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     Interview with Dr. John G. Barrow 
     Date: March 16, 1992
     Location: Winston, Georgia 
     Interviewer: Stephen Strickland

           The following interview was conducted by Stephen P.
     Strickland, Ph.D. with Dr.  John G. Barrow who was director of the
     Georgia Regional Medical Program from 1967 to 1975.  The
     conversation took place at Dr.  Barrow's home in Winston, Georgia
     on March 16, 1992.

           Strickland: Tell me about your odyssey from medical school
     onwards.

           Barrow: I graduated in 1943 from Emory medical school.  The
     war had come along and our whole class volunteered.  But they
     didn't want us as privates they wanted us as doctors and I think my
     last year of medical school was paid for by the Army.  Then when I
     graduated they wanted me to have an internship before I went in the
     Army, so I had an internship and one year of residency at Emory at
     Grady Hospital.  Then I went on into the Armed Forces and was
     assigned to Ft.  Sam Houston, TX in the redistribution center
     taking Army PoW's returning from Germany who were being released
     from the hospital at that time and examining them for their
     qualifications to go overseas to fight the Japanese in the Pacific
     Theatre.  I was very opposed to this and so I found as many heart
     murmurs as I possible could with my Colonel's permission.

           .... I had been the first cardiac fellow that Emory ever
     trained so when the war was over we set up the cardiac clinics at
     Grady Hospital.  Bruce Logan and I together and started operating
     the cardiac and hypertension clinic at Grady and then they asked me
     to start training the Cardiac Fellows that came to Emory.  So I was
     in charge of the Cardiac Fellows program for a few years.
     Strickland: Then from there, get me to the Regional Medical
     Program, I guess that came 15 years later.

           I always had taught half time and practiced half time.  I
     gave half time to Emory and I had my own private practice because
     Emory didn't pay anything and I had to make a living.  But most of
     my practice was at Georgia Baptist Hospital.  They had developed an
     internship and residency training program in five areas But it had
     not had a full time director of medical education and they were not
     getting anything at that time but foreign graduates and they hated
     it.  They wanted some good graduates, they wanted to be a first
     class training program, so they asked me if I would give up my
     practice and come in as full time Director of medical education.
     So for six years I directed the medical education program there and
     changed it so that we had all American residents when I left.

           Strickland: What years were those?

           Barrow: 1961-67

           Strickland: And in that period you really made it into a
     first class institution.

           Barrow: The Regional Medical Program came along about that
     time and the Medical Association of Georgia was very interested in
     becomming the grantee and not letting it get in the hands of the
     medical school.  They felt that if the medical schools got it it
     would simply be a way of them tunnelling money into the medical
     schools and it wouldn't really create a better medical system in
     the state of Georgia.  So they asked me if I would quit the
     Director of Med.  Education job and take the directorship of the
     RMP if they became fiscal agent.  I agreed and they did become
     physical agent and so I went to work for RMP at that time and
     stayed with them until RMP closed.  Strickland: You probably know
     that most of the RMP's have a medical school as the fiscal agent or
     coordinator.  Even when that wasn't LI LIL-1, if LIiui-L.- w,i.,. a
     sL-pL-i-a Le L@ntity, It: w,-l,-,. medical school.

           Barrow: And if you will look at the records of the RMP'S, the
     best RMP's were the ones that were not in the medicals schools.  In
     my opinion.

           Strickland: Is that just because medical schools are always
     needing money, looking for money?

           Barrow: They probably amended their own programs without
     considering the needs of the community.

           Strickland: On the other hand, about the medical
     associations, certainly the AMA was sort of skeptical at first and
     I assume some of the state medical societies were skeptical..

           Barrow: They were, a lot of were, but MAG had some good
     leadership at that time and I spoke up for RMP because I knew its
     origins and I felt like it was a good program.

           Strickland: Who was at the MAG at that time?

           Barrow: I can't tell you who was president at that time.

           Strickland: Well it doesn't matter.

