February 22, 2003 - UC Berkley: I went with the Peace Corps in Thailand as a Peace Corps physician

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I went with the Peace Corps in Thailand as a Peace Corps physician



I went with the Peace Corps in Thailand as a Peace Corps physician

Interview History II The AIDS Epidemic
The AIDS Epidemic in San Francisco: The Medical Response, 1981-1984, Volume I

[Interview 1: March 23, 1993]
I Education and Career

##40
Education and Early Career

Hughes
Dr. Silverman, could you give me a brief summary of your education and early career?

Silverman
Yes, I went to Washington and Lee University [1956-1960] for my undergraduate work, and then to Tulane Medical School [1960-1964] for my medical training. Then after interning at Los Angeles County General Hospital, I went with the Peace Corps in Thailand as a Peace Corps physician. Then I became regional medical director for Southeast Asia and the Pacific [1967-1968] for the Peace Corps.

[tape interruption]

I then went back to school to get a master's degree in public health at Harvard [University] [1969], then went with the Food and Drug Administration as special assistant to the commissioner [1969-1970], and then director of the Office of Consumer Affairs [1970-1972]. I really wanted to get closer to the people, because from Washington it is very difficult to see any impact on people. So I became director of health in Wichita, Kansas [1972-1977], and also ultimately medical director of Planned Parenthood for Kansas [1976-1977].

Then in 1977--I guess it was it was as early as '76--I saw an ad for a job as director of health in San Francisco and applied, and ultimately was appointed, to start in May of 1977, a job which I held until January of 1985.
Interest in Public Health

Hughes
Why public health? That started with the M.P.H. [Master of Public Health] degree [1969]?

Silverman
Well, I guess it started even a little before that, although I probably didn't know it at the time. When I was in medical school, between my sophomore and junior year I worked as a research assistant in South America. I think that planted the seed--the idea of doing some public health-type work. And then Peace Corps really solidified my interest. I realized after Peace Corps, even though I was taking care of all the volunteers we had in Thailand, that I could never practice medicine the way I did there. I was with them when they were healthy, and so when they were sick, I really knew them. I used to be "Merv" when they were well and "Dr. Silverman" when they were sick, and that was a very interesting relationship.

I realized I could never have something like that in the States, and that a private practice would be too confining, and that the real way of dealing with diseases was to prevent them rather than trying to treat them after the fact. So that's when I went to Harvard and also did what was really a residency in preventive medicine, and then got my boards [1970] in the specialty of preventive medicine.

Hughes
With the idea of becoming a public health director?

Silverman
I'm not sure that I really thought about what exactly I would do. I just found out after being in Washington and the federal government, and though I was born and raised in Washington D.C., I realized that it was too far away from really having an impact on people. I thought local health was really where I should be, found that to be the thing I enjoyed most, and actually spent a total of almost thirteen years [1972-1985] in local health in Wichita and San Francisco.

When I went to medical school, I didn't even think about public health as an option. In those days, people in public health were either people from private practice who were retiring, or people in the military, or people who just couldn't make it in private practice. So public health wasn't held in the highest esteem.

But what happened with Peace Corps is a lot of young physicians, who probably had no thought of going into public health, had their heads turned around during and after the Peace Corps experience. So there was a whole cadre of young, energetic, eager individuals going into public health, and I think that sort of rejuvenated the whole system.

Hughes
Did the experience in Kansas tie in with what you were going to be doing in San Francisco?

Silverman
In absolutely no way, shape, or form! [laughter] There were no pressure groups. I think Native Americans, the Indians, were a little bit vocal, but you could ignore them and not have to worry about it.
Director, San Francisco Department of Public Health, 1977-1986
Comparison with the Department of Public Health in Kansas

Silverman
Then coming to San Francisco, where on every corner there is another interest group based on race, religion, ethnicity, age, disability, sexual orientation, medical society, or hospital affiliation, you name it, was a real eye-opener, and so a real education for me.

Hughes
Did you realize what you were getting into?

