Document EvMp14L5GN6ewv75y7eLR0bvb

Health Policy Advisory Center No. 40 April 1972 HEALTH PAC BULLETIN WOMEN AND THE HEALTH SYSTEM Women have a unique relationship to the health system. As patients, they require not only the general health care needed by any adult, man or woman, but also the specialized services related to their repro- ductive system. As workers in the health system, they make up 70 percent of the entire health labor force. As mothers, they are in most cases directly responsible for the day day - to - care of their children, in- cluding health care. women In the past, women have generally seen their problems with the health system in terms of a person person - to - struggle: one woman dealing with a patronizing male gynecologist, a woman health worker struggling with an oppressive supervisor, another woman frustrated in attempts to get good pediatric care for her children. This BULLETIN, focusing on a larger view of these personal struggles, deals with some of the health institutions which con- trol women as patients and as workers. (The issue of pediatric care as it affects women is not discussed here.) Women as Patients Of all the factors keeping women in the narrowly defined role of wife and mother, one of the most important has been the biology of their own bodies. The various medical needs associated with the repro- ductive system make women particularly dependent on the health system. Some of these, such as venereal disease and can- cer, affect both men and women; but most are unique to women: vaginal infections, disorders related to the menstrual cycle, and most importantly, reproduction itself. Through most of history, pregnancy, child- birth and childcare have kept women in the home, controlled by men; the most common methods of birth control, with- drawal and later the condom, were di- rectly controlled by men. Increased con- sciousness on the part of women and ad- vances in birth control technology have helped to bring about radical changes in the status of women. Fifty years ago, women were imprison- ed for demanding contraceptive services; today, the federal government, big busi- ness, and the medical establishment are all in favor of birth control. From its begin- nings, the Women's Movement has fought for the right of women to birth control and abortion; in 1972, the Movement finds it- self on the same side of the fence with John D. Rockefeller III in pushing for these services. The discussion of the birth con- trol movement in this BULLETIN centers on the various interest groups that have been involved in birth control in the US and how the economic and political pri- orities of the federal government and private business have shaped national policy regarding birth control. Uncle Sam is now the major provider of birth control services in this country and his concentration is unmistakably on the poor. This raises issues which, though not explored in depth in this discussion, should be emphasized: more and more both poor and middle - class women, and especially third world women, are finding that birth control services are accessible and free while other health services for themselves and their children are not. It is clear that there is a gap between what women want good - comprehensive health care and what priorities of the health system determine will be provided. CONTENTS 3 US Family Planning 13 Methodist Hospital 15 Women Health Workers Women as Workers Women who work in the health system find that they are doubly oppressed, as workers and as women. There are reasons why women make up such a large per- centage of the labor force in health insti- tutions. Historically, women have as- sumed roles of cooking, cleaning, nurtur- ing, and caring for the bodily needs of others; these functions are readily trans- lated into job categories in health institu- tions. With the exception of the most pro- fessional positions, jobs in the health sys- tem have traditionally been low paying - . Because other jobs were not available, es- pecially ones that could accommodate their family commitments, women have been forced into these low salaried - posi- tions. The rigid hierarchy existing in health institutions requires a large pool of low level - workers. Women, socialized from birth into passive roles and trained to see their major interest as home and family, have been more easily channeled into narrow unchallenging job categories. In nursing especially, women have tried to counter this trend by profession- alizing the role of the registered nurse. This BULLETIN traces the consequences of this professionalization and the narrow definition of job categories. It points to the rocky road ahead for women health workers if they continue to counter the hierarchical domination of the health system by developing hierarchies and di- visions of their own. Women Struggle with the Health System As women become aware of how the health system controls their lives, their anger and frustration have grown. This anger has exploded in many different ways, and as a result, women are becom- ing more and more active in struggles to gain control of their own lives and to take some measure of control over those health institutions which have oppressed them. Women have long taken major roles in struggles with the health system. They _ have led community groups fighting for better health care from urban New York City to rural Eastern Kentucky, have or- ganized parents'committees pushing for improved pediatric services from hos- pitals, and have been a major force in struggles of hospital workers. The BUL- LETIN has reported on these struggles in 2 the past, but for the first time in this issue, it focuses on the role of women as a dis- tinct group, the Women's Movement, and the Movement's involvement with health issues. The Women's Movement has concen- trated much energy on the struggle for ex- panded birth control and abortion ser- vices. Groups of women have organized abortion and birth control services and re- ferral systems. These activities have been important in providing much needed ser- vices. Yet women working in such pro- grams have often become frustrated, real- izing that women's health needs extend far beyond birth control and abortion. Thus, many women's groups turned to broader aspects of health care. Women have been the backbone of many free clinics and have even set up clinics serv- ing women exclusively. But again, many women have found this work limited and frustrating, seeing themselves providing patchwork medical care and, by doing its work, actually taking pressure off that larger health system. Some groups have begun to focus pressure directly on the health institutions. There are many prob- lems in doing this. Health institutions seem monolithic in nature. The constitu- ency of the Women's Movement is still largely middle - class women, and while they are dissatisfied with health care, they do not generally use health institu- tions, such as hospital outpatient depart- ments, for primary health care. Thus, their discontent does not alway lead to a nat- ural focus on a single institution. In spite of this, organized groups of women have been able to have some effect on health institutions. In San Francisco, one group makes referrals for all health problems and serves as patient advocates with the institutions. In upstate New York, another group put pressure on a federally funded family planning program and brought about major changes in the development of the program. A more powerful thrust for change comes when women form alliances with other groups to put pressure on commonly used health institutions. Such was the case in a recent struggle at Methodist Hospital in Brooklyn, discussed in this BULLETIN. As one woman activist stated, " On our own, we're really limited. We need to form alliances with groups of workers inside the institutions and we have to work in coalition with other con- sumer and community groups. But we have legitimate interests and needs, and if we're organized in groups we can be- qin to work. " This BULLETIN was prepared collectively by Amy Brodkey, Rachel Fruchter, Margo Levine, Susan Reverby and Jean Sharpe. THE BIRTH CONTROLLERS A New York City family planning official recently stated that there are basically four " banners " under which birth control can be " sold ": -the poulation problem -the " welfare syndrome " _ the health of women -the individual right of each woman to birth control All are legitimate areas of human con- cern. Birth control is particularly impor- tant to women individually - , as a right and as a matter of health; and to the Women's Movement, as a point of struggle for the same goals. However, the concern of those individuals and institutions con- trolling most birth control programs in the US today is directed more narrowly to- ward the issues of population and " wel- farism. " It is not only crucial that women understand the functioning of their own bodies, but it is equally important that they understand interests of those institutions which would offer women these services. This discussion will trace the develop- ment in the US of the birth control move- ment; examine the roles of various inter- est groups that have been involved in the movement; and show how those groups have used birth control to further their own interests. Birth of the Movement There is a widespread misconception that before the advent of the condom and later, more sophisticated devices, men ' and women were completely unable to control the number of children they pro- duced. While birth control has become a subject of public debate only in recent years, contraception is certainly nothing new. As early as 1850 BC Egyptian med- ical experts described mixtures to be rub- bed on, swallowed, or inserted to prevent pregnancy. Interest in the subject has never waned. In the early 1800's a new discussion evolved in Europe concerning economic and social justifications for contraception. Robert Thomas Malthus, clergyman and son of an English country gentleman, be- came well known for his dire predictions about the population " explosion. " Malthus directed his population concerns toward the poor, claiming that their production of too many children caused poverty. Efforts to provide relief to the poor were fruitless or even harmful since making their lives better would encourage them to have still more children. The early birth control movement in Europe and later in the US was deeply influenced by Malthus and most early European groups were called Neo Malthusian - Leagues. In these years the selection of contra- ceptives was quite limited. Before the de- velopment of rubber condoms provided another widely available contraceptive in the 1800's, most people depended on techniques which had been known for cen- turies: withdrawal (by far the most widely used), douching with a wide va- riety of chemical mixtures, intravaginal sponges or cloths (supposedly offering a mechanical barrier to the sperm). Unso- phisticated as these methods may seem, people were able to control their own re- 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. Subscripions, changes of address, and other correspondence should be mailed to the above address. Staff: Constance Bloomfield, Des Callan, Oliver Fein, Marsha Handelman, Ronda Kotelchuck, Howard Levy, and Susan Reverby. Associates: Robb Burlage, Morgantown, West Virginia; Vicki Cooper, Chicago; Barbara Ehrenreich, John Ehrenheich, Long Island; Ruth Galanter, Los Angeles; Kenneth Kimerling, New York City. 1972. 