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Interview with Dr. John M. Packard
Date:  November 5, 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.
John Packard in connection with NLM's series of studies on the
history of the Regional Medical Programs and its legislation in
the United States.  
     Dr. Packard, you were the executive director of the Alabama
Regional Medical Program back in the good old days, were you not?

Packard:  That's right.  It started in the tail end of 1968 and
going on till the ground began shaking under our feet in 1973.

Lindberg:  [Laughter]  I was digging around in that same ground. 
Tell me what interested you in that program.  What got you
excited enough to leave Florida and then come to Alabama?

Packard:  I really have not been able to put my finger on what it
was that excited us so much down in Pensacola, but we had a small
program with an internship and a couple of residencies.  When the
medical literature began to be full of the [Dr. Michael] DeBakey
report and the Regional Medical Programs and the comprehensive
demonstration units, we got very interested.  I think part of it
may be that Pensacola is 400 miles from the medical school in
Gainesville, and there's no direct way to get there.  The other
medical schools are some distance away, and we thought this might
be a chance to build up our own expertise.  But we were
interested enough so that during the summer of '64, I think, we
invited Dr. DeBakey to come speak to us, although he couldn't at
the last minute.  I went to see him in Houston to check with him.

Lindberg:  I understand that the story is that he had to make a
house call and he couldn't be present for your visit.

Packard:  Not only a house call, sir, but a house call to the
Queen of Belgium.

Lindberg:  A palace call.

Packard:  How could we compete?  But it was great.

Lindberg:  Did he help you get into RMP?

Packard:  No, but he assured us that we did not have to stay with
the state of Florida if it looked logically we would be better
off affiliating with Alabama or even Mississippi.  Indeed, when I
was preparing for the interview, I've got a fair bit of
correspondence back and forth to Birmingham and even Jackson,
Mississippi.  But Pensacola stayed with Florida RMP.  I was
invited to come up and work with the Alabama RMP.

Lindberg:  Alabama is regarded as one of the notable RMP
programs.  What was so good about it?  Let's ask you to boast a
little bit about your own program.  

Packard:  I think in many ways we had it easier than most
programs.  In the first place, our region was the state
boundaries, and this let us deal with one medical association,
one hospital association.  At that time we had just one medical
school.  We had about one of everything as compared to the
Memphis RMP, which had part of Tennessee, part of Arkansas, part
of Mississippi, a little tiny bit of Kentucky, and some of
Mississippi.  Incredible!  
     Secondly, we had really visionary leadership with Joe Volker
[phonetic] at the helm of the university and Dick Hill just moved
up to vice president when I came.  Cliff Meader [phonetic] was
dean and a visionary sort of a fellow.  They recruited Ben Wells
to be the first coordinator, and Ben was a KGO bureaucrat trained
in the VA [Veterans Administration], and his first move was to
make the immediate past president of the medical association the
associate director of RMP.  So he coopted, essentially, the
doctors, who in Alabama, by law, were the state board of health. 
The executive committee was also the state board of medical
examiners.  So you had the doctors on your side.  
     But the second big advantage, I think, was that Alabama was
grossly understaffed with physicians, with nurses, at that time
with hospital beds.  Almost anything you could do was not only
gratefully received, but it made a difference.  I think a lot of
places, there was competition, there was a lot of doubt about
this program, so that there was resistance.  I sensed very little
resistance.

Lindberg:  I can believe that.  I know one of the things that's
often misunderstood about RMP is the concept that a lot of funds
and money and resources would flow through from RMP, and the
reverse is the case.  It was a means of planning and organizing
and bringing to optimal use what resources were available locally
and what new things could be brought in.  I don't think any great
amount of federal funds fell on you because of being an RMP
program.

Packard:  No.  And I think the realization that they wouldn't
came fairly early.  That helped expectations from getting too
high.  On many occasions I would work with a group of doctors or
hospital administrators, or both, on some small project.  They
were asking, say, for $10,000, but as they planned, as I told
them there was great doubt that we would get this $10,000, the
funds became available locally and it made a much better program
because it was theirs.  The fact that RMP pulled them together
and facilitated it was something that we really couldn't boast
about, and I think that was part of our undoing in the long run.

Lindberg:  Do you think RMP did, in fact, pull them together and
help that planning?

Packard:  Oh, yes.  

Lindberg:  There seems to be a common belief that the successful
programs had a prominent role.

Packard:  Yes.  

Lindberg:  I'd like to ask you about another famous name.  I did
know Joe Volker and I can easily imagine he would have been a
great, great strength at that school.  How about Senator Lister
Hill?  We're sitting today in the Lister Hill Building.  He was a
tremendous help to NIH overall and to the library specifically. 
Was he active politically during the time of RMP when you were
there?

Packard:  I think he was right at the end of his term.  I don't
believe I ever met Senator Hill.  Of course, his name was all
over, and the conference rooms that we used at the medical school
were not quite this big, but the walls were papered with degrees
and certificates and awards.

Lindberg:  He'd been a fine senator.