           Barrow: But MAG was generally in favor of the program and
     just wanted to make sure that it Georgials RMP didn't funnel into
     the medical schools just for medical school purposes.

           Strickland: Right.

           Barrow: They wanted it to be a community program to
     strengthen medicine in the community, because they understood that
     improving the care for heart, cancer and stroke was what it was all
     about.

           Strickland: Yes

           Barrow: And they did not feel that just by giving the medical
     schools more money was going to achieve anything.  So that is why
     they applied.

           Strickland: I guess since you knew everybody at Emory and had
     been on the faculty, that you had good relationships with the
     medical schools.

           Barrow: With both medical schools.  We gave a number of
     projects to the medical schools and our continuing education was
     divided between the two medical schools.  And the other thing we
     did: we got the medical school for the first time to go out and
     meet with the community doctors to find out their needs.  So every
     task force that we had, had representatives from both Emory and the
     Medical College of Georgia on it.

           Strickland: You didn't try to do it on a county-by-county
     basis, did you?

           Barrow: No, we had our state divided into areas and we had
     area coordinators, young men who would travel that area of the
     state and talk to the local doctors and the local people and find
     out what the needs were.  They would bring this information back to
     the task forces.  And as I said we had representatives from the
     medical schools, representives from the county medical societies on
     all the task forces.  So the leaders of our state medical system
     really took an active part in RMP.

           Strickland: I can't quite rember how many counties Georgia
     has: is it 142?

           Barrow: 159.

           Strickland: Does every county have its own medical society?

           Barrow: No, many of them are multi-county medical societies.
     Especially with the smaller counties, there are as many as five
     counties in one medical society.

           Strickland: Do you have any idea how many practicing
     physicians there are in Georgia?  Or were at the point in time?

           Barrow: No, I-can find out from MAG.

           Strickland: I just wonder if, particularly in that period,
     you felt that through these regions you were pretty much reaching
     all practicing physicians so that they could in fact make their
     input?

           Barrow: I think we may have reached 75%; I don't think we
     reached the 25% who never attended medical meetings or who never
     went to medical society meetings and things of that sort.  But we
     spoke to nearly every major medical society in the state and we had
     good cooperation.  Strickland: How did you organize it?  Is that
     the first thing you did was to set up your regions?

           Barrow: We got the task forces together in the areas we felt
     were important and the task forces then indicated to us how we are
     to organize the state.  For example one of our maDor ideas was to
     create medical centers within 30 or 40 miles of everybody within
     the state that would be able to treat heart, cancer and stroke in a
     first class manner.  Therefore we developed what we call Medical
     Centers of Expertise built around the major hospitals in the state.
     Thomasville had one, Albany had one, Valdosta had one, Savanah had
     one, Brunswick had one, Augusta had one, Macon had one, Atlanta had
     one and in north GA, there were centers in Rome, Gainsville, and a
     couple more towns.  But major medical centers that already existed
     became the center for RMP in that area.

           Strickland: Did you continue with the emphasis on heart,
     cancer and stroke?

           Barrow: Yes, a lot of our M.D.'s continued with that
     emphasis.

           Strickland: Because it seems, almost from the start some
     RMP's submerged that to some other interests or needs.

           Barrow: I think that is right.  A lot of that is a result of
     the need of the medical schools for particular areas and if they
     were the grantee then they would funnel the money that way.
     Strickland: And there has always been, particular in rural areas,
     enormous concern about emergency medical services.

           Barrow: Yes.  Before RMPS started, we had nurse practicioners
     in many of the towns that did not have a doctor.  And those nurse
     pracitioners had ready access to the nearest of the good local
     doctors and they referred these patients to the good local doctors.
     Any many times they would be told by the doctor what to do for the
     treatment in an emergency and they went ahead and gave the
     treatment under his supervision.  So I was very sorry that this
     stopped when when RMP stopped, because I think it is so important
     for every town in GA to have medical care available.