3 production; when economic pressures made the limitation of family size critical to survival, such as during national de- pressions, men and women did, in fact, have fewer children. Until the late 19th century, contracep- tion in the US remained a private affair; there was little public discussion of birth control or mention of the subject in state or federal laws. That period in US history was one of great social unrest and change. In 1873, in an upsurge of Victo- rian moralism, a self righteous - Anthony Comstock and his Society for the Suppres- sion of Vice joined forces with an equally self righteous - Congress and enacted fed- eral legislation (the " Comstock Laws ") prohibiting the mailing, transport, or im- porting of " obscene, lewd, or lascivious " materials. The laws were passed with lit- tle discussion; most of those who voted were not even aware that " all information and devices pertaining to preventing con- ception " were included in the ban. Thus, contraception came under public control and open discussion and exchange of in- formation about birth control were stifled. Even physicians for a long time could not legally give contraceptives to their private " The restlessness produced in a rapidly growing population is magnified by the preponderance of youth. In a completely youthful population, impatience to realize rising expectations is likely to be pronounced. Extreme nationalism has often been the result. " -Rockefeller Fund's Prospect for America " patients. However, many continued to do so privately in their offices, usually with- out interference. The late nineteenth and early twentieth centuries, influenced by industrialization and urbanization, were periods of radi- cally changing ideas. There were new ways of thinking about the family, about sexuality, about standards of living. A discussion in the New American Republic at the turn of the century frankly stated 4 that " the modern family " limited its size in order to enjoy a certain " style of living " and " social position " they felt would be threatened by more children. Indeed, the shrinking size of the American family at this period was a matter of great concern to many people. President Theodore Roose- velt, representing one faction of the upper class, insisted that the American people were committing " race suicide. " He felt that the family should be the " servant of the state " and should provide children to build national strength. Furthermore, he considered the " worst evil " to be that the " old native American stock " was less fer- tile than the immigrant population. " Race suicide, " more explicitly by the upper and middle classes, formed a basis for strug- gles against birth control by some indi- viduals interested in maintaining the power of the upper class. The influences of this period also pro- duced new ways of thinking about the status of women. Feminist reformers had long been struggling for property owner- ship and the vote. By the early 1900's a few more militant feminists had begun to ask broader questions about women's roles. The Woman Rebel One of these was a nurse, Margaret Sanger. In New York's Greenwich Vil- lage she became closely associated with some of the outstanding socialists, labor organizers and feminists of the pe- riod. Margaret Sanger was very much drawn to the new ideas she encountered and soon joined the Socialist Party. At the same time she also met well known anar- chist and feminist Emma Goldman, a long - time advocate of the right of women to contraception. Margaret Sanger kept up her nursing career. In the course of ner work as a visit- ing nurse, she was called to a Lower East Siae tenement to treat a young woman who had tried to abort herself. The physi- cian told the woman not to " get caught " again, that another pregnancy might be fatal for her. His only reply to her pleas for advice about contraception was that her husband should " sleep on the roof. " Three months later, Margaret Sanger was called to see the same woman, but this time the abortion attempt proved fatal. As a nurse, she had witnessed similar tra- gedies time and time again, but that night was a turning point for her. She renounced nursing- " I will not go back to merely keeping people alive... I was finished with palliatives and superficial cures; 1 was resolved to do something to change the destiny of mothers whose miseries were as vast as the sky. " Margaret Sanger's answer was to teach women about birth control. Shortly thereafter, Margaret Sanger traveled to France where she felt she could learn more about contraception. There, she learned about methods of birth control and exchanged ideas with French radicals involved in the birth control movement. Returning to the US, she wrote and printed a newsletter, The Woman Rebel, which damned the Rockefellers (she blasted John D. as a " blackhearted plutocrat whose soft flabby hands carry no standard but that of greed "), religion (with which, she stated, the upper class was trying to " drug " the labor force), and marriage (which she described as " form of property regulation in which wives are sex chattel "-) . She also pub- lished a controversial and illegal pamph- let discussing various contraceptive tech- niques and urging women to learn to use them and teach them to each other. Much of Margaret Sanger's early work was directed toward the emancipation of women. She wrote and lectured passion- ately of the right of women to be free from compulsory family life and child- bearing, free to find other means of ful- filling their lives. A few of her Greenwich Village friends joined Margaret Sanger touring the US, lecturing on birth control. Although this was a period of great upheaval and activ- ity in the American socialist - labor move- ment, most individuals involved in it did not see birth control or women's issues in general as being of great importance to their cause at that time. In 1914 postal authorities declared The Woman Rebel illegal under the Comstock Laws and brought charges against Mar- garet Sanger. After months of frustrated legal maneuvering, she decided to leave the country to avoid imprisonment. Her year of exile in London was the most cri- tical period in the development of her ideas about the struggle for birth control. Margaret Sanger's closest associates in England were the prominent English Mal- thusians, the Drysdales, and Havelock Ellis, internationally recognized sexual psychologist. These friends became her tutors and under them she studied not only contraceptive techniques but popula- tion economics and eugenics. Her mentors instilled in her the value of prudence and insisted that to be successful in the US, she must concentrate on only one issue- birth control and leave aside denuncia- tions of capitalism, oppression of women and religion. She also traveled to Holland to visit Europe's first birth control clinic. There she met with birth control special- ists who taught her use of the diaphragm. They also insisted that contraception was strictly a medical matter, not something women could " learn and teach others. " While Margaret Sanger was traveling and studying in Europe in 1915, the birth control movement in the US began to assume organizational form and direction. No doubt influenced by Margaret Sanger's dramatic exile, supporters of birth control formed groups for public advocacy of contraception. Emma Goldman began to speak more explicitly on birth control and lectured all over the US. Most of the or- ganizing was among upper middle - class " How can we reduce reproduction?... If parent- hood is a right, population control is impossible. " _Garrett Hardin, professor of biology, University of California, quoted in Population Growth and Family Planning women, generally quite conservative, who shunned association with Emma Goldman and other radicals. In 1915, they organized the National Birth Control League, the first American birth control organization. The League worked to change state and federal laws prohibiting birth control. In 1916 Margaret Sanger returned to the US and went on a national speaking tour to generate public interest in birth control. Back in New York City, she opened the first American birth control clinic in the Brownsville area of Brooklyn. Clinic work- ers expected police interference and it came soon after the clinic opened. Both Margaret Sanger and her sister, Ethel Byrne, the clinic's co founder - , were arrest- ed, tried, convicted and jailed; the clinic was closed. Their trials and imprisonment, Ethel Byrne's hunger strike and the result- ant forced feedings by authorities gener- ated tremendous public sympathy for them and for the birth control movement. As women became aware of the existence of better contraceptives, they became more and more vocal in their demands for these services. Public interest in birth control increased and the League grew. Margaret Sanger gradually came to the conclusion that to lead an effective struggle to make con- traceptives accessible to all women, she would need more support than could be supplied by the handful of political rad- icals who had taken up the fight. Thus, she joined forces with the women of the 5 League and became leader of that organ- ization. (The League later became known as the American Birth Control League- ABCL.) By the 1920's the nature of the birth con- trol movement was set: the ABCL then boasted more than 37,000 members, mostly white, middle - class, native - born Protestant women. Birth control was touted as a way to protect American society from the immi- grant masses and the unfit, rather than a step toward better health and the emanci- pation of women. The propaganda of the birth control movement reflected the eugenics concern of the upper middle - class and underscored the conversion of the movement from a radical program of social change to a conservative program of social control. The Medical Profession and Birth Control While Margaret Sanger and upper- middle class women were buiding a base of support, the reactions of the med- ical profession to birth control were mix- ed. Doctors felt that the birth control move- ment was a propaganda struggle waged by " hysterical women, " and associated it