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Health Policy Advisory Center No. 38 February 1972 HEALTH / PAC BULLETIN THE SELLING OF THE FREE CLINICS The National Free Clinic Council confer- ence, held at the Shoreham Hotel in Wash- ington, D.C. from January 14 to 17, was the Altamont of the free clinic movement. Most of the 800 registrants who came to the conference expected to join in a gen- eral celebration of free clinic activities and information sharing. Instead they be- came passive witnesses to the violence done their movement by the conference organizers. While the conferees spent their time wandering from one cancelled meet- ing to another, encountering barrages of hostile rhetoric at those meetings which actually transpired, and searching for nat- ural foods, the real business of the confer- ence was being conducted behind closed doors. By the end of the conference, free clinic workers straggled home to their clinics, wiped - out and disenchanted with the National Free Clinic Council and the Conference's bad vibes. The conference organizers, on the other hand, managed to establish the National Free Clinic Council (NFCC) as the sole representative of free clinic activities across the country. Then, after almost everyone had gone home they proceeded to claim a $ 1 million contract which had been awaiting them at Nixon's Special Action Office on Drug Abuse Prevention. While no murders occurred at this Alta- mont, one need only look to NFCC's his- tory to see that, under its leadership, the life of the free clinic movement is seriously compromised. The cultural validity of free clinics as alternate institutions hangs in the balance; so also does the political validity of free clinics as a challenge to the nation's medical institutions. The Washington Post sounded the death knell in more positive terms: " Free clinics have now become a part of organized medicine. " Up From the Haight The National Free Clinic Council came into being in late 1970. It was the brain child of David Smith, founder of the first free clinic located in Haight Ashbury - (see BULLETIN, October, 1971). The Haight- Ashbury Clinic catapulted into national prominence as an innovative service for the flower children, street people and bad trippers who flocked to San Francisco dur- " Free clinics are a part of the total health delivery system and want to be recognized as such. " -David Smith ing the 1967 " Summer of Love. " Smith's reputation rose with that of his clinic. As one conferee said, " Whether you like it or not, Smith is seen as the expert on free clinics, and the expert on drugs. " Smith's success has not been limited to the Haight Ashbury - Free Clinic. He has written two books; he helped found STASH (the Student Association for the Study of Hallucinogens); he is an editor of the Journal of Psychedelic Drugs, consult- ant on drug abuse to the Department of Psychiatry at San Francisco General Hos- pital, Assistant Clinical Professor of Tox- icology at the University of California Medical Center, and a member of the President's Advisory Committee on Teacher Drug Abuse Education. Despite Smith's personal success, the Haight Ashbury - Free Clinic soon found it- self in dire financial straits. As the charm of the flower children wore thin, contribu- tions to the Haight Ashbury - Clinic and others like it began to dry up; the Haight Clinic lost one of its biggest contributors when rock music promoter, Bill Graham, quit the business. So Smith came up with the National Free Clinic Council as a solu- tion to his and other clinics'financial prob- lems. In an interview given to Health - PAC last summer, Smith advised that the " free clinic movement must move to a solid base of community or federal financing. " To accomplish this, the " NFCC will take on a lobbying role. " Although Smith is recognized in the " straight world " as the expert on free clinics, his attitudes about the role of free clinics are not generally representative of the thousands of young people who run them. First, most free clinics are seen as alternate institutions. They are operated on shoe string - budgets with volunteer labor. They are anti establishment - in style and tone. And they attempt, with varying degrees of success, to provide de- professionalized medical care in a demo- cratic, anti racist - , anti sexist - work and ser- vice environment (see BULLETIN, October, 1971). Rather than being an alternative to the existing medical system, Smith's Council and his conference were designed to dem- onstrate that, " Free clinics are a part of the total health care delivery system and want to be recognized as such. " While some clinics see their service role as a launching pad for attacking and chal- lenging existing medical institutions, Smith's political agenda for free clinics falls along more traditional lines. He cau- tions free clinics " to be very careful that what you're doing politically isn't jeopard- izing your primary mission, which is to be a doctor and take care of people first. " NFCC Getting - It Together So unbeknownst to most of the esti- mated two hundred clinics in the country, Smith organized the National Free Clinic Council as a means of integratina free clinics into the health delivery establish- ment. The original Board of the NFCC was pulled together in late 1970, with little pre- tense of representativeness. According to one informant, " Smith waved his hand to put people on the Board. " The Board turned out to be largely professional. It included one drug company (Pfizer) representa- tive and representatives of white drug- culture hip clinics; but no Blacks, Chicanos Published by the Health Policy Advisory Center, 17 Murray Street, New York, N. Y. 10007. Telephone (212) 267- 8890. The Health - PAC BULLETIN is published monthly, except during the months of July and August when it is published bi monthly - . Yearly subscriptions: $ 5 students, $ 7 others. Second - class postage paid at New York, N. Y. Subscriptions changes - of - address, and other correspondence should be mailed to the above address. Staff: Constance Bloomfield, Des Callan. Oliver Fein, Marsha Handelman, Ronda Kotelchuck, Howard Levy, and Susan Reverby. Associates: Robb Burlage, Morgantown, West Virginia; Vicki Cooper, Chicago; Barbara Ehrenreich, John Ehrenheich, Long Island; Ruth Galanter, Los Angeles; Kenneth Kimerling, New York City. 1972. 2 or women. The first annual conference of the NFCC was held in January, 1971, at the University of California Medical Cen- ter and dealt with drugs. James Oss (Coordinator for Drug Abuse Education at Hoffman LaRoche - Pharma- CONTENTS Free Clinics 1 San Francisco General 9 Letters 16 ceuticals) was appointed Executive Direc- tor of the NFCC. In September, 1971 plans got underway for the Second Annual NFCC Conference. By this time the NFCC was going big, but the style was still the same. The agenda was oriented toward drug " abuse " and funding free clinics. The panelists were to be largely profes- sional. The preliminary agenda did not include one Third World panelist. The accountability and representative- ness of the NFCC appeared to be of little concern. Asked about membership in the NFCC, Smith said, " All the free clinics in the country are members, or they will be when we send out the mailings for the conference. If they don't like the idea, they will have to unjoin. " Some free clinic workers became sus- picious of the whole event when the NFCC first circulated invitations and agendas. The conference was to be located in Wash- ington, the seat of establishment power. It was to be held at the Shoreham Hotel - a convention hotel of grand and elegantly gilted mirrored and chandeliered pro- portions, procured and paid for by Pfizer Pharmaceuticals (24,000 $) and the De- partment of Health, Education and Wel- fare (13,000 $). While Smith had been forced to revise the agenda somewhat (there was now a Minorities Panel), it still resembled an AMA Convention. A People's Free Medical