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SS Health Policy Advisory | Center oe FS 2313 No. 37 January 1972 ry NB. HEALTH / PAC BULLETIN BULLETIN ; y Pissed tie Editorial: INSTITUTIONAL ORGANIZING A movement for radical change in the health system has grown to significant proportions in the last few years. Its pri- mary goal has been fairly clear - the total restructuring of the health system in the interest of people, not profit or heirarchy. But how to achieve that goal has not been so clear. The focus has often been the dramatic or episodic. Many health activists have set up " alternate institutions " like free clinics or neighborhood health centers. But there has been a growing recognition that meaningful change must be fashioned at the heart of the health system. Health institutions - hospitals, medical schools and centers represent - the primary con- centration of power and wealth in the health system. More and more they are responsible for the delivery of inadequate health services to large segments of com- munities throughout the nation. Finally, they are accessible and vulnerable to the organizing efforts of workers and com- munity groups. The concept of institutional organizing follows from the knowledge that the needs and interests of institutions and those who control them differ from the needs and interests of the workers who run the insti- tutions and the communities which receive their services. The result most often is neglect or exploitation of the latter groups. Organizing of workers within institutions, in coalition with community forces, at- tempts to change the priorities, decision- making and ultimately control of those institutions. The health movement is young and many strategies remain untried or half- tried. The three - year struggle to improve patient care and work conditions at Lin- coln Hospital in the Bronx allows us to glimpse one of the first thin threads of a sustained struggle to achieve worker- community control within a health insti- tution. Initially many at Lincoln felt that con- trol of the hospital on behalf of the com- munity was the key goal. Time and prac- tice have shown, however, that the work- ers at the hospital are in fact pivotal. Their actions have made the greatest inroads and have had the most continuity. This arises in part out of the differences in the relation of workers and community residents to a hospital. Workers are at the hospital every day. A major part of their lives is spent there. Far more than out- siders, they know how it actually runs. Community people visit the hospital infre- quently and when they do, it is often un- der conditions of great personal stress - the worst condition for focusing attention on the institution. Furthermore, workers at the hospital are concentrated in one place and are relatively accessible to each other. Thus it has happend at Lincoln that the slogan of " community - worker control " has to some degree shifted toward " worker control, " even as those involved have at- tempted to develop creative tactics to unite workers and patients. Lincoln today is just beginning to be a different place in which to work or to be sick. Workers have succeeded in driving a very small wedge, allowing them to be- gin to control parts of their work environ- ment. A wide and creative range of tactics has come to hand, some eruptive and some painstakingly slow. One hallmark is that workers have been extremly care- ful to safeguard patient welfare. Rather, when the crunch has come, ironically it has been those in positions of power who deserted the patients. But if significant gains have been made, the Lincoln struggle raises some critical questions for any group intending to en- gage in institutional organizing, First, who is the constituency for such political work? It is obvious that hospital workers are not homogeneous. It is already clear at Lin- coln that white male professionals cannot lead the majority of hospital workers who are non professional - , often poor, third world and women. Instead it appears that they can only lead those like themselves, supporting other hospital workers, but leaving the leadership to the workers own choosing. What the final relationship will be, however, between the profes- sionals and non professionals - is still unanswered. Beyond the gray areas involving leader- ship and constituency, there are other un- answered questions: What should be the target of the organizing? Should it be the public hospital itself or the affiliated, and often controlling, medical school? Are de- mands to be placed upon city and county officials or upon hospital administrators, rN medical school deans, and chiefs of de- partments? Finally, while it seems true that the role of workers in effecting a radical restruc- turing of health services has been under- estimated in the past, the relationship be- tween worker and community demands is far from settled. What happens in the event of conflicts between the two? Which receives priority? This Bulletin does not pretend to answer all of these questions. Some of the prob- lems have yet to be confronted at Lincoln Hospital. Other struggles are in progress in other hospitals. As more experience is gained, hopefully, the lingering questions will be answered. In the meantime, the gains won so far at Lincoln are impressive. And among the more impressive have been the changes in outlook which have taken place for those who have been involved in these struggles. These changes have amounted to nothing less than a fundamental redefi- nition of themselves, their needs, and their place in society. These changes will not easily be reversed. EMANCIPATION OF LINCOLN 400,000 Puerto Rican and black people live in New York's South Bronx, is one of the nation's worst ghettos. Survival in this com- munity is a daily struggle. Unemployment is severe. 80 percent of all housing is dete- riorating, Transportation is poor; schools, overcrowded. In health, the picture re- mains just as bleak. The infant mortality rate is 30 per 1000 live births - twice the national average. Heroin overdose is the leading cause of death among adolescents and young adults; tuberculosis in the South Bronx runs three times the national rates. Major health needs are met by one municipal hospital: Lincoln. Although Lincoln Hospital is located in an inaccessible and desolate corner of the South Bronx, it is very much a part of that community. Its neighbors are ware- houses and a bread factory. The hospital sits on a hill of broken glass, slag, and rubble, overlooking the Bruckner Express- 2 way. Trash and litter accumulate in the hallways. Rats and mice scamper across the wards. Last winter the paint lead levels on the walls of the pediatric wards were found to be higher than lead levels in the homes of the children who were being hospitalized for lead poisoning. The corridors are lined with patients who wait for hours to see doctors. Staff shortages are severe in all job categories. Broken equipment is stockpiled in closets because the money for repairs has vanished in recent City economy moves. As the South Bronx's only public hospi- tal, Lincoln is straining at the seams. It has 346 beds - one tenth the number of New York's King's County Hospital. Its size pales in comparsion with other public hospitals serving similar needs - like Chicago's Cook County. Lincoln's range of services is woefully inadequate. Neurosurgical and preventive dental programs have never existed. Home care and elective surgery have been cut in the budget squeeze. The ex- cessive use of Lincoln's emergency room indicates both the dimension of need in the community and the inadequacy of the hospital's response. Although known throughout the Bronx as the " butcher shop, " tiny Lincoln logs more emergency visits than any other New York hospital. It is the fourth busiest emergency facility in the nation! It is within this setting that over the last three years various institutions and groups have been engaged in an ongoing strug- gle, occasionally breaking into open skirmishes, to alter the control and thus the conditions for both workers and pati- ents at Lincoln. During that time the issues, tactics and groups have changed; but there has been a groping develop- ment toward the vision of community- worker control. This article focuses on the more active, confrontational forces rather than on all the groups involved. A brief sketch of these groups (those in power and those challenging it) is followed by a historical overview of the events at Lincoln and a discussion of the issues of community - worker control and the role of white professionals. THE ACTORS The Powers That Be Albert Einstein College of Medicine- Einstein, a private medical school, con- trols almost all the hospital resources in the Bronx, including Lincoln. 