Document JQBY76pRNeR5pKgoBx5g7YGe

HEALTH / PAC BULLETIN BULLETIN Policy Health Advisory Center February No. 62 January / 1975 1 Sterilization: WOMEN FIT TO BE TIED. Medical abuses are consistent with US government policy. 7 Health Manpower: BIGGER PIE SMALLER PIECES. The growth of health workers has far outstripped most industries. 14 Media Scan: Psychoanalysis and Feminism. Juliet Mitchell. 24 Vital Signs Sterilization WOMENF ISTt erilization abuse is not the exception but TO BE the rule. It is systematic and widespread. TIED Women are often misled about the dangers of surgery, misinformed about its perma- nence and coerced while under the stress of labor or abortion. Newspapers abound with horror stories of abuses in the health system Medicaid - Mills, nursing home ripoffs, profiteering in the drug industry, unnecessary surgery and clinical research on unknowing public patients. Gen- erally these instances are treated as illegit- imate, illegal aberrations of an otherwise de- cent health care system. Bill Plympton Yet any careful examination of these so- called abuses would reveal that each can be causally connected to particular aspects at the core of our health system. For example, Medicaid Mills and nursing home scandals are the literal extensions of Medicaid and Medicare financing (see BULLETIN, Septem- ber October / , 1974), while drug company profiteering is the consequence of a health system that allows and encourages profits to be made from human misfortune. The fee for- - service system with its concomitant lavish remuneration of surgeons is the only possible explanation for all the unnecessary surgery performed. The abuses of clinical research are a function of the imperative of the med- ical system that often sets teaching and re- search before patient care. Sterilization abuse stems from a combina- tion of factors inherent in the health system plus one critical additional factor. Besides resulting from teaching and research imper- atives, profitmaking and the fee service - for - system, such abuse is the most widespread ex- ample of medicine as an instrument of social control. Sterilization is the most extreme form of birth control and birth control is official US government policy. In 1973 there were about 500,000 sterilizations performed on American women. (1) How It's Done Female sterilization is accomplished by either tying, obstructing or removing the Fal- lopian tubes (tubal ligation) or by the re- moval of the uterus (hysterectomy). (2) Tribal ligations are done by either traditional sur- gical techniques, reaching the tubes through the vagina or the abdomen, or by the newer endoscopic procedures, in which a tiny in- cision is made in the abdominal wall and the tubes are cauterized or clipped. The tradi- tional surgical procedure requires a two - or three - day hospital stay, while the endoscopic methods can be performed on an outpatient basis. None of the sterilization methods is innocu- ous. Each procedure is associated with some physical and psychological side effects. Esti- mates of mortality and morbidity are widely varied, but there is general agreement in the medical literature that some risk is attendant to each procedure. The method of postpartum sterilization most commonly employed in the US is surgical ab- 2 dominal tubal ligation performed within 48 hours of delivery. Because the peritoneal cavity must be entered, this procedure is classified as major surgery. The mortality rate from this operation is 25 per 100,000 women. (3) It is associated with a postopera- tive morbidity of from 2 to 4 percent, pri- marily from infection or bleeding. (4) The The mortality rate from surgical tubal ligation is 25 per 100,000 women. endoscopic method most commonly used is laparoscopy, in which a needle is inserted into the abdominal cavity, through which carbon dioxide is pumped until the abdomen becomes taut and the Fallopian tubes are caught with forceps and cauterized. The death rate following this operation is vari- ously estimated to be from 14 to 30 per 100,000 women. (5) There are fewer serious side ef- fects than with the other common sterilization methods, but from 1 to 2 percent of women experience bleeding, uterine perforation, ac- cidental burning or bowel trauma. (6) Less serious physical side effects include abdom- inal pain or pain during menstruation (20 to 30 percent (7)) and increase of menstrual bleeding (from 10-40 percent). (8) Psychosexual complications from female sterilization are widely reported. A 1973 study shows that the actual prevalence of re- gret among sterilization patients may be as high as 25 percent. (9) Another recent study reported that " about 40 percent of pelvic op- erations in women may be followed by a condition having certain features characteris- tic of agitated depression beginning about one month after the operation and lasting more than six months. " (10) As long ago as 1965 a report appeared in Obstetrics and Gynecology noting that " A year after the op- eration, successful emotional adjustment seems to be correlated, in a majority of women, with the presence of one striking un- realistic fantasy: the ability to become pre- nancy [sic] again! " (11) The complication rate resulting from hysterectomy is 10 to 20 times higher than that associated with tubal ligations. (12) Death from this major surgical procedure oc- curs 300 to 500 times for every 100,000 op- erations. (13) Similarly, morbidity is much higher from hysterectomy than from other sterilization techniques. One study found a 22 percent morbidity rate, while other estimates range from 10 to 34 percent. (14) While a hysterectomy is by far the more dangerous sterilization method, it has the ad- vantage of being 100 percent effective, as op- posed to a tubal ligation, which will fail one out of every hundred times. (15) The risks of tubal ligation become more significant in light of comparable risks and benefits from other types of birth control. The 1 percent fail- ure rate of the pill is the same as that of tubal ligations while IUD's fail in about 2 percent of cases. (16) The other mechanical contra- ceptive techniques are considerably less suc- cessful in preventing pregnancies. However, the physical and psychological risks associ- ated with birth control methods short of ster- ilization are minimal compared with those of tubal ligations or hysterectomies. The pill is held responsible for one death in 200,000 users. (17) Yet in 1970 the Food and Drug Ad- ministration became so concerned over the potential dangers of the pill that it required every prescription to be accompanied by warning literature. (18) Sterilization on the March Sterilization is both the most dangerous birth control method and the fastest growing. The most comprehensive sterilization sta- tistics are prepared by the Association for Voluntary Sterilization AVS (). Though these estimates must be read skeptically because of the vested interest of AVS in promoting ster- ilization, the trends they reflect are compar- able with those seen in other reports. Since 1970 the figures show an almost three - fold increase in the incidence of female steriliza- tion, from 192,000 in 1970 to 548,000 in 1974. (19) Hospital and local surveys report sim- ilarly spectacular increases. At the Univer- sity of California - Los Angeles County Med- ical Center there was a 742 percent increase in elective hysterectomies and a 470 percent increase in tubal ligations in the two years from 1971 to 1973. (20) Dr. Richard Hausknecht reported that the number of sterilizations per- formed at Mount Sinai Hospital in New York City has increased 200 percent since 1970. (21) The situation as it was in 1970 is shown in the National Fertility Study, conducted by the Office of Population Research of Prince- ton University under a grant from the US De- partment of Health, Education and Welfare (HEW). (22) A total of about 1.43 million mar- ried American women under 45, who were neither pregnant, postpartum, trying to get pregnant or naturally infertile, were sterilized in 1970, (8.5 percent of this group). That average percentage increases from young to older, white to Black and educated to unedu- cated. Only 5.6 percent of college educated - white women were sterilized and 9.7 percent of comparable Black women. Among women with less than four years of high school, 14.5 percent of white women and 31.6 percent of Black women had been surgically sterilized. Relatively few women under 30 reported they were sterilized in the 1970 survey spe- cifically, 2.8 percent of white women and 5.0 percent of Black women under 30 had been sterilized. As would be expected, a larger proportion of older women had been steril- ized, specifically 8.4 percent of white women and 32.5 percent of Black women. There is much evidence to suggest that the increase in the number of sterilizations has fueled a trend toward the sterilization of younger women with fewer children. A re- cently published study of a large hospital in St. Paul, Minnesota showed that the ratio of tubal ligations to births increased from 1 9.2: in 1968-69 to 1 4.3: in 1971. (23) In the earlier period 19.7 percent of the women were under 25, whereas three years later 29.7 percent 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 6 times per year: Jan./Feb., Mar./Apr., May June /, July Aug /., Sept./Oct. and Nov./Dec. Special reports are issued during the year. Yearly subscriptions: $ 5 students, $ 7 other individuals, $ 15 institutions. Second - class postage paid at New York, N.Y. Subscriptions, changes of address and other correspondence should be mailed to the above address. New York staff: Barbara Caress, Oliver Fein, David Kotelchuck, Ronda Kotelchuck, Louise Lander and Howard Levy. San Francisco staff: Elinor Blake, Thomas Bodenheimer, Dan Fesh bach, David Landau, Carol MZrmey. San Francisco office: 558 Capp Street, San Francisco, Cal. 94110. Telephone (415) 282-3896. Associates: Robb Burlage, Morgantown, W. Va.; Constance Bloomfield, Desmond Callan, Nancy Jervis, Kenneth Kimmerling, Marsha Love, New York City; Vicki Cooper, Chicago; Barbara Ehrenreich, John Ehrenreich, Long Island; Judy Carnoy, San Francisco; Susan Reverby, Boston, Mass. BULLETIN illustrated by Bill Plympton. 1975. were 25 or younger. The median age of wom- en sterilized in federally financed family planning programs in 1973 was 28; 4 percent of such women were under 20 and only 38 percent were over 30. (24) Even among the relatively poor women served at these clinics racial disparities are apparent. More than half of the patient population was white, but only 40 percent of those sterilized were white. At the same time, about third one - of patients were Black, while 43 percent of the sterilized women were Black. Medicine Joins the Bandwagon The editors of Family Planning Digest, the official publication of HEW's National Center for Family Planning Services, wrote in 1974: " As US professional attitudes change, it is possible that we may see sterilization be- come as important in family planning in the fifty states as it already is in Puerto Rico. " (25) (Of married Puerto Rican women, aged 15 to 44, 35 percent are sterilized; two thirds - of the women are under 30. (26)) Surveying the attitudes of mainland doctors, particularly gynecologists, it is difficult to see how much further in that direction they could change. Official accommodation to liberalization of sterilization practices in the US came in 1969, when the American College of Obstetricians and Gynecologists (ACOG) withdrew its age- parity formula. (27) by this rule of thumb sterilization could only be performed on a woman whose number of living children mul- tiplied by her age equalled 120, as, for ex- ample, a woman age 30 with four children. In 1970, the ACOG dropped its widely used recommendation that the signatures of two doctors plus a psychiatric consultation be ob- tained prior to performing a sterilization. Dr. Don Sloan, Director of Psychosomatic Med- icine at Metropolitan Hospital, a municipal institution in New York City, used to receive two or three referrals per day; since 1970 he has gotten about one per month. The liberalization of sterilization guidelines opened the floodgates to abuse. Although some of the increase in the number of opera- tions performed is due no doubt to increased demand, much of it is the result of misinfor- mation and coercion. Women are often con- vinced to undergo sterilization with a soft - sell pitch. Describing laparoscopies as " bandaid surgery " and calling tubal ligations " a stitch, " doctors minimize the dangers in- volved. As one noted, women find the pro- cedure more acceptable if the term " opera- tion " is not used. (28) Gynecologist / obstetricians are surgeons, and with the birth rate falling there are fewer and fewer opportunities to learn and practice their surgical skills. " The early'rewards'for doing more operations on the poor and disad- vantaged in the form of residency certifica- tion and specialty board qualification are translated, after training, into financial re- wards wherein, the more you cut, the more money you make, " noted one report. (29) Many young gynecologists in training have united their professional needs and their political ideas. Two recent surveys are revealing. Doctors were polled about their at- titudes towards contraception for public ver- sus private patients. Of the doctors queried in Detroit, Grand Rapids, West Virginia and Memphis only 6 percent said they would rec- ommend sterilization as the method of choice to their private patients but 14 percent chose sterilization as the first method they would push with public patients. Additionally, 94 percent of the gynecologists favored com- pulsory sterilization of welfare mothers with three illegitimate children. (30) Sterilization is pushed for low income - and welfare women because many doctors believe that the poorer the woman, the less likely she is to use other methods successfully. (31) It can at least be argued that a tubal liga- tion is