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In early February 1994 Mary Woodard Lasker died, leaving one of the most extraordinary legacies in influencing public policy and national health programs of any private citizen in American history. Possessed of enormous intelligence, moderate wealth, an array of friends in key places, relentless energy and focused purpose, Mrs. Lasker saw many of her ambitions realized. She worked for the creation of the National Institute of Mental Health and of a distinct National Heart Institute within the National Institutes of Health in the 1940's; helped build a solid constituency for increasing funds for NIH beginning in the 1950's; and worked for the passage of Medicare and other Great Society programs in the 1960's. In 1970, she forged one of the most unusual alliances in American politics, that between President Richard Nixon and Senator Edward Kennedy, persuading them to launch a new national "war on cancer."

Mary Lasker and her friend and ally Dr. Michael DeBakey were instrumental in conceptualizing and organizing several plans to help President Lyndon Johnson realize his objective of reducing the deadly impact of heart disease, cancer and stroke. A central component of the early strategy was a system of Regional Medical Programs, the original blueprint of which took only a year to formulate and ten months to legislate. Unfortunately for those who thought it was a good idea the program took several years to implement. If Mike DeBakey was the "Father" of Regional Medical Programs, Mary Lasker was the "Godmother."

In May 1994 Dr. James Shannon died, at the age of 89. He too was a central figure in the development of Regional Medical Programs, having decided after much analysis that the National Institutes of Health which he directed would be the most appropriate organizational home for RMP -- at least until its merits and weaknesses could be tested in practice.

Thirty-five years have passed since the effort began to build Regional Medical Programs and a broad-based coalition to support them. With the prominent exception of Dr. DeBakey, who is still going strong, many of the great political figures of that period are gone. But aside from the personalities, much of the political landscape looks the same.

In early 1994 President Clinton was surprised when the American Medical Association, after endorsing his overall plan for national health care, withdrew its support. Thirty years earlier, President Johnson was surprised when the AMA, after tacitly joining in the effort to create a program to reduce heart disease, cancer and stroke, withdrew its representative on the relevant national commission just weeks before its report was released, then organized a concerted, hyperbolic and very bitter campaign against it.

The justification for wholesale reform of the health care system, said President Clinton, lay in the fact that the country was faced with a health care crisis. That phrase had first been used in a presidential address in, 1971, by President Nixon.

President Clinton and his principal health policy partner, first lady Hillary Rodham Clinton, articulated and proposed a scheme whereby the financing of the program would be on a national basis, but many of the decisions about provision of care would be made locally, by individuals and local providers. They indicated that states ought to have broad oversight authority, were to be central actors in the overall plan. Implicitly the proposal recognized the now established pattern of regional concentrations of health care providers and other resources.

Thirty years earlier, President Johnson and his Commission on Heart Disease, Cancer and Stroke had seen the need to build networks of regional resources. The Congress and subsequently the medical community agreed, though they insisted that the regional arrangements must be pulled together cooperatively, collegially, voluntarily.

The story that follows attempts to chronicle the history of the Heart Disease, Cancer and Stroke Amendments of 1965, subsequently known as Regional Medical Programs. It is a history of an enterprise fraught with problems, but energized by the will, skill and imagination of scores of public officials and citizens who, over the decade of the program's formal existence, bent every effort to insure the realization of fundamental purpose: putting the best, most advanced medical knowledge within the reach of the greatest number of citizens.

The underlying problem which stood in the way of realization of the RMP purpose has not been much altered in the past thirty years. That obstacle, in Irving Lewis' phrase, is "the excessively pluralistic character of American society," especially including those elements that aggregate into what is called the health care system. Another sometime architect and long-time observer of federal health programs, Dr. William Kissick, puts it thus: "In the American health care system, E. Pluribus Unum means a lot of pluribus and a dash of unum."

Whether there are in the history of Regional Medical Programs broad, fundamental or even particular lessons for the reform of American health care must be left to others to decide. But the RMP story does illustrate again certain truths about public policy and national enterprises: They cannot fully succeed without consistency of purpose, and steadiness in implementation and funding.

There is another aspect to the story of Regional Medical Programs that reveals itself to a historian and analyst of national health policy. It is that a changing context, including the identification of new national needs or new recognition of old systemic flaws, can change thoughtful judgments of what constitutes success or failure. The good that is done through collaborative human efforts, like that of individuals, should not be interred with their bones. In my judgment, Regional Medical Programs did much good.

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