with the proliferation of counter over - the - contraceptive devices- quacke"r -ya n"d not a subject for legitimate medical inter- est. However, internationally birth control was coming to be a subject for serious medical investigation, and it was a poten- tially profitable part of medical practice. The attitudes of most physicians probably represented a mixture of these ideas. As a result, most physicians, even those who gave contraceptives to their private pa- tients, felt that association with the ABCL and Margaret Sanger was professionally damaging. Medical acceptance of birth control was also seriously limited by the fact that, with the exceptions of condoms and the diaphragm with spermicidal jelly, there were no effective, medically safe contraceptives that could be easily used by large numbers of men or women. During this period, the laws were under- going changes that allowed licensed phy- sicians more space to prescribe contracep- tives legally. New York state law, for sev- eral years, had allowed physicians " law- fully practicing " to give out birth control information " for the cure or prevention of disease "; but most physicians had regard- ed this as applying only to venereal dis- ease. In 1918, a US Supreme Court opinion (regarding an appeal of the case of Mar- garet Sanger's clinic) specifically allowed a very broad definition of the word " dis- ease, " giving M.D.'s a wider latitude by which to judge the legal conditions war- ranting contraception. In 1923, Margaret Sanger opened an- 6 other clinic, the Clinical Research Bureau (CRB), across the hall from the ABCL offices. For legal purposes it was operated as the private office of Dr. Dorothy Bocker, clinic physician. The functions of the CRB included provision of services, but it was to be " above all, a first class - center for medically supervised study of contracep- tive techniques. " In 1924, Dr. Bocker pub- lished a report on over a thousand cases from the CRB. The clinic's wide experi- ence with birth control began to command the interest of physicians. One of the physicians most interested in the medical study of birth control was Robert L. Dickenson, New York gynecol- ogist and 1920 president of the American Gynecologic Association. At the same time the CRB was established, Dickenson was drawing together a group of New York gynecologists and obstetricians as the Committee on Maternal Health (CMH) " for the purpose of carrying on " .. a series of impartial, well staged - clinical tests " of contraception. Their reasons for getting involved with such clinical studies were clearly stated by Dickenson, "... we as a profession should take hold of this matter [contraception] and not let it go to the radicals and not let it receive harm by being pushed in any undignified or im- proper manner.. " As the CRB stood, neither the CMH nor any other " respon- sible medical organization " would go near it. Dickenson visited the clinic and com- mented that " to the medical profession in general... the activity of Mrs. Sanger and her organization are an anathema. However careful the professional part of the work may be, many feel that the sale of the Birth Control Review on the streets and the agitation for repeal of the law make their movement a dangerous one. " Even the ladies of the ABCL were con- sidered " radical " by the cautious and con- servative medical profession. Dr. Dickenson and the CMH attempted to conduct a study of contraceptive tech- niques by setting up an office to refer women wanting contraceptives to one of seven hospitals in the city that had agreed to cooperate. The program failed; the hos- pitals were reluctant to give such informa- tion and the patients were shy; they wanted a " special clinic. " As the'20's passed into the'30's, med- ical interest in clinical contraception grew. Margaret Sanger, the ABCL and the CRB remained officially isolated from the or- ganized medical profession, but physicians in New York and all over the country were coming to see birth control as a part of medical practice. Elsewhere in the world, researchers were investigating va- rious new contraceptive methods. The first intra uterine - device (IUD) was developed The Pop Pill G. D. Searle, the company " where'the pill'began, " is trying to keep a hold on the oral contraceptive market. Searle's sales in the mid 1960's - were successfully aimed at receptive white, middle - class patients. Then, noticing the government's interest in the late sixities in family planning and the public's ecological consciousness, Searle found a new way to push the pill. Its latest sales pitch is a series of psychedelic pamphlets on ecology and birth control geared toward humanistic doctors in municipal hospitals, family planning centers, and free clinics who service a third world poor popul- ation. The series, entitled The Ecology of Birth Control, includes a full page picture of a crying, obviously hungry, black infant sitting forlornly in a field. Searle makes no bones about which population should be controlled: " The poor are not simply always with us; they are always with us in ever greater numbers. The caseload of Federal Aid to Dependent Children has climbed to more than 4 million during the past decade, and costs have soared from about $ 600 million to more than $ 1.8 billion... The problem of helping this segment of society through birth control is complicated by such ethnic [italics ours] factors as high illiteracy among certain groups, as well as sus- picion and fear of genocide among some minorities.... " ... Our population may soon outstrip our very finite social, economic and natural resources... Can parents be persuaded to limit their offspring to two replicates who will ultimately replace them without adding to the population? Can those who still insist on large families be persuaded to turn to adoption rather than procreation to fulfill this desire? The responses to such questions will depend greatly on our ability to alter deep rooted - and even time honored public attitudes. In his work with patients and in communities the physician can play a vital role in reshaping these attitudes and beliefs, but his efforts should be supported by a nationwide educational campaign utilizing all com- munications media and techniques. There is no reason why effective advertis- ing techniques cannot be used to persuade the public to accept contraception and the small family as part of the American way of life. " in Germany and rejected as being unsafe. Japanese and Austrian scientists publish- ed new studies on the " safe period " and this became increasingly popular. Public interest in and discussion of birth control was increasing and the movement con- tinued to gain momentum. ABCL members continued lobbying efforts directed toward organized medicine and state and federal legislators. At this time, the only medically permis- sible (thus only legal) indications for birth control were quite similar to those used in the case of most abortions today: a large family, endangerment of a wo- man's health or cases in which pregnancy could mean maternal death. A woman's own wish not to be pregnant was not con- sidered. Physicians gave out information to " deserving " women - those who had done their duty to society by bearing a minimum number of children. Finally in 1930, a federal court decision allowed " advertisement and shipment of contraceptive devices intended for legal use... for the prevention of disease. " This court decision essentially released the supply of contraceptives from the strict control of the physicians. This growing de- mand for contraceptives, along with the liberalized law, resulted in a booming business in non prescription - methods of birth control. Fortune magazine reported that in the 1930's, American women spent over $ 219 million annually for contracep- tive materials. They further added that " the medically approved segment of this business is pitifully small and as a result, many women are being duped and phys- ically harmed. " One critical review stated that " neither the government, the Amer- ican Medical Association, nor any other organization will give a woman any ad- vice as to the merits of these products. "'I The liberalized laws, increased public acceptance, growing demands for birth control services by women, demands for medical leadership, and not least of all, the yearly $ 210 million going to non- medical birth control services - all had their influence on the organized medical profession. In 1937, the AMA issued a cautious statement endorsing birth control in clinics under strict medical supervision. Shortly thereafter, physicians of the CMH won a long struggle with the ABCL and essentially gained control of the Clinical Research Bureau. In the late 1930's, the ABCL merged with the now doctor - dom- inated CRB to form the Planned Parenthood 7 Federation of America (PPFA). The new board was, not surprisingly, controlled by male physicians. Slowly but steadily, PPFA began organizing local chapters all over the country, often on the base of already existing birth control groups. Wherever local chapters were organized birth control clinics soon opened. PPFA was administered and controlled by professional men from the top down. On a local level, the actual work of estab- lishing chapters and clinics was generally carried out by middle upper - class women. While most propaganda of the movement discussed provision of birth control for working - class women, patients who used the clinics were also middle and upper class. Enter the Populationists or Planning the World's Family Early in the 1930's, federal government agencies were quietly involved in support- ing birth control services for certain ethnic groups. Indirectly, federal money went to provide contraceptives to migrant workers in the Southwest and to Indians on reser- vations. Through state Maternal and Child Health programs, federal funds supported birth control in eight Southern states early 1940's, proponents of birth control were hailing it as " an effective weapon in creating a strong people... to defend our way of life. " Even more importantly, the war industries demanded workers and with the men overseas, women were needed. It was obviously not efficient to have women workers away from the job having babies. The US Public Health Ser- vice pushed states to provide birth control for women in war industries. Women had to be kept on the job line and off the maternity ward. As the war came to an end and the US became the political and economic leader of much of the world, federal government and private businessmen with interests overseas broadened their interest from the " population problem " at home to that abroad. Awareness of the world " population problem " was not completely new. The stage had been set years before by Mal- thus and, in the US, historian Will Durant had warned that