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HEALTH / PAC PAC Health BULLETIN BULLETIN BULLETIN PolACiednvctiyesr o ry 1 Double Indemnity: THE POVERTY OF AFFIRMATIVE ACTION IN THE HEALTH PROFESSIONAL SCHOOLS. Economies and federal funding slowed affirmative action in the health professional schools long be- fore Alan Bakke came before the Supreme Court. 3 Vital Signs 17 Columns WASHINGTON: CBC: What's Preventing a Health Politics? WORK ENVIRON /: WOMEN: A National Voice for Women's Health Concerns FIFTH COLUMN: Two - Hat Troubles 32 Off to a Bad Start: THE OBSTETRICAL EXPERIENCE OF THE URBAN POOR. Poor women in East Harlem con- front an alien obstetrical care system. 40 Peer Review ' Murdochian Sensationalism ' Volume 11, Number 2 November December /, 1979 ISSN 0017-9051 HPCBAR 11 1-40 (2) Medical Scho l Entrance Exam Exam Double Indemnity POVERTY TOHFE Buried in the back pages of the mammoth Sun- AFFIRMATIVE day New York Times on April 22, 1979, was the ACTION report of the findings of the general counsel of the Department of Health, Education, and Welfare that its numerous civil rights and affirmative action programs for minorities were " almost entirely un- affected " by the Supreme Court decision in the Janu infamous Bakke v. Regents of the University of California. During the entire year before the June 1978 decision, Bakke dominated the headlines. and covers of influential publications such as Sat- urday Review, The Atlantic and the New York Times Magazine. (For the Health / PAC assess- ment, see Bulletin No. 76, May June / 1977, and its special report, " The Myth of Reverse Discrimin- ation: Declining Minority Enrollment in New York City's Medical Schools " by Barbara Caress.) The Court's decision straddling - more positions than nine acrobats - found Allan Bakke entitled to a seat at the medical school of University of Cali- fornia - Davis because the school's special admission process for disadvantaged applicants violated Title VI of the Civil Rights Act of 1964. But, the Court said, consideration of race among other factors was permissable in the admissions process. When HEW's general counsel finds almost nothing affected by Bakke, the message is clear: either affirmative action has already been under- mined to such an extent that Bakke could do no further harm, or the Bakke decision was more im- portant as a media event than it was as law. For the health professions both are true. The anti- affirmative action backlash combined with the forces of inflation, changes in federal health man- power and financial aid policy, and institu- tionalized myths and racism have broken and turned the momentum of affirmative action as well as the opportunity and rationale for the health pro- fessions to suspend their largely ineffectual and ambivalent efforts at minority recruitment. This year the percentage of minorities newly entering health professional schools has regressed to levels of ten years ago when pressures for affirmative action were just beginning. Moreover, a comparable limit upon women entering the health professions can also be seen on the horizon () 1. The intent of this article is to examine these forces, developments and policy changes which are closing a door that was all too briefly and cautiously opened. A Brief History of Affirmative Action Affirmative action is rooted in political and social movements, beginning with FDR's creation of the Fair Employment Practices Commission in 1941, following a threatened march on Washing- ton by A. Phillip Randolph and other Black leaders. The presidential directive ordered an end. to racial discrimination in federal hiring, with the Fair Employment Commission empowered to in- vestigate compliance with the order. During the mid - 1960's, in response to later civil rights demonstrations and a renascent civil rights movement, President Lyndon Johnson extended equal employment coverage through Executive Orders 11246 and 11375. These Orders prohibit discrimination in employment by all employers holding federal contracts, and require affirmative 2 action programs by all government contractors and sub contractors - receiving contracts of more than $ 50,000 and employing more than 50 persons. Title VI of the Civil Rights Act of 1964 forbids discrimination against students on the basis of race, color or national origin. Title VII of the Act, as amended by the Equal Employment Opportunity Act of 1972, forbids employment discrimination on the basis of race, color, national origin, religion or sex by any employer of fifteen or more persons, public or private, whether or not they receive federal funds. The first federal sex discrimination legislation, the Equal Pay Act of 1963, was also enacted in response to the civil rights movement. It requires equal pay for equal work regardless of sex. In 1972 this was extended to cover executive and professional employees, including college and university faculty. Compliance with federal civil rights orders and statutes has been undermined by inconsistent and confused regulations issued by the bureaucracies involved and by numerous, contradictory court orders. Considerable interagency conflict between the Departments of Labor, Justice, and HEW and the Equal Employment Opportunity Commission have further diluted the responsibility for monitoring and enforcing anti discrimination - guidelines. Only in September 1978 did these agencies publish uniform guidelines for employee selection procedures. Their underlying principle is that any test or other selection procedure which has an adverse impact on minorities or women is illegal unless test performance can be clearly shown to predict job performance. Where statis- tical evidence of on going - employment discrimin- ation exists, institutions are only asked to docu- ment that good faith has gone into the effort to recruit women and minorities, not necessarily that progress has been made toward integration. The pertinence of these legal mandates for the health professions is profound, given their histor- ical discrimination against minorities and women. As recently as 1963, five American medical schools were still officially closed to Blacks (2). Not until 1964 did the American Medical Association vote to prohibit racially discriminatory member- ship policies (3). UCLA did not graduate its first Black physician until 1970 or accept its first Black dental student until 1974 (4). As recently as 1965 the National Dental Association claimed that in eleven southern state organizations the American Dental Association " only rarely accepted Negro members " (5). Full, open membership did not arrive in the American Nurses Association until Continued on Page 5 | eee eee a a Vital Signs HOME HEALTH KITS DIAGNOSED AS A BIG MONEY MAKER - If you can check the anti freeze - level in your car's radiator, why not your blood pressure? Driven by high and rising costs, aliena- tion from professional healers, the breakdown of reliance on CO- operative social healing processes, increasing self reliance - , and perhaps acceptance of the blame victim - the - philosophy, Americans have made the home- test market " the fastest growing industry in the health care arena today, " according to Mark H. Bruder, president of the recently- created Bard Home Health Care Division of C.R. Bard Inc. in New Jersey. In the three years since home tests for pregnancy were intro- duced, their sales have grown to $ 40 million and are predicted to reach $ 100 million by 1982, partly because of vigorous promotion campaigns on the way. Sales of these tests jumped 44% almost instantly in January when Warner Chilcott / , a division of Warner Lambert - Co. and manufacturer of e.p.t. (early pregnancy test), the first home pregnancy test kit, and other manufacturers began advertising on television. Experts expect this success to be followed by spend- ing $ 15 to $ 20 million annually on print and broadcast advertis- ing by Warner and its four competitors in the U.S. Nabisco's - J.B. Williams Inc., American Home Products'Whithall Labora- tories, Copyright Diagnostic Testing, and Bio Dynamics - (makers of Daisy 2). With this push, one executive predicts sales will grow by $ 10 million to $ 20 million annually. But that is about the same as the projected adver- tising expenditures, which implies that these manufacturers plan to lose money the first year or two. They apparently think it will be worth it if they can gain - or create wide acceptance for home health testing in general and their products in particular. Indeed, the size of the potential market seems to draw executives like dreams of gold laden - con- tinents once drew European colonizers. Says Bio Bio Dynamics - - Dynamics Director of Product Management James H. Frazee, " If I take the 49 million women of childbearing age in the world and multiply that number by the times they're likely to have missed a menstrual period, I come up with an astro- nomical potential for this market. " Other weapons in this latest series of voyages of conquest: * blood pressure kits, available since 1973, aimed at the 23 million Americans with hyperten- sion. Retails for $ 20 to $ 185 for the deluxe version with digital read out. urinary tract infection kits, soon to be available nationwide- retail for $ 1; * urine tests for diabetics and blood - sugar tests for insulin- dependent diabetics; And there are numerous others being developed - 9 by one company alone. That bastion of petit bourgeois - medical practice - the American Medical Association - has withered before the onslaught by monop- oly capital. Business Week magazine reports that the AMA " approves the concept of home testing but warns that patients should still be encouraged to see a physician - not treat themselves - if the test results indicated the need for medical treatment. " Home health tests do indeed have a great potential for democ- ratizing the availability of vital information about one's health at an affordable cost. In a fully democratic and socialized health care system characterized by cooperative healing healers efforts between professional healers and autonomous patients, home health tests could only help. But in modern day America, these tests promise primarily to encourage the individualization and atomiza- tion of the alienated victims of the medical system who are struggling to get more information about their health from the only people they feel they can _ trustL themselves. -George Lowrey Source: Business Week, 8/13/79. 3 DRUG STORE CHAINS SEE BIG BENEFITS OF MERCHANDISING Now it can be told. The reason prescription counters are located in the rear of many drug stores is so a customer who wants to fill a prescription must run a gauntlet of aisles crammed with general merchandise such as sporting goods, hardware, and even cameras which " drug " stores often sell for twice their wholesale cost. Another trick used by Jack Eckerd Corp., which shares honors for largest drug store chain with Walgreen Co. and Skaggs Cos., is to project a false image of a discounter. " It adver- tises weekly price specials on any- where from a dozen to 215 highly competitive drugstore items that carry low gross profit margins, " " reports Business Week magazine. That gets customers into the stores, where they also buy the higher profit general merchan- dise items they didn't originally in- tend to purchase, and may not need. Such are the kinds of merchan- dising ploys generously - known in the trade as superior " merchan- dising " that have propelled drugstore chains from 4,000 stores in 1960 to 12,6000 outlets operated by around 700 com- panies. Their share of the market has risen from 22% to 49.8% during that period. But that growth is running into hard times as their expansion has saturated some markets and brought them into head head - to - competition with other chains as well as sur- viving independents. While the competition from chains has wiped out 13,000 of the 50,000 independent drugstores that existed in 1960, the survivors in 4 this war of attrition are fighting Health / PAC Bulletin Tony Bale Pamela Brier Robb Burlage Michael E. Clark Board of Editors Hal Strelnick Glenn Jenkins David Kotelchuck Ronda Kotelchuck David Rosner Managing Editor: Marilynn Norinsky Health Policy Advisory Center Staff: Loretta Wavra MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR should be addressed to Health / PAC, 17 Murray Street, New York, N.Y. 10007. Subscription rates are $ 14 for individuals, $ 11.20 for stu- dents and $ 28 for institutions. Subscription orders should be addressed to the Publisher: Human Sciences Press, 72 Fifth Avenue, New York, N.Y. 10011. Health / PAC Bulletin is published bimonthly by Human Sciences Press. Second - class postage paid at New York, N.Y. and at additional mailing offices. 1979 Human Sciences Press Illustrations: Richard Backer (pp. 1, 32), Bill Plympton (p. 5). back with more determination restaurants are owned and and sophistication. In North Dakota, the petit bourgeoisie - operated by Walgreens. The chains are also expanding won one against big capital when in the health care market. Optical they got a law passed requiring appliance centers and hearing that 51% of a drugstore be aids stores, dental clinics, and the owned by a pharmacist. sale and leasing of convalescent As the chains compete with one aids such as hospital beds are all another, many of the small ones seen as fertile areas for expansion. can be expected to be driven into So the corner drugstore, no bankruptcy or taken over. But the longer on a corner, will soon large chains, facing saturated cease to be a drugstore as well. markets and stiffer competition, Such are the ways of monopoly will seek continued growth by capitalism: mutate in order to adapting to their changed en- grow in order to survive. If vironment. Even now, they are dinosaurs had been so smart they diversifying into department might still be around today- stores, specialty retailing opera- looking like pigeons. tions, and restaurants. Thirty - four George Lowrey Waggs and Humpty Dumpty Source: Business Week, 7/23/79. Double Indemnity was about 16 percent, actually the more " repre- sentative " goal for the AAMC. Later figures show that American medical schools fell far below this modest 12 percent goal, Continued from Page 2 not to speak of the 16 percent figure. Specifically minority enrollment increased from about 5 per- 1964, although some Black nurses were allowed cent in Academic Year 1971-72 to a peak of ANA entry in 1951 (6). This discrimination led to 8.2 percent in Academic Year 1974-75. Since the founding of the National Medical and Dental then the figure has levelled off at about 8 per- Associations and the National Association of cent (see Figure 1). Colored Graduate Nurses. The 1970 AAMC report Now, more than twenty made several additional re- years after Brown v. Board of commendations: substantial Education made segregated increases in and coordination education illegal, the " en- of financial aid to minorities; lightened " health professions the creation of an " education- continue to perpetuate racial discrimination. This contrib- utes to the appalling imbalance between the physician - popula- tion ratios of whites and Blacks - in 1974 there was one white al opportunity bank " and a network of regional centers to provide health career counseling for minority stu- dents; and expansion of the AAMC's Office of Minority physician for every 560 Affairs, established in 1969 whites in the population, but only one Black physician for every 2,800 Blacks, five times worse than the ratio for whites. Similarly in 1974 there was one white dentist for every 2,500 whites, but only one Black dentist for every CANCER with grants from the U.S. Of- fice of Economic Opportuni- ty. Seven years later, only the last goal was achieved, ac- cording to an HEW commis- - sioned evaluation (9). This was largely due to a $ 1.5 mil lion OEO grant to administer 12,500 Blacks (7). These ratios for Blacks are worse than those of the 1940s! (To some 50 programs for minori- ty students from 1969 to 1973. be sure, in some instances A 1978 report from the white doctors treat Black pa- AAMC now suggests that tients and vice versa, but the minorities will now have to pattern of white doctor - white wait until the year 2000 for patient and Black doctor- parity! (10). Although the re- Black patient is still pervasive, port comments upon the particularly in primary care federal withdrawal of support settings.) for minorities, both fiscally As the civil rights move- ment reached higher educa- B.Plympton and philosophically, its seven goals focus upon the various tion, a task force of the As- steps (and, therefore, " hur- sociation of American Medi- cal Colleges (AAMC) an- AFFIRMATIVE ACTION dles ") which minorities en- counter along the path to be- nounced in April 1970 an objective of 12 percent " representative " minority enrollment in American medical schools by 1975 (8). The AAMC in- cluded Blacks, Hispanics and Native Americans * Asian minority groups were not among the populations in- cluded in the AAMC affirmative action programs because they are not generally underrepresented in the health pro- fessions compared to their proportions in the general popula- in its minority enrollment goal. * The 12 percent figure, however, was roughly the percentage of only Blacks in the U.S. population in 1970. The percentage of Blacks, Hispanics and Native Americans combined in the U.S. population then tion. However, they do suffer discrimination and racism in the health care system as in other aspects of American life. When not otherwise designated, minority group data in this article includes Blacks, Hispanics [specifically mainland Puerto Ricans and Mexican Americans - (Chicanos) and Native Amer- icans, reflecting the AAMC data. 5 In 1974, there was one white physician for every 560 whites in the population, but only one Black physician for every 2800 Blacks, five times worse than the ratio for whites... These ratios for Blacks are worse than those of the 1940s! coming fully trained physicians. The report large- ly points the finger elsewhere for the failure of medical schools to achieve their own objectives. The AAMC report was published during the same month that the Supreme Court announced the Bakke decision. Recently, similar concerns have been shown for minorities in dentistry. Both professions plead the traditional case, bemoaning the poverty and discrimination which have left them too few qualified minority candidates for achieving parity. This is really out of their hands, they say. So under the guise of " professional stan- dards, " the buck is passed again. The Rise and Fall of Affirmative Action The political pressures of the civil rights and women's movements have produced substantial gains in the numbers of minority and women Figure 1 Percentage of Under represented - Minority Student Enrollment in Selected Health Professional Schools, 1970-71 to 1978-79 PERCENTAGE MINORITY STUDENTS ey 8 in 2 seem Medicine a 7 o" 6 " pant ween Dentistry os mane Pharmacy 5 a af Fd! veceewee Podiatry 3 ww eeemesene Optometry 2 = - Osteopathic Medicine i 71-72 72-73 73-74 74-75 75-76 76-77 77-78 78-79 ACADEMIC YEARS Sources Johnson. Davis G and Gordon Travis 1.. " Datagram Medical Student Enroliment 1974-75 Through 1978-79. " J Med Educ 54. 431-433. May 1979 Philpot. Wilbertine P. Minorities & Women in the Health Fields Applicants, Students and Workers DHEW Publication No (HRA) 79-22. October 1978 students being trained in the health professions. These gains can be found prominently displayed in each field's publications, demonstrating the pro- fession's " good faith " in seeking parity for minor- ities and women. But the accomplishments are in most cases mea- ger. Consider the traditional health professional schools of medicine, osteopathic medicine, den- 6 tistry, optometry, pharmacy and podiatry. (Nursing provides a more complicated picture, which will be addressed in a future Health / PAC Bulletin.) Of the various professional schools listed in Figures 1 and 2, minority student enrollment and Black student enrollment have substantially increased in only one (podiatry) since the Aca- demic Year 1974-75 (that is enrollment has in- creased by at least one percentage point). In the Figure 2 Percentage of Black Student Enrollment in Selected Health Professional Schools, 1970-71 to 1978-79 PERCENTAGE BLACK STUDENTS 7 h ae OP +e, Tete ee remem, oo Oe serene Medicine a 5 o eo an nena sesoeana Dentistry "Y" a summa Pharmacy 4. we sencwens Podiatry 2 ome al "eee Osteopathic Medicine "ecanneeet wees Optometry i DIGI 71-72 72-73 73-74 74-75 75-76 76-77 77-78 78-79 ACADEMIC YEARS Sources Johnson. Davis G and Gordon, Travis |. " Datagram Medical Student Enrollment. 