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  SDC AGAZ@NE                                                           7-)








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 Published by System Development Corporation                                                                        Volume 12 Number 8














                                                                  04







                                                         for Home Rule in
                                                              Health Care

                                                                  by HARRY BAIN


































     Hal  Johnson  lives  in  Roseville,  Cali-      he  has  come  to  know  quite  a  few  of      ization.  But  if  you're  getting   some
     fornia.  To  get  there  you  drive  north      Roseville's 20,000 citizens. He  sees  pa-      mellow  notion  that  he's  a   storybook
     from  Sacramento  along  U.S,   Interstate      tients every day  in  his  office  on  Oak      country  doctor,  you're  in  the   wrong
     Highway  80.  Usually   the   trip   takes      Ridge I)rive  or  at  the  Roseville  Com-      town.  The  word  for  Hal   Johnson   is
     about  20  minutes.  There's  a  lot  more      munity  Hospital  where  he's   a   member      Mod.
     traffic now than there  used  to  be,  and      of the staff. Johnson and his  five  part-        He swings in a medical and scien-
     the  once  vacant  grasslands  along   the      ners in  group  practice  are  members  of      tific sense because he works  at  it.  He
     way  are   sprouting   tract   houses   as      a  fast  disappearing  physician  minority      reads  the  right   journals   regularly-
     Sacramento  reaches  out  for  more   bed-      -the general practitioners.                     and  learns  from  them.  He  makes   the
     room space.  Roseville,  an  historic  Old        This  doesn't  seem  to   bother   John-      time to get to two  or  three  continuing
     West  railhead,  is  being   sucked   into      son. He takes pride in  what  he's  doing.      education seminars  every  year  to  keep
     the metropolis.                                 There's  no  trace  of  the  defensiveness      up-to-date.  You'll  usually   find   him
        Since  Hal  Johnson  began   practicing      you   sometimes   sense   among   GPs   in      draped across a chair at classes  offered
     medicine for  a  living  nine  years  ago,      this age of  increasing  medical  special-      by the local hospital.

                                                                                                                                   SDC MAGAZINE 3




     remarkable.  Since  July   1968,   he   has        To  capture  the  support   of   doctors      the opportunity  of  making  available  to
     been  helping  set  up  a  federally  spon-     like  Hal  Johnson,  RMP  has   to   be   a      their  patients  the  latest  advances  in
     sored  health  program  in  Roseville.   He     special program. It is.  It  is  the  first      the diagnosis of  heart  disease,  cancer,
     believes   it will  benefit  his  own   pa-     federal  health  program   to   insist   on      stroke,  and   related   illnesses."   The
     tients    and those  of   other   Roseville     grass-roots  leadership  in  the  decision-      diseases   selected    were    appropriate
     physicians.   He fought to get  it.  It  is     making    process.    Regional     advisory      targets. As a group,  they  are  our  most
     being    paid for  under  Public  Law   89-     councils call the shots,  and  the  law  is      lethal  killers,  accounting  for  71   of
     239,   passed in  1965  and  amended   last     explicit that the  councils  be  represent-      every loo deaths in America.
     year by P.L.  90-574.  Johnson,  and  thou-     ative of all elements of  the  health  com-        The   Commission   study,   now    known
     sands  of   other   physicians   who   have     munity,   including   consumers.    There's      as the De Bakey  Report,  had  called  for
     had their thinking  changed  by  this  law,     a  great  deal  more  about  RMP  that   is      the  establishment  of  "centers  of   ex-
     call  it  Regional  Medical  Programs,   or     different  from  past  government  efforts,      cellence"  for   the   dissemination   and
     simply,    RMP.                                 but first let's  talk  about  how  the  law      demonstration    of     new     knowledge.
                                                     came into being.                                 This   concept   smacked   of   too   much
                                                                                                      centralism  for  the  medical   profession
                                                            CONGRESSIONAL                             to  swallow  and  was   finally   scrapped
                                                                 RESPONSE                             by  Congress  in  favor  of   "cooperative
                                                                                                      arrangements"   among   medical   schools,
                                                     Looked at  historically,  RMP  is  dollars-      hospitals, medical  associations  and  re-
                                                     and-cents     Congressional     recognition      lated elements of  the  health  care  sys-
                                                                                                      tem.   Such    cooperative    arrangements
                                                     that  there  is  much  more   than   short-
                                                     ages  of  physicians,  other  health   spe-      are  one   of   the   most   unusual   RMP
                                                     cialists  and   hospital   beds   to   what      features.
                                                     Presidents   Johnson   and    Nixon    have        Congress  went   even   further   toward
                                                     called the  health  crisis.  Shortages  may      allaying  the  fears  of  many  physicians
                                                     grab the most  space  in  our  news  media,      when  it  declared   that   RMP   was   to
                                                     but leaders  in  the  health  sciences  are      accomplish  its  ends  "without  interfer-
                                                     beginning   to   talk   more    and    more      ing with  the  patterns,  or  the  methods
                                                     about  a  breakdown  in  our   system   for      of financing, of patient care  or  profes-
                                                     delivering health care.                          sional  practice,  or  with  the  adminis-
                                                        This  was  essentially  the  message  of      tration of hospitals...." This  guarantee,
                                                     the   President's   Commission   on   Heart      along  with  the  local   autonomy   dele-
                                                     Disease,  Cancer   and   Stroke   when   it      gated  to  individual  regional   advisory
                                                     submitted  its  report  in  December  1964.      councils,  in   large   measure   explains
                                                     Chaired  by  famed   Houston   heart   sur-      why   practicing   physicians   like   Hal
                                                     geon,  Dr.  Michael  E.   De   Bakey,   the      Johnson  have  greeted  RMP   so   warmly.
                                                     Commission  pointed  with  pride   to   the
                                                     great  strides  made  in  medical  research              DOWN TO THE
                                                     and  then  viewed  with  alarm  the   slow-               GRASS ROOTS
                                                     ness  with  which  the  results   of   this
                                                     research   were   being   made    available      Physicians  have  been  joined  in   their
                                                     to patients throughout the nation.               enthusiasm  by  nurses,  hospital   admin-
                                                        The    following    summer,     Congress      istrators, medical  educators  and  repre-
                                                     acted to  improve  the  delivery  of  medi-      sentatives  of  voluntary  health  organi-
                                                     cal  knowledge  by   passing   the   Heart,      zations,  to  name  the   most   prominent
                                                     Cancer    and    Stroke    Amendments    to      professionals    whose    membership    is
                                                     the  Public  Health   Service   Act.   This      required, along with that  of  physicians,
                                                     created    Regional    Medical     Programs      on   the   advisory   councils.   Congress
                                                     "to  afford  the  medical  profession   and      also made it clear  that  it  expected  to
                                                     the medical  institutions  of  the  nation,      see  some  average  citizens   among   the
                                                     through   ...   cooperative   arrangements,      council members.




















