The Robert Wood Johnson Foundation’s Role in the 1970s EMS Systems Movement – Part A

The Robert Wood Johnson Foundation, headquartered in Princeton, New Jersey, became a national philanthropic organization in 1972 as a result of Robert Wood Johnson’s bequest of virtually his entire estate in the form of Johnson & Johnson stock. Robert Wood Johnson led the Johnson & Johnson Company, manufacturer of health care products and services, from 1932 until his death in 1968. At the time of his death, his holdings in Johnson & Johnson were valued at about $300 million.

Johnson anticipated strong ties between the Foundation and Johnson & Johnson, which did not materialize because of new federal tax laws instituted via the Tax Reform Act of 1969. Nevertheless, Gustav (Gus) O. Lienhard, Johnson & Johnson’s president, became the Foundation’s chairman upon his retirement, and moved his office to the modest frame house that was then the Foundation’s home, on Livingston Avenue in New Brunswick.

Johnson & Johnson stock value increased four-fold in the yeas immediately following Johnson’s death, and Lienhard readied the Foundation to receive, according to a New York Times story published on December 6, 1971, $1.2 billion in Johnson & Johnson stock, making it the nation’s second largest philanthropy, next to The Ford Foundation.

The RWJF Board chose David E. Rogers, MD, dean of the medical school at Johns Hopkins University in Baltimore, as the first president of the Foundation. Rogers had no experience in philanthropy but was considered a visionary physician who contributed in substantive ways to the national debate on health policy. Rogers attracted Robert Blendon, Walsh McDermott, Margaret E. Mahoney and Terrence Keenan.

Robert Blendon in 1969 received a doctorate in science (ScD) from the Johns Hopkins University School of Public Health. Walsh McDermott (1909-1981), a well-married tubercular physician, one time head of the Division of Infectious Diseases at New York Hospital, physician member of the National Academy of Sciences, and a founder of the Institute of Medicine, was one of Rogers’ mentors. Two experienced foundation professionals, Margaret E. Mahoney and Terrance Keenan of the Carnegie Foundation and Commonwealth Fund, respectively, moved over to the fledgling RWJF.

According to John W. Murphy, an early writer-member of the RWJF staff, Dr. David Rogers of the “then unknown Robert Wood Johnson Foundation called me in the fall of 1972 to say he was seeking a writer to help “get the word out” about his foundation, and that a mutual friend had given him my name. [H]e explained that his foundation was about to receive a sizable bequest which would make it second in assets only to The Ford Foundation, and that it would target the health care field….Without meaning to sound arrogant, I candidly told David that I knew nothing about the health care field, and…My first day at RWJF marked a change in my career; indeed, my life...A simple note [on my desk] read: ‘John: Off to Bermuda for a few days to write a report on medical education. Start reading, and we’ll talk when I get back next week. Terry [Keenan].

“I grinned: here was clear evidence that indeed the foundation side of the fence was greener! Imagine, a week in Bermuda to write a report! (Parenthetically, Terry’s report became for its time the seminal reference on the financing and structure of medical education). At that point, David Rogers entered my little office, closed the door, propped his feet upon my desk, and said: “Terry suggest we start writing the annual report to tell people what we are going to do with all this money. Where shall we start?” (1) According to communications specialist Frank Karel, another early RWJF staff member, the Foundation’s goals initially encapsulated as follows: “the encouragement of institutions or individuals who are attempting to restructure the American health delivery system to make effective care more available for non-hospitalized patients.” (2)

Surveys conducted by the Foundation, according to Robert Wood Johnson biographer Lawrence G. Foster, indicated that many Americans were deeply concerned about their inability to get prompt medical help when they needed it. (3) “Using that information to help set the course, the Foundation decided to make one of its major goals improving patient access to out-of-hospital primary medical care. ‘We decided to listen to the public,’ Dr. Rogers explained, ‘and Americans were saying that they were concerned about getting help when they were sick.’” Robert Blendon, one of the original RWJF staff members noted above, recalled that David Rogers “believed that there was something wrong in America if people who could benefit from the best of medicine never got to the hospital before it was too late, or they got to the wrong place.” (4)

Meanwhile, emergency medical services ( EMS) was emerging as a feverish national interest, as evidenced by five occurrences. First, in September 1966, anonymous members of the Committee on Trauma and Committee on Shock, National Research Council, National Academy of Sciences, Washington, DC, published a 37-page monograph titled “Accidental Death and Disability: the Neglected Disease of Modern Society.” (5) The authors of this document framed accidental death and disability as a public health crisis that required immediate attention.

