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UNEDITED TRANSCRIPT OF PANEL SESSION, "THE

REPORT OF THE SURGEON GENERAL TO THE PRESIDENT

AND THE CONGRESS,"' TUESDAY, JANUARY 17, 1967

 

CHAIRMAN:

PANEL:

Storm Whaley
Vice President for Health Affairs
University of Arkansas

Michael E. DeBakey, M.D.
Professor and Chairman
Department of Surgery
College of Medicine
Baylor University .

James T. Howell, M.D.
Executive Director
Henry Ford Hospital .

Paul N. Yilvisaker, Ph.D.
Ford Foundation . oy

Ray E. Trussell, M.D.

Director

Columbia University School of
Public Health and Administrative
Medicine. ...

Bruce W. Everist, M.D.
Green Clinic
Ruston, Louisiana . ..--+ +

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10

16

20
PROCEEDINGS

(The reporting of the meeting was started with the
panel discussion. )

MR. WHALEY: Dr. DeBakey.

DR. DeBAKEY: Can we use these right here? Are
they :live? Is this working? -

Thank you very much.

I had hoped to take advantage of this opportunity to
say some of the things that I wanted to say and would like to
say to this group. But as usual, Dr. Farber has preceded me
by saying it, so eloquently and with the production of inspira -
tion to anybody who has listened to him, I feel now it would
be anticlimactic for me to say anything in regard to the
purposes and implementation of the program.

As one who participated in the development of this
program and since then has witnessed its birth and now lusty
growth, it is most gratifying to.see the tremendous interest
and concern at this conference in relation to this program's
activities.

And I must echo one of the thoughts anyway that was
expressed so well by Dr. Farber. And that is that I think
out of such interests and out of such exchange of information
and really thoughtfu1‘ consideration by so many people, the
program can't help but be better.

1 think. too. that we are at a time in the program
there
when in the wisdom of Congress meybe—it is the desire to give

it scrutiny and appraisal and suggest if there is need to
suggest modifications in the legislation. Our panel has been
concerned with this, as you know from the program, and from
the indications of the dates that the panel has worked on

this am the ad hoc committee and also the projected dates for
submission of the report.

I must say that when legislation was originally drawh,
there were certain things that we fought for in the legis lation
but were omitted from the original law through the wisdom of
Congress. And now the time has passed to ailow us to give
perhaps more prudent thought to it. I do not feel that this
has been any great loss. But at one time I thought it might
have been. | |

I think in light of the development of the program,
we really lost littie or no ground in this regard. In fact,
perhaps the program will be strengthened by the fact that we
will have had greater time to think about how best to do this.

The one perhaps factor that still gives me concern,
and I think there is reason for this on the basis of our
experience, is that if the program is going to move forward
as rapidly in the future as it has developed in the past,
there will be need to autho sone fashion the support of
construction. This is the one area that I think deserves our

mnat serious consideration at this time. Because if this is
an essential ingredient to the undergirding of the program,
then now is the time to put it in. |

I personaliy believe that it is an essential
ingredient. I be Lieve there will be need to “provide ete.
feeeef space -- space to carry out a number of the various
activities of the program that really are essential to the
program's activities. And I doubt that there is any other way
to provide that space except by funds that will support that

type of construction. I doubt seriously that there are enough local
resources for funding this type of construction. .

In fact, I am sure there is none. And, therefore,

I think there is need to give a most serious consideration.

So I would place my greatest emphasis and perhaps my own oe

upon this aspect of the report. and this aspect of any amendment
to the. legislation.

Now, the second and perhaps I was going to say equally
important aspect of the report should be concerned with whether
‘or not the legislative authority has sufficient breadth and
flexibility. And here, again, I think we owe a great deal of
thanks to those who worked on the language in the original
draft and in the subsequent modifications of it. And for this
purpose, I would specifically call attention to the tribute we
owe Dr. Dempsey in this regard because I know of the many
hours that he spent working on this.