5135 of the 8969 acute and long term beds in the Bronx are directly controlled by or affili- ated to Einstein. In terms of control, one worker at Lincoln summed up Einstein's preeminence: " The guts of the hospital are in the hands of Einstein. " This control is exercised through the Medical Board composed of the chiefs of the clinical services (medic- ine, pediatrics, radiology, etc.) at Lincoln. The chiefs of service are appointed by the medical school and receive their depart- mental budgets through the school. The quasi public - Health and Hospitals Cor- poration, which administers the municipal hospitals, gives half of Lincoln's budget (10 $ million out of last year's $ 21.1 mil- lion) to Einstein through an affiliation contract. The division of that budget and the scramble for funds between the Lincoln departments ultimately takes place in the Einstein dean's office office.. Einstein's priorities at Lincoln are poignantly dem- onstrated by the fact that Lincoln's Ein- stein offices are air conditioned - , while the overcrowded stuffy patient areas are not. Einstein has held on to Lincoln for its affiliation money and because it meets the medical school's teaching and research needs. It was rumored that given all the headaches, Einstein might pull out; but the ground has been broken for a 950 bed, $ 120 million new Lincoln. It seems less likely now that Einstein will let Lincoln go. The Health and Hospitals Corporation -The Corporation is responsible for determining the budgets for the City's eighteen municipal hospitals, including Lincoln. Again Lincoln gets short shrift. Several months ago, tentative budget al- locations showed that Lincoln would only get a 3 percent increase in fiscal year 1972, compared to an average 10 percent at most other city hospitals. The Corporation appoints the hospital's chief administrator. He is responsible for non medical - areas such as security, kitchens, housekeeping, maintenance and some professional units like nursing. But he must contend with a parallel admin- istrative structure and the fact that Ein- stein's control over professional services determines what goes on at Lincoln. Worker Groups The Work Force - With the excep- tion of the doctors, social workers and administrators, who are usually white, almost all the other workers - aides, nurses, technicians, clerks, janitors - at Lincoln are either black or Puerto Rican. Some of them live in the South Bronx community and they and their relatives use Lincoln as their hospital. Some came to work at Lincoln expressly because they wanted to be of service to their communi- ity. Lincoln's workers are divided by the traditional tracking and hierarchical se- parations of the health field. In addition, there are divisions created by differences in race (black vs. Puerto Rican), job level, and the different salaries workers receive for the same jobs depending on 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 Handelman, Ronda Kotelchuck, Howard Levy, and Susan Reverby. Associates: Robb Burlage, Morgantown, West Virginia; Vicki Cooper, Chicago: Barbara Ehrenreich, John Ehrenheich, Long Island; Ruth Galanter, Los Angeles; Kenneth Kimerling, New York City 1972. 3 whether they are paid by Einstein or the Corporation. The Unions - Due to the dual funding there are also two unions at Lincoln. Local 1199, the Drug and Hospital Workers Union represents the workers who are paid by Einstein. District Council 37, American Federation of State, County, and Municipal Employees, represents those paid by the Corporation. The unions have limited roles at the hospital. They have fought with varying. degrees of militancy on worker demands like wages, upgrading, grievances, etc. Except for tussles with the administration based on personality issues, the unions have not challenged the administration of the hospital about the quality of care it gives. On the contrary, in some instances they have functioned to discipline and police rank and file workers who were raising basic issues about patient care and working conditions. Among the problems- "... Specifically Lincoln suffers from a dearth of facilities parking - space, a good cafeteria. " - Antero La Cot, M.D. Vice Pres. of the Corporation, former administrator of Lincoln Health Revolutionary Unity Movement - The Health Revolutionary Unity Move- ment (HRUM) is a city wide - organization of black and Puerto Rican health workers. Its ten point - health program and news- paper, For the Peoples Health, demonstrate HRUM's educational and agitational focus. HRUM's Lincoln Hospital chapter grew out of the 1969 worker struggle at Lincoln's community mental health center. Since then HRUM has grown and reached work- ers within the hospital itself. Professionals - Pediatrics, Medicine and Psychiatry are staffed by full time - interns and residents, who are both American and foreign trained. Surgery and Obstetrics- Gynecology are staffed by interns and residents who rotate from the Bronx Mu- nicipal Hospital Center. In July, 1970, doc- tors for the Pediatrics Department were recruited by other interns and residents 4 on the basis of their social commitment to radical change in the delivery of medical care. They formed a group known as the Pediatrics'Collective. It has attracted members from the Medicine and Psychi- atry Departments and is now called the Lincoln Collective. Other professionals, such as nurses social workers, psychologists and nurses have come to Lincoln with goals similar to those of the Collective. Several work at the satellite community mental health centers while others work in the hospital itself. Community Groups The Community - With the exception of the politicos in the poverty program and Model Cities, there has been little aware- ness or involvement of residents in health activities within the South Bronx. Clergy- men in the Bronx Clergy Coalition have noted that residents have responded to meetings and rallies when they are on their own block or when they relate to a very specific need. The community's. support for change has grown, however, when the more radical political groups have attempted to reach them. Young Lords Party - The Young Lords are a cadre organization of young Puerto Rican revolutionaries who have taken health as one of the essential arenas around which to organize. They have been active in mounting support for actions at both Lincoln Hospital and Metropolitan Hospital in East Harlem. They are closely aligned with HRUM. Think Lincoln - In the spring of 1970, the Think Lincoln Committee was formed to do precisely what its name implies: to direct attention to Lincoln Hospital and try to improve conditions there. The group was a coalition of white, Puerto Rican, non professional - and pro- fessional hospital workers in alliance with active community people, including some of the South Bronx street gangs. Community Advisory Board Lincoln - has a Community Advisory Board that was created in 1967 as part of a city wide - dictum from the Department of Hospitals for some semblance of community in- volvement in hospital affairs. The Board members represent the usual cast of characters from poverty agencies and planning councils, " the people who join everything, " according to Ralph Alvarado, vice president of the board. " No health groups were in existence at the time. None of these people are really invested in healh; they have other agendas. " The Community Advisory Board has met sporadically since 1967. It has endorsed HRUM actions and was active in bring- ing the first Puerto Rican administrator to Lincoln. HISTORY Over the last three years, Lincoln has become a focus for community attacks from the outside and for worker revolts from within. The first explosion occurred in March, 1969, when black and Puerto Rican com- munity mental health workers supported by professionals at Lincoln's community mental health center revolted against the administration's dismissal of four fellow employees. This represented the final straw for the workers who had already experienced broken promises for para - pro- fessional upgrading and worker participa- tion in administering the center. In retali- ation, workers had a confrontation in the administrator's office which escalated into a takeover of the center. During the takeover, the workers continued to provide patient services despite worker arrests, suspensions and the actual closing of the center. Community residents, ranging from the Black Panthers to clergy and representa- tives of neighborhood social service agencies were brought