                                                                                                                                    SDC MAGAZINE - 5




            In drafting P.L.  89-239,  the  legisla-                                                      heart  disease,  cancer  and  stroke.  The
          tors  recognized  two  distinct  but   re-                                                      council    makes    its    recommendations
          lated phases in  getting  RMP  into  busi-                                                      to  the  Surgeon   General   who   author-
          ness-planning  and  operation.   In,   the                                                      izes  DRMP  to   fund   approved   propos-
          first,  the  regional   advisory   council                                                      als. So far,  none  of  our  findings  has
          draws on all the  resources  in  its  area                                                      been  reversed,  but  recently  some  have
          to  identify  what  is  needed   to   deal                                                      been  deferred  because  of  a   lack   of
          with  the  problems   related   to   heart                                                      funds."
          disease,  cancer  and   stroke   as   they                                                        Perhaps  the   most   important   factor
          exist in its own region.                                                                        in council deliberations  is  the  quality
            Once  needs  are  known,   the   council                                                      and durability of  the  voluntary  cooper-
          must get  down  to  the  task  of  setting                                                      ative  arrangements.   Says   Paul   Ward,
          priorities  among  competing   needs   and                                                      coordinator   of   the   California   RMP,
          hammering  out  the  cooperative  arrange-                                                      "All  operational  proposals   are   based
          ments   required   to   develop   remedial                                                      on    voluntary    cooperative    arrange-
          measures.  This  effort  is  supported  by                                                      ments. It's the  term  we're  stuck  with.
          planning  funds  granted  under  the   Law                                                      What  does  it  mean?  Simply  plain   old
          after  approval  of  the  National   Advi-                                                      verbal    agreements     between     given
          sory  Council  of  the  Division  of   Re-                                                      people  to  do  given   things,   provided
          gional  Medical  Programs.  DRMP  is   the                                                      they  can  get  the  resources  from   one
          capping  agency   that   administers   the                                                      place  or  another."  Once  plugged   into
          RMP  program   for   the   Department   of                                                      a  grant  proposal  and   approved,   how-
          Health,  Education  and   Welfare.   Plan-                         DR. ALFRED M. POPMA          ever,  these  verbal  agreements  take  on
          ning  grant  approval  hinges  on  accept-                                                      all the legal force of a formal  contract.
          ance  of   the   region's   organizational        The  real  decision  on  the  timeliness        In  form,  then,  RMP  goes   well   be-
          plan and method for proceeding.                 and acceptability of  operational  activi-      yond  encouraging   local   participation.
            At this point, the region  is  ready  to      ties lies with the division  as  expressed      It demands it.  Moreover,  the  tactic  of
          enter  the  operational  phase,  which  is      by  the   recommendations   of   the   Re-      local  control   has   been   strengthened
          another way  of  saying  it  is  ready  to      view  Committee  and  the   National   Ad-      through   the   philosophies    of    Drs.
          send  in  an  initial  grant  proposal  to      visory  Council  on  RMP.  The  latter  is      Robert   Q.   Marston   and   Stanley   W.
          the  Division  of  Regional  Medical  Pro-      a  body  of  distinguished  medical  prac-      Olson,  the  two   physicians   who   have
          grams.  As  required  by  the  Law,   DRMP      titioners  and  administrators   who   re-      served  as  directors   of   DRMP.   (Mar-
          won't give out money  for  patient  treat-      view   and   make    recommendations    on      ston  moved   up   in   1968   to   become
          ment  except  where  such  funds  are   to      all  regional  proposals,  again  as   re-      the  first  administrator  of  the   newly
          be  used  for   "demonstration"   purposes      quired by law.                                  created   Health   Services   and   Mental
          only, and not to  set  up  permanent  care        Dr. Alfred M.  Popma,  a  Boise,  Idaho,      Health    Administration    and     subse-
          and  treatment  programs.  There  is  also      radiologist  for  more  than  a   quarter-      quently  became  director   of   the   Na-
          no provision in  the  Law  for  money  for      century  before  turning  his  full   time      tional Institutes of  Health.)  Both  have
          construction.                                   attention to RMP,  knows  all  the  angles      employed  the  division  more  along   the
            Neither  Congress   nor   the   division      in the review process. He is  one  of  the      lines of a flexible  staff  resource  than
          has  laid  down  any  hard-and-fast  time-      16  members  of  the   National   Advisory      as   a   heavy-handed   federal   director
          table  for   moving   from   planning   to      Council,  has   served   on   the   Review      and enforcer. In keeping with  this  atti-
          operation.  It  hasn't  been  unusual  for      Committee  and  keeps   his   local   per-      tude,  the  Guidelines  put  out  by  DRMP
          the  two  to   proceed   concurrently.   A      spective  sharpened  as   program   direc-      run but 32 pages.
          few    RMP    grantees-North     Carolina,      tor of the Mountain States RMP.                   Refuting  the  notion   held   by   some
          Kansas   and   Missouri,   for    example-        "At  council  review  sessions,  we  are      that  RMP  is  the  beginning  of  a   na-
          had a long history  of  regional  coopera-      insisting  more  than   ever   on   excel-      tional  blueprint  for  dictating   stand-
          tion  and  planning  and  were   able   to      lence,"  Popma   says.   "The   successful      ards  of  medical  care,  Dr.  Olson   has
          move quickly to full  operational  status.      operational grant must  reflect  the  kind      said,  "Even  if   we   knew   enough   to
          Others  have   found   it   necessary   to      of solid region-wide  planning  that  will      draw   such   blueprints-which    we    do
          move more slowly.                               enhance  and  improve  patient   care   in      not-this  method  of   procedure   is   so




















     6   SDC MAGAZINE




           there  was  an   insistence   on   quality        Active  RMPs  now   blanket   the   Con-     tors  and  allied  health  personnel   has
           and  compliance  with  the  Law,  an   in-      tinental  United  States  and  reach   be-     been  in  the  direction   of   continuing
           sistence  that  left  some  funds  unobli-      yond  to  take  in  Alaska,  Puerto   Rico     education courses.
           gated as  indicated  by  the  carry-overs.      and Hawaii,  the  latter  grant  including        In fact,  Dr.  Dwight  Wilbur,  immedi-
           However,  the   most   recent   carry-over      Guam,   American    Samoa    and    Micro-     ate past president   'of   the    American
           of $20  million  from  1969  to  1970  was      nesia. In land  area,  the  regions  range     Medical   Association   and   a    staunch
           an   administrative   decision   of    HEW      from   Washington-Alaska    to    Washing-     RMPsupporter,hassaid:"These          [RMP]
           and  not  the  result  of  a  shortage  of      ton,  D.C.  California  leads  in  popula-     programs  should   be   primarily   educa-
           worthwhile  projects,  The  fact   remains      tion  with  nearly  20  million;  Northern     tional, for  the  better  educated  physi-
           that at the  end  of  FY  1969  (June  30)      New   England,   headquartered   in   Ver-     cians  are,  the  higher  the  quality  of
           there  were  some  $25  million  worth  of      mont,  has  but  425,000.  All   Americans     medical care they can  render....  Facili-
           approved but unfunded projects.                 now live within at  least  one  RMP  area.     ties  and  financing  are  important,  but
             In  a  March  1968   appearance   before      Because  of  regional  overlapping,   some     of  prime  importance  is  the  widespread
           the   House   Subcommittee    on    Public      live in as many as three.                      availability  of  high   quality   medical
           Health  and  Welfare,   Dr.   Michael   De        Some  states,   like   New   York   with     care.  The  key  to  this  is   more   and
           Bakey    anticipated,this     development.      five and  Ohio  with  four,  have  set  up     better  education  of  practicing   physi-
           "There  have  been  times  when   I   have      multiple  regions  within  their   bounda-     cians."   Small   wonder    the    regions
           been  guilty  of   impatience,"   he   ad-      ries.  The  opposite   has   happened   in     maintain  close  relations  with   medical
           mitted, "but the fact is  that  this  pro-      the  wide  open   spaces   of   the   West     colleges in their jurisdictions,  or  that
           gram has developed, I  think,  at  a  nor-      where  the  Western   Interstate   Commis-     operational  grants  to  date  have   been
           mal  pace  and  in  a  very  sound   way."      sion  for  Higher  Education   administers     notable   for   their    innovative    ap-
             He  pointed  out   that   the   planning      a  program  that  takes  in  four   states     proaches  to  providing  educational  pro-
           phase of  RMP  had  stressed  the  design,      and  overlaps  portions  of  four   others     grams  across  a  wide  range  of  medical
           not the  implementation,  of  health  pro-      that  have  their  own   RMP   activities.     and health specialties.
           grams.  This  resulted  in   smaller   ex-      California, in turn, is  a  single  region        Few,  if  any,  would  disagree   alto-
           penditures  than  were  projected  in  the      but  has  organized  itself  into  "areas"     gether  with  Dr.  Wilbur's   support   of
           beginning,   but   De   Bakey   emphasized      defined  by  the  medical  service   areas     continuing  education,   but   there   are
           that  regional   planning   efforts   were      of  the  state's  eight  medical  schools.     many   who   question   that   such   pro-
           about  to  pay  off  in   more   expensive        Of  the  55  organizations   that   have     grams  should  be   the   dominant   theme
           operational  programs   that   would   re-      fiscal responsibility  for  the  programs,     in RMP. Dr.  H.  Jack  Geiger  speaks  for
           quire  close  to  $300  million  by  1971.      25  are  medical  colleges  or  university     many  of  these  when   he   argues   that
           He   further   suggested   that   Congress      medical centers.  Seven  others  are  uni-     RMP  should  devote   much   greater   at-
           "contemplate   authorization   levels   of      versities,  while  the  remaining   grants     tention  to  the  total  health   problems
           some  $500  million"  by  1973  to   main-      are split  among  17  specially  chartered     of the urban and rural poor.
           tain  standards  and   momentum   in   the      foundations,   commissions   and   associ-        Now  acting  chairman  of  the  depart-
           program.                                        ations,  four  state  medical   societies,     ment  of  preventive  medicine  at   Tufts
                                                           one  advisory  council   and   one   state     University   School   of   Medicine,   Dr.
           AN EMERGING PATTERN                             agency.                                        Geiger  holds  that  the  categorical  RMP
                                                             Medical  school   involvement   in   RMP     emphasis  on  heart  disease,  cancer  and
           Through  Fiscal  Year  1969,  the  55  re-      is written into the Act, since  the  medi-     stroke  is  too  narrow  and   should   be
           gions  had  received  some  $145   million      cal colleges are at  once  a  prime  locus     broadened  to   include   not   only   all
           in   both   planning    and    operational      of   new   knowledge   through    research     disease   problems   that   confront   the
           grants. In part,  this  paid  the  freight      and  because  of  their  tradition  as   a     poor,  but  also  such   pressing   extra-
           for  the  nearly  2500  paid  staff   mem-      vehicle  for  disseminating  such   knowl-     medical  issues  as  poverty,  discrimina-
           bers  (47  percent  physicians)   in   the      edge   through    established    extension     tion, lack  of  education  and  unsanitary
           programs. It did  not  reflect  the  enor-      teaching activities  in  their  own  medi-     inner city and rural housing.
           mous  volunteer  efforts  of  the   nearly      cal  service  areas.   From   the   outset        Differences  of  opinion   like   these
           10,000privateindividuals,professional           Congress   intended    that    RMP    have     don't  intimidate  Dr.   Olson   and   his
           and  lay,  who  man   the   regional   and      heavy  educational  emphasis,  and  it  is     staff at DRMP. They  call  theirs  a  liv-
           national  advisory  councils   and   serve      something   of   an   understatement    to     ing  program  in  the  sense   that   they
           on  various  subcommittees,  task   forces      say  that  the  most  popular   and   well     expect  to  see  it  change  and  grow  as
           and local action groups.                        supported  thrust  of   RMP   among   doc-     conditions  change  and  new  health  pri-


















