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HEALTH HEALTH HEALTH Health Policy Advisory Center Volume 14, No. 2 PAC STOP BULLETIN No Golden Door The Health Care and Care Non - of the Undocumented WH, Af Pt INSIDE - Ethical Products. Illegal Practices P.7 Recap on Teeth P. 27 - HI Peer Review To the Editor: Per your March / April 1982 issue, here's a preliminary sur- vey report completed in No- vember 1982 on the impact of budget cuts from United Com- munity Services of Metropoli- tan Detroit. (What follows is an edited version L ed.) Surveys were sent to ap- proximately 175 programs in Southeast Michigan known or believed to deliver health serv- ices to adolescents; 68 were re- turned, representing 48 out of 60 possible service area " cells, " defined by 15 service categor- ies in four geographic areas. Almost nine out of ten re- spondents (60 out of 68) re- ported that they had reduced operating budgets in the past year in real dollars. Cuts in Federal funding were greatest in non health - categories, where the deep slashes in the CETA program, legal services, and social services reduced funding by 60 percent. By comparison, traditional health services for teens (family planning, VD control, pre natal - care) funded by the Federal government were cut by about 22 percent, corresponding to the average cuts made through the block grants. Michigan just barely maintained funding for mental health services from FY81 to FY82, but made reductions in health (five percent) and social services (18 percent). The most common reaction (70 percent of all agencies) to budget cuts was to reduce staff either through layoffs or through attrition. Slightly more private than public agencies Health / PAC Bulletin March - April, 1983 Board of Editors Tony Bale Howard Berliner Carl Blumenthal Pamela Brier Robb Burlage Michael E. Clark Barbara Ehrenreich Sally Guttmacher Louanne Kennedy David Kotelchuck Ronda Kotelchuck Arthur Levin Steven Meister Patricia Moccia Kate Pfordresher Marlene Price Virginia Reath Hila Richardson David Rosner Hal Strelnick Sarah Santana Richard Younge Richard Zall Editor: Jon Steinberg Staff: Roxanne Cruiz, Debra De Palma, Loretta Wavra. Associates: Des Callan, Madge Cohen, Kathy Conway, Doug Dorman, Cindy Driver, Dan Feshbach, Marsha Hurst, Mark Kleiman, Thomas Leventhal, Alan Levine, Joanne Lukomnik, Peter Medoff, Robin Omata, Doreen Rappaport, Susan Reverby, Len Rodberg, Alex Rosen, Ken Rosen- berg, Gel Stevenson, Rick Surpin, Ann Umemoto. MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR AND SUBSCRIPTION ORDERS should be addressed to Health / PAC, 17 Murray St., New York, N.Y. 10007. Subscription rates are $ 15 for individuals, $ 30 for institutions. ISSN 0017-9051 1983 Health / PAC. The Health / PAC Bulletin is published bimonthly. Second class postage paid at New York, N.Y. and at additional mailing offices. Design: Three to Make Ready Graphics / 1983 Cover by Kate Pfordresher. Articles in the Bulletin are indexed in the Health Planning and Administration data base of the National Library of Medicine and the Alternative Press Index. cut staff (72 percent vs. 64 per- cent). The next belt tightening - measure, indicated by 41 per- cent of respondents, was to re- duce or eliminate money for staff development and training. Again this was more common among private agencies (47 percent) than public agencies (32 percent). Service reduc- tions and less outreach and education were the next two commonly named responses, each in almost one third of the agencies. Some service reductions were only in the amount of fered. In other cases, entire pro- grams were eliminated, such as the CETA funded school health workers program in De- troit; a short term counseling program in an Oakland agency; free birth control services for previously pregnant teens throughout the Detroit area; three maternal and child health centers in Wayne County, and an adolescent day treatment continued to p. 6 Health / PAC Bulletin Notes & Comment The scene is familiar. Entering a government office is a step into winter. The secretary's voice is cool as she says, " I'm sorry, X is busy now. " " I have to see X, " the visitor persists. " Do you have an appointment? " " Your telephone is out of order. " " Ah, " she agrees, adding, " I'm afraid he has a very heavy schedule. " " I have something for X, " the visitor says, removing the fat envelope from a bag and putting it on her desk. The secretary takes it briskly but carefully; none of the cash falls out. " Since it is ur- gent... " she accedes with a sympathetic smile, rising and disappearing into the inner office. This baksheesh ritual is common enough in many parts of the world. We find it unfor- tunate, if not reprehensible. Bribes subvert equality. X is available to those who pay rather than to those who need. He inevitably begins to think of himself as someone who works for those who give him money more than for the public which pays what has become his base salary. If he has a conscience, X might argue with some justice that he needs the extra cash in order to survive or even to keep his job; there are many people, less competent and honest, who would be willing to put out sub- stantial sums to win it. Baksheesh is a violation of, a threat to, pre- dictability. Is the bribe necessary? Is it suffi- cient? Is it treated with contempt or gratitude? None of these concerns can be assuaged with certainty. Wresting order from the whims of nature and individuals was one of the greatest tri- umphs of the bourgeois revolution. You can- not run a complex economy efficiently with- out knowing that events will follow certain patterns. The sun must rise at an identifiable hour, the check clear in a requisite number of days, the bureaucracy issue the permit in a specified number of weeks. This necessity was recognized in the United States as the economy reached maturity. It is exactly 100 years since the merit system was introduced in the civil service following the assassination of President Garfield by a dis- gruntled office seeker - . Killing the President. can focus attention on an issue, but the need for predictability mandated the new system in any case. Political Action Committees are letterhead baksheesh. Elected representatives have al- ways been responsive to special interests, but the pressure of friends, associates, and the powerful is broad, an embrace; PAC contribu- tions are a firm handshake. Politicians are understandably reluctant to announce that they have sold their votes; the few known recent instances of lobbyists an- nouncing purchase come in the form of " He said that, and I kicked him out of my office " ' anecdotes from the righteous and aggrieved recipients of the contributions. Still, no one takes the trouble to spread so much seed un- less they expect to cultivate something or someone, and the universally agreed harvest is " access. " Put crudely - it has been, not sur- prisingly, by a close friend and advisor of President Reagan, in this case Justin Dart- access means " Talking to politicians is fine, but with a little money they hear you better. " The term " little money " is not inaccurate, even though 3,149 PAC's spent a total of $ 83 million during the 1982 congressional cam- paign. The current Washington wisdom is that $ 500 almost always buys access; as little as $ 200 generally does. The value, however, may not be that a politician hears you better, but that he or she hears you at all. Each member of Congress has sessions and committees to attend; offices to run; constitu- ents to aid in personal matters; reporters to accommodate; dinners; caucuses; events back home; bills to read, write, and vote on; often a family which can only be ignored so long; and every two or six years a campaign with fundraising, speaking, handshaking, and re- sponsiveness to questions on a multitude of issues. In the House of Representatives public health legislation comes before the Subcom- mittee on Health and the Environment of the Energy and Commerce Committee. The amount of time that its 18 members can de- l vote to health is limited by their other respon- Health / PAC Bulletin sibilities on the committee and in general. The attention they can give to any legislation that comes before the subcommittee, or that they might initiate, is limited as well. But for a lobbyist, there might well be one bill which is the focus of attention for the entire year, a bill which means millions of dollars for his or her employer. And this lob- byist, highly paid as an articulate, knowledge- able, persuasive advocate, has bought access. If a piece of legislation is of particular con- cern to the pharmaceutical industry, its lob- byists would want to talk to Representative Edward R. Madigan, a member of the Health and Environment subcommittee. Those who contributed to his 1982 campaign include Ciba Geigy - (1000 $), Abbott Laboratories (750 $), Johnson & Johnson (750 $), Smith Kline (750 $), Eli Lilly (500 $), Merck (500 $), Richard- son Vicks - (500 $), Walgreen Co. (500 $), Bristol Myers (400 $), Hoffman - La Roche (250 $), Pfizer 250 ($), Sandoz Schering ($ 25- 0P)l,ou g-h 250 ($), G.D. Searle (250 $), Sterling Drug (250 $), and Upjohn (250 $). Conceivably all of these lobbyists could hire a bus and come to Representative Madigan's office together, but if the companies wanted to say the same thing at the same time they could have made their contributions through the Pharmaceutical Manufacturers Associa- tion PAC and saved themselves the consider- able expense of hiring a lobbyist. Pfizer and Abbott may think there are nuances in their positions which must be heard separately from the Smith Kline presentation. They might also believe that after Representative Madigan has heard their cogent discussion of the issues 15 times he will not only be persuaded, he will be able to repeat the arguments forcefully in a committee as if they were his own. Representative Madigan and his colleagues might well hear differing views. Some groups which have contributed would probably want to make their opinions known on this legisla- tion even though it is not their most vital concern. In the case of Representative Madi- gan, other health related - PAC's which have bought access include the American Health Care Association (2,500 $) , the Illinois State Medical Association (2,250 $) , the American Dental Association (1000 $), the American Hospital Association (1000 $), the American Podiatry Association (1000 $), the National Association of Casualty and Surety Agents (800 $), Family Health Program, Inc. (750 $), the Health Industry Manufacturers Associa- tion (750 $), the National Association of Pri- vate Psychiatric Hospitals (600 $), the Inde- pendent Insurance Agents of America (500 $), the National Association of Life Underwriters (500 $), the National Council of Health Cen- ters (500 $), the Prudential Insuranee Company (500 $), and the Surgical Trade Association (500 $). These groups don't always agree. The Ameri- can Hospital Association and the American Medical Association were at odds this year on prospective payments to hospitals, for exam- ple. But while public expenditures for health care are expanding by billions of dollars an- nually these organizations have usually been able to find room for accommodations. This year the American Hospital Association pre- sented an Honorary Member Award, " be- stowed on persons who have made note- worthy contributions to the health care field. " to Joe D. Miller, the first director of the AMA's political action committee. The people whom not too many representa- tives have much time for are those who don't have the money to hire high powered - lobby- ists and dole out a few hundred dollars to large numbers of candidates the way drug companies like Abbott did - it spread $ 89,000 among 192 candidates in the 1982 congres- sional elections or the way the AMA did it gave $ 1.68 million to 463 candidates. The people who might not be heard could be the very ones whose health and welfare are at stake. You and me, for example. So far, the only way of offsetting the financial weight of PAC's which the American system has come up with is establishing an oligarchy. Accord- ing to Senator Alan Cranston (CA D -), at least 55 of the current members of the Senate are millionaires. The rise of de facto oligarchy and the PAC's, troubling in themselves, are deeply ominous. The history of Athens in the fifth century B.C. shows dramatically how overextension in imperial adventures can shatter the most bril- liant, prosperous, and powerful state. On a more mundane level, a decade ago in the Koreagate scandal we were shaken to find that investing a few million dollars in the entertainment of food-, sex- and fun starved - congresspersons brought a return of hundreds of millions of dollars for some astute, well- connected, and corrupt South Koreans. continued to p. 24 Health / PAC Bulletin Vital Signs ity survivor benefits (as the saying goes, they threw them- selves on the mercy of the court as orphans), the Department of Health and Human Services America on the Mend Ronald Reagan came to Washington with a promise to root out Federal waste and fraud as firm as a matinee mar- shall's pledge to clean up Dodge City. There have been problems, however. For one, the President and his corporate posse have been surrounded by disclosures of conflicts of interest, insider trading, influence peddling, extortion - scale consulting fees, violations of international law, astronomical decorating bills, and the use of public sector secretaries by an expert on the superiority of the private sec- tor to prepare his book on the subject. And now Sewergate has sloshed into town, soiling the President's reputation, if not his boots. But we're not going to cower behind the bar waiting for this media ambush to end. We're here to set the record straight by publicizing at least some of the profound progress conser- vatives have made in uncover- ing scandalous abuses of the commonwealth largely ignored by the Liberal Establishment Press Editor and Reporter (LEP- ER) cabal. In a major victory for justice, efficiency, and the American Way, upon discovering two California cases in which chil- dren who murdered their par- ents managed to collect $ 29,500 between them in Social Secur- took swift action. Past admin- istrations had foolishly issued regulations merely prohibiting anyone anyone convicted convicted of of killing killing his his or her parents from collecting survivor benefits, but in many states juveniles cannot be con- victed