           The other one of our aims that Medicare and Medicaid did away
     with was that we set up cancer, stroke, and heart clinics all over
     the state, free of charge for those that could not afford to pay.
     We had 15 or twenty of these all over the state and they would see
     any patient that could not pay the local physician.  And we
     furnished the nurses and we furnished the space and that is all it
     cost us.  The hospitals supported this so strongly that if you were
     going to be on the medical staff where we had these established,
     you had to give a certain amount of time to these free clinics.
     That was a,staff requirement.  We ended up so that we were handling
     the stroke, cancer, and heart patients with minimum charge -- much
     less than it is costing the government now.  Then our bright
     government came along and did away with it all and started paying
     everbody.  Strickland: And all this was done with the complete
     support of the MAG? Barrow: Oh yes, they wanted the poor people of
     our state to have good medical care.  They had the best doctors in
     these medical centers looking after these patients, giving the best
     care.

           Strickland: How much did that one program cost?

           Barrow: I don't have those figures at hand but I would guess
     that of the total money that RMP gave to GA over the years, about
     half of it went into those programs, it was a major part of our
     effort.

           Strickland: What were these called?

           Barrow: Regional Medical Program Cancer Clinics, Heart
     Clinics and Stroke Clinics.

           Strickland: And there were a total of at least?

           Barrow: As I recall, there were about 15 or 16.

           Strickland: My impression is that in fact RMP's didn't really
     cost a lot of money anyway.

           Barrow: No, they didn't.

           Strickland: I remember in the first years the grants were
     like one or two million dollars per program, That's not huge.

           Well, it sounds like you in GA went about it in a structural
     way: you created a system; you kept with the principal priorities
     out of the DeBakey Commission and those of the Congress that passed
     the law; and then figured out a strategy to reach as many people as
     possible in these categories.

           Barrow: That's exactly what we tried to do and we tried to do
     it as inexpensively as possible.  Having the doctors and the
     medical associations on our side helped us go into these areas and
     recruit the other doctors to give this free care.  It worked out
     real well-and I was very pleased with how many doctors we got into
     the programs of free care before it all folded.  Strickland: My
     impression is that although the law was on the books for about ten
     years given the start up time and given the business at the end
     where you thought the program was going to go by the wayside --
     that there weren't but about five or six years that you had a full
     operating schedule and funds.  Barrow: Our first program got off
     the ground in 1968 and we took a year to close in 1976.  So it
     lasted about,7 years.  The last year we spent just winding down,
     giving people a chance to make other plans.

           Strickland: Which programs did in fact continue under some
     other aegis?

           Barrow: Those twelve or so major medical centers, the
     hospitals that we supported, we financed cath clinics, cath labs
     and a lot of them that hadn't had any cathe, +-ion services and
     these sorts of things.  So people continue have these services in
     their areas.  And it was on-going, 'Aln't end when RMP ended.  But
     the free clinics were the only thing that ended when RMP ended.

           Strickland: One of the things that the Alabama people are
     proud of is their telephone referrel system.  Did you have that?

           Barrow: Yes but we had the doctors call in their nearest
     center.  In other words, they knew where their nearest center was
     and they called there.  They had numbers in everyone of these 12 or
     14 centers that they could refer patients and they could talk to
     the doctors to the problems and that sort of thing.

           Strickland: I see, so instead of a state-wide...

           Barrow: We didn't have a state-wide information network; we
     had it divided into the centers.

           Strickland: Of the practicing physicians of that time, you
     alluded to the situation of many foreign trained physicians.  But
     what percentage of physicians practicing in GA in the late sixties
     early seventies were in fact American trained.

           Barrow: Eighty-five percent.  There was not a great influx of
     these foreign trained doctors until about that time and they were
     still in the internships and training programs.  Not many of them
     wanted to go to the small towns or the small communities.

           Strickland: I suppose if you are from Calcutta, Atlanta seems
     like a small town.

           Barrow: That's right.  And so most of the foreign graduates
     were in Atlanta and Macon and one or two other places.  Savannah.

           Strickland: And of the 85% who were American trained, how
     many were trained at either Georgia Medical College or Emory?  Most
     of them?