           SDC MAGAZINE




       orities   emerge.   They've   already   seen                                                         alone  has   more   people   than   Albany,
       the    categorical     emphasis     expanded                                                         Kansas    and    Intermountain    combined.
       somewhat    through    greater     attention                                                         While   awards   have   been    made    for
       to   kidney,   respiratory,   diabetic   and                                                         projects  in  Los  Angeles,   Philadelphia,
       other diseases  that  fall  under  the  "re-                                                         St.  Louis   and   Baltimore,   they   have
       lated illnesses"  portion  of  P.L.  90-574,                                                         been  on  a  far   less   ambitious   scale
       and  they  fought   successfully   to   have                                                         than those for  some  of  the  more  thinly
       dentistry   included    within    the    RMP                                                         opulated regions.
                                                                                                            p
       rubric.                                                                                               Not  that  there   aren't   some   encour-
          Moreover,    they    have     established                                                         aging   urban    programs.    Watts-Willow-
       close  liaison  with  social  action   agen-                                                         brook,  a  project  to  develop   a   post-
       cies  both  in  HEW  (Office   of   Economic                                                         graduate  medical  center  to   serve   the
       Opportunity)   and   HUD   (Model    Cities)                                                         people   of   Central   Los   Angeles,   is
       and   have   encouraged    individual    re-                                                         widely  regarded  as  a   possible   proto-
       gions   to   forge   cooperative    arrange-                                                         type  of  future  community   health   cen-
       ments  with   these   and   other   programs                                                         ters  in  ghetto  areas.   The   Tennessee/
       wherever  possible.   (A   subsequent   sec-                                                         Mid-South  RMP,   combining   the   activi-
       tion  in  this   issue   touches   on   such                                                         ties   of   predominantly   black   Meharry
       interagency   cooperation   in    Nashville,                                                         Medical  School  with   those   of   tradi-
       Tennessee.)                                                                                          tionally   white   Vanderbilt    University
          For all this,  the  program  has  experi-                        DR. STANLEY W. OLSON             Medical  School,  is  embarked  on  a  pre-
       enced   some   disappointments.    One    of                                                         ventive   medicine   program   that   links
       the  most  persistent  has  been  the  slow-      funds,  social  fragmentation,  the   diffi-       multiphasic   screening   and    an    OEO-
       ness   with   which   RMP   has   moved   in      culty of  bringing  together  all  the  cul-       sponsored    Neighborhood    Health    Cen-
       some  of  our  largest  and   most   problem      turally  diverse   groups   that   must   be       ter in a  deteriorating  section  of  North
       ridden  urban  areas.  This  has  been   ac-      included  in  the  planning   process,   im-       Nashville.   Similar   programs   are    on
       centuated   by   the   speed   and   success      movable     bureaucracies,     indifference.       the  drawing  boards  in  such  regions  as
       realized  in  rural  and   alpine   regions.      By  and  large,  the  rural   regions   have       Illinois,  New  Jersey,  Detroit,  Washing-
       Much  of  the  problem   traces   to   hang-      had  to  deal  with  a  far  less   numerous       ton and New York City.
       ups  in  getting  RMP   organized   in   the      but   more   homogeneous    population,    a
       core  cities  where,   among   other   prob-      circumstance  that  goes  far   toward   ac-               A GLIMPSE AT
       lems,  there  is  a   plethora   of   health      counting  for  their   rapid   progress   in           VVHAT'S GOING ON
       institutions,  people  and  activities,  all      getting  into   operational   status.   Com-
       of   which   are   essentially   autonomous.      parative   operational    grant    histories       The working  draft  of  a  directory   pre-
          The  division  has  made  no  effort   to      tell  the  story  about  as  well  as   any-       pared  by  DRMP  at  the  end   of   Fiscal
       soft-pedal these difficulties in its  testi-      thing else.                                        Year  1969  required   nearly   240   pages
       mony  before  Congress  or  in  its   public         Let's  consider  the   Kansas   RMP   and       to furnish  biographical  data  on  the  55
       statements.  Olson  has  said:   "The   com-      the   Intermountain   Program    based    at       regions   and   capsule   descriptions   of
       plex  problems  of   our   cities   pose   a      Salt  Lake  City,   Utah.   These   regions,       the projects in the  41  regions  that  had
       national crisis  of  the  gravest  order....      both  largely  rural,  have  received  grant       achieved  operational   status.   Most   of
       We   recognize   that    the    complexities      funds   totaling   some   $3   million   and       the  space  was  devoted  to   the   latter
       involved   in   developing   regionalization      $7.3    million,    respectively.    Another       task.
       in  urban  areas  have   delayed   the   de-      fast-starting   group,   the   Albany    RMP         Predictably,  the   individual   projects
       velopment  of  regions  in  the  very  areas      in   upstate   New   York,   has    received       differ as markedly in  design  as  the  re-
       where   their   services   may    be    most      almost   $2.8   million.   Together,   these       gions  themselves  differ  in   topography,
       needed.  This  is  a  matter  to   which   I      regions  represent   about   eight   million       demography,     and     health     manpower
       have  already  given  a  great  deal  of  my      people.                                            and facilities. just as predictably,  there
       time  and  to  which  I   am   prepared   to         On  the  other  side  of  the  coin,  the       are  pronounced  similarities,   for   gaps
       devote  more  of   my   personal   efforts."      latest   DRMP   directory   of   operational       in   the   armamentarium   for    attacking
          Dr.  Olson's   "complexities"   are   the      grants  lists  none  for   Chicago,   Cleve-       heart  disease,  cancer  and  stroke   have
       same  bugaboos   that   plague   most   pub-      land,   New   York   City   or   Pittsburgh.       some  characteristics  that  transcend  re-
       lic  programs   in   the   cities-inadequate      The    New     York     Metropolitan     RMP       gional boundaries.


















                                                                                                                                           SDC MAGAzrNE  9




              For  example,  the  best   equipped   and      sicians, in turn, are eligible  for  coro-
            trained  personnel   are   found   in   the      nary care  seminars  right  in  their  own         TOWARD THE FUTURE
            major  hospitals   and   university   medi-      local hospitals.
            cal centers, whether  these  are  in  rural        These  projects  give   some   idea   of      Of the  many  issues  that  will  face  RMP
            or urban regions.  Logically,  then,  these      the  style,  if  not  the  scope,  of  RMP      in the 1970s,  none  is  likely  to  remain
            institutions   find   themselves   involved      coronary care activities. There are  still      more visible  than  tfie  health  needs  of
            in some  way  in  nearly  all  educational,      other innovations.  Some  of  the  regions      the  urban  poor.   Dr.   Olson   believes,
            training    or    demonstration    projects      have  installed  24-hour  telephone  hook-      "Regional     Medical     Programs      can
            that   have   won   approval   for   opera-      ups that allow  small  hospitals  to  dial      assist  in  the   improvement   of   health
            tional funding.                                  regional  medical  centers  directly   for      service activities  through  projects  that
              Commonly,   RMP   strategy    has    been      electrocardiogram  analysis  and   profes-      supplement  elements  of   both   old   and
            two-fold-to     build      on      existing      sional  consultation.  Another  twist  has      new  systems  aimed  specifically  at   the
            strengths  wherever  there  is   a   strong      been   the   development    of    coronary      urban poor.
            local  program   and   to   extend   knowl-      care  training   programs   in   hospitals         "True,  we  suffer  from  several   con-
            edge  outward  from  the  medical   centers      other  than  teaching  hospitals,  an  ap-      straints  as  we  attempt  to   deal   with
            to   the   smaller   community    hospitals      proach  that  is  especially  relevant  to      these  problems.  Facilities  are   needed,
            where   specialists    and    sophisticated      those   medical   personnel    who    live      but we  have  no  authority  to  use  funds
            equipment  are   often   nonexistent.   No-      great distances from  the  large  training      for  construction  of  facilities.  Neither
            where is this strategy  better  illustrated      institutions.   Whatever   the   approach,      may  grant  funds  be  used  to   pay   for
            than  in  the  emphasis  on  coronary  care      the  separate  regional  efforts  share  a      the  cost  of  medical  services  or   hos-
            programs,   an   emphasis   that    threads      common  bond  of  helping   the   practic-      pitalization.   Nevertheless,   there   are
            its  way  through   RMP   activities   from      ing physician, the  nurse  and  others  to      major    contributions    which    Regional
            Hawaii   to    Florida,    from    sparsely      improve their skills  in  behalf  of  cor-      Medical Programs can make....
            peopled  Idaho  to  crowded   New   Jersey.      onary patients.                                    "Regional    Medical    Programs     are
              In  the  Memphis  region,   the   Univer-        To Marc  Musser,  it  is  this  recogni-      functioning   organizations    specifically
            sity   of    Tennessee    Medical    Center      tion of the needs  of  patients,  as  much      designed to  link  the  providers  of  care
            plans  to  install  a   12-bed   "showcase"      as  the  recognition  of  the  educational      together for the  purpose  of  collectively
            coronary   care   unit   (CCU)   that   the      needs  of   health   professionals,   that      improving  services  to  patients  ....  To
            medical staff will  use  to  give  training      accounts   for   the   RMP   emphasis   on      do  this,  RMP  must  enter  into  coopera-
            and  demonstrations   to   health   profes-      coronary  care  units.  He  says,   "Coro-      tive  arrangements  with  the  many   local
            sionals  from  throughout  the  area.   The      nary  care   units   represent   increased      and  federal  programs   already   address-
            Metropolitan    Washington,    D.C.,    RMP      awareness  of  the   acute   problems   of      ing  themselves  to  health   problems   of
            is  literally  putting  its  coronary  care      patients.   RMP   picked   up   the    CCU      the urban poor.
            program   on   wheels   by   designing    a      program  at  the  right  time,  since   it         "The    [RMPI    programs    can     and
            mobile   CCU   that   will   rotate   among      combined  our  initial  emphasis  on  con-      should contribute  significantly  in  plan-
            three  hospitals  in  the  area.  The  hos-      tinuing  education  and   the   means   to      ning  general  health  services  for  these
            pitals  will  provide  their  own   nurses,      effectively meet needs in  patient  care."      populations, because it  is  only  in  this
            who will be  specially  trained,  and  phy-        What  holds  for  coronary  care  is  no      fashion  that  we   can   come   to   grips
            sicians  will  be  drawn  from  the   Heart      less  true  of  programs  in  cancer   and      specifically with  the  problems  of  heart
            Disease Control Program of HEW.                  stroke.   Most   of   the   regions   have      disease,  cancer  and   stroke."   Clearly,
              joint  action   by   the   Central   Ohio      moved  solidly  into  these   areas   with      the   DRMP   staff   doesn't   intend    to
            Heart  Association  and  the   Ohio   State      tumor  registries,  tumor  boards,  stroke      dodge its responsibilities in  the  cities.
            University  College   of   Medicine   char-      management    programs,     and     cancer         Nor, if Dr. Olson  is  to  be  believed,
            acterizes coronary  care  training  in  the      and  stroke  screening   projects.   With-      will   RMP   diminish   its   emphasis   on
            Ohio  State   RMP,   a   61-county   region      out exception,  the  regional  plans  dem-      continuing  education.  He  is  on   record
            in  the  central  and   southern   portions      onstrate  conscious  attempts   to   mount      as   being   convinced   that    continuing
            of the  state.  Nurses  from  hospitals  in      a  balanced   attack   against   all   the      education  is  one  of  the  most  signifi-
            10  core  cities  come  to   Columbus   for      diseases identified  in  the  legislation.      cant  single  components  of   RMP   activ-
            two   weeks'   intensive   training    that      (The  final  segment  of  this  issue  in-      ity.  In  years  to  come,   however,   the
            prepares  them  to  return  to  their   own      cludes  discussion  of  a  cancer  program      division  expects  to  promote  more   com-
            institutions  as  "nurse  educators."  Phy-      being developed in Boise, Idaho.)               prehensive   and   innovative    approaches

