of felonies. HHS has now closed this gaping loop- hole. Moving from strength to strength, the Reagan team has been cutting off monthly checks from a still lower form of para- site, the legally dead. By com- paring computer tapes of death records from the Veterans Ad- ministration, 11 states, and New York City with Social Security rolls, these watchdogs found 718 deceased individuals re- ceiving checks among the 6.7 million individuals screened. The average post mortem over- payment was nearly $ 15,000. Perhaps it is just as well that the LEPER cabal hasn't picked up on this scandal, though, since almost 75 percent of the money the SSA has recovered has been in uncashed checks; in most cases the families duly reported the death, but clerical or computer errors kept the payments coming to their mail- boxes. Furthermore, nearly ten percent of the supposedly de- ceased recipients have been found very much alive. The Administration is not commenting on rumors that the names of the 90 percent which are in their graves were largely provided by the voter registries of the Cook County Democratic machine in Chicago. One upping - the Administra- tion, the Republican - controlled Senate Special Committee on Aging decided to go after liv- ing adults. Just as the President predicted, in examining the Medicare system they uncov- ered unreasonable costs, kick- backs, bribery, stock manipu- lation, unnecessary procedures, and overutilization. The only problem is, the chief culprit is not the elderly but the private sector pacemaker industry. It seems manufacturers were charging three to five times their production costs to hos- pitals, which then marked the price up another 50 to 150 per- cent and passed the bills to Medicare and other insurers. Demand for pacemakers was kept at more than double the rate in any other Western na- tion by physicians wooed with kickbacks, stock options, ex- pensive Las Vegas and Carib- bean vacations, lucrative " con- sulting fees, " goldplated shot- guns, gold watches, and spe- cial " rebates. " Pacemaker sales- persons have been happy to as- sist at operations, train inex- perienced physicians eager to get in on the action, and even teach doctors how to meet and manipulate Medicare guide- lines. A dozen stellar sellers take in more than $ 1 million annually in commissions. Medical Corpse Not satisfied with their al- most all volunteer (only the employees are drafted) Civil- ian Military - Contingency Hos- pital System, the Department continued to p. 26 Health / PAC Bulletin 510 continued from p. 2 program for mentally ill teens in Detroit. Public agencies cited service reductions three times more than private agencies. This dif- ference may be explained by the fifth most popular reaction to budget cuts: almost half of all private agencies report in- creased efforts to raise funds from private sources. Public agencies are prohibited from this activity, though some re- port stepped up grant writing for government funds. Other coping methods in- clude fee scale implementation or an increase in client fees (cited by one out of five agen- cies, public and private); a growing tendency to accept clients with health insurance or who can pay for treatment; and long waiting lists (one agency in six). " " " " An open ended - question on the survey asked if the respon- dent could cite examples of teenagers whose health or well- being was adversely affected by the results of governmental budget cuts. There were speci- fic and general responses. Of the first type: * " A male client age fifteen was recently shot by police during an alleged attempted murder. For several months, the worker and the family had been trying to have the teen- ager evaluated for the possibil- ity of residential care. Because of a clinic no longer providing service and long waiting lists elsewhere, the evaluation pro- cess was delayed and the youth was shot. " * " Two babies died of Sud- den Infant Death Syndrome. Their teen mothers had been counseled by Project Redirec- tion, before this program ended. They might have known what to do to prevent such deaths if the service had not been cur- tailed. " Respondents expressed a general impression that teen pregnancy, suicidal youth, and the incidence of runaways had all increased. Says one worker in an adolescent pregnancy pro- gram, " Patients have expressed increasing anxiety regarding OW {CONMIC TRO- {AU * WITH tr > >> oci * t MttTV HIT I *. ** - t..vic >>> t..vic fo tieu tieu AtIXT ISAK WUTOWMM their ability to provide basic necessities for themselves and their children, i.e. food, shel- ter, clothing, and medical care. There has been an increase in withdrawal of family support in finances, so as to increase depression, family disruption, and psychological problems. " A worker in a rural counseling service agency reports that " Youth of (families affected by unemployment) are experienc- ing or have become victims of a variety of problems, i.e. substance abuse, domestic vio- lence, child abuse, stress / anxi- ety, inadequate nutrition, and dislocation. Unfortunately serv- ices which in the past would have assisted those in need have also been drastically cut or eliminated. " Nevertheless, three of every four agencies responding to the survey predicted that the quantity of health or human services for adolescents will increase or stay the same in 1982. How do the respondents expect to serve more clients with fewer resources? Many of the private agencies expect to succeed in their fund- raising campaigns. Theoreti- cally these private funds will replace lost public revenues. But one would have to deter- mine on a case by case basis if the private dollars are support- ing the same services or new programs. It would also be in- teresting to know if these funds are expected to be stable after the next year or so. Predictions of increased serv- ice levels in the face of budget cuts may also be explained by plans to increase staff caseloads to accommodate the anticipated high demand for services. This could be accomplished by re- ducing outreach or follow - up care, devoting less time per client, or otherwise streamlin- ing service. Some would call this cutting the " fat " in the system. Conversely, agencies could strive to maintain the same intensity and range of services by increasing worker productivity. The result may be increased staff " burnout " and stress. One of the first sets of serv- ices to be deleted in budget- cutting times is outreach, edu- cation, and counselling serv- ices. As the survey showed, one third of the agencies have taken this step, which frees up time for the community out- reach and liaison person to de- liver direct service. This trend is disheartening since outreach and education are often the only prevention - oriented serv- ices available in a community, particularly when a school dis- trict does not offer health edu- cation classes. Though agen- cies may be making very prag- matic decisions to provide treatment rather than preven- tion services in times of in- creased demand for care, the result may be increased preva- lence and costs of more severe illness in the long run. Debra Lipson Director, Adolescent Health Project United Community Services Detroit, Michigan 6 Health / PAC Bulletin Look Out for Number One Illegal Practices in the " Ethical " Medical Supply Industry by Hal Strelnick Aiming to be Number One, and getting there, is as American as Horatio Alger. Un- derdogs trying harder may win hearts at the Saturday matinee or in Avis commercials, but second - best does not impress Wall Street. The ticker tape, of course, does not register ethics or quality, and getting to the winner's circle may mean bending or breaking the rules. Once upon a time'ethical'manufacturers may have held themselves to higher standards since patients'lives depended upon the qual- ity of their products, but such scruples seem to have disappeared with snake oil and patent medicines. Despite much rhetoric and adver- tising to the contrary, the industry today hews as closely to the bottom line as any other. And the price is paid by patients and consumers. Few companies fit this model better than American Hospital Supply Corporation. Just a decade ago American stood a humble sixth in what was once called the " no technology " business of distributing hospital and medical supplies, left in the dust of Brunswick, Whit- taker's General Medical Corporation, and Searle's Will Ross, Inc. However American's sales climbed from $ 510 million in 1970 to $ 2.9 billion in 1981. capturing the hallowed Number One position with a 20 percent share of the chaotic and fragmented hospital supply market. Net in- come has grown an average of 16 percent a year, and stock analysts predict 20 percent annual growth in earnings - per - share for the Hal Strelnick teaches in the Residency Pro- gram in Social Medicine at Montefiore Hospi- tal in the Bronx and is a member of the Health /? AC Board. next five years. Its ten percent pre tax - profit margins are four times the industry average. American currently distributes 120,000 health care products and services to 7,000 hospitals around the world, everything from surgeon's masks and latex gloves to TV rentals for hos- pital patients. According to Fortune, this rags riches - to - story was accomplished " with an aggressive high - tech marketing drive that has propelled hospital - supply purchasing and 1 inventory control into the 20th century. The only problem is, what American did to become Number One is illegal. American Hospital Supply was founded in 1922 by Foster G. McGaw. Its growth and profits have made McGaw a philanthropist worth $ 75 million whose name now adorns both the fieldhouse and the medical center of Northwestern University. When McGaw began, most hospital equip- ment was owned by private physicians, and supply salesmen stopped by their client hos- pitals twice a year on cross country - treks. Salesmen literally wrote their own orders. Prices were not fixed and were often padded to fatten the salesman's commission. Accord- ing to McGaw, suppliers would scan the obit- uaries for hospital administrators, then send their hospital a shipment of supplies, claim- ing the deceased had ordered them. * Under McGaw's leadership American be- gan to manufacture the supplies it sold; he reasoned that offering exclusive products would boost profits and distinguish Ameri- can from its rivals. Acquisitions of small companies soon followed - and they haven't stopped since. In 1966 American bought Edwards Labora- Health / PAC Bulletin tories in Irvine, California, the developers of the first successful artificial heart valve and to this day the leader in the field. Edwards keeps American in the high profit, high - tech market with such new products as its widely used intracardiac catheter that measures blood flow and pressure inside the heart and sometimes obviates the need for surgery. As in many high - tech fields, inexpensive Asian labor is a key component. Edwards has capitalized on the recent influx of Vietnamese refugees in Southern California, hiring many for the fine needlework required for stitching Teflon to pig heart valves, the most common implanted today. Of the 50,000 heart valves implanted annually, two thirds - are Edwards made, and only American sells them. American refuses to let its rivals distribute Edwards catheters or heart valves. These and the 28,000 other products Ameri- can makes account for more than 40 percent of its sales and more than half of its profits. American boasts that it can sell a hospital 60 percent of all the items it needs, from plastic syringes to plastic intraocular lenses. In addi- tion, other acquisitions enable American to offer a wide variety of operating services, in- cluding pre architectural - planning, equipment leasing, data processing, and housekeeping. American's real push toward industry lead- ership began in 1970 when McGaw appointed Karl Bays as president. The then - 36 year old former Marine first set about computerizing American and then 3,000 hospital purchas- ing offices. This program is called Analytic Systems Automated Purchasing, or " ASAP. " It was no accident that the acronym also rep- resents the widely used shorthand for " as soon as possible. " By linking terminals in the hospitals to its own master computer, Ameri- can eliminated hours of paper pushing - and red tape for hospital purchasing agents order- ing the thousands of items a hospital uses every day. The hitch was, although it was faster and easier to order through ASAP, it was not cheaper. The purchasing agents became, in effect, captive customers. American did not stop with convenience. Realizing cost containment - was becoming the number one priority for most hospital admin- istrators, American went into the " con- cost - tainment " consulting business. For every dol- lar spent by hospitals on supplies, American is quick to point out, a second goes to getting them into the hands of the doctors and nurses who use them. A significant part of this ex- pense comes in carrying and storing inventory. According to James Slotterback, American's director of marketing services, " Ninety per- cent of the time we can deliver supplies to a hospital within 24 hours, so there's no reason for them to carry the old 88 day - inventory. We tell them,'Let our warehouse be your warehouse. And let us make the investment in developing cost containment - systems. We have a vested interest in your survival, and we have the resources to help you.'4 Naturally, American's cost containment consultants would recommend services like ASAP, programmed to automatically re order - supplies from American whenever the hospi- tal's inventory of syringes or surgical gowns fell below minimum levels. According to Michigan State University economist Stephen Martin, this process could go " untouched by human hands. " When the pressures of cost containment - drove hospitals to circle their wagons and form group purchasing associations, American took this opportunity to begin what Bays has called its " corporate corporate - to - approach. " American pushed contracts covering all its product lines with these purchasing groups to capture their enormous sales potential. Be- tween 1977 and 1979 American signed eight such comprehensive " corporate agreements " ' with non profit - and for profit - groups and a couple of large individual hospitals. In 1979 American signed its biggest con- tract more than twice the size of any to date with Voluntary Hospitals of America (VHA), a consortium of 29 