           Barrow: I would guess eighty percent of the doctors in
     Georgia were trained by one of those two medical schools.

           Strickland: That's really what I am trying to get at,
     actually.  It would seem to be easier if everybody graduated from
     the same medical schools, there is easier collegiality and
     cooperation.  Barrow: You refer patients to your friends who are in
     the area that you try to get help in.  You do and I do...

           Strickland: Absolutely.

           Barrow: You want to know who is going to take care of your
     patients.  I don't refer just the patients to the Emory clinic; I
     call Bob French out there and say here's what I got, who do you
     think is the best one to see my patients out there.  And Bob tells
     me who to send them to, because Bob and I have worked together for
     many years.

           Strickland: Exactly.

           Well even with the emphasis on heart, cancer and stroke, what
     other kinds of things did you initiate?  Other RMPs seemed to
     emphasize continuing medical education..

           Barrow: We had good programs in continuing medical education,
     particularly in the area of stroke.  I had had a great interest in
     stoke rehabilitation and at the time I started working on this, we
     had only three hospitals in Georgia that had even a physical
     therapist on the staff.  Now every hospital has one and they just
     didn't realize what could be done for stroke patients if you really
     got behind and rehabilitated them.  And one emphasis was to get the
     information out to all the doctors through demonstrations and
     continuing education as to what could be done for these stroke
     patients.

           Of course a tremendous amount was going on in heart surgery
     at that time.  And I was director of the Crippled Children's Cardic
     program for the state of Georgia and I was very interested in
     letting all the doctors know what they could do with these children
     that had heart disease.  So there was a lot of interest and
     continuing education but it was carried on through these twelve
     centers and that made it more successful because instead of having
     to travel to Atlanta you got within 20 or 30 miles of the
     physicians' practice.

           Strickland: Do you remember what the task forces were?  I
     guess you had task forces in Heart and Cancer and Stroke and...

           Barrow: And continuing education.  Those were the four major
     ones.  I think we had some smaller ones but those were the fours
     major ones.

           Strickland: And You had physicians and others on the task
     force?

           Barrow: Yes, we had nurses, physicians and people with
     psychiatric experience and emotional treatment experience.  We had
     also a certain number of county officials because we had to had
     certain of the counties put a considerable amount of private money
     into these free clinics.  We didn't use all RMP money.  We got the
     counties to furnish the space (a county hospital in most cases)
     free of charge.  So that it didn't cost us anything for heat,
     lights, water, or space and all we had to do was pay a nurse to be
     there and run the clinic and the doctors would give their time
     free, so the cost of these clinics was relatively small.
     Strickland: You're a cardiologist and you, I am sure, listened to
     your task forces on cancer and emergency medical services.  But in
     talking to your colleagues who were running the RMPs around the
     country, did you notice any correlation between the specialty of
     the guy in charge and what the emphasis of the program was?
     Barrow: I never really though about that and I really can't answer
     that.  I didn't make any connection... Most of the people that I
     was friendly to in RMP were the people who really had top flight
     programs and who I wanted to find out as much as I could about
     their programs and copy what I thought was good and they did the-
     same with mine.  California had a good program

           Strickland: So Georgia, Alabama, North Carolina, California
     were good.  I read a fair amount about references to the North
     Carolina program and my recollection is that Jim Musser was the
     head.  I knew him because I did a study of the Veterans medical
     care system later when he was the head of that program.  In the
     case of North Carolina, it seems there was a consortium arrangement
     among the medical schools.

           Barrow: That's right.

           Strickland: Now, how was your physical workplace?  Where was
     your office, your headquarters?

           Barrow: my office was in the Medical Association Building.
     They gave me an entire floor and I had my entire financial staff
     there.  I also had two nurses on the staff and they headquartered
     there, but travelled all over the state.  And then of course we had
     the clerical and bookkeeping people and all of them on that one
     floor of the Medical Association building.

           Strickland: How big was your staff?