Clinic in Baltimore sent off an angry letter: First we are disturbed by the structure and apparent control of the conference. Almost all of the listed speakers and mod- erators are professional people MD, PhD, LLD, RN, etc. This does not reflect the exciting sense of clinics learning about shared responsibility among lay and pro- fessional people. The very professional chauvinism we are fighting in present in- stitutions is being reflected in the Free Clinic Council.. We further question the value of the two evening presentations Saturday and Sun- day. Obviously important conference time has been allocated to the presentation of establishment positions - Teddy Kennedy and the representative of the " President's Special Action Office on Drug Abuse Prevention. " Finally, the topics for discussion are poor indeed. Of the worthwhile topics, most of them are included in the suggested small group sessions. Throughout the agenda you refer to " drug abuse. " We find the concept of " abuse " a poor start- ing point for discussion. Topics which we find important to discuss with our non professional - and professional brothers White House official and Ted Kennedy were to keynote the conference. Panels were heavily weighted toward professionals (out of 37 panelists, only 12 did not carry MD's and other degrees along with their names) and overwhelm- ingly weighted toward men (only nine of the panelists were women, four of whom were on the women's panel). Travel costs were sky high - for most of the clinic workers, with only a lucky and " All the free clinics chosen few being subsidized. Adding in- sult to injury, the National Free Clinic in the country are Council was holding elections for 14 new board members (in addition to the exist- ina 14 on Monday, long after most regis- trants would have to return to their jobs and clinics. members.. * If they don't like the idea, they will have to unjoin. " Pre Conference - Jitters - David Smith In the weeks before the conference, there was a flurry of letters to the NFCC's office in San Francisco questioning the program. There was also a flurry of travel on the part of the conference organizers to various free clinics in hopes of cooling out dissent and gathering support. The 3 and sisters are: community control of health care and free clinics, women's ser- vices, patient advocates, and so on. The one hour slot allocated to " The Role of Women in Free Clinics " is paltry indeed and does not begin to speak to the variety of considerations women are raising. In return for their letter, they were visited by Jim Oss, Executive Director of the NFCC. Clinic workers questioned Oss about the agenda: Why did there have to be an agenda? What about having a non- agenda so that people could have their own meetings when they got to Wash- ington? Oss replied, " That would solve one problem - the problem of money. We wouldn't get any [from Pfizer and HEW]. " According to another NFCC organizer, the large number of doctors and other pro- fessionals at the conference also reflected the wishes of Pfizer and company. The Shoreham Hotel also reflected their wishes: " They hoped that professionals would come to the conference; and professionals wouldn't want to stay with the rest of the people. It's also more prestigious for the men on the [Capitol] Hill. " The conference organizers maintain that its possible to get money from the " straight world " without dirtying their hands. When challenged about the financ- ing of the conference, the organizers were evasive. " I don't relate to talk about money. " " We believe we have a right to rip - off companies like Pfizer who profit off people's health. " " There are no strings attached, Pfizer just insisted upon. * " " The very professional chauvinism we are fighting in present , institutions is being reflected in the Free Clinic Council.. " I -Letter from Baltimore People's Free Medical Clinic 4 " You all use free drug samples, don't you? " " What's wrong with HEW? They pay part of my salary. " Two months before the conference, a Washington, D.C. free clinic worker ad- dressed a letter to the NFCC President sug- gesting that it would have been possible. " to put together a conference without fol- lowing the example of the APA [American Psychiatric Association] or the AMA, and to make the arrangements meet the needs and life styles of the participants. " By the end of the conference, the clinic worker's rhetorical question (" I have to ask if your values are really counter cultural? ") had been answered. The NFCC is not counter cultural; and strings were not needed be- cause the NFCC had already tied itself to the Establishment. Stomping at the Shoreham During the conference, most of the par- ticipants avoided going to the scheduled meetings on National Health Insurance and the like. Instead they chose to gather informally in hotel rooms to exchange the kind of information they came for: how to start a clinic, the role of patient advocates, midwifery, etc. In other rooms, several caucuses were meeting. Each was attempting to shape the conference and the NFCC. Even before the conference was form- ally convened convened,, dissident participants called for a meeting. The dissidents, call- ing themselves People's Priorities, were a mixed bag, although most were free clinic workers, white and non professional - . Not all of the People's Priorities caucus mem- bers (estimated 200) were political ac- tivists. About half of the group were service oriented - free clinic workers who objected to the conference agenda and the NFCC's manipulations; the other half was more concerned that free clinics avoid be- coming part of the medical establishment. While the group continued to meet throughout the conference, it labored at a severe disadvantage because it was un- aware of the real purpose for the confer- ence: to get that $ 1 million payoff that the President's Special Action Office on Drug Abuse Prevention was holding out to the NFCC. At the first general session of the con- ference (Friday night), People's Priorities got a chance to make a statement. Many (perhaps a majority) of the 800-1000 peo- ple assembled were sympathetic to the statement which questioned the direction of the NFCC. The session overwhelmingly endorsed the proposal to discuss the need for a national organization and to move the elections to a time which would suit the attendees. (As it turned out, the dis- " The NFCC has earned the respect of individual free clinics and the free clinic movement in general. " - NFCC Draft Contract Guidelines cussion and elections never occurred which suited NFCC organizers just fine.) By Friday night, Third World caucuses had also developed. Third World support was crucial to the NFCC. NFCC organizers were present at most caucus meetings, despite the fact that these were closed to everyone else. This enabled the NFCC to accomplish its purpose: dividing the Third World participants from the white, and eventually dividing them from one an- other. A cleavage quickly developed between the East Coast, largely Latino, participants who distrusted the NFCC and the West Coast members, mostly black, who strong- ly favored the NFCC. By the middle of the conference, Smith had convinced the West Coast faction to continue meeting as their own Third World caucus. Some of the East Coast people continued to caucus separately, but many decided to leave the conference altogether. When several West Coast Third World participants sug- gested that Smith was employing a divide- " and conquer -" tactic, they were forced by NFCC organizers to leave the room. None of the remaining minority caucus members objected to their ouster. With the East Coast Third World group isolated from the entire conference, the West Coast caucus was free to do NFCC's work. They pulled together a statement which said in essence, " Since we can't stop the NFCC, we might as well demand representation on the Council and get part of the rip - off. " Although everyone was still