*EOOO164* FOR RELEASE AFTER 10 A.M. TUESDAY, JANUARY 17, 1967 "THE IDEA, THE INTENT UTD THE IMPLEIENTATION"* *Speech by: Sidney Farber, M.D., Director of Research, Children's Cancer Research Foundation and Professor of Pathology, Harvard Medical School, Boston, Mass. Delivered on: January 17 (9:30 a.m..) Delivered at: Conference on Regional Medical Programs at Washington Hilton Hotel Washington, D.C. January 15-17, 1967 THE IDEA, THE INTENT AND THE IMPLEMENTATION Sidney Farber, M.D. The privilege of speaking at the First Conference on Regional Medical Programs is one for which I am deeply grateful. It is hard to believe that in a little more than a year since the historic signing by President Johnson of Public Law 89-239 on October 6, 1965, with less than a year of administrative operation, it has been possible to bring together representatives of the health professions from all over the country for a report on progress and a discussion of future plans, plans for 90% of the people of this country. This evidence of truly phenomenal progress must be heartwarming indeed to the President and the members of the Congress who have shown such deep interest in this program, and productive of new hope and courage to families throughout the land with loved ones suffering from the dread diseases with which we are here concerned. I see here today ample evidence for the statement made repeatedly during the past few months by veterans in the health professions that this program has done more to bring the many segments of the health activities of the Nation together than any other event in the history of the Nation. What is the magic which has been responsible for the achievement of a creative concert among the many separate health interests that in the past have never worked together in this fashion? What is itthat has bridged the gulf between town and gown, and lured the medical school faculty from their ivory tower into community activities in a manner never before witnessed -- that has won the enthusiastic interest and cooperation of medical 2 societies -- sharpened the focus of many diverse agencies concerned with human problems of disease -- and inspired medical schools and hospitals alike to look beyond their own institutions concerns to broad community needs? @ny reasons might be mentioned and must play a role, but the one of overriding importance above all others I am certain, is the motivation behind all activities of the health professions: the desire to give to all our people the very best in medical care. It is clear that the response of the Country to the remarkable opportunity opened by Public Law 0'9-239 stems from our devotion to those who are ill, and this transcends personal con- siderations or preoccupation with the interests of one discipline or one institution. This, then, is the greatest attraction to all of us -- the opportunity to develop programs, a program which has as its goal the delivery of the best of medical services and diagnosis and treatment to every man, woman and child in the Country, without the intolerable delay between discovery and application caused or explained by the lack of the needed medical strength, mechanisms and facilities, which will be provided in these Regional Medical Programs. The idea behind these programs is based on the simple desire to save lives -- of those people who could be saved today with the knowledge available today -- if they could have it --to save even more lives if we speed up and intensify clinical investigation to match the great strides in pre-clinical research -- to evaluate much more quickly, safely and effectively, new methods of diagnosis and treatment -- to achieve Actual prevention of the complications and progress of these dread diseases -- and to communicate with the aid of methods already 3 available and perfected by technology between and among regional programs for the rapid dissemination of knowledge to assist doctors everywhere, in the care of their patients. The development of the policy under which power and respon- sibility for whatever happens is placed at the onal level has answered the fear that the Federal Government and specifically the National Institutes of Health might dictate to any applicant or group what to do, and how to do it. The only requirement that I can find that the Federal Government has imposed has been that there must be assurances that there is understanding and commitment to the purposes of the program with true regional concert involving representa- tion of the various health agencies, and the public in any given region. As a close observer of this program and the way it has been admin- istered, I have satisfied myself that this point of view on the part of the Government is genuine, and in line with the great traditions of the research and training programs of the National Institutes of Health. It was for this reason that a wise Surgeon General put the program under the administration of the N.I.H. under the leadership of Dr. James A. Shannon who,, with his Deputy, Dr. Stuart Sessoms and a splendid staff, has presided over the greatest and strongest growth of medical research and training programs in history. You are all thoroughly familiar with the insistence on quality by the N.I.H. and the great tradition that major reliance for final decision must be placed on the expert review by non-Federal groups or our peers, our own peers, to assure that quality is maintained and scientific and professional freedom are protected. 