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HEALTH / PAC Health BULLETIN Policy Advisory Center Triple Issue Nos. 83, 84, 85 1 HSAs and Cost Control: A FEATHER ON THE CAP? Health Systems Agencies attempt to control costs without the po- wer needed to do it. 3 Vital Signs 5 The Fall and Fall of the NYCDOH 3 Deep cuts for preventive and primary care services at the New York City Department of Health. 17 Columns WASHINGTON: Battle of the Budget WOMEN: Electronic Fetal Monitoring WORK ENVIRON / : Asbestos Disease in the Courts Bringing the Chemical Warfare Back Home NEW YORK: NYC's Hospitals: Beyond Caring THE FIFTH COLUMN: Nurses'Network Formed 42 Home Health Care: COMMODITY OR COMMUNITY? Can home health care become a real alternative to impersonal hospital - based care? Media Scan 50 Every Child's Birthright: In Defense of Mothering, by Selma Fraiberg. Assessing the Efficacy and Safety of Medical Tech- nologies, by Office of Technology Assessment, Congress of the United States. HSAs and Cost Control A FEATHER In the winter of 1974 the 93rd Congress, com- ON CTAHPE? bining the fading optimism of the 60s with the emerging regulatory bent of the 70s, passed into HPCBAR 81,82 1-60 (1979) law PL93-641, the National Health Planning and Resource Development Act. Its intent was to achieve " equal access to quality health care at ISSN 0017-9051 a reasonable cost, " by reconstituting the nation's anemic network of state and local health planning agencies. Now, four years later, that network is largely in place. Yet in those few years since its inception, the political and economic environment has changed dramatically, placing new demands on the nation's health planning effort that it is ill designed - to meet. Foremost among these is the pressure to control spiralling health care costs now the dominant theme of federal health policy. The following article chronicles those growing cost control pressures, examines the ways in which the nation's health planning network has been, in part intentionally, ill equipped - for this respons- ibility, and discusses its likely impact on the future shape of health planning. A Legislative Preview Congress offered a preview of mounting cost control, regulatory anti - and special interest forces when the original authorization for PL93-641 expired last year. The attempt to renew this authorization and to strengthen the law resulted in a legislative standoff. Congress finally passed a one year - continuing resolution to maintain PL93-641 and fund it as before, postponing until this year resolution of the conflict among these contending forces. The most powerful of these forces is the pres- sure to control rising health care costs. National health expenditures have risen inexorably, reach- ing a total of $ 163 billion last year, or 737 $ per capita. A recent HEW study predicts that the tab will reach $ 1 trillion by the year 2000, con- suming over 12 percent of the GNP. The largest and most rapidly rising portion of these are hospital costs, fueled by the generous reimburse- ment policies of Medicare and Medicaid which now pay over half of all the nation's hospital costs. The pressure to control these costs is intense, stemming not only from internal budget impera- tives, but from such external sources as business and labor as well. Meanwhile, hospital cost control legislation centerpiece - of Carter health care pol- icy is sitting stalled in Congress for the second year in a row. Growing cost control pressures coincide, more- over with, an increasingly conservative political 2 climate ushered in by the passage last year of Proposition 13 in California. This climate is marked by concern for a balanced budget and re- duced social spending, a desire to turn back the The cost of health care is expected to reach $ 1 trillion by the year 2000, consuming over 12 percent of the Gross National Product. Mean- while, hospital cost control legisla- tion is sitting stalled in Congress for the second year in a row regulatory role of government, and a penchant, unfortunately missing in more expansive times, to examine carefully the effectiveness of tax sup- - ported programs. The result is intense pressure on existing health agencies, particularly regul atory ones, to show their effectiveness, and there can be no doubt in this case about the definition of effectiveness: it is cost control. Evidences of this pressure abound: Early last year the Administration abruptly announced plans to abolish the Professional Stand- ards Review Organization (PSRO) program be- cause it had proven ineffective in regulating costs. This, in spite of the fact that PSROs were osten- sibly created to assure the quality and approp- riateness of health care services, not to control costs. Following expressions of shock, the Admini- stration retreated to the position that PSROs must, for the coming year, demonstrate cost savings at least equivalent to their program costs. Then, in the fall, HEW Secretary Joseph Cali- fano summarily fired Robert Derzon, head of HEW's Health Care Financing Administration (HCFA), for proceeding too slowly with Medi- care Medicaid - reform. HEW's cost control concerns were further mani- fest by the issuance in August of the National Standards for Health Planning, a major policy e- dict to the nation's health planning agencies. These standards, which address the minimum size, utili- zation and need for health facilities, are intended to constitute the basis upon which to begin shrink- ing the health system. HSAs must now apply these Continued on Page 34 " am Vital Signs Signs HOLIER THAN THOU.. AND. MORE PROFITABLE: CLEANING UP ON HOSPITAL HOUSE- KEEPING The heads of this organization provide individual instruction to hospital housekeepers on the most efficient cleaning methods. They work side by side with the clean- ing staff, where topics such as the hospital's latest advances in open- heart surgery are discussed - and all during work time. Said Peter K. Read, director of operations at St. Luke's Hospital in Cleveland, " Before, these people looked at their work as the dirtiest job in the hospital. Now they talk about how their work relates to the patient. " The organization responsible for these innovations is not a pro- gressive union, not a radical health collective, not even a company where a liberal personnel manager is interested in humanizing menial labor. It is ServiceMaster Indus- tries Inc., a thoroughly capitalist company that is making a bundle helping hospitals cut their house- keeping costs. Going against the trend of many management con- sultant firms that contract to run entire hospitals, the Chicago - based ServiceMaster specializes in house- keeping. Its supervisors and in- structors manage the hospital's unskilled housekeeping workers. The hospital saves money by us- ing the less expensive supplies and equipment produced by Service- Master, and by getting the em- ployees to work more efficiently. ServiceMaster is growing ra- pidly, and currently has opera- tions in 742 hospitals which ge- nerated revenues of $ 275 mil- lion in 1978 triple - the level of five years ago. But, according to the February 19th Business Week, what sets ServiceMaster apart from its rivals is not so much its growth as its explicit- ly religious orientation. Its cor- porate goals are " to honor God in all we do, to help people de- velop, to pursue excellence, to grow profitably. " In a strange place, perhaps, but nevertheless an explicit statement of the ca- pitalist variant of " people be- fore profits " credo. It should be noted that Bu- siness Week quoted no workers in their story so the correlation between promise and perfor- mance is not clear. But it defi- nitely appears that ServiceMas- ter is trying to do something right. According to Alexander Balc, Jr., vice president - for de- velopment, " Our willingness to roll up our sleeves and be part of the process communicates to people that they are import- ant and there is value (in their jobs). " This non eltist - ap- proach superficial - though it may be probably looks a lot better to many workers'than the attitudes typically display- ed by their hospital bosses. But it may backfire when - and if- hospital employees begin ask- ing why profits are necessary at all. Source: Business Week, 2 / 19/79. A COMMUNITY OF INTERESTS? DEIN- STITUTINALIZED STONEWALLED It has been over three years since U.S. District Court Judge Aubrey Robinson ordered the fe- deral and District of Columbia go- vernments to work together to de- vise a plan to place almost half the patients at St. Elizabeths Hospital in more appropriate facilities in the Washington area. In 1975, the hospital's clinical staff agreed with the contention of patients'rights attorneys that 1284 of the hospi- tal's residents were capable of liv- ing in less restricted facilities in the community if only such facili- ties existed. The implementation plan is expected to be submitted to the court for approval later this month. In October of 1977, the hospi- tal resurveyed the 649 patients still remaining (of the original 1284) using a model designed by the New York State Department of Mental Hygiene. Most were de- clared no longer acceptable for community placement. The Men- tal Health Law Project, which fil- ed the original suit, maintains that using the survey to classify pa- tients as ineligible for treatment in the community because of their behavior, rather than because of their need for physical or psychia- tric treatment, raises serious legal and constitutional issues. They al- so oppose the plan to convert va- cant buildings at the old Chil- dren's Hospital in Washington or on the grounds of St. Elizabeths into " multiservice facilities " for released patients, consisting of re- sidential units and rehabilitative services. " To concentrate former mental patients in large vacant 4 structures of a kind and size not Health / PAC Bulletin Board of Editors Tony Bale Pam Brier Jane Levitt Joanne Lukomnik Robb Burlage Michael E. Clark David Kotelchuck Ronda Kotelchuck Pat Forman Glenn Jenkins Len Rodberg David Rosner Hal Strelnick Health Policy Advisory Center Staff Madge Cohen Loretta Wavra Ann Umemoto Managing Editor: Marilynn Norinsky MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR should be addressed to Health / PAC, 17 Murray Street, NY, NY 10007. Subscription rates are $ 14 for individuals, $ 11.20 for students and $ 28 for institutions. Subscription orders should be addressed to the Publisher: Human Scien- ces Press, 72 Fifth Avenue, NY, NY 10011. Health / PAC Bulletin is published bimonthly by Hu- man Sciences Press. Second - class postage paid at NY, NY, and at additional mailing offices. Health / PAC Bulletin 1979 commonly used by other mem- bers of the community, and to isolate them from normal contacts that they would otherwise have, may well obstruct their reintegra- tion into the community, " the project says in a court brief. Although Congress recently gave HEW $ 52 million to reno- vate inpatient facilities at St. Eli- zabeths, they seem unwilling to expend the monies necessary to establish community resources which would seem to make much of the hospital's function obso- lete. A report on existing commu- nity facilities, entitled Commun- ity Residences: Alternatives to In- stitutions, was prepared for the District's Department of Human Resources by the District of Co- lumbia's Municipal Research Bu- reau, Inc. It stated that the num- ber of community residences in the capital had actually declined since 1975, from 565 to 427, and that the great majority were still concentrated in the central city, with few located in more affluent Washington neighborhoods. Source: Hospital & Commun- ity Psychiatry, Jan. 1979. I | NEW YORK CITY DEPARTMENT OF HEALTH The Fall and Fall of the NYCDOH The New York City Department of Health, once perhaps the leading public health department in the country, has recently become another in the growing list of victims of this city's fiscal crisis. In the following article, some of the dyn- amics of the recent, rapid decline are outlined against the background of the Department's long, proud history. The article is condensed from Health / PAC's recent report, Preventive and Pri- mary Care During the New York City Fiscal Crisis: 1974-1978 (available from Health / PAC). The report is one product of an 18 month - study funded in part by the Samuel Rubin Foundation and the New York Community Trust. The article covers the years 1974-1977. It does not, therefore, cover more recent events which have seen the Department pushed to the brink of extinction. For example, the City's Health and Hospital Corporation (HHC) (the troubled, quasi- public agency that administers the City's 17 mu- nicipal hospitals) has recently developed a plan to absorb many of the remaining operations of the Department of Health (DOH). Given the desperate search by HHC for inpatients to fill its many empty beds, combined with the mounting shortfalls in HHC revenues, many predict that the public health orientation of these DOH services would be lost should such a trans- fer materialize. More recently, DOH officials - under mandate from City Hall to cut even deeper into their city tax levy funding - have begun to plan for the billing of non Medicaid - patients on a sliding fee scale as a means of revenue enhancement. This proposal was denounced by the Public Health Association of New York City (PHANYC) in a letter to Mayor Koch as being " contrary to the public interest. " Such billing, PHANYC pointed out, has been shown to discourage use by the " working poor " (those ineligible for Medicaid and uncovered by private insurance or other means to pay and perhaps total 1.5 million - New Yorkers), who, given their marginal incomes, rarely view preventive services as a top priority. A sliding fee scale would thus be counterproductive as it " will surely put these services out of reach for thousands of New York families. " Such recent moves, and the policies pursued 5 by DOH during the 1974-1977 period, are in- dications of a real change in the definition of the role of public health programs as operated by local government. Traditionally, programs such as preventive screening, venereal disease, immuni zation, child or school health, have been provided on the basis of " need " rather than " demand. " Thus, they were generally free and targeted to achieve maximum health impact, rather than to reach those already demanding such services or willing to pay for them. This " needs based " or epidemiologic principle has long been seen as intrinsic to the effectiveness of public health programming. It is a key differ- ence between most public health and most main- stream medical programs, and it probably rep- resents a key reason why DOH services are so vul- nerable in a time of fiscal crisis. Preventive services are, in general, a low pri- ority, unglamorous part of the medical system. In an era of high technology - , " moon - shot " medi- cine, taking an immunization history from a pre- school child or tracking down a high - risk preg- nancy in a ghetto neighborhood may be brushed aside as mundane compared to the expensive, glamorous and dominant specialized medicine of the large teaching and research centers. Further, the interests and the ideology associated with mainstream, marketplace medicine often deny the relevance of such " life enhancing " efforts. New York's fiscal crisis has pushed such under- lying tensions - and the article makes clear they are old tensions - to the point of open conflict. The crisis in the City's budget and the scramble to cut spending and programs has created what Dr. Lowell Bellin, former NYC Commissioner of Health, calls a " lifeboat mentality. " While Dr. Bellin is correct in his characterization, it is just such a mentality which allows those who, like Dr. Bellin himself, believe that the public sector is inherently weak and trouble - ridden, an opportunity to advocate their own preference for marketplace medicine. This position then gets promoted as a new, more " rational " criterion for planning. Thus, for example, the answer to screening programs without adequate follow- up is to eliminate the screening program, not to guarantee the follow - up. Services offered by other providers are jettisoned as " duplicative, " whether or not the poor and working poor using the pro- grams have access to these other providers. The accompanying article indicates that the decisions to cut services and / or spending were, at times, " very painful " for those involved. However, it would be a mistake to assume that those who played key policy making - roles during the fiscal crisis were simply following orders. In the case of Dr. Bellin, for example, he indicated in a speech delivered early in his administration, that his own personal preference for the role of health departments was, to quote the title of the speech, " More Quality and Cost Control, Less Direct Delivery of Health Services. " Some pol- icy makers, in other words, brought an ideology opposed to public sector services into office with them. In fairness, this process did not begin nor will it end with Dr. Bellin or any of the other recent DOH Commissioners who share such an approach. The status of DOH and the public health mission it shared with many local departments of health throughout the country have been in trouble since at least the late 1960s, when the glamour of " systems analysis, " " modern management skills,'" and the growth of the hospital oriented - Medicare and Medicaid reimbursement systems (and the revenues they offered) combined to shift virtu- ally all of the City's health policy attention and priorities to HHC and the operation of the munici- pal hospitals. Thus it is not surprising that even those func- tions Bellin and his colleagues actually did de- fend - the quality control and monitoring func- tions - have also been taken from DOH and trans- ferred, for the most part, to the New York State Office of Health Systems Management (OHSM). Whether the loss of even these minimal public health functions by DOH is permanent, is not yet clear. What is however clear is that the conflict between truly public health services and the priorities of the medical marketplace is far from resolved in cities like New York. If public health sector opponents continue to hold sway, it will not be long before the poor and working poor, and eventually all New Yorkers, will feel the effect. The primary and preventive services traditionally provided by the DOH have had a measurable impact on the health status of many New Yorkers. Without such services, the current " lifeboat mentality " may rapidly trans- form New York City into a " sinking ship. " The Editorial Board Since the beginning of the New York City fis- cal crisis in 1974, the City's Department of Health (DOH) has undergone drastic reductions in its budget that have severely affected its levels of ser- vices and personnel. In order to understand the full impact of these cuts, however, it is necessary to see them against a backdrop of long standing tensions which have marked the Department's history. The basic question underlying many of these tensions concerns the definition of the proper role of a local health department. To this day, around the country, this question remains a source of real debate. According to a recent report, one quarter of all reporting local health departments today render " personal health services " (that is, treatments to individual patients) and this proportion has grown steadily in this century. Such services may take the form of well person - care only child ( health exams, immunizations, PAP smears), or well person - and sick person - care provided to spe- cific categories of the population (child health or geriatric care), or care for a particular problem (tu- berculosis). In some cities, the provision of per- sonal health services extends to the provision of comprehensive ambulatory care both - routine acute care (primary care) and preventive services. (Newark, Boston, part of Atlanta, Denver, and Detroit all have some form of comprehensive am- bulatory care system run by their city or county health departments). In some localities, health departments are the only providers of such services as family planning, maternal and child care, home care, school health and chronic disease programs. In many localities, health departments are the only providers of free personal services for poor people. In 1975, such services accounted to 72 percent of all expenditures (or $ 2 billion annually) by state health agencies (1). The New York City DOH has historically been at the forefront of providing these direct personal health services. But the progress in offering them has not been linear. Throughout its long and dis- tinguished history, the expansion of DOH func- tions to include direct personal services has been a source of tension and controversy concerning the appropriateness of such involvement and the manner in which it was to be achieved. With the onset of the fiscal crisis, such services have again come under attack. A key element in the conflict is that, since health department ser- vices are targeted for poor people, they are often " poor programs " -that is, they receive only mar- ginal support in the best of times. In 1974, less than five percent of the $ 41.7 billion of tax money expended for health services in the U.S. was allocated to health departments. As a result, health department programs are often the " last funded " and the " first de funded -. " On the other hand, most of today's health care dollar is allocated to the hospital sector. This in- cludes a growing role for hospital - based pre- ventive and primary ambulatory care. There are, however, serious questions about the appropriate- ness of the hospital as a base for such services. Hospitals, in general, are not oriented toward preventive care or health promotion, but to acute care; their orientation is often to diseases, not whole people; to individual cures rather than community problems; and to keeping beds full of people, not keeping people out of beds. It has also become increasingly clear that basing services in hospitals is likely to increase overall costs. Hospital costs in particular have driven health costs skyward in recent years. Moreover, it is not clear that hospitals have the capacity to handle increased ambulatory ser- vices. Last year in New York City, over a million and a half people used DOH clinics. It is ques- tionable whether hospitals, whose outpatient de- partments and emergency rooms are already over- crowded, could handle such an increased load. Health departments are unique among Ameri- can health providers. Their epidemiologic orienta- tion and statutory mandates to cover whole communities put them in a unique position to monitor not only the quality of services deliv- ered, but also the appropriateness of the mix. Hospitals, in contrast, tend to monitor only the needs of those that use them, rather than the needs of the community as a whole. According to Dean Myron Wegman, " It might be well to build on the principle used in record keeping in many Child Health Stations, of tab- ulating not only the immunizations performed, but rather the number of eligible children whose immunization status is not satisfactory. The idea of measuring tasks undone instead of counting 7 procedures carried out could be extended to the whole gamut of basic health services to which all citizens are entitled " (2). New York's fiscal crisis has pushed underlying tensions to the point of open conflict. The crisis in the City's budget and the scramble to cut spending and programs has created what a former City Health Commis- sioner calls a'lifeboat mentality ' This kind of health care delivery model is one that approaches the provision of services from the perspective of need. Most other health care pro- viders, including hospitals, approach the ques- tion from the perspective of demand. Ideological- ly, this latter orientation leads to " marketing " services to " consumers " who can " purchase " them if their " effective demand " is improved. But the health problems faced by large, urban, often low income - populations have proved stub- bornly immune to this market approach. High infant and maternal mortality rates, for example, rooted in poor nutrition, substandard educational levels and poor housing, have remained alarmingly high despite all the onslaughts of market medicine. Meanwhile, market providers seldom undertake the kinds of programs that could seriously attack such problems nutritional - and prenatal coun- seling, birth control programs, and an aggressive outreach to find pockets of high risk because - they represent a " poor return " in either direct reimbursements or potential new inpatients. For many, the only viable solution to the cur- rent conflict is an expansion of the public health model of service delivery. However, New York seems firmly headed in the opposite direction- toward strengthening the market model. In recent years, in New York City, those services delivered on the basis of need have been cut first and deep- est and this trend seems likely to continue in the coming months. In the pages that follow, the extent of these cuts and the rationale for them will be explored. The reader will note persistent references to cut- 8 ting " fat " and to reducing services that were previously " underutilized " or " available else- where. " The question remains whether such explanations miss the mark entirely. In the words of one veteran professional in the Department, " I really worry whether anyone realizes what is lost by turning away from the concept of treating health as a public problem, and health care as a public service? " The Role of District Health Services In November, 1974, as New York City entered a severe fiscal crisis, the City's Department of Health began a period of unprecedented reduc tions in its budget, services, and personnel. From 1974-1977, the Department's tax levy budget was reduced by 20%, from $ 50 million to $ 40 million. Its staff size was reduced by 28%, from 6,000 to 4,300. A hiring freeze, imposed in 1975 and 1976 on all city agencies, made it impossible to replace key professional staff. Over this period, the Department cut programs its policymakers classified as " enhancing life -" (rather than " saving life - "), programs such as dental, school and child health, audiometric and eye testing, chest clinics, public health social work, education, and nutrition. These reductions took place despite a con- tinuing need for the services by New York City's poor. In 1974, approximately 938,000 of the City's total population of 7.8 million were on welfare. For them, for the City's working poor, and for the City's estimated one million illegal aliens, the Department of Health was a primary source of free health care. The DOH has a long history of providing direct personal health services, free of charge, to the City's poor. As immigrant groups streamed in- to New York, the DOH responded, sometimes from fear, sometimes compassion, with a number of public health innovations, many generally re- cognized as " firsts " for a municipal health de- partment. In the early 1900s, the Department began to offer a wide range of free personal services through its District Health Services program. These neigh- borhood - based Health Centers were seen at that time as the answer to the special out hospital - of - health problems of the urban poor, chiefly infec- tious diseases and infant malnutrition. In January of 1915 the City's first Health District was es- tablished on the Lower East Side of Manhattan. This experimental health center quickly proved itself successful and four similar centers were o- pened the following year. In 1917, District Health Officers were ap- pointed on a full time - basis and, in 1918, three more health districts were planned for Brook- lyn (3). However, growing opposition from the New York Academy of Medicine and other medi- cal societies halted further progress and by 1918 the newly created - District Health Administration within the Department had already vanished. The health center movement was catching on nationally, however. C.E.A. Winslow noted in 1919 that " the most striking and typical de- velopment of the public health movement of the present day is the health center. " A 1919 Red Cross survey revealed 72 health centers in 49 American communities, with 33 more planned, most under public control. By 1930, a White House conference had obtained data from 1,511 major and minor health centers in the United States (4). In 1929, a plan for the consolidation of district administration was developed under Health Com- missioner Shirley W. Wynne. The plan proposed 30 districts throughout the City, each with a health center serving as headquarters for both the field activities of the Department and private health and welfare agencies. Impressed, Mayor James J. Walker appropriated money the fol- lowing year for the implementation of this plan. Although this funding was later withdrawn be- cause of the Depression, a persistent Commissioner Wynne managed to procure funds to establish sev- en centers in the City's worst " sore spots. " In 1934, Mayor Fiorello LaGuardia endorsed the district health program, declaring, " We are going to have other health centers all over the city be- cause the people have a right to be healthy. " In spite of such support, the seven function- ing districts found themselves continuously em- broiled in conflict. Within the Department con- flict existed between the Department's special- ized services, centrally - based in Bureaus, and the more general, community - based District services. External attacks were also frequent as the District services seemed to represent the most clearcut challenge to those in private medical practice. Thus, while the district health system continued to grow, its progress was constantly stymied by these built - in conflicts. Following a 1947 blizzard, in which the dis- trict health officers were impaired in their ability to respond to the emergency due to internal con- flicts over lines of authority, Commissioner New York City Department of Health Firsts S` School nursing service with routine exami- nation of children (1902-1905). S` Employment of public health nurses by the Health Department (1902). S` Well baby clinic, associated with the dis- pensing of free milk (1908). S` Laboratory for making serologic tests for syphilis and fixation tests for gonorrhea (1912). S` Venereal disease clinics (1913). e@ Bureau of Health Education (1914). S` Dental clinics in public schools but under control of Health Department (1921). S` Nutrition education service (1932). S` Cardiac consultation clinics (1948). Mustard made them " responsible for all local- ized activities of DOH in their districts....which heretofore were directed by the respective bureaus in central office, and [gave them the] authority to make any necessary decisions and allocations of personnel. " This gave the district health of- ficers the strongest authority that they ever had, and went a long way toward allowing them to gain control over activites within the districts during the following decade (3). The early 1960s witnessed a shift toward a new standard of comprehensive care, and the Department, with the help of federal funding, set up new programs for geriatrics, pediatrics and generalized medical care in the districts. Prenatal and tuberculosis clinics were expanded and were affiliated with hospitals. Twenty Child Health Stations, which functioned as satellites of the Dis- trict Centers, were converted and upgraded to Pediatric Treatment Centers (providing both sick- and well child - services). Nationally, the War on Poverty witnessed legislation creating OEO Neigh- borhood Health Centers (NHCs), and seven such NHCs were soon created in New York City. The Model Cities and Comprehensive Health Planning programs also facilitated community 9 organizations to work with district health of- ficers in seeking federal funding for local health programs (5). Since 1974, however, under the leadership of Commissioners Lowell E. Bellin and Pasquale J. Imperato, this trend has been almost complete- ly reversed. Their belief that the DOH should not deliver direct personal services, coupled with the severe demands of the fiscal crisis, has resulted in the widespread curtailment or elimination of many of the Department's most vital services. The Fiscal Crisis The fiscal crisis first received widespread