Document 8V0wpaG8OQbRQXYdZo2YzDymm

Health Policy Advisory Center No. 35 November 1971 # 38 mas HEALTH / PAC BULLETIN FUNDING MEDICAL EDUCATION: A HIDDEN AGENDA All the hullaballoo over National Health Insurance has overshadowed Congress ' most significant 1971 health legislation: the Health Professions Educational Assist- ance (HPEA) Amendments. These rela- tively unheard of amendments to the 1963 HPE- Act will authorize an unprecedented $ 3.5 billion for medical education over the next three years. They will make medical education No. 2 in terms of federal health expenditures, surpassed only by Medicare and Medicaid. Yet, for all the promised money in the HPEA legislation, there will be little im pact on the nation's health manpower crisis. The nation suffers a critical shortage of not only doctors, but of other health workers also. Dr. Roger Egeberg, former Assistant Secretary for Health in the De- partment of Health, Education and Wel- fare, stated last year: " The United States now needs about 50,000 more physicians, a couple of hundred thousand more nurses, and almost 150,000 more tech- nicians. " But the shortages are not merely numerical. Using the distribution of doc- tors as the most extreme example, there are severe ethnic, geographic and class imbalances as well. For doctors alone, less than two percent are Black, even though Blacks make up more than 12 per- cent of the nation's population. In addition to racial and numerical shortages there exists a maldistribution of health personnel. Recently New York's Senator Javits said: " Despite the glut of doctors on Park Avenue, there are parts of the state with only one doctor for 15, - 000 people. " HPEA Amendments In response to this crisis, Congress has offered the HPEA amendments, recently given the inappropriate title, " the Com- prehensive Health Manpower Training Act of 1971. " HPEA deals with only parts of the crisis. It covers schools of medicine, osteopathy, dentistry, optometry, pharm- acy, podiatry and veterinary medicine. Support for nursing comes under the Nurse Training Amendments (see box on p. 3), which amounts to at most, fourth one - of the support for the other health profes- sions represented in HPEA. Other health workers, such as occupational therapists, radiology technicians, etc. are covered under a third piece of legislation, the Allied Health Manpower Act of 1970. But the lion's share of the money is going primarily for the training of doctors. The most obvious departure from past legislation in the 1971 HPEA Amendments is the huge boost in the level of federal funding for health professional schools: for medical school alone, the HPEA authorization is at least three times larger than last year's appropriations. But more significantly, the 1971 HPEA Amendments fix the pattern of federal aid to medical education - a pattern that favors direct institutional support over and above stu- dent assistance. Institutional Support Institutional support means federal money sent directly to the administration of a school. In contrast, student assistance routes federal loans or scholarships through the student to the institution. Un- der the 1971 HPEA Amendments, there are four categories of institutional support: (1) Capitation grants, $ 234 million; (2) Special Project Grants, $ 118 million; (3) Construction Grants, $ 225 million; and (4) CONTENTS 1 Funding Medical Education 7 Attica 10 Columbus Assistance for schools in financial distress, $ 20 million. Each year, from 1972 on, these grants are slated to increase. The major financial incentives within the amendments are directed at increas- ing student enrollment and shortening from four to three years, the time it takes to graduate. Thus, capitation grants going directly to the schools are calculated on the basis of the following formula: for M.O.D. schools (medicine, osteopathy, dentistry), 2,500 $ for every enrolled stu- dent plus 4,000 $ for each graduate com- pleting school in four years or $ 6,000 for each graduate completing school in three years. These capitation grants have one condition increased - student enrollment. This " mandatory enrollment increase " must equal 5 percent per year for schools with freshmen classes of 100 or over; 10 percent per year for schools with fresh- men classes below 100. In addition, the amendments authorize " bonus capitation support " for schools which increase their enrollment by 5 percent over and above the " mandatory enrollment increase. " De- spite all this, the most optimistic projec- tion under these incentives is that it will take at least eleven years just to make up today's deficit of physicians. Capitation grants are not linked to in- creased minority enrollment or increased women's enrollment. Those areas are left to special project grants. While special project grants have been authorized $ 116 million less than capitation grants, they are supposed to provide an incentive for changing enrollment patterns with regard to race and sex, as well as for providing curriculum reform. Schools must devise grant applications dealing with special programs for training in family medicine; for developing interdisciplinary training among HPEA schools and schools of nurs- ing and public health; for encouraging minority enrollment; for experimental teaching; etc. All these critical tasks are secondary to boosting enrollment. Student Non Support - The most striking problem with the 1971 HPEA amendments is the paucity of sup- port offered directly to students through student assistance programs: loans will be limited to $ 50 million for fiscal year 1972 and it is estimated that scholarship aid will not amount to more than $ 12 mil- lion. This means that the HPEA amend- ments authorize 10 times more money for institutional support than they do for stu- dent support. If these loans were to go to medical students alone (actually they are intended to cover all HPEA students in- cluding dentistry and pharmacy), then only 35 percent of all medical students en- rolled in medical school today would be able to get the maximum loan of $ 3,500. Likewise, less than 8 percent of all medi- cal students would be able to get maxi- mum scholarship grants under the limited funds authorized. It is all too apparent, that health science students will have to continue to work part time - jobs, marry and be supported by their spouses, be descended from wealthy families or seek commercial loans to get through their education. This is particularly true with the acceleration of private medical school tuitions (from $ 1,005 in 1958 to 2,270 $ in 1970) and the constantly rising cost of living. In 1968, the average medical student had annual expenses, including tuition, totalling $ 4, - 394. Considering inflation this figure is probably over $ 5,000 this year. In 1968, students paid for their education and liv- ing expenses in the following ways: 29 percent from spouse's income; 25 percent from