ORAL HISTORY PROJECT

Robert E. Cooke, MD

Interviewed by Robert Grayson, MD

September 8, 1996 Vero Beach, Florida

2003 American Academy of Pediatrics Elk Grove Village, IL

Robert E. Cooke, MD Interviewed by Robert Grayson, MD

Preface i About the Interviewer ii Interview of Robert E. Cooke, MD 1 Index of Interview 42 Curriculum Vitae, Robert E. Cooke, MD 45

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PREFACE Oral history has its roots in the sharing of stories which has occurred throughout the centuries. It is a primary source of historical data, gathering information from living individuals via recorded interviews. Outstanding pediatricians and other leaders in child health care are being interviewed as part of the Oral History Project at the Pediatric History Center of the American Academy of Pediatrics. Under the direction of the Historical Archives Advisory Committee, its purpose is to record and preserve the recollections of those who have made important contributions to the advancement of the health care of children through the collection of spoken memories and personal narrations. This volume is the written record of one oral history interview. The reader is reminded that this is a verbatim transcript of spoken rather than written prose. It is intended to supplement other available sources of information about the individuals, organizations, institutions, and events that are discussed. The use of face-to-face interviews provides a unique opportunity to capture a firsthand, eyewitness account of events in an interactive session. Its importance lies less in the recitation of facts, names, and dates than in the interpretation of these by the speaker. Historical Archives Advisory Committee, 2003/2004 Howard A. Pearson, MD, FAAP, Chair David Annunziato, MD, FAAP Jeffrey P. Baker, MD, FAAP Lawrence M. Gartner, MD, FAAP Doris A. Howell, MD, FAAP James E. Strain, MD, FAAP

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ABOUT THE INTERVIEWER

Robert Grayson, MD, FAAP

Robert Grayson, MD, received his MD from Columbia College of Physicians and Surgeons. Following military service during World War II, he completed an internship at Mt. Sinai Hospital in New York City and residencies at Willard Parker Hospital and Duke Hospital. Dr. Grayson engaged in the private practice of pediatrics in Miami Beach for nearly 40 years. He also held academic appointments at the University of Miami School of Medicine where he taught medical students and residents, focusing on neonatal intensive care, ambulatory pediatrics, office practice, and office preceptorships. An active fellow of the American Academy of Pediatrics, Dr. Grayson served as chapter chair, alternate district chair, and district chair. He also served on numerous committees and was instrumental in the development of a Section on Senior Members, acting as its first chair and was editor of the Senior Bulletin for ten years.

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Interview of Robert E. Cooke, MD

DR. GRAYSON: We are at Dr. Robert Cooke’s home in Vero Beach [Florida] for an interview with him. We are sitting on a porch out here in a delightful place just beginning to reminisce about pediatrics in general. Let me go into a little of the background. We have your curriculum vita; the [American] Academy [of Pediatrics] forwarded it to me, so a lot of the details are really recorded already. We don't necessarily have to go through them again. But as I understand it, you are from Massachusetts originally, went to Yale [University]. Tell me about Sheffield. DR. COOKE: Well, Sheffield Scientific School was really the science branch of undergraduate Yale. And it awarded a BS degree rather than an AB degree. DR. GRAYSON: What was your major? DR. COOKE: Actually, physiological chemistry. I must have been the only student in physiological chemistry. [Laughs] Sheffield Scientific School, maybe ten years later, was incorporated into so-called Yale College; it kind of exists only as a name. But that was the accurate designation when I was there. DR. GRAYSON: What was your major there at Sheffield, Bob? DR. COOKE: It was physiological chemistry, and actually that was given at the medical school. DR. GRAYSON: Oh. And then entered Yale Medical School right after that? DR. COOKE: Yes. DR. GRAYSON: What year did you graduate from undergraduate? DR. COOKE: '41. And then '44 from Medical School. DR. GRAYSON: This was during the war years. DR. COOKE: Yes. DR. GRAYSON: I also graduated in December of '43. We were accelerated if you remember. Were you participating in any of the Army or Navy programs while you were there?

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DR. COOKE: Yes, I was in the ASTP [Army Specialized Training Program]. That was a very interesting experience, because in our particular part of the world the Army decided we were going to be real privates. We weren't going to be like the Navy people who lived a good life, had lovely uniforms. We were actually sent over by the Army people with our fatigue uniforms on to do clerkships. There was general rebellion and the Army withdrew its requirement, and we could wear a white coat and a tie and a decent looking shirt and trousers. But the first day or two of our clerkship, we were wearing fatigues. It was just terrible. The Army experience then was a very discouraging kind of thing; they seemed to have no concept of what medical education was all about. But we survived it. DR. GRAYSON: The purpose, I guess, was to keep us in medical school rather than draft us. This is the way it was explained to me. I was ASTP also, and almost didn't get back to medical school. It’s a funny story. This is your interview, but it fits in. We went to Camp Upton to be inducted; you probably went to one of the camps up in Connecticut. They gave us a code test as part of the examination or IQ examination. I was a radio amateur at that time, and I could take code at about 20 words a minute. And when they finished and saw my code test they said, "You're going to Camp Mammoth; you're in the signal corps." I said, "No, I want to go back to medical school." But it was still the Army. DR. COOKE: Yes, same thing. We went to Fort Devins; we had to dig out some of the stuff under the barracks. There had been a lot of accumulation of debris. There were elevated barracks and we were assigned to dig out underneath the barracks, clean up and so forth and so forth. Then they sent us back to Yale on a train, and it must have been 150 degrees in the train. They had no air conditioning; the windows wouldn't open; and we sat on a siding for hours and hours. Finally, [we] got back to New Haven, and we decided we'd had enough of the military after that. DR. GRAYSON: [Laughs] DR. COOKE: So what we did, and it's really pretty disgraceful as you look back, we chopped down a lot of branches from the trees around. We were in our fatigues, and we put all these branches all over us, to camouflage, and we marched through the center of New Haven. Well, man, did that cause a stir in the Army! [Laughs] And they came down on us like a ton of bricks. I was married at the time, and we couldn't visit home. We were confined to the dormitories at Yale, and they made life miserable for some time.

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We used to do guard duty. I don't know if you had the same experience, but we'd do guard duty around this dumpy dormitory near the medical school. We would carry a gun, with no bullets, fortunately, or we'd have killed somebody. I have to confess the only time I cheated in my whole life was when we took our final exam. You probably had the same thing. We had to have a final exam on military strategy and so forth. This was in July, as I remember, or maybe it was later than that, August, but it was hot as blazes. And the whole company turned out with their raincoats on, on a bright, sunny day. Under our raincoats was this book that had all the information that was required for the test. All of us sat there, I'm sure that the people running the test knew it, we all sat there and turned the pages with our feet while we were taking this test. You know, how many men made up a company, and questions that I don't think anybody could answer. They'd have a blank and you'd have to fill in if it was a "the" or an "a", or a "u" or something else; but, that was really just ridiculous. DR. GRAYSON: When you saw what the Army did with us at that time you wonder how we ever won the war. DR. COOKE: Well, I took my internship and residency then, right after getting out of medical school. I was exempted for that period of time. And then we went down to Fort Sam Houston, which had moved from… DR. GRAYSON: Carlisle [Barracks]. I went to Carlisle. DR. COOKE: Carlisle. Moved to Fort Sam. And then at Fort Sam we had a good time. My brother was a pediatric surgeon, but did a lot of pediatrics before he became the pediatric surgeon at Hartford Hospital. He was with me, and [Denton A.] Cooley, the vascular surgeon; we were all together. We did a lot of things together, and I got to know Cooley pretty well. I remember we all had a map exercise. [Laughs] We had a compass, and we had to do compass readings; and we did a compass reading right next to an iron pole, because there was a light there and we could see. And that threw our compass off. We went off in the wrong direction on this field thing; we got lost. We were a disgrace to the company, all the three of us, but we managed to get through. Then I sat around Fort Sam waiting for an assignment for a long, long time. Then I got assigned to First Army, up in Burlington, Vermont at Fort Ethan Allen. It was a recruiting and induction station. We had a big 4th of July parade after I’d been there a few months, and I was the highest-ranking Army officer in the state of Vermont at that particular time, as a first lieutenant. [Laughs] That was it.

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I moved to Albany when they closed Fort Ethan Allen, did induction work there, and then transferred to Boston Army Base. I had a very interesting experience when I was in Albany. When I was an intern, I had admitted, cared for and treated the first case of tuberculous meningitis cured with streptomycin. And I had written this up, actually in the Yale Journal of Biology and Medicine. And while I was in Albany, I got a telephone call that said, "This is the overseas operator, and we have a call from a Professor Zuckerman of the presidium of the Academy of Sciences of the USSR." I had a neat guy who was working with me from Brooklyn, who was a real jokester, and I thought this was something this guy had hooked up. I said, "I don't know any Professor Zuckerman in the Soviet Union," and so I didn't accept the call. Well, about three hours later, I got another call back and it said, "This is the overseas operator. I have a call for Dr. Robert Cooke from Professor Zuckerman of the presidium of the Academy of Sciences of the USSR. Are you the Robert Cooke that wrote a paper on tuberculous meningitis?" And I said "Yes I am," and then they put me on. There was a translator in between, and I talked with Zuckerman for, I don't know, maybe twenty minutes. He wanted to know about our experience in treating tuberculous meningitis, because his daughter had developed tuberculous meningitis. And he seemed to be very reasonable, and he said, "I would like you to come over and consult and see this child, my daughter." And I asked him how it could be arranged, and he said, "Well there's a meeting of Soviet scientists in New York." That was just when the UN [United Nations] was just getting going, but I didn't know how I was going to meet these people. He didn't know where they were. So I called up [Stanhope] Bayne-Jones. I don’t know if you remember him, but Bayne-Jones was a bigwig. He had actually been dean at Yale Medical School, and he was a general at that time and was in charge of the medical liaison between the U.S. allied forces and Russians. And he had come back and was in New York City, and I went down to see Bayne-Jones. He told me that this group was meeting at Luchows [Restaurant] in New York City.

DR. GRAYSON: 14th Street. DR. COOKE: And that I should meet them there. I could tell them about the situation; they may be helpful. Well, I went down in my uniform as a first lieutenant. In walked these five or six typical Soviet Union type people, big, rather stocky, all in dark clothes. I introduced myself, and they were remarkably uncordial. So I explained the situation to them, and one of the people there was a Russian-American named Stern. And his daughter, this is a small world, his daughter was in charge of this case, and he was super unfriendly, because this was obviously Zuckerman going around his daughter.

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This was in the Soviet Union, and so he said, "There's nothing you could do, nothing could be done," and so forth. I left and went back to Albany. And, you know, felt very sorry that we couldn't give some information. So I sent a telegram, a long one, to the embassy in Washington to be forwarded to the Russian embassy, laying out what I thought might be a treatment plan and so forth, and that's the last I ever heard of it. DR. GRAYSON: I was going to say, did you ever meet Zuckerman? DR. COOKE: I never met Zuckerman, I’m sure Zuckerman probably got… DR. GRAYSON: Canned. DR. COOKE: Canned, that's right, for going around the hierarchy. But that was my first real experience with anything very international. DR. GRAYSON: I had a similar experience. I was in the service after just a nine-month internship. I was in the service for two years and came back in '46 and my first residency was at Willard Parker Hospital in New York, which corresponded to Sydenham [Hospital] in Baltimore. And that was where we saw the last smallpox in the United States. DR. COOKE: Oh, yes, is that right? DR. GRAYSON: There were 13 or 14 cases there. I took pictures of the cases with a camera, and had reproduced them many, many times. I was at a meeting at some later time and somebody from Galveston was showing infectious disease, and up came one of my slides that we had taken. But that, again, was a very interesting experience, one that you feel is at the beginning or the end of a very important thing. That was that terrible epidemic that came from Mexico and more people were killed because of excema vaccinatum than were from smallpox itself. DR. COOKE: Sure. Sure. DR. GRAYSON: So, that was the Army experience you had. DR. COOKE: That was the Army experience. When I came out, I went back to Yale as a research fellow working pretty much in physiology, actually trying to do more basic physiology. I worked with a man named John [R.] Brobeck, who later became chairman of physiology at Penn [University of Pennsylvania]. Brobeck was interested in the problem of obesity, and he was one of the first to do stereotaxic injuries to the hypothalamus, and he produced what was at that time called hypothalamic hyperphagia. We had rats that would engorge themselves so they would die, and be tremendously obese; but they just kept on. If you gave them an unlimited of food they just kept eating and eating and

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eating, until finally the whole GI [gastrointestinal] tract would fill. Literally, the food would fill their mouths and they would suffocate. I was trying to find something, what I call the satiety factor, at that particular time. I had no luck at all. I have to say that I was treated as a clinician, I was treated by the PhDs in physiology as a real know-nothing, which I guess I was. But it was kind of an interesting experience. And I met, for the first time, a man named Don [Donald Henry] Barron, who later came to Florida as a professor of physiology. He was a great placental physiologist. It turned out that he later trained Fred [Frederick C.] Battaglia, who was later one of my residents, but that was my first contact through Don Barron. But I didn't have much success in physiology, and I spent two years in it. The second year I spent much more working with Dan [Daniel C.] Darrow on the whole matter of potassium loss and diarrhea. I got really very interested in fluid therapy and that started a whole series. DR. GRAYSON: Who were some of the folks at Yale when you were there at this particular time? DR. COOKE: Well Grover [F.] Powers was Chairman, and Paul Boisvert was in infectious disease. Jim [James D.] Trask was in infectious disease as the more senior guy who had done the polio work. He and John [Rodman] Paul, you remember, were the ones that tracked poliovirus into the GI tract and the epidemics of polio were probably from the GI route. DR. GRAYSON: These were in the early '50s, I guess, we’re talking about. DR. COOKE: Yes, this would be early '50s, actually I think my fellowship was '48 to '50, wasn’t it? It's probably in my CV, the exact date. Herb [Herbert C.] Miller was there working before he went out to Kansas. It was a very, very good department of pediatrics. Powers had done a wonderful job. Edie Jackson, Edith [B.] Jackson, was a child psychiatrist and over at the Child Studies Center, in what was then called the Institute of Human Relations at Yale, was Arnold [L.] Gesell. And with him was Catherine Amatruda, and they did that first book on developmental pediatrics; basically they were the first of the developmentalists. And I remember Arnold Gesell very well as a student and as an intern. We didn't see a lot of him, but I was really enormously impressed with how far ahead of his time he was. Arnold Gesell, I did a kind of study of Arnold a while back, nothing very deep, but Arnold Gesell in about 1912 to '14, was doing some investigations. DR. GRAYSON: Way back then.