in by the workers to help make center policy. In the end, the workers succeeded only in winning con- ventional gains in job security and pay. Because Lincoln's mental health cen- ter is physically separated from the hos- pital, the takeover did not affect the hos- pital directly. The takeover did demon- strate, however, that Lincoln was not an impenetrable institution. An atmosphere for further change had been created. Things remained quiet for a year with the exception of a brief flurry of activity from Lincoln's Community Advisory Board. In February, 1970, the City's Hospital De- partment tried to select a new administra- tor for Lincoln, without community con- sultation. The Community Advisory Board responded in outrage and formed its own search committee for a third world admin- istrator. Ultimately the City was forced to choose one of the Board's candidates- a Puerto Rican gynecologist, Dr. Antero LaCot.. In the spring of 1970 the Think Lincoln Committee came into being. It initiated a complaint table in the emergency room where patients and workers registered grievances about hospital conditions. These grievances were embodied in seven demands which were presented to Dr. LaCot. These demands included immediate construction of a new Lincoln Hospital; door door - to - preventive health services; a day care center; and total community- worker control of all services. Knowing that the administration would not act on most of the other demands, HRUM, Think Lincoln and the Young LINCOLN HIGHLIGHTS March 1969 Mental Health staff takeover of mental health center. February 1970 Comunity Advisory Board begins search for a new administrator. June 1970 Budget cuts for municipal hospitals announced. Think Lincoln - is form- ed. Complaint table is installed. Seven demands are pressed. July 14, 1970 Occupation of Administration building by Think Lincoln - , HRUM and Young Lords. July 17, 1970 Death of Carmen Rodriquez in the Obstetrics and Gynecology Depart- ment. July 20, 1970 Four new demands presented in- cluding the resignation of the head of Obstetrics Department. August 1970 Injunction taken out by the admin- istration which forbade further or- ganizing activity at Lincoln. November 1970 Takeover of Administration build- ing by HRUM, Young Lords and addicts to set up a methadone de- toxification program. November - December 1970 Culmination of power struggle in Pediatrics Department. Einhorn leaves and Helen Rodriquez is in- stalled, as head of the Department. June 1971 City Budget cuts for hospitals an- nounced. Billing action begins and continues to the present. October 1971 Psychiatry Department work stop- page. Lords also tried to bring the hospital to the community. For the next several months weekly mobile street clinics were set up to do preventive screening for lead poisoning, anemia, tuberculosis; to edu- cate the community residents about these diseases; and to place responsibility for health problems at Lincoln's door. When by July 14, 1970, the administra- tion had not responded to the demands, about 100 members of Think Lincoln, the Young Lords, and HRUM occupied the old Nurses Residence adjacent to the hos- pital. This building now houses some men- tal health services, personnel offices and 5 administrative offices. As in 1969, there was no disruption of patient care. The oc- cupiers, threatened by police attack, left the same day after two of the seven de- mands were granted: that there would be no cutbacks in services and that a preven- tive health screening clinic would be established. Three days later the death of a patient due to gross malpractice during a thera- peutic abortion rekindled the sense of life and death urgency among the insurgent forces. They called for the immediate resignation of the head of the Obstetrics Department. Shortly thereafter the resig- nation was forthcoming. However, an injunction was taken out by the hospital which prevented community groups from entering the hospital and which forbade worker meetings. " The takeovers didn't lead to immediate programs. Since the takeovers, the administration has been fearful of our power. They knew we could produce. " - An HRUM spokesman Several months later, in November, 1970, community activity surfaced again, this time in the form of a takeover of a floor of the administration building (scene of the July 14 action). A group of addicts supported by Think Lincoln, the Young Lords and HRUM wanted to institute a methadone detoxification unit. Despite fifteen arrests and initial harrassment from the hospital administration, the detoxifi- cation program has grown and thrivd. The program is entirely run and staffed by community residents. Independent of this activity but during the same period, an internal struggle was being waged in the Lincoln Pediatrics De- partment. The Pediatrics'Collective was committed to setting up a community pediatrics program that embodied the goals and strategies of community - work- er control. The Collective had actively supported the Think Lincoln summer ac- tions to the chagrin of the department's foreign housestaff and the department director, Dr. Einhorn. A five month - struggle ensued over the department's relationship 6 to the community. During this time the foreign housestaff resigned because of the turmoil at the hospital. Finally the Collective demanded Einhorn's resigna- tion because of his growing inability to administer the department and his re- sistance to community - worker control. The affair, which was played up in the press, ended with Einhorn's replacement by a Puerto Rican - Dr. Helen Rodriquez - Trias. Under Dr. Rodriguez - Trias's direction, Lincoln's Pediatric Department has charted new directions. Faced with a department torn apart by antagonism, she established a basis for unity. Through department wide meetings, including nurses aides, clerks, nurses and housestaff, problems confronting the Pediatric service were dis- cussed. A diverse group of attending physicians were recruited to fill the vacan- cies left by the staff which departed with Einhorn. The Department challenged the hospital administrator, the medical board and Einstein over funds. And the process of recruiting Puerto Rican doctors was be- gun, with a view toward making Lincoln a third world training center. 1971 began without visible agitation in or around Lincoln. By June, 1971, how- ever, the action began again - this time around threatened budget cuts. The clerks in the Pediatrics Outpatient Department, supported by the doctors, led the protest. Without the fanfare of a sit - in, takeover or strike, they stopped submitting Medi- caid billing forms, holding them until the issue of budget cuts is negotiated. The Pediatric clerks now hold approximately $ 750,000 in Medicaid forms. The history of Lincoln's struggle for emancipation goes much deeper than these surface events. It goes to the heart of defining community - worker control and the role of the white professional in the third world community. COMMUNITY - WORKER CONTROL The underlying theme of all the strug- gles at Lincoln has been community- worker control. These words have come to mean an attempt to change the nature of the health care at Lincoln by: 1) chal- lenging those who control and set prior- ties for the hospital; 2) altering the way in which daily work is determined and organized, and; 3) affecting the way work- ers relate to one another and to patients. Beneath the community - worker control slogan is the issue of power. Will men who work for Einstein and the Corpora- tion, but never use Lincoln, determine its priorities, budget, quality of care and work relations or will these things be deter- mined by the people of the South Bronx who use the hospital and the workers who staff it? The issue of community - worker control has developed at Lincoln with more em- phasis on worker than community. The community residents'relationship to the hospital is episodic; people only come when they are ill. Furthermore Lincoln is only one of a number of oppressive in- stitutions that they must deal with each day. Thus like their visits to the hospital, the community residents'role at Lincoln has also been episodic. Community residents have made de- mands on the hospital for services and have joined with worker groups to im- prove care; but not on a sustained basis. For example, the South Bronx Senior Citizens Council demanded a geriatric clinic in the Medicine Department to serve the special needs of its members. South Bronx residents were part of the Think Lincoln Committee. In Pediatrics, the parents themselves are not ill and they make frequent visits to the hospital. Thus, a tighter, more