relatively simple, cheap surgery. Hysterectomy is not. But there has been a tremendous upsurge in the number of hys- terectomies for the purpose of sterilization, or hystersterilizations, as the procedure is euphemistically called. The acting director of OB GYN / at a municipal hospital in New York City reported. " In most major teaching hos- pitals, in New York City, it is the unwritten policy to do elective hysterectomies on poor Black and Puerto Rican women, with mini- mal indications, to train residents.. At least 10 percent of gynecological surgery in New York City is done on this basis. And 99 percent of this is done on Blacks and Puerto Rican women. " (32) The same situation pre- vails at other public hospitals. An OB GYN / resident at Boston City Hospital commented: " We like to do a hysterectomy, it's more of a challenge. *.. You know, a well trained - chimpanzee can do a tubal ligation... and it's good experience for a junior resident... good training. " (33) A staff doctor at Los An- geles County Hospital contributed to a dis- cussion by saying: " Let's face it, we've all talked women into hysterectomies who didn't need them, during residency training. " (34) Training imperatives and political atti- tudes account for some of the increase in hys- terectomies. A third, compelling reason, is greed. At Albert Einstein Medical School's College Hospital in New York, a hysterec- tomy will cost 800 $, while a tubal ligation costs about $ 250. Some private doctors get as much as 1,000 $ to perform a hystersteril- ization. (35) Dr. Rosenfeld points out that " Once the doctor sells a woman on steriliza- tion, it is easy to move it up to a hysterec- tomy. " (36) Patients who ask about the effect of a hysterectomy on their sex life are told cavalierly at one major hospital in New York City, " We'll take away the baby carriage, but we'll leave you the playpen. " (37) Signing on the Dotted Line Sterilization is unlike every other form of birth control. It is for all intents and purposes irreversible. A woman making a decision of this magnitude should have access to all per- tinent information concerning the risks and benefits and the ability to make the decision in an atmosphere free of coercion. This is rarely, if ever, the case. A sterilization consent form is frequently thrust in front of a woman while she is in the midst of labor. A resident at LA USC - Hospital said, " I used to make my pitch while sew- ing up the episiotomy when the anesthesia started wearing off. " (38) According to an- other doctor at the same institution, " Some house staff would routinely ask women if they wanted their tubes tied during labor. " (39) Sterilizations are also performed concur- STER TATION Bill 510 rently with abortions, with all the attendant trauma that that procedure entails. (40) One indication of sterilization's acceptability to those who are truly informed is demon- strated by a 1972 study conducted by Albert Einstein College of Medicine. Surveying birth control practices of obstetricians and their wives, the study revealed that 4 percent of these women were sterilized, as compared to 12 percent of a comparable group of white women in the general population. (41) Others Join the Chorus The most common source of information re- garding sterilization is the booklet " Volun- tary Sterilization for Men and Women " pre- pared by Planned Parenthood - World Popula- tion (WP PP -). (42) There is no mention at all in the booklet of the potential risks or disad- vantages of sterilization. In fact, the impres- sion promoted is all wine and roses: " Women can't detect any difference from before the operation. Actually, they often find sex is more " We'll take away the baby carriage, but we'll leave you the playpen. " a pleasant because there is no reason to worry about becoming pregnant. " Not only does the pamphlet ignore any discussion of the poten- tial for severe psychological problems, as discussed previously, but it never even men- tions the physical risks nor does it compare the efficacy of tubal ligations with other forms of birth control. The sterilization booklet is inadequate even by comparison with other Planned Parent- hood literature. The booklets on the pill and IUD's at least mention some of the risks in- volved and suggest that women ask their doctors for additional information. The ster- ilization booklet is incomplete and mislead- ing to a dangerous degree. There is evidence that the necessary mod- ifications of the Planned Parenthood booklet would not discourage those who were actu- ally seeking sterilization with a full under- standing of its implications. The argument that couples seeking sterilization will be " scared off " or become " unnecessarily wor- 6 ried " by informed consent is questionable. Dr. F. J. Hulka of the University of North Carolina ' School of Medicine recently wrote concern- ing counseling of couples applying for steril- ization: " If they have had two children and are in their mid - 20s, an increasingly common pattern, I ask if they know that abortions are available. These couples are often worried both about pregnancies and surgery but are willing to have surgery because they fear pregnancy more. We tell them that if, despite use of their contraception method, pregnancy occurs, we will terminate this unwanted preg- nancy and do a tubal ligation at the same time, as an out patient - procedure. Very few couples are dissuaded from elective steriliza- tion by this offer, however, because most pa- tients seeking sterilization will not contem- plate even the possibility of pregnancy. ' Please stop our worry now,'they plead. " 43 () Even if it were established, however, that full information would " scare " potential ster- ilization patients, it is clearly their decision to make for their own reasons, whether their fears be grounded in medical fact or not. The professionals'argument evidences a pater- nalism that has been characteristic of the physician - patient relationship almost since its inception. The efforts of Dr. Bernard Rosenfeld to al- leviate the shortcomings of the Planned Par- enthood booklet are documented in corres- pondence between him and Dr. A. J. Sobrero, permanent member of the PP WP - National Medical Advisory Committee. Concluding the correspondence, Dr. Sobrero wrote: "... none of Planned Parenthood's materials is supposed to assume the burden of informing the prospective client of the benefits, risks, effectiveness, and mode of use of any meth- od of contraception.... Again let me stress that none of the printed material has been prepared nor is being advocated for use for informed consent. " (44) The Planned Parent- hood booklet, however, is the only source of information available to patients at many public hospitals. (45) (In response to the criticism mounted by Dr. Rosenfeld and others, the Planned Parenthood book has re- cently been revised, but the tone of the pamphlet has not changed.) Indicative of the pervasive misunderstand- ing concerning sterilization is the discussion in Our Bodies, Ourselves, the otherwise care- fully written book published by the Boston Womens'Health Book Collective. (46) The dis- Continued on page 10 1 GROWTH OF HEALTH & TOTAL LABOR FORCE 900 f~ 1900-1970 1900 === 100 800 1. 700 | 600 = Health Health Labor Force 500 ma 400 r 300 | 200 .. 100 1900 Total Employed Labor Force ia 1970 Health Manpower Health care is one of the largest and fast- BIGGER est growing - sectors of the American econ- PIE omy. In 1971 there were about 4.5 million SMALLER PIECES people working in hospitals, nursing homes, doctors'offices, health departments and clin- ics. (5) This total represented more workers than those employed by the auto and elec- tronic industries combined. EMPLOYMENT IN THE PRIVATE SECTOR: SELECTED INDUSTRIES 1960-1972 in (thousands) .1960 1965 1970 1972 Total Mining. Construction Electronics Auto 54,234 712 2,885 1,467 724 60,815 634 3,186 1,659 843 70,593 623 3,381 1,917 797 Health Services * 1,548 2,080 3,057 * Does not include those employed by government. 72,764 607 3.521 1,833 861 3.442 Source: Statistical Abstract of the United States, 1973. The continuing shift of focus of health - care delivery from solo practice - doctors to institu- tional settings provides the framework within which to understand the growth and develop- ment of the health - care workforce. Following the course of industrialization in the manufac- turing sector, the health - care industry in- creasingly depends upon semi skilled - and unskilled workers. Contrary to popular per- ceptions, the bulk of health workers today are not doctors and nurses but aides, orderlies, attendants, maintenance and kitchen work- ers. This has not always been the case. From Little Acorns The size and composition of the health labor force has shifted considerably over the last 70 years. It has constituted an ever - in- creasing share of the civilian labor force. At the turn of the century there were about 331,000 people in the various health occupa- tions, comprising about 1 percent of the civil- ian labor force. (2) One third - of these were doctors, one third - nurses, attendants and midwives and the remaining third were vet- erinarians, phamacists, dentists and lens makers and grinders. (The Census Bureau then included " healers and therapists " in its 7 count of doctors.) Except for the attendants, health workers were self employed - , offering the public treatments and cures of one sort or another. (4) There were few health institu- tions, and these were reserved for the sick and dying poor with chronic or selected in- fectious disease. Medical care was disbursed in the home, barber shop, office or sideshow. By 1930, at the beginning of the Great De- pression, employment in health occupations had crept up to about 2 percent of the labor force. (2) The distribution of health workers had changed radically from the beginning of the century. Doctors dropped from one third - to one fifth - of health workers, while dentists, veterinarians and chiropractors now made up about one fourth - . Nurses comprised the largest group of workers, but they had been split into two categories of about equal size-- registered nurses, those licensed by the states, and unlicensed nursing personnel. During the decade of the Depression health employment increased from 815,106 879,962 to at the same time that the total employed la- bor force was declining. Today the health - care workforce is com- plex and highly stratified, including the high- est paid - group of workers in the US and some of the lowest paid. In 1971, health services employed about 5 percent of the civilian la- bor force. (5) Nursing personnel were the largest single group of health workers, about 2 million. There were about 750,000 regis- tered nurses (RN's), 427,000 licensed practical or vocational nurses (LPN's) and about 800, - 000 aides, orderlies and attendants. Although the number of physicians tripled between 1900 and 1971, they today comprise only 7.5 percent of the health care labor force. (2,5 2,5) Industrializing the Health Workforce In 1930 less than one third - of the health labor force worked in hospitals or other insti- tutions. Today the proportion is nearly two- thirds. (5 3,) The growth of the institutional workforce began accelerating after the Sec- ond World War. In 1946 there were 830,000 hospital workers; now there are over 2.5 mil- lion. (2, 3) Concomitant with the increase in the num- bers of hospital workers has been the pro- liferation of job categories and professions. Greater New York Blue Cross, for example, recently sent a form to its member hospitals 8 asking them to enter the number of people in different jobs. The form listed 280 titles, excluding physicians. A typical medium- sized general - care hospital with 300 beds employs 1,000 people. (3) If the 280 job titles were equally distributed among this work- force, there would be fewer than four people in each category. Even with the technolog- ical complexity of modern medicine, one is hard put to imagine 280 different and distinct tasks to be performed. There is necessarily considerable overlap in the work done by different people with different titles, incomes and status. Hospitals deliver a qualitatively different product from that of manufacturing plants. Nevertheless, their labor structures demon- strate parallels with that of other industries. Hospital administrators have their counter- parts in plant management, maintaining the operation and assigning the workforce. Doc- tors as salaried employees of health institu- tions perform similarly to plant engineers in terms of their roles and responsibilities. Like engineers, doctors design the product and generally oversee the work process. Regis- tered nurses, like shop foremen, supervise work at the point of production. Other nurs- ing workers, directly providing patient care, are roughly comparable to skilled assembly- line workers. It is they who are responsible for the day - to - day creation of the product. Finally, the unskilled institutional mainte- nance people (housekeeping, food services and laundry) are not only drawn from the same labor pool as unskilled manufacturing workers, but do nearly interchangeable tasks. This analogy between health care and manufacturing hides a critical distinction. Auto workers, for example, make cars, prod- ucts of rather dubious social value. But health workers, often in spite of the organ- ization of their workplace, deliver care. The content of their labor is considered by the rest of society to be worthy of the best of human endeavor. As a service industry, hospitals contain a far greater percentage of highly trained work- ers than do typical manufacturing enter- prises. But a large part of the hospital labor force is relatively unskilled. (7 5,) Clerical workers and institutional maintenance peo- ple account for nearly 40 percent of em- ployees. Only 4 percent of the hospital work- force are physicians. There are about the same number of physicians as there are PERSONS (THOUSANDS) 3,000 - 2,500 |_ SELECTED HEALTH OCCUPATIONS: 1900-1970 (Cumulative) 2,000 |. 