      10    SDC MAGAZINE




       designed  to  make   health   professionals                                                       rocal   feedback.   Within   the   separate
       active participants  rather  than  -passive                                                       regions,  most  core  staffs  now   include
       receptacles  in  the  educational  process.                                                       a    professional    public     information
          In Olson's view  there  is  no  conflict                                                       officer.
       between  the   requirement   for   continu-                                                         It's important that  he.do  a  good  job,
       ing education and  the  need  to  do  some-                                                       for  as  Marc  Musser   has   said:   "Most
       thing in the cities. In fact,  he  believes                                                       of  the  problems  in   RMP   result   from
       that  RMP  is  flexible  enough  to  accom-                                                       failure  to  communicate   at   the   right
       modate  the  problems  of  the  rural  poor                                                       time,  Leave   someone   out   and   things
       as  well.  Education  and   social   action                                                       can  get  sticky.  You  might  think   that
       can   coexist   comfortably   in    Olson's                                                       busy doctors  could  care  less,  but  that
       philosophy,   because   he   regards   them                                                       has been  far  from  the  rule  so  far  in
       as essential to each other.                                                                       RMP.  Overlook  them  and  they   let   you
          He   sees   continuing   education    in                                                       know about it in a hurry.
       urban areas as  one  sure  way  to  achieve                                                         "Frankly,    getting    the    commitment
       better  care  and  treatment   for   disad-                                                       of local  people  is  only  the  beginning.
       vantaged  patients.  In  the   same   vein,                                                       Communications     exchange     must     be
       he   believes   that   cooperative   health                                                       reciprocal.  It  must  be   continuous.   A
       arrangements   worked   out   by   agencies                                                       lesson  all  of  us  around   the   country
       in  the  cities  can  be  copied  elsewhere                                                       have  learned  is  that   good   communica-
       to benefit the  rural  poor.  This  outlook                                                       tions  in  a  region  don't  just   happen.
       again   reflects   the   importance    DRMP                                                       You  must  do  a  lot  of  work   to   make
       attaches to balanced programs.                                                                    them  happen.  A   good   core   staff   is
          This  emphasis  is   certain   to   grow                      EDWARD M. FRIEDLANDER            essential."
       even stronger throughout the       55   re-                                                         This  basic  lesson  hasn't   been   lost
       gions  in  coming  years.   The   division-      The object is  to help  the  regions  iden-      on  Ed  Friedlander  and   his   group   at
       through  its  own   staff,   the   National      tify  weaknesses   and   eliminate   unpro-      the  division.  Early  in  the  game   they
       Advisory   Council,   outside   consultants      ductive programs. It  turns  out  to  be  a      set  in  motion  a  systematic  program  of
       and   the   Review    Committee-has    tra-      continuing responsibility.                       interregional    meetings    designed    to
       ditionally  insisted   on   excellence   in                                                       draw   together   RMP   staffs   from   the
       the   operational   proposals   that   come        GETTING TO KNOW THE                            same  geographical  parts  of   the   coun-
       before it for review.                            PUBLIC AND EACH  OTHER                           try. Such  gatherings  serve  several  pur-
          In  recent   months,   Dr.   Olson   has                                                       poses.  They   allow   for   briefings   on
       strengthened  this  policy  and  called  on      Programs   like    RMP    recognize    that      what is going on at the  federal  level  in
       the  regions  to  work  harder  than   ever      their success  is  almost  totally  depend-      regard to budget  and  legislative  policy.
       to  improve  the   quality   and   regional      ent  on  timely   and   accurate   communi-      They also serve as a  platform  for  inter-
       significance  of  their  requests.  Perhaps      cations  to  a   wide   and   heterogeneous      preting  divisional  guidelines  and   giv-
       the  most  effective  means   toward   this      set   of   audiences.   There's   Congress,      ing the  regions  a  chance  to  air  their
       end   will   be   the   encouragement    of      the  mass  media,   the   general   public,      gripes about what the  division  is  doing.
       more   rigorous   standards    of    review      the  medical  schools,   the   professional      That  way  everybody  has   a   chance   to
       and  criticism  among  the   regional   ad-      organizations,      local      governments,      learn some of  the  basic  facts  together.
       visory   councils   when   they    evaluate      state  health  agencies,  voluntary   asso-        If   the   meetings    accomplished    no
       their own operational proposals.                 ciations, and on and on and on.                  more  than  this,  chances  are  both   Dr.
          The   quest   for   excellence   doesn't        At   another   but   equally    important      Olson  and   Friedlander   would   consider
       stop  there.  Today  there  is  also   more      level,  there  is   the   requirement   for      them    worthwhile.     There's     another
       attention  than  ever  to  the  problem  of      open     communications     between     the      angle,  however,  that   may   prove   even
       project  evaluation.  All  proposals   must      division  and   the   regions   and   among      more useful to  the  regions  in  the  long
       include   formal   mechanisms   for   peri-      the   regions   themselves.   Under    DRMP      run.  Friedlander  and   his   people   are
       odic  evaluation,  and  the  division   has      Assistant  Director,   Edward   M.   Fried-      using  their  get-togethers  with  the  re-
       invested a great deal of  eff  ort  in  de-      lander,  the  division  has  worked  out  a      gions   to   encourage   permanent    chan-
       veloping sensitive  tools  for  this  task.      program   to   produce    maximum    recip-      nels  by  which  the  regions   can   corn-



