prestigious, non- profit hospitals in 22 states, including Baylor University Medical Center in Houston and Henry Ford Hospital in Detroit. VHA is a for- profit corporation, founded in 1977 to pro- vide its members management services, econ- omies of scale, and political clout. Their con- tract called for " competitive " prices, speci- fied ceilings on price increases, and rebates based upon the hospitals'annual per bed - purchases. American was to be shown com- petitors'prices so it could " match " them or " walk away " from low profit business. Both sides referred to the arrangement as a " part- nership " for cost containment - , which VHA extended to other major suppliers. Adminis- trators and purchasing agents unsettled by this transformation of the traditional adver- sarial relations between buyer and seller were told in writing by American that their com- 80 Health / PAC Bulletin BET YER R - LiFE Lise MEDICAL SUPPLY COST CONTAINMENT SPECIAL LOST 104 ! PATENT 2 for 1 SALE ANTIBIOTICS TETRACYCLINE may ONLY (TWO MONTHS CHEAP BEYOND USE DATE) BLOOD DELIVERIES IN HEART VALVES ODD SIZES 24 hours PRODUCTS -one previous -- owner Cunless we don't L make it) fi ia a. 116 pliance " boils down to a matter of trust. ' Sales 6r Marketing Management magazine honored American for signing VHA with its Distinguished " Winner's Circle " Award for " winning new customers by making 117 a major change in industry buying patterns. These new patterns had a few flaws. For one, no hospital could qualify for a rebate unless all the hospitals achieved their quotas; Tallahassee Memorial's rebate depended upon purchasing by Riverside Methodist Hospital in Columbus, Ohio, creating collective a pres- sure to " buy American. " At one VHA board meeting the American group marketing presi- dent, who attended all their meetings to " score- board " their progress and keep the pressure on, told the hospitals'chief executive officers, " Some of you have joined the church but still haven't gotten religion! " To meet its quota, Henry Ford Hospital knowingly bought faul- ty needles and miscalibrated syringes from American's Pharmaseal division but did not use them on patients. In three years, VHA hospitals quadrupled their purchases from ^ American. Although the contract called torj eompeti ^^ tive " prices, American pushed its rebates, price caps, and consulting as the major sources of savings. In fact, American could not boast of low prices because on many standard items its prices were not only uncompetitive, they were outrageous. A Becton Dickinson - surgi- cal clip that some distributors sell for a penny was sold by American for as much as $ 6.55. Yet when ordering supplies on the American ASAP computer terminal, no prices appear at all * so the purchaser does not necessarily realize the costs. With this little trick, accord- Health / PAC Bulletin 9 ing to a study by a Wall Street brokerage house, American improved its profit margin from one to three percent because " prices are not even actively considered by the purchaser at the moment the order is placed. " 8 In the fall of 1979 four tiny local hospital supply distributors decided to fight back. They filed a six count - anti trust - suit against American, citing the VHA members as con- spirators but not defendants. American's de- fense, as summarized in its post trial - brief, was that it had " not done anything that is ' wrong'or predatory or even controversial. (It) is in the business of selling hospital sup- plies for a profit. It wanted to sell more..... It is what salesmen do for a living. # " 9 In other words, this was business as usual. In April 1982 after 81 days, 43 witnesses, and 15,000 pages of testimony, District Judge Douglas W. Hillman in Grand Rapids, Michi- gan, found American guilty of restraint of trade, anti competitive - practices, and attempts to monopolize the market in seven Midwest- ern cities. He enjoined the corporation from enforcing its VHA contract in those cities and awarded treble damages of $ 430,600. Hillman noted that VHA and American had agreed to work to " preclude formal bidding " by Ameri- can's competitors, to disclose competitor's bids so American could match them and as- sume new VHA business, and to standardize along American's product specifications. 10 According to Michigan State's Martin, a spe- cialist in industrial organization who advised the plaintiff's attorney and testified at the trial, the court's ruling " accepted the argu- ment that the VHA American - contract inter- fered with price competition by obscuring prices at the point of purchase..., so that in its ideal form, price is not even considered when an item is purchased. " As for cost containment - , economies of scale, and rebates, the hospitals seem to be left hold- ing the bag. After one hospital bought more than $ 3 million in supplies from American in 1981, it received a measly $ 13,000 rebate (about 0.4 percent), the largest American has yet to pay. When VHA and American announced the savings of their " partnership, " Charleston Area Medical Center (CAMC) in Western Virginia was shown to have saved $ 1.2 million that its purchasing agent, Robert Dietz, is still waiting for American to explain. Before the VHA contract Dietz " had no com- plaints " about American's competitor, one of the suit's plaintiffs, while American had sev- Nast Thomas eral serious backorder problems. CAMC in- 11 creased its American orders 3000 percent. At Christ Hospital in Cincinnati, American's prices usually were well beyond its bidding range, but the VHA contract led them to shift $ 500,000 worth of business to Ameri- can. Miami Valley Hospital in Dayton, Ohio, and Norton Children's Hospital in Louisville began giving business to American without allowing their existing suppliers to rebid- despite American's previous poor service to each. 12 As for American's consulting on materials- management, this consisted of having the VHA Materials Management Committee junket to American plants in California and Illinois and recommend standardization exclusively for American products. According to econo- mist Martin, American consultants almost in- variably recommended that American take complete charge of the hospital's purchasing, " letting the fox into the chicken coop. " American has renegotiated the VHA con- tract but is appealing the decision in Cincin- nati's Sixth Circuit Court. President Bays told the New York Times, " We don't believe we have lost any business as a result of the suit. " Legal hurdles, however, are nothing new for American. In 1974 the Federal Trade Com- mission subpoenaed American records in an anti trust - probe into its " acquisition and trade practices " that was dropped four years later. In 1975 American had to recall ten million bottles of intravenous fluids when some were found contaminated with mold in its Georgia production plant. Health / PAC Bulletin  i4 This adversity at home may have spurred American to expand its research and devel- opment in its high - tech Edwards division and to invest in its international and export divisions. Its international operations, both manufacturing and distribution, have grown exponentially from $ 10 million a year in 1966 to $ 410 million last year, contributing 18 per- cent of total earnings and yielding a 16 per- cent return on investment. Of course, not all growth is earned by hon- est competition. In 1976 the Security and Ex- change Commission (SECJ accused American of covering up $ 4.6 million in payoffs involv- ing the construction of King Faisal Specialty Hospital in Saudi Arabia and in 1978 of $ 1.3 million paid to associates of South Korean President Park in return for the contract to build Seoul National University Hospital. Since 1976 the company has been under a Federal court injunction to take steps against these payments and ones in Mexico and two other countries, as well. Other Companies, Same Policies While it has often been observed that pre- serving a fortune does not require the ques- tionable practices used to amass it, even blue chip corporations seem unable to shake the habits developed on their way to the top. Ven- erable, established blue chips also get caught with their hands in the cookie jar. Number One in the production of health care products has not been disputed in many years Johnson & Johnson rang up almost $ 5 billion in sales in 1980, more than twice the gross of American Hospital Supply. In July 1981 a Federal jury in Minneapolis found Johnson & Johnson guilty of fraud in acquiring an electronic painkilling device in order to suppress it and keep it from reaching the market to compete with its best selling - painkiller Tylenol. According to Judge Miles Lord of the U.S. District Court, the evidence indicated that Johnson & Johnson had engaged in fraud of " the most extreme and culpable nature. " 13 In 1970 two employees of Medtronic, a leading pacemaker manufacturer, developed a method for electrically stimulating the skin that relieved and sometimes cured debilitat- ing chronic pain. They called their invention a " transcutaneous electrical nerve stimulator " and in 1971 set up their own company, Stimu- lation Technology, Inc., known as Stimtech. Sales of their product reached $ 1 million in 1974, and Stimtech remained the market leader despite competition from the Japanese and other American firms. Seeking more capital for research to decrease the cost and size of their device, the inventors accepted Johnson & Johnson's offer to buy Stimtech out for $ 1.3 million. They were promised a share of up to $ 7 million in future profits, a Johnson & Johnson label, and active international marketing. Instead, the acquisi- tion produced only headaches - the device lost money, the inventors were dismissed from their new positions and Johnson & John- son refused to sell Stimtech back to them even though it was losing money. In May 1979, the inventors sued Johnson & Johnson for breach of contract and for fraudu- lently buying their device to suppress it. Two years later a Federal jury found in favor of the inventors and ordered Johnson & Johnson to pay $ 170.4 million in damages and anti trust - fines. Meanwhile, Stimtech's sales reached $ 5.3 million in 1979, but since the suit was initiated both by the Dow Corning - Corpora- tion and the 3M Corporation have marketed competing devices - with a price and size about a third of Stimtech's. While the nerve stimulator was giving John- son & Johnson stress upsets, executives at Hoffman LaRoche - , the Number One producer of vitamins and tranquilizers, were probably reaching for their best selling - Valium or Lib- rium over their own legal problems. In 1974 the European Economic Commu- nity brought charges against Roche for abus- ing its dominant position in the vitamin mar- Health / PAC Bulletin 11 Firm Name Medical Industry Dishoner Role Year Illegal Practice Abbott 1971 60 count indictment reduced to single count of con- spiracy for 3.4 million bottles of contaminated in- travenous solution (largest product recall in FDA his- tory). Pleaded nolo contendre and paid $ 1,000 fine. 1982 among several American firms charged by Dutch gov- ernment with " price fixing. " " Airco, Inc. 1982 $ 3 million in punitive damages assessed for respir- ator marketed 8 years when known to be defective with " reckless regard for the consequences. " American Cyanamid 1974 price fixing (dyes); nolo plea. 1981 settled suits for international price fixing of antibiotics with governments of West Germany, India, Columbia and the Philippines. Bristol - Myers 1979 FTC administrative law judge found advertising for Bufferin and Excedrin misrepresentative. 1981 settled ten year suit with Justice Department for fraud- ulently procuring the patent for the antibiotic ampi- cillin. Dupont Lilly Litton 1982 1982 1974 1979 1974 1963-81 among American firms settling in an international antibiotic price fixing suit (see American Cyanamid). among American firms charged by Dutch government with price fixing. price fixing (dyes); nolo plea. defendant in more than 95 product liability suits for DES related - problems. price fixing (paper labels -trial) conviction. 43 complaints and 24 violations of National Labor Relations Act. 3M 1973 illegal campaign contributions - company and chair- man pleaded guilty. 1975 SEC consent decree for $ 643,000 illegal political slush fund. McDonnell Douglas Merck 1979 1979 1974-82 defendant in sex discrimination suit brought by NOW indicted by Justice Department for fraud and conspir- acy in Pakistani bribery scheme. defendant in more than 350 product liability suits for DES related - problems. ket by preferential rebates for large customers. found guilty of breaking the Common Mar- The case was based largely on documents _ ket's laws of commerce and fined $ 390,000. leaked by one of its own executives, whom In 1979 the European Court of Justice upheld Roche had arrested for industrial espionage the conviction on appeal but reduced the fine in Switzerland in 1975. In 1976 Roche was to $ 260,000. Health / PAC Bulletin Firm Name Pfizer Richardson - Merrell (now Dow Merrell -) A.H. Robbins Schering Plough Smith Kline Squibb Sterling Drug Upjohn Warner Lambert - Year Illegal Practice 1968 patent fraud (with American Cyanamid) in obtaining tetracycline patent; price fixing (with American Cyanamid & Bristol Myers) of antibiotics. 1981 1982 1974-81 1979 1982 settled international price fixing suit (see American Cyanamid). among American firms charged with price fixing by the Dutch government. Admitted falsifying data required by the FDA and $ 80,000; nolo plea. Defendant in 4,680 Dalkon Shield related - product liability suits. defendant in more than 20 related DES - product liabil- ity suits. among American firms accused of price fixing by the Dutch Government. 1981 1982 1981 1982 Justice Department investigation for illegal delays in reporting adverse reactions to the anti hypertensive - medication, Selacryn, later withdrawn from the market. defendant in more than 50 Selacryn - related product liability suits. settled international price fixing suit with (American Cyanamid, Bristol - Myers, Pfizer, and Upjohn). among American firms accused of price fixing by Dutch Government. 1978 SEC violations for inadequate financial disclosures to stock holders. 