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DR. COOKE: Way back, and it wasn’t until the '20s that he published a lot; but he had published a little bit around 1914 or so on early child development. He did all his scales and things, and people haven't added a heck of a lot since that time. DR. GRAYSON: He was a pioneer. DR. COOKE: Oh, absolutely. And never properly recognized. He was an extremely verbose guy, and I think he probably drove people away a little bit by his verbosity. For instance, he had a teaching device, which I thought was fantastic. He took a baby, let's say at four months, and he did motion pictures of him, of the baby manipulating objects and so forth. Then he took the same baby at eight months. And he would mount the film together in a split screen, and you would see this same baby at four months and at eight months, manipulating objects entirely differently. It's a wonderful teaching tool; it hasn't been used much since that time. And Gesell, instead of calling it, you know, double screen or something, he always referred to it as split cinematography. And it was never motion pictures; it was always cinematography. It was rather typical of Arnold Gesell that he used the biggest words he could possibly find to say the simplest things. DR. GRAYSON: Was he an MD? Or PhD? DR. COOKE: PhD. You know, I’m not sure whether he got his MD later, but his first work—I think he stayed a PhD. But he was really a genius. You know how he'd collect his material? Arnold Gesell had a little bag of toys, and it was the same toys that people used later to see what the child did in fine motor work and so forth. And he would go house-to-house with this little bag of toys and ask the housewives if they would mind if he did some play with the children. And then he would record this information very carefully, and that's what made up his standards. DR. GRAYSON: That's interesting. He had a great following after he was there in development pediatrics. Yale has been outstanding. DR. COOKE: Oh, absolutely. But you know, Gesell was shunted off, so he started his own institute. He was actually shunted out of Yale after a number of years, and started the Gesell Institute [of Human Development]. Unfortunately, Amatruda died quite young; she was extraordinarily competent. DR. GRAYSON: Milton [J.] Senn. DR. COOKE: And then Milton Senn came along. Milton Senn was my chief about the time I went to [Johns] Hopkins [University School of Medicine]; he was there for a few years.

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DR. GRAYSON: I'm trying to remember the name of the pediatrician who started Head Start or at least was an advisor to Head Start from Yale. DR. COOKE: That was me. DR. GRAYSON: Yes, you, but there was somebody else there then. I’m trying to remember his name. DR. COOKE: Well, there was , Ed [Edward] . DR. GRAYSON: Oh, Ed . DR. COOKE: Yes, Ed Zigler didn't start Head Start; that's one of the things that gets a little bit corrupted. DR. GRAYSON: Well, I'm glad I asked the question. DR. COOKE: I'll tell you the Head Start story eventually. DR. GRAYSON: Ok. DR. COOKE: But Ed, unfortunately, has been designated as the creator of Head Start but that wasn't quite right. Ed was not a pediatrician, you know, Ed was a psychologist. DR. GRAYSON: It's important to put this down somewhere in the records, by those of you who remember this firsthand. I did read about Head Start and I want to go into that more. I was a strong supporter of it at the time, in spite of the problem the Academy was having with [Robert S.] Mendelsohn. That’s another story. DR. COOKE: I know. DR. GRAYSON: But I was a consultant down our way and was involved in it. You went to Hopkins then in '56? DR. COOKE: Yes, I went to Hopkins in '56. My work at Yale was primarily in electrolyte work. And we did a lot of work that somehow got the attention. I was trying to figure out when I was writing this thing for my talk, how come I got picked for Hopkins. I'm really never sure why. DR. GRAYSON: Who was chief preceding you? DR. COOKE: At Hopkins? [Francis] Schwentker?

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DR. GRAYSON: Oh, I don't know anything about that. [Edwards A.] Park is the only one I remember. DR. COOKE: Yes, Schwentker had a relatively short time there. He was in infectious disease, and had a very unfortunate, tragic death. DR. GRAYSON: Oh, sorry to hear that. DR. COOKE: Lawson Wilkins was acting for a little while, before they recruited me. And there were really great people at Hopkins , but the department as a kind of institution deteriorated very significantly after Schwentker’s death. And the residency didn't fill, and so it really is amazing. DR. GRAYSON: Interesting. DR. COOKE: But one of the interesting things--you know, even up through Park's time, pediatrics was an elective. And with Wilkins becoming acting, and the promise of a permanent chairman, they made pediatrics a required course just that year. DR. GRAYSON: That's interesting, because it was already required at Columbia. DR. COOKE: Oh, yes, most… DR. GRAYSON: [Rustin] McIntosh was very active, and had a very good department with a lot of very interesting, and good people there, as you know. You were there for about 16 years, if I remember? DR. COOKE: Yes, I think 17 years, '56 to '73. DR. GRAYSON: Our paths almost crossed as I mentioned to you over the phone. Our daughter trained at [Harriet Lane]. She was a Harvard Med [Medical] School graduate. She was married, and she and her husband needed to get appointments together. So he was at the NIH [National Institutes of Health] and she trained at Hopkins, at the time Bob [Robert M.] Blizzard was acting. And of course we had Bill [William L.] Nyhan, who came down to Miami and was a very interesting and very important person. He was the one that really began to build the department. DR. COOKE: Oh, he did. He did. Bill was a great scientist, he really was. DR. GRAYSON: Brought in some really great people. And I think that’s when the Mailman [Child Development Center] down there began to take off with Bill.

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How did you get interested in developmental pediatrics? DR. COOKE: Well, let me tell you that story, because that's a long one and it really made an enormous change in a lot of things in pediatrics and other areas. When I took over Hopkins , as I say, the place was somewhat in the doldrums, and we had a terrible physical plant. I mean, Harriet Lane [Home for Invalid Children] was a great name, but it was physically very, very difficult. I give you a couple of anecdotes about that because they might be of some interest. The day I arrived, I found a letter on my desk, which was a letter of resignation from Helen [B.] Taussig. And she said in the letter that if I wanted to replace her, she understood perfectly, if I wanted to rebuild the department. So, you can imagine, I’m 35 years old and I’m gonna replace HelenTaussig. Wilkins was very supportive. He had his own little empire, but was just an excellent man to work with. He was so pleased to get out of the job of being chairman, because he hated that kind of administrative-like stuff. I went over to see Leo Kanner who, as you remember, was the father of autism and I think, at that time, the leading person in child psychiatry in America. Leo was in a little office in one of the wings of the Harriet Lane. It looked like a closet, it was dank and dark, and with great flakes of paint coming off the ceiling. And we talked a little bit, and Leo said "What is the time table for the new children's medical center?" And I said, "It ought to be completed in about four years." And Leo said, "It's absolutely on time," he said, "When I came in 1929 they told me it was four years away." [Laughs] Leo was a remarkable man, great sense of humor. DR. GRAYSON: His textbook was one that we all used and knew. DR. COOKE: He was a terrific fellow. And so 1958, '59 and so forth, those are watershed years, and the [Johns Hopkins] Children's Center was built as a result of the merging of three groups. There was a Eudowood TB [Tuberculosis] Sanitarium for children, which, as TB disappeared, the need disappeared. They had sold their land for an enormous sum of money because a giant shopping center was built on it; it was the first big shopping center on the edges of Baltimore. So they had a lot of money that couldn't be used for TB much anymore. And Robert Garrett, who was the lawyer for the B&O [Baltimore and Ohio] Railroad, when the railroads were really robber barons, had put a large sum of money aside for a surgical hospital for children. And Barry Wood, the great Harvard football player, was the vice president for medical affairs, and Barry planned to bring some people down to try to bring all these together. Grover Powers , my old chief, was one. Robert Gross, the pediatric surgeon at Harvard, was the surgical representative on this whole

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committee, and Walsh McDermott, who was a professor of medicine at Cornell [University]. The three of them came down and they provided a report, which indicated how much more could be accomplished if these people in the Harriet Lane pooled resources with the hospital to build the Children's Center. I think that was in 1957, and they brought together about 35 million dollars, which at that time was a lot of money. And so that got the Children's Center underpinning and so the planning was started, etc. Then, about a year later, I got a call from Dick [Richard] Masland who had done this book for the Association for Retarded Citizens, then the National Association for Retarded Children, on mental subnormality. Which is a fantastic book, done back in '56 or '57. Excellent. DR. GRAYSON: The name of that again? DR. COOKE: Mental Subnormality [New York: Basic Books, 1958]. Masland and two psychologists from Yale, whose names escape me at the moment [Seymour B. Sarason, Thomas Gladwin]. But anyway, he'd become associate director at the National Institute of Neurological Diseases and Blindness, and then became director. And he called me and said that he'd been asked by the [Joseph P.] Kennedy [Jr.] Foundation to solicit some proposals for research in the field of mental retardation. So I wrote a proposal to them, and I had some personal things because I had two profoundly retarded children. [Cri du Chat]. DR. GRAYSON: Oh, really. DR. COOKE: Yes, they were the first Cri du Chat diagnosed in this country. A diagnosis was made by a cyto-geneticist up at Yale. And that was just about six months after [Jerome] Lajeune described Cri du Chat. And these two children were absolutely textbook Cri du Chat. One has died, the other is at the Southburg Training School in Connecticut; she's now 45 years old. And I think [she is] the oldest living one, profoundly retarded, and very medically fragile now, but still surviving. But anyway, they knew my personal interest, I think, and so they came to see me at the Harriet Lane. I remember the visit so well. It was Mrs. [Eunice Kennedy] Shriver, the president's sister, and her husband, [Robert] Sargent Shriver [Jr.], who ran for vice-president along with [George] McGovern (not very successfully). [Laughs] Two or three other people were along for the site visit. And they sat in my office in Harriet Lane. It was kind of a dumpy place, and we went on and I had the notion that they would be interested in something that encompassed a good part of the medical school if not the university. And so I had four candidates that I proposed as Kennedy scholars. One of them was Don [Donald N.] Medearis [Jr.], who became chairman, just retired at Mass General [Massachusetts General Hospital], he was in virology working

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on CMV [cytomegalovirus]. And John Menkes, who was the discoverer of maple syrup urine disease, and Menkes kinky hair syndrome and so forth; he was a neurologist. A man named Andre Hellegers , who was in obstetrics, and later founded the Kennedy Institute of Ethics at Georgetown [University]. And Henry VanderLoos who was in neuro-anatomy. It was a big surprise to these people to find someone asking for money for other departments instead of just my own. Medearis was the only one in my department. And we proposed support of these people, some funds to build laboratories at Hopkins in the new Children's Center, and a fluid research fund, which I had used for my work at Yale. A fluid research fund was money that was sort of collected from various sources, and it was Yale’s to support local research. And you'd apply with a simple application and much of the work that Darrow and Ed [Edward L.] Pratt, who was a fellow at the time at Yale, who then went on to Cincinnati, was supported by money from the fluid research fund instead of from the NIH. And I had this fluid research fund, which allowed grants to be made around the university concerning the mental retardation problem. It was a very useful way of getting other people interested, to have that money dangling for them to get projects going. So they gave us a grant of $1.2 million, which in 1958 was a whopping grant. And so my own personal interest in the field of developmental work got expanded a good deal by this money. And over the course of the next several years, the amount of money from the Kennedy Foundation probably exceeded a couple million dollars, which was a whale of a lot in 1958. DR. GRAYSON: That was for bricks and mortar as well as for teaching? DR. COOKE: Well, the bricks and mortar was a relatively small part of it. We started sort of the first course in mental retardation, and the important part of it wasn't so much the grant as what this led to subsequently. About a year later, John [F.] Kennedy was campaigning for president, and he asked me to write some material for his campaign. I wrote some stuff on child health, which I don't think he ever used, but he was elected. The day after his election, I got a telephone call from Wilbur Cohen, who later became Secretary of the Department of Health, Education and Welfare. Wilbur Cohen at that time was at [University of] Michigan, in social work. He was dean of the School of Education, as I remember. And Wilbur asked me to serve on the transition Task Force on Health and Social Security for the new Kennedy administration. I'm sure he called me because Mrs. Shriver remembered my stuff on mental retardation; that was her great interest. I'd had contact with her and with her husband and some of the things they were doing after the grant, and so I accepted.

