Document LJJmVZ7yyoZ4rBNMyRGZ5mDvq

HEALTH / PAC Health BULLETIN PolicAydvi sory Center No. 79 November / December 1977 1 Health Care by the Ton: CRISIS IN THE MINE WORKERS'HEALTH AND WELFARE PROGRAMS. Tying benefits to production and financial mismanagement have combined to threaten the future of the Mine Workers'health and pension programs. 9 Scandal at Gauley Bridge: LOOKING BACK AT THE NATION'S WORST OCCUPATIONAL TRAGEDY. Never in Ameri- can history have race, class and occupational hazards conspired to kill so many so quickly. 17 Columns: WASHINGTON: Cost Control WOMEN: Lay Midwifery NEW YORK: Body Snatchers WORK ENVIRON / : OSHA Cancer Policy 34 Vital Signs 37 Cumulative Index 8 TONS HIZELL6ETU 5 7 Health Care by the Ton NDIS CRISIS IN THE MINE WORKERS ' HEALTH AND The United Mine Workers'Welfare and Retire- ment Funds have pioneered a comprehensive health health care delivery system in the US coal fields WELFARE PROGRAMS for over a quarter of a century. A model for health - care reformers - and anathema to " free enterprise - enterprise " medical medical practitioners practitioners - it was once the largest prepaid medical group prac- COAL - tice in the US. At its peak, this system of union hospitals, community health clinics and local doc- tors cared for nearly two million miners and their families. Today the system is in shambles. The hospitals have long been sold. Most clinics have been cut loose. Miners'benefits have suffered cutback after cutback. Now the Funds face a financial crisis and their continued operation has become a major issue in the nationwide strike by miners. The following article by Curtis Seltzer traces the history of the Funds, recounts their important accomplishments and seeks to identify the under- lying causes of the present crisis. The roots of the crisis in the Funds, the author suggests, lie both in the financial manipulations of Fund monies by UMWA presidents Lewis and Boyle and in the unusual financing mechanism by which Fund income and miner benefits - are linked directly to the tonnage of coal mined. When miners first struck over health care cut- backs last summer, Max Fine, Director of the labor backed - Committee for National Health Insurance, stressed that this is not the problem of a single union. Indeed, Fine noted, the crisis in the Funds touches major and precedent - setting national health issues: universal coverage, the regressiveness of copayment and coinsurance, and the content of progressively - organized com- munity based health services, among others. We trust miners and their families whose health benefits, jobs and incomes are currently on the line will find this history useful in their long strug- gle. Its lessons are many and important for all who seek a health system comprehensive in scope, preventive in orientation, free at the point of de- livery and controlled by those who use it and work in it. In the lobby of the United Mine Workers'head- quarters in Washington, DC, an outsized bust of John L. Lewis watches the fumblings of his succes- sors. Not only does Lewis watch, he judges. His is a constant, scowling glare, fashioned deliberately to inspire fear and awe. Lewis'shadow darkens the union of coal miners in life and death. Like a polygon, Lewis had many sides. It fol- lows that the institutions he shaped to express his view of the world would be as complicated. So it is with the United Mine Workers of America (UMWA) a coal miners'union - and its Welfare and Retirement Funds. The fund, designed in 1946 to provide health care and pensions to coal miners and their families, has been and is today a source both of comfort and anguish to its bene- ficiaries. After four years of erratic beginnings the Fund was reconstituted in 1950 at a time when the coal industry was losing its two biggest markets: railroads and commercial heating. John L. Lewis, longtime president of the UMWA, saw the industry collapsing and - to save it switched - from fiery opposition to the big coal operators to a strategy of helping them cut labor costs through encouraging labor saving - mechanization. In return, Lewis persuaded the industry to finance a self contained - , UMWA controlled - health and re- tirement plan, and thus the UMWA Welfare and Retirement Fund was born. In the decade that followed the Fund built and sponsored a unique health system, one of the most progressive in the nation - a network of hospitals * Until the 1974 contract, the UMWA health and pension plan was known as the Welfare and Retirement Fund. The 1974 contract divided the plan into four parts, collectively called The Funds in this article. When used in the singular, Fund refers to the pre 1974 - plan. STATEMENT REQUIRED BY THE ACT OF AUGUST 12, 1970; SECTION 3685, TITLE 39, UNITED STATES CODE, SHOWING THE OWNERSHIP, MANAGE- MENT AND CIRCULATION OF THE HEALTH / PAC BULLETIN. 1. Title of Publication: Health / PAC BULLETIN. 2 Date of Filing: October 1, 1977. 3. Frequency of issue: Bi monthly - . 3A. No. of issues published annually: Six. 3B. Annual subscription price: student 8.00 $; regular $ 10.00; institutional $ 20.00. 4. Office of publication: 17 Murray Street, New York, New York 10007. 5. General business office of publishers: 17 Murray Street, New York, New York 10007. 6. Publisher: Health Policy Advisory Center, Inc.; Editor: Ronda Kotelchuck, c o / Health / PAC, 17 Murray St., N.Y., N.Y. 10007; Managing Editor: Michael E. Clark c o / Health / PAC, 17 Murray St., N.Y., N.Y. 10007. 7. Owner: (If owned by a corporation, its name and address must be stated and also immediately thereunder the names and addresses of stockholders owning or holding 1 percent or more of total amount of stock. If not owned by a cor- poration, the names and addresses of the individual owners must be given. If owned by a partnership or other unincorporated firm, its name and address, as well as that of each individual must be given.) Private, non profit - member- ship corporation: Health Policy Advisory Center, 17 Murray Street, New York, N.Y. 10007. Members: Barbara Caress, Oliver Fein, David Kotelchuck, Ronda Kotelchuck, Kenneth Rosenberg and Loretta Wavra. 2 8. Known bondholders, mortgagees, and other security holders owning or hold ing 1 percent or more of total amount of bonds, mortgages or other securities: None. 9. For completion by nonprofit organizations authorized to mail at special rates (Section 132, 122, PSM). The purpose, function, and nonprofit status of this organization and the exempt status for Federal income tax purposes: Have not changed during preceding 12 months. 10. Extent and nature of circulation: average number of copies each issue during preceding 12 months: total number of copies printed (net press run): 5,250; paid circulation: (1) sales through dealers and carriers, street vendors and counter sales: 10; (2) mail subscriptions: 2,623; total paid circulation: 2,633; free distribution by mail, carrier or other means, samples, complimentary, and other free copies: 259; total distribution: 2,892; copies not distributed: (1) office use, left over, unaccounted for, spoiled after printing: 2,358; (2) returns from news agents: 0; total: 5,250. - Actual number of single issue published nearest to filing date: total number of copies printed (net press run): 4,500; paid circulation: () 1 sales through dealers and carriers, street vendors and counter sales: 60; (2) mail subscriptions: 2,988; total paid circulation: 3,048; free distribution by mail, carrier of other means, samples, complimentary and other free copies: 53; total distribution: 3,101; copies not distributed (1) office use, left over, unaccounted for, spoiled afte printing: 1,399; (2) returns from news agents: 0; total: 4,500. I certify that the statements made by me above are correct and complete. (Signed) Ronda Kotelchuck, Editor. and community clinics that offered prepaid, nearly comprehensive health care in the coal- fields. " The broadest medical care plan under- taken for a nationwide industrial grouping up to that time in the United States, extending services to almost two million people, " one commentator described it. Yet the Fund has been from its inception beset with contradictions. It has been marked by a peculiar sweet - and - sour flavor explained in part by the collection of cooks that have seasoned it over the years. The Fund has always been a creature of collective bargaining between the union and the coal operators. By informal agree- ment UMWA presidents have always controlled its assets and set basic institutional directions until 1973. Meanwhile the Fund's medical program was conceived and implemented by some of America's most radical medical people. The resulting oil water - and - mixture of progres- sive medical personnel and conservative - and While the service oriented - left- wingers strove to build a model health care system, UMWA presidents Lewis and Boyle turned the Fund into a carnival of financial jugglers, pickpockets and sideshow sharpies. often corrupt UMWA - presidents has fermented in the Fund for some 25 years. While the service- oriented left wingers - strove to build a model health - care system, UMWA presidents Lewis and Boyle turned the Fund into a carnival of financial jugglers, pickpockets, and sideshow sharpies. Each group defined mutually contradictory roles for the Fund. Consequently, the Fund has given medical care and denied it. It has offered hope and destroyed it. The nub of an even more important set of contradictions lies in the financing of the Fund. The level of mine workers'health pension - and - benefits have always been pegged to the level of output of unionized operators. By linking benefits Table 1 Fatalities and Disabling Injuries US Coal Industry Years 1906-1910 1911-1915 1916-1920 1921-1925 1926-1930 1931-1935 1936-1940 1941-1945 1946-1950 1951-1955 1956-1960 1961-1965 1966-1970 1971-1975 1976 Fatalities 13,288 12,583 12,097 11,077 11,175 6,202 6,326 6,554 4,353 2,610 1,902 1,368 1,229 757 141 Disabling Injuries NA NA NA NA 99,981 * 322,355 292,984 313,233 239,151 126,488 76,833 55,482 51,669 55,874 13,944 1906-1976 SOURCE: Reference 25. * Data for 1930 only. 91,662. 1,647,994 to production and productivity, the Fund tied itself closely to the fortunes of the industry. The plan was barely in place when in the early 1960s it began a series of contractions which have re- duced it from a vision of a comprehensive health system to little more than a health insurance scheme. The hospitals have been sold, prepayment axed, clinic support cut, eligibility and benefit levels dramatically reduced. Last June these cutbacks precipitated a summer - long wildcat strike of 80,000 miners and are now a major issue in the nationwide UMWA strike. Today the Fund stands at the crossroads of his- torical changes both in the industry and in the union. The UMWA - big coal operator alliance that structured the political economy of the industry since 1950 has collapsed. The traditional Eastern leadership of the industry by Consolidation Coal and US Steel is now challenged by big union- non - ized, strip mines in the West, led by Amax. And Published by the Health Policy Advisory Center, 17 Murray Street, New York, N.Y. 10007. Telephone (212) 267-8890. The Health / PAC BULLETIN is published 6 times per year: Jan./Feb., Mar./Apr., May June /, July / Aug., Sept./Oct. and Nov./Dec Nov./Dec. Special reports are issued during the year. Yearly subscriptions: 8 $ students, 10 $ other individuals, 20 $ institutions. Second - class postage paid at New York, N.Y. Subscriptions, changes of address and other correspondence should be mailed to the above address. New York staff: Barbara Caress, Oliver Fein, David Kotelchuck, Ronda Kotelchuck, Ken Rosenberg and Loretta Wavra. Associates: Robb Burlage, Len Rodberg, Washington, D.C.; Constance Bloomfield, Desmond Callan, Michael Clark, Nancy Jervis, Kenneth Kimmerling, Louise Lander, Steven London, Marsha Love, New York City; Vicki Cooper, Chicago; Barbara Ehrenreich, John Ehrenreich, Long Island; Robin Baker, Elinor Blake, Judy Carnoy, Dan Feshbach, Carol Mermey, Ellen Shaffer, San Francisco; Susan Reverby, Boston, Mass. BULLETIN illustrated by Keith Bendis. Health Policy Advisory Center, Inc., 1977. 