4 The caliber and dedication of the primary review group under Dr. George James and of the members of the Natienal Advisory Council on Regional Medical Programs have been responsible for sound and important decisions so far. I have had the opportunity to attend a number of the meetings of this new Council as a representative of the National Advisory Cancer Council, and can assure you that the stipulation of the Public Law concerning membership on the Council has resulted in the appointment of men and women in whose vision, fairness and wisdom you can have complete confidence. It is a great pleasure for me to add that in continuation of the highest standards of excellence which the N.I.H. has always maintained in its administra- tion, the Division of Regional Medical Program staff, headed by Dr. Robert Marston, is one of the most able, enthusiastic and helpful groups I have encountered in or out of Government. The appropriation needs of the program will require solid justification and the strongest support from all of us, so that its full potential may be realized. I have a sad personal detail to share with you. Just a few days ago, actually two weeks ago last Thursday, before the tragic sudden death of Congressman John E. Fogarty, I had the privilege of a long discussion with him on one of his periodic visits. We discussed the many programs of the N.I.H., and he spoke of his deep interest in the several categorical institutes and in the Institute of General Medical Sciences in which he had great pride. He then turned to a consideration of the rapid progress in the Regional Medical Program activity and remarked that this was the goal for which everything else in the N.I.H. was dedicated, for, as he put it, -this is the payoff' -- it is here that the newly generated 5 knowledge from medical research must be applied as rapidly as possible for the good of patients everywhere. I can still hear his words of deep concern about the availability of sufficient money properly to support the Regional Medical Programs in this time of budgetary pressures. I am confident that among the large number of devoted and informed members of the Congress there will be found a leader worthy of taking his place, for the Congress has shown its dedication to health and medical research and its understanding of the importance of the N.I.H. programs by their appropriation record these past 20 years. These years witnessed the construction of a remarkable founda- tion for the programs with which we are concerned in this Conference. Unless there is adequate volume and continuity of support, the great promise of this Program cannot be fulfilled and the high hopes which have been raised throughout the Nation will end in bitter disappointment. The principle of diversification of support is built into the Law and the administrative regulations and has been under discussion as one of the issues at this Conference. The need for the provision by the Federal Government of enough support to insure a critical mass of medical strength, however, is a prerequisite to fulfillment of the Program. We should remind ourselves and the Government, too, that all experience in the support of biomedical research and in the support of construction of research and hospital facilities has shown that substantial Federal support attracts sub- stantial support from other sources. These words so far have been spoken in gratitude and recog- nition of the great progress that has been made in such a short period of time. There are some tough issues, however, that must be 6 - faced now and in the immediate future in connection with these program activities. I would like to discuss a few of the sensitive problems that most be solved, particularly in connection with the Report that must be made to the President and to the Congress on June 30, 1967. The first question which was rais@,J particularly before the Congress passed this Law was whether this Program could make effective. progress without interfering with the practice of medicine in a given area. It is my hope and expectation that there will be inter- ference -- of a very special kind -- with the practice of medicine by these programs -- interference that will bring good both to the practitioner and to the patient. May I cite my own personal experience in this connection which gave me confidence that these Regional Medical programs would be a great success throughout the country. Just 20 years ago, January Ist, I organized a Children's Cancer Research Foundation, a private institution affiliated with a medical school and surrounding existing hospitals. This Institution was concerned with both funda- mental and applied research and with the care and study of children with acute leukemia and all other forms of cancer found in children. From the very beginning we established a relationship with the doctors of the region of our country with these words: 'We are here to assist you in the care of @ur patient". What we did was to accept any patient sent to us by any doctor, make all the diagnostic studies and then carry out all the expensive laboratory studies and specialized therapy. As soon as possible we put the patient back under the care of his own doctor, because the best place for any patient is at home as soon as that is possible. The doctor is backed by a partnership with a research institution, one kind of a regional center, it has been these years, which carries out all the expensive diagnostic 7 and follow-up studies and provides the specialized treatment not available to the doctor in his own community. I am happy to report to you that in these 20 years of close cooperation with doctors throughout New England, I have not heard a single complaint from any doctor that we had interfered with his relation- ship to the patient, or the family, or taken anything from him that properly belong-?d to hir.. Tihit -Y,-- havr-, done for thy Doctor, hoT,7pver, is to place behind him the knowledge and skills of experts who are not in the private practice of medicine, and to provide for him forms of therapy for his patient for whom he had nothing else to offer. The doctor makes his contribution to the generation of new knowledge by his reports to us which parallel our reports to him. By this method we enable the doctor to face both himself and the family secure in the knowledge that he was obtaining for his patient the results of research carried out