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Health Policy Advisory Center Volume 13, Number 3 HEALTH Billions Billions Billions Billions from from PAC Bandaids Bandaids The Booming BULLETIN = Medical Medical Medical Medical Supply Industry Y, xV/ f} 4 , MY EE TIED Orso wy S ~ = * = "=. ae = TAS OO RON SN SS \Y Inside How to navemh\ Measure Cutbacks P. 11 , Avoiding X traneous - Rays P. 29 Health / PAC Bulletin May June / 1982 Board of Editors Tony Bale Pamela Brier Robb Burlage Michael E. Clark Barbara Ehrenreich Louanne Kennedy David Kotelchuck Ronda Kotelchuck Richard Zall Arthur Levin Patricia Moccia Marilyn Norinsky Kate Pfordresher David Rosner Sara Santana Hal Strelnick Richard Younge Associates: Des Callan, Madge Cohen, Kathy Conway, Doug Dornan, Cindy Driver, Dan Feshbach, Marsha Hurst, Mark Kleiman, Thomas Leventhal, Alan Levine, Joanne Lukomnik, Peter Medoff, Robin Omata, Doreen Rap- paport, Susan Reverby, Len Rodberg, Alex Rosen, Ken Rosenberg, Gel Stevenson, Rick Surpin, Ann Umemoto. To the Editor: This drug debate is very pro- vocative. I can't wait to see how it ends. So far, I'm with Dr. Ehrenreich. I am deathly tired of trying to talk people out of taking penicillin for colds. Let the drug companies turn their advertising budgets loose on the public directly and leave me out of it. Naturally they will not push DES for spotting since everyone in the industry is so public spirited - and honorable. And if they did, our government would take care of them in short order - con- sumer protection being its top priority, as we all know. . Robert M. Roth, M.D. Onawa, Iowa Editor: Jon Steinberg Staff: Carl Blumenthal, Debra De Palma, Dana Hughes, Dear Comrades: Ellen Kolber, Peter Medoff, Steven Meister, Loretta Wavra. MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR AND SUBSCRIPTION ORDERS should be addressed to Health / PAC, 17 Murray St., New York, N.Y. 10007. Subscription rates are $ 15 for individuals, $ 30 for institu- tions. Cover by Kate Pfordresher. We were pleased to see the ar- ticle on the Civilian Military Contingency Hospital System (CMCHS) Plan in the Novem- ber / December issue of the Bulletin. However, we were dis- turbed by the description of the 1982 Health / PAC. The Health / PAC Bulletin is published bimonthly. Se- cond class postage paid at New York, N.Y. and at additional mailing offices. Articles in the Bulletin are indexed in the Health Planning and Administration data base of the National Library of Medicine. opposition to the plan which credits Physicians for Social Re- sponsibility (PSR) with initiating and leading the fight. It is to be expected that the bourgeois press would attempt to project a liberal group of professionals To the Editor: not be resolved until promotion into the leading position in a I was very interested in the three comments about my article that you published. I liked all three very much. I wondered, though, why all three commen- tators chose to discuss whether of OTC's is more strictly regu- lated, so that manufacturers must provide consumers with full disclosures on the OTC products. This would have the advan- popular movement. Such a group, which receives tens of thousands of dollars from the Rockefeller Foundation, and en- joys enormous financial and media advantages because of its OTC's [over the counter drugs] should be available, rather than the issue of OTC promotion, which is the core of the article. tage of making both physicians and patients aware of the actions and risks of OTC products, and would also cause the industry to members'professional creden- tials and social status, hardly needs hype from the left. Opposition to CMCHS was in- On the one hand, the availa- think twice about introducing itiated by a group of health care bility issue is a serious and important one, and I think the comments on it provide an ex- cellent balance to my article. On the other hand, my own opinion new OTC's that carry significant risks that would, along with benefits, need to be emphasized to consumers. Dana Delibovi workers in the San Francisco Bay Area who formed the Com- mittee to Oppose CMCHS in March of 1981. We launched a campaign in the Oakland and 2 is that availability problems may New York, NY Berkeley area based on opposi- Health / PAC Bulletin COXZ1 FZLE LEMONESTOLNIE BEZOOTSIJUNGIGE LOGONS TO CONNETTE E BUJUODOFFLIOZESTLEIDDIGHED ' Z LZ fiLfi A Letter from the Editor Our long - time readers know that the Bulletin has attacked government health care programs for waste, paternalism, and misdirection of resources with a bulldog consistency which matches Reader's Digest in its assaults on Communist Tyranny. But our concern was always to enhance the effectiveness of funding, not to eliminate it. Those in power have a different agenda. The most common measures of national health are infant mortality and life expectancy. It is indis- putable that the American record in both categories could be dramatically improved if just a fraction of the funds poured into high technology medicine were devoted to expanding prenatal and infant care. Instead, these programs as well as many others have been brutally slashed. Who pays? The infant mortality rate in the nation's capital, which happens to be 80 percent Black, is 23 per thousand while the national rate is 13 per thousand. Those excess ten deaths per thousand (actually more, since they bring up the national average) among the poor, the Black, the uneducated, in Washington, D.C., and all over the country are on the heads of those who deny the monies which could save them. No doubt in the name of saving money, rather than lives, the Reagan Administration will no longer collect much of the data which would reveal the damage caused by its health care cutbacks, just as it has already curtailed surveys on labor disputes, workplace accidents, environmental damage, and many other unpleasant facts. But the scars are on the nation. In this issue we begin our contribution to taking the toll of the Reagan cutbacks - which in many cases only compound earlier damage under previous administrations. The full measure will not even be calculable for years, but every contribution to the record is important and valuable. Future generations - those children who survive - should know what was done to them. And why. This degradation of our lives, our air quality, our ability to earn a livelihood, our safety in the workplace, our security from military adventures abroad and nuclear holocaust here at home, is justified in the name of making free enterprise work. Free enterprise used to be known as capitalism, but the system gave itself a bad name. These days it isn't hard to see why. Jon Steinberg UECRSELUIUEREUULENEAGGTENI(OFA4000400090N000800%00100000888N0S408I400G00UU8SU0NENSUUCGCUESEONULNUSNGOEEODEQQENUTSOQOOONETEETIRORECTEGSTESRESOECONNCNISENNGI IUCROGCRIIEGN PTR UTE RL EET ER baa tion not only to nuclear warfare, which is one possible scenario envisioned by CMCHS, but also to military invasion of third world countries which is more specifically dealt with by the plan. Hospital workers'unions and community groups in our area have also been vocal in resisting and pointing out the racist implications of the grow- ing militarism reflected in this plan, particularly in the transfer of resources from human ser- vices to the military. Trade unionists have also expressed particular concern with the ac- cess to personel records which the military would gain under the CMCHS plan. Several months after work was begun on this issue PSR was ap- proached, largely by leftists both within and outside that group, and urged to take up the issue. They have since used their considerable resources to publi- cize CMCHS widely and effec- tively, but have steadfastly resisted approaching any issues other than nuclear war raised by CMCHS, and have projected themselves as the main opposi- tion. Through the efforts of PSR members, trade unionists, and community activists, several local hospitals have been in- duced to reject CMCHS. In summary, while we ap- plaud the work of PSR we hope that the Health / PAC Bulletin will not perpetuate the myth that doctors and other professionals make history, while workers sit quietly by. We would encourage people to continue to raise CMCHS in a broad context of workers'rights, anti imperial- - ism, and opposition to resource transfer from social services to the military, while working co- operatively with groups such as PSR who are opposed to CMCHS from a more narrow perspective. Committee to Defend the People's Health 4170 - E Piedmont Ave., Room 24 Oakland, CA 94611 Health / PAC Bulletin To the Editor: I was disappointed to see you implying in a recent issue that environmental hazards present a conflict between wages and health. And Tony Mazzocchi's assertion that communities faced with those hazards are only in- terested in " getting rid of the plant, " also does a disservice to the many coalitions of workers and community groups who have fought side by side for safer industrial processes. Here in Pennsylvania, one city (Phila- delphia) has already passed a right know - to - bill that will help to protect both workers and com- munities. Other cities are work- ing on similar legislation. The fact is, environmental pollutants are the result of an in- dustrial process that cares little about human welfare. Instead, " the bottom line " determines how things get produced and that's what's responsible for the hazards that affect both workers and communities. Gaining control over that process is in the interest of all people exposed to the hazard of industrial production. To ac- complish that objective, a unity of action will have to emerge. Presenting health issues as adversarial to workers'other in- terests (such as wages or job security) only serves to work against that unity. Sincerely, Milt Baer, Pittsburgh, PA NOTES & COMMENT It would be dishonest to say there wasn't a little initial scepticism around the Health / PAC office when Ronald Reagan declared that supply side economics would aid all Americans. It seemed to us that even if a rising tide lifts all boats, in this particular sea of prosperity the trickle down strategy provides salt water for the working poor and leaves those without boats drowning. But when various Reagan Administration offi- cials proposed a policy of including all govern- ment benefits in determining income, I realized we might have been too hasty. Just to be sure, I took a trip up to a public hospital to find out. Squeezing past the lines in the waiting room and stepping gently over the patients awaiting admission to the emergency room, I knew that so many people in such obvious pain must have a good reason for enduring so much trouble for so long. The reason was readily apparent. Aren't peo- ple willing to stand patiently at the ski lifts in Gstaad and Vail? Won't they quietly wait their turn at a blackjack table in Monte Carlo or for their Concorde flight to Paris? This hospital, I was told, was on the verge of becoming a water- ing hole of the new haute monde: the Beautiful Patients. " See that fellow over there in the second bed, " whispered an awed doctor, " he's got a kidney problem worth $ 10,000 a week in Medicare payments. " Health / PAC Bulletin " And all he has to do to earn it is lie in bed, " I said, " Rockefeller should be so lucky. " " That's nothing, " interjected another physi- cian, " This guy over here is going to make $ 50,000 in a few hours when we do operations on his detached retina. " " But then he'll be through, " I pointed out. " We might fail, " replied the doctor, " And then he'll come back and rake in more cash. " " What a racket, " I thought out loud, " Not only will the government give them a bundle, it'll all be tax free. No wonder people are dying to get in here. " " Well, " responded a nurse, " There may be another reason. Since they'll be earning so much here, the Reagan Administration will take them off food stamps, so as soon as they leave they'll starve to death. " " See, " I said, " people are always criticizing the President for favoring the rich, but here we see he's willing to let them starve just like anyone else. " Erratum Astute readers may have noticed that the Bulletin had two November - December 1981 issues and no January February - 1982 issue. The second of these was the January February - issue. We regret any confusion. Meanwhile, another AMA- Vital Signs the American Management Association has begun mar- keting its training course en- titled " Collection Strategies & Techniques " to physicians and health - care managers. For a Putting the " Pro " into mere (deductible tax - ) $ 645 it Pro Competition - will explain " how to establish and maintain a permanent en- Reagan Increases Benefits With the recession fully upon us, official unemployment over nine percent and rising, and real unemployment in the double digits of last season's in- flation, most of us are tightening our belts. thusiasm for the rewarding pro- fession of collection..., how to get instant access to proper rebuttals to debtor's excuses and words and phrases that " give you power and results.... According to its brochure, the Several readers have written in to question whether the ad in the last issue of the Bulletin for The medical profession and the AMA, however, are tighten- ing their accounting. To reduce the impact of the recession on the medical pro- " AMA takes no position on any public issues, speaks for no group and espouses no cause other than that of better management. " the book Mean, Rough, and Tough by Milton " Bear " Nuckles (Turkey paperback, $ 4.95) was genuine. " Surely, " writes E. Coli of Trala, LA, " hospitals already strapped for funds wouldn't shell out big bucks for union- busters when they could prob- ably keep out a union them- selves by merely doubling wages, drastically increasing benefits, and improving work- ing conditions. " Well, E. Coli, they don't have to pay for their union suits. Spurred by intense lobbying from the American Hospital Association and its own commit- fession, the AMA has joined VISA and MasterCard in mak- ing interest on overdue ac- counts not only profitable, but ethical! According to Bernard D. Hirsch, general counsel for the AMA, " Everyone pays their credit card bills and car loans, but the doctor is the last one to get paid. " The AMA believes this is the one reason why real income for physicans (as well as everyone else) peaked in 1972 and has been declining since. AMA bylaws were changed this year from reading that " it is not in the best interest of the public or the profession to charge interest on an unpaid Medical administrators can learn how to keep unions out - at govern- ment expense. For those with more modest pocketbooks or captive patients, the Center to Promote Health Care Studies offers a one day course in " Keeping Your Health Facility Union - Free. " Continu- ing education credits are of- fered to nursing home and hos- pital administrators under the rubric, " With so much at stake, ment to reordering priorities, bill or note " to something more you... as a prudent health the Reagan Administration has decided that Medicaid will pay for management costs incurred in trying to prevent union organization. This reversal of Carter Administration policy, adopted by the Department of Health