1974 75 Through 1978-79, " J Med Educ 54: 431-433. May 1979 Philpot, Wilbertine P. Minorbes & Women in the Health Fields Applicants, Students. and Workers DHEW Publication No. (HRS) 79-22, October 1978 other schools, minority and Black student enroll- ment have remained essentially constant or dropped slightly since then. Especially serious is the trend of decreasing Black enrollment since 1974 in the two largest of the professional schools, medicine and dentistry. Also, still lower levels of minority student enrollment continue in schools of osteopathic medicine, optometry and podiatry. Within the field of pharmacy, the single field. where a recovery is being made, almost all the im- provement is accounted for by the four primarily Black pharmacy schools: Howard, Florida A M &, Texas Southern and Xavier Universities. These four programs account for more Black pharmacy students and graduates than all 68 predominantly white institutions combined that collectively enroll less that two percent Black pharmacy students! While progress toward parity for minorities in the health professional schools is usually discussed in terms of total minority enrollment, these figures are not the most sensitive to changes in the student body. First year enrollments are frequently pre- sented as trends by representatives of the pro- fessions, like the AAMC, typically inflated by including all repeating and re enrolling - minority students. The key issue is whether institutions are actively recruiting and retaining new minority students. If they are not, minority enrollment figures will inevitably fall in the future. The most sensitive indicator of minority participation in a field is the percentage of the first year enrollment of new minority students admitted and matriculated, excluding repeaters and re- enrollees. The data for these minority student admissions are revealing. With the exception of Academic Year 1974-75, minority admissions to the first year of medical school have hardly changed since 1971, when the AAMC affirmative action program began (see Figure 3). What's more, Black student admissions to medical schools, again with the exception of 1974-75, have been falling quite steadily since 1971 (Figure 3). The current rates of Black medical school admissions are well below the 1971 levels! As for dentistry, total minority admissions rates have climbed very slowly since 1971-72, but for the last three years they have stagnated at 6.8 percent. Black student admission rates, however, have slowly but steadily declined since 1971-72. Osteopathic medicine doubled its very low minor- ity admission rate between 1973-74 and 1974- 75. This level of admissions has been maintained for all under represented - minorities, but not for Blacks, whose percentage in the first year enroll- ments has declined since 1974-75 (Figure 3). Figure 3 Percentage of Black and Total Under represented - Minority Student First Year Enrollments at Selected Health Professional Schools, 1971-72 to 1977-78 PERCENTAGE MINORITY 9 STUDENTS 8 ia * Total emcees Medicine 76T otal Total 5 Blacks 4 3 2 Tota! Blacks Dentistry j | Medicine Osteopathic 1 71-72 72-73 73-74 74-75 75-76 76-77 77-78 non - repeating ACADEMIC YEARS Source Philpot, Wilbertine P, Minorities & Women in the Health Fields Applicants. Students, and Workers DHEW Publication No (HRA) 79-22, October 1978 Thus according to this more sensitive indicator, the admission rate of new minority students, the much heralded affirmative action programs of the AAMC have had little impact on minority admis- sions. And since the inception of this program in 1971, the representation of Black students in these health professional schools has actually dropped, The enrollment figures used by the AAMC obscure this failure, but they will do so only temp- orarily eventually, if present trends continue, these figures too will reflect the drop in Black admission rates and the stagnation in overall minority admission rates. The worsening situation for Blacks is also re- flected in the declining percentage of Black appli- cants accepted to medical schools (Table 1). The enrollment of women in health professional schools presents, so far, quite a different story. In every one of the six types of schools reported there has been a steady, significant increase in the enrollment of women (see Figure 4). For example, enrollment of women in medical schools more than doubled between Academic Years 1971 and 1978, from about 11 percent to 24 percent, res- pectively. In optometry, female enrollment jumped from about 4 to 15 percent during the same time period. Freshman admission rates for women and minorities by individual medical school - the best and worst of them - are given in Table 2. Only recently have there been trends that might suggest a ceiling for women entering medicine. During the last two years the number of women applying to medical schools has decreased, while current admission rates for men and women remain nearly identical. This decline in applica- tions would suggest a plateau of about 30 percent of women's representation in medicine. This is sig- nificantly below the percentage of women in the population and the 49 percent figure for female enrollment in higher education. As noted above, minority groups have reached a similar ceiling of about 8 percent, also well below their respective proportion in the population. (The distribution of women and minority enrollments today are sum- marized in Table 3.) However these seemingly fixed limits are not generally considered quotas. Current ideology holds that the levels in the 1950's that applied to Jews, white ethnics and Blacks were quotas be- cause they were set by the institution. But today, it is said, minority students are under represented - because of lack of proper qualifications, including lack of education and lack of motivation. While these distinctions are arbitrary, the result is the same as before, low levels of most minority groups 7 eee ee eee eee eee ee nee eeee eee eee eee ee nee The anti affirmative - action backlash, inflation, institutionalized racism and changes in financial aid policy have turned the momentum of affirmative action, allowing the health professions to suspend their largely ineffectual efforts at minority recruitment in health professional - schools. The distinctions are perpetuated, often unknowingly, by advocates of affirmative action, so that the institutions and the functions which continued discrimination serves are not examined. (These myths will be discussed. in the second part of this study, to be published in the next issue of the Bulletin.) Let us examine now some of the financial barriers to entrance into the health professions. Double Indemnity: Financial Barriers to the Health Professions Headlines greeted the emergence out of the closet of financial and class barriers to the health professional schools. In 1976 the AMA's own American Medical News announced, " Money Be- coming Admissions Criterion "! But this is nothing new. The unchanging class composition of medical schools over the last sixty years provides clear evidence that class and its correlate, family income, have long been major determinants of admissions (see " Medical Education Since Flexner, " Health / PAC Bulletin No. 76, May June /, 1977). The financial barriers to the health professions should be obvious. After completing college, students must be prepared for three or more addi- tional years of study, almost never under conditions which might allow part time - work. The expense of the training itself serves not only as an economic, but a psychological deterrent to low and middle income students. These compound barriers presented by the competition for admis- sion, including sexual and racial stereotypes. But the costs of health professional schools are the final financial barrier to a professional education. Throughout life, persistent obstacles are placed in the paths of many women, most minority and all Year 1970-71 1971-72 1972-73 1973-74 1974-75 1975-76 1976-77 Table 1 Application and Acceptance of Blacks to Medical Schools Number of Applicants 1,250 1,552 2,382 2,227 2,423 2,288 2,523 Number of Acceptances 642 810 857 977 1,000 931 966 Percent Accepted 51.4 52.2 36.0 44.9 42.2 40.7 38.3 Sources: Dube, W.F., Johnson, D.G. Study, " of U.S. Medical School Applicants, 1974-1975, " J Med Educ 51: 877-896, 1976. Gordon, T.L., Johnson, D.G., " Study of U.S. Medical School Applicants, 1975-76, " J Med Educ 52: 707-730, 1977. Gordon, T.L., " Datagram: Applicants for 1976-77 First Year - Medical School Class, " J Med Educ 52: 780-782, 1977. Johnson, D.G., Smith, V.C., and Tarnoff, S.L., " Recruitment and Progress of Minority Medical School Entrants, 1970-1972, " J Med Educ 50: 713-755, 1975. Schildhaus, Sam, An Exploratory Evaluation... of U.S. Medical Schools'Efforts to Achieve Equal Representation of Minority Students. DHEW Publication No. (HRA) 78-735, December 1977. Table 2 Affirmative Action and Inaction: Best and Worst Medical Schools Best Recruitment and Admissions Under Represented - Minorities (Percent Admitted) * Women (Percent Admitted) 1. Meharry Medical College (98.5) 2. Howard University (76.6) 3. College of Medicine of New Jersey (25.5) Stanford University (22.1) 4. 5. Univ. California - San Francisco (21.6) 6. Michigan State University (21.0) 3. 7. Univ. New Mexico (16.4) 8. SUNY Buffalo - (16.3) 9. Baylor University (16.1) 10. Cornell University (14.9) 11. Harvard University (14.5) 1. Medical College of Pennsylvania (60.8) 2 . Univ. Puerto Rico (45.8) 3. Univ. Missouri - Kansas City (43.4) 4. Univ. California - San Francisco (42.1) 5. Morehouse (41.7) 6. Howard University (40.3) 7. Michigan State University (36.8) 8. Northeastern Ohio (36.7) 9. Mount Sinai (36.3) 1 . 10. Northwestern (33.9) SUNY Buffalo - (33.8) Worst Recruitment and Admissions Under Represented - Minorities (Percent Admitted) ** ** 1. Univ. West Virginia (0) 2. Univ. South Dakota (0) 3. Albany Medical College 1.2 () 4. Univ. Oregon (1.3) 5. Univ. Nebraska (1.6) 10. 3. 6. Univ. Connecticut (1.9) 7. Univ. Virginia (1.9) 8. Johns Hopkins University (2.1) 9. Univ. Nevada (2.1) Univ. Miami (2.3) 11. Univ. Tennessee (2.5) Women (Percent Admitted) 1. Univ. Utah (9.0) 2. South Alabama (13.0) 3. Univ. Chicago - Pritzker (14.4) 4. Univ. West Virginia (14.8 14.8) 5. Texas Tech (15.0) 6. Univ. South Dakota (15.4) 10. 7. Uniformed Services (15.6) 8. South Florida (16.4) 9. Univ. Minnesota - Duluth (16.7) 1110.. VUannidve.r bOirletg oUnn i(ve1r8s.i3t)y (16.9) * Percentage of minorities enrolled in first year class, 1976-77. Percentage women enrolled in first year class, 1978-79. ** Percentage of minorities enrolled averaged over first year classes in 1975-76 and 1976-77 in schools admitting six or fewer minority students during those two years. None of these schools had fifteen or more minorities enrolled in all classes during 1976-77. Percentage of women enrolled in first year class, 1976-77. Sources: Braslow, Judith B., " Current Status of Women in Academic Medicine, " paper presented at the Regional Conference on Women in Medicine, New York, March 24, 1979. Hodge, Juel L., ed., Minority Student Opportunities in United States Medical Schools, 1978-79. Washington, D.C.: AAMC, 1977. Philpot, Wilbertine P., Minorities & Women in the Health Fields: Applicants, Students, and Workers. DHEW Publication No. (HRA) 79-22, October 1978. low income - students who aspire to a professional career. Despite the New Frontier, the Great Society and the War on Poverty, the percentage of the U.S. population which is impoverished has not substan- tially changed since 1969 - from 12.1 percent in 9 ee ee eee e eee a eee reer ener ee re ee ee ee Recently, there have been signs of a ceiling for women entering medicine. During the last two years, the number of women applying to medical schools has decreased - a decline suggesting a plateau of about 30 percent of women's representaiton in medicine ee ee ree reece eee cece eee 1969 to 11.8 percent in 1976 (11). But who is affected by poverty has changed dramatically. The poverty rate among the elderly dropped 41 percent from 1969 to 1976, while it rose 14 percent for children under eighteen. In 1959 the poverty rate among Blacks was three times that of whites, by 1976 the rate was three and one half - times the white rate. Women have always had less earning power than men in the United States - for example, in 1959 the female poverty rate was two and - - a - half times that of males. By 1975 the rate was four - and - a - half times the male rate. Thus the face of poverty has changed. Today the poor are younger and more likely to be female and Black than in the 1950s. From the beginning of their educations in pri- mary and secondary schools until until _ their attendance at college, the poor have less of their own personal resources to spend for their educa- tion, and less government money is spent on them (12). The property tax structure which fin- ances most primary and secondary education has led to vast discrepancies in the amount spent on each student, consistently favoring white, subur- ban, upper middle - class children over poor min- ority and urban, collar blue - children. The conse- quences of this are twofold: (a) members of the highest socioeconomic classes are disproportion- ately concentrated in the high " ability " and the lowest socioeconomic classes in the low " ability " groups among high school graduates; and (b) even among those in the highest " ability " group, fewer poor and minority students enter college, a cumulative consequence of inadequate counsel- ing, support, and financial aid, fewer role models. lower teacher expectation and admission bias, eC Table 3 Distribution of Women and Minorities in Higher Education and the Health Professional Schools, 1977-78 Distribution by Race: White Black Hispanic: Mexican American - (Chicano) Puerto Rican Native American Asian Percent of U.S. Population 86.6 11.6 3.9 3.1 0.8 0.4 1.3 Percent of Full Time - Enrollment All Higher Education Selected Health Professional Schools * Medical Schools 81.3 9.7 4.3 88.2 5.0 2.2 86.6 6.0 1.8 0.6 1.8 0.3 2.7 1.4 0.4 0.3 2.4 Distribution by Gender: Men Women 49.0 51.0 51.2 48.8 73.0 27.0 76.3 23.7 * includes pharmacy, dentistry, optometry, allopathic and osteopathic medicine. Source: Vetter, Betty M., Babco, Eleanor L., and McIntire, Judith, Professional Women and Minorities: A Manpower Data Resource Service. Washington, D.C.: Scientific Manpower Commission, November 1978. 10 OOOO EO ----_-- Figure 4 Women Students Enrolled in Selected Health Professional Schools 40 PERCENTAGE WOMEN _ seem 36 | o STUDENTS - ao? 32 ww ae 28 ae 24 - ron eons! veewes Pharmacy Medicine Medicine 20 16 mame Optometry ******* Osteopathic Medicine mee Dentistry wermese Podiatry 12 8 4 71-72 72-73 73-74 74-75 75 76 76-77 77-78 78-79 ACADEMIC YEAR Sources Johnson, Davis Through and Gordon. Travis 1. " Datagram Medical Student Enrolment 1974 1975 Through 1978-1979, "! Med Edu 54 43: 433 May, 1979 Vetter Betty M. Babco, Eleanor L and Meinture, Judity, Professional Women and Minorities A Manpower Data Resource Service Washington, DC. Smentite Man power Commission, 1978 real and perceived (13,15). Affluence is the impor- tant prerequisite for higher education: over the past fifty years a 10 percent increase in family in- come is associated with a 12 percent increase in college enrollment (15). Once enrolled in college a similar double bind faces poor, working class, and minority students. In all public institutions of higher education with varying degrees of selectivity the median family income of their students is directly proportional to the money and resources committed to educate each student - the higher the median income, the more money spent per student (16). Minority stu- dents are disproportionately represented in two year and four year colleges which spend the least per full time - pupil; the resources spent by highly selective universities, which have the highest median family income and lowest minority enroll- ments, is more than three times that spent per student by the institutions which the greatest percentage of minorities attend (16). This discre- pancy is present in public institutions alone; including private institutions with their greater prestige, selectivity, and tuitions and their lower percentages of working class and minority students only make these statistics worse! Among 1974 applicants to medical schools, 66 percent of whites attended schools which had expended more than $ 2,500 per student, while only 55 percent of Blacks and 40 percent of Chicanos had. Both Black and white applicants from the more affluent schools are accepted at a rate one- third higher than applicants from the less endowed colleges 17 (). The disadvantaged also contribute a greater percentage of their family's total income toward their education than do more affluent students. Students whose family income is less than $ 5,000, while only 8.2 percent of the national undergra- duate body are 10.4 percent of the total relying on personal savings, 13.9 percent of those depending on earnings while taking courses, 17.5. percent of those depending upon their spouses ' savings or earnings, 31.1 percent of those using Social Security benefits, and 38.8 percent of those using other sources (mostly extended family contributions) (18). Once in college the type and amount of finan- cial aid makes a significant difference in whether or not a minority student completes his or her schooling. The size of scholarships or grants is a major factor in the persistence of Black students in college; loans and work study - programs seem to enhance Black students'ability to stay in col- lege, especially in predominantly white institutions (19). * The financial aid programs enacted by Con- gress under the Education Amendments of 1972 are beginning to have a visible impact on the ac- cess to and completion of higher education for low income - and minority group students. These aid programs include Basic Educational Oppor- tunity Grants (BEOG), Supplemental Educational Opportunity Grants (SEOG), State Student Incen- Figure 5 Annual Appropriations for Selected Federal Student Aid ANNUAL APPROPRIATIONS (MILLIONS OF DOLLARS) $ 40 Guaranteed Student Loans to Medical Students $ 30 Health Professional Loans $ 20 $ 10 Health Professional Scholarships 1965 1966 1967 1968 1969 1979 1971 1972 1973 1974 1975 1976 1977 1978 1979 FISCAL YEAR Sources Genera. Accounting Office, Congressional Objectives of Fedemi Loans and Scholar ships to Health Professions Students Not Being Mer Washington DC Government Printing Office. May 24 1974, Reig Sonia Bureau of Health Manpower DHEW, telephone interview, June 15, 1979 annua. reports Medical Education in the Urated States JAMA 1971 through 1978 * Considerable problems still exist in assessing these programs as records are not kept on all those who apply for financial aid or the dollar amounts which each recipient receives from each and all sources; although data are kept by race national / origin and sex, all the minorities are pooled and no data are available which might discern the awards made to, for example, white men or black women. Another important limitation for women and minorities is the restriction made upon part time - students, who must attend at least time half - to be eligible. 