3 the UMWA is fragmented. Like a directionless meteor, it has broken from its rank - and - file orbit and disintegrates in space. The future of coalfield health care and pensions is directly tied to the strength of the UMWA in collective bargaining - a strength which is being severely tested now. Origins Prior to 1945 occupational safety and health, not to mention health care benefits, took a back seat to what John L. Lewis considered more ur- gent demands: union recognition, the union shop, the eight hour - day and higher wages. Yet be- Between 1920 and 1950, an average of over 1,000 miners died on the job each year and another 50,000 were injured. tween 1920 and 1950, an average of over 1,000 miners died on the job each year and another 50,000 were injured. Of the 41,677 miners retir- ing between 1948 and 1951, 47 percent did so because they were disabled, reported the UMWA Welfare and Retirement Fund. (See Table 1.) The only health care available usually was pro- vided by a company - hired doctor who was supported by a compulsory - and later, volun- tary wage - deduction called " the check - off. " By the mid 1940s - , 70 percent of coal miners had a company doctor prepayment - plan, 4 but dissatis- faction with the quality of care was widespread and justified. Occupational death, disability and disease coupled with a staggeringly deficient community health care system in the coalfields was an open sore. World War II imposed a wage freeze - on Ameri- can workers. Health care benefits were wedged into collective bargaining, however, when the National Labor Board ruled that a sickness benefit program not exceeding five percent of payroll 5 costs was acceptably non inflationary -. Com- panies faced with excess profits could deduct the costs of health benefits as business expenses with "... little actual expense, since they would have had in any case to have paid much of it out in taxes. " The Department of Labor estimated about 600,000 US workers " were covered by health. benefit plans established through collective bar- 4 gaining " by 1945.7 In the spring of 1945 Lewis demanded an industrial health plan from the operators. (Pensions were not part of the original proposal.) The plan would be financed by a 10 cent - per - ton royalty on UMWA - mined coal. The operators re- fused. Labor Secretary Frances Perkins, in unsuc- cessful mediation attempts, rejected the health plan demand. Miners walked out when their con- tract expired in 1945. President Truman subse- quently seized the mines and the miners returned to work under a conditional contract with the US government soon after. Lewis renewed the demand for health benefits and linked it with a pension plan in his 1946 nego- tiations with Secretary of the Interior Julius Krug, manager of the now federalized - coal industry. Lewis argued for compensation, not prevention. " Social insurance and pensions should be con- sidered as part of normal business costs to take care of temporary and permanent depreciation in the human'machine'in much the same way as provision is made for depreciation and insurance of plant and machinery. This obligation should be among the first charges in revenue. "... the men who own the coal mines in this country, and use up the manpower of our indus- try.. should. bear that... cost of production. "'10 Linking Health Benefits to Production Lewis first asked that the health and welfare fund be financed by a seven percent payroll tax on operators, but soon shifted back to a tonnage royalty for reasons shrouded in historical mists. Financing the Fund on the basis of output vested the UMWA with an interest in higher production and productivity, but not necessarily in a large number of working miners. Eventually, Lewis persuaded Krug to go along with a five cent royalty (five cents to the Fund for every ton of coal mined), and the Fund was born in 1946. Financing the Fund on the basis of output vested the UMWA with an interest in higher pro- duction and productivity, but not necessarily in a large number of working miners. In other words, the scope and quality of UMWA health care was to depend on the marketplace success of the coal operators, not on employment in the coalfields. (In contrast, almost all other union health plans are (UMH) Johnc CEWIS. E FUND THE BENDIS financed by employer and / or employee contribu- tions per worker, thus linking the size of the bene- fit fund to the size of the laborforce.) It also soon became apparent that when health and safety concerns in the workplace rubbed against productivity goals, production won. In an ironic way, then, the Fund " won " as the rank - and- file was losing. But what Lewis conceded in occu- pational health and safety, he hoped to make good through quality health care provided by the Fund. No Fund, No Coal Between 1946 and 1950 Lewis'Welfare and Retirement Fund was repeatedly sabotaged by federal administrators and industry opponents. '1 15 Krug refused to activate the Fund by refusing to name the third (neutral) trustee. " No Fund, no coal, " threatened Lewis in the fall of 1946, only to be hit with a temporary restraining order. Miners nevertheless struck and Lewis and the UMWA were slugged with big contempt penalties. Only after a federal study - the Boone Report - docu- mented the disgraceful level of coalfield health care and the Centralia (Illinois) mining disaster claimed 111 victims did Krug activate the Fund. The 1947 contract included a ten cent - royalty for the Fund. But the Fund was thwarted again when the operators deadlocked with Lewis over a $ 1,200 annual pension. The operators'trustee filed four suits to stop the Fund's operation. Strikes and Taft Hartley - injunctions followed one another like rungs on a ladder. Finally, in 1948, the operators activated both the health care and pension provisions. The demand for coal, however, dropped like a lead sinker that year and another round of strikes, in- junctions and impasse commenced. The Fund had made a beginning by 1950, but by then the dynamics of collective bargaining and coal's loss of the railroad and home heating - markets kept its books balanced on the edge of bankruptcy. Labor of Love The 1950 contract negotiated between Lewis and George Love of Consolidation Coal (Consol) is a benchmark in coal history. Cheap oil was When health and safety concerns in the workplace rubbed against productivity goals, production won. driving dirty coal from its traditional markets. Thousands of miners were out of work. 12 Hundreds of thousands were working short weeks. The big coal operators wrote this prescrip- tion for themselves: 1) concentrate production in a handful of dominant companies; 2) anoint a " -Consol's Czar " Love - to end intra industry - chaos; 13 3) mechanize production to reduce labor costs and to increase profitability; 4) accommo- date Lewis in order to guarantee a stable work force; 5) delete the clause from the contract which had given the UMWA and its locals the legal right to strike since 1947; and 6) forestall additional federal intervention in coal affairs. Put simply, Love reoriented the big operators from trying to 6 break the UMWA to using it. " The policy of the UMWA will inevitably bring about the utmost employment of machinery of which coal mining is physically capable. " ' -John L. Lewis (1925) Coincidentally, Lewis had wanted to ally with coal oligarchs for years, but they had never given him the chance. His own prescription for the industry, set out first in his book, The Miners'Fight for American Standards, which appeared in 1925, called for concentrated production units, mechanization and free enterprise coordinated through an industry - union alliance. 14 In his own words: " The policy of the United Mine Workers of America at this time [1925] is neither new nor rev- olutionary. It does not command the admiration of visionaries and Utopians. It ought to have the support of every thinking business man in the United States because it proposes to allow natural laws free play in the production and distribution of coal. " (p. 15) " The policy of the United Mine Workers of America will inevitably bring about the utmost employment of machinery of which coal mining is physically capable.... Fair wages and American standards of living are inextricably bound up with the progressive substitutions of mechanical for human power. " (pp. 108-109) the ".. development of low cost operations [mechanized] will automatically eliminate the un- economic mine and anything which retards the development of low cost operations and forces them to divide the market with less well equipped mines will inevitably delay the mechanization of the industry. " (p. 113) Mechanization, he believed, would make the coal industry competitive with oil and gas and bring high wages and benefits to those miners who continued to work. That was the catch: mech- anization meant most miners - three out of four- would no longer be miners. (Between 1950 and 1969 the workforce fell from 415,000 to 124,000.15) Many argue that Lewis had little choice with regard to mechanization. But it is one thing to phase in machines while seeking as many protections for the workforce as can be nego- tiated. It is quite another to simply write off thou- sands of loyal union members as industrial surplus. ------ Financing Mechanization So Lewis and Love made their deal. They agreed to stabilize labor relations. The right to strike was axed and the UMWA did not authorize a contract strike for the next 20 years. Lewis had demanded publicly in 1950 a guaranteed annual wage of 200 work days, a big wage increase and a 20 cent boost in the Fund royalty. He settled for much less. Lewis agreed to help Love and the companies finance mechanization and drive the small operators out of business. Lewis loaned mil- lions of UMWA dollars to the big companies to finance their mechanization plans in the 1950s By 1956 the Fund had completed a chain of 10 coalfield hospitals and helped to organize several dozen clinics that employed doctors - both general practitioners and specialists - in group practices. Services included inpatient and out- patient hospital care, in hospital - physicians'care, rehabilitation, nursing home services, pharmaceu- ticals, short - term therapy in " good prognosis " mental cases and major appliances. Eyeglasses and dental care were not included. The clinics provided comprehensive primary health care to their participants on a prepaid basis. They stressed continuous health super- vision, health maintenance, disease prevention, early detection, outpatient specialist consultation, Lewis loaned millions of UMWA dollars to the big companies to finance their mechanization plans in the 1950s while he masterminded an " organizing " campaign against the small independents characterized by terror and dynamite. family centered - rehabilitation and social services. In some cases the clinics were organized and built by the UMWA; in others, locally organized - group practices were financed by the UMWA. Where neither arrangement could be made, flat rate - retainers were worked out with the most compe- tent local providers to treat miners and _ their families. In addition, thousands of widows re- ceived modest death and maintenance benefits; while he masterminded an " organizing " campaign modest pensions were distributed to eligible retirees. against the small independents characterized by terror and dynamite. His goal was extermination, not organization. 