and Human Services ' Health Care Financing Admini- befitting the times: " physicians who have experienced prob- lems with delinquent bills may properly choose to request that payment be made at the time of treatment or add interest or other reasonable charges to delinquent accounts. ' The AMA leaves the interest facility manager... must be prepared for the inevitable knock on your door. " Jackson, Lewis, Schnitzler & Krupman- " the nation's largest law firm devoted exclusively to the prac- tice of labor and employment law in behalf of management " - will teach us to understand stration, does stipulate that the rate entirely up to the indivi- " why health care employees un- management activities must be dual doctor, but he or she must ionize " and " how to act if you re- legal. still comply with state usury ceive a demand for recog- Jon Steinberg laws. nition. " 5 Health / PAC Bulletin We don't know exactly what Jackson, Lewis, Schnitzler & Krupman prescribe for labor pains, but we suspect it's not natural birth. Hal Strelnick (Hal Strelnick is a member of the Health / PAC Board and a doctor teaching at Montefiore Hospital in the Bronx.) Community Unity My center is giving way. My right is pulled back... Situa- tion excellent, I am attacking. - - General Ferdinand Foch, Battle of the Marne, WWI Wounded by cuts in the budgets of OSHA and EPA, and assaults on the laws these agencies are supposed to enforce, trade unionists and environmentalists pressing for right know - to - legis- lation in states and localities might take up the motto of the French Marshal. Although labeling the ingre- dients of some consumer prod- ucts and providing informed medical consent are precedents, the impetus for right know - to - legislation comes from the occu- pational safety and health move- ment. The OSHAct of 1971 gave workers in the private sector the right to inspect their medical and exposure records, but since 1976 OSHA has stalled stan- dards for labeling the chemicals workers handle. Spurred by Federal inaction, the first generation of worker right know - to - bills was passed in Virginia (1979), Maine (1979), California (1980), Michigan (1980), New York (1980), and West Virginia (1981). Under these laws, right to know is a matter between workers and bosses. The state may safeguard trade secrets, protect an inquisi- tive worker from retaliation by management, and levy fines for violations, but it is the company which must inform and train workers. Enforcement depends on worker militancy, not the state whose appropriations for over- sight were rare. The next stage began in Feb- ruary, 1981, with the passage of a worker and community right - to- know bill in Philadelphia. Since then access by communities has often become a provision tacked onto what are essentially worker bills or else separate community bills have been put through after worker right know - to - laws had been placed on the books. These community access pro- visions and bills rely on decen- tralization of authority only in the sense that to date most have been passed by municipalities. While the worker bills have been the product of a consciously preventive strategy, the commu- nity right know - to - movement has been a response to particu- lar problems; air pollution in Philadelphia, the highest U.S. cancer rate in Cincinnati, tri- chloroethylene in Santa Mon- ica's drinking water, trade secret battles with StanChem in Con- necticut, and fire hazards in Val- lejo, California. In all cases, in- stead of obtaining information about toxic substances at indivi- dual businesses, citizens get it from a central governmental authority, whether fire, health, labor, environmental, or other. Connecticut was the breakthrough state. Even before this stage has won widespread acceptance, a third wave is breaking. Bills passed in Cincinnati and Connecticut combine workplace disclosure with reporting to local authori- ties. Even stronger bills are com- ing up in New Jersey and Massa- chusetts. This new approach al- ready has corporate officials so worried that Reagan OSHA offi- cials are proposing a limited Federal labeling standard for chemicals to preempt stricter local regulation. Right - to - know legislation has advanced to a third stage. Getting worker community - disclosure bills might seem a logical step, but until recently no coalition was pushing for it. Unions rarely venture outside the plant in the United States. Environmentalists have been concerned about the health ef- fects of pollution for years, but have rarely been organized on a neighborhood basis, or even by community. However since Love Canal, the problems of hazar- dous materials- transport, stor- age, use, and disposal - have produced an unprecedented amount of political activity at the environmental grass roots. Citi- zen action groups such as Mass- achusetts Fair Share, New York Public Interest Research Group, Ohio Public Interest Campaign, and Connecticut Citizens Action Group (CCAG), which do have lower middle - - class, largely urban constituencies organized by neighborhood, are taking the lead. (Continued on page 31.) Health / PAC Bulletin Billions from Bandaids by Hal Strelnick (This is the first article of a series on the and cursed a small camera that produced instant medical equipment and supply industry, a part pictures of the screen image, then disappeared of Health / PAC's examination of the for profit - with them. An orderly entered with a different health sector.) wheelchair, its Everest & Jennings label secure, Dorothy Morrison (not her real name) was get- and took Dorothy back to her original room. The ting worried. Her first baby had been due in the labor suite air was filled with the sound of beep- last week of April; it was the first week of May ing machines. and nothing had happened. In the health center As she re attached - Dorothy's fetal monitor and waiting room, she went over and over her abdo- slipped an intravenous needle into the back of men with her eyes and hands. The doctor examined her and said he wanted her hand, the midwife explained, " We are going to give the baby a'challenge test'to see if he to arrange a hospital test to see if the baby was needs to be delivered now. The medicine we are ready to deliver. When Dorothy arrived on the maternity floor at the hospital, the nurses giving you will stimulate contractions that we will watch on the monitor. " She attached the ushered her into an empty labor room and asked intravenous needle to a long plastic tube from a her to lie down on a hospital bed beside a large bottle hanging above the bed and then wove the machine that they soon were attaching to her tubing into another machine that appeared to abdomen. Soon the machine a- n electronic count the drops of liquid medicine from the bot- fetal monitor - was broadcasting her baby's tle. The counting machine said " IMED Pump " heartbeats and recording the weak contractions on its label. Soon Dorothy was having painful of her uterus on a roll of graph paper like so contractions every six or seven minutes and many tiny earthquakes on a seismograph. Occa- sionally, a doctor or midwife popped into the squeezing the metal label still in her hand. Mid- wives and doctors came in to examine the room, looked quickly at the machine's mark- ings, and disappeared. From her perspective machines and left with an " Everything's just fine... " Dorothy could read only the machine's label, Finally, her midwife returned to turn off the " hp - Hewlett Packard. " IMED pump, remove the intravenous needle A nurse appeared with a wheelchair, saying, and the large belts around her abdomen, and " You've got to get an'echo,'" and removed the smile. " Everything's just fine, " she said, " You monitoring belt. In the elevator she explained, can go home now. Come back in a couple of " We are going to the radiology department for a days if you haven't gone into labor. Oh, and sonogram of the baby to determine its size and remember to stop by the billing office with your position, and the position of the placenta. " insurance card on your way out. " Dorothy toyed nervously with the wheelchair's Dorothy left the hospital thinking she had metal label, " Everest and Jennings, " which spent more time with machines than with all the came off in her hand. health workers combined. Ten days later, after In the x ray - department she was attached to another day of pitocin challenge tests, she had another machine that projected what she was an eight pound six ounce baby boy by spontane- told were small images of her baby on a tiny television screen. It was labeled Matrix, not Sony or Sylvania. The technician played with ous natural childbirth in the same hospital. Compared to what many get, Dorothy had received " high quality " medical care. Yet all the expensive, complex tests from equipment costing thousands of dollars had " proved " only (Hal Strelnick is a member of the Health / PAC that she and her baby did not need further Board and a doctor teaching at Montefiore medical intervention - an induced delivery or Hospital in the Bronx.) Ceasarean section. 7 Health / PAC Bulletin Was Dorothy Morrison a victim or a benefi- ciary of the new medical technologies? This is not a question which is often asked. Indeed, sur- prisingly few questions are asked of an industry which is transforming medical practice in waves of " technological imperatives " that often leave health consumers gasping in the undertow. Even midwives committed to natural childbirth are not free of this pull. None of the tests Dorothy Morrison received had undergone rigorous clinical testing before their acceptance as standard medical practices and widespread adoption by hospitals. While pharmaceuticals must undergo extensive, if not always sufficiently rigorous, examination before they are approved for marketing, sellers of a new medical technology until recently had only to convince doctors and hospitals that it was bet- ter than last year's model to win wide sales. Intensive care units, for example, became standard in hospitals before their efficacy was even tested, let alone proven - and even today many health professionals doubt that their objective value could be demonstrated.'Since then ICU's have not only created an entirely new market for many small technologies, they have spawned a new generation of specialty units --- coronary, respiratory, neonatal, neurosurgical, cardiovascular surgical, burn, and trauma- each with still more demands for specialized equipment now deemed essential for " standard medical care. " Although still called the " hidden segment of the medical business, " 2 the extraordinary growth and influence of the hospital and medi- cal supply industry ensure that it will not remain unnoticed much longer. Once largely the prov- ince of small, " ethical " specialty manufacturers such as Matrix and IMED, it is now increasingly dominated by specialty monopolies such as Everest & Jennings, the wheelchair king; cor- porate giants like Hewlett Packard - and Fortune 500 conglomerates. To cite one recent takeover, IMED corporation was acquired in June, 1982, for $ 465 million by Warner Lambert - , makers of Bromo Seltzer - , Cool Ray sunglasses, Freshen- Up and Bubblicious gums, Lady Schick razors, and American Optical's fiber optic encloso- scopes, among other products. Revlon has become the world's first total eye care conglomerate, manufacturing everything from mascara and eye shadow to intraocular lenses, permanent contact lenses, and contact lens solutions. Bowling ball and sports equip- ment makers have applied their expertise to blood plasma filters and sterile syringes (AMF) and surgical instruments (Brunswick). Mc- Donnell Douglas - has soared beyond F 15 - jet fighters with its Vitek antibiotic infection fighers, hospital computer systems, and medical equip- ment financing. Other military contractors have rushed in behind them (see box). The Medical Industrial - Complex IS the Military Industrial - Complex The following major military contractors have significant holdings in hospital and medical supplies: FY 1979 Medical Defense Defense Sales Sales Rank McDonnell- Douglas N.A. $ 3,200 2 medical infor- mation ser- vices, electro- phoresis, infu- sion equip- ment General Electric $ 413.8 2,000 4 CAT scanners, patient monitors Lockheed N.A. 1,800 5 medical infor- mation systems Raytheon N.A. 1,200 9 medical & radiological imaging equipment Litton 50 832 11 patient monitors Honeywell patient monitors 27 658 17 RCA x ray - equip- ment 74.1 487 22 Textron 30.2 477 23 ophthalmic goods (in millions of dollars) Health / PAC Bulletin Like other unexplored territories, the medical and hospital supply industry has uncertain boundaries. An industry is usually defined as a group of firms with similar production processes that sell interchangeable products to a common group of buyers. Where products run from bandaids to hearing aids and their manufac- turers range from tiny firms that specialize in one or two devices to large corporations that deal in numerous hospital product lines and subsidiaries of large conglomerates, this paradigm does not fit very well. As in the " leisure time " industry, the defini- tion is clearest in consumption. Thus the medi- cal and hospital supply industry can be consid- ered all the equipment, devices, and supplies used by doctor's offices, clinics, medical labora- tories, hospitals, nursing homes, and occasional patients. (Calling the industry " hospital and medical supply " rather than the other commonly used term, " medical technology, " avoids the connotation of high technology, which repre- sents only one segment of the whole.) If the five Standard Industrial Census (SIC) categories that most closely fit the description of the industry - x rays - and electro medical - devices, surgical instruments, surgical supplies, dental equipment, and ophthalmic goods - are totaled, almost 3000 companies were involved Figure 1. $ 11.6 Value of Shipments of Medical, Surgical, and Dental Equipment, Instruments, and Supplies : 0 y $ 8.3 8 " 6 $ 5.1 4 3 $ 1.8 $ 3.3 1967 1972 1975 1978 1981 || X ray - & electromedical equipmen! Surgical & medical instruments CJ Surgical appliances & supplies Dental equipment & supplies Source U.S. Dept. of Commerce. Bureau of the Census. U.S. Industrial Outlook 1981 & Census of Manufactures, Industry MC67-1-36E Series: MC67-1-36E, MC67-1- 38A MC72-1.38B, MC72-1-36E Figure 2. Growth Record Medical Supplies (21 firms) 400 Net Income Revenues )% 10 = 300 (1970 Growth Percnt 200 Revenues - Net Income Pharmaceuticals (22 firms) 100 1976 1977 1978 1979 Source: Standard & Poors data with sales of $ 7.3 billion in 1977. Yet even here there is still room for ambiguity. In 1981, sales were $ 9 billion according to a Stanford Research Institute study, * $ 11.6 billion according to the U.S. Industrial Outlook published by the De- partment of Commerce, and $ 13 billion accord- ing to Standard & Poor's. It is clear, however, that whatever figure is used the industry has been expanding pheno- menally. As a major beneficiary of the six fold - growth of total health expenditures between 1960 and 1977, its sales have nearly doubled every five years since 1967 (see figure 1). Cur- rently the industry rings up just over half as much as the pharmaceutical industry and is gaining fast (see figure 