Document G75pLMLp1NZ27GN2mXB6xDRN

Health Policy Center Advisory No. 33 September 1971 HEALTH PAC HEALTH IN THE INDUSTRIAL HEARTLAND America's greatest industrial concentra- tion lies in a relatively small nine state area, extending from Pittsburgh to St. Louis and from the great lakes to Northern Appalachia. Over 40 percent of the na- tion's manufactures are produced in this area, valued at more than $ 103 billion. It is the home of the nation's largest indus- trial corporation. General Motors; it is the leading source of coal, which now supplies more than 50 percent of the nation's elec- tric power; it is the major production site. for steel, automobiles, tires, and machine tools. It is America's " Industrial Heart- land. " In this issue, the BULLETIN turns to this industrially - important region of mid- dle America. We focus on two industrial cities, Cleveland and Cincinnati, and a major source of raw material for their in- dustries, Northern Appalachia. Behind both urban and rural settings, there lurks a similar industrial power structure. Whether absentee, as in Ap- palachia or ever present - , as in Cleveland, this industrial elite plays a central role in the health of the region. It dominates the boards of the largest, most prestigious medical institutions, as demonstrated in Cleveland and recently confirmed in a study of Detroit (published in Hospitals August 1, 1971). Less obvious, is the rela- tionship of this industrial establishment to inadequate, public health institutions, like Cincinnati's Department of Health. These tax supported - institutions suffer from chronic under financing - caused in large measure by low corporate taxes (Ohio ranks lowest in the nation for corporate taxes) and maintained by the consistent lobbying efforts of powerful industrial in- terests. The industrial elite not only dominates the major medical resources, it is also a major cause of health hazards which plague the region. It pours pollution over the cities and devastates the countryside with strip mining. Its plants are the source of rising industrial accidents and newly- recognized industrial diseases. For in- stance, the mechanization which brinqs the coal industry more profits, brings its miners black lung more quickly and more devastatingly. Meanwhile, the major medical institu- tions of the region make only gestures to meet the mounting industrial casualties. Programs for treating industrially - related diseases are token; industrial health re- search and teaching is virtually non- existent; and advocacy on behalf of the industrially - injured is unthinkable. This in- stitutional behavior reflects the priorities of the industrial establishment that domi- nates the major medical centers. Yet it is often difficult to identify the role of the industrial establishment and to hold it accountable for the failures of the health system. Boards of Trustees function in elusive, non public - ways ways.. The health movement is often forced instead to deal with the front - men - the administrators, deans and Commissioners of Health. Public institutions become the major focus of in- surgent activity, as in Cincinnati, because they bear the public responsibility for health services, yet are given only a pit- tance of the resources. The health move- ment must find new strategies to move beyond these front - men and public institu- tions, to the people that hold the real pow- er over health conditions and health care. The Appalachian coal miners pose one such strategy. By focussing on indus- trial health and safety, the miners find themselves locked in battle with the in- dustrial elite which is responsible for the major cause of the miners'poor health, as well as the lack of facilities to treat it. In so doing they not only confront the true source of power in their own health area, but they are also launching an exemplary preventive health struggle. CONTENTS 2 Cincinnati 8 Appalachia 13 Cleveland CINCINNATI: PEOPLE'S HEALTH MOVEMENT Cincinnati, Ohio, situated across the river from Kentucky, is a midwestern city. with a southern exposure. It is a strongly Republican town, the home of the " Taft Dynasty. " Political conservatism is a way of life in Cincinnati. Despite the political climate, an insurgent health movement has sprung up there. To understand its origins, requires a deeper look at the con- text from which it has flowered. Cincinnati is the home of Procter and Gamble, General Electric, General Mo- tors, Ford and the Cincinnati Milling Machine Company. It also hosts the Cin- cinnati Reds for which a new $ 50 million river front - stadium was completed last year, at, of course, the taxpayer's ex- pense. The city fathers and businessmen are euphoric about the city's " major league facility. " The people who live in the city's dilapidated housing, ride its privately - owned, expensive buslines, send their children to its overcrowded schools and use its inaccessible and inadequate health services, however, think the city's human service facilities are strictly " bush, league. " Each year thousands of people migrate to and settle in Cincinnati's black and Appalachian white ghettoes. It is the first industrial oasis on the way north. The new immigrants'litany is familiar: high unemployment, crime, drugs, poor hous- ing and health, discrimination and abuse from the local police. " White " poverty is very visible in Cincinnati where Appala- chian whites become a " colonized " minor- ity, separated from affluent Cincinnatians by their culture, chronic poverty and dialect. Both black and Appalachian peo- ple are virtually excluded from the indus- trial job market because of inadequate education and their so called - " unadap- tive " culture. Bush League Empire Cincinnati's health resources are dom- inated by a " medical empire ": in this case the University of Cincinnati Medical College. All of the city's major health institutions are located within three- quarters of a mile from one another. Adjacent to the medical college is the only acute care public hospital, the 610- bed General Hospital which is controlled by the medical college. Cincinnati Med- ical College's department chairmen are also the department heads at General. In fact. General Hospital is the medical col- lege's major teaching and research center. Across the street is the research- oriented Children's Hospital, partially built with Proctor and Gamble's sudsy money. Children's Hospital has a $ 1.23 mil- lion research endowment, but constantly runs in the red for hospital operating ex- penses. It is also utilized by the medical college as a teaching and research center but remains autonomous semi - . 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, S7 others. Second - class postage paid at New York, N. Y. Subscriptions changes - of - address, and other correspondence should be mailed to the above address. Staif: Constance Bloomfield, Des Callan, Oliver Fein, Marsha Handelman, Ronda Kotelchuck, Howard Levy, and Susan Reverby. Associates: Robb Burlage, Morgantown, Barbara Ehrenreich, lohn Ehrenheich, Long Island; Ruth Galanter, Los Angeles; Kenneth Kimmerling, New York City. 1971. 2 Nearby, are the other hospitals with which the medical school maintains teaching affiliations: Veteran's Adminis- tration Hospital, Jewish Hospital, and, for the medical care of the city's well - to - do citizens, the 94 bed - elite Holmes Hospital. Not far off are Christ, Bethesda and Good Samaritan Hospitals. Cincinnati hospitals have been involved. in major building programs. A new build- ing for in patient - care at General Hospital was opened just two years ago. However, its out patient - department remains in the dreary, over crowded - quarters. Helter- skelter expansionsim at Christ Hospital, resulted in a recently completed $ 2 million pediatric pavilion despite the lack of a pediatric staff. Meanwhile, from its win- dows one can see the recently expanded and underutilized Children's Hospital with its full resident - coverage and re- nowned staff of pediatric experts. The General Hospital - Medical College (MC GH -) complex is the colossus of med- ical care in Cincinnati. It has an intern- resident staff of over two hundred doctors, and in addition, trains another six hun- dred medical students as well as hun- dreds of nursing students. Because GH MC - has major responsi- bility for the care of the poor, it is a much - used facility; it is also very much hated and criticized. Since 1965, the Med- ical College has graduated only one black student. During the 1967 ghetto- rebellions, the hospital was guarded by the Ohio National Guard (of Kent State fame). Despite this vigilance, bullets were fired at the hospital. Chronic Crisis Insurgency within Cincinnati's medical empire has been slow in developing. The hospitals and health institutions have, by and large, been successful in preventing or stifling union activity among hospital workers. The student and intern resident - staff are, for the most part, conservative or " apolitical. " A housestaff association. exists, but it is primarily concerned with salary issues. It has successfully raised salaries from $ 3,500 in 1967 to the present $ 9,000 a year. The relatively few activist students at the medical and nursing col- leges have worked primarily outside their schools helping to organize a free clinic, researching and organizing a screening program for lead poisoning with the com- munity council of Mt. Auburn, and parti- cipating in antiwar and women's libera- tion groups. The Cambodian invasion saw the temporary involvement of many more students who went out on strike, thereby closing the university and med- ical college. Cincinnati has been in the throes of a chronic health care crisis. Several areas of the city have been without direct med- ical services for decades. Over the years, sporadic outcries have forced the City's Health Department to provide pediatric care through half - day, well baby - clinics held in several poor communities. And, over the years, small concessions to a few needy areas have been made with ex- pansion of the Health Department's adult services beyond VD and TB control to some general care. Still the entire Health Department bud- get is only $ 3.5 million a year, and less than $ 2 million of this amount is spent on community facilities. This does not include the nearly $ 2 million spent re- cently for the new Health Department Headquarters, which provides limited clinic services, appropriately enough, in its basement. That the care rendered is poor is no secret. A few months ago a member of the medical school faculty and Assistant Health Commissioner of the Health Department, Dr. Mary Agna, said: " The city has a totally inadequate, sec- ond class - system of public health. Its ser- vices and equipment are extremely poor. The equipment and methods are so bad I'm surprised anyone practices medicine down there. " Health conditions are so poor in Cincin- nati that the development of a health movement could not be postponed for- ever. In 1969, despite the quiescence of health students and health workers, the East End Community began to act. Led by welfare rights members, this community, lacking any doctor or health facility and isolated from mass transportation, organ- ized itself. With some additional help from a United States Public Health Ser- vice (PHS) officer, this primarily white, poor and low income - community, devel- oped a plan for a neighborhood health center. Health Councils A mass meeting was held and plans. for a community - controlled health center were approved. Four thousand dollars. " seed money " was obtained from a Cin- cinnati foundation; a building was rented and refurbished by the community using donated and secondhand equipment. The clinic now has a budget of $ 26,000 which is raised from charitable, private sources. It has maintained community control by avoiding city funds, which are invariably associated with economic guidelines and central supervision by the City's Health Department. Although it was unrealistic to expect 3 private philanthropic agencies to finance health centers in every neighborhood, communities followed the lead of the East End community and neighborhood health facilities soon became a priority issue. In one neighborhood, community people, together with several young people work- ing as conscientious objectors, began or- ganizing around health care demands. Other communities " got it together " with no outside help. By August, 1970, groups sprang up in English Woods, Price Hill. Winton Woods, Clermont County and sev- eral other communities. In each of these