11 tive Grants (SSIG), College Work Study - (CWS), National Direct Student Loans (NDSL), and Guar- anteed Student Loans (GSL). They accounted for $ 3 billion or 37 percent of the Office of Educa- tion's fiscal budget in 1976. All these grants are awarded on the basis of financial need. While minority students made up 12 percent of all undergraduates in 1974-75, they received 33.6 percent of the total number of grants and National Direct Student Loans. Women made up 42.8 per- cent of full time - students, but received 51 percent of the total number of awards (although more men than women participate in multiple programs) (20). The impact which these programs have had is considerable. For example, while the proportion of whites of college age who actually attend col- lege has declined since 1970, the proportion of Blacks and Hispanics has increased. Thus for the population between age 16 and 34, Blacks actual- ly had a higher percentage enrolled as of 1976 than whites (21). In 1977 for the $ 5,000-10,000 5,000-10,000 income range, 17 percent of all Blacks from 18 to 24 years entered college, compared to 15 per- cent of whites and 11 percent of Hispanics. In the $ 10,000-15,000 income bracket, these figures. were 21 percent of Blacks and 17 percent of whites and Hispanics (22). The grants awarded consistently follow their designed intention - to assist low income students attain access to post- secondary education. Only for the private market Guaranteed Student Loans (GSL) do students whose family incomes are less than $ 7,000 receive less support than those whose family incomes are higher. The success and consistency of these need based - programs stand in marked contrast with the financial aid record in the health Figure 6 Average Annual Medical Student Expenses, Tuition, and Financial Aid, 1968-1977 DOLLARS $ 10,000 $ 9,000 Total ov Expenses per Student $ 8.000 $ 7,000 $ 6.000 $ 5,000 $ 4.000 4.000 $ 3.000 $ 2,000 $ 1.000 Average Student Loan ee Aver Tuition Clust Average Scholarship Award 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 YEAR Source Gordon Trave! " Studies of Medical Student Financing 1977 Wachination DC AAMC DSS Report 78-2, October 1978 Survey on How Medical Students Finance Their Education 1974-75 DHEW Pabacation No HRA 76 94 December 1975 Annual reports Medical Education in the United States: aura the Ameron Medal Ass 1971 through 1978 professions. The financial barriers at the final hurdle in reaching medical or dental school despite federal commitments to equal access actually have be- come more formidable in the past decade. A study in 1964 of graduates of predominantly Black colleges demonstrated that 70 percent of the men and 50 percent of the women had wanted to study medicine but could not do so for financial reasons (23). In 1977 when Black undergraduates at two schools, Texas Southern and Prairie View A M &, were asked why they thought there were not more Blacks in medical schools, 69 percent of the respondents cited in- adequate financial assistance as very important (24). Their impressions are an accurate assess- ment, for even those minority students who do Table 4 Percentage Distribution of U.S. Medical Students by Family Income, 1976-77 Less than $ 5,000 $ 5,000 to $ 9,999 $ 10,000 to $ 14,999 $ 15,000 to $ 19,999 $ 20,000 or more All U.S. * 13 23 24 18 22 White 2.9 8.7 21.3 16.7 50.3 Black 22.3 25.2 23.5 11.4 17.6 Hispanic & Indian 15.6 25.2 27.4 11.3 20.6 Total 5.0 10.8 21.8 16.1 46.2 * for 1974 (from U.S. Bureau of the Census) Sources: Dube, W.F., " Datagram: Socioeconomic Background of Minority and Other U.S. Medical Stu- dents, 1976-77, " J Med Educ 53: 443-445, May 1978. U.S. Bureau of the Census, Money Income and Poverty Status of Families and Persons in the United States: 1974. Series P 60 -, No. 99, July 1975. 12 1975 enter medical school are on the average signifi- cantly poorer than their peers (Table 4). " Money is the big problem, " Dario Prieto, Director of Minority Affairs at the AAMC, told the Medical Tribune. This was echoed by Dr. John Cooper, President of the AAMC. He acknowl edged that minority students stopped applying to medical schools when the federal dollars began drying up, tuition and interest rates skyrocketed, and scholarships plummeted, while still suggesting that the problem might be in the eye of the be- holder, " As a result, the perception that minority and other low income - students have of the indebt- edness they must incur places medicine beyond their realm of possibilities, as they view it. " (25) (My emphasis H.S.) But more than psychologi- cal deterrence is at work. More than twice the proportion of minority students were already entering medical schools in debt than whites in 1974, when the declines in new enrollments began. Almost 90 percent anticipated debts be- fore graduation with a mean anticipated debt of $ 13,300, four times what they entered with, which was actually an improvement from 1971 (26). Minority students continue to apply, but their acceptance rates fell Table ( 1). They were not the recipients of special interest admissions (see Box). Federal Financial Support for Health Professional Education With financial problems a major barrier to medi- cal education and with only hearted half - , ineffec- tive support for integration from private groups within the health system such as the AAMC, it is no surprise that minority and women's groups have turned to the federal government for finan- cial and political support. As noted above, federal programs appear to have had a positive impact on minority and female enrollment in other areas of higher education. But the role of federal support for the health professional schools since 1974, although nominally designed to " increase access of students from all income levels to health professions careers " (27), has actually made access even more difficult. Federal withdrawal and reorganiza- tion of financial aid support correspond in time with the zenith of affirmative action; its demise fol- lowed directly the decline in need based - financial aid without court order or headlines. Early federal support for health professional education in the U.S. was built into a provision of the Social Security Act of 1935 authorizing grants to states for training and maintaining public health services. In 1952 the President's Commission on the Health Needs of the Nation called attention to shortages in health care personnel and recom- mended federal aid for the health professional schools, including medicine, dentistry, nursing, and public health, and again in 1958 the Surgeon General's Consultant Group on Medical Educa- tion reiterated these recommendations. The dramatic launching of Sputnik precipitated the first federal venture into direct student assistance with the National Defense Education Act (1958), Minority students stopped applying to medical schools when the federal dollars began drying up, tuition and interest rates skyrocketed and scholarships plummeted which has provided the precedent for all subse- quent student aid. After an unsuccessful effort in 1961, the Kennedy Administration re introduced - a bill which proposed a five year student loan pro- gram and a ten year construction - grant program for medical, osteopathic, dental, nursing, optometry, podiatry, pharmacy, and public health schools. In 1963 the Health Professions. Education Assistance Act was passed and signed into law (P.L. 88-129). In 1964 and 1965 the law was amended to extend the student loan program, encourage expansion through a system of grants based on the number of students in a school (called a " capitation " program), and establish a Health Professions Scholarship program. Allied health professions were included in 1966. (These were years of major federal activity in health care- Medicare and Medicaid were passed in 1965.) The Health Manpower Act of 1968 (P.L. 90- 490) integrated all of the previous legislation, ex- tended the federal matching for construction, and provided further special project grants designed to increase enrollment and develop new types of health professionals. Many schools reported rising costs and claimed that they were unable to expand without significant additional assistance. From 1964 to 1970 more than $ 800 million was appropriated under this legislation with 17 per- cent going to student financial aid. In 1971 the Comprehensive Health Manpower Training Act extended the loan and scholarship programs with added loan forgiveness - for serving in shortage areas. A major shift took place in the federal approach to institutional needs, moving from " last dollar " distress grants to " first dollar " operating subsidies in the form of significantly 13 The Sophie Davis Center: One Step Forward, Two Steps Back In 1973 the Sophie Davis Center for Bio- The Bio Med - program also required Medical Education (Med Bio - program) was courses in medical sociology and politics, opened at City College of New York community organizing, epidemiology, and (CCNY). From the beginning, affirmative. field experience in community agencies to action was one of the program's goals but help maintain and develop the students ' not the only one. After two years of successful affirmative action, the program joined the na- tional trend of declining minority admissions. Two very different interest groups sup- ported the Bio Med - program. Some of the college science faculty complained that since 1969 the quality of students had de- clined. In 1969 the City University of New York began a policy of " open admissions " admitting any New York City high school graduate. The science faculty wanted to at- tract the " good students " back to CCNY. A medical school might do the trick. Black and Hispanic community and stu- dent organizations wanted to promote the training of physicians for their communities. One way to attain this goal was to increase the number of minority medical students, commitment toward urban primary care. In September 1973 the first class admitted was in fact representative of the racial mix of the city's high schools. Fourteen Hispanics, ten Blacks, and nine Asians were in the origi- nal class of 62. Half of the class were women. At this time Blacks and Hispanics made up one third of the New York City population and more than half of the city's high school population. By the time that class had completed its first year, controversy surrounded the program. In May 1974, Harry Lustig, Dean of Liberal Arts at CCNY, charged that the Bio Med - program was pressured into the use of racial quotas by community groups from Harlem - the neighborhood where CCNY is located. The oft used - particularly Blacks and Hispanics from the city's public schools. Robert Marshak, pres- ident of CCNY at this time, stated, " Keeping charge that underqualified minority students were taking the places of better qualified students was trotted out for another go- in mind their representation in the college. around. B'nai B'rith began to investigate a and in New York City generally, we want to charge of reverse discrimination brought by get substantial numbers of minority students " (New York Times, 6/6/73). the father of two white students with good academic records who were not admitted. The Bio Med - program was structured dif- Proponents of affirmative action insisted ferently from traditional medical programs. that the racial composition of the first class The Bio Medical - program would lead to a was attained while adhering to selection. M.D. degree six years after high school- criteria of academic performance plus social instead of the usual four years of college fol- commitment. A New York City Human lowed by four years of medical school. Stu- Rights Commission investigation reported in dents admitted to the program would spend the New York Times on June 8, 1974, said four years at CCNY and then transfer into that " recruitment was based on commitment one of eight medical schools for the final two to serve as a physician in an urban area and years of clinical training leading to the M.D. represented a concern for scholastic The science faculty now had an academ- achievement, geographical location, com- ically rigorous training program to attract munity sensitivity and concern, all of which the type of students they felt would save the are vital ingredients for bio medical - pursuits. " college from its supposed academic decline. Despite controversy over reverse discrim- Those who wanted to train more minority ination, the Bio Med - program admitted 22 physicians saw different advantages. This Blacks, 14 Hispanics, and 5 Asians to its program trained doctors two years faster second class of 68 students. than a traditional program. Also instead ot During the first two years of the program's the usual two barriers to medical educa- operation, a number of minority students tion college - and medical - school admissions - a student once admitted into ran into academic trouble. Inner - city New York schools did not offer decent prepara- the Bio Med - program is guaranteed a spot tion in science. Students, no matter how in one of the affiliated medical schools. talented or motivated, could not be 14 expected to survive an accelerated medical program without extra academic help. August 18, 1976, Federal Judge Marvin Frankel found that " 19 whites and Asians Students complained that the program brought them in but did not make a good had been intentionally eliminated on the basis of race from the list of students selected faith effort to keep them there. The tutorial in 1974. " and remedial help made necessary by poor quality public schools was unavailable. The selection process which resulted in a high proportion of minority students was not Minority students were subjected to the hu- the main issue of the suit. If the Bio Med - pro- miliation of accusations that they were not gram selected students based on criteria qualified to be in the program. The New York Post ran a series of arti- giving social commitment and academic performance equal weight, as it did during cles " exposing " students who were given a the first two years of the program, the second chance on some exams. Although court's ruling might not have been made. make - up exams are common practice at The court found fault with the process used many medical schools, the CCNY adminis- to fill places of students who were invited to tration began to give in to the pressure. In- stead of starting programs to help students attend the program but decided not to. Race could not be the sole criterion for call- with less extensive preparation, it talked about criteria for academic probation and dismissal. In Fall 1977, only 35 of the original 62 students completed the required ing people off the waiting list, because this implies the existence of so called - " Black slots " and " Hispanic slots. " Between 1975 and now, the CCNY courses at CCNY and were ready to con- tinue to the final two years of training. In 1975 a new admission procedure science faculty who see the Bio Med - pro- gram as a method to up grade - academic standards at CCNY have had the upper began, weighted more in favor of academic hand. This year the advocates of urban preparation. Scores in science and mathe- community medicine have made some matics regents exams received more careful gains. The Fall 1979 entering class has consideration. This eliminated many minor- ity students from the picture, because many predominantly Black and Hispanic high schools do not even offer the courses needed to prepare for the regents exams. The Bio Med - classes of 1975-1978 slid about 18 percent Blacks and Hispanics and 11 percent Asians. According to Jack Geiger, professor of community medicine at the program, several factors contributed to this advance. A new program called the Bridge to Med- back toward the national average number icine provides science education for select- of minority students. Increasingly, more stu- dents came from suburban and middle - class ed high school students. If the science classes they need are not available at their backgrounds. schools, they take the required courses at The commitment to bring the " good stu- dents " back to CCNY took priority over the need to change the complexion of medical school classes. As the number of minority City College. Several of the incoming stu- dents were in this program. Programs are starting to recruit Bio Med - students from the families of the members of students from the inner - city fell, so did the New York City labor unions. An option for level of students'interest in primary care students to go through in seven or eight and community health. The instructors of years instead of the very intense six is being the community health courses had a hard time interesting suburban students in urban developed. Whether the Bio Med - program can con- community health. Anti affirmative - action forces in the pro- gram received legal blessing in August 1976. Despite the fact that affirmative action was on its way to being discarded, B'nai B'rith and the Italian American Center for tinue to admit minority students at an in- creasing rate and provide the support necessary to keep these students remains to be seen. In a period of a downward trend in minority medical school admissions and de- creasing support for affirmative action in Urban Affairs failed a Bakke - like suit to employment and education, it will be a guarantee that affirmative action would not struggle. be practiced at the Bio Med - program. On -Richard Younge 15 larger grants allocated on a per student - basis if schools agreed to expand. The effort to influence specialty choice and geographic distribution and to increase the proportion of minority students was made through special project grants to schools. This included support for regional health centers, family medicine departments and general Admissions to the health professional schools have largely replicated the existing hierarchy in the society, in the profession, and, particularly, in the schools themselves dentistry training programs, and projects designed for " identifying, recruiting, and selecting " individuals from disadvantaged backgrounds. These programs were to facilitate entry of disad- vantaged students, provide counseling and other services to retain them, provide pre admission - programs, and publicize sources of financial aid. These newer efforts to affect specialty choice and geographic distribution and to increase minority students were, in effect, voluntary for the schools. as they provided the " carrot " of aid without the " stick " of active enforcement of the conditions for the aid written into the law. Almost immediately after the passage of this Comprehensive Manpower legislation a re- examination of federal health manpower policy began. The doctor shortage was understood more clearly to reflect maldistribution of physicians by medical specialty and geography, which even a substantial increase in traditionally selected and trained health professionals would not relieve. Still the language and cultural barriers to health care were not addresed. Nor was the evidence that low income students traditionally choose primary care practices even without incentives or obligation and that professionals of all racial and ethnic groups largely serve their own communities (28). Nor was the evidence of the ineffectiveness of capitation grants as a means of promoting access examined (29, 30). In 1973 Congress established the first programs -the Public Health Service and Physician Short- age Area scholarships - to provide financial aid in exchange for an obligation to serve in a shortage area without regard for financial need. A similar Armed Forces scholarship was established under 16 the Department of Defense to meet the military's physician needs. In 1974 a complete phase - out of the Health Professions Scholarships was begun, and support for the loan program began to decline. After the House Senate - Conference committee could not agree on how to achieve geographic and specialty redistribution during the preceding Congress, a consensus emerged that resulted in the Health Professions Educational Assistance Act of 1976 P.L. (94-484). As amended in 1977, its major student financial assistance programs include the following: -National Health Service Corps (NHSC) scholarships - an expanded continuation of ser- vice obligated - financial aid awarded without re- gard for financial need; - -Health Professions Student Loans (HPSL) - continued at diminished levels and limited to stu- dents with " exceptional financial need " with interest raised from 3 to 7 percent; Figure 7 Total Annual Medical Student Financial Need vs. Total Scholarship and Loan Funds Available, 1968-1977 600 $ $ 500 MILLIONS OF DOLLARS DOLLARS $ 400 ee Total Student Needs $ 300 $ 200 $ 100 aeneees Total of Student Loans nm det ere oT, Total of Student Scholarships 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 YEAR Sources Gordon, Travis L. L. Studies of Medical Student Financing. 