fit and
then to keep them accountable for this as they came up for review
to be renewed and for additional funding.

Rehm:  Do you think that, from the outset, there was a sufficient
understanding on everyone's part as to exactly what the RMPs were
designed to do, or the very diversity that you talk about become
a bit of a problem?

Pahl:  Well, I think no one, in the beginning, really understood
what the RMPs were supposed to do, any more than today.  If you
had asked citizens, "What should we do?" I really don't believe
that anyone would have raised his hand for that.  We did know
that the program had its origin in the concerns about heart
disease, cancer, and stroke.

Rehm:  Yes.

Pahl:  So this was always a focus.  However, the focus got
diminished in later years as new priorities arose within the
federal government to try to help meet the problems of health
care.  In fact, this is one of the reasons I personally believe
that the program was finally found to be "unworkable."
     It is very difficult to start a program and, within a very
short of time, have people who have never worked together, maybe
even never met together before, come together and work
effectively to devise, to assess needs, to establish priorities,
to devise programs that might meet those needs, to spend money,
and to evaluate the results of their efforts and then modify what
they're doing so that they can improve it.  It can't be done in a
few short years.  Look at the welfare programs that we have in
the county.  We're still not satisfied with how we dispense, or
almost any other national program.  I believe, however, as the
program went on, the different regions performed remarkably well
in assessing their own priorities and needs which may not have
met the needs of what others in Washington may have liked to see. 
     The second thing is, I believe that they designed--and
failed, in certain instances--but then they could modify, delete,
or add to program activities.  And in addition to that, the RMPs
were always accountable to the citizens of the state and to the
agencies and the representatives of those agencies that made up
their advisory groups and committees.  If things weren't going
well, they would hear about it from each other, so there was a
built-in control.

Rehm:  Dr. Pahl, as a Ph.D, how did you find yourself working in
concert with M.D.s, with health professionals, specifically
health professions?  Did you find that there was any conflict of
ideas or approaches or anything else that came out of your
background that may not have been in concert with what their
ideas were?

Pahl:  From my point of view, no.  The reason is, I believe, I
have been privileged, since 1960, to be with the National
Institutes of Health.  In my capacities in a variety of programs,
I've worked with, I guess, every medical school in the country,
many research hospitals and research programs.  This was in the
research medium but, nonetheless, I think for twenty years I've
had both longstanding relationships and, I believe, long-term
friends who occupy all kinds of positions as M.D.s in the medical
research and health care delivery field.  I saw no conflict.  On
the contrary, I felt that what I could bring was something
different, and that was an experience of, at that time, ten years
of having worked with a great variety of institutions in my prior
NIH responsibilities.  I had worked with research institutes,
hospitals, free-standing agencies, not with state directors of
health, but apart from that, a tremendous range of activities
with the deans of the various medical schools and associated
hospitals.  So I found meeting some of these people just with
different hats on with the RMP.  
     I, indeed, never pretended to try to indicate to those whom
I respect what they should be doing medically.  I think we all
shared the same concerns and the same goals of improving the
education, the transfer of scientific results from the
laboratories to the communities, and the collaboration among
parties within regions to assess and work out their own
destinies.

Rehm:  You talked about your long history with NIH.  Can you talk
a little bit about why the RMPs were transferred from the
National Institutes to the Health Services and Mental Health
Administration (HSMHA)?  I know that occurred before you became
deputy director, but talk a little bit about why.

Pahl:  Well, it seemed very natural.  NIH is a preeminent
biomedical research institution and it does not have as its
constituency community interactions, by and large.  It does not
deal at the level of heath care delivery services.  It is not
concerned with access to health care.  It is interested in, but
not--except for the Lister Hill Center and National Library of
Medicine--it is not concerned with the continuing education. 
It's the focus of the whole institution.  It's kind of an orphan
in a biomedical research environment.  
     When the Health Services and Mental Health Administration
was established, it seemed logical to me, then, and still does
now, that it would be appropriate to have it transferred to that
organization because they work with the kinds of programs and
populations, communities and agencies which we had to learn to
deal with.

Rehm:  So you feel that the transfer of the programs from NIH to
the Health Services and Mental Health was a positive move.  What
impact did it have on the program?

Pahl:  Well, I didn't say it was a positive move.  I said that I
could see that it was appropriate.

Rehm:  Yes.

Pahl:  I'd like to liken the Health Services and Mental Health
Administration to the early years of NASA.  One reorganization
after another.  Now, that does not make for a positive impact on
the constituent programs.  NASA, in its early years--I know from
friends who worked there--was chaotic.  The letterhead was out of
date.  They had to print up next letterhead.  The same thing is
true with--we called it HSMHA, Health Services and Mental Health
Administration.  They pulled together a number of organizations
to make the Health Services and Mental Health Administration. 
They had to learn to work together.  At one time, my program was
in three--even for a while in four--different bureaus, larger
organizations within the services at one time and it was almost
administratively impossible to manage.

Rehm:  That can have a very detrimental effect on morale, for
example.