1 believe that experience now shows that it was wise -

Luana i¢ ac flaxible as possible. And I would hope that we
would continue to hold to this flexibility.

| Obviously there are certain standards and guidelines
in terms of standardizations that are necessary to maintain
quality and excellence. But the flexibility is essential to
meet the varying conditions and circumstances that exist
throughout the breadth of our country where there are many
different ways of doing things and not necessarily less effec-
tive or less successful. We/should be adapt £5 or at least
adaptable to those local circumstances so as to take the best
of the local circumstances and to use them in the most effec-
tive way.

I would doubt that we would want to in any way
change the legislative authority to certainly provide for any
lessening of that flexibility. J would urge that we maintain
that as strongly as we can.

Those are the two main things that I would say are
eaten, most important, to our future in effecting this
program as a successful and useful program in achieving the
goals that we all are seeking for it.

Thank you, Dr. Whaley.

MR. WHALEY: Thank you, Dr. DeBakey.

(Applause. )

Another member of the committee who has been working
on the report, also a member of the National Advisory Council

of the Regional Medical Programs as is Dr. DeBakey, is Dr.
James T. Howell, Executive Director of Henry Ford Hospital.

He has brought to bear particularly his experiences in

hospital administration, particularly teaching hospital adminis -
tration.

Dr. Howell.

DR. HOWELL: Thank you.

uy enthusiasm for this public law in its initial
year of activity has stemmed primarily from the simple
flexibility and the brevity of the law. It has provided lots
of latitude in which we may work, At the same time, in its
simplicity and in its brevity, it does lead to some interpretive
questions for which we must provide the solutions.

One must look to the legislative history for some of
the answers to the interpretive questions which naturally
arise. |

Then, the National Advisory Council in drawing up
guidelines has aiso had to look to these interpretive
questions for proper solutions. In doing it, as Dr. DeBakey
has said, we have attempted to keep this flexibility, this sim-
plicity.

. Some people ;

This may bother ,as is evident from discussions in

the corridors at this meeting, in telephone calis that have

come in, in questions to the staff, in visits that I have been

asked to make to various places in the country with regard

~ sa . Bo ee eh Bee Nek da
Keeping the flexibility, permitting the opportunities
at local levels for the determination of local need as well as
local desire, in mechanisms by which the various professional
elements of our health resources may work is something which,
like Dr. DeBakey, I feel must be preserved in the law. The
penetration of the law must soon become deeper than it is now.
The direction of the penetration will be to the community.

And the first challenge in my estimation will go to the
physicians of the community.

The second challenge, I believe, will be one which
is determinant of the arena in the community in which the
penetration of the law and its activities is to be held.

I believe that in that arena, we must consider the
hospital. It is here where modern instrumentation is most
Likely to occur, where space provisions may be made for
education, for research effort. It is here that most phys iciahs
do congregate for various types of meetings by tradition.

Accordingly, I would say that the second challenge which
must be issued must be in the field of the hospital itself.

Like Dr. DeBakey, I feel that those of us who have
been working at the National Advisory Council level on this
law, believing in its simplicity and in its flexibility, that
relatively little needs to be changed in the 1aw itself by
amendment. I believe that the National Advisory Council, the

staff af Recvional Medical Prorrams. has attemnted to take each
of the proposals brought to us from various regions derived

at the local level and really to try to find some mechanism

by which this can be awarded once it is determined to be within
the intent of the law.

This, I personally would like to see Stele the
lack of structure or the lack of precision in spelling things
out one, two, three, bothers ems people, then I would hope
that we could look beyond this toward a greater opportunity
for participation at the local level. |

One other thing that has been brought to me as a
problem has to do with an evaluation procedure, And I listenei
to it yesterday in a discussion group. And I have had many
questions posed to me with respect to evaluation. |

Most of the problem centers about, it would seem, th
evaluation of physicians. And I believe we need to think of
some other elements that must come into an evaluation procedure,
ones that perhaps in our initial efforts may take precedence
over the others.

