UNEDITED TRANSCRIPT OF PANEL SESSION, "THE REPORT OF THE SURGEON GENERAL TO THE PRESIDENT AND THE CONGRESS," TUESDAY, JANUARY 17, 1967 CHAIRMAN: Storm Whaley Vice President for Health Affairs University of Arkansas PANEL: Michael E. DeBakey, M.D. Professor and Chairman Department of Surgery- College of Medicine Baylor University . . . . . . . .page 3 James T. Howell, M.D. Executive Director Henry Ford Hospital . . . . . . .page 7 Paul N. Ylvisaker, Ph.D. Ford Foundation . . ... . . . . .page 10 Ray E. Trussell, M.D. Director Columbia University School of Public Health and Administrative Medicine . . . . . . . . . . . . .page 16 Bruce W. Everist, M.D. Green Clinic Ruston, Louisiana . . . . . . . .page 20 3 P R 0 C B E D I N G S (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 workin ? 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 fo r 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 outlof such exchange of information and really thoughtful consideration by so many people, the program can't help but be better. T.think. too. that we are at a time in the program 4 ,when in the wisdom of Congress is the desire to give it scrutiny and appraisal and sugges@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 and the ad hoc committee and also the projected dates for submission of the report. I must say that w@ n legislation was originally drawjh, there were certain things that we fought for in the legislation but were omitted from the original law through the wisdom of Congress. And now the time has passed to allow 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 little 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 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 n some fashion the support of construction. This is the one area that I think deserves our mng;t serious consideration at this time. Because if this is 5 an essential ingredient to the undergirding of the program, then now is the time to put it in. I personally believe that it is an essential ingredient. I believe there will be need to provide space -- space to carry oat 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 Eim sure there is none. And, therefore, I think there is need to give this most serious consideration. So I would place my greatest emphasis and perhaps my own focus 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 o 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 thi@ regard because I know of the many hours .that he spent workin ' on this. 9 I believe that experience now shows that it was wise fln-rihle as possible. And I would hope that we 6 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. W:olshould be adapttA 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. would urge that we,maintain that as strongly as we can. Those are the two main things that.I would say are 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 Pro grams as is Dr. I)eBakey, is Dr. 7 james T. Howello Executive Director of Henry Ford Hospital. He has brought to bear particularly his experiences in hospital administration,' particularly teaching hospital admin@- tration. Dr. Howell. DR. HOWELL: Thank you. My 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 also 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. c ip This may bother as s evident from discussions in@ the corridors at this meeting, in telephone calls that have come in, in questions to the staff, in visits that I have been asked to make to var ious places in the country with regard 8 Keeping the flexibility, permitting the opportunities at local levels for the determination of local need as well as local desir@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 physicians 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 flex ibility, that relatively little needs to be changed in the law itself by amendment. I believe that the National Advisory Council, the .Rtnff nf Rpainnal Medinnl 'Prnffra@q- has a'ttamnted tn take each 9 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 'Lf the see e2m@ lack of structure or the lacl-. of precision in spelling things out one, two, three,bothers 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 listener 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, thB 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 progra@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 bear 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. Ylvisaker 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. Ylvisaker. DR. YLVISAKER: Thank you. I 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,llhe 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." (Laughter.) I 'Would like to complicate the lives of my friends 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 goin g, 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 distance in the last few years. And this legislation, #\ MedicarO in your field, certainly are case3in 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 whoi 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 Cgenesis -- '%'hat 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 2S 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 people who are doing remarkable work in very di fferent places-, and that the need is not so much sometimes to centralize or to concentrate even at the regional levelas to produce this kind,of.instantaneous communication so that ultimately a patient in need of help 13 medical profession are @ 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 becom4.P 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 i$ 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 saii that the problem is going to be that of the community. I could not agree more. The problem is going to be to relate the growth of medicine both in its excellence and in its patterns of serviceto 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 combination7,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 i 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 productionand 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 ki pattern for it which provides equal access to the citizen consumer. vnti neonle 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,,Iike 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 engineer-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? thich is one of the questions that I think you have to.answer before you are through. And the f inal one, probably, to throw at you is: Are you going to develop consumer complaint mechanisms in your 4. 1L.