Document B25ONozERgY2N4ZXN5JXkkKw

HEALTH / PAC BULLETIN Policy HealAdtvhis ory Center 1 Pathologies of Place and Disorders of Mind: " COMMUNITY LIVING " FOR EX MENTAL - PA- TIENTS IN NEW YORK CITY. The state of New York has been able to reduce its institutionalized patient load at the expense of neighborhoods and the ex patients -. 3 Vital Signs 13 Columns WASHINGTON: Blue Boards of Happiness URBAN: Community Clinics in Seattle: A System that Works WOMEN: Birth of a Struggle WORK ENVIRON / : OSHA Act Axed 23 Business at the Bedside: HEALTH CARE IN BROOKLYN, 1890-1915. By the second decade of the 20th century, hospitals were turned from charity institutions for all regardless - of ability to pay, with uniform care services - into money conscious - corporations seeking to attract a better class of patient. Y, Volume 11, Number 4 March / April, 1980 ISSN 0017-9051 HPCBAR 11 (4) 1-32 0 Pathologies of Place and Disorders of Mind " COMMUNITY When is a mental health problem not a men- LIVING " FOR EX MENTAL - tal health problem? PATIENTS IN For thousands of ex mental - patients, re entry - in- NEW YORK to life outside the asylum walls means endless CITY rounds of defeat and demoralization. Prolonged periods of hospitalization often weaken the capaci- ty for social interaction, damage the ability to deal with independent living, and leave many ex- patients extremely wary of offers of help. Add to this whatever abiding disabilities and / or residual peculiarities (or " symptoms ") that may persist despite the most powerful pharmacological agents, and it is easy to see why under - the best of conditions - ex - patients find it difficult to manage the newly bestowed freedom that comes with release. For vast numbers of ex patients - , however, " under the best of conditions " is never realized in practice, further complicating the question of ex- patients'ability to handle " freedom. " To exercise deliberation and choice presumes there is some- thing to consider and choose - a presumption wildly at odds with the everyday situation of most ex patients -. The courts have directed humanely - , many feel that the " least restrictive " treatment alter- natives be employed for ex patients - . But for many ex patients - , this is experienced as a new form of societal rejection. This is less due to the fact that some people are callous and uncaring than it is to the fact that the material necessities of a decent livelihood prove terribly difficult to procure. In this respect, the ex patient's - plight parallels that of other unproductive populations at the margins of polite society. In the pages that follow, we examine one of the basic material necessities - housing. The facts sug- gest that present circumstances contrive to ensure the failure of " community living " for ex mental - pa- tients because New York remains a house divided against itself - with one bureaucracy handling strictly " mental health " problems, and a myriad of others handling housing, food, emergency assistance, etc. For many of New York's ex- patients, the impossibility of securing adequate housing becomes the major threat in the day - to- day struggle for peace of mind. To Find A Home The fact that it was the fiftieth anniversary of the Great Crash didn't change things much for An- drew. He got up early to go to mass at St. Francis Church one of the few accessible warm spots in the city at six in the morning. The friars don't seem to mind you nodding off in the back pews, and afterwards, they give out coffee and baloney sand- wiches. Last night, Andrew was lucky. He slept, as he put it, " at the Princeton Club, up on 43rd Street. " He means on the sidewalk outside, where the blowers from inside the building provide an in- termittent stream of warm air. He hasn't worked " for some time, " has " something of a drinking problem " and has been in and out of mental hospitals. Uptown, the commuters at the 110th 110th Street Sta- tion haven't quite gotten used to Annie's using the place as her private urinal. Annie carries all of her worldly goods in a Lord & Taylor bag, smells pro- foundly bad and looks a mess. It isn't clear that this is simply evidence of a sadly disordered mind there - is too much cunning to her statement that her disheveled appearance keeps strangers away. Annie sleeps " around, " on the trains when she can, and finds most of her food, it seems, by rummaging through garbage. No, she doesn't know who the President is and she'd probably 2 have difficulty counting backwards from 100 by sevens. These people have two things in common: they are homeless and they have some difficulty negotiating the ordinary transactions of everyday life, let alone the byzantine procedures of a welfare application. Their lot is an increasingly common one. The friars at St. Francis report a 40 percent in- crease in the numbers of people in their breadline compared with last year, partly due to a growing number of ex mental - patients, whose arrange- ments for " community living -shaky " to begin. with have - simply fallen apart. The plight of people released from mental insti- tutions to " the community " has been well docu- mented by the media, by local politicians respond- ing to outraged neighborhoods, by mental health professions and, not least of all, by ex patients - themselves. There is a curious irony here. The tales of horror that emanated from institutions just over a decade ago have followed their victims into the community. " Deinstitutionalization " has become re institutionalization - . Old walls are torn down, but new, less visible ones are erected. Someone has called it moving " from back wards to back alleys. " Whatever it is called, it still adds up to ghettoizing the mentally disabled. New York State, recognized as a national leader in mental health, offers a prototype case. Until recently, state officials were still proclaiming the loftiest of intentions in the face of obvious and re- calcitrant failure as thousands of ex patients - are left to make do as best they can in subways, parks, single - room occupancy hotels (SRO), the notorious adult homes and the Men's and Women's Shelters. Estimates of the number of mentally disabled in New York vary widely depending on one's source. One source, the Associate Commissioner of the State's Office of Mental Health, has calculated on the basis of aggregated county - by - county data that there are 79,900 chronically mentally ill peo- ple in " the community " in New York State, 47,000 of which reside in New York City () 1. Legacy of Deinstitutionalization The origins of deinstitutionalization can be traced to three developments: the synthesis of powerful " psychotic anti -" drugs in the early 1950s (2); a growing recognition by the public and profes- sionals that institutional treatment was less than therapeutic for most and harmful for many (3); and, finally, the efforts of state and local govern- ments to cut costs (4). The relevance of this last fac- tor is especially important when one notes that costs of inpatient care were rising simultaneously with pressure to renovate the deteriorating insti- Continued on Page 6 FAST... FAST FAST ... FAST RELIEF, SPELLED P O - R - - F - I - T - S " Pain has become the disease, " says Arthur F. Battista, co director - of New York University Medical Center's Comprehensive Pain Center. And if pain is a disease, then its treatment can be a market. That is one of the rules of capitalist medical systems. And true to form, about 40 companies have already generated a $ 30 million annual market selling 40,000 transcutaneous neurostimulators -mechanisms attached to the pa- tient's skin which are supposed to block the brain's perception of pain. Unfortunately for their manufac- turers, transcutaneous stimulators have a couple of drawbacks. Only about 10 per cent of the energy reaches the affected nerves and only about 70 per cent of the pa- tients that use them are really helped. Further, they have to be plugged in. But in capitalism, product problems are market op- portunities. So companies are developing implantable stimu- lators. Some are powered by long - life batteries and others can be recharged from outside the body by radio waves -, a pro- cedure first used to recharge bat- Vital Signs teries on satellites. To compete with all these mechanical devices, more pain killing pills are being developed. Hopefully, these new pills will also be less addictive than previous pain killers. The reason for all this frenzied activity is not that pain hurts, although it does. Pain has become costly to business. When people suffer pain they do not work as ef- ficiently. And they may even seek costly and perhaps reimbursed -medical treatment for their chronic backaches. According to Dr. Richard D. Black, director co - of Johns Hopkins Pain Center in Baltimore, chronic pain " is the third largest economic medical problem, next to cancer and car- diovascular disease. " Lower back pain disables five million in an average year and costs $ 1.5 billion in hospital and doctor bills. Workmen's Compensation bills for back pain run in the hundreds of millions of dollars. And the lost work and medical costs for the six million people disabled by arthri- tis out - of the 21 million who have the disease comes to $ 10 billion per year. There can be no doubt of the need for such advances. But as always, there is potential danger in how they are used and who decides. Here, the danger is ram- pant that they will be misused by company doctors and those op- posed to preventing occupational hazards. In the near future a com- pany doctor will be able to stop any pain from interfering with a full day's work. Who knows? May- be they can make cancer painless. An employee just keeps working around the local carcinogen until he or she drops dead painlessly - . -George Lowery Source: Business Week, Dec. 10, 1979 HOW TO SQUEEZE PROFIT FROM A LEMON The medical malpractice insurance crisis crisis.... again The belief that crises can be solved without changing underly- ing causes is one of the great and transparent fallacies of liberal and conservative thought. It is like the inventor of the gattling gun think- ing his invention would make war so horrible that humans would cease forever to wage it. More recently, liberals and conser- vatives thought the crisis in medical malpractice insurance had been solved by limiting the patient's right to sue and by set- ting up some inhouse or coopera- tive insurance companies, often owned by the client hospitals or doctors. These cooperatives, incidently, should not be interpreted as col- lective action in the socialist mold. Rather, these " pan bed - mutuals " are cases of the attempt by mono- poly capital to drop losing pro- positions into the public lap- " lemon socialism. " But their efforts were short circuited by physicians and hospitals which want to keep the public out of " their " business at all costs. And these costs may be higher than they imagined. For once again, malpractice insurance rates are on their way up. Recently, Aetna Life and Casualty Co. raised premiums charged to Connecticut doctors by 24.5 owe xwbr; International Telephone and Telegraph subsidiary Hart- ford Insurance Group hit Col- orado doctors with a 20 percent hike; and St. Paul Fire and Marine Insurance Co. boosted rates in 20 of the 30 states in which it insures nearly 44,000 physicians. Discussions of the reasons for 3 the rate hikes sound like an old phonograph record: more claims; greater severity of claims; claims staying open for more than a year (40 per cent of losses paid by the Hartford Group are from ac- cidents prior to 1977); expanded concepts of liability; a fading of the defensive medicine practiced after the last crisis; more sophisti- cated lawyers; and generous juries. Mostly, doctors and lawyers blame each other. Just as in the medical encounter, the pa- tient is the silent legal partner. No one raises the possibility that there are too many malpractice suits because there is too much malpractice. And as in 1974-1975, victim blaming is running rampant. Says Business Week: " Publicity about high jury verdicts - such as the $ 7.6 million recently awarded to an 18 year - old California girl who became a quadriplegic when an overdose of radiation damaged her spinal cord'whets the ap- petites of plaintiffs,'" according to Donald J. Fager, consultant for the New York State doctors'mutual. (Editor's note: such awards are almost always lowered substantial- ly on appeal.) Indeed, one can see patients climbing all over each other to be first in line to become a quadriplegic so they too may be awarded multimillion dollar jury verdicts and get their pictures in the paper. -George Lowery Sources: Business Week, Nov. 23, 1979 and Dec. 4, 1978, and Sylvia Law and Steven Polan, Pain and Profit, The Politics of Malpractice. THE OLD SHELL GAME In an ironic twist, the leading free market - advocates on the 4 Health and Environment Subcom- Health / PAC Bulletin Tony Bale Pamela Brier Robb Burlage Michael E. Clark Board of Editors Hal Strelnick Glenn Jenkins David Kotelchuck Ronda Kotelchuck David Rosner Managing Editor: Marilynn Norinsky Health Policy Advisory Center Staff: Loretta Wavra MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR should be addressed to Health / PAC, 17 Murray Street, New York, N.Y. 10007. Subscription rates are $ 14 for individuals, $ 11.20 for stu- dents and $ 28 for institutions. Subscription orders should be addressed to the Publisher: Human Sciences Press, 72 Fifth Avenue, New York, N.Y. 10011. Health / PAC Bulletin is published bimonthly by Human Sciences Press. Second - class postage paid at New York, N.Y. and at additional mailing offices. 1980 Human Sciences Press Illustrations by David Celsi (pp. 1, 7, 23, 25, 27, 29) mittee of the House Commerce Committee are moving quickly to deprive consumers of the very in- formation which would make meaningful choice between com- peting providers possible. The Subcommittee has passed a " com- promise " bill which will keep con- sumers from getting quality of care information about individual physicians or hospitals. The infor- mation is collected by Professional Standards Review Organizations (PSROs). PSROs are funded and regulated by the federal govern- ment, and their decisions can deny Medicaid or Medicare reim- bursement for medical treatment. Although they are strictly con- trolled by local physicians, the PSROs collect information and deny payment in the name of the federal government. Arguing that this relationship made them sub- ject to the Freedom of Information Act (FOIA), Ralph Nader's Public Citizen Health Research Group has sued to force disclosure of PSRO data. After initial court decisions favored the consumer group, conservative Congressmen sought to exempt PSROs from FOIA. In December the Health Subcomittee passed a " com- promise " bill which would prevent the release of any data under FOIA until six months after a final court decision - ample time for Congress to change the law and protect physician secrecy. This development is especially troubling in light of increasing pressures for hospital closures and regionalization. Health Systems Agencies (HSAs) will be forced to decide which hospitals should be closed without being able to com- pare the quality of care at the in- stitutions. It will be equally im- possible to quickly estimate the racial composition of a hospital's patients if the HSAs, and HEW's Office of Civil Rights, are denied the demographic profiles of each hospital's patients which the PSROs compile. Because of this, the Health Sub- committee is urging HEW to rapidly make hospital - specific data available to the planning agencies. Yet HCFA is resisting PSRO disclosure of hospital- specific data. In this effort they are getting extra help from a very well placed - source. It seems that HEW General Counsel Jody Bernstein's husband is a physician who has claimed that disclosure of PSRO data will prevent doctors from talking to their patients. Both the planning agencies and the civil rights advocates face a tough road ahead. The battle for the data may well be the first real test of whether or not HEW Secretary Patricia Harris will place a com- mitment to civil rights above private professional prerogatives. -Mark Kleiman 5 CALTH / PAC is is proud to announce that it is the national distributor of HealthRight Women's Health Literature Pamphlets by HealthRight BULK (25 or more) SINGLE Breast Cancer (HealthRight reprint) 25 Health Story (your personal medical record) 35 50 | 15 25 WMheanto pCaauns eO ne Woman Do? (3 ways to get better health care) 35 50 The Gynecological Check - up 35 50 Infections of the Vagina Hearty nce a 40 60 Vacuum Aspiration Abortion 35 50 Saline Abortion 35 50 Packet 5 1 copy of each pamphlet listed above Herpes Booklet by The Santa Cruz Women's Women's Health Collective Hysterectomy by Suzanne Morgan | 50 $ 3.00 $ 1.00 50 Postage and handling: 50 for a single item;.60 $ for orders under $ 2.50; 90 for orders from $ 2.50 to $ 15.00. Address all inquiries to Health / PAC, 17 Murray Street, New York, N.Y. 10007. 