1

                        THOMAS S. NIGHSWANDER

                           August 4, 1996

                         Dr. Fitzhugh Mullan,
                             interviewer


Mullan:    We're sitting on Dr. Nighswander's back porch, I guess,

bedroom porch, in Anchorage, Alaska.      The date is the fourth of
August, 1996.    Everything at the moment is very green, a variety

of evergreen and deciduous trees.       I suppose it isn't this green

all year 'round.



Nighswander:    Oh, generally, end of September, it's all yellows

and oranges and the leaves are gone and it turns to white.

Actually, you can see the mountains.      During the wintertime you
really get a much better view of the mountains.      You get nestled
in here in the summertime.



Mullan:    There are no moose and there are no pussycats at the

moment, or no rabbits, all that inhabit these environs, I'm told.



Nighswander:    That's exactly right.



Mullan:    Pussycats and rabbits I've seen.



Nighswander:    And if you're lucky, we'll get a moose that'll come

on down.
                                                                       2

Mullan:    You didn't start here.   Why don't you tell me about

where you came from.



Nighswander:    I've got to include Ruth a little bit in this

story, because she's very much a part of it.     Ruth and I actually
went to high school together back in Kent, Ohio, and for some

reason, we went to several universities.      I went to Kent State
long before it became famous, and Ruth went down to Wittenberg in

Springfield, Ohio.    Even though we'd gone to high school, in

fact, dated in our senior year, we went off to separate

universities, but kept corresponding.
     Later on in college, the relationship developed further and
further, and finally in our senior year we decided we were going

to go in the Peace Corps.    I don't know why, but I'd always
wanted to go to Africa before I ever went to Europe.     We'd never

traveled.   My dad had worked for the city of Akron in the water
department for thirty years, as had my grandfather, so there was
sixty years of working in the water works.      In fact, I've worked

for the city of Akron water department in the summertime during
college.    So we kind of came out of that background.   Dad nor my

mother had gone onto college, nor had Ruth's parents, for that
matter.    Her parents came from Germany when they were in their

twenties, so Ruth is first-generation American.     But anyway, for

some reason I'd gotten real interested in going to Africa, I

guess from something I'd read.      I remember once meeting a
missionary who had been in Africa, talking about Africa drumming

at night, and it sounded fascinating.
                                                                       3

       Neither of us had ever considered health as a career at all.

I had an undergraduate degree in sociology and philosophy, and
Ruth was an elementary schoolteacher with credentials for

teaching German at the secondary level.     So we applied for the

Peace Corps, and we decided that if we got accepted to the Peace

Corps, we'd get married, and if we didn't, we wouldn't.     We would

wait.     [Laughter] Those decisions were easy at those times.
We'd    wait.   But anyway, we got accepted into the Peace Corps,

and we thought we'd probably be teaching.     It's much easier to
place couples in teaching positions than any other activity.      But

some GS-5 clerk, I've always suspected, had our applications, and
when they decided which pile to toss it in, they tossed it in

this pile that said "tuberculosis public health, Nyasaland."



Mullan:    Nyasaland.



Nighswander:     Which was the prior name of Malawi.   Malawi became

independent in 1964.



Mullan:    It was French?



Nighswander:     It was a foreign British colony, south of Tanzania,

nestled in between Mozambique and then Northern Rhodesia, now

Zambia.    But the toss of the pile went to Nyasaland in public
health.    This is 1964.    We got married on a Sunday, a week after

I graduated from college.     Ruthie had gotten out a semester

earlier and was teaching in Cleveland at the time, in fact, was
                                                                     4

teaching German.    We got married on a Sunday, and on Monday
morning we were off for Peace Corps training, the first six weeks
at Harvard, and the second six weeks at Chapel Hill, with a guy

by the name of Dr. John Castle.



Mullan:   This was at Harvard?



Nighswander:     Castle was chair of the Department of Epidemiology,

Chapel Hill.     His name soon will be familiar to you as you

connect with this.     I'll jump ahead in this story and say that

there were 40 of us on this project, tuberculosis/public health,

in Malawi.     Malawi becomes independent in October of 19--I'm

sorry, while we were in training.    While we were in training, we
started training in June, and actually, Malawi became independent

from Britain in that July, so July 6, 1964 is their Independence

Day in Malawi.     So henceforth will be known as Malawi.

     To jump ahead a little bit, but out of the forty of us on

that project, all of us were what we called at those times BA

generalists those years.



Mullan:   Did you actually call yourselves that?



Nighswander:     Well, that was the name that the Peace Corps had

given to us.     Today, out of the group, there's six physicians,

two dentists, a quarter of the group have master's in public

health. [Laughter] It was one of those life-defining events for

many of us.     In fact, we had a sense of it while we were there.
                                                                        5

      Well, Dr. John Castle and Dr. Cecil Sloan had very

interesting backgrounds.        They had worked in South Africa in a
small group who was led by Sidney Clark.        In fact, I don't know

if you know Clark's early story, but maybe you know him better
than I do.     Have you ever met him and talked to him?



Mullan:    Yes.    I mean, if it's relevant to the story.



Nighswander:      Yes.   Right.   It's relevant to the story.   The

issue was that they got assigned to work in South Africa, and one

of the issues was to get the kids immunized.       They had to get the
women together, and they started a nutrition group with the
women.    This was community development work around health.      The

bottom line is it became so successful, the kids started to live
and they all got kicked out of South Africa.       This group, Kark,

Castle and Sloan, and there were several others, were the

founding fathers of Community Oriented Primary Health Care.

Anyway, Castle and Sloan were the ones that really were the ones
behind this Peace Corps p r o j e c t .
      So our introduction to medicine, a field that I had never

considered--(I graduated from college with 15 hours of geology,

that was my entire science background)--resulted from a toss into

this pile that says "tuberculosis/public health."        It turns out

these folks really did the original thinking and writing about

community health and medicine, and it obviously had an influence

on all of us.      The project worked within the communities to help
                                                                      6

identify and treat tuberculosis in out-hospital settings in

Malawi.
     About two-thirds of the way through that experience in
Malawi, I started thinking about medicine as pretty interesting

stuff, what     we were doing was akin to some of the stuff in

sociology:    working with groups, trying to figure out what
motivates groups of people in communities and so forth.



Mullan:    Tuberculosis was the focus?



Nighswander:     Yes, TB was the focus, exactly right.   The

principle clearly was the same.



Mullan:    TB was endemic?



Nighswander:     It was widespread and, God, it's even gotten worse

recently.      We went   back to Malawi in '84. That's later in the

story, but, yes, it's awful, because of AIDS and its association
with TB.



Mullan:    Tell me, before we go ahead, let's go back for a moment.

Tell me a little more about your rearing in Kent.     You were born

in Kent?



Nighswander:     Yes--I, my dad, and grandfather were all born in

Akron, Ohio.    Kent is about 10 miles from Akron.   I was raised

with an older sister and younger brother, with a very modest
                                                                           7

income.     I guess maybe we were poor.    Maybe, I don't know.    I

didn't feel like it.     Well, Dad was a city employee, and Mom
worked various and sundry j o b s off and on.    Both Ruth and I were

blessed with very supportive, helpful families, and we had a
wonderful childhood, basically.



Mullan:    Any doctors in your youth at all?



Nighswander:    No.    None whatsoever.   There were not any really

role models.     I can't even remember the names of my early
physicians.     I remember all my schoolteachers, but I can't

remember the names of any physicians at all, not from that

period.    That's interesting.



Mullan:    How about religious background?



Nighswander:    Yes.   We were real involved.    I was a member of the

First Christian Church of Kent, considered the seminary, of
course.    The first time I heard of Africa, I think, was probably
at a church camp.      That's where that medical missionary was.       I

used to substitute preach in the summer when the minister was

gone.     I started that in high school.    I did it in college a few

times.



Mullan:    Did you consider the ministry?
                                                                       8

Nighswander:    Actually, during college, about my junior year or

so, I actually visited the seminary at Oberlin and considered it

briefly, not really seriously.     I, fortunately, woke up to my

senses.     [Laughter] But actually had considered it.    The church
was real important in my youth, and then continues to be off and

on.   Our spiritual journey led us to became Unitarian.    Right at

the moment because of their religious education program, we are

Episcopalians, but once you're a Unitarian, you can be anything.
You can kind of go with the flow, so it's a lot easier.
Likewise, Ruth's had a very similar experience, too, because she

was real involved with the church.     She was a camp counselor in

church, at her church camp, and obviously became very active with

Lutherans.     This is a big Lutheran country.   The Alaska Nation

Medical Center is a big Lutheran country, too.



Mullan:    Were religious values important to you?



Nighswander:    Yes.   Well, there are a couple of issues, I think,

concepts.    One is this idea of this world community, where you
have some responsibility for others beyond yourself.      I think
that was real important.     I think the "dignity of man'' kind of
issue, that was one that was really inculcated by my parents.        No

matter who you were or what kind of work you did, a human being

was a human being, and they deserved respect and value and

dignity.    I'm still real comfortable walking into a group of

beer-drinking, blue-collared workers.     That's real easy for me to

sit down and communicate with them.     I feel real comfortable in
                                                                        9

those kind of settings.     That's the way I was raised.    I worked
on a farm part of time growing up, a large farm, and then the
work with the city workers.     You get used to it.   Civil service

is in my genes, I guess, working for the government.       My Dad and

Grandfather worked for the City of Akron for a combined total of
60 years.




Mullan:     In the City of Akron of the United States.



Nighswander:    That's right.



Mullan:   All government.



Nighswander:    All government including the Peace Corps.     That's

all government, all the same.     That clearly has been real

influential, although in fairness, I think that a lot of us who
joined the Peace Corps in those years were responding to the call
from [John F.] Kennedy.     But there's some altruism there, and

there's some real practical things.     I mean, it sound like a

great way to go travel and see the world, and a real adventure,

and along the way, in a modest way, if you could help others,

that would be great, too.



Mullan:   What was the experience like?
                                                                     10

Nighswander:    The day-to-day experience was very positive for us.

Ruth and I were stationed in the north part of the country, Nkata

Bay, on Lake Malawi.     It's one of those great lakes that fill up

the rift valley of Africa (Lake Tanzania, Lake Victoria, and Lake

Malawi) which stretches for a few hundred miles.



Mullan:   Nkata is the same as the Nkata Freedom Party of South

Africa notoriety?



Nighswander:    Yes.   But this is among the Tonga Tribe, which is

kind of an outcast.    Not an outcast, it was a separate tribe

which was considered somewhat haughty and arrogant.



Mullan:   Within Malawi.



Nighswander:    Yes, within Malawi.   Beautiful setting.   We were

there right at the end of the colonial period.     Lived for a while

in the DC's house.


Mullan:   DC?



Nighswander:    District commissioner, and next to the OC (the

Officer in Charge of the police).     This is the old colonial days.

I had tea at four o'clock at the OC's house with his wife, which

was delivered by white-gloved houseboys and so on and so forth.

In my second coming, I want to come back as a British colonial.

I mean, they had a great life, in 1930 or so.    We arrived just as
                                                                    11

the British Civil Service was disappearing, being replaced by a
Malawian Civil Service.    For a long time at Nkata Bay after the
office in charge of the police, (the Webbs) left, Ruth and I were

basically the only folks (white Europeans)    the only Europeans
there.    All the rest were Malawians.
     There were two aspects of experience.    We really started our

marriage there.    It was a situation where we were both obviously

well known in Kent, had been reared there.    We were plucked out,
went to Africa where we had to establish our own identity.     We
were trained to do the equal work and giving the TB skin test,
basically, is what we did, taking X-rays, and actually reading X-

rays, then handing out INH by the bucketsful.    But we were

trained to do it, so we had to work out this relationship, how we
were going to work together.    Twenty-four hours a day, I mean,
that was it.