1980 1981 1978 1979 defendant in patent infringement suit. settled international price fixing suit. Supreme Court upheld FTC's order to include $ 10 mil- lion of disclaimers for their cold treatment products. convicted of reckless manslaughter and criminally. negligent homicide in magnesium stearate - related factory explosion. SOURCES: Fortune; In These Times; Multinational Monitor; New York Times; Wall Street Journal; Moskowitz, Melton; Katz, Michael & Levering, Robert, Everybody's Business: An Almanac - the Irreverent Guide to Corporate America, N.Y.: Harper & Row, 1980. Hospital Corporation of American, the Num- ber One proprietary hospital chain, has also run into legal problems. In August 1982 HCA was charged by the FTC with anti trust - viola- tions in Chattanooga, Tennessee, where it had acquired hospitals through takeovers of two other chains in 1981. The case is awaiting trial. It might be argued that being Number One leads to undue scrutiny by regulatory agen- Health / PAC Bulletin 13 cies and the courts, unsympathetic treatment by juries, and nuisance suits by disgruntled employees. However, as the accompanying table indicates, a sizeable proportion of the ' ethical'pharmaceutical and medical supply industry has already been caught on the wrong side of the law. Despite lax enforcement of anti trust - laws and token prosecution of white collar criminals, corporate convictions still run from patent fraud to political fraud in maintaining illegal slush funds. The health care industry, unfortunately, is not unique. A 1980 Fortune study of 1,043 major corporations found 11 percent convicted of bribery, fraud, tax evasion, illegal political contributions, and / or criminal anti trust - vio- lations. This remarkable figure actually ex- cluded civil anti trust - suits (like American's), FTC complaints, and undetected criminal or 14 corrupt practices. According to Stanley Sporkin, the SEC's enforcement director, cor- rupt corporate practices derive from the " bot- tom line - philosophy.... Where people are not lining their own pockets, you can only explain corporate crime in terms of'produce or perish. " This " philosophy " obviously in- fects the products and business practices of the manufacturers and distributors of drugs and medical equipment upon which patients all over the world rely. Irwin Ross, author of the Fortune study and no radical, concluded, " Simple economic incentives explain most illegal behavior: corruption seems to pay... " Consumers and patients ultimately pay for such practices - in higher prices and defec- tive products - while the corporations defend their profits and themselves as American Hos- pital Supply did, justifying their actions by arguing that this is just " what salesmen do for a living. " Ha J Strelnick (Acknowledgements: Special assistance in preparing this article was provided by Health / PAC interns Dana Hughes, Ellen Kolher, and Steve Meister, made available through the Health Science Research Train- ing Program of the New York City Depart- ment of Health.) I Footnotes 1. Pillsbury, Anne B., " The Hard Selling - Supplier to the Sick, " Fortune 106: 56-61, July 1982 26,. 2. " Bringing Order to the Industry, " Hospitals, August 1,1975. 3. " Expanding to Meet Needs of the Sick, " Business Week, April 29 1961,. 4. Pillsbury, op cit., p. 59. 5. Hillman, Douglas W., Judgement: White and White, Inc., Bluefield Supply Company, Crocker - Fels Co.. and RansdelJ Surgical, Inc. vs. American Hospital Supply Corporation. Grand Rapids, MI: United States of America District Court for the Western District of Michigan, Southern Division, Case NO. G79-633 CA1, April 22,1982. 6. Ibid. 7. " American Hospital Supply's Pricing Promise, " Sales & * Marketing Management, January 14 1980,. 8. Abramowitz, Kenneth, Sanford C. Bernstein & Co., telephone interview, Oct. 8,1982. 9. Montgomery, William A. et al., Defendant's Post- Trial Brief: White and White vs. American Hospital Supply Corporation. Grand Rapids, MI: U.S. District Court for the Western District of Michigan, Southern Division, August 21 1981, . 10. Judgement, White and White vs. American Hospital Supply Corporation op. cit. 11. Ibid. 12. Ibid. 13. Friedman, Thomas L., " Johnson & Johnson Fraud Suit: Did Concern, To Aid Itself, Stifle Device? " New York Times, August 26 1981,. 14. Ross, Irwin, " How Lawless Are Big Companies? " Fortune 102: 56-64, December 1 1980,. G WHITE COAT oF CLENCHED FIST The Political Education of an American Physician m by Fitzhugh Mullan, M.D. Teeming with the life of a big city hospital and as timely as the current investigations of the medical profession, WHITE COAT, CLENCHED FIST is an insightful, probing portrait of the generation that came of age during the sixties and an impartial indictment of America's most indispensable, admired, and unchecked profession. Regular Price- $ 9.95 Special Price for Readers of the Health / PAC Bulletin - S5.00 I enclose $ - Please send me _copies of White Coat. Clenched Fist ei Mail to: Health / PAC. 17 Murray Street. New York. New York, 10007. Allow six weeks for delivery-. Health / PAC Bulletin No Golden Door The Health Care and Non Care - of the Undocumented by Sally Guttmacher An estimated 3.5 million to six million workers and their families are living in the United States with little, if any, recognized right to health care. These people are, in fact, denied the full range of social and economic rights, with the justification that they have violated our immigration laws by working here without the necessary legal papers. Not only is this situation contrary to the U.N. Charter of Basic Human Rights, but it would seem contrary to our self interest - since many of us come into intimate contact with these workers as restaurant staff, house cleaners, and babysitters. The common image of undocumented work- ers is men and women slipping across the Rio Grande to enjoy higher pay in jobs which rightly belong to American citizens. Reality, however, is more complicated. Most of these people come to the U.S. as victims of the world economy; in many cases it would be fair to say that they are already participants in the U.S. economy before they leave home. Although the impact of U.S. interests abroad is complex and much debated there is little doubt that the policies of U.S. multinationals can ultimately compel people to migrate. To cite one stark example, when American ag- ribusiness corporations purchase local land, peasants may be forced to leave for urban centers already flooded by unemployed refu- gees from the countryside. Corporations, cer- tainly, say the real culprit for massive unem- Sally Guttmacher is an assistant professor in the Department of Urban Studies at Rut- gers Newark - ; an adjunct assistant professor at the School of Public Health, Columbia; and a member of the Health / PAC Board. ployment is government policies. The local government often ping pongs the blame back. Meanwhile the problem grows year by year. To the hungry, the U.S. may not appear to be the land of milk and honey, but at least it offers the hope of steady pay at wages far above what they could expect to find at home. Word of the opportunities comes not only from friends and kin who have already found their way, but from recruiters who actively seek out and transport workers eager to enter the United States despite the risk of being discovered without proper documents. This recruitment is at least tacitly supported by many agricultural and industrial employers because the workers brought in accept low pay and poor conditions and the chances that the Immigration and Naturalization Service will seize and deport them are relatively low. This system also serves broader economic interests. It generates antagonisms and fears which impede unionization and other forms of organizing, and makes it possible to deny a significant segment of the workforce social welfare and health services without a politi- cally awkward formal decision to exclude people indisputably in need. It is difficult for the undocumented to protest. The United States is not alone in employ- ing foreign workers; all the Western European nations do (if we include Italy, where the migrants are actually Italians from the impov- erished south). As in the U.S., many labor economists argue that these workers are do- ing jobs which the native workforce consid- ers too ill paid - or unpleasant. Closer exami- nation, however, suggests that in each coun- try policies respond to political pressures from particular industries and to more gen- Health / PAC Bulletin 15 eral wage and employment considerations. Whatever the variations within Europe, the " guest workers, " as they are commonly called there, can expect treatment sharply different from what their counterparts in the U.S. re- ceive. In Europe, the rate of immigration is strictly controlled. The status of the immi- grants is explicitly defined; often they are guaranteed significant legal protection and social services. All residents, including non- citizens, have access to health care through the national health services. In the U.S., the flow of labor is not reg- ulated. Despite lip service to the idea that im- migration should be carefully controlled and occasional publicity campaigns and round- ups, the borders remain unsealed. The status of these migrants is at best marginally defined by law aside from regulations governing immigration and providing for deportation. Federal, state, and local governments all deny responsibility for the health care of undocu- mented patients. Those who cannot pay for private care find themselves at the mercy of local practices and the whim of individual administrators and functionaries. If anything, the situation is deteriorating. Although the Federal government, as the source of immigration law, would seem to be the most appropriate agency for dealing with immigrant problems, the current Administra- tion is unlikely to do anything other than pass the problem to the states. Given their rapidly rising Medicaid expenditures and depleted resources, it is hardly surprising that they have not been enthusiastic about taking on an additional health care burden. Local govern- ments are reducing the little they have of fered, citing Federal cuts and their shrinking tax base. The rise in the number of undocumented workers from Central and South America and the Caribbean is a direct result of the intensifi- cation of economic and political pressures in those areas. If INS apprehensions of the un- documented are any guide, immigration from our neighbors to the South began to jump sharply after the new immigration leg- islation was passed in 1965. This legislation drastically changed the composition of the immigrant labor force to the U.S.. Prior to that time, quotas for each nationally established in the 1920's greatly favored the British and Northern Europeans. The new system set limits in various immigrant categories, but no longer favored specific nationalities to the same extent. New immigrants did have to prove that they had a specific offer of employ- ment at the prevailing wage rate before they could obtain a visa, but with the easing of national restrictions, poor and working class Latin Americans began to outnumber the bet- ter off European migrants. As the flow of legal immigrants increased from Latin American countries, so did the flow of the undocu- mented, who were now able to hide and be sheltered in sizable compatriot communities. Exactly how many people have chosen to circumvent the U.S. immigration system is difficult to determine, partly because of the variety of migration patterns that have devel- oped. These patterns are related to type of employment, the expense of travel, and the ease of crossing the border without being picked up by the INS. Some cross the U.S.- Mexican border daily, others several times a year. Thousands of Mexicans immigrate sea- sonally, following the harvest from crop to crop in the Southwest and then returning home when the season is over. Some West Indians and people from the Spanish speaking - Caribbean do the same on the East Coast. Other immigrants who are unable to travel back and forth frequently due to the expense or to the political situation may stay here for years at a time. Manufacturing, for example, often provides more permanent employment in a single location than does agricultural work. Thus, Caribbeans or Chinese who mi- grate to New York seeking work in the gar- ment industry may essentially settle in a com- munity of compatriots. These different patterns as well as social class origins and whether or not the workers are accompanied by their families can be ex- pected to affect health status and health needs. In general, by virtue of their conditions of living and working, migrants and illegal immigrants especially - risk ill health more than non migrants - of comparable age and other personal characteristics. Among the negative factors are low income, poor occu- pational safety and health conditions, poor diet, unfamiliarity with health services, and stresses generated by living in a strange and sometimes hostile environment. Not the least of their problems is the constant fear of being reported, detained, and ultimately expelled. This in turn exacerbates stress, compels them to tolerate over priced - , crowded, substandard housing, and makes them reluctant to com- plain about working conditions. It also may 16 Health / PAC Bulletin " They don't suffer; GuorgeBaer ff Pmidwi *, Philadelphia and they can't even speak English. R19e0a2d ing Roilrond a Immigrant coal workers eventually won shorter hours, higher wages and union recognition, setting prece- dents for off of organised labor. Today, a new underclass struggles for economic justice: working women who on the overage earn only 59 cents for every dollar a man makes. Pay Equity. Another step toward justice. Service Employees International Union, AFL - CIO, CIC 9to5, National Association of Working WomeR Health / PAC Bulletin 17 deter them from seeking out those public health services to which they may be entitled, such as pre- and post natal - care. These problems may partially explain the resurgence of tuberculosis, an infectious dis- ease which had been thought no longer a threat, in major metropolitan areas such as New York City. Serious dental problems, hear- ing loss, and other disorders easily prevent- able through adequate screening programs and prophylactic care are also endemic among the children of migrant workers. Diabetes, hypertension, and other chronic diseases af flict migrant farmworkers disproportionately. Many also suffer the affects of pesticide poi- soning. The peculiar context of the lives of undocu- mented workers generates stress with its nega- tive consequences not only among undocu- mented workers themselves, but