                                                                                                                                       SDC MAGAZINE




















            municate   regularly   with   each   other,      moving   from    a    circumstance    where      ties are clamoring to get into RMP."
            separately and as groups.                        there  has  been  a  surplus  of   funds-at         Speaking to  the  same  point,  Califor-
              DRMP    is    convinced-as    are    many      times    an     embarrassing     surplus-to      nia's Ward said, "I  suppose  that  at  the
            of the regions-that there     is  a   many-      one  in  which  the  reverse  will  be  the      present time you  can  say  that  the  pro-
            fold pay-off  in  this  kind  of  activity.      case.  Looking  at   applications   already      gram is at its most critical  stage.  Years
            For  one  thing,  a   frank   exchange   of      in hand, we can  predict  that  the  aggre-      of planning  are  coming  to  a  head,  and
            data  on  operational   program   successes      gate  demand  for  grant  funds  will   ex-      the projects are rolling  in.  Now  if  you
            and  failures  can  help   the   respective      ceed  our  appropriations  in  the   Fiscal      don't  get  the  money  in   a   reasonable
            regions  avoid  expensive   false   starts.      Year  1970.  Beyond   that,   the   amounts      time,  the  people   who   made   the   co-
            For another,  it  can  provide  late-start-      that   the   Review   Committee   and   the      operative    arrangements     move     away
            ing  regions  with  helpful  tips  on   how      National  Advisory  Council   will   likely      or  change  their  minds,  and   you   have
            to  secure  the  enthusiasm  of  their  own      recommend   for   approval   from   yet-to-      to try to put it all together again.  Well,
            people  and  how  to  initiate  the   plan-      be-received  applications  will  also   ex-      that's very wasteful.
            ning  process.  Of  increasing  importance,      ceed available funds."                              "Understand  me,  it's   not   hard   to
            it can also help  iron  out  jurisdictional        Because  RMP   didn't   spend   all   the      sell   Congress   on   RMP.    They    were
            problems  or  stimulate   cooperative   ar-      money  Congress  made   available   to   it      always  willing  to  authorize  just  about
            rangements   among   regions   whose   pro-      in  the  first  four  years,  some  of  the      as much  as  the  program  could  use,  be-
            grams overlap each other.                        lawmakers   have   been    dubious    about      cause  their  opinion  of  us  was   always
              At   a   February   1969    meeting    in      whether  program  requests   do   in   fact      high.  The  only  thing  Congress  has  had
            Tampa,  Florida,   the   coordinators   and      represent   a   reasonable   estimate    of      against us is  that  in  the  beginning  we
            other staff of the  15  regions  that  make      need.    Although    final    Congressional      asked   for   too   much-more    than    we
            up  the   Southeastern   Region   furnished      appropriations  for  RMP  grants  are   yet      could  realistically  use.  That   is   the
            proof   that   interregional    cooperation      to  be  voted,   this   dubiousness,   com-      problem."
            and  exchange  are  gaining  in   apprecia-      bined   with   Administrative   and    Con-         Ward  feels  much  the   same   as   Dr.
            tion.  Spurred  by  Marc  Musser  and   Dr.      gressional  belt-tightening,  resulted   in      De  Bakey  did  when  he   testified   last
            J.   Gordon   Barrow   who   directs    the      a    House     Appropriations     Committee      year  before  the   House-that   the   pro-
            Georgia   RMP,   the   Southeastern   group      recommendation   of    $50    million    in      gram  must  continue  to   grow   and   ex-
            voted  to  share  the  cost  of  an  inter-      grants for FY 1970.  This  is  $24  million      pand.  Characterizing  RMP   as   a   means
            regional     coordinator     whose     task      less   than   the   Administration    asked      for   distributing    medical    knowledge,
            would  be  to  "ride  circuit"  among   the      for  and  $70  million   below   what   was      Ward   draws   an    analogy    from    the
            regions   and   keep   everyone    apprised      authorized by legislation.                       business   world:   "You   know,    General
            of  what  his  neighbors  are  doing.   The        Many  in  RMP  regard  this  as  a   body      Motors  would  never  think   of   develop-
            new  man  has  already  been  on  the   job      blow to  the  future  health  of  the  pro-      ing  a  new   automobile   and   then   not
            for several months.                              gram.   Both   Marc   Musser    and    Paul      spend  some  of  their  resources  on  cam-
                                                             Ward  serve  on   the   Coordinators'Steer-      paigns to get  it  in  the  hands  of  cus-
                 BUDGET OUTLOOK                              ing  Committee,  a  group  of  10   coordi-      tomers.  The  same   is   true   today   in
                                                             nators elected  by  their  fellows  to  ad-      medicine.  You  might  just  as  well  for-
            The fact that the regions are           now      vise   DRMP   on   national   policy    and      get the research  unless  you  are  willing
            ready  to  look  beyond  their  own   imme-      programs.    Ward    and    Musser    think      to  devote  some  money  to   distribution.
            diate  interests  is  an  indication   that      present   funding   projections   are   far         "That's  what  RMP  is  all  about,  and
            the  four-year-old   RMP   is   coming   of      from adequate.                                   if we  are  talking  $100  million   as   a
            age.  Further  proof-if   any   is   really        Musser   calls   the    budget    outlook      plateau for all time,  we  are  engaged  in
            needed-lies  in  the  rate  at  which  pro-      unpromising.    He    warns    that    some      the  wrong   kind   of   planning.   You've
            grams  are  moving  out  of  planning  into      programs  may  have   to   cut   back   and      got   to   preserve   your   momentum   and
            operational status. It  is  at  this  point      that  the  fiscal  situation  will   almost      the  faith  that  people  have   manifested
            that  RMP  requires  much   higher   levels      certainly  discourage   new   starts.   "On      in  the  future  of  the  program.   Other-
            of  financial  support.  The   program   is      the whole," he  says,  "this  is  occurring      wise  the   voluntary   contributions   and
            already feelinc, a pinch.                        with  the  worst  possible  timing,   since      local participation will largely  be  lost.
              Says  Dr.   Olson:   "Clearly,   we   are      so  many  new   localities   and   communi-      That is what would really hurt."

      12 - SDC MAGAZINE











                                   Contrast, Cooperation
                                   and Quality

















                                   About 120 miles east of Memphis the Tennessee River wheels  north  and  rolls  past  Wayne,  Perry,  Humphrey,
                                   Houston and  Stewart  Counties.  The  Tennessee/  Mid-South  RMP  begins  along  the  river's  east  bank  and
                                   stretches some 400 miles farther east to the Virginia line. It takes in 74 counties in Tennessee and a cluster
                                   of 14 more in southwestern Kentucky.
                                     That's room enough for a lot of contrast. The 3600 residents of  rural  Van  Buren  County  follow  a  life-
                                   style that has its roots in the cotton and tobacco culture of the antebellum South.  Over  in  urban  Davidson
                                   County, some 400,000 Tennesseeans are setting a pace that's about as  hectic  as  you'll  find  in  any  other
                                   metropolitan section of the  nation.  Altogether,  RMP  is  planning  or  providing  services  for  some  2.75
                                   million citizens in the region.
                                     Tennessee/ Mid-South  activities  hub  around  Nashville,  probably  less  famous  now  as  the  educational
                                   and cultural "Athens of the South" than  as  the  home  of  the  Grand  Ole  0pry  and  a  burgeoning  country
                                   and western  recording  industry.  Nashville's  importance  to  RMP,  however,  stems  from  the  presence  of
                                   seven large hospitals and Vanderbilt and Meharry medical schools.
                                     Both schools are committed to the success  of  RMP.  Vanderbilt  administers  the  RMP  grant,  and  faculty
                                   from both institutions have been generous in volunteering  assistance  to  the  program.  The  same  goes  for
                                   most of the hospita';s throughout the region and f6r such seats of higher learning as  Fisk,  George  Peabody,
                                   Tennessee State and the University of Tennessee.
                                     Tennessee/ Mid-South  went  into  business  on  November  1,  1966,  and  began  operational  activities  15
                                   months later. There are now 28 active operational projects, with another four approved  but  not  yet  funded.
                                   The annual budget comes to about one dollar for every  resident  of  the  region.  Much  of  the  emphasis  is
                                   on training programs that give physicians and  hospital  personnel  a  chance  to  improve  and  expand  their
                                   skills in the detection, diagnosis and treatment of heart  disease,  cancer  and  stroke.  The  programs  have
                                   generally started with existing strengths and built from  there-more  often  than  not  with  imagination  and
                                   a willingness to dare something new.


                                                                                                                                   SDC MAGAZINE - 13





















                           NEIGHBORHOOD HEALTH CENTER



























        They call it North  Nashville.  Like  other  inner  city  neigh-
        borhoods  in  other  American  cities,  it   traces   a   jagged
        poverty   scar   through   broken   streets   where   half   the
        dwellings  are  either  deteriorating  or  dilapidated.   Thirty
        thousand  people  live  here.  Of  the  adults  over  25   years
        of  age,  only  one  in  three  has  made  it  past  the  eighth
        grade.  Three  of  every  five  families  have  annual   incomes
        of  less  than  $3000,  and   women   head   half   the   house-
        holds.  Negroes  make  up  80   percent   of   the   population.

        Across  the  country,  RMP  has  had  trouble  getting   started                                        A major  aim  of  the  project  is  to  learn  how  screening
        in places  like  North  Nashville.  But  health  officials  here                                        services,   combined   with   treatment   services   at   the
        think  they  have  come  up   with   an   approach   to   assure                                        neighborhood  health  center,  affect  levels  of  health  in
        delivery  of  quality  health  services  to  Nashville's   urban                                        the area. This will  be  tested  over  a  10-year  period  by
        poor.  The  plan   revolves   around   interagency   cooperation     Testing for visual acuity          clinicians on the  project  and  by  social  scientists  from
        between   RMP   and    a    new    OEO-sponsored    neighborhood     and visual field,                  the  Center  for  Community   Studies   at   George   Peabody
        health center that  is  one  of  the  first  to  be  constructed                                        College.
        in the South.
                                                                                                                The clinical  program  will  utilize  21  screening  stations
        The center,  which  began  in  a  run-down  store  on  Jefferson                                        to  provide  such  services  as  electrocardiography,  visual
        Street,  will  soon  move  into  brand  new   quarters.   Super-                                        acuity  testing,   spirometry,   blood   pressure,   cervical
        vised  by  faculty  and  staff  from  Meharry  Medical  College,                                        cytology and a battery  of  27  blood  tests.  Hours  will  b
        it  will   offer   comprehensive   care   and   treatment   with                                        from 1 p.m. till 9 p.m.  to  make  it  easier  for  those  wh
        emphasis on  the  dignity  of  the  patient.  It  will  also  be                                        have to work every day,  and  the  patient  will  spend  from
        closely   tied   to   another   Meharry    project,    sponsored                                        one to three hours on his visit to the lab.
        through RMP and  aimed  at  bettering  the  health  lot  of  the
        disadvantaged,  not  only  in  North  Nashville,  but   in   the                                        The  screening  sequence  will  be  automated  in  an   effor
        rest of the city as well.                                                                               to  conserve  time  for  the  attending  physicians  and  mak
                                                                                                                test results available  as  soon  as  possible.  Much  of  th
        Called  the   multiphasic   screening   laboratory,   and   cen-                                        work will be carried  on  by  nurses  and  technicians,  with
        tered in  Lyttle  Hall  across  from  Hubbard  Hospital  on  the                                        many of the  latter  trained  and  qualified  as  part  of  a
        Meharry  campus,  this  operational  RMP  project   will   offer                                        educational emphasis  in  the  program.  To  be  eligible  fo
        the  latest  advances  in  the  detection  of   heart   disease,                                        screening,  patients  must  be  referred  by  a  private   ph
        cancer  and  stroke  and  other  disorders  that  may  lead   to                                        sician,  a  public   agency   or   the   neighborhood   healt
        those illnesses.                                                                                        center.  The  goal  is  about  25,000  examinations   annuall







     14 - SI)C MAGAZINE

























                                                                                                                                 Surgeon  Frank   A.   Perry
                                                                                                                                 of Meharry is  project  di-
                                                                                                                                 rector of  the  multiphasic
                                                                                                                                 screening   program.    His
                                                                                                                                 view: "We will be  able  to
                                                                                                                                 apply   preventive    meas-
                                                                                                                                 ures   on   a    continuing
                                                                                                                                 basis  as  opposed  to  the
                                                                                                                                 episodic care that  is  now
                                                                                                                                 the rule in this  area.  We
                                                                                                                                 have  good  people.   We're
                                                                                                                                 excited about our  future."