Mullan:    How was it?



Nighswander:    We went through some interesting times.   It wasn't

anything that was going to blow apart our marriage or anything

like that, but I think the strength of our marriage has been that
start.    Where you got away from friends and family, and you're on

your own, and you had to figure it out how you're going to do it.

Some couples didn't make it.    You would see it happen when

vacation time, holiday would come, they'd start taking separate

holidays.    The first tell tale sign.   [Laughter]
                                                                   12

     The idea, then and now with the Peace Corps (because we

obviously stayed in contact with the Peace Corps), was to train
host-country nationals.    It's the concept that's still used.    So

we had local folks we were working side by side with and passing

on the skills that we had, modest as they were.    We felt very

good about our experience, and many people in Malawi (the Peace
Corps in Malawi), I think, felt that our being so isolated, and
up where we were led to a pretty ideal experience.    We felt that

way about it.

     Many of the Malawians that we were in contact with in 1964,

we're still in contact with, and were able to reestablish our
contacts in 1984.   When we were back in D.C., in 1996,.we had the

Malawian Ambassador over for dinner.   We have a Malawian here in

Anchorage who housesat for us last month while we were gone.      So

we've stayed in real close contact with Malawi.     So I think that

not only our personal kind of experience and what it meant to us

at the time and in the future were significant.     The

contributions--what contributions we did make     were quite modest.



Mullan:    That is a question I wanted to ask, because it's so

often been said of the Peace Corps and other such experiences
that while they fly under the banner of transfer of technology,

or altruism, or white man's contribution, or whatever, in fact,

they do more for the participant than they do for the recipient

country.



Nighswander:    Clearly.
                                                                    13

Mullan:   Is it clear?    I've always felt a little ambivalent about

it.



Nighswander:    In our situation, I think that was clear.    It might

have been different in 1984 when we were back for the year, when
we were more highly skilled.    We'll get to that period.    I think

in '84, it turns out that Ruth probably made a more significant

contribution than I did.    I was on a World Bank Health Planning

Project and basically you don't do health planning in a
dictatorship.   But Ruth was teaching at the Community College of
Nursing, and I think that probably was important.



Mullan:   With the INH you dispensed, and with the--



Nighswander:    For individual, fair enough.   For the individual

patients that we took care of, you betcha.     I think on a one-to-
one and the number--and I don't remember what the number is now--

in terms of people that were diagnosed and treated in the

villages, yes, that worked.    The problem is that even that system
that we had, that we developed and experimented with, was too
expensive for a very poor country to maintain.    Even in 1984,

Malawi ran out of petrol three times, the police don't even have

gasoline to get around.    Just even getting drugs out to the local

communities--90 percent of that country is rural--is almost an

impossible feat.   Here we had two people dedicated just to one

disease traveling by motorcycle down village paths.    Not

sustainable in that kind of an environment because of the nature
                                                                       14

of the infrastructure.     What makes sense to us here, and I'm sure
I don't need to tell you this,      just doesn't work in a lot of
these developing countries.      It's apples and oranges.



Mullan:   Yes.    Yours was a medical care intervention in that

situation, where even public health was absolutely rudimentary.



Nighswander:     Absolutely.   Absolutely.     I'll give you the '84

story, talking about oral rehydration therapy.        There was a
conference that CDC [Centers for Disease Control] had in Malawi

in '84.   Some of the people attending it said, "Listen, why are
we hydrating?     We don't have water."      There was a drought in some

parts of Africa at that time.       Having water available or water

that was drinkable was just not possible, regardless of trying to

get the oral rehydration salts delivered, which is another issue.

But just the basic drinkable water was not available.



Mullan:   Salt and water.



Nighswander:     Yes.   That's exactly right.



Mullan:   It was a seminal experience for you, I would gather,

both in terms of your ongoing connection to Malawi and also in

terms of thinking about what you wanted to do with yourself when

you came back.     Tell me about that.
                                                                       15

Nighswander:    The decision came down to this.    I didn't know

anything about medicine whatsoever, except the exposure we'd had.
Dr. Bill Peck was the in-host country director of this project.

He was employed by the University of North Carolina.        I think he

was on the faculty of the University of North Carolina at the

time.   He's been an old TB guy from around the U.S.    ,   and Bill

was probably at the time in his mid- or late fifties, and
although John Castle and Cecil Sloan would come over from time to

time, Bill was the one that did that in-country medical support,

read a lot of our X-rays and whatnot, and told me one time after

we'd gone through an X-ray session, he said, "You know, Tom, I

bet you could become a physician."
     Well, I remember some sleepless nights.      That's because I

knew that I was a modest student.    I wasn't a stellar student at
Kent State in terms of grades.    If I were interested in medicine,

I'd have to go back to undergraduate school and do some pre-

medical sciences, number one, and I didn't know how I'd do with

that.   But it came down to if I didn't give it a try, in 15

years, on a bad day in another career, I'd really kick myself in
the pants and say, "Yes, why didn't you give it a try?"        The

worst-case scenario was I'd go back t undergraduate school, it
wouldn't work out, or I wasn't capable, and fifteen years later

I'd be able to say, "Well, at least I gave it a try."        I'm in
another career, having a bad day.    I would ask, "God, why didn't

I go into medicine?"    I'd say to myself, "Well, I tried that, it

didn't work."   Basically, that was how I made    basic decision.

If I didn't give it a try, I'd really kick myself in the future.
                                                                     16

Mullan:   What did you do?



Nighswander:    So what I did was, I came home.   I enrolled back in

Kent State University.    I was able to do that by mail.   I had

enough contacts there.    Two weeks after I got out back in the

country, I went to see a guy by the name of Dr. Jack Coy      at Case
Western Reserve University.    Jack was a legend in his own time.
He's still living at 96. Dr. Coy was the "admissions committee"

at Western Reserve and had been for many years.    This was in the

sixties, and I told Coy I wanted to go to medical school.     He

said, "Well, that's interesting.    Let's see how you do.''

[Laughter]
     In the meantime, I had written to some other schools at the
same time, including Chapel Hill.



Mullan:    You were taking all the sciences, blitzing them?



Nighswander:    Well, I hadn't started yet.   I was getting ready to

start.    W e got home in July of '66 now, and I saw Dr. Coy right

as soon as I got back.    I wrote to Chapel Hill, and I never even

got a letter back from them.    Western Reserve was obviously the

only school that was ever going to be interested.     I went back,

yes, and I took physics, chemistry, and biology.     In December--it

was a quarter system--I got a four-point.     I sent the grades up
to Dr. Coy, and Dr. Coy said, "You keep on like this, I'll

guarantee you admission. Maybe not this year, but I can in the

following year."    I had showed him how I could meet Western
                                                                         17

Reserve's minimal requirements in a year or summer.         Second

quarter I did well, and the beginning of the summer they had
someone drop out of the Fall class and I got in.          So I went a

year and a summer--



Mullan:    You took organic during the summer?



Nighswander:     I took organic during the second summer.      Within

the following year of leaving the Peace Corps, I was in first-

year medical school, Western Reserve because of Jack Coy,

clearly.



Mullan:    How did you feel about the sciences? How was that year?



Nighswander:    It was a rugged year.   God, it was tough.       I mean,

here's a sociology major with 15 hours of Geology, and I

struggled.     I struggled that first year in medical school.        I

remember that as a real heavy year.         I think I might have even
flunked the first exam.    I felt bad, and Coy was real

encouraging.    Basically, I had a very positive experience in

medical school.    Just had our twenty-fifth medical school reunion
about three weeks ago, saw a lot of old classmates.         But Western
Reserve was well known for "bent arrows,        .   Coy had an uncanny--

he really liked a lot of varieties in his classes, so he picked

these oddballs.    Jack Geiger [phonetic] graduated with me.

Geiger was another one of C o y ' s guys.    And Dave Sacher

[phonetic].    Dave was a year ahead of me, kind of interesting
                                                                        18

background.    We were called his bent arrows.   There were straight

arrows and bent arrows.     [Laughter] He was just interesting in
someone that was a great soccer player or was a great musician.

That was the Western Reserve tradition and, in fact, still is.

Except now they've got a big admissions committee, and just as an

aside, I'm on the admissions committee at the University of

Washington, and we spend more faculty time admitting students to

the University of Washington than we do teaching them.     I mean,

the admissions, I'm a drone interviewer.     The real power's in the

executive committee.    There's hours and hours of faculty time

that goes into admissions, and Jack Coy did it all and obviously

did very well with it.



Mullan:    How was the medical school experience?



Nighswander:    Medical school was a very positive experience.      I

realized, well, that's the late sixties, and Western Reserve was

kind of a little place, people were protesting the war and so on

and so forth.    But good friends.   It was an excellent faculty.
At Western Reserve, you don't enter medical school, you enter the

medical profession, and you're told that from day one when you
walk in.    "If you don't make it in four years, it's our fault.

It's the medical school's fault.     We admitted you, and damn it,

you are going to graduate."    So it wasn't any of this stuff--the

old days--where you count down four, and they'll be gone at the
end of the year.    Western Reserve was very good.   I always felt
very positive about that.
                                                                       19

Mullan:    It was a political time.   Were you involved in the

politics at all?


Nighswander:    Not really.   I had a lot of classmates who were.

There was a big black bag protest--Lilly.     We all turned in our

black bags because Lilly Drug Company was trying to buy us off

with black bags and stethoscopes.      So there was a big black bag

protest.    But more importantly, all the stuff was going on in
Vietnam at the time, and we were pretty much out of that, except

that the draft board was down my neck and paying real close

attention to what I was doing, where I was going.      But I wasn't

the activist.    It wasn't, and hasn't been, really my nature to be

the active protester, more behind the scenes.



Mullan:    How about the community medicine side of it?



Nighswander:    Yes, the community medicine stuff.    Again, Western

Reserve, by tradition, had been real involved with that.      We were

assigned, in day one basically, to an inner-city black family in
which the woman was pregnant, and you followed her pregnancy,
generally, the first year of the child's      life.   I got involved

with that family all four years.      Although in terms of the

community stuff, I really worked pretty hard in medical school

academically and didn't spend a lot of other time outside.



Mullan:    How did it square with your Third World experience?

Quite different?
                                                                       20

Nighswander:    Yes.   It was different.   Of course, this was all

new, and it was real hard, frankly, to fit it kind of altogether,

because of the amount of the resources that we were using in

Cleveland.     I become more and more aware of where the emphasis
should be later on when I was able to digest that whole

experience.    These were pretty monumental changes for me, in
retrospect, not having thought about medicine at all, and with no

really exposure whatsoever, and then coming in the door of

medicine through this community health perspective.


Western Reserve at the time, even though they had this community
piece, was really a hotbed of internal medicine and specialty

training.    I do remember looking around, and this did bother me,

and trying to see physicians on faculty that I thought had the

kind of lifestyle and doing the kinds of things that I was

interested in, and I didn't find them.       Most were pretty focused

on academic careers.     I remember distinctly a very popular

obstetrician/gynecologist faculty member, well known for his
research and patient care.    He committed suicide.     It turns out
his professional life was doing very well, loved by his faculty,
loved by his students and patients, and his personal life was in
shambles.    That's what did him in.   I remember that well.



Mullan:     In terms of identifying with--



Nighswander:    Yes.   You're trying to pick out models, and,

really, the guy that was the most exciting at the time was Dr.
                                                                     21

John Castle.   As a matter of fact, for the two medical school

summer projects, for the summers we had to do a project, kind of
a senior projects, I went back to Chapel Hill and Jim Castle

worked in Claxton, Georgia, with Dr. Curtis Haines.     I don't know

if you know Curtis Haines.    You know about him?   The reason he's
familiar is the American Academy of Family Practice now has this

award "Dr. Curtis Haines Award."    It turns out he's a generalist

physician in Claxton, Georgia, doing various community-based

research.   So Ruth and I were down with Curtis Haines between our

first and second summers in Claxton, George.     It's a project
sponsored in collaboration with the Department of Epidemiology at

Chapel Hill, the Claxton, Georgia, Heart Research Study.