also in their familes and others intimately connected with them. According to the Archdiocese of Brook- lyn, N.Y., there is a disturbingly high amount of domestic violence in households of undoc- umented workers, commonly resulting in a 4 high incidence of child abuse and battering. Relatively high frequencies of emotional dis- orders have also been noted. These are prob- ably caused in part by the pressures of daily living in the " host " country, but may also stem from a sense of failure or rejection by the mother country where the workers have been unable to sustain themselves and their fam- ily. Children of undocumented workers who grow up in the U.S. may not face the same variety of infectious and parasitic disease as their migrant parents were exposed to, but as they reach adolescence they must learn to deal with drugs, violence, and other dangers that fall heavily on those living in impover- ished conditions in the United States. And they must often cope on their own. Migrants generally have limited access, at best, to ef fective informal familial or community sup- port structures. There are numerous reasons why it is very difficult to develop reliable health statistics about people residing here illegally. With the exception of government income maintenance or public assistance programs, citizenship papers are not necessary to receive services. Health or social service agencies rarely re- quire them. Estimates of family utilization are difficult to obtain because of the variation in the status of different family members; fre- quently parents who are undocumented have children born here, who are automatically U.S. citizens. Another big gap in the available information is the extent to which undocu- mented workers rely upon private physicians whom they pay in cash. It is reasonable to suppose that people here illegally would pre- fer to use private practitioners, who are less likely than institutions to turn their patients in to the INS. Although it is impossible to have full confi- dence in the accuracy of any facts about the use of health services by undocumented work- ers and their families, some rough conclusions can be formulated. Although there may be substantial socio- economic and sex differences in the demo- graphic profile of workers who migrate to the Southwest U.S., chiefly from Mexico, as com- pared to those who come to the Northeast from the Caribbean and Central America, most migrant workers tend to be young adults between 15 and 44. In general, people in this age range tend to be light consumers of health services, except for maternity care. Attempts have been made at some more specific estimates. According to one research- er who examined the use of health services by six groups of undocumented workers appre- hended by immigration authorities between 1976 and 1978, roughly one quarter to one half used hospital or clinic services while in the United States. 5 This level of usage is high given the relatively short time that many of the people had been in the country. Statistics complied by the Los Angeles Coun- ty Department of Health in 1980-81 suggest- ing that the unreimbursed costs for inpatient care for the undocumented amounted to $ 103.3 million were used by the American Hospital Association to argue that the undocumented contribute to the financial shortfalls of hospi- tals in certain regions. " This approach of blaming migrants for over- loads in social programs is common, but not necessarily justified. Los Angeles County also reports that only 40 percent of hospital charges to undocumented indigents are never paid. Furthermore, the study mentioned above found that about two fifths of the undocumented workers apprehended between 1976 and 1978 had had hospitalization insurance premiums deducted from their wages. Unless they are paid " off the books, " all undocumented work- ers pay Federal, state, and Social Security taxes; and like everyone else all pay sales, excise, and gasoline taxes. Health / PAC Bulletin can poffibly it made for a (Jun ^ CmnX'll ** *! ^ New York City has an undocumented popu- lation estimated at between 400,000 and one million. It is thought that the largest single group is from the Dominican Republic, on the assumption of proportionality between regis- tered and unregistered aliens New York City Department of City Planning data for 1980 indicate that there are 88,350 registered aliens of Dominican origin; Chinese, numbering 44,443,, are the second largest group. Even though many of these people are not subjected to the extreme conditions found in some agricultural situations, theirs are bad enough. One of the industries in New York which has attracted a large proportion of His- panic and Chinese women workers is garment manufacturing. As companies have escaped union labor by fleeing to the South or the Third World, they have been replaced by sweat shops reminiscent of those found in New York City at the turn of the century. These shops typically have a life span - meas- ured in months. They close before they can be detected or inspected by OSHA or other au- thorities who might fine them for being poor- ly lit, crowded, and badly ventilated. Franz Leichter, a state legislator from New York City, has reported that the women who work in these shops are commonly paid around $ 15 for an eight hour day. 10 At a conference on the situation of undocumented workers in New York City held in May 1982, a machine Cruikshan George operator who worked in such shops reported that with the recent cuts in public funding for daycare, many women had no choice but to bring their small children with them to work. Garment piece work done at home, a sys- tem common in Third World countries, is re emerging - in the U.S. and other industrial- ized Western countries. This is even more poorly paid than work in the sweat shops, and sometimes involves small children direct- ly in the work process. There is little doubt that this system increases the probability of injury at home, especially for children; acci- dents were already the leading cause of mor- bidity and mortality for U.S. children, and are particularly high for those who live in poverty. According to an official report issued in 1982, since 1978 newly reported cases of tu- berculosis in the city have risen by 21 per- cent. The increase in TB among very young children is particularly worrisome, a jump of 112.5 percent for children under five. a Accord- ing to the report this can be attributed in part to the influx of immigrants from countries in the Caribbean, Central and South America, and Asia, where TB is common. City officials fear the public health problems will grow even worse, since the undocumented try to avoid contact with public authorities. In ad- dition to the problems associated with delay in seeking care, they are concerned about the dangers of having a substantial number of Health / PAC Bulletin cases which go undetected. They fear many of them will go unmonitored by public health authorities because private physicians treat- ing undocumented workers do not want to expose their patients to possible deportation by reporting positive TB results to the Depart- ment of Health. Eligibility for Health Services New York has a relatively progressive policy toward the undocumented and has historically had a fairly broad network of social services available to the poor and needy regardless of citizenship status. Undocumented workers are, however, at significant disadvantage and their vulnerability is heightened by the cut- backs in public services. Hospitals and other institutions are under heavy financial pres- sure to diminish non paying - case loads -. Many facilities important to the well being - of the uninsured working poor hospitals - and clin- ics, day care - centers, legal aid offices, and more are required to provide emergency care to anyone who needs it, including the undocumented, but this does not actually guarantee that individuals who appear at an emergency room for treatment will actually NACL /Schifrn Rebca be cared for. Emergency care partly depends on the willingness of hospital staff to desig- nate a case as an emergency, and staffs of different facilities differ in the degree to which they limit access. For example, although the law requiring emergency treatment applies to all hospitals, there is an understanding that the publically funded hospitals have a stronger obligation than either the voluntary or pro- prietary hospitals. It also appears that this obligation may be felt more or less strongly at various municipal institutions. It has been reported, for example, that Bellevue was rou- tinely turning the names of suspected undoc- umented patients over to the INS. 12 A further deterrent to use of hospital emer- gency services is the forms promising guar- antee of payment, which patients or their families are usually required to sign at the time of admission. It is not uncommon for people to interpret these forms as signifying that treatment will be withheld until paid for. In fact, any hospital that has been supported by Federal Hill Burton - money - and most large institutions have been - is required to treat emergency cases before it establishes the pa- tient's ability to pay. However, not many immigrant workers know enough about the peculiarities of our health care system to en- quire about Hill Burton - funding when they are brought to the hospital admitting room. In addition to these obstacles, foreign mi- grants confront state administrators who have frequently been known to say that only United States citizens and legal permanent residents are eligible for Medicaid. This is not quite accurate. Courts have ruled that many foreign migrants without permanent resident status- the technical phrase is " otherwise permanent- ly residing in the U.S. under color of law " - have certain entitlements. People in this group as well as those in a number of entitlement categories such as Public Assistance Recipients Under Home Relief or Aid to Families with Dependent Children (AFDC) would be Medi- caid eligible under New York law. The problem is, the meaning of these desig- nations is subject to varying interpretations. The U.S. Department of Health and Human Services has interpreted the category of aliens eligible for Medicaid very narrowly to include only those who have been granted indefinite voluntary departure status or indefinite stays of deportation; those who arrived in the United States before June 30 1948,; and refugees who have been granted conditional entrance to the Health / PAC Bulletin United States. New York City, on the other hand, defines " Immigrants Living in the United States Under Color of Law " as all aliens who reside in this country with the knowledge and acquiescence of the Immigra- tion and Naturalization Service. 13 This would presumably include all individuals who are awaiting legal determination of their right to remain in the United States. The City of New York's Health and Hospi- tal Corporation estimates that it lost about $ 57.5 million in fiscal 1982 because the Fed- eral Government and New York State refused to cover the cost of services provided to un- documented workers and their families. Con- cern about this loss of Medicaid reimburse- ment is the primary reason that New York City is currently suing the Secretary of Health and Human Services as well as the Acting Commissioner of the New York State Depart- ment of Social Services for Medicaid cover- age of undocumented aliens. The city maintains that the Medicaid eligi- bility requirement promulgated by the Sec- retary of Health and Human Services, which states that only citizens, legal aliens or Aliens in the United States Under Color of Law are entitled to Medicaid coverage, is in conflict with the Social Security Act, which explicitly does not exclude aliens from the Medicaid program. The city is also arguing that the eligibility requirement which excludes medi- cally needy persons from the Medicaid pro- gram solely because of their status as aliens is in conflict with the express purpose of the Medicaid program, which is to aid those indi- viduals whose incomes are insufficient to meet the cost of necessary health care. The irony is that if New York City wins, this victory could have negative long term - impli- cations for some of the undocumented, as shall be explained below. These attempts and pressures to limit the availability of publicly funded health care mean that foreign migrants who wish to as- sert their eligibility are likely to require a legal advocate who will argue their case in court. Needless to say, this option is unavail- able to all but a handful, especially after the cuts in legal services to the poor. Spurred by concern about the high propor- tion of whites non - among the current wave of migrants, about unemployment among United States citizens, and by fear that the deteriora- tion of the international economy will lead to a totally uncontrollable flood of aliens, as Grafica de Taler /Cdon Celia well as by humane considerations, the Gov- ernment appears on the verge of passing new immigration legislation. The expressed goal of this legislation is to stem the tide of illegal immigration. An implicit intent is to increase the employment opportunities of U.S. citizens who, some argue, must compete with undocu- mented workers in the labor market. 15 During the first two weeks in April both the House and Senate immigration subcommit- tees completed markup of the Immigration Reform and Control Act of 1983. On May 18th it was passed in the Senate. Passage in the House is expected in the next few months. The Act is basically a reintroduction of the immigration bill sponsored by Senator Alan Simpson (WY R -) and Congressman Romano Mazzoli (KY D -) which failed to pass in the House of Representatives during the lame- duck session of the 1982 Congress. Although the Senate and House versions of the bill differ to some extent, both retain the three major provisions of last year's - sanc- tions against employers who knowingly hire undocumented workers; a legalization or am- Health / PAC Bulletin 21 nesty system to cover all undocumented work- ers and their families who arrived in the U.S. before a specified date; and a continuation of the H - 2 program for the employment of tem- porary agricultural workers. Employer Sanctions Employers who knowingly hire an undoc- umented worker will be liable for penalties of $ 1000 to $ 3000 per offense. In the House ver- sion, employers of four or more workers will be required to verify the resident status of their employees. Documents such as a U.S. passport, social security card, birth certificate. driver's license, or alien identification card must be presented to the employer to satisfy this requirement. Critics of this aspect of the bill such as the American Civil Liberties Union, argue that employer sanctions pose a threat to civil lib- erties. Members of the Hispanic community, which would be a permanent target in any crackdown because of the large number of recent immigrants from Latin America and the Caribbean, have been quick to point out that since there would be limited resources for enforcement, the bill may actually encour- age discrimination or even blackmail along racial and ethnic lines. Employers may sim- ply refuse to accept as valid the documents of those they wish to avoid hiring. 