                                                                                                                                 At the blood pressure  sta-
                                                                                                                                 tion,  determinations   are
                                                                                                                                 made on both arms.

















































                                                                                                                                            SDC MAGAZINE   15




















          Williamson  County  Hospital  is  just  outside  Franklin,  a
          rural community of  10,000  on  the  L&N  railroad  17  miles
          south of Nashville. Last year the 100-bed hospital ad-
          mitted  4128  patients  from  its  medical  service  area  of
          30,000 people.  About  one  of  every  15  admissions  was  a
          cardiac patient, 22  of  whom  died.  Physicians  and  nurses
          at Williamson are working to  lower  that  figure  through  a
          cooperative   RMP   arrangement   with   Vanderbilt   Medical
          School's coronary care center.

          The  project,  under  the  direction  of  Dr.  Noel  Hunt  of
          Vanderbilt and  Dr.  Robert  Hollister  of  Franklin,  is  an
          effort to find out if a  small  community  hospital  can  and
          should  maintain  a  coronary  care  unit.   Williamson   has
          set up  a  2-bed  unit  and  designed  a  33-hour  course  to
          prepare its staff for handling the coronary patient. It  also
          sent  nurse  Martha  Miller  through  the  rigorous  coronary
          nursing program at Baptist Hospital in Nashville.















                                                                            Through a dual  monitoring  system,  patients  at  Williamson  can  also  be  monitored  b
                                                                            the nursing and professional staff  at  Vanderbilt.  Moreover,  there  is  a  24-hour  oat
                                                                            phone hookup to pass vital patient data between attending staff  at  the  two  institution
                                                                            This arrangement allows any  of  the  nurses  or  10  physicians  on  the  Williamson  sta
                                                                            to have immediate access  to  faculty  cardiologists  and  highly  trained  cardiac  nurse
                                                                            at the medical school. Patients, the people for whom all this is being done, have
                                                                            already benefitted. Williamson administrator Cliff Gardner credits the program with
                                                                            saving seven cardiac patients in its first seven months of operation.













    18 - SDC MAGAZINE
























































                   r,








                      I


















                                 I                                                    m


                                                                                                                                                 SDC MAGAZINE - 19






























































                                                                                                                     The dual  monitorin
                                                                                                                     tem   allows   Vand
                                                                                                                     physicians  and   n
                                                                                                                     to follow the identic
                                                                                                                     tient signs display
                                                                                                                     the nurse's station i
                                                                                                                     liamson  County  Ho






























        20  SDC MAGAZINE






























































                              In an emergency,  cardiac
                              nurse  Martha  Miller  of
                              Williamson   has   nurses
                              Bonnie Land  and  Jeanine
                              Jolly and  the  full  re-
                              sources  of  Vanderbilt's
                              coronary   care    center
                              right at her  fingertips.








                                                                                                                                    SDC MAGAZINE - 21























           Many  of  the  RNs  in  the
           coronary  care   unit'   at
           Nashville's Baptist  Hospi-
           tal  have  completed   that
           institution's  widely   re-
           spected   8-week   training
           program in  coronary  nurs-
           ing   and   have   received
           their   treasured   Cardiac
           Nurse   Specialist    pins.
           Most  of  them  now   teach
           alongside the  25  hospital
           staff   members   responsi-
           ble for the  curriculum  in
           the  program.  Given  three
           times a  year,  the  course
           is restricted  to  30  stu-
           dents  drawn  mainly   from
           the region, but  also  from
           as far  away  as  the  West    Baptist Hospital is a 625-bed general facility with teaching programs for interns and residents and a professional
           Coast.  As  RMP   develops,    that is more than 90 percent specialist. Its coronary care unit, established in 1964, was the first in Tennessee and
           Baptist will  be  the  pri-    several surrounding states. Today, it plays a central role in cardiac nurse training and patient consultation progr
           mary  resource  for   coro-    carried out through cooperative arrangements with RMP and several small community hospitals in distant to
           nary nurse training.
                                          The intensive care pavilion at Baptist accommodates eight patients, while an adjoining 14-bed progressive care
                                          ion is reserved for those who, in their physicians' judgment, require less intensive supervision.

                                          The coronary care unit will also perform a major advisory and consultative role in the Tennessee/ Mid-South coro
                                          care network, a hookup that will tie 11 small hospitals to coronary care centers at Vanderbilt and Baptist. Baptis
                                          already linked to 2-bed units at Crossville and Tullahoma, with Manchester slated to join the net soon.
































       22   SDC MAGAZINE


























                                                          A Case Study in
                                                             Grass-Roots
                                                                Planning
    Al Popma and his  wife,  Dorothy,  were  born  in  Orange  City,  a   throughout  most  of  the  western  states.  As  a  WICHE  commis-
    little farming town at the  northwestern  tip  of  Iowa.  Both  are   sioner, Al  helped  draft  the  planning  grant  application  that
    from Dutch stock  as  are  most  of  the  people  who  live  around   established the RMP program he now directs.
    Orange City. They came  to  Boise,  Idaho,  in  1938  when  Al  was     He has strong convictions about RMP.  "I  came  into  this  pro-
    a young doctor  about  to  begin  the  practice  of  radiology.  He   gram," he says, "because it is  perhaps  the  first  program  with
    kept at it until 1966 when he "retired" to take  a  full-time  post   federal dollars in it that has some local autonomy. For the  first
    as program director of the Mountain States RMP.                       time we feel that we  have  an  opportunity  to  produce  projects
       By that time Al had become  one  of  the  best  known  and  most   without regard to state boundaries. This is truly a first in  fed-
    respected radiologists in his part of the country  and  a  familiar   eral  health  programs.  We  are  also  discovering  that  through
    figure in medical circles at the state and national levels.  He  is   RMP, and again for the  first  time,  we  can  develop  autonomous
    a past  president  of  the  Idaho  Medical  Association,  and  when   projects ... that people at the  grassroots  can  make  determina-
    the American  Cancer  Society  was  reorganized  in  1945,  he  was   tions about their own future in health care."
    one of the original board members.  He  later  served  as  national     These  advantages  share  prominence  with   what   Popma   sees
    president of the society.                                             as   RMP's   greatest   long-range   contribution-the   encourage-
      From 1953 until  1966  he  was  a  commissioner  of  the  Western   ment of  permanent  continuing  education  programs  that  benefit
    Interstate   Commission   for   Higher   Education   (WICHE),   the   the patient by helping physicians, nurses and  other  health  pro-
    organization  that  administers  the  Mountain   States   RMP   and   fessionals improve their  skills.  He  discusses  this  and  other
    is  involved  in  the  total  spectrum  of   educational   planning   RMP issues in the following pages.