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The transition Task Force is, to me, one of the most interesting things historically. The transition Task Force for Health and Social Security for the Kennedy administration consisted of Wilbur Cohen as chairman; a guy named Jim [James] Dixon who was a pediatrician who actually had gone into public health in Colorado, who became president of Antioch College at that particular time; a man named Dean Clark who was the administrator for the Massachusetts General Hospital; Red [Herman M.] Somers , who was at Haverford College as an economist; and someone named Elizabeth Wickenden, who was a social worker (but she wasn't on the task force actually; she was kind of an observer, but she was a good friend of Lyndon Johnson’s,) and Josh [Joshua] Lederberg who was the Nobel prize winner out in California, who never attended because we had no travel money. We had no secretarial money; we had no per diems; we had nothing. Wilbur Cohen had a portable typewriter, and that task force met in the Mayflower Hotel. It was in November. The heat was on full blast in the Mayflower; you couldn't open the windows and we couldn't shut off the heat. We sat there in our shirtsleeves sweating away, while Wilbur with his portable typewriter typed this transition report. Included in that transition report were recommendations for medical care for the elderly, the National Institute of Child Health and Human Development, the Institute of Medicine , and some changes in the aid to dependent children. DR. GRAYSON: Really. DR. COOKE: About the National Institute of Child Health, they asked me what ought to be done for children. I had had a very interesting experience a month or two before that, which led to this particular suggestion of mine. NIH had come out with a program for clinical research centers that were to be placed in various universities around the country. They permitted patients to be studied in the hospital at no expense to the patient, no expense to the hospital, and no expense to the third parties. A lot of it was laboratory investigation, so that laboratories would be paid for and so forth--a very good idea. But the only problem was, it was just for adults. And that really got my dander up. I didn't know the NIH hierarchy particularly well. But Harry [H.] Gordon, who was then the chief at Sinai Hospital [of Baltimore] and in my department as associate professor at the time, was familiar with the bureaucracy. I called up Harry Gordon and I said, "I'd like to go see Jim [James A.] Shannon," who was the head of NIH at that particular time. I was pretty sure Harry knew him. And Harry said, "Fine, we'll go over and see him." So we went over to see Shannon, in Building 1 at NIH, and sat down in Shannon's office. I started out and explained that this new proposed clinical research center was a great idea, but they had left out children, and I thought

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that was very unfair and should be corrected. Shannon said, and this is almost a quote, "You know, there are no death-dealing diseases in childhood. Any grandmother could care for children, and they do not need any special research." Well, that’s the way the meeting ended. So that was about it for a period of time. DR. GRAYSON: I had asked Bob Cooke about Harriet Lane and how it got its name, and he was just explaining this to me. If I can trouble you just to go back to that little bit again, Bob. DR. COOKE: Yes, this was the niece of a president, and I have to check it out but I think it was [James] Buchanan, who was the bachelor president. She was hostess in the White House. [She] married a wealthy merchant and they had two children, who both died of rheumatic fever in their early childhood. In response to that, her husband gave a considerable amount of money to create the children's hospital in Baltimore, and it was named after his wife, Harriet Lane. That was amalgamated with Johns Hopkins Hospital, but as a kind of separate entity, with its own board of managers. The building was actually built by [Clemens] von Pirquet in the early part of the 20th century. The exact date I don't remember, but von Pirquet had come from Austria as a great allergist in pediatrics. He stayed, I think, a year, possibly two; evidently hated the summers in Baltimore, hated the way he was treated, and he went back to Austria. The next academic year opened, they didn't hear from von Pirquet. It went on, I guess, for months and they never heard from him. They tried to contact him; he never replied. Finally, they decided he wasn't coming back. Then there was a search, and John Howland was then chosen as chairman, and Howland came and really brought science to pediatrics for the first time. That was Howland's great contribution, and the department flourished. But the Harriet Lane Home was a remarkable physical structure, which bore the imprint of von Pirquet. Von Pirquet’s office was off the amphitheater. There were some steps down from his office to the amphitheater, so he could enter in a way that nobody else could, which was very important. And there were no seats in the amphitheater, there was basically almost shelving. There were wide platforms and people would stand while great grand rounds and von Pirquet's lectures and so on were conducted. Afterwards some kind of wooden seats, that looked a little bit like a potty chair, were put down on those. They moved around, but at least you could sit on something other than the marble flooring, and people didn't have to stand any longer. But he also designed the building so that I think the net space to gross must have been about 40%, because it was all corridors. I'm told that is the reason for the huge wide stairway in the center of the building. That's so von

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Pirquet could climb the steps, and parade with his entourage to either side so they could hear all these words of wisdom. That was the design of the Harriet Lane. There was an elevator in the Harriet Lane that had copper doors that moved literally at a snails’ pace. Dr. [Edwards A.] Park at one time remarked, I'm told, that this elevator had held up science more than any other instrument he knew of. DR. GRAYSON: [Laughs] DR. COOKE: I can remember very well; it was the kind of elevator that you had to slam the doors closed and if they weren't closed tight, it wouldn't move. So somebody would go upstairs, not close the doors properly, and people down below would bang on the doors until someone would come along and open them up. [Laughs] But there was a laboratory on the top floor when I went to Hopkins, which was so hot (there was no air conditioning obviously then, and the electrical circuits were inadequate to carry any window air conditioners) that the scientists working up there, and there were a number of good ones, put Reynolds Wrap up on the windows. The whole place looked like an aluminum structure. I’d describe it as an aluminum palace, with Reynolds Wrap trying to keep the heat out of this top floor. It was really just, just awful. But a lot of good work got done up there, and there were some really terrific people; and young people as well as older people. Taussig and Wilkins, and Harriet Guild was there, Leo Kanner. There were some young people who were really excellent. Bill [William] Zinkham was there in hematology as a young guy; Barton Childs , who sort of revolutionized thinking about genetics in pediatrics, was there as a young man, Leon Eisenberg in child psychiatry; Katherine Neill was there in cardiology; a number of very good young people. And Mel [Mary Ellen] Avery was a first year resident. There was great potential there, even though it hadn't been developed adequately, I think. A group came down from Yale with me, students followed and some residents. One was Jerry [Gerald] Odell, who became Mr. Bilirubin in pediatrics. Another was Saul Brusilow who has done all this really wonderful work in urea cycle disease. Then Norm [Norman] Fost came down, who became kind of the bioethics man eventually. Norm came down from Yale. Fred Battaglia, as I mentioned, who is really a great, great guy. I guess he’s president of the American Pediatric Society now. And Guy McKhann who was really, I think, probably the greatest pediatric neurologist in the world, came as a resident. So we were very fortunate in getting some terrific residents, and the place began to grow and prosper. You know, you get one crop of residents and that attracts another crop of good residents, and so forth.

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Now one of the things that helped us a lot, Waldo Nelson took over the Journal of Pediatrics about, I would have thought, '57 or so. Pretty close to the time I went to Hopkins, and he asked me to join the board. And the Journal was in its doldrums at that particular time. It was tough getting good articles, so I asked Waldo if he would mind having a Hopkins issue. So he agreed, and we had a Hopkins issue, a special issue on work that was going on at our place. And as I look back, I think it was a great advertising tool for Hopkins , because it really was a very good issue that showed all the good work that was going on there. But to get back to this political issue, after the gift from the Kennedy Foundation, I had quite a lot of contact with the Kennedy administration, with the President, the President’s panel. One of the things that, as I mentioned, I don’t know was it on the record or were we just talking informally, but how places like the Mailman Child Development Center got going. DR. GRAYSON: I would be interested in hearing this. DR. COOKE: The President’s transition panel made its report to the President, and he accepted the report and went ahead with implementation. Part of the report was the proposal to create some ten mental retardation research centers around the country. And they were basically going to be copies of what we were starting at Hopkins with the Kennedy money. But these had to be built and so the recommendation to the President was to build these research centers. In response to that report and the report of this Joint Commission on Mental Illness and Health, which had taken place a couple of years before, the President put together a message on mental health and mental retardation. And he sent this out to his sister, Eunice Shriver, with a comment that the mental retardation report didn't seem to have very much in the way of interest, wasn't much exciting there. So she asked me if there was something I had thought of which might be more exciting. I had visited and sent one of my students to Rosewood [State Hospital] and was so depressed by the visit, describing it as a zoo, "that human zoo." I had also gone to the [Henry] Phipps [Psychiatric Clinic], which was the mental health center and psychiatric center on the grounds of the Hopkins hospital, and the contrast seemed so great. So I suggested to Eunice Shriver that what we needed were facilities like the Phipps on the grounds of the major medical centers. I described interdisciplinary training programs and service programs and clinical research that could be done there. She thought it was a good idea, asked me to write a couple of paragraphs, which I did. A few weeks later, I guess, they appeared in the President’s message on mental health and mental retardation. He described the research centers, but also these new university-affiliated facilities for the mentally retarded. The bill

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provided a considerable amount of money for construction of what was the Mailman Center at [University of] Miami, and some for 15 such university affiliated facilities that were built, and funded 75% by the federal government, 25% other private sources. DR. GRAYSON: That's what I was going to ask. Was this Hill-Burton money? DR. COOKE: Well, actually it wasn't; it was a special appropriation. But you're right, the agency that administered that money was the Hill-Burton agency. And they appointed a committee to supervise the review of proposals and so forth. It's interesting how that worked out. There were two factions on the committee, one representing the educators, and the other representing the more medical side. And applications from places like the Mailman and Hopkins and Children's Hospital and so forth, when I was at the meetings would end up being approved. And when I wasn't there, the education ones would be approved. [Laughs] And so we had two kinds of places, one where the emphasis was rather heavily medical, and the other emphasis heavily educational and social. And then what's happened in that has been a proliferation of those, not in terms of physical plants because the money stopped with the Vietnam War. The Johnson administration just stopped pretty much every social program at that particular time, that required a lot of money, and so the original 15 existed. But then the others came along as so-called university-affiliated programs, which carry on the original mission but without the physical plant and so forth. They've done very well. They really have been amazingly successful as centers for training of pediatricians, particularly in child development and abnormalities in child development. With the Kennedy Institute in Baltimore, I think, being an extraordinarily successful place. Its budget is up now to $40 million a year.

DR. GRAYSON: An interesting thing about the Mailman is change, since Rod Howell came on board as chairman of the department at the University of Miami. For a long time the Mailman was not considered part of the Department of Pediatrics. It sat sort of isolated from pediatrics. When Rod Howell joined the department, he said, "Yes, this is pediatrics. It is all part of the whole." He moved his departmental office to the Mailman building, recognized developmental pediatrics as part of the pediatric program, and the residents are much more involved. DR. COOKE: Well, we had the advantage that when the Kennedy Institute was built in Baltimore, why, I was chairman and that was my major interest. That was a big interest of mine so we kept a tight hold on it. But I think it's been pretty successful, and I can remember visiting the Mailman many times. And at times it was like the morgue, there were no patients there and it was very quiet. Nice, beautiful building and interiors, but it

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didn't seem to have the spark that was needed. And, I'm sure Rod has made this a much more vibrant place. DR. GRAYSON: He's been concerned with research and this is, of course, what the Mailman is doing so much of, not only laboratory research but clinical research too. We're following our premature babies now developmentally much more than they ever did with interesting results. So I look to the Kennedy Foundation as being the beginning really, in our era of developmental pediatrics. DR. COOKE: I think that's sort of been true all over the country. Actually this was the spark that got this going, and the number of developmental pediatricians is now increased very substantially. But the university-affiliated programs are in every state now; Congress has provided money for these and it's been a successful venture. DR. GRAYSON: I don't think the Kennedy Foundation has gotten enough recognition on this. There are lots of reasons; it’s political as much as anything, and you don't like to give somebody credit if they're not on your political side, so to speak. Tell me a little bit about Head Start, Bob. We started this before. I know you were very much involved with this. DR. COOKE: My contacts with the Shrivers continued over the next few years, and when the Johnson administration decided on the "War on Poverty," why, they picked Sargent Shriver to head this war on poverty. Then, I think he'd been there about four or five months, when he called me up one day and said that he'd like me to help out in doing something about children. The term was, "to break the cycle of poverty," which was almost like a genetic situation where it's handed down from one generation to the next. And he then arranged for me to work with some of the administrative people in his Office of Economic Opportunity. And he would arrange for a car to pick me up in Baltimore, bring me down to Washington, and I worked with some of the people in Washington. The program for children had no name at that particular moment. There were a bunch of names tossed around and someone, I don't know who it was, said, "Why don't we call it Head Start?" I think Shriver takes credit for the name, maybe it is, but maybe it's somebody else; but, anyway, he certainly approved of it. This new children's program was to be an educational program. It was to be essentially a pre-kindergarten program. And that didn't seem to me to be quite adequate. I remember inviting Ed Davens , who was on my staff at Hopkins but was commissioner of health for the state of Maryland, and he and I spent a luncheon talking about what Head Start ought to be. And we decided it ought to be a comprehensive child development program. That meant it ought to have a health component; it ought to have a nutritional component; it ought to have parents involved in some way and have some kind of an educational program.

