The Business of Government Hour


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The Business of Government Hour features a conversation about management with a government executive who is changing the way government does business. The executives discuss their careers and the management challenges facing their organizations. Past government executives include Administrators, Chief Financial Officers, Chief Information Officers, Chief Operating Officers, Commissioners, Controllers, Directors, and Undersecretaries.

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Dr. Marilyn Gaston interview

Friday, February 22nd, 2002 - 20:00
Dr. Marilyn Gaston
Radio show date: 
Sat, 02/23/2002
Intro text: 
Dr. Marilyn Gaston
Complete transcript: 

Arlington, Virginia

Thursday, December 20, 2001

Mr. Lawrence: Welcome to The Business of Government Hour. I'm Paul Lawrence, a partner at PricewaterhouseCoopers and the co-chair of The Endowment for The Business of Government. We created The Endowment in 1998 to encourage discussion and research into new approaches to improving government effectiveness. Find out more about the Endowment by visiting us on the Web at

The Business of Government Hour features a conversation about management with a government executive who is changing the way government does business.

Our conversation today is with Dr. Marilyn Gaston, Director, Bureau of Primary Health Care, Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Good morning, Dr. Gaston.

Dr. Gaston: Good morning.

Mr. Lawrence: And joining us in our conversation is another PwC partner, Fred Fagerstrom.

Good Morning, Fred.

Mr. Fagerstrom: Good morning, Paul.

Mr. Lawrence: Well, Dr. Gaston that sure was a mouthful when I introduced you.

Dr. Gaston: Yes, it was.

Mr. Lawrence: Perhaps you could tell our listeners about the organization's mission and its activities.

Dr. Gaston: Well, first of all, let me just say that our agency, the Health Resources and Services Administration, or HRSA, for short, is the focal point in the Department of Health and Human Services for actually getting health care to under-served communities; meaning that we build health centers; we place health care providers, so that it makes us very different from NIH, which is -- which everyone knows -- is the research agency; CDC is the epidemiologic agency; FDA is the regulatory agency; and ours is really getting health care to people throughout the nation that don't have it.

Our listening audience might be surprised to know that there are millions of people in our country that really face multiple barriers to getting health care. I think we're all kind of aware of the barrier of being uninsured, what that places on us. And that's an important one, the financial aspects, but there are barriers that, even if they had a health care card, that they would have difficulty surmounting.

For instance, there are areas where people are so isolated in this country -- they drive for hundreds of miles to try and get to some health care. There are cultural barriers; there are language barriers; there are attitudinal barriers; there -- we could go on and on.

Our system itself even presents barriers to people, so that what we are trying to do is help communities and people that are under-served, uninsured, disadvantaged, especially poor. We target poor people throughout the nation to get -- to increase -- our mission is to increase access to quality health care for them, and also to improve their health outcomes. And that's what we do every day.

In the agency, what I do is direct the bureau that gets primary health care -- that's the family doctor -- that's the first contact that we all know about. As opposed to the tertiary care part of the system, which is the hospital. Okay? We're the primary care. And this is where most people get their care -- in a primary care. That's where prevention goes on, early diagnosis, early treatment. If that system is strong then we as a nation will save money.

We don't want people to go to the ER -- in the emergency room for everything; that's very costly. And we certainly want to keep people out of the hospital. We want to -- if they go to the hospital, we want to decrease their hospital stay. Not only will that improve their health, but also save money. And so that's what primary care aims to do.

In the agency, we also have a bureau that looks specifically at maternal and child health. We have a bureau that looks specifically at HIV AIDS, and we have a bureau that looks specifically at training and placement of health care providers across the nation.

So that's HRSA and that's our focus.

Mr. Lawrence: How big is the bureau and what type people work on your team?

Dr. Gaston: We have upwards of 400 people at this point. Most of them are trained in health care. But we have some -- a number of administrators, you know, budget people and administrators. But we have physicians in the bureau; we have nurses; we have people that are trained in public health. So we have a number of people who have a master's in public health. And these degrees that are given at Hopkins and at various universities and they come directly into the system from there. But most of them are really well trained and interested in health care, per se.

Mr. Fagerstrom: You started to touch on your role at the bureau. Could you expand on your role at the bureau, please?

Dr. Gaston: Yes. My role as director, I guess, as any director, is to not only oversee and ensure the work and look at the progress that's supposed to be going on, but to provide leadership in terms of vision; to provide leadership in terms of helping everyone in the bureau -- they really are the ones that are doing the work. I'm there to serve them. The people in the bureau are the heart and soul of the work that we do. And so I'm there in a partnership role.