to " offset the yellow peril, " the US ought to " spread birth con- trol knowledge abroad so as to de- crease the quantity of peoples whose unchecked reproduction threatens interna- tional peace. " A New York Herald Tribune " The new governmental concern is based on the assumption that large family size, early, unwanted, out wedlock - of - pregnancies, broken homes, etc., bear the major responsibility for the poor's state of poverty. In fact, the contrary is known to be true. Poverty and racism with concomitant poor health care and resources are among the major causes of large families, broken homes, illegitimacy, as well as _ chronic ill health and the premature death of the poor and black. " _ Laura Anderson, testimony to the Commission on Population Growth and the American Future, May 4, 1971. - (none in any other parts of the country) where " spacing child -" was a part of pub- lic health programs for poor, mostly black women. Economic pressures of wartime pro- vided an impetus for further federal in- volvement with family planning. In the 8 cartoon of 1946 showed, under the title " Freedom from Want, " a figure of kindly Uncle Sam with a basket of food confront- ing the starving slant eyed - masses with outstretched bowls. Uncle Sam better says, " Birth control, maybe you'd better come along. " The'40's and'50's saw a tremendous increase in concern over population. One after another private organization sprang up, dedicated to the proposition that over- population of the world is the central menace of our age: the Hugh Moore Fund, The Population Reference Bureau, the Committee to Check the Population Explo- sion, and, most powerful and respected of all, the Population Council, established, funded and administered by the Rocke- fellers. The overlapping rosters of these groups read like Who's Who in high finance and business in the Rocke- US - fellers, DuPonts, Fords, Mellons (see refer- ences for a more extensive discussion of " The establishment of a family planning center in a black community which does not have adequate health care facilities... [leads to the conclusion] that white interests are the role of American corporations and their leaders in birth control overseas). All have worked tirelessly and contributed heavily to publicizing the population menace, birth controlling - Third World peoples abroad, and influencing the US govern- ment to step up its involvement in birth con- trol both at home and abroad. Many government officials, fearful of domestic controversy (especially among the staunchly anti birth - control Roman Catholic hierarchy) held to a publicly conservative position on birth control. In 1958 a presidential commission suggested that "... foreign development aid be ex- tended to local maternal and child wel- more concerned with causing black babies not to get born, than they are with the sur- vival of those already born. " L Naomi Gray, testimony to the Commission on Population Growth and the American Future, April 15, 1971 fare programs for the formulation of na- tional policy plans on population and to further research on population control. " President Eisenhower's reply was, " I can- not imagine anything more emphatically a subject that is not a proper political or governmental activity... This govern- ment... will not... as long as I am here have a positive policy. that has to do with the problem of birth control... That's not our business. " Eisenhower held to that US. There were now available at least two highly effective methods of birth con- trol which were suitable for mass distribu- tion. The ever profit oriented - drug com- panies enjoyed an economic boom unlike anything since the antibiotic era. Not sur- prisingly, the industry jumped aboard the birth control bandwagon. stand, but he was the last president to PPFA Joins the Populationists take a position against federal govern- ment involvement in birth control. In the early'60's, the major private birth control organization, PPFA, joined forces Technological Advances Until the late 50's'birth control pro- grams in the US and overseas were seri- ously hindered by the fact that there were no highly effective contraceptives suitable for mass distribution. In 1959, Oppen- Z heimer reported on his use of an intrauter- ine coil that effectively prevented concep- tion with few side effects. Numerous varie- ties of IUDs followed which could be man- ufactured cheaply and distributed by the hundreds of thousands. At the same time, clinical trials of the first oral contraceptive were carried out, primarily among poor Puerto Rican and Haitian women. In 1960, with the populationists. Until then, PPFA's primary public thrust had been to stress the relationship of family planning to maternal and child health. In 1962, the Federation merged with the World Popula- tion Emergency Fund, a citizens'group created two years earlier to foster support for birth control overseas. The merger was explicitly "... to create a strong US organ- ization for action on domestic and interna- tional population problems. " The new organization was Planned Parenthood- World Population (WP PP -). In 1963, private populationists and PP- WP began a major public push for signif- icant federal involvement in birth control " The Pill " (Enovid) was introduced to the US market. programs, foreign and domestic. Influen- tial, long time - members of those popula- These technological advances radically tion groups already mentioned estab- influenced the birth control scene in the lished The Population Crisis Committee to 9 be "... the political arm of the population control movement, " to publish ads, lobby government officials and promote public support for government aid to family planning. Abroa*d At that time the primary thrust of the populationists was still toward the " teem- ing masses " of Asia and Latin America. The US government joined the Fords and Rockefellers, who had long taken an ac- tive interest in controlling the birth rate of the foreign poor. The US Agency for International Development quietly sup- ported birth control abroad for nearly a decade before the US did so openly at home. In the mid 60's -, Congress approved amendments to the Foreign Assistance Act and the Food for Freedom Act, author- izing use of US funds in these programs for birth control. President Johnson firmly established his position in his 1965 State of the Union Address saying, " I will seek new ways to use our knowledge to help deal with the explosion in world popula- tion... " And further, in his " Birth Control Bargain Speech, " he stated that "... less than $ 5 invested in population control is worth $ 100 invested in economic growth. " ... and At Home While efforts to spread birth control overseas continued, developments in the US demanded the attention of popula- tionists and the federal government. The decades of the 40's'and'50's brought huge waves of rural Southern Blacks and later, of Puerto Ricans, to settle in urban centers of the Northeast. Unrest in the ghettos and rising welfare and unemploy- ments rolls made the poor all too visible; state and federal governments found it easier to " control " these populations than deal with their problems. This approach was reinforced by sociologists, who assert- ed that the poor's fecundity contributed to poverty. The " discovery " of poverty in the 1960's resulted in a proliferation of government agencies to wage the " war on poverty. " The Office of Economic Opportunity was one of the first of these. In 1965, it was the first federal agency to make a direct grant for birth control services. Not surprisingly, this initial program was developed in a low income - community in the South. Along with the " discovery of poverty, " the federal government also " rediscover- ed " mental retardation and entered into this war with a similar battle plan. Gov- ernment sponsored studies determined that premature births were associated with a higher incidence of mental retarda- tion, and that prematurity was more com- mon among young, poor women having children close together without adequate 10 prenatal care. So, in the'60's, Congress passed the Maternal and Child Health and Mental Retardation Amendments to the Social Security Act, providing funds, at first just for pre natal - care, later with more and more emphasis on birth control. The interest of the federal government in the profitable domestic effects of birth control was growing rapidly. With that " $ 5 investment " in birth control, the gov- ernment could hope to decrease " illegit- imacy, " cut down the welfare rolls, and lower the number of mental retardates who burden the society. No wonder J. Mayone Stycos, population expert in residence at Cornell University, called birth control " the bargain of the decade. " Washington Steps up Activity Up to now, Congress had had little to say directly about birth control. In the mid 60's - Senator Ernest Gruening, with an impressive list of Senate co sponsors - , in- troduced the first significant domestic family planning legislation to the Con- gress, calling for establishment of an Office of Population Affairs and for a White House Conference on Population. Its significance lay in the fact that it prompted extensive public hearings which stretched over two years and involved more than one hundred witnesses - lead- ing spokesmen of the populationists, churches, welfare agencies and medicine. The hearings, in the words of supporting legislators, for the first time publicly " doc- umented the existence of a critical family- planning problem in the US, " " establish- ed the utter inadequacy of the govern- ment's response to the problem " and " demonstrated to the Congress the breadth of religious and political support for government action. " By the late'60's Congress was ready to act. Although they still had lingering fears about the reaction of anti birth - control forces, legislators were becoming even more disturbed by rising discontent among the poor in the US, particularly in the inner cities. In 1967, Congress enacted legislation requiring the states to provide family planning services in their public health programs and to women on welfare. Federal funds were allocated to finance the " social services " necessary for the " prevention of illegitimacy and and _ the strengthening of family life " among wel- fare recipients. OEO made family plan- ning a " National Emphasis " program and Congress, in a most un Comstockian - gesture, rescinded previous restrictions against use of federal funds for birth con- trol services to unmarried women. The " War on Poverty " may have been grind- ing to a halt, but the " War on Human Re- production " was escalating. Under the Nixon administration, the birth control offensive expanded. Until now, the government had not, except in small measure, provided contraceptive services directly. Early in 1968, Senator