1977-78. " Washington.. DC AAMC. DSS Report 78-2, October 1978 Survey on How Medical Students Finance Their Education, 1974-75 DHEW Publication No (HRA) 76-94, December 1975 Annual reports, Medical Education in the United States, " Journal of the American Medical Association, 1971 through 1978 -Scholarships for Exceptional Financial Need (-need E-F Nba)se d financial aid without a service obligation for first year students only; and -Health Education Assistance Loans (HEAL) - new, federally - insured bank loans at 12 percent (plus a 2 percent insurance premium) without sub- sidies (see Financial Aid Sources, page 27). After the Act was signed by President Ford on October 12, 1976, almost two years passed before the publication of the regulations for its student aid programs. Regulations for two of the programs (EFN and HEAL) were published during the summer of 1978, without opportunity for public comment. As a result, for almost three years health professions financial aid was in limbo. Continued on Page 25 WASHINGTON CBC: WHAT'S PREVENTING A HEALTH POLITICS? In late September the Congres- sional Black Caucus (CBC) held its annual Conference here, with upwards of 10,000 people parti- cipating in events, looking in- tensely toward 1980 and the 1980's. No " candidates, " includ- ing President Carter and Senator Kennedy, were asked to speak to the Caucus this year. They had " debated " back back - to - the year before. The meeting came, however, just as the growing gleam in the eye of the Senator still known as " Mr. National Health Insurance " was giving ear- lier expected - than - birth to candi- dacy. Representative John Conyers, Jr. (MI D -), who is leading a " dump Carter " movement, de- clared: " We put him in office. We can't let someone else take him out. " A sharply critical report was re- leased before the Caucus con- ference stressing the limits of spe- cific Administration programs and performance thus far, includ- ing health care and inner - city en- vironment and community devel- opment. They range from D- minus on the Economy to A- minus on Foreign Policy. No real programmatic offensive was in evidence including - health and health services. The personal poli- tics of fund raising - and survival appeared to be the order of the day. No gathering of office holders - can match CBC for its range of individual political commitments and increasing Congressional responsibilities essential to a " new public health movement " -fund- ing priority for preventive and primary health services, equity and appropriateness for medical services, and occupational / envir- onmental / social health action. To- gether with Labor and the broad- er progressive alliances, CBC in- dividuals have articulated a call not only for civil rights in health but for public services commit- ment for low income - communi- ties, for health planning for the neediest consumers, and for public action regarding the inner city environment. Meanwhile, sixteen of the seventeen CBC Congress - people are urban Democrats, one is an urban Republican; none are U.S. Senators. Caucus Health " Brain Trust " convener, Congressman Louis Stokes of Cleveland, is on the Labor / HEW Appropriations Committee. Not visible on health policy questions as such, he is an important advocate, for example, for community health center and child health assessment program funding. This is in close coopera- tion with groups like the National Association of Community Health Centers. Congressman Ronald Dellums has gained the support of much of the Caucus as at least courtesy co sponsors - of his radical Na- tional Health Services Bill (see, Washington Column, Nov. - Dec., 1977). Dellums directly addresses health policy in the Congress only as Chairman of the District of Columbia Committee and as part of military and foreign policy committee issues. For example, his Infant Nutrition Act of 1979 would prohibit sales promotion of baby bottle formula in under- developed countries by U.S. companies, requiring proof that formula will only reach those who can use it safely. Rep. Charles Rangel (NY D -), among others in the Caucus, has . meanwhile been saddled with the President's watered - down Hospi- tal Cost Containment - Bill thus - taking the full attack from the Medical Lobby (including the American Hospital Association, the Federation of American Hos- pitals, and the American Medical Association). The Lobby asks, for its part, why the basic necessity of health services alone should be singled out for Administrative pressure and held hostage against comprehensive NHI when gov- ernment industry and bank - sub- sidizing policies escalate costs without such restraint in energy, food, and housing. There are cer- tainly doubts whether the pro- posed voluntary transitional - ceil- ing approach will actually cut in- flation for people. In this Congressional term, Rangel became Chairman of the Health Subcommittee of the House Ways and Means Committee, from which national health financing and hospital cost containment - emanates. Reportedly wrangling Carter Ad- ministration support as he voted at the end of the last Congres- sional session for Carter's natural gas price deregulation, Rangel apparently has also been given some HEW review power on health projects close to home in Harlem. Rangel is " courtesy " introducer of the President's Na- tional Health Insurance package, but is additionally considering a maverick financing bill of his 17 own, probably along with James Corman (CA D -), who broke " to the left " of Kennedy. Demonstrating determined sav. vy as a health oriented - fresh- man CBC Member is Mickey Le- land, who now holds Barbara Jor- dan's old seat from Houston, Texas. The May '79 CHAN Newsletter of the Consumer Co- alition for Health (CCH) and the Public Citizen Health Research Group lauds Leland's role " in mobilizing support from the Con- - gressional Black Caucus " and firmly encouraging Rep. Henry Waxman (CA D - and new Chair- man of the House Health and En- vironment Subcommittee) " to break with with the conservative majority on the Subcommittee and work hard on the full Com- mittee to restore civil rights and consumer protection " in the re- cent health planning renewal and amendments showdowns. Leland, a founding member of the Houston chapter of the Medi- cal Committee for Human Rights, is a pharmacy - trained activist who has long had an interest in consumer health and civil rights issues. As a Texas state legislator, he chaired successful committee action in that conservative cham- ber on issues like generic drug substitution and Health Mainten- ance Organization enablement. A co sponsor - of the Dellums Bill, but more recently visible as a Kennedy Bill Co Introducer - , Leland appears to be focusing on particular health consumer rights and environmental protection legislation where some Congres- sional committee leverage can be developed now. Congressmen Parren Mitchell (MD D -) and Conyers both have been outspoken on inner city en- vironmental problems. Freshman Congressman William Gray of Phi- ladelphia, who has become inter- ested in occupational health is- sues, keynoted a local conference 18 last spring on industrial cancer. The inability of the Caucus yet to generate bold, unified repre- sentation on the health and health services issue especially - those currently impacting inner - city minorities -- lies neither in indivi- dual failures to grasp policy nor simply in the quandry of trying to carry progressive agendas against a regressive national poli- tical climate. Rather, there is a decided tendency for deeper urban health questions and alter- native strategies to get lost in the fragmentation of Congressional committee and Executive agency business. This fragmentation is fed by the limits and contradictions of both Kennedy and Carter ap- proaches for medical care finan- cing and regulation, and divisions in the House of Labor between, for example, the old health insur- ance lobby and new occupational health movements. It is paralleled by the desperate search by Black political leaders for any unified leverage for minority - assisting economic development. There are some few rewards for parti- cular leadership stances in rela- tion to current Party leaders. There is a vast " mobilization of bias " against root issues such as the relation between health services and urban survival being legiti- mately linked together in the poli- tical arena. Even in the quickly reshuffling momentum of internal Party con- flict, Blacks and Hispanics who were the most committed voting groups in 1976 for Carter, might re pose -, in the Democratic Party and outside, basic social commit- ment issues including health and health services. But the'Eighties health politics of economic and fiscal scarcity, frightening corporate industrial - illness, and of the limited regula- tion for assuring any guarantee of equal distribution of efficacious medicine cannot be answered simply by a'Sixties chorus for more loose federal entitlements and authorizations. Basic questions need to be de- bated and understood if the poli- tical coalition around health issues is to be built. Which corporate en- tities specifically are threatening our lives and health and those now of our children's children? What local services are we defending to maintain or effec- tively expand? Exactly how are we to regulate, allocate and re- organize the medical technology and caring resources that now distort community - based and caring and public health action? Until there is a more unified and activist organizing base to sup- port actions of the CBC opposed - by powerful lobbies and a perva- sive conservative atmosphere- the Caucus probably is not the place to expect a new public health politics to emerge. There are health programs in the jurisdiction of the inner cities represented in the Caucus which might prove to be better models * to support than the currently available policy positions on the Hill. The New York Post recently chided embattled New York City health planners for overlooking networks of health centers which " now flourish in several major cities, including Chicago, Detroit and _ Newark. " The Post con- cluded: " Perhaps the.. experts should simply have visited New Jersey. " Between this September in Washington and next August at the Democratic Convention in New York City a Black political convention that also re examines - its role in an overall progressive block could be generated from turf other than this currently burned - over zone of the Poto- mac. Maybe they'll meet in New Jersey... --Robb Burlage WORK ENVIRON F11 LOST TIME AND LOST LIVES Last June, the Bureau of Labor Statistics (BLS) of the U.S. Depart- ment of Labor finally came out with its summary of occupational injuries and illness for 1977. The results are disturbing to those concerned about worker health and safety. And they will almost certainly provide ammuni- tion to those vocal business and political interests who have long sought to undermine the current occupational health and safety movement and to destroy the federal OSHA agency. The BLS report, entitled " Occu- pational Injuries and illnesses in 1977: Summary, " (Report No. 561; June, 1979) announced a 6 percent increase in the rate of lost time injuries and illness for manu- facturing workers between 1976 and 1977 from 4.8 to 5.1 lost workday incidents per 100 workers per year. The 1977 injury and illness rate is the highest since the late 1940's, just after World War II! One might argue that such a comparison of 1940's and 1970's rates is rough at best since in 1971 OSHA modified the stan- dard classification procedure for recording lost time injuries. But even so, the trend since 1971 has been one of increasing lost time injury and illness rates. OSHA started publishing statis- tical summaries based on re- quired annual employer reports on injuries, illness and deaths in 1972, the first full year in which OSHA was in force. For every year since then, except 1975, OSHA has reported a higher rate of lost time injuries and illness than the year before. (The sum- maries, by the way, always take about a year and one half to com- pile - an unnecessarily long time and a tipoff of the low priority the Labor Department assigns them.) As seen in the accompanying graph, the lost time rate for manufacturing has increased from 4.2 lost time injuries and ill- ness per 100 workers in 1972 to 5.1 in 1977, an increase of 21 percent! Remember, this comes on top of a 29 percent increase in this rate between 1961 and 1970; and this was one of the key factors in building support for passage of the OSHA Act in 1970 (see, for example, Ashford, Crisis in the Workplace, p. 46 or the Health / PAC Bulletin, No. 44, September 1972, p. 15). So in OSHA's first six years, it has not been able to stem the rising tide of injuries and illness on the job which helped prompt the law's passage in the first place. Indeed, if anything, the picture today with respect to disabling injuries and illness is worse than when OSHA was passed in 1970. But working people and their families, as well as other ordinary Americans, expect and deserve something better from OSHA. They have supported OSHA- and, I believe, will support it- so long as it shows a record of ac- complishment in protecting the lives and health of American working people. I believe OSHA has won sup- port in the past for its actions in regulating health hazards such as asbestos, polyvinyl chloride plas- tic and DBCP insecticide. During the 1972-1977 period discussed above, the annual occupational death rate has dropped by 2.5 percent, a small drop but a move in the right direction. And, I sus- pect, the large fines levied against companies responsible for major disasters involving loss of lives- fines tens and hundreds of times larger than similar OSHA fines in the past are welcomed as a warning to large companies that avoidable disasters are being taken seriously, even though this action won't help the workers who died. If OSHA is to improve its safety record, it will have to expand the scope of its safety standards to cover a great many more unsafe situations than it now does But for every fatality caused by the job there are roughly 500 lost time - injuries and illnesses, a total of 2.2 million of them re- ported in 1977. And most of OSHA's enforcement resources go into the safety part of inspec- tions. Ordinary citizens legiti- mately expect this vast effort of OSHA inspectors and expendi- ture of OSHA resources to pay off in a reduced or at least stable rate of injuries, rather than the ever increasing rate which is now the case. 19 Some people in OSHA have Disabling Injuries & Illness per 100 Workers apparently been trying to wish away this problem by asserting, at least informally, that the dis- abling injury rate hasn't really 5.0 5.1, been rising recently, it just looks that way because the reporting of lost time injuries is getting better. 4.8 This sounds like a tune from the late, unlamented J. Edgar 4.7 Hoover's songbook - rapes and other violent crimes are not going up, they're just being reported. 4.5 4.5 more often - and it's just as badly off key -. For if the rise in serious manufacturing injuries was only due to better reporting, then we 4.2 would expect to see a similar rise in other employment sectors and we don't see them. For example, 4.0 '71 in the same six year period 1972- 1977, disabling injuries and ill- '73 '75 "7 7 ness in the construction industry fell by 2 percent. The corres- ponding rates in the trade and Disabling Injury and Illness Rate for U.S. Manufacturing Workers (1972-1977) service sectors went up in the same period, but only by 4 and 10 percent, respectively. In short, of the seven other employment sectors besides manufacturing, Source: Annual summaries of occupational injuries and illness, U.S. Dept. of Labor, Bureau of Labor Statistics + none rose more than 10 percent in this period, except transporta- analyzes statistics involving dis- This suggests that if OSHA is to tion and public utilities (18%). So abling injuries and illness for the improve its safety record, it will the 21 percent rise in the manu- state of California between 1948 have to expand the scope of its facturing injury rate stands out and 1975. He shows that based safety standards to cover a great among employment sectors. It on trends in the pre OSHA - many more unsafe situations than must be taken as a real rise in dis- period (1948-1970), the current it now does. If it can't or won't do abling injuries and be acted upon high disabling injury rates would this, it can expect grave political accordingly. be even higher without OSHA. problems, since its business and In light of the above, is OSHA He estimates that in California political enemies will surely make doing any good at all in the safety OSHA has cut down the rate of the general public aware of the area? Yes, it is, I believe, but not lost time - injuries and illness for agency's failures. Health and anywhere good enough. This view is given support by a recent study entitled " Regulating Safety: An Economic and Political Analy. manufacturing workers by 3 to 5 percent. The reason this number is so low, he shows, is that only 5 to 10 percent of all disabling in- safety activists should press OSHA on this matter and, even more important, give safety issues the kind of careful attention they sis of Occupational Safety and Health Policy " by John Mendeloff (MIT Press, 1979). The author juries and illness result from de- tectable violations of OSHA safe- ty standards. have always deserved but not often been given. -David -David Kotelchuck 20 SUBSCRIBE! WOMEN Q A NATIONAL VOICE FOR WOMEN'S HEALTH CONCERNS " When I appeared as an expert witness before Senator Kennedy's Subcommittee on Health Hearings on DES in 1975, it was clear to me that the Women's Health Move- ment had had little impact at the federal level. There was an obvious need for efforts at both the grass- roots and national levels, " said Belita Cowan, one of the five founders of the National Women's Health Network (NWHN). And so, Ms. Cowan, Phyllis Chesler, Mary Howell, Barbara Seaman, and Alice Wolfson formed the NWHN, a non profit - organization repre- senting more than 1,000 health groups and individuals across the country, including the American Foundation for Maternal and Child Health, and the Boston Women's Health Book Collective, authors of Our Bodies, Ourselves and Ourselves and Our Children. The Network serves as a com- munications and action network for the Women's Health Move- ment in this country. Network News, a bi monthly - newsletter, and emergency NewsAlerts serve to disseminate critical infor- mation on women's health issues. At the federal level, the Network presents a feminist health per- spective to Congress and the health regulatory agencies. The NWHN is an educational group which presents its findings and analyses in the form of testimony at the invitation of Congress rather than lobbying. An equally crucial role at the federal level is that of monitoring the health policy de- velopments of agencies, organi- zations, and the Congress itself. The Network sends out News- Alerts to its membership when- ever local actions and initiatives are necessary. The Network focuses much of its activity on issues of reproduc- tive freedom including safe con- traception, safe childbirth prac- tices and safe, legal abortions, as well as campaigns against sterili- zation abuse and overprescribed menopausal estrogen drugs. " National Women's Health Net- work regards access to safe, legal abortions as a basic right of all women irrespective of age or marital or economic status... The Network is irrevocably op- posed to the elimination of public funds to finance abortions for low income women, as an erosion of equal rights under the law, and insupportable limitation of the choice of women to whom society gives the fewest options, and an example of legislated class dis- crimination which endangers the lives and health of the women whom it affects..... Lack of finan- cial access to abortion services forces many women to accept sterilization as a form of birth control, losing their childbearing capacity forever because they fear pregnancy in adverse cir- cumstances... ...... The right to abortion is in- extricably intertwined with a number of other issues, whose ul- timate resolution may make abor- tion a crucial but less frequently exercised right. The NWHN sup- ports struggles around these issues, particularly the fight against sterilization abuse, and the movements for child care ser- vices and pregnancy disability rights... 