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HEALTH / PAC Health BULLETIN BULLETIN PoliAdcviys ory Center Volume II, Number 5 0017-9I0S51S NM ay / June, 1980 HPC BAR II (5) 1-36 : 1 Losing Patience: A LOOK BACK AT CORPORATE MEDICINE IN THE ASBESTOS INDUSTRY. Recently un- covered Johns Manville - internal documents from the fifties reveal a broad pattern of cor- porate medical abuse. 3 Vital Signs 23 The 1981 Health Budget: TROUBLE AHEAD, TROUBLE BEHIND. Carter's 1981 budget, plus inflation, promises deep cuts in health services. 15 Columns URBAN: Philadelphia Sans PGH WORK ENVIRON / : Return of the OSHA Cancer Policy WOMEN: Hyde Amendment Overturned: Things May Get More Fair THE FIFTH COLUMN: NY Nurses Hit the Bricks 32 Media Scan The Therapeutic Touch by Dolores Krieger Losing Losing Patience Losing Patience A LOOK BACK " What AT CORPORATE did he know? And when did he know MEDICINE IN it? " These terse questions by Senator Howard THE INDUSTRY ASBESTOS Baker cut straight straight to the heart of President President Nix- Nix- on's culpability in the Watergate scandal. They are no less apt in establishing the culpability of the asbestos industry in the scandal of epidemic deaths among asbestos workers. What did the corporate management of the asbestos industry industry know about the certain deadliness of asbestos exposure to its workers, and when did they know it? Medical studies for over half a century have singled out asbestos as a major occupational killer. (See Health / PAC BULLETIN, No. 61, Nov. - Dec., 1974.) Yet for years Johns- Manville, giant of the US asbestos industry, with over $ 1 billion in sales annually and 21 plants across the US, publicly denied or minimized its lethal role. Retrospective ex- amination reveals overwhelming circumstan- tial evidence that for decades Johns Manville - has acted with the full knowledge of damaging medical consequences to its workers. Yet like Watergate, circumstantial evidence, no matter how overwhelming, is insufficient to finally establish culpability, either among large segments of public opinion or in many courts. Whether the epidemic of asbestos deaths was the unfortunate, but unforeseen consequence of ignorant, well meaning - corporate decision- makers or the necessary human cost of a carefully calculated corporate decision, rests upon finding the " smoking gun " -irrefutable, self incriminating - evidence that those in ques- tion acted in full knowledge of the conse- quences of their actions. For President Nixon, the smoking gun was discovery of the Watergate tapes. For the Johns Manville company, the smoking guns are just coming to light as the result of legal re- quests in literally thousands of lawsuits being waged against the asbestos industry by workers, consumers and their families. The following series of medical conferences on workers'health were conducted by Johns- Manville corporate medical staff during the period 1957-58, long after asbestos was recognized by industry to be an occupational health hazard, but still several years before it was brought to public and broader medical at- tention as a serious health hazard. These reports were introduced into the public record and verified as authentic by Johns Manville company officials during the now famous - case of Vela vs. Wise, in which a worker received $ 365,000 in a successful suit against a corporate physician for not informing him of his asbestos - related illness. The records were obtained from the company by Paul Gil- lenwater, a Knoxville attorney representing asbestos workers and users in a number of re- cent suits, who has made them available to Health / PAC. The reports are especially illuminating of the multiple roles played by Johns Manville - M (J -) corporate physicians www.www.B.com.ca.com roles as doctors, law- 2 yers and managerial officials. They show in case after case delays and failures to inform their worker / patients of known or suspected medical conditions and attempts to disguise or gloss over the seriousness of their signs and symptoms. These reports highlight the critical conflict of interest which company physicians face are they primarily legal advisors to and protectors of their corporate employers, or are they primarily medical advisors to their work- er patients /? Or can they be both simultaneous- ly without compromising one interest or the other? What They Don't Know Won't Hurt Us In some cases physicians simply decided not to tell workers of known or suspected medical conditions. For example, in the follow- ing two cases doctors observed possible lung tumors in the X rays - and yet decided explicitly not to tell the affected workers. In the first case, this is indicated on the record by the notation " No H.C. " or No Health Counselling. (All em- phases and insertions in this and following quotes are the author's.) The first case oc- curred during the medical conference of July 10, 1957: Patient A: Male, 50 years old. Hired in 1932. " Minimal " exposure to silica, asbestos fibre, Portland Cement - 12 years. X ray -: Equivocal area of increased density right apex... Diagnosis: Might be infection or tumor. No oc- cupational disease or TB. X ray - changes of un- known origin. Dr. Z: 1. No tab 2. No AHS (Air Hygiene Survey) 3. Do not notify plant manager 4. No H.C. (No Health Counselling). In another case, at the conference of April 9, 1958: Patient B: Male, no age given. Nurse W: On 3/26/58 - -[ Dr. A, a physician af- filiated with the Somerset County, NJ Tuber- culosis Association] reported-'Presence of a solitary lesion at the right 5th anterior rib and interspace, is confirmed. I am unable to iden- tify it in earlier films, although it is suggested a year ago by a much smaller slight density. A question is raised as to whether a similar densi- ty lies peripherally to it. I would advise this le- sion being evaluated. Solitary nodules raise a question of neoplasm as well as TB which should not be ignored. Continued on Page 7 " << GOING OVER LIKE A LEAD BALLOON Lead poisoning, like drug abuse, is moving out of the ghetto and into the suburbs. Re- cent surveys in Baltimore and Philadelphia have found half of the reported cases of childhood lead poisoning outside the so- called " lead belt " or " inner city. " Children from middle and upper middle class homes in rural Dutchess County, New York, and Litchfield County, Connecticut, were found with excessive lead levels. More than 40 percent of children tested in Charleston, North Carolina, had excessive blood lead levels. Even ten years ago ingestion of lead paint, the classical source of lead poison- ing in children, could account for only three of four cases. Now, old cracking and chipped paint accounts for about half of the detected cases, while the epidemic grows. Between 1973 and 1978, 163,000 children were found with undue lead absorp- tion, 21,000 21,000 requiring intensive treatment. On some fronts efforts to minimize lead exposure have been successful. In 1971 so- called " lead " pencils were found to have as much as 12.5 percent lead on their painted surfaces (and, of course, none in their graphite " leads "). The standards, self imposed - by the Signs Vital Signs manufacturers themselves, limit this now to no more than one percent lead paint. (The old wives'warnings were prudent!) Under pressure from the FDA following surveys of evaporated milk showing potentially hazar- dous lead contents, the infant formula industry has presented evidence on the impact of lead soldering used to seal canned baby foods. The industry's representatives have presented studies showing little measurable increase in lead content during the canning pro- cess of their evaporated milk, canned infant formulas, canned Children of lead workers and those living near lead smelters have been shown to be particularly vulnerable to lead poi- soning.... Meanwhile, President Carter is relax- ing restrictions on the use of leaded gasoline a fruit and vegetable juices, and glass packed - baby foods. Dr. Herbert Needleman, chairperson of the Center for Disease Control's advisory com- mittee for the prevention of childhood lead poisoning, recently published a study of over 2,000 children from Chelsea and Somerville, Massachusetts, two working class suburbs of Boston. Playing the role of the Tooth Fairy, Needleman and his associates collected the deciduous teeth of first and second graders and ex- amined them for their lead con- tent. Controlling for their parents'education, socio- economic status, and I.Q., the study demonstrated marked dif- ferences between high- and low lead - exposures in teachers ' behavioral ratings and in a broad battery of intelligence and performance tests. This confirms other studies which have found higher incidence of gross and fine motor problems, irritability, impaired cognition, and hyperactivity among lead- exposed children which appear to become permanent at some point without treatment. All these problems, Needleman learned, were dose related -, undermining the long standing - belief that blood lead levels below a certain value were " safe. " Few, if any, of these children had been exposed to lead paint. Increasing evidence has shown that the major sources of - lead today are airborne par- ticles inhaled and fallout in street dust and soil. The lead content in one gram (roughly, teaspoon) of New York City street sweepings or dirt from MacArthur Park in Los Angeles (remember, " All the sweet green icing flowing down "?) contains ten times the permissi- ble daily intake for small children. Only small amounts of such dirt ingested regularly would provide potentially dangerous amounts of lead. And just this happens. A recent study of children in Rochester, New York, demonstrated how household dust concentrations of lead correlated with the children's blood levels and such common habits as dirt eating - , thumb sucking - , and mouthing objects. The source of 98 percent of this airborne lead fallout is automobile exhaust. Much of this comes from the combustion of leaded gasolines, but with the energy crisis, increasing amounts are coming from diesel 3 fuels with their heavy par- ticulate emissions. The En- vironmental Protection Agency recognized this, and in 1978 directed states to develop monitoring programs for lead levels in the air and to begin control mechanisms where levels were above accepted standards. The EPA then pro- posed more stringent standards for air lead levels, originally scheduled to go into effect last year. Since the latest energy crisis, however, the Department of Energy has advocated further relaxing the current restrictions on the use of leaded gas. Presi- dent Carter, persisting with his " moral equivalent of war " until he actually has one, has ordered the EPA to delay im- plementing the lower standards for the legal amounts of lead permitted in gasoline. Knowledge about the some 20,000 particulate compounds emitted in diesel exhaust is in such a primitive state that stan- dards remain years away. The problem of lead pollu- tion, however, remains ubi- quitous with the intellectual development of countless children at stake. Children of lead workers and those living near lead smelters have already been shown to be particularly vulnerable. Recently, analysis of vegetables grown in urban " greening " gardens have shown unacceptably high lead contents. Researchers from Harvard and the California In- stitute of Technology had to go to the arid deserts of Peru to unearth 1,600 year old bodies to find human remains without significant amounts of lead. Their conclusion, summarized by Dr. Jonathan Ericson, is per- tinent to the current public health controversy, " Based on what we already know about 4 lead poisoning and its effect on Health / PAC Bulletin Tony Bale Pamela Brier Robb Burlage Michael E. Clark Jaime Inclan Board of Editors Hal Strelnick Glenn Jenkins David Kotelchuck Ronda Kotelchuck Arthur Levin David Rosner Des Callan Madge Cohen Kathy Conway Doug Dornan Cindy Driver Dan Feshbach Marsha Hurst Louanne Kennedy Mark Kleiman Thomas Leventhal Alan Levine Associates Richard Younge Joanne Lukomnik Peter Medoff Robin Omata Doreen Rappaport Susan Reverby Len Rodberg Alex Rosen Ken Rosenberg Gel Stevenson Rick Surpin Ann Umemoto Managing Editor: Marilynn Norinsky Staff: Kate Pfordresher, Loretta Wavra MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR should be addressed to Health / PAC, 17 Murray Street, New York, N.Y. 10007. Subscription rates are $ 14 for individuals, $ 11.20 for students and $ 28 for institutions. Subscription orders should be addressed to the Publisher: Human Sciences Press, 72 Fifth Avenue, New York, N.Y. 10011. Health / PAC Bulletin is published bimonthly by Human Sciences Press. Second - class postage paid at New York, N.Y. and at additional mailing offices. 1980 Human Sciences Press Illustrations by David Celsi (pp. 1, 7, 33) and Bill Plympton (pp. 16, 17, 22, 23). neurological functions, it is ex- Sources: tremely important for us to re- Charney, E., et al., " Increased evaluate now the critical levels Lead Absorption in Inner City of lead permissible in our socie- ty. " For the Department of Children: Where Does the Lead Come From? " Pediatrics 65: Energy and President Carter, 226-31, Feb. 1980. so far, this conclusion has gone " Formula Makers Move Toward over like a lead balloon. So, Lead - Free Cans, " Community many states, though mandated Nutrition Institute Weekly by the EPA to develop standar- Report 10: 7, January 24, 1980. dized lead monitoring pro- Harris, Michael, " Getting the cedures, are still waiting to see lead out: The energy crisis com- which way the wind blows the pounds a threat to public. lead balloon. health, " The Progressive 43: -Hal Strelnick 27, October 1979. Lin - Fu, Jane S., " Preventing Lead Poisoning in Children, " Children Today, January- February 1973 (reprinted DHEW Publication No. (HSA) 78-5143). Needleman, H.L., et al., " Defi- cits in Psychologic and Classroom Performance of Children with Elevated Dentine Lead Levels, " NEJM 300: 689-95, March 29, 1979. THAT AIN'T JUST CHICKEN FEED For those who have believed that the major misuse of an- tibiotics came from profligate physicians prescribing inap- propriately for the common cold and other viral infections, this is " chicken feed " compared to the vast amounts of an- tibiotics now fed to livestock as part of standard feeds. About 40 percent of the 20 million pounds of antibiotics produced in the United States each year goes in- to animal feeds, according to the Office of Technology Assessment. Low dosage, non therapeutic - antibiotics were first added to feeds in the early 1950s, when livestock producers began ad- ding the nutrient broth in which antibiotics are made to animal feeds. The broth, which had been regarded until then as waste, contained low levels of antibiotics and was a by- product of their manufacture. The livestock producers soon recognized that their livestock being fed the broth were grow- ing larger and faster. The de- mand for antibiotics in animal feed boomed. The drug com- panies quickly turned this waste product into a $ 50 million in- dustry. Livestock kept in clean, well- kept settings grow to optimum weight without the use of an- tibiotics. Only animals - cattle, chickens, or pigs raised - in un- sanitary conditions benefit from the antibiotic - induced weight gains. Livestock producers con- tend that the latter course is cheaper. This results, accor- ding to OTA estimates, in 90 percent of pigs and veal calves, 60 percent of all cattle, and all poultry receiving low level an- tibiotics in their