16 When the big operators later met secretly to Challenge to American Medicine In the late 1940s the Fund hired politically active medical administrators and doctors for key engineer a series of mergers among themselves, Lewis praised their effort.17 Lewis had encouraged Love's initiatives for industrial oligar- chy in 1950 in return for which Love gave Lewis absolute control of the Fund and a 30 cent - per - ton royalty, enough to change appreciably the quality of health care for working miners throughout the coalfields. (The royalty was increased to 40 cents per ton in 1952, where it remained for the next 20 The Body Count Coal mining has never been a safe occupa- tion, nor is it safe today, although great im- provements have been made since 1970. Between 1906 and 1976, government years.) Because Lewis had destroyed most elements of agencies report that 91,662 coal miners were killed. (See Table 1.) If coal mining rank - and - file control - things like contract ratifica- tion, local self rule -, and rank - and - file participation were an American war, it would rank third in number of deaths behind World War II in collective bargaining - in the 1920s, there was neither check nor balance on the Love Lewis - pact or its 20 year - reign. (407,316 dead) and World War I (116,708 dead). 26 Between 1930 and 1976, coal miners A Health System Blossoms sustained more nonfatal disabling injuries than have all of America's soldiers in all of From the Fund's point of view, the 1950 con- tract appeared to solve its financial worries. A America's principal wars between the Rep volution and Viet Nam. Coal mine injuries in higher royalty and stable output meant the Fund could begin to plan an alternative system of health care for miners - a UMWA - owned, prepaid health care system in the coalfields. For those who quali- the 1930-1976 period numbered 1,647,994. Nonfatal wounds in American wars are estimated to total 1,580,000, according to the National Safety Council. 26 fied, health care was prepaid, and nearly com- prehensive. 7 jobs. Many came to the Fund as refugees from Truman's red hunting - in the Public Health Service and later from McCarthy's binge. Lewis was willing to hire medical radicals in the teeth of McCarthyism because of their professional ability and willingness to work for a militant labor union. They in turn got jobs and a chance to do good work; he got a good health care system for his dwindling membership. Each side made its peace with the other. The radicals didn't challenge Lewis'alliance with the big companies, the fixed tonnage royalty or the eligibility cutbacks. In fact, advocacy of better health care led the Fund's idealists to welcome the cold cash Lewis coaxed from coal operators. Lewis in turn backed up the radicals when they were attacked by the AMA for practicing " socialized " medicine. And attacked they were. The Fund's challenge to traditional fee service - for - care and its advocacy of group practice with consumer control enraged state and national medical societies who sabo- taged and red baited - the Fund throughout the 1950s. 18 Medical societies in Pennsylvania, Illi- nois, West Virginia and Colorado tried to break the Fund's quality - of - care rules and retainer ar- rangements. In Pennsylvania, the president of the Allegheny County Medical Society charged the Fund was " 19 " compromising the free practice of medicine, ' and two hospitals refused to grant privileges to clinic practitioners. Hospitals in East Kentucky and Ohio used the same tactic. When the Fund decided in April, 1955 that beneficiaries must have preadmission consultations with an ap- propriate specialist to determine the necessity of hospitalization, county medical societies and the AMA condemned the Fund for discriminating against general practitioners. The day after the AMA passed a resolution to this effect, the Fund's medical administrator retreated, withdrawing the directive. When a local hospital in Russellton, Pennsylvania denied privileges to clinic physicians in 1956, however, the Fund boycotted it. The Fund tried to stick to its principles while avoiding a totally adversary relationship with organized medicine. The AMA in 1957 adopted. guidelines - and even tried to get Fund agree- ment affirming - the rightness of fee service - for - payments and asserting the principle that " the medical profession does not concede to a third party such as the Fund... the prerogative of passing judgment on the treatment rendered by physicians, including the necessity of hospitaliza- tions, length of stay, and the like. " 20 The Fund re- 8 taliated by dropping about 29 percent of the phy- sicians on its approved lists. Although state and national medical societies called upon their mem- bers to boycott the Fund, local coalfield doctors worked out truces with the Fund because so much of their income came from treating coal miners. Short of national health insurance (which labor had pressed on Congress since the 1940s), the Fund's health care system was as good as there was in the United States in the 1950s. Limitations of the Fund Yet, as good as the Fund was, it had its limits. The 1950 contract reconstituted the Fund under the absolute control of three appointed trustees: The radicals didn't challenge Lewis ' alliance with the big companies, the fixed tonnage royalty or the eligibility cutbacks. Lewis in turn backed them up when they were attacked by the AMA for practicing " socialized medicine. " one chosen by the UMWA, a second by the operators and the third by the first two. Although Lewis retired as UMWA president in 1960, he served as the union's Fund trustee until 1969 and ran the show. His choice for the neutral trustee was Josephine Roche, a confidant, who served until the early 1970s. She was never known to vote against Lewis. Rank - and - file or beneficiary participation in top level - Fund decision - making was _ totally absent. Neither miners nor beneficiaries were ever asked to advise the trustees or Fund admin- istrators. While policy was made by professionals within the framework established by Lewis, Fund doctors and medical administrators at lower levels tried to devise ways of making medical programs accountable to miners and consumers; many of the clinics were consumer controlled - . At the level of health services, it was the Fund's principle and practice to make coal miners and their families the central constituency of the system rather than health providers - a radical notion both then and now. Most of the notoriety the Fund suffered from its " man bag - " role in Lewis'financial manipulations derived from the terms of the corrupting alliance the UMWA had contrived with the major com- panies. When good medical principles conflicted with the requirements of industrial stability and (Continued on Page 25) WORKER KETTER ANDA'S THE NATION'S WORST OCCUPA- TIONAL TRAGEDY. Scandal at Gauley Bridge It has been called miners'asthma, potters'rot, grinders'consumption, sewer disease, rock tuber- culosis, ganisters'disease, stonehewers'phthisis and tunnelitis. Today we know it as silicosis - an occupational disease threatening the lives of over one million workers, according to Labor Depart- ment estimates. The most prevalent of dust di- seases, silicosis threatens foundry workers, sand- blasters, tunnel workers, coal and metal miners, and those engaged in the manufacture of abrasive soaps, rubber or stone products, concrete, pot- tery, brick, glass, machinery, insulation and paint. Silicosis is caused by the inhalation of micro- scopic particles of silica dust. Once inhaled, these tiny particles pass unimpeded through the body's respiratory defenses and find their way into the air sacs of the lungs. The lung tissue reacts to their presence by forming scar tissue which, being hard and inelastic, cannot exchange oxygen and carbon dioxide between the blood and the lungs. The result is a wracking cough, chest pains, short- ness of breath and an increased susceptibility to tuberculosis, pneumonia and other lung infec- tions. At first victims experience shortness of breath only during physical exertion; eventually the individual reaches a point at which any move- ment is exhausting. " Silicosis may take one of two forms. In acute or rapidly developing silicosis, symptoms appear eight to ten months after first exposure and death may follow within a year. The course of chronic silicosis is similar though less rapid; symptoms may not appear for many years after exposure. Silicosis is probably the oldest occupational disease it has been known for centuries. The symptoms were first noted by Hippocrates in the Fourth Century B.C.2 References abound up through the Twentieth Century, both with regard to its cause and to methods of prevention. Wet drilling as a means of prevention was patented in Britain as early as 1713.3 As mechanization introduced electric drills and air hammers, the amount of dust in the air increased and silicosis increased as well. By 1914, studies revealed that silicosis rates were running as high as 80 percent among miners, 4 and silica was labelled " the most harmful industrial dust. " 5 At about the same time, the US Bureau of Mines began a 20 year - campaign advising industries of the dangers of silicosis and informing them of the means of prevention: " Wet drilling, adequate and proper ventilation and circulation of air, the use of respirators by workmen and drills equipped with a suction or vacuum cup mechanism, " 6 were the principal methods recommended. Thus, in 1927, when the New Kanawha Power Company filed a declaration of intent to build a water tunnel in the southern part of West Virginia, silicosis was a well recognized - , preventable occu- pational disease. Silicosis is probably the oldest occupational disease - the first symptoms were noted by Hippocrates in the Fourth Century B.C. The tunnel was begun in 1930 and completed in 1932 through the efforts of nearly 5,000 workers mostly black, mostly unskilled and entirely non unionized - . By 1936, less than four years later, 500 of these men were known dead from silicosis; 1,500 more were known to have been disabled by the disease, and countless others were undoubtedly affected. An investigation into this tragedy by a House subcommittee subse- quently found " irrefutable proof that the disaster at Gauley Bridge need not have happened. " 7 How it happened, why it happened, and the results of its happening, bear further examination. The Tragedy at Gauley Bridge In May, 1927, the New Kanawha Power Com- pany filed a declaration of intent to construct a hydroelectric power station on the New and Kanawha Rivers in southern West Virginia. A sub- sidiary of Union Carbide and Carbon Company, NKP was licensed by the West Virginia Power Commission in the following year. The stated pur- pose of the project was to supply much needed - power, through public sale, to the neighboring communities. In reality, the project was planned to supply power to another Union Carbide sub- sidiary, the Electro Metallurgical - Company of Alloy, West Virginia. (This latter objective was for- malized in 1933 when Electro Metallurgical - bought out New Kanawha Power and assumed control of the project.) Of the 35 contractors bidding on the construc- tion contract, NKP selected the Rinehart and Dennis Company of Charlottesville, Virginia - a 10 traveling contracting firm with thirty years experience in the field. The contract called for the construction of a power station to include a 3.75 mile tunnel to divert water from New River, through the Hawks'Nest Mountain, to a hydro- electric plant at Gauley Bridge. This 30,000 horsepower project was to include a diversion dam, power house, surge chamber, excavation and other