family gifts; 24 percent from stu- dent's own earnings or savings; 12 percent from loans outside the family; 3 percent from grants or scholarships; and 6 percent from all other sources. The present HPEA amendments will do little to change this pattern of student dependency on family and spouse. It is likely that low in- come students will continue to shy away from medicine for lack of financial re- sources, perpetuating the present skewed distribution of medical students from the middle and upper income brackets. While student hardship and perpetua- tion of financial barriers to education for low income students will continue, the federal government will be pouring more Published by the Health Policy Advisory Center, 17 Murray Street, New York, N. Y. 10007. Telephone 212 () 267- 8890. The Health - PAC BULLETIN is published monthly, except during the months of July and August when it is published bi monthly - . Yearly subscriptions: $ 5 students, 7 $ others. Second - class postage paid at New York, N. Y. Subscriptions changes - of - address, and other correspondence should be mailed to the above address. Staff: Constance Bloomfield, Des Callan, Oliver Fein, Marsha Handleman, Ronda Kotelchuck. Howard Levy, and Susan Reverby. Associates: Robb Burlage, Morgantown, West Virginia; Barbara Ehrenreich, John Ehrenreich, Long Island: Ruth Galanter, Los Angeles; Kenneth Kimerling, New York City. 2 than $ 1 billion per year into health sci- ence schools and each medical school will be getting approximately 6,000 $ per student in institutional support through capitation and special projects grants. Evidence from medical schools, concern- ing their present state of financing, sug- gests there is another agenda financial - solvency of the nation's medical educa- tion institutions - lurking behind the man- power trappings of the HPEA amend- ments. Medical School Financing Over the last two years, over 61 of the nation's 101 medical schools have been awarded special grants by the federal government on the basis of some " condi- tion of financial distress. " Medical school expenditures have gone up twice as fast in the past decade as expenditures in higher education generally, yet the num- ber of students in medical school has in- creased at only half the rate of students in other fields. The cost crisis in medical education has deep roots that penetrate back to the turn of the century. In 1906 the number of American medi- cal schools peaked at 162. By 1915 only 96 medical schools remained. The Car- negie Foundation's Flexner report on American medical schools, published in 1910 was largely responsible for the de- crease. This was the first foray into medi- cal education by the Carnegie Founda- tion, noted for its interest in all types of education. Abraham Flexner was em- ployed by the Carnegie Foundation and commissioned by the American Medical Association's Committee on Medical Edu- cation to study and recommend reforms for the American system of medical edu- cation. Flexner visited every medical school in the United States and he classi- fied the variety of medical schools into three types: " the clinical type, which de- rives more or less directly from the ap- prentice system; the university - type which emphasizes the ideals of scientific devel- opment; and the proprietary type, the educational policies of which may be as- sumed to be modified by commercial con- siderations. " (4) Flexner's report favored the university based medical school and led to the enactment of state laws about medical licensure that forced the closing of many schools that did not have a uni- versity connection. These widely - touted reforms were as much, if not more, in the interest of the American Medical Association as they were in the interest of the patient. As long as anyone from an apprenticeship or proprietary school could call himself a doctor, public confidence in medicine Nurses into the Act Along with the Health Professions Educational Assistance Amendments, Congress passed the Nurse Training Act of 1971. The doctors'amendments are separated from the nurses ', not out of Congressional chauvinism, but to provide political visibility for the nurses. The amount of Congressional authorization is another matter. The nurses were funded at one fourth - the level of the doctors. Of course, nurs- ing education is much less expensive than medical education; but, the total number of nursing students 164,545 ( ) is more than three times the number of medical students. The Nurse Training Act is a mini- HPEA. All the categories are essen- tially the same, only the authorized amounts are smaller. The distinction between institutional support and stu- dent assistance is maintained. For fiscal year 1972 there are four cate- gories of institutional support: (1) Cap- itation grants, 78 $ million; (2) Special Project grants, 20 $ million; (3) Con- struction grants, 35 $ million; (4) As- sistance for schools in financial dis- tress, $ 15 million. The Capitation grants are calculated on a formula which gives each school $ 250 per fulltime enrolled student, plus $ 500 for each graduate or $ 900 for each graduate in a nursing speciality. To be eligible for capitation support, each nursing school must increase its freshman class enrollment by 5 per- cent. Bonus capitation support is available for any school that in- creases its freshman class enroll- ment by 10 percent. This amounts to $ 100 per student in the first year class. Student assistance, as in the HPEA amendments, is much smaller than institutional support. Congress has authorized $ 25 million in loans, $ 20 million in traineeships for graduate nurse training and an unspecified amount of scholarship aid. All of these authorizations must first be ap- propriated by Congress and second made available by the President through the Department of Health, Education and Welfare. These proc- esses are still off in the future. 