As a leader, I believe in participatory management. Another leader might look at it another way, but that's what I see my role as being. I have a management role, of course, in terms of budget and people and projects. But I also have a role that looks at, well, where are we going to be 10 years from now? Where are we headed? Where have we gone? What do we need to change? So in terms of providing some direction along with the senior leadership, that's the role that I play.

Mr. Fagerstrom: Wonderful. Maybe you could spend a little time talking about your career and tell us a little bit about that.

Dr. Gaston: Well, let me see, where to start? How much time do we have? Let me see if I can make it real short. I think that I really realized very early, as a little girl, that I wanted to be a physician. I think at the time, I even knew that I wanted to work with poor and under-served people, because I grew up poor. I grew up in the projects and we didn't have any health insurance either.

And one day, my mother fainted in our living room and I, of course, it scared me half to death. I didn't know, really, what to do and we didn't have 911 back then in 19-huh-huh.

So -- well, you know, the listening audience needs to know, there are many places in the country that still don't have 911. You know, we live in such a highly technical, especially in these urban areas -- we forget that many of our rural and frontier areas still don't have 911. But anyway. So now everybody will really appreciate that, hopefully, as something that we have.

She fainted because she had cancer of the cervix and had bled from the normal hemoglobin of around 13 or 14 down to 2.

Now, that was a good example of how people that are poor -- people that are uninsured, even today, put off getting care until they are really, really very sick. And that was a major issue.

I now see, though, that another part of that was that she really was so busy taking care of us that she wasn't taking care of herself. And that knowledge and reality has prompted me in the last few years to write a book targeting women to really help them take care of themselves and their health a lot better.

That prompted me to know that I wanted to be a physician. So I went through medical school. I didn't get a lot of encouragement back then because I'm African American; I'm a woman; I was poor. Someone even had the nerve to tell me I couldn't do it because I was Catholic. Anyway, I made it through.

And I knew throughout my training that I was going to work in poor communities. I worked in Haiti while I was in training. I went to Appalachia and spent time -- so I really learned the issues in many different communities about the trouble with access to care.

I became a pediatrician and got interested in sickle cell disease, because I was seeing a lot of African-American babies with sickle cell disease. And I started a sickle cell center at the University of Cincinnati, where I went to school. The reason that that's important is because it also gave me an opportunity to see how to get health care to very special populations. For instance, homeless populations, migrant farm workers, sickle cell communities -- those kinds of, particularly isolating, either because of illness or because of occupation or because of lifestyle, with AIDS, et cetera, are very specific groups that we have to target, too -- with unique access approaches to help get them into care.

And then I wound up -- I started a community health center in a very under-served community right outside of Cincinnati, where I grew up. So I had the opportunity to head this bureau. It was just the dream job of my life, because in the bureau, what we do is build; actually build, as I said, community health centers. We build health centers and put them out in the very under-served areas.

We now have over 3,000 health centers across the nation and in the territories, serving upwards of 12 million people. These health centers are owned and -- they're very unique because they're not federal health centers, even though we administer them and we help to fund them. But we're in partnership with these communities and they're owned by the community.

And we now know that the way to solve our health care problems in this nation, one of the ways is that people need to take charge. When they take charge of their own health and decide to make a change in their access issues in their communities -- make a change in their health problems in their communities, they're going to decrease their infant mortality rate and really focus on that and take charge. They can do it. And so that's what we're there to do is to partner with them.

And so now, to come back as the director of the Bureau of Primary Health Care and do it -- so I've come from isolated communities, in terms of providing care and increasing access in dealing with health outcomes, to now, on a national basis to do that. It's been one of the most rewarding things of my life.

Mr. Lawrence: This is a good stopping point and it's time for a break.

Come back with us after the break as we continue our discussion with Dr. Marilyn Gaston of the U.S. Department of Health and Human Services.

This is The Business of Government Hour.


Mr. Lawrence: Welcome back to The Business of Government Hour. I'm Paul Lawrence, a partner at PricewaterhouseCoopers. Today's conversation is with Dr. Marilyn Gaston, Director, Bureau of Primary Health Care, Health Resources and Services Administration at the U.S. Department of Health and Human Services.

Joining us is our conversation is Fred Fagerstrom, another PwC partner.