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Well then, how are we going to start this thing? The first step was to try to get together a planning group. Well, I had had some experience; I'd given a lecture out in Minneapolis a few years before that on some aspect of child development, mental retardation or something, and on the same program there was a young guy from Yale named Ed Zigler. And Ed told about his experiments using children, both retarded and normal, in which he would set up these artificial games in which you either won whether you did the game right or didn't, or you lost whether you did it right or not. And after a number of unsuccessful experiences, your whole learning approach changed. Or, if you were real successful. And he talked about this as inwardly and outwardly directed. Well I remembered that talk, and it struck me that one of the things that was so difficult for these children of poor people was repeated failure. So I thought, well, motivation is a terribly important element in the lives of these children, so let's get Ed Zigler on the committee, so Ed was recruited. And then on NICHD’s council, that had been put together some months before that, there was a man named Urie Bronfenbrenner from Cornell. Well, Urie was very interested in the family. And he wrote about the importance of the family in the development of the child, and so I recruited Urie Bronfenbrenner to develop the family part of it. And then there were several others in the nutrition area and particularly in the early education area, child psych. [E.] Perry Crump [Jr.], who was the professor at Meharry [Medical College], and had a lot of experience with minority children obviously. So we recruited Perry, and this steering committee was put together. I was contacted by the White House, Christmas Day of '64 I guess. They asked me if I would be the head of this steering committee that was going to do Head Start, and I obviously said yes, and we put this committee together. And I think our first meeting probably was in February and by May we had the whole Head Start outlined. We submitted a report to Sargent Shriver which has carried the name of the "Cooke Memorandum" ever since. It was about two pages that I wrote, describing what this new program would be and why it was needed and so forth. And so it was launched originally for a relatively small number of children, and Shriver, who never thinks small, said, "We've got to do this in terms of hundreds of thousands." And it was a very interesting debate. The committee was made up largely of academicians, as you can imagine, and so they thought it would be very important to have a pilot study. And Shriver says, "The pilot study will never get off the ground; you've got to launch it." I agreed with him, and so this was launched in June of that same year. And I don't remember exactly the number of children involved, but it was about 100,000 children the first year.

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DR. GRAYSON: Was Shriver still on board even though Johnson was President at that time? DR. COOKE: Yes, Johnson had asked him to stay on. You see the Office of Economic Opportunity was created by Johnson. And Sargent Shriver had run the Peace Corps. Kennedy had appointed him to organize and run the Peace Corps, and then Johnson moved him over from Peace Corps over to the war on poverty, Office of Economic Opportunity. And so he was intimately involved in that. His idea for Head Start actually, looking back, came from the work of Susan Gray, who was a psychologist at Peabody College in Nashville. And he'd gone down there looking at them for a grant to create a [John F.] Kennedy Center [for Research on Human Development] down in Peabody. Susan Gray presented her work with children of impoverished families, intellectually impoverished as well as economically impoverished, and he was very impressed with how much improved these children were in their development with intervention. And so he thought they ought to do the same thing with all children, and that was really why he pushed Head Start. DR. GRAYSON: The early reports were very encouraging. The one comment that was made, as I remember it, is that this should have gone on for several more years, because you lost ground if you didn't continue a little bit longer. DR. COOKE: Well, the early reports were unreasonably encouraging--that a few months' exposure made these great differences in IQ. Leon Eisenberg, who was a pretty good man as a child psychiatrist, wrote that they had gained—I don’t know—15 points in a few months in IQ. Everyone thought this was just miraculous, all these improvements. But I think what was happening, looking back, was that everyone was teaching to the test. Nobody will read this, I hope, because I don’t want them to cut off funds for Head Start; but I think a lot of their early enthusiasm was because people were doing things with these children that were things not done intentionally, but things that were measured actually in developmental testing. And so the children did well because they were experienced in doing those things. Whereas the kids that didn’t have the Head Start training, this was all new to them. DR. GRAYSON: The same thing is happening with the SATs [Scholastic Aptitude Test] now. Our granddaughter is in her junior year, and they take preliminary courses on SATs, I mean, they're preparing… DR. COOKE: I wish they did that at my school, where my kids go. But it's what I call teaching to the test. And every time somebody comes along, now take the

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Rameys [Craig and Sharon] who are doing really beautiful work in child development in the Carolinas. But always, you have to ask yourself, is this because these kids are being taught to the test without the exact realization by the teachers? Child development just has a certain number of motor items, a certain number of fine motor and language and so forth, and if you drill kids along those lines, you're obviously going to improve their performance. And does that mean their cognition is that much improved? I have a little trouble with that one. DR. GRAYSON: The question is, can they cope with every day life because of this? Regardless of scores--forget scores--do they do better in what they have to do because of the skill training? It may be that it's a combination. DR. COOKE: There's controversy. There's controversy. On the other hand, if you have no experience, it's sort of like starting all over again, you know, every time. So, it may improve social behavior a good deal and so forth, but I don't think that the truly super scientific confirmation of all these benefits has come along yet. Somebody takes a piece out of this study, and somebody takes a piece out of that study, and somebody else, to show that the long term benefits are considerable, but I think the evidence is still slim. On the other hand, I know darn well it's better than sitting at home and looking at a TV tube. DR. GRAYSON: How does Head Start stand now? I notice there's an increase of funding. DR. COOKE: Oh, it's up in the billions now. DR. GRAYSON: Now. Still there's a long way to go; they're not reaching enough kids. DR. COOKE: Well, they're reaching out to a fair amount. I think the big interest now is in quality and more follow-through. As you pointed out, do you get enough out of that initial exposure to carry you on, or should there be more? Now, transition into school is improved; I think the kids are unquestionably better prepared for school than they were. They're in better health; immunizations are considerably better. The most convincing part of the benefits of Head Start has been in the medical, nutritional and parent involvement. The academic is still more controversial, I would think. But they’re doing some with the disabled, although I think probably not as much as they might; but, it’s a significant part of Head Start now. I've said many times; I think it's probably the most successful social experiment of the 20th century. But the remarkable thing was how easy it was to get it going. I mean, as I look back, it was so easy to get the National Institute of Child Health. It was so easy to get mental retardation centers and

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research centers and UAFs [University Affiliated Facility] going. I mean, it really was. Each one of those, I can remember going and testifying before Congress, and it was a matter of a couple of days. When I think of the President's Task Force on National Health Care Reform of the [William J.] Clinton administration, we (the Kennedy committee) spent maybe five bucks, and they (Clinton) spent about 15 million. And we got more accomplished in a few days with no dollars than they've accomplished now. Everything has just seemed to me to be so controversial now; there wouldn't be university-affiliated facilities built now. I don't care what, there wouldn't be MR [mental retardation] research centers, wouldn't be a National Institute of Child Health. You know, I think that everything is politicked to death, almost, at the present time. It's very discouraging. DR. GRAYSON: It sure is. I mean, here your account of how you were able to get something done through an administration, through Congress. Our experience in the Academy now has been mostly, much more difficult to get anything through. We came up a few years ago, while I was still on the Board, with actually a legislative program to provide health care for children and pregnant women. It was a small part of health care. And we worked hard to get it; we spent a lot of money to get the thing going. Yet it never got anywhere because nobody was willing to be involved out front. DR. COOKE: Well, there are so many competing interests. And for some reason right from the top down there was real interest in doing things at that time. And as I look back, I've had a lot of accomplishments, but I just know I never could have those accomplishments now. DR. GRAYSON: Much harder. DR. COOKE: Oh, never would succeed doing that. DR. GRAYSON: Here the Clintons came in with a very important concept, which was comparable to what Kennedy and Johnson wanted to do. And it was ripped apart for many reasons. Their advisors were not the ones that probably should have been involved with it, but, whatever; it's been much more difficult to get anything accomplished. Any one little part of health care now is a real battle. And it isn't always money; it's turf. DR. COOKE: Yes, absolutely. DR. GRAYSON: In your relationship with the Academy of Pediatrics, I notice that you chaired committees, obviously you worked with a lot of people in the Academy. The Academy has become more politically active now than it was in the ‘60s, when we didn't even have a Washington office. We didn't have a lot of people in the administration and in the executive branch of the Academy who were willing to

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work hard for advocacy for kids. What do you see is the role of the Academy now, speaking for 50,000 people involved in pediatrics? DR. COOKE: Well, you know, I certainly applaud what they’re trying to do. I think there's a terrible handicap though, and that is that whatever an organization does like that is regarded with suspicion by the Congress as self-serving. That's the great handicap to any kind of political activity. If I were to criticize the Academy, which I have no right to do but I don't hesitate (laughs), I think they've got to work through parents much more. I think the power in this country does not rest with professional organizations, as much as they might think because of their knowledge base and better understanding of need, but I think they have to work through the parent. I can look back in my own experience with NICHD; I think the PTA was a substantial help. Now the Academy was in on it, too, but I think people in Congress probably listened more to a parent group even then, than they did to professional groups, and it’s gotten much worse now. I mean anybody that comes up with a block of people, whether they're gay or whether they're parents or whatever else, that has a lot of clout. DR. GRAYSON: Sure it does. DR. COOKE: And I think that (although I don't know enough about what the Academy is doing, which is my fault), they have to develop their power base with parents. I have to tell you something that isn't in my CV but it's relevant to this. In the middle of the [Richard M.] Nixon administration, I got very depressed about what was happening in Vietnam, and we had just moved into Cambodia. I had some odd funds, actually came from a financial deal I had worked out with Yearbook Publishers for the Harriet Lane Handbook. I had some money, and I wrote and had printed a folder, which explained the divisiveness of the war in families and how we ought to end the Vietnamese war, pull out. Well, that was printed and it was mailed, a sample copy; I’m sure you got one. It was mailed to every pediatrician in the country; we had the mailing list. These were to be left in pediatricians' offices, for parents to take if they wanted to. There was a tear-off section, and if the parent took the thing they could it tear off and send it in to the White House, saying that they as a parent were concerned about the Vietnam war and it was divisive to families, etc. Well, to my knowledge, there were literally thousands of these sent to the White House, it was probably the largest mailing campaign, and I got letters from people around the country saying I was a Communist. DR. GRAYSON: Of course.

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DR. COOKE: And that I didn't support our fighting forces and, "Go back to the Soviet Union," and so forth and so forth. It was really pretty bad. But a lot of people evidently wrote in and sent these in. About five months later I got a letter, signed by President Nixon, thanking me for his support of the Vietnamese, of the campaign in Vietnam. [Laughs] DR. GRAYSON: [Laughs] Talk about the spin on things. DR. COOKE: Signed by Richard Nixon! But in between, what happened was that the IRS [Internal Revenue Service] came and investigated the Johns Hopkins Hospital, threatened to take away their privilege as a 501(c)3. They investigated my finances. DR. GRAYSON: That’s interesting. I think you had mentioned Jim Lancaster, when I spoke with you. DR. COOKE: Yes. DR. GRAYSON: 'Cause this ties in with something there. Jim was a very honest guy. He got up in a meeting of the Miami Pediatrics Society one time, our annual meeting. This was at the time of Kent State, and he had written a poem criticizing Nixon, criticizing Kent State, criticizing the war, and it was amazing how people were hostile to him. They were so nasty to him because he took a stand on something that was morally wrong. And you know, but Jim was brave enough to read it aloud. DR. COOKE: I'm interested. We were along the same line. DR. GRAYSON: Yes, about the pigs at Kent State and so forth, you know. Oh, it was a hard time for this country. DR. COOKE: Oh, it was, I know. But the sequel of that thank you note by Richard Nixon was really… DR. GRAYSON: Now about medical education, I know that you're concerned about this. I've read some of the comments that you made at the [John] Howland [Award] acceptance speech about the subspecialties in pediatrics, how researchers divide. Tell us a little bit about your ideas on this, Bob. DR. COOKE: Yes, well, I wish I knew how to solve the problem. I can identify the problem, but how to solve it is a different situation. What's happened, obviously, is that medicine has become so much more complicated than it used to be. You can be a damn good pediatrician and not know enough about many different areas to be able to handle them in the most effective way. And so, as a consequence, there's been more and more and more specialization; some of it probably necessary and some of it not.

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Why the specialization, I think, has probably been more to compete in the research arena more than anything else. That to me has been one of the most serious problems in terms of the financing of academic pediatrics. And as I pointed out in the Howland lecture, the subspecialization for competitive research has led to terrible fragmentation, it seems to me, within departments, with subspecialty divisions of one and maybe two people because of the financial limitations. Whereas they're competing against departments of internal medicine, where there are divisions of ten or twelve people. Trying to provide clinical care and do competitive research in each of these subspecialties is almost an impossibility. As a consequence, pediatric research is very, very handicapped it seems to me. The additional handicap, as I pointed out, is that pediatric academic departments care for an awful lot of Medicaid patients, and adult departments care for a lot of Medicare patients. And the reimbursements are utterly different and, as a consequence, departments of medicine have flourished and can afford these subspecialty divisions and their research and their PhDs, who don't earn money from patient care, but indirectly they get their money from patient care. Whereas departments of pediatrics, the researcher is up to his neck taking clinical care of these subspecialty patients and they cannot compete with the adult people for grants. And, as a consequence, we see research by MDs in pediatrics going down and down and down, research by PhDs not in departments of pediatrics going up and up and up. And so the research dollars are drying up for pediatrics. And that doesn't, I think for the long run, bode very well. Now how to turn that around requires, I think, a whole readjustment of reimbursement by Medicaid, which doesn't seem very feasible. And I'm afraid the whole field is going to be plunged into this when they go into more and more managed care. There's going to be more and more competition to get prices down and subcontracts down and so forth, so how you're going to have all these super-specialties financed and have money enough for research, I don't know. So, I think the Academy and I think the Board and all the rest have gone overboard. Do you need a sports medicine subspecialty, you know, in pediatrics? DR. GRAYSON: Well, we wonder about this. Some of that is caused by the practitioners themselves wanting to be identified with a particular thing, and part of it, of course, is the response of the American Board of Pediatrics, in creating the subspecialty qualifications and certifications. And then the residency review committee is the third party in this.