1,500 echnicians a 1,000 a LPN's Attendants Vase 500 | \\ Be RNZ' s >. 4 0.8. Vets & Pharmacists Crey rrr 2 1900 cee ry 7s eee . aotere: Doctors Doctors Doctors estgprissrietiypensd PPE EEY Doctors 1950 1910 1920 1930 1940 Dentists ETT ERE UE ERED ED 1960 1970 maintenance men in American hospitals. The greatest concentration of hospital workers is in nursing services. They run the gamut from skilled (RN's and LPN's) to skilled semi - (aides) to unskilled (orderlies and attendants). Of all hospital employees 43.5 percent are RN's 16.2 (percent) or LPN's and LVN's (7.4 per- cent) or aides, orderlies and attendants (19.9 percent). The remainder of hospital workers are in clinical laboratory services (3.5 per- cent), clinical technology (3.2 percent), phar- macy (0.8 percent), administration (0.6 per- cent), dentistry (0.6 percent) and even smaller representations in other categories. The Last Ten Years Having created Blue Cross in the 1930's, hospitals assured themselves financial secu- rity and laid the foundations for industrial growth. After World War II, the growth of hospital laborpower was constant and steady. Incorporating a similar financing mechanism, Medicare and Medicaid have re- sulted in a growth rate that has been spec- tacular. The number of people employed in the health - care industry increased by more than 60 percent in the years 1965-71. (6 5,) This is 30 times the rate of growth of the population as a whole and 15 times faster than the growth of the civilian labor force. (1) Personnel costs have remained a constant percentage of hospital expenditures since 1965, about 60 percent. (3) Although such costs have been increasing, other costs have risen at the same rate. But net hospital in- come and net assets have increased far more rapidly. The total net assets of nonprofit gen- eral hospitals increased by slightly more than 90 percent between 1967 and 1973, com- pared with 79 percent during the seven years immediately before the implementation of Medicare and Medicaid. (3) Of the 13.5 $ mil- lion increase in hospital net assets $ 5.5 mil- lion was for new equipment. (3) The introduction of new technology into most industries makes them less labor in- tensive; more product can be produced with fewer workers. The reverse has generally been the case with hospitals. New technol- ogy in hospitals has necessitated the training and hiring of additional workers to operate or monitor the machines, while at the same time a full complement of staff is needed to maintain existing services. As a result the fastest growing - health occupations during the last decade have been technological or support workers. For example, while the total workforce was increasing by 60 percent, the number of electrocardiograph technicians grew by 79 percent. (5) Thus the last ten years have seen the accel- eration of the manpower changes evidenced in earlier decades. Most notable about the recent period has been the enormous expan- sion in the numbers of people employed in the health - care industry. Secondly, there is increasing concentration in institutional set- tings. And this institutional labor force is be- coming more and more fragmented and strat- ified into a multitude of professions and titles. -Barbara Caress References 1.2 .1 .U .SSt.a tDiesptiacratlm eAnbts torfa cHt eoafl tthh,e EUdnuictaetd iSotna taensd (W1e9l7f3)a.r e, Health Manpower Source Book: Allied Health Manpower, 1950- 1980 (1970). 3. American Hospital Association, Hospital Statistics: 1974 Edition (Chicago, 1974 1974). 4. William L. Kissick, " Health Manpower in Transition, " M53i-l9l0.b ank Memorial Fund Quarterly, XLVI (January, 1968), 5. National Center for Health Statistics, Health Resources Statistics: Health Manpower and Health Facilities 1972-73. 6. National Center for Health Statistics, Health Resources Statistics: Health Manpower and Health Resources 1968. 7. pHowEeWr Miann tphoew eHre aAltdhm iSneirsvitcrea tIinoduns,t rTye c19h6n5o-l7o5g yMa ya n(d , M19a6n7)-. eee Sterilization Continued from page 6 cussion of sterilization begins with the clearly erroneous statement that "... sterilization is " ... 100 percent effective... As indicated above, ten women out of every thousand who undergo tubal ligation for sterilization will become pregnant. The book suggests, as does the Planned Parenthood booklet, that sterilizations and information regarding them are available from the Association for Vol- untary Sterilization, a group confessedly more interested in population control than reproductive freedom. Most importantly, there is no mention in the book of mortality or morbidity associated with sterilization. Paying some deference to the possible psychological implications of vasectomies for men, the writer suggests that men who are anxious about the effect of a vasectomy upon their sexual performance "...... should not have vasectomies, because worrying about sexual performance is likely to impair a man's ability to have an erection, even though the production of sperm and male hormones continues. " Women, how- ever, receive less consideration. First, the au- thors include the testimony of one woman who experienced intense pre operation - fear of regret, but who subsequently was relieved " that she was free to proceed with her life. " There is no mention of the high rate of regret 10 associated with sterilization, especially if the decision is made by a patient under 30, made during a time of stress, based on possibly temporary financial circumstances or initi- ated by the physician. In the last situation, a regret rate of 32 percent has been docu- mented. (47) The importance of alerting wom- en to this possibility is evidenced by a find- ing reported in the American Journal of Ob- stetrics and Gynecology that most of the women who regretted the sterilization be- came frigid (June, 1964). Our Bodies, Ourselves compounds the error by suggesting as does the Planned Parent- hood booklet, that a woman's sexual response is not lessened at all by sterilization but in fact " usually improves as soon as she no longer fears pregnancy. " Finally, in stark contrast to the suggestion that a man who fears sterilization should not risk the possi- bility of altered sexual performance, women are told merely that they will " have to deal with their own deeply internalized feelings that someone who is infertile is inferior. " This summary treatment of sterilization is es- pecially regrettable in light of the 30 pages of the book devoted to an extensive discus- sion of almost every aspect of other contra- ceptive methods. Medicine as Handmaiden of Public Policy Doctors'attitudes toward sterilization and the misinformation about its impact stem from the same source: a clear - cut change in government attitude toward population con- trol. Though budget belt tightening - is today the byword for most government - financed health care, this is not the case for contra- ceptive services. On December 9, 1974, in im- plementation of amendments to the federal Medicaid law, HEW proposed to increase the federal contribution for birth control services provided to Medicaid recipients from 50 to 90 percent. And to further add to its expend- itures, HEW intends to transfer family plan- ning from optional to mandatory services, thus obliging every state to provide these services to every welfare woman. (49) The government's involvement with family planning has a long and checkered history. Fifty years ago, Margaret Sanger was jailed for demanding contraceptive services. Through most of the years that women fought for birth control and abortion, the govern- ment steadfastly opposed their efforts. (50) Today, however, contraception has been em- braced as a major ingredient of public policy. Open availability of birth control devices and accessibility of services is the result of two divergent perspectives. On the one hand, there are those who want birth control as a right and a matter of health, an important element in the demand by women for control of their bodies. But birth control is also an instrument of population control. For ex- ample, Dr. Curtis Wood, past President of the Association for Voluntary Sterilization, is an outspoken exponent of population con- trol: " People pollute, and too many people crowded too close together cause many of our social and economic problems. These, in turn, are aggravated by involuntary and ir- responsible parenthood. As physicians we have obligations to our individual patients, but we also have obligation to the society of which we are a part. The welfare mess, as it has been called, cries out for solutions, one of which is fertility control. " (51) Even more bluntly, a doctor who routinely performs sterilizations explained, " A resi- dent who was up the entire night with some woman, or a doctor who just got his income tax back and realized it all went to welfare and unemployment was more likely to push harder. " (52) One of the more spectacular applications of the population - control ideology involved an Aiken, South Carolina obstetrician / gyne- cologist who refused to deliver a third baby for a welfare mother unless she first submit- ted to sterilization. An investigation by the South Carolina Department of Social Services revealed that the doctor, Clovis Pierce, had performed 28 sterilizations during a six month - period. The investigation was initiated when Pierce tried to coerce a white welfare mother into accepting sterilization. Although Pierce was decertified by the Department and bar- red from providing obstetric services for Medicaid money, he is still permitted to re- ceive federal program grants for gynecolog- ical treatment provided to indigent patients. (53) His nurse commented that although the overwhelming majority of the patients ster- ilized had been Black, " This is not a civil rights thing, or a racial thing, it is just wel- fare. " (54) " The welfare mess, as it has been called, cries out for solutions, one of which is fertility control. " Dr. Curtis Wood, past President Association for Voluntary Sterilization. Asked about Pierce's policy, Dr. Wood, the man from AVS, said: " I admire his courage. I'm sympathetic to his point of view. How- ever, I question his method. After 30 years of delivering babies, I've found that if the doc- tor does a proper job of offering sterilization to these women (on welfare], a high percent- age of them would accept it. I have found that after three or four minutes of talking with them, they will accept it they - want the sex, but not the babies. " (55) As befits his station, John D. Rockefeller III, Chairman of the President's Commission on Population and the American Future, made the same point far more tactfully: " The Commission believes that slowing the rate of the population growth would ease the prob- lems facing the American government in the years ahead. Demand for government serv- ices will be less than they would be otherwise, and resources available for the support of education, health and other government services would be greater. " (56) Then President Nixon nominally rejected the Commission's report because it called for the legalization of abortion. The facts, how- 11 ever, tell a very different story. Between 1967 and 1973 federal support for family planning services increased more than 1,300 percent, from $ 11 million to 149 $ million. (57) Dr. Louis Hellman, Assistant Secretary of HEW for Population Services, estimates total federal expenditures for family planning between 1970 and 1975 at $ 1 billion. (58) Just as spectacular has been the growth of US spending for its birth control program abroad. The Agency for International Devel- opment (AID) increased its birth control pro- gram budget from $ 2.1 million in 1965 to $ 100 million in 1971. (59) In 1974 AID distributed 100 million birth control pills a month, paid for the insertion of innumerable IUD's and provided the money and manpower for count- less sterilizations. (60) " It is better for all the world if society can prevent those who are manifestly unfit from continuing their kind. " US Supreme Court Justice Oliver Wendell Holmes In the government's own words, providing birth control services is population control. Replying to a United Nations questionnaire on population policy, it said the United States ' policy was to actively provide the widest dis- tribution of birth control services. " This posi- tion, " the paper noted, " implies a policy de facto towards a further decrease in the rate of population growth. " (61) Lifting the parity formula and removing all formal impediments to sterilization, the American College of Obstetrics and Gyne- cology was bowing to the prevailing winds. Whether he knows it or not, the GYN OB / resident who said in defense of sterilization, " I just don't think it's good for them [welfare recipients] to drive around in a 1950 Chevy full of kids, " was an agent of government policy. (62) HEW's proposed changes in birth control services were capped off with a final twist, contained in the last paragraph. " Not in- cluded under this definition [of family plan- 12 ning services] are abortions performed either for therapeutic or non therapeutic - purposes. " (63) HEW is happy to pay 90 percent of the costs of sterilization, but not abortion. Compulsory sterilization of " incompetents " has long been a matter of law. Upholding a Virginia statute that allowed for the involun- tary sterilization of an institutionalized per- son when the state determined that such a procedure was in the best interests of so- ciety, Supreme Court Justice Oliver Wendell Holmes wrote: " Experience has shown that heredity plays an important part in the trans- mission of insanity and imbecility... the Public Welfare may call upon the best citi- zens for their lives. It would be strange if it could not call upon those who already sap the strength of the state for those lesser sac- rifices.... It is better for all the world... if society can prevent those who are manifestly unfit from continuing their kind. " (64) The line between voluntary and involun- tary sterilization is becoming thinner all the time. -Barbara Caress (Much of the initial research for this article was carried out by Nikki Heidepriem, a third year - student at New York University Law School. The conclu- sions of course are those of the author.) References 1. 