2). Put another way, in 1979, even excluding capital equipment, total expenditures just for hospital supplies were almost $ 14,000 per bed.5 As in the computer industry, hundreds of companies have participated in this bonanza. " Growth (in real terms) of all five medical device industries has occurred more largely as a result of increased numbers of establishments of all sizes than increased size of establishments, " noted a 1980 Food and Drug Administration report, " though there is some tendency for the largest establishments to increase their (large) share of product shipments. " 6 Health / PAC Bulletin Table 1. Market Shares Needles - & Syringes " Fundamentally, I think the supply industry is stronger today than it was five years ago, " James Tullis, a vice president - at Morgan Stanley & Company told a recent symposium. " The fact is Corporations Dickinson Becton - Baxter Travenol - (Fenwall) Sales (in millions) $ 105 N.A. Brunswick (includes Sherwood Medical and Monojet) 35 American Hospital Supply (includes Pharmaceal) 25 Johnson & Johnson (includes Jelco) 10 Percent of Market 40 13 9 4 that during the last five years the number of competitors has been shrinking. The market share held by the leaders has been going up. If you consider that from a long term - standpoint, it's basically positive to profitability. I think right now, we're moving out of a pretty competitive environment. " What Tullis is referring to is a growing tendency for a single company to dominate a series of product lines, with a market share significantly larger than competitors '. " The existence of the gap between the leading firm and the next firm is striking, " noted H. Elizabeth Wenchel, director of a study of the industry for G.D. Searle (in- the Department of Health and Human Services. cludes Will Ross) 10 4 " It indicates that the gradation of sales of the Source: calculated from A Profile of the Medical Tech- companies reflects an abrupt quantum change, nology Industry and Governmental Policies, National Center for Health Services Research, PHS, DHHS, June 30, 1981. not a smooth continuum.... (It) provides unam- biguous indication of concentration, which is at a level higher than exists in many other industries. " 1 (Continued on page 19.) This picture can be misleading, however, since it conveys the impression that large and small firms are competing in a free market. Re- cent entries into the industry have generally found a niche with new or substantially different J.P. Morgan Medical Supply and Pharmaceutical Holdings (Rank in top ten shareholders) products that do not directly compete with ex- isting lines, such as Intramedics'innovative intraocular lenses for cataract patients coming on the market to compete with Revlon's Coburn Optical products. But in the vast market for disposable syringes and needles, for example, only established giants hold the economies of scale, capital resources, and sales capabilities that give them an overwhelming edge (see table 1). There aren't too many medium - sized fish in American Cyanimid (1) American Home Products (1) AMF (2) Avon (2) Johnson & Johnson (2) RCA (2) Merck (3) Pfizer (3) Sterling Drug (3) General Electric (3) 3M (4) Searle (4) Dow (4) Proctor & Gamble (4) the hospital and medical supply pond. More than 80 percent of the 3000 companies in 1977 had annual sales of less than $ 20 million. Almost all the rest were huge, usually pouring out num- Textron (5) Honeywell (5) Celanese (6) DuPont (6) SmithKline (6) erous product lines. In an economy where olig- opoly is the rule, the medical supply industry is still exceptional. Whether separated out by number of employees or assets, in each of the Bausch & Lomb (8) American Standard (8) Baxter Travenol (9) Burroughs (9) Chesebrough - Ponds (9) five SIC categories the eight largest firms win half to three quarters of total sales. Even this Monsanto (9) Squibb (9) understates the degree of concentration; the in- dustry's corporate interlocks webbing out of J.P. * Holds voting rights for the beneficiaries Morgan and Co. alone are truly astounding (see box). 10 To an investment broker, this is good news. Source: Corporate Data Exchange Stock Ownership Directory Health / PAC Bulletin Wound Watch by Carl Blumenthal " Now there, " said the Queen, " it takes all the distasteful than the Republicans'- and many running you can do to keep in the same place. If Democrats seemed more interested in scoring you want to get somewhere else, you must run at political points for the November elections than least twice as fast as that! " -Alice in Wonderland in aiding the needy. The answer, for many activists, is intensified grassroots organizing. One of their most popu- When Bob Hope appeared at a fundraiser for Cape Cod Hospital in 1978, the Cape Cod lar new techniques for mobilizing communities is monitoring the effects of cuts on the health and Health Care Coalition protested that denying care of their constituents. As the Cape Cod health care to poor people is no laughing mat- ter. Its members were out in force chanting, Health Care Coalition put it, " Hope doesn't pay our bills. " " Cape Cod Hospital, share the wealth - Give poor people quality health. ' There is, unfortunately, a lot to monitor. Workers, minorities, women, children, the The coalition had more than a clever rhyme- poor, the elderly, the disabled are being denied ster; it had activists who did their homework. health care at a time when other cutbacks in Feminists, trade unionists, social workers, the everything from nutrition programs to fuel sub- poor, and the elderly were all there together. sidies heightens their vulnerability to disease. The hospital was compelled to open its doors a Separating out the effect of each form of depri- little wider. The group's greatest victory was a vation has never been easy; collecting and ruling by the Department of Health, Education, analyzing all the data will be even more difficult and Welfare that hospitals receiving Federal now, since statistical data is one of the first funds could not deny anyone emergency care. " frills " the Reagan Administration is lopping off That, of course, was a different Washington era, when it was possible to reason with bureau- all government programs - sort of a budgetary killing of the messenger who brings the bad crats who were still trying to balance quality and news. (Both the National Center for Health Ser- cost within the limits of the legislation. Today vice Research and the National Center for activists find themselves running a stretcher Health Statistics have been affected.) service behind the Reagan Administration People engaged in obtaining this information scorched earth policy. independently know this will not be a short - term Organizations such as the Cape Cod Health process. Because the bulk of Federal health care Care Coalition which for years sought alterna- monies - M edicare and Medicaid disburse- tives to piecemeal Federal programs have been rewarded with budget cuts and block grants. ments is spent on acute and long term - care for a relatively small number of people, the conse- After a year in which they were thrown off quences of benefit reductions aren't likely to ap- balance by these attacks on health care for low income people, they are beginning to regroup pear in gross measures of mortality and morbid- ity for some time. In addition, the compounded in new coalitions which lobby Congress and effects of cuts in related programs will show up propose alternative budgets to win support for in deterioration of health among the deprived less guns, more butter policies. only over time. As the recent votes on the 1983 budget indi- At least in the short term, therefore, epidemi- cate, so far they have made little headway in ology appears to be on the side of the Reagan Washington. Health advocates found them- rhetoricians. They will no doubt claim that the selves supporting Democratic party funding cuts haven't affected the health of the poor; in authorizations which were only somewhat less the long run poor people will be better off since " the economic security of the country assures Carl Blumenthal is a member of the Health / PAC the well being - of its citizens. " (This is one more staff. indication that President Reagan has never read 11 Health / PAC Bulletin Keynes, who pointed out that " in the long run we'll all be dead. ") To disprove the conservative assertions before the tragic rebuttal emerges epidemiologically, the new Federal policies must be linked in slightly less scientific form to changes in health status which show up in time to make an impres- sion on local communities and the electorate.. . Even this more modest goal can only be reached by surmounting several methodologi- cal obstacles. Adjustments on the state and local level and even efforts by administrators and clients to accommodate the Federal cuts must be taken into account. So must confounding influ- ences of private and public efforts in fields such as education, employment, and welfare. Finally, the characteristics of the local population must be included. Even if the resources can be found to set up the elaborate monitoring system re- quired, by the time it is in place and revealing changes gross enough to measure, the Reagan policies will be doing irreparable harm to thousands of the most vulnerable members of society. At least one municipal health official has asked us if there is any point in documenting the disasters when the Administration has been happy to ignore overwhelming evidence of the cost effectiveness - , let alone the human benefits, of the Women, Infants and Children Supple- mental Food Program (WIC) and others. Supporters of this position argue that the assumption behind monitoring is that knowl- edge is power enough, but in fact knowledge without political power is like facts without a theory. This is a strong argument, particularly when coupled with its corollary that progressive resources are limited and should not be diverted into information - gathering. Activists engaged in monitoring projects have a number of responses. They point out that although epidemiology relies heavily on body counts to demonstrate cause and effect, surveys can be designed to include easily understood - early warning systems. These can be used to generate extensive publicity and increased public awareness. If prodded, educators and researchers can make the tools of their trade Kate wwwww VS Gabbe SOSRORAD tS SUS Pfordesh 12 Health / PAC Bulletin more accessible; activists can assist them in devising interviews and questionnaires which obtain valuable information a traditional academic approach might have overlooked. Finally, it has already been found that many of the people around the country who are involved in monitoring projects have never seen them- selves as political activists; it is very possible that their experiences and new knowledge will motivate many of them to become involved in organizations and movements to ensure a more equitable society. The information which follows was gathered through communications with some 50 organi- zations around the country. Because national groups were the main sources, the list is a little top heavy - , but it is clear that once the efforts currently filtering down to states and localities begin to take off, this pyramid will turn rightside up and be much larger. The national groups also generally have greater resources to develop systematic monitoring projects, but we did find that a surprising amount of ad hoc monitoring is already in progress on the local level. The Health Policy Advisory Center believes that this activity is so vital and significant that we are devoting a considerable proportion of our resources to aiding its expansion, coordination, and development. Health / PAC will be happy to offer suggestions to any local group which would like to link up with one or more national surveys so that aggregate data can be increased and their reliability improved. The Bulletin will also continue to monitor the monitors. Please take a few moments to let us know about any health watches we may have missed so that our listing can be as complete as possible. If no monitoring project exists in your area and you would like help in starting one, please contact us or one of the groups listed below. NATIONAL MONITORS American Medical Student Association " Health Watch " 14650 Lee Road P.O. Box 131 Chantilly, VA 22021 800-336-0158 Contact: Patrick Romano AMSA is asking students, housestaff and others to provide it with case reports about problems of access inappropri- - ate transfer, premature discharge, denial of service, etc.- etc.- particularly for poor and elderly people and women and children. Its purpose is to document inadequacies in the system, not to blow the whistle on individuals or institutions. Cases are to be verified by medical records or multiple in- terviews. This information will be used for Congressional hearings and lobbying, reports to the media, and local actions. With the help of Dr. Victor Sidel, head of the Department of Social Medicine at New York's Montefiore Hospital, model research protocols are being drafted so that students and faculty can study the effects on populations at risk. Several projects are underway in Los Angeles, Boston, and New York. For example, students at New York's Harlem Hospital are measuring the nutritional status (e.g. hematocrit and serum albumen) of infants. Other hotbeds of activity are San Francisco; Washington, D.C.; and Chicago. AMSA is working closely with the Children's Defense Fund and the National Health Law Program (NHLP). survey of public health agencies in three states, two coun- ties, and two cities. If it proceeds, the Association will query 10 states, one in each DHHS region, including California, Massachusetts, Michigan and New York. The focus would be block grants and categorical pro- grams, with an emphasis on child health. Expenditures, service reductions, personnel cuts, and health outcomes would be examined. The surveys would be supplemented by reports from state and local affiliates of APHA. APHA is also coordinating other monitors; it has already held a confer- ence and published the first issue of APHA Monitor. Association for Maternal and Child Health and Crippled Children Services c o / Utah Department of Health Salt Lake City, UT 84113 801-533-6161 Contact: Peter Van Dyck, MD, MPH The final draft of a data collection form is now circulating in a committee of the nation's MCH / CC directors. The Asso- ciation is looking at some 20 services in the MCH Block Grant for specific health problems, such as PKU, cystic fibrosis, anemia, rubella, dental caries, lead poisoning and accidents. It will identify target population, utilization, outcome, (unmet) need, and cost, with the goal of proving effectiveness cost - to Congress. The emphasis is on well- defined services that have measurable outcomes documented in the past. American Public Health Association 1015 15th Street, NW Center on Budget and Policy Priorities Washington, DC 20005 236 Massachusetts Avenue, NE, # 305 202-789-5617 Contact: Thomas Elwood, Ph.D. Washington, DC 20002 202-544-0591 " The primary emphasis of the APHA effort is to document Contacts: Bob Greenstein / Jennie Hefferon linkages between national priority shifts and changes in state The Center is developing a program of self help - for local and local agencies and client utilization. " people - mainly the press - to analyze what is happening in At the time of this report, APHA had just pretested a their communities. Nutrition is a prime concern. 