3 Millions for Less How will the HPEA amendments ef- fect the average medical student? The very early experience at New York's Albert Einstein College of Medicine (AECOM) suggests some of the problems. This year AECOM re- ceived a $ 12 million five year - grant under the special project provisions of the 1968 HPEA amendments. The grant will make AECOM one of the first medical schools to experiment with a three - year medical education program. School started at the unusually early date of August 2nd. Although the total length of schooling (approxi- mately 32 months) will be the same for three year and four year gradu- ates, the pre clinical - years have been condensed from the usual 16-18 months to 13 months. The result is that students have exams every three weeks. In anatomy, time ran out at the ankle, and students had to re- schedule time to study the foot. Last year neurobiology was taught in 6 weeks'this year it will be taught in four. As one student commented, " Everyone is anxious and strung out. The competition is worse than ever. " One of the major consequences of this streamlined form of medical edu- cation is the elimination of summer vacations. " There are three weeks off next August, " points out one student, " but they're just before National Boards in September. " Fortunately, students in the three year program can switch anytime to the four year one. It is still to early to tell how many will take this option. The three - year curriculum may not benefit the student. But it sure does help AECOM. For a school that has real trouble in meeting its payroll, the $ 2.4 million first installment of the grant was a godsend. would be undermined. The Flexner Re- forms legitimized doctors and the AMA. Just as significant, but less well known, was the Flexner Report's influence on medical school financing. Up to 1910, medical schools were financed primarily from fees paid by students. This was the basis of the proprietary schools that op- erated as a commercial venture to make profit, rather than teach medicine. Flex- ner's Report helped drive out these profit making schools and brought in the philan- thropist. As the 1932 Commission on Medi- 4 cal Education (supported again by Car- negie and the AMA) points out: " The [ Flexner Report] also attracted the atten- tion of philanthropists to the financial needs of university medicine and marked the beginning of substantial contributions to the program. " (5) By 1926-27, almost 25 percent of medical school financing came from " endowment income. " During the'30s and'40s, state and local government support for medical education increased in response to the depression. In part, this was due to an increase in the number of state universities and state university - related medical schools. In part, private medical schools began to de- pend on state governments for subsidy. By 1947-48, state and local governments accounted for the largest share of medical school income (34 percent) while philan- thropy had dropped to only 9 percent. Federal government involvement in medical school finances was very late in coming. Unwittingly, the Carnegie / Flex- ner Report, by emphasizing the scientific basis of medicine and the necessity for a university relationship, helped establish the entree for federal financing - research. Federal money for bio medical - research amounted to $ 3 million in 1940, much of which did not go to medical schools. By 1947-48, this medical school portion of medical bio - research had grown to $ 8 mil- lion and by 1970 it had soared to over 400 $ million. As James L. Dennis, Dean of the Oklahoma Medical School recently de- clared, " Federal support for sponsored categorical research has been a basic factor in permitting the growth (perhaps even the survival) of medical schools in recent years " (ital added). By 1967-68, re- search had become the largest single source of medical school income amount- ing to 43 percent, with over 80 percent of all research funds coming from the fed- eral government. All this research money basically sup- ported the medical schools'faculty. In the ten year period from 1960 to 1970, the federal government's research contribu- tion to medical schools increased by 400 percent. Concomitantly, the medical schools'fulltime faculty increased 105 per- cent. But by the end of the decade the research bubble had burst. In 1969-70, federal government expenditures for bio- medical research levelled off. Perhaps it was a matter of diminishing returns - peo- ple were still dying of heart disease, stroke and cancer. More likely, research lost out to " guns " money for the Vietnam War. With increased faculties, but inadequate research money to support them, most medical schools found themselves in a severe financial bind. The crisis has not been alleviated by the small increases in medical school income derived from " faculty practice. " Although Medicare and Medicaid boosted income in the fac- ulty practice sector (because poor patients now could pay for doctor care), this was a mere pittance in terms of the medical schools'need. By 1968, it accounted for no more than 7 percent of the medical schools'income. (This source of income is reflected in " teaching hospital " and " med- ical service fund " income, see Chart I.) A new way had to be found for federal funding of medical schools. The ground. work was laid by the 1963 Health Profes- sions Education Act HPEA () , which pro- vided construction grants for eductional facilities and loans for medical students. In 1965, this Act was expanded over the opposition of the American Medcial As- sociation to include federal funds for the actual operation of medical schools and student scholarships. The deans through their organization, the Association of American Medical Colleges (AAMC) consistently pushed for federal govern- ment funding. By 1968, the hand writing - was on the wall. Uneasily the AMA switched sides and joined the AAMC in pushing for ex- pansion of the HPEA Act. The result was gratifying: institutional support for medi- cal schools rose from $ 25.5 million in 1968 to $ 76 million in 1971. But even this was grossly inadequate. Carnegie Foundation to the Rescue In October, 1970, just before HPEA legislation came up for renewal, the Carnegie Foundation for the Advance- ment of Teaching released a report en- titled: " Higher Education and the Nation's Health Policies for Medical and Dental Education. " This is perhaps the most significant report on medical education since the Flexner Report. Like the Flexner Report it talks about different types of medical schools that are called models. There is the " Flexner model, " which is based on research, but which the report says " leads to expensive duplication and can lead to some loss in quality. " In addi- tion, the report points to two new models: " 1 () the health delivery model, where the medical school, in addition to training, does research in health care delivery, ad- vises local hospitals and health authori- ties, works with community colleges and comprehensive colleges on training of al- lied health personnel, carries on continu- ing education for health personnel, and generally orients itself to external service; and (2) the integrated science model, where most or all of the basic science (and social science) instruction is carried on within the main campus (or other gen- eral campuses) and not duplicated in the medical school, which provides mainly clinical instruction. " The Carnegie Report is not primarily concerned with models. Rather, its major emphasis is on financing medical educa- tion, cutting costs, rationalizing and streamlining the medical education proc- ess. Though many words are devoted to curriculum change and increasing minori- ty student enrollment in medical schools, suggestions for reforms in these areas are Sources of Medical School Income Source 1947-48 1959-60 1967-68 (in millions of dollars) Sponsored Research ...................... Federal oo..0oooececcccceeeecteeeees Non Federal - 200oo0000...0coccecccee State and Local Governments .......... ' Training Grants 0000. Overhead (from contracts & grants) .. Other Gifts and Grants ....................... Tuition and Fees 0.0.0.0. Medical Service Funds ....................... Others (includes RMP, CMHC, etc.) ... Teaching Hospitals 00, Endowment (unrestricted) .............. Misc. University Income & Reserves.. TOTAL oie $ 17.1 (24%) $ 134.4 (38%) $ 473.3 (43%) 8.0 (11%) 92.2 (26%) 389.6 (36%) 9.1 (13%) 25.0 (34%) 42.2 (26%) 60.9 (17%) 83.7 (8%) 159.4 (15%) 6.9 (10%) 12.1 (17%) 4.7 (6%) 6.7 (9%) 21.4 (6%) 16.2 (5%) 17.0 (5%) 25.8 (7%) 10.9 (3%) 12.7 (4%) 17.5 (5%) 18.7 (5%) 18.0 (5%) 93.7 (9%) 82.5 (8%) 53.3 (5%) 48.3 (4%) 48.0 (4%) 44.0 (4%) 36.7 (3%) 29.6 (3%) 27.9 (3%) $ 72.5 $ 353.5 $ 1,096.7 Compiled from: Rashi Fein, Financing Medical Education (1971) and Journal of Medical Education, Datagrams, 1969-71. 