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Interview with Nathan J. Stark, M.D.  
Date:  October 8, 1991
Location:  National Library of Medicine
           Bethesda, Maryland
Interviewer:  Donald Lindberg, M.D.
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 Mr.
Nathan Stark as part of NLM's study of the history of Regional
Medical Programs (RMP) in the United States.  
     Nate, thanks so much for being with us.

Stark:  A pleasure.  

Lindberg:  I should have said the Honorable Nathan Stark, because
you were Under Secretary of HEW from 1979 to '81, I guess.  But
we're going to return to an earlier moment in history before you
were Honorable.  You were the Chairman of the RMP Advisory
Committee in the State of Missouri, as I recall, from '67 to '71. 
So you saw RMP firing up.  Is that right?

Stark:  Right.  You are absolutely right.  And firing up, it was.

Lindberg:  Now, in real life at that same time, of course, you
were Vice President of Hallmark Cards, an associate and colleague
of Joyce Hall, so you knew the community very, very well and you
knew the business interests very well and the interests of the
community in health care.  

Stark:  That is right.

Lindberg:  Did you think RMP was going to help?

Stark:  I thought it would.  In fact, I was very impressed with
it.  Of course, you must remember that we had a real dynamo in
Columbia at that time--Vernon Wilson.  Vernon Wilson didn't wait
for the ink to dry on the legislation before he had a council, of
which I was a member, and chairman.  He had a staff recruited and
he had the application in the mail and was one of the first
programs to be funded for development, and I think one of the
very first to be funded for operations.  So we moved very
quickly.

Lindberg:  One of my colleagues in international health affairs
counseled me in a project we're involved in, and he said, "You've
got to find yourself the local jet stream."  And I think Vern was
definitely the local jet stream.

Stark:  Exactly.  We often wondered, when he finally went to
Washington, whether he would change Washington or Washington
would change him.  I think it's a toss-up.  [Laughter]

Lindberg:  I don't think he totally overcame Washington, but I'm
sure it was better for his being there.  

Stark:  I was also very pleased because the legislation itself
provided for public membership, and I felt that was a very
important part of it, principally for the same reason that I
think it was helpful to have the public involved in every phase
of our health care system, we are going to be, one day, users of
it.

Lindberg:  Absolutely.  

Stark:  So it was very gratifying to be able to participate in
the initial stages of this program.

Lindberg:  I personally saw more non-medical participation in
these councils and guidance and conferencing on RMP than I've
ever seen in any medical activity I've been associated with.  Did
you have any difficulty finding public members?  

Stark:  No, we did not.  What we tried to do, however, with
public members who had some knowledge of the health field, it's
very difficult to begin from scratch to initiate them into it,
and it's a very complex field to begin with.

Lindberg:  I'm strongly in favor of the public members.  I ask
that, though, because in the end--we're jumping ahead, of
course--but by '73 there were oversight hearings, and one of the
criticisms levied against RMP is that it was said to be provider
oriented, whereas Comprehensive Health Planning (CHP) was said to
be consumer oriented or something to that effect.  I never saw
any evidence of that.  In fact, I saw the reverse, that RMP
welcomed and always had public members.  

Stark:  That was certainly true in Missouri.  

Lindberg:  How about the beginning of all this?  Let's touch
lightly on that.  It had started, of course, before you became
chairman.  What's your view about the beginning of it?  What did
people expect it to do?

Stark:  Of course, reading the DeBakey Commission report, there
may have been expectations that this kind of program would be a
rather centrist type of program.  As you know, the DeBakey
report indicated central groups which would reach out into
subunits and deliver exceptional health care.  As it turned out,
the RMP, at least my reading of it, even at that time, it would
be more of a decentralized program dealing in large part with the
local scene.  

Lindberg:  A lot of local determination.

Stark:  And I liked that.  It gave an opportunity for innovation
to come from both ends.  The other part of it that I liked, being
peripherally associated with the university and medical schools,
I felt that it was an especially attractive program inasmuch as
it brought together the university as a medical center and had
them reach out to the communities, which was something that
hadn't been done too often up to that time.  

Lindberg:  No, that's right.

Stark:  It was more of an ivory tower approach.

Lindberg:  Given all of those changes, when we look back now,
particularly younger faculty have difficulty imagining how
isolated the medical schools really were.  