These deal with phenomenon. These deal with processes.
These deal with various types of measurements which we may
place upon goals | or objectives of the program, rather than
necessarily an evaluation procedure upon physicians themselves.

Accordingly, I would hasten to ask you to think of
evaluation procedures in terms of phenomena or procedures or

processes rather than an evaluation of human events.
Thank you for the opportunity of a few words.

(Applause. )

MR. WHALEY: Thank you, Dr. Howell.

One of the members of the committee who brought to
pear his experience and refreshing point of view and a point
of view that was perhaps a bit different is Dr. Paul N.
Ylvisaker of the Ford Foundation. Dr. Yivisaker has been
advisor to the United Nations, many different roles to the
Federal Government, and soon will begin his career in State
government. His particular concern has been in the area of
urban affairs, and he has moved the committee and sometimes
jarred the committee with the things he has had to say.

And I hope you will jar us this morning, Dr.
Yivisaker.

DR. YLVISAKER: Thank you.

J have just returned from some eye surgery and
yesterday had to face the New Jersey Senate Committee for a
confirmation of a new appointment and they asked me the usual
questions. How do you pronounce your name? How old are you?

And I could answer that by saying: I could go to the
bar with any of you without embarrassment.

And, finally, when this was all done, one of them
observed, "Well,"he says, “Commissioner, I will give you one
thing: you are the first Commissioner in New Jersey who ever

came into office with a black eye."
11

(Laughter. )
I would like to complicate the lives of i friends
Narieona\

here in this room and in the Institutes of Health and the
Public Health Service. This is the wrong time to do this
because the mood of the country right now is that we have done
enough for a while and let's retrench. And the mood of an
administrator must always be, in that case, I will retrench
a little more than the public expects me to. |

I certainly am not going to rouse any sleeping dogs.
And once I have got a good thing going, I don't want to risk
it at this time. But there are a few of us, I think, who
foolishly or otherwise are willing to say a few things that I
think have to be said in the United States today.

And that is, yes, we have gone a remarkably long

and

distance in the last few years. And this legislation, Medicare
in your field, certainly are a casesin point. But we have a
fantastic distance to go. |

We are facing an incomplete revolution in the United
States which is working itself out with great rapidity. And
this revolution is on top of an even greater revolution going
on in the world around us. The revolution is simply the
assertion of the individual for equal treatment at a time when
resources are very scarce and they can scarcely go around to
do the things we presently want. |

But I would like to in this mood complicate the.
12

discussion and the life of the United States and administrators
a bit on this point. The point I would like to make has to do
partly with the phrasing used in this legislation.

This is a Regional Medical Program. Those of us who
have worked with regional problems for a long time know what a
Holy Grail this thing called a region is. And as a matter of
fact, usually when you use the word, you are oversimplifying
the issue. And you are doing what they said in African @enesis
_- "What a human being usually does is to add a territorial
ambition to an otherwise complicated existence."

Now, a region, some wag once defined as that area
which is safely larger or smaller than the last one whose prob-
lems we couldn't solve.

(Laughter.)

And when we begin to work for the perfect definition
of a region either as principle of organizing medical services
or principle of organizing any services, we soon realize the
tremendous complexity of American life. It cries out, perhaps
not so much for decentralization which becomes a centralization,
as for instantaneous communication among peopie who are doing
remarkable work in very different places, and that the need
is not so much sometimes to centralize or to concentrate even
at the regional level ,as to produce this kind of instantaneous

communication so that ultimately a patient in need of help
and
13

medical profession are Wiee know where research is and how to
avail themselves of it.

Now, the point I would like to drive home very hard
is that you cannot retreat from the complexity which has becom¢
urban America into either regional patterns exclusively or
into professional patterns, And what I fear basically about the
way this legislation so far has been drafted and carried out ig
that it has given to too narrow a base, which is a medical
profession and largely the medical research and academic
community, the power to work out what is one of the great
moving forces in the United States today.