Pahl:  Well, it did.  And this was one of the things which just
happened because of the move.  Of course, the new agency had
difficulties, and I can appreciate the difficulty, but in terms
of managing a program, it was very, very complicated as a result
of moving into the new agency.

Rehm:  You had an opportunity during your years as deputy
director and then director of the program to really get an
overview of the RMPs.  From your perspective now, what were the
major accomplishments, Dr. Pahl?

Pahl:  I think the major accomplishment--I hope some of the
former directors of the program and some of the Regional Medical
Program directors would agree with me--was to give back to
communities and regions a certain say as to what their problems
really are and then give them the wherewithal and give them a
chance to try to do something about those problems.  What this
did was to encourage the program and encouraged the communication
between hospitals on opposite sides of cities in different parts
of the state.  It not only encouraged people in hospitals and
medical centers to come together, the private health agencies
could sit at the same table.   We had lay persons on the Regional
Advisory Group committees and we had the professional societies,
not just the doctors' various professional societies, but also
the nurses and the other allied health personnel were there.  We
were very interested in trying to get the citizens to take an
interest in the program and, at one time for several years, we
had over 2,000 something, 2,300 or so, citizens, leaders in
institutions of higher education and hospitals and private
citizens and private agencies.  All kinds of institutions within
that region spend their weekends at retreats in state parks and
other places in order to discuss the needs for the citizens of
the state or whatever the boundaries were of the region, to try
to think about what can the money that is available do to help
meet some of those needs.  How will we evaluate the success of
the programs?  What resources are needed?  Do we need building,
monies, people, training?  And people talked together for a
common good and that was exciting.  
     I've attended some of the--well, I tried to attend some of
the Regional Advisory Group meetings, and they were exciting
things because these people are giving up their Saturdays and
their Sundays at a state park to talk about better health care,
whether it's for urban disadvantaged, rural, or even the well-to-
do, to try to improve the education of the doctors and the allied
health personnel, to try to bring benefits so that people can get
to hospitals on time, to try to see what resources are needed, to
reallocate.  It was the communication and the working together
and being accountable for monies that Washington provided but
giving them the freedom to decide what it was they wanted to do,
how to do it, and then to compete effectively there had to be
national review of how well, in fact, they had done.

Rehm:  Washington is precisely where I want to take you, because
you were the director as the program was being terminated.

Pahl:  Yes.

Rehm:  Why do you think that it came to the kind of end that it
did?  What was going on at the time?  How did you see its demise?

Pahl:  Oh, everyone sees its demise differently, I suspect.

Rehm:  Of course.

Pahl:  The thing that, I believe, caused its demise is the fact
that it started off in 1965 with a clear vision that the DeBakey
Commission had of establishing regional medical complexes with
some new institutions that would tie together doctors and medical
centers, associated hospitals, and other research institutions in
the region so that the benefits of the science could be more
quickly transferred and disseminated throughout the region.  As
the legislation went through, this got transformed into
specialized centers for heart disease, cancer, and stroke.  As
the legislation became modified and rather than so much
construction, it was decided to use existing centers and existing
facilities and depend more on cooperative arrangements which then
broadened out into the Regional Medical Program concept idea
which each region would define its own boundaries.
Rehm:  Right.

Pahl:  There were few overlaps, but each region would define its
boundaries.  They would be responsible for planning, priority
setting, management and operation of programs, and evaluation. 
But it was always understood that the region would be left alone
to decide what their priorities were.  
     The problem is that that's not what happened.  What happened
was, over the of period time from 1967, when the first programs
got started, the government was impatient and wanted all problems
solved.  Problems keep popping up.  There are problems in
Emergency Medical Services.  There are problems in heart disease,
cancer, and stroke.  There are problems in access to care,
availability of care, quality of care.  There are problems in
continuing education of allied health professionals and other
diseases, arthritis centers and kidney centers and so forth.  
     As the program matured and as each new secretary of Health,
Education and Welfare came in, as each new director came onto the
scene, priorities were filtered down. The RMPs were given very
clear instructions as to what the priorities were.  They kept
changing.  Now, it's easier to write a change in priority than it
is to gear up and meet that priority, particularly when you have
people who are working along a certain direction in a region.  I
believe the program literally became a vehicle for what anyone
wanted to do in the health care delivery area.  
     Even in 1973 when funds were being impounded, even in 1973
when it was decided to phase out the program, they were
earmarking what funds were left to establish a new initiative for
arthritis centers, $4.5 million for arthritis centers.  Why? 
Because of the various political pressures and so forth that came
up.  Not that we didn't need arthritis centers, but it was just
one of many, many things.  The Regional Medical Program directors
would be thrown off base with the new priority issuances as each
new secretary came in.  We ended up buying ambulances and heart
mobiles and training emergency medical personnel.

Rehm:  So too many priorities, too many goals, and too many
expectations?