Stark:  That's very true.  I found the same thing true when I
went to the University of Pittsburgh.  We were quite isolated,
and it's very difficult to get people to move out into the
community.  
     The other thing that I thought would happen here, and was a
little disappointed in community health planning.  I was very
much involved with that.  Not CHP, but in voluntary health
planning.  But when CHP came, it seemed like there was very
little definition and became too highly politicized.  RMP, I
don't believe ever did.

Lindberg:  Planning is a word that can certainly put fear into
people.

Stark:  Yes.  

Lindberg:  I'm beginning to understand more and more why that is. 
Nate, could you say something about the expectations of people in
Missouri?  What did they want to see RMP do?  You must have tried
to gather all of that information and put it together as the
council leader.

Stark:  Yes.  There was a great hope, even on the part of the
council, that RMP would lead toward a better health care delivery
system, that we could take all of this scientific medical
knowledge that was then available, but not yet spread out to the
consumer or to the various locales, and particularly in Missouri,
to the rural areas.  In fact, one of our prime projects was at
Smithville, where we had a community hospital, and I think we did
enough to stimulate interest there, not only in the newest
techniques in medical science--this is a rural hospital--but also
in the then talked about terms of continuity of care.  

Lindberg:  Essentially you were talking about models, then,
weren't you?

Stark:  Right.  This was one of the models that we hoped to
deliver throughout the state, and we did deal with another
community hospital down in Springfield, which was more interested
in coronary care techniques.  There we started a program, if
memory serves me right, on EKGs.  This may have been the
forerunner of going to computerized EKGs.

Lindberg:  I ran that, as a matter of fact.

Stark:  Oh, you did?  Well, I didn't know that.

Lindberg:  It was dependent upon a discovery by Caesar Kasaris
[phonetic] in the Public Health Service, the analytic algorithms. 
That got translated into community service.

Stark:  That was very outstanding.  I think that the fact that we
were able to mobilize not only the man and womanpower and others
throughout the state in participating in this program, but I
think we really mobilized the university and medical center.  As
we saw it, from our group, it was not just a medical school
program.  In fact, we included professors of engineering, we
included professors of communication.  In fact, I remember the
professor of communication played a very large role in getting us
oriented toward communicating.

Lindberg:  Will Stevenson.  I wish he were here to be
interviewed.

Stark:  Will Stevenson.  Right.

Lindberg:  Wonderful guy.  

Stark:  I think the fact that the entire university was
mobilizing its resources to do this kind of a service to study
the health care systems, to look at the kinds of technical
devices which were in being, but which were not either accessible
or known to people outside the university community.

Lindberg:  Nate, I think the things you are saying are, as
always, right on.  I'll contrast that with things that you didn't
say.  You didn't say, "Those guys told the people, the state of
Missouri, that we're going to change in a short while the
incidence and prevalence of heart disease, cancer, and stroke,
and we're going to eliminate that and change it."  That isn't
what you said.  That isn't what you heard.  That isn't what you
expected.  You spoke about changes in delivery of health care and
the patterns and the up-to-dateness and closing the gap.  Those
were the things that you said.  Am I interpreting that correctly?

Stark:  You're absolutely right.  I think that when we started
this program, heart, stroke, and cancer, we also recognized that
this is only three of many, many diseases, and that probably this
program, as it matured, would probably expand into more and more
of these types of incidents of disease and health.

Lindberg:  During the time that you were involved in it, had the
chronic renal dialysis been added as an RMP responsibility?

Stark:  No, not while I was--that came later.  

Stark:  I think they added that and they added Emergency Medical
Services.

Stark:  Right.

Lindberg:  You were before that, I gather.

Stark:  Right.  

Lindberg:  How about interplay with Comprehensive Health
Planning?  We touched upon that.  How did that work out in your
experience?

Stark:  As I said, I was very closely related to Comprehensive
Health Planning.  I had been chairman of the regional voluntary
health planning, which encompassed both Kansas and Missouri,
around Kansas City.  But I could not really--we tried.  We tried
very hard to bring whatever thoughts we had in Regional Medical
Programs into the planning process through CHP, but I never did
find a really good fit.  The best recollection I have is that
there was a rather adverse relationship between the two.  At
least in our region there was.

Lindberg:  Yes.  Something akin to oil and water.

Stark:  Yes.  As a matter of fact, as a Regional Medical Program,
we worked much better with the state of Kansas than we did with
our own Comprehensive Health Planning group.  