510 perfunctory and relatively insignificant (e.g., the creation of an educational op- portunity bank, improving curriculum by tying more closely together basic science and clinical instruction). The real reforms appear to be directed at cutting medical education costs such as, reducing from four to three years the time it takes to get an M.D. degree, or combining science work on campus and in the medical school, thus reducing the duplication, or reducing the ratio of faculty to students; and rationalizing medical school financ- ing by for example, increasing federal financial support for medical education, while not decreasing state support, and holding federal research expenditures steady as a percentage of the Gross Na- tional Product. The Senate version of the 1971 HPEA Amendments sponsored by Senator Ken- nedy used the Carnegie recommenda- tions down to the specific dollar amounts. Although the House version was con- siderably more conservative than the Senate's, the trends established by the 1971 HPEA Amendments are apparent and consistent with the Carnegie Report: first, they increase federal support for medical education three times over 1971 appropriations; second, they favor institu- tional support far above student support; third, they emhasize increased enrollment and shortening of medical education (streamlining "") above increased minori- ty enrollment and substantive curriculum reform. Impact of HPEA Amendments The obvious impact on medical schools of the HPEA amendments will be to shift financing from federal research support towards general institutional support. But the ramifications of this shift are not so ob- vious. Changes in the source of medical school income will be reflected in changes within the internal power structure of the schools. In the recent past, the dominance of re- search money within the medical school has fostered the development of depart- mental and individual researcher auto- nomy. In fact, some individual big name - researchers have been so independent that they can move whole research staffs numbering 15-20 people and expensive re- search equipment from one institution to another. Within medical schools, depart- mental heads have developed baronies of their own, from which they vie with each other for teaching time, laboratory space and power on the executive faculty. In contrast, the deans and central adminis- tration of the medical school are often quite weak. They have no financial base 6 from which to wield power and end up mediating the differences between autono- mous departmental forces. The HPEA amendments will change this distribution of power. Capitation and spe- cial project grants will go directly to the deans and administrators, who will parcel money out to support faculty for teaching and even research purposes. Power will shift from the departmental heads and autonomous researchers to the dean's of- fice. With this consolidation of power with- in the school's central bureaucracy, the anachronistic baronial power structure based in separate departments will fade away. Medical schools will step into 20th Century forms of corporate management and control. William N. Hubbard, Jr., M.D., former dean of the Medical School at the Uni- versity of Michigan, Ann Arbor, now Vice President and General Manager, Pharma- ceutical Division, The Upjohn Company, was aware of the corporatization of the medical school, when he said: " Maximiza- tion of budget size with minimal loss of institutional independence is the academic [i.e., medical school] equivalent of the profit motive in the business sector of our economy. " He also anticipated the im- portance of the HPEA amendments in pro- viding medical schools with a new source of income not tied to research or faculty practice: " An institutional grant program for physician education which does not compete with the power of income gen- eration from service and research sources will not change significantly the mix of efforts of the faculty. " In other words, give the institution the (dean) the money and the faculty will follow the institution's (the dean's) priorities. This is the hidden agenda of the HPEA amendments - a realignment of medical school power structure and priorities. Like- wise, it is one of the unstated purposes of the Carnegie Foundation Report. This comes as no surprise, however. A glance at the advisory committee on medical edu- cation to the Carnegie Commission on Higher Education gives ample explana- tion. Of the eight members of the advisory committee, three are medical school deans, one is head of a department of psychiatry, another is director of a uni- versity affiliated research institute. The classic department head, such as chair- man of the department of medicine or bio- chemistry, is absent. However, there is a systems - man - the former director of health planning for the University of Cali- fornia, presently corporate planner for the Kaiser Foundation Health Plan. This is certainly a dean's team if there ever was one. What's wrong with these shifts of pow- er? It is about time that medical schools left the middle ages. Certainly, medical education needs to be supported in and of itself not through research grants. Teach- ing must have high priority, if doctors are to be trained well, rather than being a by- product of research and faculty practice. But it is not clear that such new priorities will emerge with the new sources of fund- ing. The shift of power from departmental heads to deans is a shift within the same group of people who have run medical schools in the past. In fact, the corporat- ization and centralization of the medical school, signals a step away from in- creased faculty, student and community control of the institution. Now, medical schools will be capable of persuing institu- tional priorities directed at " empire build- ing " unfettered by departmental resist- ance and financial constraints. Research for this article was done by Stanley