substantial, relationship between worker and community forces has developed into new organizational forms like a Pediatric Parents Association (see page 16.) In contrast, the non professional - and professional workers are at Lincoln every day; it is a focus and a definition for their lives. From this base changes at Lincoln have come. This is not to say that the community has taken a disinterested role. However, over the course of the last three years, sustained political activity has come from workers. The relationship be- tween the community and workers is clearly illustrated in the development of the Health Revolutionary Unity Movement. HRUM: A Strategy for Creating Space Since 1969, HRUM has taken on the task of building political awareness and consciousness among the black and Puerto Rican workers at Lincoln. HRUM is the thread of continuity which has woven in and out of Lincoln over the last three years.. It was the mental health unit takeover, during which workers provided services under their own direction, that created the vision of a new way to perform hospital jobs. The process of taking condol was a turning point in the consciousness of some of the participants. It was during this pe- riod that a growing connection was made between the demands of workers and the needs of patients. The link between community and work- er was forged when HRUM members united with the Think Lincoln Committee in the Spring of 1970 to press the seven demands and to establish a community- worker complaint table. The grievances submitted were not just documented. Doctors taking extended lunch breaks were confronted and told to return to their clinics. When complaints were made about poor garbage removal in the hall- ways, the garbage was collected and dumped in the Administrator's office. The garbage removal schedule improved the very next day. These actions and their emphasis on the community meant that HRUM found it- self doing less and less day to day organ- izing among the workers. Their militant actions and rhetoric ran the risk of alien- ating some of the hospital workers. Some workers saw the community demand for more service simply presenting more work for them. Although most of the non profes- - sional workers at Lincoln are third world, there is an inherent antagonism between the users and providers of service. Ein- stein and the Corporation can take advan- tage of this conflict and translate com- munity demands into threats to workers by refusing to increase either the number of workers or their pay. Many workers also felt threatened by the issues raised and the groups with which HRUM was aligning itself. In keeping with the direction of the Young Lords Party and the Black Panthers, HRUM be- gan to address itself to health issues that are of concern to what they called the " proletariate lumpen -, " i. e. the street people, high school drop - outs, addicts, etc. For example, in the fall of 1970, HRUM joined in the occupation of the sixth floor of the Administration Building to set up a detoxification program for the addicts. However, since the addicts line up for the Detox Program right next to the nurses ' lockers, many of the nurses saw HRUM's community service as a threat to their safety and needs. " Our goal is self- determination, and the way to that is community- worker control. " - Daniel Argote, HRUM member 7 HRUM was forced to reevaluate its strategy. It has now moved back to worker organizing within the hospital. According to Kathy Larkin, an HRUM spokeswoman, their day day - to - energies are spent in talking to workers. " We lay out what the problems are, challenge them to see the issues. We point out that the division among the workers and the community is not their fault. We try to show them why this happens. " In line with this strategy, HRUM recently showed a film of the 1969 mental health takeover to emphasize that the issues and conditions that led to the action are still relevant to Lincoln and that workers can organize to change these conditions. About 250 workers showed up to see the film. HRUM's new posture is also reflected in its attitude toward the unions. 1199 and DE TOX: The heroin detoxication program is one of several positive programs that have emerged from the last few years of ferment in and around Lincoln Hospital. The program was inititated by three third world political organizations. It is run with a strong element of worker control. And instead of offering group therapy, it provides PE (Political Education) for the estimated 5,000 addicts who have gone through its methadone withdrawal cycles. The idea for the Lincoln Detox Program came from the work of the Young Lords and Black Panther Parties and the Health Revolutionary Unity Movement (HRUM). These groups, along with ex addicts - , had been trying to organize addicts in the fall of 1970. In the South Bronx in order to do any organizing in the community, one must confront the problem of drugs. Addiction (and its com- panions, crime and police) is one of the worst of the " peoples'ills "; it controls significant portions of everyone's life in that community. The addicts, according to the political analysis of these groups, can be seen as a potentially'revolutionary'group. According to an early participant in the Detox Program, " Addicts are a lumpen class - they don't produce anything but crime.... Addicts have a keen sense of hardship and they must stay away from the police. " The intent of the organizing effort was to bring political consciousness to their keen sense of hardship and explain why " both groups [addicts and organizers] are fighting the cops. " Because there were no facilities in the South Bronx for detoxifying addicts and because of their strong political objections to both methadone mainte- nence and therapeutic community drug programs, the three political groups and some unaffiliated addicts ex - started meeting with hospital officials to pursue the idea of a detoxification program at Lincoln. Lincoln had been plan- ning to institute a small drug program for some time; funds were anticipated from the City's Addiction Services Agency ASA (). After some fruitless meetings and no anticipation of action on Lincoln's part, the doctors'call " on - " rooms on the Administration Building's sixth floor were seized on November 10, 1970. When an impromptu detox program was set up during the takeover, the hospital quickly moved in to break up the action. Fifteen people were arrested and negotiations with the hospital started. After only several days of meetings, the groups won the use of Lincoln's anticipated ASA funds; the use of the old Nurses'Auditorium in the Administration Building for the Detox Program; and a little office space in the Psychiatry Department. The Program got underway immediately with 25 addicts, four counselors and volunteers from the community and the hospital medical staff. In fact, during the five months that elapsed before funds actually came through, the Program was run by the activist group entirely on volunteer labor; individual doctors from the Psychiatry and Pediatrics Department also contributed their time. Lincoln Hospital itself made no effort to locate staff or reimburse the workers for their labors. Since then the Detox Program has provided 30 ten day - withdrawal cycles with approximately 200 addicts in each cycle. The staff now consists of a direc- tor, 12 counselors, 39 other clerical and medical workers, and anywhere from 5 to 30 volunteers per cycle. 