13 Health / PAC Bulletin Activists already in the field with their questionnaires will inevitably waste effort if they do not collaborate with academics. Child Health Information Council Health Security Action Council 3113 Woodley Road, NW " Citizens'Health Program Monitoring Project " Washington, DC 20008 1757 N Street, NW 202-483-7150 Washington, DC 20036 Contacts: Lisbeth Schorr / C. Arden Miller, MD Contact: Ginny Bader Sponsored by the University of North Carolina's School of 202-223-9685 Public Health, this endeavor will result in " a set of 10 to 20 critical indicators of child health status which are relatively Modeled partly after Child Watch, the Project asks groups of citizens to interview the administrators of health mainte- easy and practical to obtain and widely regarded as impor- nance organizations, community and public hospitals, nurs- tant and significant. " The Council will encourage monitors ing homes, community (mental) health centers, and to use the indicators and will try to coordinate and synthesize Medicaid programs. The data sought are sources of reim- their efforts. It wants to bridge what it sees as a gap between bursement, utilization, access, availability, staffing, and policy advocacy / groups and agencies that collect informa- tion about MCH. personal impacts. HSAC is halfway to its goal of committees in 20 states gathering information, which it will aggregate for lobbying. Children's Defense Fund " Child Watch: Looking Out for America's Children " 1520 New Hampshire Avenue, NW Washington, DC 20010 800-424-9602 It intends to have these groups " make their observations and recommendations for improvements known to [state] legisla- tors and program directors, [holding] them accountable for the quality of the services delivered and the manner in which choices are made about how public monies are divided up. 148 " Contacts: Helen Blank / Fran Eizenstatt With the help of ten national organizations, CDF has ini- tiated more than 40 Child Watches in 28 states and in the District of Columbia. Using legions of volunteers, CDF is seeking information about health and welfare programs for children, in particular the Women, Infants and Children Supplemental Food Program (WIC) and Medicaid. Interviews are arranged with advocates, heads of private agencies, health care providers, Medicaid and WIC ad- ministrators, parents, and others concerned about children's health care. Each program is examined in depth, National Council on Aging 1828 L Street, NW Washington, DC 20036 202-479-1200 Contact: Harold Shepard, Ph.D. The Council recently distributed a questionnaire to 3000 workers in agencies serving elderly people to elicit informa- tion about what cuts have occurred, particularly in nutrition and screening programs. It has also asked for anecdotes from users of senior centers. and CDF hopes to correlate the results of the individual sur- veys. Questions are asked about expenditures, eligibility for benefits, access, unmet needs, health status and personal impacts. In its Child Watch Manual CDF outlines a nine month - schedule of repeated interviews and public briefings to keep abreast of changes in health and care. While reports are to be made to the national office, the accent is on using them locally, mostly to get media attention. National Health Law Program 2639 South La Cienega Boulevard Los Angeles, CA 90034 213-204-6010 Contact: Gerri Dallek 1424 16th Street, NW # 304 Washington, DC 20036 202-232-7061 Contact: Judy Waxman Foundation for Child Development 345 East 46th Street # 700 New York, NY 10017 212-697-3150 Predominantly concerned with Medicaid cuts and prob- lems of access for poor people, NHLP has been collecting case reports in these areas for many months. It has played a leading role in the budget coalitions and has a grasp of what Contact: Toni Porter Health care is just one of the human services the Founda- is happening in many states. A good source of contacts for activists. tion is watching in New York, Philadelphia, Jacksonville, Houston, Los Angeles and Indianapolis. With the help of Urban Institute organizations in each of these cities, the Foundation is study- 2100 M Street, NW ing expenditures, staffing and case loads for children's pro- Washington, DC 20037 grams in the private and public sectors between 1980 and 1983. Through budgetary analysis and interviews with deci- 202-223-1950 Contact: Randall Bovbjerg sion makers, it will discover to what degree cities, states and Surveying six states to see how they are apportioning cuts the private sector have compensated for federal shortfalls in and block grants, the Institute is interested in how money is 14 funding. being allocated, how recipients are responding to program Health / PAC Bulletin changes, and how the impacts of cuts in AFDC, food stamps, Medicaid, etc., interact. Using econometric modeling as a tool. While they are not documenting impacts, the following three coalitions know a lot about national, state, and local budgets: Coalition on Block Grants and Human Needs 1000 Wisconsin Avenue, NW Washington, DC 20007 202-333-0822 Contacts: Shirley Downs / Will Carter CIO AFL - Budget Coalition 815 16th Street, NW # 309 Washington, DC 20006 202-637-5086 Contacts: Barbara Warden / Ronda Trail Fair Budget Action Campaign 1319 F Street, NW Washington, DC 20004 202-393-5060 Contacts: Russ Sykes Bristow / Harden STATE MUNICIPAL / MONITORS Community Service Society " Child Watch " 105 East 22nd Street New York, NY 10010 212-254-8900 Contacts: Anjean Carter Eleanor / Marshall This is one of the many terminals of the Children's Defense Fund network. CSS is using the same approach of in depth - interviews with knowledgeable parties. As far as the ques- tionnaire for providers is concerned, CSS is more con- cerned about differences among facilities than among personnel. It is examining the effects of cuts in MCH pro- grams in addition to those in Medicaid and WIC. Religious Committee on the New York City Health Crisis 490 Riverside Drive New York, NY 10027 212-222-5900 X226 Contact: JoAnn Thompson With budget cuts a reality since 1974, the future is now in a city that once had a public health system comparable to those of the largest states in the country. In some parts of New York, a number of health status measures, particularly of maternal and child health, are now at levels comparable to those in Third World countries. Pooling the efforts of a number of advocacy groups, the Religious Committee is watching school dental ( ) health programs, the municipal Health Status Documentation Project c / o Linda Nelson 112 First Street Ithaca, NY 14850 hospitals especially their delivery of ambulatory care home care, prevention programs, and health status. It has briefed the City Council and Board of Estimate on these issues. 607-256-6445 Contact: Sandy Kelman, Ph.D. Coordinated by a committee of the regional Health Systems Agency, this project is looking for the heart of the matter in Tompkins County, NY, i.e., health status indices and surrogate measures for poor and elderly people, preg- nant women, infants, and children. While relying on the health department's vital statistics, including birth and death certificates, and the hospital's medical records abstracts, the committee is also checking shopping lists of home bound - people, sales of dog food, and weights of ani- mals left at the vets. It may collect figures on access and use students and faculty from Cornell to survey what is not on record. Its targets for exposing their findings are the county legislature and civic groups. Michigan League for Human Services 200 Mill Street Lansing, MI 48933 517-487-5436 Contact: Sharon Willard The United Way of Michigan is paying for a year's worth of reporting on the consequences of the recession and of state and Federal cutbacks. The League is analyzing pro- grams and budgets statewide, studying the agencies that deliver them (caseload, demand, unmet needs, etc.) and putting together a list of indicators. Nutrition and child health are among them and the effects of unemployment are a special concern. A survey of delivery networks is under- way; clients will be surveyed next. The organization is also working with Wayne State University in a study of the impact Poverty Education and Research Center 500 West 13th Street of cutbacks on 600 families in Detroit and possibly in other cities. Austin, TX 78701 512-474-5019 Contact: Karen Langley The Center is one of 15 statewide coalitions working with Washtenaw County Coalition for a Fair Budget c o / Kathy Derrin ; 912 South Seventh Street the Coalition on Block Grants and Human Needs. While the Ann Arbor, MI 48103 focus is lobbying, some work is devoted to following the With the help of the Student Association at the University results of cuts. Primary care - community and migrant of Michigan's School of Public Health, the Coalition has health centers - and Medicaid are primary concerns. surveyed 50 health and human service agencies about the Sources of information are the Governor's Office of Federal effects of the cuts. A report is expected by the end of the and State Relations, state agencies, program directors, and summer; it should be a model of cooperation between public case reports from Legal Services centers. health schools and advocacy groups. 15 Health / PAC Bulletin Monitoring: Five Points to Plug (Into) Who Should Monitor squabbling over a shrinking budgetary pie. Measuring the cuts may entail watching broad The wide variety of organizations recording service areas, and this in itself provides a poten- signs of stress reflects the broadly felt need for tial stimulus to multi interest - coalitions. this information. They fall roughly into two Groups with the resources and predisposition groups. Activists, advocates, and lobbyists are to look at human services comprehensively compiling reports from clients and providers. should begin with maternal and child health. Public health officials, researchers, and educa- MCH programs reach a considerable portion of tors can provide valuable rigor, but often sit on the population, including many middle - class their data bases. Ideally, the two groups cooper- families, providing a particularly large reservoir ate. New groups can generally utilize these ex- of support. The MCH lobby already has the most isting resources, but they must have their own and best organized monitors. " energies, people, and money to contribute. The reasons for this prominence are epidemi- Activists already in the field with their ques- ological as well as political, according to Joanne tionnaires gathering ammunition will inevitably Lukomnik, a former top official of the National waste some of their effort if they do not collabo- Health Service Corps now working in biomedi- rate with academics skilled in health survey tech- cal education at the City University of New York. niques. Given its short preparation time, Child " It is easiest to see health status changes in Watch is a prototype for such cooperation. children and [prospective] mothers right away, " Monitors must also be prepared to find that she explained, " With elderly and disabled peo- despite the views of bureaucrats with a vested in- ple we see changes in access, but the health terest in a particular program, it might not be status indicators are harder to determine. " working, or working as efficiently as it should. Motherhood and childhood are generally Activists must always keep in mind that the ulti- supported in this country. When the President is mate goal is not collecting information - that talking about child health, he claims in effect would be a deathwatch. What we want to do is that no one is hurt by the cuts or there aren't any; fight harmful cuts and propose superior alter- these assertions are fairly easy to disprove. Ef- natives to provide decent, accessible, com- munity controlled - health care for all. forts to improve conditions based on race, sexu- ality, poverty, disability, and old age are less What to Watch popular; rebutting an Administration argument that we can't afford programs to ameliorate con- The projects listed above are evenly divided ditions for the disabled is more difficult. between those that assess the cuts across the Maternal and child health monitoring is also a board and those that single out specific popula- tions. This reflects the conflicting priorities of good starting place because many of the ex- amples which show the effectiveness of preven- monitoring. Because time is short and resources tion and primary care are in this area, such as relatively meager, the most effective measure- WIC and Early Periodic Screening, Diagnosis, ments will be narrowly defined. Yet the con- and Treatment. The Department of Health and solidation of programs into block grants will Human Services apparently disagrees, since it make it increasingly difficult to link any decline has recently proposed cutting EPSDT; this is ex- health with a specific cutback. actly the kind of cutback whose exposure can This problem of " confounding variables " is generate an immediate public outcry. also an opportunity for building coalitions beyond the health care arena. Food and nutri- Where to Get the Facts tion programs, environmental regulation, job The activities of the 15 monitoring groups training, and energy assistance have relatively listed above can be split into three categories: direct impacts on health which should be of con- tales of horror, documentation of changing de- cern to their advocates. The environmental and mand for services, and investigations of fluc- labor movements in particular are potentially tuating health status. Joanne Lukomnik argues powerful allies. Bringing these groups together that the first two are most important politically. would confound the Reagan Administration, " Do access studies first, " she advised, 16 which is counting on a fragmented opposition " They're for everyone. Then document the Health / PAC Bulletin individual cases - what happens when unemployment benefits run out, the kids have no Medicaid, the working poor can't use com- GOT THE munity health centers, the hypertension patient can't get medicine. Quick and dirty studies can be attacked on methodological grounds. BAD - NEWS BLUES? Surveys require controls. Health indicators have all sorts of complications. " There are also more and less rigorous ways of interviewing consumers and providers and veri- fying stories. AMSA, CDF, HSAC, and CSS are among the most experienced in these methods, and are aware of the vast number of volunteers needed to maintain high standards. Fortunately, data is already available to com- plement much of the case report work and lay the groundwork, however shaky, for correlating expenditures, utilization, and health status. Health systems agencies (HSA's), professional service review organizations (PSRO's), health departments, state agencies, providers- 1979 Hubig Dan _.. Are reports of bigger bombs, shrinking so- cial services and Moral Majority crusades get- ting you