Padilla and Oliver Fein. (Stanley Padilla is a fourth - year medical student at the University of New Mexico and was a summer intern at Health - PAC.) ATTICA: MURDER BY OMISSION The State moves in mysterious ways, its wonders to perform. Many times its per- formance assumes a brutal clarity, and one is left without wonder, only rage. Such was Attica September - 13, 1971. It would be a mistake, however, to be- lieve that the appalling disregard for hu- man life exhibited by Governor Rockefeller on that day was an isolated phenomenon involving only a single unresponsive po- litical figure. To the prisoners at Attica, the va bullets fired by Rockefeller's troops were simply tangible evidence of the less bla- tant homicidal policies governing their lives daily. Among those issues leading the prison- ers to rebel was health care. One inmate stated to his lawyer, " Within this prison for years our blacks, latinos, and poor whites have been denied medical atten- tion. We have gone to the Prison Hospital when we got sick, and the racist doctors refused to treat us. As a consequence, eight inmates died within just four months in 1971. " Thus two demands of the Attica Prisoners'Manifesto of September 8 at- tacked the inadequate prison health care system. M@ " We demand a change in medical staff, and medical policy and procedure. The Attica Prison Hospital is totally in- adequate, understaffed, and prejudiced in the treatment of inmates. Numerous'mis- takes'are made; improper and erroneous medication is given by untrained person- nel. OE We demand periodical check - ups on all prisoners and sufficient licensed prac- titioners available 24 hours a day. " What had been the mechanism for de- livery of health care prior to the rebellion? Primary medical care at Attica was deliv- ered by two state employed - doctors, one full time - and one part time -. Responsibility for further consultative care had been in- formally assumed by faculty of the Uni- versity of Buffalo (UB) Medical School, 40 miles away. As described by Dr. LeRoy Pesch Dean of the School of Medicine, " The Medical School of the State Uni- versity of New York at Buffalo and Erie County's Meyer Memorial Hospital (a teaching affiliate of the medical school) have been deeply involved in meeting the medical needs of the Attica facility for the past five years. " Aside from elective sur- gical procedures performed by Meyer Hospital house staff at the prison, the Uni- versity's'deep involvement'was limited to epidemiological studies using the in- mates, and to the provision of Buffalo physicians in emergency situations. * Limited though it was, the historical connection between Attica and the Uni- versity of Buffalo made the latter institu- tion the logical one to respond to the medical crisis created by the state troop- ers on Monday, September 13. On the afternoon after the shootings, the Uni- versity of Buffalo and Meyer Hospital sent only 14 doctors and medical students out to Attica to treat the estimated 400 wounded men. In addition, an emergency call for upstate physicians was being cir- culated. It seemed therefore quite reason- 7 able to the fifteen nurses and doctors who came from New York City Monday eve- ning to offer assistance to the University of Buffalo in treating the wounded prison- ers. This offer of aid even seemed reason- The most telling indictment of the UB Medical Center's commitment to health care at Attica came from Dean Pesch. In spite of assurances on Monday night that he was anxious to facilitate the medical able to Federal Judge Curtin, who signed team's entry into Attica, Tuesday after- a court injunction Monday night to allow noon he stated publicly that medical care this medical team immediate access to the inside the prison was adequate and there- prison. But a short time after receiving the fore there was no need for the New York court order the fifteen doctors and nurses group to enter the prison. The justification were unconditionally denied entry at the for his change in position consisted of an gates of Attica. explanation of the delicacy of his status Rule Not Reason at the medical school as a proponent of a black student admission program in the It was clear that reason was not the face of a staunchly right wing - county and rule. As they waited outside Attica all state legislature, which supplied the Monday night and Tuesday morning, re- school's, and the program's, funding. ports of the medical situation inside the While the goal of the black student admis- prison were communicated to the mem- sion program at Buffalo is 25 percent, bers of the medical team. From these Pesch has only managed to increase black reports it became clear that medical re- admissions from 6 percent in 1969 to 8.8 sponsibility was being abdicated in de- percent in 1971. ference to the political priorities of the state prison authorities. Medical Responsibility According to W. G. Schenk, Director of The medical institution's lack of com- Surgery at UB and Meyer, fifty prisoners mitment to Attica soon became more than had, on Monday afternoon the 13th, been insensitivity; it progressed to medical ir- judged so critically wounded as to re- quire transfer to Meyer. Within a short time, Meyer Hospital had marshalled emergency personnel and equipment in order to receive the fifty men. Only eight men arrived; Warden Mancusi had re- fused to allow any other men to be trans- ferred from the prison. Rather than chal- lenging the warden's'medical judgment ', Dr. Schenk remained silent. As a result, the UB doctors were forced that day to perform twenty - five operations, including three abdominal laparotomies, in the responsibility. Descriptions of troopers ' clubbing injured and delirious inmates in order to quiet them, leaked out. Two house. staff doctors from Meyer who told the press of guards'brutality were denied re entry - . According to reports from within the prison, mutilations and castrations were performed in the prison infirmary on the bodies of men killed the day of the attack. No one knows how many men, de- prived of immediate physical exams to establish the presence or absence of in- small prison operating room, often operat- juries, were subsequently beaten and had ing on two men at the same time. By 11 their injuries ascribed to September 13. PM Monday night, their surgical marathon Members of the negotiating committee re- - completed, all the UB doctors were ported that three of the men'found dead ' ordered out of the prison by the warden. were seen alive after the official onslaught The nurse inmates - were returned to their had ended. However, independent doc- cells and the one remaining prison doctor tors were still not getting in. The committ- announced he was going to bed. One UB ment of Dean Pesch and UB is perhaps doctor shrugging his shoulders, referred to the post operative - patients, " Well, best described by a third - year medical student at