And let me draw this perspective a bit for you.

Ted Howell said that the problem is going to be that of the
community. I could not agree more, The problem is going to ba
to relate the growth of medicine , both in its excellence and in
its patterns of service,to the patterns of distribution of the
American population and its mood and its aspirations.

| Now, we have got to become, in all the professions and
all the services, market and consumer oriented. If you don't,
within two years, your medical schools will be picketed by a
combination. of the American Mayors, Federation and CORE,

(Laughter. )

And I wonder if your medical faculties are ready for

that experience.

to that experience is going to come when this
(14

legislation comes up before some of the committees and some of
the more consumer public-oriented figures are going to begin

to ask you some questions. Unfortunately, they will tend to be
of only one kind which are the more familiar ones you have heard
and probably the most important ones which. relate to the patterns
of medical care and to that consumer out there and how this

will affect his life.

Let me add a few other considerations.

We are now in the United States going into a service
economy based on large metropolitan areas. We have patterned
those metropolitan areas on manufacturing and the mass |
production and consumption of material goods.

The organizing principle of the metropolis in the
days ahead will become the mass production and consumption of
strategic services. And these services will be largely in the
hands of certain guilds and certain public professions.

That is, City Hall is going to be picketed because it doesn't
give garbage services equally to Harlem and the rest of the.
community. And you will be picketed because you are not giving
adequate and equal access to many of these consumers.

Now, the planners of the future metropolis are going
to have to get hold of the service economy and its growth and
try to get some inde pattern for it which provides equal
access to the citizen consumer.

vou neovle are now like the highway engineers, laying
15

hold of one of the great growth industries of the United
States which is medicine, like education, like law, and like
these other services. How are you organizing this? How even
physically will you distribute the resources? Will it con-
tribute to an orderly growth of the community or like the
highway program, will it become eng ineer-oriented -- in this
case doctor-oriented -- producing a wonderful engineered system
with cloverleaves and the rest, but very little relevance to
the community of which it is a part?

Second, the growth sector is the service sector.
It is here that the unemployed or the great market for employ-
ment will come. Is there in your planning for these regional
“centers, which is the planning for the profession and the
science and the growth of medicine, thought for how you can
distribute the employment all the way from the highest levels
of skill down almost even to the leaf raking areas Which we are
going to be called upon to provide in the next years? That. is,
have you got nonprofessional employment worked into this? .
Are you extending this research and the work of the profession
down to new occupations which are available to the poor? \hich
is one of the questions that I think you have to answer before
you are through.

And the final one, probably, to throw at you is:

Are you going to develop consumer complaint mechanisms in your

_ ~ - . . - 4A Sf 2426 £6 2hn Aa nf
16

the consumer and you are the growth industry, where is the
consumer complaint mechanism?

Now, you have noticed the police review board is a
beginning. The Ombundsman % coming, and you better watch out
for the Ombundsman in your profession. There is not a single
local medical group you have ever taiked to whose Young Turks
have not said nervously, "We are not policing our profession;
we are not market oriented."

The Ombundsman -- will it come your way or will you
anticipate it?

These are some of the questions, and I hope I haven't
rocked you too much. Thank you.

(Applause. )

MR, WHALEY: I will restrain the panel at this point
and cail on Dr. Ray Trussell, Director of Columbia University
School of Public Health and Administrative Medicine. Dr.
Trussell has brought to our committee rich years of experience
in the field of public health and education.

pr. Trussell.

DR. TRUSSELL: Thank you.

I want to congratulate Paul on his carefully planned
out career. He has gone from the international levei to the
Federal level, and now he is going to the State level. And

I only want to invite him to New york City where we could use
17

(Laughter. )

The legislation which we are discussing today --
yesterday and today -- is the manifestation of a positive
attitude on the part of the Congress toward health. This is
an attitude which is not shared universally throughout the
United States.