1. Association for Voluntary Sterilization, Inc., " Estimate of Numbers of Voluntary Sterilizations Performed, " Novem- ber, 1974 mimeo () . 2. Cedric W. Porter, Jr. and Jaroslav F. Hulka, " Female Ster- ilization in Current Clinical Practice, " Family Planning Perspectives, VI Winter 1974), 30. 3. H. B. Presser, " Voluntary Sterilization: A World View, " Reports on Population / Family Planning, No. 5 (1970), 4. p. 1. 4. Porter and Hulka, op. cit., p. 37. 5. Ibid. 6. Ibid. 7. Lu and Chun, " A Long Term Follow - up Study of 1,055 Cases of Post Partum - Tubal Ligation, " Obstetrics British Commonwealth, Vol. 74, p. 875. 8. Ibid. 9. Whitehouse. " Sterilization of Young Wives, " British Med- ical Journal, June 19, 1971, p. 707. 10. Bernard Rosenfeld, M.D., " Female Contraception, " unpub- lished manuscript, 1974. 11. Barlow, Gunther, John and Meltzer, " Hysterectomy and Tubal Ligation: A Psychiatric Comparison, " Obstetrics and Gynecology, XXV April ( , 1965), 520. 12. Porter and Hulka, op. cit., p. 35. 13. Ibid. 14. Ibid. 15. 15. Presser Presser, op. cit cit., P. P. 9 16. Ibid Ibid. 17. Rosenfeld, Wolfe and McGarrah, " Health Research Group Study on Surgical Sterilization,'October 29, 1973. 18. J. B. Lippincott Company, " Hazards of Medication -- A Manual on Drug Interaction, Incompatabilities. Contrain- dications and Adverse Effects, " 1972. 19. Association for Voluntary Sterilization, op. cit. 20. " Sterilization: Despite Higher Risks, Some Doctors Still Prefer Hysterectomy to Tubal Ligation, " Family Planning Digest, II (January, 1973), 9. 21. Newsday, January 2, 1974, p. 4A. 22. Charles F. Westoff. " The Modernization of U.S. Contra- c1e9p72t)i,v e9 .P ractice, " Family Planning Perspectives, IV (July, 23. L. E. Edwards and E. Y. Hakanson, " Changing Status_of Status_of Tubal Sterilization: An Evaluation of Fourteen Years'Ex- perience, " American Journal of Obstetrics and Gynecol ogy, CXV (1973), 347. 24. Denton Vaughan and Gerald Sparer, " Ethnic Group and Welfare Status of Women Sterilized in Federally Funded Ftaimviels,y VPIl a(nFnailnlg, P1r9o7g4r)a,m s2 2P4r.o grams, " Family Planning Perspec- 2265. .I biFd.a mily Planning Digest, I (May, 1972), 6. 2287.. HMuclGkaar raanhd, P"o rtVeorl,u notpa.r yc iFte.m,a pl.e 3F0e.m ale Sterilization: Abuses, Risks and Guidelines, " Hastings Center Report, June, 1974, p. 5. 29. Ibid., p. 6. 30. " Physician Attitudes: MDs Assume Poor Can't Remember to Take Pill, " Family Planning Digest, I (January, 1972), 3. 31. " Physician Attitudes, " op. cit. 32. Newsday, op. cit. 33. Rosenfeld, Wolfe and McGarrah, op. cit., p. 6. 34. Ibid., p. 8. 35. Interview with Dr. Erwin Kaiser. 36. Rosenfeld, op. cit. 37. Interview with Dr. Don Sloan. 38. Los Angeles Times, op. cit. 39. Ibid. 40. Sloan, op. cit. 41. Newsday, op. cit. 42. Planned Parenthood - World Population, " Voluntary Ster- ilization for Men and Women. ' 43H.o sHpuilktaa,l "P rVaocltuinctaer,y VSItIe r(iNloivzaetmiboenr:, T1h9e7 2Ro)l,e 1o1f9 .P hysician. " 44. Letter from A. J. Sobrero, M.D. to Bernard Rosenfeld, M.D., May 17, 1974. 45. Letter from Bernard Rosenfeld, M.D. to Ms. Gina Johnson, Editor of Publications, Planned Parenthood - World Popu- lation, April 5, 1974. 46. Boston Women's Health Book Collective, Our Bodies, Our- selves (New York: Simon and Schuster, 1973). 47. Barnes and Zuspan, " Patient Reaction to Puerperal Sur- 48. AGgdyiacnmaesl,c o"Sl toFegermyia,ll eiL zXSatXteVir oi(nlJ,iaz an"t uiAaomrney,r ,i" c1Aa9mn6e r8Ji)oc,ua rn6 n5Aam.le roifc anO bJsotuertnrail cosf aOnbd- stetrics and Gynecology, LXXXIX (June 1964), 395. 49. Federal Register, Vol. 39, No. 237 (December 9, 1974). 50. Jean Sharpe, " The Birth Controllers, " Health / PAC Bulle- tin, No. 40 (April, 1972), pp. 3-12. 51. Contemporary Obstetrics and Gynecology, I (1973), 31. 5532.. NLeowss dAanyg,e loeps. Tciimte.s , op. cit. 54. Rosenfeld, Wolfe and McGarrah, op. cit., p. 3. 55. Newsday, op. cit. 56. John D. Rockefeller III, " A Call for Stabilization, " New York Times, April 30, 1972 (special supplement sponsored by the Population Crisis Committee in association with the Planned Parenthood Federation of America). 57. " DHEW 5 Year - Plan Report: Program Served 3.2 Million in FY 1973; Provider Countries, Agencies Increase, " Fam- ily Planning Digest, III (May, 1974). 58. " Birth Curb Leaders Cite Future Needs, " American Med- ical News, May 6, 1974, p. 16. 59. Sharpe, op. cit. 60. R. T. Ravenhold and John Chao, " Availability of Family FPalmainlnyi nPgl aSnenrivnigc ePse rtshpee cKteiyv etso, RVaIp i(dF aFlelr t1i9l7i4t),y 2R1e7d.u ction, 61. W. Parker Mauldin, ,azli Choucri, Frank Notestein and Michael Teitelbaum, " A Report on Bucharest: The World Pguosptu,l a1t9i7o4n, C"o nSfteurdeinecse iann dF atmhiel yP oPplualnantiinogn, TVr i(bDuencee,m beAru,- 1974), 393. 62. Los Angeles Times, op. cit. 63. Federal Register, op. cit. 64. Morris E. Davis, " Involuntary Sterilization: A History of Social Control, " Journal of Black Health Perspectives, I (September August - , 1974), 46. NEW FROM HEALTH / PAC'S WEST COAST OFFICE CLOSING THE DOOR ON THE POOR The Dismantling of California's County Hospitals - What are the national trends that spell doom for public hospitals? -How have these forces caused the closure or private takeover of 40% of California's hospitals? _Why does Medicaid fail to insure decent health care for low- income people? For a detailed look at health policy toward the poor, read this major new Health / PAC study (230 pages, charts and tables). $ 7.50 (Special rate for non institutional - Health / PAC subscribers: $ 4.00) Order from: Health / PAC 558 Capp Street San Francisco, CA. 94110 Payment must accompany all orders. 13 major portion of the book is therefore devoted to criticism Media Scan of theorists who have been of consequence to the feminist PSYCHOANALYSIS AND FEMINISM Y, By Juliet Mitchell New ( York: Pantheon, 1974) The thesis of Juliet Mitchell's movement, in particular Wil- helm Reich and R. D. Laing. In the process, Mitchell under- mines present notions of what the feminist movement is all about. Further, she does so in controversial book, Psycho- analysis and Feminism, is that the oppression of women is not a function of a society dominated by men but is a re- sult of a cultural process whose dominating figure is the father. History up to now has been the result of a law im- a way that implicates much of radical politics - both those of the counterculture and those of a Marxist variety. Thus, it is not surprising that critics would rather pan the book than deal with its contribu- tions. In fairness, however, to posed upon male children by their fathers and the lack of such a law for female chil- Mitchell's many critics, the book has many flaws, not all of which are defensible. One dren. In making her arguments Mitchell relies heavily on Freud, accepting in the main his analysis of feminine maso- chism, passivity and limited superego development. Fem- inists must in her view accept Freud in order to make a cul- of the most important is the fact that, although the book claims to be a kind of synthe- sis of Marx and Freud, Mit- chell apparently is ignorant of others who have worked on such a project, in particular those associated with the so- tural revolution that will over- called Frankfurt school- throw patriarchy. Radicals have criticized Mit- Adorno, Horkhiemer, Fromm, Marcuse and Habermas, chell for abandoning the social revolution in favor of the among others. Her apparent ignorance of the work of this vague notion of cultural revo- lution. They regard her posi- tion as ahistorical, as portray- ing the family as an archetypal institution that does not under- group lends her book a certain navet, especially with re- spect to Marx. She relies heav- ily on Engels rather than on Marx for an understanding of go change. Feminists criticize Mitchell because her reliance the Marxist social critique- a mistake that the Frankfurt on Freud seems to predicate the inferiority of women, which they would prefer to regard as a myth propagated by male chauvinists. The book has, in school would never have made. (1) Another problem with the book is that it is in some ways badly written. In the process short, aroused a storm of nega- tive criticism from the very community to which it is ad- dressed. of drawing together a number of complicated theoretical po- sitions in order to focus on feminism, her prose emerges The book is indeed ambi- as a disconcerting admixture tious. Mitchell wishes to rede- of technical and everyday lan- fine the problems of sexuality and to offer feminists a new guage. Further, the structure of the book is awkward. Mit- 14 theory and a new politics. A chell tries to place each of the major figures she writes about into an historical context in order to show how his thought is related to his milieu. On the other hand, the level of her critique is so theoretical and abstract that the relationship between the thinker and the world about which he was thinking becomes irrelevant. Having nothing to do with such defects, Mitchell's book has to overcome resistance in- trinsic to its subject. It tries to state a problem that, because it is difficult even to articulate in the modern context, escapes the reader who does not wish to listen. Mitchell is unwilling to see " femaleness " and " maleness " as either biolog- ical givens or as socially im- posed distinctions. She sees the self, and its male or female attributes, as an identity form- ed by the child in his relations with others. The self is neither socially created nor given in nature but created in a sepa- rate sphere called culture. (2) By utilizing Freud's notions of the unconscious and of infan- tile sexuality, Mitchell believes that we can approach the " dis- contents of civilization " and our emancipation from them with new eyes. (3) Back to the Basics Mitchell argues that both the unconscious and infantile sexuality are for Freud theo- retical constructs whose value derives from their ability to ac- count for the process of devel- opment of the infant from a bundle of drives to a self- directed human individual. Freud's notion of the uncon- scious is that it is a structure and content of the mind of which we are generally ob- livious but that affects our acts and our thoughts even if we are conscious of acting and thinking in a quite different The self is neither socially created nor given in nature but created in a separate sphere called culture. way. The evidence for the existence of the unconscious comes from the analysis of errors, forgetting and ordinary dreams. The unconscious does not communicate to us direct- ly but can only be known through a process of decipher- ing its activities. It has a story to tell but refuses to tell it di- rectly; we only hear bits and pieces of the story in our dreams, in our repetitive activ- ities and in our compulsions. The story it has to tell is that of our own process of self- formation, whose history is lost in our infantile past. Infantile sexuality refers to the sensations of bodily pleas- ures and the losses of those pleasures on which our initial models of self are based: "... the ego is the precipitate of abandoned object cathexes and that it contains the history of these object choices -. " (4) Our conscious life emerges in accordance with the past, which we have hidden from ourselves but whose contents very often unwittingly- - make themselves known in the form of anxiety, guilt, and so on. What psychoanalysis has done is to provide modes of deciphering the activities of the unconscious in such a way as to enable us to gain control over our own life history. According to Mitchell, Freud describes a differential pro- cess of the acquisition of cul- ture in the male and the fe- male. It is this description that feminists have objected to. It asserts that the process of self- formation assures a secondary place in culture for the female. Mitchell employs two models for presenting this differential creation of the self. The first describes the process from the outside, that is, as it would ap- pear to an observer. The sec- ond model presents the same process from the inside, the child's own model. In the first model, Freud singles out the father as the central figure. It is not the nur- turing activity of the mother, but rather the intrusion of the father into the mother - child re- lationship that makes possible the transition from animal functioning to cultural being. The mother - child relationship is, as such, an animal relation- ship. It is the appearance of the father and his insistence that the relationship be broken that destroys that relationship and makes possible a new re- lationship in which the child experiences himself as a sepa- rate entity. The breaking of the mother- child relationship means some- thing quite different for the male from what it means for the female child. For the male child the paradigm is the Oedi- pus complex, in which the original attachment to the mother must be replaced with an identification with the fa- ther in such a way that the de- sire " to have " (and to be part of) the mother is transformed into the desire " to be like " the father. The original love object of the boy is not altered, but the realization of the original attachment is deferred to a fu- ture time, when the boy shall be as " big " as his father - liter- ally and symbolically. For the female child, how- 15 ever, the process is consider- ably different. Here the initial attachment is also to the mother. The first task which the child must accomplish is to shift that attachment onto the father. It is only secondarily that the child must inhibit her desire for the father and effect an identification with the mother. This second require- ment is not so strongly de- 0 16 manded precisely because of the incomplete abandonment of the desire for the mother. Consequently, the female child never develops the strong identification and internalized inhibition that leads to the erection of the superego in the boy and consequently his abil- ity to sublimate his desires in- to work and other forms of cul- tural activity. 