minor features. The original plan called for a tunnel 32 feet wide, but when initial test bores by Rinehart and Dennis geologists revealed that the rock through which they would be drilling was from 97-99% pure silica, the plan was changed. Rinehart and Dennis was instructed to increase the tunnel size to 46 feet and the extremely valuable silica rock was loaded onto railroad cars at the tunnel mouth, and shipped directly to Electro Metallurgical - where it was to be used without - refining - in their manufacturing plant.9 With full knowledge that they would be tunnel- ling through pure silica, Rinehart and Dennis set out to recruit a work force. In early 1930, with un- employment estimated to be 15 million nationally, they had no trouble finding what Time Magazine later called " cheap, transient labor, colored and white. " 10 Primarily unskilled, non union -, black workers, from as far away as Pennsylvania, Georgia, North and South Carolina, Florida, Kentucky, Alabama and Ohio signed up, as did hundreds of workers from neighboring towns who thought that the Gauley project would provide steady work at good wages. Some were The tunnel was begun in 1930 and completed in 1932 through the efforts of nearly 5,000 workers. By 1936, 500 were known to be dead; 1,500 were disabled. unemployed miners, familiar with conditions underground; many others were farm workers from the south with no experience with mining or its dangers. None were informed of the hazardous nature of the work they were about to under- take Rinehart - and Dennis did not post notices of the danger. The men had not voluntarily assumed the risk they were about to undertake. Rinehart and Dennis later stated that a total of 4,948 workers were employed during the two years of construction; 3,280 were black. The maximum number of workers employed at any one time was 1,250, of whom 850 were black.12 This represents a turnover rate of over 300%. An estimated 2,000 black and 500 white men worked underground at one time or another, constructing what was later to be tragically called the " Tunnel of Death. " Working Conditions Excavation began in June, 1930 and " from that point on the venality of the contractors was almost beyond conception. Disregarding even the most elementary health and safety precautions or the warnings of the West Virginia Bureau of Mines they pushed the job through with presumably but one thought in mind - that speed means money, " according to US Rep. Vito Mar- cantonio who spearheaded a special subcommit- tee of the House which investigated the incident.13 The conditions under which the work was con- ducted can only be described as horrendous. Neither ignorance nor inexperience could explain away the callous disregard of human life: the dangers of silica dust were commonly known; the methods of prevention readily available. Testimony abounds as to the levels of dust in the tunnel: " the dust was so thick in the tunnel that the atmosphere resembled a patch of dense fog, " said one worker.14 " You couldn't see ten feet ahead of you, even with the headlite of the donkey engine. " " You couldn't tell a white man from a colored man, fifteen feet away. " " Silica dust covered us from head to feet, got in our hair, our eyes, our throats, befouled our drinking water. " " Strong husky men gasped, choked and collapsed on the ground and were carried outside to revive. " 15 " There was so much dust, " testified one driller, " that the trees nearby the camps looked like'somebody had sprinkled flour all around.'" " Man after man testified to this condition and many more testified that it was due, in the main, to the use of dry drills. The initial contract called for wet drilling drilling - run with a stream of water spraying over the points to catch the dust and pre- vent it from flying into the air yet - this was not done. Even though wet drilling was known to be far safer than dry drilling, it was also slower and as a result, more expensive. Thus while all 16 drills used on the project were equipped with water heads, they were generally - but not always - run dry. As several workers later testified, foremen assigned men to act as " lookouts " to warn them of the arrival of state inspectors so that dry drilling could be stopped. As a result, several inspectors were able to testify that when they visited the site, - the tunnel was practically dust free. This conscious decision to place profit over human rights was probably a key cause of the deaths and disease this project generated. Although West Virginia mining law requires a thirty minute wait before re entering - a tunnel after blasting, 17 a host of men testified that they were driven back in immediately after the blasts. " If you wanted to keep your job, " declared Deacon Jones, a local worker and lay preacher, " you had to go back right away. " Black workers were sent in before whites. " Foremen used pick handles and drilling steel to knock the Negroes on the head if " Disregarding even the most elementary health and safety pre- cautions... they pushed the job through with presumably but one thought in mind - that speed means money. " -US Rep. Vito Marcantonio they refused to enter immediately, " declared an engineer on the project. " The men were handled worse than I have ever seen before. " 18 The locomotive cars which carried the rock out of the headings were powered by gas motors, in spite of the repeated admonishments by inspectors of the Bureau of Mines to use battery powered cars. The gas fumes from the cars made the workers drowsy, and at times poisoned them. One night twenty - eight men were reportedly carried out of the tunnel because of carbon monoxide fumes from these gasoline motors. 19 The ventilation in the Hawks Nest Tunnel was declared wholly inadequate by workers, doctors, engineers and other experts. A 24 inch ventilation duct and an 18 inch fan were used to provide fresh air to the men. (One contractor, testifying in court for Rinehart and Dennis, told of working in a tunnel half the size of Gauley Bridge, and using a 24 inch duct and 24 inch fan.) 20 No personal protection was provided by Rine- hart and Dennis for its employees. This in spite of the high dust levels and in spite of Bureau of Mine warnings to contractors as far back as 1914 that adequate ventilation and respirators should be provided and in spite of the fact that New Kanawha Power provided its own engineers with 11 masks for use whenever they went underground. Masks cost approximately $ 2.50 in 1930 and, as the purchasing agent for Rinehart and Dennis suc- cinctly stated, as reported by the US House Sub- committee, " I wouldn't give $ 2.50 for all the niggers on the job. " 21 Twenty hours a day, six days a week, the tunnel excavation continued. Two shifts of workers were each paid for 10 hours of duty, although they often worked up to 12 hours a day. " There was so much dust that the trees nearby the camps looked like ' somebody had sprinkled flour all around.'" -Testimony of a Driller In 1930, when excavation began, workers were paid 50 cents an hour for their labor. As the de- pression wore on, wages were cut back to 40 cents, then 30 cents and finally to 25 cents an hour. Weekly pay checks could only be cashed at the company commissary - at a charge of 10 percent per week. The only way to avoid the 10 percent surcharge was to hold the check for a week - but no credit was given for purchases, so few could avail themselves of this privilege. Rinehart and Dennis charged 50 to 75 cents a week for the shacks it provided in the camps. Twenty - five to thirty blacks (workers and, in some cases, their families) lived in these shacks which were approximately 10 to 12 feet wide, with only two to three bunks provided in each. The rent did not include linens, coal, electricity or a stove which workers and their families had to purchase themselves. Coal cost 25 to 50 cents per week and was taken out of the pay checks regardless of whether or not it was used. Mandatory " health insurance " -doctor and hospital fees was also extracted from the weekly check. Black workers paid 75 cents a week for the doctor; white workers, 50 cents. For his fee a worker could expect the following: " black pills " for everything from a wracking cough to a broken leg; and a diagnosis of " tunnelitis " or perhaps pneumonia as silicosis began to strike in epidemic proportions. Sick workers were not, however, to be excused from their day's labor. Several reported that they were forced to hide out from the shack " rouster " if they were too ill to work. The shack " rouster " was 12 a licensed deputy sheriff, appointed after a recom- mendation by Rinehart and Dennis, who made daily shack rounds for the company to insure that all who were scheduled to work did so. 22 The Impact Soon illness began to spread among workers. on the project. After as little as six weeks ' exposure to the highly concentrated - silica dust, men became ill. Wracking coughs and shortness of breath were commonplace within nine months after the project began. By 1931, " men were dying like flies. " 23 " The ambulance clanged day and night to the Coal Valley Hospital. " " The turn- over in negro workers was tremendous. " 24 In spite of Rinehart and Dennis'later denials- denials of unsafe conditions, denials of any deaths from silicosis - it is apparent that the illnesses and deaths which resulted were not only known to them, but expected by them. For as the purchas- ing agent for the contractor candidly stated, " I knew we was going to kill these niggers, but I didn't know it was going to be this soon. " 25 Sen. Holt of West Virginia reported that the company further stated openly that " if we kill off those, there were plenty of other men to be had. " 26 More important than these off cuff - the - remarks, however, was the fact that early in the project Rinehart and Dennis contracted with a nearby undertaker to bury the dead at $ 55 apiece. Asked why he had accepted the job at a price so low that the local Gauley Bridge undertaker had evidently refused, H.C. White declared that the " company had assured him there would be a large number of deaths. " 27 " I wouldn't give 2.50 $ for all the niggers on the job. " -Testimony of Purchasing Agent, Rinehart and Dennis, commenting on $ 2.50 cost of a face mask. Mr. White performed his tasks with great ef- ficiency - the standard time between death and burial was three hours. In this manner the com- pany was able to avoid both the filing of a death certificiate and the performance of a possibly in- criminating autopsy. 28 The actual number of workers buried in these mass, unmarked graves was unknown to Mr. White, as he claimed in court that his records had been lost. Subsequent investigation revealed that 169 men are buried in this field in Summerville " with cornstalks as their only gravestones and with no other means of identification. " 29 The actual number of workers who were eventually affected has been hotly contested. Not only were records " lost " but diagnoses of pneu- monia, tuberculosis or tunnelitis added to the con- fusion. Death certificates, when filed, rarely mentioned the fact that the deceased had worked on the project. Many men had left the area before the situation was made public; many others fled in panic when the dangers were finally revealed. It has been generally concluded after considerable investigation, however, that few of the 2,500 men who worked underground escaped the deadly effects of silica dust. The Reaction The magnitude of the tragedy was not widely understood until the spring of 1933 when the first of many lawsuits against Rinehart and Dennis was filed. Over the next several years, hundreds of workers or their survivors were to bring suit against the company. Settlements, for those lucky enough to receive anything, ranged from $ 80- $ 250 for blacks and from $ 1,000 350- $ for whites. 