neighborhoods, community residents cre- ated " Community Health Councils " which determined priorities and operational pro- cedures. The Health Department soon became the target of insurgent community groups. The inadequate Department of Health clinics became vulnerable as the most vis- ible manifestation of the city's lack of concern for people's health needs. English Woods, an integrated commu- nity concentrated in the Metropolitan Housing Project, and Price Hill, a white area composed of a large concentration of Appalachians, were the pacesetters. Representatives of the Community Health Councils from these communities spoke before the City Council demanding the resignation of the unresponsive Health Commissioner, as well as immediate funds for health services in their communities. The people attended council meetings en- masse, with full media coverage. Mrs. Beverly Dixon of English Woods, and Mrs. Icey Judd of Price Hill demanded $ 20,000 for each community to establish health centers. Petitions followed, demanding in- creased health services and the resigna- tion of the Commissioner of Health. In August, 1970, residents of English Woods descended upon the City Council Finance Committee, to demand city funds for the operation of a health center in their community. They were angry and frustrated at the run around - they had been given by the City and Department of Health since their initial request in February, 1970. The English Woods Health Board demanded the right to con- trol the facility, set the budget, hire and fire all personnel and to determine policy. After further pressure at a full City Coun- cil hearing, the community was given $ 12,000 for operation of a health facility for the last quarter of 1970. The English Woods Health Board (a seven member - board elected by the community) began interviewing and hiring personnel from custodians to doctors. They obtained space in the Metropolitan Housing Project and began to furnish it. In October, when the 4 English Woods Health Board had obtained commitments to contracts for doctors and nurses, the Board and community support- ers went to the Health Commissioner for endorsement of the contracts and release of the committed monies. The Commission- er was under great pressure from the City to curb the community revolt against his department. After a series of long meetings with the community and night - long vigils at his office, he affirmed the local boards ' right to direct the clinic, and signed a contract with the English Woods Health Board to this effect. The clinic started op- erating in October, 1970, with an ap- proved budget of $ 48,000. By March, 1971, the English Woods Health Center had expanded to five days a week, with evening sessions arranged for working people. Its staff, largely from the community, has worked collectively under the direction of the Community Board's policy quidelines. In the wake of this success, the Price Hill community has begun a campaign to expand the Health Department Clinic in Price Hill and turn it over to the Community Health Council for operation. So far, the City has not met these demands. Lundberg Report While communities challenged the Health Department for expanded and community - controlled health services, a crisis developed within the Health Depart- ment itself. Doctors, nurses, assistarit a - ministrators and maintenance workers re- signed in increasing numbers, complain- ing of low salaries, poor working condi- tions, and inadequate patient services provided by the Health Department. The crisis reached the point where a clinic in the black community of Avondale had to be closed for lack of a doctor. A petition demanding the resignation of the Health Department's Commissioner, Dr. James Wharton, drew the signatures of 176 em- ployees and was made public. At the same time, the community broad- ened its attack against the Health De- partment to include the Board of Health. The Board of Health is a five member - board appointed by the Mayor for 10 year - terms. Some board members had served since 1952. The Board approves health expenditures and sets policy for the Department of Health. Community groups accused the Board of " being an exclusive club which holds secret meet- ings and attempts to maintain all power. " They called for a reorganization of the Board to represent the interests of the consumers of health services. With both the Board of Health and the Health Commissioner under fire from the community and Health Department work- ers, the City Council agreed to an out- side study of the Health Department. Three University of Cincinnati faculty / members were selected as the investigat- k ing team. Their report, the Lundberg Re- Olj port \, was a severe indictment of the \ Health Department. It called for the resig- nation of the Commissioner as well as the entire Board of Health. It noted " strong resistance to innovation and change. Slug- gish bureaucratic methods have proved ineffective in dealing with the problems raised by community pressures. " Attention was called to the " norm of secrecy " and a " climate of distrust. " The report criticized the absence of any long term - planning and dissipation of energy in " crisis solu- tions. " The Board of Health was called " ineffective, and trapped in traditional solutions and methods.'" PHM Meanwhile, some community people, feeling the need for a unified voice, organ- ized an open membership group called the People's Health Movement (PHM). PHM's early membership consisted of 80 to 100 people representing welfare families, in- dustrial workers, professionals, health workers and students. At first, the Health Commissioner re- fused to release the results of the Lund- berg Report. But under growing pressure from the alliance between lower echelon - Health Department workers, the communi- ty and the People's Health Movement, the It Stank L They Struck While trade journals advertised Cincinnati's " healthy labor climate, " 650 mem- bers of the International Chemical Workers Union, Local 342, fought a nine- month long strike against the Hilton Davis Company in Cincinnati. The strike began on June 8, 1970 in conjunction with a strike of chemical workers at the Rensselaer, New York plant of the Sterling Drug Company, parent company of Hilton - Davis. Sterling had a total net sales in 1969 of $ 594,159,000 and makes Phillips Milk of Magnesia, Haley's M.O., Fletcher's Castoria, Lysol Products, Midol, as well as owning Winthrop and Breon Lab- oratories. Hilton - Davis workers demanded a safety committee with worker representa- tion to inspect the plant because of hazardous working conditions and danger- ous pollution both inside and outside the plant. They also demanded an 80- cent hour - an - wage increase including a cost living - of - clause. The strike received support from many elements of the community. Organized labor called for a boycott of Bayer aspirin and other Sterling products. Electrical and auto workers on strike at the time against G.E., G.M. and Ford over issues including health and safety, gave monetary aid to the Chemical workers and walked on the picket line. Members of Operating Engineers Union, Local 20, were fired for honoring the Chemical Workers'picket line. Activists from the People's Health Movement (see above) gave strong support to the Sterling boy- cott and walked the picket line. Workers were joined by students from Antioch College and the University of Cincinnati whose arrests gave the strike almost its only publicity. The press played down the strike and the issues behind it, especially the air pollution issue. During the strike, Hilton - Davis workers got $ 25 a week in strike benefits and food stamps. In December the company canceled the workers'health and hos- pital benefits and workers experienced first hand the inadequate health facil- ities available to the poor in good as well as in hard times. Hilton - Davis refused to consider the demand for a health and safety com- mittee. After 20 weeks of the strike, the company issued its " final offer, " and then placed classified ads for " replacements " for over 500 positions and began hiring in an attempt to break the strike. Finally, in March 1971 the union called an end to the strike. The workers were forced to settle for 33 cents - - an - hour wage increase for this year, with a five percent hike over the next two years, and a partial cost living - of - clause. None of the health and safety demands was met and no health and safety committee was established in the plant. Since the strike, a number of Hilton - Davis workers, together with workers laid off from other industries (10,000 workers have been laid off in Cincinnati during the last six months) have joined the struggle for improved health care as a result of their experience with poor health conditions in the work - place and their encounter with inadequate health facilities in the community. _ Health Commissioner resigned in Novem- ber, 1970, to be followed shortly thereafter by the resignation of the entire Board of Health. PHM began to draw up demands for the reorganization of the Board of Health with a resident consumer - majority, and for a voice in choosing the new health commissioner. Following the resignations of the Board and Commissioner, PHM ap- peared before the City Council with 60 people. Mrs. Dorothy Green of English Woods said, " The Commissioner is one man and can't be all the problem. The poor and working people have to control. the Board of Health. " In January, 1971, the Mayor appointed a new Board of Health. In a token conces- sion to the community, Lorena Jewell, a 40 year - - old working mother was appoint- ed to the Board. She had been recom- mended by community groups, including PHM. However, the other four members of the new Board included two reappoint- ments from the old board, and two es- tablishment health leaders. Protests mounted against the composition of the new board, but were unsuccessful. In April a rally was held in a down- town park with the slogan " Unite To Fight, Health Is A Right. " About 300 per- sons heard speakers from the People's Health Movement, Welfare Rights Or- ganization, Black Workers Liberation League, health workers and consumers from all parts of the City. After the rally, 200 people marched into the City Council under the PHM banner and demanded a charter amendment for a People's Board of Health and comprehensive health. services. The continuing pressure over these de- mands from the community and PHM has forced the Council to draw up a charter amendment revising the Board of Health to a 9 member - Board with 3 year - terms. The health movement is now rallying to secure a provision in the amendment re- quiring a consumer resident - majority be- fore the proposal is placed on the ballot in November. The community received another slap in the face in the selection of an acting Commissioner of Health. The Community Health Councils and PHM asked for veto power in both the choice of the new Com- missioner and in the interim appointment. These demands were ignored when Dr. Mitchell Zavon, Assistant Commissioner for Environmental Health was appointed as acting Commissioner of Health. Zavon, Shell and Lead The community distrusted Dr. Zavon because of his position on lead poisining, 6 among other things. Dr. Zavon denies that lead poisoning is a " serious " problem in Cincinnati, and opposes lead screening clinics and education campaigns as " scare " tactics. He rejects the Surgeon General's guidelines on toxic lead levels and thinks treatment is warranted only in symptomatic children. Yet, in August, 1971, the results of screening 194 preschool children in the predominantly black Mt. Auburn commu- nity showed that sixty children had ab- normally elevated blood levels of lead. Follow - up testing is still being performed, but already 29 children have had the di- agnosis of lead poisoning (by the Sur- geon General's standards) confirmed. In addition, Dr. Zavon, while he was Cincinnati's Assistant Commissioner for Environmental Health, also maintained a private industrial consulting firm and was a paid consultant to the Shell Oil Com- pany, even testifying on behalf of Shell before Congress. He was the only health. officer in the United States to endorse Shell's " Pest No - Strip " (see box p. 7). Because of Dr. Zavon's activities on be- half of Shell and against the community with regard to lead poisoning, PHM, citizens groups and Department of Health employees have called for his resigna- tion. This is consistent with PHM's pro- gram calling for environmental protection and