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DR. COOKE: Hospitals are less and less enthusiastic about supporting all these subspecialties. And it's going to get worse with managed care. They're going to have to contract with some provider outfit and if they're supporting a lot of residency training . . . Residency training—I have my own kooky ideas about that. A classmate of mine at Yale, who became president of Yale, Kingman Brewster, Jr. Anyway, he proposed, when he was president of Yale, that there be established an educational bank. And the educational bank was a large fund. He never was very clear as to how it got established in the first place, but it was to basically loan money to students going through college. And that money would be paid back on a percentage of income earned subsequently. The theory was that if college gave you a super start, and you earned a lot of money, then you ought to pay back more than if you went into a job, let's say as teaching; where you'd pay back a percentage, but it would be a much smaller absolute amount. That was the concept, and that money would come back, and that would finance the support of students coming in future years, and so forth. That's the educational thing. I always thought that was a good idea, but for all colleges it would amount to a sum of money that was absolutely out of any realm of practicality. But an educational bank for residency training, you're not talking about hundreds of thousands of college students. You're talking about a relatively small number. And the principle that you would pay back according to earnings always seemed to me to be a reasonable one when you come to specialization and so forth. So I've thought that residency training ought to be financed by an educational bank that the federal government would establish, so residents would be basically paid out of that so that they would not be required to be paid out of service dollars. And where you've got managed care coming in, and they're going to cut down more and more residency training and so forth because it costs a lot; I think someone ought to revive the educational bank theory. You know I've written a little book about health care. I won't bother you with it now. Nobody will publish it, it's too radical. It seems to me that it's a way of keeping training out from dependence on service dollars. Now, a certain percentage of the residents' time is obviously in service, but there ought to be a substantial amount of time too that would be called training, education of residents, and I think that ought to be paid for out of an educational bank. Then the residents, as they become earners, it would be easy enough to collect through the IRS a percentage of the income so that if you're a pediatrician or a general practitioner your absolute payback would be less, would be a percentage of your earnings. The ophthalmologist would pay back a lot, but it wouldn't be any more percentage than anybody else. And I think that idea is one that ought to be thought of.

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The other is the support of research, which I just think has to be financed by the federal government. I can't see HMOs financing research, and I can see hospitals being cut back, and universities have endowments that are not that large. So research is going to disappear if the federal government doesn't support it. The point that I made in my Howland address about research, I think research dollars have to be indexed to service dollars. And the theory behind that is simply based on what every successful industrial operation does. And that is a certain significant portion of their costs are in research and development. If you don't do that, your industry disappears. If you can't keep up with new product development, new approaches, then you don't exist for a long time in industry and I think that's equally true in medicine. We've never indexed our research dollars to our service growth, and as the service thing has gone up into the 900 billion, one trillion pretty soon, research has gone up but it hasn't followed that curve. DR. GRAYSON: Is there a danger in that though? In industry, research is often governed by the financial outcome to the industry supporting that research. In other words, it's research for a particular end, a better product. DR. COOKE: Oh, yes, well I think you have to maintain the belief in the health field that you do a lot of things that don't have a payoff for a long time. I mean, basic research in genetics, for instance. If we didn't have it we'd be years and years and years behind and the future for genetic development is tremendous. And, so you need support, and I've never espoused the notion that if, let's say, because AIDS is a problem that you ought to spend 50 times more money to cure AIDS than a lot of other things. You can't index exactly to the problem; I've never felt that. But if the general budget for service goes up, I think the research budget ought to follow it. And it's never been indexed that way. The research dollars have stayed here and the service dollars have gone up like this, and I think that's not a good way for the health industry to proceed. Now I think some thought in the allocation of dollars has got to go towards asking the question, "Does this have financial benefit?" You've got to give some thought to that; that if you've got coronary disease as a huge fiscal problem because of the costs of heart transplants and triple bypasses, blah, blah, blah. I think you have to give some thought in your research programs to how you prevent these kinds of things. The same way with cancer research and so forth. That's just kind of reasonable in this allocation of resources. But the fundamental principle, I think, that has to guide the funding of research is this notion of indexing the service dollar. DR. GRAYSON: I see what you mean. It's going to be even more so now as they are allocating funds to states, which will be controlled in 50 different states, and this worries me. I mean, I can remember when a lot of the things which were controlled by

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states were never adequate in many states. If Congress were to pass funding into state control, I would be concerned that it would make it even more difficult for medical education and medical research. DR. COOKE: Well, I think they have to be separated from the service arena, and that's why the educational bank approach appeals to me. DR. GRAYSON: I've never heard that concept before, but it's an interesting one. Medical education has become so expensive. I just read an interesting article in the New York Times rather recently, which stated that many of the Ivy League and better universities were what they called "need blind" in their admissions policy; that is, estimate for need came after admitting a person on the basis of quality. But it's going to happen now, with the funds drying up except for some of the major endowed schools, that it's going to be the education of the rich rather than the best. DR. COOKE: Well that's the problem. The educational bank approach might work with medical schools, because you don't have such a large number of students. It wouldn't work at the college level. That was the fallacy of the original proposal. DR. GRAYSON: It wasn't this guy who became president of the National Baseball League? DR. COOKE: No, it's not Giamatti, it was before Giamatti. If you’ve got a second, I’ll get the name. DR. GRAYSON: Ok. DR. COOKE: Yes. The president of Yale that proposed the educational bank was Kingman Brewster. He was in my class at Yale and really a very brilliant man. DR. GRAYSON: We were talking off the record a few minutes ago, about the problem of medical ethics in general, and there are several phases of this I'd like to hear your ideas on. One of these is the ethics in research, the ethics in prolongation of life in certain situations, and even more important in this current day of managed care, the ethics of the bottom line versus the best for the patient. I'm interested in hearing your ideas, because I noticed you've been on an advisory committee to the Hastings Center, if I read correctly. DR. COOKE: And also the Kennedy Institute of Ethics, at Georgetown [University]. Well, my introduction to the subject is like so many things, through clinical cases. When I was first chairman at Hopkins, we had a Downs Syndrome baby with duodenal atresia. And despite trying to convince the parents [to operate], and getting the clergy to participate; the clergy were

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perfectly willing to abide by the parents' decision not to operate on the baby. I went to the chief judge of Maryland, who was a friend of mine, and he said the court no way would ever intervene. The baby was allowed to die, and didn't have surgery done. And that was upsetting. So a year or two later, a similar case came along. [J.] Alex Haller [Jr.], who was a pediatric surgeon at Hopkins , was the surgeon in charge. The family refused surgery, and Alex said he 'd abide by the wishes of the family. Our house staff took care of the baby until it died; it took 14 or 15 days for the baby to die of starvation. That was real upsetting. At that particular time, and with the previous case, I tried to get some people interested. I tried to get some clergy interested in the problem; I tried to get actually the people in the Kennedy Foundation interested, and others, with no luck. This case came along, and the Foundation was planning a symposium, in conjunction with what were called the [Joseph P. Kennedy, Jr.] International Awards on mental retardation, in which they gave some significant prizes and so forth to people who had done research or service things, etc. I got the Foundation interested enough to make a movie on this subject, and the movie was called Who Should Survive. It was done by Charlie [Charles] Guggenheim, who has done some fantastic [things]. He did the one on Bobby [Robert F.] Kennedy that was shown at the Democratic National Convention, that was so fantastic and powerful. And he got the awards at Cannes [Film] Festival for this film. So he made, Who Should Survive. It was shown at the international symposium, and it's been shown over 10,000 times in this country. And it was the re-creation of this problem. The house officers that were involved were still there. Bill [William G.] Bartholome, the pediatric resident, became a bioethicist down in Kansas; Norm Fost, who played a big role in the development of the film. It was said by a very distinguished medical historian that this was the beginning of the interest in bioethics in this country. And from there, the Kennedy Foundation went to support the Georgetown [Kennedy] Institute of Ethics, which had a course for leaders in American medicine for intense bioethics teaching. I went up to Harvard for a sabbatical for a year and worked in the Divinity School before I went out to be vice chancellor at [University of] Wisconsin [Madison], and Norm Fost got his master’s degree there at Harvard. Really a fairly major effort in bioethics was launched, and caught on around the country so that medical school after medical school has developed courses in bioethics and so forth. But I think the major initiative, according to outside people at least, was this particular film on a Downs Syndrome baby, that's called The Hopkins Baby--a very powerful film. I used it in some of my teaching. I remember having a class out of Wisconsin, when I was out there as vice chancellor. I took and read the case to the

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students, there were about 50 students in this lecture hall. And I picked a jury of about eight people from the student body, and I told them about the case. I made a usual clinical presentation, and then had them vote. The jury voted about what ought to be done with this baby, and it was unanimous that they ought to abide by the parents' wishes. I then showed the film, and I had them vote again, and, of course, needless to say it was unanimous in the other direction, because they were exposed to this human experience of letting a baby die that would be easily saved and so forth. Downs Syndrome, an awful lot of kids with Downs Syndrome are doing pretty well in this country now. One of them is a television star, and a couple of them… DR. GRAYSON: Who is that? DR. COOKE: Well there is this program. DR. GRAYSON: Oh really? DR. COOKE: Yes, where the star of the program has Downs Syndrome. Susie, do you know the name of that program where the, one of the players was a Downs Syndrome? I don’t remember the title either, because I never watched TV very much, but it’s interesting that he really… Susie: Life Goes On. (Bob Cooke’s daughter) DR. COOKE: Life Goes On. Yes, Life Goes On. With the Kennedy Institute and Hastings Center taking an active role, why, I think medical education incorporated more and more of medical ethics in terms of problems such as this issue of survival and so forth. It's become much more complicated now because technology can keep alive persons who are really terribly damaged or have the potential to be damaged. That's the hardest part, it seems to me, is to know how to handle this issue of potential difficulties in life later on. Now with my own children, for instance, (Wendy is 44 and can't walk or talk); in many ways, you know, if Wendy died probably she'd be better off, but it's just hard for me to accept that. The notion of meaningful life is, to me, a very tricky area. It's used a lot that, "So and so won't have a meaningful life," etc. What I always say about it is that a frog’s life to a man is not very meaningful, but a man's life to a frog isn't very meaningful either. So I think we should have a bit of humility here about what's meaningful or not; it's very important. And you know, at times severely damaged children are meaningful to their parents. It may be a difficult life for the parent, but it still may be to them, at least, a meaningful life. I think the approach that I've taken has been, oddly enough, based on a kind of legal-moral theory. There was a philosopher at Yale who moved to Harvard,

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whose name has escaped me at the moment [Roderick Firth], who proposed what I found to be very helpful in these situations. And it was basically the "ideal moral judge." This being a religious ethicist, he said, "Now who is the ideal judge?" And the answer was God. Well, what are the qualities that God has that makes him an ideal judge? One is that he knows everything; he's omniscient; God is omniscient. Two, God is omnipercipient. Omnipercipient is not a term we use a lot, but one that means, "able to perceive how all others are affected." Three, impartial and dispassionate. That's the ideal judge. And I've taken that a step further, and said, "How do we approximate that in real life, the ideal judge?" Well, one, we try to get all the facts we possibly can together. Second, we try to find out how all other people might be affected, the parents, the caretakers, the child themselves, blah, blah, blah. And then, how do you get impartiality? Well, you do that through the same system that we have in the judiciary which is multiple decision-makers, not just one person. So when you apply that then to the moral dilemma, let's say, of keeping a child alive or not keeping him alive, you try to get all the facts. Very recently, an article that I saw in Pediatrics was helpful in this regard in that the most difficult problems of those newborns were you don't know which way they're going and so forth. The article made it clear that if you survived for, I don't know, 48 to 72 hours, then the outcome is quite good. So, my feeling is, well, let's try to keep them alive for that period. If they don't make it, then you haven't made the decision, nature has made the decision. So you work hard, and if they survive that period you've got a pretty good chance that you're going to have a fairly good individual. If they don't, you've done a good job otherwise. Now, it's all statistical. With the individual case, of course, there are going to be exceptions and so forth, but it seems to me that when you come down to the extremely damaged individual, and there's survival there, what do you do beyond that? Well, then, I try to get the opinion of as many people as I can, and so the nurses that are involved, the physicians that are involved, the parents that are involved, and so forth. That group makes a kind of group decision about what ought to be done. And if it's unanimous as in a judicial decision, then you go ahead and end or you don't end. And so I tend to use this jury-like system for decision making. That's the approach I take to these difficult, ethical dilemmas that constantly arise. It’s cumbersome, but what's the hurry, you know, we're all going to die; don't rush it particularly. You know, it's expensive a little bit. I don't know if you know John Freeman. DR. GRAYSON: John’s at Hopkins too, isn’t he? A neurologist. DR. COOKE: Yes, he was one of my residents. John and I have always been on opposite sides of every issue. But John wrote a little article for Pediatrics