in the dark about the awaiting million dollars, most of the East Coast Third World group saw the light about the NFCC. A Puerto Rican free clinic worker said, " The manipulations were so transparently obvious that you would think nobody could have been fooled. But I guess that wasn't true. " A free clinic worker from New York's Chinatown said, " We would prefer to look to the People's Republic of China, not the NFCC, as a model for changing the health care system. " Anything in a Pinch Back at the general session Saturday night, the People's Priorities caucus almost brought the conference to a standstill, by asking questions of the NFCC which were clearly arousing the support of most of the body. However, it must be said that a significant portion of those in sympathy would have been sympathetic to any anti- organizational stance. While no disruption occurred, the NFCC representatives and many of the Southern California delegates called the People's Priorities group disrup- tive; it was strongly implied that they were " outsiders who didn't work in free clinics. " As they pressed their objections about having NFCC represent free clinics, they were treated with the kind of con- tempt one usually expects from the Nixon Administration. Smith announced that, " Everybody is against everything, but no one, except the [West Coast] blacks are for anything. " When that failed to pull the meeting back together around the NFCC, a little bit of luck or theatrics man- aged to get things back in line. " Maybe the Shoreham Hotel is not a people's facility. " Letter - from Baltimore People's Free Medical Clinic 10 Jim Oss, Executive Director of NFCC, was chairing the meeting and staved off disaster with what one conferee called, " The greatest coup since Nixon's Checkers speech. " In the midst of the chaos, he asked for a " couple of seconds to pull my- self together. " He then began to weep and was greeted with much encouragement from the audience, " Go to it, Jim. " " Let it all hang out. Do it. " " That's what you're here for. " Oss, back in tune with the meet- ing, extended his arms in the crucifix po- sition, with two supporters on either side. A third, in a fashion unknown in the Biblical version, held the microphone for Oss who revived his rap: " I've never met fend the ballot. At the time, few believed him when he said, " I can't relate too well to this ballot. " By the end of the next week, however, Smith had asked Oss to resign and it became clear that Smith had been calling the shots.) While the NFCC circulated its ballot, the People's Priorities caucus also circu- lated an opinion poll. The latter asked. whether or not free clinic workers attend- ing the conference were given a mandate to vote on anything. Of the 210 people who responded, 121 stated that they were not empowered to vote. The result of the NFCC ballot was never clear, but as time went on it became irrelevant anyway. " If the presently constituted NFCC has its way, the energy of the free clinic movement will, within a few years, be at the service of the health power structure. " -Statement, People's Priority Caucus anybody working in a free clinic who I didn't like. We just thought we could pull this conference off to help you people. We don't want to run a political trip on you; we just want to help. But it hasn't come to- gether yet, and I don't think I can go on tonight. Maybe we should come back tomorrow morning at 9:30 and try to get it together. " The audience was turned on; and a third of the assembly linked arms, ringed Oss and the Regency Ball- room and swung from side to side in silence. With that grand finale, further discussion of the need for and role of a National Free Clinic Council was also silenced. On Sunday morning there was to be another general session. With the confer- ence appearing to fall to pieces around him, Smith decided to have a paper ballot rather than risk an open discussion of the NFCC. In private, some members of the NFCC had argued that no vote should be taken, since so many clinics were unable to get to the conference. One member of the NFCC Executive Committee said, " Smith decided the ballot was necessary; it didn't matter what anyone else said. Smith would go ahead and do things in the name of the Executive Committee. " The ballot asked: " Should the National Free Clinic Council continue to function as an information exchange source while working toward a constitution developed by and acceptable to its member free clinics? " (While Smith was behind the scenes, Jim Oss was left to publicly de- 6 Realpolitik On Sunday negotiations continued with the Third World caucus (now almost ex- clusively West Coast). Smith was pre- sented with a demand that 50 percent of the NFCC Board be Third World and that all the old Board members resign. A clas- sic power politics exchange then took place. According to one informant, Smith said in effect, " Without us you can't get any money. " Smith capitulated to their de- mand. With the cards on the table, Smith brought out the money and announced the million dollar contract. By Monday morning, with only a hand- ful of conferees left at the Shoreham, the real work started. Another Third World caucus was held where it was decided how the seats on the Board would be di- vided up among whites, Blacks, Indians, Asians, Chicanos, and Latinos. Later, the few conferees left pressured the Board to accept some regional and some female representation. This group became the Ad Hoc Working Executive Committee of the NFCC. Smith then took the Ad Hoc Committee over to meet John Kramer, the Associate Director of Program Development of Nixon's Special Action Office on Drug Abuse Prevention. Kramer assured those present that al- most any clinic could qualify for the money and that almost no strings would be attached. This assuaged the fears among Third World clinics, many of which have no drug programs. Smith added that, " We [the Executive Committee] will be the persons who will define policy. " This was hardly reassuring to the many free clinics which have thus far been excluded from decision - making. Outlines of the federal contract, drawn up for the meeting, were not very reassur- ing either. The proposal states that $ 1 mil- lion will be made available, 100,000 $ of which goes to the NFCC for administra- tion. The NFCC will " develop and dis- tribute desirable policy and operational guidelines to a wide range of free clinics. " In addition, NFCC " will subcontract to free clinics that conform to the guidelines " for the distribution of funds. Individual grants will not exceed $ 20,000. Even though the members of the Ad Hoc Committee have been requested to get the responses of free clinics in their region to the proposal, it is pretty clear that David Smith and com- pany will do the writing of the final con- tract. The contract must be submitted to National Institute of Mental Health within a month for funding. There are no further meetings of the Ad Hoc Committee plan- ned prior to that date. Smith and his NFCC have now donned the mantle of the free clinic movement. Despite the shambles of the Shoreham conference and the overwhelming sense of the conferees to have little or nothing to do with the NFCC, the contract guidelines read: ful of the federal bureaucracy. The NFCC has earned the respect of individual free clinics and the free clinic movement in general. Individual free clinics would not be hesitant to deal with the NFCC as they would be with any other contractor. Since there is no other qualified organ- ization which possesses the necessary and unique knowledge about the free clinic movement and has credibility with the movement, NFCC is the sole source which can be awarded a contract... What it all means is that the conference was a sham. Free clinic workers allowed themselves to be used to legitimize the NFCC. Before the conference, Smith had considerable power. As an ex worker - at the Haight Ashbury - Clinic remarked, " If you need publicity, you