0 0 0 Plympton The second model of the child's transformation attempts to show how the breaking of the mother - child relationship occurs from within the child's experience. It is within this model that the constructs of the " castration complex " and " penis envy " are located. For Freud these are technical terms for describing the means that the child employs to ac- complish the above described - transformations. In Freud's scheme of things the bisexuality of the infant is a necessary construct. The pro- cess of acquiring sexual iden- tity has little or nothing to do with either anatomical distinc- tions, biological urges or so- cially imposed roles. Masculin- ity and femininity are " mental ideas, " to use Freud's lan- guage, which have all the more power because they are unconscious. As mental ideas they describe without our awareness, the stages we have gone through and the wounds we have received in becoming male and female. In the view of the child, the penis and the clitoris are iden- tical objects of auto erotic - sat- isfaction. As such they are the anatomical referent for a very particular kind of anxiety. The form of this anxiety in the boy is fear of castration, the loss of the object of satisfaction. It is a fear that inspires his desire " to be like " his father and " to be recognized " by him, whose most important result is his ne- gation of his desire " to have " his mother. This moment of ne- gation is at the same time the establishment of his father's demands within himself as the model of his own self demands - (the superego) and the over- coming of the Oedipus com- plex. For the girl, however, the in- significance of the clitoris, not as an object providing pleas- ure but in comparison to the externality of the boy's penis gives rise to the recognition of her lack and the wounding of her vanity, which is similar to the wounding the boy receives in his attempt to compete with his father. This lack, which the girl perceives as characteristic of her mother as well, leads to the girl's hatred and contempt for the mother. She shifts her desire " to have " onto her fa- ther and develops an incom- plete desire " to be like " her mother. The resolution of the shift in desire as well as the identification with the mother is always incomplete. The in- cest taboo which - the boy comes to recognize and which thereafter constitutes his pro- cess of self regulat-i onnev e-r fully takes place for the girl. She still wants " to be like " her father and " to have " the orig- inal object - the mother. Her recognition that she cannot consists in " not being able, " and thus the love of the father remains a kind of substitute gratification. The desire " to have " remains primary but is altered into the desire to have a baby, particularly a boy, which will be a replacement for the longed - for penis. What- ever resolution does occur is accompanied by the shift away from the clitoris as a source of pleasure onto the vagina. Naturally, and Mit- chell does not imply otherwise, the paradigms outlined above may and do have other resolu- tions in a variety of permuta- tions and combinations. In this second model of dif- ferential formation the phallus plays a major role. Symbolical- ly it is the object around which the infant makes the distinc- tions of difference and same- ness, upon whose grounds identification (modeling self -) takes place. The social rela- tionships between parents and children, while they set the stage for the inter subjective - drama, are relatively indiffer- ent to the archetypal establish- ment of culture itself. Here the father is the symbolic father, or more accurately the phal- lus. His power rests in the ne- gation or wounding of desire, which is in a sense turned back upon itself and which be- comes the child's desire not for unification with the source of pleasure but for the pleasure of being recognized by an- other who is not oneself. It is this which transforms the child into the human child. It is the phallus that represents patri- archal culture, and that fact makes it more than the father's penis or the father's social power. Patriarchal culture is no mere ideological form of experience but - up to now- the condition under which all culture becomes possible. The phallus is the negation of the mother - child dyad and hence the law of an otherwise law- less and solipsistic infantile universe. Having stated her view that the problems for feminism de- rive from the peculiar cultural constitution of human beings, Mitchell looks at two thinkers who have been of importance Patriarchal culture is no mere ideological form of experience but - up to now - the condition under which culture becomes possible. to radical, particularly count- erculture, movements. Both Wilhelm Reich and R. D. Laing have offered descriptions of our cultural experience that have impressed many of us who feel alienated in and dis- satisfied with our society. In fact, Mitchell chooses to look critically at these thinkers pre- cisely because their descrip- tions of the functions of social institutions, especially the fam- ily, have had so much power. Indeed, she finds their descrip- tions much more interesting than those that have emerged from the established psycho- analytic community. Mitchell makes her critique of Reich and Laing by adopt- ing the Freudian position dog- matically. (5) She asks what is lost if one neglects such con- cepts as the unconscious and infantile sexuality. Her an- swer is that a good bit of ana- lytical power is lost. She shows that despite the acuity of their sociological descrip- tions, both Reich and Laing fail to tell us why society is as it is. Rather, when they try to provide an explanation, they produce mystifications - a kind of secular religion, or ideol- ogy. In substance her argu- ment is that both Reich and Laing ultimately restate in a 20th Century - version what Durkheim once called the re- ligion of the individual - the modern belief in the absolute datum of the individual and his " experience. " Reich: The Ideology of Sex Economy - To Mitchell's credit, she at- tempts to take on the whole of Reich's broken corpus. The po- sitions he takes as the radical activist of sexual politics and the quietist high priest of org- onomy are in her view coher- ent. The prime target of crit- 17 icism is Reich's reduction of the unconscious to a biolog- ical construct whose literal content is sexual (instinctual) energy. This leads to a kind of naive Roussequianism in which the biologically pure in- dividual is imprisoned in his sociological relationships. The individual's task is one of freeing himself from this fall into the world of alienated being through the release of his repressed sexual energies. The corollary of Reich's re- jection of the unconscious as one's own repressed and there- fore alienated history is the re- jection of infantile sexuality, by which and through which this history is formed and given a language. The conse- quence of these two rejections is pansexualism: " Free sexual expression became the highest good; and naturally it follow- ed from this that the child's sexual impulses were not only not to be discouraged but, on the contrary, fostered and sat- isfied - the meaning of'infan- tile sexuality'becomes entire- ly and simply social. A liber- tarian education in a liber- tarian society can provide the answer. The larger question of the acquisition of the human order, the transmission of the most residual demands of the general culture is excluded. " (6) Despite Reich's effort to unite Freud and Marx in a descrip- tive sex economy - , Mitchell ar- gues that he has misunder- stood both of them. The under- lying difficulty is Reich's no- tion of dialectics. Although we cannot go into this difficulty here and in fact Mitchell gives it rather short shrift - the point is that Reich sees dialec- tics as a falsifying differenti- ation of nature out of a pre- established harmony and 18 unity. A first and necessarily " false " differentiation is the sexual one upon which all other social differentiation is ultimately based. ~ Reich's theory is that patri- archy is the sexual suppression of children, upon which the economic and political func- tions of the family are carried out. Patriarchy, and capitalism as one of its agents, " inaugu- rates the necessity of compul- sive marriage, which involves sexual suppression which, in turn, becomes a personal struggle against one's own sex- uality. " (7) The modern " au- thoritarian family " reproduces the conditions under which po- litical as opposed to economic domination is expressed. The family is seen as the social institution where the demands and requirements of the social order are provided for by the functional equivalent of the authoritarian state Father - as Fhrer. Sexual repression hatched in the family to serve the demands of the social or- der must be liberated. " Both psychoanalysis and Marxism are reduced to the sociology of the family and as the family as a social institution is found to be at fault, natural biology can be made to triumph against social evils. " (8) Reich's ultimate proposal is that, nonetheless, we are pre- paring for a new stage of phy- logenesis that resides in a " universal vaginal orgonatic functioning. " This means an obliteration of the socially im- posed distinction male female - and a return to a unity whose overtones are religious. He of- fers a religious reconciliation in which good and evil, male and female, are a differentia- tion out of the all being - whose name is Woman. Mitchell draws two conclu- sions from her examination of Reich. First, to neglect the problems of an unconscious mental life for those of biology is paradoxically to be locked into an analysis of the social institution of the family. The Oedipus complex thus be- comes a description of the so- cial relationships within the family. Different family struc- tures must produce different results. So far as women are concerned, however, this has not been true, as witness, for example, the ubiquity of cul- tural conceptions of the wom- an as passive, as representing the profane as opposed to the sacred, and so on. 9 () Secondly, Reich's concep- tion is imprisoning in some- what the same sense as neu- rosis is. Just as in neurosis one is compelled to repeat in phan- tasy the conflicts of one's past mental life, whose appropri- ateness to a real present is highly dubious, so Reich, lacking the tools for decipher- ing the unconscious, is obliged to repeat the cultural phanta- sies of the past in his own work. The return to an undif- ferentiated oneness with the all is perhaps a satisfying ex- pression of the uninhibited sex- uality of the infant, but it is not an adequate theory to ac- count for cultural change. This is reminiscent of religious con- structions of past eras in which the future was a return to a lost paradise. It is this form of reconciliation of the experi- ence of an alienated existence, a reconciliation at the level of speculative thought, which Mitchell calls ideology. Laing: Knots and More Knots Laing has no room in his theory for either a concept of an unconscious or of infantile sexuality, largely because he has eliminated the idea of a subject who creates meanings. Laing is interested in " per- sons, " by which he means the network of relationships in which an individual is in- volved. The key categories of his analysis are behavior and perception. Distortions occur not in individual subjects but in relationships, when the be- havior of one member is mis- perceived by the other. Be- cause A misperceives the be- havior of B, he defines B through his misperception. B is thus defined not as what he is but as what A misperceives him to be. B then reacts to A's behavior toward him, which is not what B understands him- self to be, and so on. In this way the distinction " sane " and " mad " is produced as the relationships between persons grow more and more distorted. It is interesting in this context to note that Laing's book Sanity, Madness and the Family, Volume I, on the schiz- ophrenic family, which was supposed to be followed by Volume 2, on the nonschizo- phrenic family, has been re- issued without the volume number; the work on non- schizophrenic families never took place. Presumably Laing no longer could find a family he considered non schizo- - phrenic. Given his categories and the possibilities for dis- torted interrelations, this is not hard to believe. Mitchell ar- gues quite convincingly that Laing, because he concerns himself with " behavior " and not with " meaning " is ulti- mately reduced to demon- strating over and over the mundane observation that be- havior and perception are not congruent. Mitchell's point here is quite clear. Because Laing sees the individual only as a conscious subject, the location of distort- ing and distorted processes of FEMINISM AND PSYCHOANLYSI LAING ORDS Bill Plympton REICH ORGONE Box self understanding - must be functions of the content of his conscious perceptions (misper- ceptions). Since for Laing the subject only exists on the con- scious level, his lack of self- understanding must then be a function of other people's dis- torted perception of his behav- ior as it reflected back to him as in a mirror. Thus any defini- tion of the person's behavior that is not equivalent to his self understanding - is an alien- ation of his behavior. While this leads to Laing's political radicalism, in that many of the categories of our social experience limit and de- fine us in ways that are anti- thetical