Lindberg:  Pretty amazing.  But you were, I gather from what you
said, planning across two states and across this wonderful river
that divides it.

Stark:  Exactly.  And what we did there was to organize a liaison
committee between both states with the University of Kansas and
the University of Missouri, of course, participating, in order to
avoid any kind of duplication of effort and to have more
cooperation.  I think that's one of the principal roles that I
found coming out of the Regional Medical Programs, and that is
the ability to get these diverse groups and institutions together
in a cooperative way.  

Lindberg:  Convener, coordinator role.  

Stark:  Right.

Lindberg:  Let's touch formally on the area that I think you
probably also had a good opportunity to observe, namely what were
the best things that got accomplished?  Were there any things you
saw that you are personally proud of, that RMP did or even tried
to do?

Stark:  This is nothing specific to it, but the very fact that it
was able to bring this cooperative spirit amongst all of these
diverse groups was a very important role that I think we played
in it.  I think the various awards that we made in the hospitals
and in terms of not only diagnostic equipment, but in terms of
passing on medical technical advice and so on, as I mentioned in
Smithville and as I mentioned in Springfield, the type of help we
gave to these small urban areas and to the rural communities was
very important.  
     I think one of the outstanding features of RMP had to do
with professional education, continuing education.  I now sit on
this Committee for Continuing Medical Education and I can
recognize that without having had this kind of a basis, which was
started with RMP, we might not have had this kind of formalized
program, ongoing and continuing medical education.  So that
really stands out as an outstanding part of the program, in my
mind.

Lindberg:  I have to ask you, at least give you an opportunity to
say if the world that we're describing, RMP and these plans,
these activities, looked different to you when you were under
secretary, so to speak at the top of this huge, huge government
agency, than it did when you were granted a Distinguished Public
Citizen in Kansas City.  But anyway, dealing with these small
projects in small towns.

Stark:  Of course, we weren't dealing with RMP at that time.

Lindberg:  No.  No.

Stark:  But we were dealing with small projects in small towns. 
There's no question about it.  My only regret is that we couldn't
have come up--we were so preoccupied all the time I was in that
position with cost containment, that we paid very little
attention to really the health care delivery system.  This is
rather unfortunate, and I think we're still back in the Dark
Ages.  I don't think we've progressed very far since 1974 or '75
to 1990 in this regard.  We're still talking about the same
problems.

Lindberg:  When we talk about outreach, the underserved
population, they're the same populations that were underserved in
the sixties.  

Stark:  It's increased a little bit.  I can remember back in '74
we talked about 30 million or 32 million.  Now we're talking
about 37 to 40 million.  

Lindberg:  Uninsured.

Stark:  Uninsured and underserved.  And we're still talking about
the maldistribution of professions in the rural areas.  

Lindberg:  In fact, you'd have to say grossly underserved.  How
about the winding-down, or the termination?  One person we
interviewed spoke of the "assassination" of RMP.  That was Roger
Egeberg.  You may have guessed that.  Why did it all come to an
end?  

Stark:  I think probably it came to an end for several reasons. 
One reason, I'm going to use my own experiences with the same
organization, and that is the Office of Management and Budget.  I
think they were too preoccupied with a charge to look at budgets
rather than programs.  I think at that point they were viewing
this particular program as more of an experiment than a program. 
I don't think that Caspar Weinberger, who was then the
secretary--no, I guess he was in OMB at the time--was very keen
on the program, and never was keen on the program.  If you get
this kind of adverse position and Congress, again, dealing with
matters of budget, something is going to suffer, and this is one
that had to take the hit.  

Lindberg:  Did you see any RMP programs or activities that you
thought could have been improved?  They weren't perfect, I'm
sure.

Stark:  Going back that far, I'd have to say that I can't recall
any.  Let me correct that.  There was one.  In fact, I was used
as a patient in this one.  We had a chair that was developed, if
you remember.

Lindberg:  [Laughter]  I do.  Silly project.

Stark:  And it took your blood pressure and EKG by just sitting
in the chair.  

Lindberg:  Foolishness.

Stark:  And that may have been one that failed, and properly so.

Lindberg:  Right.  Well, you can't win them all.  

Stark:  But one of the nice things, again, is that even though
this might have been a university project, those things that they
were working on eventually were to be spread to the rest of the
nation and at least they had the best brains working on
everything, and hopefully some of them would come to some good
fruition.  