Mr. Fagerstrom: We know that the Bureau of Primary Health Care initiated the movement toward 100 percent access and zero health disparities in 1998. Can you describe this movement and its goals and its activities?

Dr. Gaston: We are very committed and dedicated to these goals. You know, people say, these are really outlandish goals -- 100 percent? How can you ever reach100 percent of anything? A hundred percent access to care; is that possible in this nation? And eliminate all these health disparities that we have between our poor and non-poor, between our minorities and non-minorities, et cetera?

Here we are. We are working every day very hard to try to reach as many underserved people in the nation. Okay, so if you want some results that are measurable, you want some goals -- you know, how close are we to doing it? And what's acceptable? Do we want to reach 80 percent of the people? Do we want to reach 90 percent? No, we want everybody in this nation to have quality primary health care. That's what we want. I'm sure all of you would agree. So we just put a number -- we want 100 percent of our Americans to be in quality health care. So that's where we get the 100 percent.

Now we also realize that, you know, we used to have goals that said we want to reduce the health care disparities. Well, we're talking about -- for instance, let me just give you a good example of health disparity: The Latino community and the African American community are twice, maybe two to three times more likely to have diabetes and to die from it and have complications.

We don't believe that that's just because they're Latino or African American or what. We know there are a whole lot of factors that we have some control over, and we shouldn't have these disparities in our nation. We used to say, well, we're going to reduce that disparity. Well, how far? You're going to reduce it in half? Is that acceptable? No. You want to eliminate that disparity. You want to eliminate all the disparities in life expectancy. You want to eliminate -- we want everybody in our nation to have optimal health. So that's where those goals came from.

We also realized that we -- the reason we started a movement is because we can't just have -- these should be goals for our nation, not just for the Bureau of Primary Health Care; not just for the Department of Health and Human Services; that we as Americans need to strive for this. And no one group can do it. We can't do it by ourselves in the government, you know. What we're doing with -- you know, the budget we have is over $2 billion. We're only reaching one-fifth of the need that's out there.

So we knew we had to engage as many partners as we could, at the state level, at the local level, both public and private. We knew we had to build strong public/private partnerships. That's what this movement is about. We knew we had to mobilize.

I said a little earlier that communities have solutions in them, and once they get moving on it, they can really put them in place and make some headway. So that communities need to get mobilized around this and get outraged with their own health care outcomes that need to be changed.

What's been exciting for me is, you know, you always have a group of partners you're working with. And we're most comfortable with our health care partners, okay? But we have reached out to all kinds of different partners: United Way is one we haven't worked with before. We have business partners now. We have a number of faith-based partnerships, because we know that frequently, the message from the minister in the pulpit about health is a lot more powerful than what it would be from any of us as physicians or health care providers.

We see this movement sweeping the nation and we're just very pleased with it.

Mr. Lawrence: The partnerships are key. Tell us about the challenges of creating these partnerships.

Dr. Gaston: One of the things we've learned, especially from working right on the front line in communities, that it's frequently very difficult. As you said, a lot of challenges. There are turf issues; there's competition going on, especially in this health care environment. But once people get motivated around a goal; that once you raise it above the turf, the organization, or the historical attitudinal issues, and raise it to the goal of we want everybody in our community to have 100 percent access. Or we want to eliminate our disparity in infant mortality rate. And everybody now is moving in that direction; the competition is with the goal and not with each other. And that is one of the successful strategies that we are beginning to even learn how to go into a community and help them sit around the table and begin to do that together.

Mr. Fagerstrom: What results have you seen through the movement so far?

Dr. Gaston: Like I said, we're learning a lot more about the partnerships and how to help communities move forward along this. We're learning -- the results are -- there are some communities that have eliminated a disparity, depending on which one they choose. There's a community that we talk about frequently: Contra Costa County in California. A whole county came together and decided that they were going to eliminate the disparity in their African-American women and their Latino women in terms of early diagnosis of breast cancer. You know, that the outcome and of course, the earlier you get diagnosed the better the outcome's going to be.

Well if you have poor women, you have uninsured women, you have minority women, there are educational levels that vary -- they are getting diagnosed late. And that's why their outcomes are as poor as they are. They decided they were going to eliminate it. After five years -- they pulled everybody in that county together. As I said, the churches, the businesses, the schools, everybody. They have eliminated it.

The Latino women and the African-American women, now, their rates of early diagnosis are the same as the white women in that community; the same as the middle-class women in that community; the same as the Asian-American women, who really -- the Asian-American women have the best rates in terms of early diagnosis.