Joseph Tydings, long - time proponent of family planning legislation, started push- ing for passage of a major bill committing large amounts of government personnel and funds to domestic birth control pro- grams; discussions of the bill stretched over the next three years. In July, 1969, in the first presidential address ever directed solely to the " problem of population growth, " President Nixon proposed the adoption of a national goal to provide, in the next five years, birth control services to all US women who want them. In the fall of 1969, HEW Secretary Finch established the National Center for Family Planning Services. The Center's impact was not apparent, however, until Congress in 1970 passed the Tydings spon- sored Family Planning Services and Pop- ulation Research Act. This act was the first legislation dealing solely with family planning and sought eventually to pro- vide such services to all poor women. The law also gave the National Center power to coordinate all federally funded domes- tic birth control programs. Some of the Center's administrators are primarily con- cerned with family planning as a health service to women. However, they seem overwhelmed by those with a heavy popu- lation control orientation. It is clear that President Nixon is com- mitted to population control. But the pri- vate populationists are still marching several paces ahead. The President still opposes abortion. His Commission on Population Growth and the American Future (chaired by John D. Rockefeller III) has called for the liberalization of abortion laws. The Commission also rec- ommends expansion of day care - facilities, liberalized laws concerning voluntary sterilization and increased efforts to pro- vide contraceptives to teen agers - . Back at the Clinic PP WP - still occupies the unique position of being the leading provider of family planning information, education and ser- vices. As repository of expertise in the country in birth control, it has significantly helped shape legislation and public policy. PP WP - today is a loose conglom- eration of local affiliates with a central office and administration in New York City. General policies are set by the na- tional office, but each affiliate is generally free to pursue its own priorities, provide what services it wishes to whom it wishes depending upon the inclinations of the local staff. Nationally, PP WP - now stress- AIDing the Poor The Southwest Foundation for Re- search and Education, a San Antonio birth control research center associ- ated with Planned Parenthood, con- ducted a study of the side effects of The Pill. Of the 398 women involved, 76 were given " dummy pills. " These women were not informed that they were merely taking a placebo. In four months, ten had become preg- nant * a not very surprising side effect! The experiment was financed by grants from Syntex Labs, a major birth control pill manufacturer, and the Agency for International Devel- opment (AID). Syntex was interested in the study because publicity about the side effects of the pill has hurt sales. They hoped this study would uncover few side effects in pill users (as it naturally did). AID was inter- ested in the study as part of its long- range strategy to control the " popula- tion explosion. " As has been true since the beginning of Pill experi- ments, the recent research was con- ducted on a non white - women, in this case multiparous Chicano women. AID has been pushing birth con- trol since 1965 when it supplied 11 percent of the total third world popu- lation control funds coming from Aimerican sources. By 1968, AID pro- vided about 55% of such funding. In 1965, AID spent $ 2.1 million; by 1971 its population control budget in- creased to $ 100 million. At the same time, AID expenditures in other health programs decreased from $ 126 to $ 77 million. Back home, the San Antonio ex- periment has caught the attention of women throughout the country. Five thousand copies of the original ex- pose which appeared in Medical World News April ( 16, 1971) were dis- tributed at the Women's Health Con- ference in New York. Third world women in other parts of the country are contemplating legal actions against those responsible for the ir- responsible San Antonio experiment. 11 " They [those in charge of birth control programs] see women as wombs to be deactivated rather than human lives to be fulfilled. " Rachel _ Cowan " Equador: Birth Controlling the People " es family planning as a right for the health and welfare of mothers and chil- dren; local affiliates may choose other emphases. For example, in Chicago the PP WP - affiliate passed a resolution adopt- ing the two child - family as an ideal, one expression of its heavy population - control orientation. The past ten years have seen significant changes in WP PP -, particularly in regard to its relation to the government. Nation- wide, many affiliates are already essen- tially dependent on federal funding. Others, such as the New York City affili- ate, have tried to maintain their inde- pendence. But recently, PPNYC has had both internal and external pressure to ac- cept more government money. For ex- ample, in the past six years, Medicaid cutbacks in New York City have thrown huge numbers of " medically indigent " women into the lap of PPNYC for contra- ceptive care. Last year PPNYC felt they could no longer operate without federal funds. They are now seeking federal money for training, information and edu- cation, venereal disease screening and treatment, and direct subsidy of patient services. In Summary The history of the birth control move- ment in the US reveals at least two groups with differing motives for their involve- ment: those who want to make birth con- trol services available to all who want them as a right and matter of health; and those who are using birth control as a way to further their own institutional and class interests. At present, the latter are clearly in control. 12 Their primary objectives are to: (1) decrease the welfare rolls by de- creasing the birth rate of the poor rather than by attacking the roots of poverty; (2) obscure fundamental problems such as poverty and racism, implying that the poor can climb the economic ladder simply by using birth control and having smaller families; (3) control population growth, both at home and abroad, helping to control grow- ing unrest among the poor and maintain the political and economic status guo. Most efforts of the birth controllers have been directed toward women. Women looking for total health care often find that while birth control services are easily accessible and free, other services are not. Contraceptive care is offered in a special- ized clinic that pays little attention to other aspects of health, even closely related ones such as venereal disease or gyne- cologic problems. The Women's Movement has been deeply involved in fighting for the right of women to birth control and abortion ser- vices. Now they find that the federal gov- ernment, wealthy businessmen, and al- most everyone else seems interested in it as well. As stated by one women's group, " ... we find that a portion of our fight [for birth control and abortion] has a reaction- ary as well as a progressive potential. We have been trying to open up laws around birth control and abortion without moving to effectively control its use... Although we have gained much in momentum and awareness in the last years, we are per- haps further from real female control of reproduction than we were when we started. " Women have long been the con- sumers of birth control services. They are now beginning to realize that they must control the policies, direction and adminis- tration of these programs. - Jean Sharpe. Jean Sharpe interned at the University of Alabama Medical Center, Birmingham, Alabama and worked for the Emory University Family Planning Program in Atlanta, Georgia, before coming to Health - PAC as a student intern. References 1. Cowen, Rachel. " Equador: Birth Controlling the Peo- ple, " Ramparts, October, 1971. 2. Hellman, Louis M., Frank N. Beckles, Philip A. Corf- man, " A Five Year - Plan for Population Research and Family Planning Services, " Family Planning Perspec- tives, Vol. 3, No. 4, October, 1971. 3. Kennedy, David M., Birth Control in America, Yale, 1970. 4. Lincoln, Richard, " S. 2108: Capital Hill Debates the Future of Population and Family Planning, " Family Planning Perspectives, Vol. 2, No. 1, January, 1970. 5. NACLA, Newsletter, " Population Control in the Third World. " Vol. 4, No. 8, December, 1970. 6. Scheyer, Stanley C., " DHEW's New Center: The Na- tional Commitment to Family Planning, " Family Plan- ning Perspectives, Vol. 2, No. 1, October, 1970. 7. Stycos, J. Mayone, " Some Minority Opinions on_Birth on_Birth Control, " Hastings Center Institute - of Society, Ethics and the Life Sciences, June, 1971. 8. Weissman, Steve, " Why the Population Bomb is a Rockefeller Baby, Ramparts, May, 1970. HALF OF maintains a loose affiliation with the Downstate Medical School of the State Uni- versity. Like other voluntary hospitals in New York, it receives most of its funds from public and publicly regulated sources, such as Blue Cross, Medicare, Medicaid, the federally funded Maternal and Infant Care (MIC) program, and New York State's Ghetto Medicine Program. Homework For Change During the summer, women from Half of Brooklyn gathered ammunition. Their BROOKLYN research on the services, programs, power structure, funding sources and groups in- terested in Methodist yielded important information. From personal experience, in- terviews and a recent City Health Depart- ment site visit report, they found more DESCENDS ON than ample proof of the poor outpatient care dispensed by the hospital. This re- port, written in June, 1971, complained of " infrequent scheduling of general medical METHODIST and pediatric clinics. ...l. ack of patient assignment to a primary physician. denial of services to patients without the required fee... lack of routine preventive medicine services, " and more and more. Last spring some members of a women's group called Half of Brooklyn began to turn their energies to health care. Half of Brooklyn is a loosely linked federation of consciousness raising groups and project collectives. The health group decided to focus on their local community hospital, Methodist Hospital. Many of the women had used Method- ist for various services and were well aware of the poor quality of much of its care. In the discussions, they rejected such alternatives as abortion counseling and running a three day Pap smear clinic out of their small storefront. As one mem- ber of the group explained, " These proj- ects would have taken up our time in per- forming services which Methodist should have been providing anyway. Besides, most women here use Methodist, so we realized that we should