11 .. The [NWHN] opposes the use of arguments and policies on the abortion issue which stem from an analysis which suggests that population control is an ele- ment in the movement for repro- ductive rights. The NWHN does not support the population control analysis. It takes its stand on the inalienable right of each woman to control her body and her life " (1). Two of the most visible actions organized by the NWHN on the abortion question were the August 11 Day of Outrage in 1977 and the Mother's Day Mo- / therhood by Choice march in Washington in 1978. Less well- publicized was their strong objec- tion to the February, 1979, meeting called by National NOW to bring pro choice - and anti- abortion groups together " to seek ways to lessen the need for abor- tion, to reduce the incidence of unwanted pregnancy, and to end the polarization and violence sur- rounding the abortion issue " (2). Contraception has long been a concern of women's health acti- visits especially - the assurance of safe, accessible contraception for all women who want it. Of equal importance is the need for in- formed consent, in all aspects of health care, but especially in this respect. As part of this concern, the NWHN testified before the U.S. Senate and the House Select Committee on Population in May 1978, the FDA Symposium on Over Counter - the - vaginal contra- ceptives and Health Research Group birth control pill hearings. In 1977, the Network developed an IUD information compliance survey with the Federation of Or- ganizations for Professional Women. The Network has ad- dressed itself to the issue of estro- gen use, drug reform, and patient 21 At Congressional hearings, witnesses testified that Depo Provera - was especially appropriate for those of low'income status,'the Illiterate ' or semiliterate'and the ' unmotivated.'In the U.S., this is substantiated by the fact that the drug is largely administered to poor, minority, mentally retarded and institutionalized women packet inserts. Currently, the most visible project in this arena is the Depo Provera - Registry and education campaign. Depo Provera - (medroxy progesterone acetate), manufac- tured by the Upjohn Company, is not approved by the FDA for contraceptive use, for use in pregnancy, for the treatment of endometriosis, or for inducing a woman's menstrual period as a " pregnancy test. " However, since 1973 it has been approved for use as a palliative treatment for incur- able uterine cancer (3). The FDA considers the drug experimental for use as a contraceptive. Some of its more serious side effects in- clude the possible increased risk of breast and cervical cancer, congenital malformations in chil- dren exposed in utero, irregular bleeding patterns, prolonged menstrual bleeding, decreased libido, loss of hair, acute depres- sion, and delayed return to fer- tility or possibly permanent infer- tility. Depo Provera - has caused endometrial cancer in rhesus monkeys (according to an as yet unpublished ten year - study by the Upjohn Company) and malig- nant breast tumors in female beagles. In March, 1978, the FDA re- fused to approve Depo Provera - (known as " The Shot ") as a con- traceptive, " saying the benefits would not outweigh the risks. Upjohn appealed the rejection and cited the drug's use as a con- traceptive in more than 60 coun- tries " (4). An informal survey, conducted by the Institute for the Study of Medical Ethics in 1977, 22 found that 16 of 50 Los Angeles physicians prescribe the drug for contraceptive purposes (5). In fact, it is estimated that " 3 to 5 mil- lion women presently use this drug as a contraceptive world- wide " (6). At Congressional hearings be- fore the House Select Committee on Population, August 1978, wit- nesses testified that Depo - Pro- vera's use was especially appro- priate for those of " low economic status, " for the " illiterate or semi- literate woman " and for the " un- motivated " (7). In the U.S., this is substantiated by the fact that the drug is largely administered to poor, minority, mentally re- tarded, and institutionalized wo- men (8). Because of its questionable safety and its racist usage, Depo- Provera has become a major tar- get of NWHN activity. A national Registry has been established to enable the Network " to identify and to assist women who may have been injured by the drug, " according to Cowan. The Net- work has also sent protest letters to the AMA, and will soon give testimony to the FDA, urging non- approval of Depo Provera - as a contraceptive and that FDA alert physicians and the public to its risks. Any member of the Network is eligible for election to its 14- member Board of Directors. " The composition of the Board of Dir- ectors shall attempt to reflect the broad spectrum of the potential membership " (9). The current board, according to Cowan, is re- presentative of all components of the Network's membership (race, age, geography, constituency, collectives, providers and con- sumers). Some of the other group members include East Harlem Council for Human Services, Co- alition for the Medical Rights of Women, American College of Nurse Midwives -, Feminist Wo- men's Health Centers, Philadel- phia Women's Health Concerns Committee, and UAW Solidarity House. The dues structure differ- entiates between individuals, un- employed / low income members, women's, health or consumer groups, and businesses. For further information on the Network, write to them at: National Women's Health Network Parklane Building Suite 105 2025 " " I Street NW Washington, D.C. 20006 -Marilynn Norinsky REFERENCES 1. Position Paper on Abortion, National Women's Health Network, adopted June 4, 1978. 2. from telegram sent by National NOW as invitation to February 15, 1979, meeting in Washington, D.C. 3. Jon Foreman, " Battle Erupts in South- land Over Use of Controversial Con- traceptive ", Herald Examiner, July 12, 1977, page Bl. 4. " FDA asks Upjohn to Revise the La- bel on Anticancer Drug, " Wall Street Journal, June 8, 1979, page 8. 5.6 .5 .P hFiolriepm aCno, rpfamgaen ,B lD.i rector of the Cen- ter for Population Research, quoted in Network NewsAlert on Depo- Provera, National Women's Health Network. 7. Network NewsAlert on Depo - Pro- vera, National Women's Health Net- work. 8. Ibid. 9. 9. By laws -, National Women's Health Network, published in National Wo- men's Health Network News, Decem- ber 1977 January - 1978, page 3. THE FIFTH FIFTH COLUMN 2 TWO HAT TROUBLES The union organizing program of the American Nurses Associa- tion (ANA), run through the state nurse associations (SNAs), is in serious trouble. By their own figures, the number of members under contract has recently declined from 100,000 to 75,000. A number of complex factors are responsible for this decline. Prominent among them are lack of commitment to serious organiz- ing and economic issues on the part of professionalist - oriented SNA leaderships, and apprecia- tion of this lack of commitment by the rank - and - file which has led to breakaway movements, and recently increased competition from established unions. The most extreme example of lack of commitment is that of the Texas Nurses Association (TNA). Last April, the TNA convention voted to get out of the organizing business. Not only is the TNA not going to organize any more units, but it is actually moving to decertify itself as the collective bargaining agent in the units it has already won. While first citing the perpetual problem of workers and manage- ment belonging to the same organization, the TNA resolution goes on to state its most serious concerns, " hereas (W), the political atmosphere in Texas is such that unionism is seen as interfering with an individual's right to work, the continuation of collective bargaining activity can be a deterrent to other activities of the TNA, including legislative issues. " A clearer statement of SNA priorities would be difficult to find. One of the largest breakaway movements has occurred in Wisconsin, where 1200 nurses voted to break with the Wisconsin Nurses Association (WNA) over its refusal to make needed by law - changes, or to commit sufficient resources to serve the rank - and- file. The WNA resisted efforts to insulate bargaining units from hospital charges of conflict of interests. (See Bulletin, No. 80, p. 9). Last year, the WNA withdrew a petition for election at a Green Bay hospital rather than face charges of management domina- tion, leaving the working nurses high and dry. It seems that a nursing supervisor at the hospital was also the president - elect of the WNA. The organized Wisconsin nurses, now the United Profes- sionals for Quality Health Care, also became incensed when it was learned that of their $ 105 a year mandatory dues, only $ 65 was being used for collective bar- gaining related purposes. Wis- consin is by no means the only SNA which depends on the dues of unionized members to underwrite its other activities. In states where the 1985 Proposal and similar legislation is being actively promoted, working nurses are thereby paying to have themselves stabbed in the back! What will become of indepen- dent unions such as the United Professionals remains to be seen. Many of them retain undiluted professional conceptions, and do not yet appreciate the need for unity with other health workers. Effective representation requires tight organization, money, exper- ience and expertise components - which newly launched indepen- dent unions are generally short of. Ultimately, independent The New York State Nurses Association refuses to believe that nurses could possible vote for anything but the professional organization unions must address the question of amalgamation. The major contenders in the nursing field are the League of Registered Nurses of 1199, and the American Federation of Tea- chers. 1199 formed its nurse divi- sion two years ago following a successful drive at Brookdale Medical Center in Brooklyn. Since then, 1199 has registered successes and made contacts locally and nationally. The AFT's nursing division is one year old. It is financed by a $ 1 million war chest, and cap- tained by a number of ex ANA - staffers. The major distinction between the two is that 1199 organizes nurses into a division which is part of a larger, industry - wide union, while the AFT is apparently or- ganizing on a craft union, pro- fessional - only basis in much the same way as the SNAs. 23 A major showdown is coming in New York. The contract cover- ing more than six thousand nurses in the municipal hospital system, now represented by the New York State Nurses Associa- tion (NYSNA) is up for renewal in early 1980. Both 1199 and the AFT have launched vigorous organizing campaigns among municipal nurses to bring a new election. The loss of six thousand nurses in one fell swoop could cause the entire SNA representation system to come unglued. The victor would have instant authority. The NYSNA, however, is tak- ing the challenge in a cavalier mood. They apparently refuse to believe that nurses could possibly vote for anything but the profes- sional organization. One of the challengers stands a good chance of success given the " low profile " that the NYSNA has maintained in the city hospitals until recently. It will be particularly fitting that a blow with such national implica- tions should strike the NYSNA, the vanguard of professionalism among the SNAs. These developments from in- side and outside of the SNAs might have the effect of further isolating union conscious - working nurses from the professional or- ganizations. To a certain extent, the SNAs undertook unioniza- tion of nurses out of fear of being swept aside by activist working nurses. It is not fair to say, how- ever, that all SNAs are abject failures at representing nurses, or that all unions are without flaws. A few SNAs, such as California, have at times effectively repre- sented working nurses. There- fore, it is necessary to look at the merits of individual situations. Perhaps the day will come when the ANA and the SNAs which refuse to fight effectively for the real interests of working nurses will be limited to the nurses they represent best supervisors - , educators and graduate degree holders. -Glenn Jenkins COMMISSION FOR THE ADVANCEMENT OF PUBLIC INTEREST ORGANIZATIONS Announcing a New Publication PERIODICALS OF PUBLIC INTEREST A Citizen's Guide Periodicals of Public Interest Organizations - A Citizen's Guide introduces the reader to 103 newspapers, newsletters, magazines and journals published by 96 national, public interest / citizen organizations. These periodicals convey news and information, often not found elsewhere, which can help their readers be more effective citizens; give students fresh perspectives on current public issues; and inform governmental actions at neighborhood and community, state and federal levels. Ralph Nader has called them " a neglected dimension of adult education and an invitation to civic involvement. " The Guide is available from the Commission at 1875 Connecticut Avenue, NW, # 1013, Washington, DC 20009. Prices are $ 4 to public interest / citizen groups; $ 5 to individuals (personal checks), government, schools and public libraries; $ 15 to all others. Make checks payable to the Commission; payment must accompany order. For information on special rates for bulk orders, contact the Commission. ISBN No. 0-9602744-1-3 Library of Congress Catalog Card No. 79-88697 24 EEE rrr EEE Double Indemnity Continued from Page 16 The Impact of Federal Funding and Financial Aid on Affirmative Action The three stated objectives for federal involve- ment in health professions education are: (a) increasing the aggregate supply of health profes- sionals, (b) improving the geographic and special- ty distribution of these professionals, and (c) increasing access of students from all income levels to health professional education. With general expansion of the social services, including the health sector, and fear of a doctor shortage during the late 1960s and early 1970s, academic health centers and the federal government found in these priorities a common self interest - . The first priority, increasing medical personnel, has been achieved. So much so, in fact, that dramatic expansion of the health professions has now created fears of a doctor excess, with its attendant high salary and equipment costs and its impact in driving up medical cost inflation. The second priority, geographic and specialty reallo- cation, has proved more knotty. Mild constraints such as easily met " quotas " for primary care train- ing as a prerequisite for capitation and service- obligated financial aid, as well as new actors with- in the old medical hierarchy, such as family medi- cine and mid level - practitioners, have performed cosmetic surgery but have not had much impact on maldistribution of physicians. The goal of direct student financial assistance had been to increase access to the health pro- fessions for low income students and, thus, stimu- late applications which would then allow the schools to be more selective and improve quality (31). From 1965 to 1973 a total of $ 295.3 million were allocated for loans and scholarships to the health professions schools for students with " exceptional financial need. " Linking access to increased competition did inflate grade and test. scores, but it actually reduced the representation of low income students between 1963 and 1967 (23). (See Table 5.) It proved a windfall for afflu- ent students and for the schools. Between 1970-71 and 1974-75 successful political pressure for increased minority enroll- ments dramatically increased funding of the scholarship and loan programs and produced a " down filter - " effect of increased aid to minority students. For example, in 1971, 40 percent of Blacks, 34 percent of Native Americans, 27 per- cent of Spanish surnamed - , and 26 percent of Asians received federal scholarships compared to 22 percent for all medical students (32). As a re- ee ee see enc c nce eee cen Table 5 Distribution of Medical Students by Family Income Compared to All U.S. Families Less than $ 5000 $ 5,000 to $ 9,999 $ 10,000 to $ 14,999 $ 15,000 to $ 19,999 $ 24,999 20,000 to $ $ 25,000 or more Ratio of Median Income of Medical Student Families to All U.S. Families Academic Year: 1963 Med. 15% 36 20 15 All U.S. 36% 44 15 4 14 1 1.59 Academic Year: 1967 Med. All U.S. 9% 28 22 25% 41 22 21 10 20 2 1.63 Academic Year: 1974b Med. All U.S. 6% 11 18 15 13 37 13% 23 24 18 02 10 12 1.58 Sources: USDHEW, Health Professions Educational Assistance Program: Report to the President and the Congress. Washington, D.C.: USDHEW, September 1970. USDHEW, Survey of How Medical Students Finance Their Education, 1974-75. Washington, D.C.: DHEW Publication No. (HRA) 76-94, December 1975. 25 Ce eee e errr rere eee eeeeee eee eee ce ec Table 6 Distribution of Selected Financial Aid Programs for Medical Students by Family Income, 1974-75 Scholarships Loans Family Income Health Public Health Professional __ Service Armed Forces Nat. Med. Guaranteed Health Fellowship - Student Professional Less than $ 10,000 $ 10,000 to $ 14,999 $ 15,000 to $ 19,999 $ 20,000 to $ 29,999 More than $ 30,000 24.2 37.3 23.6 10.0 4.8 100% 17.5 17.5 13.1 27.5 24.4 100% 17.2 23.7 22.3 19.9 16.9 100% 45.2 29.0 12.9 9.7 3.2 100% 21.0 23.5 19.5 22.9 13.1 100% 27.9 27.8 18.6 18.2 7.8 100% Source: calculated from Mantovani, Richard E., Studies of Medical Student Financing: Trends in Medi- cal Student Financing, 1973-74 Through 1975-76. Washington, D.C.: Association of Ameri- can Medical Colleges, January 1978. sult the proportion of medical students from low income backgrounds increased 25 percent rela- tive to the national family income distribution and the proportion from families with incomes over $ 25,000 decreased 28 percent during this five year period (27). But toward the mid 70's - the backlash set in. Be- tween the 1973-74 and 1975-76 academic The Bakke case has merely diverted attention from the responsibility and complicity of academic institutions in draining the affirmative action movement of its momentum and funding years combined support for affirmative action through the Bureau of Health Manpower - that is, formula and special projects grants, as well as stu- dent loans and scholarships - decreased almost $ 103 million! A study assessing affirmative action efforts for HEW noted a direct correspondence between federal funding and increases in minority enroll- ment: While non minority - enrollment has continued to increase, minority first year - enrollment has followed the same pattern of change as the levels of Bureau of Health Manpower funding except for an apparent one year de- lay. The sharp increase in BHM support in 1973-74 was reflected in increased minority 26 student enrollment during the 1974-75 academic year. Similarly, the drop in BHM funding to below the Fiscal Year 1973 level appeared to result in a significant drop in the number of nonrepeating, first year - mi- nority students enrolled in U.S. medical schools. Thus, the substantial changes in the two most recent Fiscal Years, after a generally increasing trend of funds support, appears to have had major effects on the enrollment levels of minority students in medical educa- tion (9). They attributed this change to the costs to the schools of these more expensive students who require more financial aid and are more likely to repeat years or take a decelerated course. De- creasing capitation and financial aid and the increasing costs of inflation made schools even more reluctant to admit low income students. Minority programs, as usual, were on " soft money " and lacked institutional support. The head- lines appropriately began reading, " Money Be- coming Admissions Criterion " (33). As this funding support waned, so did the very concept of " based need -" financial aid. For twelve years, in which these programs largely supported the sons of professionals, no question of " equity " was raised. But when minorities and women first began entering the health professions schools and benefitting, the Republican Administrations con- veniently recognized that graduation from these schools virtually assured comfortable incomes and a " high rate of return " on their educational investment (28). Only then did they question the equity of non obligated - service - subsidies. Not only did this new policy deny those historically most likely to serve in shortage areas of " need- based " assistance, it began to concentrate more Financial Aid Sources from the Health Professions Education Assistance Act of 1976 National Health Service Corps (NHSC) scholarships: recipients receive tuition, educational expenses, and a monthly stipend and are, in turn obligated to serve in a shortage area for each year of scholarship support; applicants who have second thoughts and fail to accept the scholarship are liable for damages of $ 1,500. The pen- alty for failing to fulfill the service obligation is three times the total scholarship assistance plus interest at the maximum prevailing rate, payable in one year. Priority for awards are to be given to first year students and are sex- and color blind -. Awards are made without regard for financial need. Health Professions Student Loans (HPSL): loan pool is funded at diminished levels through 1980. Loans are limited to students with " exceptional financial need " and limited to an annual maximum adjusted to tuition costs. Interest is raised from 3 to 7 percent. Scholarships for Exceptional Finan- cial Need (EFN): need based - financial aid with the same benefits as the NHSC scholar- ships but without a service obligation, but limited to two first year students at each medical, osteopathic, and dental school