attention in November, 1974. In response to the City's severe financial condition, New York State set up the Emergency Financial Control Board in September, 1975 to oversee the City's financial plans. In one such financial plan that the City was required to submit to the Board, the expense budget was cut by $ 200 million for the fiscal years ending June 30, 1976, 1977, and 1978 (6). In 1975, the City's total expense budget was slightly over 13 $ billion, of which 31% went into human services. From this $ 13 billion, DOH received a modest $ 90 million, of which only $ 50 million was raised from City tax levy funds. Most of the City's operating expense budget is con- trolled by law, funding such entitlement programs as public assistance and Medicaid, or paying past obligations such as debt service and pension contributions. Budget cuts, therefore, had to be implemented in those parts of the budget. that the City could control. These " controllable expenses " made up $ 2.4 billion or 26% of the 1975 total operating expense budget (6). Virtually all of the Department of Health's budget fell into this category. (See " NYC Public Hospitals, " Health / PAC BULLETIN, No. 69, March / April 1976) (7). As early as November, 1974, the City's Office of Management and Budget (OMB) requested that the Department of Health terminate 57 employees for a $ 1.5 million savings in tax levy money. This request was part of an overall effort by the City to quickly demonstrate its determination to balance the budget in the face of possible default, and the Department was asked to respond within 24 hours. Commissioner Lowell E. Bellin designated First Deputy Commissioner Pasquale J. Imperato to 10 supervise the requested cuts. Dr. Imperato spent most of the next 13 months doing little else. He immediately began meeting with the Department's top administrative staff which included Anthony C. Mustalish, Deputy Commissioner for District Health Services, Gerald Flanders, District Health Services Administrator, and various bureau chiefs to formulate a response. It was decided that the reductions would come by virtually eliminating such bureaus as Social Work, Nutrition and Public Health Education, by reducing funding to the Health Research Council, by closing three District Health Centers, and by leaving vacant positions unfilled. In order to avert an administrative crisis and to anticipate further cuts during the fiscal crisis, Dr. Imperato and his staff formulated a com- prehensive policy on future budget reductions. Since 1974, under a succession of three commissioners, the Depart- ment of Health has been virtually destroyed. The District Health Ser- vices have been cut back and rele- gated to the status of an unwanted ' child'while the regulatory functions have slowly been'adopted'by the state Department of Health activities were reclassified into two categories: " life preserving " and " life enhancing. " Infectious disease control was con- sidered to be life preserving; dental public health was considered life enhancing. Life enhancing ac- tivities, underutilized services and services for which there were alternative (DOH non -) resources received lowest priority. For several reasons most of the proposed cuts were in District Services, which then consumed approximately 30% of the Department's bud- get, about $ 15 million of the total tax levy, and about half of the Department's personnel. One significant reason was that tax revenues could be maximized by cutting the District Ser- vices budget since it is matched on a 1: 1 ratio by state and federal funding whereas other Depart- mental programs are matched more favorably. Thus, cutting District Services was thought to be more cost effective and was philosophically ' Nobody ever died of bad teeth and bad gums. I had to weigh that against diphtheria innoculations. I didn't have money for both ' -Lowell Bellin former NYC Commissioner of the Department of Health in line with Commissioner Bellin's goal of moving away from personal services. In May, 1975, Mayor Abraham Beame pub- lished his first " crisis budget, " which included a drastic $ 18 million cut in tax levy - support for DOH. Although these cuts were never imple- mented, those from an " austerity budget, " pub- lished at the same time, were. On May 30, 1975, the Office of Management and Budget requested that 255 specific positions be terminated from DOH's budget. The Department set its own pri- orities and proposed the termination of 255 em- ployees in four programs: Ghetto Medicine, Methadone Maintenance, the Health Research Council (eliminated) and the Neighborhood Ma- ternity Center in the Bronx (6). DOH officials never publicly attacked or ques- tioned the City's priorities in cutting preventive services. In fact, the criteria of " life enhancing " versus " life preserving " worked to reinforce the medical bias towards treatment as opposed to ear- ly intervention. Neither was quality of care the main issue. The Bronx Neighborhood Maternity Center, for example, where the services were well liked -, highly rated for quality and heavily utilized was closed. In Autumn, 1975, the OMB requested a fur- ther $ 3 million reduction in tax levy funds. The Department of Health eliminated their con- tributions to the Ghetto Medicine Program; the Board of Education cut 970,000 $ from its part of the School Health Program; and the Depart- ment of Health replaced 50,000 school physician hours with pediatric nurse associates taken from the existing public health nurse corps. In July, 1976, OMB requested another $ 4.4 million reduction from the tax levy contribu- tion to the Department of Health's budget. Some District Health Centers, Chest Clinics and Child Health Stations were closed and dental, labora- tory and prison health services were reduced. The total tax levy reduction in the Department of Health's budget during the most intense period of the fiscal crisis totalled a 20% reduction, from $ 50 million to $ 40 million. The remainder of the Department's operating budget of about $ 90 mil- lion in 1975 consisted of matching state and fed- eral funds. These were reduced proportionately with City cuts, so that $ 1 tax levy savings meant a $ 2 loss in actual operating funds (6). From the beginning of the fiscal crisis in November, 1974, to the middle of 1977, the De- partment of Health lost 28% of its work force. The Department was reduced from 4,400 full time - and 1,600 part time - personnel, to 3,300 and 1,000 respectively. There were approximately 400 full- time terminations. Resignations and retirements accounted for the remainder. A hiring freeze was Table 1 The Impact of the Fiscal Crisis on District Health Services (New York City Department of Health, 1974-1978) Services July, 1974 District Health Centers 22 Satellite Health Centers 5 Health Education and Outreach 2 Nutrition 630 Public Health Social Work 630 General Immunization Clinics 10 Prenatal, Postpartum and Family Planning 8698 8698 Sickle Cell Testing Centers Lead Poisoning Centers Working Paper Clinics 8698 Jan., 1978 13 13 6 0 0 0 5 745 % Change -41 +20 -100 -100 -100 -50 -13 -33 -29 -17 instituted in early 1975 and no new programs were initiated. DOH had the highest attrition rate of any City Department. Many of those leaving were young professionals, managers and executives able to obtain attractive jobs elsewhere. Many _ able supervisors left and the quality and quantity of the Department's services were seriously com- promised. Discussion New York City's Department of Health was once unique among local health departments in 11 Direct Service Cutbacks: 1974-1978 Child Health Stations Eye Clinics Child Health Stations provide such free preven- Department of Health Eye Clinics primarily pro- tive services as new born - infant care; well child - vide screening for eye pathology and correc- evaluation; growth and evaluation assessment; tion of vision problems, usually refractive er- child health assurance programs (CHAP); im- rors. The program is for children only. There is munizations; screening for treatable disorders; little follow - up as patients are referred to lo- parent counseling and education; and women, cal practitioners. The clinics are staffed by De- infant, and children (WIC) supplemental feeding partment optometrists and opthamologists (8). programs. 22 Child Health Stations which have Between 1974 and 1978, 12 of an original been upgraded to Pediatric Treatment Centers 22 Eye Clinics were closed, a 55% reduction. also provide primary medical care for sick chil- Annual hours for physicians and public health dren up to age twelve (8). assistants have also been reduced by 50%, as During the period between July 1, 1974 and July 1, 1976, 20 of the original 78 Child Health Stations and Pediatric Treatment Centers were have both volume of service and costs 206,000 ($ in 1973-74 to $ 104,843 in 1976-77). The com- plete closure of all DOH Eye Clinics has been pro- closed, a 26% drop. Between FY 73-74 and FY 76-77, there has been approximately an 8% re- duction in visits to Child Health Stations. In posed and considered at various times since the onset of the fiscal crisis. Social Hygiene Clinics the same period, there has been a 10% reduc- tion in physician hours, a 13% reduction in public health nursing hours and an 18% drop in public health assistant hours. DOH operated Venereal Disease Clinics throughout the city, providing free care for screen- ing, contact investigation and case finding. The program involves intake, laboratory, physician Dental Services Dental services which had included examina- diagnosis and treatment (8). Between FY 73-74 and FY 76-77, two clinics tion, treatment, prevention and education, have been cut significantly since 1974. At that time, there were 27 clinics situated in Health Centers were closed, physician hours were cut by 20%, public health assistants'hours were cut by 25% and public health nurses'hours were cut by and 164 in schools. In 1978, there were only 12%. However, total patient visits increased by 18 Health Center clinics and 105 school clinics 3% during this period. remaining, about a 33% drop in both instances. Between FY 74-75 and FY 76-77, direct clinic expenditures were reduced by 45%. Dental ser- vices suffered a 47% reduction in annual dentist Public Health, Social Work, Nutrition and Education Since 1974 these three programs have been virtually eliminated. Only a small core of these hours, a 56% reduction in annual dental hygienist hours and a 46% drop in annual dental assistant hours. health professionals is still retained in the Central Office of District Health Services to lend support to the few remaining district programs. Nutrition Chest Clinics counseling to low income and disadvantaged The Department of Health operates Chest Clinics in both its own District Health Centers mothers and the elderly has been drastically curtailed as have such health education activi- and in municipal hospitals. Health Center Clinics ties as consumer education, participation in health provide screening exams, x rays -, sputum induc- planning and health consumer advisory commit- tion, case finding and treatment for patients with tees, school health education programs, hos- tuberculosis and associated diseases (8). Between pital staff and patients'education programs, ma- 1974 and 1978, the number of Chest Clinics in ternal and child health and family planning pro- District Services have been cut by 35%, from 27 grams. By 1975, there were no social workers in 1974 to 17 in 1978. 12 left at decentralized service facilities, and referrals Direct Service Cutbacks: 1974-1978 could be handled only by telephone through the as working paper and athletic team exams (8). remaining staff in the Central Office. Between 1974 and 1976, School Health Ser- General Immunization Between 1974 and 1978, General Immuniza- tion Clinics in District Health Centers were cut by 50%, from 10 in 1974 to five as of Spring 1978. These clinics administer shots for trave- lers, anti rabies - and influenza shots. (Preschool immunizations are provided in the Child Health Stations and in the School Health Programs.) Sickle Cell Testing Sickle Cell Testing Clinics offer screening for the sickle cell trait among Black People, but offer no follow - up of genetic counseling ser- vices. Since 1974, Sickle Cell Testing Services in District Health Centers have been cut from six to four. Lead Poisoning Clinics Two Lead Poisoning Screening Services have been eliminated from District Services Health Centers since 1974, reducing the number from seven to five. vices have been significantly reduced. Some 50,000 physician hours have been eliminated from an original 80,000 physician hours annually, a 65% drop. Both fourth grade and eighth grade examinations were eliminated. Pediatric nurse associates were introduced into the program to partially offset the reduction in physician hours. This represents a significant change in the program and a marked reduction in cost. Prison Health Prison Health services witnessed a 25% reduc- tion in FY 74-75 which resulted in a loss of 7 physicians, 52 nurses (mostly RNs), as well as a 47% drop in dentists and a 50% reduction in dental hours. One third of the pharmacists were dropped and all the program analysts at the Prison Health Services Central Office were elimina- ted. Mental Health Services were perhaps cut back the most, losing 30% of the part time - psychiatrists, 50% of the social workers (including the psych- Tropical Disease Clinics iatric aftercare program, and 30% of the psych- The Tropical Disease Clinics provide complete ologists. Psychiatric services had to be almost diagnostic laboratory analysis, treatment and completely eliminated at the two largest insti- follow - up for tropical diseases - a significant pub- tutions - the House of Detention for Men and the lic health problem in a major port city such as Correctional Institution for Men. Remaining New York. Since 1974, the Lower East Side staff have had to carry increased patient loads. Clinic has been closed and the Bushwick Health Laboratory Services Center Clinic has been cut back while the Wash- Between 1975 and 1976, Public Health Labora- ington Heights and Morrisania Clinics have been left relatively intact. School Health tory Services witnessed a 26% reduction in staff and a 10% reduction in the number of specimens processed. Free vaccine distribution and the The School Health Program is divided into provision of tuberculosis testing material to pri- the Elementary & Junior High School Division vate physicians have been eliminated. and the High School Division. It is a screening Environmental Health and referral system employing public health nur- The Environmental Health Services budget was ses and paraprofessionals who review school health cut by 5% for FY 76-77. This resulted in more records and organize work in each school for than a 20% loss in field staff for General Opera- physicians, nurse practitioners and nurses. The tions. Further losses are projected to include elim- Elementary & Jr. High program includes screen- ination of the drug audit and milk dating pro- ing, admissions, follow - up and referral as well as grams, and reductions in the number of inspec- daily inspections, nurse record review and con- tions of pet shops and stables, theatres and caba- ferences. The High School program is similar, rets, surveillance of summer feeding programs, except that more effort is directed towards the in service - training and food, water, fluoride and specialized needs of High School students, such foreign substances sampling. 13 the nation. According to former Commissioner Lowell Bellin, the Department " has been cited In some localities, health depart- ments are the only providers of such services as family planning, mater- nal and child care, home care, school health and chronic disease programs in American Schools of Public Health as an Olym- pus of professional excellence. " (9). Historically, it was the nation's largest local health depart- ment, and was instrumental in the introduction of many public health innovations, especially in the realm of free personal services. Because of its distinguished record, the Depart- ment has enjoyed wide respect both locally and nationally. Many of its programs and innovations were widely copied and indeed many of its admini- strators went on to head other health depart- ments throughout the country. Since 1974, however, a combination of three factors has led to the virtual dismantling of the Department as a major force on New York's health scene: 1. the serious ramifications of the fiscal crisis; 2. the philosophical opposition by the Depart- ment's Commissioners to providing direct personal services; and 3. the steady erosion by the New York State Health Department of the City Depart- ment's regulatory and standard setting functions. In Commissioner Bellin's view, a great many public health services are already delivered in the private sector, and this shift toward private care is occuring throughout the country. Similarly, Commissioner Imperato felt that DOH should only provide services where there were no other providers available. They argued that DOH facili- ties were never meant to be comprehensive, and that a growing number of the poor and indigent were already using hospitals, Neighborhood Health Centers, Neighborhood Family Care Centers and related facilities that provide more comprehensive care. Both Commissioners saw the fiscal crisis as a result of too many city services. In Dr. Imperato's view, the fiscal crisis resulted from rising costs of services combined with a shrinking tax base (6). As he saw it, the influx of poor people demanding Table 2 Distribution of Budget Cuts and Their Impact (New York City Department of Health, 1974-1978) Clinics and Personal Health Services Number of Facilities July, 1974 = Jan., 1978 % Reduction Patient Visits FY 73-74 FY 77-78 % Change Child Health Stations and Pediatric Treatment Centers Dental Health (including school clinics) School Health (all levels) Chest (tuberculosis and Combined) Venereal Disease Eye Tropical Disease . 78 191 1,537 26 14 21 4 57 138 1,300 (est.) 16 12 8 3 -27 -30 -15 -38 -14 -62 -25 330,163 305,985 * 217,470+ 45,920 197,716 115,966 193,407+ 156,233 174,635 29,047 196,087 16,020 * 24,571+ 14,450 -7 -79 -41 -19 +11 -45 -41 + Fiscal Year 1974-5 * Fiscal Year 1976-7 Sources: Mustalish, A.C. Working Paper for the Health and Hospital Corporation Considering the Assumption of Opera- tional Responsibilities of District Health Services of the New York City Department of Health. New York: Health and Hospital Corporation, May 1978. 14 Nestlebaum, Z. Review of Department of Health documents. free services was a major contributing factor to the City's virtual bankruptcy. This philosophical position was reinforced by the belief that District Health Services contained a great deal of " fat. " According to Deputy Com- missioner Mustalish, there was a lot of " excess personnel, second rate people, inappropriate activity and ineffectual programs. Many of the cuts were long overdue. " He felt that the budget cuts were good overall decisions, giving the De- partment an opportunity to clean house and to bring the District Services system up to date. This point of view breaks sharply with the traditional model of public health services deliv- ery. Since 1974, instead of delivery based on need, the DOH has moved toward delivery based on demand. The shift is from a service to a mar- ket model. The criteria for reducing services was not declining community need, but utilization. statistics and short - run measures of efficiency. No doubt, this change of focus from what Dean Wegman remembers as " everything that might affect a citizen's health, " to what Drs. Bellin and Imperato call a " lifeboat mentality, " was partly a consequence of the fiscal crisis. Some cuts were laudable efforts to weed out actual fat from Dis- trict Services programs. Health officers who were second rate and ineffectual, according to Dr. Mus- talish, were dropped or forced into retirement. Physicians who were being paid salaries without ever working, including one earning $ 25,000 an- nually as director of a tropical disease clinic who had not had a case in years, were dropped as well. DOH planners also considered the master plan for District Health Services, drawn up in the 1930s, as hopelessly dated. Demographic shifts had left Health Centers in areas that did not need them, because other providers were avail- able. The Lower East Side Health Center's lo- cation on " hospital row, " distant from the slums, was cited as one reason for closing it. (Some agencies that formerly occupied the DOH build- ings as part of their " in kind contributions to federal and state programs were able to take over the facilities following the removal of DOH programs and personnel.) Scattered categorical programs often competed with programs offering more comprehensive medical care. In the case of well baby - clinics, for example, their declining registration (without a comparable reduction in services) was used to justify upgrading a few into comprehensive, full- time Pediatric Treatment Centers, while closing many others. Isolated Chest Clinics were closed and chest tuberculosis - clinics, which primarily Decisions to cut services and / or spending were, at times, very ' pain- ful'for those involved. However, it would be a mistake to assume that those who played key policy- making roles during the fiscal crisis were simply following orders. Some brought an ideology opposed to public sector services into office with them served drug addicts, alcoholics and the aged, were transferred into hospital settings. Two part- time VD clinics were closed and the rest upgraded to full time - operations. The DOH officials used several rationales to justify reductions. Eye Clinics, sickle cell screen- ing, lead poisoning case finding and school health examinations were cut back because they lacked follow - up; Immunization Clinics (for adults and travelers), CHAP (Child Health Assurance Pro- gram) in day care centers, and school health because they duplicated services; and dental care because, in Dr. Bellin's words, " Nobody ever died of bad teeth and bad gums. I had to weigh that against diphtheria innoculations. I didn't have money for both. " The Commissioners'choices were not easy. In a recent interview, Dr. Bellin noted, " It was a very painful time to be Commissioner. These cuts had to be made. None of us enjoyed it. " While City officials continued to cut back the personal health services of DOH, the Department's regulatory and monitoring functions were coming under attack from another quarter. Beginning in the late 1960s the New York State Health De- partment began usurping many City DOH func- tions and asserting increasing control over the ci- ty's health activities. The regulation of the Medic- aid and Ghetto Medicine programs; inspection of hospitals, nursing homes and supermarkets; and certain environmental activities eventually passed into State hands. 15 With the creation of the State Office of Health Systems Management in 1977, the State's influ- ence grew markedly. Bellin and Imperato, who felt, as did most local health experts, that the City could do a better job than the " long arm " of the state, went to court, on the basis of home rule, to prevent the loss of DOH's Medicaid functions. But their attempt failed, and the gradual loss of regulatory functions from city to state continues, leaving the DOH, in Dr. Imperato's words, with " what the State Health Department doesn't want. " Before the fiscal crisis began, the DOH, as the major public health institution in New York City, had a long, outstanding tradition. Though not perfect, it played a vital role for the City's poor throughout its 75 year history. However, since 1974, under a succession of three Commissioners, the Department has been virtually destroyed. The District Health Services have been cut back and relegated to the status of an " unwanted child, " while the regulatory functions have slowly been " adopted " by the state. With the cutbacks in personal health services and the loss of most of its regulatory functions, the actual survival of the DOH is in question. What is also in question is the health status of the three million poor and working poor people liv. ing in New York City who have relied on the DOH New Yorkers who have benefited directly and indirectly from the DOH's public health services. Attempts to alleviate the fiscal crisis by cutting back on health services may in the long run turn out to have had the opposite effect. - Zamir Nestlebaum Zamir Nestlebaum is a medical student at the University of Massachusetts. References 1. Bellin, L.E. The Fall and Rise of the New York City Health Department. Public Health Association of New York Public Health Notes: August, 1974. 2. Bellin, L.E., Kavaler, F. Policing Publicly Funded Health Care for Poor Quality, Overutilization, and Fraud The New York City Medicaid Experience. Presented to Medical Care Section, American Public Health Association. November 11, 1969. 3. Duffy, John. A History of Public Health in New York City. New York: Russell Sage Foundation, 1968. 4. Eidsvold, G., Mustalish, A.C., Novick, L. The New York City Department of Health: Lessons In A Lead Poisoning Control Program. American Journal of Public Health 64 (10), 1974. 5. Caress, B. and London, S. NYC Public Hospitals. Health / PAC BULLETIN, No. 69, 1976. 6. Imperato, P.J. The Effect of New York City's Fiscal Crisis on the Department of Health. Bulletin of the New York Academy of Medicine. 54, 276, 1978. 7. Kaufman, Herbert. New York City Health Centers, State and Local Government: A Case Book. Univer- sity of Alabama Press, 1963. 8. Medical Tribune, pp. 18-20, 1966. 9. Miller, C.A. et al. A Survey of Local Public Health Departments and Their Directors. American Journal of Public Health, 67, 931-39, 1977. 10. Mustalish, Anthony C. Working Paper for the Health and Hospitals Corporation Considering the Assump- tion of Operational Responsibilities of District Health Services of the New York City Department of Health. May, 1978. 11. Mustalish, A.C., Eidsvold, G., Novick, L. Decentrali- zation in the New York City Department of Health: Reorganization of A Public Health Agency. Ameri- can Journal of Public Health 66 (12), 1976. 12. Novick, L., Mustalish, A.C., Eidsvold, G.: Coverting Child Health Stations to Pediatric Treatment Centers. Medical Care, Vol. 13, No. 9, September, 1975. 13. Novick, L., Mustalish, A.C., Eidsvold, G.: The New York City Department of Health: Establishment of A Sickle Cell Screening Program. Presented at Amer- ican Public Health Association Annual Meeting, San Francisco, November 7, 1973. 14. Rosen, George. The First Neighborhood Health Cen- ter Movement: Its Rise and Fall. From Medical Police to Social Medicine: Essays on the History of Health Care. New York: Science History Publica- tions, 1974. 15. Stoeckle, John D., Candib, Lucy M. The Neighbor- hood Health Center Reform - Ideas of Yesterday and Today. New England Journal of Medicine 280, 1385-90, June 19, 1969. 16. Wegman, Myron. Health Departments: Then And Now. American Journal of Public Health 67, 913-14, 1977. 17. Weinstein, Israel. Eighty Years of Public Health in New York City. Bulletin of the New York Academy of Medicine 23 (4), 221-223, April, 1947. 16S UBS( CRI} BE! WASHINGTON BATTLE OF THE BUDGET The Congressional budget- ing process of 1979, for Fiscal '80, is crawling forward with low- ered expectations but some lobby- ing intentions to, add - on. One thing was clear after this Carter executive budget cycle. HEW Secretary Joseph Califano's " put- it flagpole - up - the -" advertising ag- ency approach to health budget- ing, with a little help from Ted- dy Kennedy's midterm Democrat- ic Convention " Memphis Blues, " had survived the bigger media campaign in the sky with some lingering programmatic corners. That bigger ad campaign, of course, has been generated by the chief executive's personal account executive, Jerry Rafshoon. Raf- shoon's Right thinking -, " shaft- ' flagpole em - with - the - " approach to federal budgeting had called for across - the - board cuts in all agency requests of at least $ 30 Billion, with $ 3 Billion to come from already totally marginal - health expenditures alone. Many of the $ 3 Billion cuts officially were reinstated on ap- peal from Califano. The entire package of " discretionary " federal health expenditures and program " initiatives " (beyond more than $ 44 Billion for Medicare and Medicaid entitlements) was sold on paper as either immediately cost cutting - or cost containing - or as eventually producing econo- mies through preventive health measures. An asserted $ 1.7 Bil- lion federal savings during fiscal 1980 is to come from held over - and watered - down hospital cost containment legislation, which has become a rhetorical centerpiece of President Carter's " infla- anti - tion strategy. " The only other major program initiative asks $ 288 million for a over held - and scaled - down Child Health As- surance Program (CHAP), to ex- tend Medicaid eligibility and ex- pand program benefits to two million poor children and 100,000 low income - pregnant women. Otherwise budgeting more sav- ings in the HEW appeal were various Medicare and Medicaid cost control measures. Only Rosa- lynn Carter's favorite public chari- ty, mental health, received a net $ 59 million increase over the cur- rent year, but related drug abuse and alcoholism funding was re- duced in favor of a state lump formula grant program approach. Only a few public whimpers were heard from official budget cutters at OMB (the Office of Management and Budget). But un- til Memphis and revelation of the President's own vulnerable lines to Kennedy and Labor on health. as " their " arena of expenditure, those called - for $ 3 Billion slash- ings for federal health were being treated internally at OMB as very real. The cool hands at the White House then treated the HEW Secretary's National Health (Insurance) Plan, for staged universal coverage and carefully regulated doctor's re- imbursements, like a 1985 pri- ority. The President is into rationed hospital days (the pro- posed Hospital Cost Containment Act) to match his rationed gal- lons of gas as highest domestic priorities for 1979. Carter will have nothing of ex- panded health insurance entitle- 17 ment this year beyond possibly a narrow catastrophic illness bill from Senator Russell Long that makes the old Long Ribicoff - bill's Medicaid coverage expan- sion look like old fashioned - liber- alism. There has been a race of pathos between White House The People with the responsibility for the health budget do not have clear ideas about making public and community services more effective and reaching the greatest need. They are gener- ally suspicious of government involvement. moderates, attempting to tack on sneak entitlements, and NHI advocates, including United Auto Workers'Doug Fraser and the new Progressive Alliance, trying to kill such pre emptive - cata- strophic insurance coverage. Meanwhile, Califano's mostly- National Health Plan of financ- ing. " He won't stand for infla- tion fighting - imagery cutting $ 2 Billion more out of that budget, " said one, hopefully. What it took late in 1978, a meataxe by OMB. Second, at their side are the actual OMB technicians with re- sponsibility for the health bud- get. Mostly accountants and busi- ness, economics and administra- restored health budget - quite modest at that: a few Billion for in Memphis Democratic Mid- Term Convention confrontations tion graduates, they do not begin with clear ideas about making all Public Health Service programs compared to upwards of $ 50 Billion associated with Medicare and Hubert Humphrey Building (HEW) midnight memo writing -, to even marginally save communi- public and community services more effective and reaching the greatest need. They are generally and Medicaid reimbursements to hospitals and doctors - held up rather well under early Con-. ty health services initiatives, may be chillingly instructive for the future. Needed federal communi- suspicious of any government sub- stitution for the efficiency and freedom of the private market- gressional committee scrutiny. Of course, Senator Kennedy, rather ty based - programs faced three layers of resistance within the place. Thus, if Health Main- tenance Organizations (HMOs) ceremoniously as the lobbyist for all health expenditures, criti- cized the research