30 The trials themselves were described as a " macabre burlesque " 1 and were characterized by jury tampering, threats and intimidation. The company denied that conditions were in any way unsafe or unhealthy, or that anyone had died of silicosis as a result of their employment on the project. They even went so far as to claim that they had never heard of the disease. While hardly satisfactory for the defendants, the lawsuits did serve to bring the situation into the public eye. Much of the eventual stir, however, focused on the impact of the lawsuit " racket " on industry instead of the needless tragedy that maimed and killed hundreds of workers. As Selleck reports of this period in his official history of the Industrial Medical Association written in 1962, silicosis suits were widely con- sidered to be an organized racket, a fraud. 32 Industry was portrayed as the true victim of enter- prising lawyers and workers out to make a quick buck. As more and more workers across the country took to the courts seeking damages for death or disability from conditions of employment, industry turned to the state legislatures in an effort to pro- tect themselves from what could have become a very costly situation both politically and economically. Workmen's Compensation Decades before this tragic incident, industry had realized that Workmen's Compensation for industrial accidents made good business sense. (See Health / PAC BULLETIN, July August - 1976.) Not only did it place clear limits on employer liability, but it did so under the auspices of state legislatures which were known for their respon- siveness to local interests. In 1934 none of the state programs compen- sated specifically for silicosis, but a flurry of legis- lation during the following years resulted in 16 states developing programs that compensated for K. BENDIS occupational diseases in general. An examination of these laws quickly reveals that they were, indeed, set up primarily to protect the com- panies - not the employees. All too typical was the West Virginia Work- men's Compensation legislation which was designed specifically to exclude Gauley Bridge victims from coverage and which gave little 13 protection to potential victims of similar disas- ters.33 The West Virginia law, for example, allowed compensation for silicosis only under the following conditions: A worker must have been employed for two years at the same job. * He must have filed his claim within one year after leaving the job and, Early in the project Rinehart and Dennis contracted with a nearby undertaker to bury the dead at $ 55 apiece. " The company assured him that there would be a large number of deaths. " -Testimony, Congressional Hearings He must have given a complete life history to his employer at the start of employment and, * He must never have broken any safety rules. 34 Congressional Investigation The scandal of the Gauley Bridge was not exposed to the public until several months after the passage of the West Virginia legislation, nearly four years after the tunneling was complete. Time magazine credited this exposure to the radical press which " dug up the skeleton of Gauley Bridge and rattled its bones. " These " rattlings " were heard by Representative Vito Marcantonio of Harlem, who introduced the legislation which led to the House Labor subcommittee investiga- tion of this incident. 35 These hearings exposed the magnitude of the tragedy to full public view. After hearing testi- mony of doctors, lawyers, social workers, engineers, workers and their families, the commit- tee charged the company with negligence. That " such negligence was either willful or the result of inexcusable and indefensible ignorance there can be no doubt on the face of the evidence presented to the committee, " declared the report of the full House committee. 36 Representatives of the companies involved again denied all the charges lodged against them and again declared themselves to be the true victims of this disaster. Although they declined to testify before the committee, they made their position known through the pages of the Engineering 14 News Record - and the New York Times. An editorial in the Engineering News Record - labelled the committee's charges " the most unwarranted and vicious that have ever been hurled against a reputable contractor anywhere. " 37 A Union Carbide spokesman declared that the company was " very proud of its safety record everywhere " and denied that there had been a single death attributable to silicosis! 38 P.H. Faul- coner, president of Rinehart and Dennis, labelled the charges misrepresentations and falsehoods. In his official response to the committee's charges he stated that: " The methods used in this construction were the standard or better, than have been used not only by us but by other tunnel builders, both on private and in government projects. We used every safeguard of life and health that was known to us or other contractors in similar work. Wet drilling was insisted on at all times...Conditions were better in this tunnel, and were so considered by many visiting engineers and contractors, than in any other tunnel we had ever seen. We did not furnish nor use dust masks or respirators because no need for them was apparent. The disease sili- cosis was not known to us, nor to other contractors of our acquaintance, before we were surprised by the bringing of damage suits... We know of no case of silicosis contracted on this job. " 39 (Emphasis added.) Yet, in spite of all their denials, the facts remain: hundreds, perhaps thousands of workers need- lessly died of silicosis contracted while construct- ing the Gauley Bridge tunnel. In their drive for " The disease silicosis was not known to us, nor to the other contractors of our acquaintance, before we were surprised by the bringing of damage suits... We know of no case of silicosis contracted on this job. " P.H. Faulconer, President of Rinehart and Dennis. profits, the company completely disregarded the health, safety or future of these men and their families. Contributory Factors But the drive for profits motivates all industrial activity - in fact all economic activity - in this country and, in and of itself, can not explain how and why this tragedy was allowed to occur.. Several other factors appear to have been contributory. First, the massive unemployment generated by the Depression allowed employers to force workers into accepting progressively deteriorat- ing conditions. One either accepted a job on the employer's terms, or did not work. Second, the drive to industrial unionism had not yet reached most workers, especially the black and poor laborers in the South. Thus, workers had no real weapon available to them to use in seeking decent, safe working conditions from the company. In fact, what little advance recorded in occupational health prior to the depression came to a grinding halt by the 1930s. Third, discrimination by the employers against black (and other minority) workers clearly exacer- bated the situation. Not only did they suffer from the general negligence of the company, but they were made to endure conditions and treatment " worse than if they was mules. " 40 Because there were black workers on the job the company tolerated far worse conditions than they would have if the work force had been all white. Compounding these conditions - perhaps because of these conditions - no adequate legisla- tion existed to protect employees against employer negligence or to adequately compen- sate victims. Thus, the drive for profits, which motivated these companies, was able to move ahead virtual- ly unfettered by any countervailing force. Gauley Bridge has become a symbol of indus- trial disaster. It has, in fact, been described as the most horrible industrial disaster in history. To avert such disasters, the federal Occupa- tional Safety and Health Act (OSHA) was SUBSCRIBE TO THE HEALTH / PAC BULLETIN Name_ Address. I would like to subscribe to the Health / PAC Bulletin Y' Student subscription $ 8 Y' Regular subscription $ 10 Y' Institutional subscription $ 20 Y' Enclosed is my check for $. Affiliation HEALTH / PAC BULLETIN 17 Murray Street * New York City, N.Y. 10007. 15 established in 1970. While it has identified many life threatening - substances, few have been fully studied; fewer still have had standards set for their control. Today, silica dust remains one of the five worst hazards facing American workers - with well over one million workers daily exposed to its dangers, according to the federal OSHA agency. 41 It might be argued, however, that the Gauley Bridge incident was unique, a freak accident, and thus its significance to us is open to question. How- ever, while it may be true that a tragedy of this Today, silica dust remains one of the five worst hazards facing American workers - with well over one million workers daily exposed to its dangers. -Occupational Safety and Health Administration magnitude with so many lives lost in so short a time is not likely to occur today, it must be recognized that thousands still die from similar conditions. The deaths may be occurring slowly from chronic rather than acute silicosis, but the deaths are occurring. Between 1954 and 1963, 1,129 workers in New York State alone received workers compen- sation for occupational dust diseases, 95 percent of them for cases of silicosis. Of these 1,129 workers, 451 had died nearly - the same number known dead in the Gauley Bridge scandal - and 567 were permanently and totally disabled. 42 In- 1973 alone, again only in New York State, a total of 103 workers were compensated for silicosis and other dust diseases, of whom 51 died and 39 were permanently and totally disabled. 43 These 51 deaths represented 80 percent of all occupa- tional death cases compensated by New York State that year. 44 Compounding the ineffectiveness of the gov- ernment response is the unwillingness of the indus- trial medical profession to acknowledge the magnitude of occupational safety and health problems. This is evidenced in the Industrial Medical Association - sponsored account of this in- cident, published only 15 years ago, in which the Gauley Bridge tragedy was said to have occurred " like a bolt of lightning " and which saw the trag- edy of the situation as the subsequent rash of law- suits which they describe as representing a " fraud 16 that was...... practiced on an extensive scale. " 45 Thus while the Gauley Bridge incident is in some respects unique - as are all such incidents- the lesson it suggests has yet to be learned: that it is not lack of knowledge which perpetuates occu- pational problems but a lack of commitment to change on the part of those with the power to do so. The recent scandal of the pesticide DBCP and its sterilizing effects upon workers gives continu- ing evidence for this. Until workers'lives are con- sidered more valuable than employers'profits, such tragic deaths will undoubtedly continue. --Pat Forman (Pat Forman is a graduate student at the Columbia University School of Public Health.) REFERENCES 1. For fuller discussion see, for example, Donald Hunter, The Diseases of Occupations, Boston, 1962; and Jeanne M. Stellman and Susan Daum, Work is Dangerous to Your Health, New York, 1973. 2. Andres Czemnek, " Target Health Hazard: Silica, " Job Safety and Health, 1 2:, January, 1973, p. 25. (Published by the Occupational Safety and Health Administration, US Department of Labor.) 3. " An Investigation Relating to Health Conditions of Workers Employed in the Construction and Maintenance of Public Utilities, " Hearings before Special Subcommittee of the House Committee on Labor, January and Feburary. 1936, p. 150. (Hereafter referred to as " Hearings ".) 