                                                                                                                                 SDC MAGAZINE - 23




          Al  Popma  has  long  been  concerned  about  the  lack  of   formal   coordination  among  them  and  quite  often  there   was   duplica-
          continuing  education  programs  for  doctors,  nurses   and   other   tion of course content and expenditures."
          health  professionals  who  practice  in  Idaho,   Montana,   Nevada     This was  the  situation  as  Popma  remembers  it  in  1965  when
          and  Wyoming,  the   four   states   that   together   compose   the   Congress  passed  P.L.   89-239   and   launched   RMP.   From   the
          Mountain  States  RMP.  In  his  13  years  as   a   WICHE   commis-   outset,  he   and   other   WICHE   members   were   determined   to
          sioner, he became  convinced  that  one  of  the  region's  greatest   include  Idaho,  Montana,   Nevada   and   Wyo'ming   in   the   new
          needs  was  for  some  permanent  mechanism  to  create   and   sus-   program. The first order  of  business  was  to  sit  down  and  put
          tain such education and training eff orts.                             together an application for an RMP planning grant.
            "WICHE  undertook  a   @mber   of   studies   to   assess   health     "This  was  drafted  by  the  advisory   council,   working   with
          training requirements in the four  state  region,"  he  recalls.  "A   Dr.   Kevin   Bunnell,   associate   director   of   WICHE,"   Popma
          number of years  ago,  for  example,  we  made  a  study  of  health   recollects. "To assist in the effort, the  council  recruited  three
          manpower  needs  and  came  out  with  very   accurate   predictions   distinguished   practicing   physicians    from    the    region-Dr.
          of  the  demand  for  health  personnel,  particularly   physicians,   Frank  McPhail  from  Montana,  Dr.  Francis  Barrett   of   Wyoming
          over the next couple of decades.                                       and   Dr.   Fred   Anderson   from   Nevada.    All    were    WICHE
            "And following  the  lead  of  the  Faulkner  Study  on  the  need   commissioners."
          for medical  schools,in  this  region,  WICHE  set  up  an  advisory     The  group  got  the  job  done,  producing  an  application  that
          council on  medical  education  facilities.  I  became  chairman  of   was  approved  by  the  Division  of  Regional   Medical   Programs.
          the council,  and  it  was  largely  through  its  work  that  WICHE   Mountain  States  RMP,  with   Al   Popma   as   program   director,
          grew interested in the legislative  hearings  that  led  up  to  the   began its life in  November  1966.  It  was-and  still  is-the  only
          establishment of RMP.  In  fact,  the  council  went  to  Washington   RMP  region  without  at  least  one  medical  school,   a   circum-
          to  testify  before  the  House  committee  that  eventually   wrote   stance  that  some  had  thought  would  make  the  area  ineligible
          the RMP law."                                                          for RMP funding.
            Popma  and  other  council  members  felt  at  the  time  that   a     In  Popma's  view,  the  absence  of  medical   schools   is   the
          grass-roots  program  such  as  RMP  would  provide  the  spark  for   major reason  there  has  been  a  lack  of  coordination  and  con-
          permanent  educational  activities  in  the  four  state  area.  "We   tinuity in continuing  education  activities  in  the  four  states.
          were  in  agreement,"  Popma  says,  "that   although   we   had   a   Not having medical schools also  created  a  set  of  organizational
          myriad  of  continuing  education  courses  most  were  on  a   hit-   problems for the fledgling Mountain States program.
          and-run basis.                                                           "One of the first things  we  had  to  do  to  meet  the  require-
            "Nothing  was  formally  organized,  and   the   professions   de-   ments  of  the  Law,"  Popma  says,  "was  to  organize  a  regional
          pended  almost  entirely  on  volunteer   agencies-the   Heart   As-   advisory group.  To  satisfy  the  requirement  for  medical  school
          sociation,  the  Cancer  Society,  the  medical  associations,   the   representation we had  to  go  outside  our  boundaries.  Logically,
          nursing societies and so on. To put  it  another  way,  the  profes-   we went to  medical  colleges  in  surrounding  areas  to  take  ad-
          sional groups themselves  were  entirely  responsible  for  sustain-   vantage  of  traditional  relationships  to  practicing   physicians
          ing continuing education  in  the  four  states.  There  was  little   in our region.









































      24  SDC MAGAZINE




                                 "We invited  representatives  from  the  schools  in  Washington
                              and  Oregon  and  chose  Paul  Ward  to   represent   the   several
                              California  institutions.  For  representation  on   our   southern
                              border,  we  turned  to  the  new  schools  in  Arizona   and   New
                              Mexico. Since  our  physicians  have  always  had  strong  ties  to
                              the  Universities  of  Utah  and   Colorado,   we   added   members
                              from both medical schools. Then  we  went  a  little  farther  away
                              and took  in  representatives  from  the  medical  college  at  the
                              University  of  Minnesota,  the  medical  schools  in   North   and
                              South Dakota, and from Creighton University in Omaha."
                                 Once  medical  school  representation  was   settled,   Mountain
                              States asked for recommendations  from  each  of  its  four  states
                              to  round  out  advisory  council   membership.   Seventeen   addi-
                              tional  people  were  added,   including   three   Indian   members
                              who speak for the major minority group  in  the  region.  With  its
                              ,advisory  group  selected,  the  program  was  ready  to  turn  to
                              other matters.
                                 Looking back,  Popma  recalls  that  no  one  in  the  sprawling
                              region  had  accurate  information  on  what   medical   facilities
                              were available or  what  the  training  and  educational  needs  of
                              health  professionals  were.  "We  recognized  that   we   had   to
                              assess  these  needs,"  he  says,  "and  we  decided  to  ask   the
                              people at the grass-roots level to tell us what they had  to  have.
                              With this  information,  we  could  then  attempt  to  design  ade-
                              quate programs."
                                 After  examining  several  alternatives,  RMP  and  WICHE  staff
                              members  decided  that  the  best  approach  was  a  field   survey
                              using  direct  mail  questionnaires.  "There   was   one   problem,
                              though,"  Popma  remembers.  "Never  having  devised   such   ques-
                              tionnaires  or  formulated  computer  programs  for  this  kind  of       John Gerdes is  one  of  those  qualified
                              data analysis, we came to  the  conclusion  very  quickly  that  we       people who are in such  short  supply  in
                              required  some  rather  sophisticated   assistance.   And   so   we       health  programs  across   the   country.
                              made   an   arrangement   with   System   Development   Corporation       He was  on  the  faculty  of  the  School
                              to provide us the necessary know-how."                                    of Public Health  at  the  University  of
                                 Even  while  the  agreement  was  in  negotiation,  the  program       Pittsburgh  but  came  West  because   he
                              was having to face up to the task of  creating  a  regional  organ-       preferred  the  clean  air  and   outdoor
                              ization that could  carry  out  the  survey  work  and  become  the       life.
                              permanent  staff  resource  for  long-range  planning   and   oper-         Al Popma says Gerdes  is  "one  of  the
                              ational activities.                                                       top-notch  young  men  anywhere  in   the
                                 "We decided  to  set  up  an  office  in  each  state  and  were       country  when  it  comes  to   developing
                              fortunate  enough  to  secure  four  outstanding  practicing   phy-       the   kind   of    community    supported
                              sicians to  serve  as  state  directors,"  Popma  notes.  "Although       health   programs   required   in   RMP."
                              there have been  changes,  we  retain  excellent  state  leadership       Among   other   projects,   Gerdes    has
                              in  Drs.  Sidney  Pratt  of  Great  Falls,  Montana,   Dr.   Claude       been prominent  in  planning  an  inhala-
                              Grizzle  of  Cheyenne,  Wyoming,  David  Barton  of  Boise,  Idaho,       tion therapy  training  program  for  the
                              and Lorne Phillips  of  Reno  and  Las  Vegas,  Nevada.  The  open-       region.
                              ing of our regional office in Boise was the  final  touch  to  give         "It began in the  fall  of  1968  at  a
                              a true regional flavor to the whole program."                             meeting  in  Las  Vegas  where  we   were
                                 Of course, it wasn't quite as simple as  it  reads  today,  some       trying to compile a  list  of  physicians
                              three  years  later.  Says  Popma,  "Compared  to  other  programs,       who  might  be  interested  in  undertak-
                              we had kind of a rough time  getting  going.  Most  of  the  others       ing such a program,"  Gerdes  says.  "Dr.
                              emanated  from   medical   schools   where   there   were   trained       Richard Browning,  a  Las  Vegas  intern-
                              people to write applications and get the program rolling.                 ist, had already  gotten  one  under  way
                                 "We had to  start  from  scratch.  We  had  absolutely  nothing.       for the state of Nevada,  and  our  state
                              We had to rent office space here  in  Boise  and  in  each  of  the       directors were  anxious  to  find  a  way
                              states, and we had  to  recruit  qualified  people.  To  be  frank,
                              there's a critical shortage of manpower to do  this  kind  of  job.












     26 - SDC MAGAZINE






     to extend it to other parts of the  region.
       "We  already  knew   of   another   inha-
     lation  therapy   training   program   just
     25  miles  from  our  regional  office   at
     Caldwell    Memorial    Hospital,    Idaho.
     It  was  being  run  by  Charles  Reed,   a
     31-year-old internist, as  part  of.a  two-
     year  program  at  nearby   Treasure   Val-
     ley junior College."
       Gerdes   asked    Reed    and    Browning
     if  they  would  be   willing   to   expand
     their  programs  to  include   shorter-term
     training  for  personnel  of  hospitals  in
     the  region.  Both  were   receptive,   and
     they  sat  down  together'  to   design   a
     curriculum  and  draft  a  grant   proposal
     to   set   up   complementary    inhalation
     therapy  training  institutes  at  Caldwell
     and  at  the   Southern   Nevada   Memorial
     Hospital,  Las  Vegas.   The   request   is
     pending before DRMP.
       "The  exciting  thing  about  this   pro-
     gram,"  says  Gerdes,  "is  that  two  com-
     munity    physicians,    in     communities
     1000  miles  apart,  are  working  in  con-
     cert  on  a  common  project  with  a  real
     regional  emphasis   and   outlook.   Even-
     tually,  if  we  can  interest  other  phy-
     sicians  like  Drs.   Reed   and   Browning
     in  becoming  instructors,   we   hope   to
     make  this  curriculum  available  to  hos-
     pitals throughout the four states.
       Gerdes  points  out  that   up   to   now
     Dr.  Reed's  program  has  been  aimed   at
     students going  for  a  junior  college  AA
     degree  or  expecting  to  transfer  to   a
     four-year  school.  The   Mountain   States
     emphasis,  predictably,  will  be  on  mak-
     ing  the  training  available  to  hospital
     personnel or  others  who  have  the  apti-
     tude  to  become  inhalation   technicians.
       Says  Gerdes:  "Typical  enrollees   will
     come  from   small   community   hospitals.
     They may  be  RNs,  but  we  hope  also  to
     attract  students  who,  while  they   have
     no  special  medical  training,   do   have
     the aptitude to  learn  the  material.  Our
     theory  is  that   we   can   upgrade   the
     skills  not  only  of  RNs,  but  also   of
     licensed    practical    nurses,    nurse's  For patients with heart and      respiratory  diseases,  inhalation  therapy  can   afford
     aides  and  others  with  the  ability  and  short-term relief and be a      significant  factor  toward   recovery.   The   inhalation
     desire to acquire this  training.  This  is  therapist also comes  into  play  in  such  emergency  situations  as  cardiac  arrest  or
     consistent   with   the   Mountain   States  serious chest injury. The latter  is  simulated  here  by  students  and  faculty  of  the
     philosophy of training its own."             Caldwell Memorial Hospital Inhalation Therapy Training Program.













