Interview with Dr. William Ruhe 
Date:  August 29, 1991 
Interviewer:  Dr. Donald A.B. Lindberg
Location:  National Library of Medicine
           Bethesda, Maryland
Transcriber:  Techni-type Transcriptions/DDR



Lindberg:  Today it is my privilege and pleasure to interview Dr.
William Ruhe in connection with our study of the legislation and
history of Regional Medical Programs in the United States.  
     Bill, thanks so much for being with us.  I'm going to ask
you a number of questions about various aspects of the program,
but one of the areas you know, I think, a good bit about, and
others not so much, that's how the program got started, the
translation from the heart, cancer, stroke commission report, the
DeBakey report, to the legislation and then the initial
implementation of the program.  What do you remember from those
days?

Ruhe:  I'm not sure that I'm really qualified to say what
happened. I have memories of what I thought was taking place,
what was happening at the time.  When the legislation was
proposed, I was assigned, along with a couple of other AMA staff
people, to write a critique of the legislation, analysis of
proposed legislation, and to try to develop a position for AMA on
it, and found the bills were rather confusing because they were
quite general in nature and non-specific.  It was extremely
difficult to tell precisely what was going to be done if the
bills were to be passed.  But everybody understood that the bills
were based upon the report of the DeBakey commission which had
appeared the end of the previous year.  
     So we went back to the DeBakey commission report and re-
educated ourselves on that.  It was very specific in many of its
recommendations, and I think there were something like thirty-
five recommendations in the report.  If one tried to translate
the recommendations of the report into the proposed legislation,
one had great difficulty in tracking how did one lead from one
thing to another.

Lindberg:  It definitely changes character.

Ruhe:  That's right.  No question about it.

Lindberg:  What were some of the major--

Ruhe:  Well, I think that what happened, and a lot of it was as a
result of objections raised by some people, including AMA, but
certainly not limited to AMA, the original report spoke, for
example, of regional medical complexes, complexes not defined,
but I think in almost everybody's mind, that evoked the image of
large construction efforts, new buildings, new centers assembled
in either existing locations or new locations.

Lindberg:  Those wouldn't have been unwelcome in most medical
centers, would they?

Ruhe:  Well, I think not, although it's interesting that a lot of
the people from some medical centers were apprehensive about them
because they didn't see them necessarily as being put under their
direction.  Nobody wants a rival complex established right on
your same campus.

Lindberg:  So AAMC, as well as AMA, had their doubts?

Ruhe:  I think many people in the AAMC did.  I'm not sure that
AAMC ever took a strong position on the legislation of any kind,
but I know that many people who were in medical centers were
concerned about what might come out.  But I think that one of the
things that was done was that the term "complexes" was changed
and it was changed to Regional Medical Programs, which is quite
different, a very significant change in language, just that one
word.  

Lindberg:  In fact, the legal authority for construction was
removed, or denied.

Ruhe:  Exactly.  Although in the original bill I think that was
still in, but it was lost in the procedure between the bill and
the final--that's right, somewhere along the line.  So that
change did make a significant change, and also there was then
clearly a statement in the legislative history that the intention
was to use existing facilities and existing structures and to
develop them as the major centers rather than to build new ones. 
Of course, that made a big difference as well.  
     But all of those things, to me, I was kind of an observer of
that.  I wasn't really on the inside.  I'm not really sure how
and precisely why some of those changes were made.  

Lindberg:  You were, however, a member of the group with
particular responsibility under law to write a progress report,
an evaluation and report to the president, wasn't it, in '67?

Ruhe:  That's correct.  

Lindberg:  How did that go?  Did you see progress?  Were you
enthusiastic?  Was the group unanimous or were they divided?

Ruhe:  I think you've asked about four different questions there,
and the answer to the first one is yes, I did see progress.  I
think things had been accomplished.  Two, I was not really
enthusiastic.  I had always had reservations, for a variety of
reasons.  Nevertheless, the report which went in, while I don't
think everybody was unanimous in the language or perhaps even the
tone of the report, I think most people were persuaded that RMP
was a good thing at that time, was doing good things, and that
its tenure should be extended.  I think the report proposed there
should be a five-year extension to give it a chance to accomplish
some of the things which had just barely gotten under way by that
time.  
     Of course, one of the problems was that there was difficulty
in getting geared up between the planning grant and the actual
operational grant, and in many cases some of the regions of the
country, while they had been approved for operational grants,
hadn't really accomplished very much at that time.  