feeds. Two theories are offered for the weight gain in antibiotic - fed animals. One argument asserts that the antibiotics help the animals defend against infec- tious diseases and keeps them healthy - -- an ounce of preven- tion is worth a pound of beef. The second argument maintains that the antibiotics alter the balance of bacteria which nor- The widespread use of antibiotics has led to bacterial resistance to commonly used drugs, such as penicillin mally live in the animal's in- testinal tracts, reducing the competition between animal and bacteria for vital nutrients, fattening the calf for less. The wide spread - use of anti- biotics has led to the wide- spread development of bacteri- al resistance to the commonly used drugs, penicillin and tetracycline. Through selective survival and transmission of resistance through genetic in- formation passed in plasmids, increasing numbers of bacteria are growing immune to man's armamentarium of antibiotics. Strains of gonorrhea, typhoid, and meningitis, once suscepti- ble to penicillin, have become resistant to conventional treatments. One specialist in resistant bacteria research predicted that " in 25 or 50 years the vast majority of antibiotics will be rendered useless " for human therapy by the spread of this resistance. Although it is difficult to establish the direct link between resistant bacteria causing human disease and the use of antibiotic - enriched feeds (especially with physician and lay misuse of antibiotics), epidemiological evidence ex- ists. Several years ago Ger- many, the Netherlands, and other Common Market coun- tries banned penicillin and tetracycline use in animal feeds and have since found a marked reduction in infections caused by bacteria resistant to these drugs. In 1977 the Food and Drug Administration moved to follow the Common Market example and restrict the use of antibi- otics in animal feed in order to reduce the population of resis- tant bacteria in the world. Pressed by the pharmaceutical giants- American Cyanamid, Pfizer, and Merck, Sharpe, and Dohme C- on gress postponed any FDA action until a study could be completed by the Na- tional Academy of Science. The pharmaceutical industry also convinced farmers that a re- striction on penicillin and tetracycline would mean a ban on all antibiotics in animal feeds, including those alter- natives suggested by the FDA, bacitracin and tylosin, which are rarely used in human ther- apy and do not give rise to resis- tant plasmids. Dr. Stanley Falkow, a pro- fessor of medicine and micro- biology at the University of Washington, has claimed that the only reason why livestock producers have not switched to these alternatives is that " farmers have been getting bad information from the drug com- panies. " He believes that the 5 drug companies have misled meat and poultry producers in- to thinking that they would not receive the same yield from the alternative drugs. Although the NAS report is not due until this spring, early reports have learned that the study will recommend more studies. So the next time you hear the one about the travelling drug detail man and the farmer's daughter, you will know what he was selling the farmer. It ain't just chicken feed! It would serve him right if his dose were resistant to penicillin! -Hal Strelnick Source: Tom Monte, " An- tibiotics in Feed Becoming " Useless in Human Therapy, ' Nutrition Action 7: 3-6, February 1980. " Urology Today " - Enjoyable and Profitable The Norwich - Eaton Televi- sion Network, a division of Nor- wich ~ Eaton Pharmaceuticals, which is in turn a division of MortonNorwich, a Chicago- based company that manufac- tures and sells salt (Morton salt- remember?), pharmaceutical, household, and specialty chemical products throughout the world, recently released the first of a series of television shows for doctors. The video- cassette shows will be offered on a free loan basis to physicians " for convenient viewing on home or office playback units, " according to the press release announcing the show's release, " as well as to professional groups and hospitals. Addi- tionally, NETVN will be distri- buted automatically to residency training programs at some 169 major teaching institutions. " Why didn't this rather obvious innovation come out of a medical school or other part of the non profit - sector? The prob- lem is that the profit sector can be counted on to produce useful innovations, but then- then- and this will be recognized by theoretical buffs as the contradiction within private sector innovations - pervert them. The first show released, " Urology Today, " was produced with the help of 15 advisors from the American Urological Association who " carefully weighed and decided upon timely topics to be covered in the urology series. " It probably would not have been done much differently in the Soviet Union, except it would then have to be approved by several more com- mittees. This will be followed by three more shows on various as- pects of urology over the coming year, all to be presented " in an interesting and enjoyable way. " So far so good. But the inno- vation's perversion doesn't take long to appear. One future " how - to NETVN show " will dis- cuss running a cost effective - of- fice practice. And after they have produced " Urology Today " type shows in all the other specialties, they will have to ex- pand their market into addi- tional shows on each specialty. After all, no self respecting - company can let a profitable product line lapse. So we can anticipate titles like: Urology and You; All You Ever Wanted To Know About Urology But Were Afraid to Ask In Medical School; The Coming Crisis in Urology; and How To Profit From the Coming Crisis in Urology. -George -George Lowrey 6 Losing Patience Continued from Page 2 Dr. X: When we received this report, we had not H.C. the man. There might be a case if the man were not H.C. and we needed the family doctor. I thought we should re ray - X - the man and then go through proper pro- cedure. For- tunately it disappeared. He had been told nothing. It is a flexible situation. Dr. Smith: No O.D. (Occupa- tional Disease), no cancer, no TB. Re ray - X - in six months. In the case of Patient A, the doctors actively suspected an in- fection or tumor, yet did not tell the patient of their suspicions - or take any other special action. In the case of Patient B, the doctors eliminated to their own satisfaction the possibility of cancer, but did not tell the pa- tient of their observations or suspicions. To be sure, these medical decisions were made in the context of physician - patient relationships two decades ago. No doubt some doctors even to- day would argue for the wisdom of the deci- sions not to inform, especially in the latter case above. But in neither case did the affected worker know of his potentially grave condition, so that he might consult other specialists who might have performed additional tests, perhaps made a different diagnosis and possibly taken more aggressive medical action such as, for ex- ample, exploratory surgery. And since the doctors did not inform the workers, in neither case could they choose to leave their dusty job, to stop smoking or to exercise any other limited preventive measure. Throughout, the outside observer is left with the nagging question: Would these physicians have acted in the same manner with respect to these patients if they did not also have obligations to their employer, the Johns Manville Corporation? Unhealthy, Unwealthy and Unadvised The OC- cupational disease which these doctors encountered most often was asbestosis, a disabling, often fatal lung disease similar to coal miners ' " Black Lung. " Asbestosis is marked, many years after workers'first ex- posure to as- bestos dust by breathlessness, coughing and scarring of the lung tissue, which can be seen on X rays -. Asbestosis is also one of a larger group of lung dust diseases called " pneumoconioses, " a term the J M - doctors often used in their diagnoses. The corporate medical strategy for asbesto- sis, as these medical conferences indicate, was initially not to tell workers that they had the disease. But as the disease progressed (upon continued exposure) and the worker became disabled, the company physician would reveal to the victim slowly and in guarded terms- his or her true condition. This strategy was summed up in a now famous memo by Dr. Smith to his corporate superiors in February, 1949: It must be remembered that although these men have the x ray - evidence of as- bestosis, they are working today and definitely are not disabled from asbestosis. They have not been told of this 7 ee ee rrr ee eee e cece cee In some cases, company physicians simply decide to tell workers of known or suspected medical conditions. Workers then cannot choose to leave their dusty job, quit smoking or exercise any other limited preventive measures. diagnosis for it is felt that as long as the man feels well, is happy at home and at work, and his physical condition remains good, nothing should be said. When he becomes disabled and sick, then the diagnosis should be made and the claim submitted by the Company. [Smith's em- phasis D.K.] The fibrosis of this disease. is irreversible and permanent so that eventually compensation will be paid to each of these men. But as long as the man is not disabled it is felt that he should not be told of his condition so that he can live and work in peace, and the Company can benefit by his many years of experience. In the following medical case reports, the first date indicating some chest X ray - abnor- mality in the patient that triggered physician concern is indicated by an " N.D., " a " No Dust " restriction, by means of which these physicians advised the company management to place the worker in a non dusty - environment. The health counselling session (H.C. " ") was clearly the time when the physician had a personal meet- ing with the worker / patient to review his or her medical situation, to present the medical diagnosis and advise on job or personal medi- cal precautions (e.g., give up smoking). Often several years elapsed between this No Dust restriction and the Health Counselling session. Sometimes, as the record below indicated, some mention was made of the person's medical condition short of a full counselling session. Consider the following case from the March 5, 1958 medical conference: Patient C: Male, 50 years old. Dr. Z: Hired in 1925. Pipe machine operator. 22 years exposure to silica, cement, and asbestos in transite pipe. Carpenter for 4 years. Nurse W: N.D. in 1948. Pneumoconiosis men- tioned in 1954. H.C. in 1956 of X ray - changes. Diagnosis: Early to moderate mixed pneumoconiosis... Dr. Z: 1. Tab 2. Notify plant manager 3. Check with Nurse V: Should these men be advised? 8 Dr. Z: We can put transite pipe out of business from this list alone. Thus six years elapsed between the physi- cians'No Dust advisory restriction in 1948 and the " mention " of pneumoconiosis in 1954. Another two years elapsed before a full health counselling session was given. Such delay would hardly seem in the patient's interest- and would most assuredly be in the company's interest.. As indicated in Dr. Z's last comment, these physicians were well aware of the extent and severity of the dust disease problem at least in the transite pipe division (where asbestos dust is added to a cement mixture to make a very strong type of water pipe). Yet three years before, in 1955, Dr. Smith, one of these par- ticipants, said in the AMA Archives of En- vironmental Health (p. 203), " Of all workers exposed to the fibers, very few develop asbes- tosis. " But in certain departments, it appears, the doctors were aware that the situation was not so rosy. This perception does not appear anywhere in the Smith paper. Consider another patient conference on July 23, 1957: Patient D: Male, 58 years old. Nurse W: 5'9 " tall, weighs 268 lbs. N.D. in 1947. 19 years in the coal mines. Dr. Z: Hired in 1941. 6 years potential exposure to Portland Cement, asbestos fibre, and silica... In 1947, he went to R.G. as sweeper. Diagnosis: Mixed Pneumoconiosis, moderate- ly advanced.... Dr. Z: 1. Tab 2. Advise the plant manager 3. No H.C. So 10 years after the doctors proposed a No Dust restriction- which could explain the worker's transfer to sweeper in 1947 - and with a diagnosis of a " moderately advanced " pneu- moconiosis, the company medical department was not ready to offer the man a health counselling session. A clue to the doctors ' reasons for not recommending a health counselling session is given in a later comment on this same patient by Dr. Smith, " I see no reason to bring a man in like this, it is dangerous. " The danger is clearly to the com- pany, not the man. As if to underscore this, Dr. X immediately responds, " Now take that woman, she is very nervous. If she is called in, she will get hysterical and I am sure you will have a claim on your hands. " As a previous conference record showed, the woman referred to was diagnosed by the com- pany physicians as having " Moderately Ad- vanced Asbestosis. " Based on these diagnoses and most state worker compensation laws at the time, both workers, of course, would appear entitled to compensation for these work related - illnesses. Dust to Dust These same doctors were equally parsimo- nious with their advice to transfer workers to non dusty - areas. Thus in their medical con- ference of April 9, 1958, the following inter- change took place: Patient E: Male, 53 years old. Dr. Z: Records indicate Asbestosis in 2-51. Man was advised about dust in his lungs in 1-55. [Dr. A] reported on 2/1/57'Original undated X ray - shows no abnormality.... In the absence of clinical or occupational data, it is not my belief that tuberculosis is a factor in this situation. It does not resemble any silicosis with which I am familiar. It seems to me to be one of the cases of pleural involvement you keep sending me, manifesting parenchymal elements after eigh- teen years. I would still advise occasional sputum examinations and X rays - at six month intervals. ' Diagnosis: Early to moderate Pneumoconiosis. X Ray -: The right apex shows an area of in- creased density present in previous X rays -... Dr. Z: 1. Tab 2. Notify plant manager 3. Do not transfer 4. Pending future changes indicated by the Medical Department. So four years after the company medical de- partment diagnosed asbestosis, the worker was advised about " dust in his lungs. " By 1958 this person has progressed to " early to moderate asbestosis. " Then, with no reasons given, the medical conference's firm advice is " no transfer " at that time. This sounds like the prac- tice of the company's doctor, not the patient's. The long delay between the medical obser- vation of X ray - changes and notification of the workers was not exceptional, it was common practice. During the four reported medical conferences, a total of 20 workers had the dates both of the No Dust restriction and of their Health Counselling session recorded on their medical report. In only two of the 20 cases were workers counselled about their medical condi- tion before the doctors recommended that management transfer them to a non dusty - job, as one would have expected to be done. In five of the 20 cases the workers were health coun- selled at the same time or within the same year Corporate physicians often function in the multiple roles of personal doc- tor, legal advisor and corporate manager - and the demands of these roles are routinely in conflict that they were placed on a no dust - restriction. (See Table). But in 13 cases, that is for almost two thirds - of the group, the health counselling session took place years after the doctors had recommended a no dust - restriction. The delays for these 13 cases ranged from 2 to 10 years! And in some instances the person had not been health counselled by the time of the medical conference and it was further decided at the conference that they should not then be health counselled (see, for example, the case of Pa- tient D). For these 13 cases, the average delay for counselling after the doctors had recom- mended that the workers be transferred was 3.6 years. Affected workers, moreover, were not told that the doctors had recommended that they be placed on a No Dust restriction. In part we know this from interviews with Johns Manville - manufacturing workers, who told of being transferred and only years later finding out this was done by the company for medical reasons -see Health / PAC BULLETIN, No. 50, March 1973, p. 6. Also if the company physicians had promptly told the workers that they were rec- ommending transfers, they obviously would have had to tell workers the medical reasons for this in which case they would not have had to record years later that they told workers of " dust in the lungs " (Patient E), " mentioned " pneumoconiosis (Patient C), or " health coun- selled of X ray - changes " (Patients C and I). 