go to Smith; if you need funding, you go to Smith. Make no mistake about it, in California, Smith controls most of the free clinics. " Now Smith has a lot more power, and it is obvious from his immediate plans that he will do everything he can to wed free clinics to the medical establishment. In late February, Smith will run a conference at the University of California entitled: " Drug Abuse 1972: A National Sympo- sium. " The conference is supported by the conservative Diane Linkletter Fund (of Art Linkletter, " kids say the darndest things " fame), and will cost $ 30 to attend. " If we do not recognize what we are doing, burying our heads in the ego filled -, short - term gratification of providing'service'while ignoring our larger role, then we are irresponsible; or rather, we are in part responsible for the perpetuation of an unjust, unhealthy, profit oriented system. " " I -Statement, People's Priority Caucus This contract need not be procured through the competitive process [as are most government contracts] as NFCC is a sole source for the following reasons: The NFCC, the only national organiza- tion of free clinics, is the sole entity able to effectively deal with and sub contract - with individual free clinic programs for drug education and training. The free clinic movement maintains a philosophy which discourages excessive government restraints, and accordingly, individual free clinics are extremely protective of their autonomy and, in general, distrust- The panelists are again mostly white, pro- fessional men; among them will be Smith's new friend John Kramer of the President's Special Action Office. While it was clear from the Shoreham conference, that Smith had made allies with many free clinics (particularly those in Southern California), it is far from clear that the majority of free clinics will go along with Smith's seemingly naive sup- porters. (Most " of the people at this confer- ence have been so nice. Dr. Egeberg [high ranking HEW official] was so kind in addressing the conference, he's such a 7 lovely man. I don't understand these peo- ple who simply want to destroy what's good in this society. ") Nor will most free clinic workers go along with the frenzied spiritualism which gripped other Smith supporters. (If " noth- ing else comes out of this conference, I think we should affirm something. Let's all stand up together and affirm something- anything! ") With Smith at the helm or down in the cabin, it can be expected that free clinics will either steer their programs toward the mainstream of American medicine or they will wither away from want of funds. During the conference, one of the groups of free clinic workers that gathered in the People's Priorities caucus released the following scenario for the NFCC: The national free clinic council (NFCC), given its present leadership, will insure that the free clinic movement continues to support the existing health care system. WHY? As clinics begin to seek federal funding - which the council will facilitate - they will be unwilling to confront established health institutions. In effect, free clinics will become appendages of powerful health institutions: organizing formerly un- insured patients into profitable private in- surance plans, marketing drugs to people who might not otherwise use them, in- corporating into medical school complexes such that their patients are used as teach- ing material, etc. If the presently constituted NFCC has its way, the energy of the free clinic move- ment will, within a few years, be at the service of the health power structure. If we do not recognize what we are doing, burying our heads in the ego filled -, short term gratification of providing " ser- vice " while ignoring our larger role, then we are irresponsible, or rather, we are in part responsible for the perpetuation of an unjust, unhealthy, profit oriented - system. The alternative is for free clinics to re- ject alliances with drug companies, with the Nixon administration, and with the conservative leadership of the NFCC, for a start. The statement asked free clinic workers to address themselves to the question of how free clinics can succeed in challeng- ing and redirecting established health care institutions. As the conference drew to a close this question had still not been answered. _Constance Bloomfield and Howard Levy 8 LETTERS (Continued from Page 16) budgeting if there wasn't any more money? The answer turns out to be they didn't give administrators the freedom, precisely because there isn't the money. M We once suggested that the real reason for the Corporation - never mind the fluff about " taking things out of poli- tics, etc was. " - to free the City from the fiscal millstone the hospitals had come to be. Under the Corporation the hospitals couldn't come running to City Hall every time they needed dough they'd - be stuck with their own internal, independent bud- get, like the Port Authority. Why else was the City's Budget Bureau a prime source of agitation for the Corporation and later the chief designer of its financial and management structure? Now it looks very much as if this sinister suspicion was right on the nose: Lindsay can say, " Yeah, our hospitals fell apart, but they're not part of the City. You see, we have this Corporation. " OE And we even said that another real purpose of the Corporation was not, of course, " to abolish the two class - system, " but in fact to solidfy, protect, preserve and bolster that racist system for all time. (See for example my Social Policy article in January February - , 1971.) That the pri- vate hospitals needed a buffer system of public (now quasi public - ) hospitals to ab- sorb the unwashed hordes, to house the scientifically interesting pieces of pathol- ogy washed up from the ghettos, to keep the heat on City Hall and away from the wood paneled - board rooms of the Em- pires.: Finally, I would try to expand beyond the old analysis, to begin to see what is happening with the hospitals as part of the general washout catastrophe of the public sector, and to begin to see that, in turn, as a heavy portent for capitalism itself. It's not just the hospitals; it's the subways, the schools, the universities, the libraries. Something of world - wide historic significance is going on when, in the cen- ter of the empire, children go without milk at school, highways stop being repaired, and health cutbacks face even the rich with the ancient threat of epidemics. It's not a matter of moralizing: Things just don't work anymore. Barbara Ehrenreich Old Westbury, New York (Health - PAC Associate) TREMORS AT SAN FRANCISCO GENERAL Struggles to improve patient care at most hospitals throughout the country appear to be as fragmented and episodic as the patient care the hospitals themselves de- liver. It is only after reflecting upon sev- eral years of struggle that a thread of con- tinuity emerges. This process is not inevi- table; it requires careful analysis of exist- ing forces by the new and different groups that develop out of previous struggles. When this reflection occurs, the struggle for change can take on more meaning and depth. Such is the case at San Francisco General Hospital (SFGH). SFGH is the only county hospital serv- ing most of San Francisco's quarter of a million poor people. The patients who use this hospital are from diverse cultural and ethnic backgrounds - B lacks, Latins, Chinese, Filipinos, American Indians and Anglo. The administrative responsibility for the hospital is divided between an in- flexible, penny pinching - city bureaucracy and an academically oriented affiliate in- stitution, the University of California Med- ical School (UC). For the city bureaucracy, SFGH repre- sents another tentacle of the public sector. Hospital employment provides a source of patronage for city officials. Beyond patron- age, city officials are most concerned with containing the budget in order to reduce the city's fiscal liabilities. The Medical School, on