and education cuts. While any decent NHP coverage seems unlikely this fis- cally testy year, aides believe Califano will come back stronger by next December, as the 1980 Presidential election year looms, for '81 federal health program initiatives emphasizing more com- munity - based, prevention - oriented cost effectiveness - initiatives and even for real steps toward a allegedly Democratic Administra- tion, even before they reached an increasingly fiscally pledged - Congress. First, the top remains Raf- shoon's image boosting - aggregate budget cutting and balancing (read: " inflation - fighting ") to ap- pease the Right - wing capture of taxpayer imagination: The Presi- dent has had a dream... a $ 30 Billion cut; health seems burgeon- ing and ripe; cut $ 3 Billion there......... this to be executed with are really a good idea, surely more private medical and financial insti- tutions will start marketing and more people will enroll in them; in that case, why are any more government funds needed? Simi- larly, don't Medicare, Medicaid and private insurance cover most people now, and can't most of the others go to hospital emergency rooms and community clinics? Can't you just take at least 10% of the waste off the top of Medi- care and Medicaid as they are cur- rently run and get services which are just as good? If there's going to be a surplus of doctors, why Califano likes to package slim ideas with sexy names but he doesn't generally warm to the less glamorous tasks of reorganizing existing federal financing toward the most needed and appropriate services and controls. invest any more federal funds in assisting minority and low- income health professional stu- dents or in supporting them to work in underserved areas? Won't the market naturally take care of their distribution? There is auto- 18 matic support for so called - cost- containment and fraud and abuse management programs. Finally, at the Secretary and departmental level there are ad- ditional problems of narrow ori- entation. Despite Califano's rela- tive reputation as a public expen- diture liberal, as the President swings to being a Right appeasing - broker, the HEW Secretary is sometimes stubbornly dense a- bout how to develop any compre- hensive and effective federal ap- proach to restructuring health ser- vices. His blind impatience about reorganizaing and unifying Medi- care and Medicaid in the Health Care Financing Administration (HCFA) led to the departure of Robert Derzon, an administrator who at least knew health financ- ing, and his replacement by a ge- neric Califano whiz kid who keeps asking, " Now what is Medicaid? " The Secretary himself is hap- piest as a Great Society acro- nymist, packaging slender items with sexy names for sale on the Hill: (Great! let's call it the Pregnant Smoking Teenagers'Pro- gram (PSTP!). Califano doesn't generally warm to the less glam- orous tasks of reorganizing exist- ing federal financing toward the most needed and appropriate ser- vices and controls over excess and uneven charges. Nor does he seem terribly interested in interfacing federal resources with state and local governments for stronger community - based ser- vices in the underserved areas. Prevention has been a rising slogan at HEW but it has focused on cigarette smoking and life- styles, evoking only a single shot at environmental causes of cancer for the political consump- tion of labor leaders. It has cer- tainly not included a crusade to support the marshalling of scien- tific evidence or action against the systemic industrial causes of illness, a joint undertaking of HEW's National Institute for Oc- cupational Safety and Health Health,, under new Director Dr. Anthony Robbins, the Occupational Safe- ty and Health Administration (OSHA) and the Environmental Protection Agency. The HEW Secretary does con- tinue, almost by default, to haunt this Administration and the unhealthy society as at least a potential advocate of real- er steps toward a National Health Plan squeezed through more uni- versal financing, of cost contain- - ment and planning emphasizing community - based alternative lev- els of health services, and of some prevention that could end up with corporate targets. That is, if a human programmatic pre- sence is tolerated above and de- manded popularly as the 1980 Election Year approaches. However, unless something. breaks loose politically in the cities... something with the potential to shake together the now cowed - and fragmented labor, * consumer, and environmental citi- zen lobbies to demand a totally new take on federal health ex- penditures... the midnight oil- burners within the Carter pro- cess won't be able to hold any budget lines for the unrepresented and underserved neediest infants, children, women, and elderly. Then, forget the working poor and undocumented workers / illegal aliens totally cut out of health en- titlement and the moderate in- come working / class communities needing new organizational hand- les for appropriate health ser- vices access in weak market areas. Some of their worst ideological enemies are to be found here within this allegedy Democrat- ic Administration. Richard Nix- on had a dream of social pri- vatism that continues to per- meate the upper middle - layers of the federal government for health. -Robb Burlage 19 WOMEN Q 20 ELECTRONIC FETAL MONITORING The woman's contractions have been in progress for several hours, serious but not severe, regular but still manageable with the ear- ly deep chest - breathing she has learned in her childbirth classes. She and her husband go to the hospital and are excorted to a small bare labor room, where her personal belongings are taken away and she is given a hos- pital gown. On the bedtable at her side is a black box with a blank graph facing forward. She walks slowly around the small room while her husband times her contractions, now getting longer, stronger, and more fre- quent. Soon the resident comes into the room, asks her to lie down, and proceeds to connect her to the black box through various leads. An external belt holds ultrasound conductors to her abdomen; her membranes are ruptured so that two elec- tronic leads can be placed in- ternally, one - a spiral electrode- into the fetal scalp, and the other between the fetus and the wall of the uterus. A needle connected to a bottle of intravenous solu- tion is inserted in her vein, and she and her husband are left to continue their breathing and tim- ing of contractions. This woman in labor has been connected to an Electronic Fetal Monitor (EFM). Electronic fetal heart monitoring was developed to help prevent fetal death or damage due to lack of oxygen during birth. By detecting stress in the fetus, it alerts obstetri- cians to potential problems so that they can intervene in the birth process and deliver the ba- by quickly if necessary. EFM was first done in " high risk " mothers who, because of problems in this or previous pregnancies, were thought to have the greatest risk of a difficult labor and de- livery with possible damage to the infant. It is now done routinely in all births in major urban teach- ing hospitals, and it has been esti- mated that at least half of all births nationwide are monitored. One of the most widely used textbooks of Obstetrics and Gyne- cology states that, " Even though continuous monitoring of all par- turients is not now feasible, this is a goal that must be sought " (1). A recent study of the impact of EFM on cesarean section rates noted the common pattern of EFM acceptance and use in hospitals: " Fetal monitoring was introduced to Evanston Hospital in 1970, and its use was sporadic (less than 5% of patients) until 1974 when use of the monitors greatly increased. By 1975, rout- ine monitoring of patients in labor was standard (85%) " (2). Risks and Benefits Proponents of EFM point out that since monitoring was intro- duced, there has been a dram- atic drop in the infant mortality rate in the United States from 20/1000 in 1970 to an estimated 14/1000 in 1977. Obstetricians have attributed this decline in mortality rates to changes in their practice, including electronic fetal monitoring and a more aggressive approach to labor and delivery. Although the use of electronic monitoring has been a major factor in the drop of infant mortality in the U.S. since 1970, it has increased the risk of death for the mother. Among the complications are cesarian section, uterine perfora- tion, vaginal laceration and fetal distress Assuming causality when a co- incidence of trends occurs, how- ever, is a common fallacy. A num- ber of other changes in society (including the widespread availabi- lity and use of family planning and abortion) have contributed to the decline of infant death rates, and no causal association between the recent trends of more obstetri- cal intervention and lowered death rates has been established. The best way to test the bene- fits of EFM is by randomized con- trolled trials which compare elec- tronically monitored and humanly (nurse) monitored women in terms of differences in infant health at birth. Only four of these trials have been conduct- ed. These studies have been done on both low and high risk moth- ers. Neither the randomized con- trolled studies nor other studies done on larger populations with less rigorous methodology have shown any medical benefit of EFM for low risk - mothers (3,4). For high - risk mothers the evi- dence is contradictory. In two studies, Haverkamp found no difference between EFM and nurse monitored infants (5), but in an Australian study Renou found that infant outcome was better for the EFM group (6). One thing however, has been convincingly demonstrated by these studies: fetal monitor leads to more aggressive obstetric man- agement. In every study of EFM, the rate of medical intervention by cesarean section increased dramatically (usually the incidence doubled in five years after intro- duction of EFM). There is contro- versy about how much of the rise in the C section - rate is directly due to fetal monitoring. Most authors agree that there has been an in- crease in the diagnosis of fetal distress leading to cesarean section, although Kelso found that the more than twofold increased rate of C section - in his monitored group could not be attributed to in- creased fetal distress diagnoses (7). Although the risk of maternal death from cesarean section is small, it is at least ten times as great as for vaginal delivery. This fact, combined with Haddad's finding that only half of the moni- tored women in his study who re- ceived a cesarean section actually needed one (8), leads to the dis- turbing conclusion that there are many unnecessary deaths from cesarean sections as a result of EFM. Cesarean section carries with it other risks to both mother and child such as postoperative in- fection or anesthesia complica- tions, as well as the many psycho- logical problems of separation of mother and child at birth, diffi- culty breast feeding, and recover- ing from major surgery. Monitoring has other risks for mother and child. An external monitor requires the woman to re- main in a supine position, the position which one obstetrician has called the worst conceivable for labor and delivery (9). The monitor not only restricts the movement of the mother, making her uncomfortable, but also may adversely affect uterine activity and the maintenance of normal blood pressure. Internal monitoring is even more directly harmful to mother and fetus. It requires the artificial rupture of membranes. These membranes, when left intact dur- ing the first stage of labor, protect the fetus from damage and dis- tress by equally distributing the pressure of uterine contractions. Thus, because it involves ruptur- ing of the membranes, fetal moni- toring can not only detect fetal distress but can also cause it. Injury or infection of the fetal scalp at the site of the electrode attachment is another not infre- quent complication of internal monitoring (10). In addition to this medical complication, no mention has ever been given to the possible psychological trauma to an infant whose first sensation from the outside world is the screwing of an electrode into his or her head. The major risk of EFM to the mother, other than that of cesarean section, is that of infection from insertion of the electrodes (11). Other infrequent complications such as uterine perforation, bleed- ing after the vaginal insertion of 21 The dehumanization of the birth process not only isolates the woman from her childbirth experience but also isolates the birthing family from the physician in what should be a team effort the intrauterine catheter, or minor the direct costs of EFM to be a powerful male dominated - ob- vaginal and cervical lacerations about $ 80 million per year (12). stetrical specialty, and changed a when the scalp electrode is applied have been noted in the literature. This figure does not include costs of unnecessary cesarean sections family centered - __ life celebrating - event to an isolated and alienating Who benefits from EFM? The which may result from EFM, nor medical crisis. The ultimate in infant? The mother? The obstetri- does it include the high costs of medicalized childbirth is the cesa- cians? The hospitals? There is very little evidence to show that infants the resulting morbidity and mor- tality of EFM and C section - pro- rean section. This surgical proce- dure, apparently closely connect- who have been electronically monitored have less risk of death cedures. Given the very limited benefits yet shown, they conclude, ed with the use of EFM as a diag- nostic tool, is also the ultimate in or damage. Studies which have shown a slight advantage of moni- toring for the infant have demon- " One can only say that EFM does not appear to be a cost effective - procedure. " physician controlled - childbirth. There are medical non - conse- quences of routine EFM use that strated that this advantage is limit- ed to high risk infants. Aside from a somewhat false sense of security provided by the presence of such awesome technology, there is no medical benefit to the mother. In Consequences of Increased EFM Use Routine EFM is part of a num- ber of interrelated though some- times apparently contradictory trends in obstetrical care and child- are particularly troubling because they are so little explored. Moni- toring has a profound impact on the relationships between people involved in the laboring process. The monitor becomes the sub- addition, there are the increased risks to both mother and infant to be weighed against these small, if not nonexistent, benefits. Physicians and hospitals may indirectly benefit from the use of EFM. The birth rate is declining. Financial and political pressures to regionalize, consolidate, and cut hospital cost and capacity bearing. One trend, the move to- ward increasing use of technology in the birth process, has most re- cently focused on diagnostic technologies - invasive and non- invasive - such as EFM, sonogra- phy, oxytocin challenge tests (OCT), and amniocentesis. Previ- ously, technological development concerned methods of extraction ject of conversation, the source of information and expertise, the basis for management decisions, the " protector " of the birth ex- perience and the baby, the voice of the baby, the voice of the health professional, a source of distraction, and a catalyst for communication between mother and father (13). weigh heavily on obstetrical units built and staffed for continual -notably forceps and cesarean section and medications to ease The physician compounds this dehumanization of the labor ex- post - war baby booms. Obstetrics has become one of the most fre- or eliminate the pain of childbirth. Between diagnosis and delivery perience by dehumanizing the decision - making process. A resi- quently sued medical specialties, and defensive medical practice is there is also technology applied to labor induction - and stimulation dent recently commented, with little apparent angst, " When the becoming standard. All these pres- sures result in increased medical of labor by oxytoxic agents - and the medications required to make monitor shows a slow fetal heart rate, we section. If the baby intervention in labor and delivery, induced labor tolerable. The use comes out crying and screaming, even as these interventions are in- of these technologies has removed we wonder what happened, but creasingly discovered to be harm- childbirth from the home to the we have no alternative. " With ob- ful to mother and fetus. hospital, changed midwife atten- stetrical malpractice premiums at 22 Banta and Thacker estimate dance to physician delivery, built $ 16,000 a year, and the EFM making a permanent record of the labor process, physician decision- making comes close to being a technocratic exercise, and the skill of being able to humanly auscul- tate a laboring mother and her child becomes obsolete. Ironically, decreasing the role of the physi- cian as primary source of informa- tion and skilled decision - maker distances the physician from the patient, leaving her him / vulner- able to lawsuit if something goes wrong with the delivery. The de- humanization of the birth process not only isolates the woman from her childbirth experience, but iso- lates the birthing family from the physician in what is ideally a team effort. Frequently, use of EFM prolongs this isolation and intensi- fies its effects by leading to cesa- rean delivery and routine separa- tion of child from the mother after cesarean birth. It is yet another unfortunate irony that as we be- gin to understand the severe effects of maternal - infant separation on both mother and child (14), the incidence of routine mother - infant separation is increasing. The irony of a cesarean section rate which may be approaching one in four or five births is that at the same time families are becom- ing increasingly involved in efforts to control their own childbirth ex- periences. And it is precisely among the educated, middle - class families who are most involved in regaining control over their own childbirth experiences that the in- crease in the rate of technological interventions has been the greatest. Two studies which have review- ed scientific findings regarding the medical risks and benefits of EFM have reached virtually the same conclusion. Ettner states decisive- ly, " It is apparent that the bene- fits of EFM do not outweigh the risks " (15). Banta and Thacker similarly conclude, " The diffusion of EFM is an example of a widely used technology of uncertain benefit associated with definite risks and financial costs " (16). Women seeking obstetrical care should realize, however, that today's physicians are being train- ed to use EFM, without regard for the growing evidence showing little benefit and possible harm. To again quote one of the most widely used textbook of obste- trics and Gynecology in its discus- sion of EFM, " It seems clear that the returns are great and that the art and science of FHR monitor- ing have advanced to the point where this capability should not be limited to the larger medical centers " (17). In deciding on ob- stetrical care, women should find out whether routine EFM will be part of that care, and if so, should consider the implications of this for their labor and delivery. New regulations for the use of EFM are being developed by the National Institute of Child Health and Human Development. (In the September issue of Health / PAC BULLETIN, we will take a look at them. - Marsha Hurst and Pamela S. Summey References 1. Danforth, David N. (ed.) Obstetrics and Gynecology (third edition). New York: Harper & Row, 1977, p. 751. 2. Hughey, Michael J., et al. The ef- fect of fetal monitoring on the inci- dence of Cesarean section. Obste- trics and Gynecology 49 515:, 1979. 3. Kelso, Ian M., et al. An assessment of continous fetal heart rate moni- toring in labor. A randomized trial. American Journal of Obstetrics and Gynecology 131 526-532: , 1978. 4. Neutra, Raymond R., et al. Effect of fetal monitoring on neonatal death rates. New England Journal of Medicine 299 324-326: , 1978. 5. Haverkamp, Albert D., et al. The evaluation of continuous fetal heart rate monitoring in high - risk preg- nancy. American Journal of Obste- trics and Gynecology 125 310-320: , 1976. 6. Renou, Peter, et al. Controlled trial of fetal intensive care. American Journal of Obstetrics and Gyneco- logy 126 470-476: , 1976. 7. Kelso, op. cit. 8. Haddad, Hani, and Laurence E. Lundy. Changing indications for Cesarean section. A 38 year - experi- ence at a community hospital. Obstetrics and Gynecology 51: 133-137, 1978. 9. Caldeyro - Barcia, Roberto. Some consequences of obstetrical in- terference. Birth and the Family Journal 2 34-38: , 1975. 10.Okada, D.M., A.W. Chow, and V.T. Bruce. Neonatal scalp abcess and fetal monitoring: factors associated with infection. American Journal of Obstetrics and Gynecology 129: 185-189, 1977. 11. Hagen, David. Maternal febrile mor- bidity associated with fetal moni- toring and Cesarean secton. Obste- trics and Gynecology 46: 260-262, 1975. 12. Banta, H. David and Stephen B. Thacker. Policies toward medical technology: the case of electronic fetal monitoring. Paper presented at APHA meetings, October 17, 1978. 13. Starkman, Monica. Fetal monitor- ing. Psychologic consequences and management recommendations. Obstetrics and Gynecology 50: 500-504, 1977. 14. Klaus, Marshall H. and John H. Kennell. Maternal - Infant Bonding: The Impact of Early Separation or Loss on Family Development. St. Louis: Mosby, 1976. 15. Ettner, Frederick M. Hospital tech- nology breeds pathology. Women and Health 2:19, 1977. 16. Banta and Thacker, op. cit., p. 16. 17. Danforth, op. cit., p. 751. 23 WORK ENVIRON F 24 ASBESTOS DISEASE IN THE COURTS This year a new buzz word will come of age in the lexicon of oc- cupational health. It is " white lung, " a code name for the pro- found damage asbestos dust causes to lung tissue. There is nothing new about " white lung " or the diseases it en- compasses; asbestosis, lung cancer and mesothelioma, a previously rare tumor which turns the lining of the chest or abdominal cavity into a cancerous from of concrete. But for the first time compensa- tion for the estimated 5,000 to 10,000 people who die each year from asbestos related disease is a realistic prospect. There have been a number of developments; the most signifi- cant is that product liability law- yers have declared open season on big asbestos manufacturers, firms like Johns Manville -, Raybestos- Manhattan Inc. and Owens Corn- ing. The argument is simple. The manufacturers knew asbestos fibers could kill as early as the 1930's when the nonflammable silicate mineral came into wide- spread use. But warnings and pro- tection either for asbestos workers or others who used asbestos pro- ducts in insulation, textile or paints were inadequate to non- existent. The health evidence incriminat- ing asbestos is very solid. Even HEW Secretary Joseph Califano has officially warned workers of its dangers. But hard evidence of an industrial cover - up was scant, until Congressional hearings in San Francisco in October, 1978. Within a week, lawyers for Local 9 of the Marine & Shipbuilders Workers, AFL - CIO, based in Los Angeles, filed a $ 1 billion action on behalf of more than 5,000 workers. " I tend to be rather cyni- cal but I have never seen anything like this, " said David Epstein, an attorney for the plaintiffs. " You might go home at night and fanta- size about how great it would be for our case if so and so wrote a letter to their medical chief and said don't tell your workers about the health hazards of asbestos. The next day, lo and behold, you find out that it is true. The largest settle ment in an asbestos - related suit to date has involved 400 former workers at a Pittsburgh Corning Corporation plant near Tyler, Texas who reach- ed a $ 20 million agreement last year with defendants including as- bestos suppliers and the federal go- vernment. All told, more than 2,000 actions are now pending na- tionwide, involving the Groton, Conn. shipyard, the Philadelphia Naval Shipyard and Raybestos- Manhattan's Passaic, N.J. plant a- mong others. Third party suits are not with- out major drawbacks. The most obvious is that they do nothing to reverse the debility of those who file actions. Indeed, Clarence Borel, a Texas insulation worker who brought a landmark case in the early 1970's, died long before the U.S. Court of Appeals for the Fifth Circuit awarded his widow $ 79,000 in 1973. On the other hand, as an eco- nomic incentive for strong preven- tive medicine programs, torts law has a chance to succeed where workmen's compensation and fed- eral health standards have often failed. One might argue that work- ers struggles are best fought through trade unions or the politi- cal process, not in court rooms, where the workers role is minor and cases take years to decide. But there is no denying that pro- duct liability suits can be an effec- tive tool. Consider for example some of the safety debacles that have been publicized in recent years. Velsicol Chemical Corp. has about 80 civil damage suits pending against it in Michigan for its role in the Michi- gan PBB disaster. The total, ac- cording to the Wall Street Journal, for settling 650 other claims, mostly for loss of cattle that ate the tainted food, is 40 $ million. Just as interesting are suits steaming from Allied Chemical's kepone disaster in Hopewell, Va. Richmond attorney Edward W. Taylor has filed 100 lawsuits on behalf of workers and their fami- ies, with total claims exceeding $ 100 million. Fifty seven - have been settled but the dollar amounts are being kept secret. " My guess is all the cases will be settled before they go to trial, " Taylor said. " I don't imagine (Allied) wants any more bad pub- licity and they don't want to set a precedent. " One alternative to third party - suits are workmen's compensation laws, which now cover better than 85 per cent of the labor force. Under most state statutes, work- ers forfeit the right to sue their employers over injuries and illness on the job in return for guananteed payments, no matter who was at fault for the incidents. A major problem with these laws was illu- strated by the kepone case, where Allied's lawyers have tried to prove the company was in fact the employer of the injured workers-- and thus immune from and suit - not just a supplier of chemicals to Life Sciences, Inc. This illustrates what Purdue professor James Robert Chelius calls the " poten- tially perverse incentives of work- ers'compensation. " In a 1977 American Enterprise Institute study, he argues that a worker's right to sue should be restored in just such instances of " serious em- ployer negligence. " Asbestos cases have taken the lead in product liability suits be- cause the diseases are so wide- spread and the dangers so clear cut. Their ultimate success is any- body's guess. High priced legal and medical talent used by the asbestos industry have helped keep settlements down. The aver- age per case is less than $ 25,000- and that is covered by insurance- according to a report Jons Man- - ville filed with the Securities & Exchange Commission last March. On the other hand, firms like Manville, Pittsburgh - Corning, Arm- strong, Raybestos Manhattan -, Owens Corning - , Certain - Teed and UNARCO have an overwhelming legacy of inaction and deceit. And, as revealed in the San Francisco hearings, they now have to ex- plain away letters from high com- pany officials urging deletion of compromising data from scientific studies or recommendations that workers with confirmed chest - x- ray abnormalities not be informed of their illnesses. " I have the doc- ket backed up for almost a year and a half, " attorney Paul Gillen- water of Knoxville, Tenn. said last year. " Nobody has ever been able to get a jury really mad at these people. But it's only a mat- ter of time before we do. " -Robert Steinbrook Robert Steinbrook is a senior at the University of Pennsylvania School of Medicine. BRINGING THE CHEMICAL WAR- FARE BACK HOME While the U.S. no longer rains death on Vietnam from the skies, some of the chemicals created for that purpose have become part of the American way of death. The avowed purposes are no longer de- foliation for military purposes but the end result is just as deadly. Business as usual produces deadly toxic substances: the victims are workers and, increasingly, citizens in the community. Few persons or places are immune to the attack. American society increasingly re- sembles a combat zone where the people are under assault from the products and wastes of industrial production. On March 1, the Environmental Protection Agency banned most uses of the herbicides - 2, 4, 5 T - and Silvex. Both contain dioxin, one of the deadliest poisons known. 2, 4, 5 T - and dioxin were ingredients of Agent Orange, over 11 million gallons of which were sprayed on South Vietnam be- tween 1965 and 1970. Findings of birth defects and stillbirths in mice, coupled with public outcry, led to cessation of its use. But its ingredient, 2, 4, 5 T -, continued to be widely used in U.S. forests by timber companies, utilities, and agribusiness until a study showing increased miscarriages in Alsea, Oregon led to a ban. Once again, it took a human tragedy to stimu- late action when heeding warnings from animal studies could have prevented widespread diffusion into the environment. Silvex, homeowners may know, is a widely used home garden weed killer. If you're not being sprayed with dioxin, or using it in your 25 garden, you may be living on it. At least that's what some residents of Niagra Falls, New York have discovered. Over 80 toxic chemi- system by April 1978. Now EPA talks about January 1980 almost - two years beyond the statutory deadline. cals from the Hooker Chemical While EPA fiddles with its re- Company dump at Love Canal gulations, more and more hot have been found in samples taken spots ignite. Employees of the from nearby houses and back- Robinson Brick & Tile Company yards. It's estimated there may be in Denver, learned in February 130 pounds of dioxin in the Love Canal dump and another 2,000 pounds in the Hyde Park dump in Niagara Falls. Studies of health ef- fects are just beginning, but al- ready there are clear suggestions of increases in birth defects, mis- carriages, liver cancers, hyperac- tive children, and seizures. The Love Canal neighborhood has for example, that their factory is built on an old uranium waste dump emitting dangerous levels of radiation. Twenty - two such radio- active dumps have been found in Colorado alone. Large numbers of the 70 million Americans depen- dent on groundwater for drinking water are finding their sources polluted by toxic chemicals. Such damage can occur almost any- been declared a federal disaster where. " Midnight dumpers " have area. deposited their massive toxic Public outrage at the Love Canal disaster has finally spurred EPA to get on with its tasks man- dated under the Resource Recov- ery Act of 1976. Reports of toxic dumps have begun to come in loads along the roads, streams and vacant land of America. Many un- known toxic hot spots sit like un- exploded bombs waiting to do their damage to the unsuspecting humans who come into contact with them. from around the country raising the specter of further " Love Canals. " EPA reversed its earlier policy of trying not to publicize the dangers and actually sought to count and identify possible haz- ardous waste sites. A quick check by EPA regional offices identified over 32,000 waste sites with po- tential adverse public health con- sequences. America Explodes Sometimes, whole towns come under attack. Three years ago, a Hooker chlorine tank car ex- ploded killing four Niagara Falls residents and hospitalizing 90 others, some of them exposed while shopping three miles away. As the rate of train derailments has doubled in the last decade, deaths have risen faster. One EPA's first estimate of cleanup costs for existing chemical waste weekend last February, 23 people were killed in two separate tank dumps is a nice round $ 50 billion. car accidents involving tank car But the sum will only clean up leaks and explosions. Between past messes. An additional 35 mil- January 1, 1976 and June 30, lion tons of hazardous waste are 1978, the Louisville & Nashville produced every year most - of Railroad had 121 accidents involv- which is disposed of inadequately. ing hazardous cargo: damage in- cluded 19 deaths, 71 serious in- Safe waste management costs juries, and evacuation of 7,280 from 10 to 40 times as much as people from towns in seven states . the methods most commonly used. Such explosions and evacuations, EPA had a Congressional man- complete with armed forces in gas date to promulgate regulations for masks, evoke familiar war imagery. 