9 A Rose by Any Other Name When company physicians told workers of asbestos - related health problems they were consciously guarded in the words they chose. For example, they avoided such litigious words as " pneumoconiosis, " as in the following discussion at the July 10, 1957 medical con- ference: Patient F: Male, 46 years old. Nurse W: N.D. (No Dust restriction) in 1954, H.C. (Health Counselled) in 1956... Dr. Z: Hired in 8/12/29. 28 years potential ex- posure to asbestos fibre, diatomaceous earth (calcined and natural). Nurse W: Advised of X ray - changes. Dr. Y: When records say X ray - changes due to Pneumoconiosis, we would not use the term Pneumoconiosis to patient. Dr. X: I spoke to this man and told him of the changes in his lungs. He said he is in a clean area. Dr. Z:...... He says it is a clean area, I disagree with him it is dusty. Diagnosis: Early mixed Pneumoconiosis, plus old arrested TB in the right mid lung - field. The doctors were also careful to keep certain information out of the medical files. For exam- On the - - job safety had not changed. What changed was not corporate in- terests but the medical and social stage on which these were acted out ple, after a brief discussion about a patient at the July 10, 1957, conference the following in- terchange took place: Patient G: Male, 41 years old. Dr. Z: 1. Tab 2. Notify plant manager 3. AHS (Air Hygiene Survey) 3. We do not have many non dusty - areas. It has to be worked on. Nurse W: Would you clarify- does the AHS report come to the Medical Department? 10 Dr. Z: I trust you do not put anything about the AHS in the medical folders. Nurse V: Do you recall at the first meeting, we decided to use initials to denote what has been done. We need something to show we did something about the changes when they were noted. Dr. Z: Say referred to the Safety Department. Nurse V: This is a change from what we decided at the first conference. Dr. Smith: If we put in AHS, it means we have advised you to have a survey done but no reasons are recorded in the files. An attorney might say what did you do. They can answer we requested studies and they can then say they do not know the results of these studies. Dr. X: But if it is requested and you do not get satisfaction? Dr. Smith: That is not your responsibility. I think it good for you two doctors to know what the dust counts are but I do not think we should give any advice on that. Dust counts are not current. And with our present engineering changes, you would not have the latest changes. If anyone is worried about their work area, thing. will handle the whole Doctor Lawyer /? Throughout these reports legal issues are in- extricably interwoven with medical ones. Some physician concerns such as avoiding medical malpractice suits, are to some extent part of most doctors'practice. But others, such as con- cern for protecting the company from compen- sation suits and their attendant costs, inevitably place the doctors in the adversarial role of ad- vising the company and its lawyers how to fight workers'claims. Then the conflict between the doctors'(supposedly) primary concern for their patients and their allegiance and identification with the company breaks into the open. Consider the case of Patient H, a woman of 49 years who was diagnosed by the company medical department as having " moderately ad- vanced asbestosis, precipitated by earlier in- fection. " Dr. Smith said at that time: " She should not work in dust. She is moving fast. She should have no dust exposure. " Yet at the July 23, 1957 medical conference, discussion about her case focussed on how to help avoid her filing a compensation claim (to which, one assumes, she was entitled, based on the doctors'diagnosis): Dr. X: Now take that woman, she is very nervous. If she is called in, she will get hysterical and I am sure you will have a claim on your hands. Dr. Smith: I will go along with that, but when you do X rays -, do a physical as well. Nurse V: If she is transferred to another job, wouldn't that also precipitate something. Dr. X: Mrs. is working with no complaints. It is one year since she was H.C. Dr. Smith: As a doctor, you cannot leave her where she is today. Nurse V: If there are bad working conditions, she is to be transferred then? Dr. Smith: You are precipitating the situation by transferring. Despite the doctor's own beliefs that transfer to a non dusty - job was urgently necessary, they did not see their role as strong patient advo- cates for transfer within the company. On the contrary they discussed how to soften the blow to the sick woman if she was not transferred: Dr. X: Will you explain the transfer to her? Dr. Z: Either I or the plant manager will discuss this with her. I think we should tell her the reason we are transferring to place her in a non dusty - area. If we cannot transfer her, I will come back to the conference and What say - ' shall I do? ' Dr. Smith: We were going to explore, with the manager, the phases of transfer. If we cannot transfer, then we will come back to the con- ference and see what is what... Dr. X: I will discuss this with her and soften this for her. I will say - we have recommended- etc. Dr. Z: No, I do not want it to be said that you recommended. Say that we have discussed the possibility of a transfer and [Dr. Z] may contact her about this in the future. If you say you recommend and it is not done, she would get upset. Similarly for: Patient I: Female, 49 years old. Nurse W: N.D. (No Dust restriction) in 1952 and H.C. (Health Counselled) 7-55. Dr. Z: Hired in 1929. Prior to JM employment, she worked in a cigar factory. From 1941 to date she has been a spinner in A Building. 17 years potential exposure to asbestos fibre. In H.C. what was she told? Nurse W: X ray - changes showing Pneumoco- niosis. Diagnosis: First stage asbestosis... Dr. X: You may precipitate something in the calling of the patient for examination. After all, they are producing and taking home a good pay, you may be creating a crisis. We may ag- gravate this into something decisive. Whatever the " crisis " is that " you may be creating ", it does not appear in the doctor's mind to be asbestosis, which the person already had at that time. Or, in the April 9, 1958 conference: Patient J: Male, 55 years old, 18 years of ex- posure to asbestos dust. Dr. Z: The question is, third shift or come off the job? Dr. Smith: We have to be practical. I would OK him for third shift, he is in a non dusty - area. Otherwise he may be out of a job, precipitate a claim and everybody is involved and in trou- ble. Diagnosis: Early Asbestosis and arrested TB. The apotheosis of the doctor's central con- cern with legal matters - heading off litigation against the company, protecting themselves from a malpractice suit and subjugating medical practice to company needs as opposed to patient's - comes in a revealing discussion during the March 5, 1958 medical conference: Patient K: Male, 52 years old. Dr. Z: He is working now. Was at Glen Gardner [TB Sanatorium] in 1950 for about 1 years. Dr. X: No change basically. SCTBA [Somerset County TB Association] is watching him and X rayed - him in February. They informed him. through his family doctor that he has to go to the Sanatorium. He said we took X rays - in December and did not tell him there are more changes in 2-25-58. [Dr. A] agreed on this. The employee was upset and implied that we are trying to hide things from him. He came in this Monday and gave us a form letter requesting all our X rays - of him. I requested he give us auth- orization and that we would then be happy to send him the X rays -. We have to send these films to Glen Gardner but I wanted them for conference. Dr. Z: I think there will be litigation. His brother has been talking litigation for a while. His brother was involved in a box car accident and there is a third party action... Dr. X: I wonder if procedure - wise we could be criticized about our handling of this care, he knew we took X rays - and he was not told of 11 changes. Should we not change our procedure when TB is involved. We could tell the man that we are sending those X rays - to SCTBA and let them follow through. Dr. Smith: They should follow up. They do sputums. We do not. It is their responsibility... Dr. Z: 28 years employment and he is 52 years of age. What is the answer D i saL b ility Retire- ment? He is getting VA benefits on the basis of TB... I foresee 100 percent total disability. They have us over a barrel... We have to outguess these people at this point, we do not know when or if they will file. Nurse V: I do not think it is too wild a guess. His brother said,'I told him never to go back to H Building with his chest, it will kill him. ' Dr. Smith: Even if he gets through this one, he will break down before he is 65 years old. Dr. Z: What about procedure? Dr. X: I think we should go back to our old system. Medically, as a doctor, I am responsi- ble. SCTBA would carry on from there. Dr. Z: I don't think we raised any objection to SCTBA but only after conference. Dr. X: But prior to that, we would send films to Dr. A on a routine basis. This is procedure around here. Two doctors - A and are B on state salary. They go to various institutions. Dr. Z: If that is their function, should industry have to assume these responsibilities. Would they not be Dr. A's functions? Dr. Smith: We take the X rays - for our own pro- tection, not for social obligation. There is no problem sending them out, but after confer- ence. Strictly a Management Decision Not only do legal issues permeate the medical discussions described in these con- ference reports, these doctors also identify closely with management. In so doing, they make managerial - type decisions decisions - which seek to deflect (justified) worker suspi- cions of health hazards and advise that sick workers not be transferred. These latter deci- sions, especially, are clearly in the company's managerial interests, but fly in the face of the workers'health needs to limit or eliminate asbestos exposure. From a conference on July 23, 1957: Patient L: Male, 30 years old. Hired in 1943, No Dust restriction advised in 1954. Presently a packer and inspector in asbestos. 13 half - and - a - years of potential exposure to asbestos, celite and silica. Diagnosis: Early Pneumoconiosis, mixed. Dr. Z: Has he been health counselled? Nurse W: No. Dr. X: Get deep inspiration on Re ray - X -. Dr. Smith: Do not do anything for 6 months and bring up for conference then. Dr. X: Do we do AHS (Air Hygiene Survey) Dr. Z: As a block packer and every time he does his job, there is dust. Dr. X: If you take this man off, you will put another man on the same job. The area must be cleaned up. Dr. Smith: That is a long range - idea. Dr. Z: 1. Tab 2. AHA 3. Advise plant manager, to clean up area. 4. Bring up in 3 months to conference af- ter X rays -. Dr. Smith: I do not think the plant manager should be advised. There may be changes in the picture. We can give a better decision after a Time Intervals Between Recommended No Dust (N.D.) Restrictions and Health Counselling (H.C.) Sessions Counselling before Job Restriction Counselling at same Counselling delayed time or within one one year or more after year after Job Restriction Job Restriction Number of Cases Percent of Cases Restriction 2 - 10% 5 25% 13 65% Average Delay between N.D. and H.C. = 3.6 years; Range of delays = 2 to 10 years. 12 short period of time. Dr. Z: I think the plant manager should be told there is a potential liability. Also, here is a job that should be cleaned up. I work all the building in the AHS not to make it too obvious. This coverup and concern for liability is managerial, not medical. Nevertheless its con- sequences pale in comparison to the potential human devastation of the doctors'recommenda- tions not to transfer workers known to have asbestosis or other pneumoconioses. It took a brief few moments, and no apparent agonizing on the doctors'parts to decide in one such case, printed in full below, on July 10, 1957: Patient M: Male, 53 years old. Dr. Z: Hired in 1919. Was in Service. Has been in Textiles 39 years and had exposure to asbestos dust. Nurse W: Mention of Pneumoconiosis in 1952. Advised of this in 1954. Diagnosis: Early asbestosis. X Ray -: Present film, compared with film of 1-17-57, there is now an increase in rib and car- diac shadow. Right hilar shadow also appears to be enlarged. Otherwise there is no change. Dr. Z: 1. Tab 2. Notify plant manager 3. Do not transfer. Similarly, brusquely, another ill person is kept on a very dusty job for seven more months, after having been diagnosed as having pneumoconiosis four years earlier: Patient N: Male, 48 years old. Dr. Z: Hired in 1940. 3 years in the Army. Presently a crane operator in Transite Pipe. 14 years potential exposure to silica, cement and asbestos. Nurse W: H.C. about chest changes. Records indicate Pneumoconiosis in 1954. Diagnosis: Early mixed Pneumoconiosis. X Ray -: Diffuse linear exaggeration... No change since previous film. Dr. Z: 1. Tab 2. Notify plant manager 3. Man is in worst job in I Building 4. Leave on his job until review after his next physical. Dr. Z: I hate to think of him on his job. Dr. Smith: Leave him there until October. Another serious case is discussed on March 5, 1958, and resolved in what can only be call- ed cold blooded - terms. It is presented in full below: Patient O: Male, 52 years old. Dr. Z: Hired in 1933. 23 years potential ex- posure to Silica, Cement and Asbestos - Transite Pipe. Is presently shift foreman. Nurse W: Worked as truck driver 1921-1933. Mention of Pneumoconiosis in 1952. Was H.C. in 12-54. & P S (Patch and Sputum tests - DK) were neg. Dr. Smith: Advanced Pneumoconiosis. Dr. Z: Should we change him? Dr. Smith: Won't make any difference. Dr. X: If he hits 65 I will be surprised. Dr. Z: He is to be watched carefully and retire on disability, if necessary. 