So we have seen that. We have seen community health centers eliminate disparities as it relates to infant mortality, so we know that it can be done. You know, five years ago, when we really set these goals, there was a little, you know -- people started questioning us, can we really do this, you know, this is not going to be successful, people are going to get discouraged. We would wonder, well, you know, is this possible? But we kept using it for the reasons I said before. Anything else is not acceptable.

But I'm telling you, we see these outcomes being achieved in communities. We have communities where 90 percent of the people are all in care. Now, they don't have insurance; they still don't have insurance, but they're in care, okay. And I think that's what we need to hear, too. When we put health centers out, by law, they are mandated to see uninsured patients. One of the reasons they can do that is they get money from us. But also, we work very closely with Medicaid. And the combination of getting adequate Medicaid rates to pay for certain patients and then the one -- if the grant is paying for the uninsured patients, we're doing outreach to help people get into care and providing culturally competent care, we really can reach almost everybody in that community.

Mr. Lawrence: You mentioned working with institutions of faith. The President has a faith-based initiative and you have a small version of it. I wonder if you could tell us about some of those experiences.

Dr. Gaston: Yes, those are very good. I'm glad you mentioned the President, because one of the things that we're really excited about is one of his major initiatives, too, that you haven't heard a lot about is that he is significantly increasing the growth of health centers over the next five years. It's in his budget plans. He wants to expand health centers by adding at least 1,200 new and expanded health centers over the next five years, increasing by 6,000 more people into care. So that's exciting.

We also think that his initiative to focus on the faith community is really important; that we have to do that, we agree with that and we have done it in health centers.

One of the reasons, again, that as I mentioned earlier, churches are after the same thing that -- the faith community and the health community, we have the same goals. We have the same mission. We're frequently in the same community; we're working with the same people. The fact that we haven't partnered more in the past is surprising to me.

We know, for all of us -- let me just say for all of us, not just the people we're trying to target -- but to really live in health and wellness, we all have to live a holistic life. We have to focus on our physical health, our emotional health, but also on our spiritual health. And so there are more and more data to show the impact of spirituality on health. So that our health centers, many of them, have partnered with the faith community to such a degree that they have prayer rooms in them; they have ministers on the staff. We're talking about primary care. You know, hospitals have always done that; they've had that. But we're talking about -- not for people that are dying, but for people that are well; that we're trying to keep well by using that kind of approach from the faith community.

Also, some of the churches, once they focus on health, too, and develop a project for their congregation, they need to have a health care system that can work in partnership with them to help them reach their goals. These kinds of partnerships are just absolutely critical, and they enhance the mission of both the mission of faith and health communities.

Mr. Lawrence: That is a good point for us to stop for a break.

Come back with us after the break as we continue our discussion with Dr. Marilyn Gaston of the U.S. Department of Health and Human Services.

This is The Business of Government Hour.


Mr. Lawrence: Welcome back to The Business of Government Hour. I'm Paul Lawrence, a partner at PricewaterhouseCoopers. And today's conversation is with Dr. Marilyn Gaston, Director, Bureau of Primary Health Care, Health Resources and Services Administration at the U.S. Department of Health and Human Services.

Joining us in our conversation is Fred Fagerstrom, another PwC partner.

Mr. Fagerstrom: We know that the Bureau describes a customer-focused delivery system as one that serves the universal population. Can you explain the premise of this vision, and also, given the customer-focused vision, who do you consider to be your customers?

Dr. Gaston: Fred, the customers for us are the people that we're trying to serve. That's our number one customer; the people that need quality health care, the people that are having health outcomes that we know they deserve to be better and that we know they can have. So it's the people that we're trying to reach across -- the millions of people that are having trouble getting health care.

One of the things we have learned from this program, because you've heard me talk about the health centers that we build and put out there. We're in partnership; these are not federal programs, but the communities own them. They own them because they are run by community boards. They are run by the people that come to the health center. So this helps them to take charge of their care. So they are the ones that say when are the hours of operation, what are the services that are needed in this community? What kind of people do we want to hire to take care it, et cetera. So that they really run it. That makes a big difference in terms of -- that's why, when you see one health center, you've just seen one health center. Because they're all very different in each community.