26 a cradle - to - grave waste disposal Communities are fighting back: The Love Canal Homeowners Association, led by its women, are pressing for evacuation, cleanup, and compensation. Arrests occur- red after pickets blocked traffic. In Warrenton, North Carolina, fearing " another Love Canal, " large numbers have militantly pro- tested using their county as a dump site for PCB contaminated soil which the state proposed to bury close to the water table, in violation of Federal regulations, rather than pay the cost of ship- ment to a secure site in Alabama. North Carolina has no adequate hazardous waste disposal site. All the recent publicity, includ- ing an explosion at a New Jersey disposal site which took 6 lives, has helped fuel local opposition around the country. Existing dumps have been closed and pro- posed new waste disposal sites blocked. Communities are de- manding that existing dumps be found and cleaned - up. A big ques- tion remains whether taxpayers or industry and insurance companies will foot the bill. People around the country no longer trust indus- try and government's ability to safely handle toxic wastes. Industry public relations cam- paigns argue that the risks are a small price to pay for the great benefits derived from chemicals. Dow, makers of 2, 4, 5 T - and napalm, now tells us that natural dioxins are a bigger hazard than theirs and that the decision to ban 2, 4, 5 T - is based on irrational fears. Industry appraisals of risks and benefits increasingly resemble the " destroy the village in order to save it " logic used in Vietnam. The discovery of a vast poison- ing of America through toxic wastes is the latest in a chain of shocks from the pervasive harmful effects of toxic substances in our society. How was it possible for so much lethal material to be lost only to resurface virtually every- where or anywhere? The prolifera- tion of lawsuits by GIs exposed to dioxin in Vietnam, Love Canal re- sidents and others may provide some compensation to victims, but little protection for the rest of us. Regulation comes too little and too late. The lawmakers fight last year's war even as new threats continue to make _ themselves known. Increasingly, the ways of organizing production cannot safely contain the hazardous sub- stances that threaten us. The po- tent hazards produced in our in- dustrial processes have outgrown the social relations in which these processes are embedded. The re- sult is death, destruction and growing insecurity at the lethal threats posed by toxic substances. Only a system of community- worker surveillance and control and a massive shifting of priorities towards a safe society and away from short term profits can pro- duce a country at peace with its own potential chemical weapons. Either we begin to reorganize the way industrial production is con- ducted in this country or we'll continue to inhabit a perpetual war zone. -Tony Bale What's Happening in NEW YORK OPD VOLUNTARY HOSPITALS + 5% vail AMBULATO Department of Health Health Centers - 41% Child Health Stations - 26% Dental Clinics - 33% Eye Clinics - 55% Pa Public Hth Social NutritionisWtorske rs WASTEFUL WASTEFUL lic Health Nutritionists Prstic Health Educators WASTEFUL WASTEFUL WASTEFUL mily Health Workers 092% ? ? HHG GUSIA Get the facts Send for HEALTH / PAC's Special Report PUBLICLY SUPPORTED PREVENTIVE AND PRIMARY CARE DURING THE NEW YORK CITY FISCAL CRISIS: 1974-1977 PART ONE: THE IMPACT D & H $ 10million NEW YORK Please send me THE HEALTH / PAC Special Report Price: $ 13.50 per copy plus $ 2 postage Name Address Copies Enclosed is my check for $. Mail to: Health / PAC, 17 Murray Street, New York, N.Y. 10007 27 NEW YORK M NYC'S HOSPITALS: BEYOND CARING In September, 1978, New York City's Mayor Koch got some rather unsettling news. The Emer- gency Financial Control Board (EFCB) completed its audit of the city budget projections for the coming years. The EFCB conclud- ed that the city would be at least $ 450 million in the red during FY 1981; and if spending continued at the present rate the city would be more than $ 1 billion behind by FY 1983 that magic year during which the Koch Administration and the preceding Beame Admini- stration promised the Congress and U.S. Treasury Department that the city's books would be ba- lanced. It took only a few months for the mayor to announce that the city's financial condition dictated drastic cuts in public hospital spending. By mid November - , the New York Times predicted that the so called - " big cuts " would un- doubtedly center first on the Health and Hospitals Corporation (HHC). According to the Mayor's health advisors, the figure is pro- bably close to $ 80 million. Meanwhile, in the face of pro- tests from defenders of the public hospital system, the Mayor turned to Governor Carey for help in closing some 5,000 public and pri- vate hospital beds in the city. Ru- mors about a state compiled - " hit 28 list " for hospital closings have led to speculation about the Gover- nor's willingness to close private hospitals. New York's three major newspapers have called for joint city state - action even in the face of public outcry. What looked initially like a story of racist budget cutting of public hospitals is rapidly turning into a case of medical abandon- ment by and of our health care system. The crisis not only threat- ens a large component of the pub- lic hsopital system, but is moving right into the board rooms of the city's major voluntary (private, non profit - ) medical centers. And in its wake, our ability to get and pay for care is rapidly being un- dermined. Koch's predilection to take his pound of flesh from the HHC budget was encouraged by his new and dear friend, Dr. Martin Cher- kasky, president of Montefiore Hospital in the North Bronx. The good doctor is reported to have told Koch that something in the order of half a billion dollars could be carved out of the HHC's hide, if only some courageous po- litician were willing to take on those with vested interests. Koch named Cherkasky his special assis- tant for health, an ambassador without portfolio, whose task was to help get the city solvent by turning the Corporation into a corpse. Running through all of the public comment on the HHC is the oft cited - waste and misman- agement of the public system. The clear, not unstated implication is that under other auspices the job could be done and better. But the facts are otherwise. It costs about $ 245 a day to keep a patient in an HHC hospital. This is an all inclusive rate; it co- vers the costs of physician services as well as the traditional nursing and hotel components of hospital Using hospitals for primary care. The value of physician ser- care, as many people do, is a very vices already figured into the expensive way to get medical ser- HHC's costs is 47.50 $ a day. Sub- vices. Medicaid, for example, re- tracting the cost of doctors from the HHC rate means that the Cor- poration spends about $ 200 a day. Compared to the costs in vo- luntary hospitals of comparable size, $ 200 a day is one of the best buys in town. Montefiore, Dr. Cherkasky's home base, for ex- ample, bills Medicaid for $ 325 a Thinking that inefficien- cy is the source of the system's woes is like be- lieving that a monthly welfare grant of $ 543 for a family of four is excessive. imburses up to $ 50 a visit (which most hospitals claim is inade- quate) whereas a non Medicaid - visit to a private doctor probably wouldn't cost more than $ 25 or $ 30. But most people don't have a choice. If they don't feel well, there aren't any doctors'offices for them to go to even if they had day. the money to pay. There probably is a good deal of waste and mismanagement in the municipal hospitals. Certainly there have been legions of reports by funding agencies, task forces, panels and accounting firms which have detailed numerous instances of potential savings. But thinking that inefficiency is the source of the system's woes is like believing that a monthly welfare grant of 543 $ for a family of four in 1979 is excessive. It may be more than the public wants to contribute, but it is not enough to live on. out of the tax levy savings. Clos- ing Metropolitan would result in only a $ 7.5 million savings in the first year. Since some of the costs, mothballing, pensions, etc., would eventually disappear as city obli- gations, the savings would be in- creased in a couple of years. In order to make up 80 $ mil- lion, the HHC would have to close a minimum of six municipal hos- Despite the fact that the Upper East Side has one of the highest concentrations of doctors any- where in the world, most neigh- borhoods in the city have been virtually abandoned by private doctors. Morrisania, Mott Haven, Pelham Bay, Brownsville and Bushwick have less than one prac- ticing physician per thousand po- pulation. And the situation is get- ting worse. Between 1966 and 1976, there was a decline of 2,800 office - based physicians in the city. There are less than 10,000 doctors Managerial reform of the HHC pitals. Saving this tax levy money with office practices in NYC to- will not save much money. The means a reduction of about $ 450 day, as compared with 13,275 just only way to substantially reduce million in total Corporation a decade ago. the city's tax levy support of the spending since a closed hospital The HHC's statistics bear out Corporation is to close or get rid of hospitals. But it will take a lot cannot receive Medicaid, Medicare or any other reimbursements. the hypothesis that people are us- ing the hospital clinics as they of hospital closings to save $ 80 An analysis of where the city previously used doctors'of- million. tax levy money is spent pinpoints fices. In just six years, between For example, if Metropolitan Hospital, the 788 - bed East Harlem municipal hospital which has been targeted for possible closing or transfer to NY Medical College, were no longer run by the city the total tax levy savings from its $ 79.1 million budget would be $ 18.3 million. But on going - ex- both the sources of the problems and the difficulty with all the pro- posed solutions. The HHC calcu- lates that about half of the $ 408 million tax levy money it is receiv- ing this year from the city pays for the services to the medically indigent. Most of the HHC's ex- penditures for the medically indi- 1970 and 1976, the number of outpatient visits to HHC institu- tions increased by 1.6 million or 53 percent. If a significant part of the HHC's capacity is reduced through the closing or selling of hospitals, its patients would have two alternatives. They can go penditures for debt service - , pen- sions, allocated city overhead, gent are incurred through outpa- tient services because almost any- without care, particularly ambula- tory care or they can turn to the mothballing, unrecovered HHC one without adequate coverage voluntary hospitals. But the cost overhead costs, medical record would become eligible for Medi- of care in the voluntaries is, more maintenance and transfer costs caid after paying the costs of a often than not, higher than the would take a $ 10.8 million bite day or two in the hospital. cost of care in the city hospitals. 29 To take half of the city hospital's inpatient load in voluntary hos- pitals would cost the system near- ly 100 $ million more. Even if the private hospitals could increase their capacity to handle more patients, who is go- ing to pay? According to Joe Hoffman, the new president of the HHC, fully one third - of the patients seen in the municipal outpatient departments are SO- called " self - pay. " These people are billed on a sliding scale of from $ 2 to $ 46 for each visit. Few can pay the whole cost of their care. Even the most elaborate billing system in the world won't get money from someone who doesn't have it. Perhaps sometime in the past, the voluntary hospitals would have been able to absorb some of the cost of care for the unsponsor- ed patients in their generally fat budgets. Not anymore. Since 1975, the State of NY has been trying to hold a tight lid on both Medicaid and Blue Cross reim- bursement rates. (The state is caught in a terrible bind. It has guaranteed most of the half a billion dollars in mortgage com- mitments of the voluntary hospi- tals. The primary source of in- come the hospitals have to pay off this debt is their reimbursement income. The tighter the state holds reimbursement, the more likely it is that some hospitals will face bankruptcy and thus default on their mortgages and force the state to make good on the loans, thus jeopardizing the state's fis- cal solvency.) Medicaid expenditures in the city, to private providers, both doctors and hospitals, have in- creased by only 6.6 percent be- tween 1976 and 1978. This rate of increase looks even smaller 30 when viewed in the context of a national medical care inflation rate of about fifteen percent a year. Nineteen private hospitals have closed their doors since New Year's day, 1976. Seventy - eight of the 87 voluntary and proprietary (making profit -) hospitals in the city reported operating losses in 1977. But hospitals have always claimed poverty. More telling is the fact that 33 institutions were technically bankrupt, meaning that they lacked the assets to pay their debts if three or more credi- tors decided to call them in. And with one large, recently closed vo- luntary hospital, Flower Fifth Avenue, paying only 60 cents on the dollar, suppliers just might be frightened enough to call in their money. The list of hospitals in serious financial disarray includes both small marginal institutions and some of the city's major medical centers. The big five superhospi- tals Montefiore, Mount Sinai, New York, Presbyterian and NYU reported in early 1978 combin- ed operating deficits of more than $ 50 million. Montefiore and NYU are still probably crying wolf, but Although the gross sum of public funds spent for health is growing very slowly, the more power- ful institutions are seek- ing an immediate plun- der of HHC's $ 1 billion. the situation at Sinai, Presbyterian and New York is quite serious. Each is facing increased competi- tion for paying patients from sub- urban hospitals and an increasing- ly tough rate setting - commission which is less easily swayed than in the past by the influence and power of the voluntary hospital trustees. Although the gross sum of public funds being spent for health care is growing very slowly, the more powerful institutions are seeking a redistribution of the $ 4 billion pot. An obvious target is the HHC's $ 1 billion. Perhaps in pursuit of this re- distribution, 60 board members of voluntary hospitals contributed a total of $ 162,250 to Koch's campaign. Even if fewer patients can be served for the money saved from the private hospitals'point of view, it would be far better to have it invested in their presti- gious and in many cases debt - rid- den institutions. Regardless of how the volunta- ries manipulate to increase their reimbursement and their share of paying patients, none is in a posi- tion to absorb an increase in non- paying or part paying - patients. The few hospitals in poor neigh- borhoods which have extended their services to surrounding communities find themselves in desperate straits. Brooklyn Jewish Hospital in Bedford Stuyvesant - filed for a Chapter 11 bankrupt- cy on February 8. Following on the heels of this action came the public announcement that in or- der to restore solvency, Brooklyn Jewish would have to begin deny- ing services to non paying - patients. Another case in point is Bronx Lebanon Hospital located in the depressed mid Bronx - . The hospi- tal is reporting an annual deficit of $ 4 million a year. Both Bronx Lebanon and its more solvent neighbor to the north, Monte- fiore, see more than 200,000 am- bulatory care (outpatient and e- mergency room) patients a year. Both report they spend about $ 80 for each patient encounter. Both receive about $ 50 as reim- bursement for each covered pa- tient. But Bronx Lebanon nets only about $ 30 to cover the cost of a visit and Montefiore makes about $ 60. Montefiore is thriving; Bronx Lebanon is on the verge of bankruptcy. Were Montefiore to absorb some of the patients denired care because of the closing of city hos- pitals, it too might find itself on the brink. Montefiore is unlikely to step over into that abyss. More likely, patients will find it harder and harder to get medical care un- til they are sick enough to need hospitalization and thereby be- come financially desperate enough to qualify for Medicaid. The health care system has very little impact on the rate at which people get sick and die. But when it functions, it is able to re- lieve suffering. The closing of city hospitals will probably show up in increased incidence of TB and ve- nereal disease, more premature births and perhaps a higher infant death rate. But it won't appear on any vital statistics tables suffer- - ing cannot be quantified. Reducing the city's tax levy commitment helps to solve Koch's budget problems. The transfer of reimbursed patients to the volun- tary hospitals begins to ameliorate some of their fiscal problems. But it can only be done at the expense of uninsured patients. The alternative is a total re- organization of the way health care services are organized and de- livered. There is too much expen- sive hospital care and too little affordable ambulatory care. There are too few primary care physi- cians and too many specialists. $ 7 billion is a lot of money for New York and New Yorkers to spend on health care, but it won't buy what we need until the system is reorganized. Reorganiza- tion requires disenfranchising the priorities of the big, private teach- ing hospitals. We do not know any politician currently in or seeking office willing to take them on. - Barbara Caress and Pam Brier HEALTH POLICY QUARTERLY Evaluation and Utilization Editors: Herbert Schulberg, Ph.D. and Edmund Ricci, Ph.D. If public health needs are to be met, it is essential that health care delivery be organized and administered effectively. To this end, the attention of legislators and health officials has increasingly focused on the need for greater links between comprehensive service deli- very and program evaluation. This in- formative periodical stimulates vital communication between makers program evaluators and policy makers - in all phases of public health administration. It includes the five major stages of successful service delivery health pol icy formulation: program planning; ex- periments in health care delivery; eval- nation of current health programs; and the dissemination and utilization of evaluation studies. Besides providing a forum where the reciprocal activities of evaluators and policy makers - can be explored, Health Policy Quarterly will assess emerging trends in evaluation and health care delivery. The periodical will critically examine such topical issues as: the adoption of new technologies by health care practitioners; implications of service delivery patterns for health care financing; and the utilization of evaluation data at federal, state, and local levels. ISSN 0163-5107 Quarterly Order 635-8 Order 636-6 Individuals Institutions $ 18.00 $ 35.00 ADVISORY BOARD Acton, Jan, Ph.D., Rand Corporation S` Altman, Isidore, Ph.D., University of Pittsburgh S` Anderson, Ronald, Ph.D., University of Chicago @ Baker, Frank, Ph.D., S.U.N.Y. Buffalo * Curran, William, J.D., Harvard Medical School * Demone, Harold, Ph.D., Rutgers University i Detre, Thomas, M.D., University of Pittsburgh e@ Haggerty, Robert, M.D., University of Rochester S` Mott, Basil, Ph.D., University of New Hampshire @ Rosenthal, Gerald, Ph.D., National Center for Health Services Research, HEW S` Sechrest, Lee, Ph.D., Florida State University S` Shortell, Steven, Ph.D., University of Washington e Zweig, Franklin, Ph.D., Senate Committee on Human Re- sources CONTENTS Do You Need Good Health Services Research to have Good Health Policy?, Gerald Rosenthal e The Congressional View of Evaluation in Health Policy Decision Making, Franklin Zweig S` The " Meaning " of Information in Health Policy Decision Making, Wil- liam Filstead @ Mental Health Service Policy and Program Evaluation: Living in Sin?, Steven Sharfstein, Charles Windle e The Policy of Deinstitution- alization: The Search for Fact amongst Conjecture, John Noble S` Achieve- ment Crisis Prevention: Applications in Health Planning, Joseph Eaton S` Converting Evaluative Data to Policy: The Process of Generalization, Lee Sechrest Bulk Student Subscriptions at $ 9.00 Five or more students may subscribe at this low rate if a member of a facul- ty certifies their student status and sends names and addresses together with full payment. As a courtesy, the faculty member may also subscribe at the bulk rate. Future issues will include articles on: * Factors affecting the adoption of new technologies by S` The community impact of innovative home care for the health care practitioners i Uses of evaluation data in policy formulation at federal, aged e Priority setting for pre hospital - and critical care medicine state, and local governmental levels e Health manpower options and health care tasks S` Implications of service utilization patterns for health care financing i Management information systems and patient confidentiality i Quality of care at centralized and decentralized health care facilities i Cost benefit -a nalyses of PSROs * Data validity and policy decisions i Cost benefit -a nalyses of community and institutional i Clinical research and the policy of deinstitutionalization care a HUMAN SCIENCES PRESS 72 Fifth Avenue 3 Henrietta Street : m@ NEW YORK, NY 10011 S` LONDON, WC2E 8LU 31 THE FIFTH COLUMN NURSES'NETWORK FORMED Starting with nurses who are friends of Health / PAC, we have developed a mailing list with heavy concentrations on both coasts, and contacts with small groups of working nurses in Boston, Philadelphia, and New York. The Nurses'Network would like to serve as an information exchange between activist nurses in different parts of the country- a sort of " bulletin board " for the rank - and - file movement. It is Nurses today are faced with a host of problems with strong po- litical roots. Ideas and proposals for change are legion, and insep- erable from the problems of the health care system. The Nurses ' Network has been established to serve as the focus of the discus- sion toward a political agenda for activist nurses and students. Poll Organized nursing leader- ship seems to be heading in a different direction than its membership with regard to baccalaureate nursing. A poll conducted by RN magazine finds that 72% of the RNs The question of organization is crucial. We must grapple with the question of which organi- zations are best for us inde- - pendent unions, union with other health workers, or the state as- sociations. The historical organi- zations of nurses, the ANA and NLN, with their aggressively pro- vincial view of professionalism, seem incapable of fully meet- ing the needs of rank - and - file, working nurses. A new voice is needed. surveyed opposed the divi- sion of nursing into tech- nical and professional levels- a policy called for by the ANA with a target date of 1985. Furthermore, 91% of the 10,000 polled favor the concept of a career ladder that would allow several basic training options for entering the profession and mobility within the profes- sion. Around the country there are Source: Health Planning and individuals and small groups of Manpower Reports, 1/3/79 activist nurses who are tryiing to address the problems of nurs- ing. Up until now, they have usu- ally acted independently and in isolation from one another. The hoped that such an information Nurses'Network would like to exchange will lay the basis for try to end that isolation, and be concerted action in the future. part of the struggle to build re- Through periodic mailings, we 32 sponsive groups. will try to keep our readers a- A Fifth Column For over ten years, Health / PAC has been providing a critical analysis of the health care system, with special emphasis on the issues of priorities in planning and delivery, politics and econom- ics. While providing an overview analysis for the information of progressive workers within the system, Health / PAC has only devoted sporadic attention to the aspirations and experiences of the planners, policy makers - , and hospital workers working for change in their respective roles. Characterized by rising expec- tations and a steady growth in numbers, health care workers can be a potent force for change. In the tradition of keeping our readers informed of new de- velopments in the health care field, and in the spirit of encour- aging activity among health care workers and professionals, Health / PAC Bulletin introduces " The Fifth Column. " " The Fifth Column " will attempt to reflect the experiences and organizing efforts of health care workers. Rather than ana- lyzing policy as a distinct entity, we hope to explore how policy impacts on the workforce, and how health care workers can ul- timately influence policy. One developing area is the growing interest of health care workers in their organization as workers. Considerable organ- izing efforts have been spurred by the legalization of collective bargaining in voluntary hospitals beginning in 1974. While set- backs are bound to occur, union organizing efforts should con- tinue for the foreseeable future and may affect the balance of forces in large institutions. While the ideology of professionalism enjoys continued popularity, it remains to be seen if it will be used to justify further hierarchical isolation between professionals and workers, or be used as a focus for asserting pride and demanding a measure of control over the work environment. The policy maker - and the lowest paid hospital worker alike are concerned with the humane delivery of health care. When political and economic policies stand between health care workers and their goals, frustration and alienation increase. Consequently, there is a natural ten- dency toward a recognition of common problems - a community of interests. " The Fifth Column " will be used as a forum for expressing this community of interests, for exploring causes of discontent and pointing to possible solutions. Letters from activists and extended news items on manpower policies and organizing efforts will be the medium. The Editorial Board invites comments and contributions from activist health care workers among our readers. The Editorial Board breast of new publications of in- terest, upcoming meetings, and samples of the work of active groups of nurses. Introduction to the work of other nurses around the country should help end the isolation felt by many concerned working nurses. Toward this end, the Nurses'Network has already co sponsored - a lively meeting of activist nurses in the New York City area. Articles and comments on nursing will be appearing regu- larly in the pages of Health / PAC BULLETIN. Other contributions will be offered to such magazines as Ms., where appropriate. Addi- tional material will be distributed separately in the Nurses'Network newsletter as the situation de- mands and funds permit. We ask you to send the Nurses ' Network news about what's going on in your area. Announcements of meetings, suggestions for read- ing, and additions to the mailing list are most welcomed. If you or your group issues a leaflet or writes an article, send us a copy. Perhaps the most valuable prac- tical benefit of an information exchange is the opportunity for working nurses to learn from the experiences of others. Finally, send letters, news items and other written contributions for con- sideration for Health / PAC BUL- LETIN, or other publications. We would like to see the real issues in nursing presented to the large progressive health care movement. Only by working together can we hope to lift the stifling hand of conservative tradition from nursing, and begin to solve the real problems of today's working nurses. For further information write: Nurses'Network, c o / Health / PAC, 17 Murray Street, New York, N.Y. 10007. 