factory inspection programs, as well as comprehensive neighborhood health centers and free transportation to health clinics and hospitals. Workers Arise Health workers are becoming a vital part of Cincinnati's health movement. The Cincinnati Health Employees Council, made up of public health staff nurses, sanitarians, clerical and maintenance workers, has evolved out of the wide- spread discontent felt within the Depart- ment of Health. At a recent meeting held to discuss pay, benefits and career ad- vancement, its Chairman said, " The com- munity people are the ones who are speaking up and they are going to win. And notice, they're not saying request, they are saying demand! I suggest that we put that word in our vocabulary and stop acting like third class - citizens. " These and other health workers are be- coming active in PHM, as are women ac- tive in women's liberation groups. A group of students at the medical college are researching Cincinnati's health power structure. This growing health movement is being given feature prominence in the City's new worker oriented - newspaper Movin on Up. Zavon's Shell Game Shell Chemical Company's " Pest No - Strip " is a slow release - pesticide whose active ingredient is Vapona, DDVP. DDVP was discovered in 1955 by the Public Health Service (PHS) and is chemically related to nerve gases used in World War II. The organic phosphate - compound was tested by the PHS in Haiti, Upper Volta and Nigeria. " Pest No - Strip " was approved for human use by the Department of Agricul- ture in 1963, over the objections of the PHS. It has since been learned that three Department of Agriculture consultants who were involved with the regulatory status of " Pest No - Strip " were employed by Shell Chemical. One of these con- sultants was Dr. Mitchell Zavon, until recently Cincinnati's acting Health Com- missioner. By 1970, the Food and Drug Administration had taken a second look at " Pest No - " and discovered that when it is used in kitchens, the strip leaves unacceptable levels of insecticide in foods. After initial resistance, Shell Chem- ical included a package warning against the kitchen use of " Pest No -. " But the controversey is still unsettled. Prof. Goran Lofroth of the University of Stockholm claims that DDVP makes dogs more susceptible to barbiturate poisoning, may cause chromosome abnormalities in peas, and may increase mutation rates in bacteria. Many scientists recommend a maximum intake of DDVP far below the level produced in the three month life span - of " Pest No - Strip. " At the present time, neither the FDA nor the Department of Agricuture con- templates any further action against the product. APC All Purpose Cure The health movement in Cincinnati has scored some impressive gains. Until now, however, it has chosen not to attack the most powerful health institutions in the city the General Hospital Medical Col- lege (MC GH -) and the large voluntary hospitals. Previous community pressures against GH MC - have been deflected by the creation of Ambulatory Patient Care, Inc. (APC). APC was formed under the impetus of a $ 131,375 OEO grant to the University of Cincinnati in 1969. Its board consisted of " representatives of the poor " selected from the thirteen target areas served by the local OEO agency, the Community Action Commission. The medical school and hospital contributed some deans, pro- fessors and administrators. The Chief Administrator of General Hospital, was chosen as Chairman of the Board of APC, Inc. The Board was supposed to develop. plans for a $ 7 million neighborhood health care program. Two years later and most of the money spent, a plan was sub- mitted to OEO calling for General Hos- pital to send $ 7 million to develop neigh- borhood health centers in three poor communities, two black and one white. OEO rejected the proposal as too poorly planned and chided the administrator to improve existing services at General Hos- pital. With its veneer stripped away, GH MC - is now more vulnerable than ever before. The Lundberg Report fueled opposition against the Department of Health. Community groups, health workers and a sprinkling of industrial workers and students, are beginning to see that the Lundberg Reports'criticisms of the Health Department can be applied with equal justification to GH MC - and to all of the private medical institutions in the City. As the empire expands, people demanding better health care are beginning to realize that they are merely afforded the right to listen to the next promise and the next of the empire's grandiose schemes. A, The perspective of the health insurg- ents, especially the community people, has developed through struggle with auto- cratic and unresponsive agencies of the City government and the health bu - j reaucracy. While major institutions such] as General Hospital - Medical College Com- plex have so far escaped the brunt of an organized attack, the insurgents'commit- ment to and their understanding of com- munity control and its ramifications is growing rapidly and threatens this em- pire's security. - Gene Inch, M.D., former resident at Cincinnati Children's Hospital. He is presently serving with the U.S. Army, Fort Bragg, N.C. 7 OLE KING COAL In the last five years an occupational health and safety movement has flour- ished among Appalachian soft coal miners despite the concerted opposition, or at best indifference, of the coal com- panies, the United Mine Workers'Union, local, state and federal government offi- cials, and the universities and medical centers of Appalachia. The struggle for minimal guarantees of health and safety have led to wildcat strikes, marches on Washington, and suc- cessful multi million - dollar law suits. Fol- lowing the disaster at Farmington, West Virginia which took 78 lives in 1968, miners and an aroused public pushed through the federal Coal Mine Health and Safety Act. This granted the legal basis for the first real protection against the twin scourges of mining accidents and coal workers'pneumoconiosis or black lung disease. In the course of this strug- gle, insurgents have knocked the United Mine Workers, once revered for its con- cern about health, reeling under charges of graft, collusion with management, and denial of members'rights. The mobilization of Appalachian miners is a significant development in an arena of increasing attention and concern with- in the health movement - that of occupa- tional health and safety. What has caused miners to mobilize? Why has the opposi- tion seemed so monolithic? And having at last cracked the monolith, what course will the struggle take now? For generations miners in the eastern coal fields have battled a rapacious coal 8 industry, which had guilefully bought up mineral rights of most of the Appalachian coal fields with broad form deeds; ex- tracted vast sums of wealth from the mines at fantastic profit to absentee owners; fought pitched battles with mine union organizers; and built a society in which homes, stores, doctors, county and state governments were literally owned by the coal companies. During the 1930's and 1940's the heroes were the United Mine Workers with its legendary president, John L. Lewis, who for the first time brought the companies to their knees and brought some measure of dignity to a miner's life. But when John F. Kennedy toured West Virginia in the spring before the 1960 election, and Harry Caudill in 1962 wrote Night Comes to the Cumber lands, Amer- icans learned of desolation, hunger and unemployment in the mountains, a dying. coal industry, and a union which although it had built eight Miners'Memorial Hos- pitals where virtually no modern health services had existed before, no longer seemed able or even willing to fight for its members. The New Economics of Coal Ten years later too few Americans un- derstand the new economics of coal. Coal production is now well over 500,000, - 000 tons a year, within shouting distance of its peak year in 1947. Though the rail- road and home heating markets have dis- appeared, coal now supplies 53% of the electric power of the nation, and accord- ing to Fortune has an excellent long term outlook: " The federal government now views coal as'the cornerstone of our energy philosophy for the coming genera- tions.'Conversion of coal to gas, gaso- oline and oil, now on a pilot plant basis, is becoming feasible and economical. Coal, in terms of heating value, com- prises 75% of the known fuel reserves in the U.S., whereas oil is but 5% and shale oil 13%. With this new picture, several of the largest coal companies have been bought up by oil firms. Consolidated Coal, largest in the industry and long dominated by the Hanna Mellon - interests of Cleveland and Pittsburgh, has been taken over by Continental Oil, heavily infused with Rockefeller money. Indeed, Consolidated was the special creation of George M. Humphrey, Cleveland lawyer and finan- cier. (See pp. 15 and 19.) The mergers have given the coal indus- try giants exceptional capital resources and financial flexibility with which to carry through large scale mechanization of the mines. This has meant increased productivity on the one hand, and whole- sale cuts in the work force on the other. Productivity of American miners, with the new machinery, is 4 or 5 times that of miners in England and continental Euro- pean countries. The price of this produc- tivity, however, has been increased health and safety hazards for those who mine the coal. Recent years have brought drastic change not only to underground mining. Strip mining has been transformed and has boomed due to the development of huge trucks and earth moving machinery and new road construction. Stripping re- quires a relatively small but extremely productive work force and little invest- ment compared to the expense of extend- ing and operating deep underground mines. But it also ruins the land in an es- pecially devastating way: mountain tops and sides, trees and top soil are torn away irreplaceably. Rivers are filled with acid drainage and silt. People's homes. are crushed. Left behind is devastation, resembling post - war Vietnam or the moun- tains on the moon. It is this devastation which has called forth such vigorous protest, by mountain people, editors, writers, ecologists. And caught in the bind, as is often the case, are the poor and working people of the mountains. They are asked to choose be- tween jobs free from the dangers of roof falls and black lung, on the one hand, and the integrity of their land on the other. The United Mine Workers Much of the history of Appalachian soft coal miners in the last forty years is the history of their union, its heyday and its decline. Decades of mine wars launched by open - shop coal operators and fought by their gunmen were finally won in the 1930's by the United Mine Workers of America (UMWA). Drawing heavily on the benevolent support of President Roose- velt, the union signed up hundreds of thousands of members. The union forced operators to sign contracts and wages rose rapidly under the impact of massive strikes. By the end of World War II the national union membership stood at 600,000 active members. By 1950, however, the industry had en- tered a decline, hastened by its loss of two mainstay markets, the railroads and home heating, to a competitive fuel oil. After the final bitter national strike of 1950 (there has been none in 21 years since), union president John L. Lewis negotiated the first industry - wide contract in coal history. The industry agreed to pay 30 cents a ton royalty to the UMWA Welfare and Retirement Fund and in re- turn, the operators were given a free hand to mechanize the mines without union opposition. This, in effect, lent union leadership sup- port to the process of eliminating jobs for union members. It also tied the inter- ests of the leadership to production and productivity, not only by its acquiescence to mechanization, but by its interest in higher royalties for the Welfare Fund. For the union the result has been in many ways disastrous. The union's mem- bership dropped from 600,000 nationally to 193,000 in 1969. Only half of these are active members; the rest are retired. The unionized sector of the industry be- gan to shrink drastically in the late fifties. and early sixties, especially in Eastern Kentucky. Small non union - mines began to spread rapidly, and miners, forced to work in them to feed their families, lost their union welfare benefits. Moreover, the union began to cooperate with big. management in support of coal's fortunes in Congress and elsewhere. For example, Lewis lent