to our self under- - standing, it also leads in the direction of his mysticism. It is the voyage within self that can return us to the wholeness from which we have been sep- arated by the " egoic " func- tions of role playing and false self definition - (i.e., that depend- ent on the misperceptions of our behavior by others.) Mitchell defines Laing's movement toward mysticism as having been implicit in his work from the first: " In the early work, the schizophrenic's ' madness'is found to be an in- telligible response to certain mad making - social pressures; in the middle work the mad- making social pressures come to seem the real madness; by default, the schizophrenic's re- sponse has moved from being intelligible to being'normal '; in the late works the schizo- phrenic's madness has be- come the true sanity from which the vast majority of peo- ple are divorced. Many critics 19 have decried Laing's descent / ascent into mysticism, but it is clearly the logical process of his preoccupations. " (10) By defining the person only at the level of consciousness, Laing can only reproduce the contents of consciousness - the conflict between self and other, between my perception of my behavior and the other's perceptions of my behavior. As an important example of what is missed in such a per- spective, Mitchell offers the following: In his case studies of " schizophrenics, " Laing (by chance) offers only those of women. All the portraits of these women center around the mother - child relationship. The father is conspicuous by his absence. In Freud's view, the problem of psychosis emerges precisely from this " Oedipal pre -" world of mother and child in which the child's " self " has not yet been formed. Since Freud's analysis of both female psychology and psy- chosis located this mother- child relationship as crucial, Mitchell finds it important that Laing does not even notice the absence of the father. She shows in this that while his own studies give evidence of the validity of the Freudian view, Laing does not even acknowl- edge the problem: " " .. in leav- ing out the father, he [Laing] is omitting to give any signif- icance to the patriarchal law and order in which all our families are placed. The im- portance of the patriarchal law is as absent from his ac- counts as it is from the pre- Oedipal phase within which psychosis develops - his'sci- ence'is thus, like ideology, purely reflective, a mirror - im- age of the predicament. " (11) In Mitchell's view, Laing, like Reich, becomes an ideol- 20 = ogist. Beginning with a socio- logical definition of the per- son, Laing eliminates the no- tion of an unconscious and con- sequently of a past that informs the person's current actions without his conscious knowl- edge. All events take place in an eternal present of social re- lationships that cannot be elucidated beyond the level of A misperceiving B and B mis- perceiving A and so on and on. The reconciliation of this situation of alienation is a mystical journey into oneself in which all alienation is elim- inated. If we adopt the positions of Reich and Laing, the problems of female oppression arise out of social institutions, particu- larly the family. In Reich's view this is a result of the sex- ual oppression of children pro- duced by the demands of an authoritarian political struc- ture. Laing, on the other hand, sees the family as defining the child out of his " natural " hu- manity. The task which emerges from this analysis is the transformation of social in- stitutions, particularly the fam- ily. The demands which follow from this analysis include so- cial justice for women, equal opportunities in the workplace, the establishment of a matri- archal society, new forms for the socialization of children and, in its most dramatic form, the demand to eliminate the family. Untying the Knot While Mitchell does not deny that the family, and the consequent roles demanded of the female, are oppressive, she feels that the problem is not simply that of a male dom- - inated society, although that is a sympton of the problem. The real problem, as she un- derstands it, is created from the differential ways in which culture is acquired by men and women. It is the role of the father in the institution of self that must be examined, criti- cized and overcome. The prob- lem stated in this way is a problem of a father dominated - culture. It is this assertion of the cen- trality of patriarchal culture that leads to what appears to be a major contradiction in Mitchell's book, a contradic- tion that has given her critics more than sufficient ammuni- tion for a rejection of her work. If it is true, as she claims, that the father represents in the child's mental life a necessary image of law by means of which culture becomes pos- sible, and if culture is acquired differentially by males and fe- males, then how is it possible to introduce any change? Are we not left with a situation that, like fate, can be ameli- orated but not altered? Are we not all simply stuck with the Father as a symbol of the wounds of culture's violent origins? Mitchell's answer to this criticism is complex and de- serves our attention. Whether she actually overcomes the criticism remains to be seen. What she tries to show is that what was once necessary as a precondition of human cul- ture has ceased to be neces- sary. In making this argument she first describes the patri- archal origins of civilization, using the work of Claude Lvi- Strauss to bolster the Freudian myth of the patriarchal origins of culture. The Freudian myth, as pre- sented in Totem and Taboo as elsewhere, is used by Freud to support his claim that " ontog- eny repeats phylogeny. " That is, Freud - and Mitchell follows him in this holds - that what is necessary to account for hu- FREUD MARX ENGELS PSYCHOANALYSIS AND FEMINISM fo ae Ee Bill Plympton man culture is the assumption that the life history of the indi- vidual and the life history of the species is the same history. Freud argues that in order to have culture, one must have law - a form of order that when internalized, regularizes hu- man relationships. How was it possible for our humanoid an- cestors to inhibit their desires in such a way to accept law? Freud's answer to this is the following myth. In the beginning the father, because he is the strongest, monopolizes all the women in the group. His sons hate and envy his privileges. They take their revenge upon him by kill- ing him. Having done so, they feel remorse because they loved as well as hated the father. They make a pact re- nouncing further monopolistic relations with mothers and sis- ters and sign it by eating mor- sels of the father's flesh. The father's actual prohibition of the son's relations with their mothers and sisters becomes an internalized mental inhibi- tion, which is the first law. The accomplishment of this inter- nal denial is recapitulated, in Freud's view, in the Oedipus complex of every male child. The claim of truth that Freud makes for this myth is not that it happened just this way but that some internalized prohibi- tion is necessary for the tran- sition from natural to cultural being. The transition from nature to culture is also a primary concern of Lvi Strauss -. (12) He argues that in all known societies the problem of this transformation is a problem of exchange and that the first and most important exchange is that of sexual objects. As it turns out, however, in all known societies men have ex- changed women, rather than women exchanging men. The motive Lvi Strauss - assigns to exchange is that it is the act that establishes a human rela- tionship. What this means is that the situation is not one of barter, where an object is ex- changed for an object, but rather that the object is a me- diator of an exchange of pure- ly human goods prestige - , re- spect, recognition. The ex- changed object, as such, serves to establish the relation- ship between individuals who otherwise are not related; it brings into existence not an instrumental relationship in which need serves need, but a reciprocal relationship in which the desire of the one for recognition is met by a re- sponse by the other and so on. Lvi Strauss - argues that the precondition for such ex- change is an establishment of differences. In the all impor- - tant case where groups of brothers exchange their sis- ters, the crucial differentia- tions are " my sister " (mother) and " not my sister " (mother). " My sister " is a forbidden ob- ject (the incest taboo) which the sisters of others are not and are therefore possible ob- jects of desire for men. Mitchell believes that the Freudian myth accounts for the initial inhibition that dis- tinguishes among women and thereby establishes the pre- 21 conditions for exchange and thus inaugurates the network of kinship relations, both as a system of interactions and a system of production. Lvi- Strauss'account of the origins of culture, like Freud's, de- mands an internalized prohibi- tion that must be generated in men but need not be gener- ated in women. This for Mitchell is the nature of patri- archal culture. Mitchell claims that while such demands and such a dif- ferential may have been nec- essary. In fact, if we look at our civilization, we know three things: First, exchange and production are no longer de- pendent on kinship or organ- ization. Second, as kinship be- comes a negligible factor in the condition of production and exchange, the family's senti- mental value increases and the demand that it be recog- nized as " natural " and " vital " increases. Third, as the family draws together as a senti- mental unit, it increases the temptations that the incest ta- boo prohibits, and the demand for renunciation takes higher and higher tolls on the indi- vidual in the form of neurosis and psychosis. From these observations, Mitchell argues that the estab- lishment of minimal differ- ences via the kinship system and the consequent demand that women function within that system are no longer nec- essary. The exchanges and in- terrelationships are establish- ed in a system of production which is social in the broadest sense, that it is no longer a system imposed upon man by his needs for subsistence but one that is freely created by him. Secondly, it follows that the family no longer provides the 22 setting in which necessary dif- ferentiations are created. Rather the nuclear, " biologi- cal " family plays a role in mod- ern society as an ideological force which perpetuates an outmoded form of cultural ex- istence. This suggests that the problem of the woman's move- ment is the critique of the ide- ology of patriarchal culture as the first step toward a genuine overcoming of patriarchal cul- ture. The problem must be made conscious in order that its implications can be dealt with. It is in this context that Mitchell has suggested that the feminist cultural revolution must be made along with a so- cialist revolution. The nuclear family, she says, has persisted in socialist societies because its modus operandi springs from different sources than those of the economy. The task of the socialist revolution is a task of transforming the social relationships of produc- tion. The task of the cultural revolution is that of trans- forming cultural conditions of exchange. The patriarchal es- tablishment of cultural ex- change was once necessary to the system of production. It no longer is. Now the social system of production has made possible the establishment of new forms of cultural ex- change. It must be understood as such in order for a new form of action to emerge to change current reality. Now the social system of production has made possible the establishment of new forms of cultural exchange. This is all very well at the level of theory, although - and I think her Marxist critics are right in this Mitchell's - sepa- ration of a cultural from a so- cial revolution seems to reflect her limited understanding of Marx's notion of a social revo- lution. What she seems to mean by a socialist revolution is what many people would call state capitalism. Particu- larly for those of us who would say that there has been no revolution as Marx anticipated it, this particular division of things does not make much sense. At first sight, Mitchell's no- tion of a new praxis for fem- inism does not make much sense either. Actually, she does not recommend a new praxis at all. She merely points to certain practices that devel- oped in London during World War II integration - of women into the work force, extension of compulsory education, es- tablishment of preschool pro- grams, distribution of food and other necessities through com- munal restaurants and so on. One might well ask, does it make sense to talk about over- coming mankind's universal experience of patriarchy by establishing more day care - centers and by creating wage- slaves of women? One's first response is, " You must be kid- ding! " One could hazard a guess as to what Mitchell has in mind here, but she does not really tell us. She might mean that rather than the break - up of the family in Reichian terms, she envisions the ex- tension of the family into non- patriarchal forms. Such a cul- tural family would not be de- fined with reference to biology but with reference to the social system of production. In other words, there would still be so- cial entities that provide chil- dren with models for identifi- cation, with images of self in accordance with which they can transform themselves but these models need not be male or female in the usual sense. The nurturer can be a male as well as a female. The figure who breaks the dyadic nurtur- ing relationship can be a wom- as well as a man. The child's task of self formation - can and should take place out- side the family described by the female's nurturing role and the male's role as the nega- tion of that nurturing relation- ship. Be that as it may, Mitchell does not really deal with this problem in anything like the depth it deserves. On the other hand, perhaps