33 Continued from Page 2 to their local areas, incorporate them into their plans and then set about the task of implementing them. Finally, in October HEW, with the concurrence of the Office of Management and Budget (OMB), moved to assess the cost savings attributable to the nation's planning effort. Frightened, the Am- erican Health Planning Association (AHPA), trade association of health planners, leapt into action with its own survey, the results of which were out long before OMB and HEW could even agree on the forms. The growing pressures on health planning are not limited to cost control, however. A variety of other special interest groups have also made themselves heard. HSAs are mandated to address measures which would improve the health status of their populations in their plans. Although they have pitifully little power to implement their proposals, many plans include strong sections on prevention and environmental and occupational health, raising such issues as auto safety, smoking in public places, gun control, pollution and work- place hazards. Such stances have triggered reaction by those special interests who saw renewal of the legislation as the occasion to seek redress. An example of this process occurred when the Northern Virginia HSA took a strong public stand on the right of Medicaid recipients to publicly- funded abortion and also recommended passage of a county law against smoking in public build- ings. The result was a furor which eventually led Fairfax County to withdraw its financial support of the HSA and Senator Richard Schweiker (R- Because of the failure of all other cost control efforts, the mantle of cost control is now being thrust on planning agencies. To the extent that Congress and the Administra- tion insist on cost control as the measure of HSA effectiveness, their failure is preordained a Pa.), ranking Republican on the HEW Appropria- tions Subcommittee, to attempt to trim the HSA's wings with regard to " controversial " health 34 issues. The auto and tobacco lobbies'expressed con- cern over efforts to renew the health planning law and the threat of Right Lifers - to - to tie up the bill with an anti abortion - amendment may have thrown it into its final, lethal stall. Rather than fighting issue by issue, however, these groups settled for a single compromise amendment, fashioned by Senator Schweiker, limiting the scope of HSAs primarily to " health care delivery and the elimination of duplication and waste, " rather than wider ranging - and potentially more controversial areas. Even this position was a con- siderable step back from a more stringent stand which would have limited HSAs exclusively, not just primarily, to health care delivery. Finally, attempts to strengthen PL93-641 enraged the AMA, whose early opposition was critical in scuttling the bill. The original law had left a large loophole in the authority of health. planning agencies to regulate health system expan- sion. Planning authority is currently limited to institutional health care providers only, leaving private physicians and others free to purchase major medical equipment and sell their services at will. Thus when the application of a Miami hospital to purchase a scanner was denied, a group of physicians rented space in the medical office building across the street and installed a scanner. The same thing happened in Cincinnati when Bethesda North Hospital ran into prob- lems in getting HSA approval for a brain scan- ner. The fact that Cincinnati was already over- supplied with scanners was irrelevant. The proposed amendments to PL93-641 would have closed this loophole, extending planning au- thority to the purchase of all major equipment, regardless of its location. Raising the specter of big brother horning in on private practice, the AMA fought this reform bitterly and succeeded during the final days in having it withdrawn. By the time the bill reached the floor of the House, three days before Congress adjourned, the AMA, the AHA, and the AHPA groups - frequent- ly at odds - had finally come to terms on a single issue: all wanted this bill passed this year. Each group felt it had secured the best possible com- promises and each feared the erosion of its posi- tion under the intensifying pressures of the coming year. For HSAs the stakes were particularly high. Rep. Paul Rogers, (Fla D -.), architect of PL93-641 and chief proponent of health planning, was re- tiring and would not be present in the next session to defend planning interests. Nevertheless, the vari- ous parties had simply gotten their act together too late and the clock ran out. What will happen to the planning bill when it is reintroduced this year is unclear. Speculation is rife, although the strongest rumor has it that lawmakers will quickly submit a bill identical to last year's, hoping that the final momentum and consensus will endure long enough to allow its passage. Whatever the vagaries of Congress, however, the pressures which manifest themselves last year are clear and their implications for health plan- ning grim. Because of the failure of all other cost control efforts, the mantle of cost control is now being thrust on planning agencies. While cost con- trol was clearly a motivating factor in the bill's passage, PL93-641 failed to provide the new plan- ning agencies with the tools to effect it. By virtue of their lack of power, the primitive state of the art and contradictions in their composition and functions, planning agencies are pitifully ill equip- - ped to inherit that mantle. To the extent that Congress and the Administration insist on cost control as the measure of HSA effectiveness, their failure is preordained. Background PL93-641 replaced three previous federal pro- grams: Comprehensive Health Planning, the Re- gional Medical Program and the Hill Burton - Hospital Construction Program. It created a network of local agencies called Health Systems Agencies (HSAs), a network of two part - state- level agencies called State Health Coordinating Councils (SHCCs), and State Health Planning and Development Agencies (SHPDAs), and six regional health planning centers. HSAs are governed by independent, consumer- dominated boards of directors. Elaborate rules govern their composition to assure that they are broadly representative of consumer, provider and other interests in their communities. Each agency is responsible for a " health service area " with a population ranging from 500,000 to 3 million, and each has at least one " area sub - " or community level advisory council. At the state level, SHPDAs carry out planning, resource allocation and regulatory functions with the advice of Statewide Health Coordinating Councils, which are unpaid, governor appointed - bodies, similarly representative of the state. The SHPDA in many ways serves as staff to the SHCC and the two roughly parallel at the state level the roles and responsibilities of HSAs at the local level. One of the first tasks faced by state and local planning agencies is the development of five year - plans (Health Systems Plans or HSPs, in the case of HSAs, and State Health Plans in the case of state agencies). These plans examine the health sta- tus of the population and inventory existing health resources, identifying resource needs and surpluses. On the basis of its plan, the HSA establishes priority problems to be addressed and frames these into a one year -, Annual Implementa- tion Plan, which largely constitutes the basis of its implementation activities. (Hereafter planning will be discussed largely in terms of HSAs, although most of the arguments apply equally to state health planning agencies.) Power - Or Lack of It What was to distinguish PL93-641 from pre- vious health planning efforts was that, rather than simply planning, HSAs were to be given power to implement their plans. As originally conceived, these powers were impressive. They were to in- clude: (1) rate setting power over Medicare and Medicaid reimbursements; (2) the power to ap- prove and disapprove the use of HEW Public - Health Service monies coming into a local area; (3) distribution of Area Health Services Development Funds to aid in establishing needed health services; (4) the power to certify and decertify health facili- ties and services on the basis of need; and (5) the power to approve and disapprove expansion or changes in health services. The actuality of these powers, however, is far from impressive. It reflects a long standing - am- bivalence on the part of Congress and HEW to- ward health care cost control. The rhetoric is good and the intent is no doubt genuine. But the political power of the interests that would suffer from serious cost control measures - large hospi- tals and medical schools, medical equipment, supply and drug manufacturers, banks, etc. - is such that HEW and Congress always end up side- stepping the real issues at the critical moment (1). Thus the very creation of HSAs sidestepped the primary cause of rising costs: Medicaid and Medi- care reimbursement practices enacted by Congress and administered by HEW. Again, while talking 35 a good line, HEW and Congress sidestepped the issue of equipping HSAs to achieve cost control. The result is that now, under increasing pressure, HSAs are being sent forth to do proxy battle with the monster of rising armed costs - with a table- knife. And in the new found - atmosphere of pro- gram effectiveness, the word is, that if they fail, they can also be expected to take the rap. The first proposed HSA power- that of setting Medicare and Medicaid reimbursement rates as a means of enforcing HSA decisions -- was quickly withdrawn and dispatched into near oblivion - . It remains only in a vestigial state in the law, as fund- ing for six demonstration rate setting projects nationwide. The power to approve and disapprove HEW / PHS monies has not been granted to HSAs, nor does it seem to be in the offing. Area Health Services Development Funds have never been appropriated and, in the atmosphere of cost control, it is inconceivable that they ever will be. All that remains of the power of certification in PL93-641 is an atrophied anomaly known as " appropriateness review. " Every five years HSAs are required to review health care facilities and services in their areas, evaluating their appropriate- ness to the area's health needs. While implementa- tion was a major concern at many other junctures in PL93-641, it was curiously absent in the case of appropriateness review. Presumably a finding of appropriateness or inappropriateness by an HSA will be a self implementing - truth, powerful enough in its mere statement to bring about a more ap- propriate and rational health system. Very curious, indeed. Yet parody of the original that it is, approp- riateness review is still controversial enough to The lack of HSA power to achieve cost control is rivalled only by the lack of data to guide a policy for achieving such ends. Lack of such information means that HSAs are reduced to making many important policies and decisions by guess and by gosh 36 keep HEW scraping and shuffling. The first ap- propriateness review was to be completed within three years of an HSA's official designation. Yet HEW has stalled for over two years in issuing regu- lations. And, lest appropriateness review prove an item too hot to handle, HEW announced in May that HSAs are not to name names. Their first reviews are to be areawide, applying only to ser- vices in the aggregate, rather than being " institu- tion specific. " This latest masterpiece of compro- mise was delivered by the American Hospital As- sociation over the objections of HSAs, rate setting commissions and Blue Cross (2). This leaves the core of HSA " power " in their Certificate of Need (CON) review. To receive Medicaid or Medicare reimbursement for the de- preciation of any capital expense over $ 150,000, institutional providers of health care must first receive CON approval. HSAs review CON appli- cations, assessing them on the basis of the area's need for the service or facility. Although HSA findings are advisory and final decisions are made at the state level, they still have significant im- pact. Disapproval of a project carries with it the certainty of careful public scrutiny and many facilities would rather withdraw or modify their applications than risk such disapproval. Noticeably absent from the HSA arsenal, how- ever, is any generic linkage with agencies or organizations which do have power in the health system, including third party - payers, rate setting commissions, state licensing and certification bodies, and even PSROs. An HSA, therefore, has little, if anything, to offer as an incentive to institutions to open, close or alter services. Nor do they have authority over basic elements of the health system, such as private physicians, home care and domiciliary services, health manpower or federal hospitals such as those operated by the VA and the Public Health Service. " Thus the Act carried on the by now - venerable Congressional tradition of calling grandly for changes in the health care system without being willing to touch its principle actors, " concludes noted expert, Katherine Bauer, in a recent study (3). Again she states, " the Planning Act excludes from the purview of the agencies it creates most of the key elements that currently determine the way the U.S. health system actually operates " (4). " Physicians and other health professionals con- tinue to function just as autonomously as before, the basic way the system is financed continues unchanged and the new review and regulatory functions prescribed by the Act are simply super- imposed on the existing, complicated regulatory structure, not integrated with it " 5 (). HSAs are reduced to piggybacking on other programs for hard clout. Voluntary as such co- operation is, the clout is nevertheless growing, fed perhaps by the confidence among those who would control costs that there is safety in num- bers. Thus rate setting programs, (of which there are now ten independent state programs, 25 Blue Cross and two state hospital association - admini- stered programs) have pulled in behind HSAs, at least to the extent of frequently refusing to reimburse hospitals for capital improvements that have not received prior CON approval. HEW has also sought the cooperation of other federal agencies funding hospital construction. HUD, which has helped to fund 139 projects worth $ 1.655 billion, has recently agreed to abide by the National Standards for Health Plan- ning in granting loan insurance to hospitals. HEW is trying to work out similar agreements with the Department of Agriculture, Interior and Commerce, the Farmers Home Administra- tion, the Veteran's Administration and the Ap- palachian Regional Commission. Finally, pri- vate financiers are increasingly reluctant to loan money for projects lacking CON approval. The sole exception to this hand hat - in - approach to planning agency power has been New York State, pioneer of both CON regulation and hos- pital cost control programs. There the planning apparatus is integrated into the State Department of Health which is also responsible for setting Medicaid rates, advising on Blue Cross rates and setting prospective rates for hospitals under the New York Hospital Cost Control Act. New York's Commissioner of Health, moreover, has the power to decertify institutions on the basis of appropriateness. New York is the sole state where hospital interests do not dominate the struc- ture and decision - making process of the CON agency (6). The State of the Art The lack of HSA power to achieve cost control is rivalled only by the lack of data to guide a pol- icy for achieving such ends. No data exist on the systemwide or long term - impact of different cost cutting - policies. The ability to assess com- munity health needs is exceedingly primitive. The clinical effectiveness of health services in treating specific maladies or in influencing general health status has presented itself as a policy or research issue only in the last few years. If cost control pressures threaten to consign planning to the back seat, resource development is likely to wind up in the fifth balcony No means exist to evaluate the lifetime costs, including income loss and welfare costs, of pa- tients with avoidable illnesses or conditions. Com- parative costs of comparable care in alternative settings is unknown. Comparisons of direct treat- ment costs of patients with identical conditions in different hospitals have not been conducted. Comparable risks and benefits of different levels of diagnosis and treatment services according to outcome have not been assessed. There are no data on institutional costs that would identify targets of excess costs (7). Lack of such information means that HSAs are reduced to making many important policies and decisions by guess and by gosh - a poor basis on which to defend these decisions to the pub- lic or to the courts where every HSA can expect to land if it bucks the providers too hard. Regionalization a.k.a. Monopolization Data are so poor that they cast doubt, if not discredit, on the central, cost controlling - thrust of the planning program: reduction and regionali- zation of the health care system. Low occupancies and utilization rates have led HEW to conclude that the nation suffers a serious excess of health facilities particularly - hospitals. Estimates of unnecessary beds range as high as 250,000. These empty beds cost nearly as much as filled beds, but do not generate patient revenues. Furthermore, the little research data in existence suggests that the supply of health services creates its own demand (dubbed " Roem- er's Law "). Finally, researchers are finding that the availability of services and frequency of medi- cal procedures bears little, if any, relation to the health status of populations. Combined, these three emergent and poorly. understood facts form the basis of HEW's major planning and cost control policy: elimination of unneeded facilities and services and control of the growth of new ones. HEW has begun to codi- 37 fy this policy in the form of the National Stan- dards for Health Planning. These Standards, which now exist only for acute care facilities, call for a 10 percent reduction in hospital beds during the next five years, from 4.4 beds per 1000 population to 4.0, to be followed by a further reduction to 3.7 in the following five years. Occupancy rates are to increase from an average of 75 percent to 80 percent; obstetrical units should have a mini- mum of 1,500 births annually; pediatric units should have at least 20 beds; open heart surgery units should conduct 200 procedures a year, etc. Facilities or services not meeting these standards should consolidate, convert or close. The effect of this thrust will be the regionaliza- tion of health services, an ostensibly more rational basis for distributing health care resources. The real effect is more likely to be the merger or elimination of smaller institutions and services and consolidation of the system around fewer, larger and, not coincidentally, more expensive institutions. In less mystified industries this process is known as monopolization. Its motive force is the giants of the industry in question and its means are government regulation. Moreover, it rarely, if ever, serves consumer interests in the cost, quality or variety of the product. The parallels of monopolization to recent de- velopments in the health system are striking. The American Hospital Association has been in the forefront of support for CON legislation since 1968 (8), just as the large voluntary hospitals in New York State actively promoted passage of that state's CON law - the first in the nation- in 1964. Until the advent of PL93-641, repre- sentatives of these influential hospitals con- trolled New York's local health planning coun- cils, administered the CON program, and thus effectively orchestrated the development of the health system. Regulation generally serves to block the entry of new providers into the market, but rarely is it able or willing to stem the flow of resources into the industry, argues Mark Chassin, in a mono- graph on cost control strategies (9). Drawing para- llels from the airline industry, Chassin states, " Regulation in these oligopolistic industries. has led to price increases as the regulators allowed the producers to reach cartel - like agreements and en- force them where it had not previously been possible " (10). 38 Since regulation prevents the carriers (airlines) from utilizing price rivalry to obtain larger market shares, they turn to service quality rivalry in their endeavors to obtain increased shares of the cartel benefits available to each market. This causes them to buy more and newer equipment and facilities, and to utilize more personnel and provide the su- perior service " (11). Recently, planning officials have become con- cerned that regionalization, or monopolization, may violate the law. Last February officials of the Central Virginia HSA, challenged by the local hospital association, sought an advisory opinion from the FTC on whether voluntary merger or collaboration among providers to reduce facilities and services violates the Sherman Trust Anti - Act. Preliminary FTC staff opinion holds that it does, and a final decision from the Justice Department is expected shortly. " If Justice determines that these cooperative arrangements constitute restraint of trade, HEW officials fear the entire planning program will be undermined, " particularly in light of its reliance on cooperation by providers in lieu of serious enforcement power, states the Health Finance Letter (12). Lawmakers are hastily at- tempting to write into the new HSA bill a clarifica- tion of legislative intent that might exempt HSAs from such consideration. Conflicts of Purpose Finally, the pressures of cost control exacer- bate latent conflicts built into the basic purposes, structures and functions of PL93-641. The Preamble to PL93-641 states " the achieve- ment of equal access to quality health care at a reasonable cost is a priority of the federal govern- ment. Lawmakers in 1974 may not have foreseen- or perhaps did not care to specify - what should happen if these three stated priorities - equal ac- cess, quality care and reasonable cost came - into conflict. Now reasonable cost has clearly become the do- minant federal priority, while HSA staffs, boards and constituencies have come together largely a- round equal access and quality care. Providers par- ticipate in HSAs for defensive reasons - to protect their own self interests - interests which seldom co- incide with cost control. Consumers are more fre- quently health activists from their local communi- ties or from special need groups such as the elder- ly, the handicapped, etc., who have no wish to pre- side over cost cutting, especially if it is aimed at their own communities. Together, these two groups are more likely to act as advocates for the local health system than they are as its regulators, particularly if cost control pressures from Washing- ton become more stringent. This conflict in priorities underscores a serious predicament for achieving cost control: while in the abstract, everyone agrees with its importance, in reality, cost control has little or no constituen- cy. The convoluted structure of health care finan- cing insulates the consumer and thus leaves state and federal budgeters alone as its only avid consti- tuency. Conflicts in Function Cost control pressure also creates a tension be- tween the basic functions of HSAs: planning, regu- lation and resource development. Planning took precedence in the initial period after passage of PL93-641. Production of state and local health systems plans was necessary, not only for agencies Scorecard for HSAs In the four years that have elapsed since passage of PL93-641, much of the nation's network of state and local agencies has been put into place. As of September, 1978, 213 health ser- vice areas had been established and 205 Health Systems Agencies (HSAs) had been designated. Of these, 147 had received final, or official, designation by HEW, while the remaining 57 operated in a status of " condi- tional " designation, meaning that they were still in the organizational stage and had not yet met all HEW conditions for final designa- tion. Approximately 60 percent of these HSAs evolved from the old Comprehensive Health Planning " B " (local) agencies, while the ba- lance have been created anew. Of the total, 180 HSAs are private, nonprofit agencies; four are units of local government and 21 are regional planning boards. HSA governing boards vary in size from a low of 15 members to a high of 137. Na- tionwide, consumers comprise 53 percent of all HSA board members. " Subarea " or com- munity - level advisory boards vary in number and size from Arizona Area I, with a single subarea council of 15 members, to New York Area VII with 33 councils numbering a total of 1,800 members. Across the country, subarea councils total 500 with a total mem- bership of 15,000. HSAs are funded mainly by grants from the federal government, calculated on a per capita basis according to the population in a health service area. Funding started in 1976 at $.28 per capita and has risen to.44 $ per capita in 1978. Federal grants to HSAs aver- aged $ 473,000 each in 1977. Total funding of HSAs has risen from $ 64 million in 1976 to $ 107 million in 1978. As of September, all 50 State Health Co- ordinating Councils (SHCCs) had been esta- blished. These voluntary, governor - appoint- ed bodies ranged in membership from a low of 13 in Wyoming to a high of 83 in Massa- chusetts. Consumers comprised 53 percent of SHCC members; 60 percent of these must represent local HSAs. As of September, all 50 State Health Planning and Development Agencies (SHPDAs) had also been established. Their operation is contracted by HEW to state go- vernments; HEW provides 75 percent of SHPDA funding. Currently, 26 SHPDAs are located in state health departments; 20 are in state health and welfare departments; six are in governor's offices and three exist by some other arrangement. Federal SHPDA appropriations have risen from $ 19 million in 1976 to $ 29.5 million in 1978. A major priority of HEW in the current year is to complete the final designation of all HSAs. (Data taken from presentation made by Henry A. Foley, Health Resources Admini- stration Director, to the National Council on Health Planning and Development, Sept. 8, 1978.) 39 to receive official HEW designation, but to create a credible basis on which to implement regulation. Now, under pressure of cost control, the emphasis will necessarily shift to regulation, specifically, to CON review. The two approaches harbor inherent conflicts. Planning attempts to take a long range -, system- wide view while CON review is necessarily con- ducted on a narrow case - by - case, short - term reac- tive basis. CON review is exceedingly concrete; it must be completed on a rigorous schedule; its out- come is tangible as is its impact on the system. Planning, beyond the gestures minimally necessary to please HEW, is often far from concrete and its outcome not necessarily tangible. In spite of HEW's emphasis on a good plan, the HSP is only one of 12 factors which must be taken into ac- count in a CON review. Moreover, actions which will realize tangible savings in the short - run often conflict with those which are most rational and cost efficient - in the long term -. The ability of systemwide, long - term planning considerations to stand up against short - term, im- mediate cost factors is hurt badly by the primitive state of the art described earlier. Until recently, no target goals for capital spending existed to provide HSAs with a context for making specific review decisions. Secretary Califano has just suggested a nationwide maximum of 3 $ billion to be adopted by HSAs as a voluntary guideline. If cost control pressures threaten to consign planning to the back seat, resource development is likely to wind up in the fifth balcony. It is unlike- ly in a period of economic contraction, when the problem is defined as having a surplus of health re- sources, that funds will be available for creating new ones. Developing alternatives to a system based on expensive, crisis oriented - , high techno- logy care, however, is the only route to long term - cost effectiveness. Unfortunately, this requires in- creased investment in the short - term. Primary and preventive care, public health and education, which might comprise this alternative, receive unanimous lip service in times of plenty; in times of contraction, the concensus evaporates and they are the first programs to go. Economic adversity rarely begets greater cost effectiveness. Rather the opposite: it causes retrenchment a- round the vested interests of the status quo. In this climate, such programs will be viewed as suspect, as new spending programs, untried experiments 40 and amenities compared with the life saving - basics offered by the acute care system. Such services of- fer a ripe and expedient target for pre emptive - cut- backs. Moreover, little constituency exists to fight for as yet non existent - programs, no matter how sensible their rationale, while established programs have developed a dependence among both workers and users, and therefore a constituency to guard a- gainst cost cutting. The Cost Savings Tally The effectiveness of programs such as HSAs has only recently become an issue of public, profes- sional and political concern, and HEW - OMB and AHPA studies no doubt are the first of many. To LS The growing pressures on health planning are not limited to cost con- trol. A variety of special interest groups - auto and tobacco lobbyists, Right Lifers - to -, etc. have - also made themselves heard date, the results of the cost impact of HSAs, or more specifically of the CON programs, is mixed. The most careful study was conducted before the passage of PL93-641 by Salkever and Bice who carefully analyzed the cost impact of CON pro- grams from 1968 to 1972, comparing them to costs in states having no CON programs (13). The results suggest that while CON programs may have held down increased in the total number of hospi- tal beds, they had no impact whatsoever on total hospital investment. Clearly, surplus income was invested in hospital assets which were exempt from CON approval (14). This is known as the fea- ther pillow - principle of hospital cost control. Ano- ther study conducted by Hellinger confirms this conclusion. It shows CON having no effect on to- tal hospital investment, although it does not distin- guish hospital beds from plant assets (15). On the other side of the ledger is a recent study by the Congressional Budget Office showing that some state CON programs have reduced the rate of bed expansion by as much as four percent and slowed the acquisition of plant assets per bed by 10 percent in a period when plants assets increased an average of 40 percent (16). Not surprisingly, the AHPA study found CON programs to be marvelously effective (17). Of 205 HSAs, 139 reported an aggregate of 5,717 short- term hospital beds disapproved, converted or eli- minated for an aggregate savings of $ 553 million; another $ 457 million that would have been spent on unnecessary renovations was also saved, for a total saving in in hospital - capital expenditures of over $ 1 billion. If all facilities (not just hospitals) are considered, $ 1.8 billion out of a total $ 7 bil- lion was saved, or approximately 25 percent of all proposed capital investment. Operating the 139 HSAs and related state agen- cies meanwhile, cost a total of $ 215 billion, for a rate of return of $ 8 saved for every $ 1 spent on CON programs. It should be noted, however, that the AHPA study was a quick - and - dirty one con- ducted for the purpose of arguing the HSA cause before an increasingly skeptical Congress and Ad- ministration. The results may only prove that ef- fectiveness is in the eye of the beholder. Conclusion: What Terms Effectiveness? HSAs in their regulatory role may achieve some modest preemptive cost savings. These are quite unlikely to dent the spiral of health care costs, however. It is in their planning role that HSAs perhaps have the most important contribution to make, al- though it may not earn them the necessary brown- ie points in Washington. It is the task of HSAs to constantly hold up the systemwide, long term - view of what cost effective - health care is. They must create a professional community and a public that understand the difference between short - term ex- pediency and long - term rationality; that under- stand that the causes of inflation lie largely in the increasing reliance on a high - cost, high technology - curative approach to the health problems of indivi- duals; that understand that effectiveness and cost savings will be achieved in a system that begins with a concern for the health status of the popula- tion and measures which affect it, a system which places public health, health promotion, preven- tion and primary care at its heart and not at its periphery; that understands that such a change will require a new model of what effective health care is, as well as a shift in resources and in politi- cal power within the health system. Defined in this manner, HSAs need not shrink from the task of cost control. There need not be a polarity between that which will ultimately save money and that which will prove most effective in meeting the health needs of the country. The key is in keeping the long - run, system wide view. Defined in this manner, HSAs also have reason- able tools with which to tackle the job. While they have pitifully little ability to exercise raw power, they have considerable ability to influence the climate of opinion within which health in- stitutions operate. Their power lies not in nose- to nose - regulatory confrontations, but in their ability to educate, organize, and catalyze. Their fate clearly depends on the speed and skill with which they can accomplish these tasks. -Ronda Kotelchuck Formerly Senior Policy Analyst, Health / PAC References 1. For a legislative history with an excellent discussion of different lobbies and compromises involved in PL93-641, see Lander, L., If At First You Don't Suc- ceed..., Health / PAC BULLETIN, No. 70, 1976. 2. Health Planning and Manpower Reports, August 16, 1978. 3. Bauer, K.G., The Arranged Marriage of Health Plan- ing and Regulation for Cost Containment Under PL93-641: Some Issues to be Faced, Harvard Univer- sity, Center for Community Health and Medical Care, NTIS HRP 0900130, December, 1977. Ibid., p. 221. 4. 5. 6. Idem. See Caress, B. & Kotelchuck, R., Politics make strange beds. Health / PAC BULLETIN, No. 77, 1977. 7. Bauer, op. cit. 8. Dorsey, J.L., Certification of Need Laws. Arch Surg., 106, 765, 1973. Cited in Chassin, M., Certificate of Need. In Medical Care, XVI, No. 10. Supplement, 1978. 9. Chassin, op. cit., p. 23. 10. Ibid., p. 22. 11. Jordan, W.A., Producer Protection, Prior Market Structure, and the Effects of Government Regula- tion. J. Law Econ. 15 (151), 1972. Cited in Chassin, op. cit., p. 22. 12. Health Finance Letter, September 25, 1978. 13. Salkever, D.S., & Bice, T.W., The Impact of Certifi- cation of Need Controls on Hospital Investment. Mil- bank Memorial Fund Quarterly, 54 (185), 1976. Cited in Chassin, op. cit. 14. Chassin, op. cit. 15. Hellinger, F.J., The Effect of Certificate of Need Legislation on Hospital Investment. Inquiry 13 (187) Cited in Chassin, op. cit. 16. Reported in Health Planning and Manpower Reports, August 30, 1978. 17. Selected Preliminary Results from a Survey of Health Planning Agencies: HSA Performance Under Certificate of Need and 1122 Programs, American Health Planning Association, November 28, 1978. 