union funds to Cleveland mil- lionaire Cyrus Eaton to buy into a non- union Kentucky coal firm seeking to enter the Tennessee Valley Authority's coal market. When Eaton was successful and became chairman of the board, he recip- rocated and signed a union contract with his creditors. Yet this cozy relationship of union leaders with big operators did not extend to the membership. Union members were unable to elect their leaders. Large salaries, pensions and job security became the rule for the union leaders; low wages, unsafe working conditions, threatened unemploy- ment and a pittance pension became the lot of the miners. The UMWA Welfare Fund had financed a benefit program for health and other needs of the men and their families. Eight Miners'Hospitals were built in the early sixties (for union members only), bringing high quality medical care to the mountains for the first time. But the Fund could not long afford the expenses of underwriting private medical care in a depressed single industry society. Rather than close them, the UMWA un- loaded ownership of the hospitals to a non profit - regional chain, Appalachian Regional Hospitals, set up and financed by church and government leaders. More recent revelations, however, have shown extensive manipulation and mis- management of the Welfare Fund. Mil- lions had been lost by investing Welfare Fund money in non interest - - bearing ac- counts in the union's own National Bank of Washington. In this situation a struggle for democ- 9 racy in the union arose. Rank - and - file movements in the late sixties focused on mismanagement of the welfare fund, neg- lect of health and safety issues and change of the leadership of the union. W.A. (Tony) Boyle, John L. Lewis'suc- cessor since 1980, faced opposition can- didate Jock Yablonski. Boyle won primari- ly on the strength of the vote of retired miners (still members of the union), whose pension was raised $ 35 a month just before the election. Yablonski's assassination by by hired thugs 21 months ago only increased the furor in the coal fields. Retired miners and widows sued in federal court to ex- pose mismanagement of the welfare fund and recently succeeded in knocking Boyle out as trustee of the fund. New organiza- tions, such as Miners for Democracy, have emerged within the union, focusing on the soft coal contract which ends October 1. A recent report in The Miners Voice, news- paper of the rank and file movement with- in the UMWA, points out that rank and file. contract demands center on a unique com- bination of economic and health and safety issues. Particularly important is the demand for a required safety shift for maintenance and repairs, and time to let coal dust settle, in addition to a six hour - work - day with three production shifts. Other safety demands are: y * triaTa doctor or nurse be present at the mines at all times; l * that all dust samples be taken by union men; i that the right to strike during the con- tract over safety issues or repeated con- tract violations be guaranteed. Solely Coal mining has long been the most dangerous and disabling occupation in the United States. 100,000 have died vi- olent deaths in the mines since the turn of the century and well over a million suffered injury. Massive explosions, tak- ing scores to hundreds of lives, have been repeatedly attributed to the same causes through the years: critical accumulations of methane gas, inadequate ventilation, sparks from unshielded electrical equip- ment. And repeatedly accounts of these disasters tell of defective safety measures by the companies: ungrounded ma- chinery, poor maintenance, improper han- dling of explosives, lack of safety pro- grams and the like. Like a litany, too, are repeated accounts of state and fed- eral inspections that fail to lead to the correction of safety violations before dis- aster strikes. The 1969 Coal Mine Heatlh and Safety Act was passed after miners, public and Congressional uproar following the trage- dy at Farmington, W. Va. in Consolidated Coal's huge No. 9 mine in which 78 died. Far stricter controls than ever before were imposed on methane gas, on dust levels permissible in the mines, and on the shielding and grounding of electrical equipment, etc. Federal mine inspectors were, for the first time given authority to close a mine if it poses an imminent dan- ger. Yet not only did the coal operators fight the law every step of the way before passage, but by law suits and political in- fluence they succeeded in nullifying any real enforcement of its new safety pro- visions for many months. The Bureau of Mines delayed several weeks in publishing the details of mine. safety requirements set forth in the new law, prompting three Congressmen and a West Virginia miner to finally sue for their immediate publication. Later a group of small Eastern Kentucky oper- ators sued the Bureau. When a judge granted a restraining order to prevent en- forcement of the safety rules in that area, the Bureau stopped all safety enforce- ment in all mines throughout the country by its entire staff of inspectors. The Bureau was supposed to have 1000 inspectors in the field by June 30 of this year. On May 28, the Wall Street Journal said the Bureau had hoped to have 705 by June 30, but in fact would have only 500. On May 29, in actuality, the Bureau had 251 inspectors in the field and 52 supervisors. The uproar over mine safety enforce- ment became so great last year that Senator Harrison Williams of New Jersey, in August, succeeded in launching an in- vestigation of the Bureau of Mines by the General Accounting Office (GAO), which is responsible to Congress, The GAO re- leased its report early last June and charged thoroughgoing negligence on the part of the Bureau. The report dis- closed that: * Only 31% of the required safety inspections, and only 1% of the required health inspections had been made by December 31, 1970. * The Bureau had failed to use its power to close mines when inspectors found repeated safety violations. Inspec- tions had been " at times extremely lenient, confusing, uncertain and inequitable " concerning safety enforcement. The Bureau had failed to force op- erators to begin required dust sampling and had allowed them to submit " errone- ous data. " * It had done little to induce operators to submit required plans for roof control, 10 ventilation and emergency action when a fan fails. In the face of this barrage of criticism, one of the first moves of Rogers C.B. Morton, Nixon's new appointee as Secre- tary of the Interior (whose department oversees the Bureau of Mines), was to hire public relations man Harry Tre- leaven, with high GOP connections, to seek ways to improve the public image of the Bureau. Following the study, Tre- leaven, on his own initiative, launched a public relations campaign claiming that the key to the dangers in the mines was the miners'carelessness, not com- pany negligence and pressure for pro- duction. A year - and - a - half after new " strict " federal law, safety enforcement in the mines continues to be lax. In 1970 deaths in the mines actually increased from a pervious yearly average of 140 to 200 and over 10,000 injuries were recorded. Unable to secure action from industry, government or their own union, miner's have resorted to wildcat walkouts to recti- fy conditions. Two large mines in south- western Pennsylvania were struck in early January. At the Gateway Coal Company miners demanded a special federal inspec- tion for excessive coal dust. At the Buckeye Coal Company mine in Nemacolin, they acted to speed workmen's compensation benefits to a miner injured on the job. Black Lung Less dramatic but far more prevalent than mine disasters is black lung or coal workers'pneumoconiosis (CWP). This newly designated disease was unknown to medical scientists in this country only a few short years ago. In fact, standard medical textbooks of the 1950's state coal dust is harmless. Yet evidence is fast ac- cumulating that coal dust already known to propagate fire and explosion in a mine, is responsible for a specific respira- tory disease of miners that can, within as little as five years in extreme cases, leave a man choking for breath, blue from lack of oxygen, and, in all, totally disabled and doomed to an early death. Known treatment is ineffectual. In fact, by far the best treatment is prevention of the disease by reducing the dust in the mines. The 1969 Coal Mine Health and Safety Act for the first time gave legal recogni- tion to this disabling disease. The Act established compensation for men al- ready disabled by the disease and in addition it set maximum permissible con- centrations of dust in the mines, to re- duce or prevent future cases of illness. One of the first rounds in the struggle for the new health and safety law focused on the permissible level of dust in the mines. Most experts felt no more than 3 milligrams of dust per cubic meter of air was acceptable. Yet when the coal oper- ators in 1969 screamed they could not meet that standard in mines producing coal for federal contracts, Nixon's Secre- tary of Labor, George Schultz, obligingly relaxed the standard to 4.5 milligrams, half again the acceptable level. When the law was finally passed, it did require the 3 milligram dust level by June 30, 1971. In a report delivered to a mining confer- ence on November 7, 1970, Robert K. Jones of the Kentucky State Department of Health revealed that some miners in that state were breathing not half again, but 76 times the maximum concentration of coal dust deemed safe by federal law! This study also revealed that 57.4% of the state's underground mines exceeded the federal limits effective June 30, 1970. For a three - year period ending in 1972, the new law set up a federal compensa- tion program for black lung cases, to be administered by the Social Security Ad- ministration. After 1972, the program will revert to the states, whose workmen's compensation funds are paid mostly by the employers. Administration of the black lung pro- gram by Social Security has been in- credibly bureaucratic and restrictive. The Social Security Administration has relied on inexpensive and possibly misleading. X ray - and breathing tests to establish di- agnosis and state of total disability. The burden of proof has been placed totally on the miner (or his widow). Social Se- curity has done virtually nothing to make available adequate adequate testing facilities, staffed with competent, sympathetic doc- tors in the coal country. Closer to the coal fields and fortified by an unmatched experience of examining some 4,000 miners in the last eight years, Dr. Donald Rasmussen of the Appala- chian Regional Hospital in Beckley, West Virginia, has reported that X rays - and breathing tests are not at all a reliable guide to degree of disability. He states. that gas studies of blood oxygen and carbon dioxide correlate best with func- tional disability. Rasmussen warns that not only are traditional researchers un- derestimating the extent of black lung, but the new mining methods of recent years, particularly new drilling machines, are making pulmonary cripples earlier and faster than older methods. Hence he forecasts a rising tide of black lung, cases in the next several years. As of April 30, 1971, 286,000 claims had been filed across the country and 246,000 processed (45,500 in West Virginia and 11 28,000 in Kentucky). Of those processed, no less than 58% were disallowed. Denial letters did not even tell of rights of appeal. Even more incredible, the denial for miners (not widows) varied from 33% in Pennsylvania, which has a public - run black lung diagnostic and compensation program, to an enormous 78% in Kentucky (highest in the country). Some have sought to explain this discrepancy by the greater poverty and resulting " compensa- tion - itis " in Kentucky. However, they ap- pear to have overlooked the great influ- ence of the coal companies on both state and federal office holders in Kentucky, as state takeover of the black lung pro- gram looms 16 months ahead. State university medical centers have made gestures toward the black lung problem faced by miners. The Public Health Service has set up the Appala- chian Laboratory for Occupational Res- piratory Diseases (ALFORD), sometimes known as the " Byrd Sanctuary " after its mentor, Senator Robert Byrd, at the Uni- versity of West Virginia. In its two years. of existence the laboratory has spent most of its time and energy preparing for ex- pansion into a luxurious new building equipped with extensive machines and a salubrious surrounding golf course. At the present, ALFORD is engaged in a clinical (largely X ray -) study of 31 mines with 20,000 to 30,000 miners participating. A report on its findings is said to be due later this year. The University of Kentucky, recently under attack for its stingy attention to the problems of poor people and miners of the eastern region of the state, has re- sponded in a publicity release that quan- tified its efforts on the miners'behalf. During 1970, 280 miners were referred by Social Security for lung function tests. About 100 new patients a year from the mountains are seen in the outpatient clinic for chest disease. 