5 Pathologies of Place Continued from Page 2 tutions in order to comply with more stringent ac- creditation criteria. Unionization of state employees also increased the public expense of psychiatric hospitalization, despite efforts by unions to compromise on some issues and to develop deinstitutionalization strategies of their own. Most notably, the State's burden could be shifted to federally financed entitlement systems (i.e., SSI and Welfare) and to local programs when patients were discharged into " the com- munity " (5). The numbers involved were staggering. The nationwide state hospitals census which had in- creased steadily since asylums were first con- structed in the early nineteenth century, reaching a peak of 559,000 in 1955, began to drop precipitiously from 1961-1970. Combining stricter admission criteria with rapid discharge policies, New York State was able to reduce its in- patient population from 85,000 in 1965 to 25,000 to date (6). The State's Five Year - Plan for Mental Health (1979-1983) projects that this population will drop to 18,000 by 1983. The declining census obscures the fact that State readmission rates for former mental patients climb- ed markedly, reaching 65 percent of all admis- sions in 1974 (7). The readmission rates indicate For many of New York's ex mental - patients, the impossibility of securing adequate housing becomes the major threat in the day day - to - struggle for peace of mind that Imany have failed to " make it " in the communi- ty and can even pass the heightened admission barriers to reside " inside, " albeit for shorter average stays. The rates would be multiplied many times if they included all those who seek admission or are brought for admission by police, family or others, but are refused. Manhattan State Hospital, for example, currently refuses to hospitalize 40 percent of those referred from Bellevue Municipal Hospital (7b). New York City is estimated currently to hold 40 percent of the State's population and 57 percent of the State hospital inpatient population (8). Of the estimated 47,000 chronically mentally disabled people living outside hospitals in the City, at least 5200 are (conservatively) estimated to be homeless, surviving as best they can on the streets (8b). In the face of cutbacks and threatened clos- ing, municipal hospitals provide the bulk of the Ci- ty's emergency mental health services and short- term inpatient treatments. The few aftercare facilities and the services of the City's Department of Social Services are swamped by referrals following discharge from the hospitals. One of the Robberies and assaults in SROs are common, most never reported. Ex- patients - among the more defenseless of the city's population - are easy prey key problems they face along with their newly discharged clients is that no one has planned for the basic problem of a place to stay - a home. Few Choices The search for housing theoretically begins. while an individual is still an inpatient, as part of " discharge planning. " This is widely recognized to be " a joke ", according to one member of the Quali- ty of Care Commission for the State's mental health system. Dishcarge planning, in most cases, amounts to giving the soon - to - be ex patient - the ad- dress of the Department of Social Services and a subway token to get there (9). It be a mistake, however, to ascribe the place- ment of ex patients - in substandard housing solely to administrative bungling, neglect or corruption. Horror stories, of course, abound, but simple greed does not adequately account for the ubiqui- ty of the problems. Even the most humane intent is shipwrecked on one brute fact: decent, low- income housing alternatives do not exist (see Box). Dangerous, filthy and relatively expensive cells exist in SROs and PPHAs (private proprietary homes for adults). Cots in dormitories or wire- ceilinged cubicles can be had at the Bowery's flophouses. There is space for up to 200 on the concrete floor of the " big room " at the Men's Shelter. But even these options do not meet the de- mand. Many are turned away daily even from these because they are " undesirable " -that is, 6 E 0.01 & even less desirable than the people who are ac- cepted or because there is, in fact, no spare room, cot or floorspace. During the summer months, parks are resorted to even - preferred - to the other choices. The winter months are more forbidding. These " surplus people " are warned to " keep circulating. " There are few refuges: even passing time in 24 hour - coffee shops requires money and rea- sonable behavior as well as a presentable ap- pearance. SROs The " SRO phenomenon " as it has been called- - characterized as " the conspicuous clustering of de- viant single people in specific buildings " (-had 10) its origins in the housing shortage produced by the wartime migration of workers and servicemen in the 1940s. Landlords suddenly found it profitable to convert tenements into single - room hotels. The postwar economic boom attracted families as well, who huddled in cramped quarters while bread- winners attempted to gain some measure of finan- cial security. Many of them failed to do so, and an uneasy alliance grew be- tween the City's Department of Welfare and the more marginal SROs. Migrant families were joined by ex inmates - , discharged patients and homeless con- valescents. Conditions deteriorated to the point that a 1960 law forbade rentals to tenants with children. The resulting outflux of poor families was quickly countered by an inflow of single men, mostly from the Bowery. Urban renewal efforts in the'60s had their peculiar effects as well. As whole blocks of " unrenewable " hotels were reduced to rubble, their populations were displaced elsewhere. Middle - class neighborhoods were invaded, the new residents offending sensibilities and depressing real estate - values. Charges of " spreading urban blight " were heard with increasing frequency. These were intensified when, in the late 60s, an old figure, the ex mental - patient, began to accumulate in harrowing numbers. Public outrage mounted as " proper " neighborhoods read their demise in the appearance of local clusters of ex- patients. SRO residents, typically paying around $ month 150 / , live in tiny rooms and usually share bathroom and kitchen facilities at the end of an open hall. Some officials talk as though it were planned that way. According to the National Executive Board on SROs: .. kitchens and private bathrooms are often not considered necessary by many older peo- ple who have never had them. Heat, security and cleanliness are much more important to the quality of life of tenants than room size or even private bathrooms (11). Such a proposition reveals a great deal about the bureaucratic mentality that often does the " plan- ning " for the ex patient - population. It ignores the reality that SRO tenants rarely have heat, security or clean quarters. It is not apparent why ex- patients should be forced to trade one " necessity " for another in any event. Nor do the stated " pref- erences " square at all with our own experience in talking with tenants. (We are quite curious about the origins of these and similar " judgements " about ex patients -). For better or worse, the National Executive 7 Several forces have exacerbated conditions for SRO residents. New York City's J 51 - program grants tax abatements to developers who convert SROs into middle and upper class residential housing. This has led to the closing of several SROs and dislocation of tenants; some SROs have been emptied over the weekend Board does not set standards for SROs. The pre- sent reality is that SRO tenants exist at the mercy of individual SRO landlords, who consider heat, security, cleanliness, room size and private bath- rooms as secondary to collecting maximum rent and maintaining high occupancy rates. The resulting conditions typically resemble those described by one reporter in a recent article: The halls and stairways are dimly lit, unswept, littered with debris and fallen plaster. Throughout the halls, there's the stink of toilets overflowing with paper, feces and urine. Some of the toilets haven't worked in months. Electri- cal wires are exposed where plaster has been knocked out of the walls. Doors to the rooms have been broken, patched with boards. Locks have been gouged (12). One hotel on the Upper West Side was cited for over 250 violations of the City Health Code and its owner fined $ 37,500; it remains in operation while the case is in litigation (13). Robberies and assaults are common, most never reported. Ex patients- - among the more defenseless of the city's popula- tion are easy prey. Estimates of former psychiatric patients in SROs are difficult to obtain. Many SRO residents are justifiably hesitant about admitting psychiatric his- tories for fear of being rehospitalized. Estimates of ex patients - in SROs range from ten to twenty thou- sand. The greatest concentrations in Manhattan are currently on the Upper West Side and in the Murray Hill area. The New York City Department of Social Ser- vices has provided on site - assistance to SRO tenants for several years, including hot lunch pro- grams as well as recreational and rehabilitation programs staffed by case workers, part time - physi- cians and nurses. A new " Community Support Services " program has augmented their staff. Both are admirable efforts and both help, despite a con- text which presents staggering obstacles to the or- dinary notion of " service. " Given such obstacles, it is remarkable what some dedicated workers have manged to accom- plish in certain SROs with the most meager of re- sources. The Aberdeen Hotel on 32nd Street is 8 one such example. For nine years, Al Pettis and his small staff have worked to transform this hovel. To- day, one stumbles across elements of genuine community at the Aberdeen: tenants are offered support, companionship, assistance in managing money and dealing with the demands of SRO management and activities - all despite their own shaky mental status and the deteriorating physical structure of the hotel (13b 13b). The great majority of SROs have no such pro- grams. In the past, managers occasionally agreed to such programs in hopes of getting more refer- rals and hence a higher occupancy rate. Now empty units are scarce, and the rooms in which programs operate could be rented out. Several forces have exacerbated conditions for SRO residents. The City's J 51 - program grants general tax abatements (which total approximately $ 40 million annually) (14) to developers who con- vert SROs into middle / upper class residential housing - clearly the more profitable real estate holding. This has led to the closing of several SROs and dislocation of residents. Harrassment of tenants by owners eager to empty their buildings for conversion has included the use of dogs and sawed - off shotguns at early morning hours; some SROs have been emptied over a weekend. Tenants, especially disabled ones, rarely exercise their legal rights to prevent such harassment. In addition to the number of SROs that have closed, others have raised their prices above the designated lower priced - hotel level. In March 1978, there were 23 percent fewer lower priced - hotels than in January 1975 (15). Waiting lists for vacancies are growing as hotels report near- capacity occupancy. Predictably, the cheap drama and outrageous characters that are everyday fare in SROs has recently occasioned exploitation of a new sort. CBS is preparing a pilot script for a serial situation comedy based on one SRO and its inhabitants. The SRO situation has its comic aspects, to be sure, but to reduce it to personal idiosyncrasy and con- fusion is to misread both the scale and the intran- sigence of the suffering involved. One wonders what SRO residents themselves will feel, watching the dirty particulars of their lives parodied on the television set wired near the ceiling of a small bleak room lined with chairs. The Context of the Housing Problem Decent cost low - housing is increasingly hard to come by in New York City. In recent years, housing stock has declined and the quality of what remains on the market has deteriorated. At the same time rents have been increasing and incomes shrinking. The resulting hardship falls on many households, but is especially acute for low income - households and the single elderly, as the following excerpts from Peter Marcuse's re- cent study, Rental Housing in the City of New York: Supply and Conditions 1975- 1978 (January 1979), make clear. Level of Rents No matter how one examines the data on renter household incomes for New York City in the aggregate, having adequate income for the necessities of life in New York City ap- pears to be a problem for an increasing number of renter households. (p. 27) The long term - trend of the rent income ratio has been up. After a relatively stable period between 1950 and 1960, it began a slow trend upward starting in 1960, with a possi- ble partial and temporary decline between 1968 and 1970, but a sharp increase be- tween 1970 and 1975, and a continuing in- crease between 1975 and 1978.... Both changes in rents and changes in incomes. contribute to this pattern. Median rents in- creased by 23.8 percent in the last three years alone, while median income has been substantially stagnant - rising seven percent and the cost of living rose 19.8 percent. Thus, at the same time as rent is tak- ing a higher portion of income, the cost of commodities other than rent has also gone up faster than incomes (although not as fast as rents, at the median) (pp. 197f.)