In New York State which has some of the most progres-
sive health legislation in the country, the State Constitution
has one sentence in which the word "health" appears. And
there are some people in the upcoming Constitutional Convention
in April who would do away with any roleblon® to health, holding
that the police power in the State is enough to take all
necessary measures.

There are others, and I share this view, who believe
that a pos itive statement indicating the extent of the public
concern should be included in the State Constitution so there

with
would be no mistake about the will of the people im this

respect Z the kinds of problems that we are discussing here
at the present time,

The Congress has enacted since 1956 about 65 major
pieces of legisiation in the health field. If this leaves any
question in anybody's mind in this room that the public intent

is that the best that the scientists and medicine have to offer

shall reach the most people, they really should go and read
18

ve Sveshin
kaklLeottear, instruction, on what the public wants and what the

public hopes it is going to get.

The Congress has handed back to the scientific
community the particular job of saying under what conditions
the scientific community thinks it can deliver what it already
knows and how it can deliver what it will know in the future as
a consequence of research. This is an unusual function for the
scientific community. It is not used to planning nome anything
that it doesn't want to do. It is used to planning very
meticulously and very effectively for the things that it does
want to do.

And yet the community and the scientific community
must come together if we are to satisfy what is clearly the
expressed intent of the public and the use of public funds.
‘Yet, there is ambivalence in the minds of the Government about
how these things are to be achieved.

We have the Regional Medical program legislation
underway. We have legislation passed in the last week of the
Congress which puts a similar but broader planning function in
the’ hands of the State agencies and aiso parallel or competitive
areawide planning agencies as soon as this is funded.

Now, appropriately, it has not been discussed here
in this conference because this was explained to us very
clearly by Dr. Marston last night, there are discussions going

‘om at tha naliev level: And nobody knows how much money there
19

will be, but those of us who have had to do with the delivery
of health services are ul ng that in the report to the
Congress there be mentioned the need for coordination of these
multiple planning efforts being engendered by Federal action
in the longstanding Hill-Burton program, the Regional Medical
Program, which is now getting off the ground and the as yet
inactive but still coming up State agency approach. If the
scientists can't get together with the administrators at the
local level, then the vacuum that will result will only be a
vacuum into which Government moves.

I can tell you from my own experience ,with the
limited amount of tax money available in this country, Govern-
ment tends to move only into t#@® vacuums and only when they
are convinced that they absolutely must move. Yet, the public
expectation is such that the Government has clearly moved
far beyond the thinking of the scientific community.

We have an enormous opportunity to maintain a working
partnership in this country in contrast to the rapid or slow
collapse into a total governmental system which has occurred
in other countries. I look for an uneasy but happy marriage
petween the Government and the private sector as a consequence
of Regional Medical Programs. And I feel if they do not fulfill
the expectations that the marriage will get very lopsided and

may, indeed, become no marriage at all.

ae abt mee mto ine ar it is coincidental, I guess
20

that in this very building ,in the next room jis a consumer

group, the Teamsters, who contrary to their headlines are

a very concerned group of union leaders, the largest union in
the country and with a deep concern in you and your productivity
and with your concern for the total needs of the public. .-

we have worked with this kind of labor ieader for
many years and his management counterpart. They finance
research, they finance demonstrations on a regional basis
in the New York area. They support legislation. They supported
legislation in New York which provides this looking-over-the-
shoulder function that Paul talked about -- namely, medical
auditing by the State Department of Health.

But the State Department of Health in turn has turned
to the State medical society for a partnership arrangement.. so
that Government and the professions with consumer support have
an opportunity to discharge this function of keeping an eye on
how well the public is served.

There is much going on around us -- so much that we
mus t be careful not to be like a fish. The fish swims around
in the water all day, and he never stops to think about the
water in which he is swimming. And yet the water in which the
scientific community today swims has changed tremendously as a
consequence of public understanding and of congressional: and
legislative action. And I think it is terribly important that

ma rantiza that the water has changed in which we scientific
21

fish are swimming. And we petter get used to it and adapt
to it and try and meet the new temperature of our times.