1. Tab 2. Notify plant manager 3. Do not transfer 4. Watch carefully 5. Retire if necessary. The above cases reveal a good deal about the practice of corporate physicians in the domi- nant company of one large industry over 20 years ago. But what light do these medical con- ferences shed on corporate medicine as prac- ticed today? First, they clearly reveal that corporate physicians often function in the multiple roles of personal physician, legal advisor and cor- porate manager - and that the demands of these roles are routinely in conflict. The various roles company physicians play and the reasons that corporations hire the par- ticular individuals they do have not changed for decades. What has changed is not cor- porate interests, but the medical and social stage upon which these are acted out. The passage of the OSHA Act ten years ago and the growing worker and public awareness of oc- cupational health hazards have significantly shifted this field of medicine out of private cor- porate and medical offices, onto the factory floor and into the public hearing chamber. As a result of these changes, one would not expect physicians in large corporations today to speak as the doctors of Johns Manville - spoke in the late 1950s. But many corporate physi- cians today carry with them as direct personal experiences or through social tradition the values and relationships derived from that period. And one still sees quite clearly the old conflict between patient medical needs and corporate legal and managerial priorities. As they have been doing for decades, many cor- porate physicians continue to " resolve " this 13 conflict by opting to serve company interests before those of their worker / patients. Since outsiders to this day rarely see the " smoking gun " that reveals the doctors'choices between corporate and patient interests - and thus seldom consider the detailed implications for their medical practice of such choices - these Johns Manville medical reports, despite their age, give us an important glimpse into this part of the corporate world. The basic dilemma of corporate medicine re- mains today what it has been for decades: Who is the patient - the company or the worker? -David Kotelchuck Names and Abbreviations Used in this Text In the reports quoted in the text of this article, patient's and doctor's names are not used. While the documents are on the public record, the use of individual names does not seem warranted in this case. In particular, the affected workers and their families have a right not to have their medical conditions discussed or revealed publicly any more than was necessary in the legal suits for which they were originally gathered. Because how- ever the reports reveal medical and social attitudes on the part of the company and its corporate physicians that are of broader interest and importance, con- ference discussions are reproduced in this article with the workers'names deleted so that others cannot identify them. The names of the corporate physi- cians are also not presented, not because we particularly wish to protect them (al- though the law does to some extent pro- tect the confidentiality of doctor patient - relationships) but simply because publi- cation of their names does not appear to serve any broader purpose here. The single exception is our use of the name of Dr. Kenneth W. Smith, who was Cor- porate Medical Director of Johns - Man- ville at the time of the conferences. Dr. Smith, who participated in all of the reported conferences, spoke with special authority as an officer of the corporation and did not appear in the reports to have personally examined or spoken with any of the affected workers. The same six doc- tors and nurses were listed as present at each of the four medical conferences reported and those other than Dr. Smith are consistently referred to as Nurses V and W, and Doctors X, Y and Z. The reports of the medical conferences had a standard format: After reading the patient's name, department number and age, one medical staff person would discuss the patient's work record and ex- posure to potentially harmful dusts. Then the worker's X ray - films were described, as was his or her diagnosis by the com- pany medical department as of the time of the conference. The collected staff then discussed the patient's medical situation and working conditions, then one of them made recommendations for the confer- ence which included flagging the person's medical records (Tab " " or " No Tab "), notifying the plant manager, holding a medical conference with the worker (H.C. " " or " No H.C. " - that is, " Health Counselling " or " No Health Counselling "), conducting an air hygiene survey where the person works (A.H.S. "" or " No A.H.S. "), and transfer- ring the worker to less dusty or non dusty - jobs. The industrial hygiene survey and job transfers were, according to the reports, clearly advisory recommenda- tions to other departments of the corpora- tion, which might or might not act upon them. The first three - tabbing the records, notifying the plant manager and holding a health counselling session with the workers represented - represented actions which were undertaken by the medical depart- ment itself. Many abbreviations are used in these records, such as " O.D. " for occupational disease and " T.B. " for Tuberculosis. The abbreviations are presented as printed in the text of the reports, followed by their translation (according to the author) in brackets. Most abbreviations were obvi- ous in the context of the few dozen case reports presented, although some uncer- tainty persists, especially in the abbrevi- ations of department names. 14 URBAN PHILADELPHIA SANS PGH " Tens of thousands of finan- cially needy and / or medically underserved Philadelphians did not have their health needs met by the combined health ser- vices of public and private facilities before the closing of Philadelphia General Hospital (PGH) and their needs are still not being met today. " Thus begins the October 4, 1979 press release of the Fellowship Commission con- cluding its three year effort to document and understand the consequences of the closing of PGH. As significant as this statement is for a people- oriented view of the Philadel- phia health scene, it, of course, begs the PGH question. The PGH question has been around for several decades. During the first half of this cen- tury, however, the key role of PGH was unquestioned. It pro- vided a quantity and range of services unmatched by any other hospital in the metropolitan area which in- cludes the nation's fourth largest city. As with similar local public hospitals in urban areas with disproportionately large numbers of no- and low- income people, PGH provided both ordinary inpatient and out- patient services and an im- pressive number and quality of extraordinary services without hassling patients for payment. It was one of the nation's largest hospitals, having in its prime well over 2,000 beds. Its reputa- tion in medical circles was ex- cellent, attracting to its intern- ships and residencies well qualified graduates of the best medical schools throughout the country. In the 1950s and'60s, the city government sponsored several major studies of the city's pro- per role in the health field. Recommendations of the earlier studies were implemented in- cluding the closing of the physically separate infectious diseases hospital, the expansion of ambulatory services and district health centers, and the development of financial and professional relationships with Philadelphia's medical schools and voluntary hospitals. The later studies recommended, among other things, the con- struction of a $ 105 million general hospital building and the modernization of the con- cept and organization of PGH in keeping with the radical changes occuring in medical care financing and health field social policy. These recommen- dations were not implemented as they were made shortly before the start of the city's disastrous Rizzo Administra- tion. In December, 1971, even before taking office as mayor, Frank Rizzo was reported in the daily press to believe that PGH should be closed. From that time to the official announcement on February 15, 1976 that PGH would be phased out, PGH was plundered of its resources by the local academic institutions, and its staff and budget were mercilessly whit- tled away by benign neglect. Like the deaths of the multitudes of paupers it had served continuously since 1739, PGH's official demise on June 17, 1977 occured without ceremony or even public notice. On July 21, 1976, a signifi- cant community conference convened by four prestigious community organizations, in- cluding the Fellowship Com- mission, expressed grave con- cern that those served by PGH might not receive uninter- rupted, quality medical care after it closed. The unsatisfac- tory response of the city ad- ministration to this concern during the subsequent months of the phase out period pro- voked the Fellowship Commis- sion to undertake a formal evaluation of the alternative services offered by the city. The intended base of the evaluation was a study done by JRB Associates, a proprietary management consultant firm headquartered in Virginia. It was financed by a $ 15,000 grant from a Philadelphia philan- thropy. JRB began the study in May, 1977 and its final report came out on February 2, 1979. This is eight months earlier than the press release quoted in the first paragraph. Moreover, that quote, the only one of the so called " main conclusions " discussed in the press release, is not to be found anywhere in the two documents on which the press release is presumably based and which were simultan- eously made public: 1) an Ex- ecutive Summary of the JRB Report and 2) a statement of " Observations and Recommen- dations " by the Fellowship Commission on the JRB study. The substantive and time distance between the main con- clusion of the Fellowship Com- mission, as quoted above, and the JRB study report is ac- counted for by the extensive 15 supplemental work undertaken by the Fellowship Commission's own staff in response to continu- ing severe criticism of JRB's study and later of the drafts of the Fellowship Commission's statement by several members of the study's advisory panel, including the author of this column. Criticism of the Fellowship Commission's newly acquired sophistication about the Philadelphia health scene con- stitutes the first paragraph of the Rizzo administration's for- mal reaction to the Com- mission's press release: " the efforts of the Com- mission to assess these health needs of the financially needy and medically underserved Philadelphians] and the provision of related medical services do ap- pear to go beyond the scope of a study alleged- ly following up on the impact of the closing of the Philadelphia General Hospital... an obvious lack of intellec- tual integrity. " The Fellowship Com- mission is the nation's oldest private human rights agency but its PGH effort was its first Ye major venture into the health field. The study was seriously handicap- ped from the beginning by grossly inadequate funds and by study staff who were complete strangers to the Philadelphia health scene. The first fundamental defi- ciency of the design of the JRB study was that it was not a study of actual PGH users before and after the closing of PGH. In- stead a variety of secondary date was to be used. However, the most relevant secondary date was often not available from the organizations which 16 had them, the Philadelphia Department of Public Health and the hospitals which provid- ed the alternative services after PGH closed. The second fundamental cipal substitute for PGH's am- bulatory services. Because of the flaws in both study design and study execu- tion, the data base is inade- deficiency of the study design was that the base of comparison was PGH in the period im- mediately preceding its closing when the predictable results of years of neglect and uncertain- ty as to its future were profound and visible. This deficiency is reflected in several statements in the study report implying that the problems of PGH in its ter- quate to draw conclusions responsive to the central study objective -- " Are the previous users of PGH and those like them receiving the equivalent medical care which they re- quire? " This assessment is expressed by the Fellowship Commission in somewhat more refined language: " The Fellowship Commission cautions all those utilizing the JRB report to treat JRB's fin- dings [and conclusions] as indicative not definitive... because they are based largely upon the availability [i.e. the existence of DUE TO CLOSED LACK OF FUNDS {{Z alternative services] and not upon documented information on the ser- vices actually received by traditional users of PGH. " The Fellowship Com- mission's three year ef- fort has been the only structured attempt to evaluate the conse- ' MUNICIPAL HOSPITAL quences of the closing of PGH. The City Adminis- tration of Mayor Frank Rizzo which delivered the coup degrace to PGH, had no interest in evaluating the conse- -B. Plympton quences of that action. Thus, three years after minal period were the cause of the closing of PGH, the question its death rather than the symp- is still asked in Philadelphia, as toms of its underlying neglected elsewhere, " What were the con- illness. sequences? " The question will The study did include a small remain unanswered until a pro- community survey which perly designed and executed helped define some issues, in study is completed. particular, the large percen- -Walter J. Lear tage of an apparently well- (Walter J. Lear was a member of informed group of low income the Fellowship Commission's people who did not know about study advisory paneland cur- Philadelphia's family medical rently is president of the Physi- care centers, the City's prin- cian's Forum.) WORK ENVIRON F RETURN OF THE OSHA CANCER POLICY Question: How many OSHA employees does it take to change a light bulb? Answer: Fifty. Forty nine to hold hearings and write a stan- dard and one to change the bulb. If that light bulb is a car- cinogen standard, the hearings and delays will drag on for years. Meanwhile, for every carcinogen removed from the workplace, a dozen new car- cinogens will have been in- troduced. In its first nine years, the Oc- cupational Safety and Health Administration (OSHA) issued standards for only 18 workplace carcinogens. At the same time, OSHA recognizes over 500 workplace substances that might be candidates for regula- tion as carcinogens. The Na- tional Institute of Occupational Safety and Health (NIOSH) has compiled a list of over 2,000 potential cancer causing agents used by US workers. With 500 new toxic chemicals introduced to the workplace each year, the cancer problem threatens to move far beyond OSHA's grasp. Carcinogen standards typi- cally came only after epidemi- ological studies have revealed a big body count in the past with many more victims to come. Without human victims, the regulatory wheels do not turn. Even in the face of major oc- cupational tragedies, OSHA has been slow to act. A report prepared by three government research institutes estimates between 13-18 percent of all cancer deaths in the United States in the next 30-35 years will be asbestos related, but in- credibly OSHA still has not moved to regulate asbestos as a carcinogen. In October, 1977, OSHA pro- posed a new cancer policy to speed up and strengthen its regulatory process. (See Health / PAC BULLETIN, Nov- ember December - , 1977.) On January 22, 1980 - some 250,000 pages later OSHA - finished reviewing a massive hearing record and issued its proposal. Scheduled to go into effect 90 days after the an- nouncement, the policy faces inevitable court tests. The OSHA cancer policy sets no timetable for regulating the backlog of