That is being customer-focused. Now, in the Bureau, our bottom line and how we make decisions is really based on what is in the best interest of the people that we're trying to serve, and so that customer focus makes a major difference. It maintains the quality of the care; it improves the level of cultural competence that we're trying to achieve. And so we think that is the only way to do business.

Now, we do have other customers, too. For instance, you might say that the Hill is a customer; that we are there to serve at the will of the Hill. The Administration -- the Secretary is a customer of ours. We're there to serve with the Secretary. Also, all of our constituents -- the American Medical Association is a customer. All of our partners that we work with are also customers, but number one are the people that need the care.

Mr. Lawrence: Part of your work at the Bureau we know involves providing grants to fund community health care programs. Could you talk to us about the grant process; what type of programs do you fund and how is selection made?

Dr. Gaston: Right. That's a good question. One of the main challenges in the Bureau, as you heard me say; we put health care into needy areas. Well, the question is how do you determine need? What are the criteria? Is it based on poverty? Yes, that's a very important one. Is it based on how many physicians are already in an area? Yes. Those are the two most important providers in terms of the neediest -- scoring, in a way.

But also, it might be related to how many are unemployed; what about uninsured? All kinds of aspects. So that the main driver for us in making any decision is need; so that when an application comes in, there are various criteria that we score and rank applications on in terms of where -- how needy is that community?

What are the health indices? How high or how low is their life expectancy? How high is their incidence of syphilis? How high is it? So various health indices also tell us the need in a community. Applications come in from various communities, okay? And we have objective review committees. We have peers that look at these applications and then rank them. And then we make the decision at the Bureau based on those scores, also based on recommendations from our state partners. We don't do this at the federal level without input from the state where they are, because they're their local states and they know very well where they think the neediest areas are. So we do this in combination with them.

So we look at need, number one. We also look at their capability to provide this; you know, how successful are they going to be? We don't want to build a health center here one year and then in two years it's going down the tubes because they haven't been able to sustain in this competitive environment what they need to do to provide quality care.

So a number of things come into play as we make those decisions.

Mr. Fagerstrom: How do you measure the results? What might be the role of patient surveys or other mechanisms and performance measures in determining the quality of care provided?

Dr. Gaston: That's one of the most difficult things that we are facing. We're doing a better job, but we need to improve that. Patient surveys are very important because they do give you a sense of the quality of care as the patient perceives it. But there are a whole lot of other measures that we think are important.

For instance, we monitor very closely these programs. We send out every three to five years, depending upon how well a center is doing -- you know, we might send them out every year, depending on how well they're doing. But usually, it's about three to five years, we send out a team of consultants that go in the center; they might spend three to five days in there. They look at the budgets; they look at how the programs are managed; they look at how is the board interacting; they review charts, patient charts, and see if they are providing the care that should go on. So we look at the clinical aspects. And they interview patients while they're there. So there's a thorough review; almost the way JACO, the Joint Commission for Accreditation for hospitals, and in fact, many of our centers are also reviewed by JACO and get accredited in terms of how well they're doing the job.

So we take this very seriously. Also, we not only do that to see, you know, not to be the police necessarily or try to defund the program. But to say, okay, you got an A in clinical, you've got a B in your patient satisfaction, but you know, your billing and your management needs some help. So we're going to send some consultants in and help you improve that. So it's a constant process of improvement. Quality improvement is what goes on, too.

And that's another way that -- and, you know, as I said, Fred, we take it very seriously. We put a fair amount of money in it to ensure that these programs are good programs.

Mr. Lawrence: What are the management challenges of coordinating these programs? They're across the country, communities, different organizations, different governments. The partnerships you describe, how does it all really happen?

Dr. Gaston: You know, that's a major challenge that I have. When you talk about the role of the regulator; yeah, how does the director pull all of this together? And it is a feat.

One of the ways that we try to do it is, number one, we have this huge infrastructure out there; meaning that it's not only at the community level with the programs that are giving the care. I mentioned, we have a whole state infrastructure, too, that's involved with each of those health centers and their respective -- we have a regional infrastructure that is also helping to monitor and look at. So all of them give communication to one another. And also, we have clinical networks of physicians and nurses that are involved in every state, that are looking at what's going on with the care and where the need is, et cetera.

And then they communicate not only with each other, but then they come to a focal point, which is in the Bureau and in the agency. And that's how we try to do it. It's tough.