the other hand, sees SFGH primarily as a site for training students and house staff. UC is dependent upon SFGH as one of its major teaching hospitals. At least one third of the Medical School's students and house staff receive training at SFGH. Many faculty members maintain their university appointments and access to research subjects through their relationship to SFGH. Indeed, much of UC's training programs could not exist anywhere else in San Francisco: no other hospital has the'case material'to offer training in trauma surgery, for example. Two Years of Turmoil UC and the City do not hold good patient care or non professional - working condi- tions as high priorities. Their joint neglect has led over the past two years to sporadic struggles, including petitions, strikes, and direct personal confrontations with hospi- tal officials, by both patients and workers. In early March, 1970, San Francisco Mayor Alioto refused to grant hospital workers sufficient salary increases to keep pace with the galloping cost of living. The Mayor also claimed that no money was available to meet intern demands that their salaries be increased and that patient services be improved. Some of these needs which have been voiced for years included longer pharmacy and clinic hours, more 9 social services and ward clerks, and sat- ellite decentralized health facilities. By the second week in March, both the interns and the unionized hospital workers were ready to strike. On March 13, 1970, the hospital workers walked off their jobs and formed picket lines around the hos- pital. They were joined by 10,000 other municipal workers who struck simultane- ously over their own wage demands. The prospect existed that the City would be paralyzed by a general strike. The hospi- tal's interns, however, decided not to add their weight to the protest by joining the strike; they reached their decision after being cowed by the threatened loss of their medical licenses. By the next work- day, the workers were forced to capitulate in an early settlement of the strike. The City and union united against the rank and file and the hospital workers won only minimal wage gains. The unsatisfactory settlement left many hospital workers keenly disappointed. The patient care de- mands never made it to the negotiating table, and action upon them was shelved. By January, 1971, the chickens came home to roost at SFGH (see BULLETIN, March, 1971). For four days 90 percent of the interns went out on strike. Two months earlier, they had detailed 101 demands for themselves, improved patient services, as well as demands oriented around the needs of non professional - hospital workers. Unfortunately, these latter demands were overshadowed; during the subsequent negotiations they were finally eclipsed, by a demand to increase intern salaries to $ 13,000 a year. The interns had failed to win prior support for their demands from either patient or community groups " I have seen multitudes of cases of maltreatment of patients. I have maltreated patients myself forced to it by dehumanizing condi- tions. " - - Testimony at JCAH Hearing 10 " Disposable surgeon's gloves are wrapped in brown paper and used again. " - Testimony at JCAH Hearing or the hospital workers. When, as should have been anticipated, no one came to their support, the interns'strike was de- feated. All the demands were shelved and forgotten again. Summing up the two years of turmoil at SFGH, one involved doctor said: " The struggles may have led to increased con- sciousness and awareness about the poli- tical aspects of health care. But this is a highly subjective matter and can't be mea- sured. What can be measured are the objective improvements in patient care and worker benefits at the hospital: there were none. " Maggots at the Hearings Dissatisfaction, however, at SFGH con- tinued, and by March, 1971, the struggle erupted again. A group of interns, hospital workers and community - based lawyers began to organize around the impending visit of the Joint Committee on the Accred- itation of Hospitals (JCAH) survey team. Though JCAH is a private body, com- posed of representatives of the American Medical Association, American Hospital Association, American College of Sur- geons and the American College of Phys- icians, without their accreditation hospi- tals'reimbursements from Medicare and Medicaid become jeopardized. In addi- tion, lack of accreditation can result in the loss of intern and resident training programs. Thus JCAH accreditation proceedings were seen by the ad hoc group of interns, hospital workers and lawyers as a tacti- cally opportune time to raise the issues of poor patient care. By March the ad hoc group had documented hundreds of in- stances of medical and sanitary neglect at SFGH. When the JCAH inspection team arrived, the committee insisted upon ac- companying them on their tour of the hospital and presenting their own evi- dence to the J,,AH team. Some of the evi- dence presented included statements that: OE hospital drugs were improperly su- pervised and inefficiently stocked M@ patients'beds stood near open win- dows littered with pigeon droppings OE disposable syringes, intravenous catheters and other plastic items were reused although they should be thrown away @ the psychiatric building, where wir- ing is exposed and cleaning solu- tions have been used in suicide at- tempts, was unfit for human occu- pancy and should be closed down immediately @ open, overflowing garbage bins and cans littered hallways and corridors OE bedding was sorely inadequate, linens were left dirty, and dishes were washed in water not hot enough to sterilize them M medical records were improperly kept, often lost, and frequently failed to accompany the patients from service to service. Typical testimony included: Barbara Joan Fulp, a registered nurse The " shortage of linens is so acute that linen is hidden and locked up. The dishwasher on Ward 42 is broken and completely inoperative. Bedpan sterilizers do not work. " Thomas S. Bodenheimer, a doctor in the out patient - clinic- " I have seen multitudes of cases of maltreatment of patients. I have maltreated patients myself - forced to do it by dehumanizing conditions. " Gregg Powell, a licensed vocational nurse " Irrigation syringes clearly stamp- ed'destroy after use'are re sterilized - and issued from central supply for re use -. Dis- posable surgeons'gloves are wrapped in brown paper and used again. " Robert Marvan, an intern- " I can show photostats of a patient's chart noting that ants were found in his bed; maggots were found in the neck of a patient operated on for a gunshot wound. " Five months after the hearings, the JCAH placed the hospital on one year ' probationary status.'The JCAH team warned the hospital's administrators that if the deficiencies were not corrected, ac- creditation would be lost altogether in 1972. Three community organizations, whose members are forced to use SFGH, were unwilling to go through another year of medical neglect. They filed suit in U.S. District Court in Washington, D.C. The plaintiffs (the California Legislative " The shortage of linen is so acute that linen is hidden and locked up. " - Testimony at JCAH Hearings Council for Older Americans, Self Help - for the Elderly, and the Centro de Salud, a free clinic associated with Los Siete de la Raza), charged that the Federal Government cannot legally pay, through Medicare and Medicaid, for care at SFGH which is " unsafe, unsanitary and in- humane... " Moreover, the suit contends that the government acts illegally by de- legating the power to set quality standards for hospitals to a private agency, the ICAH. A Longer View- The Thursday Noon Committee In July, 1971, a small group of hospital workers, mostly young doctors and social workers, began to meet. Many members of the group, which came to be known as the Thursday Noon Committee, had parti- cipated in earlier intern initiated actions but were frustrated at having worked hard only to accomplish so little. It was clear to the group that a different, long range - strategy had to be developed. The Thurs- day Noon Committee decided upon three basic principles: OE The group must be more broadly based than interns alone, yet sufficiently homogenous to agree on a unified political approach. The group would speak only for itself and not try to represent or speak for the predominantly conservative or apathe- tic interns - nor would they speak for other groups within the hospital. OE The building of a coalition of forces- professionals, hospital workers, and com- munity activists - would be crucial. This kind of coalition cannot be developed as an afterthought during the midst of a crisis. 