...For the first time in the City's recent history, more than half (57 percent) of all tenants are paying more than 25 percent of their gross incomes for rents and utilities. The median gross rent income - ratio in 1978 was 28.3 percent; in 1975, it was 24.7 percent; 10 years ago it was 21.0 percent (p. 8). Availability of Low Income - Housing and its Quality Faced with virtually no vacancies within their price range among standard units, it is no wonder that many low income house- holds are forced to accept dilapidated units even of rentals that are little savings to them over what other households pay for standard units. There are, after all, 11,100 vacant dilapidated units for rent in New York City. These units are not considered " available for rent " for purposes of measuring the availability of adequate housing, since dilapidated units are not by definition ade- quate, but that does not necessarily mean that they are not on the market. When a household, particularly a low income house- hold, goes out to seek an empty apartment within its means in the City of New York, it will find that 16 percent of all vacant units for rent, and undoubtedly far greater propor- tions of units for rent within its price range, are dilapidated. It is these low income households that will end up in dilapidated units, whether or not they save money by doing so. It is thus understandable that rent income - ratios will be almost as high in dilapidated units as in standard ones; those forced to live in dilapidated units in the first place have too little choice to bargain (p. 212). Single Person - Households The continuing increase in single persons living alone is one of the major phenomena on the New York housing scene. Since 1965, the number of renter households of each size decreased with the exception of the number of single person - households. Single person - households went from 26.9 percent of all renter households in 1965 to 33.7 percent in 1975, and in 1978 ac- counted for 37.2 percent of all renter households. In Manhattan, over 50 percent of all households today are single persons (p. 21).. Singles have a lower median in- come than renters as a whole. In part this is because of the greater percent of singles who are age 65 or older, the majority of whom are likely to be on fixed incomes (p. 49). The'problem'is the nettlesome presence of these individuals - the mentally disabled, discharged into the community, have become visible. Most solutions all have the effect of removing objects from the public's eye Private Proprietary Homes for Adults Another substantial number of discharged psychiatric patients, approximately 6,650, reside in the State's notorious private proprietary homes for adults (PPHAs), with the greatest concentration in the NYC metropolitan area. An investigative report by the Deputy Attorney General (March, 1979) exposed the pervasiveness of: unhealthy, unsanitary, and unsafe living condi- tions, poor nutrition, failure to provide even minimal services and recreational programs, deficiencies relating to medical care and the ad- ministration of medication and numerous viola- tions of local buildings, fire and safety codes (16). The questionable circumstances around a num- ber of deaths of PPHA residents, combined with numerous suicides, underscore the extreme pre- cariousness of such living conditions. During one month in 1977, one PPHA witnessed: an attempted rape by an incoherent resident walking around naked; a knife point - demand for $ 5.00; four fights or assaults in the course of a day by one resident; five other assaults, in- cluding one with a broken bottle and one with an iron pipe... two suicide attempts... and missing residents (17). Adult home residents are entitled to $ 444 per month through supplemental security income payments, of which all but an $ 18 to $ 38 personal allowance goes to the adult home. The minimal in- come of the adult home industry in the State has been estimated at $ 8.4 million monthly (18). " Ac- tivity programs " range from the well intended - but infantilizing to the downright ludicrous. One case manager reported to us a particularly poignant in- stance of the lunacy that can be installed there: she was trying to recruit women for a sewing group when she discovered these women had spent 40 years in the sweatshops as garment workers. The Shelters The Men's Shelter located on the Bowery pro- vides meals, showers, clothing and medical care to 10 approximately 10,000 men annually. The State Department of Social Services licenses and funds 50 percent of the Shelter's operating costs; the Ci- ty matches this amount. A study in 1976, based on 1,235 men provided with sleeping accommoda- tions on a given night, found that 30 percent of them had previous psychiatric hospitalization (s) (19). Estimates based on interviews with clients placed the percentage of significant, overt mental illness in that same group at nearly 50 percent or over 600 men on that single night. Again reflecting the underlying housing and related problems, the supervisor of the Shelter's psychiatric unit notes that this is not simply due to failure to plan: Most of the men don't come directly from the State hospital.. usually community plans are made for them, but they fall apart.. Either they are thrown out of their SRO, their welfare stopped or they never followed through with referrals to a clinic (20). The Shelter serves three meals a day to about 1,500 men and dispenses 800 lodging vouchers redeemable in one of the Bowery lodging (flop) houses under contract with the Men's Shelter. The liquor store on a nearby corner has a steady clientele. During the winter, 1,200 men seek lodg- ing each night. When the Shelter exhausts its sup- ply of vouchers, the remaining men sleep on a concrete floor in the shelter's " big room. " Once the " big room " is filled to capacity, men are turned back into the street. In the fall of 1979, upwards of 200 were turned away every night. The official spokesperson for Human Resources Administration (HRA), the agency that operates the Shelter, has denied (in an affidavit) that any men are turned away from the big room. Pro- viders in nearby service programs, men living on the Shelter's vouchers, and " off the record " information from HRA functionaries all argue otherwise. It is unknown how many men are never counted as being turned away because they know their vouchers have long since been exhausted. The lodging houses - dirty, unhealthy and dangerous - offer dormitory space for approx- imately 100 men sleeping in a single room or in separate five by seven foot cubicles with a small cot and wire ceilings cubicles - which would not meet federal regulations for prison cells. The State Department of Social Services says it is consider- ing denying its license and withdrawing support unless conditions are ameliorated. Without replacement, such action would, in fact, exacer- bate the situation. Meanwhile, a recent city report concluded that the Shelter " resembles nothing so much as a 19th century asylum " (21). The surrounding neighborhoods are justifiably Neighborhood residents are outraged when their streets are turned into running sewers because a shelter has only two toilets for the 500 men who eat there... a outraged when their streets are turned into run- ning sewers because the Shelter supplies only two toilets for the 1,500 men who live there. They are equally upset when men wander the streets aimless- ly all day because the flophouses they sleep in throw them out at 7-8 in the morning and will not allow them back in until late afternoon. Neither of these concerns is an automatic byproduct of the disabilities of the ex inmate - or wino, but reflect the structured neglect that characterizes provisions for their living arrangements. The City - run equivalent for homeless women is also located on the Lower East Side, and has 77 beds. Competition to get in is fierce. During one four month - period, 407 women were turned away. Many are rejected because they refuse to be questioned, to take showers, or to undergo the mandatory physical and psychiatric examinations. Proposed Solutions Surveying recently proposed solutions to the severe housing shortage facing disabled, depen- dent people in New York City results in some uncertainty as to which is worse: the problem or the proposed solutions. Neither seriously meets the needs of mentally disabled adults. The " problem " recently has been the nettlesome presence of such individuals: the mentally disabled, discharged into the community, have become visible. The " solu- tions, " it will be noted, all have the effect of remov- ing objects from the public's eye. The " Country Retreat " Alternative Camp LaGuardia, a 1,000 bed facility operated by the NYS Department of Social Services in upstate New York, claims to restore men's health through " fresh air, nutritious food, proper rest and work training " (22). Its regimen has reminded more than one observer of the workhouses of the 19th century. Men from the Shelter are encour- aged to go there and stay indefinitely. The Island Alternative Two islands, Wards and North Brothers, are also being considered for the surplus Shelter popula- tion. On Wards Island, the State Office of Mental Health owns a vacant building which was formerly part of Manhattan Psychiatric Center. The State has been reluctant to give the Island to the City for the purpose of housing surplus population from the Shelter, and it is simultaneously being con- sidered for four other undesirable and dependent populations. Should the Island be designated for the excess Shelter population, men would go there on a voluntary basis, although their only alternative may be freezing to death, adding a particular urgency to such " voluntarism. " North Brothers Island, owned by the City, lies in the waters off the South Bronx. Its remaining buildings were former- ly used for tuberculosis treatment. One minor problem with this site is that there is currently no access to the island. (One wonders whether the Ci- ty has contemplated restoring the 15th century - " ship of fools perhaps " converting one of the Cir- cle Liners to carry the more disorderly of the mad on soothing tours around Manhattan.) The Winter Storage Alternative Rows of cots in State armories have been con- a ... They are equally upset when men wander the streets aimlessly all day because the flophouses they sleep in throw them out at 7 in the morning and will not let them back in until late afternoon sidered as emergency measures for the homeless this winter. A high proportion of persons needing these emergency provisions would, again, be dis- charged ex mental - patients. The program was con- ceived to operate for only the five coldest months, putting the men back on the streets in the Spring. The Back - to - the Asylum Alternative Others, less concerned with cosmetic surgery, have rediscovered the house mad - in its classical 11 Reeser e e ec n e e e r e Residents of SROs and Shelters generally do not demand essential services for fear of being rehospitalized, indicating that although community living may be difficult, even treacherous, the institution is worse form. A National Institute of Mental Health (NIMH) study re affirms - that " custody and asylum " are per- manent institutional needs in any society (25). The New York State Mental Health Subcommittee on Community Aftercare concluded that: The Department Office of Mental Health must seek to locate those discharged patients who are not'making it'in the facilities where they presently reside, and it must urge their return to the state hospital for further care, with the understanding that they will be returned to the community in more appropriate accommoda- tions when that is feasible (26). Now that inpatient costs of treating a patient in a psychiatric hospital have risen to $ 30,000 per year, it is unlikely that the State will reinstitu- tionalize many, however, at least not within the same highly regulated structures. More likely, old institutional forms will be tinkered with to create less costly structures. As for re release - at some future date once " feasible " accommodations have been arranged, given the past history of neglect and abuse, ex patients - wisely suspect these to be paper promises. The Conversion Alternative Perhaps inevitably, the State Office of Mental Health has proposed to convert those buildings on the grounds of mental institutions that can no longer meet federal and State regulations for new- ly accredited " domiciliary care facilities " (DCFs). These facilities would be occupied by residents transferred from the inpatient buildings across the paths, in patients - now in substandard housing in the community, and a third, peculiarly undefined category, " the new chronics. " Among the stated advantages of such facilities would be improved staffing ratios for inpatients, heading toward the mandated JCAH (Joint Commission on Accredita- tion of Hospitals) levels, and the removal of these buildings from the hospital classification, thus ex- empting them from the JCAH survey altogether and its more stringent treatment, health and safety criteria. Reimbursement to State hospitals from third par- ty payers is currently linked to a facility's compli ance with the standards of JCAH, an agency which 12 apparently had " traditionally been sympathetic to the financial plight of state hospitals and conse- quently had not required rigid compliance to all life safety codes, staffing ratios, patient require- ments, etc " (23). More recently, under pressure from legislative authorities, the JCAH is strictly en- forcing standards for state institutions. Residents of DCFS would be guaranteed none of the rights (i.e., right to treatment, right to minimum wage remuneration for labor performed and rights around the process of commitment and discharge) that have been won by patients'activists in recent years. These rights have been legally limited, for the most part, to inpatient settings. The conversion of state hospital buildings to DCFs, it is suggested, would require " modest cost and staffing levels. " Unquestionably, it would mean a large increase in resident capacity (24). The ominous feature in all of this, of course, is that residents will be as isolated from the community as are inpatients and yet legal- ly and statistically would be considered as residing in a " community - based " structure. To criticize the forms community care has taken or the remedies currently under discus- sion - is not to conclude that institutional care is the alternative. Recent, somewhat glib arguments that the mental hospital has a new role to play in ad- vocating for the mentally disabled, or that the men- tal hospital is a necessary and supportive part of " the community, " strain the credulity of those familiar with the recent history of such institutions. While the names of public institutions for the men- tally disabled have changed from lunatic asylums and " farms for the insane " to state hospitals, and most recently to mental health institutes or psychia- tric centers, conditions for individuals inside re- main generally deplorable. And, according to a 1978 survey of inhabitants of State hospitals, 28 percent of the current inpatient population are capable of being discharged, but remain " back- logged " for lack of community placements (27). It is frequently observed that those who live in SROs, the Shelters and on the streets do not con- tact or respond to available services for fear of be- ing rehospitalized, indicating that although com- munity living may be inhospitable, even treacher- ous, the institution is worse. James Prevost, current State Commissioner of Mental Health, reflects some official awareness of this last point. In an in- Continued on Page 21 WASHINGTON BLUE BOARDS OF HAPPINESS Physician control of Blue Shield boards and reimbursement com- mittees is like money in the bank according to a recent report of the Federal Trade Commission. A detailed econometric study by the FTC found that Blue Shield boards controlled by local medical societies reimburse physi- cians at a rate at least 16 percent higher than more independent boards do. Even when factors which could affect the charges for medical services are taken into ac- count, the FTC found that physi- cian domination of Blue Shield boards costs US consumers an ad- ditional $ 500 million annual- ly equal - to the entire annual budget of New York City's Health and Hospitals Corporation. The national study is a signifi- cant boost to growing local efforts to turn control of these key in- surors over to the premium pay- ing public. In 1978 the Penn- sylvania legislature passed a law requiring that Blue Cross, the largest single insuror of inpatient services, turn its board over to a majority of subscriber represen- tatives. Similar legislation in Michigan is being enthusiastically supported by the United Auto - Workers. In the most promising legal development, Ohio's Assis- tant Attorney General Charles Weller forced the Ohio State Medical Association to agree to turn over Blue Shield of Ohio to a board of subscriber represen- tatives. The settlement terms pro- hibit the medical association from having any representatives on the Blue Shield board or rate setting - committees. The Ohio Attorney General has recently announced a similar victory against a provider controlled - dental in- surance program. The ground breaking - FTC report was the first shot in an