make our de- mands on it. " Methodist is in many ways a typical urban community hospital. Located in the ethnically and economically mixed Park Slope neighborhood, this 471 bed facility is the primary source of health care for thousands of Italian, Irish, Jewish, Puerto Rican and Black residents of South Brook- It concluded that care was provided " al- most entirely at the convenience of the hospital... intermittent, episodic, unco- ordinated and without follow - up.'" The occasion of this highly critical re- port was Methodist's receipt of $ 207,900 from the 1970-71 Ghetto Medicine Program. This program is administered through the City Department of Health using New York State and local tax funds. The money is supposed to be used by selected volun- tary hospitals to subsidize comprehensive ambulatory care to low income patients. The contract between the City and the re- cipient hospitals also calls for ill defined - , but significant, community involvement in decisions about use of the funds. The women found that Methodist had dealt with this by setting up an Ambulatory Care Service Advisory Committee (AC- SAC), whose 51% racially mixed com- munity membership was hampered by the hospital's withholding of information. Women Meet Tenants Group At the same time as the women prepared to look closer into the hospital's ambula- tory care, they also were aware of opposi- tion to its expansion plans into the neigh- borhood. Methodist has under way a $ 90 million development program for staff housing, a parking garage and building of new medical facilities. The hospital has bought up sound, rent controlled brown- stones on the adjacent block. These apart- ments were to be vacated and demolished lyn. Indeed, it is the only major health institution in Park Slope. The hospital to build Seney House, a 16 story staff resi- dence, and a three story parking garage. 13 The proposed complex was severely crit- icized by a hospital - hired urban planner for its location, exorbitant rent and lack of community facilities. Those tenants not yet vacated, primarily white working peo- ple, ex students - and the elderly, in addi- tion to some Blacks and Puerto Ricans, organized themselves into TMHA, the Ten- ants of Methodist Hospital Association. They began a vigorous opposition to their own harrassment and removal and to the hospital's expansion plans. The women of Half of Brooklyn started to discuss the hospital with the Tenants Association, the more active members of the Ambulatory Care Advisory Commit- tee, and with other groups such as the Park Slope Day Care Collective and the Park Slope Neighborhood Tenants Coun- cil. Through intensive leafleting and a pro- test demonstration at the hospital, these groups were able to attract over 300 com- munity residents of varied ages and ethnic origins to a meeting called by Methodist on September 27th. The hospital's agenda involved creation of a new organization to give the stamp of community approval to Methodist's expansion plans. The agenda of the 300 residents was different: they demanded that the hospital halt its plans to build Seney House and the park- ing garage, cease harrassment of tenants refusing to vacate, improve health care offered the community, and involve the community in any future decisions of the hospital. After being told by Methodist spokesmen that the hospital would not be bound by decisions reached by its own. rubber stamp organization, the 300 resi- dents unanimously rejected it and voted " no confidence " in the " hospital adminis- trators and their planners.'" The next week the movement was also joined at a large rally by representatives of the Central Brooklyn Independent Dem- ocrats, the South Brooklyn Education Committee and the Park Slope Health Planning Council. Over the next few months tenants held periodic demonstrations to fight evictions and to support particularly harrassed families. The hospital has been forced to delay the October demolition of 17 brown- stones to March or later. The tenants ' strategy has been to advertise their cause. and gain broader community support to oppose possible forced evictions by the hospital. Women Take On Clinic Meanwhile, the women's group has di- rected most of its attention to health care issues. They began by circulating ques- tionnaires and leaflets, attending clinics at the hospital, and researching the insti- tution. In November the Ambuatory Care 14 Advisory Committee (ACSAC) held an open public meeting for the purpose of nominating new members. At this meeting the hospital agreed to try to extend pedi- atric clinic hours, set up a child care center in the hospital, and reduce clinic fees. Two of the women have been elected to the ACSAC, and much of the stra- tegy of the women's group is now cen- tered around a struggle for real power in the Advisory Committee. Through it, the community activists have influenced the hospital to institute Pap smears for women in all clinics, a minimal sickle cell anemia screening program, and a policy of assign- ing patients a primary physician. As one woman stated, " Right now the thing that has to be done is to implement the Ghetto Medicine Law. In the process of doing this we will become more and more involved with other people using and working in the hospital. " Aside from its role in the ACSAC, the women's group wishes to work with other women patients of Methodist Hospital. They want to assist them, educate them on women's health problems, and eventu- ally broaden the base of community in- volvement in the struggle with the hos- pital. To this end they have begun small group educational sessions which take place in clinic waiting rooms. They also distribute a " Gyn Checklist " to women in the gynecology clinic. Many problems have yet to be solved. Mass enthusiasm and unity among groups has waxed and waned. The pillars of the effort remain the women's group and the tenants'association. Although Half of Brooklyn has hoped for a broader base, so far there is not really active participa- tion, except sporadically, of significant numbers of Methodist patients and work- ers. While the women from Half of Brooklyn recognize the need to speak to the needs and involvement of Methodist Hospital workers, predominantly women, progress in this direction has been slow. Half of Brooklyn women realize that theirs must be a long term commitment to this task. It is by the same token, necessarily prema- ture to proclaim the effort a success. At a time when the women's health movement seems to be searching for new directions, the events at Methodist Hos- pital are important to examine. Here a women's health group has engaged in a long term commitment to change a major health institution. The group has formed alliances with other constituencies of the hospital, while maintaining its identity and priorities. -Amy Brodkey. Amy Brodkey is a medical student at the University of Pennsylvania. She was a sum- mer student intern at Health - PAC. HEALTH: WOMEN'S WORK Womanpower is the manpower of the health field: 75 percent of all health work- ers are women. Control over this work force is crucial to those who control the health system. The labor force within the health system is changing rapidly. There has been a vast increase in the number of health workers, from 2.9 million in 1960 to 3.9 mil- lion by 1969 to a projected 6.85 million by 1980. The roles they play are also chang- ing: at the turn of the century, 80 percent of all health workers were doctors; today only 12 percent are doctors. New occupa- tional divisions have developed to the point where there are now over 375 inde- pendent occupations. With their numerical supremacy, women health workers are a powerful potential power for change. Womanpower The predominance of women in the the health system developed historically be- cause of two factors. Most jobs in health are dead end, low wage, semi skilled - or unskilled. This kind of work has tradition- ally gone to women, especially third world women. Also, health care jobs, with the exception of doctors and administra- tors, reflect the institutionalization of tra- ditional women's functions: nurturing, caring, cooking, educating, cleaning. In the health system these functions become the jobs of nurse, housekeeper, dietician, clerk, social worker and technician. Women are 98 percent of registered nurses, 64 percent of cooks, 74 percent of aides and attendants, 96 percent of prac- tical nurses, 94 percent of nutritionists and dieticians, 95 percent of office workers, 80 percent of physical therapists, 75 percent of X ray - technicians, 90 percent of medical technologists and 89 percent of medical social workers. Almost all dental hygien- ists, medical librarians and clerks are women. While women fulfill the " feminine func- tions " men make the decisions. Men are 93 percent of doctors, 90 percent of chiro- practors, 98 percent of dentists, and 80 percent of hospital administrators. There is even a feminine role for woman doctors. The phrase " a woman's place is in the home " has been changed to " a woman's place is in pediatrics or child psychiatry, " according to one woman doctor. Wage differentials for the same job fol- low sex lines. In almost every field, espe- cially where women overwhelmingly pre- dominate, the wage difference is great. Thus the 145,942 women practical nurses receive on the average ten dollars less per week than their 3,350 male counter- parts. Men's and women's salaries were equal in only one field: medical technol- ogy. Women health workers on the top suffer as well. Women doctors tend to take salaried institutional positions rather than go into higher paying private practice. And they can also expect less advance- ment. A 1969 Department of Labor study of hospital wages demonstrates the follow- ing weekly wage differentials: Physical Therapists Males $ 166.50 Females 155.50 X ray - Technicians Males Females 131.00 116.50 Food Service Supervisors Males 137.50 Females 96.00 Housekeeping Chiefs Males Females 154.50 96.00 Practical Nurses Males Females 108.50 98.50 Nurses'Aides Males Females 82.00 75.50 Why Health Work? Columbia University manpower econ- omist Eli Ginsberg describes the predica- ments of the health system: " A field which 15 attracts a disproportionate number of women, many of them young, will tend to have the following characteristics: a low wage scale, heavy turnover, excessive training costs, and relatively little accumu- lation of skill through experience. " While the description may be true, Ginsberg puts the burden of blame for these prob- lems on women rather than on the low wages and alienating work conditions of the health system. The " disproportionate " number of wo- men reflects the fact that women have few other choices. As one medical social work- er said, " What do you do as a woman? The options were to be a nurse, teacher or social worker. " In