down? Are even your favorite left wing - magazines mired in Reagan - esque gloom? Well, there is an alternative! For 16 years, one magazine has followed the people who are doing something about war, poverty and injustice. especially hospitals and nursing homes - the Census Bureau, medical and public health schools, and the National Center for Health Statistics all have valuable information on file. Most important are HSA's. Of the original 204, 160 are still around. Because they have been among the early victims of the cuts, noted Harry Cain, director of the American Health Planning Association, the HSA's don't have the resources to monitor their effects, but they do have ac- cessible aggregate population data, information on particular providers submitted in applica- tions for certificates of need and Federal grants, Draft resisters, antinuclear protesters, femin- ists, conversion organizers, Indian activists, the Anti Klan - Network - these are just a few of the folks who appear on the pages of WIN Magazine every two weeks. Subscribe to WIN and get the good news about the growing nonviolent move- ment for social change. Y' No more bad news -b lues for me. Here's $ 20, send me a year of WIN. Y' Here's $ 11. I'll try WIN for six months. Y' Here's $ 1 for a sample copy. Name Address patient origin studies, and case mix statistics. In using this information, researchers must be wary of relying exclusively on providers for determination of needs, since existing data measure only demand for current services. This seemingly methodological consideration has the most profound political implications. It could mean the difference between defending an un- satisfactory status quo against cutbacks and seiz- ing this opportunity to prove that restructuring the health care system would deliver higher quality care for less money. So far the cuts have hit hardest in the areas which are most cost ef- fective, such as health promotion, disease pre- City State / / Zip Send your order to: WIN / 326 Livingston St./Brooklyn, NY 11217 vention, and primary and home care. The health care system's bias toward acute and institutional care, with its concomitant distortions in service allocation and consumption, has been accentu- ated. This is more evidence that government health care policies serve interests, not people, and it should be noted in all monitoring work. 17 Health / PAC Bulletin The most useful connections to find are those between health status or surrogate measures and specific programs. There isn't space here to discuss the gaps in data stratified by morbidity, age, income geo- graphy, etc., nor to catalogue exactly what can be found in the other locations. We would like to note, however, that short of Freedom of Informa- tion Act requests to Federal agencies it is possi- ble to find a great deal at the National Center for Health Statistics. Health United States is a handy reference of what is published annually. Com- puter tapes of state and county statistics can often be purchased. When wading through a sea of statistics it is obviously useful to have a helping hand. Sander Kelman, a professor of Urban Planning at Cor- nell active in the Tompkins County Health Status Documentation Project, advises working through existing health channels where possi- ble. Professor Kelman said that having a com- mittee which includes doctors, the local health and mental health commissioners, the Planned Parenthood director, and a hospital represen- tative has opened many doors to needed infor- mation. Officially, he noted, the monitoring is " an ongoing function of the local health plan- ning council. Formally, it has nothing to do with Reaganomics. " How to Make Connections Among the many difficulties monitors face, tracing the wiring in the black box we call the health care system is among the more formida- ble. Many of the inputs and outputs that ought to be diagrammed have been identified by Drs. Mary Peoples and C. Arden Miller of the University of North Carolina in their recent arti- cle on monitoring and by Dr. Peter Van Dyck, director of Utah's Maternal and Child Health secondary to diarrhea, both potentially fatal diseases, could increase. " 8 Surrogate measures are more sensitive to short term changes, these researchers note. Peter Van Dyck and other MCH directors are looking at immunization status, anemia levels, adequacy of prenatal care, number of adoles- cent pregnancies, etc. To measure declines in access, CDF, AMSA, HSAC, and CSS are already asking about rou- tine care, crisis services, eligibility require- ments, fees, waiting time, admissions and discharges, and staffing and equipment. Find- ings in all these areas will be valuable to health care advocates as well as academics, so both should welcome exchanges of information. However, even the best of short term statistical studies won't be conclusive, warned Anjean Carter of the CSS Child Watch. " We're collect- ing gross data on infant mortality, late prenatal care, and birth weight, " she explained. " We're doing neighborhoods that are medically under- served - health manpower shortage areas or areas where there is no prenatal care at all. But these aren't statistical samples. We can't really correlate them. We'll be able to say, Where ' the infant mortality rate is such and such, 100,000 $ was cut from such and such programs. " ' One local health official who likes to season his current pessimism with a little positive think- ing suggested that even if it doesn't have any effect in Washington, a local monitoring project can help concerned administrators who are compelled to practice budgetary triage with their remaining funding. Beyond Facts programs. They all suggest that the most useful connec- tions to find are those between health status or A monitor does not record and report passive- ly. Since the ends are political, it is delusory to insist the means are " value - free. " Choices must surrogate measures, such as the number of be made about what data to collect, how to adolescent pregnancies, and specific programs. " For example, " wrote Peoples and Miller, " primary care services may become sufficiently inaccessible that parents may not take their collect it, and how to report it. Since the infor- mation presented to hearings, political repre- sentatives, press conferences, meetings, and demonstrations will be provocative, horror children to appropriate providers until a disease stories must be mixed with hard facts. Clients has progressed to an irreversible point. Thus, can report the figures as well as providers can 18 the incidence of pneumonia or dehydration tell the tales of woe. Health / PAC Bulletin Health care advocates can learn a great deal from the success of groups like the Cape Cod Health Care Coalition and Love Canal Home- owner's Association about researching and re- cruiting, grabbing headlines, and cornering politicians. But Joanne Lukomnik suggests that each group or coalition must link monitoring to local conditions. It is best to start with whatever has gotten your goat, she advises. Most advocates have the skills and the will to organize their clients and communities, but in the present climate the flesh may still be weak. Monitoring can be a way of reactivating political muscles, of convincing people that it is possible to do more than run in place, waiting for the Queen of Hearts or her Presidential equivalent to cut off more heads. 1. Peoples, Mary D. and Miller, C. Arden, " Monitoring and Assessment of Federal Cutbacks and Consolida- tions: Effects on Maternal and Child Health, " Bush Insti- tute Conference, Washington, D.C., May 5, 1982, p. 2. 2. Ibid., p. 9. This is an excellent overview of the methodo- logical problems and challenges of monitoring. A revi- sion in progress will give more attention to advocacy and management needs for data. 3. The list which follows is dervied from telephone inter- views with most of the contacts mentioned, the above article by Peoples and Miller, and the American Public Health Association Monitor, no. 1, March 1982. 4. 4. Peoples, p. 17. 4. 5. Ibid., p. 16. 6. Health Security Action Council, " Citizens'Health Pro- gram Monitoring Projects, " Spring, 1982, p. 2. 7. Peoples, pp. 12-21. 8. Ibid., p. 6. SLSTUEEAESALNDIQUALSTSENGLEGAUIBISIONESESSORCERSEOAELSAOCENEAOCUSSCAGSREOUSCCOSCAzOCHO [311 00000000RUUCAEELS90GN00SERSEUNURCEOGOLANRNERACACACOONCEGSSNGE FSGEUO0L ISUCGULINGRERESGOONGROONTEONOSEULERINQUOETIN Important news for 10 million Americans Health Protection for Operators of CRTs VDTs / Find out the eyestrain dangers - , muscle pain, indigestion, stress - and some simple ways to minimize them in this booklet produced by the New York Committee for Occupational Safety and Health. Available from Health / PAC, 17 Murray St., New York, N.Y. 10007, for $ 1 plus 25 postage for in- dividuals and $ 3 plus 25 for institutions and corporations. USES ASRS DNELEGELAeh PR ie tHAeLILEeGARE T ET OERFIEL--KETJUHURN HALILEGARET ET OERFIEL--KETJUHURN HALILEGARET ET OERFIEL--KETJUHURN HALILEGARET ET OERFIEL--KETJUHURN HALILEGARET ET OERFIEL--KETJUHURN HALILEGARET ET OERFIEL--KETJUHURN eeenTTeae Billions from Bandaids (continued from Page 10.) Hewlett Packard - , for example, enjoys twice Consumers have reason to be less enthusiastic the market share of the nearest competitor in pa- about this trend than stockholders. For them it tient monitors; Becton Dickinson - ships three can mean paying for inflated profits, cosmetic times more needles and syringes than the innovation, and shoddy products. A prime runner - up (see tables 1 and 2). The ability of example of all is wheelchairs, a market in which such firms to dominate their markets can be the Los Angeles manufacturer Everest & Jen- imagined when it is realized that American eco- nings has a virtual stranglehold (see box- nomic theorists generally declare an industry " Holding a Captive Market Hostage "). Market competitive only if the market shares of the four, largest firms are five to ten percent or less. dominance stifles technological innovation, too. William Winpisinger, head of the Machinists " Companies which have commanding posi- union, has said a highly placed official of the De- tions, virtual monopolies, within a rapidly partment of Commerce in the Carter Admini- growing market.. might. be characterized as a stration involved in its Domestic Policy Review ' technological monopoly,'whereby a specific on Industrial Innovation told him that the company so dominates a field that it has an effec- tive monopoly, " observed David Lothson, a government intended to continue funding re- search and development for small businesses senior investment officer with Chemical Bank. only because their acquisition seemed to be the Examples he cites include New England Nuclear only way of getting new technologies into the (a Dupont subsidiary producing radioisotope), larger corporations. 12 Servicemaster Industries, National Medical The giants of American industry realized long Care (dialysis), Shared Medical Systems (com- ago that the cheapest way to deal with the com- puterized information systems), and Metpath petition is to swallow it whole. A prime example (clinical laboratories). of this horizontal integration is the called so - 19 Health / PAC Bulletin Size offers another advantage familiar to pur- Table 2. chasers of inexpensive Polaroid cameras who Market Shares Patient - Monitors are subsequently staggered by the price of film. Large national distributors can afford to " pack- Corporations Hewlett Packard - Narco Scientific (includes Air Shields) Squibb (includes Spacelabs & Tektronix) Sales (in millions) $ 75 Percent of Market 21 30 0 22 6 age " low or no cost equipment for lease or purchase with profitable supplies, services, or training. Thus bargain prices for intravenous pumps guarantee profitable sales of disposable, plastic tubing sets; electronic thermometers are coupled with disposable probes and covers; clinical laboratory diagnostic analyzers can seem like a good buy when the manufacturer gets handsome profits from their testing reagents, maintenance and service, and addi- Litton 20 6 tional components to expand or update process- Warner Lambert - 20 6 ing. Leasing or loan packages for a line of Honeywell 18 General Electric 12 Abbot Laboratories 10 Dickinson Becton 2 5 capital equipment often " addict " a hospital or other purchaser to vast quantities of compatible 3 supplies and services. Hidden in the Economic 3 Recovery Act of 1981 is a special tax deduction 1 for donations of such equipment to medical Source: calculated from A Profile of the Medical Tech- nology Industry and Governmental Policies, National Center for Health Services Research, PHS, DHHS, June 30, 1981. schools, which makes this practice even more profitable. These arrangements can also per- mit institutions to duck a Certificate of Need examination by keeping the equipment under the $ 150,000 capital investment trigger price. " competing " lines of surgical sutures, Ethicon and Surgicon, both owned by Johnson & John- son. Johnson & Johnson's Technicare dominated the CAT scan market until 1980, when second ranking General Electric bought EMI Technol- Even excluding lease and loss leader - jug- gling, the lady selling lipsticks in homes could learn a lot from her coworker in Avon's medical supply division. Experience has shown the in- dustry that its purchasers are more influenced ogy, a British firm then third in sales; now all these companies have to worry about is weak Figure 3. competition from Siemens A.G., the West Ger- man electronics behemoth, and Pfizer, the phar- Comparative Profitability maceutical house (see figure 3). The top three firms control 92 percent of the market; J.P. Morgan is the second largest stockholder in one of them and the third largest in the other two 10 Pharmaceuticals (see box). 18 Within most segments of the industry, hori- zontal integration is the only way to go because 17 in vertical integration, hospital and medical supplies already rival petroleum, 13 where com- pany control of every step from exploration to the gas tank has been the classic model. As Ex- xon and Mobil have proved, this not only secures supplies all the way down the line- which may be important for a new, exotic pro- percent 10 in ( 15 Equity on 14 Return 13 12 Medical Supplies All Manufacturers duct - it permits shuffling of costs and profits all 1=1 along the production line to maximize income and minimize taxes. Pharmaceutical companies 1975 1978 1977 1978 1979 1900 enjoying tax holidays in Puerto Rico might owe more of their net profits to creativity in account- 2200 ing than in research. Source: StNanedwa rYdo r&k T iTmiemse sP,o orMsa,y H1373 1981, Andrea Pereira Health / PAC Bulletin by sales personnel and company and product images than by genuine differences in price, Table 3. safety, or specifications. Advertising (as a per- cent are of sales) consequently receives twice the resources of the national industrial average, Market Shares Surgical - Instruments & Supplies providing the lifeblood of the medical journals that conveniently reinforce the American bias toward capital intensive - medicine. This inten- sive promotion usually bears closer resem- Corporation (Subsidiaries) Surgical Instruments Supplies Surgical Sales Market Sales Market (in Share ) - Share millions) millions) blance to consumer pitches than to other Johnson & Johnson industrial - goods advertising, employing emo- tional appeals to proclaim superficial changes in style and design.16 Hospital purchasing practices distorted by personal preferences of medical and nursing staff certainly deserve some responsibility for this phenomenon. A 1980 Government Ac- (including Uniral, Applied Medical Research, Codman & Shiertleff, Ortho- diagnostic Instru- ments, Jelco, Ohio Nuclear, Extracorpo- real Medical Spe- cialties, Ethicon, Permacel, Invacare, counting Office report revealed institutions in the six cities surveyed were accepting price variations as large as 300 percent for identical hospital supplies. 