Lindberg:  Did you think that more got done in the rural areas
than in the metropolitan areas?

Ruhe:  I think that's true, at least where there happened to be
some people who were enthusiastic about the concept and really
used a lot of energy in getting it going.  I think the reverse is
true, that the most difficult places to get going were the large
centers, particularly where there were multiple medical schools. 
I think that's understandable.  Here are cases where schools
simply, in the same city, had rarely communicated with each
other, let alone cooperated with each other, and they had been
rivals for many things, often hospital beds, facilities, dollars. 
It was pretty hard to get such people together.  
     All I have to do is remember how difficult it was in
Chicago.  Originally I think there had been an intent that there
would be a regional in northern Illinois, in the Chicago area,
and I can recall--I was not present, but again hearing his story
of how Mayor Daley got together a lot of the people from various
institutions and was very stern with them because they'd been so
slow in making any progress and tried very hard to get them to--

Lindberg:  Daley wanted it to happen, then?

Ruhe:  He wanted it to happen, and he wanted it to happen with
the greater Chicago area as one of the complexes.  But it didn't
wind up that way and never did really get that accomplished. 
Eventually there was a region--Illinois had an RMP.  But those
things were pretty hard to do, and I think it was tough in New
York City, it was tough in Philadelphia, it was tough in all the
places where you had existing strong centers already doing many
of the things, or at least in their mind doing the things which
it was proposed that the new Regional Medical Programs would
bring about.

Lindberg:  I think the very biggest cities didn't show RMP at its
best.  

Ruhe:  That's right.

Lindberg:  If I step ahead and ask you what was its best, you
must have visited and site visited and studied reports and, of
course, you were on the committee that George James chaired, that
evaluated proposals.  What was the best that you saw out of all
this?

Ruhe:  Without trying to identify specific regions, to say one
was better than another, I would say that the things which to me
were most impressive were the success with which they did achieve
cooperative arrangements in many settings.  I think it was
probably the best shining example of what RMP was able to do.  It
did bring together what had been frequently disparate groups. 
When you get together teaching and non-teaching hospitals and
health departments and medical schools, it was a lot easier in a
state where there was only one medical school, but even there to
bring those groups together, the so-called leaders in health care
delivery and many of the allied health groups, to bring the
nurses in and bring many others, specifically non-physician
groups, and have them working together for the same goals and
cooperating in what they were doing, I think that was quite
impressive in many of the places.  

Lindberg:  Is there such a convening function now?

Ruhe:  I don't think there is.

Lindberg:  I don't think so either.

Ruhe:  It's disappointing that these things did not endure.  I
don't know how long they did endure after RMP quit.  I had the
impression that some of this cooperation and collaboration did
continue for a few years, at least, but as long as the people who
were engaged in initial arrangement were still there, maybe still
living, still active.  But over time they were gradually
forgotten and again the organizations and institutions tended to
turn in themselves and worry about their own particular problems
and not be very much interested in these larger, more general
activities.  That's too bad.

Lindberg:  It was said in the '73 oversight hearings that RMP
activities would be taken up and covered by Comprehensive Health
Planning and Hill-Burton and so forth.  I don't know if anyone
really believed that.  It didn't actually work that way, did it?

Ruhe:  It certainly didn't.  Again, I have no inside knowledge on
this.  Just observing it from a distance, it seemed to me like
that was the kiss of death.  I thought that was simply a way of
disposing of it.  I think by that time the administration had
determined not to fund the RMPs and it was a program that was
being disposed of, and this was a pretty good way to dispose of
it.  I think because the goals were somewhat different and the
methods of proceeding were different.  One thing about the CHP
legislation was that, if anything, it was more esoteric than the
original RMP legislation, because you really didn't know what was
being proposed or how it would be done.  To subject the RMP to
CHP oversight and review and to have it subject to the same
planning procedures which other activities did, I think was bound
to kill it in time.  