                                                                                                                                     SDC MAGAZINE  27




               And  since  we  were  highly  geared  toward  field   research   and
               obtaining  information,.  we  had  to  find   people   who   thought
               along these lines."
                 Eventually the offices did -get  set  up  and  staffed,  at  which
               point  Mountain  States  was  ready   to   sit   down   with   SDC's
               Health   and   Environmental   Systems   Department    to    develop
               the series of questionnaires that  eventually  would  go  to  nearly
               all health personnel in the four states.
                 "Our  survey  universe  included  physicians,   dentists,   regis-
               tered nurses, licensed practical  nurses,  hospital  administrators,
               X-ray  and  lab  technologists,  physical  therapists....  I   think
               there were  eight  categories  we  wanted  to  reach,"  Popma  says.
               Deciding  just  how  to  reach  these  groups  required   that   the
               Boise staff  meet  regularly  with  state  offices  and  representa-
               tives  from  SDC  to  work  out  questionnaire  logic  and  wording.
                 "It took a lot of time and a lot of  wheel  spinning  to  come  up
               with  the  proper  questions,"   Popma   recalls.   "Some   of   our
               people  had  never  done  this,  and  you  can  imagine  that  there
               were  problems.  Often  there  was  quibbling  or  quarreling   over
               the correctness of a single word."
                When  the  rough  spots  were  ironed  out  to   the   point   that
               everyone could  live  with  the  results,  the  questionnaires  were
               printed  and  mailed  to  100  percent  of  all   health   personnel
               except  RNs  and  licensed  practical  nurses.   These   populations
               were  large  enough  to   require   use   of   a   random   sampling
               procedure.
                "Across the region  we  had  better  than  a  50  percent  return,"
               Popma  says   with   satisfaction.   "The   data   were   keypunched
               and  put  on  the  SDC  computer  in  Santa  Monica.  So   far,   we
               have run two analyses on this file,  and  the  results  have  helped
               us in devising certain operational activities.  After  all,  provid-
               ing  data  for  operational  programs  was  the  purpose  and  func-
               tion of the questionnaires."
                At  the  same  time  the  health   professional   survey   was   in
               progress,  Popma's  staff  was  also  busy  collecting   information
               on health facilities in the region.  To  get  an  accurate  line  on
               such  things  as  the  number  of  hospital  beds,  the  number  and
               location of  nursing  homes,  and  the  adequacy  of  transportation
               services, the staff designed what it now calls its Health  Profiles.
                "These  focus  down  to  county  levels,"  Popma   explains,   "and
               enable us to tell what the health  facilities  needs  are  in  indi-
               vidual  communities.  I  should  mention  that  SDC  didn't   assist
               on this  effort.  We  devised  it  almost  completely  on  our  own.
               Naturally  there  were  times  when  SDC  looked  at  what  we  were
               doing and made suggestions, but  the  work  was  almost  all  ours."
                However, SDC did have a  lot  to  do  with  a  third  data  gather-
               ing effort aimed  at  consumers  of  health  services.  This  survey





















        28 - SDC MAGAZINE




          is perhaps unique to date  in  RMP.  "As  far  as  I  know,"  Popma   nearby large medical center with facilities  to  care  for  him.  So
          says, "ours is the only  RMP'that  has  made  a  systematic  broad-   these people die at home.
          scale effort to find out what kind  'of health services  the  ordi-     "We recognized that if we were going  to  be  able  to  take  care
          nary citizen wants  to  have  available  for  patients  with  heart   of such patients we had  to  help  establish  facilities  and  train
          disease, cancer, stroke and the related diseases.                     people  in  small  hospitals,"  Popma  explains.   'Our   philosophy
            "This questionnaire, which  we  call  the  Survey  of  Consumers,   is that if a coronary care unit is good  for  patients  in  the  Los
          went out to 10,000  people  in  the  four  states,"  Popma  recaps.   Angeles metropolitan area, it is also  good  for  those  in  Shelby,
          "We  drew  our  random  sample  from  telephone   directories   and   Montana. If we accepted the  tenet  that  a  hospital  has  to  have
          from a list  maintained  by  fhe  Department  of  Agriculture  that   300 beds before a coronary care unit  is  financially  feasible,  we
          shows families  without  telephone  service.  Again,  our  rate  of   wouldn't have any coronary care programs."
          return was over 50 percent."                                            Believing  this,  Popma  and  his  associates  sat  down  and  de-
            All told, the Mountain States  RMP  now  has  three  large  files   vised  a  prototype  program  to   prepare   both   physicians   and
          of information-health professionals,  health  facilities  and  con-   nurses  to  provide  coronary  care  in  the  small   hospital.   On
          sumers,  "This  planning  data  base  took  almost  two  years   to   March 1,  1968,  thanks  in  large  measure  to  the  leadership  of
          assemble," Popma sighs,  "but  when  it  is  all  put  together  it   Montana   physician,   Frank   McPhail,   Mountain   States   opened
          gives  us  a  sound  basis  for  developing  operational  projects.   its first  coronary  training  center  at  St.  Patrick's  Hospital,
          Both  the  professional  and  consumer  files  are  stored  on  the   Missoula,  Montana.  The  project  draws  on  cooperative   arrange-
          computer in Santa Monica."                                            ments  among  the  hospital,  RMP,  the  University   of   Mont-ana
            Part  of  the  agreement  between   Mountain   States   and   SDC   and   the   University   of   Washington   Medical   School    which
          was  that  there  would  be  someone  from   the   Health   Systems   furnishes  consultants.  About   120   people   went   through   the
          Department  full  time  in  Boise.  Speaking  of  the  arrangement,   course in its first 16 months.
          Popma  says,  "we  had  Bob  Mendenhall  who  did  a  very   excel-     "A  second  interesting  operational   program   we   have   going
          lent job for us. He is one of the  finest  people  we  ever  worked   aims at providing  the  latest  training  in  cancer  diagnosis  and
          with. No job was too  great,  and  there  was  never  any  question   treatment,"  Popma  notes.  "There  is  something   for   physicians
          of hours. If it took till midnight, Bob would be there to do it.      and  for  both  the  practicing  and   student   nurse.   Practicing
            "I  was  very  interested  in  Bob.  Our  kind  of  program   was   nurses  will  have  a  chance  to  come  to  the   Mountain   States
          something new for him since it was  the  first  time  he  had  been   Tumor  Institute  that  we  are  developing  in   association   with
          with  a  program  that  fundamentally  and   physically   was   at-   St. Luke's  Hospital  in  Boise.  Here  they  can  study  and  learn
          tached to the practice of medicine,  Naturally,  there  was  a  lot   the latest techniques in cancer nursing.
          he  didn't  know,  but  he  learned  very  well  and  quickly   and     "Undergraduate  nurses  who  matriculate  at   the   four   bacca-
          blended  in  with  no  difficulty.  Bob  gave   us   a   tremendous   laureate nursing schools  in  the  region  will  have  a  chance  to
          amount  of  help,  and  I  was  sorry  when  the  contract  was  up   enter the same program on an  elective  basis.  Since  none  of  the
          and he had to leave for a job elsewhere."                             schools has facilities for this kind of  training,  the  opportunity
            (Mendenhall  is  now  project  leader  for  SDC  on  a  study  to   to  attend  the  institute  should  provide  a  new   dimension   in
          assess  health  care  requirements  for  residents  of  the   rural   baccalaureate nursing programs."
          Upper Kennebec Valley  in  the  state  of  Maine,  The  corporation     Like  RMP  administrators  in  other   regions,   Al   Popma   has
          retains  its  ties  with  Mountain  States  RMP,  however,  through   given a lot of thought to what it takes  not  only  to  get  a  pro-
          a formal consulting agreement.)                                       gram started, but also  to  keep  it  moving  over  the  long  haul.
            Popma is quick to point out that not  all  the  effort  in  Moun-   "In my judgment," he says, "the first thing  that  has  to  be  done
          tain States has  been  taken  up  with  the  surveys.  The  program   is to sell the practicing  physicians  and  the  medical  societies.
          has  five  operational  programs  under   way,   another   approved   You need more than their interest;  you  have  got  to  have  their.
          by  DRMP  and  four  more  pending  DRMP   review   and   approval.   participation. This also holds  true  for  nurses,  hospital  admin-
            "We did  a  small  study  in  Montana  to  assess  the  needs  in   istrators and other professionals."
          coronary care,"  Popma  says,  "and  we  learned  that  85  percent     Reactions  to  RMP  have  varied  among  physicians  in  the  four
          of people having heart attacks  die  at  home.  Now  Montana  is  a   state area. At the outset, there was a lot  of  fear  and  suspicion
          rural area with many  small  hospitals  of  from  15  to  50  beds,   in  some  communities.  "We  tried   to   convince   everyone   that
          meaning that  the  coronary  patient  can't  be  transported  to  a   RMP  was  their  program  and  was  under  their   control,"   Popma




















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