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Shepherd: −obstetrician in the whole damn country that will do a third the number of patients I do. And they get twice, three times as much money.

Gatewood: Right. [laughs]

Shepherd: So you have to be a, first thing you have to be to be a public health physician is a (?) kind of religious fanatic. Public health is your religion, and you work like, I mean, just like a missionary, you know. The same thing, you know. It’s the same thing.

Gatewood: Exactly. This is one tape in a series of interviews on healthcare in the twentieth century, rural . Sponsored by the Oral History Commission, and the Folk History Foundation. I’m in the office of Dr. −

Shepherd: M. A. Shepherd.

Gatewood: M. A. Shepherd. Dr. Shepherd is the medical director with the regional health office here in . Dr. Shepherd has just returned from a long day at the family planning clinic in . Dr. Shepherd, can you briefly tell me your educational, well, we’ll get to that. Where are you a native of?

Shepherd: I was born on the Smithtown Ridge in . But my father moved his family to a farm, in the north part of . And I attended school at (Science?) Hill there. This was from the time that I was three or four years old that I lived on the farm. And−

Gatewood: Where did you get your college education and your medical training?

Shepherd: Well, I, before World War II, I went to a couple of years. And when I came back out of the service, I had the benefit of the GI Bill behind me, so I could go to medical school, and did, at the . Then I practiced in private practice for a couple of years at . And then I went into public health work doing a two-year stint in , Webster and counties as a tri-county health officer. From there, I went to the at for my masters in public health degree. Just as soon as I qualified for my boards in preventive medicine, I took those, and was certified by the American Board of Preventative Medicine in the, oh, I forgot what year.

Gatewood: That’s not that important. What made you feel you should get into the public health field? Did this, did you have some exposure to preventative medicine at the ? Or did this come out of the frustrations of your private practice?

Shepherd: It came out of the frustrations of private practice. is no different from most of the other medical schools. There’s very little of preventative medicine taught there. And what is taught is really, I mean, the students have very little interest in it. And it goes over their heads. They’re not interested or concerned with preventative medicine.

Gatewood: So in like introductory courses in college, it’s a lot of stuff there−

Shepherd: They don’t, no interest, they don’t pay any attention to it, it don’t stick with them. When they come out, they know nothing about preventative medicine. So I was like one of those. But then private practice, I was somewhat frustrated after a couple of years in which I had lots of people with problems. And they came to me too late. And the reason they came to me too late was because they were poor, they had no way to go, nowhere to get to be reached. Nobody was reaching them with what they needed to know about how to take care of their health, you see. And so when I saw them, they were terminal with heart disease, hypertension, and you name it. These kinds of things, and this is very frustrating. I felt like I was working myself to death, and I wasn’t accomplishing very much in private practice. I did lots of surgery. I did a general practice. And I did obstetrics and mental health and pediatrics and surgery and psychiatry and even industrial health. [laughs] And I was working myself to death. So I, I went seven days a week, around the clock. And after two years of no sleep, I was kind of a physical wreck, and I had to make a change. And even though I didn’t think I would like public health, it was a place to work until I had decided what I wanted to do. And I liked it because it’s approaching the control of disease in man at the right stage, where you can do something about it. And one man can save hundreds of lives. In no time at all, you can see where you’re saving lives. You can see where you’re preventing disease and suffering and so forth. But the initial attraction it had for me was the freedom from the telephone, and freedom to relax on weekends, and not just be fighting a crisis all the time.

Gatewood: Get a little Sabbath rest. [laughs]

Shepherd: That’s right.

Gatewood: Now you had this practice, then you went and got a masters degree in public health from . Did you come directly here from ?

Shepherd: Yes, I did. I had two−

Gatewood: Was that, was that regional office here then?

Shepherd: I had two years in public health before I went to . In this two years, I decided that public health was what I wanted. And then I went to and specialized in public health. And I came here. I came here as a county health officer in three counties. And these changed from time to time. In other words, I gave up one county and took another. But I stayed in three counties for four years. At that time, Dr. Tigue, commissioner of health, had persuaded me to establish a regional office of the State Department of Health here in . This is an idea that had been knocking about in our heads for about three or four years. In fact, since I had come back from the , they had asked me if when they were ready I would head up a regional office of the State Department of Health. They wanted to divide the state into six regions, so it could be managed more closely to where the problems were.