90 per cent of the staff are ex addicts - many of whom came through the Detox Program themselves. The Program does not 800 HRUM have always been at odds. The Union's position at Lincoln was typified by their refusal to support the workers ' action during the mental health take- over. In denying 1199 support, the Union's Vice President commented; " If the work- ers want to challenge who should be management, who should control the cen- ter, that is their own affair. " HRUM has been critical of the Union's role of policing the workers and keeping the lid on conflict with the hospital administration. However, the unions play a crucial role by providing workers with certain pro- tections, grievance machinery and negot- iated wages and benefits. It was clear to HRUM members that these protections could not be ignored or regarded as un- real. HRUM is not trying to build an altern- CLEARING THEIR HEADS compile statistics on the number of addicts who remain drug - free after detox- ification, but staff members assume that their success rate is comparable to other more conventional drug rehabilitation programs. The Program still operates out of the Nurses Auditorium, which is seen as one of its greatest handicaps. There is no quiet or space for confidential con- versation. Counselors sit at long tables down the center; addicts sit in rows of folding chairs on either side. Medical histories are taken and tests given at the foot of the stage. Methadone is dispensed from trays of carefully watched cups up on the stage itself. If the South Bronx is in a state of siege, and drugs are part of the battle, then the Nurses Auditorium can only remind one of make- shift hospital scenes in war movies. Although the Young Lords, Black Panthers, and HRUM have pulled out of the Detox Program " because of their own political priorities " the philosophy of those groups continues to guide the therapeutic and administrative aspects of the program. During its first year of operation each department (like medical aides) elected its department head and these department heads met together to make program- matic decisions. A short time ago however this system was overturned by the employees. Workers within each department (having " had PE ") now elect one representative for every five workers. These representatives sit on the Discipli- nary and Grievance Committee, and this body makes all decisions for the program. This committee's meetings are supplemented by General Meetings of addicts, volunteers, and workers every two weeks. The Detox Program does not want to be seen as simply the place that dis- penses methadone or maintains addicts on it. For that reason, it has established rules about the frequency that an addict may come in for the ten day with- drawal cycles. (An addict must wait 30 days for a second cycle and ten months for a third). That is also why the Detox Program has instituted PE (Political Education). The Detox Program does not dispute the value of providing support for detox- ified addicts. Support, however, comes in terms of survival needs for life in the South Bronx, rather than in terms of establishing an alternate and distinct " supportive environment " or " therapeutic community. " The Program gets many eligible addicts onto the welfare rolls; helps locate housing, arranges for medical treatment within the hospital. It also works closely with the Spirit of Logos, an organization of ex addicts - who attempt to organize other addicts around the economic and political causes of their addiction. PE at the Detox Program is offered to both addicts and workers in the pro- gram. PE sessions, in small groups, occur in corners of the Auditorium during the afternoons. PE sessions focus on " conditions in the community ... we are out to deal with the contradictions and problems of that class of people. " All addicts are asked to participate, but there is no coercion involved, and one- third attend at most. It is obvious that the Detox Program staff view addiction as an affliction which arises out of socioeconomic conditions, rather than individual neuroses. Therefore, the Program emphasizes PE, rather than the personal encounter - type therapy of other programs. _Constance Bloomfield 9 ate union or take over the present union structure. Rather HRUM organizers tell workers what the unions'limitations are and they advocate support for radical caucuses within the unions. In keeping with this new approach, an HRUM mem- ber agreed to speak at a DC 37 budget cut rally and HRUM met with Local 1199 representatives to try and win their sup- port for rallies following the Attica Prison rebellion. HRUM is also moving closer to other rank - and - file organizations. HRUM helped sponsor a conference in early December with the Federation of Puerto Rican Work- ers. It is also considering working closely with the Black Workers'Congress (a group that grew out of black worker or- ganizing in the Detroit auto plants). HRUM continues to maintain unity de- spite its racial and sexual divisions. In recognition that 75 percent of hospital workers are women, HRUM's leadership is female. While racial differences have divided workers at Lincoln for many years, HRUM has been able to unite black and Puerto Rican workers in its organiza- tion. Making Day - to - Day Changes Worker community - actions obviously challenge the authority and control of both the Health and Hospitals Corpora- tion and the Albert Einstein College of Medicine over day day - to - affairs at Lincoln. The spectacular tactics (like takeovers) and less well known - rebel- lions (like the billing action) have made small dents in the control these institu- tions hold. But a clear, defined long range - strategy for shaking these institutions has yet to be devised. The activists are, how- ever, clearly aware that the more basic changes made in the work process and work relationships are essential to build- ing for more concentrated assaults. The Psychiatry Department: Changing Job Roles The Psychiatry Department uses a pro- gressive team work approach. Within the teams there is no functional difference be- tween social workers, psychiatrists or mental health workers. However, the cler- ical workers have not been included in the breakdown of job distinctions. This fall a Manpower Career Develop- ment Administration (MCDA) program for training community people to become mental health workers was introduced into the department. The clerical workers were again excluded despite earlier promises of upgrading. Many of the clericals had been stuck in the same dead - end positions for years. Angry at being once again excluded and at the lack of support from Local 1199, 10 they organized a workers'committee and called a work stoppage. They were sup- ported by housestaff and other profes- sionals who not only agreed with their demands but had grievances of their own. The administration backed down, and 1199 stepped in to negotiate the settlement. The clerical workers won inclusion in the training program, but as a result, com- munity trainees were dropped by MCDA with no guarantees that their training will be continued. Unfortunately this presents a classic case of the division between the community and workers, exacerbated by a tight money situation. The key element in the incident was the unity of the clerical workers with the doctors and other professionals over basic work issues. " We knew, " said one activ- ist, " that just asking and being polite wasn't enough. We knew how other issues have been won at Lincoln and we decided to take action for our demands. " An End to Doctor Dominated - Clinics One of the most exciting changes at Lincoln has taken place in the Pediatrics Department. Here some decision - making within the various services (outpatient, wards, etc.) has been taken over by a committee drawn from all levels of the health hierarchy. The worker committee in the Pediatric Outpatient Department Clinic is the most developed. It is divided into two groups: a general clinic group of all workers and " We're more together as a unit. We're not under- lings to anyone. No one is holding us back. " -Tony Cruz, pediatric out- patient clerk. doctors; and an elected steering commit- tee with clerk, nurse and doctor represent- atives. The steering committee deals with the ongoing running of the clinic and such issues as the processing of charts; how innovations can be made to allow for more patient privacy; and the more difficult issue of doctor attitudes and work practices. General meetings are used to acquaint the entire staff with different as- pects of pediatric care. One week the pub- lic health nurse spoke about her function; at another time, workers and doctors went to see a public health child care facility. Billing Action: No Green for Red Budget cutting has always been an issue at Lincoln. Each cut is normal- ly accompanied by a flurry of pro- test from department heads and oc- cassionally from the unions, and then things settle back into the usual desperate situation. Recently differ- ent tactics have been used. The July, 1970, Administration Building take- over was, in part, inspired by the cut- backs. 