workplace carcino- gens; the policy does not re- quire OSHA to regulate any minimum number each year. Dr. Eula Bingham, Assistant Secretary of Labor for Occupa- tional Safety and Health, hesi- tantly predicts the new policy will allow OSHA to raise its average number of carcinogen standards from two to 10 per year. Scientific Debate The new OSHA policy takes the bold step of reaffirming the scientific basis for regulating carcinogens long advocated by organized labor and environ- mentalists. Industry had tried to shake the argument but failed to 17 3.P provide any compelling data to prove its contentions that animal tests are unreliable, that there are safe threshhold levels for carcinogens, that negative epidemiology studies are more important than positive animal studies, and that carcinogens can be ranked as " strong " or " weak " with existing research techniques. The OSHA policy offers industry the option of returning to prove its conten- tions if and when there is signifi- cant new evidence that war- rants reopening the issue. Meanwhile, the lengthy de- bate on the scientific grounding of carcinogen regulation will be closed in the interest of ex- pediting new standards. Posi- tive results in well conducted long term animal studies will be deemed sufficient to regulate when positive human epidem- iological results are unavailable. Regulation will be based on the scientific principle that there is no safe level of ex- posure to a carcinogen. OSHA has decided that, at least as of now, industry has lost the scien- tific debate underlying carcino- gen detection and control for lack of solid evidence to support its theories. Every three years OSHA will review the scientific basis of its position. Industry has termed OSHA's reluctance to regulate deadly chemicals on its own unsupported theories a " freeze on science. " Two Categories At the heart of OSHA's new policy is the establishment of two categories: Category I and II carcinogens. A Category I carcinogen is one where posi- tive results have been found in humans, or in a single mam- malian species in a long term test where the results agree with some other scientific evidence of a carcinogenic hazard - such 18 as short term tests, or in a single long term test in a mammalian species where OSHA feels the requirement for other evidence is not necessary. Exposures to Category I carcinogens are to be at the " lowest feasible level, " primarily through the use of engineering and work practice controls. Where suitable substitutes exist, OSHA may order a " no occupational ex- posure level " set. A Category II carcinogen is one where evidence of carcino- genicity is only suggestive or where it shows evidence of car- cinogenicity in a single mam- malian species without sup- porting evidence in other tests that OSHA deems necessary. Exposure levels will not be guided by the " lowest feasible level " test; instead, they will be set on a case by case basis. Most Category II substances will be there because of insufficient knowledge of their effects. OSHA hopes that such a classi- fication will stimulate research to resolve the ambiguities. Regulatory Process At least twice a year OSHA will make a priority list of ap- proximately ten candidates for regulation in each category, based on factors such as esti- mated numbers exposed and possible potency of the car- cinogen. Inclusion on the list does not mean regulatory action must proceed. OSHA can also choose to regulate substances not on the list. When OSHA publishes a notice of proposed rule making for a Category I carcinogen, it can choose not to issue an emergency temporary standard, unlike the require- ment for such a standard in the original proposal. After OSHA issues a notice of proposed rulemaking on a sus- pected carcinogen, comments will be solicited and hearings begun. OSHA hopes to com- plete the whole process and issue a standard within a year. Hearings will consider such issues as feasible exposure levels, whether the carcinogen belongs in the proposed category, and various provi- sions of the model standard, such as medical surveillance procedures. The cancer policy does not require rate retention for workers medically removed from exposure to carcinogens. Challenges Ahead The AFL - CIO has sued in the District of Columbia Circuit Court to restore the automatic emergency temporary standard provision. They fear that with- out such a provision, and without responsive OSHA leadership such as that provid- ed by Dr. Bingham, few stan- dards would actually get imple- mented. Industry has run to its favorite Federal Court challenging the standard on numerous grounds. If the policy survives the court test in recognizable form, the crucial question remains how forcefully OSHA will follow through to remove or limit car- cinogens in the workplace. With its cancer policy, OSHA has put itself out front as a target of the well financed - industry- led efforts to curb regulation. Yet even with this new policy, OSHA is under no obligation to actually issue standards. Much depends on whether labor, en- vironmentalists, and other groups can put together a politi- cal bloc that will push agencies such as OSHA into taking on in- dustry, enforce the law, and save lives. The cancer policy gives OSHA a powerful new tool to do its job, but it is the out- come of the rapidly intensifying political struggle around regulation that will determine whether the job ever gets done. -Tony Bale WOMEN Q HYDE AMENDMENT OVERTURNED: THINGS MAY GET MORE FAIR In 1977, when asked if poor women should be refused abor- tions simply because they were poor, President Carter replied, " Well, as you know there are many things in life that are not fair, that wealthy people can af- ford and poor people can't... " For those who believe that every woman should have the right to control her own body, life may become a bit fairer. The Hyde Amendment, which restricts federal funding for Medicaid abortions, has been declared unconstitutional by two Federal District Court judges in Illinois and New York. On February 19, 1980, the Supreme Court agreed to hear the two cases, Zbaraz v. Quern and McRae v. Harris, together. In a move that surprised many, the Court also refused HEW's request to delay resumption of Medicaid funding for abortion until a final decision is made. Both decisions found the Hyde Amendment illegal on constitutional grounds. This column will deal primarily with the McRae decision, both because of its broader findings and because the lengthy docu- ment presents evidence of the substantial impact the Hyde Amendment has made on the lives and health of poor women and their children. Congress passed the first Hyde Amendment as a rider to the HEW appropriations bill in 1976, specifically limiting federal Medicaid funding to abortion where " the life of the mother would be endangered if the fetus were carried to term Though. " the precise wor- ding chaged slightly over the years (an exception for rape and incest victims who report promptly to law enforcement or public health officials was add- ed in 1977), the effect of the Hyde Amendment, in all its forms, was to immediately reduce the federal funding for abortion by 99 percent. Many law suits challenging state limitations have been filed and have been largely success- ful. However, only Zbaraz v. Quern and McRae v. Harris challenge the federal Hyde Amendment directly and would affect Medicaid funding for abortion throughout the entire country. At issue in the McRae case is whether the Hyde. Amendment makes a valid distinction between women who need an abortion for medical reasons and those who seek abortion out of convenience. If the law can't truly distinguish between " therapeutic " and " therapeutic non -" abortions, it is unequally harming some Medicaid recipients and violates their right to equal pro- tection under the law. The se- cond questions is whether the amendment, which was lobbied for by the Catholic Church from its particular religious view- point, constitutes a violation of a poor women's right to freedom of religion. In McRae v. Harris, Judge Dooling found the Hyde Amendment restrictions to be unduly harsh. The amendment bars a woman and her physician from considering all health and relevant social factors in deciding for an abortion. It ex- cludes nearly all the situations that were specifically noted in the Supreme Court's 1973 deci- sions that liberalized abortion. In fact, by restricting Medicaid abortions in cases of known fetal defect, the Hyde Amendment creates a situation even more restrictive than that which ex- isted prior to 1973. The evidence produced in the McRae case also shows that the " life endangerment " stan- dard does not work to separate " therapeutic " from " non- therapeutic " abortions in the real world. The medical pro- viders who testified agreed that even in cases where the mother suffered from a disease that might meet the life endanger- ment standard, the outcome of the pregnancy depended great- ly on the woman's psychological, physical, en- vironmental and economic situation. Most severe and life- threatening conditions do not become obvious until late in pregnancy when the health risk of abortion is highest. The evidence in the case carefully documents the ex- acerbating effects of poverty on the already low health status of poor women: high maternal and infant mortality (especially among adolescents), poor nutrition and lack of access to prenatal care. When Medicaid funding is withdrawn, poor women have no where else to go. The aver- age price of an abortion is equal 19 to the average entire month's welfare benefit for a three per- son household. The only choices for a woman, then, are to carry the unwanted pregnan- cy to term, seek an unsafe, il- legal abortion, or deprive herself and her children of what little money they do have to pay for the procedure. These restrictions recreate the in- equality between poor and non- poor women's access to safe, legal abortions which was consideration in the 1973 Supreme Court decision liberalizing abortion. For these reasons, Dooling concluded that the Hyde Amendment violates the poor woman's right to equal protection and privacy under the Fifth Amendment. Only the staunchest fetal fanatics believe that a woman who is the victim of rape or in- cest should be forced to carry a resulting pregnancy to term. Given the general problem of under reportage of rape and in- cest, the 1977 and 1978 Hyde Amendments have not allevi- ated the suffering of these women. As the evidence showed, victims of rape and in- cest are most often denied Medicaid abortions because of the 60 day reporting require- ment. Judge Dooling also found that a woman's right to religious freedom is restricted by the Hyde Amendment. The legisla- tive initiative for passage of the amendment grew out of a moral conviction that abortion is murder - - a conviction held by several, but certainly not all, religions (for example, Reform and Conservative Judaism, the United Methodists and Ameri- can Baptist Churches). Though Dooling found as fact that the Catholic Church was directly involved in the Pro Life - political movement, he stopped short of ruling the amendment unconstitutional for this reason alone. He found the Hyde Amendment unconstitutional because it prevents a woman from choosing abortion in ac- cordance with her own personal religious beliefs. The Dooling decision in McRae v. Harris is a landmark decision. What emerges is a clear picture of the relation- ships among poverty, ill health and the decision to bear a child. By withholding abortion fun- ding under Medicaid, society denies the right of a poor woman to control her own life and body, forcing her into man- datory child bearing and rais- ing, without allowing her the means to deal successfully with it. Proponents of the Hyde Amendment and similar restric- tions have not expressed the same enthusiasm for full em- ployment, a guaranteed mini- mum annual income, adequate child care, decent housing, comprehensive health care, etc., that they have for restric- ting abortion. Although one has a right to life, one has no right to expect a secure, humane life. Should the Supreme Court agree with the decisions in the McRae and Zbaraz cases, Medicaid financing for abor- tions will be fully restored as a medically necessary service. without further restriction. The only avenue then open to the anti abortion - lobby would be the proposed Right - to - Life Amendment to the Constitu- tion. While this does not appear to be a political reality, it would be overly optimistic to believe that the " Right - to - Life Move- ment " will cease to exist. Even if restrictions on Medicaid fund- ing for abortions were illegal, anti abortionists - could still lob- by for the restrictions which, if passed, will wreak havoc on poor women's lives before the courts can respond. The tactics of harassment and destruction (firebombings of clinics, anonymous phone calls to cli- ents, sit ins -, etc.) that have been employed so effectively in the recent past will probably continue... and escalate. Abortion is a fundamental component of any woman's freedom. Since there are no 100 percent effective (not to men- tion safe) methods of contracep- tion, even the most diligently " careful " woman can become pregnant. Without the avail- ability of safe and accessible abortions, women are forced in- to compulsory motherhood or genuine risk to their health and well being -. The decisions in McRae v. Harris and Zbaraz v. Quern are a hopeful sign that the right to abortion finally will be realized for all women. -Marilynn Norinsky and Kate Pfordresher 2200 THE FIFTH COLUMN WJ NY NURSES HIT THE BRICKS In the last two months, RNs at many NYC voluntary hospitals have negotiated new contracts. The content of the new contracts has been as varied as the nature of the negotiations which led to the final settlements: three voluntary hospitals were struck - Maimonides, Kingsbrook and Columbia Presbyterian - Medical Center (CPMC); Beth Israel successfully negotiated after posting a strike notice; Mt. Sinai RNs were forced into in- terest arbitration. Marching with picket signs reading " Nurses on Strike for Better Patient Care " and " Nurses have Rights Too, " over 2,000 RNs at three New York Ci- ty voluntary hospitals went on strike during the week of February 1 to 8. The nurses, represented by the New York State Nurses'Association. (NYSNA), maintained a unified and militant presence during the strike actions. " We're united: we're fed up, and we'll be out here until we get a de- cent contract, " stated one nurse on the picket line at Maimonides Hospital. It was only two years ago that rank and file pressure forced NYSNA to remove a " strike no -" clause from its governing rules. These recent strikes were the first in NYSNA history and came at a time when the organization is facing a serious challenge to its representation of 6,000 City Hospital nurses from District 1199's League of Registered Nurses and the United Federa- tion of Teachers. Thus these strikes and the contracts they produced were an important proving ground for NYSNA. Perhaps these strikes can be considered a NYSNA warmup for the upcoming city elections which will decide who will be the collective bargaining agent for the city nurses. Although wage increases were important in all the con- tract struggles due to the ever increasing rate of inflation, non economic - issues of working conditions and patient care were as important or of greater importance. These issues in- clude: mandatory overtime, shift rotation, weekend