anywhere, and diagnostic and therapeutic assistance of a caliber not otherwise available to him. It is true that one cannot easily apply what has worked in one part of the country to another area, and this is good, but I am confident that the variations best suited for a given region can be worked out along the lines of the formula I have suggested. Above all, I plead for flexibility in this program from region to region in this country, flexi- bility within any one region, as experience dictates what is best for the progress of this program. I have spent the major portion of my life in the field of cancer research and care and must state that the time has long since passed, if it ever existed, when any one doctor, no matter what his specialty, can give proper care to any one patient with cancer. From the moment of suspicion or discovery of the tumor, the patient should have the benefit of discussion and consultation of a whole group of people, which will include the surgeon who must operate, if operation is the choice; the radiotherapist; the internist with special knowledge of cancer and cancer chemotherapy; the pathologist, the hematologist and any other specialist recuired in a given case. Such a patient's family too, should be given the benefit of study by epidemiologists and trained fact finders who seek to learn more about the background or causation of cancer in a particular case. Rehabilitation, long-term care facilities, as well as home care programs, are all required if patients are to receive the best care possible. Specialized activities, therefore, require a framework of cooperative arrangements involving a wide variety of individuals, institutions, and agencies if they are to be effective. In view of the problems stated in the issue paDer in this regard, I would like to review the manner in which the Presi-dent's Commission on Heart Disease, Cancer and Stroke dealt with this question. Early in its deliberations the Commission faced up to the issue that was inherent in the categorical nature of its charter. On the basis of thorough discussions of the full Commission and the advice of expert consultants, the policy decision was made that it could not react adequately to the three categories of health that were its charae without becoming involved in the broader gamut of health problems. The Commission in its Report has stated, and I quote, -But heart disease, cancer and stroke cannot realistically be considered apart from the broad problems of American science and medicine.i: It consequently gave consideration to some of the underlying problems, some of which Dr. Dempsey has already mentioned, although 9 broader than the categorical areas with which we were concerned. Thus attention was given to the support of medical and continuing" education, and of medical libraries' better methods of constant communication between and among Centers and between Centers and doctors, and the need for some mechanisms for achieving cooperative relation- ships among the major health resources that were considered essential to progress against the problems of heart, stroke and cancer. Mention should be made too, of the broad scope of the recommendations in the DeBakey Report which were not included in this legislation at this time, but which can be supported in part today through other programs of the N.I.H. These include the creation of Centers of Excellence in the sciences basic to medicine and in the several disciplines in the clinical fields. It is my hope that these recommendations will not be neglected and that support, adequate support, will be found too for the educational and research activities which are essential for the successful operation of these medical programs. The question has been asked my many: "Is the present program weaker or better than that advocated in the DeBakey Report?' The answer is clear. When all the planning carried out by the hundreds of experts in the many regions of the country is complete -- and all the new needs discovered or uncovered by such studies are supported, the program will, indeed must be better than the original recommenda- tions or Dr. DeBakey and the Commission will certainly be sorely disappointed. I believe that the categorical thrust is important to this program, particularly at the outset. Specialized activities must be 10 - ions to be effective. I think related to the more generalized funct this is why Congress made so clear in enacting the law that the program was to have a broad.involvement of all of the health activities in the region. Clearly, the program should not serve to bring about further fragmentation in the health field. Its very nature is that of an instrument of synthesis among diverse elements, agencies and individuals. The representative of a medical society is ouoted as having said 'If this cooperation among all of these health resources in our state is good for heart disease, cancer and stroke, shouldn't it be good in helping to meet other healtb:,..needs?" I think the answer is obvious. It should be of such benefit. I am sure we all agree that if the cooperative pattern of the regional medical programs for heart disease, cancer and stroke has by-product values of importance to the total health problem of the region involved, we have reason for satis- faction, not dismay. These programs are developing just as the medical schools are taking measure of the needs of the communities around them. These programs, I believe, are responsible for accelerating this trend. There are still those who oppose involvement in a meaningful way of the medical schools in these programs on the ground that a medical school is only an educational institution. I believe that a medical school is an educational institution - and something more. It must be a center of medical research, not restricted in amount and kind merely to meet the educational needs - the medical school must take leadership in the solution of problems of disease, in