effort to promulgate a legally binding FTC rule limiting physician con- trol of Blue Shield boards because of the stifling effect it has on com- petition. In addition to its work on Blue Shield, the FTC has taken the lead in exposing the " Medigap " in- surance industry. " Medigap " poli- cies are sold to elderly citizens, ostensibly to cover the gaps in Medicare coverage. Because many of the policies overlap with Medicare, unreasonably exclude common conditions, and have unrealistically low payment levels, they are often nearly useless to the tens of millions of seniors who pur- chase them. High pressure fear tactics used by many insurance agents add to the problem. The FTC has also drawn blood with its report on cancer in- surance. Cancer insurance al- ready grosses several hundred million dollars per year. It was given a big boost after the Three Mile Island nuclear disaster last year. Agents for the leading cancer insurance companies reported great success selling their policies door door - to - in the Harrisburg area and in other com- munities with nearby nuclear plants. Although most commercial insurors pay out in benefits 80-90 percent of what they take in, the cancer insurors pay out less than half their take as benefits. The rest goes for lavish commissions and profits. Most policies have so many exclusions that they pay for less than one - fifth of the actual cost of cancer treatment for those in- dividuals who do get cancer. The Agony and the FTC Such activism does not go un- noticed - or unavenged. The in- surance industry, the American Medical Association and the American Dental Association are all taking leading roles in a major corporate attack on the FTC's authority. It is virtually certain that the FTC will be stripped of its abili- ty to even investigate any in- surance matters. An amendment, sponsored by Senator McClure (ID R -), would prevent the FTC from studying or regulating the conduct of any " state regulated professions. " In theory, doctors, lawyers and den- tists are already regulated by state licensing boards which control their conduct and protect con- sumers. This theory ignores the reality that professionals dominate on state licensing bodies and use them to protect and advance pro- fessional prerogatives. Only California, New York and Mary- land have experimented by plac- ing a significant number of non- professional public members on licensing boards. The McClure amendment is opposed by a wide range of labor and consumer groups. Despite this concerted defense of the FTC, the amend- ment has a 50-50 chance of pass- ing. The attack from the health in- dustry is only one part of an even bleaker picture. Other amend- ments would void FTC activities in the areas of children's television advertising, funeral homes, large agricultural combines and mobile homes. Although consumer groups have mounted a last- minute defense, it may be too little and too late. This drives home an important lesson for regulators 13 URBAN M COMMUNITY CLINICS IN SEATTLE: A SYSTEM THAT WORKS Over the past decade, Seattle has developed a network of com- munity - based primary care clinics which today seem to be thriving. What are some of the reasons that the Seattle experience has suc- ceeded where others have not? By many of the traditional mea- sures, there is certainly no lack of health care in the Seattle - King County area. The ratio of physi- cians to the general population is higher than all but a few places in the country. There is a large medical school (University of Washington) reputed to be among the finest. One of the oldest HMOs in the nation Group - Health Co- operative of Puget Sound - pre- sently has nearly a quarter - million local enrollees out of some 1.2- 1.4 million residents in the greater Seattle area. In the face of this apparent bounty, however, a large seg- ment of Seattle's population lacks access to routine health care: the uninsured " medically indigent, " including the working poor, mem- bers of the city's ethnic minorities, and a variety of marginal people with alternative lifestyles who find existing primary care services in- accessible and / or unacceptable. In response to this need, a varie- ty of community controlled clinics were formed in Seattle in the late 1960s with funding from a variety of sources, including Model Cities and Office of Economic Opportunity (OEO) grants. These have developed into some 20 medical and five dental facilities that today provide 70,000 patient contacts yearly and wield signifi- cant political power. Seattle has traditionally been a city of neighborhoods. Built on multiple hills, the geography of the area promotes the sense of neighborhood, with political " clubs " and Community Councils that have played an active role in local politics for many years. Ac- cording to Linda Doupe, Presi- dent of the Central Seattle Com- munity Council Federation, these organizations often represent widely disparate views. The issues they raise and the stands they take are sometimes exclusionary and elitist, at other times radically idealistic. As in most cities, they nearly always focus on issues close to home: schools, parks, health, safety and preservation of life style. Their role in stabilizing and strengthening neighborhoods is undeniable. In the late'60s several factors accentuated the need for addi- tional health care in Seattle's neighborhoods. Two of the major factors were significant cutbacks in the county hospital clinic sys- tem and a prolonged economic recession precipitated by massive layoffs at the Boeing Company, one of the city's major employers. The clinics that were developed reflect the diversity of the com- munities they serve: the inner city elderly, " skid rowers, " Blacks, Chicanos, Native Americans, Asians, women, street people, youth, residents in a number of low income - housing projects and " garden communities. " Such diversity means the clinics are unique in a real sense, and each reflects varying individual needs and life styles. The clinics share commonly stated goals: providing con- tinuous, quality primary care, pa- tient service in a humanistic fashion, affordable prices and an emphasis on preventive care. All have community boards which actively participate in planning, implementation, maintenance and evaluation of the clinic's programs. Innovative organization has been one key to continued growth. and stability. Some clinics are run as collectives (in 1980!) without hierarchy or salary differences. Innovative use of local and federal resources has strengthened the positions of all parties, involved, including government agencies Others are molded along more traditional lines. All of the clinics utilize some variation of a multidisciplinary team of medical providers, social service personnel, patient ad- vocates and outreach workers and volunteers. Most direct medi- cal care is provided by mid level - practitioners. Some clinics offer alternatives to traditional Western medicine. Central to the vitality of the community clinic network has been the role of Seattle's US Public Health Service (USPHS) Hospital. In the early 1970s, the USPHS Hospital system nationally 15 In a bold move to both provide needed care and strengthen its community ties, the Public Health Service Hospital negotiated agreements of affiliation with each of the various clinics. The clinics agreed to provide care for low income patients and the hospital agreed to provide secondary and ancillary services was under severe political pres- sure from the Nixon admnistration and was in serious danger of be- ing disbanded. In a bold move to both provide desperately needed care and strengthen its commun- ity ties, the hospital negotiated agreements of affiliation with each of the various clinics. Under this agreement, the clinics agreed to provide primary care for low- income patients as well as all PHS beneficiaries (federal employees and other original users of the old USPHS Hospital system). The hospital agreed to provide secon- dary and ancillary services in- cluding laboratory, x ray -, special- ty consultations and inpatient admissions. The consequences have been extremely favorable for all in- volved. The clinics gained a powerful political ally as well as a high quality backup resource. The hospital gained a substantial increase in both inpatient and out- patient volume plus new support from the community. Today, federal officials proudly speak of the Seattle experience as a model for governmental involvement in local health care. National Health Service Corps personnel have been utilized since the early phases of development of the Seattle clinics. The Seattle Indian Health Board - one clinic in the system - got approval for the use of NHSC personnel as ear- ly as 1972. Subsequently, several of the larger clinics formed two consortia, each of which de- veloped its own umbrella com- munity board and administration, 16 while member clinics maintained their own individual boards and administrative structure. By 1976, Health Manpower Shortage Area (HMSA) designation for many of the clinic catchments was ac- complished. Shared NHSC per- sonnel were assigned to the con- sortia beginning in July, 1977. The USPHS Hospital Director functions as project officer for this unique project, and additional ad- ministrative personnel and a clinical coordinator were added at Seattle's Community Develop- ment Block Grant revenues have been allotted by the city to help the clinics provide service to their medically indigent patients. Several clinics already obtain grants from the King County general fund. The Seattle - King County Health Department has also been closely involved in both planning and monitoring clinic programs as well as providing some ancillary lab and x ray - ser- the hospital to facilitate the pro- ject. More recently, added funding has been obtained from the Urban Health Initiative (UHI) program and additional personnel have been assigned to several innova- tive projects. A cooperative effort between the Seattle - King County Jail and two community clinics was begun in 1979, the first of its kind in the country. In another co- operative venture, Planned Parenthood and two clinics have vices, immunizations and screen- ing. Other agencies, such as the HSA, have become active sup- porters in the development of this network. The model developed in Seattle bears close study. Innovative utilization of local and federal resources has strengthened the positions of all parties involved, in- cluding governmental agencies. Agency cooperation has general- ly been good. Perhaps most cen- tral to the success of the whole joined forces in a program to ad- dress the problems of teenage and other high - risk pregnancies by providing enhanced prenatal and maternity services. The Seattle network has also en- system has been its roots in well established communities and strong local commitment to health services for the entire Seattle population. Finally, the utilization of diverse resources including the joyed strong political support. At NHSC, UHI, the USPHS Hospi- a national level, Senator Warren tal, the local Health Department Magnuson has been an instru and other local governmental mental supporter. Both city and agencies has created a broad county governments have lent financial and political base which much needed financial support, strongly favors the continued suc- making health care a major priori- cess of the project. ty. Mayor Royer's primary ad- - -William Shaw visor on health issues gained near- (William Shaw is a physician ly 10 years experience working who works at the Pioneer within the community clinic Square Neighborhood Health system. Station, one of the clinics in For 1980, over $ 1 million of Seattle's system.) WORK ENVIRON F OSHA ACT AXED Recently in this column we dis- cussed OSHA's failure to stem the growing rate of lost time - injuries among US manufacturing work- ers (see Health / PAC BULLETIN, Vol. 11, No. 2, pp. 19-20). I sug- gested that to improve its record OSHA will have to expand the scope of its safety standards to cover a great many more unsafe situations than it now does. " If OSHA can't or won't do this, it can expect grave political pro- blems, since its business and poli- tical enemies will surely make the general public aware of the agen- cy's failures. " Well, in just a few short months this has happened - with a ven- geance! Citing OSHA's inability to stem the lost time - injury rate- industry's lost time - injury rate, it should be added Senator - Rich- ard Schweiker (PA R -) has intro- duced the so called - " Occupation- al Safety and Health Improve- ments Act of 1980 (S2153). Of course, many proposed amendments to OSHA are intro- duced each year and in the past many have been passed in one or both Houses of Congress only to be killed later in joint Senate- House conference committee or by Presidential veto. What makes this bill's chance for passage so much greater than past OSHA amendments is the long term - buildup of industry opposition to OSHA and the bill's sponsorship in the Senate not only by Repub- licans Schweiker, Governor Rea- gan's Vice Presidential - choice in the 1976 presidential race, and freshman Orrin Hatch (UT R -), a chief spokesman for the Senate's raving rightwing, but by promi- nent Democrats as well. Among the Democrats are Senator Har- rison Williams (NJ D -), co author - of the original OSHA Act and pre- viously OSHA's strongest, most consistent defender in the Senate, Senator Alan Cranston (CA D -), Assistant Democratic Majority Leader in the Senate and one of President Carter's closest Senatorial allies, and Senator Frank Church (ID D -), chairman of the powerful Senate Foreign Rela- tions Committee. A Bad Taste All Around The bill itself is a much more comprehensive rewrite of the OSHA Act than other OSHA amendments in the past. It would exempt an estimated 94 percent of all US businesses and indus- tries from OSHA OSHA inspections, based on the companies'fatality and lost time - injury records for the previous year as determined primarily from worker's compen- sation reports. It would also eliminate or lower fines for OSHA violations from firms that establish advisory " " labor management - safety committees and regular safety and health consultation programs. Senator Williams couched his support for the amendment as " one method " to " effectively tar- get limited enforcement resources so that it (OSHA) concentrates on the most unsafe workplaces " (Congressional Record, Dec. 19, 1979, p. S19252). But Schwei- ker, citing rising US lost time - in- jury rates, makes clear the true spirit behind the bill: " The bottom line is this: After nine years under the Act's present safety regulatory scheme, we are left with no demonstrable evidence that it works and a bad taste all around from the experience, " (op. cit., p. S19249 - author's emphasis). Schweiker says there is a " bad taste all around, " but workers with " The bottom line is this: After After nine nine years under OSHA's present safety regulatory scheme, we are left with no demonstrable evidence that it works ' -Senator Schweiker (PA R -) whom I and many others have spoken don't have any such bad taste about OSHA. They support OSHA, although it is weak and they would like it to be stronger and more effective. The bad taste is in industry's mouth. For OSHA has been a thorn in industry's side for many years (to switch meta- phors) and industry is using OSHA's real failures in the safety field as a smokescreen to accom- plish their long term - goal - to mortally weaken the Act if not kill it outright. What is a Safety Inspection? What is a Health Inspection? Specifically, the bill would exempt all firms from " safety in- spections " or other investigations by NIOSH or OSHA (for exam- ple, to check company records) 17 OSHA has been a thorn in industry's side for many years and industry is us ing OSHA's real failures in the safety field as a smokescreen to accomplish their long term - goal - to kill the agency outright a if during the previous year the company did not report