Mullan:   You had a sense of not having role models on the

faculty, or having trouble finding them?



Nighswander:   Yes.



Mullan:   Did you have a developing sense, or any kind of sense of

what you wanted to do?



Nighswander:   Yes.   The orientation we had gotten at the Peace

Corps from Castle and Kark.   Basically, I knew what really made

sense to me was community ownership, when the community owns

their own health, then things can happen.     The question is what

kind of role does community ownership play.    Kark wrote an early
                                                                        22

book called The S o c i a l Practice of Medicine.   I've got it.   I

don't know if you've ever seen it or not.



Mullan:   I don't think so.



Nighswander:   It's a 1952 book.    I just looked for it downstairs.

I thought you'd be interested.     I think I've got it at the

office, as a matter of fact.     You didn't find that at Western

Reserve, and the closest person that I knew that could talk about

that, and had actually had experience with community medicine and
developed work around that was Castle.      Did you ever meet him at

all?



Mullan:   I never did.



Nighswander:   We had a Peace Corps reunion last summer.



Mullan:   He died several years ago.



Nighswander:   He died.   Yes, he had lymphoma, Hogkins.      He died

in the late seventies.    We met up again through the Clinical

Scholars Program in 1975.     He was on the board for that.

Actually, we stayed in contact.     But it was Castle.    At our Peace

Corps reunion, 25 of us were discussing John.        It was Castle who

was my model, everybody was inspired by him.



Mullan:   Twenty-five was--
                                                                        23

Nighswander:    Our Peace Corps volunteer group--that group from

Malawi IV.     It was clear that it was Castle who WAS an
inspiration,, and we all felt uniquely treated by him.        It turns

out we weren't unique.     He treated everyone that way.



Mullan:    How many of you were there?



Nighswander:    There were 40 of us in the project in '64, and

there were about 25 of us that got together.        That was a 30-year
reunion.    It was '94 was when we got together.



Mullan:    Again, the numbers of physicians?



Nighswander:    We had six physicians, one dentist, and a quarter

of the group have master's in public health.        Isn't that amazing?
When you think about it, there's something intuitive about it

when a community owns their own problems.        They can make things

happen.



Mullan:    As you went through medical school, was your family

supportive? What sort of attitude did they take?        This is quite
different than the Akron Water Works.



Nighswander:    Oh.   Oh, well, gosh.   Yes.    It turns out all of us

graduated from college, the three kids.        Sue, my older sister,

she went on to graduate school, and I went to medical school.          My

parents couldn't have been happier.      They were delighted.
                                                                    24

Mullan:   How about finances?



Nighswander:   We did it on our own.   We weren't supported by the

family at all.    Ruth was teaching at the time.   We took out some
loans, but she also went back and got a master's degree while I

was in medical school.    We don't remember how we did it, but we

didn't get any help from the family.    As soon as we left the

Peace Corps, we had some money in the bank.    We had two or three

thousand in the bank.



Mullan:   Scholarship?



Nighswander:     There was some scholarship money and there was some

no-interest loans, and that's how we did it.



Mullan:   You're reaching the end of school, and now it comes time

to translate going into action.



Nighswander:   Well, the problem is was I was coming up against

these people who were going into internships with second-night

call or better even every-night call so you don't lose half the
good cases and all that kind of stuff.     I didn't want that.   Then

there was this community medicine piece.     I looked around the

country and got real interested in Kaiser.    They were only in

California--very interesting program, trying to keep people

healthy, and out of the acute care system.    I started my
                                                                      25

internship with Kaiser on Gary Boulevard, one of the premier

prototype HMOs.


Mullan:   That's San Francisco.



Nighswander:   San Francisco.    And I had another enjoyable time.

All my medical training I enjoyed.     We were busy,   but we lived

in interesting places with interesting people, and Kaiser had a

lot of physicians on staff whom I could relate to.



Mullan:   Hold on a second.



Mullan:   This is Dr. Nighswander, tape one, side two, continued.



Nighswander:   Not only relate to medically, but they were

interested in lifestyle issues.     Not that they were doing the

kind of medicine I was interested in necessarily, but the family

was always important.   Ruth and I (by this time, we were married

seven years), we didn't have kids.     But spending time with her

and having a life of your own, I have outside interests, and so
did the Kaiser physicians.      They didn't have the community
medicine piece as such, but certainly lifestyle issues were

important to them.

     My big deal was the draft board.     The draft board is now

getting very interested in what I was doing.     This was 1971-72,

and they were very interested in what I'm going to do after my

first year of internship.     I was on the old rotating internship.
                                                                      26

I started looking around for alternatives, and one of the

alternatives was obviously the Public Health Service.     There was
this new program.    As soon as [Richard M.] Nixon had signed

authorization for the National Health Service Corps (I think it

was about December or January of ' 7 2 ) , I was on the horn, and
called.   I called Washington and applied, because it was either
Vietnam or the Public Health Service.     I had already taken an

induction physical to go to Vietnam.     I got this telegram from

David Kindig, and it was Arkansas and the NHSC.     Oh, God!     I

started making phone calls, and there was a potential NHSC
program in Alaska.    I called the regional health director, Dave
Johnson, as a matter of fact.



Mullan:   In Seattle?



Nighswander:   In Seattle.   And another guy who was the medical

director, a cardiologist named Willard Johnson.      I had also heard

from the Indian Health Service, and there was a \\good"place in
Harlem, Montana.     I remember I called up there and the current

physician said, "Ought to be a great clinical experience."
[Laughter] And I thought, "That sounds suspicious."       I asked him

more, and they were underfunded.     In fact, I called Willard

Johnson after that.     I remember this well.   Willard said, "Tom,

you don't want to go to Harlem.     It is underfunded, understaffed.

We've got something brewing up in Alaska you might be interested

in."   It was this Alaska Health Manpower Corporation.    He said,
                                                                      27

"We want to try start some mid-level practitioner programs in

Alaska. I'


Mullan:      This is Dave Johnson, the Regional Director?



Nighswander:      This was Willard Johnson.    Willard was a

cardiologist.     He was one of Dave's deputies.



Mullan:      This was Public Health Service?



Nighswander:      Public Health Service, absolutely, out of Seattle.

He s a i d , "You might want to make a few calls up there and see."
Boy, this was probably June now, because I'd had held off on the
National Service Corps' first offer.        They'd sent me another

option in Florida.      But once I heard about something in Alaska,

Alaska did sound really interesting.



Mullan:      Had you ever been to Alaska?



Nighswander:     No.   But, you know, it sounded like great country,

interesting, new frontier, last frontier, whatever it was.



Mullan:      Can I just before we pursue Alaska, a couple of things

on the internship.     Now the health maintenance organization and

graduate medical education are a big and controversial issue.

Kaiser of Northern California is a place that medical education

has gone on within an HMO for many years.        What in 1971 was one's
                                                                   28

perspective on an HMO or managed care, both in general and as an
intern?



Nighswander:    I think that Kaiser was clearly a successful

program.    It had gone through an early phase in California where

Kaiser physicians were not only renegades but obviously second-

class citizens and Communists.    What is this?   Hospital staff
being salaried physicians.    Even in the early seventies,

especially on the East Coast, I think a lot of my colleagues, and

even the faculty at Western Reserve thought that I had jumped

ship.     I mean, they really thought they made a mistake with this
one, my going out and do that.    Particularly, this idea of

capitation, physicians (this became controversial later on)
received    incentives to keep people healthy.    The Permanente

Medical Group, received capitate dollars to take care of

patients, and if they didn't use all those dollars, they got a

bonus at the end of the year.
The training program was excellent.    These were a group of

physicians who were pretty cost-conscious.    You made judicious
use of procedures and the laboratory.    Obviously, there was no

incentive for them to do big expensive cases.     Busy, lots of
patients, a lot of common stuff.    There was general surgery in
high volume, so you got to do lots of things.



Mullan:    Did you have a sense that you were seeing a vision of

the future, or you were seeing an interesting sideshow?
                                                                         29

Nighswander:    It was an interesting sideshow at the time.       I

mean, it was a way of practicing medicine, though, that made
sense to me.    I guess there were great features of it.       One was

the group practice.     I just couldn't envision myself being a solo

practitioner.    That was number one.    Number two, my family had

always been salaried.     I couldn't imagine, even then, of charging

anybody for what I did.     This like fee-for-service kind of
thing--



Mullan:   It was comfortable.



Nighswander:     It was comfortable.    Philosophically, I thought it

was the way to do it, and I thought that I saw really excellent

care at a real reasonable price, and enjoyed the physicians, the

way they talked about patients, the way they talk about medicine.
They obviously were not in it for the big bucks, although money

was really never an issue for us.       So it was a group of
physicians that I liked and had a lifestyle that I liked, too.

They clearly had a l i f e beyond medicine.



Mullan:   Did you at all consider, if it hadn't been for Vietnam,

would you have stayed on in that system?



Nighswander:    Yes.   Yes, I did.   In fact, it was unclear whether

NHSC in Alaska was going to come through now we're into June of

that year.     The work is over the first of July, and I applied for

a California license, in fact, had made arrangements.      They had
                                                                            30

said, "We'd be happy to have you stay on."       So that was a real
honest alternative and
option.



Mullan:      It turned out Alaska was looming.



Nighswander:     Yes, but Alaska was looming.    There was this new

organization up here called the Alaska Health Manpower
Corporation. Its purpose was to get together all the various and

sundry agencies in 1972 in Alaska who were involved with
education, health careers, and also do some experimental work in

developing mid-level practitioner clinics.       Mid-level

practitioners were, in 1972, physician assistants.         They were

brand new on the scene.     That first PA program was at Duke and

started in the early sixties.
     There was a new training program at the University of

Washington, run by a guy by the name of Dave Lawrence.            I don't
know if you know David or not.     Dave ran the Medex      program that

had just gotten started.      It had been started by Dick Smith,
who's out in Hawaii now.     When Dave had taken over for Dick, in
fact, they had seven students here in Alaska in 1972 who needed

to have some coordination work done.      Even    though    the

assignment for National Health Service Corps to the Alaska Health

Manpower Corporation was to develop three remote community mid-

level practitioner sites somewhere in the State, the Medex

program from the University of Washington was other duties as

assigned .
                                                                     31

Mullan:   This was a National Health Service Corps position?



Nighswander:   This was a National Health Service Corps position.

Early days, lots of flexibility.     It's one thing I've learned
about new programs.   If you get in early, you've got a lot more

flexibility than later on.

     Gosh, to get the position, I talked to the Public Health

Director of Alaska at the time, who's long ago retired, the new

director of the Alaska Health Manpower Corporation, a guy by the
name of Bill Deak, a genius and controversial.     In July 1972 he
was in California at the time, and actually on his way to Alaska,

stopped in San Francisco to interview me.     Time was marching.     I

was done with my internship.     I still didn't know what I was

going to do, but it took with Bill, and up we came.



Mullan:   He was in the Public Health Service, too?



Nighswander:   He was not.   The Alaska Health Manpower Corporation

was a consortium.   Money came from the Regional Medical Program's
Bill was hired by--this RMP project.     So up we come with this

background and I started going out and visiting communities and

these little community boards.



Mullan:   You moved to Anchorage?