Silverman
After I was appointed, I was sort of stunned, like the dog who's caught the car. What do you do with it now, after you've chased it? I really was very concerned that I had decided to do something that I might not have the ability to do, that maybe according to the Peter principle, I had reached my level of incompetence in Wichita, and what was I going to do here? So it was scary, but it was very exciting.

Hughes
Scary mainly from the standpoint of the factions that had to be dealt with?

Silverman
Yes. There is a classic little postcard that shows Dorothy and Toto from The Wizard of Oz in a leather bar in San Francisco saying, "Toto, I don't think we're in Kansas any more." It was very clear to me that I wasn't in Kansas any more.

I had in Kansas a department of around 100 people, and just classic public health problems. I didn't have mental health; I had alcohol but no substance abuse; I didn't have any of the medical services, really. We had some clinics in the health department, and a budget I think of several million dollars. I don't remember. Then here I had a budget of several hundred million dollars, and 5,000 employees. I used to say then--I don't say now--that we were involved in everything from bathhouses to brain surgery. Of course, I didn't realize that bathhouses were going to be a major part of my experience here.

What makes the San Francisco Public Health Department so unique and I think so great compared with others around the country is that it is an umbrella agency that truly has everything, from emergency care--the emergency medical services, ambulance services, a major trauma center in northern California--to an acute care hospital, San Francisco General; Laguna Honda Hospital, for long-term care; and then mental health and drug abuse and alcohol--just everything. There was really no aspect of health care that wasn't somehow touched by the health department.

In Kansas, I would sometimes have to have my secretary or nurse stay on the phone all day going through the yellow pages, trying to find a physician who would take a public patient--a patient on Medicaid, which here is Medi-Cal. Here, if the health department took a Medi-Cal patient, the medical society was upset, or sometimes the hospitals were upset.

Relations with Other San Francisco Institutions

Silverman
I became very actively involved in the medical society from day one. In fact, on my first day here, which was the second of May [1977], that night was a medical society meeting and I went to it, and was active throughout my tenure here. I realized that we had to work with these people, because they actually saw the health department as competition.

Hughes
So there was a tension between the medical society and the health department?

Silverman
Oh, yes. And there had been, but as I became an active member of the society, we worked very cooperatively. In fact, until this year when I didn't run, I've been elected as a delegate of the San Francisco Medical Society to the California Medical Association for the last dozen years. If there was a public health issue, the medical society would call me for my advice and usually they would follow it. I was on the Political Committee, looking at the political issues in the city, and state. The medical society and the health department worked very, very closely during those years. Which is what I think should happen.

Hughes
How was the relationship between the health department and the university?

Silverman
Well, that was actually fairly good, because we were trying to get a new contract between the university and the city for San Francisco General Hospital. So although there were some tensions, I think it was very clear to myself and many of us that this was a very symbiotic relationship. The university really needed us, and we really needed the university.

Now, there's always arguing about who got the better end of the deal, and I don't know that anyone really did. But we could not have run the hospital without the university, and I don't think the university could have had the kind of clinical experience without the hospital.

Hughes
Were you immediately involved in that negotiation?

Silverman
Yes, relatively soon after I arrived in 1977.

Hughes
Did the terms remain what they had been?

Silverman
We never arrived at a contract by the time I left in 1985. I assume one has been reached, but I haven't seen it.

Hughes
Were there any other particular issues during the years in San Francisco right before the AIDS epidemic?

Silverman
Well, there were many, many issues. I closed the emergency aid stations [1978], which was very controversial. There were emergency aid stations around the city that were giving very, very poor care, but it was something the city was used to. If you burned yourself, cut yourself, had a little problem, thought you maybe had some pressure in your chest or whatever, you'd go to these places. A lot of people went there who were on Kaiser [Permanente] but rather than going all the way across town, if they could get it done there, it would save them time and money, and mostly energy.