and one first year student at other health pro- fessions schools. Health Education Assistance Loans (HEAL): new, federally insured bank loans administered by the Office of Education. rather than the Bureau of Health Manpower and modeled after the guaranteed student loans. The loans are limited to $ 10,000 annually and only half of any medical school class may borrow in this program. The interest rate ceiling is 12 percent (plus a 2 percent insurance premium) without sub- sidies; interest must be paid by the student or accrued while in school. Forgiveness of these loans for service in shortage areas is at the discretion of HEW. federal dollars on fewer, more affluent students (Table 6)! Still, Cliff Allen, Director of the Division of Financial Aid at the Bureau of Health Manpower, can say without irony that these changes will have " no effect " on the composition of the health professions'student body and that the priority is putting " a cap on funding. " Already during the last two years there have been the first declines in more than fifteen years in the number of applicants to medical and dental schools, primarily due to the loss of lower and lower- middle income applicants (34). The private sector yields a similar story. The National Medical Fellowships program, founded in 1946 to increase opportunities in medicine for Blacks and expanded in 1970 to include other minorities, has followed the same trajectory as the Health Professions Scholarship and Loan funding. Although the total number of Blacks and minorities entering medical schools has leveled off since 1975-76, the NMF awards peaked in numbers in 1974-75 and in dollars in 1973-74, and continue to decline. In 1978, in order to eliminate a deficit and achieve long term - stability, the NMF scholarships fell below their 1971 number and their 1970 total amount (35). Another major source of private financial aid support ended in 1976-77 when the Robert Wood Johnson Stu- dent Aid Program was terminated, although it still maintains some loan funds under the United Student Aid Funds. The alternatives which remain for low income students who manage to gain admission to the professional schools include the service obligated - scholarships - the NHSC and Armed Forces pro- grams and the Exceptional Financial Need award, for first year students only. There are the several loan programs administered by the Office of Education (HEAL, GSL, NDSL) and the much diminished Health Professions Student Loan pro- gram, as well as limited school and private support. Except for the very wealthy, almost all students will graduate with either service obliga- tions in a shortage area or large accumulated debts of college and professional education. While the former addresses the geographic distribution problem temporarily, scholarships do not guaran- tee continuous care to underserved areas and commit lengthy and expensive support to both the student and National Health Service Corps (NHSC) practitioner in the field. Those most likely to stay in the shortage areas beyond their obliga- 27 Special Interest Admissions On occasion university presidents, deans, and other top academics do make " special interest admissions " outside normal admis- sions procedures and standards.... " Bene- fit " to the school is said to be the controlling factor in such admissions. The national media in the last 2 years have carred reports indicating that profes- sional school admissions have, in some cases, been viewed as a means of maintain- ing good relations with influential or well - to- do individuals who are in a position to assist university appropriations or endowment funds. Most recently news accounts have focused on remarks of the president of Bos- ton University during a 1973 school com- mittee meeting. A transcript quotes Presi- dent John R. Silber as having said: We need, for example, a list of ad- missions considerations that we've given. There have been any number of people crawling all over me for ad- mission to our Medical School and our Law School who have never been tapped systematically for a gift to this university. I'm not ashamed to sell those indulgences. We don't admit someone to our Medical School or our Law School who isn't qualified to get in, but at the same time when we facilitate that admission there's no rea- son why we shouldn't go right back to the person, the father of the person who's been admitted and talk to him about a major gift to the school. We have not done this systematically. At the University of California at Davis, the dean of the medical school, in several in- stances reported in the Los Angeles Times, intervened in the admissions process " to correct injustices in the admissions proce- dures and for public relations reasons. " ' In October 1975, New Physician maga- zine reported that school records indicated that the Chicago Medical School had in 1973 favored 77 out of 91 qualified appli- cants on whose behalf pledges of financial support were made to the institution over other applicants otherwise equally qualified. Most recently, NBC television's " Weekend " program reported on illegal and questionable admissions procedures in the State of Pennsylvania. The U.S. Attorney for the Eastern District of Pennsylvania charged: [hese T] schools live and die by what happens in Harrisburg [the State capi- tal], and I think that's why the legisla- tors and the politicians have this kind of hammer over the schools. It is pretty clear, the word on the street is you have to pay off somebody to get into medical school. * * * It is extremely pervasive, far more pervasive than we thought when the investigation started. Legislative pressure on the medical school admissions process in Pennsylvania appears to be a matter of routine, according to one academic official. Dean Joseph DiPalma of Hahnemann Medical College in Philadel phia explained on the same " Weekend " program: I would say of all the applications we have, more than half of them will have a letter from a legislator. and certainly when any politician recom- mends a candidate, and does so very strongly, I would be foolish to say that I didn't try to listen and I didn't try to do everything possible that I could. Let's say there's an instance where there's two applicants for admissions, and one of these applicants is favored by a prominent politician, well na- turally you'll take the one who's favored since the world works by doing favors.. -United States Commission on Civil Rights June 1978 tions, the NHSC volunteers, are now under a 28 hiring freeze. Low income students, both minority and majority, given limited resources, will have to accept either a service debt or a significant monetary debt. The latter exacerbates the geo- graphic, specialty, and language / culture maldis- tribution, among practitioners since lucrative spe- cialty practices required to repay huge debts are not to be found in the existing rural and inner city shortage areas. The Commercial Student Loan Market This is not without design. As the numbers and size of this loan market grows, it has been priva- tized, with federal government assuming the financial risks. As can be seen quite dramatically, while the federal Health Professions Loans and Scholarships are being phased out, the private Guaranteed Student Loans have skyrocketed. (Figure 6). In 1970 Guaranteed Student Loans accounted for about one quarter - of all loans to medical students, but by 1977 it accounted for almost 60 percent. The GSL program was initi- ated in 1965 to subsidize and insure commercial borrowing. The American Bankers Association (ABA) clear- ly indicated in a 1975 report that its members were reluctant to make guaranteed loans because of the low interest rates, which were almost two percent below the prevailing market rate. Although the guarantees provide some advantage by eliminating the risks of default, the ABA com- plained that the various guarantors were slow to refund on defaults (which were increasing rapidly in number), that the Office of Education was in- consistent in pursuing defaultors, and that the fre- quent changes in federal regulations created constant administrative problems. A second sur- vey in 1975 by the Office of Education found that the banks'major objections to the loan programs were their low income and long repayment periods, which during inflationary periods further subsidized the borrower. That study found that, without substantial changes in the program, less than 30 percent of the lending banks planned to increase their GSL holdings, and most of these were smaller banks. To put it simply, the banks had told the federal government that without more profit, they would not participate in the program. Congress responded by giving them what they wanted. To support the banks, the Student Loan Market- ing Association (SLMA or " Sallie Mae ") had been created in 1972. It is a federally chartered - , pri- vate corporation which purchases large blocks of student notes from lenders with money borrowed at favorable interest rates from the Federal Financing Bank. The cash which Sallie Mae pro- vides the lender is then reloaned at four percent above its cost or " leveraged " by repeated borrow- ing from Sallie Mae at 80 percent of the face value of the student loans, multiplying the lender's original capital severalfold, resulting in dramatic rates of return - easily as much as 24 percent on an original $ 100,000 investment, according to former HEW Secretary Joseph Califano (36)! Sallie Mae, originally designed to attract private capital for student loans, is now 98 percent public capital and deals with only about 100 of the largest of the 8,500 lenders in the GSL program! This was not enough, as the 1975 ABA report clearly indicated. To spread the profits around to all its members, the ABA still wanted higher interest rates. So, the Tax Reform Act of 1976 was passed, permitting non profit - organizations to pur- chase the guaranteed loans by issuing tax exempt - bonds. The interest rate of the guaranteed loans were raised to 12 percent - 7 percent paid by the student and 5 percent by the federal government. What's more, the recently created Health Educa- tion Assistance Loan program surpassed the market with a 12 percent interest rate plus an additional 2 percent insurance premium, for a total allowed interest rate of 14 percent! As the commercial interest rates began to soar, former Secretary Califano moved to cut federal contributions to these programs and to cut off loans to Americans studying in foreign medical schools. While the student pays 7 percent interest on a Guaranteed Student Loan, the federal gov. ernment must pay this to the banks while the stu- dent is still in school, as well as the additional 5 per- cent " allowance " during the life of the loan. The fed- eral government also absorbs the costs of defaults and many collections. Califano's proposed " federal bank " would eliminate the additional costs paid to support the banks'commercial rates. His proposal echoes the AAMC's 1970 recommendations. Charles W.V. Meares, Chairman of the Board of United Student Aid Funds, Inc., supported by the Robert Wood Johnson Foundation, objected, calling the current subsidy program " a happy combination of Government and private - sector activity " and cited the growing participation of lenders. He challenged Califano's implication that private lenders are reaping considerable profits from student loans, noting that the subsidized interest rate of 12 percent is very near the going market rate (37). If this is true for the Guaranteed Student Loan program at 12 percent, the HEAL's 14 percent rate promises quite a windfall for the private lenders. Both will continue the public sub- sidy of the largest banks " leveraging " with Sallie Mae. Medical School Costs Over the last decade total expenses have risen far more quickly than loans or scholarships, so 29 increasing amounts must be paid from student and family resources (Figures 6 and 7). To com- pound this, the numbers of students who must share these resources have increased, while the Exceptional Financial Need, Armed Forces, and National Health Service Corps (NHSC) programs concentrate the total available support among a smaller number of students, only 1.2, 3.6, and 6.6 percent of this year's entering class, respectively. Since the Armed Forces and NHSC scholarships are not awarded according to need, they exacer- bate the already class related - financial support that actually provides subsidies to the more wealthy, whose tuitions at more expensive private schools are thereby paid from the public purse. In the name of equitably distributing the service obli- gations, the class inequities continue to be served, just as they were when the non disadvantaged - benefitted from the poor and erratic administra- tion of the Health Professions aid. Only the private National Medical Fellowship program, aimed spe- cifically at minority students, has consistently followed " based need - " distribution and as a result distributes most of its money to low income students (Table 5). At the beginning of the AAMC affirmative action program in Academic Year 1971, 60 percent of students with family incomes less than $ 10,000 received federal scholarships and 90 percent loans; by Academic Year 1974-75 when minority admissions peaked, this had already declined to 24 and 46 percent, respectively (27). More than half of Black and almost half of Hispanic and Native American medical students came from these low income families in 1974-75 (17). The medical schools blamed Congress for this squeeze upon the disadvantaged. But they were, in fact, those who since 1963 administered the federal assistance disproportionately to the advantaged, in part because the disadvantaged were not admitted in the first place. Under the banner of academic freedom they mobilized the powerful lobbying effort through the AAMC that prevented Congress from imposing meaningful quotas for primary care training, for students committed to service in shortage areas, and for American transfers from foreign medical schools, and from significantly cutting capitation grants. However when it came to major cuts in affirmative action programs and to development of regres- sive financial aid formulas, somehow, they want the public to believe, they lost their political clout. In the absence of strong outside influences, such as the civil rights movement, the self interest - of health professional institutions is not served by 30 vigorously defending progressive, need based - financial aid or need based - admissions (i.e., serv- ing the needs of the nation rather than the pro- fession and the schools). Admissions to the health professional schools since Flexner have largely replicated the existing hierarchy in the society, in the profession, and, particularly, in the schools themselves. (See Part II of this article.) During the past decades'expansion of the health profes- sional schools'enrollments and funding, additional places and financial aid dollars were given to women and minorities without losing a single white seat and without significant re allocation - of resources or places to the disadvantaged. Women and minorities might bring, given suffi- cient numbers, a set of values and priorities which would challenge the business - as - usual conduct of the academic health centers. They might chal- lenge the way in which " their people " receive care from academic training institutions, the models for the profession, and the manner in which medicine and the other health professions function as a social control and policing agent upon women, minorities, and the poor. They might also challenge the ideology which serves the needs of the status quo and capital, turning social and political problems, like stress, malnutri- tion, and occupational health, into medical ones. Quite predictably, after the pressure of the civil rights movement waned and fiscal austerity and lowered expectations took its place, the academic health establishment has regressed in its admis- sions policies. The Bakke case has merely diverted attention from the responsibility and complicity of academic institutions in draining the affirmative action movement of its momentum and funding. Meanwhile, investments are secured, federal sup- port curtailed, and health professional education returns to business - as - usual. Equal opportunity will remain a mirage as long as opportunities are sold on the marketplace to the highest bidder. - Hal Strelnick References 1. Rodgers, Joann Ellison, and Hershberger, Robert D., " Woman Physicians: Catalyzing Great Change, " Medical World News 20: 61-72, June 11, 1979. 2. Raup, R. et al., " Negro Students in Medical Schools in the United States, " Journal of Medical Education 39: 444, 1964. 3. Weaver, Jerry L., and Garrett, Sharon D., " Sexism and Racism in the American Health Industry: A Comparative Analysis, " International Journal of Health Services 8: 677- 703, 1978. 4. Blackwell, James E., " In Support of Preferential Admis- sions and Affirmative Action in Higher Education: Pre- & Post Bakke - Considerations, " mimeograph, University of Massachusetts - Boston, May 1977. 5. Curtis, James L., Blacks, Medical Schools, and Society. Ann Arbor: University of Michigan Press, 1971. 6. Morais, Herbert M., The History of the Negro in Medi- cine. New York: International Library of Negro Life and History, 1968. 7. Blackwell, op. cit. 8. Association of American Medical Colleges, " Report of the Association of American Medical Colleges Task Force to the Inter Association - Committee on Expanding Educa- tional Opportunities in Medicine for Blacks and Other Minority Students, " Washington, D.C.: Association of American Medical Colleges, April 22, 1970. 9. Schildhaus, Sam, and Jaggar, Franz M., An Exploratory Evaluation... of U.S. Medical Schools'Efforts to Achieve Equal Representation of Minority Students. DHEW Pub- lication No. (HRA) 78-635, December 1977. 10. Association of American Medical Colleges, " Report of the Association of American Medical Colleges Task Force on Minority Student Opportunities in Medicine, " Washington, D.C.: Association of American Medical Colleges, June 1978. 11. Currie, Elliot, " The New Face of Poverty, " The Progres- sive 43: 38-40, January 1979. 12. Berke, Joel S., Campbell, Alan K., and Goettel, Robert J., Financing Equal Educational Opportunity: Alternatives for State Finance. Berkeley, CA: McCutcheon, 1972, and Berke, Joel S., and Kurst, Michael W., Federal Aid to Education: Who Benefits? Who Governs? Lexington, MA: D.C. Health, 1972. " 13. Melnick, Vijaya L., and Hamilton, Franklin D., eds., Minorities in Science: The Challenge for Change in Bio- medicine. New York: Plenum Press, 1977. 14. Sedlacek, William E., and Brooks, Glenwood C., Ra- cism in American Education: A Model for Change. Chi- cago: Nelson - Hall, 1976. 15. File, Jonathan, " Applying the Goals of Student Financial Aid, " ERIC Higher / Education Report No. 10. Washing- ton, D.C.: American Association for Higher Education, 1975. 16. Astin, Alexander W., " The Myth of Equal Access in Public Higher Education, " Atlanta: Southern Education Foun- dation, July 1975. 17. Student National Medical Association, Minority Medical Students: Who They Are, Their Progress, Career Aspira- tions, Their Future in Medical School. DHEW Publica- tion No. (HRA) 78-625, 1978. 18. Bureau of the Census, " Income and Expenses of Student Enrolled in Postsecondary Schools, October 1973, " Series P 20 -, No. 281, June 1975. 19. Astin, Alexander W., Financial Aid and Student Persis- tence. Los Angeles: Higher Education Research Institute, July 1975. 20. Atelsek, Frank J., and Gomberg, Irene L., Student Assis- tance: Participants and Programs, 1974-75. Washington, D.C.: American Council on Education, Higher Education Panel Reports, No. 27, December 1975. 21. Vetter, Betty M., Babco, Eleanor L., and McIntire, Judith, Professional Women and Minorities: A Manpower Data Resource Service. Washington, D.C.: Scientific Man- power Commission, November 1978. 22. Astin, Alexander, King, Margo R., and Richardson, Gerald T., The American Freshman: National Norms for Fall 1977. Los Angeles: Cooperative Institutional Research, 1978. 23. U.S. Department of Health, Education, and Welfare, Health Professions Educational Assistance Program: Re- port to the President and the Congress. Washington, D.C.: Government Printing Office, September 1970. 24. Bruhn, J.G., and Hrachovy, R.A., " Black College Stu- dents'Attitudes Toward Opportunities in the Health Pro- fessions, " Journal of Medical Education 52: 847-849, 1977. 25. Griffiths, Joel, " Med Schools Vow No'Sliding Bakke - , ' But Plea for Funds, " Medical Tribune, October 11, 1978. 