one or more injuries each involving at least two lost workdays. OSHA could only enter the firm one injury, even a fatality, and still be exempt from inspection. cumstances: * An incident occurs involving a fatality or the hospitalization of two or more employees, * An imminent danger of a seri- ous nature occurs in the work- place (presumably reported by some one inside, since the OSHA inspector is initially barred from entering), * A worker reports a suspected violation to OSHA and after the employer is notified of the com- plaint OSHA has not been given " satisfactory assurances that appropriate action, if any, has been taken, " or OSHA wishes to conduct a health hazard investigation. (The proposed amendment, by the way, does not specify how to distinguish a safety from a health investigation - how's that for creating a legal wrangle that will keep inspectors out of the workplace while lawyers on all sides are busy at hearings and in the courts?) Then to keep the legal kettle boiling further - and the inspec- tors stewing on the outside of the plants - the bill stipulates that " where distinctly separate activi- ties are performed at a single physical location, each activity shall be treated as a separate workplace "! Think of the license that this provision alone will give employers - for example, if two welders were killed or injured on the job in the previous year, the 18 company can try to keep the OSHA inspector out of the machinists'work area, etc. And if the OSHA inspector is entitled to enter the plant based on any of the above specifications and if further the company has an " advisory " safety committee and a hazard consultation program, then the company cannot be fined for any serious violations found, even if it has caused a worker's death. Finally to assure that the bill gives the employer an even break ()!, it also allows employers yet another escape hatch from OSHA investigation. If the com- pany had no fatalities caused by occupational injuries during the previous year and the rate of lost- time injuries in the plant is below the national average of four lost- time injuries per hundred full time - workers in that year (the specific rate limits for plants of various size are given in the bill), the firm is also exempt from the inspections. The First of the Worst What are the quintessentially worst features of this bill, among the many candidates in its two short pages? With exemptions from inspec- tion based on weak, poorly ad- ministered state worker's com- pensation laws, the bill encour- ages employer manipulation and deception on worker comp reports. (For example, in a number of states like Rhode Is- land injured workers are en- couraged to file for compensa- tion under the relatively more generous state medical disabil- ity laws than under the state comp laws. Since the disability laws use state funds to com- pensate for any disabling in- jury or illness, no matter what its cause, this system keeps employer comp insurance rates down and leaves occupational incidents unreported or under- reported. Similar problems abound in other states). * The bill largely removes work- ers'greatest power under OSHA, the threat to call in OSHA if a company does not improve health and safety con- ditions in the plant. Typically OSHA inspections in any given plant are infrequent and inade- quate, but the threat of one, with the attendant uncertainty faced by management, is a powerful weapon in workers ' hands. * Finally the bill makes the OSHA Act the antithesis of a preventive health measure. Only after workers are killed or maimed could OSHA enter most plants and then perhaps as much as a year after if the in- cidents occur early in the year of the firm's exemption. The public health concepts em- bodied in this bill represent the most advanced thinking of the Nineteenth Century applied to the problems of the Twentieth! As for setting priorities for OSHA inspections, which the bill purports to do, it is one thing for Congress to set OSHA inspection priorities, it is quite another to eliminate OSHA's right to inspect most workplaces, as this bill does. The New York Committee for Occupational Safety and Health (P.O. Box 3285, Grand Central Station, NY, NY 10017) is coor- dinating activity against this measure, as are other COSH groups and labor unions around the country. -David Kotelchuck WOMEN Q BIRTH OF A STRUGGLE Marianne Doshi, Elizabeth Leg- gett, Carolle Baya, and Rosalie Tarpening are just four of the most recent victims of the struggle for humane, safe childbirth. As birth rates declined during the 1960s the practice of obstetric medicine became less profitable, simply because there were fewer patients to receive this care. And as existing standard obstetric practice has come under fire from a number of different fronts, because of its dehumanizing obsession with technology, its high costs, and its less than laudable infant mortality statistics, more and more women turn to the only real alternative: homebirth. And as the popularity of home- birth increases, the medical com- munity becomes more threatened -and more vicious. California legislators introduced legislation in 1977 to legalize lay midwifery and give it autonomy from the medical profession (see " Lay Midwifery: The Old Becomes the New? ", Health / PAC BULLETIN, no. 79, November / December 1977). By September 1978, when the bill became law, there was no mention of mid- wives at all. The bill had become an authorization for any govern- ment agency to apply to sponsor a pilot project for " training in- novative health care personnel. " The change in emphasis is at- tributed to the California Medical Association's (CMA) strong op- position. This organized opposi- tion to midwifery extended to the delivery of medical care itself, as clearly evidenced by the case of Marianne Doshi, a lay midwife from San Luis Obispo, charged with second degree murder and practicing medicine without a license. After an apparently uneventful labor, the baby of a couple Doshi attended at a home delivery ex- hibited breathing difficulties at birth. Doshi administered mouth- to mouth - resuscitation until the local fire men - arrived and me- chanically induced breathing. The infant and her mother were taken to Sierra Vista Hospital, where the mother was refused ad- mission because she had no at- tending obstetrician. Numerous sources report that this was the result of an agreement among local county obstetricians to refuse prenatal consultation and care for women planning to deliv- er at home. The baby was subse- quently flown 200 miles to Mt. Zion Hospital in San Francisco, where she died five days later. The parents filed no charges against Doshi. Doshi was arrested and charged, however, by the County of San Luis Obispo. Doshi was cleared of both charges on October 20, 1978, by San Luis Obispo Superior Court Judge Richard Kirkpatrick. In his ruling Kirkpatrick defended the right of parents to deliver children at home and called for better com- munication between the medical community, the educational com- munity, midwives and parents seeking alternative childbirths. John N. Miller, Chairman of the California chapter of the Ameri- can College of Obstetricians and Gynecologists, commented after the hearing, " The difficulty I find with the judge's decision is that these people are totally unlicens- ed. They are just a group of peo- ple, some with no qualifications, whose only experience in some cases is having watched five or six people give birth. They have no comprehension of the complica- tions that can arise in childbirth. " Yet the very bill which would have established licensure criteria (education, apprenticeship, etc.). was the very bill decimated by the CMA, Miller himself and numerous other medical groups and individuals. Midwifery itself is not the issue. Midwifery is a growing specializa- tion in the nursing profession. What is at issue is who becomes a midwife, where the midwife at- tends births, and how much auto- nomy the midwife has. The nursing profession has recognized both the criticisms of modern obstetric practice and the demands of women to have more wholistic, supportive prenatal and delivery care, and created a mid- wifery specialty, certified by the American College of Nurse Mid- wives. Certified nurse midwives do much to alleviate a number of the recent criticisms, but they have not been able to solve all of them. By state regulation, and professional choice, most nurse midwives confine their practice to hospitals or birthing centers. Thus the demand for home birth atten- dants is largely ignored by the obstetrical profession and cer- tified nurse midwives. Nurse mid- wives bring with them a medical bias towards birth, at least moreso than lay midwives. Nurse mid- wives are trained to see them- selves as " apprentices " of obstetri- cians, having the same relation to 19 them that physician assistants have to family practitioners. In Tennessee, where The Farm is known for its safety record of midwife attended - out hospital - of - deliveries, Elizabeth Leggett, RN, had her nursing license revoked by the Tennessee Board of Nurs- ing for practicing midwifery with- out certification. Tennessee has no laws regulating lay midwives, and lay midwifery is specifically ex- empt from the state's medical practice act. The charges? " Un- professional conduct, performing functions she is not prepared to handle, and being unfit or in- competent to handle forseeable consequences. " At issue here was the fact that Leggett was an RN, since, " If she weren't a nurse, the board would have no case, because Tennessee law does not regulate midwives, " according to Elizabeth Hocker, RN, executive director of the Tennessee Board of Nursing. Doctors in Tennessee are no more receptive to homebirths than are doctors in California. The Childbirth Information Associa- tion has " been looking for over three years for a doctor to help us set up a safe home delivery ser- vice for women who want it. " One such doctor was found, but was allegedly threatened with loss of hospital privileges until he withdrew his assistance. President of the Tennessee Medical Associa- tion, John B. Dorian, feels that anything is better than the home for delivery. " The specialty of gynecology actually got its start from the repair of home deliv- eries, " commented Dr. Terry De- Witt, a " local obstetrician " who re- fuses prenatal care to any woman anticipating home delivery. The attacks keep coming. In St. Augustine, Florida, Carolle Baya, a birth attendant and home birth educator, was charged with prac- ticing midwifery and medicine without a license. Although there had been no bad outcomes or parent complaints concerning Baya's birth attendances, the charges were initiated by Dr. An- thony Mussalem, one of the two practicing obstetricians in her community. Dr. Mussalem's com- plaints led to Baya's termination as a Lamaze instructor for the Coun- ty School Board and to the (afore- mentioned) charges from the State Attorney's Office, as well as an attempted injunction to " tem- porarily and permanently enjoin Baya from attending home child- birth " until she was granted a mid- wifery license. The attempted in- junction would have been the ultimate licensure catch - 22 - is contingent upon attendance of a specified number of births! Baya had been pursuing licensure as a midwife for over a year prior to the levying of charges against her. Florida's 1931 statutes regard- ing midwifery were declared un- constitutional by Judge Richard O. Watson in a six page opinion, October 10, 1979. The opinion applies only to the Baya case, unless, after appeal by the State and the Department of Health and Rehabilitation Services (HRS), the decision is upheld in the Florida Supreme Court. As of December 1979, no appeal had been filed. HRS, however, proposed new regulations for midwives while the decision was being awaited. Among other provisions, the legislation would require a physi- cian to " certify " a patient as suitable for lay midwife delivery and to forbid lay midwives to at- tend a woman having her first baby. It is expected that this legislation will be introduced in 1980. The most recent case to come to our attention, and the most serious known charge to date, is that of Rosalie Tarpening. Tarpening is a licensed physical therapist who first assisted at a friend's home delivery some 10 years ago in Madera (Monterey County), Cali- fornia. Since then, Tarpening as- sisted over 350 home births, with an infant mortality rate of 2.7 1,000 / live births. The rates for the county were so high (23.9 / 1,000), that a trial program recruiting nurse midwives was in- itiated, lowering the rates to 10.2 1000 /. Tarpening's rates compare most favorably with the county statistics cited above. Until November 28, 1979, Tarpening had no problems in any of her assistances. On that date, Tarpen- ing assisted in what was to become a still birth. Although the family had no complaints, the District Attorney, after learning of Tarpening's presence at the home, charged her with first degree murder and practicing medicine without a license. The preliminary hearing is scheduled for February 28, 1980. The struggles for the legitimiza- tion of lay midwifery cited here. are part of a much larger struggle in obstetrics, and health care in general, today. Financial factors lend credibility to the cries of women for nonhospital - based deliveries, since the latter are ob- viously less costly. Traditionally, childbirth has been woman's do- main. The development of forceps and anesthetic technology allow- ed the male medical profession to dominate childbirth here in the United States. As the women's health movement grows stronger, this dominance is challenged. The cases cited here are just the begin- ning of a long, protracted struggle for the control of a human birth experience and for the control by women of their own bodies. -Marilynn -Marilynn Norinsky (Editor's note: For further informa- tion, see The Federal Monitor, volumes 1 and 2.) 