Now, technology, we're getting better and better as we use more and more of the technology. We have a major challenge with that, because still, there are hard-to-reach areas. With technology, the rural areas, again, here we are; you know, in the urban areas, it's okay. It's hard with poor health centers that might not have enough money to get up to speed technologically. We should have electronic medical records in all these centers, and that's the way we're moving but you know, we've got a long way to go. Almost 4,000 health centers all doing the same thing and technologically on the cutting edge; we have to move in that direction. And that's a vision for the next five years, that we -- in five years, we will really be way down the road when it comes to technology.

Centers are doing teleconferencing. For instance, in the isolated areas, there are some centers in really isolated areas where there might be one room, and a nurse practitioner's in there. And a doctor might fly in once or twice a week -- helicopter, et cetera.

But also, if you put some capability for that nurse to teleconference out to a medical center what's going on with a patient, well that revolutionizes the care for that community. And so more and more of that is going on, too. And how do you coordinate all that? I think that, again, we're going to try to do a much better job technologically, but it's a real challenge.

Mr. Lawrence: That's a good stopping point for a break. Rejoin us after the break as we continue our discussion with Dr. Marilyn Gaston of the U.S. Department of Health and Human Services.

This is The Business of Government Hour.


Mr. Lawrence: Welcome back to The Business of Government Hour. I'm Paul Lawrence, a partner at PricewaterhouseCoopers. And this morning's conversation is with Dr. Marilyn Gaston, Director, Bureau of Primary Health Care, Health Resources and Services Administration at the U.S. Department of Health and Human Services.

Joining us is our conversation is Fred Fagerstrom, another PwC partner.

Mr. Fagerstrom: Electronic government offers numerous opportunities to do business in Web-based technologies and the Internet to extend the government's services. How is the Bureau online changing the way that public health care providers and the population access your programs?

Dr. Gaston: It has really increased our access. Our partners just -- it has increased exponentially, needless to say. The challenge, though, is, we want to know the way that our middle-class community is accessing online services in terms of health information. We would like to know how that's happening in our poorer communities.

We're very worried that with this growth technologically, that the gap between the haves and the have-nots between the poor and the non-poor is going to really increase in that arena. And we know that not only are we struggling to help people with access to health care, but also access to information. And we cannot let this gap keep getting wider and wider and wider. So a real challenge for us is how to do it.

We've put in place some demos where there have been some donated palm-held, almost like PalmPilots, where you can keep records. And we've also set it up so that patients can try to access their own health care record and understand, see their tests. And I'll be very interested in how these results will come out.

Also, you know, on the horizon for everybody is that there would be home monitoring. And you know, that's very exciting. And that gives everybody a chance to begin to take more and more of an interest and take more and more charge of their own health from their own home. But, again, how will that work in South Dakota? How will that work in inner city Harlem? How will that work along the U.S.-Mexico border? So that we have a number of challenges in terms of, again, increasing access to all the opportunities and potential that are coming on-board.

Again, as I mentioned in the previous segment, the ability to not only use telecommunications as it relates to patient care, but also in terms of the providers; that isolated providers need to have a steady stream of information, too. So that the ability for them to access an NIH conference around a particular area or even conferences that we have constantly. I mentioned earlier I was just at a major quality conference in Florida with over 4,000 people. But wouldn't that have been great to have the ability to satellite that to all these health centers so they could participate in the discussion? Not only the uplinks, the downlinks so that they could be very interactive.

I think there's just on the horizon all kinds of potential for us to try to grab that will revolutionize the information that's available and also around patient care.

Mr. Lawrence: You describe the challenges as primarily technological; how can we get electronic communication there. Have we solved the privacy and the security issue? I know everybody gets excited about providing this information until they realize it's going to be on the Web and someone who we might not want to see it will see it. How's that being worked?

Dr. Gaston: I don't think we've solved that, although I must just express my ignorance and maybe we have it and I'm just not aware of it at this point. I don't get a sense that we have. And I think that we're just as behind in that arena as we are in terms of getting an electronic medical record more widely utilized across the nation.

You know, I look at the private sector and look at business. And we look -- the Giant. I mean, you go into the Giant and you don't see paper flying around every time that you're checking out. I mean the private sector is a lot further advanced than we are in the health care system. I mean, the fact that we have these old outdated charts that get lost -- papers are, you know, well, you know the story. That it's something that I'm glad to see the Secretary wants us to focus on -- the Secretary of HHS; and I hope that over the next four years we see it really grow.

Mr. Fagerstrom: What's the role of the Bureau in the Emergency Response Plan and in preparing for possible future emergencies?