Second, also in 1966, the US Congress enacted the National Highway Safety Act of 1966, which authorized the Department of Transportation to set guidelines for EMS and provide funds for the purchase of ambulances and equipment, the installation of communication systems, the development and support of emergency medical technical training programs, and the development of statewide EMS plans. (6).

Third, in 1971 Jack Webb (1920-1982) and Robert Cinader (1924-1982) created and produced the Los Angeles-based, 60-minute television program called “Emergency!” which ran until 1978 and which many people credit with arousing the American public’s interest in emergency medical care. (See SEMP Biot #258: Emergency! TV Show: Hollywood’s Role in the EMS Systems Movement” available at: http://www.semp.us/biots/biot_258.html)

Fourth, in 1972 President Richard M. Nixon issued a presidential directive to HEW to fund five HEW demonstration projects to develop five “total EMS systems.” Two occurrences preceded this presidential initiative. In 1968 a Department of Health, Education, and Welfare (HEW) advisory committee on traffic safety chaired by Dr. Daniel P. Moynihan concluded that the department should assume primary federal responsibility for EMS. In June 1970 a steering committed on emergency health care and injury control chaired by Dr. Jesse Steinfeld, then Surgeon General of the US Public Health Service, recommended that HEW consolidate all federal efforts in EMS. (7)

The Nixon administration designated the Health Services and Mental Health Administration as the lead agency within the HEW to oversee the five contracts totaling $16 million, which the State of Arkansas, a three-county area of Southern California (San Diego), a seven-county area of Northeastern Florida (Jacksonville), the entire state of Illinois, and a seven-county area in Southeaster Ohio (Athens) received. The primary purpose of the EMS demonstration projects were to develop and demonstrate various approaches to providing EMS (but not actually provide those services) in a systematic and comprehensive manner so that other states and communities could use these experiences in developing their own EMS systems. (7)

Fifth, in the summer of 1972, The Robert Wood Johnson Foundation decided to make a major commitment to the EMS field. Its focus, according to Sadler, Sadler, and Webb, was on the “front end of the emergency care system, namely the point of citizen access to emergency medical care. The Foundation recognized that in most parts of the country most citizens had no easily identifiable place to call when they needed emergency medical assistance. Further, in those few places where a well-publicized emergency medical telephone number existed, the person receiving the call seldom had training in how to deal with a request for emergency medical help. Even with trained dispatch personnel, the necessary assistance was often not readily mobilized because of the inability of the several emergency response agencies (ambulance, police, fire, and hospitals) to communicate effectively.

“It was further evident that were communications systems did exist, many were constrained by political struggles and jurisdictional boundaries which prevented a patient from being taken to the most appropriate place for care. The Foundation concluded that emergency medical care could be strengthened through regionally based communication systems which integrated an area’s emergency care resources into a comprehensive network of services.

Foundation staff member Robert Blendon was charged with getting the program moving and sought out Blair Sadler, then an assistant professor of law at Yale University; Canadian medical doctor David Boyd, then a rapidly-rising star from humble beginnings as a surgery resident at Cook County Hospital in Chicago, Illinois, to de facto EMS director of the State of Illinois, to director of the Division of Emergency Medical Services in HEW; and Floridian Eugene Nagel, MD, known for his pioneering work on prehospital cardiac care.

Nagel said, “The Robert Wood Johnson Foundation was unique at the time. The charge given to us by the Foundation was, if we had $15 million to spend on EMS, how would we spend it, and what good should we expect it to do? The Foundation wanted the program to be a catalyst. ‘We’d like you to look for the key log in the EMS logjam,’ they told us. ‘Use the $15 million to break that key log and get things moving.’” (8)

David Rogers and his advisory group envisioned the program as a one-shot effort that would create improved access to the emergency medical-care system across the country. They designed the program “like a series of building blocks,” according to Sadler. “It had three basic components. The first was technology, which was basically radios. The second was training, which was twofold. One part had to do with upgrading the skills of people who were still called ambulance attendants. The rest was about training dispatchers in basic emergency medicine. The third part was interagency coordination, which was perhaps the most difficult of all.” (8)

The advisory group considered which professional discipline should serve as the lead agency in receiving the RWJF grants: A police agency? A health department? A hospital? In the end, the committed, according to Blair Sadler, decided that “it was quite appropriate in some cases that the lead agencies would be the police department, because [police departments] had the dispatch capability. In other cases, it might be the country administrative officer, a large hospital, or the health department. We didn’t care. We held them all to the same standards, but they were all diverse agencies. It didn’t matter to us who the lead agency was, as long as that entity had the ability to bring all the key EMS players to the table. Fire departments were applying for grants from The Robert Wood Johnson Foundation. That was unheard of. At a time when foundations were focused on medical schools, hospitals, and clinics, we had consortiums of public safety agencies submitting proposals. It was like Mars and Venus coming together on one planet.” (9)