Nighswander:   Yes, we came to Anchorage.    We came up to Anchorage

that August 1972, site unseen.      I was assigned to an old
                                                                     32

apartment building on Eighth Avenue with this Alaska Health

Manpower Corporation.    The board included the Hospital
Association and the Mental Health Association, the State Medical

Society.    This was a town with 70,000, that's what Anchorage was

in 1972.    Within a month, after an internship, I was down talking

to the little health board in Craig, Alaska, across from

Ketchikan, on Prince William Islands.    Then I went to Yakutat,

which you flew over on the way up there.    Eventually I went to

Galena, which is up on the Yukon River, and talked to--well, I

was going to talk to the mayor, but the day I got there, when I

was coming in town, this was in December, the mayor had just

mushed out of town for his trap line.    Roger Huntington was the

mayor at the time.
     So I'm going around and talking to these community-based

health boards.    Well, they weren't called health boards.   There

were two or three people in these communities who were interested

in improving the health of the community with some kind of a

practitioner.    You had to   explain what a PA was at the time, and

most of them had community health aides.    I went out the Aleutian
chain to Unalaska, which is 800 miles out on the chain.      They

were interested.     I had the time to go back again and again.     By

this time, in Alaska, these villages had been used to consultants
flying in and flying out, and never be heard from again.     But I

actually did go back.    I had the wherewithal to go back again.



Mullan:    Where were you going to get mid-level practitioners

from?
                                                                      33

Nighswander:    That I didn't know.    I just knew there was a few

programs around.



Mullan:    You were trafficking the idea.



Nighswander:    Yes, I was marketing the idea.    We didn't have an

idea, but somehow we could put it together.      But in the meantime,

I was also helping arrange for and monitor the preceptorship of

the seven PAS who were up here in 1972.      One you're going to see
is John.    I remember distinctly the first bite we got from a
community.     I was really discouraged.    I had been up here six
months and nothing was happening.      I said, "Well, honey, we'll
see.    We'll stay here for two years, and I gave it the best shot.

Enough of that."    Because I was expecting people just to hop
right on the bandwagon, and go ahead and buy it by hook, line,

and sinker.     It turns out working with communities doesn't work

that way.

       Anyway, gee, in January that year, Yakutat called me back,

"We are interested.     In fact, we've talked to the legislature,
and we think we can get a new health facility down here."      The
first bite was Yakutat, and the first program that got going.
       I'll jump ahead of the story.   Three mid-level practitioner

programs got developed by community boards       in Yakutat, Galena

and Unalaska.    They're still in existence today.    And they are

owned by and run by the community.     Remember Roger Huntington,

who leaves Galena on the dog team to go out mushing the first

time I arrived, I was best man at his wedding in 1979.      Larry and
                                                                   34

Carolyn Powell, the mayor at Yakutat at the time, eventually
became close personal friends.
     The work was what you and I believe in.    There were three or

four people in these communities who were interested in health

issues, about the health of their community, and were willing to

take it on.    What it reinforced was this idea of "We've looked at

the enemy, it's us, and what are we going to do about it?"     I
mean, that's an epiphany in a community when that happens.     To a

greater and lesser extent, it happened in all three communities,
and many, many more communities in different circumstances.
     With the National Service Corps, we had some resources to

provide, but what I've learned over time, what's made those

programs successful, is the community ownership piece.     You must

give the program away.    It's not your program.   The National
Service Corps resources help jump start it, but now their
programs are independently funded.



Mullan:   So that was '72, '73.



Nighswander:    That was '72, '73, '74.   Three years.   I'd say the

third year things really got rolling.     I stayed a third year.



Mullan:   Besides getting those programs started you were you

doing other things?



Nighswander:    Yes.
                                                                    35

Mullan:   You were the class coordinator f o r the Medex Program?



Nighswander:   Yes, the Medex Program.   That's how I got tied in

with Dave Lawrence.



Mullan:   They were rotating students up from Seattle.



Nighswander:   They were rotating students up.   I was doing the

coordination and got involved with a lot of health things.     It

was a small state at the time, well, still is.    I was involved

with the State Medical Society.   Rod Wilson, who you're going to

meet tomorrow, Rod was president of the State Medical Society at
the time.   So I first met Rod and did some stuff with them.   He

was a young Turk.     But it's just amazing that the group of us

are all still involved in it.
     Then I was on the auxiliary faculty at the Alaska Native

Medical Center helping with the community health, teaching the

community health aid program.



Mullan:   Were you practicing at all?



Nighswander:   No, I was really weak clinically, even though I was

a supervisor for these mid-level practitioners.    I did see
patients over at the Alaska Native Medical Center on a part-time

basis.    Then after I went out and helped established these three

community-based programs, I was the supervising physician for the

physician assistants who were out there.
                                                                           36

Mullan:     So you were doing more teaching and community organizing

than practicing.



Nighswander:    Yes.    Really.   Yes.



Mullan:    You had some instinct that you needed to go in public

medicine?



Nighswander:    Yes.    There was no question about that.     Well, I

wanted two things.      I wanted clinical medicine and I really

wanted a master's in public health.       I wanted some more
background in epidemiology.       Dr. Ted Phillips came up.    Actually,

Ted was on the advisory committee of the Clinical Scholars

Program.    Well, I didn't know at the time.    He came up and he

wanted to meet me.     By this time the Regional Medical Program was
based in Seattle.      People had heard about these three community
programs, and I was able to get them started, and they were

ongoing and functioning.     So I was getting decent press.      Ted

came up and had lunch, and talked about a fellowship program that

they were starting at the University of Washington.      Again, it
was going to be the first year of a new program.      They were
looking for interesting people and although I didn't quite fit

because they were really interested in people who had a residency

training, Ted thought I might be able to work something out.           I

said, "Gee, I'd be interested.''
                                                                     37

Mullan:    Say more, just for the record, about the Clinical

Scholars Program.



Nighswander:    It is a program sponsored by Robert Johnson

Foundation in which, as it has evolved, clinicians who have been

interested in issues beyond clinical medicine--beyond pure one-

to-one patient encounters--interested in issues related to health

policy, medical education, or community health or university-

based research, are given an opportunity for a two-year
fellowship program to explore some of those issues with

discipline.    The early clinical scholars have pursued careers in

these areas very successfully.



Mullan:    But you went into it for two years.    You went back to

Seattle?



Nighswander:   Went back to Seattle for two years.    A real busy

two years, because I worked on a MPH and worked in a residency

program.    They gave me some clinical credit for being up here,
and in the clinical scholarship program.    So we stayed down for

two years and did it all.



Mullan:    You both did clinical training and an MPH?



Nighswander:    In the School of Public Health.



Mullan:    How was it?
                                                                     38

Nighswander:    We had a delightful time.   I've been blessed.

Wonderful people.


Mullan:   The clinical time was in family medicine?



Nighswander:    The clinical time was in family medicine.



Mullan:   By that time you had come to identify yourself as a

Family Practitioner?



Nighswander:    Yes.   It was clear from the work that I had done up

here, and if I were interested in coming back.    My inclination

and interest was in being a generalist physician.     Family

practice was the most appropriate specialty for me, even though I

hadn't really identified what I was going to do afterwards.
That's where my clinical interests were.     It fit well.

     The other piece of it was this policy stuff and how that

might fit.     The two people who were real heavily involved with me
at the time was Gil Oman.     I don't know if you know Gil at all.

Then Dave Rogers, the Foundation President.     The Foundation,

incidentally, was relatively new at the time.     Robert Johnson
Foundation was relatively new.



Mullan:   Was that the first class of clinical scholars?



Nighswander:    Yes.   That was the first class of clinical

scholars.    Although Dave Rogers told me that he was interested in
                                                                     39

clinical scholars going into a clinical academic career path, he

would not at all be disappointed if a few of us migrated and did

other kinds of things.



Mullan:    The real world.



Nighswander:    Yes.   There were a few dineros [phonetic] around, I

guess.    I never thought of it--the dinero routine.   Gills real

intense.


Mullan:    What was he doing then?



Nighswander:    At the time, Gil was the director of the Clinical

Scholars Program for the University of Washington and on the

genetics faculty.      He went back and served in the [Jimmy] Carter

White House.    For two years he was there, he was on Carter's

science staff.    I think Gil wanted me to stay, as we approached
the end of the two years,      in some kind of academic family
practice.    Although, others like Dave Rogers thought it was

clearly appropriate if I wanted to come back to Alaska and do

something up here.      The possibility that was open up in Alaska

was the development of a family practice setting at the Alaska

native Medical Center, which was a new idea.



Mullan:     Family practice setting as in training?



Nighswander:    No.
                                                                     40

Mullan:   Practicing?



Nighswander:   Practicing.



Mullan:   Organizing appropriate services around a family practice

model.



Nighswander:   Yes, a family practice model.    The Alaska Native

Medical Center had a typical out-patient department that also was

responsible for the emergency room, and for health aides phone

consultation in about forty-some villages around south central

Alaska, south of the Alaska Range, out the Aleutian Chain, down
Kodiak Island, up in Mat Valley.



Mullan:   Health aides are Native people, trained?



Nighswander:   Usually women, 16 weeks of training, traditionally

over about a three-year period of time, in every Native community

in the state that's over 100 people.    They are the primary care

providers, start IVs if necessary, do suturing.    They really are
the primary care provider in these communities.    We have them, as

I said, throughout the state.     It's a well-established program.

There are four different training centers.     If the health aid is

overwhelmed with a medical issue, the patient will be transferred

by air to their local hospital.    For example, the hospital in

Nome Kotzebue, or Bethel.    If the patient needs additional care,
                                                                       41

they'll fly into Anchorage, which is really a tertiary care
center.



Mullan:    "We" being the Alaska--



Nighswander:    The Alaskan Native Medical Center.    So even

yesterday,     I was on the phone to Nenilchick, which is actually

on the Kenai Peninsula, with a patient.      When you work in the

emergency room, which we do, we supervise, provide medical backup

support all the way out the Aleutian chain to Atka, which is

1,200 miles out, with a village of 180 people out there.        So that

was the program, when I returned in '77--



Mullan:    What year--



Nighswander:     '75 to '77 down in Seattle in the Clinical Scholars

Program.



Mullan:    In '77 you re-entered the Public Health Service?



Nighswander:    Correct.   Exactly.    I wasn't sponsored by PHS in

the Clinical Scholars Program.       Who did I talk do?   I probably

talked to Ed Martin by that time.       I talked to him about getting
some sponsorship and staying in the Public Health Service, and

doing a clinical scholar, but it was cumbersome.      So I
deactivated my commission in 1975.
                                                                    42

Mullan:    When you come back in '77, you were in the Indian Health

Service?



Nighswander:   Yes.   So back in '77, I come back in '77 in the

Indian Health Service.    The hospital, the Alaska Native Medical
Center, was willing to put more resources into the out-patient

department, to develop a kind of family practice clinic.     It was
unclear what they wanted to do unless they had   more resources.

So I brought four people with me, brand-new physicians, and we

had a core group with that.



Mullan:    Family practitioners?



Nighswander:   Well, they were all family practice oriented.   At

the time we didn't have that many family practitioners around.
One was family practice; one had generalist with pediatric

training, who had been at the CDC, wanted to get back in clinical

training; two other guys who were general practice folks who had
some work experience.    I think that was the original group that

we had.
     We had a core group to do something with this unmanageable

out-patient department, which also ran the emergency room, and

serviced these forty-some villages, with not only with phone

calls, but village visits.

     It's at about the same time that the WAMI program was

starting-- Washington, Alaska, Montana, Idaho--where they wanted

to do community-based training, outside of the University of
                                                                       43

Washington for medical students.        We were in very early
discussions in '77 or '78 with that group, even some discussions
about actually developing a family practice residency in the

state of Alaska, which in 1997 is going to happen.         Our first

residents get admitted next July.