- A 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 iscoming, and you better watch out for the Ombundsman in your profession. There is not a single local medical group you have ever talked to whose Young Turks have not said nervously, IlVe 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 call 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. Dr. Trussell. DR. TRUSSELL: Thank you. I want to congratulate Paul on his carefully planned out career. He has gone from the international level 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 un iversally 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 Consti tutional Convention in April who would do away with any rog!a*!ion to health, holding that the police power in the State is enough to take all necessary measures. There are others, and I share this vie-w, who believe, that a positive statement indicating the extent of the public concern should be included in the State Constitution so there would be no mistake about the will of the people i-m this respect im the kinds of problems that we are discussing here at the present time. The Congress has enacted since 1956 about 65 major pieces.of legislation 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 or& rAw 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 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 also 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 nr%linv 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 uifng 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 Re gional 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 Governmentmoves. I can tell you from my own experiencewith the limited amount of tax money available in this country, Govern- ment tends to move only into t4W 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 workint 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 between 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. it is Coincidental, I guess 20 that in this very building in the next room, is a consumer group, the Teamsters, who contrary to their headlines are a very concerned group of union leaders, the largest union ill 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 leader 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 turneid to the State medical society for a partnership arrangement.. so that Government and the professions with consumer support havei 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 must 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.--. a nd legislative action. And I think it.is terribly important that thnt the water has changed in which we scientific 21 f ish are swimming. And we better get used to it and adapt to it and try and meet the new temperature of our times. I think I ha vO said enough for the moment. (Applause.) mR. WHALEY: Another member of the National Advisory Council who is in private practice of medicine in Ruston, Louisiana, is Dr. Bruce Everist. Dr. Everist. DR. EVERIST: I would like to ask the indulgence of this audience in some empathy if you can imagine a.country doct or having to follow one of the most honored physicians in the country, two directors, a vice president and a commissioner. (Laughter.) It is obvious that I can only be dilutely paraphrastic. in @oub.@i a Public Law 89-239 is a good law, new, .eilp',m 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 function. This is enough to unsettle the most sophisticated.of government staff. This lack of regulatory function and of coercive nrivate sector., And they have 22 understandable misgivings when they see Government acting Iik$ 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, Mr. Cohen and Dr. DeBakey on the same program. (Laughter.) I am not a lexicographer but I thinlt the word shoul'd be not "mix", but "courage." Semantics aside, Public Law 89-239 has other virtues than clarity, brevity 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- bility for the indigent as a good neighbor, the affluent for a fee. This can no longer obtain for the poor for our current concept 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, but with the lines of responsibility clearly drawn. American medicine is conservative enough to resist undue pressure and yet responsive enough to effect this change. tn all men, but it is 23 probing for new and better ways of delivering health care without wholly disrupting the established tradition of medicini3. 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 ftw all health agenci4ps 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. V,'HALEY: I am sure you can understand now that il 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. HOIVELL: One of the very Major concerns that I have had with the law itself 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 work-able 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? I 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 ylvisaker has mentioned, ANN the regions within a major urban areaW How may they be put together? How may they share, information? What is their organizational structure? W a is the communication across these regions? Now. I propose this as a major issue in which we on 25 the National Advisory Council are going to require a tremendous 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 Advisory Council level as well. MR. WHALEY: Thank you, Dr. Howell. Orthers? 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, wou ld he be goo4 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 explic it in mind when I used the word "Ombundsman" 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 Ombundsman concept has begun sweeping the coontry. inside of ten years, it has gone from, you know, where did that come from, to almost a common figure of'speech in the United States. It is being adpated in a number of jurisdiction.sin Long Island, as I recall, in one of the New York suburba'n counties. And I think you will see probably many municipalities adopt it Very cv ickl+;aj shortly. It will be,an "4 thing. 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 goin@ 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 experimenting with it before the public might foist it o o the various. professional groups. it So, as I say, yes and no. I.am talking about a waves a- concept, a demand, but I -'am feeling my vay in the institution. 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, fftr 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 3.nterests thsft 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 between Federal financing mW. this program, you see, and 28 financing from other sources of activities. This, of course, points up the variety of sources ot 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 also 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. So I think Congress would take some interest in *"I having these aspects of the financing. MR. WHALEY:, our time has run out. I 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 all of us for what you have done. Dr. Olson. (Applause.) ,nu nt-qnw. 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. iVe 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 devoteO 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 all, his great knowledge of the needs of the country for med ical 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 that made by Mr. Fogarty. The enormity of his contributions will be felt all over this c ountry and over the world for generations to come. It was felt proper that all of us who had benefited 1. 4- 4- n mrkyngn ni- i n h i tZ Mtn ,MnrV_ 30 (The group stood in silence.) DR. OLSON: This 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 ard 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 home 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 Programs. I have come to know this staff and their capabilities in the past seven weeks that I have been associated with the preparation of this conference. I should'like to take just a moment to recognize several people ^,,+c+nnding fashion. 31 These are MIC/. Judy Silsb,y, Mr. Lyman Van Nostrand, Mr. Edward Friedlander, Miss Dale Carter, Mr. Charles Hilsenroth, Mr. Stillman lYright 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 all night, to get out the various things that were needed for the conference program' and registration. I would like to ask,the staff that is here if they would stand and if we might recognize their very significant I contribution. ,(Applause.) I would call 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 32 what needs to be retained, what needs to be changed. Dr. 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 I have. Thank you very much. (,A p.plause.) (Whereupon, at 10:50 o'clock a.m., the meeting adjourned.)