I think I have. said enough for the moment .

 

(Applause. )

MR, WHALEY: Another member of the National Advisory
Council who is in private practice of medicine saseesswet in
Ruston, Louisiana, is Dr. Bruce Everist.

Dr. Everist.

DR, EVERIST: I would like to ask the induigence of
this audience in some empathy if you can imagine a country _
doctor having to follow one of the most honored physicians in
the country, two directors, a vice president and a commissionef.

(Laughter. )

It is obvious that I can only be dilutely paraphrast{c.

Public Law 89-239 is a good law, new, Robes,
imaginative, and even artistic. The language is so clear,
concise and brief that it seems the law could only have been
passed by accident.

| (Laughter. )

The lack of obfuscation and the serendipitous nature
of the ‘law leave it devoid of the usual stringent measures for
coercion and regulatory gunction. This is enough to unsettle
the most sophisticated of government staff.

This lack of regulatory function and of coercive

_ te nin maw ta the nrivate sector... And they have
22

understandable misgivings when they see Government acting like
a true Christian gentleman.

(Laughter.)
Incidentally, the clarity of the law is not matched

‘

in this conference.

(Laughter.)

 

Mix as used in Washington means putting Dr. Hudson,
Mx. Cohen and Dr. DeBakey on the same program.

(Laughter. )

I am not a lexicographer, but I think the word should
be not "mix", but "courage."

Semantics aside, Public Law 39-239 has other virtues
than clarity, previty and conciseness. It places a new emphas is
and a new direction on local responsibility for the health of
all citizens. Doctors in the past have assumed this responsi-
pility for the indigent as a good neighbor, the affluent for
a fee. This can no longer obtain for the poor for our current
coucept allows for equal medical attention for the poor as
for the rich. But as a right, not as a gift.

I have no doubt but that this change can be made by
local physicians in concert with Government, put with the
lines of responsibility clearly drawn. American medicine is
consexvative enough to resist undue pressure and yet res pons ive

enough to effect this change.

naa thinee to all men, but it is A
23

probing for new and better ways of delivering health care
without wholly disrupting the established tradition of medicing.

For examples, continuing education requires no
dissembling on our part. We recognize our need for current
knowledge. And most of us will admit that we don't always
have it.

Cooperative arrangementS among eam a11 health agenci¢s
have already begun at this conference. And they have been
relatively painless,

Demonstration of patient care is not a restrictive
or nebulous term, but rather a unique opportunity for broadening
the educational process to include the patient.

‘It is a good law. It was a good law when it was
written, And I think it is the good fortune of the people at
this conference to make it a good law in practice, not by
accident, but by deSign.

(Applause. )

MR. WHALEY: I am Sure you can understand now that it
was truly restraint on my part that I refrained from mentioning
that Dr. Everist is the poet laureateof our Council. His
performance today is just exactly like I have seen many times.
And I have applied for the publication rights of the gems which
he has dropped. So far I haven't gotten them. And you as
applicants, some of you might shudder to think he happened to

be the reviewer. of your application,
24

(Laughter. )

He gets to the point.

I am sure we have other comments from members of
the panel. And I will recognize anyone who wishes to be
recognized in the panel.

Dr. Howell.

DR, HOWELL: One of the very major concerns that
I have had with the law itseif has to do with the interregional
program. What do we anticipate will happen one of these days
when methodological approaches with an evaluation or measurement
will determine that there are workable plans with more effec-
tiveness than perhaps others?

Another concern in the interregional area has to do
with gaps of areas of the country that are not now covered.

And what will we do here on the National Advisory Council to
make certain that these areas have been covered?

J think there is a major problem for us to consider
with respect to the sharing of information from one region to
another.

And then I think one of the problems is the one that
Paul Yivisaker has ment ioned, me the regions within a major
urban areag. How may they be put together? How may they share
information? What is their organizational structure? What
is the communication across these regions?