1971 was the year of the " billing action. " During a meeting in the Pediatrics Outpatient Department in early June, the upcoming budget cuts were dis- cussed. Members of the department sent a letter to the administration de- manding an end to the cutbacks and threatening action. When no word was forthcoming, they took action. The Medicaid forms that the city uses to collect its Medicaid reim- bursements began to " disappear. " To date, the forms, worth almost $ 750,000 dollars, have not found their way to the Health and Hospitals Corporation's coffers. Participants say that the forms are being held for ran- som until the budget cuts are re- stored. This action, while dramatic, has no negative effect on patient care. The administrators responded at first by threatening to press criminal charges. The DC 37 union represent- ative refused to back his members up and even threatened them with job loss. However, the workers have been supported by HRUM and by Lincoln's Community Advisory Board. It is clear now that both Einstein and the Corporation are keeping the lid on the case. Observers say the Corporation is willing to lose the money; it is a drop in the bucket and is a danger to them only if similar ac- tions spread to other departments and hospitals. Because of the legal implications, worker fears of firings, the lack of union support, and lack of publicity, the action has not spread. Unless workers in other hospitals feel suffic- ient support from fellow workers and doctors, Lincoln's billing action will remain an isolated harassment. Similar groups in the Pediatric Emer- gency Room and on the wards have met sporadically. But the clinic committee is the most developed. It grew out of opposition to the arbitrary practices of the clinic Director. Workers, as well as doctors, wanted to have the meetings and pushed to continue them in the face of harass- ment, mainly from the nursing hierarchy. When the more vocal nurses started to attend, they organized other nurses and clerical workers to attend and participate. The committee has been supported by parents of pediatric patients, although the parents do not attend meetings. This committee has changed the role that different level workers have histor- ically played, or more accurately not play- ed, in hospital decision - making. More im- portantly, it has changed the way people relate to one another, has offered the pos- sibility of an honest exchange of ideas and experience and has provided a forum for political unity and action. ' These changes have affected on the- - job relationships between workers and patients; this ultimately affects patient care. The changing attitudes and roles of pediatric clerks demonstrates the poten- tial of day day - to - internal changes. The clerks in the out patient - depart- ment and emergency room are the first and last representatives of the hospital to see patients. They are responsible for checking patients in, making appoint- ments, directing patients to other services and generally explaining hospital pro- cedures. They are, as one clerk put it, " the foot soldiers in the hospital. " Lacking an atmosphere of change, clerks turn their frustration over their rigidly defined roles into apathy and even misdirected hostility toward one another and toward patients. Their anger at the doctors and their supervisors is usually more subtle and covert. In most depart- ments, clerks do not go out of their way to redirect wandering and confused patients. The usual comment is " that's not my job. " The contrast in the Pediatrics Depart- ment is striking. First of all, worker opin- ions are respected - clerks are not in- timidated by higher echelon - workers. " The biggest change, " says Gladys Aponte, an out patient - department clerk, " is the creation of an atmosphere for struggle. We're not afraid any more to tell doctors when they're doing something wrong. We won't lose our job... we're not afraid to initiate actions, to do something. " In Pediatrics, worker anger toward the doctors is more openly expressed than in the usual hospital situation. In one in- stance, a doctor was called to the steering committee and confronted about his be- haivor and attitudes toward both workers 11 and patients. The community has noticed the change. When queried by visiting nurses about what they thought had changed at Lincoln over the last three years, patient's families invariably an- swered; pediatrics. The Medicine Department is now begin- ning to make similar changes. It has adopt- ed a team approach in its clinic, and team members, including doctors, nurses, social workers, etc., meet after each session to discuss medical and administrative prob- lems encountered there. One outgrowth of the struggle for com- munity worker - control is a changed per- ception, among workers, of their own dignity, worth and ability. Small victories have provided these " new workers " with a vision of different power and work rela- tionships. At Lincoln, this process has created an atmosphere which is encourag- ing workers to seek control over more areas of their work lives. Accountability to Whom? Traditionally doctors are held account- able only to each other, to chiefs of ser- vice, or to administrators. At Lincoln this concept of accountability has been challenged. Patients and the community demanded accountability in in the Obstetrics - Gyne- cology Department following the death on July 17, 1970, of Carmen Rodriguez during a therapeutic abortion.. A doctor who knew her from another program, saw the chart and felt that proper care had not been given. Doctors have faced this situ- ation many times before; if they act at all it is to call a clinical conference of the other doctors to discuss the case. Instead the information was given to the Think Lincoln complaint table. A " peo- ple's clinical conference " was called to discuss the case. Using a " medical Nurem- berg " principle, it was determined that the head of the department is respon- sible for the actions of his staff. Since Dr. J. J. Smith, the chief of the department, refused to take this responsibility or to accede to the community demand for bet- ter services, he was forced to resign. " The patients want service. If you can't give them that, you can't give them anything else. " _- A Lincoln doctor 12 WHITE PROFESSIONALS Each year hundreds of white middle class medical students receive their clinic- al training in municipal hospitals servic- ing third world communities. Students are trained to view the patients they treat as " teaching material " and the hospital workers below them as doctor's " hand- maidens. " For those 20 percent of stu- dents who pursue their internships and residencies in public hospitals, the same socialization process continues. To those few, who choose to resist these pressures and to serve their patients, the task is literally impossible, especially if faced alone. The overwhelming demands placed on interns and residents and their inabili- ty to alter priorities within the hospital, mitigates against most individual at- tempts at change. Furthermore, young doctors run the risk of unwittingly falling into a missionary or mercenary role. In order to deal with some of these problems, a group of interns and resi- dents at Lincoln (and some that rotated through Lincoln from the Bronx Municipal Hospital Center) drew up a proposal for a Lincoln community pediatrics program in fall, 1969: " By concentrating a signi- ficant number of people with a socially conscious orientation in one hospital and work situation a critical mass of people may be created which will be able to change rather than merely adapt to and attempt to survive in a difficult work situ- ation.'" During the winter and spring of 1970, thirty - two interns and residents and a few nurses were recruited by the group to work in this new, but relatively undefined program. While the recruitment efforts were neither helped nor hampered by Einstein, they were endorsed by Dr. Arnold Einhorn, Director of Pediatrics at Lincoln. For Einhorn, it was the first time in decades that an American - trained pe- diatric staff would come to Lincoln, thus enhancing the prestige of his program. The Collective's Program The Collective's program goals were derived from the experience of some of the housestaff in the Student Health Organization summer ghetto projects. Ac- cording to two of the original doctors, Fitzhugh Mullan and Charlotte Fein, the Pediatric Collective had two goals: OE Commitment to provide continuity of care to a colonized community. The clinic- al program reflected this commitment by stressing the development of " primary rather than sub specialty - physicians " and through offering a community elective for experience outside the hospital. OE The " democratization of work rela- tions " by breaking down the traditional hospital hierarchy. Several programs have since emerged from the Collective: Continuity Clinic - In the past, pediatric patients were frequently assigned un- necessarily to numerous sub specialty - clinics in (keeping with Einstein's interest in specialty training and research). Now, according to a Collective newsletter for patients, " The doctor making the initial contact with the patient (in the emergency room, wards, clinics, nursery) acts as the primary physician for the children of that family on all subsequent visits. " In addi- tion to reducing