Gatewood: What year was that, approximately?

Shepherd: That was in 1964 that they established, that I established the regional office here.

Gatewood: Now the regional office presently covers all the ADD district of Cumberland, ADD district does it−

Shepherd: and . Those two ADD districts were covered by the regional office. See, there are fifteen ADD districts in , but we were going to cover them with six regional offices for public health purposes. Public health management.

Gatewood: Now you are presently the medical director of this regional office.

Shepherd: I’m medical director of an entirely different concept from the regional office, the regional established. After eight years in the regional office, which was a branch office of the office of local health administration at the state level, and was a state-run office, found that it couldn’t, it couldn’t very well affect the programs, it couldn’t work effectively with the program management in the 22 counties I had. Because each county health department had its own local board, and was sort of locally autonomous, you see. And then they could make up their minds whether they was going to do something or not.

Gatewood: Right.

Shepherd: And as regional director, I had no power over them, really. I didn’t even have the power to cut their money off, because that money is pretty well committed by the politicians. And I didn’t have even the control of it, much less the programs. Because they were locally autonomous. And I was principally an advisor and consultant, without authority. So after eight years of this, we decided that the only way you’re really going to change programs and keep them current with a change in public health needs was to establish a district of counties which would have the authority and power to hire and fire the staff, and make program decisions. And this would have a district board of health composed of representatives from each of the county boards.

Gatewood: Now when was this local board established here in Pulaski?

Shepherd: The district, you’re talking about the district−

Gatewood: No, sir. I’m talking about the, trying to go way back. The first full time public health officer. Do you remember when that was, here in Pulaski?

Shepherd: Hmm. I really, I don’t really know. It’s been−

Gatewood: Just approximate date to give us a feel for it. Before we ever had any public health work except maybe a part time private physician. You can’t recall exactly when that− Was it Dr. (Norfleet?) that was the first in the county?

Shepherd: No, we had many before Dr. (Norfleet?)

Gatewood: I see.

Shepherd: The county health department in and in the majority of counties in are old. Seventy-five or more years ago, you know. Long before I was born. [laughs] And I can remember a lot of health officers before Dr. Norfleet. I can name, name a few of them, given a little time. Dr. (Seevers?) was the one who was health officer when I enrolled in the primary grades of school. There was, (Uris?) followed him. And there was a whole line of health officers. I can remember at least a half a dozen of them.

Gatewood: Dr. (Seevers?) was a company town doctor in McCreary, wasn’t he? At one time?

Shepherd: Yes, I believe he was.

Gatewood: Well, let’s go on, because we’ve got a limited amount of time, into the current. When you, you established the district office, when was that?

Shepherd: The district office was established in 1971. In February, 1971, we got our charter. And it’s the first district health department in the state of . Formed by contiguous counties, the fiscal courts. Taking action to converge their county health departments into a single health department to serve those counties.

Gatewood: Now I know you’ve just come back from a grueling day with family health clinics. I’m somewhat familiar just as an outsider coming in to what I conceive as a real problem in these rural, isolated areas, in terms of delivering babies. Could you comment a little bit on that? I interviewed Lena Stephens. And while I’m sure she’s a well meaning person and is doing the work, there seems to be− Could you comment on the situation in the counties now? In that area. It’s not just here. It’s , too. Of the crisis, it seems to me almost the crisis, of obstetrics.

Shepherd: Yes. Well, I’ve been conversant with the problems of obstetrics in this general area, of course, for the last 25 years I’ve worked pretty, pretty close to it. And given prenatal care that whole time in some areas where it was not obtainable anywhere except at the health department. And in the early part of these years, Lena Stephens and Joe−

Gatewood: Roberts.

Shepherd: Roberts, you know, delivered the majority of the babies in . And we gave prenatal care to a lot of them at the health department. In those days, of course, the infant mortality rate varied anywhere from forty to sixty. But even in , where all of the family doctors delivered babies, they didn’t get prenatal care back then. We had a survey along just about 1970. I mean, along about the time that the district health department was formed. And there was 55 percent of women coming to term in that did not have prenatal care. And of course, this has changed. Nearly all of them are getting prenatal care now. Because the health department is providing prenatal care for the one-third of the population that cannot obtain it privately. And of course, that figure of one-third has been what has transpired in the last decade. Presently, we’re heading into a new decade in which the people that cannot obtain it privately is going to rapidly mushroom, you see.