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way back, talking about why babies with myelomeningocele should suffer, when they shouldn't be allowed to stay alive and, you know, repair done and so forth, because they're going to go through all this suffering of medical care later, and you know, all the complications, etc. And I wrote a little editorial that was put in right next to it which said, "Whose suffering?" I was trying to explain that suffering for an infant is a very different situation from suffering from an adult who can think about all the other possibilities they could be doing and all the freedom they'd have if they didn't have their abnormalities, and all the pain they're going to go through etc. The infant doesn't have any of that. Suffering is a highly subjective issue. And so I differed about what ought to be done with a myelomeningocele. I think in general people have tended to be much more likely now to provide care than they used to be and outcomes are better and so forth. So that's been my little bit of approach to the medical ethics side. I think the year at Harvard with the Divinity School was probably good, I think it converted in a way to be—I’m not much of a Christian, but, I got to think a little bit about issues that I hadn't been involved in before. With the allocation of resources, I just think that that is a dilemma that has to be solved, not by ethics, but by real tough financial investigation. My little manuscript here, which nobody will accept, lays out a health care system which eliminates approximately 20% of the cost, around two hundred billion a year. Basically, it's what I call a regional health care public utility. And I argue that health care is now considered a necessity, just as much as heat, light, power, communication, and so forth; but it isn't treated as a utility. And, as a consequence, costs are far higher and the escalation of costs far faster than anything you could imagine in the way of utilities. You build an atomic power plant, you have all sorts of shutdowns and so forth; yet Florida Power and Light rates have gone up about 1 or 2 percent maximum—well less than that, less than one percent a year, over the last 20 years. Now why? Well, partly controlled, has to operate for profit so it keeps an eye on cost, yet in general service is pretty damn good. There's no competition, and yet it's somewhat regulated. Well, I got on to this idea when the Congress was debating for almost two years the issue of television, cable television. And I got so disgusted with all the time and effort that was put in on whether cable television ought to be regulated, whether it ought to be utility, whether it ought to be local, general and so forth. Nothing was being done in the health arena, so I decided I'm going to do something about this and I wrote my little book on health care as a public utility. I eliminate the insurance industry completely. I eliminate Medicare and I eliminate Medicaid. And I say, people pay for their rent out of their pockets; if

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they're poor they may get a voucher or they pay for it out of their welfare payments. If you don't have insurance intermediaries, the doctor's office doesn't become a business office; it becomes a health care office. If you make it for-profit--and this is a hitch that nobody has thought of but myself, and I'm a little conceited on that one--I make the public utility tax-exempt for both interest and capital gains. And that brings in rich people to finance the health care system. And my public utility, I figured out there would be approximately 20 in the country, which means that you have huge enrollments. So you can charge each person the same amount every month. You pay to the public utility just the way you pay your electric bills. Now there are problems, such as over-usage; I have some ways of dealing with that that are not punitive but mildly restrictive. You get basically a lower rate if you use your health care system a little bit less. If somebody is a big over-user, you've got money enough in the system to give them counseling and so forth, because most over-users are not deliberate consumers, you know; they need help. DR. GRAYSON: They need to talk to somebody. DR. COOKE: Right, absolutely. You can have outreach to low income populations because it's good for business. And you've got enough capital to do it. You don't have competition, which I'm convinced drives up costs. And these damn medical economists that talk about how costs are going to be lowered by competition; that's a joke. DR. GRAYSON: Oh, no way. DR. COOKE: Do nothing but drive it up. You've got to advertise; and you've got to cut back services so you can be competitive. This is the short version. DR. GRAYSON: Oh, I've got to get your book. Is it published? DR. COOKE: Nobody will publish it. Seriously. Here's the big manuscript. DR. GRAYSON: Ok. They won't publish it because this is against their interest of course. The insurance companies make… DR. COOKE: I know. Yes. It's about two hundred billion, the additional cost. And you know doctors are willing to work for a salary, if it's reasonable. See, one of the other benefits, I've heard many times, that physicians complain that they, unlike executives in other industries, have no way of acquiring stock in their business. With a utility such as this, they can have benefits just like other executives, which gives them a certain stake, but not such a big stake they’re going to deprive patients of what they need.

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Now the other huge advantage of this is that it gives a huge amount of choice to people. If you've got a utility that's covering 20 million people, then you’ve got a very large number of doctors that can serve you. So the choice becomes much more. You know, choice at the present time, with our present system, is negligible. You’ve got this HMO [Health Maintenance Organization] that's got about three docs, and a pediatrician, and you’ve got another one over here; it's a terrible system. DR. GRAYSON: Absolutely. DR. COOKE: And then getting rid of Medicaid and Medicare—the bureaucracy in Washington is just terrible. My little book here is full of illustrations of what happened in my own family. My mother, who died a couple years ago, when she was 93 or 94 she was in a nursing home here in Florida. And her Medicare benefits had been exhausted. She had had amputations, stroke, constant infections of her bladder, multiple problems. And her Medicare benefits had been exhausted. And so her Medi-Gap insurance was supposed to kick in. Well, Medi-Gap insurance won't kick in unless you've got official notification from Medicare that the benefits are exhausted. I tried. My wife, Sharon, used to work for Blue Cross-Blue Shield in Chicago when she graduated from college, so she knew the system pretty well. She would write and give all the detail and you know, back and forth. Two and a half years, we could not get a notification from Medicare that her benefits were exhausted. So her Medi-Gap insurance couldn't kick in, bills were mounting up, you know. Well one day I was sitting in Sargent Shriver’s office and I said, "You know, I think this is collusion between Medicare, the insurance companies, the nursing homes." He said, "What do you mean?" And I explained the thing. He said, "I'm going to call up Jay [John D.] Rockefeller," who was chairman of the Senate committee that supervises Medicare. So he gets on the phone, and Jay says, "I'll have one of my staff look into it." So his staff calls me up. I had written and called; one day I started at 8:30 in the morning to call this number I had finally identified in the Medicare establishment of the federal government that might do something about this. And at 8:30 I started calling. Nobody answered; nobody answered. At nine o’clock, the line was busy. And I called every half-hour through the whole day. At 4:30 the line was no longer busy but nobody answered. Clearly somebody took the phone off the hook, you know. And so I got a call from Rockefeller's people and explained the situation and about ten days later got a call from the people in the Medicare agency asking what could be done, blah, blah, blah. Finally, $27,000 later in the Medi-Gap insurance, we got the thing straightened out. Well the cost involved, and every doctor I know says the insurance companies are now running the whole health business.

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DR. GRAYSON: They tell you how to practice and, the bottom line is the important thing. This is what I meant by the ethics of managed care. I have written a letter to the editor of AAP News at the time the Hillary [Rodham] Clinton health reform thing was in Congress. And I said, "Managed care, no; quality, yes." DR. COOKE: Oh, well, the big problem with the Clinton bill is it still kept the insurance industry in it even more than it was before, and it became more managed care without any control. DR. GRAYSON: It opened up a whole door to managed care. DR. COOKE: Oh, yes, I thought that was a terrible bill and as I point out in this thing, my big disagreement with their bill. DR. GRAYSON: I'm glad to see that somebody is speaking out; I'm sorry that nobody will publish it. DR. COOKE: Well, you know, if you make the base big enough you can spread the cost. For example, the future of pediatrics, and medicine, is going to be the adequate identification of genetic tendencies. I talked about that in an article years ago and what I call "anticipatory pediatrics," which was to try to find out what susceptibilities were. And then you can kind of direct your efforts in prevention of the problem in a targeted way, rather than shooting everywhere, which is terribly expensive. And it's clear now that, with the advancement in genetics, you ought to be able to nail down pretty well in another decade or so many of the susceptibilities that people have and handle the cases. Well, that's going to cost money, that kind of thing. You're not going to get that paid for by small, competitive HMOs. They've got to be very large; you've got to spread the cost of this because all of us are going to have diseases of one type or another. So if somebody's mentally retarded in a 20 million caseload, you can afford to provide some services for that person. Your child may have some other problem that is equally expensive, etc. So, it's equitable to spread the cost across the board, but you have to have a big base. DR. GRAYSON: Which is what the insurance companies do. DR. COOKE: Sure. So the other thing that I talk about in there, you mentioned, and that is what's happened to the administrative side of the business. When I went to Hopkins , and every place then was similar, heads of hospitals were called superintendents or administrators. And at some point, somebody decided that hospitals were corporate ventures, no longer eleemosynary institutions, and they became presidents. And then the nurses became vice-presidents. The head of nursing, and the head of this and that, they were vice-presidents, and salaries went up astronomically. And now some of the salaries of administrators have been at outrageous levels. I ran a

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hospital; I know damn well that I wasn't important. I was half as important as the doctors. DR. GRAYSON: And this is where the cost goes up. DR. COOKE: Oh, it's just awful. And then you get competition. You go back to Baltimore, and there’s a building there named after the president of the hospital, who just retired. It's an ambulatory care building, and I'll bet you Hyatt hasn't built a building as elaborate as that one. It's about two thirds atrium. About one third administration, and maybe one third clinical. And it's just to attract patients. DR. GRAYSON: Let's talk about retirement, Bob. One of the questions I wanted to ask is how did you choose Florida for your retirement years? I presume you've been down here for awhile. DR. COOKE: I guess this is going on the ninth year. Well, before I was at Buffalo Children’s [Children's Hospital of Buffalo], I had remarried and had a couple of children. When I was president of the Medical College of Pennsylvania, I had left that and decided I was going to enjoy life. But then I had remarried and had a couple of children. So to be able to afford to educate those kids, I had to go back to work. I went to Children’s and ran the rehab center, and then was the head of pediatrics. And after enough years, I decided that I want to enjoy life. I was a big sailor, liked the water, and so I started looking for a place to live near the water. We began in Marion, Massachusetts. I was looking for private school for the kids. My folks weren't wealthy at all, but they put me through private school, and I was really rather impressed with private school education, particularly with the public schools deteriorating. And so, I started in Marion where there's a Tabor Academy and I worked down the coast, to Florida, and worked the West Coast and was interested in several places. Then finally I came to Vero Beach and there's a very good private school here, St. Edward's School. It seemed to be a community that was small enough and had enough young people and old people (my wife's a lot younger than I am) that this might not be bad; so we decided to move to Florida. And I still commute to Washington every two weeks for the Kennedy Foundation. I haven't retired. I get up at 5:30 three to five times a week to, I have to get up at 5:00, but they have to be at swimming at 5:30 in the morning. One of my girls is one of the better swimmers in the state. She swims for the school. She's just entering sophomore year now, high school, but she's been the mainstay of the swim team in the 7th, 8th, 9th grades, and junior national swimmer. Really quite good. But that keeps me very busy.

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DR. GRAYSON: I can imagine. DR. COOKE: I am really stuck getting up in the winter when it's pitch black, but I just think this poor kid's got to go in and swim for two hours. She swims five hours a day which is a lot of work, and then homework and stuff. But that's kept me going I think, whereas other people that don’t have that luxury, it's hard. There are times when I just wonder why don't I use my time productively, but I still am a major adviser to the Kennedy family, and so I'm up there for a couple of days every two weeks, and it keeps me going. DR. GRAYSON: That's very important. DR. COOKE: And I think about health care problems and so forth. But at times, why you know, you get discouraged about getting older and not being as healthy as you used to be and so forth. DR. GRAYSON: Well this is why we started the Senior Section. You mentioned before the Academy is looked upon sometimes as a trade union, if you will, self-serving. Well of all the medical associations, I think we're the least self-serving. DR. COOKE: Oh, I don't think there's any question. DR. GRAYSON: I mean when you compare us to the AMA [American Medical Association], or some of the surgical subspecialties, we're saints. You know, you go into the legislatures and they say, "You're on the side of the angels." Basically we are. DR. COOKE: Oh, no question about that. You know, my remarks about the organization being self-serving. It's impossible not to regard… DR. GRAYSON: It's the perception; we don't feel so, but the public does. DR. COOKE: That's right. But I do think that you have such a resource in parents. You know, parents trust pediatricians. DR. GRAYSON: What, we hope our seniors as they slow down, would have more time to go to parent groups, or have more time to advocate for kids. You've been a great advocate, as I look at the history of the NICHD. We need more people like this, and there are those available if we could only motivate them. DR. COOKE: Well the pediatrician in practice is a much more important force than their role at the present time really. And the Academy, I think, ought to be sending material to pediatricians for parents that have a political slant to them, I really do. I know that the Academy is not for profit, so it’s not against

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the law, not against the IRS, if there was more material. I just look back in my campaign against Vietnam, and the response from parents was sizeable. DR. GRAYSON: Well we have a good Washington Office now who can get to the people, Jackie Noyes and her group are quite good in representing pediatricians... DR. COOKE: I haven't had much contact with them. DR. GRAYSON: …rather than the Academy. And, in the sense, representing our patients, really. DR. COOKE: Yes. That's what the message has to be. What the patient, what the parents want is really the key message. DR. GRAYSON: Well the problem we have now with government is that the feeling in government right now is cost cutting, and there's very little compassion left, unfortunately. DR. COOKE: One thing I didn't mention about this regional utility, getting government out of this and insurance companies; I feel that industry ought to get out of the supplying of and paying for health care. I mean, they don't pay for people's rent other than through salaries. And industry is very, very reluctant to provide more and more money for health benefits because there's no control; they don't have any control. Why shouldn't a person pay for his health care just as much as he pays his rent or some other thing? Industry doesn't give you a check to pay for your heat, and I don't think they ought to be contracting with insurance companies to pay for the health insurance. DR. GRAYSON: It started with the automobile industry and the unions. DR. COOKE: Oh, yes. Unions and others would oppose this idea, because the union then loses its muscle, you know. The politician loses his muscle, because he can always argue for better Medicare benefits, etc., etc. But the fact is that if you want to really save money, that's the way to go. And you can still have quality, because you can set up safeguards. If you capitalize the industry, if it becomes a for-profit, stock, tax-exempt gains, etc. You can capitalize the system in a way so that every pediatrician’s office, every physician's office, is part of a computer network. And quality control becomes very easy. You have a patient come in complaining of XYZ, how long does it take to get surgical intervention? If you're computerized properly, you can audit what goes on very well and keep your quality of care. When I was at Stanford Hospital, I happened to have prostate cancer that spread. And I went to Stanford for radiation, and…