the fact that Mitchell hasn't any remedies should not dis- turb us too much. She has of- fered us a critique of ideology that in the long run might be more useful than an unreflec- tive program of action. Mitchell's critique of Reich and Laing is reminiscent of an old debate in which Marx engaged with the " Left Hegelians " of his day, who believed that one made revolutions simply by changing one's consciousness of reality. The reconciliations of the contradictions of reality could be righted theoretically. This is what Laing and Reich do. They describe the contra- dictions of reality, but they re- solve them by theoretically abolishing them. As Mitchell powerfully shows, those who attempt merely to describe re- ality end up caught in the re- ality that they describe; they are reduced to resolving the contradictions they see in spec- lative thought. Mitchell shows that the power of a Freudian analysis comes from the constructs of the unconscious and of infan- tile sexuality. It is through these constructs that cultural reality can be seen not as it is given but in the process of its construction. An analogy that may elucidate this point is Freud's notion of the role of an external or a somatic stimulus in the construction of a dream. Freud says that indeed a bell or a belly - ache can stimulate a dream, but it cannot account for the dream that is created; otherwise all dreams caused by the same stimulus would be the same. A reductive analy- sis of a dream holds that its explanation is the stimulus. Freud claims that the stimulus itself is assimilated to a world of meanings that refer to mat- ters quite different from ringing bells or aching stomachs. This world of meanings can be in- terpreted only in the frame- work of the dream itself. The stimulus acquires its meaning from a context whose contents is the distorted and fragmented wishes of one's past infantile history. Culture is similarly constructed in accordance with demands that cannot be reduced either to biological needs or to sociological func- tions. What the notion of the unconscious does, in an analy- tic framework, is to provide a method for reconstructing the contradictions and tensions of the process of acquiring our present identity and for de- scribing the emergence of the self. I do not think that Mitchell herself uses these constructs to make a cultural analysis. What she does provide is an understanding of what tools are there. Particularly, she shows that there are tools the use of which could provide a new analysis of the problems of feminism and the family context out of which they emerge. -Sharon Garman Pavlovich - (The author teaches human- ities at the Cooper Union in New York City.) References 1. 1. In the 1930's the Frankfurt school was concerned with the family. The large- ly untranslated Studien ber Auto- ritt und Familie is only one ex- ample. Those interested in the Marx- Freud synthesis of this school might examine the essay " Authority and the Family " in Max Horkheimer, Crit- ical Theory (Herder and Herder, 1972). Othere relevant works of this school are Herbert Marcuse, Eros and Civilization, Jrgen Habermas, Knowl- edge and Human Interests (especial- ly the chapter on Freud), and Erich Fromm, Escape from Freedom. 2. 2. Mitchell adopts the position of the French psychoanalyst Jacques Lacan for her understanding of Freud. Lacan emphasizes that part of the Freudian view that makes the problem of the intersubjective creation of the self central. Lacan's notion is that the self is first of all a self reflected as in a mirror, in the mother's face as she reacts to the child's needs and de- mands. It is only through this alien- ated image of self that the child can create an image of self. The percep- tive reader will see that this is the basic assumption of Mitchell's criti- cism of Reich and Laing. While they hold that all objectifications of the self are alienation, Lacan believes that it only through such aliena- ' tions " that the self becomes possible. The best introduction to Lacan is Anthony Wilden (ed. and trans.), The Language of Self, (Johns Hopkins, 1968). 3. Mitchell makes the argument several times in her book that the Freud she is discussing is not the same as that which is popular in American and British psychiatry. The neo Freudians - have in her view debased Freud by ignoring his most important contribu- tions, including the death instinct and the unconscious, as something other than a pool of biological urges. 4. Sigmund Freud, The Ego and the Id (New York: Norton, 1960), p. 19. 5. There is as one critic has noted a theological structure to Mitchell's ar- gument here. She adopts Freud's po- sition uncritically in order to see how others, by diverging from him, have made errors. This criticism is essen- tially correct, but the proof of the pudding is in the eating. As I have tried to show. I think something valid comes of this procedure. 6. Juliet Mitchell, Psychoanalysis and Feminism, pp. 171-172. 7. Ibid., p. 211. 8. Ibid., p. 215. 9. These are my examples of types of " the female " that one can find in the most casual perusal of the an- thropological literature. 10. Mitchell, op. cit., pp. 277-278. 11. Ibid., p. 291. 12. The work of Claude Lvi Strauss - has been the subject of a good bit of rad- ical criticism. This then becomes a basis from which to attack Mitchell. However, much of the criticism of Lvi Strauss - has been of the implica- tions he draws from his analysis - a static conception of man's nature and an ahistorical bias. One need not throw out his babies along with their bath water. I do not think Mitchell's dependance on Lvi Strauss -' analysis means her adoption of his philosoph- ical positions. Lvi Strauss -' most ac- cessible work is Tristes Tropiques, al- though it does not bear directly on problems discussed by Mitchell. One might also look at his collection of es- says entitled Structural Anthropology. 23 " iy 24 Vital Signs FACTS AND FIGURES Preliminary figures on health expenditures for Fiscal Year 1974 are now available. Highlights reported in HEW's Research and Statistics Notes, November 29, 1974, include: OE US health spending reached $ 104.2 billion, up from 94.2 $ billion in fiscal 1973. This amounted to a per capita - expenditure of $ 485, up from $ 442 last year. OE Total spending increased 10.6 percent over fiscal 1973, slightly more than the in- crease in 1973, when wage and price controls were in ef- fect for the industry. OE Despite these increases, health expenditures remained at the 1973 proportion of GNP -7.7 percent. OE Public spending on health increased at twice the rate of private spending, due mainly to substantial increases in tutes of Health grants would be hit hardest. Medicare bene- ficiaries under Ford's proposal would be asked to pay 10 per- cent of the cost of hospitaliza- tion under Part A, and to pay an increased deductible of $ 67 a year for physicians'services under Part B. A maximum for out pocket - of - costs under each program would be set at $ 750 a year. The Administration proposes to reduce the federal share of Medicaid expendi- tures from 50 percent to 40 per- cent. Most of these cuts will require congressional action They come on top of substan- tial budget cuts made by Con- gress in HMO and PSRO funds in the recently passed HEW appropriations bill, as well as a number of cuts made through regulatory and ad- ministrative actions. There are rumors that the President's Fis- cal Year 1976 budget will em- body even more drastic cuts. (Washington Report on Med- icine and Health, December 2, 1974.) Medicare and Medicaid ex- penditures. OE The largest expenditure category continues to be hos- pital care, accounting for 39 percent of total spending. The full report and analysis of the previous year's health expenditures generally ap- pears in the February issue of the Social Security Bulletin. FORD REVERSES GEAR SICK PATIENTS, HEALTHY INTEREST The sale of tax exempt - rev- enue bonds for private hos- pital construction is becoming big business, reports the No- vember 13 New York Post. Sales reached 583 $ million in the first six months of 1974 and were expected to reach $ 2 bil lion by the end of the year in the 27 states where such bonds President Ford recently re- leased a proposal for cutbacks amounting to $ 2.5 billion in the Department of Health, Educa- tion and Welfare's budget for fiscal 1975. This would include $ 276 million in health pro- grams, $ 882 million in Medi- care and $ 368 million in Medi- caid. Among health programs, Burton Hill - hospital construc- tion funds and National Insti- are now permitted, according to Robert McCormick, invest- ment banker for Dillon Reade and Company. Recent bonds have had a return rate of 8 percent. Hospitals are turning to tax- exempt bonds as an alterna- tive to bank loans and private financing as construction costs skyrocket, and investors are turning to them as they realize the security as well as rate of return on the investment. " Sta- tistically, there are very few defaults on hospital obliga- tions. Hospitals are seen as a good risk, since people get sick regardless of the econ- omy, " said McCormick. More pertinent is the fact that 90 percent of hospital bills are paid by third party - insurers, so that " the risk is underwrit- ten and insured to a large de- gree, " and that " the trend to- ward a national health insur- ance program adds further backing to hospital bond own- ership. " SICK PATIENTS, HEALTHY TAX DODGE Finally, if profits aren't your main worry, but taxes are, there is the Howard Hughes style of health system invest- ment. Jack Anderson (Decem- ber 19, 1974) reports that the phantom billionaire has man- aged to pay no federal taxes whatsoever throughout most of the last decade (except for one year when he reportedly got stuck with a 7 $ million tab). Apparently one of his chief tax saving - devices was giving money to the Howard Hughes Medical Institute. SICK PATIENTS, HEALTHY PROFITS If bonds aren't your bag, however, there are more ways than one to make profits on the health system, even during these recession - ridden days. For example, Hospital Affili- ates, Inc., a hospital manage- ment firm, has announced an 18 percent increase in earn- ings per share for the quarter ending September 30, 1974, the 18th consecutive quarter in which it has achieved a sub- stantial increase in earnings per share, according to the Washington Report on Med- icine and Health (November 11, 1974). Then there is Community Psychiatric Centers, Inc., a largely California - based chain of acute - care psychiatric hos- pitals, which is " headed for its sixth consecutive year of rec- ord profits, " according to Bar- rons (December 23, 1974). Prof- its per share were up 19 per- cent for the year ending No- vember 30, 1974 compared with the previous year. Bar- rons reports that 85 percent of the company's billings come from private insurance, less than 10 percent from Medicare and the rest from Medicaid. SAVED IN THE NICK OF TIME It appears that recent strug- gles to keep Public Health Service hospitals open have re- sulted in victory. In an unex- pected policy reversal, the fed- eral government announced on December 15 that it plans to revitalize the network of nine hospitals and 26 clinics that now serve primarily mer- chant seamen, Coast Guards- men, Indians and federal pris- oners. Dr. Edward Hinman, new director of the system. has announced an expanded program for the hospitals, in- cluding community patient care, alcoholism and drug abuse research, day care for the disabled, rehabilitation, preventive dental care and health screening for poor chil- dren. HOSPITAL HAZARDS The National Institute for Occupational Safety and Health (NIOSH) is now con- ducting its first study on work hazards in hospitals. Its initial report concludes that " the safety record of hospitals is in- ferior to that of many indus- tries that send accident victims to these facilities. " The report goes on to show that " during 1958 through 1970, the injury frequency rate for medical and other health services increased 14.8 per- cent. State hospitals showed an injury frequency rate of 21.4 [per million employee hours] by 1970, far in excess of the 15.2 rate of manufactur- ing industries for the same year. " (NIOSH, Hospital Oc- cupational Health Services Study, Environmental Health and Safety Control, July, 1974, p. 1, HEW Publication No. (NIOSH) 75-101.) LABOR DEPARTMENT TURNS A DEAF EAR The US Labor Department re- cently surprised its supporters -nothing surprises its growing ranks of critics - by announc- ing its intention to maintain the present 90 decibel stand- ard for industrial noise ex- posure. This came after both the Environmental Protection Agency (EPA) and the Nation- al Institute for Occupational Safety and Health (NIOSH) recommended lowering the standard to 85 decibels. NIOSH had even conducted its own study, which showed evidence of hearing impairment among 49 percent of all workers age 55 to 70 years who were ex- posed to 90 decibels for 20 years or more. An economic feasibility study commissioned by the Labor Department, the kind of study that in the past had been used by the Depart- ment to justify inaction, con- cluded that 1.68 million work- ers will be handicapped if present noise exposure levels continue, but that 1.47 million will escape hearing impair- ment if the standard is low- ered to 85 decibels. The Labor Department decision is being challenged by the EPA, which 25 1 says it will attempt to appeal it to the President's Council on Environmental Quality, if nec- essary. The Labor Department deci- sion was announced by the Assistant Secretary for Occu- pational Safety and Health, John Stender, who suffers a hearing disability from work- ing for many years as a boiler- maker. MEET THE AMERICAN MORALITY ASSOCIATION Alas, the AMA has fallen short of the tide of social progress once more. Delegates to its annual clinical session failed to endorse the removal of criminal penalties against consenting adults, other than married