Lindberg:  It didn't take much time.

Ruhe:  It didn't take much time.  But, of course, if at the same
time you cut off the funds, that speeds the process.  

Lindberg:  It does, indeed.  Do you think that people were
fearful in these times in the beginning and the initial
flourishing of RMP, were they fearful that this was the beginning
of socialized medicine?

Ruhe:  Oh, there were many who saw it as that.  I was on the AMA
staff at the time, as I mentioned, and there's no doubt that AMA
as an organization was apprehensive about this, and there's no
doubt that many physician groups around the country were
apprehensive about it.  As RMP got started, we would get phone
calls and letters from individual physicians or sometimes from
county societies expressing alarm and concern about what was
happening here, and this looks like a step toward government
control and government direction in the practice of medicine. 
There's no doubt that a lot of people feared that, and I think
that was one of the things which influenced the nature of the AMA
testimony, but it was by no means limited to AMA.  There were
other people who were apprehensive, too, and I think the full-
time academic community was by no means sanguine about the idea
of all this coming on.  There was a fair amount of, "What are
they going to do to me now?" kind of philosophy, which you'd hear
in the halls at meetings and things of that sort, but which
usually didn't surface in hearings or come out in print.  So I
think that the concern about what was going to come about as a
result of RMP was fairly widespread.  

Lindberg:  I was surprised to discover in some schools that the
Regional Medical Program activity was viewed as a kind of foreign
body, because in the best of them, or at least in Missouri, it
was viewed as the most exciting activity for the school.  

Ruhe:  I think it did vary widely from institution to
institution.  In general, the so-called larger, more powerful,
more prestigious institutions were less interested in this than
were, let's say, some of the lesser institutions, less well
funded, which didn't have the same horizons and the same
opportunities.  Many schools--and I believe many faculty members
at many schools--saw it as an opportunity to get funding for
things which they thought ought to be done and which could be
either adapted directly into the goals of RMP or could be
tailored somewhat so that they would fit into a project as part
of the RMP.  So after a short time, there developed a fair amount
of enthusiasm for doing that kind of thing, and any new source of
funding is always attractive, of course, to medical centers. 
They're always looking for additional places to get money.  Then
there began to be a little bit of excitement also, which was
generated, which translated into the thought that, "Well, maybe
that can do important things for our region."  So some enthusiasm
grew, then, as a result.  When that happened, I think a lot of
the apprehension was overcome.

Lindberg:  Of course, one of the questions we're always
interested in nowadays is evaluation.  There were attempts to
evaluate RMP.  Globally it may have been evaluated on the basis
of its ability to eliminate heart disease, cancer, and stroke. 
Do you think that's so?

Ruhe:  Well, I don't think there's any question about it.  When
the report of the DeBakey commission was sent to the president,
it was labeled The Report of the Commission to Conquer Heart
Disease, Cancer, and Stroke.  Well, I think even the most
supportive of persons would agree that was oversell, but it was
obviously part of the political philosophy at that time, and I
think we have to acknowledge that RMP was just another component
of the Great Society program in the health field.  The idea, of
course, was to sell something to the public which would be
exciting and would be new and striking and would save many, many
lives.  The concept that one could ever conquer heart disease,
cancer, and stroke was a very inviting thing, I think, to non-
professional people.  I don't believe people within medicine or
other health care professions really believed that could be done,
so that if one were to evaluate it in the sense "Did it
eliminate, did it conquer heart disease, cancer, and stroke," the
answer is no.  

Lindberg:  Do you suppose there was a time when no one believed
you could eliminate or conquer Ricketts and diphtheria and
typhoid?

Ruhe:  Perhaps among many individuals, although I'm not so sure
that was ever a professionwide philosophy.  Maybe AIDS today,
there are some people who will say there will never be a cure or
a vaccine.

Lindberg:  Oh, I hope there will be.

Ruhe:  I feel sure there will be.  

Lindberg:  Actually, compared with the amount of money which has
been mobilized against AIDS, the whole Regional Medical Program
activity was essentially minuscule.