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DR. GRAYSON: Henry Kaplan was there at the time? DR. COOKE: Henry Kaplan was my teacher in medical school. But he had just died before I went out, and one of my close friends at Yale had taken over. This guy happened to be the world’s expert in radiation of prostate cancer. They put me through the hyperthermia protocol. I think I was case number eight, in which they open you up and they put electrodes in externally, and heat the prostate up to 110, and the theory is to denature the polymerases that are responsible for the DNA replication. And that may alter the chance of the cancer continuing. And I got opened up, and had the procedure. I was back to my room the next day, with electrodes and radiation implants and so forth. I asked the nurse on the second day after the surgery, "When were you giving me my heparin?" And, because I know damn well with the kind of pelvic manipulation, I was a good risk of an embolism, particularly with hyperthermia. And she said, "You're not getting any heparin." I said, "I'm pretty sure I ought to be getting some heparin." So she went back to the nurses' notes and said, "No heparin orders." And I said, "You call up the physician in charge here because I think I should be getting some heparin." Well, in the doctor's orders was the order for heparin. DR. GRAYSON: Never transferred it over. DR. COOKE: And what had happened when I was brought up from the OR, the clerk, the ward clerk, had a fainting spell; not because of me but just coincidental. DR. GRAYSON: [Laughs] DR. COOKE: And somebody took over the order writing, and she thought that my orders were finished. And so several of my orders were left out. And that is so easily obviated by a computerized system with the doctor's orders automatically transmitted into the nurse's orders, electronically. It must happen, we know it does happen all the time, these human errors. They're unavoidable in a certain sense, but unless you adequately capitalize the system you're going to have that kind of thing and malpractice is going to continue and so forth. And it's real malpractice, the suit there would have been enormous on what happened to me. But, good medicine requires the use of high technology, and competing HMOs, and so forth, don't have the money. DR. GRAYSON: Or if they have the money, it's going to other places. DR. COOKE: Going to executive salaries.

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DR. GRAYSON: When the goal is so high that you're willing to do something which is immoral, certainly ethically wrong, I wonder how we can train researchers not to be quite so competitive too. DR. COOKE: Well, I think it's part of the whole morass of our society at the moment. I look back on my own work when I was doing research, and there was absolutely, and it sounds so naïve now, there was absolutely no thought about personal financial gain from your research. But when I worked with Darrow, Darrow's solution was developed and he didn't get a nickel from that. He never thought about putting a patent on it or a copyright or anything else. I developed, with a guy named Crowley who became vice-president for health affairs eventually out at Stanford, some solutions that were pretty widely used. We thought this was something everybody ought to benefit from. I went to Hopkins and we designed a crib, my pride of that time, when we built the Children's Center. My kids get after me now like crazy, they say, "Dad, you’d be real rich," and so forth. All the cribs at that time you needed two hands to lower the sides, so you had to put the baby in or put the baby down. So we designed a crib where there was a one-hand pull, which is used I think just about everywhere. You hold the baby on your shoulder, give it a squeeze, put the baby in and then it’s over. Well, we never thought about putting a copyright or a patent on things. Now, if somebody develops something under the university auspices, under NIH auspices, they run out and they start a corporation and sell the product; and the goal is to see how much money they can make from it. That is so different from what it used to be. Now, that same spirit now goes into trying to make a big name for yourself in some research field, so you're going to make an awful lot of money or you go to a corporation and they make you chief of research or something else. I have a relative who went with the FDA when he completed his years of practice. He decided he wanted to go with government, get a retirement and so forth, but he worked with the FDA. And his job was investigating protocols as to whether or not they were falsified and so forth. He said, "You could not imagine the amount of falsification that went on from the best universities in this country." And it just seems to me incredible that you would do this unless there's some motive that you’re going to get great gain. DR. GRAYSON: It's the greed. DR. COOKE: Yes. I know. The notion of integrity is terribly worrisome, and maybe it’s just old people who are looking back and saying that.

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DR. GRAYSON: I would like to say that we, as pediatricians, could influence kids in a way that would change this a little. I often thought when I went into pediatrics that my goal was to make better citizens of the kids that are under my care. DR. COOKE: Well, yes. I don't know what it is with our society. Well, one of my kids was taking an ancient history course. In looking over the work with them, why, it's so clear that one society after another decayed from earliest times in our history. One society after another would decay, and it was always the same reason. You had terrible separation between the people in power and the others and after awhile the society deteriorated. The people on top didn't do anything for themselves and they became basically worthless, and you've had a breakdown in society. And it looks like that's exactly what's happening at the present time. END OF TAPE

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Index

A Academy of Sciences of the USSR, 4 Albany, New York, 4, 5 Amatruda, Catherine, 6, 7 American Academy of Pediatrics, 1, 4, 8, 22, 23,

25, 37 American Board of Pediatrics, 22, 25 Army Specialized Training Program, 2 Avery, Mary Ellen, 15

B Barron, Donald Henry, 6 Bartholome, William G., 29 Battaglia, Frederick C., 6, 15 Bayne-Jones, Stanhope, 4 Boisvert, Paul, 6 Brewster Jr., Kingman, 26, 28 Brobeck, John R., 5 Bronfenbrenner, Urie, 19 Brusilow, Saul, 15 Buchanan, James, 14

C Carlisle Barracks, 3 Child Studies Center, 6 Children's Hospital of Buffalo, 36 Childs, Barton, 15 Clark, Dean, 13 Clinton, Hillary Rodham, 34 Clinton, William J., 22, 34 Cohen, Wilbur, 12, 13 Cooley, Denton A., 3 Cri du Chat, 11 Crump Jr., E. Perry, 19

D Darrow, Daniel C., 6, 12, 39 Davens, Ed, 18 Dixon, James, 13 Downs Syndrome, 28, 29, 30

E educational bank, 26, 27, 28 Eisenberg, Leon, 15, 20 Eudowood Tuberculosis Sanitarium, 10

F Firth, Roderick, 30

Fort Devins, 2 Fort Ethan Allen, 3, 4 Fort Sam Houston, 3 Fost, Norman, 15, 29 Freeman, John, 31

G Garrett, Robert, 10 Gesell Institute of Human Development, 7 Gesell, Arnold L., 6, 7 Gladwin, Thomas, 11 Gordon, Harry H., 13 Gray, Susan, 20 Gross, Robert, 11 Guggenheim, Charles, 29 Guild, Harriet, 15

H Haller Jr., J. Alex, 28 Harriet Lane Handbook , 23 Harriet Lane Home for Invalid Children, 9, 10, 11,

14, 15 Harvard Divinity School, 29, 32 Hastings Center, 28, 30 Head Start, 8, 18, 19, 20, 21 health care system, 32 Hellegers, Andre, 12 Henry Phipps Psychiatric Clinic, 16

I Institute of Medicine, 13

J Jackson, Edith B., 6 John F. Kennedy Center for Research on Human

Development, 20 Johns Hopkins Children's Center, 10, 11, 12, 40 Johns Hopkins Hospital, 14, 15, 16, 24, 28 Johns Hopkins University School of Medicine, 7,

8, 9, 10, 12, 16, 17, 18, 28, 31, 35, 40 Johnson, Lyndon B., 13, 17, 18, 20, 22 Joint Commission on Mental Illness and Health,

16 Joseph P. Kennedy Jr. Foundation, 11, 12, 16,

18, 22, 29, 36 Joseph P. Kennedy, Jr. International Awards, 29 Journal of Pediatrics, 16

K Kanner, Leo, 10, 15

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Kaplan, Henry, 38 Kennedy Institute [Baltimore], 17 Kennedy Institute of Ethics, 12, 28, 29, 30 Kennedy, John F., 12, 13, 16, 17, 20, 22 Kennedy, Robert F., 29

L Lajeune, Jerome, 11 Lederberg, Joshua, 13

M Mailman Child Development Center, 10, 16, 17,

18 Masland, Richard, 11 Mayflower Hotel, 13 McDermott, Walsh, 11 McKhann, Guy, 15 Medearis Jr., Donald N., 12 Medicaid, 25, 32, 34 Medical College of Pennsylvania, 36 medical ethics, 28, 30, 32 Medicare, 25, 32, 34, 38 Menkes, John, 12 mental retardation, 11, 12, 16, 17, 19, 22, 29 Miller, Herbert C., 6 myelomeningocele, 31

N National Association for Retarded Children, 11 National Institute of Child Health and Human

Development, 13, 19, 22, 23, 37 Neill, Katherine, 15 Nelson, Waldo, 16 Nixon, Richard M., 23, 24

O Odell, Gerald, 15 Office of Economic Opportunity, 18, 20

P Park, Edwards A., 9, 15 Paul, John Rodman, 6 Powers, Grover F., 6, 11 Pratt, Edward L., 12 President's Task Force on National Health Care

Reform, 22 prostate cancer, 38

R Ramey, Craig and Sharon, 21

Rockefeller, John D., 34 Rosewood State Hospital, 16

S Sarason, Seymour B., 11 Schwentker, Francis, 8, 9 Senn, Milton, 7 Shannon, James A., 13, 14 Sheffield Scientific School, 1 Shriver Jr., Robert Sargent, 11, 18, 19, 20, 34 Shriver, Eunice Kennedy, 11, 12, 16 Somers, Herman M., 13 Soviet Union, 4 Stanford Hospital, 38 streptomycin, 4

T Task Force on Health and Social Security, 12 Taussig, Helen B., 10, 15 The Hopkins Baby, 29 Trask, James D., 6 tuberculous meningitis, 4

U University of Wisconsin-Madison, 29 utility [health care as a], 32, 33, 38

V VanderLoos, Henry, 12 Vietnam war, 17, 23, 24, 37 von Pirquet, Clemens, 14, 15

W War on Poverty, 18 Who Should Survive, 29 Wickenden, Elizabeth, 13 Wilkins, Lawson, 9, 10, 15 Wood, Barry, 10, 11

Y Yale College, 1 Yale University, 1, 2, 4, 5, 6, 7, 8, 11, 12, 15, 19,

26, 28, 30, 38

Z Zigler, Edward, 8, 19 Zinkham, William, 15 Zuckerman, Professor, 4, 5

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CURRICULUM VITAE

ROBERT E. COOKE, MD

BORN: ATTLEBORO, MASSACHUSETTS, NOVEMBER 13, 1920 ACADEMIC DEGREES: YALE UNIVERSITY, MED. SC. D. (HON) 1994 UNIVERSITY OF MIAMI, SC. D. (HON) 1971 YALE UNIVERSITY SCHOOL OF MEDICINE, M.D. 1944 SHEFFIELD SCIENTIFIC SCHOOL, B.S. 1941 TRAINING: CAPE AND ISLAND FAMILY INSTITUTE, CERTIFICATION 1982 JOHN AND MARY R. MARKLE SCHOLAR IN MEDICAL SCIENCE 1951-55 POSTDOCTORAL FELLOW, NIH AT YALE UNIVERSITY 1948-50 RESIDENT, GRACE-NEW HAVEN HOSPITAL 1950-51 ASSISTANT RESIDENT, NEW HAVEN HOSPITAL 1945-46 INTERN, NEW HAVEN HOSPITAL 1944-45 MILITARY TRAINING: LIEUTENANT TO CAPTAIN, MEDICAL CORPS, UNITED STATES ARMY 1946-48 ACADEMIC APPOINTMENTS: PROFESSOR EMERITUS, STATE UNIVERSITY OF NEW YORK AT BUFFALO 1988- PEDIATRICIAN-IN-CHIEF, CHILDREN’S HOSPITAL, BUFFALO 1985-88 CHAIRMAN, DEPT. OF PEDIATRICS SCHOOL OF MEDICINE, STATE UNIVERSITY OF NEW YORK AT BUFFALO 1985-88 EXECUTIVE COMMITTEE, BOARD OF TRUSTEES, CHILDREN’S HOSPITAL, BUFFALO, NY 1985-88 EXECUTIVE COMMITTEE, MEDICAL STAFF, CHILDREN’S HOSPITAL OF BUFFALO, NY 1985-88 EXECUTIVE COMMITTEE, SCHOOL OF MEDICINE, STATE UNIVERSITY OF NEW YORK AT BUFFALO 1985-88

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A. CONGER GOODYEAR PROFESSOR OF PEDIATRICS, STATE UNIVERSITY OF NEW YORK AT BUFFALO 1982-88 MEDICAL DIRECTOR, ROBERT WARNER REHABILITATION CENTER, CHILDREN’S HOSPITAL, BUFFALO, NEW YORK 1982-88 VISITING PROFESSOR OF PEDIATRICS, ST. LOUIS UNIVERSITY SCHOOL OF MEDICINE 1981-82 PROFESSOR OF PEDIATRICS, MEDICAL COLLEGE OF PENNSYLVANIA 1977-80 RESIDENT, MEDICAL COLLEGE OF PENNSYLVANIA 1977-80 ADVISOR TO THE PRESIDENT ON HEALTH AFFAIRS, UNIVERSITY OF WISCONSIN- MADISON 1973-77