Dr. Gaston: Every time I've heard Secretary Tommy Thompson talk recently, clearly, he sees his health centers as being front and center in terms of an emergency response; you know, front line. And that's a major challenge for us, too, because the whole health care system, the providers need to be educated in terms of being able to make a response.

And CDC is playing a major role in that education. I don't know how many conferences online they've had to educate providers, which have been excellent. So our front-line providers are the ones that are going to pick up -- as you know, the first kind -- any kind of symptom from anthrax or anything else, and they're certainly going to be the front line in terms of any kind of therapy, explanation, et cetera.

With the disaster in New York, we had 12 health centers in that arena. Some were for homeless people that -- see, that's another thing people don't think about; that not only were people that lived there displaced, but the homeless community was also. And you know, many of our homeless are very stable, they stay within a certain radius. And even though they might move, they really are pretty much fixed to their health care system, too, so that our health care for the homeless programs were shut for a long period of time.

Many of the other centers that were opened were just deluged with people that were afraid, as you might imagine. The issues that they were seeing around them -- respiratory. Well, those are the front line -- it's also our private-sector private doctors are the front line, and how do we, number one, educate that front-line force but also work with the system for emergency preparedness. There's a whole system out there for emergencies, as you know, too. So that somehow, we have to inter-relate. Again, we're back to how do we coordinate better; how do we communicate better and how do we integrate and work as a force and we're not at odds and duplicating things.

Mr. Lawrence: What advice would you give to a young person who's perhaps interested in a career in public health?

Dr. Gaston: I guess the main advice is for them to, number one, explore why they want to do it. What are their goals in life and what are they trying to accomplish?

Number two, I would suggest that they really learn as much as they can about it; get some role models in that arena and go, really try to jump in knee-deep into some actual public health experiences. I think, you know, at this point in time, there are all kinds of opportunities in public health that are expanding. There are going to be even newer areas. Certainly, as we just talked about, emergency preparedness.

I think that this whole area of public health and access to care is an area that we see a number of students from Hopkins and from Howard and from GW and Georgetown that are finding very interesting and want to make a career out of it. We're also seeing, you know, as we're having an explosion of immigrants in the nation, there are students of all kinds of backgrounds and disciplines and racial/ethnic minorities that want to go to this area.

You know, young people are kind of captured by the Peace Corps idea, and that's why, you know, President Kennedy's idea worked so well. So anybody that's interested in that, the public health service is certainly ready-made for that, too.

Mr. Fagerstrom: What's your vision for the Bureau of Primary Health Care over the next 10 years?

Dr. Gaston: We will reach 100 percent access in the next 10 years. There's no question in my mind. We can do it. We will eliminate some disparities. We're on the road to doing it now. I'm not sure we'll eliminate all of them, but we will -- over the next 10 years, we'll learn what it's going to take to do it and we'll understand much, much better from research, from experience, on what we need to do that.

Hopefully, we will change our health care system over the next 10 years from a treatment-oriented system, okay; catching things in the tertiary care, all the money and effort and the energy on that tertiary care; to a system that has the focus on prevention, early diagnosis, early treatment, health promotion, disease prevention. That's where we need to spend the money because, then, that's where we're going to save the money.

We will have a system over the next 10 years that is of the highest quality in this world. We are beginning to focus on that now. We're not going to have a statistic that says 98,000 deaths were caused by medical errors 10 years from now. We will have a system that's very culturally competent and one that is constantly monitoring its quality and being judged by that.

And we'll have a system that's going to be accountable to the people that we're serving, accountable to one another and accountable to the nation. And we will not be -- in 10 years we won't be 18th in the world in terms of life expectancy for our women and 24th in the world in terms of our life expectancy for men. We will be much better off in terms of our health outcomes in general.

Mr. Lawrence: Well, Dr. Gaston, I'm afraid we're out of time.

Dr. Gaston: Oh, my goodness.

Mr. Lawrence: Fred and I want to thank you for joining us this morning.

Dr. Gaston: Thank you so much for having me. I've enjoyed it.

Mr. Lawrence: This has been The Business of Government Hour, featuring a conversation with Dr. Marilyn Gaston of the U.S. Department of Health and Human Services.

Be sure and visit us on the Web at There, you can learn more about our programs and get a transcript of today's conversation. Again, that's

This is Paul Lawrence. See you next week.

Dr. Marilyn Gaston interview
Dr. Marilyn Gaston

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