fragmentation of care, the Collective's system has increased the opportunities for favorable relationships to develop, has led to greater utilization of services and to more efficient use of time because of familiarity with the pati- ent's problems. " Medical Records - The Collective has pioneered the " Weed System " for medical recording keeping within the hospital. This system organizes the usually chaotic medical chart, so that medical problems are not buried in the mass of detail and forgotten. It emphsizes preventive care and facilitates continuity of care. Community Elective - As part of their training, Pediatrics housestaff now spend one month on community work. The com- munity elective has been plagued with many problems. At first, the Collective anticipated working in conjunction with HRUM and the Young Lords, but this never came to fruition because both groups were preoccupied with other ac- tivities at Lincoln. The housestaff have also been involved in recruiting new doctors and establishing ward and outpatient meetings. It is only recently, that the Col- lective has been able to get the elective out into the community as originally in- tended. Some housestaff have worked with community residents interested in establishing a day care center; others have responded to requests from com- munity groups. Relations with Community Groups ' Most of the Collective's long work day is spent in practicing medicine on the wards, in the clinics, or in the Pediatric Emergency Room. The little remaining time early in the morning or in the even- ing is often used for ward and collective meetings or Spanish and karate classes. The lunch hour is utilized as well for medical lectures and social medicine sem- inars. In addition to all this, Collective members feel a sense of responsibility to respond to demands for services from groups in the community. Thus Collective members helped staff Black Panther clinics last year, gave physical examina- " The edges of the caste system for doctors are very tight. " -Mike Smith, Lincoln psychiatrist tions to addicts in the Detox Program (see box, pp. 8-9) and lent support to the Young Lords and HRUM during the July, 1970, takeover of the Administration Building. In the course of giving service to com- munity groups, Collective members have emphasized the need to perform a " de- colonizing role " by transferring their skills to community residents who can continue to provide service on an on going - basis. The Collective's most recent commitment to the Community Medical Corps is an illustration of this role (see box, p. 14). The structure of work at the hospital does not allow for sustained commitment to community projects. This problem was not overcome by the community elective either. The Collective often does not real- istically assess the amount of time a pro- ject will take. Several critics in the Collec- tive have voiced their frustrations: " Most projects are well received. People think they're great idea. The problem is getting people to follow through once the com- mitment is made. " Problems with the Collective Identity Although the Pediatrics Collective has from the start aimed toward equalizing tasks among all department personnel and improving the notoriously bad hospi- tal work relations, their notable accom- plishments have not been without blemish. The Collective has had a history of poor relations with the foreign housestaff at Lincoln. They failed to win the support of the predominantly Thai, Filipino and In- dian doctors, who were already there be- fore the Collective arrived on the scene. Nor have they related well to the new 13 group of foreign doctors recruited last July. One foreign doctor spoke for most of the foreign trained - staff, when he said: " The foreign doctors have felt pushed around by the white doctors. In eastern culture, our people learn not to be so ag- gressive. Though we are sympathetic to efforts of some of the Collective members, we also feel threatened by their aggres- sion. Even though the Collective doesn't want to be racist, it is a white man's social club. " The foreign doctors have recently formed a caucus in which they, as an independent force, will discuss their own problems and seek ways to serve the community. The Collective has also had problems relating to the non doctor - staff. Despite their self consciousness - , some have fallen into the pitfalls of professionalism. Ac- cording to one long time - Lincoln nurse, " Physicians think they can do it all and they can't do it all. They must develop respect for the people that work here. We can explain and teach about illness. We know what the environment is like. " Part of the difficulty that the housestaff has in relating to other workers derives from the hip lifestyle that many of them have adopted. The long hair and casual dress permitted doctors because of their privileged status are often options not open to other workers. Some nurses have voiced criticism of a few of the " freaky- looking " doctors'hygiene: " They don't wash their hands after seeing a patient. That's not practicing good medicine. Sometimes, they don't change their shirts Community Medical Corps The Community Medical Corps (CMC) was begun in the summer of 1970 by two medical students from Albert Einstein College of Medicine. Financed through Einstein's Community Medicine Department and the New York City Health Services Administration, CMC developed a door door - to - screening pro- gram for lead poisoning. " The purpose, " according to one of the CMC's student initiators, " was to develop a health care system by using outreach programs so the community can learn about health. We wanted to train para medics - from the community to help show that anyone can learn how to do these simple tests. " The first summer 110 Neighborhood Youth Corps workers divided into ten teams supervised by medical and nursing students and screened 3,000 chil- dren in several South Bronx neighborhoods in eight weeks. After the summer, seven community residents were hired to work full time on the project. The Health Services Administration (HSA), in a maximum efficiency drive, instituted a quota system, requiring that 165 tests be done every week in order for the workers to receive their wages (2.85 $ per hour for a 35 hour week, with no fringe benefits or health insurance). Outside doctors were paid a flat 13.85 $ per hour to draw blood from patients, regardless of the number of tests taken. At their own initiative, the workers also instituted tuber- culosis and anemia testing to provide more comprehensive screening. Even with extra time for these additional tests, the workers were able to screen 12,500 children. But in order to reach their quota, most of the workers had to work up to 70 hours per week, yet they continued to get paid on a 35 hour - a- week basis. The community workers began to challenge the doctors about their working conditions and wages. They pointed out that there was a dual system of pay- ment: piece work for community workers and hourly wages for the doctors. The Einstein students insisted on adhering to the HSA guidelines for the pro- gram. The community workers sought to abolish the quota system and estab- lish more worker control of the program. Finally, the Einstein students locked the community workers out of their store front office. When the CMC workers found themselves on the streets, they approached Dr. Helen Rodriquez - Trias for help. The Department of Pediatrics at Lincoln Hospital agreed to provide physician services and back - up for the program, including training for CMC members in basic pediatric skills. A proposal for refunding CMC was then submitted to HSA, where it is presently pending. At the same, the Einstein students have taken the remaining money al- located for the CMC program and plan to establish their own program else- where in the Bronx. In addition, they have gone after a grant from HSA, which will undoubtedly compete with CMC's request. And of course, the Department of Community Medicine at Einstein, conduit for the original grant, stands by declaring its " neutrality. " 14 for weeks. Mothers complain to us that they don't want to take their children to that kind of doctor. " Meeting Meetings, Meetings The Collective also has its own internal problems, largely focusing around its members'anti authoritarianism - - unwill- ingness to make or carry out group deci- sions. This is not surprising, considering the background of most of the Collective members. As medical students, many of them resisted the socialization process in- dividually, resulting in isolation from other students. In order to face this issue and their difficulty