50 to 60 a year are inpatients with similar disorders. And 60 to 80 are carried as long term outpa- tients with chronic lung disease, paid for up to recently by a federal research grant that has now run out. The Black Lung Movement This is the setting in which the Black Lung Association (BLA) has sprung to life and grown rapidly in the Appalachian coal counties. It was born in December, 1968, when miners in West Virginia's Fayette and Kanawha Counties joined to demand of the state legislature that workmen's com- pensation be allowed for black lung vic- tims. Three doctors, Rasmussen, Buff and Wells, traveled the state speaking to miners'groups in their behalf. In Febru- 12 ary, 1989, a wildcat strike was set off at Winding Gulf Mine in Raleigh County. Within 5 days it spread to 42,000 of the 44,000 coal miners of West Virginia. No coal was mined for 23 days until a bill was passed and signed by the Governor. Spurred by this major victory, the Asso- ciation moved on to press for the federal law that eventually became the 1969 Coal Mine Health and Safety Act. Goals of the B.L.A. " 1. To make coal mining a safe and healthy occupation. To ensure enforcement of the federal coal mine health and safety act of 1969. To im- prove state laws and their enforce- ment. 2. To improve the administration of all benefit programs for coal miners and to work for their improvement: state workmen's compensation pro- grams, federal social security dis- ability programs, the federal black lung program, the UMWA Welfare and Retirement Fund. 3. To return democracy to our union. To return constitutional rights of the rank and file to elect their dis- trict officials. To end corruption and featherbedding by relatives of our union's leaders. " In the summer of 1970, another dissi- dent group stepped forward. The Dis- abled Miners of West Virginia, stung by progressive reductions in medical benefits and pensions from the UMWA Welfare and Retirement Fund, sought unsuccess- fully time after time to meet with W.A. (Tony) Boyle, union president and trustee of the fund. Circulating by means of rov- ing pickets, they soon pulled 200,000 miners off the job in West Virginia, East- ern Ohio and Western Pennsylvania. Em- ployers sped to the courts to get federal injunctions against the wildcat walkout. Over a 3 month - period they were eventual- ly successful, and the walkout was de- feated. But the struggle for rights within the union had advanced and was picked up by others in the movement. September, 1970, brought the first major wave of benefit denials under Social Security and the Black Lung Association. began an educational campaign on the rights of appeal. As a result, 14 or more local chapters of the Association sprang up in Virginia, West Virginia and Ken- tucky. Last winter BLA worked to train lay advocates to press black lung claims and appeal of denials. And during the 1971 West Virginia legislative session, BLA joined other union dissidents to form the Workers Alliance for Fair Compensa- tion. While the Alliance did not achieve its main goals, it made significant gains, including cost of living escalators for those on workmen's compensation. Fed up with the evasions and delays on the part of the government black lung program, this past June BLA organized. hundreds of miners and miners'widows in a bus delegation from the coal fields to Washington. The delegation presented the following demands: * All eligible miners and widows have. a right to complete and impartial ex- aminations. * We want properly equipped clinics, such as the one in Beckley, established throughout the coal fields. * We want the use of X ray - evidence stopped. This is not the law and must be removed. * We demand proper assistance in filing and processing claims. * We want widows'claims decided on more liberal evidence. * We want a dollar for dollar offset between compensation and black lung. benefits stopped. The health and safety movement has succeeded in crossing old lines that usual- ly divide the rank and file from retired and disabled miners. It includes both miners and their families; black as well as white workers. In an industry which in many places has been deserted by the union, the movement unites both union and non- union workers. It cooperates with welfare. rights and poor people's organizations and has merged the struggle for a better union contract with that for democracy within the union itself. The organization of Appalachian miners. around occupational health and safety issues holds important lessons for the health movement as a whole. The work- place makes up one third - to one half - of every worker's health environment, and if the health movement is to address the causes of poor health rather than simply its treatment, it cannot ignore occupa- tional health and safety conditions. In attacking the causes of black lung, mine explosions and roof falls -, miners are truly conducting a struggle for environ- mental and preventive health. Not surprisingly, to achieve these goals, the miners find themselves pitted against the major economic forces of that region. -the coal companies which control its resources and which are responsible for its low wages, widespread unemploy- ment, lack of medical facilities, blight, pollution, and supine governmental sys- tem. And, unfortunately they find them- selves facing reluctant health institutions, which are not yet ready to make this commitment to treating the causes of illness. Des Callan CLEVELAND'S HEALTH ESTABLISHMENT Cleveland " the mistake on the lake " - is no accident. Its major problems - pov- erty, pollution, racial strife are a pre- dictable consequence of the city's eco- nomic and social setting. Cleveland is a city with an economic concentration in a few heavy industries - iron ore, steel, oil and steel using - companies (machinery, trucks, automobiles) and a social concen- tration in the core city of black and poor whites surrounded by a white middle and upper income suburban ring. Unlike most midwestern cities, Cleve- land is regarded by many as a progres- sive leader in private social welfare and health. It is the site of the first " red feather " campaign for community - wide support of private welfare agencies. It boasts a na- tionally renowned medical school with a reputation for innovative, community - ori- ented teaching. But, today, Cleveland's health record 13 belies its reputation. Preventive health. care is sliding backwards as the City's Health Department finds its budget cut by almost 50 percent; increasing numbers of poor patients are " dumped " from the city's private, voluntary hospitals to the single county hospital; expansion of the lone OEO Neighborhood Health Center proceeds at snail's pace with doubt that the new center will ever open; and Uni- versity Hospitals, the major source of outpatient medical care besides the coun- ty hospital, threatens to cut its outpatient budget so severely that patients will ac- tually be turned away. Cleveland, like a host of mid western - , industrial cities from Pittsburgh to Milwaukee, faces a health crisis. But in Cleveland, perhaps more than in most cities, this health crisis can be linked to a health establishment, which is part and parcel of the city's industrial, cor- porate and banking elite. Rarely can it be demonstrated so clearly that the leaders of a city's major health institutions are also the leaders of its business and so- cialite community. Health Institutions Cleveland proper is divided into two sub cities -, the east side and west side, separated by the Cuyahoga River and its surrounding industrial " flats. " The east side is predominantly black with several small enclaves of white European ethnic people, ringed by wealthy white suburbs like Shaker Heights. The west side is al- most entirely white, including many poor Appalachians, people of middle European descent, and some Puerto Ricans. More and more Clevelanders find it dif- ficult to afford a private practitioner. In- creasing numbers of them must resort to outpatient clinics at Cleveland's major hospitals. Meanwhile, the small voluntary hospitals and even the major teaching hospitals, caught within the city limits, increasingly serve a suburban population. On the west side there are only a few small voluntary hospitals and most of them do not offer outpatient services. This leaves Cleveland Metropolitan General Hospital (Metro) as the major hospital with outpatient facilities on the west side. It is also the only public acute care hospital in the entire city. So, it must serve not only a sizable indigent west side community, but also those poor from the east side who are either rejected from clinics and emer- gency wards of the major private hospitals or who choose to obtain their care at Metro. Over 60 percent of Metro's patients pay the dollar, to travel IV2 hours to come from the east side by bus. Metro is the typical public hospital: long lines of 14 patients wait in the registration area; the outpatient clinics are flowerless and drab and almost always overcrowded; inpa- tient wards are understaffed; and there are virtually no outreach or satellite serv- ices in the community. As one west sider (a long time neighbor of the hospital). remarked: " City hospital's still thought of as a butcher shop'round here. " Virtually all of Cleveland's major priv- ate hospitals are located on the east side. They include such middle - sized voluntary institiutions as Mt. Sinai, St. Luke's and St. Vincent's hospitals, all of which have outpatient clinics and emergency wards. These hospitals were built, not to serve the poor people now living on the east side, but to serve the rich people who once lived there. The Cleveland Clinic is a 600 - bed vol- untary hospital modelled after the Mayo Clinic. It operates entirely on a fee for- - service basis, with a staff of full time - sal- aried specialists. For those, who need (and can afford) a kidney transplant, open heart surgery or specialty diagnos- tic work - up, it's a great place to go. There are well appointed - , wood panelled wait- ing rooms; multi course - dinners and beau- ticians; even a plush motel, the Clinic Inn, run by the Clinic for patients under- going diagnostic check - ups. But there is no outpatient department and only limited emergency room services, so that the black community which surrounds the Clinic can hardly set foot inside it. Only a third of the Clinic's patients come from Cleveland anyway; the others like an Argentine government official recently flown to the Clinic for heart surgery, come from the " whole world. " Even though the Cleveland Clinic has an international reputation, its signif- icance in the Cleveland health system pales in comparison to the University. Medical Center (UMC). Located just twenty blocks from the Clinic on Cleve- land's east side, the University Medical Center is the city's largest and most pres- tigious medical complex. It consists of the Case Western Reserve University Med- ical School (CWRU) and its affiliated University Hospitals, a seven hospital -, 965 - bed complex. UCM is rich. Its yearly operating bud- get totals more than $ 50 million. The med- ical school budget alone has grown from $ 2.2 million in 1950 (with 34 percent of the funds coming from the federal govern- ment) to $ 16.4 million in 1970 (with 59 percent from federal funds). With this 750 percent increase in funds in the last twenty years medical student enrollment at CWRU only increased 12 percent. UMC is powerful. Its trustees include some of the most powerful and wealthy aristocrats in Cleveland. Old Cleveland families such as the Humphreys, the Hannas and the Prentisses poured money into UMC in the early days. Today their descendants and top officers of the family companies still dominate the boards of University Hospitals and of CWRU. For example, University Hospitals'50 member - board collectively holds 40 directorships in Cleveland's top industries, banks and utilities. (Many of the board members