4. Czernek, op. cit., p. 26. 5. Lorin Kerr, M.D., " Coal Miners and Pneumonconiosis, " Archives of Environ- mental Health, 16 April, 1968, p. 579. 6. Hearings, op. cit., p. 201. 7. Vito Marcantonio, " Dusty Death, " New Republic, 86, March 4, 1936, p. 105. 8. " Wild Silicosis Tales Reach Congress, " in Engineering Record News - , January 16, 1936, p. 105. 9. Hearings, op. cit., p. 20. 10. " Silicosis, " Time Magazine, 27, January 6, 1936, p. 58. 11. Hearings, op. cit., p. 20. 12. Engineering News Record - , op. cit., p. 58. 13. Marcantonio, op. cit., p. 106. 14. Hearings, op. cit., p. 4. 15. Marcantonio, op. cit., p. 106. 16. Hearings, op. cit., p. 67. 17. Ibid., p. 18. 18. Ibid., p. 62. 19. Ibid., p. 55. 20. Ibid., p. 20. 21. Ibid., p. 9. 22. Ibid., p. 8. 23. Marcantonio, op. cit., p. 105. 24. Hearings, op. cit., p. 9. 25. Ibid. 26. Ibid., p. 129. 27. Ibid., p. 10. 28. Joseph A. Page and Mary Win O'Brien. Bitter Wages, New York, Grossman, 1973, p. 61. 29. Hearings, op. cit., Resolution 449, p. 1. 30. Page, op. cit., p. 62. 31. Page, op. cit., p. 62. 32. Henry B. Selleck, Occupational Health in America, Chapter XX. " The " Gauley Bridge Episode. " Detroit, 1962, pp 234-5.. 33. 33. 33. Hearings, op. cit., Bulletin of International Juridical Association, article on the West Virginia Workmen's Compensation Law of December, 1935, as entered in evidence, p. 117.8. 34. Monthly Labor Review, January, 1937, op. cit., p. 116 116. 35. Time, op. cit., p. 58. 36. Hearings, op. cit., final subcommittee report to the Chairman of the House Committee on Labor, February 5, 1936, p. 202. 37. Engineering News Record - , January 16, 1936, op. cit., p. 104. 38. " Silicosis Relief Organized Here, " New York Times, January 25, 1936. 39. Hearings, op. cit., p. 9. 40. Ibid., p. 9. 41. Czernek, op. cit., p. 29. 42. New York State Workmen's Compensation Board, Report on the Feasibility of Compensating for Partially Disabling Dust Diseases, June, 1966, p. 105. (We thank Eric Frumin for sharing this information with us.) 43. 43. New York State Workmen's Compensation Board, " Compensated Cases Closed, 1973, " Research and Statistics Bulletin, No. 31, July, 1976, p. 69. 44. Ibid., p. 9. 45. Selleck, op. cit., pp. 234-5. ' HEALTH HEALTH / PAC BULLETIN Nov./Dec Nov./Dec. 1977 WASHINGTON it did in blocking his bill. Now Sen- ator Richard Schweiker (R., Pa) has introduced backed AHA - leg- islation that would turn cost con- tainment efforts over to the al- ways more malleable states. And, at the urging of Representative Dan Rostenkowski (D., Ill.), whose ADAM SMITH NOMINATED COST CONTROL DIRECTOR One year later, in Carter's Wash- ington, health policy seems to be marching backward into time. Lofty plans for health system re- organization and national health insurance, due a year ago, have dwindled instead into promises House Committee is considering these bills, the AHA, the Fed- eration of American Hospitals, and the AMA are rushing to put together a " voluntary " cost con- tainment program that will rely on adverse publicity to pressure hos- pitals into cost reductions. The AHA, having already launched a nationwide ad campaign to coun- ter its bad press, knows in ad- vance what a soft touch that will be. that " principles " of a national health program will be " outlined " sometime in the next year. Health, in Carter's Washington, has become a dollar problem and cost containment the watchword. Now as clumsy bureaucratic measures falter on this front, the destiny of this backward slide may be clear. Carter is redis- covering the wonders of Adam Smith's " free market -wonders " Health, in Carter's Washington, has become a dollar problem and cost containment the watch- word. to be worked not upon the mono- polies of the health system but- you guessed it upon - the already heavily - loaded backs of con- sumers. . Stumbles and Stalls Cost containment remains an unsolved puzzle. Carter's hos- pital cost control bill is stuck in Congress, having suffered such severe attacks from the medical industry, led by the American Hospital Association, that HEW Secretary Joseph Califano comp- lained that he wished the AHA would devote as much energy to controlling waste in hospitals as Meanwhile, HEW's other cost control efforts stumble along. A recently completed - HEW Depart- mental evaluation of PSROs finds them to be ineffective at cutting costs. Its new HSA based - plan- ning structure, too, is having trouble getting off the ground. Health planning guidelines pro- posed by HEW to limit the avail- ability of hospital beds and ser- vices have come under sharp attack, with more than 12,000 mostly critical - comments re- ceived so far. The regs have been viewed uniformly as too restric- tive, too much oriented toward cost control rather than health care enhancement, and too bind- ing on HSAs. And so the search for cost containment goes on, taking HEW Secretary Califano to such diverse zones as Wisconsin, Texas, California, Canada, Eng- land, and Germany in search of the Holy Mixed Medical - Econ- omy, while back at home HEW is hiring dozens of economists to solve its health insurance and planning dilemmas. The Light at the End of the Tunnel? In the latest wrinkle, Califano has called in a former Pentagon Whiz Kid Stanford - turned - _ busi- ness professor, Alain Enthoven, to apply to social policy the same wisdom that was applied a dec- ade ago to taming the arms race and pacifying Vietnam. Enthoven's Plan, termed the Consumer Choice Health Plan, is being touted to the White House and the business community as a way to use the competitive market place to tame medical inflation and build a national health insur- ance program. HEW has con- ducted a two day - seminar for business and labor representatives on the Plan, at a plush setting on Virginia's Skyline Drive, and Califano has presented the Plan at a White House meeting with Carter and other key advisors. The search for cost con- tainment goes on, taking HEW Secretary Califano to such diverse zones as Wisconsin, Texas, California, Canada, England and Germany in search of the Holy Mixed Medical - Economy. 17 17 17 Industry, too, loves Enthoven; he health systems, i.e., HMOs, In- they can pocket the savings! keynoted recent conferences of dividual Practice Associations, Enthoven's Plan embodies the the Washington Business Group etc. (True to his free market - ideol- worst aspects of the Carter ad- on Health and the Group Health ogy, Enthoven does not include ministration's drive to return Association of America. Community Health Centers America's economy to a fondly- Having seen their earlier cost among the organized health sys- remembered " free market. " It is containment initiatives either be right in line with the views of rejected or fail, Califano and his cohorts now want to turn cost control over to the victims of rising costs, the consumers. For The Enthoven Plan is not a health plan; it is a cost control plan. Its Carter's chief economic advisor, Charles Schultze, who has written recently that " harnessing " material self interest - was " perhaps the most the Enthoven Plan is not a health objective is to encourage important social invention man- plan; it is a cost control plan. Its objective is to encourage con- consumers to spend less on health care. kind has yet made. " Picking up on Carter's by notorious - now - sumers to spend less on health assertion that " life is unfair, " care by eliminating the propor- tionate tax deduction on insurance premiums and out pocket - of - ex- penses, by making employer health benefit contributions tax- able, and by encouraging the publication of pricing information that will lead the consumer to choose the lowest - cost health plan. To compensate for this loss of tax tems he wants to encourage.) However, no subsidy is provided in the Plan to encourage the creation of HMOs, beyond their supposed cost advantage to the the consumer. Max Fine, director of organized labor's consumer lobby, the Committee for Nation- al Health Insurance, has sharply attacked the Enthoven Plan, point- Enthoven puts down any attempt to compare his plan with " some hypothetical egalitarian ideal. " In a time of multibillion - dollar insurance giants, metro region- - wide hospital empires, and powerful professional control groups, Enthoven would elimin- ate whatever slim bargaining power workers now have through their unions and insist that selec- Califano has called in a ing out that " HMOs will not be started unless there are real in- tion of a health plan be an individ- ual matter of " consumer choice. " former Pentagon Whiz Kid Stanford - turned - business professor, Alain Enthoven, to apply to social policy the same wisdom that was applied a decade ago to taming the arms race and pacifying Vietnam. breaks, Enthoven would give a fixed tax credit to all households that join a qualified private in- surance or prepaid health plan, centives for providers to start them, for consumers to join them, and a sizable resource develop- ment fund to get them off the ground. " The Plan would set up an elab- orate process of federally - regu- lated consumer information and open season - enrollment intended to spur competition among alter- native health plans though - it is silent on how it is going to create competition in the highly mono- - polized medical care financing in- dustry. Enthoven assumes that competing plans will somehow appear, and he then wants to In the face of such thinking, can things get any worse? Per- haps they can. Califano, recently Enthoven told the Washington BizGroup that the consumers should shop for the best health plan exactly as they would for a car- if the consumers choose to purchase a Chevy instead of a Cadillac, they can pocket the savings. and it would give an income - tested " give consumers an incentive to aN voucher for health plan costs to low income - households. seek out systems that provide care economically by letting them taken with the cost cutting - virtues of HMOs, has called the Fortune- The Plan's most direct antece- keep the savings. " He told the 500 corporations to a February 7 dent is the AMA's Medicredit Washington BizGroup that the summit meeting to exhort them to Plan, which also would have pro- vided a tax subsidy for private consumers should shop for the best health plan exactly as they form their own company - town medical plans. No Plan - or Biz- insurance premiums. What is new would for a car - if the consumers Plan? Is this what we've all been here is Enthoven's attempt to use choose to purchase a Chevy waiting for? consumer pressure to contain instead of a Cadillac, he told the -Len Rodberg and Robb Burlage 1 costs and en8 courage " organi zed " represR entatives of BigE Business, S WOMEN Q LAY MIDWIFERY: THE OLD BECOMES THE NEW? The practice of lay midwifery- delivery of a child by anyone other than a licensed physician or midwife nuse -i s illegal in the United States today. A precedent- setting bill supported - amazingly enough by the Brown Administra- tion before the California State Legislature now proposes to change that. There have always been mid- wives special - birth attendants have aided women in labor and delivery in every culture.'While it is estimated that 80% of the births in the world are attended by midwives, the practice of mid- wifery has only recently reemerg- ed as a legitimate occupation- and then only as nurse midwifery- - in the US.2 The right of midwives to prac- tice - i.e., assist in normal child- birth without the supervision of an attending physician - directly challenges the medical profes- sion's current monopoly over the definition and treatment of child- birth in this society. Challengers cite growing evidence indicating the dangers of hospital births and the success of home births as alternatives. In California, the struggle