17 The GAO found no consis- tent relationship between lower prices and higher volume sales; the study also concluded that group purchasing did not always insure lower prices. The Inspector General of the Department of Health and Human Services estimated in 1980 that such poor procurement practices cost hospitals $ 1.3 billion annually. Like the pharmaceutical industry, the supply industry fields armies of " detail men " who pro- vide advice, information, and services. Gener- ally, the larger the firm, the heavier its reliance on both personal selling and heavy advertis- ing. 18 These " personal selling methods " reached a high point in 1977 on Long Island, where surgical supply sales personnel were found to be actually performing surgery while purveying their latest wares.19 The many similarities to the pharmaceutical industry are more than coincidental. Gobbling up firms in a sister industry is a natural strategy at a time when pharmaceutical profits are slug- gish. This " epidemic of acquisitions involving medical products and equipment companies " Technicare, and Surgicon) Becton Dickinson $ 146.6 6% (including Alrich Precision, Vanguard / Elec- trodyne, Clay Adams, Drake Wil- lock, Bard Parker, and Medical Development) American Hospital Supply (including Heyer Schulte -, Ed- ward Laboratories, 240.4 10% V. Mueller Div., Pharmaseal Labs, and Hamilton In- dustries) Warner Lambert - (including all Orthopedic Ap- pliances, Parke Davis, Snowden Pencer, and Deseret Pharmaceu- tical) 92.5 4% American Sterilizer Company Brunswick (including Sherwood Medical Industries) 106.4 4% C.R. Bard (including Wm. Henry Re- search, Burnett In- struments, Macback and USCI Divi- $ 562.7 17% 9806 3% 233.5 7% 67 2% 109 3% offers " technological expertise and prospects for future growth, " in the words of Business Week. 20 SmithKline, cash - rich with profits from Taga- met, the nation's most profitable drug, recently sions) Bristol Myers (including Zimmer Mfg. Co.) Cordis Corporation 99.3 4% 89.2 4% 80.6 3% merged with Beckman, a manufacturer of scien- tific instruments, in one typical acquisition. SmithKline was eager to gain a foothold in the Pfizer (including Shiley Labs, United Division, Howmedica) 88 2% burgeoning biotechnology industry - Beckman was among the exclusive guests at the recent Colgate Palmolive (including Kendall) 71 2% biotechnology summit conference at Pajaro Source: Economic Information Systems, Share of the Dunes sponsored by Stanford, Harvard, MIT, Market Report, 1979. 21 Cal Tech, and the University of California. In Health / PAC Bulletin an artist's future. see here is What you rendering of your What doctors say: " God bless you. You've quintupled my income and given me more time for my family in the bargain. " Patience Kanwate, M.D., Pishaw, Arkansas " Now the only strokes I have to deal with are on " the golf course. ' Eule B. Rich, M.D., Park Avenue, New York Perira menstruay Andrea vaccination Thead ache ARTHRITIS vision re throat, problems tooth . Y, Y, N ZOUGH, hausea boburns allergy ache 'C UTS DIZZINESS fever 100 109 108 1073 be Humant Doc - is the breakthrough which for the first time applies the full range of space - age tech- nologies to medical diagnosis and treatment. After the patient presses one or more of the easy- to understand - keys shown, a soothing, authorita- tive voice responds with an appropriate witticism. Humant Doc - then gently extends the needles, tubes, sensors, and other instruments to perform a complete battery of tests. The patient is relaxed by a light musical interlude. The state - of - the - art Doc Humant - computer analyses the test results instantly and emits a slip. of medical stationery with the name of the illness, a prescription, and a schedule of future visits. After inserting a valid Medicaid, Medicare, Blue Gross, VISA, or other appropriate card into the slot provided, the patient is permitted to leave. Tests by independent researchers show that Doc- Humant can carry five times the normal patient load. Only seven percent of the patients in one study complained Doc Humant - provided care inferior to what they were accustomed to. A grati- fying 52 percent declared that Doc Humant - of- fered the most careful and considerate medical care they had ever received. Doc Human. tAn ot h- er product from the Armageddon Corporation, " Serving you with 22 everything from air freshener to binary weapons. " ' Health / PAC Bulletin return, Beckman gained a pharmaceutical sales force and a mechanism for moving products through the Food and Drug Administration. 21 These " incestuous " acquisitions, in the words of James Tullis, are part of a " strong trend of consolidation between two big industries.... Management expertise in the hospital supply in- dustry far exceeds anything I see in the pharma- ceutical industry... in () the rapidity with which they introduce new products or change their marketing strategy. " Despite this fancy footwork relative to the pharmaceutical industry, some hospital and medical suppliers are reaching the " mature " stage in their growth cycle (see Gel Stevenson, " Profiles in Medicine, " Health / Pac Bulletin No. 72, Sept./Oct. 1976). Positions are consolidated; markets are saturated. The next logical step is a move into overseas markets, and the industry is out there. In the 1960's, U.S. medical supply im- port were rising at the highest rate in the indus- trialized world; most of this increase came in standardized devices and supplies. Since then exports have surged ahead so rapidly - 16 to 20 percent a year - t hat by 1980 $ 3 worth was shipped out for every $ 1 brought in. The 1981 U.S. Industrial Outlook predicted their value would be over $ 2 billion in that year. 22 Since 1967, exports of x ray - and electromedical equip- ment have multiplied 18 fold - - nine - fold since 1972. West Germany and Japan may be surpass- ing the U.S. in other industries, but not here. Reasons for this success are readily apparent. Although American corporations may publicly complain about domestic regulation, relatively high U.S. quality control standards secure their domestic market by raising a high hurdle against foreign competitors. These American producers and distributors also benefit from an unusually high level of brand and company loyalty, characteristic of the medical market as a whole, as well as many " first chance " opportuni- ties in foreign markets where the product has not been available previously. Because the goal of providing the most sophis- ticated care for those who can afford it occupies a higher position in American medicine than in more egalitarian health care systems, a high proportion of the world's technological ad- vances are consequently achieved and mar- keted here. In addition, the many foreign doc- tors who receive specialized training in Ameri- can institutions are likely to want the latest equipment when they return home. Apologists for capitalism generally describe profits as the market's means to accomplish social and economic ends, while critics empha- size the social and economic distortions arising when profits themselves become the social and economic end. Worrying about the ethics of such a system is not the business of medical and hospital supply industry executives. As in all American industry, their concern is the bottom line. High profits in an industry may indicate economic health and managerial efficiency. They may also mean exploiting and underpay- ing workers here or in the Third World or cut- ting corners on materials, design, and safety testing. Or that a few firms grip a market so tightly that they can set prices without fear of competition. Among the 1981 Fortune 500 companies, pharmaceuticals ranked second in return on sales (behind mining and crude oil) and third in return on stockholders'equity (after tobacco and beverages). 23 Along with these gratifying profits the ethical drug industry has attracted a steady barrage of criticism which reached a crescendo in the embarrassing exposures of the Kefauver hearings in the early 1960's. As we have seen, if the medical and hospital supply industry were subjected to similar scruti- ny there is reason to believe investigators would discover that its " ethical " nomenclature also belongs to a past era. Its newness as a major in- Table 4. Market Shares - CAT Scanners Sales Corporations (in millions) Johnson & Johnson (Technicare) $ 90.8 General Electric (includes EMI Tech) 8838 Pfizer 8380 Siemens A.G. (West Germany) 10 North American Philips (Nether- lands) 5 Elscint Ltd. (U.K.) 2 2 Omnimedical Services 1 Percent of Market 41 37 14 5 221 21 0.5 Source: calculated from A Profile of the Medical Tech- nology Industry and Governmental Policies, National Center for Health Services Research, PHS, DHHS, June 30, 1981. Health / PAC Bulletin " 23 Holding A Captive Market Hostage In 1978 a quadriplegic patient using an Everest & Jennings power wheelchair died of third degree burns when its electric wiring caught fire and she could not get out. In another incident, an Everest & Jennings wheelchair caught fire, the driver lost control; the control crossbar broke, hurling him to the ground so violently that he required treatment in a hospital emergency room. George Mason, a Michigan state assistant attorney general, found himself hurtling to the ground from his E & J " Remarkable Mark 20 " when a wheel fell off; later his chair stalled in the middle of a busy traffic intersection in downtown Lansing. On both occasions he was rescued by horrified bystanders. The Remarkable Mark 20 was later withdrawn from the market. Defective products under most circumstances would drive consumers to other manufacturers, but according to the Department of Justice E & J customers are handicapped by its control of more than 90 percent of the most profitable sector of the market, prescription wheelchairs, and, since 1955, of more than two thirds of ail wheelchair sales (including those used in airports and hotels). Not satisfied with this commanding position, E & J has attempted to buy out three of the six other companies manufacturing wheelchairs in the United States, and successfully acquired outright or in partnership the largest wheelchair producers in Germany, England, Canada, and Mexico. When the Johnson Wheelchair Company of Toronto, then the sole Canadian manufacturer, refused an E & J bid in 1962, they were told to expect a new factory " down the street. " Johnson's owners reconsidered and sold. E & J's legal department has been as busy as the acquisitions staff, suing almost every competi- tor in the country for alleged patent infringements. The Justice Department decided these suits. were pure harassment. For the consumer, such monopolistic control has meant inflated prices and limited innovation. In its anti trust - suit against E & J, the Department of Justice asserted that the company was raking in profits of more than 50 percent on prescription chairs and more than 100 percent on many parts. Repairs on E & J chairs are frequent and lengthy, requiring users to own and maintain spares. The parts are particularly expensive, costing from one and a half to twenty times compar- able parts from auto supply or hardware stores - but E & J won't repair wheelchairs that contain parts it didn't make. According to Dr. Robert Spindel, a specialist in rehabilitation medicine at Montefiore Hospital in the Bronx, the E & J chair is so constructed and repairs so lengthy that pur- chasing a new one is often the natural response after any breakdown. This travesty was outrageous enough to win a segment on television's " 60 Minutes. " While rejecting the notion that expensive repairs and limited longevity are " planned obsoles- cence, Ralf Hotchkiss, an Oakland engineer and wheelchair inventor who is himself disabled, describes E & J's behavior as " benign neglect " where they believe shoddy products and limited innovation " won't hurt too many people. " What E & J does well, he says, is take other company's innovations and mass produce them. The result is slow, incremental improvement. Unlike many medical devices, the wheelchair of today would easily be recognized by our grandparents. The basic design is exactly what it was in 1935 when the late Harry Jennings, Sr. developed the first E & J wheelchair. The major advance of this chair was its ability to fold up and fit into the trunk of a car, but this design is less suited to today's motorized versions with their added weight and stress. " I've sat in my wheelchair and watched men walk on the moon, " commented a bitter Becky Heinrichs, a 31 year - - old secretary in Bakersfield, California, who has been paraplegic since birth, " I know science was able to do that. I know it has developed strong, new light materials. Why is the wheelchair I'm sitting in like the one I sat in as a child? " A part of the answer to her question lies in the long standing - collusion between E & J and the Federal government, first with the Veterans Administration and more recently with the Food and Drug Administration's Bureau of Medical Devices. According to Donald Wright at the VA's Pros- thetic Center in New York, " All the wheelchair specifications in earlier VA standards described the typical E & J chair... " Rather than specifications for how a chair should perform, its durabili- 24 Health / PAC Bulletin ty or strength, the VA specified its appearance and construction materials, a policy that Wright and a colleague wrote, " stifles creativity in development and severely restricts the use of new materials and construction methods. It may also fix costs at higher necessary - than - levels. " Recently the VA changed its policy but now the Bureau of Medical Devices has placed wheelchairs in the same category as tongue depressors, requiring only " quality manufacturing practices " except when major design innovations appear. Then pre market - testing and approval must be carried out. In a 1975 court deposition E & J officials testified that their products did not undergo longevity testing and that the Remarkable Mark 20 had no scientific testing before being placed on the market. The E & J officials knew of no written quality control programs at their plant or trade association standards for wheelchairs, what the Bureau means by " good manufacturing prac- tices. " Frank Pipari, a consumer safety officer at the Bureau, told one reporter, " I'm convinced that in most cases of problems with wheelchairs, the chairs are being used incorrectly by the users. " Enough said. In 1977 the Department of Justice initiated an anti trust - suit against E & J, calling for