schedul- ing, elimination of non nursing - duties, and job security. Al- though nurses have little ex- perience in turning these issues into contract language, some progress was made in these contracts. Recently, Beth Israel nurses. have also negotiated a new con- tract, which has drawn much at- tention as more and more nurses have begun to compare contracts and explore collective bargaining alternatives. Beth. Israel's 600 RNs, who have recently joined District 1199's Science and Liberation SCIENCE AND LIBERATION is a collection of essays on the role of science and scientists in the modern world. Grouped into four sections, the more than 20 articles cover the important issues of: the myth of the neutrality of science, science and social control, working in science, and new approaches to science teaching and working. Edited by Rita Arditti, Pat Brennan, Steve Cavrak 398 pp. $ 15.00 hardback; $ 6.50 paperback Send check or money order to South End Press Box 68, Astor Station Boston, MA 02123 35% discount for an order of five or more, plus 75 postage for first book and 20 for each additional book. 21 League of Registered Nurses, posted a ten day strike notice. The nurses were fully prepared to strike, but this proved un- necessary, due to the unity of the RNs and the support of the STRIKE other hospital workers who are also represented by 1199. A new contract providing signifi- cant wage and benefit in- creases, every other weekend off and a decrease in shift rota- tion was won in down - to - the- wire negotiating sessions. The determination of thousands of RNs on the picket lines and at the negotiating tables led to some gains being won with improvements in benefits and working condi- tions. Now the difficult task of enforcing these contracts on the job begins. In the past, NYSNA, with only 11 collective bargain- ing reps to service 30 hospitals, has had a real problem enforc- ing contracts and processing grievances. Nurses will be look- ing to see whether NYSNA's committment to the strike ac- ' tions will lead to the correction of these problems. It is also difficult to assess how these contract negotiations have affected the historical an- tagonisms between RNs and other hospital workers. In the past, RNs have been in the posi- tion of keeping the hospitals functioning during strikes by their fellow workers while at the same time benefiting from the strikes. Confused by the ideol- ogy of " professionalism ", often unorganized and fearful, motivated by concern for pa- tients, nurses have worked long hours of overtime and actually prolonged strike situations. At the various institutions where there were NYSNA strikes, the strike committees spoke of hav- ing the support of some MDs, other workers and community members. However, no formal 22 organizational support from the other unions involved was evi- dent. On the other hand, at Beth Israel, where nurses are in the same union as the other hospital workers, plans for con- crete mutual support were made. During the last week of negotiations, workers wore badges stating " We support our 1199 RNs, " and they visited the director of the hospital. The Hospital's fear of concurrent job actions may have been a major factor in avoiding a strike at that institution. Nurses must not wait for their collective bargaining represen- tatives to lead the way. They themselves can take the steps to begin bridging the gaps and building the unity between themselves and the hospital workers. This will ultimately lead to an increase in strength for all involved in dealing with the hospital administration. Although these and other problems remain, the unity and activism of the nurses points the way to a potential change in Nursing. Nurses have become more active than in the past and must demand from their collec- tive bargaining units an organi- zation which provides for and encourages participation from the membership. Though ad- ministrators and educators would like us to change the labels without changing the basic power relationships, nurses are seeking real control over their working conditions and the ability to affect a real change in the delivery of pa- tient care. As active par- ticipants in our unions and organizations, whatever they may be, in constantly seeking to democratize them and make them more responsive to our needs, we can go a long way toward achieving those goals of better patient care and more control over our working condi- tions. -Nurses'Network Sill Plympton The 1981 Health Budget TARHOEUADB,L E The Carter administration sent a tough, lean, TROUBLE and programatically conservative $ 61 billion BEHIND budget to Congress. Although this represents a $ 5 billion increase over 1980, the rate of infla- tion in the economy means the budget actually represents a 3.2 percent cut in health expen- ditures over the current year. Worse yet, the looming economic crisis may well force further retrenchment. The ink had scarcely dried on the budget when the Administration began talking of a 10 percent across the board cut in all agency budgets - except the Department of Defense. The Carter version of " fiscal restraint " means " modest increases " which fail to keep pace with inflation for many programs, a few new areas of investment, and a few deep cuts, such as the proposed elimination of the federal capitation grant for medical schools and a ma- jor cut in money for nurse training. The Carter budget is bounded by three demanding and equally contradictory political and economic realities: inflation, militarism, and the requirements of a political campaign. Carter is responding to inflation with a tradi- tional Republican strategy of " cooling " the already paralyzed economy by curbing federal spending especially in the area of social and human services. Even if Carter were not so in- clined, he is being pushed in that direction by Congressional pressure. Resolutions have been introduced in the House and the Senate to limit the federal budget to a fixed percentage of the Gross National Product. If the House resolution is passed, Congress will have to hold the 1982 budget to 20 percent of the GNP - a cut of at least $ 57 billion. Ironically, the Senate version introduced by Warren Magnuson (Wash D - ) would force even deeper cuts of $ 75 billion in the 1982 budget. These proposals amount to a federal Jarvis initiative. Carter strategists hope to head off such measures by demonstrating restraint in their own budget re- 23 Health Care Financing Administration (in millions of dollars) Medicare Medicaid 0.0.0.0. ....... 0000 eee eee ........00..2...0...00..0.. Quality Assurance ...............0.. Research and Demonstration .......... All HCFA other.. ..0.000...0.0000. TOTAL.. 1979 $ 29,148 12,407 29 16 55 $ 41,655 1980 $ 33,542 14,160 30 24 65 $ 47,821 1981 $ 37,349 15,768 34 28 71 $ 53,250 % Changet +11.4 + 11.4 13.3 + +16.7 +16.7 + 9.2 + 11.4 quests. Many analysts expect a federal budget cut of $ 20-40 billion. That the " restraint " is limited to human and social services, and does not extend to the military budget, is so common that it shocks no one anymore. This is the " passive euthanasia " approach to federal health programs while MX missile systems, rapid deployment systems, and other mechanisms of international intervention abound. Health advocates may take some comfort in the fact that the upcoming elections mean we will be spared the worst of the cuts, but the comfort should be small indeed. Carter cannot afford to risk angering the remnants of the old labor - civil rights liberal - coalition so long as there is the threat of a Kennedy candidacy, and so long as he sees a strong need to rally Democratic troops against a Republican chal- lenge this fall. We may therefore expect that this year's strategy of allowing inflation to eat away program funds will be replaced by a " slash and gouge " approach in 1982 that effects major attacks on important programs. Food and Drug Administration (in thousands of dollars) 11971 9 11 11191801 1111198 1 % Change Bureau of Foods. $1 18171,9 0171 11 11$1 913 ,171911 1 111$1 916,151017 + 2.9 Bureau of Drugs and Devices 1111 111113 9,101 481 1 151540,,28966 2 1111 1111 + 3.1 Bureau of Radiological Health 1111 111120 ,91141 11 2232.,72237 3 1111 1111 + 2.4 Natl. Center for Toxicological Research 1111 14,069 1111 14,779 1111 15,158 1111 + 1111 2.6 Program Management 1111 39,729 1111 42,381 1111 42,899 1111 + 1111 1.2 Building and Facilities. 1111 10,459 1111 4,372 1111 29,663 1111 1111 +585.44 TOTAL.1 111 $ 312,126 $ 328,332 328,332 $ 362,462 + 10.4 * New name for what remains of the Department of Health, Education and Welfare since the Department of Education was created. The percent change from 1980 to 1981 does not include an adjustment for the inflation rate of 14 percent. The actual increase or decrease is therefore understated in terms of 1981 dollars. Source: Arnstein, Sherry, Editor, Government Relations Note, Vol. VI, No. 2, National Health 24 Council, January 28, 1980. Within these limitations, the budget is still worth examining as a statement of federal in- tent. It tells something of programs the ad- ministration feels some commitment to and which programs are in deep trouble. The budget also tells us where in the health system some of the most critical stresses will be felt. (See box on Budgetary Highlights by Agency.) Budgetary Overview " As inflation forces expansion of uncontrol- lable entitlement programs, the health budget becomes more like a horse and rabbit stew, " says Sherry Arnstein of the National Health Council. The Health Care Financing Admini- stration (HCFA) is the horse, and all the discre- tionary public health programs are the rabbit. Medicare and Medicaid account for some 86 percent of the federal health budget. Despite some small increases in Public Health Service programs, Administration budgeteers are shouting " hold that line " when reviewing most discretionary programs. The stew is being lightly seasoned with just enough increases to keep the beneficiaries of some categorical pro- grams happy until the year's end. There are three major new outlays, and one major cut which telegraphs the Administration strategy. CHAP The Administration is pressing for enact- ment of the Child Health Assurance Program (CHAP) early enough to launch it this July. Over $ 400 million has been set aside for the program, which would mandate medical, den- tal, vision, hearing, pharmaceutical, and men- tal health benefits for 100,000 pregnant women and nearly two million income low - children. Yet the program itself is in trouble, as reported in last issue's Washington column. Far- reaching anti abortion - amendments have soured many women's groups on the bill, leav- ing a few women's and children's groups, and the low income - advocates to go it alone. Primary Care Required state coverage of comprehensive primary care in clinics would add another $ 52 million to Medicaid. The Public Health Service also plans to construct fourteen new community health centers CHCs ( ) and expand services at another fifty - one CHCs. The overall CHC budget will be upgraded by 14.3 percent, one of the few federal health programs to actually keep pace with inflation. NHSC The best news is the National Health Service Corps (NHSC) budget. NHSC is being slotted for a $ 52 million increase, a 43 percent im- provement over 1980, even taking inflation into account. Current plans include a 61 percent increase in the present corps, to include 4,500 health care professionals. The Office of Management and Budget strongly opposes the Corps'growth, preferring to increase federal subsidies to the private sector via Medicare and Medicaid. In this area, at least, the public health advocates appear to have beaten the budgeteers at least for this year. Professional Education The Administration once again will seek to eliminate capitation grants to medical schools. entirely. Nurse training will also be cut 76 per- cent. The supply of physicians and nurses has doubled since 1960, and HEW believes that there are more than enough professionals to go around. This, of course, ignores the geographi- cal and specialty maldistribution of physicians and the retention problem afflicting the nurs- ing profession. HEW apparently believes that neither of these problems will be solved so long as a steady stream of federal dollars provides symptomatic relief. These cuts will be strongly opposed by the American Medical Association and the American Nurses'Association. The AMA's heavy campaign contributions guarantee stormy weather for at least this Carter proposed - cut. Other cuts will likely be tolerated by the AMA, and will survive Congressional review. NHSC scholarships will be hiked 9.3 percent, which will be substantially less than anticipated tuition increases at most medical schools. Special scholarships for exceptionally needy medical students (i.e., anyone without $ 25,000 to put on the table) are being held at their pre- sent levels, which, given the 14 percent rate of inflation, is the equivalent of a 14 percent cut. Specific Programs The Health Care Financing Administration. continues to sit atop a spiraling budget it has done little to control. Current HCFA strategy is to hold the line on major increases by pushing cost containment and increasingly aggressive regulatory approaches. The Alice - in- Wonderland mentality which pervades their policy making - can be seen in HCFA's list of 25 Center for Disease Control (in millions of dollars) 1979 1980 1981 % Changet Health Promotion: Prevention Formula Grants ........... - Risk Reduction / Health Education ...... 10 14 10 17 + 21.1 Total eee 0.02 Preventive Services: $ 10 $ 14 $ 27 + 92.9 Venereal Diseases. 39 48 48 - Immunization 0000 c - .......... eee 47 30 30 Chronic Diseases. .........0 0.00055 15 18 19 + 5.6 Total.... ee. ee s Health Protection: $ 101 $ 96 $ 97 + 1.0 Fluoridation. 2 7 10 + 42.9 Environmental Hazards .............. 28 30 31 + 3.3 Epidemic Services... 27 28 30 + 7.1 Occupational Safety and Health. 62 81 83 + 2.5 Technology Development and Application.. 27 25 27 00.00 ae = Total. eee 00. cee Other CDC: $ 144 $ 173 $ 181 + 4.6 Buildings and Facilities. .............. 2 11 30 +172.7 +172.7 Health Incentive Grants ...........005 90 68 52 + 23.5 Program Management ...........6..- 4 4 4 - Total ec . eee. ee s $ 96 $ 83 $ 86 + 3.6 TOTAL. ccc cc tenes $ 351 $ 366 $ 391 + 6.8 proposed savings, which includes $ 780 million to be saved through the passage of a cost containment bill1 1 - the same bill which was defeated by more than a 2-1 vote in the House of Representatives! HCFA's inability to attack the true sources of medical inflation has led to a program which strikes the hardest at the weakest hospitals in the system - public and in- ner city community hospitals. Despite Congressional hearings into the plight of distressed hospitals serving poor com- munities. HCFA has refused to develop a pro- gram to save these hospitals. HCFA officially believes that private hospitals will pick up the slack, Quentin Young, Medical Director of Chicago's beleaguered Cook County Hospital has decried HCFA's " Marie Antoinette Theory, " as he calls it. In recent congressional testimony, Young wryly speculated whether poor patients unable to enjoy the simple fare of public health care would magically dine on 26 escargot at voluntary hospitals. HCFA's true at- titude was revealed in a private meeting when its chief, Leonard Schaeffer, reportedly belit- tled undocumented workers as " wetbacks, " and denied that their care posed a problem. There, at least, is agreement that screws are loose in HCFA, and that some form of screw- tightening is mandatory. HCFA plans to step up its Research and Demonstration projects to $ 58 million, an absolute increase of 8.3 per- cent, even taking inflation into account. HCFA's R & D programs are a mixed bag. Although $ 14 million went to bail out besieged Brooklyn Jewish Hospital last year (after inten- sive politicking and White House intervention), most of the money is earmarked for systems rationalization - often in the form of cutbacks and closures. Other screw tightening - will be taking place in the long term - care area. HCFA has already attempted to hold all state nursing home reim- bursement programs to a nationally - estab- lished median. This meat - axe approach will Health Services Administration (in millions of dollars) Community Health Centers ........... National Health Service Corps ......... Indian Health Service.. Indian Health Facilities. Migrant Health .............. 