26. Mantovani, Richard E., Gordon, Travis L., and Johnson, Davis G., Medical Student Indebtedness and Career Plans, 1974-75. DHEW Publication No. (HRA) 77-21, September 1976. 27. Congressional Budget Office, " The Role of Aid to Medical, Osteopathic, and Dental Students in a New Health Man- power Education Policy: Staff Working Paper, " Washing- ton, D.C.: Government Printing Office, August 10, 1976. 28. Montoya, Roberto, Hayes Bautista - , David, Gonzales, Luis, and Smeloff, Edward, " Minority Dental School Graduates: Do They Serve Minority Communities? " American Journal of Public Health 68: 1017-1019, October 1978; Lieberson, S., " Ethnic Groups and the Practice of Medicine, " American Sociological Review 23: 542, 1958; Robertson, L.S., " On the Intraurban Ecology of Primary Care Physicians, " Social Science and Medicine 4: 227, 1970; and Elesh, D., and Schollaert, P.T., " Race and Urban Medicine: Factors Affecting the Distribution of Physicians in Chicago, " Journal of Health and Social Behavior 13: 236, 1972. 29. Fein, Rashi, and Weber, Gerald, Financing Medical Edu- cation. New York: McGraw - Hill, 1971. 30. Feldstein, Paul, Financing Dental Care: An Economic Analysis. Lexington, MA: D.C. Heath, 1973. 31. General Accounting Office, " Congressional Objectives of Federal Loans and Scholarships to Health Professions Students Not Being Met, " Washington, D.C.: Government Printing Office, May 24, 1974. 32. U.S. Department of Health, Education, and Welfare, " A New Bureau, A Sharper Focus: Annual Report of Fiscal 1975 Activities, Bureau of Health Manpower, " DHEW Publication No. (HRA) 76-9, 1975. 33. American Medical Association, " Money Becoming Ad- missions Criterion, " American Medical News, February 8, 1976. 34. Graham, James, " An Analysis of the Decline in Dental School Applicants, " American Dental Association, 1978, quoted in Association of American Medical Colleges, " Report of the Association of American Medical Colleges Task Force on Student Financing, " Washington, D.C.: Association of American Medical Colleges, September 1978. 35. National Medical Fellowships, " Special Report: Aspects of the Work of NMF, " mimeograph, New York: National Medical Fellowships, Inc., March 1979. 36. Califano, Joseph A., " Testimony Before the Sub Commit- - tee on Postsecondary Education of the House Committee on Education and Labor, " Washington, D.C.: Department of Health, Education, and Welfare, March 20, 1979. 37. Meares, Charles W.V., " Preserving Loans to Students, " New York Times, May 31, 1979. 31 n | Clinic Case Private Care Off To a Bad Start THE Both the objective and subjective experience of OBSTETRICAL EXPERIENCE childbirth have changed dramatically for many OF THE URBAN middle class women in the last decade. The pur- POOR pose of this article is to examine the subjective reality of a very different group of women - low income, mainly Hispanic women in East Harlem. It focuses on the use of obstetrical services, the relationship between health seeking - behaviors and knowledge, information and beliefs about the childbirth experience and the impact of the insti- tutional setting on the prenatal, intrapartum and postpartum experiences of low income - , Hispanic women. East Harlem is a low income - residential com- munity of approximately 135,000 people in New York City. The bulk of the population currently consists of migrants, mainly Black (35 percent) and Puerto Rican (48 percent), and white ethnics (17 percent), mainly Italian. The median East Harlem family income in 1972 was $ 5,895, and the families earning less than $ 5,000 per year were almost double that for all of New York City. One out of every three families in East Harlem is 32 below the poverty level. Public assistance is a common reality in this community, with 44 per- cent of the population dependent upon it for survival. Women in East Harlem between the ages of fif- teen and forty - four comprise almost 30 percent of the total population of women. Data show that women in East Harlem have more children than women elsewhere, at a younger age, and more frequently without being married. In 1970 the rate of live births per 1,000 females in New York City was 81.5, in Manhattan 65.5, and in East Harlem 82.9. Among the Puerto Rican women in East Harlem, this rate jumped to 96.6. The per- centage of births out of wedlock were significantly higher in East Harlem (52.1 percent) than in Manhattan (37.3 percent) in 1976. Although re- cent data shows infant mortality to be declining in all areas of the city, the infant mortality rate of 23.5 death per 1,000 live births in East Harlem re- mains quite high compared to that of 19.3 in New York City. In 1976, 12.1 percent of births in East Harlem were premature or low birth weight (less than 2,501 grams) compared with 9.5 percent citywide. In spite of a multitude of health service facilities in East Harlem, very little is known about the particular health needs of Hispanic women and their families, or their use of services. A 1970 household survey conducted by Johnson (1) in East Harlem was a first step toward answering these questions. The results clearly showed that health was a high priority among Hispanic women in East Harlem, and that they perceived their health to be worse than either blacks or whites in the area. Our study, reported here, was intended to explore in more depth some issues raised by that study. Study Methods and Sample Population The nature of our inquiry was exploratory. It was geared to examine two major areas: the na- ture of the intrapartum experience; and the atti- tudes and expectations of our sample populations toward the birth experience. Two major methods were used to explore these areas: one was an ex- tensive open ended - questionnaire which was administered to 26 women who came to the pediatric or family planning clinics of the neigh- borhood health center; ** the other was an open- ended interview conducted with personnel of the community - based neighborhood health center. In addition, unpublished reports and studies con- ducted at the neighborhood health center were also used. All of the women interviewed were of childbear- ing age and all had given birth to at least one, and usually more children. Most were Hispanic (nine- teen), predominantly Puerto Rican, and the re- maining seven were Black American. The majori- ty of the women had spaced their children two or more years apart, and for those women who had more than two children the spacing was usually four or more years, with some of the women over thirty years of age having had seven to eleven years spacing between children. The majority of women were on Medicaid, with only a few on the neighborhood health center fee scale that indi- * Within the area there are four hospitals, five child health sta- tions, four methadone treatment centers, four halfway houses for drug addicts, six school dental clinics, two nursing homes, a District Health Center, and a community - based neighbor- hood health center, which opened in June 1975. Few private physicians practice in East Harlem. " Medicaid mills, " however, abound, with roughly twenty operating at any one time. ** The limitations of our methodology included pro NHC - respondent bias because the interviews were conducted on- site and self selection - problems generated by choosing women who were registered at and users of a primary care center. cated some working income for the family. Of the eight women who worked outside the home, most were in paraprofessional occupations based in the community, such as teacher's aide, community worker, and community health workers. Utilization of Obstetrical Services The municipal hospital and the university teach- ing hospital were the most frequently used facili- ties in East Harlem. Over half of the women inter- viewed used both these facilities during any given time period. Although the neighborhood health center was used on a continuous basis for pedia- tric care, the two hospitals were used for emer- gency, routine or particularly acute problems of the women themselves, as well as for emergency pediatric problems that occurred when the neigh- borhood health center was closed. The greatest number of women used the municipal hospital clinic connected to the obstetrical service of another teaching hospital (now closed) for prenatal care. It also provided food coupons under the Maternal - Infant Care (MIC) program. Three women used the Harlem Hospital Clinic in Central Harlem; the remainder used other hospital facili- ties or private physicians. Decisions to use facilities were not made arbitrarily, but were based on both previous experience and on recommenda- tions of informal networks of friends and relatives, particularly mothers. In seeking obstetrical care, the women were very much aware of the attitudes of hospital staff- both nurses and doctors. They usually obtained such information by asking others or from their own previous experience. Many women described instances of being ignored or of being " cursed out " by the doctor for screaming while in labor. In one instance, an adolescent who gave birth at a municipal hospital described her inter- action with staff during labor: " The nurses encouraged me to keep my baby. They stated,'If you enjoyed making it, keep it.'Later when the doctor was examining her, he stated,'This isn't going to hurt you any more than when you were doing it.'" Such experiences partially determined the women's own use of facilities; they also provided the basis for recommendations to others. Their use as criteria, however, also reflected the respon- dents'limited sense of control. The women specifi- cally described as bad experiences verbal abuse from medical staff. They usually did not generalize these specific instances of abuse to the institution as a whole, however, unless abuse was wide- spread and continual, as appeared to be the case, 33 for example, of the nursing staff at the local muni- cipal hospital. In general, however, the women rarely claimed to have had degrading experiences, although they described incidents such as no medication during childbirth when requested, frequent examination by several " doctors " (probably medi- cal students) and sexist remarks by physicians or snide comments by nurses which made the patient uncomfortable. Although the patients did not perceive these as bad or particularly disturbing experiences, perhaps because they were irregular, they nevertheless appeared to take precautions to avoid further use of that facility. The large num- bers of students participating in the internal exam- inations of laboring women, comprised one of the few consistent complaints. One young woman be- came so accustomed to examinations by different doctors training - in - that it took her a number of nocturnal visits to realize that the man who woke her up in the middle of each night to give her an internal while she was in the hospital for a tubal infection was sexually assaulting her. Except for cases of extreme abuse or obvious medical negligence, however, the women in our sample, like most poor women, took their object status for granted. Their responses were con- gruent with the generalization that the poor pay for their penury with their privacy, often with their dignity, and not infrequently with their health and that of their family. These women in East Harlem did not consider that their privacy or dignity was rightfully part of their patient status. Thus they fre- quently made decisions based on their perception of the facility's technical expertise as it applied to their physical health and that of their infants, rather than upon the actual quality of care received. Knowledge, Information and Beliefs Culturally these women are prepared for a very negative and unfulfilling obstetrical experience, and this expectation is reinforced by the health care providers they encounter. The birth experi- ence for these women is not a " joyful " nor pleasant one. This can be attributed to several factors: Primarily the cultural ethos has identified the birth experience as a painful one which the woman must undergo alone. Oftentimes the result is a state of fear and virtual hysteria. The close association of pain with childbirth is rooted in the fairly recent history of Puerto Ricans who are mainly from rural and / or agricultural communities where women frequently delivered their own chil- dren under adverse conditions, often without the 34 help of trained personnel. Many of the mothers and grandmothers of these women have de- scribed horror tales which are reinforced by being passed down for generations and which, no doubt, have become grossly exaggerated. Coupled with this is the fact that men, be they fathers, husbands or male birth attendants, have not traditionally played a significant role in the birth experience due to stratification of roles in tra- ditional rural Hispanic society. Childbirth has been perceived as a woman's function, and the person who usually provides both the support and the " fears " is the mother of the woman. Thus the culture expects women to express pain during labor and delivery. This reaction is antithetical to the current providers of health care, however. The fear suffered by these women may make them tense, which makes childbirth even more difficult. In obstetrical practice, it is no recent phenomenon that patient race, ethnicity, class and institutional exigencies are the strongest deter- minants of what technologies are employed during childbirth Many of these cultural attitudes are integral to the belief systems of these women. They expected the birth experience to be unbearably painful; they did not expect, and in many instances did not want, their male partners to participate in the birth experience, and often sought help or solace instead from their mothers during labor and delivery. In some instances they were accom- panied to the hospital by the husband or a relative of the husband or the mother. One woman did want her husband to join her in the labor room; he was not allowed, in this case, because he had not taken childbirth classes. In the majority of cases, however, the patients'choice was to have the baby alone. Because the sample population perceived the birth experience as a negative one, very few women attended childbirth classes. Unless these were specially designed to be bicultural and bi- lingual (2), childbirth classes often conflicted with the realities of everyday living of these respon- dents. The main reference group for these women was their immediate families and friends, whose negative view of the birth experience would be more influential in " preparing " them for the birth experience than would the teaching of nonrela- tives. As one woman stated when asked about childbirth classes, " I am chicken and am not interested in childbirth classes because I don't want natural childbirth. " This attitude was rela- tively common among the women interviewed. In some instances the failure of the women inter- viewed to demand or take advantage of different options in childbirth experience may have been related more to the woman's perception of her own lack of resources than to objective condi- tions. When questioned about feeding practices, many women interviewed in East Harlem, for example, said that they decided not to breastfeed because they thought they had to eat well in order for their breast milk to be healthy for their babies, and they did not feel they could afford such nutri- tious eating habits. These women also tended to reject natural childbirth classes because they could not count on a support person to be present for classes, and for labor and delivery. Most saw childbirth as an ordeal to be suffered through, and felt removed from the largely middle - class, grow- ing conception of childbirth as a family oriented - experience. As a result of cultural and systematic barriers to childbirth education, most of the women had not been prepared for the birth experience and were uninformed about birth procedures. Although the women interviewed mentioned having several complications, such as high blood pressure, and water retention and swelling (preeclampsia), they did not understand the implications. Whether this lack of knowledge was due to communication bar- riers, cultural inhibitions regarding the discussion of sexuality and / or the negative attitudes of health care providers is difficult to determine. Possibly a combination of all three factors fostered the unpreparedness of these women for the birth experience. The data suggests that women with little education and less money often feel that, as wards of the health care system, they must be un- questioning recipients of its services. Several women mentioned wanting " something to kill the pain " during labor, but not asking for it. This passivity led women to not question various procedures such as fetal monitoring even though the laboring mother felt permission should have been requested. This passive response is to some extent learned behavior. A number of women described situations in which they had responded actively only to be threatened (cursed " out ") or ig- nored. One woman, in labor with her first child, said she didn't know anything and was screaming. Her doctors kept " cursing " at her, threatening to leave her unless she kept quiet. Another respondent who repeatedly questioned a report of abnormal cells on her pap smear said no one would explain the meaning of " abnormal. " " I got the feeling that I should stop bugging them. " She then described problems in understanding directions and obtaining medical follow - up that reflected an indirect and self destructive - response. While her attitude toward her health providers be- came overtly passive, her non compliance - denoted active resistance to a forced depen- dency. Among low income - women, repeated experiences which reinforce the passive patient role, the lack of exposure and familiarity with the advantages of alternatives in obstetrical care and a lack of a personal " gatekeeper " (private physi- cian) all contribute to a pattern of care in which the woman has no active role. Options, even when formally available, are meaningless within an institutional setting which sees no participatory role for these women. Prenatal, Intrapartum and Postpartum Institutional Experience The women in East Harlem sought and received prenatal care on a regular basis, most (15) begin- ning prenatal care during the first trimester. The most frequently occurring problems during preg- nancy, each affecting more than half of the women interviewed, were water retention, swelling and high weight gain. The majority of women received anesthesia during labor. Four- teen had requested anesthesia and ten had not. A number of women expressed not understanding why they were given anesthesia during labor. Of those women who requested anesthesia, only one was given a choice as to the type of anesthesia desired, and she was, at the time, a private patient in a private hospital. The majority of women received injections upon entering the labor room without explanations or queries as to whether they wanted the anesthesia. These women reported that they felt " sleepy; " other women reported that they weren't aware of being given medication but did not remember the experience and " felt dizzy. " Several women reported having their arms and legs bound to their beds during labor and / or delivery: " They scared me because they put all these machines around you and strapped you. " Another stated, " They threw you on a table as if you were a piece of meat. They put rubber on your legs. " Many women who were " forced to deliver naturally " received injections or gas after the delivery of the child. Close to half of the respon- dents said that they had asked for anesthesia but their requests were denied. One woman describes this experience: " It was my first baby and I wasn't used to it. I carried on terrible and had fits. I had asked the doctor for something during labor but 35 The majority of women received injections of an anesthetic upon entering the room without explanations or queries. Several women reported having their arms and legs bound to the beds during labor and / or delivery... the doctor never came back with anything. I guess that they wanted me to have my baby on my own. I was given gas during delivery. " Two approaches to pain relief - are used by the obstetrical system for low income - minority women. Either anesthesia is administered as soon as the woman enters the labor room in order to deliver the child for her without her participation or interference; or, labor is induced or hastened. by chemical stimulation upon