           Barrow: Roughly fifteen people.

           Strickland: And half of those were financial and half were
     professional?

           Barrow: No, no, I had only two financial people, one officer
     and one assistant.  one of my personal friends was the financial
     officer and I knew his competence and he was extremely good and
     honest and I had real confidence in him.  Incidently we never had
     an audit exception as long as we were in RMP. And then we had four
     secretaries because we had a great many of our field people come in
     and dictate work for the secretaries; and we had the area
     coordinators, five of them.

           Strickland: What kind of professionals were they?  Were they
     health related or...

           Barrow: No they were not medical professionals.  Most of
     these were young, college educated men with an interest in
     travelling over the state.  They did not have a background in
     medicine, they just travelled and talked RMP is what it amounted
     to.  They were communication people, lets put it that way.

           Strickland: How did the grants part of it work...

           Barrow: The task forces reviewed the grants pertaining to
     that area ...

           Strickland: In other words, anybody could submit a grant...

           Barrow: In other words all of them were centralized in that
     particular task force that was dealing with that area of expertise
     and we had people from the medical schools and MAG and people from
     all theses local areas in each of the task forces.

           Strickland: So what you had was your established priorities
     and interests and you publicized these and the five regions knew
     what they were and any medical provider or trainer in the state
     could then just submit a proposal and say, we want to this in
     pursuit of these objectives that you have named.

           Barrow: And many times we would actually stimulate the
     proposals.  We would go down and talk people into submitting a
     proposal.  They were then looked at by the task forces which then
     ordered them by priority in their areas.  Then the executive
     committee, which was made up of representatives of both medical
     schools, a rep.  from MAG and a representative from those twelve
     centers, took those prioritized items from each of those task
     forces and came up with an executive recommendation that went into
     Washington.

           Strickland: Do you remember the magnitude of the amount of
     your grants every year?

           Barrow: No, that has gone out of my memory... I am sure that
     some of my people could tell you but we never had a massive grant
     program.  We had one of the better programs but I would be
     surprised if we spent over $25 million the whole time.

           Strickland: That was my impression; that it went to about $2-
     3 million a year.

           Barrow: Yeah,' as I said so much was given once you got the
     stimulus so much was given by the local people that it didn't cost
     us much to do these programs.

           Strickland: What has happened to the low-income people today
     here in Georgia that have the same kind of health and medical
     problems.  Barrow: They go to the nearest hospital and are put on
     Medicaid and Medicare and they get what medicaid and medicare will
     pay for and that is all.

           Strickland: And in Alabama the entry level is so low, you
     have to be desperately poor.  I think the entry level is $2,000
     before you are eligible.

           Barrow: In Georgia too, not quite as low as Alabama but it is
     low.  And so there are a lot of people that fall in that gap that
     cannot aford to pay full medical care, don't have insurance and
     still live on a farm so they are not eligible for Medicaid and they
     just really have a problem.

           Strickland: Is there any rationale in your mind for
     reestablishing regional medical programs?  Did it perform a
     function that is not being performed anymore that needs to be?
     Obviously one of the things that inspired Dr.  Lindburgh to convene
     that -meeting in December in Washington -- and also to ask me-to do
     this history - - is his question that maybe there are implications
     for RMPs in the future.  We are once again talking about the
     revision of the health care system.. I think particularly about
     financial barriers to care.

           Barrow: I think how much cheaper it would be to care for the
     poor people in these clinics -- having doctors give their time free
     of charge -- than it is under the present system.  I think that it
     would cut the cost of medical care to the government by a
     tremendous amount of money.  But I am not sure that it would work
     now that you have paid the doctors so long to do this; there would
     be a rebellion on the doctors' parts to do this again.  In other
     words, before RMP came along, a lot of these doctors were seeing
     these patients in their offices and not charging them because they
     knew they were poor and couldn't pay.  They were doing it because
     the doctors that referred them also referred their paying patients
     to them too and they didn't want to hurt that doctor's feelings.  I
     did that for many years; many patients I treated didn't pay me a
     dime.