11 OE Energy should be concentrated upon a few important areas of the hospital, rather than a diffuse and unachievable conglo- meration of innumerable (i. e., 101) de- mands. The Thursday Noon Committee chose two programmatic issues for 1971-1972: follow - up action on on the accreditation issue; and emergency room improve- ments. Bill Increase Rolled Back Almost before the Thursday Noon Com- mittee could embark on these issues, the hospital's administration created its own headache. In October, 1971, the hospital instituted new billing procedures. The new procedures were in response to a MediCal (California Medicaid) " reform " which affected the income eligibility levels for poor patients. Before this " reform, " med- ically indigent patients received no, or at most, very small bills from SFGH. With the new " reform " in hand, many patients formerly receiving free care were told they would receive bills; patients with savings in the bank had to spend down to the last $ 600 in their accounts before they could receive free care. In response to the new billing proce- dure, the Thursday Noon Committee issued a leaflet which described, in considerable detail, exactly how the new billing rules affected patients and linked the effort to rescind the new billing rules to the hospi- tal accreditation issue and hospital workers'job security: Another issue of importance to hospital workers is contained in this situation: SFGH is on'probation'and may have its accreditation lifted entirely. Despite this, few of the improvements designated as essential by the Joint Commission on Ac- creditation of Hospitals seem to have been made. At the same time, the billing stand- ards of SFGH have been converted to ones which are virtually identical to those of a private hospital. It is well known that many private hospitals in San Francisco would like to close down SFGH in order to fill their own empty beds with SFGH patients. If SFGH does not bring its own JCAH Gets The Joint Commission on Accreditation of Hospitals (JCAH) is a private body, which sets national standards and conducts biennial surveys for certification of hospitals and other health institutions. JACH is comprised of 22 commis- sioners, 18 of whom are MD's. Four major organizations appoint most of the commissioners. The American Medical Association and the American Hospital Association each appoint seven commissioners, while the American College of Surgeons and the American College of Physicians name three commissioners each. In 1970, under pressure from consumer groups led by the National Welfare Rights Organization, JCAH was forced to open up their surveys to include consumer and health worker viewpoints. The following report of activity around these JCAH hearings comes from the Health Law Newsletter published by the National Health and Environmental Law Program, 405 Hilgard Avenue, Los Angeles, California 90024. That organization will help local groups find out when the JCAH survey team will visit their hospital. Since its decision to hear health workers and consumers as well as administrators, the Joint Commission on Hospital Accreditation has received an earful. To date, most presentations we know about have occurred in public hospi- tals, which are the last hope and the main source of care for the poor and the elderly. M@ At Washington D.C. General Hospital, the Senior Citizens Clearinghouse, the Greater Washington Council of Senior Citizens, and the D.C. Family Wel- fare Rights Organization (represented by the Center for Law and Social Policy, Legal Services for the Elderly, and NHELP) documented continuing violations 12 health care up to minimal standards, and then bills patients as if they were in a private hospital, the question immediately arises: Why should SFGH continue to ex- ist? Is someone trying to set up SFGH to be closed down as'unnecessary, and is this the real motivation behind the high bill policy? The Committee, following the lead of hospital social workers, protested the new regulations. A two page memo to SFGH Administrator Charles Monedero describ- ed the inhumane results the billing pro- cedure would have on patients who would not seek treatment because they couldn't afford to pay the bills. The memo demand- ed that " no patient be given a bill higher than what he would have received under the old SFGH standards. " The Committee warned that " it is going to be impossible to serve the poor community of San Fran- cisco and serve them bills at the same time. " A few weeks later, following " negotia- tions " between the Committee and various city and hospital officials, the battle of the billing policy was won. Dr. Curry, Director of Public Health for the City, announced that SFGH would return to its former, more lenient billing standards. In addition, Dr. Curry agreed to the second demand that a billing committee be formed from a cross- section of the hospital's staff to advise the hospital administration on the formation and enforcement of all billing policies. " Both of these actions, " in the words of the Thursday Noon Committee, " represent major victories for hospital workers in their struggle for a more humane billing system. " The victory was assisted by the ability of the Committee to gather, pub- lish and disseminate accurate information about the billing system. The Committee provided hospital workers with a steady stream of information concerning each and every memo, conference and " negoti- ation session " which took place around the billing fight. During the billing fight the Thursday Noon Committee developed a new and effective tactic. They would re- quest meetings with hospital and health officials, bring as many people as they An Earful of the JCAH Standards of Accreditation and continued failure to implement improvements ordered last year. They also demanded further changes in JCAH policies which keep all information secret from everyone but the hospi- tal administrators. @ At LA County - USC Medical Center, the Interns and Residents Assn. (re- presented by NHELP) has actively pushed for improvements in staffing and equipment for the past two years. They presented the JCAH survey team with extensive documentation of the difficulties and even deaths resulting from in- adequate resources. The California Nurses Association offered a similar state- ment, focusing particularly on the lack of nurses. Poor working conditions and inadequate salaries have left 41 percent of the RN slots unfilled. In each of these cases, the groups involved sought to use the fact that JCAH accreditation is necessary for a hospital to receive Medicare pay- ments as leverage to force improvements in care. They also asked that con- sumers be given a greater role in monitoring the hospitals'quality of care and compliance with JCAH improvement recommendations. OE At UCLA Medical Center, the situation and the presentations were some- what different. UCLA is an academic medical center, more like a major volun- tary hospital than like the city and county hospitals. At UCLA, the Medical Committee for Human Rights and the Venice Health Council focused on the hospital's failure to meet the needs of surrounding communities and to pioneer new forms of health care delivery and on abuses of basic patient rights to privacy, dignity