Buffalo Medical School who they're young and strong; I guess they'll arrived at Attica on September 13 soon be all right with no care. " To the New York City medical team waiting outside after the shotting stopped: " When I arrived I was told to evaluate the prison gates, it appeared that Dr. this one inmate who had gunshot wounds Schenk had shirked medical responsibili- to both legs with obvious open fractures. ty in accepting both the restriction on The inmate was delirious, moaning in transfer of pre surgical - patients and the pain. I heard two guards tell the inmate abandonment of the twenty - five post - op- to shut up. When he did not comply, they erative patients. Monday night, Dr. Evans began to beat the wounded man over the Calkins, Director of Medicine at UB Medi- head with clubs and gun butts. I stopped cal School, stated by telephone to one of the New York City doctors that " medical them; in disbelief I told them to leave the man alone. I then waited for over one malpractice " was being performed at At- hour until my attending physician re- tica; by Tuesday morning he joined Dr. turned. I told him about what had hap- Schenk in silence because Warden Man- pened and asked him about transferring cusi had requested a pledge of'security '. the man to our hospital in Buffalo. He 8 replied that that was impossible because ices to the inmates of Attica, while recog- the prison officials had identified this man nizing that legal responsibility for the in- as one of the ring leaders of the uprising mates'medical care remains with the and would under no circumstances sanc- Department of Correction. tion his transfer. He said I shouldn't get involved. " OE The University and its Medical School further offer to institute plans to Even if the contradictions inherent in Pesch's concerned ' ' refusal to act had assure comprehensive care at Attica on a longterm basis. " escaped the Dean, they were not missed by the student body at the University. The UB Ad Hoc Committee to Support the When this agreement was released by Dean Pesch to the press on Friday, Sep- tember 17, as an " immediate and compas- Attica Prisoners charged that " While the shooting at Attica stopped, the murder still goes on. We cannot rely on the same sionate response " to the health situation at Attica, 41 men had already died. people who caused these conditions to The Aftermath alleviate them. " In recognition of UB's medical and ethical responsibility to take the lead in assuring health care to the in- mates of Attica, this campus - wide group, with the voted support of over 200 medical students, presented the following list of demands to Dean Pesch at a meeting Wednesday morning, September 15: M@ " We demand that the University of Buffalo Medical School accept full re- sponsibility for the health care of all in- mates at Attica Prison. M We demand a public statement of all medical treatments and examinations performed since the beginning of the re- bellion, including a listing by name of all inmates, the treatment undertaken, their physical conditions, and their present lo- cations. @ We demand the formation of an ob- jective Medical Review Board, including physicians chosen by prisoners and their families. @ We demand that families of dying and injured prisoners be immediately giv- en full visitation rights. It would be at least minimally optimistic to terminate on the note of this formal and public assumption of medical responsibili- ty by the University of Buffalo Medical School and Meyer Hospital. Unfortunate- ly, events subsequent to the release of Dean Pesch's statement not only throw serious doubt on the sincerity of the Uni- versity in adhering to the agreement but also refute the political validity of the Dean's delicate fence walking between medical principle and state pocketbook. One week after Dean Pesch announced that the long range - prison health program would most certainly be set up with the aid of black doctors from the National Medical Association, Dr. Alyce Gullattee, President of the NMA, was refused entry into Attica. The fate of Pesch himself is a more ominous indication of the shakey fu- ture of the prison health program and of the black admission program. Having skillfully equivocated in order to protect " my position and my black student admis- sion program, " the Dean was invited to the home of Dr. Ketter, President of the @ We demand a full public statement detailing the relationship between the University of Buffalo and Attica State Prison. " University of Buffalo, on Thursday after- noon, September 30. According to Pesch, what ensued was a general discussion of problems and future projects for the Med- In response to further hedging by the Dean that morning, several hundred stu- dents participated in a rally and sit - in at ical School. Thursday evening Pesch ar- rived home from his meeting only to be greeted with headlines in the Buffalo the Dean's office Wednesday afternoon evening paper announcing his'resigna- and evening. At last on Friday, Septem- tion'as Dean of the Medical School. ber 17, Dean Pesch tiptoed into action. Dean Pesch was the fourth in a series Making it clear that he wasn't negotiating " in response to their [students] demands but in response to the professional de- of reportedly liberal department heads at the University of Buffalo to be resigned in such manner within that week. " I don't mands that we provide the best medical care possible, " the Dean announced a formal three - part agreement between the New York State Department of Corrections and the UB Medical Center: OE " The Buffalo Medical School proposes have to be the'good boy'any longer, " he stated to a group of students the next day. " You can publicize what really hap- pened. " He related that Ketter had charged him with lowering the standards of the medical school through the black immediately to expand its present sur- admission program. But when asked if he gical program at Attica to include general medical care. planned to fight this seeming purge of liberals, the Dean replied, " No, I cannot OE The faculty of the Medical School jeopardize the black student admission also offer full medical consultative serv- program. " 9 Several conclusions emerge from the medical crisis brought on by the Attica massacre. Despite State attempts to shroud the practices of the prison health system, non prison - employed medical par- ticipants can serve a valuable function in exposing the realities of health care inside the prisons. The involvement of the Uni- versity of Buffalo with Attica, although in- sufficient, at least facilitated the entry of Buffalo house staff and medical students who made public otherwise unseen bru- talities. Although denied entry to the prison, the New York City medical team at least by its presence highlighted the fact that the State prison authorities placed more value on internal security than the care of post operative - patients. The medical school and its affiliate hos- pitals can and should play a prominent role in opening the prisons to public view and accountability. There is a danger, however, as with Attica, that the medical institutions will give political priorities precedence over medical needs. When medical ethics are manipulated to fit comfortably into po- litical pocketbooks, one ends up with an empty bag. What is common to President Ketter's indictment of the black student admission program, to Dean Pesch's re- luctance to assume responsibility for medical care at Attica, and to Governor Rockefeller's order to shoot the men in- side Attica, is the commitment of power- ful men to the maintenance of a blatantly racist social order. In refusing to assume a complete and conscientious responsi- bility for the health needs of the Attica prisoners, Dean Pesch and the University of Buffalo Medical School share, with Rockefeller, responsibility for the deaths at Attica. One does not have to kill with guns alone Marcia. - Sollek. (Marcia Sol- lek is a fourth - year medical student at the University of Cincinnati.) GOODBYE, COLUMBUS Throughout the country, urban neighbor- hoods are increasingly having to fight for their survival against the expansion of large institutions. After a year - and - a - half long battle, residents of " Bedpan Alley, " a neighborhood so dubbed because it con- tains the largest concentration of medical institutions in New York City, are cele- brating what may be an unprecedented victory in the conflict of home institu- - vs. - tion. Columbus Discovers 19th Street The 200 block - of East 19th Street has been been a pleasant, relatively - safe block lo- cated in the midst of one of Manhattan's few remaining traditional working class neighborhoods. It is rapidly being taken over, however, as the home of Columbus Hospital and its professional staff. Columbus Hospital is a small, voluntary Catholic institution with expanding ambi- 10 tions. Next door to its present facility, Columbus has purchased land and is planning a new building to replace its present plant. To compete for upper echelon - hospital personnel, in 1968 Columbus pur- chased one luxury high - rise on the block (and forced its tenants out as their leases expired) and acquired options to rent apartments as they were vacated in yet another high - rise. But its most controversial acquisition has been that of two buildings housing 48 families across the street from the hos- pital. The buildings were purchased sur- reptitiously in December, 1969, and the tenants were ordered out the following spring. Only after organizing themselves and conducting their own investigation did the tenants discover that their new landlord was Columbus Hospital and that it intended to demolish their structurally- sound, low rent - apartments to provide parking for 27 staff cars. In order to get rid of the tenants, the hospital turned to heavy handed - tactics. First, to " manage " the buildings, it hired the Urban Relocation Company (URC), an official sounding - , private realty com- pany notorious in New York for its expedi- tious, if unscrupulous, means of " convinc- ing " tenants to leave their homes. The old building superintendent was fired and a URC superintendent moved in, along with his large German Shepherd dog which was allowed to roam the hallways unleashed, Building maintenance virtual- ly ceased; vacant apartments were boarded up, inviting junkies and burglars; heat and hot water were cut off on numer- ous occasions, including Christmas day, 1970; and the remaining tenants were al- ternately lied to, bribed, and threatened- all in clear violation of New York City's rent control and eviction regulations. Tenants Discover Columbus Columbus succeeded in intimidating and forcing out some of the poor and non- English speaking tenants, but as those re- maining realized what was happening, they quickly organized themselves into the 19th Street Branch of the Neighbor- hood Save Our Homes Committee. Action began in the summer of 1970. Four families became squatters, attempt- ing to move into apartments which had already been vacated. Columbus Hospital moved quickly, however, arresting the squatters, their supporters, and two sym- pathetic tenants. It also initiated dis- possess actions against the two tenants which were to drag on for months and months. That winter the Committee con- ducted a highly publicized - " paint - in " in the neglected buildings. This was followed shortly by a telegram written in Latin to the Pope, asking his intervention with the Rome based - Missionary Sisters of the Sacred Heart, the order which runs Colum- bus Hospital. (Ironically, the Missionary Sisters were founded by Mother Cabrini, the first and only American saint, whose fame rests on her devotion to homeless immigrants in New York City.) The Committee instituted harassment proceedings against the hospital, based on violations of New York City's rent control laws; successfully fought the dispossess action against its two member, and con- ducted a variety of demonstrations and leaflet campaigns. But the real break- through came with the filing of a suit by the Committee to halt a state loan for the hospital's new addition. " Actually there were two separate issues: the disposition of the two buildings and the larger issue of the hospital's ex- pansion, " commented one of the Commit- tee's spokesmen. " We linked the two issues by showing that the public loan made it possible for Columbus to use its own money to buy the building and oust 48 families in favor of 27 staff cars. We also used the suit to bring Columbus to the bargaining table regarding the two buildings. " Tenants Rock Columbus'Boat The 19th Street Committee began to in- vestigate and found that in 1965 Colum- bus had applied for the required approval of the Department Social Welfare to build a nine story - addition on the land it had acquired next door. The $ 8.5 million new building, which was to be privately fi- nanced, was designed to provide staff housing, a convent, a first floor - parking garage, and 118 additional hospital beds. However, in 1969 public funds became available under the State Hospital Mort- gage Loan Act. Columbus'plans suddenly blossomed and it applied for a loan to build a $ 44 million, sixteen - story addition. Interestingly, the new plans called for neither staff housing nor the on site - garage needs which Columbus could presumably now meet by privately ac- quiring other properties in the neighbor- hood. The old hospital building was to be renovated for doctors'suites and for a 41- car garage, which would produce several hundred thousand dollars income each year (according to the hospital's own statements). As the Committee probed more deeply in hopes of appealing or protesting the new loans, it discovered that Columbus had never gone back to the Department of Social Welfare to get approval for its