sit on the boards of several corporations.) The University Hopsitals'board is really a family affair among Cleveland's aris- tocracy; no less than 23 members are re- lated to a least one other board member. One of the coziest family groupings on the board is that of the Hanna / Hum- phrey Ireland / dynasty (see " The Hanna Industrial Complex, " by Edie and Fred. Goff, published by NACLA, P.O. Box 57, Cathedral Park Station, N.Y., N.Y. 10025, 350). There's Gilbert Humphrey (chair- man of Hanna Mining), Gilbert's father- in law - R. L. Ireland (retired director of Hanna Mining), Gilbert's sister Mrs. Royal Firman, Jr. and her husband (until 1969) and (until his death in 1970) Gil- bert's father George M. Humphrey (former Secretary of the Treasury under Eisen- hower). In this year's Board elections for University Hospitals, a descendant of the Mather family and an Ireland were ap- pointed trustees. UMC is the city's most influential medi- cal institution in an informal sense. It plays a dominant role in the local Regional Med- ical Program, and, according to a local health planner, " Nothing happens in the health area here without [UMC's] OK. " But UMC's formal control over the Cleve- land health system is even more impres- sive. It has become the center of Cleve- land's only " medical empire. " Affiliations link CWRU and University Hospitals to six other major Cleveland hospitals: two large voluntary hospitals (Mt. Sinai and St. Luke's); three county hospitals (Metro for acute care, Highland View and Sunny Acres for chronic care), and the VA hos- pital. Together these hospitals include 4,100 beds out of 6,550 acute care general beds in the city and 9,000 in the entire county, and virtually all the outpatient clinics in the city. " Nothing happens in the health area here with- out UMC's O.K. " -Cleveland Health Planner UMC's affiliations flow primarily from the fact that it includes CWRU Medical School, the only medical school in North- eastern Ohio. ,,WRU Medical School has affiliated with all of the public hospitals in Cleveland: the VA hospital, Metro and the two county chronic care hospitals. These affiliations allow the medical school to send its students, interns and residents to these hospitals for training. It enables staff doctors at the affiliated hospitals to obtain federal research grants. The medical school benefits by enlarging its clinical faculty at reduced or no cost. Similarly, the recent affiliations with Mt. Sinai and St. Luke's bring no direct funds to UMC. All affiliations give more power to UMC. Yet, UMC has only utilized its " empire based " powers to further its own narrow aims. It has certainly not been exemplary in promoting new forms of health care de- livery. With regard to the poor, UMC has not initiated a single program of com- munity outreach. And although UMC has board members on Cleveland's only OEO sponsored - Neighborhood Health Center, it was the Department of Health that took the initiative to apply for funds. Likewise, UMC's outpatient clinics have no satellites and UMC has been resistant to community pressures to staff satellites in Glenville and Hough. What is more, during the spring of 1971, UMC cut back its clinic services by 13 percent and threatened to make addi- tional cuts amounting to 33 percentL " re- ductions which would effect the number of patients ", according to the Plain Dealer. UMC claims that funds had to be diverted from the capital budget to meet the deficit and that to prevent this from happening again, clinic services will be cut. Apparently, the Board of Trustees thinks less of the health of Cleveland's poor, than it does of building another new edifice. UMC has also carefully protected its sta- tus as northeast Ohio's only medical school. Its most serious rival has been Cleveland Metropolitan General Hospital. Metro, though a county hospital, boasts a large scale research program. Metro has aspired to become the " Massachusetts General Hospital " of the midwest. It is widely believed that pressure from UMC trustees blocked Metro's bid for state funds for a medical school during the 1960's and is presently delaying Cleveland State Uni- versity's request to the State Regents to start a medical school on its campus. The Controllers Who controls Cleveland's health sys- tem? At first glance, it would seem that the managers of Cleveland's only " med- ical empire " the deans, administrators. 15 doctors at UMC - hold all the power. But deeper probing unearths another group -the business and high society represent- atives who, through their presence on the boards of the leading health and social welfare institutions, command the major role in Clevland's health establishment. For purposes of clarity, this group is sep- arated into " business oligarchs " and " high society. " Of course, this distinction is somewhat artificial. Both the " business oligarchs " and the " high society " repre- sentatives overlap overlap,, control enormous wealth and ultimately make decisions. based upon their own political and economic interests. The Business oligarchs: Cleveland is run by a group of no more than 50 men, the men who direct its top corporations. (See " The Cleveland Papers, " prepared by the Cleveland Radical Research Group, 2238 Grandview Avenue, Cleve- land Heights, Ohio.) These men control the city economically through their power as employers of hundreds of thousands of workers, culturally through their control of the schools, newspapers and museums, and politically through their ability to finance mayoral candidates and lobby at City Hall and in the State Capitol. They exert their influence in every sector of community life housing - , education, so- cial welfare and health. A few examples: Willis Boyer, the president of Republic Steel (Cleveland's largest company un- til recently) sits on the boards of Univer- sity Hospitals, CWRU, the Cleveland De- velopment Foundation (a major funder of urban renewal) and the Commission on Health and Social Services (spon- sored by the United Appeal). He has also served on the boards of the United Ap- peal and the Regional Hospital Planning Council. In his business life, he is a director of Sherwin Williams - paint and chemical company, National City Bank of Cleve- land and the Marathon Oil Company, as well as Republic Steel. (Republic and 9 Hospital Workers Hospital workers, particularly non professional - workers, have been among the lowest paid of all American workers. In Cleveland in 1966, nurses'aides (women) were earning a mean wage of $ 58.50 a week, while kitchen help (wom- en) were earning $ 1.38 an hour and porters (men) $ 1.60 an hour. In addition to low wages, hospital working conditions have been poor, with no avenue for redress of grievances. To fight these injustices, hospital workers have struggled to form unions. In Cleveland, the conflict between the hospital workers and the administrators / trustees surfaced in the mid 60's -. As early as 1963, University Hospitals bitterly attacked unionization efforts among its workers. Part of the union anti - campaign was a letter to all em- ployees: " University Hospitals, however, as your employer, is opposed to rec- ognizing any union or organization which seeks to act for hospital employees. This has been our position for many years. " As reasons, they offered: (1) UH has a good record of improving wages: 2 () the ultimate threat of a union is a strike " which in a hospital is unthinkable ", and (3) as a non profit - institution, UH is not required by law to recognize a union. Not much union organizing occurred until 1967. Then Local 47 of the Build- ing Service and Maintenance Workers led a year - long strike at St. Luke's Hospital for higher wages, better working conditions and the right to organize hospital workers at St. Luke's. Tensions ran high. Several trustees'homes were firebombed, and many striking employees were arrested. For the first six months, the trustees refused to negotiate with the workers. An arbiter was called in, but was unable out work out a settlement. After ten months. Mayor Stokes and the City Council threatened to pass a labor rela- tions law, requiring non profit - institutions (such as hospitals) to recognize any duly elected union. Pressure from throughout the health establishment was placed on St. Luke's to recognize Local 47, since other hospitals did not want to be forced to hold union elections. St. Luke's gave in. Subsequently, Local 47 led successful drives to unionize maintenance workers at Forrest City and Women's Hospitals, and presently has cases in court against Lutheran and Fairview General Hospitals. However, attempts at unionization have been squashed at the big private hospitals on Cleveland's east side - Mt. Sinai, UMC and the Cleveland Clinic. The model union buster - has been Mr. Sidney Lewine, administrator at Mt. Sinai. Lewine has his administration approach each long term - employee indi- 16 Sherwin Williams are among Cleveland's top polluters.) George Karch, the chairman of Cleve- land Trust Bank, sits on the boards of CWRU, Cleveland Clinic, Health Hill (a private pediatric hospital), the Cleveland Foundation and the Cleveland Develop- ment Foundation. He is a director of Ogle- bay Norton (iron ore mining), Reliance Electric Company, Cleveland Twist Drill Co., Medusa Portland Cement, Warner and Swasey (machine tools). White Motor Co., North American Rockwell Corp., and over ten smaller firms. J.D. Wright, chairman of TRW Corp. (auto and airplane parts), sits on the boards of University Hospitals, the Cleve- land Foundation and, formerly, the United Appeal. He is a director of Republic Steel, Goodyear Tire, National City Bank, Sher- win Williams and Eastman Kodak. H. Stuart Stuart Harrison, chairman of Cleveland Cliffs Iron Co., is on the board of University Hospitals, the Cleveland Foundation and the Cleveland Develop- ment Foundation. He is a director of over 19 companies, including Jones and Laugh- lin Steel, Medusa Portland Cement, Cleveland Trust Bank, White Motor Com- pany, Weatherhead (ordnance), Mid- land Ross and LTV (a conglomerate). These men, plus others not listed, hold the ultimate power over long range - plan- ning for Cleveland's health institutions. As hospital and medical school trustees, as members of important city wide - health funding and planning bodies, they con- trol hospitals'long term - construction and expansion programs and set the overall tone of health policy in Cleveland. But the corporate interests of these men often run against the health interests of the people of Cleveland. They direct the companies which have poisoned Lake Erie and made Cleveland's air a health hazard. They direct the banks which re- fuse to finance decent homes for poor peo- ple. They are members of the Chamber Union Story vidually, with a personal appeal for the hospital and against the union. Short- term employees are reached through the most sympathetic long term - workers. This, combined with judicious letters and selective pay raises, resulted in union defeat by 12 votes in 1968. Similar tactics have been used at UMC and the Cleveland Clinic. In 1968, James Harding, the Cleveland Clinic's administrator sent the following letter to all employees: " We are sure you are aware that for the past few months a'dues hungry'building service union has been pressuring Cleveland Clinic employees to sign cards... You should be warned that in an attempt to win an election and take over all Cleveland Clinic employees, this union will say anything and promise anything which it thinks will persuade you into voting it into power. When you read this slick union propaganda, always keep in mind that employees in another hospital who fell for the union found them- selves out on the sidewalk without a job, without pay, in a strike that lasted for nearly one year. " ' In Cleveland's public hospitals, the struggle was less protracted. In 1967, Local 1746 of the American Federation of State, County and Municipal Em- ployees (AFSCME) conducted a six month - strike at Sunny Acres Hospital (a public chronic care facility). Rather than face strikes at the two remaining public hospitals (Metro and Highland View), the county government recognized the union for all three hospitals. In 1969, nurses at St. Vincent's Hospital fought to get the Ohio Nurses'Asso- ciation recognized as their bargaining agent. Concerned primarily with issues of working conditions and " dignity ", the nurses walked out. For two months, St. Vincent's administrator refused to recognize the Ohio Nurses'Association, until City Council forced capitulation by passage of the Cleveland Labor Relations Law. Responses to these organizing efforts have consistently met with bitter oppo- sition. Striking non professionals - got little or no support from their professional co workers - . Professional associations did not want to be linked with " workers struggles ". j one ^ Jot doctor supported the striking nurses at St. Vincent's. White workers were separated from black workers. Out of the 450 striking workers at St. Luke's, 448 were black. These divisions maintained through racism, sexism and professionalism stood the hospitals in good stead. 