Packard:  But I don't think that the fact that he was Alabama
senator meant that there was any special favoritism towards
Alabama as far as the RMP went.

Lindberg:  Oh, no, I'm sure there wasn't.  I wondered if he were
active enough to appreciate what you were doing and played in any
role in either encouraging or guiding.  

Packard:  I'm sure that he must have.

Lindberg:  I'm sure one would have paid attention to what he
said.  

Packard:  Indeed.  I think Dick Hill would be a good one to ask
when you see him.  

Lindberg:  What clinical areas were ones that you focused on?

Packard:  As a cardiologist, and seeing that heart disease was in
the title of the act, that was our main thrust.  We had two
projects in training coronary care nurses.  Then we had another
one that was part of our multimedia library that we loaned out
self-contained instructional units, nine of them, to hospitals
around the state.  We did a good deal of consulting work in
setting up small intensive care units.  Then it became evident
that the pre-hospital care was almost as important as what went
on in the hospitals.  So we moved into the emergency medicine
thrust well before it was authorized or commanded.  
     But we didn't neglect cancer.  We had a regional program
that performed dosimetry, setting up the doses of radiation.  We
had another project where we set a radiation therapy unit up at
one of the hospitals in the north part of the state as the first
segment of a demonstration unit.  
     On stroke we funded a very innovative program that was
developed at the VA Hospital in Tuscaloosa called Reality
Orientation.  In brief, there were not only signs everywhere that
said, "Today is Monday, November the 11th," but everybody that
worked on the ward in these geriatric wards or the nursing homes
would say, "Mr. Jones, your bed has the red bed cover.  Today is
Monday, November 11th."  It proved to reduce the need for
sedatives for these old patients.  The turnover of the nurses'
aides and other personnel dropped way down.  People enjoyed
working there.  That program was used all over the states and
still is.

Lindberg:  Isn't that interesting.  

Packard:  A good investment of about 10,000 bucks.

Lindberg:  Terrific.  You know, when the end came, so to speak,
for RMP, one of the things that John Zapp said in the overview
hearings is that in his view the administration had damned RMP
because it was dominated by the health care providers as opposed
to Comprehensive Health Planning, that was consumer oriented.  I
always felt that that was an unfair characterization, but there
was a difference between the two programs.  From the point of
view that you've described of these different activities in
Alabama, it seems to me that they're very easily understood by a
lay audience.  Did you have advisory groups in which lay people
were prominent or contributory?

Packard:  Oh, indeed.  Of course, the regional advisory group
that set up by law had--I forget what percent of non-
professionals on it, probably 25 or 30 percent.

Lindberg:  I thought the ones in Missouri were super people. 
They didn't have any trouble at all understanding the kind of
thing you just described.

Packard:  In fact, I think towards the end the chairman was a
layman.  But very early on we funded personnel to work in each of
the Comprehensive Health Planning areas of the state, seven of
them.  

Lindberg:  How did that interaction go?

Packard:  That went very well.  Of course, towards the end, by
law we had to have our grants that the advisory group approves
okayed by the Comprehensive Health Planning people.  But we were
all meeting together.  In fact, our nurse educator with RMP was
married to an M.D. who was directing the state CHP agency.

Lindberg:  That could help.

Packard:  So we were in bed together as well as in the field.

Lindberg:  How about the governor?  What role did the governor
play?  The governor, I guess, really controlled the CHP pretty
well, didn't he?

Packard:  Yes.  The health department and the governor, I guess,
were much more comfortable with CHP, because they were part of an
organized structure and they were ported up to the state office. 
RMP, on the contrary, was often regarded as sort of a loose
cannon.  We were only accountable sort of to the university, but
that was mostly on our fiscal affairs.  Somebody in Washington
was looking after us a little bit, but I'm sure it made some of
the entrenched state bureaucrats very uneasy to have us poking
around.

Lindberg:  So your governor tilted toward the CHP?

Packard:  I would say so, but he made me an honorary lieutenant
colonel, so . . . [Laughter]  There was a certain amount of
politics going on.  

Lindberg:  Another factor that has been discussed and maybe I can
raise with you is the question of focus.  Of course, RMP, to
begin with, clearly came out of the heart disease, cancer, and
stroke commission report, but it then later broadened its focus
to be almost, in some people's view, defocused.  Then it added
EMS, Emergency Medical Services, and then it added kidney, which
are two very specific programs.  So it was specific, non-
specific, and then maybe overly specific again, in some people's
view.  Did you find that confused the folk in Alabama in or
outside of the program, or didn't it matter?  If it did, which
was the best way to be?

Packard:  A good question.  I don't think for most of the people
it made a bit of difference.  One of the beauties, I think one of
the strengths of the program, once we achieved what I think they
call mature status, was that in essence the regional advisory
group could allocate money at their discretion and their
priorities.  So what Washington was saying was at times sort of
in the distance.  Since the Emergency Medical Systems were close
to my heart and we were already working on it, that didn't bother
us.  I think what did bother us a lot was the switch that came
when the law said we shouldn't interrupt the way medicine is
practice and financed, to a complete switch where you will
concentrate on providing care to the needy, primary care, health
maintenance organizations, and very definitely interfering with
the way medicine was practiced.  That caused much anxiety.