in work relations, the Collective has turned its attention inward, through meetings. There are bi weekly - meetings in which all Collective members discuss concrete issues and projects. At the end of these meetings a " criticism - self - criticism " ses- sion is held where members point out to each other in what ways their actions offend and ultimately oppress their co- workers. On alternate weeks, the Collective breaks down into five small groups which discuss in more detail the problems raised in the large meetings. Collective mem- bers are urged to attend one, if not both of these sessions. In recent months, the small group meetings have become more important because the setting allows for more intimate discussion and criticism of the role of the white doctor. In addition, some Collective members meet for breakfast at the hospital. Because they precede the rigors of a typical day's work, these sessions are relaxed and afford the opportunity for Collective mem- bers to get to know each other personally. Over the last six months, a new group called the Health Revolutionary Alliance (HRA) has been relating to the Collec- tive at many of these meetings. HRA is a city wide - organization of white health workers, some of whom were early mem- bers of HRUM, but left the organization when it decided to focus entirely on a third world constituency. Some HRA ' members work at Lincoln and they now function to provide the Collective with a liaison to HRUM. In the last year and a half the Collec- tive members have wrestled among them- selves to deal with criticism leveled by other staff. The results show some changes in the Collective's view of its constituency and function. In terms of its constituency, the Collective has had a large turnover in its membership. Forty of the interns and residents who came in July 1970 spent a year at Lincoln and then moved on. A new crop came in July 1971 to take their place. This change, of course, meant that the Collective members had to spend time getting to know one another, form- ing new relationships with other hospital personnel, while fitting into the grueling work routine. Still the Collective has grown to fifty members and spread to two other depart- ments - Medicine and Psychiatry. Its members are all white, almost all male and doctors. When the Collective first started, attempts were made to recruit nurses as well. A few even joined the group. But as in many groups of this kind which are dominated by male professionals, cries of professionalism and sexism were quickly voiced by women in the Collec- tive. Avis Shapiro, a social worker from the Psychiatry Department said, " If you're not a doctor, you feel out of place. You don't feel that it's worth it to try to change the discussion because people really don't listen to one another when they talk. No one responds to the point of the person speaking before him. And women have consistently been ignored. " Some women doctors have also shied away from the Collective. According to Elinor Graham, a pediatric resident: " Women doctors were consistently put down. The meetings con- sisted of male egos jousting back and forth. They wouldn't listen to one another. They were never concrete, only theore- tical. " As a result, many women have dropped out of the Collective while con- tinuing to work at the hospital. Gradually the Collective has revised its assessment of its membership. It now ad- mits that it is a group made up primarily of doctors and that it works with other kinds of personnel in the hospital to im- prove medical care. The Collective has also changed its posture about its function. During the Einhorn crisis, Collective members ran the department, even though this alien- ated other housestaff and personnel in the process. This has changed in the last year, as the Collective has become one of several voices in the Pediatrics Depart- ment, along with foreign housestaff and workers. The development of outpatient department and ward meetings where doctors are only one of the participants and not the dominant force in decision- making is another sign of this change. These meetings are more appropriate set- tings than the rarefied atmosphere of a Collective meeting for challenges from workers about racism, sexism and pro- fessionalism. White Politics The Collective has had to face the crucial issue of the role of white profes- sionals in a third world community. An 15 HRUM member has said, " Their role is to serve the people with their technical skills in a human way. We know what class they're coming from. They must understand that they are the weakest link. " The response from the Collective, not unlike other white movement groups, has been the politics of guilt and the poli- tics of adventurism. Both arise out of the Collective's inability to work out a self- conscious definition of their role. A guilt response has often resulted in the group's virtually unquestioning support of HRUM. The Collective has acted not as an auto- nomous unit, with a unified political per- spective, that should be dealt with on its own terms. The other response is to " organize the community, " which arises out of a romantic notion about the medical savior who leads other people's strug- gles; or the voyeuristic tendency that de- fines a " total politic " as " rapping with the Lords. " Some Collective members have chosen another alternative. Their primary role is to use their medical skills in a humane way in their daily work and to challenge the medical establishment, thereby creat- ing space for community groups and workers to gain control. This requires a long term commitment to building a poli- tically conscious staff. One of the new steps toward this goal is the recruitment plan for the next year's house staff. A committee composed of parents from the Pediatrics Parents As- sociation (a recently formed group of parents concerned about health care at Lincoln), HRUM members, clerks, nurses and doctors have taken on collectively the task of selecting prospective house staff. Members of the interview committee ask the prospective house staff specific ques- tions, not only about such traditional mat- ters as past training and professional in- terests, but about how they feel they will be able to function in a third world com- munity, taking criticism from parents and workers, accepting authority from third world staff members. Those who are be- ing interviewed on a particular day are also questioned as a group by the com- mittee in such direct ways as presenta- tion of a case by a parent with discussion by the group, and by skits simulating everyday hospital situations in which the group members take part and " play themselves. " THE LONG HAUL Two themes have emerged from Lin- coln's struggle for worker community - con- trol: (1) The breaking down of hier- archies and altering the way workers and patients relate every day is critical for building a base for change; (2) The chal- lenging of the control and priorities of an institution is both catalytic and necessary for change. The experiences of Lincoln show the im- portance of political self consciousness - , as a way to define respective roles in the struggle. This self definition - is crucial if different class and racial groups are to be organized and to enter into alliances which wil effect change. As one partici- pant in the 1969 mental health takeover put it:'We must be very clear about who is organizing whom. It is not the role of white professionals to take on the work of HRUM and the Young Lords, to go out rapping in a third world community. " Day - to - day base building is slow and its manifestations do not make front page news. The work of challenging Lincoln's administration and ultimately the powers of its affiliated medical school and the Health and Hospitals Corporation is just as difficult. As these institutions are linked into the working of the whole society, the challenges also cannot be separated from the demands for changes outside the hos- pital walls. Despite these obstacles, one thing is clear: Lincoln has made some steps toward emancipation. - Susan Reverby and Marsha Handelman Earlier Lincoln Stories Detailed accounts of events at Lincoln are found in the following issues of the BULETIN, available at 60 each: April, 1969: May, 1969: September, 1969: September, 1970: October, 1970: December, 1970: January, 1971: Bronxmanship and Taking Care Lincoln Brigade II New York: Empire City and Report Bronx Community Wants Control Empire Roundup Lincoln Detox Box Pediatrics Collective Lincoln is analyzed at length in Chapter 18 of The American Health Empire: Power, Profits, and Politics (Vintage Books, 1971, $ 1.95). 16