     Anyway, over the time period that I was as chief of family

practice here, we put all those pieces together, did a training

program, organized a Family Practice Department.        In addition to

the classic out-patient department, we tried to change walk-in

patients to appointment patients using a family practice model.
This WAS to be done within a hospital that had developed along

university lines, with subspecialty medicine, a pediatric

department, OB/GYN, etc.

     We were blessed here, and always have been, with a very
senior staff   ,   very stable staff.   As opposed to a lot of the
Indian Health Service settings, we had people who were here for

the long term, and worked together, so that has always worked out

very well.

     We started the WAMI training program here.       We started
Introduction to Family Practice as a catalog course at the

medical school.      It's one of the required rotations.    There were

two family practice curriculums in the state, one here and the
other one in Ketchikan.     Did very well for that program.     That

program grew, and, of course, the number of patients grew, and so

forth.    I stayed in that position until 1984.



Mullan:   This was Chief of Family Practice?
                                                                      44

Nighswander:     Chief of Family Practice.



Mullan:    This was a kind of developmental mission.



Nighswander:     Developmental mission with pretty close university

ties to the University of Washington.      I stayed involved with
medical politics in the State, on various and sundry committees

with the State Medical Society.

      Then I got a call from Management Science for Health out of

Boston, to whom I had sent      a CV some years before.   There was a
World Bank Health Project in Malawi, and they needed someone to
go to Africa, ' 8 4 .   So they called, and I was thinking of other

names of people I knew who might be interested.      They said, "NO,

we're interested in you."

      I said, "Well, there's no way."    Ruth was a community health
nurse at the time.      She was a community health rehab nurse at the
time, and the kids were in school.



Mullan:    Had Ruth gone back to nursing school?



Nighswander:    Oh, yes.    Because of Malawi, she ended up becoming

a nurse.



Mullan:    When was that?



Nighswander:    When she got up here in '72.   She went back to AMU,

Alaska Methodist University.     Ruthie had taught   back in
                                                                      45

Cleveland and in Kent when I was in medical school.     She got a
master's degree in education, before coming up here in '72. When
we arrived here, she thought she might be interested in nursing
but didn't want to spend that much time in school.      So she goes

over to Alaska Methodist University and said, "Gee, how about the

two-year program?"

     They said, "You have enough credits.      I bet you in two years

you could get a four-year degree."     So that's what she did, she

ended up getting a four-year degree.

     In the meantime, personally, we got into kids after ten
years of marriage.     For some reason couldn't have any genetic

kids, so we got into adoption.     So our daughter's Alaska Native.

You probably don't even know that.



Mullan:   No.



Nighswander:    Well, half Native and half English lawyer.      She was

just on the phone.     She's down at Pacific Lutheran   University
right now.      She's 21.   We adopted her before the Indian Child

Welfare Act.



Mullan:   Which proscribes?     Prohibits?



Nighswander:    Yes, basically.    It corrects what many felt were

inappropriate adoptions, especially in the Lower 48.      It gives

the tribe the first choice to place the child.     We adopted

Heather in 1974 when she was two months old.     Heather was with us
                                                                           46

in Seattle.    She was born late November of ' 7 4 ,   and we got her in

February of ' 7 5 .



Mullan:     How many children have you got?



Nighswander:     We've got two, Heather and Sam.       Sammy's also

adopted .
       The phone call came from Management Science for Health in
'84, and they wanted us to consider going to Malawi.         Ruth and I

went out backpacking that next weekend and started talking about

it.    The more we talked about it, we said, "We probably could do

it."    Interesting opportunity, and we had stayed in contact with
Malawi.
       I called back.    It was early in '84.   Actually, they had

filled the position when I called back the following Monday.           So

it was out of the question, except the person for the position

didn't work out, and about two months later they called again and

said, "Would you consider going?      The project was helping develop
a ten-year national health plan for Malawi.        It was being
required by the World Bank for them to get additional funding.

They need a deputy chief of party."
       I said, "Sure."    So I inactivated my commission again.       At

the time Everett Rhodes was Director of IHS and Everett called

and said, "Gee, don't inactivate your commission.          We'll figure

out some way to do this, putting people on loan."
                                                                      47

     Remember that era.      I don't know who all abused it, but it

was enough people so that they were putting restrictions on
loaning people.    [Laughter] They had to squelch it, and there

was just no way to do it quickly.      So I inactivated.

     We went to Malawi for that year with a group led by a Brit,

a British guy.    Very good.    It was a terribly frustrating few

months, because we were all fired real soon after we got there.
The bottom line, the short story is, you just don't do health

planning in a dictatorship.      I mean, you sit down with the
principals, the principal secretary for the Ministry of Health,

and all the deputies, and you think you get a decision, and

nothing happens.
     The project blew up in November 19985, and I was taking a

year off, and I didn't want to come home.       So Ruth started

working in Kamazu Community College of Nursing, on the faculty.

I rejoined the Peace Corps, actually, in country working for the

Peace Corps Director.     This is a side story.    Scott Faulkner, who

was a political appointee, was the Peace Corps Director in

Malawi.   He had worked in the [Ronald] Reagan transition team.
Professional Republican, right?      We get a franked envelope from

him last December, and he's back.      "Hear you might come back to
D.C., Tom.   Look me up.''     "1 work for Newt Gingrich. I'

[Laughter]



Mullan:   I'm confused.
                                                                     48

Nighswander:    Scott Faulkner was Peace Corps Director in Malawi

in 1984, and I worked for him.    He's a very conservative

Republican.



Mullan:     He now works for Newt Gingrich?



Nighswander:    And now works for Newt Gingrich.    He's the Chief

Administrative Officer for the House.     So on the House side of

Congress, he runs everything from flowers, to all the

concessions, to the members-only dining room, all the furniture,

and a $40 million budget.

     The reason I wore my tux back in D.C., in the last six

months, was Scott Faulkner, some of the stuff that Scott got us

into, it was just one of the things.



Mullan:     What did you do in '84?



Nighswander: Initially I did some Peace Corps clinical, medical

work for the few months that I worked for him full time, and then

some planning activities to develop health programs for Peace
Corps volunteers.



     The last three months I was there, I worked as a

pediatrician in the government hospital.      That's real Third world

medicine.     Sixty beds, 180 kids, and I think we had about 40 kids

die in the few months I was there.     We were right in the middle

of meningitis season.    Every child   prophylactically gets
                                                                       49

phenobarbital to prevent seizures.       They have meningitis, but the
whole country ran out of phenobarbital.        There wasn't any.    It's
one of these impossible situations that it would be useful for

everyone to do.      Really, it's incredible.



Mullan:    Pause on that for a minute.    Your reflections on your

second time in Malawi.      Had things prospered, and did you make

any different kind of difference?



Nighswander:   No.     It was interesting.   We went back to some of

the same villages we worked in 20 years prior to that, 1964, as a

matter of fact.      Went back to Nkata Bay.    We were remembered, and

met some of or old clinical officers.        That country is run by

clinical    officers who are not physicians.      They have four years
of training after secondary school, and they run the hospital
system.    They're called clinical officers, not medical officers.

They do C-sections.      They've done special training for some

opthamology skills, so they do eye surgery,        I mean they do
marvelous work.      Some of those senior clinical officers, we made

contact with them again.
     But going back to the villages, in many ways the villages

were worse off.      The British Civil Service had been replaced now

fully by Malawian Civil Service who were really disenchanted with

working in a dictatorship.      The Life President of the country, a

banned physician in the colonial days, who led them to

independence in 1964, was still in power.        He became more and

more paranoid the older he got.      Two of the ministers who had
                                                                      50

been in his cabinet the Spring of 1984 had a disagreement with

him and died "in an auto accident."       They were murdered by the
Special Police.      There's been a trial ongoing because of that.


Mullan:    Hold on a sec.



Nighswander:      The total contribution that we made in 1984-85, I

think, in retrospect, was what Ruth did in teaching at the Kamuzu

College of Nursing where she had nursing students on the hospital
wards.    Although, again for us, personally it was a wonderful

experience.      Heather was in standard six.    She went to Bishop
MacKenzie Boarding School as a day student and Sammy was too
young to remember.      He was a couple of years old.

     But wonderful friends.      We re-established contacts with

Malawiars from 20 years prior from former Peace Corps days.

Malawi is called the warm heart of Africa.        That's on their

travel brochures.       They are wonderful people, and the country is

beautiful--called the Switzerland of Africa--high plateaus,
lakes.    It's a great place.    You ought to go visit.



Mullan:   Yes.    So the year was up, and you had to figure out

whether you're going to come back to Public Health Service or

something else.



Nighswander:     Yes.    I was a free agent.   We left.   I had been in

the Public Health Service 13      years, and Ward Huolburt, Indian

Health Service Medical Director,      called.    I don't know if you've
                                                                    51

ever met Ward when he was chief medical officer.    He wanted me to

go to our perennial difficult-to-fill spot in Aberdeen.



Mullan:    Aberdeen, South Dakota?



Nighswander:    Yes, the Dakotas, the plains.   I had promised Ruth

and Heather, in particular, both of them, that we'd come back

here.    Actually, we had a house in Anchorage, and it was leased

for the year.    Although I inactivated my commission, we wanted to

come back to Alaska to do something.    There was a position soon

to be vacated called Director of Community Health Services for
the Alaska Native Medical Center.    I came back and went into that

position shortly after I returned.

        I was in charge of all the activities that occur beyond the

walls of the medical center.    It was at a time when Alaska
Natives were in the process of developing contracts and compacts

to manage their own health care.     I was interested in this early

on in my career, starting in the Peace Corps in Malawi in 1964.
There had been enabling legislation passed in '77, ' 7 9 , the first
638 legislation, to give tribes more and more power, to manage

their own health care.    I've said many times, when you own your
own health care system, you own your own health care.     The issue

of "looking at the enemy, it's us, and what are we going to do

about it?"

     This movement was really getting going at this time, with

some high energy and enthusiasm and it has continued.    To give

you the bottom line:     the Indian Health Service does not exist
                                                                          52

in Alaska anymore.    The only program the federal government runs
is the Alaska Native Medical Center.     The Alaska area offices
downsized to less than half of what it was, and it's continuing

to shrink.     The hospital is going to be managed by a consortium

of Native corporations, probably within the next two to three
years.    They'll work it out politically.       Originally the
government ran seven programs including seven hospitals.          All are

now being managed by local tribally run boards, who are part of

regional non-profit Native corporations      .

Mullan:   Successfully so?



Nighswander:    Very successfully so.   Absolutely.     They sometimes

have shaky starts.    Brystal Bay is the best example.      They took
over in the mid-seventies and they fired all the physicians but
one.   You know, "Dr. X treated my aunt, made her wait, and didn't

give her the right medicine," dah-dah, dah-dah, dah-dah.          A lot
of the tribal boards have gone through that kind of thing, and
then the boards have matured.    They have been able to generate

more resources, and frankly have had more flexibility, captured
third-party reimbursements.     They are nonprofit organized in the

state of Alaska.    Not only have they been able to do it

successfully, but the clinical system has stayed intact.          Our

ANMC physicians travel to the field, to these regional-based

hospitals doing clinics.     The health system has been able to

remain intact
                                                                     53

       I think that was a big worry we all had.   As hospitals were

separated out, people feared there would be this great loss of
the system that we've had.    Frankly, it's the best I've seen

anyplace in the world--starting with the village community health

aide, to the regional hospital, to our tertiary center, and if we

needed heart valve surgery, Dr. Shumway did it for us down in
Stanford.   We bought it.


       So it has been a regional health care system.    In fact, it's

an HMO.   There a defined community-based population.      In many
places it's the whole community.    This lends itself to the kind

of concept that Sidney Kark was talking about in 1952, it turns

out.


Mullan:   You have a defined population and deal with

epidemiology.