20 Pathologies of Place Continued from Page 12 house memorandum responding to the suggestion that " patients " in SROs (the state vacillates between calling them " patients " and " patients ex -" ) would be better kept in institutions, he wrote: Hard though, that it may be to believe, however, many of the individuals living in those facilities are there by choice and state a preference for remaining rather than returning to the hospital. If these individuals are prisoners, they are prisoners of poverty not of the mental health system. Were SSI benefits adequate. Were jobs really available. Were low income housing sufficient. Most of these in- dividuals could live quite capably in communi- ty settings. While they may be living in cir- cumstances far less than ideal, many of them prefer those circumstances to a hospital en- vironment (28). Ironically, however, Prevost's remarks neglect a more commonly stated prerequisite for successful community survival - readily available and suffi- cient mental health services. Whether intentional or not, the omission is a rather telling one because the " more services " mentality is a deeply ingrained and widely proclaimed one, receiving its latest and most illustrious endorsement from the President's Commission on Mental Health (29). What the mentally disabled need, however, is less often more services than it is a more decent life. One ex patient - has described his situation as follows: I realize you got to have a place to live when you leave the hospital, and (patients) take what they can find. (But in an SRO) you're still isolated and by yourself. Most of all, you aren't living in a place that you chose for yourself. It was simply arranged for you Many of us. with just a little help, could live with each other in a real apartment of our own (30). It is sometimes objected that these are " social " -not " therapeutic " -needs, thus the con- cern, properly, of the welfare - not the mental health system - . But it has long been recognized that pathologies of place compound disorders of the mind. One study under way in Pittsburgh in- dicates that among ex patients - living in the com- munity, the severity of roaches in the home is a bet- ter predictor of re hospitalization - than the severity of symptoms in the sensorium (31). Service bureaucracies are inherently ingrown, overweight and firmly entrenched. In a period of fiscal cutbacks, their de facto priority has become their own survival. In " the field " (or " front - lines "), mental health workers tiptoe daily round the edge of despair: demoralization is rampant, caseloads are huge and efforts at finding decent housing for their charges are futile when there is none to be had. The " helpfulness " of such professions becomes a cruel joke to practitioner and ex patient - alike. Meanwhile, public disgust scales new heights in outrage over the eyesore of the sidewalk psychotic. Even reconstructed liberals, survivors of all the failures of the Great Society, are overheard muttering, " I don't care what you do with them, just get them off my street. " It would be wishful thinking to encourage ex- patients to " hold out " till the next turn of prosperity arrives. Nor is there any real hope in shuttling them off to some well ordered - oblivion. The City, for its part, might be taken as seriously concerned if it were to propose legislation revers- ing the J 51 - " gentrification " program, thus pro- viding incentives for upgrading low income - hous- ing. The result might then be shelter which respected the privacy and dignity of even the un- washed and deranged - in short, providing both short - term refuges and long term - possibilities for setting up housekeeping on one's own or with Shelter is a fundamental human need, not a mental health service to be given and withheld on the basis of one's mental status. Nor does it require mental health expertise to know that security and stability of environment promotes stability of mind others. However, in the words of one City ad- ministrator we interviewed, " this is still a landlord's town. " So long as that remains the case, articles like this can go on restating the problems that result. Fluctuations in the real estate market and cost- cutting by State and City governments facing fis- 21 cal crises force the mentally disabled to live in expensive, unsafe, substandard housing, and on the streets. Many of their routine fears and unusual behaviors are best understood as reactions to con- ditions none of us could truly be asked to tolerate. Shelter is, after all, a fundamental human need; it is not a mental health service to be given and witheld on the basis of one's mental status. Nor does it re- quire mental health expertise to know that security and stability of environment promotes stability of mind. -Ellen Baxter and Kim Hopper (Ellen Baxter and Kim Hopper work at the Com- munity Service Society of New York on a research project examining the quality of life for mentally disabled adults in the'community'of New York City.) References 1. Lund, D.A., " The Mentally Impaired and the Long Term - Care Systems: A Profile of Needs. " A paper prepared for the State Communities Aid Association, New York, June 4, 1979. 2. Brill, H. and R. Patton, " Psychopharmacology and the Current Revolution in Mental Health Services. " Pro- ceedings of the Fourth World Congress of Psychiatry, Amsterdam, 1966. 3. Goffman, E., Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Garden City, N.Y.: Doubleday, 1961. 4. Scull, A., Decarceration: Community Treatment and the Deviant A Radical View. Englewood Cliffs, N.J.: Prentice - Hall, 1977. 5. See " Service Integration for Deinstitutionalization: Cost Benefit / Analysis, " Vol. 5, Rehabilitation Services Administration of HEW, April, 1975 and Baxter, E., " Deinstitutionalization: A Critical Analysis ", forthcoming in Social Policy for reviews of this evidence. 6. See Lander, L., " The Mental Health Con Game, " Health / PAC BULLETIN, No. 65, July August / 1975 for a more detailed analysis of New York State's mental health policy over this period. 7 . Ibid. 7 b. Testimony of Kathleen Clarkson, The Catholic Worker, at the Public Hearing of the Senate Mental Hygiene and Ad- diction Control Committee, New York City, November 14, 1979. 8. Bellamy, C., " From Country Asylums to City Streets, " Of- fice of the New York City Council President, July, 1979. 8b. Prevost, J. Year Five - Comprehensive Plan for Services to Mentally Ill Persons in New York State: 1980. October 1, 1979, p. 109. 9. Christmas, J., Final Report of the Interagency Task Force on Problems of Deinstitutionalization and the Chronically Mentally Ill, N.Y.C. Department of Mental Health, Mental Retardation and Alcoholism Services, New York City, Ju- ly 17, 1978. 10. Shapiro, J., Communities of the Alone. New York: Association Press, 1971. 11. " Single Room Occupancy: A Need for National Concern, " Special Committee on Aging, U.S. Senate, 1978. 12. Lorber, C., " The Village's Worst SRO, " The Villager, March 12, 1979. 13. Witten, M., " West Side SRO Fined $ 37,000; Biggest Ever, " The Westsider, February 2-8, 1979. 13b. Not to be alone and isolated, to have regular and varied 22 social contacts with others (be they family, friends or other tenants) has been shown to reduce hospitalization re - rates among ex patients - living in a similarly serviced hotel. See Cohen, C. and J. Sokolovsky, " Schizophrenia and social networks: ex patients - in the inner city, " Schizophrenia Bulletin 4 546-560: , 1978. 14. A press release from City Council Member Ruth Mes- singer's Office entitled, " Council Member Messinger Charges Tax Benefit Programs Favor Manhattan; Cites Abuse in J 51 - Program, " August 21, 1979. 15. Kopp, E. and K. Murphy, " Priced Lower - Hotels in New York City: 1978, " Human Resources Administration, Department of Social Services, New York City, 1978. 16. Hynes, C., " Private Proprietary Homes for Adults, " Of fice ofthe Deputy Attorney General, New York, March 31, 1979. 17. Ibid. 18. Ibid. 19. Quoted in Community Support System Contract Pro- posal for the Men's Shelter, Human Resources Ad- ministration, Department of Social Services, New York City, January 12, 1979. 20. Bellamy, op. cit. 21. Bellamy, op. cit. 22. Community Support System Contract Proposal, op. cit. 23. Miles, D., Memorandum on " Domiciliary Care Facilities, " New York State Office of Mental Health, November 29, 1978. 24. Ibid. 25. Bachrach, L., Deinstitutionalization: An Analytical Review of Sociologal Perspective, Washington, D.C., U.S. Government Printing Office, 1976. 26. New York State Assembly Sub Committee - on Communi- ty Aftercare. From the Back Wards to the Back Alleys. New York, March 15, 1978, p. 10. 27. Weisman, S., " 28% Are Held in Mental Hospitals Needlessly, New York Study Finds, " New York Times, January 15, 1978. 28. Prevost, J., Memorandum to Governor Carey on deinsti- tutionalization, New York State Office of Mental Health, October 23, 1979. 29. Summary Report ofthe President's Commission on Mental Health, U.S. Government Printing Office, Washington, D.C., 1978. 30. Peterson, R., " What are the Needs of Chronic Mental Pa- tients. " Paper delivered at the American Psychiatric Association Meetings, Washington, D.C., January 11-14, 1978. 31. Bromet, E. et al., " Community Environments of Deinstitu- tionalized Patients. " Paper delivered at the 107th Annual Meeting of the American Public Health Association, New York City, November 4, 1979. RING NURSE CELSI MCMLXXX Business at the Bedside HEALTH CARE Jewish Hospital of Brooklyn has been in end- IN B1R8O9O0K-L1Y9N1,5 stage financial condition for the past few years. The reasons for its chronic financial plight, how- ever, are subject to dispute. On the one hand, various officials maintain that its condition is the result of severe administrative mismanagement and improper business practice. On the other hand, its trustees and administrators claim that their institution is insolvent because it has been meeting the special needs of a very poor and underserved community and has not been ade- quately reimbursed. Ironically, as the following article will illustrate, it was the trustees of this very institution who, in the early years of this century, were in the forefront of a battle to instill management ideals and modern business prac- tices into what were, until that time, charitable institutions. By now Jewish Hospital's trustees have probably learned that their founders'view that the hospital is " no different from any other large, com- mercial enterprise " is probably wrong. Institutional survival and the survival of patients need not automatically conflict. But, historically at least, there has been uneasy coexistence between an institution's financial needs and the needs of the patient. This article looks into the early history of the introduction of business methods and notions of efficiency into what were once charity hospitals. The effects of an early crisis in hospital finance on the administration, organization and patient popu- lation are studied. Now, as many administrators once again turn to business to lend us advice re- garding hospital management techniques, it is especially important to review earlier experiences and learn from them. This article recently appeared in Health Care In America: Essays in Social History edited by Susan Reverby and David Rosner, both of whom have been associated with Health / PAC. This volume was published by Temple University Press in 1979 and the article is reprinted here with their permission. 23 Most of us recognize that patients are assigned space in the hospital in accordance with special medical needs. But it is also true that patients are assigned beds according to ability to pay, insur- ance coverage, and source of referral. Private and semiprivate rooms and small wards are as much a characteristic of contemporary hospitals as are the medical, surgical, and specialty services (1). The separation of patients according to economic class and other social factors has a long history. In nineteenth - century America, for in- stance, wealthier clients generally received care at home or in private doctors'offices; working- class and indigent patients often received care through the out patient - department of hospitals, local dispensaries, workers'associations (lodges) or the charity hospital. While distinctions in ser- vice for the rich and the poor have always existed in the American health system as a whole, the incorporation of differing services within the hospital is a relatively recent phenomenon. Before the turn of the century most non munici- - pal institutions were charitable in nature and served a primarily working - class population. In that sense, the nineteenth - century hospital was a " class one - " facility. While separate institutions existed for women, blacks and distinct immigra- grant groups, internally they were organized in a relatively uniform way. Patients were housed in wards with few distinctions based upon the pa- tient's ability to pay (2). Services were provided at the expense of philanthropists and hospital trus- tees. As Morris Vogel has illustrated, the nine- teenth century - facility served primarily social, rather than medical needs for working class and / or destitute persons (3). By the early 1900s a change occurred in the organization of hospital services in charity institu- tions. During that period the more modern volun- tary hospital system arose. This development entailed a dramatic reorganization of the physical space and administrative hierarchy of the hospital. First, the development of class specific - services was a prominent feature of the physical restructur- ing of the facilities. As trustees sought private pa- tients and their fees, private and semi private - rooms and wards began to displace public and charity wards. Second, as trustees sought to make their institutions more amenable to paying patients, private physicians were admitted to the institutions in the hope that they would bring their patients with them. Ironically, the authority of lay trustees declined as physicians began to exert greater control over the day day - to - services pro- 24 vided their private patients. Third, the care of the charity patient, originally the function of these facilities, was increasingly seen as an incon- venience. In New York the municipal and later the state governments were called upon to bear a larger portion of the financial responsibilities for poor patients in voluntary institutions. This article will examine some of the economic pressures that forced trustees in Brooklyn's Progressive Era hos- pitals to abandon their older, traditional functions as stewards to the poor and to allow their facilities to undergo profound, and at times disruptive, change. The decline in the charity functions of philan- thropic institutions resulted in part from the severe economic crisis that af- fected many facilities in ____ the wake of the depres- sion of the 1890s. This As hospitals depression hit Brooklyn's Brooklyn's institutions during a period when costs for modernized, health services health care were rapidly increasingly rising. In general, institu- became tions in need of money turned to the paying patient as the most likely segmented by class and a source. The provision of patient's ability hospital care ceased to be an act of charity and to pay became a commodity to be bought and sold by those who could afford it. pF The move away from charity to pay services. was rationalized as part of the larger Progressive Era movements toward order, efficiency and bureaucracy. However, the hospitals of the period also exemplify changes that do not fit neatly into any historiographic package. The appli- cation of business principles to charity hospitals had a different result: other reform movements led to greater emphasis on corporate responsibility, while changes in hospital finance placed the bur- den on individuals. Deficits Demand and Demand In the early years of the twentieth century a pro- minent Brooklyn businessman, Abraham Abra- ham, became deeply involved in the formation of the Jewish Hospital of Brooklyn. This hospital, Abraham stated, would avoid some of the chronic problems that plagued many of the city's charita- ble institutions; it would be so organized that it would " not run in debt. " Abraham, owner of Abraham and Straus, the city's largest depart- ment store, noted that a hospital was not very Laas different from other large enterprises. He believed that " charitable institutions, however laudable and worthy, should be conducted on sound business principles " (4). Abraham's concern for the development of " business principles " in charity institutions was spurred by a mounting crisis in hospital financing. During the depression years of the 1890s, many of Brooklyn's charity institutions had found their costs rising at the very time that their incomes from philanthropy were shrinking. As economic conditions worsened, working - class patients in- creasingly demanded hospital service. Ever larger numbers of patients found themselves in need of the traditional services that hospitals pro- vided shelter and food (5). As demand in- creased, so too did the costs of running the facilities. At Brooklyn Hospital, for instance, hospital utilization nearly doubled during the de- pression years, growing from just over 1,200 patients in 1895 to nearly 2,300 by 1899 (6). At Brooklyn Maternity Hospital the secretary noted a similar dramatic increase. " When the necessity for relief [is great], the greater will the demand be upon all charitable institutions for that relief " (7). Others noted that the " times have been hard.. but it is hard to turn away appeals for aid [from patients] " (8). Even in relatively good times, the use of the hospital by those who needed non- medical services and aid was common. " The coming of Spring always brings remarkable recoveries to some of our most stubborn cases, " sarcastically noted one hospital surgeon (9). At the very time that patient demand was rising, hospital trustees were faced with another