0.0000. PHS Hospitals ..............0. 02.005. Maternal and Child Health ............ Family Planning .................... Hypertension.. Emergency Medical Services .......... Other HSA.. TOTAL TOTAL.. 1979 $ 277 63 492 77 34 172 381 135 11 40 64 $ 1,746 1980 $ 342 82 549 74 40 173 380 165 20 40 77 $ 1,942 1981 $ 391 134 602 77 45 165 394 177 20 26 85 $ 2,116 % Changet +14.3 +14.3 +63.4 + 9.7 + 4.1 +12.5 - 4.6 + 3.7 + 7.3 - - 35.0 + 10.4 + 9.0 wreak havoc in states with costs significantly above the national average, such as New York and Massachusetts. It also undercuts in- novative reforms such as the Washington state effort to upgrade nursing home quality by bringing wage levels for nursing home aides up to 90 percent of parity with hospital aides. Washington's increased reimbursement and required pass through - of wage increases would be undercut by these new regulations. Although a federal court has temporarily restrained HCFA from applying these regula- tions to state Medicaid programs the outcome remains uncertain. HCFA's general strategy relies on imposing a nation - wide rule, gracelessly conceived and witlessly executed. This appears to be ad- ministratively simpler than the politically touchy task of cracking down on fraudulent providers, as was recently done in New York, where New York's Deputy Attorney General in- dicted, tried, and convicted over one hundred nursing home operators and administrators. A few modest improvements in long - term care are anticipated from HCFA's efforts to provide home health aides, to provide homemaker services, and to seek legislation eliminating the requirement that Medicare pa- tients be hospitalized for three days before becoming eligible for nursing home care. Long - term care is not the only area in which HCFA tacitly condones provider abuse. HCFA is planning to boost PSRO appropriations by a whopping 31 percent - after inflation. It con- tinues to defend the effectiveness of the Profes- sional Standards Review Organizations despite studies by the Congressional Budget Office and the General Accounting Office which sug- gest that PSROs spend at least as much, and possibly more, than they save. Meanwhile, in the other major area of Health and Human Services (HHS), Public Health Ser- vice programs do not fare nearly as well. The Food and Drug Administration is being slated for only a 2.3 percent increase (inflation in- cluded) in its program operations, with an ad- ditional $ 25 million for new laboratories. Significantly, the modest 2.6 percent increase for the FDA's Bureau of Drugs and Devices cannot possibly allow it to establish its post- marketing surveillance system being widely touted as a replacement for extensive controls prior to the marketing of new drugs. The post- marketing system called for by Sen. Kennedy's (Mass D. - ) would substitute many current con- trols for a " downstream " approach that would presumably identify drug complication prob- lems as they develop. No one is certain where the money is supposed to come from. The Health Service Administration (HSA) represents a very mixed bag of increases and devastating cuts. The CHAP, NHSC, and CHC programs have already been described. Many other programs fared poorly. The most alarming cuts are being faced by PHS's eight general hospitals. The PHS hospitals rebounded from a Nixon attack in the 1970s to develop ways of more fully integrating 27 National Institutes of Health (in millions of dollars) 1979 National Cancer Institute ............. National Heart, Lung, and Blood Institute National Institute of Dental Research........ National Institute of Arthritis, Metabolism and Digestive Diseases ... National Institute of Neurological and Communicative Disorders and Stroke. National Institute of Allergy and Infectious Diseases ................ National Institute of General Medical Sciencesc. ee. ee e National Institute of Child Health and Human Development .............. National Eye Institute ................ National Institute of Environmental Health Sciences... National Institute on Aging. Other NIH... 0. cece cc ee eee TOTAL.e ee $ 936 506 65 303 212 191 278 198 105 78 57 257 $ 3,186 1980 $ 1,001 528 69 342 242 216 313 210 113 84 70 255 $ 3,443 1981 $ 1,008 548 70 366 250 228 332 218 116 97 75 274 $ 3,582 % Changet + 0 + 3 +1 +1 + 7 + 3 + 5 + 6.1 + 3.8 + 2.7 +15.5 + 7.1 + 7.4 + 4.0 themselves into local delivery systems by pro- viding support for primary care programs. Despite this, the hospitals face a $ 12 million cut. When inflation's toll is added in, this represents a 16 percent decrease in support for the PHS hospitals. Federal support for other primary care pro- grams is also in doubt. Although the Communi- ty Health Centers are getting budget increases which will allow them to keep pace with infla- tion, the Maternal and Child Health (MCH) grants to states are receiving only a $ 15 million " increase, " which amounts to a 9 percent cut in the face of inflation. Family planning programs will sustain a similar 5 percent cut, despite their slightly increased appropriation over 1980. Even the desperately underfunded migrant health program is receiving only a $ 5 million. Alcohol, Drug Abuse, and Mental Health Administration (in millions of dollars) 1979 1980 1981 % Changet National Institute of Mental Health... $ 570 $ 620 $ 671 + 8.2 National Institute on Alcohol Abuse and Alcoholism ..............2.2... 175 190 201 + 5.8 National Institute on Drug Abuse ... 272. .. 274 .. 27 4 - St. Elizabeths Hospital............... 79 89 98 +10.1 Other.. ee eee 9 12 17 +41.7 2288 TOTAL.e ee ee $ 1,105 $ 1,185 $ 1,261 + 6.4 boost, representing a 1.5 percent loss to inflation. Inflation will also mean a 14 percent cut for HSA's hypertension screening, treatment, and referral programs. The academic researchers won a big battle with public health advocates when they won an additional $ 11.2 million for the Heart, Lung, and Blood Institute in the Na- tional Institutes of Health. Although the funds are targeted for demonstration and education projects on high blood pressure, advocates are complaining that many of NIH's programs in these areas maintain a comfortable " old boy's school " atmosphere that prefers academic con- ferences to service delivery. One such pro- gram in Georgia is spending over half a million dollars on " coordination " of hypertension pro- grams without making any efforts to increase provider participation in Medicaid, the only source of payment for many black Georgians who suffer from hypertension. The Center for Disease Control (CDC) is shifting money away from immunizations, chronic diseases, and venereal diseases (infla- tion is accomplishing an 11 percent cut) to health prevention and risk reduction pro- grams, which are being stepped up from $ 14 to $ 27 million. Much of this money will be targeted for workplace, school, and other com- munity settings. CDC is also requesting $ 25 million to enlarge its Appalachian Laboratory for Occupational Safety and Health in Morgan- town, West Virginia. Nearly all programs of the National Institutes of Health received modest " increases " which will fail to keep up with inflation. The most significant inflation induced - cuts hit the Na- tional Cancer Institute ($ 1 million increase, 12 percent cut), National Heart, Lung, and Blood Institute (20 $ million increase, nine percent cut) and the National Institute of General Medical Sciences (19 $ million increase, seven percent cut). These three institutes accounted for 53 percent of the NIH budget in 1980, and these cuts superficially suggest a weakening of the institutional research establishment. It is only when these small retrenchments are ex- amined in the context of major cutbacks in other health and health related - programs that the staying power of NIH becomes clear. Health Resources Administration (in millions of dollars) 1979 1980 1981 % Changet Health Planning .................... $ 152 $ 167 Conversion / Closure ..............-5. - $ 170 10 + 1.8 Health Professions Education: Capitation eee - - - ..... 0... cece 116 Start - up ee eas - .. 0... cee 5 3 - 100.0 Primary Care Family / Medicine ........ 58 65 83 + 27.7 Natl. Health Service Corps Scholarships. 75 86 94 + 9.3 Area Health Education Centers ... 282. 2027 9 .. 21 .. 21 - Loan Repayments...ee s 822279 2 12 + 500.0 Exceptional Need Scholarships .... 822279 .. 10 .. 10 - Disadvantaged Assistance ............ 19 822279 20 22 + 10.0 Financial Distress ................... Nursing 2.0.0... 0.000 e eee eee Public Heal0t 0.0h 00. .0. 00 s Other Health Professions ............. 5 106 17 74 7 106 17 61 9 + 28.6 29 - 72.6 17 - 29 - 52.5 Subtotal 0 cee eee 0.0.0.0... Medical Facilities Guarantee and Loan Fund 00 eee eee eee ........... Other HRA. $ 656 42 63 $ 565 45 23 $ 506 - 24 - 10.4 - 100.0 + 4.3 TOTAL. $ 761 $ 633 $ 530 - 16.3 29 Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) The ADAMHA budget with the National In- stitute of Mental Health sustained a five percent inflation - born cut despite a $ 51 million in- " crease ". Although the Administration has also requested a $ 50 million supplemental ap- propriation to the 1980 budget to increase care to minorities and the chronically mentally ill, this request may fare poorly as the Congress approaches its self imposed - budget ceiling. The Health Resources Administration has been targeted for the most extensive cuts of all the agencies in HHS. In addition to elimination of capitation grants (116 $ million) and drastic cuts in support for nurse training (77 $ million), HRA faces termination of its $ 45 million pro- gram to guarantee loans to medical facilities, the vestigial survivor of the old Burton Hill - pro- gram which fueled so much unnecessary ex- pansion. Although there are strikingly sound arguments for each of these cuts, the overall impact on HRA itself may be alarming. When these cuts are added to inflation's toll, they represent a 27 percent cutback for this agency. Cuts in Health Professions Education make the health planning program far more visible. As health planning's share of HRA's dwindling budget grows from 26 percent in 1980 to 33 per- cent in 1981, HRA may become increasingly threatened by HCFA's efforts to bring the plan- ning program under its own control, effectively vivisecting HRA itself. This obscure bureaucratic infighting has alarming implica- tions for the fate of inner city and other medically underserved areas. Although HRA has often ineptly allowed its planning agencies to ignore civil rights and access issues, the agency at least has an explicit policy of opposi- tion to service cuts where there are no alter- native sources of care for the underserved. HRA Chief Henry Foley's sensitivity to this issue stands in sharp contrast to the unremitting hostility HCFA's Leonard Schaeffer has ex- hibited toward minorities and the poor. There is little joy in Mudville to leaven HRA's institutional woes. In addition to the cuts in pro- fessional education, the health planning pro- gram is slated for a meager $ 3 million increase. Inflation will effect a net 11 percent budget cut for the planning agencies. Similarly, HRA's once ambitious - program to help finance the conversion and closure costs of excess hospitals has been whittled down to a meager $ 10 million, scarcely enough to retire the long term debt at a single facility. HRA's intentions to slice this pie " equitably " will have the gloomy virtue of disappointing everyone fairly. The virtual end to nurse education support will drastically reduce the flow of new RNs. Numerous studies have pointed to professional frustration and job dissatisfaction as the primary problems in retaining nurses. Shutting off the RN assembly lines will force hospitals to seek solutions to these problems. Yet they must seek them at precisely the point when fiscal pressures are the most intense ever, leaving facilities with very little room for discretionary innovation. Although throwing money at the Office of Assistance Secretary for Health (in millions of dollars) 1979 1980 1981 % Changet National Center for Health Services Research . $ 36 $ 33 $ 35 + 6.1 National Center for Health Statistics .. 38 .. 45 - 42 6.7 National Center for Health Care Technology. 0.0... eee eee .3 3 Health Maintenance Organizations ..... 33 59 Adolescent Health. 1 18 8 +166.7 +166.7 69 + 16.9 18 - Smoking and Health 3 13 13 ................. _- Health Promotion .................-. 3 3 6 + 100.0 Other 0... 0. cc cece eee cece 104 110 120 + 9.1 30 0 TOTAL. cee. ee e $ 218 $ 284 $ 311 + 9.5 problem of nurse retention will not solve it, it seems equally clear that bankrupting nurse training programs will only worsen the problem. The Office of the Assistant Secretary for Health's (OASH) budget is set aside for pro- grams heavily dependent on interagency cooperation (such as the National Center for Health Statistics or the National Center for Health Services Research) and for the Secretary of HEW's " showpiece " programs. Accordingly, no one was surprised to see former HEW Secretary Califano's anti smoking - program frozen at its current level. The Office of Health Maintenance Organizations (OHMO) received a hefty appropriations request outstripping inflation and allowing for a 2.6 percent increase in OHMO staffing and demonstration programs. OHMO may need all the help it can get when publicity is given to two reports HCFA sought to suppress which charge that even the best HMOs, including the consumer - owned Group Health Cooperative of Puget Sound, skim " " patients and seek to pre- vent poor and elderly persons from enrolling. The only other " winner " was the newly formed National Center for Health Care Technology, charged with the mission of evaluating the ef- fectiveness of innovative medical technology relative to its costs. This office's budget was more than doubled, from $ 3 to $ 8 million, envi- sioning a growing federal involvement in ques- tions of technology assesment. Health Related - Programs Many health related - programs are faring equally poorly. The Carter Administration plans to carve $ 817 million from child nutrition and food assistance programs by tightening eligibility standards for free and partially sub- sidized school lunches. These cuts stand in stark contrast to the Administration's bright promise of the CHAP bill. The Administration is also planning to curtail social security benefits for disabled workers, and is looking forward to even deeper cuts in the Social Security program after this fall's elections. Summary The 1981 health budget represents a major volley in the Administration's war of attrition against many public health programs. Federal failures to control the Medicare and Medicaid budgets virtually guarantee more of the same in the coming years. The only difference will be that the elections will be over, and there will be little to stand between needed public health care programs and devastating cuts. Unlike his last Democratic predecessor, President Lyndon Johnson, Carter makes no pretense of being able to purchase guns and butter. Like Carter's other economic policies, he will doubtless say that the mounting toll of disease, degradation, and disability " suits me fine.'" -Mark Kleiman Rockefeller Medicine Men Medicine and Capitalism in America by E. Richard Brown Send orders to: Health / PAC 17 Murray Street New York, N.Y. 10007 " This book tells us what health care in the United States is really all about.... No one can or should ignore this book. It's an eloquent, well documented - damning appraisal of the historical marriage between medicine and capitalism and its impact on shaping the kind of health - care system we have today. " Washington Post Originally $ 12.95. Now Only $ 10.45! Price includes postange and handling. Allow at least six weeks for delivery. 