16 The new legislation may also allow employ- ers to take advantage of workers who are un- 17 certain of their immigrant status. There are at least 26 different legal categories for those who are not legal permanent residents but have INS approval to remain in the U.S.: it is easy to conceive of ways in which employers could take advantage of employees'confusion about their status. employers With the new regulations in place, employers might express suspicion and threaten investigation to drive down wages or quell demands. Business groups such as the U.S. Chamber of Commerce have joined the Hispanic com- munity in criticizing the Bill, though their reasons, not surprisingly, are different. They point out that imposing sanctions on employ- ers who hire undocumented workers simply shifts the burden of enforcing U.S. immigra- tion law from the public sector to the private. Legalization or amnesty is a highly contro- versial aspect of the bill because it would grant legal status to migrants who are cur- rently working in the United States in viola- tion of the law. In the Senate version, aliens who entered the United States before January 1, 1977 could immediately apply for legal permanent residency status, and after five years for citizenship. Temporary resident alien status will be granted to all migrants who arrived after that date but prior to January 1, 1980 and also Cuban and Haitian entrants. After three years they would have the option of becoming permanent residents. Undocu- mented workers and their families who ar- rived after 1979 will not be eligible for am- nesty and will be subject to deportation. The House version is somewhat more liberal in this regard, setting January 1, 1982 as the cutoff date. One of the conditions that applicants for amnesty must agree to is not to apply for Federally subsidized health benefits for them- selves or their dependents for three to six years (depending upon resident status) after amnesty has been granted. In fact, they are ineligible for any form of Federal social wel- fare benefit during the period of temporary resident alien status and for three years from the date when permanent resident alien status is granted. Permanent resident aliens may ap- ply for citizenship after five years of residence. Having obtained Federal social welfare bene- fits before applying for amnesty would not automatically preclude achieving legal resi- dent status, but it could decrease the likeli- hood, since it might be argued in court that such people have not exhibited the ability to be self supporting - . Undocumented workers who brought themselves to official attention by applying for amnesty would therefore be taking a risk of deportation if they have been receiving Federal benefits. The 1982 Senate bill totally barred Federal assistance for the undocumented. The House version of the 1982 bill, however, contained provision for limited medical disability as- sistance to legalized aliens who are determined by the Attorney General and the Secretary of Health and Human Services to require medi- cal assistance in the interest of public health, or because of serious illness or injury; or to require assistance of some kind because of age, blindness or disability. The 1982 version also had a provision that each state can de- termine the eligibility status of aliens for state funded financial or medical programs as long as it remains consistent with Federal program restrictions. It is likely that the current ver- sion will have similar wording. Although the proposed immigration reform 222 Health / PAC Bulletin would ease the situation of those undocu- mented workers who are legalized, it would increase the difficulties of those who out of fear of rejection or for some other reason do not apply for amnesty, or who have arrived in the U.S. after the period designated by the legislation. Under the new bill these latter categories are likely to be large. This is prob- lematic, because analysis of the less restric- tive amnesty programs in Canada, Great Bri- tain and France during the 1970's has indi- cated that for an amnesty to succeed its terms must be attractive and threatening non - enough to encourage most of the undocumented com- munity to register. Finally, even if the employer sanctions and legalization were effective in stemming the tide of illegal immigration, another part of the bill would permit the continued hiring of temporary (H - 2) agricultural workers. In the Senate version of the bill growers would not be penalized for hiring undocumented labor- ers for at least the next three years to give them a chance to adjust their hiring to the new immigration law. This policy is aimed at insuring agricultural employers that their source of cheap labor will not abruptly be cut off. History has proved, however, that many migrants who enter as temporary workers choose to join the ranks of the more perma- nent undocumented by remaining in the host country after their temporary work permit has expired. Even though the diverse interests of groups concerned with the problem of illegal immi- gration have not been reconciled, 20 and even though in reality there is no conceivable way to seal the U.S. border against the flow of migrants, it looks as if we are about to get a new immigration law. If cynical, we might argue that the new bill is mostly window dressing, intended to allay the fears of a general public concerned about rising unemployment and increasing compe- tition for jobs. But this legislation may also serve a more important function. Although it won't stop the flow of migrants to the U.., it will help to control them while they are here. Those who choose to apply for amnesty will be subject to governmental control as well as employer intimidation, a new underclass of residents without full rights. Fearful of jeo- pardizing their immigrant status, they will be difficult to organize into unions. Those who choose to exist outside the legal mainstream will constitute a new marginalized subcul- MEXICO LNS /Lado LA Otro sis = | MIGRA El / Nichols ohn ture of laborers and employers. Any attempt to organize or unionize these " outlaw " work- ers may in itself constitute a criminal act. Their needs could legitimately go unrecog- nized, their rights unattended. Many critics question whether at a time of economic crisis the government is willing to provide the substantial additional resources needed to enforce the new law. They note that blaming rising unemployment and increas- ing competition for entry - level jobs on an in- flux of migrant workers is a well worn - stra- tegy for dividing workers. Since one of the major concerns dominating U.S. immigration policy is a desire to remain competitive on world markets, one might suspect that it is not by chance that the pending legislation would codify and create strata likely to be docile and willing to accept low wages. However miserable and degrading their conditions in the United States, foreign work- ers will continue to come by the millions as long as hope for a better life back home dries up, as Langston Hughes put it, like a raisin in the sun. To deny health and welfare services to these people - men, women, and children who are at exceptionally high risk by virtue of Health / PAC Bulletin 23 their living and working conditions - is a de- nial of human rights conferred by birth, not citizenship. 21. 16. Avila, Joaquin G., Immigration Non - Bill, The New York Times, Dec. 17,1982. 17. Hernandez, Antonia, Associate Council, Mexican American Legal Defense and Educational Fund, Sum- mary of Testimony Concerning the Immigration Re- form and Control Act of 1982, H.R. 5872 (S.2222) before the U.S. House of Representatives, Subcom- mittee on Immigration, Refugees and International Law, Committee of the Judiciary and the U.S. Senate Subcommittee on Refugee Policy, Committee on the Judiciary, Washington, D.C., April 1,1982. 18. Calvo, Janet, op. cit. 19. Avila, Joaquin G., op. cit. 20. Pear, Robert, " What the House Said in Not Voting an Immigration Bill, " The New York Times, Dec. 27, 1982. 21. Nickel, James W., " Human Rights and the Rights of Aliens, " from Brown, Peter G., and Henry Shue (eds.) The Border that Joins, Rowman Co., 1982. Notes 1. Burbach, Roger, and Patricia Flynn, Agribusiness in the Americas, Monthly Review Press, 1980. 2. Keeley, Charles, B., " Illegal Migration ", Scientific American, 246: 3, pp. 41 47 " 1982. 3. Dallek, Geraldine, " Health Care for Undocumented Immigrants: A Story of Neglect. " Clearinghouse Re- view, Aug./Sep. 1980, pp. 407 414 ". 4. Bevilacqua, Most Reverend Anthony J., Keynote Ad- dress, Conference on Undocumented Workers in New York City, Center for the Study of Human Rights, Columbia University, N.Y.C., May 6-8,1982. 5. Arnold, Fred, Providing Medical Services to Undoc- umented Immigrants: Costs and Public Policy, Inter- national Migration Review, 13: 4, pp. 706-715 1979. 6. Yeager, Martin, " Illegal Aliens: The Potential Mag- nitude of the Problem, " American Hospital Associa- tion, Office of Public Policy Analysis, Policy Brief no. 14, Nov. 17,1982. 7. 7. Dallek, Geraldine, op. cit. 8. 8. 8. Arnold, Fred, op. cit. 9. New York City Department of City Planning, Popula- tion, Research and Analysis, 1980. 10. Leichter, Franz S., New York State Senate, 29th S.D., " The Return of the Sweatshop ", Feb. 26,1981 mimeo () . 11. The City of New York: " Report of the Comptroller: The Status of Tuberculosis Control in the City of New York " Office of Policy Management, Aug. 13, 1982. 12. Dallek, Geraldine, op. cit. 13. For a more complete discussion of legal access of undocumented workers to health services in New York City, see " Undocumented Workers in New York Legal Access to Health Care ", memo, Nov. 4, 1982 by Janet Calvo, Director, New York University Law Clinic. 14. Intervenor Complaint. The City of New York and the New York City Health and Hospitals Corporation against the Secretary of the United States Depart- ment of Health and Human Services and the Acting Commissioner of the New York State Department of Social Services, U.S. District Court, Eastern District of New York, 1740 79 - Civ - (IBW). 15. Pear, Robert, " New Drive Under Way in Congress to Revamp U.S. Immigration Law ", The New York Times, Feb. 22,1983. $ 125 Abrams /Moilzer Kathie continued from p. 4 The PAC's are perfectly legal and their con- tributions generally go for the slightly more reputable purpose of spattering campaign spots on the air. Future generations, never- theless, are likely to find it pathetic that while tens of millions of Americans are deprived of health care by financial constraints, political contributions by a relatively few health care corporations and professional groups play the predominant role in determining how tens of billions of public health dollars are spent. Jon Steinberg Readers who would like to know exactly where specific health PAC's fas opposed to Health / PAC) contributed money can drop us a line; we'll be happy to share our detailed information obtained from the Federal Elec- tions Commission. + 24 Health / PAC Bulletin Bulletin Board Legal First Aid Readers of the Health / PAC Bulletin will certainly be interested in the facts contained in each issue of the Health Advocate, news- letter of the National Heath Law Program. Sub- scriptions are $ 15 a year, payable to NHeLP, 2639 S. La Cienega Blvd., Los Angeles, CA 90034. to 1970, are looking for photographs, home movies, tapes * art, letters, etc, for possible inclusion. They ask that you write and tell them what you have but do not send original material. AH responses will be kept strictly confidential. Contact them at Before Stone- wall, 630 Ninth Ave., Suite 908, New York, NY 10036, or Mass Productions, 110 First Stt San Francisco, CA 94105 / WIOES Whys The Western Institute for Occupational and Environmental Sciences produces books, pamphlets, fact sheets, tapes, and audio visual - materials on subjects ranging from " A Work- er's Guide to the Federal Employees Compen- sation System " to " PCB V to " Allergic Disor- ders. " For a literature list write WIOES, 2520 Mil via Street, Berkeley, CA 94704. Whole Health Catalogue The 1983 Guide to Health Oriented - Periodi- cals is now available, listing everything from the Health / PAC Bulletin to publications on raw foods and spiritual health. Each entry includes a brief description of the publica- tion. Copies of the Guide are $ 3.95 plus $ 1 postage from Sproutletter Publications, P.O, Box 60, Ashland, OR 97520. Canadian Propaganda Free information on acid rain, long range transport of air pollutants (LRTAP), and health is available from the Information Directorate, Health and Welfare Canada, Ottawa, KIA OK9, Canada. Ask for copies of the brochure " Acid Rain, LRTAP, and Your Health " and / or the booklet " Acid Rain and Your Health. " What's In The Wind, a 17 minute - videotape, is available on loan. Toujour Gai The producers of " Before Stonewall, " a public television - funded documentary on the U.S. lesbian and gay male community prior Ayuda Despite tremendous advances - popular health campaigns, virtual elimination of polio and measles, massive vaccination programs, construction of clinics Nicaraguan - officials readily admit that there is much to be done. Their work and popular health is suffering acutely from U.S. economic, military, and political pressures. Resources, from small items like thermometers and gloves to techni- cal equipment, are urgently needed. Two American medical students, Jim Krieger and Jan Diamond, recently completed a study tour for the World Health Organization and collected an extensive list of materials needed in the hospitals and clinics. In addition, they report that the Nicaraguan government