Nighswander:    Absolutely.   The community is really deciding its

own priorities.    Physicians are part of the team.    The only piece

that didn't work was Kark's original idea as the physician as the
leader of the team.    If you're really talking about community
ownership, I think that the physician may or may not be the

leader of that team.    The physician and clinical people are a

part of that team.    As we have progressed in our thinking about

team approaches up here with the medical center, we've gotten

very involved with Dr. Don Burwick.    I don't know if you know the
                                                                             54

Institute of Health Care Improvement (IHI). Do you know Don at
all?



Mullan:     Yes.



Nighswander:       He's up here.   In fact, Don's will spend a year up

here.     I don't know how many people know that.    He and his wife

are going to start a sabbatical year this summer.       We were

involved.     IHI has tried some of these concepts in total quality

management for community-based work.       We've been one of the

developmental sites.       Two in Canada, and eight in the United
States, and we're one.       I've been the team leader for the one up

here called Nutaqsivik to try to change the infant mortality

rate.     But clearly the lesson is community ownership.        Yes,

physicians or clinicians are part of those teams.       And when

communities get organized around health issues, things change,

just like we thought it would.

        I'll tell you a true story.    Actually, this is on video--
Eleanor McMullan, of the village of P o r t Graham, across from

Homer.     In 1974, she returns.    This is an Eyak community.         She

returns after a number of years back to her home.        I'll
paraphrase this a little bit.       The community ceased to exist as

an organized, social society. At any time of day or night, you

could walk through this community and hear people getting beat

up--men, women and children.       She took her kids out to do a beach

walk, and there's something stuck in the tidal flats in the

distance.     It's an elder woman who has been beaten up by her son,
                                                                        55

the night before, broken arm, and she is out there trying to get
food, but is stuck in the mud.      Elders are the most revered
people in Native society up here.       The respect for the elders is

deeply ingrained.       Eleanor is aghast.   She gets together a group

of women.



Mullan:     Eleanor is an Eyak herself?



Nighswander:     Yes.    She's Eyak herself.   You betcha.   In the

meantime, there have been some health care workers who come into
the community from their Regional Native Corporation at the time

called North Pacific Rim.      A social worker and mental health

worker go into this community, meet with the village council, and

hold up the mirror.       "This is what we see in your community."

They   are promptly kicked out of the community and told never to

return. The village council is part of the problem.          The village
council is full of people who are alcoholics and abusers.

       So Eleanor got together a group of women, and they met in

private.     They said, "We looked at the enemy.     It's us.   We've

got to do something about this."       They didn't say it quite that
strongly at this time.       So they invite outside helpers.    We go
in, the Alaska Medical Center, the Indian Health Service.         We

took our resources and s did the North Pacific Rim, the Division

of Family Youth Services, Parents United.        Everyone took their

programs to this community of 300 people.        Eleanor said, "And two

years, later nothing had changed."        In fact, she told me the

other day, she said, "You know, Tom, it's worse."        That's when
                                                                       56

the epiphany occurs.    "We looked at the enemy, it's us, and what

are we going to do about it?       It's got to be ourselves."


Mullan:    When you say "ourselves"--



Nighswander:    The community.     "If we're going to make changes in

our community, we've brought in the outside folks and it did not
work.



Mullan:    This is Eleanor saying this?



Nighswander:    This is Eleanor saying this.     She does say this,

actually, on the tape.    5 idebar.   We're trying to develop this
idea (community ownership)t, and we've had some people in from

the villages--kind of a focus group from various communities--to

talk about these issues.    Eleanor said, "You know, I can't come,

Tom.     Can I send this video?"   And here is this videotape taken

from her kitchen table, you know, shaky camera, and she tells
this incredible story.     It is really powerful.

        When these women actually do meet in private and say, "We've

got to do it ourselves," they proceed to do a whole series of
things.     I mean, they developed an abused women's shelter in this

community.     They owned the abuse issue personally.    When there

was an abuse case they would go to whoever did it and confront

them in the streets.     They had their lives threatened.       It's this

tight community.
                                                                     57

     The bottom line is, in 1996, Eleanor is tribal chief.        They

have a fisheries program.     Alcohol has disappeared in that
community.     If we have a smoke-free Native community, that's
going to be the first one.     It's just an incredible story.     It's

another Alkali Lake story.     I don't know if you're familiar with

Alkali Lake.     It's a British Columbia group of Indians who
basically have the same issues and do the same thing.     They took

on the issues themselves.     There are four or five models around
like that in our state where this has happened.

     Part and parcel of Native health care being taken over by

the corporations, the people are finally saying, "We can't depend
on the federal government.     It's us.   And what are we going to do
about it?"
     In my own personal career, I've been part of that process, a
player in that process--I've certainly been a promoter of it, but

it's been Alaskan Natives themselves doing it.



Mullan:   Since '84 or '85, your position has been--



Nighswander:     Yes.   Community health services.



Mullan:   As such you've been a promoter, a facilitator of these

processes?



Nighswander:     Yes.   Absolutely, and real involved as recently as

recently as Friday in the transition to Native ownership of the

hospital.
                                                                      58

        Just to give you another couple of other little stories in

the big pieces of work in which I have been involved that have
been real interesting, I do want to mention the Exxon Valdez oil

spill.     Once that happened, I didn't think I'd really be involved

at all.     It turns out the one of the many Native issues was oil

spill and subsistence foods for the villages.     That was   in our

bailiwick.     During the oil spill years, I spent 20 or 30 percent
of my time on oil spill-related activities, as chairman of the
Oil Spill Health Task Force.    There's a manuscript we're working

on now.     Through the many resources that Exxon had to provide, we

developed this great database of over 1,000 samples from various

beaches of various subspecies of fish and shellfish.      They were

potentially contaminated with hydrocarbons.      I knew nothing about

this.     Had to learn to tell fingerprints of oils and about
aromatic hydrocarbons     Fascinating stuff.   I led this group was

made up of an Exxon toxicologist, two Native groups, Department
of Fish and Game Subsistence Division, State of Alaska Department

of Health, and Division of Environmental Conservation, and NOAA.
Unlikely partners.     The FDA was involved in it.   But fascinating
stuff.    The bottom line is, I can't imagine having a greater

career.



Mullan:    The stories you tell me are fascinating in that the web

of experience they weave I think is coming through, but let me
try to tease it out a little more.    As I understand it, since
'85, your focus has been a variety of community health projects

emanating from, but not based at, the Alaska Native Medical
                                                                      59

Center, or related to, not based at.     But you've been a promoter,

you've been a facilitator, you've been a catalyst.



Nighswander:     Sure.   I think part of it is holding up the mirror,

provide community-based data, trying to fairly divvy up and talk

about resources, and how we're going to deploy resources.      In the

bigger picture, I've had specific projects related to community

health development, and the most recent one has been the

Nutaqsivik, which, translated, is "the place of renewal."      It's a
post-neonatal mortality reduction project we're working on with

IHI, Institute of Health Improvement.
     But in terms of working with the Native community, in the

community groups, it has been as a facilitator, provider of data,
individual meetings in communities with local health boards.        At
the same time I maintained an active clinical practice.      I've

been clinically involved by half of my time, including doing

Emergency Room rotations, I took ER boards two years ago, because

I was working in the ER.     So I kept active clinically until these

last six months when I was back in D.C.


Mullan:     I want to understand, because you've the only person

I'll probably be talking to from the Indian Health Service.         I'd

like to understand a bit more the perspective of the IHS

position.    But let's back into it by talking about your

relationship to, and your feeling about, the IHS as a career-long

employee.    For the sake of the record, the Indian Health Service

is part of the Public Health Service. Most of its physicians are
                                                                    60

commissioned officers, but it's a kind of subset of the larger
entity and has a bit of an identity of its own.



Nighswander:    It's real interesting.   I think in all honesty,

Fitz, the reason I joined the Public Health Service as a

Commissioned Officer in 1972 was to avoid going to Vietnam.

Coming to Alaska sounded like an interesting opportunity, and

this was a conduit, a mechanism for doing it.     I suppose if it
hadn't been Vietnam, I could have been in civil service or
commissioned corps.    I mean, I didn't give it that much thought,
frankly, except that it obviously waived my military

responsibility.



Mullan:    It fulfilled your military responsibility.



Nighswander:    Yes.   Yes, that's right.   That's exactly right.

The Alaska Native Health Service has almost been a separate

entity from the Indian Health Service, because many of the

generic issues that have been faced across the country, we've

had, but not to the extent that it's been felt in the Lower 48
states.    Yes, we've had recruiting problems, but not nearly what
they've had in the Lower 48.    We've been blessed with this stable

and senior clinical staff.
     Our relationship with the Native tribes is quite different

than in many Indian Reservations.     I think Alaska Natives were
never disenfranchised to the extent that the Lower 48 Indians

were.     So it's unusual to come along, around, amongst an angry
                                                                         61

Alaska Native.   When I talk to some of my colleagues in the Lower
48, working on some of the reservations, there's a lot of anger

there.    It's unusual up here.

     Over the years many of my physician colleagues around the

Indian Health Service have viewed Alaska as different, for all

the above reasons. In many ways Alaska has been a model for other

places in the Indian Health Service.    That's not to say other
groups are not successful.    The Navajos are quite well organized

and have identity of all their own.    The program has worked.       I
think, in my view, it's worked very well down there also.       It

looks different from Alaska, and that's fine.

     Clearly, the direction of ownership is a national agenda for

the Indian Health Service.    It was part of Dr Mike Trujillo's

testimony at the recent congressional hearings.   He's the
Director, who now is a political appointee, director of the
Indian Health Service.    I think the reason that he feels so

strongly, and the other senior leadership of Indian Health

Service feels so strongly about this is that it is the basic
principles we talked about in terms of ownership, and who owns
this program, and where is the problem, and how's it going to get

solved?
     The best example of this is in the Northern Plains Indians

in the Aberdeen area.    When I first walked into headquarters in

1978, Emery Johnson was the Director of the IHS, and the first

words out of his mouth were the problems they were having in

Aberdeen.   I returned to headquarters in January of 1996, and the

first words I heard out of the Director's mouth were the problems
                                                                    62

they were having in Aberdeen.    I felt like saying, "The Emperor
has no clothes.   There's something wrong with what we've been
doing in Aberdeen.   It hasn't worked.   It hasn't worked."

     I don't think that it will work until whatever has to happen

with the groups up there, and I don't know the northern tier

Indian groups well, but until such a time that they say, "It's us

and we're going to take it on.   We're going to do it."   They

agree that the federal government has not changed fundamental

social programs and they're right.   Even though the Navajo have
not been as aggressive with compacting and contracting, they

certainly are much more involved in taking ownership of their own

health and their own program.



Mullan:   Say a few words about what compacting means.



Nighswander:   Compacting is an evolution from the 638 contracts.



Mullan:   638 contracts being the first movement away from Indian

Health Service federally provided health care?



Nighswander:   Correct.   The new iteration of the 638 law under

compacts, in concept, is a direct transfer of money from

government to government, from the federal government to the

tribal government, bypassing the middle man-- Indian Health

Service headquarters and the area offices.   There are minimal to

no reporting requirements.   Some would say it is the federal

government leaving the money on the stump.    In fact, compacts
                                                                      63

monies to the tribes are coming through a side channel of the

Indian Health Service, but that is just for the accounting of it.
There are negotiated annual funding agreements.      That   is the

document that's being used now.    The only reporting requirements

that the tribes have are an annual three- or four-page report.
This does away with line-item funding like what we had in the

past.     We've had AIDS; fetal alcohol syndrome; maternal-child

health funding as line item funding.     This does away with that.