Pahl:  The regions were told to set their own priorities and to
meet them and then they would either be continued or not
continued, depending upon the way qualified review groups would
deem their effectiveness in carrying out their own missions.  But
as the program went on, Washington was impatient to resolve
everything.  I believe this is a very clear case.  I thought so
at the time and I believe so even more as I watch other programs
in the country.  If you give people the responsibility to do
something and then come in ten minutes later and ask them to do
something else and twenty minutes later and the next afternoon,
after a while they don't make anybody happy, even though they're
working very hard to meet what they are told are the latest
requirements.  The funding follows meeting requirements in many
instances.  So that in a way, I believe the federal government
shot itself in the foot.

Rehm:  Dr. Pahl, you obviously have some very good, positive
recollections about what the Regional Medical Programs
accomplished.  What ideas could you take from your experience
with the RMPs and translate them into positive policies today to
improve current health care?

Pahl:  Well, of course, it's probably even a more complex system
today than it was in the sixties and early seventies.  I'd like
to answer a question you haven't asked first, if I might.

Rehm:  Certainly.

Pahl:  There has to be a longer-range vision on the part of
government.  We don't except a child that's five years old to be
able to meet life's emergencies and understand the world.  At
ten, he's older, can do more, but we don't expect it.  At
eighteen, at twenty-one.  In their thirties, we say we hope
they'll mature.  Somewhere along the line, in their forties and
so forth, we begin to believe that they really now have
experienced the world enough to contribute.  Yet with a program
designed to meet the health delivery problems of, at that time, I
don't know how many millions of people, 160 million people or so,
I don't know, we expected in five years to do heart disease,
cancer, and stroke.  We expected it to move into the kidney area,
Emergency Medical Service area, health quality review--

Rehm:  Pretty big order.

Pahl:  All of these things, with funding in the beginning that
was reasonable--it was modest but reasonable--and then increased
to very significant proportions.  Then as the various people who
were impatient with what the program seemed to be accomplishing
became perhaps somewhat disappointed, the funds would vary and
they would go up and down.  In terms of actually operating
between Washington and the regions, there was a good bit of
telephoning, in which we would have to tell them that we would be
drawing back on the funds that we had promised them.  There were
impoundments of funds.  There were promises of more which did or
did not materialize.  
     Now, when you're working in communities with citizens who
aren't connected to the Washington bureaucracy and process, it's
not only very discouraging, it is disruptive of what they're
trying to accomplish locally.  People devote their time and
energy free of charge.  They do this after hours, weekends,
holidays.  They want to believe that when Washington says they
want something done and they'll keep hands off, but they will
make you accountable and will make you respond to see how well
you've performed and then interfere constantly with on-again,
off-again funding, it just disrupts any reasonable kind of
dialogue within the region.
     I'm very proud of our government.  I'm certainly proud of
being the Director of the Regional Medical Programs for a short
while, but I think that no program could possibly survive the
kind of operational difficulties that were imposed upon the
regions and asking citizens to do things and then pulling the rug
out from under their best efforts.  My suggestion, therefore, is
that regardless of whether it's in the health care delivery area
or in military weapon procurement or in welfare programs or in
agriculture policies or whatever, that the government take a
longer look and have a vision of stability over a period of
several presidential tenures.  
     We haven't solved the welfare program.  We haven't solved
maternal and child health problems.  We haven't solved
improvement of health services for Indians and Eskimos and
disadvantaged and rural populations.  We haven't solved the cost
containment problem and we immediately abandon after three, four
or five years.   This program really only got started with four
Regional Medical Programs in 1967, I believe.  It grew to fifty-
six Regional Medical Programs in the neighborhood of five years.

Rehm:  And, unfortunately, the way our system works, the vision
is as long as the next election.

Pahl:  But this is the problem.  This is the problem with so
much, I believe, of why government seems to accomplish nothing. 
Ideas are good, but it takes a while to establish community
linkages.  If you don't believe it, enter a community such as the
state of Ohio and try to work with the different sections of the
states, the different institutions, the different philosophies,
the different needs.  You have to get people to talk together, to
feel comfortable with one another.  You have to have stable
funding, not more money, planned stability of funding so that
people, when they start something which takes two years to get in
place, will work.  I happen to know because I was very close to
so many of the projects.  
     I was telling John Parascandola, before coming into the
interview, how exciting it was on one or two of the projects that
we had which made a difference for a community.  It wasn't much
money, but it made the difference between health care delivery
and no health care delivery at all.  But it takes a while to put
those things in place to evaluate them.  So a longer vision is
needed, longer stability of funding.  We've seen that in the NASA
program.  When there is pressure to put a woman in space, it
doesn't always work out successfully, not because of the woman in
space idea, but because of the pressure on the engineers, the
scientists, the production facilities that have to meet deadlines
because of political goals, not the real scientific and
humanitarian goals.

Rehm:  Dr. Pahl, I want to thank you so much for being with us
today.  It was good to talk with you.

Pahl:  Well, thank you.  It's been refreshing to think of these
things again.  Thank you very much.  It's been a pleasure.

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

[End of interview]