is very eager to arrange lecture tours for M, D / s and professors in technical fields such as respira- tory therapy. For further information, contact Jim Krieger, 131 Belvedere St, San Francisco, CA 94117,, (415) 753-0475; or Richard Garfield, 910 Riv- erside Drive, New York, NY 10032, (212) 927- 1921. Let Them Eat Poison For Export Only: Pills and Pesticides, a two- part film series dealing with the export of products banned in the VS. to the Third World, is available from Icarus Films. Part I deals with Pesticides, Part II with pills. Each is 56 minutes and rents for $ 100. Write Icarus at 200 Park Avenue South, Suite 1319, New York, NY 10003. Health / PAC Bulletin continued from p. 5 of Defense has launched a new offensive to sign doctors up for the fastest growing - practice in the country the U.S. Armed Forces. The Air Force approach is subtle. First the doctor receives a set of golf balls anonymously in the mail. Next the postal carrier brings an anonymous set of tennis balls. Then comes a full color brochure with the pitch you'll have more leisure time with the Boys in Blue. The Army and Navy have a more preremptory approach. Undeterred by the failure of the Equal Rights Amendment, they have begun a drive to re- vive the old " doctor draft " but this time with the inclusion of registration (and therefore po- tentially draft) of women phy- sicians, nurses, physical thera- pists, pharmacists, podiatrists, veterinarians, and " any other ancillary or technical " health care workers between the ages of 18 and 46. Lt. Col. Tom Schumann, director of health manpower at the Pentagon, ex- plained to columnist Ellen Goodman of the Boston Globe that " it's just a need. When you consider that many of the health - care occupations are composed primarily of females, you're not going to get the numbers you need if you can't go after the females. " The DoD has already brought proposals to the American Medical As- sociation and the American Nurses Association to obtain their support. We anticipate that not to be outdone by its earthbound com- petitors the Air Force may soon add another mailing to its se- ries: a draft notification letter accompanied by dog tags, I.D. bracelet, and radiation detector. Caseload Victory As readers of the Bulletin (Volume 13, No. 6) will recall, the Visiting Nurses Association of Cleveland strike was parti- cularly significant because the primary primary issue issue was was the the nurses nurses'' attempt to gain control over caseload, which has tradition- ally been a management pre- rogative. After maintaining their strike for six months while manage- ment refused to negotiate, the nurses won a contract which they unanimously accepted. Although it does not stipulate a specified caseload ceiling as they demanded, the nurses re- gard the settlement as a victory. Caseload is now covered in the grievance procedure and objec- tive standards have been estab- lished for determining how heavy it should be. Nurse com- plaints about excessive loads. still must go up through man- agement, but provision is made for an outside arbitrator if there is no satisfactory resolution. Structural changes have al- ready been made at VNA to ease workloads, including in- stallation of dictaphones for the nurses and efforts to make clinical supervisors more re- sponsive to field nurses. Man- agement has promised to hire more staff, including central intake personnel to facilitate referrals. Why VNA offered a reason- able settlement after months of refusing to negotiate at all is unclear. One possibility is that it feared its reputation would be irreparably harmed by the nursing shortages and inade- quacies of many nurses brought in during the strike. After the six month strike only 13 of the 44 nurses who had originally walked out re- claimed their jobs; tensions and bitterness are reported between them and the RN's who did not join them. The strikers'Ohio Nurses Association still repre- sents the agency, and they are trying hard to win their col- leagues over soon since a re- certification election could be called as early as this summer. Health Tacks Members of Congress seem to get as much pleasure from marking up the U.S. Tax Code as adolescents do from putting their imprint on a public toilet, but the results are considerably less benign. In 1982 1,846 new deductions, credits, and exclu- sions were proposed to expand loopholes already allowing an estimated $ 253.5 billion to es- cape the Treasury every year. As taxpayers know, the main beneficiaries of recent changes in the tax structure are the rich; when the regressive Social Se- curity tax increase is taken into account, many lower income - people are actually paying more taxes than ever. This broader redistribution- ist policy applies in taxes re- lated to health care. The new limits on personal medical de- ductions and the Reagan Ad- ministration's proposed tax ex- emption ceiling on employ- ment related - health insurance contributions are well publi- cized. Some proposed new treats for the wealthy, however, have received less attention. Representative Phillip Crane (IL R -) has gone beyond the dictum of " You can't take it with you, " to propose that " At least we'll make sure the gov- ernment doesn't get it. " His legislation would give a special $ 25,000 deduction on final in- come tax and on estate tax for deceased persons who donate an organ for transplant. Crane argues that if his write- off is adopted, livers, bladders, and other organs will soon be piling up in the donor banks at continued to p. 30 26 Health / PAC Bulletin * Recap on Teeth by Arthur A. Levin (Due to an error, the begin- ning of the Body English Col- umn in the previous issue was omitted. We apologize for any inconvenience, and in this col- umn combine a coherent ver- sion of the previous one with new material scheduled for this issue. L ed.) The humorist S.J. Perelman once wrote that every few years he decided it was time to allow wild Mongolian horses to drag him to the dentist. Many others who make it on their own eagerly snap up the two year old copies of Time and Read- er's Digest in the waiting room, hoping their remarkable resem- blance to quivering jello will pass unnoticed. Although almost one tenth of the population has never graced a dental chair, such re- actions do not arise from fear of the unknown. By age 65, one half of the population chews its potatoes with teeth first placed in the mouth by the firm fingers of a dentist. In 1977 it was estimated that by age 15 the average adolescent has 11. decayed, missing, or filled teeth. The anxiety, the sense of vul- nerability, and the power rela- tionships inherent in the ex- amination and manipulation of our bodily orifices by some- Body English one outside a peer relationship are a fascinating topic. We won't discuss it here. The next two columns will be limited to teeth, the mouth, dentistry, and dentists. The dental profession tells us that many problems associ- ated with teeth are preventable through regular dental care. Even dentists, however, agree that as far as caries are con- cerned, the elimination of sugar from the diet and fluoridation of water are probably the most effective preventive efforts. To their credit. dentists have long practiced preventive care through educating their patients about the dangers of sugar and the need to brush and floss ef- fectively as well as by provid- ing dental hygiene services. In this respect they are different from physicians, who have tra- ditionally been less concerned with prevention and education than with invasive, curative approaches. Dentistry as a profession dif- fers from medicine in other ways as well, although many people believe that the educa- tional requirements are equally rigorous. Unlike medicine, for example, it remains a general- ists'profession, although there has been an increasing trend towards specialization over the past decade. As in medicine, specialists are required to com- plete at least two years of train- ing beyond the basic four year course. The specialty areas in- clude: Periodontics, which concen- trates on treating gum disease and related tissue diseases with deep curettage and surgery. Endodontics is treatment of disease affecting the inside of the tooth, pulp, and nerves. Root canal work is one example. Orthodontics takes care of teeth that are out of position and other oral defects. Children with braces know such special- ists all too well. Pedodontics is a general dentistry for children. Oral Surgery is concerned with extraction. While many generalists do simple extrac- tion, complicated or extensive surgery will most likely be re- ferred to a specialist. Oral sur- geons have more experience with inhaled and intravenous anesthesia, and therefore are deemed better able to avoid or treat any anesthetic complica- tions. Oral Pathology involves di- agnosis and treatment of dis- eases the of oral cavity, includ- ing malignancies. With the exceptions of oral pathology work and orthodon- tics, most generalists can prob- ably do much of what the spe- cialist can. Whether they do it as well is a matter of debate within the profession. There is evidence in medical literature that greater experience and ex- posure to cases and procedures often produces better results. The whole subject of quality control in dentistry is murky. As many patients will attest, it is difficult to know whether you are receiving good care or bad until you suffer from the latter. Because most dentists are in solo practice even if they share an office, there is little opportunity for concurrent peer review. Judgements on _ per- formance usually occur only when the patient becomes dis- satisfied and visits another practitioner. Any bad mouth- - ing of a predecessor's work at that point doesn't improve the physical condition of the pa- tient; in any case the new den- ^ Health / PAC Bulletin 27 tist's bias is difficult to measure. There is strong evidence that dentistry could benefit from quality assessment and assur- ance. A 1974 survey showed that one half of all dental x rays - submitted to Pennsylvania Blue Shield were unsatisfactory for diagnostic purposes. Other studies have outlined addition- al areas of poor quality dentistry that could benefit from quality control. Since dental care, like medical care, is largely elective and very seldom life saving - , the potential for abuse looms large. Under our current fee serv- - for - ice system a dentist's income, like a physician's, is based on the number of procedures done, so there is an incentive to do more than is required rather than less. Only a handful of states at- tempt to compensate for the lack of quality assurance and peer review opportunities by requiring continuing education for relicensure. In another handful of states, dental socie- ties require continuing educa- tion as a condition of member- ship. However this may be lip service: there is scant evidence that continuing education alone improves quality. Many authors have written guidelines to help consumers pick a dentist who offers the appropriate high quality care. A list of negative practices may provide the easiest method for spotting the poor, inappropri- ate dental care which should be a signal to seek another prac- titioner. The following are some of the most easily recognized dental flaws: * Does not provide emer- gency care. * Does not take a complete dental and medical his- tory, including medica- tions being used, if any. * Does not do a complete examination of the oral cavity, both visually and day than a decade ago, fluori- with fingers. dation and other measures have * Does not use a probe to reduced the amount of dental explore and examine your diseases requiring treatment. gums. Traditionally, general dentistry * Does not provide instruc- practitioners have gotten most tion in good preventive of their gold from filling cavi- care, particularly brushing ties; today it is not uncommon and flossing techniques. for young people to remain * Does not discuss treatment virtually decay - free if they have plans and fees in advance. been drinking fluoridated water * Does not use a lead apron all their lives, followed some when taking x rays - to basic dietary rules, and brushed shield reproductive or- and flossed regularly. gans and does full mouth Gum disease is currently the x rays - frequently (see the biggest threat to tooth loss, and Body English column in many of the known preventive the May June / 1982 Bulle- efforts for problems related to tin for a more detailed it or dental caries are matters discussion of this.) * Does not have the neces- sary equipment to treat you for an allergic reaction to anesthesia. * Does not appear to realize your mind is in the same head as your teeth and mouth. The practitioner should answer all your questions, fully describe the treatment plan, and discuss the pros and cons of options based on your individual needs. re- sources, and preferences. No list can be complete, nor can it assure quality care. Choosing a good dentist is not an easy task and will most like- ly involve some trial and error. Many of the above practices can be checked during a first visit. If your judgement is that the care you are getting is not what it should be, or unneces- sary, it's time to change den- tists. Because the number of prac- titioners is growing much fast- er than the number of patients, the laws of supply and demand work in the consumer's favor giving you some control over both quality and costs. Although more people prob- ably have dental coverage to- of individual behavior - diet, dental hygiene - rather than professional care. Like motherhood and apple pie, the wholesomeness of the semiannual dental checkup is now in question. The only scientific study of the dental checkup, described in Lancet in 1977, concluded that there was no demonstrable benefit for patients who came in twice a year compared to those who had less frequent checkups. The authors say that dental caries in adults take two years to prog- ress to the point of penetrating tooth enamel, and this should be the major factor in setting standards for examination fre- quency. They did agree that those who had twice yearly dental examinations had slightly less tooth loss than those who went less frequently, but pointed out that in the latter group 50 per- cent of the dental caries left un- treated remineralized by them- selves, and people who visit more often run a higher risk of overtreatment, greater x ray - exposure, and thinner wallets. Since adolescence is the most active caries