Gatewood: It was headlines in the paper in . If you don’t have two thousand dollars, don’t think of having a baby.

Shepherd: And one reason it’s going to mushroom is that the doctors, you see, and have long been without any physicians that would give, that would look at a pregnant woman. I mean, they don’t give prenatal care and delivery and maternal services. No maternal care. The doctors in and do not. And that’s been, that’s held that way for a long time. In Pulaski County, about twelve years ago, ten or twelve years ago, the family doctors, all these general practitioners and people that have been giving prenatal care in delivering babies, suddenly their business offices says, “Here, look, your malpractice insurance premiums cost us $18,000 last year. We did not collect that much for maternal care. You are going in the hole, and wasting your time, by seeing pregnant women. You stop it.” So they listened to their businessman, and they quit delivering babies. I mean, it was a burden to them that they didn’t feel like they were justified in having. One of the reasons it was this way was because people who have money and can pay for good prenatal care and so forth felt that they didn’t want to be delivered just by a family doctor, you know. They wanted to be delivered by a specialist. So there were a couple of specialists that had located in town. And the ones who had money all went there. And the family doctors were left with the ones who couldn’t pay their bills. And so now that has just recently spread to the surrounding counties. The poor people in Pulaski County for several years have been able to go to Wayne County or to Casey County or over to Columbia, and get a, Clinton County, and have a family doctor deliver their baby in a hospital. But that situation has changed in the last six months. I mean the doctors in , I mean in and in , and all of them but one in , and he’s the old one, Dr. Duncan, you know−

Gatewood: (?) that case. I interviewed both, well, I interviewed Dr. Roberts, who fills in. And he’s a lot older. He doesn’t need to be−

Shepherd: Shouldn’t be. Delivering babies. That’s right.

Gatewood: I know. I talked to Dr. Duncan, and Dr. Roberts, when I interviewed him, he expressed real concern that what’s going to happen when he and Dr. Duncan are gone. So I know what you’re talking about. Even in , and seems better off than the others currently, right?

Shepherd: Of course, what we have to do, and I wish that I had twice as many hours in the day, because the problem is just so much bigger than I am. But what we have to do is expand what we’re doing presently to give adequate training and supervision and so forth to advanced registered nurse practitioners to establish birthing centers. And presently, we have just submitted a proposal to ARC, to try to get some funding to try to get us off the ground. Some sort of birthing center in Monticello, to serve Wayne and McCreary counties, as well as some portion of Pulaski County. And some parts of, and it’s on the south side of the lake. Transportation goes that way, you see. And people north of the lake, in Russell, Casey and Adair counties, would need to be served by another birthing center situated either at or . And staffing these birthing centers is going to be a problem. And there’s going to have to be government money. Because these people, the reason we have the problem in the first place, is they’re poor. This district that I serve has one of the lower per capita incomes of any districts in the whole . And a lot of people don’t realize this. They do well just to keep shoes on their children’s feet and keep them in school, you know, and a little food on the table. And they cannot afford $2,000 hospital bills for the birth of a new baby. And we have lots of factors working against family planning programs. And we have lots of failures in that program because there are too many anti-family planners in this country right now. They’re in every phase of government. We don’t have one politician that will bite the bullet and say, “We should help pay for this woman to protect herself against pregnancy.” They don’t want to say that. They all say, “The government should not pay for that.” Because they think that if they admitted the government should appropriate some money to pay for that, then they would lose votes. And we don’t have statesmen; we have politicians anymore.

Gatewood: Let’s talk just a little more about some of the other areas in the area of sanitation. Could you talk a little bit about that? You do some of that work, obviously. Do you have sanitarians on the staff?

Shepherd: Well, yes. We have, we had six sanitarians in the five-county district just before we expanded. And we acquired some new sanitarians. We probably acquired about six more, whenever we expanded. So we have ten, twelve sanitarians.