and information. These patient rights appear in the Pream- ble to the Standards and are endorsed by the JCAH as principles of Accredita- tion. 13 health care up to minimal standards, and then bills patients as if they were in a private hospital, the question immediately arises: Why should SFGH continue to ex- ist? Is someone trying to set up SFGH to be closed down as'unnecessary, and is this the real motivation behind the high bill policy? The Committee, following the lead of hospital social workers, protested the new regulations. A two page memo to SFGH Administrator Charles Monedero describ- ed the inhumane results the billing pro- cedure would have on patients who would not seek treatment because they couldn't afford to pay the bills. The memo demand- ed that " no patient be given a bill higher than what he would have received under the old SFGH standards. " The Committee warned that " it is going to be impossible to serve the poor community of San Fran- cisco and serve them bills at the same time. " A few weeks later, following " negotia- tions " between the Committee and various city and hospital officials, the battle of the billing policy was won. Dr. Curry, Director of Public Health for the City, announced that SFGH would return to its former, more lenient billing standards. In addition, Dr. Curry agreed to the second demand that a billing committee be formed from a cross- section of the hospital's staff to advise the hospital administration on the formation and enforcement of all billing policies. " Both of these actions, " in the words of the Thursday Noon Committee, " represent major victories for hospital workers in their struggle for a more humane billing system. " The victory was assisted by the ability of the Committee to gather, pub- lish and disseminate accurate information about the billing system. The Committee provided hospital workers with a steady stream of information concerning each and every memo, conference and " negoti- ation session " which took place around the billing fight. During the billing fight the Thursday Noon Committee developed a new and effective tactic. They would re- quest meetings with hospital and health officials, bring as many people as they An Earful of the JCAH Standards of Accreditation and continued failure to implement improvements ordered last year. They also demanded further changes in JCAH policies which keep all information secret from everyone but the hospi- tal administrators. @ At LA County - USC Medical Center, the Interns and Residents Assn. (re- presented by NHELP) has actively pushed for improvements in staffing and equipment for the past two years. They presented the JCAH survey team with extensive documentation of the difficulties and even deaths resulting from in- adequate resources. The California Nurses Association offered a similar state- ment, focusing particularly on the lack of nurses. Poor working conditions and inadequate salaries have left 41 percent of the RN slots unfilled. In each of these cases, the groups involved sought to use the fact that JCAH accreditation is necessary for a hospital to receive Medicare pay- ments as leverage to force improvements in care. They also asked that con- sumers be given a greater role in monitoring the hospitals'quality of care and compliance with JCAH improvement recommendations. OE At UCLA Medical Center, the situation and the presentations were some- what different. UCLA is an academic medical center, more like a major volun- tary hospital than like the city and county hospitals. At UCLA, the Medical Committee for Human Rights and the Venice Health Council focused on the hospital's failure to meet the needs of surrounding communities and to pioneer new forms of health care delivery and on abuses of basic patient rights to privacy, dignity and information. These patient rights appear in the Pream- ble to the Standards and are endorsed by the JCAH as principles of Accredita- tion. 13 could to the meeting and then insist on calling it " negotiations. " While this an- noyed the officials, it also intimidated them into actually negotiating. The conclusion drawn by the Com- mittee was that " it seems that relatively small number of hospital workers can effect important changes in in the area of hospital functioning through tenacity and carefully thought out plan- ning. It is not always necessary to resort to strikes, and at times, focusing on a win- nable demand gives workers a sense of their potential strength. " On the other hand, the Committee believes that it is also crucial to raise demands concerning issues, such as alternate control and fi- nancing, which, while not immediately winnable, serve to make people aware of the larger issues at stake. All Roads Lead to the Emergency Room With the billing action won, the Thurs- day Noon Committee was able to turn its attention to SFGH's Mission Emergency Room. Like most other public hospitals, its emergency room service for acutely ill patients is relatively good. However, pat- ients who are unable to find care else- where in the city and who use SFGH's emergency room for less than life threaten- ing problems are given short shrift. Strategically, the emergency room was selected as a target because, though it is a limited part of the hospital, it also serves a great volume of patients daily. More- over, it represents the major interface be- tween the hospital and ambulatory pa- tients, many of whom, because they are not bed ridden -, can potentially join in challenging the hospital. Thursday Noon Committee's first step was, with the help of some emergency room workers, to document the inadequa- cies of care in the present emergency area. Then, in Mid November - , an attrac- tive 12 page - " Draft Proposal " to improve " Is someone trying to set up SFGH to be closed down?... Is this the real motivation behind the high bill policy? " -Leaflet of the Thursday Noon Committee 14 services was distributed to hospital work- ers. The introduction to the proposal places the problems of emergency room service within the context of the total health care delivery system: The majority of the cases- -as in all emergency rooms- -are not true life - or- death emergencies. The emergency room has become America's fastest growing health care institution, with patient loads increasing at a rate of 10% a year. 60-70% of cases in emergency rooms across the country are not true emergencies, but are drop - ins. The enormous increase in emerg- ency room drop - ins attests to the failure of the American health system. Were an adequate number of primary care clinics easily accessible, the emergency room drop - in function would not be so vitally needed and so rapidly growing. Until the emergency room drop - in problem is solved by creating alternative sources of medical care, emergency rooms, including SFGH's Mission Emergency Room, must continue to serve the drop - in function. The bulk of the report consists of pro- posals for changes in the emergency room service. It includes sections on the triage (screening) process, the use of space (with floor plans included), the admitting office, etc. The report modestly concludes with a call for workers to meet and dis- cuss the administration and governance of the Mission Emergency Room. The mod- esty is justified by the Thursday Noon Committee's recognition that " we are doc- tors and social workers and don't pretend to speak for workers generally in the emergency room. " It is the feeling of the Thursday Noon Committee that it's " only through their own meetings that the work- ers can gain an effective voice in govern- ing Mission Emergency Room. " Thursday Noon Committee hopes that " eventually a workers'council may develop that has significant policy making functions. " The Draft Proposal has made a few waves at SFGH. For instance, the Mission Emergency Room Advisory Committee (consisting of UC faculty), which had not met in 18 months, was forced to meet around the Proposal. The Advisory