period, the Lan- cet study concluded that a 12 continued to p. 31 2208 Health / PAC Bulletin Media Scan Irving Kenneth Zola, Missing Pieces: A Chronicle of Living With a Disability (Philadelphia: Temple University Press, 1982, paperback, 246 pages). Medical sociologist Irving Zola had spent a lifetime think- ing about illness and health. Yet as a husband, father, coun- selor, teacher, and writer, he went about his business as if the braces and cane he had car- ried since adolescence as a re- sult of polio and an auto acci- dent were no more a part of him than the car he drove. Then, during a 1972 sabbati- cal from Brandeis University at the Netherlands Institute of Preventive Medicine, he spent a week at Het Dorp. Specially designed and medical self contained - , but not a medical institution, Het Dorp was a community in which 400 disabled adults re- sided, worked, and played. Rather than just observe, Zola placed himself in a wheelchair. What could have been an an- thropological exercise became a rite of passage. Zola redis- covered his disability and be- gan another rehabilitation with the help of the Dorp's residents. Missing Pieces is the account of this turning point in his life, blending personal confession with social observation to create a success story with a new message: If we overcome our weaknesses by denying, we diminish ourselves and others; by recognizing weaknesses, we lay the cornerstone of a new integrity. That it took ten years for this story to be published is evi- dence that Zola and Het Dorp were ahead of their time. It was only after many friends had read the manuscript that he decided to submit it for publi- cation. The list of publishers which rejected it is long. Zola persevered. His concern seems to have been not so much " Can society be reformed? " as " Can the reader be rehabilitated? " When he first arrives at Het Dorp, Zola feels it's too good to be true. Among its innovations are giving residents the ability and the room to move - 90 per- cent use wheelchairs - and pro- viding attendants who are al- ways on call to carry out the residents'instructions. He fears that residents will see through his act, but once in a wheelchair he finds that he has become handicapped in new ways. He has chosen sides; the staff is suddenly no longer available for interviews. Shop- ping at the supermarket, open- ing and closing doors, getting dressed, and visiting become tests of the assumed identity. " Washing up was a mess, " he relates, " Though the sink was low enough I nevertheless man- aged to soak myself thorough- ly... My body angle in a wheel- chair was different... splash- ing with water was out, and the use of a damp washcloth, what I had once called a sponge- ' bath,'was in. Again a patient- childlike feeling swept over me, but I was too busy coping to let it stay. " Mastering the chair gradual- ly, he learns the symbolism of (im-) mobility, how much we rely on images of the body to describe the spirit's condition. There is nothing good about being disabled, Zola believes, even if " being of sound mind and body " isn't all it's cracked up to be. He is all the more able to in- terpret the deeper stigmata of disability because Het Dorp has eliminated so many physi- cal signs and obstacles - atten- dants'white coats, architec- tural barriers, prohibitions on various kinds of work and play. At the Recreation Room, the Equipment Adaptation Room, the sheltered Workplace, the Administration, the Gala cele- bration, and the Council meet- ing, Zola discovers, as one of his chapter titles says, " It all depends on whether you stand or sit. " As he also becomes aware, the Administrative still regards the community's rights as priv- ileges and treats residents as dependents. A pecking order within the community is no less problematical. More than by class differences, the com- munity is divided by the dis- tinction between disability and disease. Although one require- ment for membership is medi- cal stability, about 40 percent of the residents have progres- sive conditions such as multi- ple sclerosis. Because the Ad- ministration asks people to leave when their condition de- teriorates, the fear of exclusion is acted out in prejudice di- rected against the less healthy by the healthier. Are these sour grapes simply the natural taste of an aca- demic? Perhaps that could be argued if the rest of the author's body were not engaged in the affair. Zola becomes a critical booster of the Dorp because the members he meets hold this perspective. With their physical needs met for the first time, Het Dorp ^ Health / PAC Bulletin 29 residents must begin to undo a lifetime's socialization. Even there, as Missing Pieces shows, they have to be exemplary stu- dents to survive - in fact, a dis- abled person can be defined as someone who does not take learning for granted. We have labelled this capa- city to learn through overcom- ing a " handicap. " For most of us rehabilitation is too painful to think about, let alone to ex- perience. Even Zola in this autobiography " socio -, " as he calls it, borrows the form of Utopian narratives in which the brave new world sheds light on the old. Although the residents claim him as one of their own, Zola clings to the view of a " normal " outsider. In choosing his subjects, he not unwittingly finds people who are self sufficient - as he is. Whether they have paraplegia or multiple sclerosis, most are active enough in and outside the community to excite mu- tual envy and admiration. In his conclusion, Zola spec- ulates about such missing pieces pieces as as sexuality sexuality,, anger anger,, vul- vul- nerability, and potentiality. He shows why social barriers are more destructive than archi- tectural ones; why the personal and the physical are political. This is such a " political " book that the word is hardly used or needed. It is all the more striking, therefore, that Zola ignores the work of the grassroots move- ment of disabled people of which he is a member. Since the early 1970's this movement has grown on a mixture of civil rights and self reliance. How can an American sociologist write about Het Dorp without mentioning the centers of in- dependent living in the U.S.? How can a founder of the Bos- ton Self Help - Center not in- clude illustrations from his own organization's files? The appeal to self inte-r essootn e-r or later we will all be disabled- may raise the reader's con- sciousness, but minimizing the efforts of disabled folks to change matters risks trivializ- ing any political action on their behalf. This missing piece in an otherwise fine chronicle may remind readers of the Health / PAC Bulletin that in 15 years of publication we have supported the right to health care of al- most every other minority but have virtually ignored the con- ditions of the group that is al- most synonymous with the con- sumption of illness in our so- ciety, the physically disabled. This is not merely a lapse, it is a problem. As Missing Pieces suggests, if we cannot rehabil- itate ourselves we will never be able to prevent disease in others; it will always seem easi- er to bury mistakes than to confront and eliminate them. Carl BJumenthal (Carl Blumenthal has worked for the Massachusetts Multiple Sclerosis Society and is a member of the Health / PAC Board). continued from p. 26 a rate of 10,000 a year. He pre- dicts the savings would be sub- stantial, including at least some of the $ 3 billion Medi- care spends each year on kid- ney dialysis. What Crane doesn't mention is that under his plan the value of a pound of flesh would vary considerably. Since how much deductions are worth depends on the tax bracket, the wealthy would gain far more from do- nating a posthumous cornea than would those who pay lit- tle tax or the two thirds who do not itemize deductions at all. Only estates valued at more than $ 275,000 are now taxed, so no one but heirs of the rich would derive any benefit from the second $ 25,000 write - off. Perhaps a kidney fed on pate de fois gras and caviar is more valuable, but we'd like to see the scientific data. Representative Frank Guarini (NJ D -) has contributed some- thing for the wealthy while they are still alive - at least for those who work. He attached an amendment to the gasoline bill that that sailed sailed through through Congress Congress last year which restores the deductions for for conventions conventions aboard American - owned cruise ships. For the first time since 1980 doctors will be able to en- joy their Continuing Medical Education credits and their sun all the more, knowing they are publicly subsidized. So far only four vessels qual- ify two - Mississippi steam- boats and two Hawaiian cruise ships but President Reagan's Caribbean Basin Initiative would extend the deductible conventions to include any in the Caribbean (except in Cuba and Nicaragua), including those on ships stopping there. If this proposal goes through, course material for health pro- fessional cruises would be easy to find. For starters, we suggest " Sunburn, Sunstroke, and Sun Oil Depletion Allowances "; " Portal Hypertension and Port- of Call - Portfolios "; and " Tropi- cal Medicine and Tropical Tax Havens. " 3800 Health / PAC Bulletin continued from p. 28 month interval between exami- nations might be best for ages 12-16, and 18 months for those above 16. Many dentists, it should be said, believe this is too seldom, basing their con- clusions on their own practical experience. Hopefully further scientific studies will resolve the issue. The etiology of dental dete- rioration (both caries and gum disease) is believed to be close- ly linked with the way we live principally the way we eat. What we know as a cavity is the result of progressively de- structive infectious dental car- ies. The bacterial organisms responsible for the damage are locally concentrated on a spe- cific site in the form of what is known as bacterial plaque, a kind of gooey layer that adheres to the surface of the teeth. In the presence of sucrose, glu- cose, and fructose (all forms of sugar), a fermentation process occurs. This leads to a drop in pH, the concentration of hydro- gen ions, which is more com- monly known as acidization. Repeated cycles of this pro- cess cause demineralization and development of the so- called " carious lesion. " Begin- ning in 1960, researchers, no- tably P.H. (no relation to pH) Keyes, established that a bac- teria known as streptococcus mutans may be the prime cul- prit. Other bacteria have also been implicated, lactobacillus- acidophilus and various acti- nomyes. Irving D. Mandell, DDS, notes that the human mouth is a virtual paradise for S. mutans: warm, moist, and " replete with a profusion of gourmet foods to dine upon. " His portrait of the epidemiol- ogy of dental caries is remark- ably similar to descriptions of the other major diseases thought to have a dietary connection. Caries was in evidence even before the Iron Age, although it has been found in less than five percent of the teeth from that era examined. Through the Roman era and later the in- cidence stayed around ten per- cent. Towards the end of the 17th century, however, a dra- matic increase began in the in- dustrialized world. The only break in this steady rise oc- curred during World War II, when European countries ex- perienced a marked drop. Epi- demiological studies of caries in in the the 1950's 1950's and and 1960's 1960's which which compared industrialized na- tions with less developed areas of the world found caries was much more common in the more prosperous countries, what might be called the Can- dybelt. More recently research- ers have found that as nations have industrialized and adopted Western diets (that is, eating habits, not Beverly Hills), car- ies incidence has risen. Many epidemiologists have concluded that this pattern points the way to a noncario- genic diet, consisting of the following: 1. A relatively low exposure to sucrose, fructose, and glu- cose. 2. A lot of fibrous foods. These promote vigorous chew- ing, stimulate salivation, and have a natural " toothbrush - like effect. " 3. Eating foods with " pro- tective factors " such as trace minerals and other ingredients not clearly identified as yet. In contrast, the cariogenic diet which became widespread toward the end of the 17th cen- tury contains large quantities of refined flour and sucrose. The latter was consumed in the form of sugarcane products, then flooding the market at moderate prices. Thus it could be said that there was a strong connection between slavery and the rise of tooth decay. By the twentieth century sugar consumption had soared to an average of 125 pounds per year per person in the U.S.. roughly the equivalent of eat- ing five jellybeans every wak- ing hour. Much of this is in the form of sucrose or corn syrup, both used to sweeten every- thing from ketchup to frozen egg rolls. It would be fair to assume that sugar is the first ingredient listed on more than half the prepackaged food con- tainers in any kitchen cabinet. Although few people would say only diabetics should avoid 125 pound sugar cubes, most experts believe that the pattern, form, and frequency of sugar ingestion are the most impor- tant factors in producing caries. Although it is reasonably clear that the so called - " me- chanical " variations - fluorida- tion, good brushing and floss- ing techniques frequently per- formed as well as dietary modifications can reduce sus- ceptibility or increase resis- tance to caries, we still don't know why some people will develop them and others with similar habits will not. Never- theless, anyone with teeth is lengthening the odds of keep- ing them by following a diet low in sugar and high in na- tural, coarse grains and prac- ticing good plaque control in oral hygiene. The next Body English col- umn will complete our writings on dentistry. (Obviously oral problems should be heard, and we invite our listeners in New York City to listen to the Body English program on WBAI every fourth Thursday of the month at 3 p.m.) The final col- umn will discuss current con- troversies in treatment of gum disease; concerns about the adverse effects of excess expo- Health / PAC Bulletin 31 sure to fluorides and mercury; and what's new in dental tech- niques. Arthur A. Levin is a member of the Health / PAC Board and Di- rector of the Center for Medi- cal Consumers, publisher of the newsletter Healthfacts. a Health / PAC Health Policy Advisory Center 17 Murray Street New York, New York 10007 2nd Class Postage Paid at New York, N.Y. 4fr **