41 y -------- -------- -------- Tal Home Health Care BENDIS COMMODITY In December, 1977, the U.S. Comptroller Gen- OR OR eral's Office reported to the Congress on a broad COMMUNITY? review of needs for and costs of providing home health care for older people. Although noting that the current maze of home health care agencies and programs contain serious problems, the Report nevertheless concluded that: " Until older people become greatly or extremely impaired, the cost for home health services, including the large portion provided by families and friends, is less than the cost of putting these people in institutions " (1). This statement says a lot about the growing attention being paid to one of the oldest ap- proaches to health care, home - based services. In order to understand where home health care is " at " in 1978, however, some background is necessary. History and Potential In the most general terms, home health care has come to mean those health and medical services delivered to patients in their homes by professional and allied health personnel under the direction of a physician. The optimum goal is to fully restore the patient to health and / or obtain maximum re- 42 habilitation while causing the least possible dis- ruption to daily living patterns. In fact, home care is undoubtedly the first and oldest form of health care. Until the dawn of the twentieth century the home was the setting for illness and health care, and the family, assisted from time to time by midwives and healers, was the provider of health care. While hospitals entered the scene some two hundred years before, it has only been in the last 60 years that they were seen as anything but last resorts for the poor and those too unfortunate to have a family care for them. Not surprisingly early medical institutions under- stood and respected the roles of home and family in health care. In this country in 1796, the Boston Dispensary, an out patient - clinic that also provided home visits, was founded so that, " The sick, without being pained by separation from their families, may be attended and relieved in their own homes " (2). Ideals of service for the welfare of the poor were expounded. But, in fact, the Boston Dispensary home care programs provided practice for its re- sident physicians, setting a precedent that was to prevail for many years to follow: home care as an extension of hospital medical care. Visiting resident physicians, however, were eventually displaced by the organized public health Visiting Nurse Associations. First establish- ed in 1842, these organizations began to appear throughout the U.S. in the latter 19th century, often reflecting a religious philanthropic / philoso- phy that paralleled that of the nation's prolifer- ating hospitals. First established in 1842, Visiting Nurse Associations began to appear throughout the U.S. in the latter 19th century, often reflecting a reli- gious philanthropic / philosophy... Throughout the following century, home care operated quite separately from hospitals, transla- ting services and equipment, ordinarily appropriate to the hospitals, into the home. In the last three decades, however, as hospitals have emerged as a dominant force in the health system, so too have they come to dominate that which was to be their alternative. This trend was first marked in 1947 by Dr. E.M. Bluestone, then director of New York's Montefiore Hospital, who started a home health service based in the hospital itself. As hospi- tals became more crowded during this period, home care became increasingly hospital - linked. The theme song became, " get them out of the hospital. " Dr. Bluestone referred to home care as a " hospital without walls, " an extension of the hos pital's overall medical program. " If you have a 500 - bed hospital, and 50 patients on home care, you have a 550 - bed hospital, " he concluded (3). Indeed, the priorities of the mainstream medi- cal system have come to play an increasingly large role in modern home care. Some feel that the real antecedents to today's programs are the desire to keep the poor and / or uninteresting patients out of the hospital. Others see the trend toward hospital- based programs as a move by hospitals, ever wor- ried about occupancy, to keep tabs on potential patients and the potential income they represent. Meanwhile, many point to the potential of home care as a full fledged - alternative to institutional care. Where is the reality today? Theoretically, anyone who needs health care which can safely be delivered in the home may receive home care services. It is possible to purchase home health services privately and some health in- surance policies include home care coverage. Public funds pay for home care for the elderly who are eligible for Medicare or poor who meet the Medi- caid requirements. In fact, most home health care consumers in the U.S. today suffer chronic or long term - disability. This includes some younger persons, but the majority are among the group 65 and older. Home care encompasses a wide range of services and personnel. All skilled medical services, includ- ing those of the nurse, aide and therapist, are pro- vided under the direction of the patient's physi- cian, who draws up a treatment plan and evaluates and renews it according to program reports from the home health care professionals. Registered nurses may visit weekly, or even daily for a limited time to perform such broad nursing functions as as:: supervision supervision,, evaluation, teaching, and prevention; or more direct ones such as treatments, dressing changes, injections, blood. pressure readings, enemas, urinary catheter changes or treatment of bed sores. . b" ut as hospitals became more crowded in the 20th century, home care became increasingly hospital- linked with the idea being'get them out of the hospital ' Usually through the home care agency, the nurse has access to necessary equipment (e.g., syringes, catheters, bedpans, bandages, walkers, chair lifts). Further, the nurse may assign a nurses'aide to assist the patient with personal care bathing - , shampoo, etc. The home care agency often hires home health aides directly or may subcontract these services from other agencies as we will dis- cuss later. Home care agencies may also provide occupa- tional, physical and speech therapy as part of their services. Often, such rehabilitation requires direct services of the therapist. In many cases, however, family members or friends can be taught by the therapist to eventually carry out the rehabilitative therapy themselves. 43 In addition to medical home health services as provided through VNAs, hospitals, etc., there are social service agencies which provide those non- medical services essential to maintaining chroni- cally ill and disabled patients in their homes. Homemaker services are the most popular of these. The homemaker may assist with light housekeep- ing, chores and meal preparation (usually not ex- As the U.S. experiences the rapid growth of the population of'older citizens ', the need to develop home health care as an alternative to in- stitutionalization has pushed its way to the top of the priority list... ceeding 12 hours a week). In addition, transporta- tion services for groceries and physician appoint- ments are sometimes available. The most compre- hensive programs include " Wheels Meals - on -, " group meal sites and client advocacy programs. While a patient, or a patient's family may pur- chase these " social " services, just as they may pur- chase medical services, privately, federal funds are also available for these services under Title XX of the Social Security Act and Title III and VII of the Older Americans Act. Because medical services are funded separately under Title XVIII and XIX of the Social Security Act (more commonly known as Medicare and Medicaid), the effect is often a serious fragmentation of services. Based on an artificial and often detrimental dis- tinction between " medical " and " social " services, for example, the " homemaker " (a " social ser- vices " worker) is not allowed to touch the patient, whereas the " home health aide " (a " medical " worker) is not allowed to perform any services ex- cept direct patient care. While home care is as old as human history, today it enjoys an innovative status based on its potential for responding to two pressing problems in the current health care system: spiralling costs and increasingly impersonal and ineffective insti- tutionalization. This cost factor and the recogniz- ed importance of flexible support systems to the healing process point to home care as a real alter- native to institutional care. 44 As the U.S. experiences the rapid growth of the population aged 65 years and older, the need to develop home health care as an alternative to institutionalization has pushed its way to the top of the priority list in terms of sheer numbers. Ac- cording to the U.S. Dept. of Health, Education and Welfare (1976), older persons now comprise 10.5 percent of the total U.S. population. By the year 2030, the percentage of persons over 65 years in the population is expected to reach 17 percent. Already, the population of those aged 45 and a- bove account for almost third one - of our total po- pulation. As a result, there is an increase in the po- pulation at risk medically. The U.S. Senate Com- mittee on Aging estimates that nearly " 80 percent of those who are 65 and older are afflicted with one or more chronic and degenerative health prob- lem " (4). Cost Effectiveness: Much of the excitement about home health care centers on its reduc- cost - ing potential and this comes primarily from govern- ment officials assigned the task of trying to con- tain today's $ 180 billion health system (5). The 1977 Comptroller General's " Report to Congress on Home Health Care " calls for liberaliz- ing home health benefits under Medicare, such as eliminating the requirements that beneficiaries be confined to their homes and be in need of skilled . b" ut regulations and limitations which Medicaid Medicare / have es- tablished have reduced the scope of home health care, weakening its potential as an alternative to hos- pitals or nursing homes care, and limitations on the number of home visits. In GAO's view, the costs associated with these changes would not be prohibitive and could pro- vide disincentives to institutionalization (6). Human Growth and Health Promotion: Home health care also appeals to many as a more humane approach to care for those requiring some form of care other than the alternatives represented by in- stitutionalization. By contrast with the nursing home resident or hospital inpatient, the recipient of home health services, it is argued, can maintain interpersonal ties with family and friends, can pre- serve a greater measure of independence and self- worth, and can even, in many cases, continue the personal growth and creative activity that would be impossible within institutional walls. Further, it is increasingly recognized that insti- tutionalization, when mandated by the absence of alternatives, is frequently harmful. The iatrogenesis also be assumed to be competent and intelligent human beings capable of helping to define which services or parts of services are needed. The focus exclusively on the frail and incapacitated who are one step away from institutionalization allows all decisions to be made by the professional or pro- vider. It also creates dependency in many cases. New HEW regulations allow public and nonprofit home health agencies to subcontract services from propri- etary agencies. This was done osten- sibly to increase the availability of home health services... (treatment induced illness) and psychological trauma of institutionalization are suggested in the sharp rise in mortality for persons in the first few months after entering nursing homes. 2. Narrow concern with costs: Funding for home care is generally compared with expenditures for hospital or nursing home care over relatively short periods of time typically - , one year. Reim- bursements for home care services, furthermore, have generally been held quite low. Much of the interest seems to be to provide a cheaper short run alternative to the patient - day. Unfortunately, there is some evidence that the unwillingness to devote adequate resources to home care, however, robs the services of their health promotion poten- tial, reducing home care for many recipients to the status of custodial care. Unable to prevent deterio- ration and mounting illness, such home care " ser- vices " may simply become an " add - on " to institu- tional care thus resulting in higher overall costs. The Current Problems There is growing evidence, however, that the actual development of home care services in the U.S. may proceed to deny the potential that it in- tuitively offers. Among the problems that plague the actual delivery of home care are: 1. Medicalization: The focus of home care ser- vices is generally only upon that segment of the population that is virtually on the brink of institu- tionalization. By the time a person meets these cri- teria of course, he or she is quite likely to suffer from a number of serious medical problems and / or to be largely incapacitated. To develop its poten- tial as an alternative - and deterent - to institutional care, home care services would need to be made available to a much broader range of persons. At the same time these services should be geared to encourage already existing informal community / support relationships. Rather than assuming that the home care services recipient is totally depen- dent, such an approach would assume that he or she is part of a set of ongoing family and commu- nity relationships that, with perhaps some outside help or resources, could allow the older person to continue to play an active role in many ways. Po- tential beneficiaries, under this approach, would 3. Commodification and Fragmentation: Like much of the mainstream medical system in the U.S., home care has been seriously distorted by the underlying financial dynamics that pervade the ... but it makes the maintenance of quality and appropriateness of ser- vices a monumental task. Current mechanisms for maintaining quality are rather meager resources in the face of such severe fragmentation industry. Stimulated by a reimbursement system that pays for the delivery of certain categorical ser- vice " packages " (e.g., reimbursements are for " vi- sits " or " shifts ", not for health maintenance on a caseload basis or for treatment outcomes), services have become quite fragmented. Whereas once, a single nurse may have provided all the home care required by a given individual, today that same in- dividual may receive separate (and separately re- imbursable) visits from a case manager, a visiting 45 nurse, a home health aide, a physical therapist, a social worker, etc. Proprietary home health agencies are essentially private, profit making - businesses. Probably the largest and most widely known is Upjohn Health Care Services. Business Week reports, " " like other proprietary firms, Upjohn wants to compete for .but.but the fact is, the supply of home health aides has not increased in proportion to the number of ser- vices currently being delivered the Medicare and Medicaid dollar in all states. " Homemakers Home and Health Care Services, Inc., a subsidiary of Upjohn Co. of Kalamazoo, Michi- gan, reports that it supplied 20 million hours of service in a recent year. Assuming an average price of $ 5 or $ 6 per hour, sales would produce at least $ 100 million a year - a small bite out of the home health dollar (9). The reason for this somewhat limited role is that up until January, 1976, only voluntary or public home health agencies could be certified un- der Medicare and Medicaid regulations. Proprie. tary agencies could only receive Medicare or Medi- caid reimbursements in those few states having their own licensing laws. However, new HEW regulations, promulgated in 1976, allow public and non profit - home health. agencies - e.g., the local Department of Health or local Visiting Nurse Association - to subcontract services from proprietary agencies - e.g., Home- maker Upjohn. The responsibility for supervision and control remains with the contracting agency. This was done ostensibly to increase the availabi- lity of home care services but it promises to be a boon to the proprietary sector of the industry - who can now expect to increase their " relatively small portion " of available home health funding. In New York City, another form of subcon- tracting called " vendorization " (switching from direct provision of services to paying other agents or " vendors " to perform them) has been seen more recently as the City's Department of Social Services has begun to sub contract - the provision of homemakers and home health services to private 46 providers. A general cynicism on the part of com- munity and consumer activists accompanied this change. They pointed by way of warning to the recent scandals in New York's nursing home in- dustry, which represents an already " vendorized " sector. This concern was echoed by the New York Secretary of State who recently concluded that " the basic problems in home health care involve the concept of'vendorization'of these pro- grams " (10). In addition to the entry of an increasing num- ber of private providers into home care, some ob- servers have also pointed to the direct interests of hospitals that manage to exert substantial influence over the industry as well. Recently, a growing number of hospitals have developed a home health care department of their own. From the hospital's standpoint, there are at least two advantages in be- coming directly involved as a provider: 1. The hospital may directly recover a portion of the reimbursements available for home care. Generally, hospitals sub contract - most of the direct services provision to a " community agency " (e.g., Visiting Nurses'Associations - VNAs). How- ever, the hospital may be reimbursed for providing the case management or service coordination - ser- vices that the hospitals would ordinarily provide, ...... but one home health agency official said that the subcontracting process is labor ' busting, no ques- tion about it. thirds Two - of them are paid 10 above minimum wage and receive no benefits, not even Social Security or unemployment insur- ance. The new process is aimed at preserving the exploitation ' at least partially, anyway. Thus by becoming the contractor that hires the contractor (ordinarily a VNA or similar " community agency " provider), the hospital inserts itself directly into the home care continuum and recovers an extra layer of revenues in the process. 2. By developing a direct link with the home care population, hospitals and their medical staffs may more directly market the services they nor- mally provide. By functioning as the " back up " institutions, in other words, hospitals and physi- cians stand ready to increase their own revenues from direct patient care. The home care case load becomes part of the population " base " from which the hospital can routinely " recruit " in- patient admissions. One trend, then, beginning to emerge in the home care industry is a multi tiered - , fragmented system of subcontracting and sub subcontracting - of services stimulated by the provisions of third party payers. For a given patient, home care services may be provided by a hospital home health agency which subcontracts nursing care and supervision to a VNA association which, in turn, subcontracts the provision of home health attendant services to Upjohn Home Health Services. Obviously the maintenance of quality and in- suring appropriateness of services becomes a mon- umental task under such conditions. Current mechanisms for maintaining quality - case manage- ment by professional nurses or social workers, and certification of agencies by accrediting bodies - are rather meager resources in the face of such severe fragmentation. The Home Care Worker One serious repercussion -- and, some say, the real motivation - of the vendorization and subcon- tracting phenomena in home health care services is the generally degrading impact on the home health care labor force. Most home health attendants and homemakers have traditionally been underpaid and generally overworked. Some union representa- tives have characterized home health attendants as " the most exploited of service workers (11). One home health agency official recently con- ceeded that the vendorization and subcontracting process, in fact, is aimed at preserving that exploi- " tation. " It's labor busting, no question about it, the official noted. The vendor providers can often " deliver " a labor force made up of largely time part - workers, with minimal training and less likely to organize for better wages and working conditions than if these workers were employed directly by the public or " community " home health agency. Most homemakers and home health aides are Black and Latin women. A profile of a typical homemaker / home health aide is a middle - aged woman with several children who wants to work part time while her children are in school. " Two thirds of them are considered'independent con- tractors'by the city, and are paid $ 2.75 an hour, 10 cents above the minimum wage... and receive absolutely no benefits - not even Social Security or unemployment insurance.... Because of their low wages... these workers are themselves eligible for welfare benefits. Ironically, many workers I spoke to are'too proud'to apply for these benefits. Some are illegal aliens who are afraid... of apply- ing. Others were unaware of their rights " (12). Home health workers carry out extremely diffi- cult work in isolation; often caring for chronically ill patients for indefinite periods of time, with no opportunities for advancement. Adding insult to injury is the fact that the sup- ply of home health aides has not increased in pro- portion to the increase in the number of services currently being delivered. The White House Con- ference on Aging has estimated that while the total number of homemaker - home health aides employ- ed in public and voluntary agencies is currently 30,000 - there is a " total estimated need of 300,000 " (13). As a result, home health workers face increased case loads, chronic overwork, and frequent speed - ups; clients face harried workers with less and less time available to provide the quantity or quality of services which they may require. Not surprisingly, the turnover rate is quite high among home health workers resulting, of course, in a loss of continuity of care for clients. Such working conditions have recently led a number of unions to begin organizing home care workers in New York. To date, however, such organizing remains at the embryonic level. And it is likely to be some time before home care workers or their clients see substantial improvements. Conclusion From a service with a potential for humane and cost effective care, the current home health indus- try has so far developed a fragmented, discontinu- ous, and often inappropriate maze of services whose priorities are increasingly influenced by fin- ancial incentives and institutionalized medicine. Without substantial changes in the emerging patterns, home care will not " work " as a progres- sive alternative to institutional health care. What are the chances for such changes? What are the characteristics of home health services systems that do " work "? One way home care might " work " is suggested by the important role home health care serves within the British health care system. In Britain, the widespread use of home health care and the more generous funding devoted to 47 " domiciliary services " (as the British call them) re- flects a general national policy commitment to base health care and social services in the local community. Extensive experience in that country has led to the general belief that health care can be provided with greater quality and greater cost - ef- fectiveness if it concentrates as many resources as possible in the home and in the community, rela- tive to those concentrated in institutions. The British medical system, for example, pio- neered home treatment programs (e.g., for heart attack treatments) for illnesses that are ordinarily treated only in hospitals in this country. Institu- tionalization is seen as a solution of last resort in Britain, and home care services are integrated with- in the local community health centers that are the infrastructure of the National Health Service. In this country, of course, the immediate ques- tion is more that of how to address problems with- in the current system. This process must involve a willingness to move beyond a medical model of care. This means redirecting resources toward sup- porting the increasing number of older people in our population in their attempts to live creative, active lives as first class citizens of their communi- ty and their society. The implications for the emerging home care system in this country include: 1. Shifting provider control away from large voluntary agencies and hospitals and toward com- munity - based sponsors. In those countries where home care seems to " work " best it is tightly inte- grated with a truly community - based preventive and primary health care network. (In the jargon of U.S. home care, the term " community agency " is quite misleadingly used to refer to private, nonpro- fit providers that are neither hospitals nor govern- ment agencies. We use the term " community " here to refer, instead, to services that are actually pro- vided for and accountable to a discrete community or neighborhood.) The current dual control of home care services by institutional medical providers and institution- alized social service agencies is at the heart of many problems described above. The rigid separa- tion between " hands on " and " hands off " services seems to be more a product of warfare for " turf " between social work and health professionals in this country than the result of any needs based - planning. 2. Integration of the currently fragmented and 48 discontinuous pattern of services. The varied and poorly coordinated array of professional and para- professional roles that make up the current pattern of delivery can best be understood as a response to the poor reimbursement that has been provided for home care services in the past. As home care receives increased attention and funding from state and local governments, however, the answer to up- grading quality of care is unlikely to be as simple as replacing non professional - with professional. Rather, some serious rethinking and integration of current functions such as visiting nurse, home attendant, homemaker, home health aide, and housekeeper services, is long overdue. Again, it must be remembered that in the main, older peo- ple could often remain healthy and active longer without direct care if the services they received were geared to maintaining health and facilitating personal growth. A professionalism that all of- - to - ten creates dependency may not be part of such a solution. 3; Upgrading reimbursement and broadening eligibility for services. This requires a serious commitment of resources and funding to allow ex- pansion of services to include a broader range of the population. As long as the approach remains a " ditch last - " funding to prevent hospitalization, home care will remain an " add - on " expense in the overall spiral of health care inflation. 4. Fuller recognition of the rights and needs of older people for active, creative lives and services which they may take an active role in defining. Home care services would not be seen as merely services administered to " dependent " patients, but as providing tools and skills which contribute to the individual's needs and supplement personal competence. The focus of this approach would be to develop and recognize individual and group strengths. Most home care recipients in this country are older people, and the general state of home care services is not separable, in the final analysis, from the overall conditions of their lives. To be old in America is frequently to know chronic poverty, substandard housing, ill health and a sense of abandonment by the broader society and its ser- vices. No home care " industry " that generates standardized and narrowly defined " packages " of services will wholly redress this abandonment. What is called for, instead, is a wholly new and broader look at the requirements for life sustaining - and health promoting - networks of " kith and kin " for older people in their communities. This means adequate incomes, housing, nutri- tion, medical care and social services. It means put- ting maximum emphasis on allowing persons of older age to continue to work, play and love as active community members and, whenever possible, in their own homes. Home care approached in this way grows out of concern for the quality of life rather than the narrow economics of beating health care inflation. There are, here and there around the country, groups and programs beginning to attempt to ap- proach home care in this way. If readers would like additional information, inquiries - and other comments are welcome. -Cynthia R. Driver (Cynthia Driver is a Registered Nurse who worked as a visiting nurse in Indiana and is currently co- ordinator of The Nurses'Network. The author wishes to acknowledge the interviewing assistance and collaboration of Michael E. Clark of Health / PAC and Richard Surpin and Doug Dornan of the Mutual Aid Project for Older People, New York.) References 1. " Home Health - the Need for a National Policy to Better Provide for the Elderly, " Report to the Con- gress by the Comptroller General of the United States, (U.S. General Accounting Office, 1977), p.1. 2. C.F. Ryder, " Changing Patterns in Home Health Care, " (U.S. Department of HEW, 1966), p. 5. 3. Ibid., p.6. 4. " Home Health Services in the United States, " A Re- port to the Special Committee on Aging, United States Senate. (U.S. Government Printing Office, 1972), p.2. 5. " Unhealthy Costs of Health Care, " Business Week, Sept. 4, 1978. p. 59. 6. " Home Health - the Need for a National Policy to Better Provide for the Elderly. " Op. cit., p. 1. 7. " Home Health Care, Report on the Regional Public Hearings " (U.S. Department of HEW, Sept. 20 Oct -. 1, 1976), p. 2. 8. " Home Health - the Need for a National Policy to Better Provide for the Elderly, " op. cit. 9. " Unhealthy Costs of Health Care, " op. cit. 10. Selwyn Raab, " Investigation of Private Home Care Programs Urged, " New York Times, December 12, 1977. 11. Paul Du Prul, " Household Workers: Dirty Linen, " Village Voice, June 19, 1978. 