Now. I propose this as a major issue in which we on.
290

the National Advisory Council are going to require a tremendoug¢
amount of feedback from you people. You will note that this
provision is not in the law. How this cooperative
arrangement..is to be made is largely going to depend upon you,
obviously upon us at the National Aqvisory Council level as
well,

MR, WHALEY: Thank you, Dr. Howell.

Others? Do you have questions from the audience for
just a few minutes? We have about 10 or 12 minutes.

yes.

QUESTION: I would like to ask Dr. Ylvisaker with
whom I agree entirely in terms of being consumer oriented or
market consumer oriented ~- Dr. Trussell referred to it as the
environment in which the fish swim -- whether or not reference
to the Ombundsman and consumer complaint bureau was a figure
of speech which he used with something more explicit in mind.
And if he had something more explicit in mind, would he be good
enough to tell us what he had.

‘DR. YLVISAKER: Yes and no.

First on the Ombundsman, it is interesting how this =

QUESTION: What was the question?

DR, YLVISAKER: The question is whether I had some- |:
thing more explicit in mind when I used the word “Ombunds man",
with some specific proposal for-.a complaint mechanism, a

consumer complaint mechanism.
26

Is that a fair presentation?

QUESTION: Yes.

DR, YLVISAKER: My answer was yes and no.

I have been interested to see how this Ombunds man
concept has begun sweeping the country. Inside of ten years,
it has gone from, you know, where aid that come from, to
almost a common figure of ‘speech in the United States. It is
being adpated in a number of jurisdictions ,in Long Island, as
I recall, in one of the New York suburban counties. And I
think you will see probably many municipalities adopt it very
shortly. It will be an Mepene sont ning. It will grow.

There are several things about it to keep in mind.

One is there is a public receptivity to the idea of
a consumer complaint mechanism.

Second, that they are not satisfied to start in one
field. The fact that you overthrew the New York Police Review
Board is a warning in point that no one group is probably going
to accept this, but probably you will have an overview.

Whether this is adaptable in the medical field, I
don't know. I would think that the medical profession, seeing
the trend of the times, might begin inventing a variant of the
Ombundsman and to begin experiment ing with it before the
public might foist it ox{to the various professional groups .

So, aS I say, yes and no. I.am talking about a wave,

a- concept, a demand, but I am feeling my way in the institutiop.
27

MR, WHALEY: Other questions?

QUESTION: What type of construction did Dr. DeBakey
have in mind being built into this law?

DR, DeBAKEY: Well, actually, I think it might be
best described as construction that is essential or needed to
carrying out the program, wherever it may be -~ affiliated
institutions, the center itself, and so on. It is related
primarily to program activities such as those related to
continuing education, those related to demonstration care,
those related to administration of the program, and So on.

I would say that this type of construction is pretty
hard to come by from other sources -- that is, ES other
financing. And speaking of that, Tom, if I might just take
a few more moments, I would point out that Congress has an
interest in certain aspects --

VOICE: Doctor, we can't hear you.

DR, DeBAKEY: This is better? Can you hear me now?

Well, I will just get up as close as I can to it.

Perhaps you can hear me now.

I would call your attention to the fact that there
is written into the law certain interests that Congress had in
reporting back to them about the activities. Among these are
this particular request on the part of Congress. And that is

that we return to Congress a statement of the relationship

Ser
between Federal financing pane this program, you see, and
28

financing from other sources of activities.
This, of course, points up the variety of sources of
financing for the various medical activities that we are

engaged in today. And they wanted a statement indicating what

sources are being used.

And I think it is important aiso to point out that
there are non-Federal sources of financing that are being
used in this program ,the extent of which is sometimes difficult
to determine, but it would be certainly highly desirable in
your own thinking in your own regions to try to make some
estimate of this. Because I think, for one thing, it is
important to maintain it. And in a sense, it is part of the
partnership that exists. f

So I think Congress would take some interest in
paving these aspects of the financing.