All the money is green.    And in principle, at least, the tribes
could decide to use the money for building roads.      In fact, they

do define briefly in their annual funding agreement how the money
is going to be spent.     It is a mechanism where the traditional
role of the Indian Health Service really disappears.        It's quite

different.     So who is the tribe responsible to?   Who is going to
monitor their program?     That's the question I get asked by the

traditionalists in the Indian Health Service.      The program will

be monitored by the tribal members.     The responsibility belongs

to the tribal community.



Mullan:     How is that working?



Nighswander:     In Alaska, it's worked well.   We've had our first

experience.     Here it's blended, compacts and contracts, because

we've had 638 contractors since the mid-seventies.      For Alaska

tribes, this is the next movement to even additional independence

and self determination.    We're early into the experience, because

compacts have only been around for a couple of years, but I see
                                                                     64

it perfectly appropriate for our next step as our programs up
here have matured.    I expect that although the tribal priorities
might change, and there is risk for some economies of scale, to

the extent that we can keep our clinical program intact, our

systems, our clinical consultation roles in the field, I think

Native health care is going to be in good shape.     I think Alaska

will be well served.    Frankly, I don't know.   It's an experiment.
I mean, I think the answer's still out yet.



Mullan:   You spent time, speaking now on the personal side,

serving in the interim role as the chief medical officer for the

Indian Health Service.   As you travel back and look at things
from a national perspective, how are the physicians in the Indian
Health Service?    How is that all developing?



Nighswander:   Well, a couple of things are at play.    One is the

commissioned corps, which I think for physicians in the Indian

Health Service is going to be a historical artifact, because
there is a new hiring authority called Title 38.     This is a VA
hiring authority which gives a lot more flexibility in terms of

negotiating    salaries, and also it makes the entry-level salaries
for physicians much more competitive.    Translated the last seven

physicians hired in the Navajo area, have all been Title 3 8

physicians.    The most recent physicians we've hired in Alaska are

all Title 3 8 physicians.   At least f o r the physician component, I

think that the commissioned corps members' days are limited.     I

don't know about other professional categories, and I'd love to
                                                                     65

be proven wrong, but that's the way it appears as you sit back

there.
     The programs that have been strong clinically, that had

senior staff kind of feed on themselves, they were always stable

before, and that remains the same.     I worry about the Tom

Nighswanders and the Fitz Mullans of the earlier days, that some
of the younger physicians who I see coming out, have not been

exposed to the Karks and Castles of the world, and are pretty

oriented towards hospital-based managed care and issues related

to product design, market share, etc.
     I've been called a dinosaur     [Laughter] but I happen to
think that we're right.    That worries me a little bit.   I think
that some of the physicians we get in the Indian Health Service,

the young physicians I've talked to in the last six months, they

have the interest in public health and community health.       I don't

know if they've had the exposure that you and I have had to

community issues, and that worries me a little bit.    Everyone's

getting caught up with market driven medicine, and it's certain

true in the Indian Health Service, although it is less of a
problem.    In rural areas, it's just not going to work that way,
large markets are not present.



Mullan:    You'd mentioned your interest in, and your activities,

in regard to total quality management, bringing quality concepts

into play in medical care, government-mediated medical care.       Do

you see that as an important component of where the system's

headed or where your work is headed?
                                                                    66

Nighswander:   Certainly, that is where the Alaska Native Medical

Center is headed and the feature issues are several.    One is this
idea of not only defining your various customer groups, but
defining what they need and how to provide service to them.      That

is a real critical issue.    The other is to put the decision-

making and problem-solving in the hands of the people who are

doing the work.   That's something that I've always intuitively

believed.   I've never really had all this   put together in a

discipline like it's put together in total quality management.
     The other very interesting feature of it, is this idea of

doing rapid turnaround trials, little experiments which you do

with some discipline:      trying to decide what you're trying to
do; how will you know when you got there; and what changes you're

going to make that you predict will make a difference.     It puts a
measurement piece up front.    You've got to define a change, and
you have got to define the measurement piece before you ever

start these pilot projects.

     This is as opposed to what we've done in the past.     I

compare this a lot with traditional health services research.
You go through this elaborate and time consuming methodology and

do a regression analysis to try to find out'what makes a
difference in a program.    These new methodologies are much more

amenable to working with communities, because they're much more

short-cycled and are timely.    The problem I've had working with

communities with health services research is that it takes two

years, three years to figure out what made the statistical
                                                                         67

difference.     By that time the community has gone on to some other
issue.      It's just way, way too slow.
       In   Nutaqsivik, for example, where we're looking at post

neonatal infant mortality.     There's a whole menu of interventions

that we're doing.     We have not actually put in any new resources

to do this project.     We've redesigned how some people are doing
their work.      It makes less of a difference to me what out of this
menu is making a difference.

       Let me tell you how we're measuring it, incidentally, then

you'll understand a little better.         In Anchorage we only have a

few infant deaths in a year--small numbers.        There's another way
of measuring it, besides infant mortality.        This is Tom Nola's
work--look at the days between death.        It's the concept of

walking into a plant and a sign over the door says, there's been

375 days gone by since our last accident.        You can do the same

thing with post neonatal infant mortality--the days between post
neonatal infant death.     You can apply a whole bunch of

statistical analysis to that.

       We've had this project going for two years now.      We were

having a death on the average of every fifty days in the greater

Anchorage area from that group that was just described.         It's now
180 days.     As long as that remains true, the more strength

certainty we are that the actual interventions made the

difference.     We can update this data monthly.     We do, by the way.

So it's real quick turnaround of information.        It's a pilot.

We've changed interventions from what we started back two years

ago.    We're doing it differently now because of the things that
                                                                   68

we've learned in the beginning.   We knew we had a high risk group
from some data that we saw that showed that post neonatal deaths
were occurring preferentially in a group of highly dysfunction

families.



Mullan:   You've had an interesting career as a generalist, part

time as a clinical generalist, part time as a kind of public
health generalist.   I'd be interested in your reflections on what

we now are calling generalism, but as you have observed this

phenomenon personally over the years, both in terms of your own

experiences and what you see going on around you.



Nighswander:   I worry a little bit about the public health

perspective, the community health piece.    I don't know what's

going on now in graduate medical education because in that I'm

somewhat removed from the family practice training programs.      For

example, in the generalist training programs, what is mentioned

about being responsible to the health of the community?       I think
there has been, and there continues to be a body of knowledge
about these set of issues.   I don't know how well that's being

translated to medical students and into the general primary care
internal medicine and so forth.

     It's been intuitive in pediatric over the years but there

I'm afraid that it might even get lost.    One of the pediatric

nurses in private practice said to the pediatrician for whom she

worked, "Gee, maybe we ought to get some programs to help

adolescents.   We ought to talk to some parents, get a focus
                                                                       69

group."     He said, "I know what parents think."      That's

disappointing.



Mullan:     Do you think that we ever have taught, from your

experiences in family medicine, say, have taught public health

principles, if you will?



Nighswander:       No.   No, I don't think so.


Mullan:     Yes.    I would agree.    I mean, when I use the term

"generalist," I am referring to the clinical generalist whose

perspective goes beyond the organ system or the technical

intervention, be it surgical, or radiological, or anaesthesia.
But still and all, that does not take into account a population

perspective which is not generally well taught in American

medicine.     I'm not sure it's generally well taught in general.          I

used to think this was an astigmatism and a blind side of

American medical education.          I rather think that the skills that

are necessary to worry about the individual one after another

coming to the examination room are not necessarily compatible, or

particularly compatible, with the skills necessary to think about

the community or the population as a whole.         Yes, there are

people who can cross that street and, yes, it's not an impossible

eight-lane highway to cross, but its people seem to dwell more

contentedly on one side or the other.         It's hard to get

clinicians thinking, and given their responsibilities day in and

day out for opening the door of the next examination room and
                                                                      70

dealing with Mrs. Smith's headache, or Mr. Jones' prostate, it is

not easy to get them to think about the epidemiology of headaches
or the course of prostate disease in the community as a whole.
That little lecture is in the hope you'll tell me I'm wrong.



Nighswander:    Well, yes and no.    I don't know.   Maybe we do it at

the wrong time.    I don't know.    One thing that would be

interesting to me is after you've talked to people around the
country and you talk to more senior physicians.      Many start to

practice only interested in one-to-one patient care.       I wonder

how they end up their practice?     Are they still in the same mind-

set?
       There are some things that a physician you can do that are
relatively simple.    I'll give you a for instance.      Emergency

rooms are sentinel units in a community.      If you have an

emergency room physician who is thinking about the community,

when he sees a case of carbon monoxide poisoning because of

faulty heating in the home, he should say, "You know, this is an

issue that can affect other people in the community.       I ought to
call the radio station.    I ought to call the television station,

because I'll bet you they'd do a story on this.'' Actually, we do
that at ANMC and you know what?     Television is there in a split

second.    It's a public health issue that's newsworthy, and it's a

story that needs to get out.    If you're going to deal with the

public, and deal with communities, there's a professional group

who knows how to communicate with them at your doorstep waiting

to be called.
                                                                         71

     We have done this with our electronic media in Anchorage.

They've caught onto it.     They need news.   We need to get the
information out.     Everyone wins.    The stations and the paper are

interested.     They get good public    information from their

hospital.     This happens by just thinking in terms of what is our

responsibility to the community.
     I think some of this is teachable.       You're absolutely right

in that this is so overwhelming when you're in training programs.
You're just trying to learn clinical medicine.      Can this be
taught after postgraduate education would this make a difference?

I don't know.
     Our Chief Medical Officer retires and goes to HFA in Utah.

It's a for-profit HMO--a big outfit, California-based.      He tries

to introduce community medicine/preventative health to the
organization.     They said, "30 percent of our beneficiaries turn

over every year.     We ain't interested.   It doesn't add to our

bottom line."     Eight months ago they said, "Quarterly earnings

are down.    We've got to fire some physicians."    They wanted to

fire thirteen or fourteen primary care physicians.      He left.     I

worry about that.



Mullan:     I think the best hope in that regard is a little bit

more back on your thinking, that is, to the extent that systems

are developed that are stable, I mean, right now where you have

this churning managed care profiteering environment, that term

I've heard before.    Ironically, even as the HMO arrives, the HMOs
                                                                     72

are stepping away from responsibility for health maintenance

because it isn't profitable when you have high turnover.
     When and if that market stabilizes, and you have a limited

number of large players who are providing long-term risk-sharing
of a managed sort for a population, there is much more incentive

to have a system, including the physicians, generalists, and

otherwise in it, concerned about monitoring and intervening on

population health.    So I'm optimistic, or guardedly hopeful in
that regard.



Nighswander:    Dave Lawrence--I've heard Dave in the last six

months ago or so--



Mullan:   Hang on a second.



[Begin Tape Two, Side 21



Mullan:   This is Dr. Nighswander, tape two, side two.



Nighswander:    Dave Lawrence, as you know, is now a CEO for

Northern California.    Dave says he sees this churning going on

for ten years before it really shakes out to some kind of

stability.     Kaiser is closing their flagship hospital, Oakland.
They've got a brand-new hospital.     I don't know where it is in

Northern California, that is being mothballed.    They and Group

Health, are victims of their own success.    They enrolled people

in 1948 who are still with them.     They are now old and are using
                                                                         73

a lot of resources.     They have had a very stable physician staff,
including senior cardiologists who they're paying $220,000.         New
plans coming into Northern California can get cardiology services

f o r a lot cheaper than that.    Also, they are apparently going to
do away with their physician bonus, the capitated bonus that we

mentioned.     A gastroenterologist who I know of took a $40,000 pay

cut in the last year.     I don't know what she made.       I would guess

she made $180,000.     Each Kaiser Hospital has its own business

plan, and it was either laying o f f physicians or everyone taking

a pay cut.