12. Ibid. 13. " Home Health Services in the United States, " op. cit., P. 29. PROGNOSIS NEGATIVE: CRISIS IN THE HEALTH CARE SYSTEM edited by David Kotelchuck A NEW HEALTH / PAC anthology of many of the best recent articles from the Health / PAC BULLETIN, as well as important health policy articles from other publications. published by Vintage Books (Random House). Price $ 2.95 per copy plus 21d postage to: Health / PAC 17 Murray Street New York, New York 10007 49 t 50 Media Scan Every Child's Birthright: In Defense of Mothering by Selma Fraiberg. New York: Basic Books, 1977. Selma Fraiberg's book, Every Child's Birthright: In Defense of Mothering, has been appropriated by many as the final proof that working mothers jeopardize the healthy development of their children. One wonders how the same woman who wrote The Magic Years could write a book on mothering which, since its publi- cation a year ago, has become the theoretical backbone of reaction- ary movements among women. Overall the book has been taken to mean, as one New York Times reviewer wrote, " simply... that mothers are going to have to look after their children. " Actually, Fraiberg has not written such a reactionary book, but one that reads like two sepa- rate polemics. The first argues that a child who has formed no personal human bonds during the first year of life will show a marked impairment in the capaci- ty to form relationships later in life. In tone, and largely in sub- stance, this part of the book con- stitutes an attack on working women which is simply not sub- stantiated by Fraiberg's evidence, but which has been quickly ac- cepted by the right. The second part of the book, an excellent critique of social policy as it re- lates to mothers and children, is generally less know, even by those advocating mothers'and children's rights. In place of solid evidence Frai- berg begins the first section with a pseudoanthropological description of four tribes of women who con- vene to discuss birth and child- rearing. Tribes A, B, and C have their origins in rural Mexico, Africa, and India. Tribe D moth- ers live in North America and clearly represent American moth- ers. Tribes A, B, and C share many beliefs - that breastfeeding and certain methods of carrying child- ren are best for insuring physical contact with a child, small child- ren should be included in the care of siblings, childcare wisdom should be transmitted from one generation to the next, birth itself should occur in the presence of loving relatives and other women, and finally, women should be highly valued as mothers. Tribe D mothers are different. They feed their babies scientific formula in plastic bottles and argue that this is good for mothers who do not want to be tied down. Tribe D mothers exclude other children from childcare for fear of " sibling rivalry. " They learn about babies from books, doctors, and other new mothers, not from their own mothers and grandmothers who are busy playing tennis, studying pottery, and relaxing in the sun every winter. Finally, Tribe D mothers give birth in isolated hos- pital settings. Once their child is born, they feel a loss of self - es- teem because they feel they are just mothers. Unfortunately, this opening parable is difficult to read as any- thing but a condemnation of American women who, according to Fraiberg, have much to learn. from the exemplary women of imaginary tribes. A comparison of childcare in the United States with that of other industrial coun- tries might have been of more value. Fraiberg's criticism, here, applies principally to those middle and upper class women who have a choice about working. Unfortu- nately, this criticism can be used as well against the poor, middle and working class women whose choices about work and childcare are not free of economic and social constraints. In the absence of ade- quate data to support her thesis that working mothers jeopardize the health of their children, Fraiberg argues by analogy with imaginary primitive tribes, with romanticized grand- mothers of bygone days and finally, with other species women who are employed or seeking employment. " Were she mindful of those needs - and their effects on children, her criticisms might be more helpful. Weak Argument Not only does Fraiberg's tone reflect a lack of sympathy for American women, but her use of an anthropological paradigm is in- dicative of a serious methodologi- cal flaw in her entire argument against working mothers: in the absence of adequate data to sup- port her thesis, she argues by analogy with imaginary primitive tribes, with romanticized grand- mothers of bygone days, and fin- ally, with other species. Whereas Erikson made a significant contri- bution in Childhood and Society by demonstrating how child - rear- ing practices are uniquely adapted to the needs of particular socie- ties (1), Fraiberg's idealization of It is true that most women have not totally succeeded in wresting control of their lives from doctors who dictate sterile, isolated births, from experts who offer the wisdom of " scientific study, " and from a market which mass produces baby strollers and carriers. Nor have women always succeeded in creating new forms of community in the absence of available relatives or in gaining re- spect for their motherhood apart from whatever they produce for the society. But women do not deserve all the blame in a society whose priorities preclude quality day care, flexible work hours and situations, and the freedom to choose to work while still assuring the care of children. Fraiberg makes no claim to understand the constraints on women. She states that as the child's advocate she is " not mindful of the needs of These analogies cover up for her lack of evidence to support the connection she makes between maternal em- ployment and'diseases of non attachment - ' non existent -, tribal mothers is facetious and misleading, unre- lated to our present social and economic system. Actual cross- cultural studies showed that among six different societies, those with the least community sharing of child rearing - had moth- ers who were the most inconsis- tent and likely to harbor resent- ments unrelated to their child's behavior (2). While grandmothers may enlighten us to many aspects of childcare, ours is a different world, one already subject to too much nostalgia for the days of ex- tended families. Fraiberg's anal- ogy to bonding in other species makes the mistake of the socio- biological approach in general: evidence from animal behavior is simply not directly applicable to human behavior. Instead of pre- senting once again Harlow's and Lorenz'studies, Fraiberg might have looked at actual studies of the children of working mothers. Fraiberg's analogies, then, cov- er up for her lack of evidence to support the connection she makes between maternal employment and the " diseases of non attach- - ment. " Her discussion of children who fail to thrive is based on stu- dies done on children who lived in institutions or a series of foster homes, whose mothers either died or gave up their children. The anaclytic depression of these children is far different from the reactions of children whose moth- ers work. Yet Fraiberg makes the false connection between maternal employment and such pathology. She makes a further irresponsi- ble leap in her argument when she connects all forms of deviance- crime, insanity, drug addiction, and the inability to form relation- ships with inadequate bonding. Fraiberg herself admits that the Instead of presenting analogies of bonding in other species, Fraiberg might have looked at actual studies of the children of working mothers reduced presence of a mother often correlates with lack of money, poor housing, nutrition, 51 and health care. Yet she chooses to isolate poor mothering as the factor which determines deviance. This failure to integrate a political and social analysis into her argu- ment leaves the book open to use as ideology by the right. Ultimately, then, Fraiberg's argument cannot stand on its own. Had she actually looked at the studies done on the children of working mothers, she would not have found support for her argu- ment. In fact, as Robert Coles has pointed out, " research suggests that children of mothers who free- ly choose to work outside the home are better off, other things being equal, than the children of mothers who stay home but are discontented with full time moth- ering and homemaking " (3). In an extensive review of all the studies which " bear on the question of the family life of employed moth- ers " (280 in all, including those cited by Fraiberg), Mary C. Howell noted that the marked bias of re- searchers such as Fraiberg in this field cannot be supported by the facts. The family's attitude to- ward and the actual conditions of employment, as they bear on the mother's self esteem - and energy resources, were the factors which most affected children. Howell concluded, Children are likely to be positively affected by maternal employment, and attendant changes in family function, if the mother finds satisfaction in work outside the home and if she is supported by family members. It is impressive that a num- ber of studies report that the families of nonemployed mothers (husbands, children, and the mothers themselves) are strongly opposed to mater- nal employment, principally on the grounds that the family may be harmed. When mothers are successfully and enthusias- tically employed, however, the changes reported by their fami- lies, if anything, tend to be in a If One Picture = 1000 Words Then, 32 Pictures = 4 Health / PAC Bulletins HEALTH / PAC BULLETIN BULLETIN PRESENTS A COLLECTION OF DRAWINGS BY BILL PLYMPTON 52 A follo of 32 of Bill Plympton's best drawings from the Health / PAC Bulletin. $ 5.00 each. Please send me copies of the Plympton Folio Enclosed is $ Mail to: Health / PAC, 17 Murray Street, New York, N.Y, 10007, positive direction. The myth dies hard. (4) In the second part of the book Fraiberg moves to her discussion of policy. There she argues in de- fense of the rights of children with real understanding of the limited options available to women in our society. In this broader context, where all the blame does not fall on individual women, one can appreciate her argument for consistency in child- care, for greater attention to what we can all accept as sound psycho- logical principles - that children need to feel secure and loved, at- tached to particular people, and not arbitrarily shifted from care- taker to caretaker, from foster home to foster home. We are, in fact, not outraged enough at the way children are treated in this society. For this reason we can welcome Fraiberg's second argu- ment because here she critizes the social and economic policies which make good mothering so difficult for women in America. In the second half of the book Fraiberg carefully delineates the limitations of childcare as a result of legislative failure to allocate sufficient funds for quality ser- vices. She uses her thesis that children need a consistent care- taker to criticize a court system that decides custody and place- ment of children on the basis of funding and a notion of children as property. Finally, Fraiberg makes an excellent critique of AFDC policy. She points out that the WIN program has continued to cost more than the original AFDC payments and that, while compulsory work requirements have not been broadly enforced, the WIN program still allows for pressuring welfare mothers to work. She acknowledges that eco- nomic incentives, as slight as they might be, encourage welfare mothers to work and leave their young children to the poor care available to them. She makes a convincing case that AFDC pay- ments guarantee malnutrition, poor health care, and substandard living conditions for large num- bers of children. Again, the problem with the book is that Fraiberg's criticism of mothers in the first half of the book remains to be used against the very women and children she defends in her policy analysis later. For example, children who do not work out in foster and adoptive homes are now returned to agen- cies where there is an attempt to determine if some early trauma or lack of consistent caretaker means that the child is incapable of forming relationships. If that de- termination is made, he or she may be left in an institution. The situation for many foster and adoptive children is hopeless if our psychological understanding of their problems is used against them. The same misuse of Frai- berg's findings is possible in regard to AFDC mothers. Her defense of the welfare mother's right to care for her children without compul- sory employment, can be turned to equate working mothers with the unstable homes that produce " attached non - " criminals and deviants. Her views on day care argue for the allocation of greater funds for quality services that pro- vide consistent caretakers, yet even she sometimes stresses the hopelessness of day care, and by implication, the inadequacies of those who choose it. Reactionary movements among women have used Fraiberg's book to support an ideology that extols the nuclear family while condem- ning working mothers, that op- poses day care, the ERA, and quality of work laws. In respond- ing to this, the left must avoid being forced into the false posi- tion of opposing the family and motherhood. Instead, the left can shift the blame from individual women to focus on the failure of American society to create eco- nomic and social structures which allow women work and childcare choices which will not jeopardize the mental health of their children. The left must be clear that the issues about child rearing - go be- yond raising children capable of forming relationships, as important as that is. We must concern our- selves with raising children with a social conscience, a commitment to equality, and a respect for peo- ple from other ethnic and cultural groups than their own. We must think of how childcare can in- volve fathers and other adults. We must demand that our work in- clude childcare provisions. We must bring the issues related to adoption and foster care into the open. We must, somehow, take re- sponsibility for all children. -Kathy Conway 1. Erikson, E.H. Childhood and Soci- ety. New York, W.W. Norton, 1963. 2. Minturn, L., Lambert, W.L. Mothers of Six Cultures: Antecedents of References Child Rearing. New York, Wiley, 1977, 1964, p. 64. 4. Howell, M.C. " Employed Mothers and Their Children. I & II. " 3. Coles, R. " Talk with Selma Frai- berg, " New York Times, Dec. 11, Pediatrics 72: 252-263, 327-343, August and September 1973. 53 Ke 0 : 7 (({te e ZENDLE Assessing the Efficacy and Safety of Medical Techno- logies. Office of Technology Assessment, Congress of the United States. Washington, D.C.: U.S. Government Printing Office, 1978. The heart of this report is the re- view of 17 widely practiced medi- cal interventions (1). These proce- dures were selected to illustrate the main issues in the assessment of efficacy and safety in medicine, and the enactment of policy on this basis; they were not meant to be representative of medicine as a whole. The results of the 17 cases are also enlightening in their own right; as it happens, however, the situation in medicine is even worse. The largest group of proce- dures reviewed - 10 out of 17- have little or no efficacy, pose de- finite hazards to health, are alrea- 54 dy widely used at great cost, and are fully reimbursed by third par- ty payers. These 10 procedures ac- count for about $ 6 billion of the roughly 10 $ billion total cost of the 17 taken together. The most costly and striking of these 10 are hysterectomy, coronary artery by- pass grafting, chemotherapy for lung cancer, tonsillectomy and ap- pendectomy, which combined ac- count for $ 4.7 billion in annual costs. If the current rate continues into the future, more than half of all US women will have had hyste- rectomies by age 65. The evidence reviewed by the Office of Techno- logy Assessment (OTA) clearly implies that the risks of surgery, of postoperative complications, of increases of other diseases influ- enced by ovarian hormones and of negative psychosocial psychosocial impacts considerably outweigh the health benefits when hysterectomy is this widely applied. For the remo- val of uterine cancer or the correc- tion of certain obstetric catastro- phes, there are very clearcut net benefits from hysterectomy, but the subgroup to which this bene- fit applies is small (2). The situation for coronary ar- tery bypass grafting to relieve an- gina is similar. Several studies show no gain in either relief of an- gina or life expectancy for bypass grafted patients compared with matched patients treated by the usual drug regimens. In only one study is there a subgroup of less than ten percent for whom there is a small but statistically signifi- cant increases in life expectancy (3). In addition, the evidence col- lected allows comparison not only with drug treatment, but with a placebo a sham operation in which the chest is opened and an irrelevant procedure carried out on patients with a similar distribu- tion of chronic angina and history of heart attack. The interesting finding in this, as well as most o- ther placebo controlled - scientific studies of medicine, is that a pro- pendicitis and the prevalence of appendectomy rise and fall to- gether in epidemiological compari- the main element in the effective- ness of hospitalization (10). Like appendectomy, tonsillec- perly administered placebo does very well in producing the im- sons. This and other evidence clearly implies that, throughout its history in the Twentieth Cen- tomy peaked in the 1930s and has been declining since; it still ranks as the third most commonly per- tury, appendectomy has increased formed operation, however. Like The wide and random use of antibiotics represents a substantial threat which may out- -rather than decreased mortality - risks associated with inflamed ap- pendices. The incidence of appen- dectomy has been declining since the 1930s and since the mid hysterectomy, there is a small sub- group of the total of patients, those whose inflamed tonsils are large enough to obstruct breathing or swallowing, for whom tonsillec- weigh the benefits of 1960s a policy of bed rest under tomy might seem of immediate, their proper use in a much smaller population thoughtful watch in hospital has developed, allowing rest and care to promote the body's own mech- anisms for decreasing the inflam- obvious benefit. The existing stu- dies are not sufficient to show net benefit for any other group and the risks, although smaller than in mation. operations on older people, can- provement ordinarily attributed to the specific surgery or drug treatment. For both coronary ar- tery bypass grafting and the sham operation, over 70 percent of the patients experience relief of an- gina and some extension of life expectancy (4). The efficacy of a specific tech- nique cannot be measured merely by recording the improvement of treated versus untreated patients, since a placebo, properly admini- stered, can in most cases produce the same improvement without the hazards of the so called - tech- nically designed intervention. In a Excessive and irrational prescribing of drugs adds to the growing problem of adverse reactions. In one year, between 100 and 200 Americans a day were believed to have died as a result of adverse reactions There is a very similar story, not be ignored. A well designed - clinical trial is now in progress which will help decide what pro- portion of tonsillectomies yield net benefit (11). Controlled trials of chemothe- rapy for inoperable lung cancer demonstrate that both radiother- apy and chemotherapy increase the lifespan of patients somewhat less than one year, as compared to placebo - treated patients with simi- lar disease (12). Examining out- comes more comprehensively, be- tween 1940 and 1950, only one- third of patients diagnosed as hav- ing lung cancer were treated. the case of angina, it is also possi- not covered in the report, for ul- ble to cure the condition with a cer therapies, none of which un- pill placebo or other noninvasive methods (5); in contrast, the re- ported direct mortality from coro- nary artery bypass surgery varies in these studies from 0.3 percent to 8 percent (6). til recently * produced any greater improvement than simply hospita- lizing the patient (9). Both ulcer and inflammation of the appendix have important causes in social stress, and the temporary relief of The most commonly prescribed drugs, Valium and Librium, do not work any better than a placebo. In fact, The risks of invasive mechani- cal interventions, as compared stress which is possible by extrica- ting a person from the tension - rid- the placebo may cure more with psychosocial suggestion as a den primary network is probably method of treatment, are high- lighted by the evidence cited for * duration Long - , double - blind, control- led trials of Tagamet, the latest chemi- From 1960 to 1970, 75 percent appendectomy (7). Although no controlled clinical trials have been cal nostrum in ulcer treatment, have not yet been conducted. Ulcers do heal of such patients were treated. Yet rapidly during treatment, but reappear the five year - survival rate among carried out, the death rate for ap- when the drug is withdrawn (8). lung cancer victims (8 percent for 55 males, 10 percent for females) did not change between 1950 and 1970. These survival rates apply to patients treated by all methods, including surgery, immunotherapy radiation and chemotherapy (13). Clearly, current therapy for lung cancer has very little net benefit. Total current lung cancer treat- ment absorbs at least $ 5 billion yearly (14). Two more technologies re- viewed in the report electronic - fetal monitoring and its conse- quent increase in rates of Cesarian section, and routine diagnostic use of skull X together - rays - account for almost $ 500 million in costs and raise wider questions about other similar technologies not covered in this particular report. As with many other new diag- nostic technologies, electronic fe- tal monitoring seems to be based on a solid, scientific rationale: a- mong low birth weight infants fetal distress occurs at higher rates than in normal infants and contri- butes fundamentally to the ele- In the late 18th Century, it occurred to a number of Viennese doctors that bed rest, good food and humane, caring attention was far superior therapy for more diseases than the various nostrums of the day. We are discovering much the same thing 200 years later vated risk of low birth weight. Fe- tal distress can be detected by e- 56 lectronic fetal monitoring of the fetal heart rate and blood chemis- try, making possible prompt C- section to deliver the baby before brain damage or other irreversible injury can occur. Exactly the same sort of rationale underlies the massive development of coro- nary intensive care units since a- bout 1960, and the massive push in the 1970s to get people into such units as quickly as possible after heart attack by improved networks of ambulance and emer- gency services. For both coronary care units and electronic fetal monitoring, controlled trials and epidemiolo- gical comparisons show no net be- nefit in survival or health associat- As much as 90 percent of current medical procedures have been brought into wide practice on the basis of qualitative impressions of clinical practitioners ed with the new procedures des- pite large and escalating costs (15, 16). The current cost of electronic fetal monitoring and its associated multiplication of the rate of C sec- - tion is about 300 $ million, and there is a clear pressure to equip all institutional childbirth environ- ments with fetal monitoring e- quipment (17). The costs of CCUs are much larger - at least $ 6 billion yearly (18), and more if all the di- versified delivery services are in- cluded. In both cases it is apparent that the introduction of monitor- ing technology and the more re- stricted, disruptive and impersonal routine of the new units impose psychosocial stresses which negate any possible benefits of more prompt medical intervention. In the case of electronic fetal moni- toring there is the additional pro- blem of determining whether the a Much of technical medicine is relatively worthless and risky, and it really hasn't reduced death rates or improved people's health. More important for these have been and continue to be good food, rest and humane care ee small and temporary changes in fetal heart rate and blood chemis- try now detectable are indeed va- lid indications for intervention by C section - . The criteria are current- ly not based on controlled study and favor prompt intervention for small changes. The result in many hospitals is that over 50 percent of births are now delivered by C- section, with the elevated risks this entails (19). The problem with routine diag- nostic use of skull X ray - is that the great majority of such use is for conditions which cannot be re- vealed by skull X ray -. As the OTA report puts it (page 38): " Skull X- rays have little direct impact on therapy because the underlying brain damage, not fracture, is the critical variable for treatment- and brain damage does not appear in X rays -. " Currently, skull X rays - cost about $ 250 million annually (20). Skull X ray - is only one exam- ple of the pervasive process in modern medicine by which the mere technical ability to re- veal underlying features within the body is automatically deve- loped and widely applied, regard- less of the therapeutic usefulness of this development. This is a point now well understood by the medical and public health com- munity for chest X ray -. In a pre- vious report, the OTA summariz- ed the evidence supporting this description of computerized axial tomography, or CAT scanners (21). The OTA report also reviews the evidence that prophylactic an- tibiotics in intestinal surgery yield little net benefit (22), that antihis- tamines and decongestants rou- tinely prescribed by doctors in treatment of otitis media are inef- fective (23), and that hyperbaric oxygen treatment for cognitive deficits in the elderly is worthless (24). These are all examples of the medical tendency to bring a treat- ment into routine use on the basis of a simple theory of what should work, not on the basis of direct experimental knowledge. The appalling situation describ- ed for this large group of therapies is in fact an understatement, as the OTA report briefly explains (25). The effectiveness and risk measures emerging from the con- trolled trials of the procedures are usually the work of the most com- petent and scientific of the specia- list practitioners in a given area. These measures do not reflect, therefore, the average efficacy or safety in the general medical use of these procedures, which is worse than that reported in con- trolled studies. Properly used antibiotics, for example, are highly effective and relatively safe against a wide varie- ty of bacterial infections. The same cannot be said for the aver- age medical use of antibiotics. The most common kind of antibiotic misuse is prescription of a drug to which the patient is allergic, the result of thoughtless overprescrip- tion of antibiotics in general (26). In one study, 14 percent of pa- tients treated with antimicrobials experienced adverse reactions and 90 percent of these adverse reac- tions were associated with un- necessary or inappropriate thera- py (27). Patients also die unneces- sarily because antibiotics are given without checking for the presence of resistant organisms (28), and because toxic antibiotics, such as chloramphenicol, are too widely used despite warnings (29). Such irrational _ prescribing contributes to the growing pro- blem of adverse drug reactions (30), which have come to be a sig- nificant cause of illness and even death. Between 100 and 200 Am- ericans a day are believed to have died as a result of adverse reac- tions to prescribed drugs in 1971 (31). Thus adverse drug reactions cause about as many deaths as motor vehicle accidents (140 deaths a day in 1971). As with the case of hysterec- tomy described above, antibiotics this widely and randomly used re- present a substantial threat which may outweigh the benefits of their proper use in a much smaller population. This is especially true in a country like the United States for which improved nutri- tion, environmental sanitation and immunization play the fundamen- tal roles in the reduction of infec- tious disease prevalence. On the grounds of the average medical use of antibiotics today, one might well seek to eliminate the technology altogether, despite the clearcut efficacy and relative safe- ty in controlled trials. Clearly, the appropriate use of antibiotics in the restricted group for which there is benefit is the proper poli- cy, but this discussion illustrates the gulf which separates average medical practice from the results reported in controlled trials. At the other end of the spec- trum from the ten procedures just described are a smaller group of preventively - oriented technologies which are demonstrably effective and safe, but which are generally not fully funded by third party payers. The report reviews the his- tory of the struggle to establish the usefulness of the Pap smear for preventing the progression of cervical cancer from its earliest stages (32), and the difficulties surrounding the effective popula- tion use of drug treatment for es- sential hypertension (33). The risks and benefits of mammogra- phy (34) and the sociopolitcal questions surrounding amniocen- studied until after the second World War. The sciences of medi- cine, as opposed to basic biologi- cal science, is quite recent and the (36) and multimodal therapy for Hodgkin's disease (37). Although the cases selected for the report were based on the knowledge of panel specialists in particular areas, the picture that emerges is not unrepresentative of medicine as a whole. By and large, modern medicine spends a great deal of money and effort on inef- fective and risky attempts to cure the endstages of diseases that have developed over decades prior to treatment. Attempts to prevent these diseases are underfunded and almost always contested by the medical establishment. Science and Scientism in Medicine These results seem striking and even iconoclastic; part of the rea- son for this impression is that most people, doctors included, be- lieve that medicine has been a sci- ence at least since the mid 19th - Century. In fact, the procedures of medicine were not scientifically 57 studied until after the Second World War. The sciences of medi- cine, as opposed to basic biologi- cal science, is quite recent and the studies reviewed above are some of its first fruits. This fact may seem surprising, so it will be worthwhile to briefly review the history of science in medicine, a subject the OTA report touches briefly (38). Causal understanding in sci- ence can only be based on direct experimentation involving control of all relevant variables. Until re- cently, medical treatments were derived from the various theories that unified and explained the de- scriptive and sometimes experi- mental data of basic biological and physical science. In the late 18th Century, for example, analo- gies to Newton's theory of gravi- tation and physical mechanics de- rived from it were developed in medicine. In the 19th Century, a- nalogies to chemistry and micro- biology prevailed, and the early 20th Century was marked by the mass overuse (39) of unseen radia- tion to reveal hidden structure, on analogy to developing atomic and nuclear physics. Today, the trendy thing is microminituriza- tion of electronics and computers, reflecting the enormous advances in solid state - physics in the 1960s. As the overall theories of " basic " science sometimes changed drasti- cally from one period to another, so did the vogues of " scientific " medical treatment (40). This general tendency to justi- fy medical procedures solely by analogy to basic scientific theory can be termed scientism, to dis- tinguish it from the real practice of science in medicine. Scientism converts knowledge gained in oth- er areas of thoughtful experience into symbols used in the psycho- 58 social practice of interpersonal healing. These symbols are impor- tant to medicine, not because they work " technically, " but be- cause they reinforce the world. view of society by use of its ap- parently most powerful forces. As the OTA report points out, a situation favorable to scientism still prevails in medicine. Possibly as much as 90 percent of current medical procedures have been brought into wide practice on the basis on qualitative impressions of clinical practitioners, without use of control groups, on very small numbers of studied patients. These procedures are transmitted from generation to generation in medicine by clinical and class- room experience in medical school, residency and special courses, environments in which students naturally assume that be- cause a procedure is used it is therefore scientifically valid. Phy- sicians do not base their practice on a critical reading of the litera- ture of controlled trials or animal experimentation, much less exper- imental thought within their own experience. Experimental science in medi- cine has a prehistory, the period in which the practice of deliberate experimentation and control gra- dually developed. In the late 18th Century, for example, the Vienna clinic under van Swieten and de Haen produced the first large cor- pus of exact case histories of pa- tients, including not only the symptoms, course and postmort- em anatomy of diseases, but also every treatment applied and the results. From cross comparisons - in this systematic and comprehensive re- cord of every person treated, the leaders of the Vienna clinic grad- ually became convinced that bed rest, good food, and humane, car- ing attention were the best thera- py for most diseases. They called this " expectant " or waiting treat- ment, and viewed it as noninter- vention. So far did the Vienna clinic go in the elimination of the specific nostrums of the various scientistic schools that they were widely accused of " therapeutic nihilism " (41). The systematic cross comparisons - of case histories underwent a further wave of de- velopment in the late 19th Cen- tury. In this period, simple com- parions again demonstrated the worthlessness of the great mass of scientistic medical treatments (42). The comparative evaluation of treatments from the 18th Century onward really constitutes the pre- history of scientific method in medicine, largely because of the lack of deliberate control. Addi- tional precursors of medical sci- ence in the United States occurred in the 1938 and 1961 legislative changes which resulted in the pre- market experimental testing of drugs, and to some extent equip- ment, for both safety and effica- cy. These tests are conducted largely on lower