On April 9, 1973, RWJF’s David Rogers and Duke University’s Philip Handler, PhD, who was serving as the president of the National Academy of Sciences (1969-1981), which jointly administered the RWJF program, announced that $15 million was authorized for a nationwide program to encourage communities to develop regional emergency medical response systems based around visible access points. Of note is that The RWJF made 1,100 awards totaling $318.5 million between 1972 and 1978, thus putting the relatively small amount of $15 million into some perspective. (10)

RWJF staff members tightly controlled the grants by requiring grantee compliance with a breathtaking set of minimum requirements within a year of receiving grant monies. The minimum requirements were:

1. Central and immediate citizen access to the emergency medical system;

2. Central control of communications with a single regional institution assigned responsibility for dispatch and coordination of emergency medical vehicles and services and for collection of data necessary for effective internal management and monitoring of the system;

3. Prompt central medical dispatching of appropriate emergency care to the scene of the emergency and direction of patients to appropriate medical facilities;

4. Prompt and appropriate emergency system capacity, meaning 24-hour availability of properly designed and equipp3edvehicles staffed by trained emergency medical technicians, adequately staffed and equipped 24-hour hospital or clinic emergency department capability, with substantive progress toward regionalization and categorization; adequate communications equipment for transmission of voice information between hospitals, ambulances and the central medical emergency dispatcher;

5. Access to adequate radio channels and telephone lines for a comprehensive emergency medical services systems; and

6. Assurance that after the two years of support, the program would become self-sufficient, with its subsequent operational expenditures becoming part of the budgets of the applicant or other agencies. (11)

The RWJF actively recruited grantees, something not usually done by foundations at the time, and eventually received 251 applications from 49 states and Puerto Rico. An advisory committee of the National Academy of Sciences, under the chairmanship of Dr. Robert Heyssel (1928-2001) of Johns Hopkins University School of Medicine, recommended 44 regions for grant support of up to $400,000 each. Finally, in May 1974, The RWJF announced dispersal of grant monies in May 1974 to 32 states and Puerto Rico.

Did The RWJF’s venture into emergency medical care accomplish what it set out to do? Please go to Biot #263 for Part B, available at: http://www.semp.us/biots/biot_263.html.

Sources:

1. John W. Murphy: “On the Role of the Local Foundation: Remarks for the Acceptance of the 1999 Terrance Keenan Leadership Award.” GIH 1999 Annual Meeting on Health Philanthropy. Available at: http://www.gih.org/usr_doc/49537.pdf#search='mem%20associates%2C%20inc.%20%20margaret%20mahoney'. Accessed September 12, 2005.

2. Frank Karel: “‘Getting the Word Out’: A Foundation Memoir and Personal Journey.” In “To Improve Health and Health Care – Volume IV. The Robert Wood Johnson Foundation Anthology. Available online at: http://www.rwjf.org/files/publications/books/2001/chapter_02.html. Accessed September 13, 2005.

3. Lawrence G. Foster: “Robert Wood Johnson.” Lillian Press.1999, p. 653.

4.Digby Diehl: “The Emergency Medical Services Program” In “To Improve Health and Health Care – Volume III The Robert Wood Johnson Foundation Anthology.” Available online at: http://www.rwjf.org/files/publications/books/2000/chapter_10.html. Accessed September 13, 2005.

5. Accidental Death and Disability: The Neglected Disease of Modern Society. Prepared by the Committee on Trauma and Committee on Shock, Division of Medical Sciences, National Academy of Sciences, National Research Council, Washington, DC, September, 1966. Available online at http://books.nap.edu/catalog/9978.html . Accessed on September 12, 2005.

6. Alfred Sadler, Blair Sadler, Samuel Webb: “Emergency Medical Care: the Neglected Public Service.” Ballinger Publishing Company. 1977, p. 7.

7. Ibid. p. 9.

8. Digby Diehl: The Emergency Medical Services Program” In “To Improve Health and Health Care – Volume III The Robert Wood Johnson Foundation Anthology.” 2000.

Available online at: http://www.rwjf.org/files/publications/books/2000/chapter_10.html. Accessed September 13, 2005.

9. Ibid. p. 6.

10. David Rogers: “The President’s Statement.” The Robert Wood Johnson Foundation Annual Report 1978. Princeton, NJ.: The Robert Wood Johnson Foundation, 1978. Available at: http://www.rwjf.org/files/publications/annual/AnnualReport1978.pdf. Accessed September 13, 2005.

11. Alfred Sadler, Blair Sadler, Samuel Webb: “Emergency Medical Care: the Neglected Public Service.” Ballinger Publishing Company. 1977, pp. 21-24.