interview after inter- view women health workers in New York City cited economic necessity as the key factor in choosing a health career. One nurse said, " We didn't have the money for me to go to college. My mother was a nurse and had gone to a diploma school, so I decided to become a nurse as well. " If society gives women in general few op- tions, it gives even fewer to poor and third world women. " What else could I do? " asked one Harlem Hospital nurses'aide. Turnover Although most women who work in the health system do so out of economic neces- sity, there is nevertheless high job turn- over. In 1967, the turnover rate for all workers in nursing (including practical nurses, registered nurses, aides, attend- ants and orderlies) was 60 percent, com- pared with 18 percent for women teachers in the public schools. This turnover reflects many factors. OE Dual Women Roles -i n health face the same tensions that confront women in other fields; they must work to earn money; yet they are expected to have chil- dren and care for their families. One ward clerk said, " I have a 15 year - - old daughter. She's a good girl, but if she started getting into trouble I guess I'd have to quit and stay home. " Women tend to enter the labor force be- for their children are born, to leave work while they are growing up and to re enter - after the children are either in school or out of the house. The largest number of non working - nurses are 30 to 34 years old. But both the number of women working and the length of their work experience are increasing. The percentage of mothers who work has risen twice as fast as the rate of all working women between 1940 and 1987. ' Yet, the health institutions make very few provisions for a woman's other responsibil- ities. Child care facilities and paid matern- ity leave are virtually non existent - . Some 16 special programs for part time - residencies and internships have been instituted for women doctors who have children; but neither day care nor housing close to the hospital is available for most health work- ers. In 1969, only 2 percent of the children of all working mothers in the labor force were in the limited number of day care centers; most mothers must find make - shift personal solutions or lose their income to stay home with their children. M@ Working Conditions - Most women health workers face low paying jobs and years of frustration and alienation. Low wages are only part of the problem. In study after study registered nurses stated clearly that if they leave the field, it is because of the vast discrepancy be- tween what they were trained to do and what they are allowed to do. Said one nurse, " We're really like secretaries push- ing papers around. All we do is dispense pills to the patients. Giving medications gets to be boring. The aides are the ones who really work with the patients. " One nursing educator with twelve years of nursing experience said, " Let's face it, nursing is a rotten job. You have no con- trol over hours, you rotate shifts, work weekends and holidays. You get moved from floor to floor. Sometimes you're the only one with fifty patients and yet the supervisor comes in and yells at you and you think, what do they expect from me? " Lack of fullfillment is built into all levels of hospital work. Narrow and specific job definitions mean people do the same repe- titious tasks day after day: stenographers type medical records, IV technicians start IV's, hematology technicians count blood cells. Doctors, who may do a variety of tasks, have transferred many of the mun- dane tasks to other workers, mainly wo- men. It is difficult for other health workers to break out of their narrow slots. One car- diology technician said she had not been taught anything about cardiology and that the doctors refused to answer her ques- tions. OE Hierarchy and control Narrow - job definition is reinforced by hierarchical con- trol in the health system. Lucille Kinlein, a nurse writing in the January, 1972 issue of Nursing Outlook, said " So often I knew the patient better than the physician and had scientifically based reasons for want- ing to initiate a certain action - yet I was prevented from doing so without being given equally valid reasons. The goal seemed to be to keep the institution oper- ating at a smooth pace and to placate the other professional people, rather than to help the patient to meet his needs. " Nor is it just nurses who have no control over their work. The health system is a rigid caste system. Economist Martin Karp noted: " In no other industry is the'pecking order'more evident. " The result is that because workers cannot vent their anger against the people above them, they take it out on those below them or on the pa- tients. Narrow job roles and rigid hier- archy lead to frustrations and divisiveness between health workers. The caste system in health reflects not only divisions between job categories or sex, but deeper divisions of class and race. This, of course, serves the interest of those who run the health industry. The develop- ment of this hierarchy and the concurrent problems it brings for all women health workers, is epitomized in the history and current difficulties facing the nursing field. Florence Nightingale: Gentlewomen and Domestic Servants In the nineteenth century, hospitals were part of poor houses. There was no professional nursing; poor women, many times themselves inmates of the poor- houses, did what little nursing there was. Nursing as a distinct profession began on the battlefield where disease often killed The Stranglehold The divisions within the health hierarchy are dependent upon formal educa- tion; control is maintained through accreditation of educational programs. certification of personnel by the profession and licensure by governmental agencies. Although these appear to be separate functions, the same professional peo- ple often control all three functions. According to a Department of Health Edu- cation and Welfare report, " it is not unusual to find the same individual serving at once in two capacities: for example on accrediting teams and on a state licensure board. " The views of professional associations predominate in setting standards for governmental agencies. The dominant force in all this is the AMA Council on Medical Education (CME). It accredits not only medical schools but beginning in 1933, has formu- lated the policies and curriculum standards for many allied health fields as well. In conjunction with other professional associations, the CME accredits over 15 categories of workers from inhalation therapists to medical record librarians. In nursing the National League for Nursing has the accrediting func- tion. It also has the power to cancel the credentials of a nursing school, if its policies are not followed. At the other extreme, some occupations (all women's fields) are licensed by boards that include no members of that occupation. LPNs in some states are licensed by boards that are made up exclusively of RNs. In New York, where LPNs are on the board, they cannot vote on issues about RNs. Of course, RNs can vote on all LPN related matters. Dental hygienists are licensed in every state by a dental board that includes no dental hygienists. Midwives are licensed by boards that do not include any midwives. In at least eight other occupations, there is similar lack of representation. The latest ploy is to shift all control for licensure into the hands of the health care institutions themselves. Under a system of institutional licensure, no indi- vidual, except of course a doctor or dentist, would have her or his own license. Individual health care institutions would be licensed by a state agency and within each institution the administration would be responsible for the division of labor and tasks. Under this system, an individual working in one position in a hospital might be unqualified to do the same job in a nearby institution. This new proposal, originally developed by Nathan Hershey, health law pro- fessor at the University of Pittsburgh, is supported by the AMA, the AHA and some segments of the American Public Health Association as well as HEW Sec- retary Richardson. Although the concept is still in the planning stage, it was part of the American Hospital Association's national health insurance bill and it is included as part of pending legislation in some states. In its Ameriplan national health insurance scheme the AHA claimed that in order " to alleviate personnel shortages, minimize educational costs by creating upward mobility for health personnel and to maximize individual potential... the present system of licensure of health personnel should be phased out and the... [the institutions] made responsible for the competence of all their employees. " The push for institutional licensure clearly bears watching. 17 more soldiers than did bullets. During the Crimean War of the 1850's, Florence Nightingale and a group of dedicated women proved that good nursing care could drastically decrease the mortality rate among soldiers. Nightingale returned to England after the war to introduce her concepts of professional nursing to Eng- lish hospitals. Stratification characterized the system from the beginning. The Nightingale sys- tem trained women in two categories which reflected English class divisions: " lady probationers " and regular nursing students. The lady probationers were to be gentlewomen of middle and upper class backgrounds who would have " those qual- ifications which will fit them to become superintendents. " The regular students were to be "..... well educated - domestic servants and the daughters of small farmers.... tradesmen, artisans... who have been used to household work. " These women would become regular hos- pital nurses. Because medicine was still closed to women at this time, many headed for nursing. Nightingale was clear that nurs- ing was to be a separate function, a co- profession to the doctors; but, she was not, she reassured the worried physicians, training " medical women. " US Developments Hospitals in America quickly saw the advantages of training nurses. Student nurses could be used to fill the hospitals ' nursing needs; and better still, they didn't have to be paid beyond room and board. Between 1880 and 1900 the hospital nurs- ing schools in the US grew from 15 schools with 323 students to 432 schools with 11,000 students. Since cheap student labor pro- vided the bulk of nursing care, hospitals did not hire their students after gradua- tion. Besides, most health care was de- livered at home and thus graduating nurses tended to go into private duty nurs- ing in the home. As with medicine at this time, there was no uniformity or minimal standard for nurse training. The nursing leadership began to feel the need for uniform admis- sions standards and curricula in nursing