Lindberg:  How did that come to be, do you know?

Packard:  That was one of those machinations at the national
level, but I always suspected OMB [Office of Management and
Budget] was pulling the strings, because these were all aimed, I
think, at reducing costs.  As they told me one time when I
protested this was against the law as it was written, they said,
"Well, either break the law and get funded or stick with the law
and don't have any money."  I figured they had us in a Catch-22. 
It was a lose-lose situation for us.

Lindberg:  That is unfortunate.  What practical matters made that
choice difficult?  In other words, what did you do that you
otherwise wouldn't have done?

Packard:  I had to do a lot more talking to the county medical
societies, because we had made it very specific that we would not
start any project without their blessing.  So we had to explain
why this was not going to be too dangerous.  I think from what
I've read recently, the fear of the federal government taking
over the practice of medicine was one thing that caused a lot of
concern back in the mid-sixties when it was just getting under
way.

Lindberg:  No question.

Packard:  I think this switch reactivated all those concerns and
fears.  

Lindberg:  The switch didn't do much good, as I recall it.

Packard:  No.  No.  

Lindberg:  There weren't many HMOs to get behind.

Packard:  There were not.

Lindberg:  HMO became a program that the Nixon administration
favored very strongly, as I recall it.  Did this change come in
at that point?

Packard:  I can remember one of my assistant directors writing a
paper all for it, and I didn't think it would ever fly, being an
old practitioner.  It just sounded too radical.  Actually,
they've done pretty well, but they sure didn't come about
overnight.

Lindberg:  Actually, the best known of the American HMOs was
Kaiser.  It's for sure that the Nixon administration never got
behind support of Kaiser.

Packard:  In fact, in the Birmingham area we had a big one at the
Tennessee Coal and Iron, which was the predecessor for U.S. Steel
in that area.  They had a complete HMO, including hospital, for
many, many years.

Lindberg:  In those days, of course, the mineworkers union had
hospitals also.

Packard:  That's right, up in the Appalachians.

Lindberg:  Disastrous enterprise, but they had them.  

Packard:  One thing that did bother us some, there were
considerable offers of money if you tied in with the model
cities, or if you could write a grant with Appalachian regional
commission or with the VA.  It seems to me, in retrospect, we
spent a lot of time trying to twist our goals and our objectives
to fit this other program, and then you'd find that the funding
dates were different.  Oh, it was a mess!  We did have a couple
of good projects, and one of them with the VA is still going on,
the Tuskeegee Area Health Education Center.  

Lindberg:  Is there an overall plan for health care for the
people of Alabama right now?

Packard:  The RMP funded a group that produced a plan which has
been updated at intervals by the governor.

Lindberg:  So that's the closest there is to one.

Packard:  Yes.

Lindberg:  That's good.

Packard:  There have been more specific plans for the aged and
also for the young.  There is an overall plan still around.

Lindberg:  One of the things we like to do in the study of these
historical events, which certainly RMP warrants, is to digest
that and look to the future and ask ourselves what we've learned
from this as a country.  Certainly some of the major health care
problems still exist now that existed back in the early sixties,
and we can't say they were solved, let alone eliminated.  What
should we remember about the RMP now if we launch out in further
programs in the future?  What did we do right, in other words,
that we could do again right?

Packard:  I think the first thing is putting the emphasis on
people and education.  You can spend an awful lot of money on
equipment, but if you don't have the people who know how to run
it, it doesn't work.  If you've got the trained people, somebody
will find the money to make it work. 
     Secondly, we still haven't found a way to correct the
maldistribution problem.  I was thinking particularly
geographically, but, of course, I think there are beginning steps
on getting more primary care physicians and nurses and all
trained as opposed to specialists.  But I think the lesson is
that you don't make these changes in a hurry.  It takes a long
time.  
     I think one of our first goals was to get a lot of care out
to the very smallest places.  I think we learned that you have to
depend on transportation to get people into the bigger hubs. 
There's just no end to the demand for health care, and it sure
isn't limited to the number of people who can provide it and the
number of dollars to provide it with.

Lindberg:  So if a program to address those programs nationally
were to reemerge, what would be its key elements?

Packard:  I think getting the people at the local level, doctors,
nurses, the average citizen, sitting down and identifying their
own problems and offering some solutions, the whole process
perhaps facilitated by non-threatening people such as most of the
RMP folks were, plus a source of money which I don't think needs
to be tremendous, but I think ideally it will be dispensed
locally, that accountability will be local, and there will be
enough time left so that there's no national lurch one way or the
other that tends to cut off the funds before you really get
started.

Lindberg:  No chance to do the work.

Packard:  Yes.  

Lindberg:  Dr. Packard, I thank you very much for being with us. 
I think if we can learn that lesson and put it to good use, that
will be a worthwhile thirty-minute conversation.

Packard:  Thank you, indeed.