Ruhe:  Exactly.  Very, very much so.  The number of dollars put
in, in today's terms, was peanuts, really, and when you consider
that heart disease was, and continues to be, the number one
killer, I think it's a little surprising that it wasn't possible
to make a much stronger case, to really gear up for the fight
against heart disease.  Then when the next administration came
in, its target became to fight cancer.  So you had then a
separate program for cancer.  Those things are very attractive at
the time, but they lose their luster over a period of time, and I
think that one of the problems is that it's hard to sustain that
kind of enthusiasm over time.  
     That committee which wrote the report to the president in
1967, I guess it was, which recommended additional five years of
support, they also recommended that this be made a self-
sustaining process for the foreseeable future.

Lindberg:  What did that mean?  Cash on the barrel head?

Ruhe:  Well, I think that they felt that there was potential
within the regions for making their own activity self-supporting,
because they would be viewed by the regions and by the community
as being valuable enough to the community that they would invest
their own dollars and their own political support in maintaining
these things.  A good case could be made for that in many of the
regions, but for--well, I'm not sure exactly why, but those
things--it just didn't happen that way.  

Lindberg:  You had responsibility as senior person in education
at AMA.  One of the things that did persist from these
activities, and, in fact, flourishes as the North Carolina AHEC
program, the Area Health Education Centers program, and indeed a
very fine program now, minus any federal dollars whatsoever.  Is
that what was meant by self-sustaining?

Ruhe:  Yes, that was my concept, at least, and I think that was
the concept of most of the people were on that committee who
wrote the report, that once you got it over a certain hump, that
from then on it would continue to roll from its own momentum.  

Lindberg:  But is it rolling just on state funds?  Isn't that
just robbing Peter to pay Paul?

Ruhe:  Well, I don't think that it's solely on state funds, but
you have set in position the mechanisms for obtaining support
from a variety of sources, some of them federal, some of them
private, some of them local government.  But once you have
demonstrated the capability of effecting something in a position
fashion so that it will do good for the region and for the
community, then it makes it a lot easier to get that kind of
support.  

Lindberg:  Are there a lot of those examples?

Ruhe:  I don't think so.  If there are, I don't know about them. 
But I think there are some things that were done which have
continued to go along.  Your mentioning the education brings up
the continuing education issue.  This, again, I think was one of
the original intentions, but it was one that AMA seized on.  "If
there is a threat here to the practice of medicine, why don't we
try to divert the energy and the attention to education of
practicing professionals?"  So they got strongly behind the idea
of bolstering continuing medical education with that.  That, I
think, was again one of the success stories of RMP for a time.

Lindberg:  The principle being a little education couldn't do too
much harm?

Ruhe:  I think in the name of education, many sins are frequently
committed, but usually you do go along with the idea that you
can't too much.  Certainly in continuing education, there were
many regions in the country which had done little or nothing up
to that time.  Through RMP, it was possible to initiate a good
many programs, and many of them with very innovative ideas.  So I
would say that's one of the good things which RMP did accomplish.

Lindberg:  Is that still a big problem in medicine?

Ruhe:  Well, I think it is.  I think it always will be.  Nobody
can agree completely on the best way to do things, and one of the
problems with doing that is it's extremely difficult to evaluate
any kinds of educational programs because it's very difficult to
define a good physician.  Who is a good physician?  How does one
education them?  How does one continue to bring people up to date
and maintain their proficiency and their store of knowledge?  You
know that better than I do.

Lindberg:  I don't know any doctor who isn't very well aware of
the need to keep up in education.  I agree with that.  We're
grateful for any help we get.

Ruhe:  Knowing it and doing it are sometimes two different
things.  But they used to spend a lot of time in continuing
education conferences and talking about motivating physicians to
learn.  George Miller, who was frequently involved in such
conferences, used to get a little impatient with that.  He said,
"Everybody wants to learn something, whether as a physician or
non-physician."  If it's a physician, it may be how to plant a
better rose garden if he likes roses, or learn to hit a sand
wedge out of the trap better.  He'll want to learn that if he's a
golfer.  His thesis was that everybody really would like to be
more knowledgeable and be a better physician, and that makes
sense to me, because I think that the average doctor would like
to be successful in what he does, but sometimes translating that,
again, into the enlightened, effective continuing education
program is very difficult.  