MR, WHALEY: Our time has run out. JI had written
down a few comments on the remarks of each of our panelists,
but in the words of Dr. Everist, I don't wish to be dilutely
paraphrastic because it would ruin the very fine statements
which we have had.

So, members of the panel, the deep appreciation
from ail of us for what you have done.

pr. Olson.

(Applause. )

np arson: T should like to add my word of thanks
29

to Dr. Whaley and all of the members of the panel for a very
fine presentation.

During the past week, we have all been shocked and
grieved to learn of the death of Mr. Fogarty who has had such
a deep interest in the health problems of this nation. We
have asked Dr. Sidney Farber if he would come and pay tribute
to Mr. Fogarty.

DR. FARBER : Dr. Olson and members of the Conference:
Just one week ago today, we lost John Edward Fogarty, long-
time chairman of the Committee of Appropriations concerned
particularly with matters of health and education.

There are some in this room who knew him as a devoted
friend. There are many more who had the privilege of appearing
before him as citizen witness and learned then of his great
integrity, his deep devotion, his compassion and, above ali,
his great knowledge of the needs of the country for medical re
search, training and care.

I believe it can be said without exaggeration that
no man in the history of the House of Representatives has
made a contribution as great to the health of the country oe
that made by Mr. Fogarty. The enormity of his contributions
will be felt all over this country and over the world for
generations to come.

It was felt proper that all of us who had benefited

Bonne Lt Ae hh ntandA Far a mnmant in hig mamnrv.
30

(The group stood in silence.)

DR. OLSON: phis concludes the final plenary session
of the conference.

The attendance has been a splendid one. We have had

approximately 650 registrations. We have had outstanding
representatives of the health field, both on the platform and
in the audience.

we are deeply grateful for your presence am for.
your contributions. We would ask that you make two further
contributions.

The first, you will make in the discussion sessions
to which you will adjourn in just a moment.

The second, we hope you will make after you have
returned howe and have had an opportunity to reflect on the
matters that you have had under discussion these past two days
I would hope you would write to Dr. Marston and give him your
considered judgment about any aspect of the program that you
consider to be important and significant.

Dr. Farber made reference to the capable, dedicated
and loyal staff that Dr. Marston has developed in the
Division of Regional Medical Program. I have come to know
this staff and their capabilities in the past seven weeks that
{ have been associated with the preparation of this conference.
1 should like to take just a moment to recognize several peopld

e umd teuoan antetanding fashion.
31

These are uv? Judy Silsby, Mr. Lyman Van Nostrand,
Mr. Edward Friedlander, Miss Dale Carter, Mr. Charles Hilsenroth,
Mr. Stiliman Wright and Dr. John Hamilton...

In addition, as you know, the staff has served as
recorders for the discussion sessions. The stenographers have
worked, some until 1:00 o'clock, some ail night, to get out
the various things that were needed for the conference program
and registration. |

J would like to ask the staff that is here if they
would stand and if we might recognize their very significant
contribution. }

- (Appiause.)

I would cail your attention to the fact that you
will be going into a different discussion group for this final
session. I met Dr. Pellegrino in the corridor as I was coming
into the hall this morning. And he said, "Stan, is there
anything special you want out of this discussion group?"

And I commented that he ought to use his judgment ;
that the discussion group should feel free to pursue anything
it wanted and in depth. I told him we had plenty of breadth
in the last couple of days, what we needed now was some depth.

So I would hope that participants and chairmen alike
would see some of the issues that have been So ably presented

here this morning and that you would try to come to your own
what needs to be retained, what needs to be changed.

pr. Marston, are there any things you want to add?

DR. MARSTON: No.

DR. OLSON: I would just like to say this has been

a wonderful experience for me to work with Dr. Marston.

And I hope that many of you have an equal opportunity to get to

know him as J have.

Thank you very much.

(Applause. )

(Whereupon, at 10:50 o'clock a.m,, the meeting

adjourned.)