chal- lenge to the financial security of their institutions: costs for medical supplies were growing. As bac- teriological practices began to be felt in terms of higher standards of general cleanliness, sterile sur- roundings, and aseptic surgery, a slow growth in costs for medical supplies and maintenance re- sulted (10). During the period, for instance, the use of rubber gloves, sterile bandages, supplies and equipment became a standard part of hospital expense. At Brooklyn Hospital the average cost for a day of care rose from $.89 in 1890 to $ 2.78 by 1915 (11). These two factors, rising patient demand and increasing costs for medical supplies, had a signi- ficant impact upon many hospitals. But the ulti- mate crisis in finance was a result of the fact that philanthropists could no longer make donations large enough to rescue the hospitals from their plight. In the earlier years of the nineteenth cen- tury philanthropists could be counted on to cover deficits that were chronic features in most nine- teenth century - charity facilities. Many hospitals, in fact, used small but manageable deficits as part of their appeals for funds. A deficit was seen as an indication of the worth of the institution, just as modest want was seen as proof of the worthiness of one of the hospital's inmates. Philanthropists were more willing to give to an institution that had a small end - of - the year deficit. The depression forced philanthropists to reas- sess this long standing - practice. Hospital deficits were now growing larger every year. Further- more, the trustees and philanthropists themselves were feeling the pinch of this long and severe depression. They were less willing and able to part with their money than they had been in the past. In sum, charity was proving an inadequate means of supporting the hospitals. Trustees and managers alike remarked that there was a " ten- By the early years of the 20th century, it had become apparent that a few wealthy benefactors and local subscription drives were an inadequate means of financing the city's private hospitals dency of charitable bequests to diminish " and that this was " a matter of great concern " 12 (). One trustee noted that when the " financial depression struck this land, we were obliged to struggle on as best as we could. " The president of Brooklyn Hos- pital reported in 1895 that the hospital's financial condition was poor. " On the financial side, " he re- 25 marked, " we have not been able to meet our expenses " (13). The president of one of Brooklyn's oldest specialty facilities summed up the crisis that plagued many institutions during the depression years: " Not only are the demands upon the hospital greater and the expenses consistently increasing, but the sources of revenue from individual subscription are diminishing " (14). The economic crunch that hit Brooklyn's hospi- tals served as a warning to the trustees of some institutions and as a death blow to others. During the 1890s, for instance, no fewer than five of Brooklyn's largest hospitals closed their doors. One trustee noted that Memorial Hospital " had an uphill and hopeless struggle... Disaster after disaster overtook them until burdened with debt, [it]. had to succumb " (15). When the Williams- burg Hospital in a large working - class neighbor- hood closed in the early 1900s, the trustees were deeply in debt and could not gather the necessary funds. Homeopathic Hospital struggled through the depression and was taken over by the city, 70,000 $ in debt (16). By 1899 one of the pro- minent hospitals reported that it owed $ 27,000 to various banks and that a substantial portion of its endowment had been spent 17 (). By the early years of the twentieth century, the general crisis in hospital finance had become so widely recognized that a " Conference on Hospital Needs and Hospital Finances " was called for by administrators and the Charity Organization Society. In the announcement for the meeting the sponsors noted that " heavy annual deficits are the rule rather than the exception " in most of the city's hospitals (18). In New York and Brooklyn alike, trustees and superintendents recognized that the charity system was breaking down. A few wealthy bene- factors and local annual subscription drives were an inadequate means of financing the city's Increasingly, hospitals began to look for paying patients, seeing their traditional'charity'role as an unmitigating financial burden private institutions (19). Hospital administrators and trustees were faced with the necessity of finding alternative sources of financial support. As Mr. Abraham pointed out in his own inimicable way, " In reading over the reports of [Brooklyn's] 26 charitable [institutions] they all ring... the one'leit motif and the one refrain: appeal upon appeal to the public to help pay off large mortgages and other indebtedness " (20). A new means of finan- cing charitable institutions was clearly needed. During the early 1900s, in the wake of a severe depression, trustees in many facilities began to look toward pay patients as a new source of income and as a means of forestalling the collapse of their facilities. Giving'Em the Business The traditional financial bases of most Brooklyn hospitals had been the benevolence of wealthy trustees, patrons, church - goers and other private individuals. They participated in hospital work for many reasons: partly from a sense of noblesse oblige, in order to gain or maintain recognition as community leaders or because of their interest in social control and cultural hegemony. The objects of their benevolence had uniformly been the poor and working class of the city. But by the early 1900s it was clear that there were good economic reasons for reluctant trus- tees to abandon their uniform objective of servic- ing the poor (21). Scientific medicine was changing the character of the old charity facilities, wealthier patients seemed ready to utilize the hospital and poorer persons were a severe drain on the resources of many facilities. Hospital income could be increased significantly if, first, patients could be convinced to pay for their care and, second, if a greater number of wealthier clients could be attracted to the facility. Most trustees still maintained that charity was the proper justification for the hospital. But, increas- ingly, " free " or " charity " patients were seen as a growing burden to financially pressed trustees (22). Some trustees felt that the number of poor persons admitted should be limited, while others felt that more extreme measures were necessary. Some actually refused care to those who could not pay. Especially during the depression, trustees learned that limiting the number of working - class patients who needed " free " care was the only means open to them to cut costs. " Early last winter, it became apparent that something must be done to procure immediate pecuniary relief, " one hospital president remarked. " A cruel fact stared us in the face.... We had been rolling up a debt.. After careful study, our advisors decided that. we should limit the number of inmates " (23). At a small Williamsburg facilities, trustees reluctantly observed that there was a " limit to our resources " (24). During bad times it was clear that no facility could accommodate everyone. But this practice of excluding poorer patients was carried on past the immediate depression years and became an axiom of hospital administration during the earily twentieth century. At the Brooklyn Hospital, for instance, the trustees began to see the paying patient as an important source of income and the free patient as an increasingly expendable burden. " Further space in the wards must be prepared for the [pay] service if we wish to further increase our income from this source, " the vice president - of the board of trustees declared in 1899 (25). By 1902 the trustee " decided to shut out part of the charity patients [in order to] keep expenditures down. " The hospital, the president remarked, had pre- viously " attempted to do more charity work than it could afford " (26). In 1892 only 12 percent of this hospital's income came directly from the patient. By 1905 nearly 45 percent was derived from patient payments (27). Although changes in hospital organization and administration had begun earlier in the nineteenth century, the depression of the 1890s greatly accelerated them. Specifically, the deficits made the businessman's cry for efficiency, bureaucracy and business practices more convincing to hos- pital boards. The deficits also undermined the charity orientation of many trustees. Furthermore, the crisis led to the hospitals'new dependence on physicians who claimed they could supply them with a new class of patients who could pay for care. This meant that new amenities and services would have to be provided in order to attract doctors and their patients. Advanced technology services that were of interest to prac- titioners were introduced. Private rooms, wards, doctoring and nursing had to be provided for wealthier clients. In quick succession hospital boards voted to expand their visiting and attend- ing staffs. Brooklyn Hospital increased the number of associated physicians from fewer than a dozen in 1890 to nearly sixty by 1915. At Methodist the number rose from about fifteen to fifty five - during the same period (28). The introduction of private physicians into the charity hospital had a profound and long lasting - effect on the organization of these facilities. First, trustees had traditionally seen the hospital as their private responsibility and the arrival of large numbers of physicians meant a new challenge to their authority as benefactors and stewards to the poor. Second, the physicians had a substantial impact on the underlying purpose of these institu- tions. Hospitals became more clearly defined as places for medical treatment rather than shelters for the poor and homeless. While doctors changed the tone of the wards, businessmen on the boards changed the tenor of board meetings. Like Abraham Abraham at the Jewish Hospital, businessmen gained a new im- portance at other institutions as well. The presi- dent of the board at the small Bushwick Hospital announced that H.C. Bohack, who had recently opened a chain of food stores, had joined the board. As the president saw it, " the business interests of the hospital could not more effectively be safeguarded " than by directly involving such men. At Brooklyn Hospital, Charles Pratt became president of the board. Pratt, whose family had founded the oil refineries in Greenpoint and who managed John D. Rockefeller's East Coast refineries, made substantial changes at this institu- tion as well (29). The direct effects of the involvement of all of these individuals was ambiguous. But they certainly did bring a business point of view to challenge the norms of the hospital boards. Managers and trustees, who ascribed to older paternalist ideologies, found themselves hard put to defend their roles as financial stewards when they themselves had no solution to the chronic financial crises. Older ideals began to be played down and newer business ones placed in their stead. Some trustees were often put in a quan- dary, denying that the facility had changed into a business. The president of one hospital cried out that his facility was " a work of mercy...not a business " (30). Another declared in 1907 that " we are not in hospital work to make money " (31). At the end of the Progressive Era one prominent surgeon commented on a paper about a Brooklyn hospital published in the Bulletin of the Taylor Society, the society dedicated to scientific management. The paper sought to apply prin- ciples of scientific management to the organization of the hospital. In commenting on the paper, 27 Ernest Codman, a Boston surgeon concerned and willing group of middle - class patients eager to with the rationalization of the hospital, observed use charity facilities long associated with the most that " charitable hospitals have beome businesses degrading type of care; only special services and and are... wolves in sheep's clothing " (32). new accomodations could attract the middle class. Clearly the older charitable impetus for hospital The small, financially unstable facilities of work was waning as the financial cruch hit many Brooklyn could hardly afford to build additional facilities. Charity clients were a burden. As one wings and services. Consequently, space for free trustee pointed out, " Additional income must be patients was often converted into space for pay had, and that can come only from pay patients " patients and, more often than not, formerly (33). charity patients were required to pay for their Paying Patients and Private Rooms care. At Brooklyn Hospital, for instance, the number of " free " patients grew from about 1,000 The turn away from charity affected the to 1,600 during the depression years and working - class patients in two ways. First, trustees immediately following but then dropped drama- sometimes converted " free " wards into pay wards tically from 1,600 in 1900 to 1,200 in 1903. As or rooms. This took away space previously avail- noted earlier, it was 1900 when the hospital able for indigent pa- trustees announced that tients. Second, trustees beds in the charity ward more often began to would be converted into charge working - class pay beds in order to patients for services that were previously pro- The poorest of the patients vided free. Different were increasingly seen as the levels of services were source of the financial increase income. At the same point the number of paying patients began to grow dramatically, devised for those willing problems of the hospital to pay. Also, existing rather than the victims of the ethnic and other social distinctions functioned to crisis in hospital finance. convince those who rising from just over 200 in 1899 to 1,400 by 1911. The number of private room patients, never a large number in could afford it not to use any particular year, a " lower grade " of remained relatively small service. This divided throughout the period. different working - class groups into separate In 1895, 16.3 percent of all patient days were quarters and perpetuated existing divisions used for pay ward - patients. By 1905 this category within this class. Moreover, the poorest of had grown to 44.5 percent (35). the patients, those unable to pay anything While the change in hospital space usage was for their care, were increasingly seen as the dramatic, the change in the class of the hospital source of the financial problems of the hospital patients was not. This leads to the conclusion that rather than the victims of the crisis in hospital the pay wards were primarily filled by the same finance. The " fruitful cause for the annual defi- class of patients that previously used the free ciency in the hospitals, " remarked one hospital hospital space. In Brooklyn Hospital, for example, manager in New York, " is the large number of white collar - workers accounted for 13 percent of free patients. " If the former objects of charity did the patients in 1892 and grew slowly to 21 not pay for their care, then they were now defined percent by 1902. The bulk of the patients were as the problem. " If hospital patients had more still working class - only now they had to pay for honor and pride, I do not think there would be their care. On the one hand, it was " obvious that any large deficiency, " he concluded (34). Instead there can be no very great increase in income of seeing the poorer patients as needy and con- from [pay patients] unless the accommodations...... sequently deserving of care, hospital administra- are increased at the expense of space alloted now tors viewed neediness as a moral failing of the to those [who] cannot pay at all " (36). On patient. the other hand, charging the same group of If hospitals now charged only wealthier clients patients who had previously used the facility for for their care while maintaining services to free accomplished much