Lindberg:  Is there a kind of take-home lesson here?  The times
are such that we're talking again about major changes in health
care delivery and legislation, even.  What can we say we've
learned from RMP that will help us in casting up the future?

Ruhe:  Well, that's awfully hard to say, but I have some
impressions about it.  For one thing, I think that one of the
things which, in the long run, hurt RMP was the speed with which
it was proposed and developed.  From the time of President
Johnson's Health Message in February of 1964 to the appointment
of the DeBakey commission, the final report of the DeBakey
commission which was in that same year, in October, for an
enormously importantly and complex subject to come out with a
strong report in that period of time, then the legislation come
out early the following year and the bill was signed by the end
of that year, then the whole program got started, well, you know,
that's break-neck speed for a movement of this complexity.  
     I think that when new programs are addressed and initiated
to solve major problems, people should understand, first of all,
what problems they're trying to solve.  One of the difficulties
with RMP was that it meant so many different things to different
people.  People would get a flash, maybe a vision, of the brave
new world under RMP and they would work like mad for that
particular portion of the program.  Then others would see it as
quite a different program with a different set of goals and
initiatives.  Unless you really have everybody pretty much facing
in the same direction before you start, you're going to begin to
get these divergent interests are going to pull the program
apart.

Lindberg:  We'll put you down, Bill, for a more deliberate
approach the next time.

Ruhe:  Right.

Lindberg:  In the meantime, thanks so much for being with us.

Ruhe:  Thank you very much for giving me the chance.  

[End of interview]
                           Addendum to Interview

Q:  A short comment on what was proposed, what was requested, and
then what finally happened as far as funding of RMPs and the
length of time.  Will you tell Dr. Lindberg about the proposed
versus the requested tenure of the RMPs?

Ruhe:  When new legislation is proposed, the people who are
advocates of it frequently have in mind something of permanent
existence, something that will go on almost indefinitely, but
what comes out is a balance between what is politically possible
and what is acceptable to persons who are going to make the
authorization.  Initially, RMP was funded for three years, and I
think part of that was a planning grant funding, and then it was
extended for another three years.  The advisory committee, in the
report to the president, recommended five and recommended that it
be made a continuing program, really expecting, or hoping, that
it would be continued for the foreseeable future.  
     There was considerable concern in the minds of many people
when the RMP bills were introduced into Congress.  The reasons
were multiple, they were complex, they were different among
different communities.  Practicing physicians tended to be
apprehensive about whether this was going to change the practice
of medicine.  The American Medical Association was worried about
this being a first step toward a nationalized health system. 
Many people in academic communities were concerned about what
this was going to do to their ability to direct activities within
their own centers, and it was not by any means a concerted
feeling, but there were a lot of faculty members who felt that in
some ways education was going to be taken out of their hands and
put in the hands of people who were going to be in these regions.
     So there was a general uneasiness, partly due to the fact
that this was an unknown program, was not well spelled out in
advance so that people could see precisely what was intended, and
left a great deal unsaid to worry about.  

Q:  That's pretty good.  A comment about where RMPs fit in the
Great Society.

Ruhe:  The origin of RMP is a little uncertain.  Unquestionably
there are some rather deep roots, but it began, in my judgment,
primarily for political reasons.  I'm saying political not in the
pejorative sense of party politics or things of that sort, but in
the broader sense of the time for things to happen in relation to
general happenings within society.  There isn't any question that
the Regional Medical Programs were seen as part of the Great
Society, and when President Johnson presented his health message
to the nation, it was with a great deal of misgiving about the
way in which the advances of medicine were being brought to the
patient, and he spoke of the gap between the research
laboratories and the bedside, the great killer diseases and the
importance of trying to do something about them.  
     This provided a political support for the legislation which
probably would not have been there otherwise, because the program
was sold in that fashion.  But it was, nonetheless, a part of a
much broader picture, the part of the New Society.  I think it
was to cover the health parts of that program.  

Q:  You said New Society instead of Great Society there.  Could
you rephrase that?

Ruhe:  I do not think there's any question that the proposed
legislation was to encompass the health portions of the Great
Society program, which obviously was a larger and more general
type of program for the whole country.  

Q:  Sounds good.  

[End of recording]