They were poorly run, and I just couldn't see, with the number of hospitals and the number of emergency rooms, keeping these stations open. When I closed them, there was picketing, they put pictures of me up around the neighborhood, they followed me up to Sacramento when I was appointed to the advisory committee to assist the new state director of health [Beverly Meyers], and so that was one of my early tastes of San Francisco politics. But by the time that was over, I was celebrating with them. They gave me a T-shirt, "I sat in Alemany for 43 days," and we actually ended up having a pretty good relationship. But it was a new experience.

Threat to Remove the Health Department's Jurisdiction over San Francisco General Hospital41

Silverman
There was a situation at San Francisco General--it may have been in the early years of the epidemic--where it was reported several people had died because of negligence. I had heard of only one case. The other two had not been made known to me by the administrator of the hospital. Probably one of my biggest problems is that I'm not as bastardly as I should be on certain occasions. The hospital lost accreditation. If I had fired the administrator, I'd have come out smelling like a rose. I could have said, he didn't keep me informed, blah blah blah--gone.

I wasn't aware of all the details at the time, and I didn't fire him. I figured, Let's see if we can work this out. I had a press conference. I've always felt, if I'm the head of the health department, I take responsibility. That probably wasn't totally smart. My successor was smart, and he had a person to share credit and blame. When the situation was bad, he put the person up who took the gaff, and when it was good, the health director got some of the credit.

[Roger] Boas, the chief administrative officer, used me as the scapegoat. He was going to take the hospital away from me. Which was fought by a lot of people.

Hughes
You mean take it out of your jurisdiction?

Silverman
Exactly. And [Mayor Dianne] Feinstein went along with him. I was very upset. I was getting calls from mayor's staff saying, "Gee, we're really sorry about what's happening," and I was saying, "But I was so loyal to the mayor," and they laughed, to a person. "What are you talking about? Loyalty's a one-way street here."

Ultimately the hospital remained under the jurisdiction of the health director, but only after several flip-flops by Boas.

Departmental Links with the Gay Community

Hughes
Well, talk now about the relationships between the health department and the gay community that pre-dated the epidemic.

Silverman
Well, I was involved I guess somewhat peripherally with the gay community. They had asked me to participate and ride in the Gay Liberation Day parade, which I did. I always felt that the department should reflect the city in its makeup and in its services. Certainly the lesbian and gay community was and is a very important segment of the community. I had a lesbian/gay coordinating committee within the department to help sensitize the department to issues, and also to serve as a liaison when different issues were raised. So we were sort of ahead of the game in that sense.

Hughes
Had you established that?

Silverman
I think there may have been a committee before I came. I strengthened it, and had a full-time staff person dealing with it. I don't remember whether I started it. But certainly, it got more involved after I got there.

Hughes
Was Pat Norman the committee head?

Silverman
Yes, she was head of it at the time. In fact, I know she was when the AIDS epidemic started. Now, whether she had been head all the way from the beginning, I'm not sure, but I think so.

Hughes
What sorts of things was she supposed to be dealing with?

Silverman
It was to make sure that our clinics were sensitive to issues that related specifically to the lesbian and gay community, that we were responsive to the needs of the community. I can't remember how often the committee met; it didn't meet every month, I don't believe. If an issue came up from the community, that would come generally through that group to me.

Hughes
Because of the committee, the department had links with key members in the gay community?

Silverman
Yes, I did by virtue of becoming more actively involved. There were people that I knew in the gay community who wanted me involved, so I was invited to their social affairs; I was in their parades. I would usually have my wife and kids ride in an old car or what have you, in the parades. So I just happened, both in my community here where I live and also the health department, to have friends, some of whom were members of the gay community. Maybe I spoke at one of the dinners of the Bay Area Physicians for Human Rights. I just don't remember. I was active in those ways, just as I was with the black leadership forum and the Italian-American community out at Laguna Honda, and various other groups.

Hughes
So the gay community was just another faction that you had ties with.

Silverman
Yes.
Interview History II The AIDS Epidemic



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This story has been posted in the following forums: : Headlines; COS - Thailand; Medicine; AIDS

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