the same thing. At working - class patients, the practical effect of this Brooklyn Hospital this appeared to be what was reorientation toward the paying patient might not done. The trustees periodically transformed have been terribly important. This was not the charity wards into pay wards when income was 28 case, however. In Brooklyn there was no ready needed (37). The internal organization of many facilities was also greatly affected by the change from charity to pay. Hospitals throughout Brooklyn began to assign bed space to patients according to social and economic criteria rather than medical need. Within the context of the growing acceptance of patient payment as a legitimate source of hospital revenue, it became mandatory for hospital managers to make services distinctly different for the charity and paying patients in order to convince patients that, if they could afford to, they should use the paying service. The source of referral, whether the social service and business office or the private practitioner, gave some basis for differentiating between those able to pay and those who were indigent. But the offering of different services provided a surer means of selecting out patients. The right to a private physi- cian, smaller wards or private rooms, and better food were immediately seen as prerogatives of the pay service. In contrast, charity patients were provided with care that was determined by the administration rather than by a private physician. Private patients were serviced in entirely different quarters. Some called for separate facilities for the rich and poor. The Journal of the American Medical Association pointed out that the " absolute segregation of charity patients from pay patients " was necessary if the wealthier patient was to be convinced to pay for his or her care. " Those who really have no means will perforce go to the genuine charity hospitals, while few of those who have any income will sink their pride so far as to enter an institution patronized by none but the destitute.... When the only alternative is a pay hospital where none are treated free, the deed is done. So long as rich and poor are treated under one roof, the well - to - do will not scrupple at getting free treatment [since] no stigma attaches to residence in an institution where many pay their way. " Separation of services along class lines was necessary to guarantee that clients would, if able, pay for their treatment (38). The transformation of the structure and organi- zation of the hospital preceded the introduction of wealthier clients. In many facilities private rooms and pay wards remained empty until after World War I. But in the interim many working - class patients were refused entrance, charged for services previously provided free and made to feel that the hospital was no longer concerned with their well being - . Some poorer patients were able to scrape together the necessary cash and enter the new " pay " wards. Others were forced to seek care in the growing system of public institu- tions. Still others were taken into the voluntary institutions only when payment from the city coffers was guaranteed. The relationship between the charity hospitals and the city government had a long history, dating pack to the 1840s. At that time the city of Brooklyn issued lump - sum payments to charity facilities so that these institutions would care for poor persons who were deemed to be proper recipients of the city's protection. But in the early 1900s this flat grant - system of payments was transformed into per capita, per diem payments schemes based upon a means test of all patients. The means test and new grant system further accelerated the administrators'plan to exclude those whose expenses were not covered (39). It would be naive to conclude that trustees consciously reorganized hospital services along social class lines. Rather, such actions to develop class distinct - services were an outgrowth of a complex process of financial, intellectual, and social changes that had little to do with the trustees and superintendents themselves. Once patients were accepted as a reasonable source of income, the selling of health services - through private rooms, wards, private nursing, doctors and special amenities - swiftly arose. Most trustees, in fact, had little or no understanding of how profoundly their institutions would change once patients were turned to as a source of income. In fact, the trustees'own declining authority was further threatened by the very practitioners whom they needed to save the hospital. These practi- tioners brought with them a growing expertise and professional authority that would quickly. allow them to bypass the trustee in influence (40). The decisions of trustees to change the base of their financial support had a deleterious effect on their own position as well. 29 By the end of the Progressive Era the modern outlines of an internally fragmented hospital system were apparent in many of Brooklyn's facilities. Not only were physicians much more prominent, and not only were their interests re- flected in an increasingly complex medical or- ganization, but the hospital itself was now split between public and private services. In 1916 the Brooklyn Hospital distributed a brochure with an illustration of the hospital on its cover. Engraved across the roof of one of the two wings of the hospital was the word " PUBLIC. " Across the roof of the other was the word " PRIVATE. " Between these stood the administration building that kept two worlds of medicine far apart (41). -David Rosner (David Rosner teaches in the Baruch College- Mount Sinai School of Medicine Program in Health Administration and in the Baruch Col- lege Department of History. He is also a mem- ber of the Health / PAC Editorial Board.) References 1. See, for example, the voluminous literature on the organi- zation of ward, room and private service within hospitals. The most widely known critique of such service dif- ferentiations comes from various Health / PAC publications. For instance, see Health / PAC's The American Health Empire (New York: Random House, 1970), and David Kotelchuck, ed. Prognosis Negative: Crisis in the Health Care System (New York: Vintage Books, 1976). 2. Morris Vogel, " Patrons, Practitioners, and Patients: The Voluntary Hospital in Mid - Victorian Boston, " in Victorian America, ed. by Daniel W. Howe (Philadelphia: University of Pennsylvania Press, 1976), pp. 120-21: " Patients who could not, and in most cases were forbidden to, pay any fee. " Other authors have also noted the organization of charity hospitals in the nineteenth century; see, for example, Charles Rosenberg, " And Heal The Sick: The Hospital and Patient in 19th Century American, " Journal of Social History 10 (June 1977): 482-97. 3. See, in addition to the above mentioned article, Morris Vogel, " Boston's Hospitals: 1880-1930 " (Ph.D. Diss., University of Chicago, 1974); also Susan Reverby's article in Health Care in America: Essays in Social History (S. Reverby, D. Rosner, eds.), Temple University Press, 1979, and her thesis in progress, American Studies Program, Boston University. 4. Jewish Hospital of Brooklyn, 2nd Annual Report, 1903, p. 10. 5. Such social (i.e., non medical - ) functions were an im- portant aspect of nineteenth - century hospital care. See note 3, above, for a more extended discussion of the nineteenth - century facility. 6. 6. See Brooklyn Hospital, Annual Reports, 1895, 1899. 7. Brooklyn Maternity Hospital, Annual Report, 1896, p. 11. 8. 8. See Brooklyn Nursery and Infants Hospital, Annual Report, 1896, p. 15; and Methodist Hospital, Annual Report, 1896, p. 15, for similar comments. 9. " Men and Women Who Feign Disease: Hospitals... Have To Be Constantly On Guard Against Malingerers, " New York Tribune, 1 May 1904, sec. 2, p. 2. 10. An analysis of costs at a number of Brooklyn facilities indicates that general housekeeping, maintenance and other costs grew along with a slow rise in the category of " medical supplies. " But patient demand was of great significance as well. 11. The statistical information in this article is drawn from the annual reports of the various institutions; see, for example, Brooklyn Hospital, Annual Reports, 1890-1915, for the above quoted material. 12. Frederick Sturges, " What Managers of Hospitals Say 30 About Their Financial Problems, " Charities 12 (January 1904): 32. 13. See, for example, Memorial Hospital, 10th Annual Report, 1898, p. 16: Brooklyn Eye and Ear Hospital, 13th Annual Report, 1898. In 1896 the directors noted that the " sources of revenue are diminishing " (Brooklyn Hospital, Annual Report, 1895, p. 6). See also, Charity Organization Society of New York, Report, 1900: " Several of the large private hospitals are having increased difficulty in securing...... funds [from philanthropists]. " 14. Brooklyn Eye and Ear Hospital, 29th Annual Report, 1896; Methodist Hospital, Annual Report, 1894, p. 19; and other numerous contemporary statements. 15. Jewish Hospital of Brooklyn, 2nd Annual Report, 1903, p. 8. Also Memorial Hospital's Annual Reports for the previous ten years, which outline its financial collapse. 16. Jewish Hospital, 2nd Annual Report, 1903, p. 8. See also " Williamsburg Hospital Closes, " New York Tribune, 16 January 1903, p. 7: " The trustees could see no way. they could obtain the necessary money to continue [and] they decided to abandon the work before going further into debt. " See " City Takes the Hospital, " B.D. Eagle, 26 July 1900 (The Homeopathic Hospital be- came Cumberland Hospital); " Homeopathic Hospital to Close This Evening, " B.D. Eagle, 31 March 1900; " Hos- pital Bill Hearing To Day -, " B.D. Eagle, 7 March 1900; " Anent the Homeopaths, " B.D. Eagle, 6 March 1900. 17. Editorial, The Trained Nurse and Hospital Review, 29 (September 1902): 194. See also Brooklyn Hospital, Annual Report, 1899, p. 8: " Deficits of recent years [have] resulted in a floating debt of about twenty - seven thousand dollars. " 18. " A Hospital Conference in New York, " Charities, 11 March 1905, p. 565. 19. Frederick Sturges, " What The Managers Of The Hospitals Say About Their Financial Problems, " Charities 12 (January 1904): 32. Sturges continues saying that " the founders and the charter members of the great private hospitals, and their direct descendants are the ones who are now principally carrying them, and it is extra- ordinarily difficult to interest the younger generation.. " 20. Jewish Hospital, 2nd Annual Report, 1903, p. 10. See also Frank Tucker, " The Public Conscience and the Hospital, " Charities 13 (December 1904): 285; and Tucker, " Hospital Situation in New York, " Charities 12 (January 1904): 31. 21. Morris Vogel has outlined some of the demographic factors such as changes in housing patterns and in the make - up of the work force. He has also noted some internal reasons for the introduction of private patients. See notes 2 and 3 above. 22. Jewish Hospital, Annual Report, 1903, p. 11. 23. Nursery and Infant Hospital, 23rd Annual Report, p. 16. See also, Memorial Hospital for Women and Children, Annual Report, 1898, p. 18. 24. Brooklyn Eastern District Dispensary and Hospital, Annual Report, 1891, p. 8. 25. Brooklyn Hospital, Annual Report, 1899, p. 8, and Brooklyn Hospital, Annual Report, 1900, p. 7. 26. Editorial Comment, The Trained Nurse and Hospital Review, 29 (September 1902): 194. I would like to thank Susan Reverby for providing this citation. 27. This tendency to depend increasingly upon patient payments is general to most of Brooklyn's hospitals. See, for example, the annual reports of Methodist, Jewish and other institutions. 28. See medical directories and medical registers of New York, Brooklyn and New Jersey for these years. These pub- lications put out by the local medical societies contain lists of physicans and their affiliations for specific years. 29. Bushwick and Bushwick Central Hospital, 11th Annual Report, March 1904-1905, p. 10. See also Obituary, " H.C. Bohack, " New York Times, 18 September 1931, p. 23: " President of Bohack Chain of 746 stores. H.C. Bohack was born in Germany in 1865, opened his first store in 1885. Had five stores by 1900, president of a realty corporation, director of People's National Bank, Guarantee Title and Mortgage Co., Brooklyn National Life Insurance Co., Williamsburg Savings Bank, Manhat- tan Trust. " See also Brooklyn Hospital, Minutes, 1912- 1914, for detailed description of the numerous changes that Pratt made in hospital organization. 30. Lutheran Hospital Association, Annual Report, 1914, p. 2. See also Brooklyn Homeopathic Maternity, Annual Re- port, 1899, p. 12, in which the secretary disdainfully notes that " other maternities in this and our sister city... demand pay for every patient [while] we work largely for charity. " 31. Bushwick Hospital, Annual Report, 1906-1907, p. 15. 32. See Robert L. Dickinson, " Hospital Organization As Shown By Charts of Personnel and Power Functions, " Bulletin of the Taylor Society, 3 (October 1917), pp. 1-11, and Codman's response. 33. Lutheran Hospital Association, Annual Report, 1914, p. 21; Methodist Hospital, Annual Report, 1894, p. 20. See also Long Island College Hospital, Hospital Yearbook, 1919, p. 35, for a later statement of the increasing pres- sure to get paying patients into the hospital. A.C. Bunn, " Church Hospitals, " Brooklyn Medical Journal 15 (Sep- tember 1909): 508. 34. Ogden Chisholm, " Financial Problems of New York's Hospitals, " Charities, 12 (2 June 1904): 38. 35. See the annual reports of Brooklyn Hospital for 1890- 1915; also Charles Rosenberg, " The Shaping of the American Hospital 1880-1914, " unpublished manuscript, 1978, for confirmation that many hospitals found their private services empty during the period. 36. Frank Tucker, " The Hospital Situation in New York, " Charities 12 (January 1904): 30; A.C. Bunn, " Church Hospitals, " Brooklyn Medical Journal 15 (September 1901): 510. See also Charlotte Aikens, " Relation of the Training School to the Hospital Deficit Problem. " The Trained Nurse 37 (September 1910): 157: " The Extension and Improvement of the Pay Patient Department... is one of the remedies for deficits that is meeting with general favor. " 37. Brooklyn Hospital, Executive Minutes 5 (23 January 1901): 104: " Resolved that the private accomodations of the Hospital be increased by converting Wards 10, 11, 12, and 13 or so much thereof as may be necessary, into Pay Wards without material alterations or expense. 38. Editorial, " Abolish The Hospital Grafter, " Journal of the American Medical Association 44 (27 May 1905): 1691. 39. For a fuller description of the city's involvement, see David Rosner, " Gaining Control: Reimbursement, Reform and Politics in New York's Hospitals, 1890-1915, " Amer- ican Journal of Public Health, in press, and David Rosner, " A Once Charitable Enterprise: Health Care in Brooklyn, 1890-1915 " (Ph.D. diss., History of Science Department, Harvard University, 1978), chap. 3. 40. See Gerald E. Markowitz and David K. Rosner, " Doctors in Crisis: Medical Education and Medical Reform During The Progressive Era, 1895-1915, " in Health Care in America: Essays in Social History (S. Reverby, D. Ros- ner, eds.), Temple University Press, 1979, for an ex- panded discussion of the rising professional status of the physician. 41. See brochure and illustration that is reproduced in " Brooklyn's Oldest Hospital Built Anew, " The Modern Hospital 7 (November 1916): 361-66. We Need Your Help Sustaining Associate- $ 100 or greater annual contribution. Besides renewal of your BULLETIN subscription, you receive: () 1 a free gift subscription; (2) a free copy on request of all new Health / PAC publications including our recent book, PROGNOSIS NEGATIVE; and (3) a free folio of 32 illustrations by Health / PAC artist Bill Plympton. Sustaining Contributor- $ 50 or greater contribution annually. Besides renewal of your BULLETIN subscription, you receive any two of the gifts listed above. 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