Mullan:   Let me ask just to pursue your perceptions and your

story a little bit more to tie this together.          You have been a

generalist throughout your career, ranging between clinical

generalism and population generalism.       I'm characterizing.    You

have observed the family medicine movement come alive.         You've
observed trends over the eighties which mostly could be

characterized as backsliding in terms of the well-being of the
generalist perspective, and perhaps some trends in the nineties

that seemed to be favoring generalism.       What are your

observations about the growth and well-being of the generalist
concept in the hands of the medical community over that time?



Nighswander:    Actually, I am encouraged, F i t z .    I think that with

the increasing interest in trying to do things in a cost-

effective way, that generalists are in a position to grow and

thrive in that environment, as long as they pay attention to
                                                                    74

their roots, and that is looking at their patients and trying to
best serve them.
     For example--1 don't know if you can quote me on this one,

but we're building a brand-new hospital.    It's all finished,

almost.   We're moving in June.   It's over a $100 million plant,
and I hope it's not an anachronism.    I worry about it being such,
because I can see doing a lot more things out of the hospital, at

home, starting to make house calls with various kinds of teams.

I think it would be very cost-effective.    I think it would be

popular with patients and the generalist is going to be in a
position to push that issue, because if they know their
community, and they know their families, a lot of stuff that

we've traditionally done in the hospital can be done in a

community-based setting, even in the patient's home.    Who else is

better able to do that?    The physicians going to have to balance

a whole bunch of issues when you try to do something like that.

     It's peculiar to American medicine, compared to other

systems where I know, where a patient with a    sore toe can go
directly to an orthopedist.    That really doesn't make sense in
terms of being cost-effective. Actually, Don Burwick has got an
interesting thought about this in terms of HMOs, and even our
medical center.    We've always tried in the past to have one-size-

fit-all program dealing with our population.   We have this

package that we provide.    Then at the other extreme is the most

highly customized piece of medical care,    fee-for-service private

solo practice.    They can design anything they want.   Is there
some way to meld these two so that you could do some
customization and still make it cost-effective?
     But I think that the generalist, even more so than ever, has

a place.     California is going a step beyond the generalist

physician.     Maybe it's cheaper and just as effective to have the
generalist mid-level practitioner.     Put them up front.   Actually,

I might say this     has been our experience up here.   We have some

mid-level practitioners--you're going to be talking to them--that

are pretty impressive and do a pretty decent job of primary care.


Mullan:    You work over the years, what have you liked best?    As

you think back things you've done, or incidents with patients,

what's meant the most to you?



Nighswander:     I can think of specific kinds of instances and some

general ones, too.     I think the most satisfying thing now is if
you'd walk through the medical center with me tomorrow, it's a

very positive experience, families I've known for years and
years.     I've been involved in some good times and bad.   Hugs from
patients.    Having young women come up and say, "You delivered me.

Will you deliver my child?"     I can't believe that.   Going out to
some of these villages and getting embarrassingly good treatment.

I mean, it's like getting VIP treatment out in the village.

Alaskan Natives are very gracious in the first place.       It clearly

fits within the personal attachment I feel with my patients.      The

clinic I had last week, I know all my patients.     If I don't know

them, I've known their families, or most often I know them and
                                                                    76

know their extended family.    They've not had easy lives.   It's

been tough, yet they've made it.    Clearly, that is the thing that
really sustains you over the years.



Mullan:   So the clinical side has been very gratifying.



Nighswander:   Oh, yes.   And fortunately, I learned a lesson from

Jim Felton, before he started stacking his cups. [Laughter]

Gotcha!    I saw Jim Felson in 1979 or in '80, and Jim had really

gotten so far from clinical practice that he couldn't go back to

it.    I came back and I told Ruth that it was really useful seeing

him.    I said, "I don't ever want to be in that position of losing

clinical skills.   But, too,   it's a real advantage of being able
to mix the two administrative medicine and clinical medicine,

because the advantage is that by seeing patients, it really keeps

your feet pretty flatly planted on the ground there.    You can't
get too many hair-brained ideas.   Well, you get hair-brained
ideas, but they get tested real easily by seeing patients.      I

get some of my best program ideas from seeing patients, and
listening to patients.    Patients, as you well know, tell you a

whole lot when you sit down and listen.



Mullan:   Do you have any things to look back on that you're

disappointed or terminally frustrated about?



Nighswander:   No, that's not my nature.   No, not really.   For the

things I've been interested in doing, I can't imagine having had
                                                                      77

a more satisfying career.        Part of it has been the variety of
stuff.    I mean, petrochemicals in food.     Who in the hell would
ever think you'd ever get involved with that stuff?       New

learning, new issues, new people, and an opportunity for working

with the information.

     Last year, or two years ago, they needed someone who was

disinterested, to facilitate the health care reform discussion

for the State of Alaska.     This included politicians on    both

sides of the aisle, with all the interested provider groups in

attendance, in about seven or eight weekend sessions.        I was the

facilitator for that group, and presented the legislation bill

that resulted to both at the House and the Senate Health and

Social Services Committee.       Fascinating stuff.   I was very

successful with the process.       The bill never made it out of

committee.     But still it was a unique opportunity.     I mean, I

just can't imagine.



Mullan:   What do you see doing?      What are you going to be doing a

decade from now?



Nighswander:     I don't know.    Ruth and I have been optimists over

the years.     Ideally, I would like to get together and work more

closely with Ruth on some project.       I can see us going back
overseas.    We talked about going back to Africa.     The other

alternative is to stay here and work for one of the Native

corporations.    We've talked about that.     I don't know, is the
bottom line.    We've had the happy problem of having had some
                                                                        78

interesting offers from several international foundations.         It
turns out it's one of these foundations which sponsor programs
all over the Muslim world needed a program director.        Annie Lee

Schuster--do you know Annie Lee?       Robert Wood Johnson Foundation.



Mullan:   Yes.



Nighswander:     Annie Lee got them to contact me.      God, I don't

know what I will be doing.       That's not fair.   I could ask you the

same thing.      You'd give me the same answer.     [Laughter]



Mullan:   Are there things that we haven't touched on that you'd

like to talk about?



Nighswander:     No.   No.   I wish there was some way we could

capture this community medicine piece in a meaningful way.         I
don't know enough of your story to know how you got involved with

Kark and Castle and that way of thinking, but, gosh, that really
has shaped my career.        I think they were right.   How could we
give that kind of experience to other clinicians?        Won't appeal

to everyone, but it doesn't have to.       It just needs a core group.
That's what I would love to be able to do.



Mullan:   I think that's an ongoing challenge, because you've got

a set of perceptions which are, by and large, undervalued, and

are closeted for the most part in a rather bunker mentality

public health community.       "We are the custodians of public
                                                                     79

health.    We know about population science and those spendthrift,

narrow-minded docs are using up all the resources.'' Then you've
got the medical community that either is ignorant of or
disinterested in population science, and they don't want to go
after their patients, or their procedures, or their organ system,

what have you.

     Even generalists who have in this country a fairly narrow
perspective, and all the, or most of the incentives,
reimbursement system in particular, awards piecework.     The more

piecework you can do, the more reward you'll get, and the nature

of the overall enterprise, nobody pays, clinicians anyway, to

look after them.    So that the long-term challenge of melding

public health thinking or population perspectives into the
provision of services is terribly important.     Ultimately, there

is a lot of piecework.    Ultimately, there are people who are

going to have to be narrowly and largely focused on the ache, the

pain, the death, the dying, and so forth.   But building in and

breaking down these stylized walls that exist between these two

communities is important.
     I was thinking about my little homily before, and this is
more of it.    I don't mean it to sound so negative.   This is your
story.    But I have pondered this for some time, and I guess as I

get older, I'm less of a missionary thinking you can teach

everybody to do this or have this perspective.     I think you can

certainly expose more people and recruit more people to it.      But

I believe there is going to be some amelioration in this area as

you come from, at least in terms of my own thinking, a somewhat
                                                                       80

unpredicted angle.       For instance, the mature HMO, or the mature

organization that even on a for-profit basis is providing
services, all of a sudden has a need to look at the horizon and

not just the beach.       They are going to spend time worrying about

some of the population, the demographics, and the epidemiology,

and then modifying their services in a systematic sense to try to

deal with those larger perspectives.

     We wandered away from your story.      You've had an opportunity
as a physician, as a person, as a generalist, to observe America

and American medicine from the northern exposure vantage point,

or somewhat external vantage point as you watched mostly from the
perspective of Anchorage.      Any thoughts about how you see the
system evolving?



Nighswander:    Well, a couple of things.     I just had a potential

medical student tell me that of all the recent physicians that he

had talked to, I was the first one that encouraged him to go into
medicine.



Mullan:     Of the physicians that this student had talked to, you

were the first?



Nighswander:    Yes.    Actually, this was a premed student I met

back in Boston.        I think that there is so much turmoil in the

system right now, that there is a lot of dissatisfaction among

the practicing physicians in the community.      Interestingly

enough, being in the system that I'm in right now, we were always
                                                                     81

considered as the renegades doing public medicine.      I'm in the

most stable medical environment around right now, which is
amazing to me.

     I am encouraged by the medical students who we're seeing
coming through.   As I mentioned to you before, I'm on an
interview committee for the medical school, and I get a chance to

interact with Alaska students that are in the WAMI program.     Many
of the attributes that I admired in colleagues and students are

certainly still there.   There is a sense of commitment, of

interest, of wanting to help people.   And we've got some

excellent students.   I tell many people I'm glad I'm not applying

to medical school today, because I don't think I could get in.

The folks that we're seeing, young and not so young, applying
now, are bringing with them lots of life experiences, and the

applicants that I've been talking to have gone beyond a     classic

biomedical background, and have had work experiences with various

and sundry human services groups.   So I'm encouraged by that.       I

think that my perspective has been tempered a little bit because

of my last six months being back in D.C.   When I look at public
and private medicine there is going to be a lot of turmoil, I

think, for the next few years.   In terms of the shake out, it's
hard to predict what's going to happen.

    As an aside, this big debate we had in the country about

nationalized health care and physician choice, well there's going

to be a lack of physician choice.   I'll tell you there is lack of

physician choice as the marketplace has taken   over.    So I think

it's real hard to predict what's going to happen.
                                                                       82

        For the system in which I participate right now, over which
I have had the most influence, I like the direction it's moving
because of the ownership issue.      We've been fortunate to have a

mature and experienced group of Alaskan Natives who have been in

medical care management on health boards.      They have experienced

with it.     So for our own health system, I'm quite encouraged by
it.     I'm still very enthusiastic about being a clinical

physician.



Mullan:     This is a bit of a prosaic question.   Would you tell

your kids to go into medicine?



Nighswander:     Oh, yes, sure.   Without question.   Without

question.     I'm just sorry, because a lot of my colleagues who are

so disgruntled with it; colleagues and friends who are on the

private side, I think it's tragic that they're ending up their

career on this note.      One of our private practitioners in town,

family practice M . D .   active in the American Academy of Family
Practice, traveled with me a lot, while he was on the Minority
Affairs Committee reviewing the Indian Health Service.       We always
had this running debate.       In ten years, would my practice look

more like his, or would his look more like mine.       I always told

him his practice was going to look more like mine, and that at

the end of the day, I was going to win.      Actually, it's come to

pass.     I have been in a stable environment, and have been able to

do the kinds of things I really like to do.      I've had this

incredible career with all kinds of opportunities, and I haven't
                                                                   83

had to change my employment.    I think this probably is what's

kept me interested.    A lot of my interests that I developed I've
been able to pursue, in a setting that has allowed me and, in

fact, encouraged me to do so.    So it's not been every day opening
the door to the next patient.    I've been absolutely delighted.



Mullan:   This is a good place to stop.



Nighswander:   Good.



Mullan:   Good.   Thanks.



[End of interview]