couples, who engage in sexual behavior, as recom- mended by the AMA Board of Trustees. The reason? The del- egates feared that this recom- mendation would be interpret- ed as an endorsement of pros- titution. INDEX (Dec. 31, 1974) A Abortion - Dec. '69, p.12; Mar. '70; Nov. '70, p.14; Dec. '70, p.9; Feb. '73, pp.10-11. Addiction Services Agency - June '70, p.9. Affiliations June '68; Aug. '68, p.5; Nov - Dec. '68, p.14; Winter '69; Jul Aug. -. '69, p.12; Apr. '69; Dec. '71; Sept. 73 (Montefiore - Prisons); Oct. '73 (Belle- NYU - vue); Jan. - Feb. '74 Montefio-r eN or(t h Central Bronx). Air Pollution - Oct. '70, p.10: Nov. - Dec. '74. American Assn. of Foundations of Medical Care -- Feb. '73, p.8; July Aug -. '74. American Assn. of Inhalation Therapists - Nov. '72, pp. 4-5. American Association of Medical Colleges - Jul. - Aug. '69, p.4. American Conf. of Gov't. and Industrial Hygienists- Sept. '72. American Hospital Assn. - Nov. '72, pp.7-9; July Aug -. '74. American Medical Assn. - Nov. '72, pp.3-4, 10-15; July- Aug. '74. American Natl. Standards Institute Sept. '72. American Nurses Assn. - Nov. '72, pp.8.11. Asbestos - Mar. '73; Nov. - Dec. '74. Assn. for Retarded Children - Jan. '73. Attica Prison - Nov. '71; Sept. '73, pp. 14-15 (Prison Health). B Bellevue Hospital - Sept. '73 prison ( ward); Oct. '73. Beryllium Poisoning - Sept. 72, p.13. Beth Israel Hospital - July. '68, p.2; July Aug -. '69, p.10; Sept. '69, p.13; Apr. '70, p.14; Oct. '70, p.3; Jul Aug -. '72. Beverly Enterprises Apr. 73, p.8. Biomedical Research - May '73. Birth Control Apr. '72. Birth Control Pills - Mar. '70, p.10; Apr. '72. Black Lung Disease Sept. '71. Blue Cross Jul. - Aug. '69, p.11; Sept. '69; Oct. '69, p.10; Mar. 71, p.1: Jul Aug -. '72; Oct. '72, pp.19-20,23; Sept. - Oct. 74. Boston City Hospital - Jul. Aug. '70, p.15; Oct. '73; Mar.. Apr. 74 letter (): June May - '74 (letter). Boston University Medical Center - Oct. 73. Brian, Earl - Apr. '73, p.16. Brindle, James - Oct. '72, p.17. Buffalo Medical School - Nov. '71. Bureau of Occupational Safety and Health - Sept. '72. Byssinosis Sept. '72, pp.20-23. Case Western Reserve Med. School - Jan. '70, p.12; Sept. '71. Center for the Prevention of Violence - Sept. '73. Certified Hospital Admission Program - Feb. '73, p.7. Cherkasky, Dr. Martin - Apr. '69, Jan. Feb -. '74. Chicago Health Movement - Apr. '71, p.6. Children's Hospital, Boston - Mar. '72. ' Chinese Health System -- Dec. '72. Cincinnati People's Health Movement - Sept. '71. City University of NY Proposal (Med. School) Oct --. 72, pp.11-13. Citywide Save Homes - Our - Committee (-May NY) '72, pp.4-7. Cleveland Health System - Sept. '71. Coler Hospital - Oct. '69, p.2. Columbia Medical Center - Jul. '68; Aug. '68: Nov. Dec. '68; Jul Aug.. '69, p.10; Sept. '69, p.ll; Dec. '69; Feb. '70; Oct. '70, p.9; Dec. '70, p.6; Mar. '71, p.9. Columbia Hospital - Nov. '71. Columbus Hospital -Nov (NY) . '71, pp. 10-12; May '72, p.6; Oct. 72, p.24. Committee of Interns and Residents -- Aug. '68; Sept. '69, p.15. Community Control - Oct. '68; Nov. - Dec. '69, pp.1.5; Jan. '72; June '72. Community Medical School Proposal (Lincoln) -Oct. '72, pp. 10-11. Community Mental Health - Aug. '68, p.4; Apr. '69, p.13; May '69 (Lincoln); Dec. '69. Community Mental Health Board (Dept. of Mental Health) May '69; Dec. '69. Community Mental Health Centers - May '73, p.9. Comprehensive Health Insurance Plan (-Mar CHIP).. Apr. '74. Coney Island Hospital - May '72, p.8. Consultants Oct. '70, p.11. Cook County Hospital - Apr. '73, p.7. Cornell / New York Hospital - Sept. '69, p.11. D Davis Medical School (Univ. of Calif.) - Apr. '73. pp. 10-11. Delafield Hospital - Nov. - Dec. '68, p.8; May '72, p.8. Downstate Medical Center - Sept. '69, p.13; Oct. '70, p.8. Duke Medical School - July - Aug. '74. E Einstein Montefio-r eAp r-. '69; Sept. '69, p.9; Sept. '70, p.12; Oct. '70, p.1; Jan. '71, p.6; Nov. '71; May '73 (Einstein); Sept. '73 (Montefiore - Prisons): Jan. - Feb. '74. Ellwood, Dr. Paul - Jul. - Aug. '72. F C Federal Health Policy - Nov. '70; Apr. '71, p.1; May '73. Federation of Jewish Philanthropies Apr. '69. p.9. California Public Hospitals - Apr. '73; May June - '74. Feldstein, Martin - May '73, p.17; Jan. - Feb. '74. California Nursing Assn Sept.. - - Oct. '74. 26 Carnegie Foundation - Nov. '71. Fordham Hospital - Nov. - Dec. '68, p. 13; Jul Aug -. '69, p.9. Free Health Clinics - Apr. '71, p.6; Oct. '71; Feb. '72. G Ghetto Medicine Bill Jan L. '70, p.ll; Apr. '70, p.13; Jul.- Aug. '72. Group Health Insurance (NY) -Oct. '72. Group Practice -- Nov. '70, p.9: June '71, p.8. Gouveneur Hospital - Jul. '68, p.2; Jul Aug. -. '69, p.10; Nov. '69, p.10; Feb. '70, p.8. H Haight Ashbury - Free Clinic - Oct. '71; Feb. '72. Harlem Hospital - Jul. '68, p.4; Nov. - Dec. '68, p.9; June '69, p.12; Dec. '70, p.6. Harlem Medical School Proposal - Oct. '72, pp.7-9. Harrington, Donald L Feb. '73, p.4. Harvard Medical School - Jan. '71, p.2; Oct. '73. HEW Mar. '71, p.10; May '73; July Aug -. '74. Health and Hospitals Corporation - Winter '69, pp.1-4; June '69, p.12; Sept. '69, p.7; Nov. '69, p.10; Jan. 71, p.9; Dec. '71; Feb. '72; May '72; Oct. '73; Jan Feb -. '74. Health and Hospitals Planning Council - June '68; Winter '69; Jul Aug. -. '69; Sept. '69, p.4; Apr. '71, p.5; May '72, p.5; May '73. Health Inc., Boston - Mar. '72. Health Insurance Plan of Greater NY Oct -. '72, pp.15-22; Dec. '72. Health Maintenance Organizations (HMO's) -Nov. '70; Apr. '71, p.1; Dec. '71; Jul Aug -. '72; Oct. '72, pp.15-22 (HIP); Feb. '73 (Foundations); Nov. '73 (Kaiser). Health Planning (see Health and Hosp. Planning Coun- -June cil) '68; Winter '69; Jul Aug. -. '69; Apr. '71, p.5; May '72, p.5. Health Professions Educational Assistance-- Nov., '71; May '73, p.10. Health Revolutionary Unity Movement (HRUM) -Feb. '70, p.9; Jul Aug. -. '70, p. 12; Sept. '70, p.13; Oct. '70, p.1; Dec. '70, p.9; June '71, p.10; Jan. '72; Jul Aug. -. '72. Health Services Administration L Jul. '68, p.1; Sept. '68, p.1; Sept. '69, p.8; Nov. '69, p.ll; Jan. '70, p.10; May '72; Sept. '73 (prisons). Hill BurtonM ay- '72, p.1; Jul Aug. -. '72; May '73, p.8. Hilton Davis Co. (-Sept strike) . '71, p.5. Hospital Costs -- Jan. '70, p.7; Nov. '70, p.4; June '71; May '72, p.3; Jul Aug. -. '72. Hospital Expansion - Nov. '71; Mar. '72; May '72; Mar.- Apr. 74; Nov. - Dec. '74. Hospital Worker Unions - Jul. - Aug. '70; Sept. '70, p.16: June '71, p.6; Sept. '71; Oct. '72, pp.9,23; Nov. '72, p.6; Jan. Feb. '74; Sept. - Oct. '74. I Industrial Health Foundation - Sept. '72; Mar. '73; Nov.- Dec. '74. Industrial Medical Association - Sept. '72. Institutional Licensure Nov. '72, pp.7-8. Insurance Companies - Nov. 69, p.6; Jul Aug. -. '72. Irvington House - Mar. '71, p.4. I Wor Kuen - Oct. '70, p.4. J Johns Manville - Corp. - Mar. '73; Nov. - Dec. '74. Joint Committee on Accreditation of Hospitals (JCAH) - - Feb. '72; Apr. '73. Judson Mobile Unit - Nov. '69, p.ll. K Kaiser PermanenteN ov-. '70, p.12; Nov. '73; Mar. - Apr. '74 (letter). Key, Dr. Marcus - Sept. '72, p.13. King General Hospital - Apr. '73, p.6. Knickerbocker Hospital - Nov. - Dec. '68, p.8: Oct. 172, pp. 7-9. L Law, Sylvia - Sept. - Oct. '74. Lead Poisoning - Sept. '68, p.2; Apr. '70, p.13; Jan. '71, p.8. Licensure Nov. '72, pp. 3-9. Lincoln Hospital - Apr. '69; Sept. '70, p.12; Oct. '70, p.1; Dec. '70, p.9; Jan. '71, p.6; Jan. '72; Jul Aug -. '72. Lincoln Community Mental Health Center - May '69; Sept. '69, p.10. Logan, Dr. Arthur - Oct. '72, pp.7-9. Lower East Side Neighborhood Health Council L South (LESNHCS) -Jul. '68; Jul Aug. -. '69; Sept. '69, p.14; Feb. '70, p.8; Apr. '70, p.4; Jul Aug. -. '70, p.12; Oct. '70, p.4. M Madera County Hospital - Apr. '73, p.6. Maimonides Community Mental Health Center - May '68, p.8. Martin Luther King Health Center Oct. '69, p.3. Maternal and Child Care - May '73, p.10. Maximum Liability Health Insurance -- May '73, p.17. Medicaid - Winter '69; June '69; Sept. '69, p.6; Jul Aug. -. '72; Oct. '72, p.16; Feb. '73, p.10 (Medi - Cal); Apr. '73 (Medi - Cal); May '73; May June - '74. Medicaid Mills - Jul. - Aug. '72; May June - '74. Medical Empires - Nov. - Dec. '68; Apr. '69; Sept. '69, p.9: Oct. '70; Apr. '73 (Calif). Medical Industrial Complex - Nov. '69. Medical Imperialism - Apr. '70, p.8. Medical Research - Nov. - Dec. '74. Medical School Income - Nov. '71, p.5. Medical School Proposals (NYC) -Oct. '72. Medicare - June '69, p.8; Nov. '69, p.7; Jul Aug -. '72; May '73. Mental Retardation -- Jan. '73. Merced County Hospital - Apr. '73, p.8. Methadone - June '70, pp.9,15. Methodist Hospital - Apr. '72. Metropolitan Hospital - Feb. '70. Michelson, William -- Oct. '72, pp.19-21. Military Medicine - Apr. '70; June '71, p.4. Montefiore Hospital L June '68; Apr. '69; Sept. '69; Oct. '70; May '73; Jan. - Feb. '74. Morrisania Hospital - Apr. '69; May '72, p.8; Jan. - Feb. '74. Mt. Sinai Medical Center - Oct. '70, p.7; Sept. - Oct. '74. Moore, Dr. Cyril - Oct. '72, p.11. MOTF (Mayor's Organizational Task Force on CHP) -- Apr. '71, p.5. Municipal Hospital System (Cutbacks: NYC -Winter) '69; June '69. N National Free Clinic Council - Oct. '71; Feb. '72. National Health Insurance Program - May - June '74. National Medical Enterprises - Apr. '73, p.8. National Institute for Occupational Safety and Health- Sept. '72; Mar. '73; Nov. - Dec. '74. National Safety Council - Sept. '72. Narcotics - June '70; Dec. '70, pp.6,9; Jan. '72, pp.8,9. National Health Corps - Apr. '70, p.9. National Health Insurance - June '69, p.7; Jan. '70; May '73, p.19; Mar. - Apr. '74; May June - '74; Jul Aug. -. '74 (letter). National Institutes of Health (-May NIH) '73, p.ll. Neighborhood Health Center - June '72; May '73, p.10. NENA Northeast ( Neighborhood Assn.) - Jul. '68, p.l; Aug. '68, p.13; Oct. '70, p.4; June '72. New York City Prisons - Sept. '73. New York Infirmary - June '72, p.4. New York Medical College - May '69, p.9 (Community Mental Health Ctr.); Sept. '69, p.12; Oct. '70, p.6. New York Times - Feb. '70, p.ll; May '70, p.13. New York University Medical Center Sept. '69, p.13; Apr. '70, p.7 (Bennett); Oct. '70, p.3; Mar. '71, p.4; June. '72, p.4; Sept. '73 (prison ward); Oct. '73. 27 Nixon, Richard - Nov. '70; Apr. '71, p.1; May '73; Mar. Apr. 74, Nov. - Dec. '74. North Central Bronx Hospital - May '72, p.8; Jan. - Feb. '74. Nursing - Mar. '70; Sept. '71, p.1; Apr. '72; Sept. '72 (letter); Nov. '72, p.16; Sept. - Oct. '74. Nursing Homes - Nov. '69, p.7. ce) Occupational Health - Feb. '70, p.5 (GE); May '71, p.6; Sept. 71, p.5; Sept. '72; Mar. '73; Nov. - Dec. '74. Occupational Safety and Health Sept Act -. '72, pp.15-19. Occupational Safety and Health Administration -- Sept. '72; Nov. - Dec. '74. Office of Management and Budget -May (OMB) '73, p.15. Oil, Chemical and Atomic Workers Union - Oct. '72, p.23; Nov. Dec. '74. Oil Industry Nov. - Dec. '74. Oklahoma City Apr. - Mar. " 74. P Patient Dumping - May - June '74. Patients'Rights - Oct. '69. Peace Movement - May '71, p.6. Pediatric Collective - Oct. '70; Jan. '71, p.6; Jan. '72. Peer Review - Feb. '73, p.5. Physician's Assistants - Nov. '72, pp.10-16. Piel Commission Report - June '68, p.4; Winter '69, p.7. Planners Jul. - Aug. '68, p.8. Prepaid Health Plans (PHP's) -Feb. '73, p.14, Apr. '73, p.18. Prisons May '70; Nov. '71; Sept. '73. Professional Standards Review Organizations (PSRO's) -Feb. '73, p.12; Jul Aug. -. '74. Psychiatry - May '69, p.12; May '70. Public Health Hospitals -- Mar. '71, p.8. Q Queens Medical School Proposal - Oct. " 72, pp.6-7. Quality Assurance Progam (QAP) -Jul. - Aug. '74. R Regional Medical Programs - Jul. - Aug. '69, pp.1,3; May '73, p.9. Research Guide -- Feb. '71. S Sacramento County Hospital - Apr. '73, p.9. Sacramento Foundation for Medical Care - Feb. '73, p.7. Sacramento Medical Center - Apr. '73, pp.10-11. San Francisco General Hospital - Jul. - Aug. '70, p.17; Mar. 71, p.7; Feb. '72; Feb. '73, p.15; Apr. '73, pp.20-24; Sept. '73 (prison ward). San Joaquin Foundation for Medical Care - Feb. '73, p.4. Santa Cruz General Hospital - Jan. - Feb. '74. Selikoff, Dr. Irving - Sept. " 72, p.14; Mar. '73, p.3; Nov.- Dec. '74. Shell Chemical Co. (No Pest Strip -Sept) . 71, p.5; Nov- Dec. '74 (strike). Smith, David - Oct. '71; Feb. '72. Social Workers - Sept. '70, p.ll. Soundview - Throgs Neck Tremont - Comm. Mental Health Center - May '69, p.8. Stahl, Dr. William - Oct. '72, pp.11-13. Staten Island - Mar. '71, p.8. Sterling Drug Co. Sept -. '71, p.5. Student AM -Mar. '70, p.14; Sept. '70, p.2. Student Health Organization (-Aug SHO). '68, p.3; Mar. '70, p.14; Sept. '70, p.4. St. Joseph's Mercy Hospital (Ann Arbor) -Oct. '72, p.14. St. Vincent's Hospital - Jan. '70, p.12; Mar. '71, p.6; Jul- Aug. '72. Sydenham Hospital - Nov. - Dec. '68, p.8. T Taxes June '71. Technicon Corp - Jul. - Aug. " 74. Therapeutic Communities - June '70, pp.9,15. Think LincolnSe p-t. '70, p.13; Oct. '70, p.1; Jan. '71, p.6. Thursday Noon Committee - Feb. '72; Apr. 73. Tunnel Workers - Oct. '70, p.10. Trussell, Dr. Ray Nov. - Dec. '68, p.10; Apr. '70, p.14; Jul Aug.. '72; Jan. - Feb. '74. U UCLA Medical Center - Jul. - Aug. '70, p.16; Sept. '73. United Harlem Drug Fighters - Oct. '70, p.11; Dec. '70. p.6. V Valley Medical Center - Apr. 73, p.6. Vanderbilt Clinic - May '70, p.7. Veterans Administration Hospitals - Apr. '70, p.5; May '71, p.9. W Walsh - Healy Act Sept. -. '72, p.15. Washington Heights - Inwood Community Mental Health Center Nov. - Dec. '68, p.9; Apr. '69, p.10; Dec. '69. Weinberger, Caspar - May '73, p.15. Welby, Marcus - May - June '74. Wesley Hospital (Chicago) -Jul. - Aug. '70, p.16. Willowbrook State School - Jan. '73. Women's Health - Mar. " 70; Apr. '72; Dec. '72. Y Yolo General Hospital - Apr. '73, p.6. Young Lords - Oct. 69, p.4; Feb. '70, p.9; Sept. '70, p.13; Oct. '70, p.1; Dec. '70, p.9: Jan. '72. SUBSCRIBE TO THE HEALTH / PAC BULLETIN student subscription $ 5 [] regular subscription $ 7 [] Institutional subscription $ 15 [] Name: Address: Health / PAC, 17 Murray Street, New York, New York 10007 28