schools. Above all, they sought the legal recognition of nursing through passage of nurse practice laws and the registra- tion of nurses. Thus, in 1894, leaders of nursing schools organized the Society of Superintendents of Training Schools for Nurses which in 1912 was to become the National League for Nursing Education (NLN). Recogniz- ing the need for a more broadly based group, a Nurses Associated Alumnae of United States and Canada was organized 18 in 1896. The NLN was primarliy concerned with educational standards; the Nurses Associated Alumnae with work conditions and the registration of nurses on a state- by state - basis. In 1911, the alumnae group became the American Nurses Association (ANA). The overarching concern of both organizations was the establishment and upgrading of nursing standards and the recognition of nursing as a defined pro- fession. The result of this professional- ization was the creation of an internal hierarchy within nursing. Divisions Begin Concerned with the increased costs of professional nursing, hospitals supported differentiation within the field. In 1907, the American Hospital Association (AHA) advocated distinction between three grades of nurses: the executive or teach- ing nurse, the bedside nurse, and the at- tendant or subsidiary nurse. The AHA suggested that all categories be licensed, but that the first two be classified as reg- istered nurses, while the third be called by some other title. The AHA study had little influence at the time, but it clearly indicated the hospitals'interest in foster- ing the divisions within the nursing profes- sion World War I increased the need for health workers and raised questions about their training. After the war, the Rockefeller Foundation convened a con- ference which led to a study of nursing and nursing education. Released in 1923, the study, called the Goldmark Report, suggested that nursing become part of a collegiate program. The report also recom- mended that auxilliary personnel be train- ed in shorter periods of time to carry on some of the less important nursing func- tions. The Goldmark Report attempted to do for nursing what the Flexner Report in 1910 did for medicine. The latter resulted in the upgrading and standardizing of medical training by putting it into a uni- versity setting. Following the Goldmark Report. nursing programs at Yale and sev- eral other universities were established. " Even the most cursory examination of nursing's history reveals a tragic melodrama of dependency, rejection and exploitation. " -Virginia Driscoll, NYS Nurses'Association During the Depression, droves of pri- - vate duty hurses were unemployed and many hospital - based nursing schools closed. During World War II, hospitals began to hire nurses; the increased cost led to the creation of a new subdivision in nursing - the " practical or vocational " nurse. By the post - war period, studies by the American Nursing Association recom- mended that there be a further increase in auxiliary nursing personnel on the one hand, and an upgrading of registered nurses on the other. Thus the hierarchy in nursing became more elaborate and rigid. Bedside nursing was to be done by the practical nurse and later by a new, lower category called the aide. Mean- while RN's tried to separate themselves from " lower " nursing categories by great- er specialization. Professional vs. Technical Nurse By 1964, seeds of the division planted by Florence Nightingale in the nineteenth century had come into full bloom. Indeed, divisions multiplied even within the ranks of registered nurses. The ANA recom- mended two different kinds of programs to train registered nurses: a four year - baccalaureate college program for " pro- fessional " nuses and two year - community college associate degree and hospital- based diploma programs for " technical " nurses (see BULLETINS, March, 1970 and September, 1970). The consequences of these new divi- sions were not long in coming. In the early 1960's 84 percent of all nurses had been trained in hospital - based diploma schools; by 1970 the figure was down to 52 percent. Hospital schools began closing while new associate degree community college programs expanded. In 1969, 27 percent of all nurses were trained in asso- ciate degree programs, 21 percent in the baccalaureate programs. Nursing authorities see a wide differ- ence in the functions of these two types of nurses. According to Martha Rogers, head of New York University's Division of Nurse Education, " Baccalaureate graduates in nursing are no more interchangeable with associate degree and hospital school graduates than are dentists with dental hygienists or medical doctors with phy- sician assistants. " Supervisory and admin- istrative jobs go to baccalaureate nurses, even those fresh out of school. The divi- sions are racial as well as functional: In 1968-69, 10 percent of associate degree nursing students were black, while black students were only 5 percent of those in baccalaureate programs. Black graduates of these programs actually dropped from 9.7 percent in 1962 to 4 percent in 1966. Divided We Fall With expanding institutions and devel- oping technology, division of labor in the health field has been irresistible, as it has in other industries. For the majority of health workers, this has meant special- ized, alienating, often low paying - jobs. This increasing division has threatened the nursing profession. Rather than challenging this policy or the hospital hierarchy, the nursing leader- ship has sought, throughout history, to preserve the power and status of " profes- sonal " nursing by creating its own sub- divisions and hierarchy. The result has been to divide the interests of all health workers, and to so narrow the functions of professional nursing as to threaten its existence. Today the nursing professon feels it is being squeezed from all directions. The explosion of " new careers " and man- power training programs is turning thou- sands of technical and paraprofessional health workers onto the job market. There are now over 250 new job categories such as medical records technician, dietetic technician, social health technician and family health worker - many of which fill traditional nursing functions (see box, page 20). And many are low paid -, dead- end jobs going, by and large, to third world women. Many nurses are now turning to the gray area between traditional doctor. and nurse functions - taking medical histories, screening patients, supervising routine care, etc. Nurses in this role are called nurse practitioners or " extended " nurses. There are now over fifty different training programs for " extended nursing " in pedi- atrics, obstetrics, anesthesiology, and other specialties. The only problem with this tack is that it runs headlong into another new medical vocation - the physician assistant. Devel- oped to utilize the experience of ex mili- - tary medical corpsmen, physician assist- ants " provide patient services under the supervision and direction of a licensed physician. " Rather than advocating that nurses become physician assistants, how- ever, the ANA has attempted to split the hairs that differentiate the two functions. " The term physician assistant should not be applied to any of the nurse practition- ers being prepared to function in an ex- tension of the nursing role, " stated a December, 1971, ANA position paper. Meanwhile more sweeping reforms of the nursing field are afoot. Dr. Henry Silver, developer of one of the first nurse practitioner programs, and Patricia McAltee, a nurse, reporting on a study supported by the Carnegie Corporation, 19 Original RN Functions and Activities Allied Health Worker Now Providing the Service Diet therapy Social service related - to disability, hardship, etc. Central supply service cleaning - , wrapping supplies, sterilizing packs, etc. Medical records maintenance - of charts, records, discharges, abstracts, etc. Recreation threapy activities - , games, amusements, reading materials, etc. Rehabilitation therapy Dietician and dietetic aide Medical social worker Central supply technician and worker Registered medical record librarian Recreation therapist and volunteers, candy stripers, etc. Physical therapist, occupa- tional therapist Operating room, Delivery room scrub - nurse, circulating nurse, etc. Operating room technician Bedside nursing Licensed practical nurse, aide, orderly, volunteer Nursing specialties - recovery room. post operative - nursing care, monitoring devices, hypothermia techniques, uses of pacemakers, oxygen tents, cannulae etc. Inhalation therapist, medical bio - engineering technician Employment interviews (for nursing service) Personnel director Administration (nursing unit) Ward manager and ward secretary Robert E. Kinsinger, " Training Health Service Workers: The Critical Challenge. " Proceedings of the Department of Labor, HEW Conference on Job Development and Training for Workers in Health Services, Washington, D.C., Feb. 14-17, 1966, Page 27. advocate dropping the term " nursing, " with its feminine connotations, in favor of " health care practice, " to attract men to the field. Schools of health care prac- tice would offer two curricula. " One would prepare them as providers of care, com- fort and nurturing, the other for the ex- panded scope of health care and services, involving a wide variety of direct care functions and activities " (American Journal of Nursing, January, 1972). Al- though both men and women would at- tend these schools, it seems clear which curriculum will be set up for whom. In light of the pressures and threats to the profession, nurses are becoming more militant. Many are now turning to a union approach, although there is ambivalence about whether they should join traditional unions or make the ANA their bargaining agent. This approach may be more posi- tive if it unites nurses with other hospital workers. But so far it has tended to be a defensive maneuver for nurses to tighten 20 their professional status and to keep the rigid hierarchy. United We Stand The narrow professionalism of the nurs- ing leadership has boxed nurses into a corner. As they fought for higher wages and more skilled roles, nurses have found themselves threatened from below by un- skilled, cheap labor and new technology; and insofar as they have succeeded, they now find themselves threatened from above by men coming into the field to take advantage of the higher wages and status. And the competition and division between job functions, social classes, races and sexes has worked only to the advantage of those who run the health institutions. It would seem that to achieve job con- trol, status, decent wages, and some mea- sure of job fulfillment, professional nurses must join with health workers at all levels in a struggle which would make these goals possible for all. -Susan Reverby