ex- panded plans in spite of the fact that the project's scope had increased fivefold. The more the Committee investigated, the more they uncovered discrepancies and contradictions in the procedure. For example, the first step in the process is to gain approval from the Health and Hos- pital Planning Council of Southern New York (HHPC) (previously called the Hospital Review and Planning Council). In evaluating the application, the HHPC granted Columbus credit for " locating in an underserviced area, " in spite of the fact that there are 5266 acute care hos- pital beds between 42nd Street and the tip of Manhattan and third one - of these are located in the six block - area which in- cludes Columbus (giving that area five times the national average in hospital beds). The HHPC also credited Columbus for " consumer and community participa- tion in the planning process, " even though the Committee could not find a single community group which had been con- sulted or even knew about Columbus ' plans. To obtain the loan, the hospital is re- quired to hire an accounting firm to dem- onstrate the financial feasibility of the project. The State requires the firm to re- view records given to it by the hospital. But in this case the firm stated that since the Missionary Sisters of the Sacred Heart, and not the hospital, were to pro- vide equity for the loan, any demonstra- tion of financial feasibility would require. a financial investigation of the Missionary Sisters. Yet the State explicitly instructed the firm not to investigate the Sisters. On the basis of such discrepancies, on August 20, 1971, two 19th Street tenants and a New York State Assemblyman filed a tax- payers'suit to halt approval of the loan 11 and to halt construction by Columbus Hospital. The suit brought immediate results, due largely to its timing. It was filed two weeks in advance of the scheduled final approval of the loan by the State Housing Finance Agency. To qualify, the Commit- tee discovered the hospital had to be free of all litigation. Not only did the suit threaten to entangle construction funds for months, but Columbus had been so cer- tain of approval that it had already hired a contractor and construction was well under way. The hospital recognized the tenants group with dispatch and seven days later, at the hospital's request, both sides sat down at the negotiating table. The outcome was a legal agreement in which Columbus Hospital agreed to rec- ognize the rights of tenants to live as long as they wished in the disputed buildings; to fire the Urban Relocation Company; to fix all violations in occupied apartments; to remove the tin on the windows of vacant apartments; to present all future expansion plans to the Community Planning Board; and to establish with tenants a committee empowered to decide the future disposition of the disputed buildings. In return, the plaintiffs agreed to discontinue the tax- payers'suit and the Committee agreed to discontinue the harassment proceedings. Organizers of the 19th Street Commit- tee cite certain elements which made their victory possible. First, the neighbor- hood was particularly ripe for such a struggle. Many of the residents were " dou- ble jeopardy - tenants, " having been previ- ously displaced by expansion by nearby Beth Israel Hospital. Second, it has been an " fashioned old - neighborhood " with an amiable mix of homes, stores, schools, churches and parks- " the kind of neigh- borhood you can feel an investment in, " commented one resident. The 19th Street Committee provided tactics and a structure for this discontent. According to one coordinator of the Neigh- borhood Save Our Homes Committee, " You can't ignore the importance of tech- niques that build a strong organization and keep it together. " For instance, the 19th Street Committee quickly established a subcommittee to collect and submit rent payments each month, forcing URC to deal with tenants as a single unit rather than individually. Likewise a grievance committee was established to handle all tenant complaints. Many of the actions such as the paint - in, the telegram to the Pope, and demonstrations were as impor- tant in terms of building group cohesive- nes and morale as they were in applying pressure on Columbus. " Nor can you underestimate the stra- tegic importance of cooperation of elected 12 officials. " A U.S. Congresswoman, a State Assemblyman and a City Councilman took roles of varying intensity in the strug- gle. Their participation attracted publicity to Committee actions while also boosting morale. In addition, in the midst of the heaviest tenant harassment, one official wrote letters of support to tenants, under- scoring their legal rights in the situation. " The effect was psychologically very pow- erful. " Finally, the assistance of elected officials and their aides was critical in terms of gaining access to government agencies, documents and official informa- tion. The existence of a community news- paper, in this case the Gramercy Herald, was also key. " Even if the paper has limited circulation, no institution wants to see itself splashed across the front page -. Front page news in a small community newspaper is an important entre to larger news media. " One organizer also em- phasized the importance of having an ag- gressive, pugnacious lawyer- " one you don't have to convince of your case before you start. " The 19th Street Committee also gained by drawing together people with an impressive collection of skills, includ- ing experience in media, promotion, re- search and analysis, and community organizing. The discrepancies and contradictions on which the suit was based were prim- arily the responsibility of the State and not the hospital. The lesson which this may offer similar groups is that govern- ment bureaucracy is so complex that bureaucracy can often be used against it- self and to the ends of insurgent groups. The 19th Street Committee still has work to do. First of all, its victory over Colum- bus has not been unconditional. Columbus must still live up to its agreement and may still require friendly persuasion. The 19th Street Committee will also lend its support to other branches of the Neighborhood Save Our Homes Committee which are carrying on similar struggles with other medical institutions in the area, as well as joining with other groups organizing around broader housing issues such as rent control. Finally, the Committee is planning a one day - seminar in the near future as an opportunity to examine the deeper issues and implications of the Columbus strug- gle. " Everyone came to share the concept of the right to save your own home. But there are deeper concepts which we never worked out, like: Who runs the institu- tions? Why do tenants get stomped on? What is'good'hospital planning? What is good health care? We need to know not just what we are against, but what we are for as well Ronda. " - Kotelchuck