arrival in the hos- pital, the woman is " forced to deliver naturally " and then, anesthesia is administered in the last stages of delivery or after delivery. The health care providers frequently expressed the sentiment that no painkillers should be given to these women either because the women " deserved " the pain - a reference to their alleged promiscuity - or be- cause of their reported exaggeration of and inability to tolerate pain. Medical intervention - such as the use of anes- thetic, analgesic, forceps - and induction and stimulation was frequent enough among this sample population that women who had given birth previously understood that the earlier they entered the hospital during labor, the more likely they were to undergo invasive and unwanted intervention. Thus many of these women reported during the interview that for subsequent children they preferred to wait at home or go to relatives ' house until they " thought they were ready to deliver, " in order to avoid intervention at the hos- pital. One 36 year - - old woman describes her " technique: " " For the first baby, they gave me a spinal and used forceps. For the other three chil- dren, I waited until the last minute, and then went in and there was no time for anything. " A substantial number of women, however, reported being " drowsy " after birth or having been " knocked out " after the birth experience. As one woman described, " They let me suffer it out until the end. Then I had a'convulsion'and was knocked out with gas. " She stated that she was shown the baby, but she told them to " take it away because the baby had caused so much pain. " Some women reported postpartum complications such as fevers and vaginal infections which pre- vented them from holding their child. Only three of the twenty - six women held any of their babies immediately after birth. Although the majority of 36 women (22) were shown their baby, six women reported waiting a period of one to three days prior to actually holding the infant. Infant birth weights averaged 6 pounds, 8 ounces. The average hospital stay for the mother was 5.10 days; infants stayed an average of 6.8 days. These rates may indicate a high rate of maternal and infant complications and morbidity. Two women breastfed their children. The most frequent reasons given for not breastfeeding were that it was inconvenient, it required better eating habits than the women could afford, the women were disinterested or they did not have enough milk. It is also clear that the vast majority of the women were not informed of the advantages of breastfeeding, and / or encouraged to breastfeed by the physicians or nurses. One 36 year - - old woman said about her fourth and last infant, " I couldn't breastfeed because my glucose tolerance test showed some diabetes. " Another woman, 32, with a 22 month- -o ld child, stated that she had tried breastfeeding, " but it was too painful. " Recent findings indicate that although increased information and advice caused more women to consider breastfeeding, it has no effect on the ulti- mate choice of whether to breastfeed or not. Women receiving advice and information regard- ing breastfeeding from grandmothers or other sig- nificant female figures are more likely to give it full consideration than those who were informed or advised by medical personnel, but were still unlikely to change their behavior (3). While breastfeeding has been related to post- partum mother - child bonding, these women did not know about the importance of the bonding experience and passively acquiesced to the insti- tutional practice of separating mother and infant. The majority of women did not hold their baby until several hours after the birth, and a few not for several days after birth. The women did not ques- tion this experience unless, after a few days, they feared the baby was ill or that information about their child was being kept from them. Recent demands for changes in obstetrical ser- vices stem largely from the middle class. Thus childbirth education, birth room - or labor room - deliveries, unmedicated labor and delivery, father and sibling presence, family bonding, breast- feeding and rooming - in options are increasing among private patients but are slower to spread to the lower classes. The women interviewed fre- Dt ... Many women who were forced ' to deliver naturally'received injections or gas after the delivery of the child. Close to half said that they had asked for anesthesia but their requests were denied a quently did not know these options existed. If they did know of the options, these women were unin- formed or misinformed of their value. Even if they understood and accepted the value of the options, they were unable, or believed they were unable, given the structure of ward care, to exercise them. A local teaching hospital, for example, has a pediatrics department adamantly opposed to allowing a bonding period between mother (and father) and infant. With the help of her obstetrician the private patient can generally circumvent this rule. The clinic patient, however, is more likely to be " delivered " by a resident or staff physician who has little stake in defying another department for the sake of a family he or she will never see again. Although the descriptions of those women's birth experiences would be judged by many today as negative (4), our respondents had no expectation of meaningfully altering the experi- ence of birth. Here again they accepted them- selves as passive recipients of a process over which they had little understanding, and no control. Summary and Conclusion Among Hispanic women in East Harlem the birth experience is determined by four forces. First, and probably strongest, are the institutional requirements spelled out in terms of procedures, public and private services, resident, staff and attending needs, training and practice exigencies, research requirements and conformity to profes- sional norms of practice, often in contradiction to most recent scientific findings * (5). Second, and reinforcing that pressure, is the tendency of women patients, and particularly poor women, to accept a passive role in medical care, and to become classic dependent patients, bowing to the force of medical expertise and pro- fessionalism. Third, cultural attitudes and norms passed down by generations of Hispanic women, although they stress family ties at home, tend to characterize the birth process as a painful and frightening experi- ence to be faced in isolation. Spiritual and super- stitious beliefs that foster ambivalent feelings toward the husband during pregnancy reinforce these expectations (2). * such as a universal electronic fetal heart monitoring Finally, the generally low health status of poor. populations tends to result in a number of health problems in pregnancy; these become high risk factors leading to aggressive medical manage- ment and control. These four forces work together to foster patient passivity and promote provider- controlled childbirth. In obstetrical practice, particularly in the United States, it is no recent phenomenon that patient race, ethnicity, class and institutional exigencies are the strongest determinants of technologies employed during childbirth. " Twilight Sleep, " for example, was not uniformly safe or available when it was first demanded by upper and middle class women in early Twentieth Century, and many physicians opposed it violently (6). There were, however, major advantages to the medical profession of using general anesthesia and / or amnesiacs. Specifically, their use increased the need for in hospital - births as well as the potential for complete physician control of the birthing woman during labor and delivery. Such control meant that other procedures, such as the use of forceps and episiotomies, could be managed easily and routinely. In fact, women were often classified in terms of their probable cooperative- ness, and those who appeared to be potentially difficult patients were placed in the higher medica- tion category (7). Just as today certain types of pain killing - medi- cations are more likely to be given to middle - class women than lower - class women (especially epi- dural anesthesia - a spinal anesthesia which allows a woman having a vaginal or even cesarian delivery to be awake and aware but desensitized to pain), certain obstetrical procedures are more common among the middle - class than the lower class, regardless of increased risk often faced by lower - class women because of their poorer health status. A recent British book on obstetrical prac- tices in the U.K. and the U.S. (8) underscores this phenomenon: " Social differentials account for much of the in- creased mortality in the lower social classes, yet, . an inverse law operates in obstetrical ser- vices. Variations in the use of intervention suggest that techniques such as induction, caesarian sec- tion and forceps delivery are too little employed for maximal effectiveness in lower - class popula- tions. Middle - class women are not only more 37 likely to get what they want but, through pressure groups, will work for services most related to their sexual needs. Because of shared assumptions and knowledge, middle - class women are most able to communicate their symptoms, feelings and wishes in encounters with professionals. Working - class women, by contrast, are frequently seen to be inarticulate by professionals, and discussions of possible strategies of treatment is regarded as a waste of time " (p. 162). ee Medical practitioners have learned from practicing on, teaching from and experimenting on poor women, but the women themselves have only belatedly reaped the benefits Similarly, examination of New York City birth records have shown that among low risk - New York City pregnant women who are private patients, white and who seek early prenatal care, there is a higher rate of labor and delivery inter- ventions that among pregnant women who are general service (clinic patients), non white - and who start prenatal care late in their pregnancies. On going - research appears to confirm and strengthen evidence of this class difference, showing that induction, stimulation and cesarean section rates all clearly vary directly with social class (9). Whether middle - class women receive more medical intervention because private physi- cians use more skill, care and attention, or be- cause those who pay for more medical care receive more medical care regardless of health need, is unclear. The class basis of obstetrical practice, however, seems amply clear. Medical practitioners have learned from prac- ticing on, teaching from and experimenting on poor women, but the women themselves have only belatedly reaped the benefits of bio medical - and socio medical - advances. The social control model of service delivery in the United States (10), in combination with the pressures of fee for- - service medicine, has meant that the obstetrical experience of poor women tends to be dominated by considerations of institutional and professional expediency. Middle - class demands on obstetrical practice are likely to be translated into services for the lower - class only if and when they expedite ser- vices or reduce costs or if and when the gap be- tween public and private care becomes so large as to evoke public and political criticism. 38 Aside from the possibility that poor women are poorly served medically under these conditions, there is a probability that they and their families are actually injured emotionally. The hospital intensifies the mother's already fearful and disease oriented - attitude toward childbirth, and then cements that attitude by separating mother and infant immediately after birth. The unhealthy state of mother and child is assumed, and the mother's feeling of alienation from the birth process and product is enhanced. Given current practices, the important transfer of knowledge from infant to mother during the first hours of life and the immediate development of maternal attachment feelings and attitudes (11, 12, 13) is least likely among poor, minority women in urban America than any other group. Yet, given the dif- ficulties and demands of the life outside the hospi- tal to which these women must return, it is even more important. Alice Rossi's recent description of childbirth (14) fits all too well the poor Hispanic woman, fre- quently stereotyped by providers for her high rates of mental illness and psychosomatic complaints: " _. we interfere with the natural pro- cess through medical distortion of spontaneous birth; separate the mother from the neonate for most of the critical first days of life; feed babies on a rigid hospital schedule and keep them in a brightly lit and noisy nursery; and then we send the mother and child home to an isolated setting to cope as well as she can on her own... If she breaks down under this strange regimen, we define her as incompetent in handling'normal ' female functions. " -Ruth E. Zambrana, Ph.D. is a sociologist in the Department of Community Medicine, Mt. Sinai School of Medicine, New York, and Marsha Hurst, Ph.D. teaches in the Government Department of John Jay College of Criminal Justice (CUNY), New York. References 1. Johnson, L. " East Harlem Community Health Study. " Prepared for the Department of Community Medicine, Mount Sinai School of Medicine of the City University of New York, 1972. 2. Cooper, E.J. and M.H. Centro. " Group and the Hispanic Prenatal Patient. " American Journal of Orthopsychiatry 47,4 (1977): 689-700. 3. Esteves, L.M. " Proposal for a Nutrition Education Program for Women Receiving Prenatal Care at the Dr. Martin Luther King, Jr. Health Center, Bronx, N.Y. " Unpublished paper. Mount Sinai School of Medicine of the City Uni- versity of New York, July 1978. 4. Banta, D. and S. Thacker. " Policies Toward Medical Technology: The Case of Electronic Fetal Monitoring. " Paper presented to the American Health Association Meeting, October 17, 1978. 5. Arms, S. Immaculate Deception: A New Look at Women and Childbirth in America. Boston: Houghton Mifflin, 1975. 6. Miller, L.G. " Pain, Parturition, and the Profession: Twi- light Sleep in America, " pp. 19-44 in Reverby, S. and D. Rosner, Health Care in America, Essays in Social His- tory. Philadelphia: Temple University Press, 1979. 7. Shaw, N.S. Forced Labor: Maternity Care in the United States. New York: Pergamon Press, Inc., 1974. 8. Chard, T. and M. Richard (eds.), Benefits and Hazards of the New Obstetrics. Philadelphia: J.B. Lippincott, 1977. 9. Albertsen, P., E. Jones and R. Roberts. " Uncomplicated Antepartum Course as a Predictor of Uncomplicated Labor and Delivery. " Unpublished paper, Columbia Uni- versity College of Physicians and Surgeons, New York City, March 8, 1977. 10. Ehrenreich, J. and B. " Health Care and Social Control. " Social Policy, May June / 1974: 26-40. 11. Stratton, P.M. " Criteria for Assessing the Influence of Ob- stetric Circumstances on Later Development. " Chapter 10, pp. 130-155 in Chard, T. and M. Richards (eds.), Bene- fits and Hazards of the New Obstetrics. Philadelphia: J.B. Lippincott Co., 1977. 12. Klaus, M.H. et al. " Maternal Attachment: Importance of the First Post partum - Days. " New England Journal of Medicine 286 1972 (): 460-463. 13. Rice, R.D. " Maternal - Infant Bonding: The Profound Long- term Benefits of Immediate, Continuous Skin and Eye Contact at Birth. " pp. 373-386 in Stewart, D. and L. Stewart (eds.), 21st Century Obstetrics Now, Vol. 2. Chapel Hill, N.C.: NAPSAC, Inc., 1977. 14. Rossi, A. " Children and Work in the Lives of Women. " Unpublished paper, Barnard Women's Center, 1976. U.S. POSTAL SERVICE STATEMENT OF OWNERSHIP, MANAGEMENT AND CIRCULATION 1. TITLE OF PUBLICATION (Required by 39 U.S 3683) PUBLICATION NO 2. DATE OF FILING Health / PAC Bulletin Bulletin 00 179051 PUBLISHED 9/20/79 __ 3. FREQUENCY OF 1980 NO. OF ISSUES ANNUAL SUBSCRIPTION Quarterly ANNUALLY PU6B LISHED PRICE $ 28.00 28.00 LOLATION 4. LOLATION OF KNOWN OFFICE OF PUBLICATION 981 (#, City, County, Fists and Codg ZIP) (Not printers) Fifth 22 Avenue, New York, New York 10011 S. LOCATION LOCATION OF THE HEADQUARTERS OR SENERAL BUSINESS OFFICES OFFICES OF THE PUBLISHER (NOT ring) 72 Fifth Avenue, New York, New York 10011 . 4 NAMES AND COMPLETE ADDRESSES OF PUBLISHER, EDITOR, AND MANAGING EDITOR PUBLISHER Name (and Addreom} Human Sciences Press, 72 Fifth Avenue, New York, New York 10011 EDITOR (Name and Addre MANAGING EDIHTeORa l(tNahm e PaAnCd A/dd rB ulletin, 17 Murray Street, New York, New York 10007 Marilynn Norinsky Norinsky, 17 Murray Street, New York, New York 10007 7 OMWNERa (owrnedi by la coyrpornatinon. 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PAA DD3RE.M Tark, N.Y. 10011 T * KNOWN BONDHOLTDOETARLS AMMOOUNRTT GOFA GBOENEDSS ,M ORATNGDAG EOS TMHOERTRG AGSEESC OURR OITTHYER HSEOCLUDRIETRIESS O(IWfN tIhNeGre OarRe HHOOLLDIDNIGN nGo ne1, P- EsRtaCtEeN) T OR MORE OF NAME T ADDRESS aa } a ae ob i 0 FOR COMPLETION BY NONPROFIT ORGANIZATIONS ORGANIZATIONS AUTHORIZED TO MAIL AT SPECIAL RATES (Section 133 123, POM) The purpose, function, and nonprofit status of this organisation and the exam status for federal income tax purposes (Cheeb and) HPARVEE CNEODTI CNHGA NG2E DM MOONNTTH HSS DURIANG HAVE CHANGED DURING PRECEDING MONTHS If (with changed this changed atment, publisher) publisher mur mbmit explanation of change AVERAGE NO COPIES EACH ACTUAL NO COPIES OF SINGLE 10. EXTENT AND NATURE OF CIRCULATION A. TOTAL NO COPIES PAINTED (Net Press Aun} - i PAID CIRCULATION 1. SALES THROUGH DEALERS AND CARRIERS, STREET VENDORS AND COUNTER SALES | | ISSUE DURING PRECEDING T 13 MONTHS PRECEDING SSUE (PUBLISHED PUBLISHED NEAREST TO FILING DATE 4700 + none 4400 none | 1. MAIL SUBSCRIPTIONS : 2681 a 1055 TOTAL PAID CIRCULATION (8 of 1621 and 1088) 2681 + ' 0 FREE DISTRIBUTION BY MAIL, CARRIER OR OTHER MEANS SAMPLES. COMPLIMENTARY, AND OTHER FREE COPIE i A4 t E. TOTAL DISTRIBUTION (um of C and D) 2765 COPIES NOT DISTRIBUTED 1. OFFICE UBE. LEFT OVEN, UNACCOUNTED. SPOILED AFTER PAINTING 1935 1055 - 1139 3261 1. RETURNS FROM NEWS AGENTS * TOTAL (Sum of K. FI and 2 - should equal net preat run shown In A) nons 4700 nobe 4400 SIGNATURE AND TITLE OF EDITOR, PUBLISHER, BUSINGRA 1. I certify that the statements made by me above are correct and complete. MANAGER, OR OWNER Sant 18. FOR COMPLETION BY PUBLISHERS MAILING AT THE REGULAR RATES (Section 118.131. Postal Service Manual) USC provide in pertinent part " No person who would have been entitled to mall matter under former section 4360 of this tisse shell malt such matter at the rates provided under this subsection unless he flies annually with the Postal Service a written request for permission to mail matter at such rates " In rates accordance presently authorized with the provisions by 30 of USC this statute 3620, | arby request permission to mall the publication named in item 1 at the phased postage SIGNATURE AND TITLE OF EDITOR, PUBLISHER, BUSINESS M-KAGER, OR OWNER a roo an ee PG Form Aug 1974 3526 (Page 1) (See instructions on reverse) 39 Peer Review ' Murdochian Sensationalism? ' Dear Health / PAC Bulletin: We were extremely distressed to read the bold print insert above the second page of our column on electronic fetal monitoring in the triple issue. It is not, unfor- tunately, simply a Murdochian sensationalization of the content of our article, but is a contradiction of what we have written. On these pages we argue that although proponents of electronic fetal monitoring point to the recent decline in infant mortality as proof of the effectiveness of this diag- nostic technique, there is no evidence that there is any causal relationship between increased use of EFM and decreased infant mortality rates. The boldfaced blurb completely turns around this critical point by asserting that the relationship between EFM and lower infant mortality is indeed true, and implying that the EFM debate is thus one of weigh- ing mortality risk of the infant against mortality risk of the mother. A lesser distortion occurs in the second sentence of the blurb wher the editors have listed a number of primary and secon- dary, direct and indirect, likely and unlikely, serious and non- serious complications related to the use of EFM, without, of course, saying or implying any distinction. We trust that the editors will not only publish this letter by way of correction, but will take pains to avoid this type of distortion in the future lest otherwise enthusiastic supporters will be discouraged from contributing to or reading the Bulletin. Sincerely yours, Sincerely yours, Marsha Hurst, Ph.D. Pamela Summey, M.A. Human Sciences Press 72 Fifth Avenue New York, N.Y. 10011 40