identifiable programs, in addition to the conduct of basic research. And finally, to fulfill its mission and make its full contribution to society, the medical school must make the greatest possible contribution to meeting the medical needs of the community in which it has been nurtured. This can be no token contribution - tossed from the ivory tower. If the medical schools do not meet this challenge, they will lose the greatest opportunity in the history of medical education - now so happily offered through these regional medical programs. Cognizance should be taken of the fact that medical schools traditionally are discipline-oriented, and have given little support to categorical developments of real strength. A critical mass of research and clinical strength is required to develop, accumulate and apply truly expert knowledge in a given field, as for example, in modern Cardiology or in the field of cancer. The time has come for the medical schools to embrace the development of categorical strength - and no longer to eject such developments as a cardio- vascular institute or a cancer institute as foreign bodies ill-suited to the traditional ta'oles of organization of a medical school. The challenge is here to work out in each region - how categorical strength and greatness can be achieved within a university or medical school framework. Those who solve this will find rich rewards. I have worked out such a plan - which will preserve and increase greatness of the discipline structure of the medical schools - and permit the development of maximal interdisciplinary cooperation with those whose deepest concern and dedication is to one category of the dread diseases. Other plans - and better ones - can be and will be fashioned, 12 - There is another question deserving of frank discussion - one of greatest importance to the future of the health of our people. I refer to the charge made by some before this Bill was passed that the Regional Center plan would lead to socialized medicine. I shall not attempt to define this commonly employed and badly abused term, but will assume that what is meant is Federal contrnl of the practice of medicine, or, in short @Government Medicine'. As Dr. DeBakey has pointed out repeatedly, and with him, all the members of the President's Commission, this piece of legislation and the programs that will be created by virtue of it, provide the best means of pre- venting 'Government Medicine'. We all realize the vast increase in demand for good medical care since the end of World War II alone. This is shown by the several thousand community hospitals built with the aid of the Hill-Burton Act, fathered in the Senate by that great champion of medical research and health, Senator Lister Hill. 'ilip demands for health services khich have increased so rapidly in the last year alone, for reasons with which we are all familiar, cannot be met by the available manpower and facilities utilized and distributed in the manner presently employed. And now at this Conference we proclaim the right of every man, woman and child in the categories under discussion, to the most expert in diagnosis and treatment available in the medical world today. These needs of our people, for the best in medicine - let us not call them demands - must be met either by voluntary methods with Government support through programs of the kind we are discussing here, best suited to each particular region of the country, or some system of Federal health services will be invoked. May I express a personal reaction to the 13 - frequently expressed fear of what is called the ithreat of Government medicine ? Dole are talking not about some alien land, but about our Government - in this democracy. I do not share such fear, nor will I as long as there is a forum where I have the right to speak - as long as there are men and women to harken to my words. All of us have heard, I am sure, the background sounds of predictions that the way of voluntary cooperation is sure to fail, and that it will be necessary for the public sector to take over and bring order to the health field. This I do not believe. I am confident that the Regional Medical Programs have already demonstrated the potential to fut@'fill the promise and meet the challenge that were so clearly stated in the introduction to the DeBakey Report to the President's Commission, from which I now quote: .We need to match potential with achievement, to fuse the worlds of science and practice. We need to develop and support a creative partnership among all health resources. This way - wb-th is the way of a democratic republic - is the true path to conquest of heart disease,cancer and stroke'. We must never lose sight of the goals of all @liho work in the health fields - eradication or prevention of disease and, through the application of new knowledge from research, conversion of the incurable to curable. And while these goals are being achieved, let us furnish assistance through the Regional Programs, to every doctor in the care of his patient, and to those who have no private doctor too thus making available for every patient in the country, care of the kind all of us would like to have for all patients. This may be -14 - defined as the application of all knowledge of medicine, surgery and laboratory science for the prolongation of life, the relief of pain, and hopefully the cure of patients suffering from what the Congress calls the dread diseases. The only guideline of enduring value in@the construction of these Regional Programs must be defined in terms of what is best for the patient. In the final analysis this is what the Regional Medical Programs are all about. The idea which gave birth to this program is clear. The intent of the programs should permit no misunderstanding - the implementation, within the guidelines of the law and the regulations, remains, as it should be, in the hands of those who plan in each of the many regions of the country.