animals, involve small numbers and short periods of high dosage - use to determine immediate toxicity, as opposed, for example, to long range - carci- nogenicity, and are generally inad- equately controlled, as explained below. Yet these changes resulted in the elimination of the majority of drugs in the medical compendia prior to 1938 (43). The first fully developed ex- amples of scientific method in me- dicine and psychiatry came in the 1950s with the first blind, rando- mized, controlled trials in hu- mans. The importance of conduct- ing the studies on humans and of having a thoroughly blind metho- dology is nicely illustrated by an example from psychiatry (44). In this experiment, chronic hospita- lized schizophrenics receiving nor- mal doses of phenothiazine were switched to placebo by the experi- menters, without the patients, treatment staff, or patient asses- sors being aware that a study was even being conducted. Thus, this was a " triple blind " study. In the first few weeks after placement on placebo, the placebo group did better than the matched group of patients who remained under phe- nothiazine as before in various so- cial learning tasks that were part of the hospital's normal social the- rapy program. Subsequently, the two groups did equally well in learning performance and in clini- cal appraisal of psychiatric status. Clearly, the bottle believed by nurses and patients to contain a potent drug worked wonders re- gardless of its chemical content. The Placebo Effect and Healing Perhaps the largest causal ef- fect in scientific medical studies is the interpersonal healing impact which appears in these studies most often as the effect of the placebo control. In all scientific medical evaluation studies, the theoretically inactive substance, instrument or procedure, given in the same setting and in the same way as the technically designed procedure, will always improve or cure a fraction of the patients. In the VA study of antihypertensive drugs, for example, all prospective patients were first placed on pla- cebo for two to four months, and the large fraction whose diastolic blood pressure dropped below 90 mm Hg. during this time were ex- cluded from the study. In the main study that followed this weeding out of placebo respond- ers, 40-50 percent of the men on placebo still showed significant declines in blood pressure (45). If such a study is done so as to optimize the placebo effect, the placebo will in most cases cure or improve as large a percentage as the supposedly efficacious inter- vention. The studies of coronary bypass surgery reviewed above, for example, show that a theoreti- cally useless operation, sham ope- ration as a control for mammary artery ligation, cures angina in over 70 percent of the sufferers, a percentage comparable to that found in the coronary artery by- pass graft surgery studies (3, 4). And again, the first and fourth most commonly prescribed drugs, Valium and Librium, work little better for their specific indica- tions than placebo in double - blind controlled trials (26). In the OTA report, as in the deliberations of the FDA, or any ordinary medical discussion of the efficacy and safety of drugs, e- quipment or procedures, the signi- ficance of the placebo effect is u- sually misunderstood. A proce- dure is usually considered effica- cious it is improves or cures a greater percentage of matched pa- tients than the placebo. It is con- sidered relatively safe if impair- ments or death in the treated group occur at a lower rate than a- mong untreated people. If, how- ever, a properly administered pla- cebo can cure or improve the same or even a consider- ably lesser fraction, while involv- ing no technical increment of risk compared to the untreated, the placebo will in many cases be the treatment of choice, a possibility excluded in the routine way of thinking of this issue. Or, to put the issue in its real setting, nontechnical interpersonal healing interactions are the meth- od of choice indicated from most scientific medical evaluation stu- dies. Rather than " therapeutic ni- hilism, " the true harvest of sci- ence in medicine is a substantial body of worthwhile treatments: extrication from stressful social situations, empathetic care, rest, good food, and symbolic interac- tions which may costlessly maxi- mize the interpersonal healing im- pact. The Possible Political Impact of the OTA Report These considerations, especial- ly concerning the placebo effect, are very relevant to the political substance of the OTA report. The message of the report is really very simple and could have been put in a much shorter space: sci- entific medical evaluation studies show that much of technical me- dicine is relatively worthless and risky, and third party payers should not reimburse the perfor- mance of this part of medicine. This substance is couched very cautiously; it is written as though by summarizing facts, the authors were thereby committing religious transgressions, as indeed they are. The summaries of the review of each technique, for example, are written in the most favorable possible terms to the medical pro- fession, and in some cases almost ignore the facts recounted in the immediately preceding para- graphs. The studies are surround- ed fore and aft by tens of pages of rigid bureaucratese, which give the appearance of carefulness and or- der while creating a jungle of an- lytical points and policy recom- mentations. This timidity becomes even more evident in a comparison of a draft of the original report written in 1977 with the published ver- sion. In the original, many issues are squarely confronted in terse prose, that are here eliminated from consideration. In the evi- dence for each procedure, as much selected " recent evidence " 59 favorable to the procedures is ad- ded, though this evidence is most often not scientifically compar- able to that from controlled stu- dies. Overall, the report obviously reflects a political situation in the government and in medicine in which the appearance of science holds sway and frowns upon the policy use of real science. Hidden in the complex bureau- cratic proposals for how to use the information from scientific studies of medicine are comments very revealing of this situation. The most direct way to use this information would be to have the FDA base regulatory decisions upon it, as it already does for drugs and to some extent for in- struments. This alternative is not taken seriously by the report, however, since the " FDA is basi- cally a regulatory agency and may not be able to attract the scient- ists necessary for regulating pro- cedures. Furthermore, FDA's ne- gative image with the practicing community would hamper its work (p. 102 Physicians).... would undoubtedly resist such regula- tion. The process would be expen- sive and could retard innovation " (p. 104). The information must be ga- thered and synthesized from his- torical and ongoing controlled clinical trials, and NIH currently funds the greatest number of such trials. According to the OTA re- port, however, " a system for iden- tifying technologies that need as- sessment could be developed in a number of agencies at various le- levels.... NIH has exhibited a stronger interest in developing me- dical technologies than in assess- ing them (p. 99 NIH).... could as- sume a larger role in testing both new and existing technologies for efficacy and safety. Not only has 60 NIH been reluctant to assume such an expanded role without new funding, but also NIH has re- sisted becoming deeply involved in existing medical practice (p. 101 NIH).... could undertake the task of synthesizing efficacy and safety information; however, NIH has shown little inclination to make judgements that could be used by regulatory agencies (p. 102 NIH).... could refine and expand its (information) dissemi- nation efforts However.... , NIH is reluctant to expand its role in this area, particularly in regard to practicing physicians " (p. 103). These comments about the FDA, NIH and other government bodies assume added signficance when we realize that they are practically quotations of what the heads of these agencies said to the OTA panel in interviews, as the first draft of the report notes. With the obvious ways of solv- ing the problem politically exclud- ed, the report focuses on a num- ber of government agencies which have been legally established to control reimbursement depending on the quality, efficacy and safety of procedures; but, according to the report, all such agencies have either lacked the expertise or the political clout to carry out the task, or, like the PSROs, have been dominated by the medical profes- sion and therefore rendered inef- fective. In response to the OTA report, Congress has just passed a bill, which President Carter is ex- pected to sign, establishing yet another such agency in the goven- ment at $ 25 million a year (46). A careful reading of the OTA report therefore raises a curious and troubling question: Now that science is finally possible in medi- cine, who will bell the cat? One might think that conservative mid- class dle - government cost cutters would see this as a way of lighten- ing their own tax and insurance burdens, and indeed they have been an important political force in the closing down of public hos- pitals and clinics. But these clos- ings, far from limiting the useless and dangerous parts of medicine, have instead had the greatest im- pact on the preventive and pri- mary care end, and have done no- thing to slow the avalanche of new high technology treatments of dubious merit. This result is really not surprising, since this constituency is composed in part of doctors, researchers, statisti- cians, accountants, construction company managers, drug com- pany personnel, admen, banking executives and a myriad of others whose personal self interest - is bound up with the triumph of the leading growth industry. Corporate planners interested in cutting benefit costs of control- ling worker unrest on occupation- al health issues might be possible candidates, through corporate- sponsored HMOs of Nixonian de- sign (47). While it is true that HMOs generally have lower rates of hysterectomy or other dubious medical procedures than fee for- - service institutions (48) and that important evaluation studies have been done in England under the pressure of enforced budget ceil- ings or outright reductions, the e- conomies in these organizations are not necessarily related to effi- cacy. Further, these organizations still show great excesses of unnecessary curative medicine, and are little better at preventing the social causes of disease, des- pite the putative financial incen- tive in this direction (49). Perhaps in estimating their future one should be reminded that scientis- tic medicine was legally establish- ed and massively funded by the corporate foundations not be- cause it was medically effective, but because it was necessary for political and social control (50). As this necessity has not disap- peared, neither will scientism. Reflection on the history of what actually has reduced death rates and improved people's health demonstrates the effective- ness of procedures long advocated by nonestablishment forms of me- dicine nutrition - and environ- mental health (-while 51) the evi- dence of controlled trials in scien- tistic medicine points to the im- portance of interpersonal healing and stress reduction in cure. A popular health movement practic- ing these measures is growing in the United States and other deve- loped countries today. A bridge needs to be built be- tween this movement and the practice of scientific evaluation in medicine. This is particularly true in the scientific study of interper- sonal healing phenomena. It will not be an easy bridge to build, since nonestablishment forms of medicine have for so long been ar- rogantly suppressed by scientism that they have often rejected the scientific habit of thought and in- quiry in reaction. Beyond this bridge lies the possibility of challenging the po- litical, social and economic autho- rity which scientism defends. The 1980s promise to be a decade of great social unrest and instability, so this challenge may be possible (52). If not, we shall be back to the surrealistic situation in which genuine science challenges the mi- rage of science, and loses. Like the situation of the nonscience of nu- clear waste handling and storage, this situation in medicine is a pre- monition of the nightmare of the mind which lies ahead in the world order constructed by ram- pant scientistic Progress. -Joe Eyer 1. Pages 26-56 in the OTA report. For each controversial point below, I will cite the relevant pages in the re- port and the documentation which the OTA has marshalled in this area. If the point is not contained in the OTA report, I include my own refe- rence material. 2. OTA pages 47-8; Cole, P. Elective hysterectomy: pro and con. N. Engl. J. Med. 295: 264, 1976. 3. OTA pages 42-44; The Veterans'Ad- ministration Cooperative Random- ized Study of Surgery for Coronary Arterial Occlusive Disease, Circula- tion 54 (suppl. 3), Dec. 1976; Klos- ter, F. et al. Prospective randomized study of coronary bypass surgery for chronic stable angina. Circulation 52 (suppl. II): 90, 1975; Mathur, V.S. and Guinn, G.A. Prospective ran- domized study of coronary bypass surgery in stable angina. Circulation 52 (suppl. 1): 133, 1975; Seldon, R. et al. Medical versus surgical therapy for acute coronary insufficiency. N. Engl. J. Med. 293: 1329, 1975; Braunwald, E. Coronary artery sur- gery at the crossroads. N. Engl. J. Med. 297: 661-663, 1977; Murphy, M.L. et al. Treatment of chronic stable angina. N. Engl. J. Med. 297: 621-627, 1977; NHLBI National Co- operative Study to Compare Medical and Surgical Therapy of Unstable Angina Pectoris. Summary Report to the American College of Cardiolo- gy Meeting, Las Vegas, Mar. 6-10, References 1977; Seides, S. et al. Long term an- atomic fate of coronary artery by- pass grafts and functional status of patients five years after operation. N. Engl. J. Med. 298: 1213-1217, 1978; McLaughlin, R. et al. Saphe- nous vein bypass grafting: changes in native circulation and collaterals. Circulation 51-52: I 55 - to I 77 -, 1975; Maurer, B.J. et al. Changes in grafted and nongrafted coronary ar- teries following saphenous vein by- pass grafting. Circulation 50: 293- 300, 1975; Hartman, C.W. et al. A- ortocoronary bypass surgery: corre- lation of angiographic, symptoma- tic and functional improvement. at one year. Am. J. Cardiol. 37: 352- 357, 1976; Hammermeister, K.E. et al. Aortocoronary saphenous vein bypass: failure of successful graft- ing to improve left ventricular func- tion in chronic angina. N. Eng. J. Med. 290: 186-192, 1974; Scheidt, S. et al. Unstable angina: medical management - or surgery. Cardio- vasc. Med. 541-543 2: , 1977; Hutter A.M. et al. Unstable angina pectoris. national randomized study of surgi- cal versus medical therapy: results in one, two and three vessel disease. Circulation 55-56: Suppl. 3: III 60 -, 1977; Takaro, T. et al. The VA Co- operative Randomized Study of Sur gery for Coronary Arterial Occlus- ive Disease. II. Subgoup with signi- ficant left main lesions, Circulation 54: Suppl. 3: III 107 - to 117 III -, 1976. 4. Cobb, L. et al. An evaluation of in- ternal mammary artery ligation by a double - blind technique. N. Engl. J. Med. 260: 1115-1118, 1959; Beecher, H.K. Surgery as a placebo: a quantitative study. JAMA 176: 1102-1107, 1961; Dimond, E. et al. Comparison of internal mammary artery ligation and sham operation for angina pectoris. Am. J. Cardiol. 5: 483-486, 1960. 5. Beecher, H.K. Increased stress and effectiveness of placebos and " ac- tive " drugs. Science 132: 91-2, 1960; Beecher, H.K., Measurement of Subjective Responses: Quantita- tive Effects of Drugs, Oxford Uni- versity Press, New York, 1959. 6. OTA page 43. 7. OTA pages 45-47; Acute Abdominal Conditions Research Group, Some problems in nonoperative treatment of acute appendicitis, Clin. Med.J. 2:21, 1974; Coldrey, E. Five years of conservative treatment of acute appendicitis, J. Int. Coll. Surg. 32: 255, 1959; Lemboke, P. Measuring the Quality of Medical Care through vital statistics based on hospital ser- vice areas: 1. Comparative study of appendectomy rates, Am. J. Publ. Health 42: 276, 1952; Neutra, R. Indications for the surgical treat- ment of suspected acute appendici- tis: a cost effectiveness - approach, in Costs Risks and Benefits of Surgery 61 ed. Bunker, J. et al. London, Ox. Univ. Press, 1977; Watkins, R. et al. Appendectomy experience in pre- paid group practice, N. Engl. J. Med. 293: 995, 1975. 8. Logan, R. and Forrest, J. Cimeti- dine, metiamide and gastric ulcer. Lancet 1: 650, 1976; Haggie, S. et al. Treatment of duodenal ulcer with cimetidine. Lancet 1: 4-7, 1977; Saunders, J. and Wormsley, K. Long - term effects and after - ef- fects of treatment of duodenal ulcer with metiamide. Lancet 1: 765-77, 1977; Arnold, F. et al. Acute pancreatitis in a patient treated with cimetidine. Lancet 1: 382-383, 1978; Joffe, S. and Lee, F. Acute pancreatitis after cimeti- dine administration in experimental duodenal ulcers. Lancet 1: 383, 1978; Jeffreys, D. and Vale, J. Ef- fect of cimetidine on glucose hand- ling. Lancet 1: 383, 1978. 9. For a review of the ineffectiveness of antacids, diet, anticholinergic drugs and surgery in treatment of ulcers, see: Meyer, J. et al. Treat- ment of peptic ulcer disease - a symposium at University of Califor- nia, Los Angeles, School of Medi- cine. West. J. Med. 126: 273-287, 1977; for the effectiveness of hospi- talization as a " rest " treatment, see: Silen, W., Peptic Ulcer. In Win- trobe, et al. (eds.), Harrison's Princi- ples of Internal Medicine McGraw- Hill, New York, 1974. 10. Sterling, P. and Eyer, J. Body and Soul: Chronic Arousal as a Major Cause of Disease in Modern Society (manuscript), 1979. 11.OTA 11.OTA 11.OTA pages 44-5; Stool, S. and Mast, W. Tonsillectomies and Adenoidec- tomies: are they really necessary? Bol. Assoc. Med. P.R. 65: 71, 1973; Paradise, J. Why A and T remains moot, Pediatrics 49: 648, 1972; Paradise, J. and Bluestone, C. Toward rational indications for tonsil and adenoid surgery, Hosp. Practice 11: 79, 1976; Paradise, J. et al. History of recurrent sore throat as an indication for tonsil- lectomy, N. Engl. J. Med. 298: 409, 1978. 12.OTA pages 53-55; Benefield, J. et al. Current and future concepts of lung cancer, Ann. Int. Med. 83: 93, 1975; Carbone, P. Lung cancer: perspectives and prospects, Ann. Int. Med. 83: 93, 1975; Cohen, M. Lung cancer: a status report, J. Natl. Canc. Inst. 55: 505, 1975; Wolf, J. et al. Controlled study of survival of patients with clinically inoperable lung cancer treated with radiation therapy, Am. J. Med. 40: 360, 1966; 62 13.Cutler, S. J. (ed.) End Results in Cancer U.S. Gov't. Printing Office, Washington, D.C., 1968. 14.OTA, page 55. . 15.OTA pages 39-41; Cetrulo, C. and Freeman, R. Problems and risks of fetal monitoring, in: Risks in the Practice of Modern Obstetrics S. Aladjem, Ed C.V.. Mosby, St. Louis, 1975; Goodlin, R. and Haesslin, H. When is it fetal distress? Am. J. Obstet. Gynecol, 128: 440, 1977; Haverkamp, A. et al. The evalua- tion of continuous fetal heart rate monitoring in high - risk pregnancy, Am. J. Obstet. Gynecol. 125: 310, 1976; Lee, W. and Baggish, M. The effect of unselected intrapartum fetal monitoring, Obstet. Gynecol. 47: 516, 1976; Paul, R. et al. Clini- cal fetal monitoring: its effect on cesarian section rate and perinatal mortality - five year trends. Post- grad. Med. 61: 160, 1977; Renou, P. et al., Controlled trial of fetal in- tensive care. Am. J. Obstet. Gyne- col. 126: 470, 1976; Thompson, H. et al., Factors contributing to im- proved maternal care and fetal out- come in a medium - sized city coun- - ty hospital, Am. J. Obstet. Gynecol. 116: 229, 1973; Wennberg, J. Changing patterns of risk, medical care and perinatal mortality in Ver- mont, paper presented before the American Public Health Association, Oct. 15-19, 1978. 16. Mather, H. et al. Acute myocardial infarction: home and hospital treat- ment. Brit. Med. J. 3: 334-339, 1971; Hill, J. et al., A randomized trial of home hospital - versus - man- agement for patients with suspected myocardial infarction. Lancet 1: 837-842, 1978. 17.OTA page 41. 18. Powels, J. On the limitations of modern medicine. Sci. Med. Man. 1: 1-30, 1973; The NHLBI estimates the total cost for all medical treat- ment of cardiovascular disease at $ 50 billion in 1976 (OTA page 49) out of total health care expenditures of $ 139 billion that year: Gibson, R. and Mueller, M. National Health Expenditure Highlights, Fiscal Year 1976, Research and Statistics Note no. 27, Social Security Administra- tion, Dec. 22, 1976. 19. Gassner, C. and Ledger, W. The re- lationship of hospital acquired - ma- ternal infection to invasic intrapar- tum monitoring techniques, Am. J. Obstet. Gynecol. 126: 33, 1976; Tutera, G. and Newman, R. Fetal monitoring: its effect on the peri- natal mortality and cesarian section rates and its complications, Am. J. Obstet. Gynecol. 122: 750, 1975. 20.OTA pages 37-39; Bell, B. and Loop, J. The utility and futility of radiographic skull examination for trauma, N. Engl. J. Med. 284: 236, 1971. 21.U.S. Congress, Office of Technology Assessment, Policy Implications of the Computed Tomography (CT) Scanner, U.S. Gov. Printing Office, Washington, D.C., 1978. 22.OTA pages 36-7; National Academy of Sciences National Research Council, Postoperative wound in- fection: the influence of ultraviolet irradiation of the operating room and of various other factors. Ann. Surg. 160 (Suppl.): 1, 1964; Veter- ans Administration, Ad Hoc Inter- disciplinary Advisory Committee on Antimicrobial Drug Usage, Pro- phylaxis in surgery, J. Am. Med. A. 237: 1003, 1977; Washington, J. et al. Effect of preoperative antibiotic regimen on development of infec- tion after intestinal surgery: pro- spective, randomized, double - blind study, Ann. Surg. 189: 567, 1974. 23.OTA pages 50-51; Lampert, R. et al. A critical look at oral deconges- tants, Pediatrics 55: 550, 1975. 24.OTA pages 55-56. 25. OTA, page 16. 26. for a review, see Waldron, I. In- creased prescribing of valium, librium and other drugs- drugs- an example of the influence of economic and social factors on the practice of medicine, International Journal of Health Services 7 (1): 37-62, 1977. 27. Roberts, A. and Visconti, J. The ra- tional and irrational use of systemic antimicrobial drugs, Am. J. Hosp. Pharm. 29: 828-834, 1972. 28. Simmons, H. and Stolley, P. This is medical progress? JAMA 227 (9): 1023-1028, 1974; Peterson, O. et al. An analytical study of North Caro- lina general practice, 1953-54, J. Med. Educ. 32 (12 pt. 2): 1-165, 1956. 29. Subcommittee on Health, Commit- tee on Labor and Public Welfare, United States Senate. Examination of the Pharmaceutical Industry 1973-74. page 2635, U.S. Gov. P.O., Wash. D.C. 1974; Kunin, C. et al. Use of antibiotics - a brief exposi- tion of the problem and some ten- tative solutions. Ann. Intern. Med. 79: 555-560, 1973. 30. Ogilvie, R. and Ruedy, J. Adverse drug reactions during hospitaliza- tion. Can. Med. Assoc. J. 97: 1450- 1457, 1967; for a review, see Silverman, M. and Lee, P. Pills, Pro- fits and Politics. Univ. of Calif. Press, Berkeley, 1974. 31. Silverman, op. cit. ref. 30, page 189, 653 and 1543-46. 32.OTA pages 26-29; Pap smear has been validated by epidemiological comparisons of uterine cancer rates between screened and unscreened populations, not by controlled blind trials: Christopherson, W. et al. Cervical cancer control, Cancer 38: 1357, 1976; Cramer, D. The role of cervical cytology in the de- clining morbidity and mortality of cervical cancer, Cancer 34: 2018, 1974; Miller, A. et al. Mortality from cancer of the uterus in Canada and its relation to screening for cancer of the cervix, Int. J. Canc. 17: 600, 1976. Such comparisons are complicated by uncontrollable factors, such as the recent upswing of uterine cancer due to medical use of estrogens to treat symptoms of menopause in women: for ex- ample, see: Weiss, N. et al. Increas- ing incidence of endometrial cancer in the United States. N. Engl. J. Med. 294 (23): 1259-1262, 1976; OTA, page 49. The main reason for the small return is that coronary heart disease is untouched and may be increased by antihypertensive medication. 34.OTA pages 33-36. 35.OTA pages 29-31. 36.OTA pages 51-52. Other methods of broken limb support exist, and may have less undesirable effects, such as muscle atrophy, skin infec- tions, etc. Horn, J. Away With All Pests, Monthly Review, New York, 1969. 37.OTA pages 52-53. 38.OTA pages 23-25. 47. Salmon, J. The Health Maintenance Organization Strategy: a corporate takeover of health services delivery. International Journal of Health Ser- vices 5 4 (): 609-624, 1975; Salmon, J. Monopoly capital and its reorga- nization of the health sector. Rev. Rad. Pol. Econ. 8 125-133: , Spring 1977., 48. Bunker, J. Surgical manpower: a comparison of operations and sur- geons in the United States and in England and Wales N. Engl. J. Med. 282: 135, 1970; Bunker, J. and Brown, B. The physician - patient as Antunes, C. et al. Endometrial can- 39. The critique of the overuse of X rays - cer and estrogen use: report of a is well known in medical literature. an informed consumer of surgical services N. Engl. J. Med. 290: large case control - study. N. Engl. J. Med. 300 (1): 9-13, 1979. For yet another recently emergent example, see Favus, M. et al. Thy- 1051, 1974; Bunker, et al. (eds.) Costs, Risks, and Benefits of Surgery 33.OTA 33.OTA pages 48-50. The OTA sum- mary of evidence in this case is seriously flawed. They report only the evidence of the Veterans Ad- roid cancer occurring as a late con- sequence of head neck - and - irradia- tion. N. Engl. J. Med. 294 (19): 1019, 1025, 1976. This story is Oxford University Press, New York, 1977; Bunker, J. Elective hysterec- tomy: pro and con N. Engl. J. Med. 295: 264, 1976; Bunker, J. et al. ministration Study, which showed particularly interesting because of Surgical innovation and its evalua- lowering of blood pressure, stroke and kidney damage among hyper- tensive men treated for short (3.3 years average) periods with anti- hypertensive drugs, but no change in coronary heart disease risk: Vete- its possible wide consequences, be- yond thyroid cancer alone. Since the beginning of the 20th century, an enlarged thymus in children was baselessly considered pathological by many scientistic doctors. At first tion Science 200: 937, 1978; Lewis, C. Variations in the inci- dence of surgery N. Engl. J. Med. 281 (16): 880-884, 1969. 49. Gaus, C.R. et al. Contrasts in HMO and Fee Service - for - performance rans'Administration Cooperative Study Group on Antihypertensive Agents. Effects of treatment on this condition was treated by surgi- cal removal of the thymus, and from the 1920's through the 1950's, Social Security Bulletin 39 (5): 3-14, 1976. 50. Berliner, H. A larger perspective on morbidity in hypertension: results in patients with diastolic blood pressures averaging 115 through millions of infants and children were treated by high intensity - X ir- - radition to shrink the thymus. In the Flexner report International Journal of Health Services 5 4 (): 573-592, 1975. For a review of 129 mm Hg. JAMA 202 1028-1034: , 1967; Effects of treatment on mor- bidity in hypertension. II. Results in patients with diastolic blood pressure averaging 115 through 134 mm Hg. JAMA 213: 1143-1152, 1970; Effects of treatment on mor- light of the present knowledge on the essential role of the thymus in cell mediated immunity, it can be anticipated that these children should develop deficiency immune - diseases in later life. The very high risk of thyroid cancers reported by other work in this area, see Waitz- kin, H. A Marxist view of medical care Annals of Internal Medicine 89: 264-278, 1978. 51. McKeown, T. The Modern Rise of Population. Arnold, London, 1976; McKeown, T. The Role of Medicine bidity in hypertension. III. In- Favus et al. in previously irradiated Dream, Mirage, or Nemesis Nuffield, fluence of age, diastolic pressure persons is perhaps only the tip of Provincial Hospitals Trust, London, and prior cardiovascular disease; the iceberg. 1976; Scrimshaw, N. et al. Nutri- further analysis of side effects. Cir- 40. For an informative history, see tion and infection field study in culation 45: 173-186, 1972. OTA Sigerist, H. The Great Doctors, Guatemalan villages. 1959-64. ignores reports showing increased Dover, New York, 1971. risk of coronary heart disease with 41. Sigerist, op. cit. ref. 40, pages I. Study plan and experimental de- sign. Arch. Environ. Health 14: long term - (up to 8 years) admini- 215-16. stration of antihypertensive drugs; 42. Shryock, R. The Development of 657-662, 1967; Scrimshaw, N. et al. Nutrition and infection field study for a review, see Robinson, S. Coro- Modern Medicine Hafner, New in Guatemalan villages 1959-64. nary artery disease and antihyper- tensive drugs. J. Clin. Pharmacol. 12: 123-126, 1973. This omission York, 1969. 43. Cochrane, A. Effectiveness and Ef- ficiency Nuffield Provincial Hospi- V. Disease incidence among pre- school children under natural village conditions, with improved is significant primarily because mass prophylactic use of antihyperten- sive drugs from adolescence is now being widely advocated; for exam- ple, see Stamler, J. et al. (ed.) The Hypertension Handbook, Merck, Sharpe and Dohme, West Point, Pa., 1974. In addition, even under cur- rent, more restricted conditions of use, antihypertensive drug treat- ment is only marginally cost effec- tive: it returns only $ 1.25 in saved tals Trust, Burgess, London, 1972. 44. Paul, G., Tobias, L. and Holly, B. Maintenance Psychotropic Drugs in the presence of active treatment programs: a " triple - blind " with- drawal study with long term mental patients. Arch. Gen. Psychiat. 27: 106-115, 1972. 45. See VA study, cited in reference 33. The exact fraction excluded by pre- selection against " placebo respon- ders " was not reported in these diet and with medical and public health services. Arch. Environ. Health 16: 223-225, 1968; Scrim- shaw, N. et al. Nutrition and infec- tion field study in Guatemalan villages 1959-64. IX. An evaluation of medical, social and public health benefits, with suggestions for future field study. Arch. Environ. Health 18: 51-62, 1969; Scrimshaw, N. et al. Interactions of nutrition and infection. WHO Monogr. Ser. 57: medical costs of treating endstage cardiovascular disorders for each $ 1.00 invested in drug prophylaxis: studies. 3-329, 1968. 46. Medical World News, p. 7, Oct. 16, 52.Eyer 52.Eyer, J. Transitional 1978. HMO 4: 180-204, 1978. medicine. 63 INTRODUCING Wholistic Health A WHOLE PERSON - APPROACH TO PRIMARY HEALTH CARE Tubesing, Donald A., Ph.D. WHOLISTIC HEALTH A Whole Person - Approach to Primary Health Care This pioneering work is an eloquent call for a redefinition of health and illness in the context of a broader view of life, health, and the quality of life to include the whole person - the mental, emotional, and spiritual sides af life as well as the physical. It is based on the premise that only a re- definition of health care to include the whole person will lead toward solutions to the problem of the pre- sent health care system. " I read it cover to cover, every last word, and I think it's great. It's read- able and flowing, and has a dimension of cohesiveness which I really like. -David Hibbard, M.D. Pediatrics, Boulder, Colorado " Should assist those providers serious- ly wrestling with problems of frag- mentation of health care. I am confi. dent that this book will stimulate many practitioners to join the Wholis- tic revolution in health care. " -Granger E. Westberg, D.D. Univ. of Illinois at the Medical Center Dr. Tubesing, the author of this thoughtful presentation, states empha- tically that there is much we can do in moving toward positive, workable solutions to many of the problems in contemporary health care. One solu- tion is the Wholistic Health Center " A fascinating and undoubtedly con- troversial book that deserves to be in all libraries concerned with health care. " -Library Journal project, in which Dr. Tubesing has played a central role from its incep- tion. 1978 240 PP. 0-87705-370-7 LC 78-3466 $ 14.95 HUMAN SCIENCES PRESS 72 Fifth Avenue 3 Hennetta Street ae @ NEW YORK, NY 10011 LONDON, WC2E 8LU Human Sciences Press 72 Fifth Avenue New York, New York 10011 64