divestiture of its foreign subsidiaries and cessation of numerous monopolistic business practices. In February 1979 a consent decree between the Department of Justice and E & J was reached, call- ing not for divesting its Canadian subsidiary but rather the establishment of a new independent sales and marketing company that would promote the sales of imported wheelchairs produced by E & J subsidiaries in Canada, Mexico, England, and Germany. E & I was to provide up to $ 100,000 per year for 10 years to this new company, International Medical Equipment. The Department of Justice is required to review annually for 10 years E & J's agreement to stop its text- book examples of " competitive anti - practices. " According to Ralf Hotchkiss, an Oakland engineer and wheelchair inventor who is himself disabled, the new marketing company has had little impact on sales, but the Justice Department's reviews have the potential for restraining E J's & past predatory practices. Frank DiGeorge, national advocacy director of the Paralyzed Veterans of America, said that his group had wanted to take this case all the way to the Supreme Court but they just did not have the financial resources. E & J's legal problems, however, are not over. Although the California Association of the Physically Handicapped dropped its class action suit after the consent decree, the Emerald Distributing Company of Auburn, CA, has filed a class action suit on E J's & pricing practices and in April 1982 InvaCare Corporation of Ohio filed a civil action in U.S. District Court charging E & J with monopoly practices and patent violations. InvaCare is E & J's major competitor for low cost, lightweight wheelchairs and was just beginning to enter the more lucrative prescription wheelchair business. According to E & J Senior Vice President Robert C. Birth, InvaCare's charges are groundless since the main complaint is that E & J's prices are " too low. " However, the suit may have bearing on the Justice Department's annual review. Disabled activists and advocates have turned from legal strategies to direct political action and self help - remedies for wheelchair problems including establishing independent repair services and " midnight " van pickups for broken electric wheelchairs. Responding to the Administration's " New Federalism, " on April 30th 100 disabled people " rolled out " in protest from the President's Commission on Employment of the Handicapped. They were led by Tom Andrews, director of the Maine Association of Handicapped People, who said, " Our rights, our dignity, our quality of life are being sacrificed here. " Ralf Hotchkiss has been working with Disabled People International in Singapore, Nicaragua, and the Philippines to develop lightweight wheelchairs with fewer and cheaper parts, appropriate to the needs of Third World countries. His work enabled Philippine wheelchair users to become major producers of custom - made wheelchairs and stimulated a flurry of design innovations in Managua. While defective automobiles, bicycles, and hair dryers are recalled so often now that it is no longer newsworthy, wheelchair users are still being blamed for their breakdowns and held hostage by the makers of the machines they are most dependent on. (Some research for this article was done by Betty Medsger and the Center for Investigative Reporting and published in The Progressive, March 1979.) 25 Health / PAC Bulletin dustry has probably spared it attention; so has its absence as a separate category from standard listings such as the Fortune 500 and the U.S. Of- fice of Management and Budget data (where Fortune gets its categories). When its major corporations have been sorted out from numerous other categories, they reveal better than average but otherwise unexceptional profits up until five years ago. 24 Then they took off (see figure 3), and are now well above aver- age and closing fast on the pharmaceutical industry's. One study of the industry found somewhat higher profits among the largest firms, and linked this with their monopoly or oligopoly position. 25 Measured by return on assets, some of the smallest (and most innova- tive) firms have been the most profitable, even a bit ahead of the giants, but it would be a safe bet that many of these, like IMED, have already or will soon disappear into conglomerates. Stock purchasers, of course, look for more than good current profits, particularly in an industry such as hospital supply. It " may be growing faster " than pharmaceuticals, cau- tioned Michael Harshbarger, vice president of Chicago's Northern Trust Company, but " most products have a shorter life cycle. " 26 This can be a danger to the complacent. It can also be a source of profit to companies energetic enough to leap forward, whether by developing new methods for home monitoring of blood puters and other research intensive - industries with earnings significantly above the national average, 28 " research is considered the key to profits. " 29 " We expect R & D spending by medical sup- ply firms to grow as they recognize the appar- ently strong correlation between percent of sales spent on R & D and gross profit, " predicted John R. Starr, a consultant with Arthur D. Little, Inc. In recent years this willingness to pour huge sums into new products has been fostered by confidence that money will be there to buy them. Wall Street has often described the industry as " recession - proof, " a must for every portfolio in the Reagan years. " History shows that during a recession there is relatively little impact on hospital supplies that are oriented toward direct therapy in hospitals, " advised Morgan Stanley's James Tullis, " I think a lot of the hospital sup- ' plies... tend to grow in volume even in a recession. " 30 But Tullis offered this opinion before the slashes in Medicare and Medicaid funding. The fate of the hospital industry and its purchasing power is closely tied to public expenditures on health care and the spigot appears to be closing. Despite promises of deregulation in other areas, hospital cost containment remains high on the Reagan Administration's agenda. sugar for diabetics or adding a little more chrome to last year's CAT scanner. The " major + growth in the medical technology industry in innovation and new products took place be- tween 1940 and 1965, " according to Dr. Joyce C. Lashof, dean of the University of California School of Public Health and former Assistant Director of the Congressional Office of Tech- nology Assessment. " The major change during the last 15 years has been the diffusion and JURIIDAN increased use of existing technologies rather than proliferation of new ones. "'127 Even though the number of major break- throughs may be small, the pressure to find something new has intensified. Since the 1950's the industry's investment in research and devel- opment has consistently been almost double that of all manufacturers as a percent of sales, and a higher percentage of this comes out of the com- pany treasury rather than government grants or contracts. The results have been dramatic: the annual number of patents granted for medical supply equipment has jumped nearly 100 per- cent since 1965 while the number granted to all 26 manufacturers has actually declined. As in com- Kate Pfordresher Health / PAC Bulletin Institutions are also tightening up to cover more painful, or more dangerous procedures mounting deficits. Alongside existing Certifi- and treatments. The labor saving devices should cate of Need controls for major capital equip- free staff for more direct patient care. Yet the ment, hard pressed - voluntary hospitals are reduced risks often are lost in altered medical increasingly turning to " materials management " practice which results in greater utilization, to determine their drug, equipment, and supply additional case finding, and potential iatrogene- purchasing that now accounts for 42 percent of sis. Labor savings end up meaning de skilling - or their budgets. A study conducted by Patricia proletarianizing the workforce or reductions in Gempel and David Boodman of Arthur D. Little, patient care staffing rather than more per- Inc., found cost containment is already affecting sonalized care, as patients receive more care the institutional market for health care from machines than people. The ideal patient products. 31 Hospitals are behaving more like fits the machine, the way the ideal tomato has other industries, employing techniques such as become the square, plastic one that is picked group buying, prime vendor contracts, and ven- and packaged easily and never spoils. dor performance monitoring. Even the slimmed- Medical supplies is an an industry that shapes down six percent annual real growth rate that and thrives on our American system. Whether analysts predict for the 1980's may succumb to health consumers benefit is another matter. the Reagan cutbacks and the long - term crisis of American capitalism. Those who can afford it or are adequately in- sured will increasingly find that their care Even if growth slows down or ceases entirely, resembles an assembly line where the consumer maintaining current sales will continue to is packed, processed, and, finally, consumed. reshape virtually every aspect of health care. An based office - internist can triple his or her in- Acknowledgements: Gessie Saget, a Health / come merely by performing more office proce- PAC summer intern, provided much of the dures such as electrocardiograms and simple background research for this article. Gel blood tests. 32 As the hospital labor force has become larger and better paid, disposable Stevenson provided special expertise, guidance, and encouragement. B products have replaced many items formerly cleaned, laundered, re sterilized - , and / or re- used. The major expansion in the hospital labor force has been in technicians who attend the new machines that, in turn, require new reagents, supplies, and parts. The labor- 1. Schroeder, Steven A. and Showstack, Jonathan A., " The Dynamics of Medical Technology Use: Analysis and Policy Option, " in Medical Technology: The intensive health care industry of yesterday has Culprit Behind Health Care Costs? (Washington, D.C.: yielded to a capital intensive - system where the skills and cost of the labor the new technology requires stimulate a market for still more capital Government Printing Office, DHEW Publication No. (PHS) 79-3216, 1979). 2. Todd, M.D., Malcolm, Plenary Address, Association for the Advancement of Medical Instrumentation, 12th An- investment. This " technological imperative " has nual Convention, San Francisco, CA, 1977. transformed the standards of medical practice, leading to the depersonalized health care which patients like Dorothy Morrison have too often 3. Peterson, R.D., and McPhee, C.R., Economic Organization in Medical Equipment and Supply (Lex- ington, MA: Lexington Books, D.C. Heath & Co., 1973). 4. Smithson, Luther H., Structure of the U.S. Medical received. Supply, Equipment and Device Industries (Palo Alto, What they can't sell through a promise of CA: Stanford Research Institute International, 1979). reduced labor costs, the hospital supply corpor- ations market to willing buyers through a strategy of " planned obsolescence " built into the 5. Aardsma, Allen H., " Survey points to need for more efficient inventory management, " Hospitals: 91-92 (Jan. 16, 1982). 6. U.S. Department of Health and Human Services, Food competition between institutions for medical and Drug Administration, Office of Planning and Evalu- personnel, prestige, status, and patients. CAT scanners will soon be " outmoded, " replaced by the PET (emission positron - tomography) and ation, Baseline Data on Medical Device Industries in the Census of Manufacturers (Washington, D.C.: Food and Drug Administration, No. OPE 53, July, 1980). 7. Wenchel, H. Elizabeth, A Profile of the Medical NMR (nuclear magnetic resonance) scanners Technology Industry and Government Policies, Volume like so many car models or generations of I (Hyattsville, MD: National Center for Health Services computers. Research, June 30, 1981) and Stevenson, Gel, " Laws of For patients like Dorothy Morrison and mil- Motion in the For Profit - Health Industry: A Theory and Three Examples, " International Journal of Health Ser- lions of others, this trend is a mixed blessing. vices, 8: 235-256, (1978). 27 Many of the technologies replace more invasive, 8. ibid. Health / PAC Bulletin 9. " Drug Industry Financial Analysis 1979 and Forecast 1980, " Medical Market and Media, 14: 23-45 (November, 1979). 10. Wenchel, H.E., op. cit. 11. Caves, Richard, American Industry: Structure, Con- duct, Performance (Englewood Cliffs, NJ: Prentice Hall, 1972). 12. Winpisinger, William, " A Labor Perspective on Science and Technology, " Annals of the New York Academy of Science, 334: 264-275 (1979). 13. Wenchel, H.E., op. cit. 14. Feinschreiber, Robert, " In Washington: New law en- courages donation of medical instruments, " Medical In- strumentation, 16: 65-66 (Jan. - Feb., 1982). 15. Wenchel, H.E., op. cit. 16. Peterson and McPhee, op. cit. 17. Government Accounting Office, Hospitals in the Same Area Often Pay Widely Different Prices for Compara- ble Supply Items, (Washington, D.C. Government Printing Office, 1980), and Simler, Sheila L., " Inefficient Buying May Spur Controls, " Modern Healthcare 38 (May, 1980). 18. Peterson and McPhee, op. cit., and Wenshel, H.E., op. cit. 19. Ehrenreich, Barbara, " And Now: Fuller Brush Surgeons, " Mother Jones, 11-13 (April, 1979). 20. Santry, David G., " Inside Wall Street: The merger fever in medical products, " Business Week (Sept. 18, 1978). 21. Alsop, Ronald, " SmithKline Set $ 1 Billion Merger with Beckman, " Wall Street Journal (November 27, 1981). 22. " Drug Industry Financial Analysis, " op. cit., and U.S. Department of Commerce, Bureau of the Census, U.S. Industrial Outlook 1981 (Washington, D.C.: Govern- ment Printing Office, 1981). 23. Williams, Monci Jo, and Knight, Claudine, " The For- tune Directory of the Largest U.S. Industrial Corpora- tions: The 500, " Fortune, 105: 258-286 (May 3, 1982). 24. Wenchel, H.E., op. cit. 25. ibid. 26. " Drug Industry Financial Analysis, " op. cit. 27. Lashof, Joyce C., " Government Approaches to the Management of Medical Technology, " Bulletin of the New York Academy of Medicine, 57: 36-44 (Jan. - Feb., 1981). 28. Grabowski, Henry, " Public Policy and Innovation: The Case of Pharmaceuticals, " Technovation, 1: 157-189 (1982). 29. Hayes, Thomas C., " The Drug Business Sees a Golden Era Ahead, " New York Times (May 17, 1981). 30. " Drug Industry Financial Analysis, " op. cit. 31. Gempel, Patricia, and Boodman, David, Proprietary study on health care products, Arthur D. Little, Inc., Cambridge, MA, as reported in American Medical News (July, 1980). 