Gatewood: Do you have the money to adequately, are there any problems−

Shepherd: There’s been a reduction in the dollar amount of money going into environmental health in local health departments over the years from state and federal sources. And in a poor area like this, in which the taxation from the local is, the taxing power is so low that we couldn’t expand this money locally and pick up the loss of money that we lost from state and federal sources. So that financing environmental health at the local level has been bad. And we have been, you know, sweating over the idea that maybe we will have to reduce the environmental health staff. It’s pretty tough. I mean, it’s pretty heavy. For the amount of money we got. They’ve been working for low wages. We haven’t been able to increase wages. And when we have done it, we have done it at the expense of other programs. Which may not be related to environmental health.

Gatewood: Do you, does mental health come under your jurisdiction?

Shepherd: Mental health is under another line of management in .

Gatewood: Is that the comprehensive care−

Shepherd: Comprehensive care centers.

Gatewood: What is the general, do you have them in each community? Or are they regionalized?

Shepherd: They’re regionalized. Fifteen regions in . (?) district.

Gatewood: What other types of programs do you have here, in addition to sanitation?

Shepherd: Well, there are, of course, we have quite a few programs. The highest priority, we put on family planning. And the next priority, I think, we put on the maternal and infant care programs. Which includes prenatal care, delivery, well child care. It includes the WIC program. And I don’t know if you know what the WIC program is.

Gatewood: No, I don’t.

Shepherd: That stands, the initials, WIC, stands for Women, Infancy, Children. And what it is is a nutritional supplement program funded by the, through the Department of Agriculture, to the health departments. And we, we enroll pregnant women, or infants, in this program, who have a nutritional deficiency. By virtue of history and examination, we determine that they have a nutritional deficiency. They’re not getting enough protein in their diet, or something like this. So we, in this WIC program, this is the best outreach program that we have ever had. Through this program, we get every woman who’s pregnant in for early prenatal care. Because if she has not got money and getting it through private resources, she needs this food that she’s going to get. So we write them a check for, we prescribe. It’s like writing a prescription. And it’s as good as cash money. They take it to the grocery store, and turn it over for food. But it has to be written out by the nursing staff. See, after an examination and counseling and so on, determine what they need to fill in their nutritional needs. And it has made a remarkable difference in the health of women coming to term. And I mean, when they’re in delivery, they have much higher hemoglobin levels. The babies have a better birth weight, and they’re healthier. We just had a remarkable improvement in our statistics, internal medicine statistics, for that WIC program. But we reach them with it, too. We get almost 100 percent of them. They come in because they want that program, and they want that food. So we get, not only that, it keeps their babies coming into the Well Baby Clinic, and we get them all immunized. So it is one of the best health programs that’s come down the pike.

Gatewood: It certainly sounds like it. And I can see the motivation of coming, of hunger. They need the food. That’s tremendous. And how long has this WIC program been in existence?

Shepherd: Well, we started the program before the federal program started. We started with an OEO grant in this district. Of course, this district has notoriously been the pioneer for public health programs in . I don’t know if you know that or not.

Gatewood: No.

Shepherd: But it has. Nearly all the programs we’ve got going in , we started them here first. We, of course, that’s by virtue of the fact that I started the whole district concept. I wrote up the regional plan, and put it into action here. Then the state encouraged other areas to kind of follow suit a year later, after we had a good track record, you see. Something for them to follow. But we did pilot a program similar to the WIC program, with an OEO grant here.

Gatewood: What year was that?

Shepherd: I’m trying to think my, it was about the time, it was 1971, I’m sure of that.

Gatewood: About the time you, the district, it all came, that was when you really initiated that.

Shepherd: Yes. That was one of the first things we did with the new district. Start working with mothers and babies−

[End Side A. Begin Side B.]

Shepherd: − and they knew they were high risk to be in real trouble and to have sick babies at the time they’re born. But they couldn’t do much about it if nobody was going to buy the milk and cheese and the eggs and so forth at the grocery store and take them over for that (?) gravy that they were sustaining themselves with. You see? They needed more protein in their diets, but there was no way to get it. So the nurses were really in tears over this. So we started the program to try to get them supplementary vitamins and minerals. We got (capsules?) with the OEO grant. We got some nutrition, we got baby formula on this OEO grant. We had that eighteen months before the WIC program was funded.