over the legality of the practice of lay- midwifery has reached a decisive point. The conflict over the right of midwives to practice became a public issue in 1974 when several of the midwives associated with the Birth Center in Santa Cruz were arrested for practicing med- icine without a license. A three- year court battle followed the ar- rests, which resulted in the decision that lay midwifery - cannot be prac- ticed legally in California. Those involved in the home- birth and midwifery movement have decided to go beyond the courts. Midwives continue to practice and have taken the issue to the state legislature. The Mid- wifery Practice Act of 1978 - AB 1896 was introduced to the Subcommittee on Health Person- nel on August 10, 1977, and is scheduled to go before the Calif- While it is estimated that 80% of the births in the world are attended by midwives, the practice of midwifery has only recently reemerged as a legitimate occupation- and then only as nurse- midwifery - in the US. ornia Assembly in January, 1978. This bill is supported by mid- wives, advocates of homebirth, and, significantly, Governor Jerry Brown. Those opposing the bill include some obstetricians and some nurse midwives - (a pro- fession made legal in California about two years ago). The Midwifery Practice Act of 1978 would legalize lay midwifery - and give it autonomy from the medical profession and its inter- pretation of the condition and roles of the pregnant woman, her partner, relatives and friends, and the birth attendant. Some of the significant provisions of the bill include: * Prospective midwives could choose between extensive ap- prenticeship or an educational program (to be established) for the training of midwives; The average cost of hos- pital birth in California ranges from $ 1,000 to $ 1,500; estimates of the costs of midwives ' services as licensed under AB 1896 are from $ 250 to $ 400. * Midwives would be licensed to practice independently, though in consultation with physicians, and they would be eligible for compensation under the Medi- Cal program (California's Medi- caid program); * The licensing program would be regulated by a Midwifery Ex- amining Committee appointed by the Governor and organized as an independent committee under the Board of Medical Quality Assurance; The cost of childbirth would be cut drastically; the average cost of hospital birth in California ranges from $ 1,000 to $ 1,500; estimates of costs of midwives ' services as licensed under AB 1896 are from $ 250 to $ 400. An earlier attempt to revive lay midwifery - during the period from 1830 to 1870 parallels many of the present social and political circumstances. The Pop- ular Health Movement chal- 19 lenged the monopolization of health care by the medical pro- fession, the technological and supposedly scientific basis by which the licensed medical prac- titioners substantiated their con- trol and what they felt to be the primary motive of their control- profits. Strong connections exist- ed then as now between the Pop- ular Health Movement and the newly emerging - Feminist Move- ment. They argued that the human- istic ideology presented by the medical profession was not what The Midwifery Practice Act of 1978 would legalize midwifery lay - and give it autonomy from the medical pro- fession. indeed was being practiced. In this climate of criticism and its concurrent search for alternatives gave birth to the revival of lay- midwifery. This movement was opposed by the existing medical establishment and was ultimately defeated. The activities of this period are similar in several ways to the cur- rent struggles in this country around feminism and health care. As one writer has pointed out, " The social climate of the 1960s, increasing consumer dissatisfaction with the health care system and the feminist movement have con- tributed largely toward the re- newed interest in and the increas- ingly favorable climate for the ac- ceptance and utilization of mid- wives. " " 4 If the California bill passes and lay midwives - are licensed in that state, it will reflect a new under- standing of pregnancy and child- 20 birth as " well " and " normal " con- ditions rather than the traditional view of them as " abnormal " and " dangerous " medical processes. And, perhaps more importantly, it will signify a change in the power of medicine to define and treat pregnancy and childbirth. If the California bill passes and lay- midwives are licensed in that state, it will reflect a new under- standing of pregnancy and childbirth as " well " and " normal " rather than the tradi- tional view of them as " abnormal " and " dangerous " medical processes. Whether or not the legislation passes, however, as one member of the Association for Childbirth at Home, International said, the need and demand for the home- birth alternative exists and will continue to be met.5 -Catherine Ryan Del Mar, California REFERENCES 1. Ann Sablosky. " The Power of the Forceps: A Comparative Analysis of the Midwife Historically - and Today, " in Women and Health, Vol. 1, No. 1. January February / , 1976, pp. 10-13. For an excel- lent history of the decline of midwifery in the US see B. Ehrenreich and D. English, Witches, Midwives and Nurses, Old Westbury, N.Y. The Feminist Press 1973. 2. Ibid., citing Voigt, Daisy, " Careers, " Essence Maga- zine, December, 1974. 3. 3. Lewis Mehl, M.D., " Home Delivery Research Today - A Review, " in Women and Health, Vol. 1, No. 5, September / October 1976, pp. 3.11. See also Suzanne Arms, Immaculate Deception, A New Look at Women and Childbirth in America, Boston, Houghton Mifflin Co., 1975 and Nancy Stoller Shaw, Forced Labor, Maternity Care in the United States, New York, Pergamon Press, Inc., 1974. 4. Sablosky, op. cit., p. 12. 5. Public hearing on Maternity Alternatives, San Diego, California, October 12, 1977. for responding to all calls. The importance of such con- NEW YORK complexes is rooted in the reality that both small private hospitals and municipal ones have exper- | ienced sagging inpatient utiliza- tion in recent years. Again, the factors underlying this decline are complex, but several critics have noted with alarm that one out- tracts for the hospitals that receive them is suggested by Cabrini administrator John F. Reilly's estimate that 15 percent of its in- patient admissions are generated through the ambulance service. The figure nationally is estimated to be closer to 25 percent (see " Contracting for Emergencies, " September / October, 1977, BULLETIN). come of the strategy is likely to be further monopolization of services around the major institutions. HHC's precipitous move to revoke Cabrini's contractor status seems tied up with HHC's long- RETURN OF THE At least it is clear that the range plan to regionalize all BODY SNATCHERS The war for beds - or more cor- rectly for bodies to fill them- has heated up in recent weeks among New York City's hospitals. One clear signal: early warning shots exchanged in late Novem- specter of closings has worsened the already murderous - competi- tion for patients and the income they represent. And the forms this competition can take - with results that are often literally fatal Lare strikingly foreshadowed in the ambulance skirmish and the Emergency Medical Services (EMS) into a unified system under HHC control. The plan devel- - oped with HEW funds and in col- laboration with the NYC Health Systems Agency - would incor- porate all existing ambulance ser- vices: proprietary, voluntary and ber between the private and pub- lic sector over control of the city's ambulance services. The likelihood of a war has been brewing since at least last year when New York State issues it immediately raised. The opening round was fired by the City's beleaguered Health and Hospitals Corporation (HHC -the quasi public - corporate par- ent of the 17 municipal hospitals). municipal. The plan's implemen- tation is still months away, how- ever, so that the slap at Cabrini struck some observers as either a trial balloon or a case of jumping the gun by HHC administrators. Commissioner of Health, Dr. HHC notified Manhattan's Cabrini Robert P. Whalen, signalled the Health Care Center in November State's intent to close 13 New that it was withdrawing the York City hospitals and the State Planning Commission thereafter obligingly announced its " dis- covery " of 5,000 excess beds in the city. (See " Politics Makes Strange Beds, " July August -, 1977, BULLETIN.) The rationales for cutting beds and closing institutions are com- plex, but two key arguments- $ 100,000 annual contract with Cabrini for ambulance services. Under the contract, one of sev- eral HHC has with voluntary insti- tutions throughout the the city, Cabrini is subsidized for operating HHC ambulances out of its own emergency room and staffed by its own personnel. When persons needing an am- The importance of ambulance service contracts for hospitals is suggested by a Cabrini administrator's esti- mate that 15 percent of its inpatient admissions are generated through the ambulance service. that excess beds stimulate over- utilization and thus inflate costs, and that institutions with low utili- zation rates provide inferior care bulance call " 911 " in the city, they are connected with HHC's ambulance dispatch _-_ center located in Maspeth, Queens. The figure nationally is estimated to be closer to 25 percent. -have been converted from par- Cabrini's contract " covers " one of tial truths to major ideological the 22 ambulance districts in the weapons employed by the city's city allocated to private institu- giant medical centers to focus all closings on small private or muni- cipal hospitals. This " cut anybody but us " stance by the major voluntary hospital - medical school tions, out of a total of 36 districts. Under the subsidy arrangements, the private institutions get the emergency business generated within their territory in exchange Meanwhile, reaction by Cabrini and the city's entire vol- untary hospital establishment was swift. Cabrini's Reilly directly accused HHC of trying to steal 21 Cabrini patients for nearby Bellevue (whose general care beds occupancy rate is down to near 70 percent) and added that the move was the beginning of a campaign to " pick off the vol- untaries one at a time. " (New York Times, November 30, 1977) A later story in the Times quoted such luminaries as Dr. S. If Lynaugh plans to convert the municipal system into a dead ringer for the private sector, is the Emergency Medical Services move the opening gambit in his game plan? David Pomrinse, President of the Greater New York York Hospital Association (trade association for the city's voluntaries), Dr. Lowell E. Bellin, former City Health Commissioner, acting HHC Pres- ident Joseph T. Lynaugh, and un- named HHC officials, all of whom concurred about a " fight for bodies " (Pomrinse), a " battle to fill beds " (Bellin), and a problem of " patient rustling " (Lynaugh). So serious was the perception of the Cabrini incident that representa- tives from Greater New York Hospital Association and District 1199, the union representing voluntary hospital workers, demanded an immediate meeting with Lynaugh to warn HHC off. Lynaugh reportedly assured their spokespersons only that future attacks will be preceded by ad- vance warnings. Lurking in the shadows of this battle are the ghosts of a number of enormous unresolved public 22 policy issues that continue to underly the beds war. Among pediatric care, routine surgery these are: and most forms of ambulatory * How does HHC's EMS re- gionalization plan - or the Cabrini care. (Opponents of a plan to close smaller, less utilized - obstet- decision - relate to to Lynaugh's Lynaugh's rical units on Long Island recently stated agenda for salvaging the cited a study by State