32. Schroeder, S.A., and Showstack, J.A., " Financial In- centives to Reform Medical Procedures and Laboratory Tests: Illustrative Models of Office Practice, " Medical Care, 16: 289-298 (1978). Bulletin Board Where's Poppa? Take This Job The U.S. Public Health Service is assembling Our work lives may be varied but we're all a directory of 500 publications and audiovisuals under stress. Occupational Stress: The Inside about maternal and child health. Publication is Story is a booklet which analyzes the physical expected by this summer. Get a preview from and psycho - social demands of our jobs and ex- Elaine Bratic, Office of Public Affairs, U.S. plains exercises to reduce stress pressing - hard PHS, Room 740G, 200 Independence Avenue, at the bargaining table and walking on the S.W., Washington, DC 20201. (From APRS picket line. It costs $ 3.50 for individuals and Federal Monitor, 2/15/82) $ 5.00 for organizations, plus $.80 postage and handling; $.30 more for each extra copy. Ten Generic Politics copies or more - 20% off. Order from the In- stitute for Labor and Mental Health, 3137 A recent survey by the National Consumers Telegraph Avenue, Oakland, CA 94609. League ranks health fourth among the concerns of American consumer organizations - behind energy, environment, and housing. " A Look at the Current Consumer Activist Movement: Cash and Ash Beware of death on the installment plan! Read 1981 " predicts " a shift in the consumer activist Its Your Choice: The Practical Guide to Plan- community from a concentration on product in- formation, product safety and other individual concerns to a broader emphasis on the structure ning a Funeral, by the American Association of Retired Persons and the National Retired Teach- ers Association. It's $ 4.50 from AARP / NRTA, 400 of the economy, prevention of problems and South Edward Street, Mount Prospect, IL 60056. long term - public policy. " For a look, write NCL, For information about bulk orders, write their 1522 K Street, N.W., Suite 406, Washington, DC Consumer Affairs Section, 1909 K Street, N.W., 28 20005. Washington 20049. Health / PAC Bulletin become prevention scripture Body English despite scanty evidence that this is beneficial to the teeth, let alone the chromosomes. In fact, what may be the only study, published in Lancet (8035: 422, of legal action, administrative 1977), concluded that those who convenience, and public health trudged off to the dentist for two screening. " No x ray -, " the report noted, " should ever be checkups a year had no better teeth than those who went less routine, but should be based on frequently. clinical evaluation of the patient Although they don't appear to to determine its medical affect the health of your molars, necessity. " these semiannual visits do take a Some x rays -, however, carry large bite out of your bank ac- X traneous - Rays more risk than others. Many people concerned with protect- count if you are one of the over- whelming majority which has no by Arthur A. Levin Half of all Americans are ing their unborn descendants take care to keep their sex organs unexposed. Few are dental coverage in an insurance or health plan. X rays -, of course, are extra, and many practition- ionized by an x ray - every year. As we saw in the last issue, aware that various parts of the body require photography with ers take at least a series of bite- wing pictures on every visit. assuming this is no more dan- rays of greater intensity and Dental experts generally gerous than exposing yourself to duration, with commensurately agree that a whole mouth series an instamatic lens is a mistake. higher risk. The following should be performed only when Rather than submit with the estimates of typical dosage are there is some suggestion of a cheery resignation of a World taken from X Rays -: More Harm clinical problem and bitewings War II kamikaze pilot, the pru- Than Good, by Priscilla W. should follow only when disease dent consumer should always Laws. shows up on the whole mouth. ask why an x ray - is necessary. Besides assuaging your doubts, High Dose Upper GI (gastrointestinal) The only routine aspect of a den- tal x ray - should be the lead this might encourage the practi- series (barium drink), lower apron to protect reproductive tioner to exercise caution and be GI series (barium enema), organs. sure that the decision is the right lower back (lumbar), lower one at the right time. spine (lumbosacral), mid- According to a 1976 report dle spine (thoracic), and issued by the Environmental mammography. Protection Agency, entitled " Radiation Protection Guidance for Diagnostic X Rays -, " the most Medium Dose Intravenous pyelograms (IVP exams of the kidney, Chest x rays - serve little clinical purpose for the effective way to reduce exposure would be to encourage more bladder, and ureter), gall- bladder (cholecystogra- general population. appropriate and " rational " pre- phy), pelvic and lower scription practices. Major rea- spine (lumbo - pelvic), skull, sons cited for " unnecessary " upper spine (cervical), and procedures were inexperience other kidney, bladder, or of the practitioner, intellectual ureter exams (K.U.B.) Failings of other common curiosity, fear of criticism, fear Low Dose x rays - have been exposed with of legal action, administrative Chest, shoulder, hands and greater success. Many readers curiosity, fear of criticism, fear feet, hip, upper thigh will remember lining up to (femur), and dental bite- board a bus which they thought Arthur A. Levin is a member of wings and whole mouth. was going nowhere for a chest the Health / PAC Editorial Board Even a low dose should not be x ray - (fluoroscopy). It turns out a and Director of the Center for accepted casually, and certainly few of those examined might Medical Consumers and Health not when it is offered routinely. have been stepping up for a one- Care Information. Twice annual dental x rays - have way trip to Sloan Kettering - . 29 Health / PAC Bulletin These and similar tests for jobs tients with hernias, and uro- The medical literature re- and school admissions have often exposed us to higher than necessary dosage and frequent- ly spilled radiation onto other parts of the body. When high grams and / or arteriograms for hypertensive patients - only five percent have the renal artery - disease which this is designed for. Most experts agree that gards a good radiologist as the person most qualified to judge if an x ray - is appropriate. The qualification " good " is impor- tant, however. An estimated 15 technology is involved, an ounce of prevention may require a pound of cure. Aside from entailing some danger, chest x rays - serve little clinical purpose for the general population. Tuberculosis is de- tectable by other, safer tests and lung cancer is generally agreed to be too far advanced for treat- ment by the time it shows up on a pregnant women and other women of childbearing age should avoid x rays - if at all pos- sible. When absolutely neces- sary, they should be designed to minimize exposure of the fetus and reproductive organs. A re- port by the Food and Drug Ad- ministration's Bureau of Radio- logical Health stresses that the often routine pelvimetry for to 20 percent of all American x rays - must be retaken. Some 45 percent of these retakes are necessitated by poor exposure, which a competent radiologist avoids by ensuring that the film and equipment are working pro- perly. Another 23 percent result from poor positioning of the pa- tient again - - again something a well- trained radiologist wouldn't negative. Unfortunately, this has not completely halted inappropriate use. Executives often get chest x rays - as part of the " perk " of an- nual multiphasic examinations; perhaps employers find this is an easy way to reduce the expense of generous pension plans. Workers are frequently required to get their lungs shot when en- tering a new job. Many hospitals still require all patients to have one on admission, even though the Blue Cross Association has recommended that such routine chest x rays - not be reimbursed except for surgical patients. women in labor or even simply pregnant should be given only if an individual clinical assess- ment indicates it is needed. TEALTH FACTS permit. Perhaps it isn't surprising in a country where most jurisdictions don't require a license to carry a gun that x ray - machines can be legally operated by a chimpan- zee, but still it's unnerving that only a dozen states license equipment operators. Even where regulations do exist equipment standards and in- spection can be serendipitous. New York City, for example, used to have a rigorous pro- gram, but budget cutbacks have virtually reduced this to an honor system. Consumers, therefore, are left It may be difficult to protest when you are on your back with an IV tube in your mouth in an to trust the judgement and com- petence of medical personnel and their own. Here are several intensive care unit. But if a rules which the wise consumer " portable " x ray - machine comes rolling through the door be sure there is good reason. Their dosage and focus controls are considered less effective than those of normal machines; even if the intended target is in the Mammography has probably aroused more controversy and debate than any other type of should keep in mind: 1) Always ask why any sug- gested x ray - is necessary. 2) Always insist on receiving a duplicate set of films for your personal files. This may obviate the need for a new set should the next bed you may get some rays. Hospital workers are also at risk, of course, and likely to be ex- x ray -, and the issues are too numerous and complex to be discussed adequately in a few other copy be lost and aid in a different practitioner's diag- nosis. posed regularly. Other doubtful exposures in- clude pre employment - lower paragraphs. Readers interested in more information on this test should contact the Center for 3) Don't pressure a practi- tioner to take an x ray -. Good care is sometimes less care, and spine series for longshore work- Medical Consumers, 237 many more people suffer from ers and in other occupations, Thompson St., New York, N.Y. overexposure than from under- routine barium enemas for pa- 10012. 30 exposure. Health / PAC Bulletin Vital Signs turned out workers and the com- munity. Public access was added make changes in the workplace so it gets publicized that you can (continued from P. 6) to the bill just before it passed, do something concrete. " although in a weakened form It is clear that even in places which required using the state's like Philadelphia, where a signi- Initially some worker protec- - freedom of information act to ob- ficant amount of money was tion bills passed on the strength of labor alone. By this time, cor- porate lobbying has become so tain data from the State Depart- ment of Labor. Whatever their differences of appropriated, implementation will depend on rank - and - file organizing. But once labor and intense that proposing a state- wide bill focused exclusively on means and ends, activists on both sides of the factory gate citizen activists have tasted the forbidden fruits of knowledge- either labor or the community agree that the right to know is an protected by the proper pesti- may well be an exercise in futil- ity. The 100,000 member - Massa- chusetts Fair Share found this excellent organizing tool. Said Caron Chess of the Delaware Valley Toxics Coalition, " We're cides, of course - there is no telling what they might do. -Carl Blumenthal out watching its own bill and the one supported by the state AFL- CIO wend their separate ways to still working through different ways [the Philadelphia law] can give you a handle on the toxics Carl Blumenthal is on the Health / PAC staff. the legislative shredder this problem; by bringing the infor- year. Next time the two groups will work together on a double mation to doctors; by knowing what's there you can figure out disclosure bill, promised John O'Connor, head of Fair Share's how it's being transported; and by having ambient guidelines Burning Health Issues neighborhood health and safety campaign. The AFL - CIO got the bill to the floor through the labor committee. Labor and community activ- ists in Connecticut recently showed how such cooperation can pay off. The Connecticut Council on Occupational Safety for toxics in the air you can re- duce emissions or substitute other chemicals. " Emergency planning, health surveys, pollu- tion watches, and plant inspec- tions are some of the other tactics that right know - to - allows citizens to use. Not to mention election- eering. (In Cincinnati, the president - elect of the city coun- cil won on a _ right know - to - platform.) For Jim Moran, of the Phila- delphia Project on Occupational Safety and Health, the proof is still in the pudding. " What we need is good information from (union) locals " that request it, he said, " Then we can move to If illnesses could be elimi- nated by quashing government reports on them, the Reagan Ad- ministration would be the best news in health since smallpox vaccine. In its first foray into literary eradication, the Reagan team demanded a rewrite of a pam- phlet explaining the dangers of Brown Lung disease to remove " business anti -" passages. Now a pamphlet on the effects of the deadly defoliant Agent Orange is being " reconsidered. " The Veterans'Administration recently revealed that a pam- phlet, produced during the and Health (ConnectiCOSH) Carter Administration, describ- drafted a bill providing for ing diseases connected to Agent worker and community disclo- Orange would be rewritten. sure and then brought the unions and CCAG together The Reagan Revisionists Calling the previous pamphlet " somewhat outdated, " VA through its community and labor task force on cancer. When the State legislature's environ- mental committee balked, the have turned the Agent Orange findings into a " theory. " spokesperson Larry Moen de- scribed the new publication as " a different pamphlet done by. a. different administra- AFL - CIO got the proposal to the tion. " Mr. Moen also said that re- floor as a labor bill. CCAG maining copies of the old pam- mobilized everyone it could. Demonstrations held at plants phlet had been removed from circulation. 31 Health / PAC Bulletin The earlier publication warned that many diseases have developed " among humans who have been exposed to dioxins, " a substance used in Agent Orange. It goes on to list kidney, liver, blood and nerve disorders, as well as several forms of cancer, as some of the many health effects connected to dioxin. The Reagan Revisionists have turned these findings into a " theory [that those exposed] might be subject to delayed health effects. " The new pam- phlet does not specify any of these " effects. " Instead, it ex- plains that " minute traces " of dioxin were contained in Agent Orange, and that laboratory " animal studies have shown it [dioxin] to be toxic to certain species. " It fails to mention any findings among humans unless we suppose " laboratory animals " is a reference to humans in Vietnam. In a final attempt to minimize any connections between the pamphlet and the outcries against the Vietnam defoliant, the color of the pamphlet's cover has been switched from orange to blue. Perhaps one can tell a book (or pamphlet) by its cover. Vietnam vets might not feel more secure knowing that the dangers of the hazardous chemicals they were exposed to in Southeast Asia are only " theoretical. " Ex- ecutives of Dow Chemical, man- ufacturers of Agent Orange, might draw more comfort. Another victory for the free enterprise system, aided by the Reagan Administration. -Peter Medoff Peter Medoff is on the Health / PAC staff. HEALTH / PAC HEALTH POLICY ADVISORY CENTER 17 MURRAY STREET NEW YORK, NEW YORK 10007