           Strickland: Right.

           Barrow: But when they could be handled in a clinic it was so
     much cheaper on the doctor.  It didn't take near as much time as it
     did in his own office.  So it cost him less to participate in the
     clinic and see the patients there.  And I think if you can get the
     doctors to go back to that situation, you will get medical care out
     to our poor people much cheaper.

           Strickland: Somebody wrote that one of the most important
     things that medicare did was to increase doctors' incomes.

           Barrow: No question about it.  We were all treating poor
     people for less money or no money at all.  Because there was no
     other way they could get medical care and they didn't have
     insurance.

           Now, doctors won't do that, they simply say that if you
     haven't got Medicare or Medicaid, I won't see you.

           Strickland: Some people have said the reason RMPs were done
     away with is because there had been a plethora of new programs --
     begining with Medicaid and Medicare, then RMP and CHP -- and they
     were sort of overlapping and maybe even duplicating and Regional
     Medical Programs was the one that didn't have a clear purpose by
     the end of the decade nor clear results that you could cite.

           Barrow: That's right.  For example there wasn't this free
     clinic system in a half a dozen RMPs across the country.  It really
     hadn't caught on.  I think Washington State had one.  I just don't
     remember.

           Strickland: It still would seem to me that if you had free
     clinics across the state and you had the full cooperation of the
     medical profession, that the people of Georgia and your elected
     representatives in Congress would have been very much in support of
     continuing RMPS.

           Barrow: Well, why continue with them when you can get paid
     under some other program.  Why would a hospital give the space and
     all the free care if they could get it paid for under Medicare and
     Medicaid?

           Strickland: I see.  So let me ask you what happened that
     caused the demise of RMPS?

           Barrow: The passage of Medicare and Medicaid as far as
     Georgia was concerned.  It really did away with the need for
     professionals to give their time to do what they could now get paid
     for.

           Strickland: If there was to be a new RMP with a new mandate,
     what would you include in it.  Barrow: Well, I think continuing
     education is always important.  Because in a state like Georgia
     with many doctors out in the rural areas that do not have close
     @Cess to a medical school it is important to get continuing
     education out to those community hospitals for that part of the
     state, like Albany and Thomasville for example.  And they can
     attend there because it is not so far away from their home and
     their practice that they can't attend.  They can't come to Atlanta
     or Augusta to a medical meeting therefore they neglect continuing
     education.  I think continuing education is extremely important and
     ought not be limited to heart, cAncer, stroke, it ought to include
     all advances in medical care.

           Strickland: And nothing has come along to put such a system
     in place.

           Barrow: No, I know of nothing.  The medical schools programs
     are always in Atlanta or at the school itself.

           Strickland: In Alabama you probably know that Universty
     medical school has started two year schools in general medicine,
     family practice, in Huntsville, Tuscaloosa and Montgomery so those
     centers put doctors in closer range.

           Barrow: We only have the two medical schools and they both
     want to do the more esoteric treatments and not do general
     practice.  Therefore their interest is in giving continuing
     education that will refer them patients.  That is what they are
     aiming for, to be frank about it.

           Strickland: What about this annual gathering about the
     directors of regional programs?

           Barrow: It was helpful.  Each of us got ideas from the others
     and I think it was helpful for us to do that.

           Strickland: Why did the emphasis seem to change from Heart
     Cancer Stroke then Kidney, Emergency Medical Services, General.

           Barrow: Well you have to realize that the problems were not
     all in Heart Cancer and Stroke.  There was a need in many of these
     new areas that were advancing and we didn't want to hold off in
     giving continuing education in those areas.  The questions ought to
     be how do we spread the best medical care out to the community?
     That's what it amounts to.

           That is what we tried to do and I think in Georgia we did it
     realitively successfully.  And we still I think don't have anything
     that really takes the place of it.

           Strickland: Do you think President Clinton will be amenable
     to proposing a new comprehensive health care strategy?

           Barrow: I don't think President Bush will let him!