17 of Commerce which consistently lobbies. for lower corporate taxes, hence inade- quate Medicaid and underfinanced pub- lic health services. They direct companies whose indifference to workers'safety leads to hundred of industrial accidents each year in Cleveland. To them, hos- pitals do not represent health care insti- tutions so much as they represent concen- tration of wealth and real estate. Control over the city's health institutions is just one more way that these men control the life of Cleveland. High Society: The power of the busi- ness oligarchs in the city is economic, and is based on their institutional positions as top officers and directors of leading cor- porations. " High society " members of the health establishment, on the other hand, derive their civic importance simply from who they their are - family and so- cial connections, their membership in ex- clusive clubs, etc. Their names appear- not in the business section of the paper- but in the " society " section, in Cleve- land's Blue Book and the Social Register. They are Cleveland's cultural and social arbiters, whose influence extends from the symphony and the Garden Center to the hospitals, social service agencies and foundations. To be sure, many of the high society health leaders were once business oli- garchs or descended from families who made their fortunes in coal, iron ore, oil or shipping. Families such as the Boltons, the Oglebays, the Hannas, the Severan- ces and the Mathers, after making their fortunes, set out to make Cleveland a great cultural and medical capital of the mid- west. In many cases, their current descend- ents have sold - out their shares in the family corporation, but retain their con- trol over the family foundation, e.g., the Bolton Foundation, the Elizabeth Sever- ance Prentiss Foundation, or the various Mather and Hanna Trusts (all of which fund health servcies). They also sit on hospital and health agency boards, hav- ing " inherited " these positions along with the family wealth and social position. In the area of health, the old family - members of high society cluster, not sur- prisingly, around the University Hospitals board. The Humphrey / Hanna / Ireland family grouping has been mentioned. Another example is Severance Milliken (of the old Severance family as well as the Millikens) who sits on the Boards of University Hospitals, St. Luke's Hospital, and the Cleveland Development Founda- tion. Then there are the Boltons, for whom CWRU's nursing and dental schools are named. Mrs. C.C. Bolton was on the board 18 of University Hospitals until her death. last year, while Mr. C.B. Bolton (board chairman of the exclusive Hawken School, a prep school) served on CWRU's board. There are two other categories of health. leaders in Cleveland, both subordinate to business oligarch and _ society - dom- inated boards of trustees. These are men who lack economic or social leverage of their own, and are important only be- cause of the staff positions they occupy in health institutions or agencies. They are " professionals " -doctors and admin- istrators. They have power in the internal decision - making within their institutions: decisions about personnel, administration and medical services. But their long- range decision - making powers are limit- ed. The Promoters: These are the most visible day day - to - " operatchniks " of the health establishment. They participate in the decision - making of their own institu- tions, often spearheading new programs with high public relations output. They are involved in the doings of the Hospital Association and the Regional Medical Program. They consult with the Cleveland Foundation and the Welfare Federation and lobby at the State Capitol for favor- able legislation. They are the institutional representatives to the public eye. Among these leaders are Dr. Frederick Robbins, Dean of CWRU Medical School; Mr. Samuel Wittman, Associate Dean of CRWU Medical School; Mr. Stanley Fer- guson, chief administrator of University Hospitals; Mr. Sidney Lewine, administra- tor of Mt. Sinai Hospital. Although these leaders appear to have considerable in- dependence within their spheres, their ob- jectives and activities must conform to those of the trustees that comprise their boards. The front - men: These men are not truly health leaders at all, but they are easily mistaken for leaders. The best ex- amples are the directors of the City Health Department and of the Metropolitan Health Planning Commission. Both take flack from health consumers for unpopu- lar health policies, although both belong to essentially powerless agencies. For example, Dr. Frank Ellis of the City's Health Department is often blamed for the city's failure to staff the newly built west side health clinic. But it's not his fault that the city hasn't the funds to occupy the expensive new building. Witness his impotence when the mayor, last winter, subjected the Health Department to a dis- astrous 50 percent cutback. When Dr. Lee Podlin, director of the Metropolitan Health Planning Commission was urged by local activists to take a strong stand against UMC's threatened cutbacks in clinic ser- vices (due to inadequate Medicaid reim- bursement and the Trustees unwilling- ness to continue subsidizing poor people's medical care), he maintained a gentle- manly silence. " That isn't how things are done around here, " he said. Are the health leaders, specifically the businessmen and socialites, just a ran- dom collection of names, or do they com- prise a coherent establishment? There is no evidence that they sit down together periodically to hammer out health policy for the city of Cleveland. But there is evidence that they share an _ implicit health policy and that they use hospitals for their own narrow purposes. These points are well illustrated by two case examples: the role of Cleveland's health leaders in resisting prepaid group prac- tice and in promoting urban renewal. Community Health Foundation The Community Community Health. Foundation (CHF) was founded in 1962 by the steel- workers ', painters ', plumbers ', retail clerks ', meatcutters ', machinists ', and au- tomobile workers'unions. It was con- ceived as a traditional prepaid, group practice program providing doctor's of fice and home visits, hospitalization and limited psychiatric care but excluding dental care and drugs. Membership in a group, usually a union, was prerequisite for joining. For the average Clevelander, prepaid group practice represented a real improve- ment in health care delivery. It meant that medical care could be obtained with- out regard to its cost and that preventive check - ups were encouraged. The entire family could be cared for under one roof, with a continuous medical record from doctor's office to the hospital, and an end to fragmented health services. CHF was designed to make minimal reforms, but not to solve the major shortcomings of the American health system, such as the availability of health care for the poor. (See November, 1970 Health - PAC BULLE- TIN for analysis of prepaid group prac- tice.) Nonetheless Cleveland's " health establishment " resisted its development strongly. The first sign of resistance occurred in June, 1962. After eleven months of nego- tiations between consultants hired by the unions and UMC, the word came down: UMC would not affiliate with CHF. This came as a shock to those associated with CHF. The negotiations had proceeded well, with considerable support from most of the chiefs of service at University Hos- pital, including Dr. Robert Ebert, then chief of medicine, now dean of Harvard Medical School. Although there was some dissension among the doctors, none wish- ed to block the program. The proposal was novel. CWRU was to be the site of the first prepaid group practice program affiliated directly to a medical school. (Since that time, many medical schools have established such programs, includ- ing Harvard). For CHF the benefits of a medical school affiliation were clear. First, it would guarantee high quality medical practice, at least as defined by the med- ical school. Second, perhaps more im- portant, it would assure adequate physi- cian manpower for the program. And third, it would guarantee a back - up hos- pital for CHF admissions. For the medical school, a prepaid group practice provided a convenient " captive " population for teaching, as well as the opportunity to shift the focus of medical student and house staff training from purely hospital - based medicine to out- patient medicine medicine.. The importance of finding a " new " teaching population was uppermost to those like Dr. Ebert who favored Medicare and other national health insurance programs which, by providing new medical opportunities for indigent patients, threatened to eliminate their traditional use as " teaching ma- terial. " Why then did UMC turn CHF down? In part, UMC refused because the decision was not left up to its chiefs of service. Apparently, the issue reached University Hospitals'Board of Trustees. Two reasons are commonly given to explain the Board's negative response. The first re- solves around George M. Humphrey, one of the most prominent members of the Board. Humphrey had drawn up the con- stitution and by laws - of University Hos- pitals in 1920. Shortly thereafter he be- came President of the M.A. Hanna Com- pany and in this capacity, developed a strong anti labor - bias, which he often expressed while later serving as Eisen- hower's Secretary of the Treasury. CHF had been initiated and funded by labor unions. Humphrey wasn't about to let " his " medical center affiliate with a union- dominated health plan. The clincher, however, was the drop in donations to UMC's $ 54 million expansion program. In April, 1962, UMC announced a dramatic building program which in- cluded new nursing, dental and medical school buildings. Shortly thereafter, news about the potential UMC - CHF affiliation was leaked to the press. Conservative alumni and other potential funders ap- parently withdrew their support from UMC's expansion drive. When it was all 19 over, CHF was told by one UMC spokes- man, " You've cost us over $ 2 million al- ready without even affiliating. " UMC's refusal to affiliate with CHF was a severe blow to the newly incorporated - organization. Planning Planning and year operating goals were set back by one year at least. The whole project appeared in jeopardy. Despite the risks, the labor unions back- ing CHF insisted that plans move forward. On July 4, 1964, CHF opened the doors of its new outpatient building located on the east side. Capital for construction had been raised through loans amounting to $ 500,000 from the unions and $ 650,000 from Central National Bank. The health plan grew rapidly. Within four years, membership passed 30,000. A second out- patient facility was opened in Parma, a southwestern suburb of Cleveland. But CHF was plagued with economic problems. Many of these stemmed from the lack of a CHF owned - hospital. As hospital costs leaped upward in the post- Medicare era, CHF was unable to negoti- ate the same reduced hospitalization rates as Blue Cross. CHF ended up pay- ing as much as $ 176 / day for patients hospitalized at University Hospitals. Fur- thermore, Blue Cross lagged in raising its premiums so that, to remain competitive with Blue Cross, CHF had to postpone needed increases in its own subscriber premiums. The final economic straw was the purchase of a proposed new hospital site in Independence, Ohio (south of Cleveland) for $ 400,000. After buying the land, the town unexpectedly denied CHF the necessary zoning clearances. Rising economic problems threatened. CHF with extinction. Cleveland's business and society " health leaders " now had the opportunity to rescue the program. Its dramatic growth had demonstrated CHF's vitality. But the banks closed their doors. Even Central National, which had advanced the original loan to build the east side center, reneged on its promises to help finance the new hospital. CHF was