Gatewood: One thing that I wanted to ask you is what relationship do you have to the home care service?

Shepherd: We’ve been primarily a referral agency to the home health agency here. We work closely with them, back and forth. In some counties, we house them in the same building. The main reason we, the home care program, the home health agency was established at the hospital, originally, here. Primarily because it needed to have a good, close working relationship with the private sector of medicine. And if it were established at the hospital, and function as a part of the hospital, which it did, originally, at the old city hospital. It had this built in relationship with the practicing physicians. And the health department, relationship between practicing physician and health department, has always been rather strained. And referrals from them to the health department, would be a little bit hard to come by. And we didn’t think it would work effectively. So it was set up, at my request, at the old city hospital. As a part of the hospital. Under hospital management. Then when the hospital became decrepit, because of lack of local support, community support and so on, it didn’t, it wouldn’t expand, and it couldn’t renovate and so on. They got a private hospital come in here and took its place. Well, the private, for-profit hospital refused to take the home health agency and manage it. So it was set up under an independent board. And operates now as an independent agency. But it still worked fairly closely with the health department. And we had cross-referrals between us.

Gatewood: That must be awfully confusing, though, to the people out there. As to what’s what. But−

Shepherd: There’s been, there’s been some complaint that the home health agency operates like the for profit hospital. And they don’t go unless the money is there. And things like this. So there’s been requests that the health department pick up on some home services. Principally among the people who are welfare patients, have Medicaid cards, and have things like that. And are not provided enough service to make them self-sustaining and independent and remain at home, and have to be admitted to nursing home care, which has become extremely expensive. About broke the back of the state Medicaid system. So we’ve been requested, at the health department, to develop a program of delivering preventative services with these elderly people on Medicaid cards. And try to prevent their conditions from deteriorating to the point where they have to be admitted to an institution. And it’s felt that the government can support a preventative program much more economically than it can this here terminal thing in a nursing home and so on for months and months and months. Even years.

Gatewood: It’s so much more humane, too, in the home.

Shepherd: Yes. It’s much more humane. Those people are just, they’re dragged to those nursing homes, protesting that they do not want to go. They want to stay home. And the health department is putting in motion a program to help them sustain their health at a level that they can remain home and independent. You know, whenever you’ve got hypertensive cardiovascular disease and so forth, there are things that you need to do to prevent it from deteriorating to the point where you can’t take care of yourself.

Gatewood: There’s one other development here that I’d like you to comment on. There seems to be a clinic being formed, sort of a neighborhood clinic down in . Down in . What is your opinion of that? I mean, is this going to be a private, neighborhood type thing? I believe one of the sisters that works for the, Sister Lorraine, that works for the agency we talked about, is trying to start.

Shepherd: Well, I’m, I don’t know as much as I’d like to know about that. I’ve been encouraged by the news that they’re working on. And certainly the health department will be supportive in any way we can. They definitely do need a nonprofit type of clinic working with acutely sick people in that neighborhood.

Gatewood: I think they’re kind of the ideal, I’ve just read an article in the newspaper. I haven’t had a chance to interview this sister, is that their ideal is to be a total preventive care community on a holistic approach. It sounds great, whether it can work or not.

Shepherd: I would definitely, the need is there. And I would like to tie that in with any health department program when we get it going there. So that we can enhance each other.

Gatewood: Well I appreciate so much you giving me this interview. I really do, and it gives me hope. I’ve been down here a couple of weeks, and I’ve been getting a little in the melancholy about the whole situation. [laughs] But talking to you, I feel there’s hope. And I really appreciate you giving me this interview.

Shepherd: Well, I enjoyed talking with you. I wish we had a few days to talk. [laughs]

Gatewood: Oh, I do, too. I do, too.

Shepherd: I can talk.

Gatewood: I think it would be very profitable. Very profitable.

Shepherd: I can talk for weeks on the unique and interesting kinds of situations that we’ve had in public health in these counties. Particularly . It is a unique county. It’s made a lot of history. But it would take me a long time to tell you. [laughs]

Gatewood: Right. Some day I wish we would have the time to develop this. You have a good time on your vacation. Get away from this.

Shepherd: Well, okay.

Gatewood: Thank you, sir.

Shepherd: Thank you.

[End Interview.]