VICE CHANCELLOR FOR HEALTH SCIENCES, UNIVERSITY OF WISCONSIN-MADISON 1973-77 PROFESSOR OF HISTORY OF MEDICINE, UNIVERSITY OF WISCONSIN-MADISON 1973-77 PROFESSOR OF PEDIATRICS, SCHOOL OF MEDICINE, UNIVERSITY OF WISCONSIN 1973-77 VISITING PROFESSOR, DEPARTMENT OF SOCIAL AND PREVENTIVE MEDICINE, HARVARD MEDICAL SCHOOL 1972-73 GIVEN FOUNDATION PROFESSOR OF PEDIATRICS, THE JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE 1962-73 GROVER POWERS PROFESSOR OF PEDIATRICS, THE NATIONAL ASSOCIATION FOR RETARDED CHILDREN 1957-59 PEDIATRICIAN-IN-CHIEF, THE JOHNS HOPKINS HOSPITAL 1956-73 PROFESSOR OF PEDIATRICS, THE JOHNS HOPKINS HOSPITAL 1956-73 ASSOCIATE PROFESSOR OF PEDIATRICS AND PHYSIOLOGY, YALE UNIVERSITY 1954-56 ASSOCIATE PEDIATRICIAN, GRACE-NEW HAVEN HOSPITAL 1951-54 ASSISTANT PROFESSOR OF PEDIATRICS AND PHYSIOLOGY, YALE UNIVERSITY 1951-54 INSTRUCTOR IN PEDIATRICS, YALE UNIVERSITY 1950-51 CONSULTING APPOINTMENTS: CONSULTANT, WEST SENECA DEVELOPMENTAL CENTER, WEST SENECA, NEW YORK 1983-88

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CONSULTANT, DIVISION OF THE OFFICE OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES, DEPARTMENT OF MENTAL HEALTH, COMMONWEALTH OF MASSACHUSETTS 1980-82 CONSULTANT, OFFICE OF TECHNOLOGY ASSESSMENT, CONGRESS OF THE UNITED STATES 1974-79 CONSULTANT, SCIENTIFIC ADVISORY COUNCIL, CHILDREN’S ASTHMA RESEARCH INSTITUTE AND HOSPITAL 1970-76 CONSULTANT, SUBCOMMITTEE ON CHILD HEALTH CARE, THE STATE INTERAGENCY COMMITTEE ON COMPREHENSIVE HEALTH PLANNING 1968-73 CONSULTANT, THE NATIONAL FOUNDATION— MARCH OF DIMES 1968-70 CONSULTANT, ST. LUKE’S HOSPITAL CENTER, NEW YORK CITY, NEW YORK 1967-71 CONSULTANT, DIVISION OF HOSPITALS AND MEDICAL FACILITIES, PUBLIC HEALTH SERVICE 1967-73 CONSULTANT, DEPARTMENT OF PEDIATRICS, FREEDMAN’S HOSPITAL, WASHINGTON, DC 1966-73 CONSULTANT, CLINICAL CENTER, NATIONAL INSTITUTES OF HEALTH 1962-73 COURTESY STAFF, GREATER BALTIMORE MEDICAL CENTER 1965-73 ASSOCIATE CONSULTING STAFF IN GENERAL PEDIATRICS, SINAI HOSPITAL, BALTIMORE 1959-73 CONSULTANT PEDIATRICIAN, BALTIMORE CITY HOSPITALS 1958-73 CONSULTING PEDIATRICIAN, CHILDREN’S HOSPITAL, BALTIMORE 1957-73 OTHER APPOINTMENTS: ADVISORY BOARD, NATIONAL CENTER FOR MEDICAL REHABILITATION RESEARCH 1991- CHIEF MEDICAL OFFICER, SPECIAL OLYMPICS 1988- BOARD OF DIRECTORS, INTERNATIONAL SPECIAL OLYMPICS, INC. 1983- BOARD OF DIRECTORS, ERIE COUNTY ASSOCIATION OF RETARDED CITIZENS 1983-88 CLINICAL DIRECTOR, THE HALLGARTH INSTITUTE BOURNE, MASS. 1981-82

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BOARD OF TRUSTEES, THE EUNICE KENNEDY SHRIVER CENTER, WALTHAM, MASS. 1981- CHAIRMAN, THE SCIENTIFIC ADVISORY BOARD, THE JOSEPH P. KENNEDY, JR. FOUNDATION, WASHINGTON, DC 1963- BOARD OF DIRECTORS, ELWYN INSTITUTE 1977- BOARD OF DIRECTORS, UNIVERSITY CITY SCIENCE CENTER, PHILADELPHIA 1978-79 MEMBER, GENERAL RESEARCH SUPPORT PROGRAM ADVISORY COMMITTEE, NATIONAL INSTITUTES OF HEALTH 1978- MEMBER, MEDICAL ASSISTANCE ADVISORY COUNCIL, COMMONWEALTH OF PENNSYLVANIA 1979- EDITORIAL BOARD, HUMAN EXPERIMENTATION COMMITTEE NEWSLETTER, THE HASTINGS CENTER 1977-81 MEDICAL DIRECTOR-AT-LARGE, AMERICAN CANCER SOCIETY, WISCONSIN DIVISION 1974-76 MEMBER, HEALTH MANPOWER TRAINING ASSISTANCE REVIEW COMMITTEE, VETERANS ADMINISTRATION, WASHINGTON, DC 1974-76 MEMBER, NATIONAL COMMISSION FOR THE PROTECTION OF HUMAN SUBJECTS OF BIOMEDICAL AND BEHAVIORAL

RESEARCH 1974-78 MEMBER, STEERING COMMITTEE, NATIONAL ACADEMY OF SCIENCES, INSTITUTE OF MEDICINE ON STUDY OF THE IMPACT OF LEGALIZED ABORTION 1974-75 MEDICAL EXAMINING BOARD-COUNCIL ON PHYSICIAN’S ASSISTANTS 1974-77 ENVIRONMENTAL PROGRAMS COUNCIL, UNIVERSITY OF WISCONSIN 1973-77 MENTAL RETARDATION ADMINISTRATIVE COMMITTEE, UNIVERSITY OF WISCONSIN 1973-75 LIAISON BETWEEN JOINT LONG RANGE PLANNING COMMITTEE OF MADISON HOSPITALS AND CLINICAL CANCER CENTER 1973-77 BOARD OF DIRECTORS, WISCONSIN REGIONAL MEDICAL PROGRAM, MADISON, WISCONSIN 1973-74 COMMISSION ON HOSPITAL RELATIONS AND MEDICAL EDUCATION, STATE MEDICAL SOCIETY OF WISCONSIN 1973-77

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COMMISSION ON SCIENTIFIC MEDICINE, STATE MEDICAL SOCIETY OF WISCONSIN 1973-77 JOINT LONG RANGE PLANNING COUNCIL OF MADISON HOSPITALS 1973-77 GOVERNOR’S HEALTH POLICY COUNCIL, STATE OF WISCONSIN 1973-77 EDITORIAL ADVISORY BOARD, ENCYCLOPEDIA OF BIOETHICS 1973- VISITING PROFESSOR IN THE INTERFACULTY PROGRAM IN MEDICAL ETHICS, HARVARD UNIVERSITY 1972-73 MEMBER, SPECIAL COMMITTEE ON LIFE PRESERVATION, DEPARTMENT OF HEATLH AND MENTAL HYGIENE, STATE OF MARYLAND 1972-74 BOARD OF SCIENTIFIC COUNSELORS, NATIONAL INSTITUTE OF CHILD HEALTH AND HUMAN DEVELOPMENT 1971-74 YALE UNIVERSITY COUNCIL COMMITTEE ON MEDICAL AFFAIRS 1969-74 ADVISORY BOARD, BALTIMORE ASSOCIATION FOR RETARDED CHILDREN, INC. 1968-73 BOARD OF TRUSTEES, JOHN F. KENNEDY INSTITUTE FOR THE HABILITATION OF THE MENTALLY AND PHYSICALLY HANDICAPPED, BALTIMORE 1968 PRESIDENT’S COMMITTEE ON MENTAL RETARDATION 1966-69 BOARD OF VISITORS, JOHN F. KENNEDY CHILD DEVELOPMENT CENTER, UNIVERSITY OF COLORADO 1966-70 VISITING PROFESSOR OF PEDIATRICS, HOWARD UNIVERSITY, WASHINGTON, DC 1966-73 CHAIRMAN, NATIONAL STEERING COMMITTEE, PROJECT HEAD START, OFFICE OF ECONOMIC OPPORTUNITY 1965-69 SCIENTIFIC ADVISORY COUNCIL, CHILDREN’S HOSPITAL RESEARCH FOUNDATION, CINCINNATI 1964-70 BOARD OF TRUSTEES, CHILDREN’S REHABILITATION INSTITUTE, REISTERSTOWN, MARYLAND 1964-73 SUBCOMMITTEE ON CONSTRUCTION OF UNIVERSITY AFFILIATED FACILITIES FOR THE MENTALLY RETARDED, PUBLIC HEALTH SERVICE 1964-67

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COMMITTEE TO STUDY MARYLAND’S RESIDENTIAL NEEDS FOR THE MENTALLY RETARDED 1963-65 RESEARCH AND DEMONSTRATION PANEL, OFFICE OF EDUCATION, DEPARTMENT OF HEALTH, EDUCATION AND WELFARE 1963-66 COMMITTEE ON AREAWIDE PLANNING OF FACILITIES FOR THE MENTALLY RETARDED, PUBLIC HEALTH SERVICE 1963-67 WHITE HOUSE ADVISORY COMMITTEE ON MENTAL RETARDATION 1963-65 PLANNING COUNCIL, MARYLAND STATE BOARD OF HEALTH AND MENTAL HYGIENE 1962-63 NATIONAL ADVISORY CHILD HEALTH AND HUMAN DEVELOPMENT COUNCIL (NICHD-NIH) 1963-67 PARTICIPANT IN HEARINGS FOR ESTABLISHMENT OF THE NICHD, H.R. 8398, FEB. 13-14 1962 CHAIRMAN, JOINT COMMITTEE ON PEDIATRIC RESEARCH, EDUCATION AND PRACTICE, AMERICAN ACADEMY OF PEDIATRICS 1961-68 EDITORIAL BOARD, JOURNAL OF PEDIATRICS 1961-77 PRESIDENT’S PANEL ON MENTAL RETARDATION 1961-62 LICENSE TO PRACTICE MEDICINE: STATE OF NEW YORK 1983- COMMONWEALTH OF MASSACHUSETTS 1981- STATE OF CONNECTICUT 1944-80 STATE OF MARYLAND 1956-80 STATE OF WISCONSIN 1973-77 MEMBERSHIPS: AMERICAN ACADEMY OF CEREBRAL PALSY AMERICAN ACADEMY OF PEDIATRICS AMERICAN ASSOCIATION FOR THE ADVANCEMENT OF

SCIENCE AMERICAN ASSOCIATOIN OF MEDICAL COLLEGES AMERICAN ASSOCIATION OF MENTAL DEFICIENCY AMERICAN FEDERATION FOR CLINICAL RESEARCH AMERICAN MEDICAL ASSOSICAITON AMERICAN PEDIATRIC SOCIETY AMERICAN PSYCHIATRIC ASSOCIATION (DISTINGUISHED FELLOW, 1971) AMERICAN SOCIETY FOR CLINICAL INVESTIGATION

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ASSOCIATION FOR ACADEMIC HEALTH CENTERS ASSOCIATION FOR RESEARCH IN NERVOUS AND MENTAL DISORDERS (VICE PRESIDENT, 1959) DANE COUNTY MEDICAL SOCIETY DAY CARE CHILD DEVELOPMENT COUNCIL OF AMERICA, INC. INTERURBAN CLINICAL CLUB (EMERITUS) JOHNS HOPKINS MEDICAL SOCIETY (PRESIDENT, 1967-68) MARYLAND-WASHINGTON ASSOCIATION FOR CHILD CARE IN HOSPITALS (ADVISORY BOARD) NATIONAL ACADEMY OF SCIENCES INSTITUTE OF MEDICINE NATIONAL ASSOCIATION FOR RETARDED CHILDREN, INC. NATIONAL SOCIETY FOR AUTISTIC CHILDREN, INC. (PROFESSIONAL ADVISORY BOARD) SOCIETE FRANCAISE DE PEDIATRIE (CORRESPONDING FELLOW) SOCIETY FOR PEDIATRIC RESEARCH (PRESIDENT, 1965-66; EMERITUS, 1966) STATE MEDICAL SOCIETY OF WISCONSIN COLLEGE OF PHYSICIANS, PHILADELPHIA (FELLOW, 1978-80) HONORARY SOCIETIES: SIGMA XI, MEMBER 1950 ALPHA OMEGA ALPHA 1943 SIGMA XI, ASSOCIATE 1940 PHI BETA KAPPA 1940 AURELIAN HONOR SOCIETY 1940 AWARDS:

SURGEON GENERAL’S MEDALLION OF HONOR 1992 JOHN HOWLAND MEDAL, AMERICAN PEDIATRIC SOCIETY 1991 KENNEDY INTERNATIONAL AWARD FOR DISTINGUISHED SERVICE IN THE FIELD OF MENTAL RETARDATION 1968 ST. COLETTA AWARD FOR EXCEPTIONAL LEADERSHIP IN THE FIELD OF MENTAL RETARDATION, PRESENTED BY THE CARITAS SOCIETY 1967 THE E. MEAD JOHNSON AWARD IN PEDIATRICS 1954 THE CAMPBELL GOLD MEDAL (YALE) 1944 THE PARKER PRIZE (YALE) 1944 THE PERKINS SCHOLARSHIP PRIZE (YALE) 1943 THE RAMSAY MEMORIAL SCHOLARSHIP PRIZE (YALE) 1942