Lindberg:  We're interested in drawing lessons when we can from
these programs, good or bad.  Since some of the major problems
still face the U.S. in terms of distribution of quality health
care, there is a good bit of talk in town now about perhaps new
programs to address those same issues.  What can we learn? 
What's the take-home lesson from the study of RMP?

Stark:  I suppose we have to go slowly in what we're planning,
and I think that we have to set our priorities right.  Right now
I think priorities are not necessarily in the health field, but
in those conditions that are prevailing throughout the nation
that are causing these problems in the health field. 
Unemployment is one.  Still, the maldistribution of our
professional health, our nurses, our doctors, reluctance to go
into these areas.  I can think of a large number of ways in which
we can correct these situations.  We're doing that, by the way,
in one program that I'm not chairing for Pew and Robert Wood
Johnson.  We call it Strengthening the Nurse.  But actually what
it amounts to is a reform of every hospital in the country,
reorganization, so that we better utilize not only the nurses,
but everyone within that sector.  

Lindberg:  That sounds like a pretty broad-based--

Stark:  It's an ambitious program.

Lindberg:  Supposing that you conceive of some plan to accomplish
what you just said.  How will you bring that into legislation and
in practice?  How will you work it, so to speak, so that it's
successful and doesn't follow the fate of RMP?

Stark:  I think the first thing you have to do is mobilize your
resources outside of government and in some way convince those
elements that previously had been adverse to any kinds of
programs.  I'm thinking specifically about the AMA [American
Medical Association].  Twice in my experience the AMA has come
out with some modifications to good programs that have really
destroyed those programs.  The first one was RMP.  The second one
was Medicare.  I was on HIBAC [Health Insurance Benefits Advisory
Council] at the time.

Lindberg:  Maybe you should say what that is.

Stark:  The AMA managed to get through into the legislation in
both instances the wording that nothing that is done shall change
the way medicine is practiced presently.  I didn't have this
personal experience with RMP, but I certainly did with HIBAC, and
I'm sure it was the same.  Every time the committee, the Health
Insurance Benefits Advisory Council came up with a suggestion on
how we could contain costs in the delivery of health care, we
were told, "You can't do that because that wasn't the intent of
Congress.  The intent of Congress was to run things after the
same as they were run before."  

Lindberg:  Hard to make changes that way.

Stark:  As a consequence, you know what happened to the
escalation of cost.  Well, in RMP it was much the same thing.  It
was very difficult to carry out some of the programs because of
this constraint.  

Lindberg:  In the case of RMP, it didn't have to do with cost; it
had to do with patterns and building, facilities and so forth.

Stark:  Building facilities was one pattern that they managed to
eliminate from the program.  

Stark:  One wonders if it wasn't almost fated to failure before
it started, failing to achieve its objectives.

Stark:  Of course we didn't think that.  We went into it with
great enthusiasm.

Lindberg:  Yes, indeed.  You did a wonderful job, as well.  Do
you want to go any further in terms of these lessons?

Stark:  I think that would be about all that I could--

Lindberg:  I mean, everybody's an expert here, of course.

Stark:  Yes, I know.

Lindberg:  We're entitled to predict the future.

Stark:  Yes.  I think the future is going to be with a lot of
domestic problems that are all fighting for the same dollar, and
until we can find some way of funding whatever programs we come
up with, I think one of the great things in the Regional Medical
Programs is that there were people waiting out there with great
ideas, but they had no idea of funding those ideas.  I think this
is one of the great things that the program did.  
     You asked before what I had outstanding in my mind.  It was
the fact that we were able to bring out these creative ideas from
people who just had them mulling around in their minds, and
suddenly we gave them the opportunity to bring them to fruition. 

Lindberg:  Actually, our last three presidents, even though from
two different parties, Mr. Bush, Mr. Reagan, and Mr. Carter, have
all personally emphasized voluntarism, and that strongly
characterized RMP.  I think the strength of voluntarism in the
U.S. is grossly underestimated, if you're permit the little
editorial comment.

Stark:  I agree with that.

Lindberg:  I think that might be a feature of the new programs if
we're going to succeed in them.  That's cost free and usually
saves money.  
     Nate, thanks so much for being with us.  We appreciate all
that you've done for RMP and for the department and the country,
and we're glad to see you're still hard at it.

Stark:  I'm delighted that you're doing something so it isn't
going to die in the future.  

Lindberg:  Thank you.

[End of interview]