Com- mittee endorsed the Proposal, with the im- portant exception of the suggestions for worker governance. The community or- ganizations bringing the suit around the JCAH issue have also become involved. While JCAH noted few deficiencies in the emergency room, the organizations'law- yers are now stressting the importance of the emergency room to their clients. By implication, they are threatening to stage another confrontation on the JCAH survey team's next visit. It is too early to predict what success the emergency room proposal will have at SFGH. Thursday Noon Committee has no intention of prematurely staging a con- frontation without a base of support among other hospital workers and com- munity groups. To this end, the Committee has been able to use its specific focus on the emergency room proposal as a point of discussion with workers and commun- ity organizations. Who Will Pay for Change? The Thursday Noon Committee has a rocky road ahead. Both the City and the University of California are threatened by the demand for more and better services at SFGH. The City realizes this pressure may lead to increased taxes; the Univer- sity realizes it may lead to greater commit- ment on its own part for improved patient services. Although many of the proposals to im- prove the emergency room can be accom- plished with little additional expenditure, the more sweeping suggestions for change are expensive. The city officials agree that the emergency room, in particular, and the hospital, in general, are in acute need of improvement. However, San Fran- cisco, like most cities, is in chronic finan- cial crisis and claims that it does not have the money to make improvements. The Thursday Noon Committee maintains that the City of San Francisco could, potential- ly, exercise its option to tax industry and banking, rather than tax the citizens, as a means of increasing revenues. But the Committee also recognizes that the City will not voluntary opt for shifting the tax base. The City's other options are to beg for handouts from the Federal or State governments (neither Nixon nor Reagan are notably generous when it comes to health services), or to further tax the already overtaxed working class. The latter, however, is a particularly sensitive political issue throughout the country, especially in areas where there have been'tax revolts'by middle and working class taxpayers. Moreover, the, political noise generated by the tax revolts is like the sound of music to California's Governor Reagan. The strains of the mel- ody find their way into the San Francisco Mayor's office, thus eliminating the option of raising increased revenues by further taxing the people of the city. The City of San Francisco is finally left with one last option: short changing the financing of public services. When this option is ex- ercised with regard to SFGH, the results are predictably disastrous. The solution, of course, comes down hardest on SFGH's workers and patients. " A relatively small number of hospital workers can effect important changes through tenacity and carefully thought out planning. " - Leaflet of the Thursday Noon Committee While the City is threatened by the agit- ation for better care at SFGH, UC is no less threatened. The University of Cali- fornia Medical School immediately re- acted when SFGH was placed on proba- tionary status by the JCAH. In an unpre- cedented move, born out of anxiety that its teaching program might be lost next year, the Medical School recently hired its own staff person to make certain that the JCAH's recommendations were carried out expeditiously. The explanation for UC's sudden show of concern for SFGH is not difficult to un- derstand but its concern only goes so far- far enough to preserve its own training and research freedom at San Francisco General Hospital. When, for example, interns in the past have protested the quality of pati- ent care rendered at SFGH, and have de- manded the abolition of San Francisco's two class health system, UC perceived this as a threat to its control of SFGH. Hence UC reacted by threatening the dis- sident doctors with the loss of their med- ical licenses. Despite the conflicts of interest, complex- ities and contradictions surrounding SFGH, the movement to radically upgrade the services it offers continues with undimin- ished intensity. Episodic protest in the past from various strata of the San Francisco population reveals widespread discontent with the City's and the University's health policies. Up until now, protests have been largely uncoordinated and all too often at cross purposes with one another. The past eight months, however, have seen the be- ginning of a more united attack. The part- ial success of the accreditation hearing and the complete success of the billing struggle give reason for some optimism that things at SFGH could get better. - Howard Levy 15 LETTERS Indignant Protest That Health - PAC Too Easy On New York's Hospital Corporation In the past I've criticized articles for be- ing too heavy on the analysis and too light on the tacts. In the December, 1971 article on the Health and Hospitals Corporation, you go wild with the information but seem timid about the interpretation (s). My overall feeling was, " Oh boy, would I ever love to write an editorial to go with this. " If I were writing an editorial I would first of all express my sheer outrage at what they're doing and not doing. People picketed and petitioned against this health - style Penn Central and they were told, in effect, that they were being mind- less paranoids not to put their hospitals into the hands of the " experts. " So they did, and look what happened. I didn't even think the article sounded too indig- nant about it. Then there are the little ironies which should be sketched in acid prose. For in- stance, the Corporation can't even do things that you'd think would be in their own interest, like collecting bills from poor pa- tients or from third parties. Another is that one overall effect of the Corporation was to greatly increase the salaries of all the administrators. Those administrators who are complaining now once fought for the Corporation because they were told that their salaries would increase by about 50 percent. So now we see the hospitals get- ting poorer and poorer, the people getting sicker and so forth, while the administra- tors have never had it so good. Another outrage - the nonexistent com- munity advisory boards. Remember, this was their one concession to " the com- munity " after all the protests about the Corporation. So where do they have a community advisory board? -on Welfare Island. That's really funny, and deserves language a little stronger than " Unfor- tunately at this time the notion of publicly accountable community advisory boards must also be challenged. " Also in my hypothetical editorial I would have a whole " we told you so " section. After all, how often do we get our direst predictions confirmed So promptly? For example: M@ We always said that management wasn't the major problem in the munic- ipals. The major problem was money, the sheer quantity of money. Without some financial commitment to the city hospitals, not even McNamara could have run them. There's no new form of accounting which can change red to black or turn bills into green cash. M We always said that there was a reason for red tape in the old system. Mainly, it was there to prevent anyone from spending any money. If you have to go through a thirty - step, six month - pro- cedure to buy some rubber tubing, well, you just don't buy it. So, we said, what good would it do to give the administrators of the hospitals decentralized, flexible (Continued on Page 8) Subscribe To The Health - PAC Bulletin Name Address Address Affiliation Zip Enclosed: Y' $ 7 Regular Y' $ 5 Student Back issues available at 60 each; bulk rate 35 each (10 or more). Index of past issues free on request. HEALTH POLICY ADVISORY CENTER N. Y., N. Y. 10007 (212) 267-8890 16