31 Y, Dolores Krieger, The Therapeutic Touch, Prentice- Hall, Englewood Cliffs, N.J., 1979. Paperback, $ 5.95. One of the problems that ad- vocates of professionalism in nursing must face is to define the specific content of that pro- fessionalism. While there has always been a vague sense of professionalism in nursing, and the form of nursing is changing in its upper echelon, there is still no unified and exclusive theoretical foundation for nurs- ing. Many nursing academics un- derstand this theoretical defi- ciency and firmly believe that nursing will never be respected as a learned profession until it can find an empty peg to hang its hat on. Just what is it that nurses do that no other health practitioners can do? One answer has come out of New York University -- one of the vanguards of theoretical development. Taking off from nursing's historical " nurturing " role, Dolores Krieger has developed a distinct form of pa- tient care called Therapeutic Touch (TT). Krieger's Theory of the Concentration of Energy The basic premises of 32 Therapeutic Touch are simple. Media Scan Borrowing heavily from Eastern mysticism, TT maintains that the human organism is animated by a form of " energy " or prana. This energy is organized into specific pathways or foci called chakras. Symptoms of illness appear when the " flow " of prana is disrupted, depleted, or in imbalance - - a somatic ver- sion of the energy crisis. The healer, by a " knowledge- able " placement of her hands is supposed to be able to transfer her own energy to a depleted patient, or " unruffle " any " con- gestion " in the chakras. Know- ledge on the part of the healer is less a product of scientific study than an inner almost volun- taristic, knowledge. " Conceive of the healer as an individual whose health gives him access to an overabundance of prana and whose strong sense of com- mitment and intention to help ill people gives him or her a cer- tain control over the projection of this vital energy " (1). The " Energy " of Nurses " Transfer of energy " is not a new term of art in nursing. At least ten years ago the phrase came into vogue in relation to the care of patients suffering from debilitating diseases such as chronic obstructive pulmo- nary disease. On close analysis it becomes apparent that what " transfer of energy " means in that context is intelligently organized, patient, physical care which anticipates the pa- tient's needs and improves his quality of life by relieving him of many physical burdens. This, of course, is nothing new or mysterious, and merely exemplifies the inability of nursing theoreticians to use plain English. In the institutional setting, the quality of nursing care given to patients is frequently directly proportional to the level of staffing determined by management. Nursing is a labor intensive field. Good nursing entails a heavy outlay of time to try to meet both the physical and psychological needs of pa- tients. In addition, nurses should serve as a moderating force between patients and the rigid demands of institutiona- lized health care. Because of the centrality of the staffing question, rank - and - file or union By her silence on the question of technology, medical allocation and priorities, Krieger ac- cepts the present ar- rangement as given input into decisions in this area is the most explosive non- economic issue being con- fronted by unionized nurses. Hospitals, of course, do not share the same perspective. They only see that nurses are somehow able to take up the slack whenever hit by cutbacks. In reality, what happens when nurses are speeded - up is that patients receive less and less direct care. The result is that patients take longer to get better, and staff morale plum- mets (except perhaps that of the hospital comptroller). Thus the real struggle for the " energy " of nurses is in getting the ade- quate staffing with which to spend the necessary time to have optimum effect. Where does Krieger fit into this tug war - of -? While she carefully avoids any discussion SAND www CELSI MCMLXXX MCMLXXX of what TT would look like in the institutional setting, it would appear to be opposed to the labor intensive wholistic view of nursing. The " energy " put into patient care can be reduced to a simple mechanical technique which can be performed in a matter of minutes. This reduc- tionist view of nursing may com- fort both the fiscally minded - ad- ministrator and the harassed and overworked staff nurse. " Science " and Therapeutic Touch Krieger began developing her theory of healing by the lay- ing on of hands by studying under lay healers. At first, she tried to give TT a scientific veneer. Between 1971 and 1974, she conducted a number of small studies which purport to demonstrate an elevation in the hemoglobin levels of pa- tients treated by the technique (2). No similar attempted scien- tific approach is to be found in her book. Evidence of the ef- fects of TT on the patient are ex- clusively limited now to testimonials and case studies- a practice which itself raises serious questions because of its use by quacks. Krieger has shifted her scien- tific focus to the safer ground of the effects on the healer, which has in turn signalled a subtle shift toward an emphasis on the internalization of the healing role. The turn toward focusing on the effects of Therapeutic Touch on the healer has appeared to accelerate Krieger's adoption of mysticism. In her book, she now advocates the use of dream analysis, symbolic language, yoga and mandalas. The healer is to attain some ideal inner knowledge. In a more scientific vein, Krieger has demonstrated the genuine state, as measured by the EEG and EMG (3). While this state may do wonders for the " head " of the healer, we are constrained to ask how all this is externalized? Krieger's answer - " Kirilian " photography. The energy veritably leaps from her fingertips (4). One on One Incredibly, Krieger manages to avoid the debates around technology and priorities in health care. She refrains from explicitly counterposing Therapeutic Touch to Scientific Medicine, or presenting it as an adjunct to traditional medicine. 33 The approach of Health / PAC has been to criticize the misuse of technology, the misallocation of resources, and the skewed priorities of disease treating - medicine. Health and illness are fundamentally social issues; and refusal to accept that basic premise makes it impossible to analyze the problems in the sys- tem, let alone suggest pro- gressive changes. By contrast, Therapeutic Touch is individualistic to the core. The individual " healer " approaches the individual (ill) patient with no thought of where either fits into the system for better or worse. By its silence on the questions of technology, al- location, and priorities, it ac- cepts the present arrangement as a given. Therapeutic Touch tries to be apolitical. Therapeutic Touch does fit nicely into a health care system which rejects social responsibil- ity for health. Cutbacks in ser- vices and appropriate technol- ogy become irrelevant. The success or failure of the system becomes dependent on the ability of nurses to throw themselves body and, more im- portantly, soul into their work. In this way, nurses are set up - to shoulder the failures of the health care system. Technology and Health Care There is a growing recogni- tion that the latest technology may not be efficacious in all cases. For example, many ter- minal patients are better treated by supportive, rather than cura- tive or even palliative, therapy. Doing " everything possible " can actually hasten death, and certainly increases the patient's suffering and chances of iatrogenic disorders. Krieger, however, makes no bid for the use of Therapeutic Touch when high technology is 34 ineffective. In fact, nowhere does she explicitly address the question of which patient care situations are appropriate for TT and which may be less so. Patient care situations in which technology is inappro- priate because it is too little, too late, are precisely tailor made - for intensive, wholistic, tradi-, tional nursing care. The hos- pice movement is an explicit recognition of the value of nurs- ing care over that of high technology in certain situa- tions. A 10 minute - " treatment " of TT is simply absurd and pa- thetic by comparison. Counter - Culture and Health Americans seem particularly fond of crackpot schemes (5). Next to general " style life -, " this mode of thought finds its strong- est expression in matters of health. Does TT plug itself into any of these undercurrents in health? Among the pop cultural ap- proaches to sickness and health are religion, health food, physi- cal culture (jogging against cancer), breaking machine - Il- lichism, and outright quackery. Objectively, TT should fit in along this continum, if for no other reason than its blatant mysticism. All, with the excep- tion of religion, preach in- dividual reliance and respon- sibility for health. TT may be the penultimate " me generation " view of health by emphasizing the " power " of the individual. Krieger makes no effort to place it there, or to identify with any of them. She has bigger fish to fry. Therapeutic Touch is not intended to be merely the latest health craze. Content and Context Therapeutic Touch is offered up as that unique body of knowledge which distinguishes nursing. Among unique bodies of knowledge, the selection is limited. Unfortunately for nurs- ing, science is already spoken for. Just how different is Thera- peutic Touch from Scientific Medicine? In terms of actual knowledge base, they are polar opposites; but in terms of ideology, they are almost iden- tical. Both propound an indi- vidual rather than social view of sickness and health. Both con- centrate their efforts in cure rather than prevention. Both preserve a monopoly power over " health " in the healer (although Therapeutic Touch may do this more strongly), by mystifying, ritualizing and otherwise placing knowledge beyond the reach of the average individual. The healer remains the dispenser of magic. Adoption of the medical model is no mistake. One of the hottest issues for the nursing elite is private practice for nurses. While many such schemes involve nurses remain- ing subordinate to medicine to some degree, Therapeutic Touch provides the wherewith- all to cut the cord. The price of such in- dependence, however, may be to make nursing the laughing stock of the health sciences. If private practice for doctors is tragedy, private practice for nurses, based on Therapeutic Touch, is farce (6). TT and Nurse Practitioners One of the movements which promises a far reaching - impact in the delivery of health care is specialization and nurse practi- tioners. As nurse practitioners, some nurses attain a measure of independence and receive the recognition due nursing. While there are serious problems of access and elitism among nurse practitioners, they are begin- ning to fill a need for cheaper middle - level health providers Frustration with the attempt to deliver quality nursing care is part of the social reality of which health care is a part. What is needed is not to balance ' ' the inequities of the health care hierarchy but to destroy that hierarchy. and to rehabilitate the hand- maiden reputation of nurses. Nurse practitioners have been able to gain a measure of success only by poaching on medicine's private preserve. It is unlikely that any alternative strategy would be attractive to most nurse practitioners so long as the epicenter of health care remains scientific medicine and its emphasis on diagnostics. By comparison, Therapeutic Touch is an eclectic form of therapeutics without diagnos- tics. Most nurse practitioners can be expected to shy away from any such attempt to funnel them out of the mainstream. Therapeutic Touch can only appeal to a thin layer in nurs- ing. It appeals most strongly to those who have grown dis- gusted with, or never intended to become involved with, in- stitutional nursing (7). But this is an individual cop - out and diversion, coming just as nurses are beginning to flex their col- lective muscles. Strategy for Change The hundreds of thousands of working nurses have no need of Therapeutic Touch. The prob- lems they face daily do not arise from deficiencies in their " heads, " or in the inability of nursing to define itself beyond the borders of reality. Frustration of the attempt to deliver quality nursing care is part of the social reality of which health care is a part. Much of what is done in the health care system comes through nurses. Nursing labor is central to the system's func- tioning. Nurses are in a position to realize the obvious deficien- cies of understaffing and sub- mersion of the importance of the role of nursing to the operation of the system. Because of their centrality, nurses can begin to affect change by using their collective strength. What is needed is a struggle not to " balance " the inequities of the health care hierarchy a little more at the middle level by adding another individualistic, mystifying " science " but to destroy that hierarchy. Also challenged must be the hierar- chy's systemic domination which prevents equity in effec- tive care for all and obstructs a total public health approach to the social causes of illness. Rather than looking for in- dividual solutions among con- structs, nurses should use their organized strength to demand an equal and collegial part of decision - making in a realigned health care system. -Glenn Jenkins References 1. D. Krieger, The Therapeutic Touch, 1979, Prentice - Hall, Englewood Cliffs, N.J., page 13. 2. D. Krieger, " Therapeutic Touch: The Imprimatur of Nursing, " American Journal of Nursing, May 1975, pp. 784-87. 3. D. Krieger, " Searching for Evidence of Physiological Change, " American Journal of Nursing, April 1979, pp. 660-62; The Therapeutic Touch, Appen- dix II, pp. 153-63. 4. D. Krieger, " Alternative Medicine: Therapeutic Touch, " Nursing Times, April 15, 1976, pp. 572-74; The Therapeutic Touch, p. 11. 5. C. Sogan, " Astral Projection and the House That Could Count, " Playboy, July 1978, pp. 82-86,226 82-86,226 -32. 6. P. McCarty, " Energy: Tapping the Body's Natural Resources, " The American Nurse, June 20, 1979, pp. 8 and 23. 7. J.F. Quinn, " One Nurse's Evalua- tion As a Healer, " American Jour- nal of Nursing, April 1979, pp. 662-64. 35 Human Sciences Press 72 Fifth Avenue New York, N.Y. 10011