forced to turn outside the Cleveland community for help. In 1968, CHF sought the aid of the multi- million dollar west coast Kaiser Founda- tion Health Plan (with 1970 revenues of $ 313 million). After several months of negotiation, an agreement was reached. Kaiser offered $ 3.5 million to construct a CHF hospital in Cleveland, in return for virtually complete control of the pro- gram. CHF became the Kaiser Community Health Foundation (KCHF) and Kaiser demanded that of the new nine member board six seats be reserved for Kaiser. Until the merger with Kaiser, CHF had a decidedly local flavor. Although it had been established with the aid of nation- 20 wide consultants, CHF had been initiated and controlled by local Cleveland labor unions. This had given CHF a measure of subscriber control. With the entry of Kaiser, and its persistent opposition to any form of subscriber control, CHF lost its independence. Industry now controlled KCHF and would operate it like the " busi- ness " that most prepaid group practice is about (see Health - PAC BULLETIN, No- vember, 1970). The case of the Community Health Foundation illustrates how Cleveland's " health leadership " has thwarted the de- velopment of improved forms of health. care delivery through prepaid group prac- tice. These same forces have collabo- rated in using hospitals for their own. ends, in the second case presentation: Cleveland urban renewal. For it is here, that Cleveland's major hospitals became pawns in a larger enterprise - black re- moval by white institutional real estate interests. Urban Renewal Since the mid 1950's -, the central part of Cleveland's east side has been almost entirely black. Blocked from settling in better neighborhoods, blacks coming from the South were forced to crowd into al- ready deteriorated areas, like Hough, Central and Glenville on the east side. Rising black unemployment in the late fifties and early sixties led to more crowd- ing and further deterioration. The slums extended from the heavy industrial flats. around the Cuyahoga River and _ the downtown commercial district on the west, to the university and upper class suburbs on the east. As early as 1954, Cleveland's top busi- ness leaders, the heads of Republic Steel and Cleveland Electric Illuminating Com- pany (the chief utility), decided to take action to save the city from " blight " as they called it. First, they formed a non- profit corporation, the Cleveland Develop- ment Foundation (CDF) to promote urban renewal in Cleveland. With over $ 1 million in contributions from Cleveland's top 83 firms and a $ 5 million grant from the Hanna Fund, CDF was supposed to pro- vide " seed money " and planning assist- ance to the city government's urban re- newal agency. Actually, CDF quickly supplanted the city and became a kind of private " government " for urban renewal. In addition, the University Circle Devel- opment Foundation (UCDF) was founded in 1957 to concentrate on redevelopment of CWRU and UMC and their environs. Trusteed by top board members from University Hospitals, Case and Western Reserve Universities and initiated by a grant from the Mather family, UCDF rep- resented the same interests as CDF. The pattern of urban renewal under- taken by the two development founda- tions strongly suggests that they shared a common strategy to reclaim the east side from the blacks. First, urban renewal on the east side has been primarily used to create land for industrial, commercial and institutional re use -, not for low - in- come housing. Second, the urban renewal projects comprise a dumbbell - shaped area. At one end is Erieview, the CDF- sponsored downtown renewal project, slated for office buildings, luxury apart- ments, malls and fountains; at the other end is University Circle, developed over the last ten years into a gleaming island of cultural institutions. Along the bar of the dumbbell lie the University - Euclid renewal project, the Cleveland Clinic and Cleveland State University. Just south of the bar is St. Vincent's Hospital's urban renewal area. A former top staff member of CDF ad- mitted that this arrangement was not acci- dental, but the result of a conscious stra- tegy (a " planning concept, " as he put it). That strategy was, first, to build up two white dominated - enclaves at either end of the east side Erieview - on the northwest and University Circle on the southeast and then connect these en- claves by a white corridor running through the ghetto. The Hospitals were willing instruments. in the implementation of this strategy: St. Vincent's, with planning funds from CDF, displaced over 1200 families, 95% of them black, to make room for luxury high- rise apartment buildings. When no de- velopers could be found for the high- rises, the land was sold, at reduced rates, to Cuyahoga Community College, to the Boy Scouts and the Salvation Army for new headguarters, and to some lesser vol- untary agencies. At the outset of the proj- ect, St. Vincent's board chairman de- scribed the project's relation to CDF's overall plans with touching humility: " We admit that Charity Hospital [St. Vincent's] represents but a small part of this broad development picture. The hos- pital is but a tiny plot of ground, 10% of the area involved in the entire plan [the entire St. Vincent's plan]. But in our small way we wanted to be part of this movement to reawaken the heart of Cleveland. " Cleveland Clinic in the early sixties, revealed its plans to expand four blocks along Euclid Avenue (the main artery of the " white corridor ") and cover a total of seven square blocks. By 1965, it had ac- quired all but 25 percent of the needed land, and began to look to urban renewal as a way of getting the rest. The clinic pro- ceeded to hire a full time - urban renewal coordinator and arranged with UCDF to get a piece of the University - Euclid proj- ect pie. The Clinic set up its own multi- institutional development foundation in- cluding the Health Museum, Women's Hospital (a small voluntary hospital) and the Harshaw Chemical Company, which was planning to build a research lab in the area. Since then, the Clinic has decided that urban renewal meant " too much red tape, " and returned to its private land grabbing - operations. This meant that, instead of having the right of eminent domain to displace die hard - landowners, the Clinic has, according to residents of the area, resorted to intimida- tion to secure the last little lots. Even though the Clinic has broken off its plans to work directly with UCDF on the Uni- versity - Euclid project, it retains ties to UCDF. The present director of Cleveland Clinic's expansion program Neil Car- others, is the former president of UCDF. (Prior to that he was an executive of the construction firm which did most of the re building - of University Circle for UCDF.) University Hospitals and the CWRU medical school were not simply instru- ments of the overall strategy. As key in- stitutional members of UCDF they were, in effect, co conspirators - . The boards of University Hospitals and the University are closely interlocked with those of CDF and, of course, UCDF. University Hos- pitals and the medical school, which to- gether garnered over half the funds spent on University Circle redevelopment, must be considered chief beneficiaries of UCDF's implicitly racist policies. When UCDF went into business in 1960, then president - Neil Carothers, ex- plained: " " On On several several sides University Circle has fine stable neighborhoods, but on other sides are badly deteriorating. sections where crime and disease are sky- rocketing. And no apple stays good when there are bad apples around it... Some- thing had to be done. [UCDF's] 20 year - development plan is the answer. " UCDF's short - term answer was to hire a private police force to keep the " crime and disease " out of University Circle. proper. Its long term answer was the Uni- versity - Euclid urban renewal project. Os- tensibly designed to rehabilitate slum housing, the project actually worked to force out the slum dwellers. By 1966, only 11 percent of the homes slated for re- habilitation had had even perfunctory re- pairs. Hundreds more home were destroy- ed to make room for commercial and institutional building, forced people to crowd even more tightly into the remaining dilapidated structures. Then, because the area was slated for urban renewal, the 21 city suspended enforcement of housing. codes and cut back on garbage and police services; landlords cut back on home maintenance. Rats multiplied, garbage piled up, and disease spread - right on the doorstep of Cleveland's most pres- tigious medical complex. It was UCDF's " gift " of urban renewal to the people of Hough that set the stage for the week- long riots of 1966. The net results of Cleveland's east side urban renewal projects, for which the medical institutions deserve SO much credit, can be summarized quickly: * Twice as many housing units were destroyed by urban renewal aass were built, leaving Cleveland with a severe housing shortage: Cleveland now has 55,000 substandard housing units and the number is growing every year, but the city's vacancy rate is a dangerously low 1.5 percent. * Over 4500 families, almost all black, were displaced by urban renewal. Only 40 percent of these were relocated by government agencies, the other 60 per- cent had to fend for themselves. Of those who were " lucky " enough to be relocated by the city, 56 percent were sent to areas which were already over 90 percent black; 89 percent to areas which were over 50 percent black. The St. Vincent's and University - Euclid projects were re- sponsible for most of the displacement. Cleveland's program is the classic case of urban renewal as black removal. Thomas Westropp, president of a minor Cleveland bank, said in 1970: " For some, the urban renewal program has worked very well indeed. Hospitals and educa- tional institutions have been constructed and enlarged. So have commercial and industrial interests and many service or- ganizations all with the help of urban renewal dollars. With respect to housing, however, the urban renewal program has been a disaster... I wish I could believe that all of this was accidental and brought about by the inefficiency of well- meaning people - but I just can't. The truth, it seems to me, is that it was plan- ned that way. " The history of Cleveland's urban re- newal programs illustrates how the city's health establishment, both business oli- garch and socialite, uses health institu- tions to advance their own interests. Cleveland's east side " blight " (read blacks) had to be cleared to preserve the city's downtown office center and uni- versity cultural area. Through the pro- cess, Cleveland's major east side medical institutions became " real estate empires, " as well as medical empires. The story of the Community Health Foundation suggests that these same health leaders have retarded the devel- opment of health reforms (however limited) for more than the poor. As a prepaid, group practice program, CHF serves predominantly unionized workers Lboth black and white. Yet CHF has met with persistent, if not overt, resistance from various elements within the health establishment. Both case examples, point to the exist- ence of a health establishment beyond the hospital administrators, the deans, the heads of planning agencies and health departments. There is no reason to believe that the interests of this health establishment coincide with the interests of the majority of Cleveland health con- sumers. To a man and to a woman, Cleveland's elite does not live in the city proper, but in the eastern suburbs. None of them uses the hospital clinics, the wards, the smaller hospitals and the pre- paid group practice that the average Clevelander must depend on. In fact, there are reasons to believe, that the in- terests of the health establishment actu- ally conflict with those of the average Cleveland health consumer. The former looks to a health institution as a source of prestige or as a block of real estate; the latter looks to it as a source of basic survival services. The same " boss " on the job is ultimately " boss " of the health sys- tem. For in Cleveland, perhaps more clearly than in any other American city, the health establishment is the city's " ruling class. " - Cleveland Women's Health Research Group THE AMERICAN HEALTH EMPIRE: POWER, POLITICS, AND PROFITS A REPORT FROM THE HEALTH POLICY ADVISORY CENTER The book is published by Random House and available at your bookstore in hard cover for $ 7.95. The Vintage Paperback is $ 1.95. 22