Deputy troubled municipal system? Health Commissioner Andrew Lynaugh's strategy emphasizes a Fleck that found no difference in sort of " second string " set of affil- infant mortality based on the unit's iations between municipal hospi- size). tals and " better " Medicaid mills, * Despite mounting evidence prepaid group practice plans and from throughout the country and, various other proprietary inter- indeed, the world that communi- ests. The latter would generate ty based - primary and preventive new patient business for the muni- care is more cost effective - and cipals as well as offering real com- medically sound than much of the petition to the voluntary affiliates available hospital care, why does which now provide the bulk of all NYC and NYS health policy medical staffing for HHC facilities. and politics seem to revolve The object: fill municipal beds. around hospital - based services? The danger: sacrifice of the health Why does NYC lag behind many care purpose of the public institu- US cities Newark -, Baltimore, tions to the god of institutional Detroit are examples - in moving solvency - in short, Lynaugh's toward integrated networks of plan to further voluntarize and even proprietize the municipal primary preventive / care centers that are non hospital - based? system may cost it its relevance to the health problems of the popu- lation it serves. If Lynaugh plans to While the bed war rages many NYC neighborhoods - and mil- lions of New Yorkers - have little convert the municipal system into a dead ringer for the private sec- tor, is the EMS move the opening gambit in his game plan? The overall bed closing - strategy purports to offer both re- duced costs and more effective Despite mounting evidence that com- munity - based primary delivery. Can it truly accomplish either? Critics note that the like- and preventive care is more cost effective - and liest result is a consolidation of services around fewer but larger medically sound than much of the available private institutions. It would beg incredulity to claim that such centralization will really lower costs in a service sector already marked by substantial regional monopoly. As for better delivery, hospital care, why does all NYC and NYS health policy and politics seem to revolve around hospital - based services? sharp questions need to be raised about the glib assumptions that institutions with lower occupancy rates are medically ineffective in general. In fact, many services provided by both the smaller pri- vate hospitals and the municipals probably deteriorate when cen- tralized into fewer, larger institu- or no access to routine, primary care. For answers to these and other questions, please stay tuned. -Michael E. Clark tions. Examples are maternal and ENVIRON WORK 4 OSHA CANCER POLICY: A BREATH OF FRESH AIR On October 4, 1977 Dr. Eula Bingham, Assistant Secretary of Labor for Occupational Safety and Health, published in the Fed- eral Register - in 80 pages of fine print a proposal to regulate sus- pected cancer causing - agents (carcinogens) in the workplace. The cancer policy proposal is sensible in its staged approach to regulating literally thousands of cancer suspect agents in the workplace, conservative of human life in the best traditions of public health policy (in a field where action customarily follows rather than precedes a body count) and notable as an act of political leadership by OSHA. Consequently, far out in the bureaucratic sea of paper which daily emanates from Washington, a storm of major proportions is developing. One of the surest storm signals is that, for the first time during Dr. Bingham's tenure, rumors are circulating that she may resign. The rumors have no apparent basis in developments internal to the OSHA agency, and Dr. Bingham has specifically denied them. One strongly sus- pects that the rumors are in fact a trial balloon by some industries (which seem to be the source of the rumors) to force her resigna- tion or dismissal. In the Wash- ington tradition of leaks and media manipulation, the way to launch such an idea is to first give it public reality, hoping that it will go on to become the proverbial self fulfilling - prophecy. Certainly industry is quite un- happy about the OSHA proposal and can be expected to strongly attack it when hearings begin next April in Washington. Toxic Substance Categories Basically the OSHA document proposes to classify all workplace chemicals which cause cancer in humans or animals into one of four toxic substance - categories, based on the strength of scientific evidence against the chemical, and to reduce human exposure correspondingly. Specifically, * A Category I Toxic Substance is defined as a substance which is known to cause cancer in humans, which has been shown in two separate studies to cause cancer in mammalian animals of the same or different species, or which has been shown in one mammalian study to cause cancer and in one bacterial study to cause genetic mutations. Within six months, according to the proposal, workplace ex- posure to this substance must be reduced to the " lowest feasible level " based solely on engineer- ing and and work practice - con- trols - not on use of personal pro- tective devices. (During the six- month period following _ initial classification, personal protective devices such as face masks are allowed to reduce worker ex- posure.) * A Category II Toxic Sub- stance is one shown only in one animal study to cause cancer. Also if one or both of the two animal studies needed for a Category I classification are judged incom- plete or inadequate, the material is classified in Category II. Because high exposure to suspected car- cinogens often produces other maladies as well, the proposed standard would limit exposure to Category II substances, within six months, to a level free of these other adverse health effects. Thus, in this case, where there is some, but insufficient evidence that a substance causes cancer, the proposal would at least place some limit on worker exposure until further studies can be carried out. * A Category III Toxic Sub- stance is one for which evidence of carcinogenicity (i.e., ability to cause cancer) is admittedly mea- ger. Here no new exposure stan- dard is set. OSHA is required, however, to publish the evidence leading to this categorization, thus encouraging further studies and publicly warning workers and others of the potential cancer danger. * Category IV is also one which involves publication of The cancer policy pro- posal is sensible in its staged approach to regulating literally thousands of cancer suspect agents in the workplace, conserva- tive of human life in the best traditions of public health policy and notable as an act of political leadership by OSHA. evidence, in this case for sub- stances which are suspect carcin- ogens but not now known to be used in workplaces in this country. 23 In short, action against a sub- stance is staged depending on the strength of evidence against it. Where animal tests, for example, indicate potential cancer danger, exposure must be limited to the lowest extent feasible. Where these tests are inadequate or only The OSHA document proposed to classify all workplace chemicals which cause cancer in humans or animals into one of four toxic- substance categories, based on the strength of scientific evidence against the chemical, and to reduce human exposure correspond- ingly. one animal test has been made, some limitation of exposure must be made within six months. If evidence of danger is only sug- gestive, based, for example, on a bacterial test such as the Ames test, exposure is not regulated, but the experimental evidence is publicly released. The Critical Decisions At the heart of this proposal are two fundamental policy deci- sions, which Dr. Bingham correctly admits are social deci- sions based on the weight of avail- able scientific evidence. The first is that animal studies are treated as predictive of human cancer - that is, sub- stances which cause cancer in mammalian animals are treated as posing a carcinogenic risk to humans. This proposition has been advocated consistently over the years by labor unions, en- 24 vironmental groups and groups of concerned scientists, and opposed just as vociferously by all major industries. (These arguments and the reasons why cancer tests on animals must be taken seriously, no matter how large the exposures to which they are subjected, were discussed in this column in the May June /, 1977 BULLETIN, in reference to the saccharin controversy.) This is the first time the OSHA Adminis- tration has made such an unequi- vocal policy statement on the human significance of cancer tests in animals. And it is the basis for the definition of a Category I Toxic Substance in terms of ani- mal tests. The other basic policy decision embodied in the proposal is that no safe level of exposure to a car- cinogen exists - that is, there is no threshold level below which ex- posure to a carcinogen is safe. OSHA's decision here not to set a so called - threshold limit value (TLV) for suspected carcinogens is a complete reversal of past policy. In the past, for every single OSHA standard that in- volved a cancer threat, a fixed threshold limit was set, which allows industries such as the as- bestos industry legally and rou- tinely to expose workers to known carcinogens at levels higher than absolutely necessary, given existing technology. In reaching its decision on this mat- ter, OSHA argues that, given the enormous range in individual sus- ceptibilities to cancer agents and the inability of scientists to dem- onstrate threshold effects for known human carcinogens, any exposure to a presumed carcin- ogen " must be considered to be attended by risk. " From this fol- lows the proposal that only the lowest feasible exposure to a Cat- egory I suspect carcinogen be allowed. (OSHA seems to be strict in its intention to allow only the " lowest feasible " exposure. If a non carcinogenic - substitute for a suspect carcinogen exists, for example, the substitute must be used and the suspect banned.) * * * Dr. Bingham and the OSHA Administration have taken a bold position of political leadership in dealing with the burgeoning can- cer crisis in the US. This is especi- ally true in light of the recent major defeat of forces seeking to ban saccharin production (see Vital Signs, this issue). Most of us are quite accustomed to liberal Democratic Administrations which give lip service rather than leader- ship when faced with fierce indus- try opposition. This instance may be an exception to that tradition. Passage of the proposed OSHA cancer policy has important posi- tive implications for workers and for others in the general public, and may set an important prece- At the heart of the proposal are two funda- mental policy decisions based on the weight of available scientific evidence: animal studies are treated as predictive of human cancer, and no safe level of exposure to a carcinogen is considered to exist. dent for cancer regulation by other government agencies. The proposal deserves strong support -and it will need it. -David Kotelchuck UMWA (Continued from Page 8) profits, the former suffered. To keep the big com- panies competitive with oil and gas in the electric utility market, Lewis and his successors chose not to seek an increase in the 40 cent royalty through collective bargaining for 20 years. Consequently the Fund had to cut off unemployed miners from health care. In the early 1960s the static royalty forced the Fund to sell its hospitals at a financial and spiritual loss. Without the hospitals, the Fund, like any prepaid health system, no longer had a yardstick with which to measure the quality of other coalfield health services. The Fund's medical staff had to fudge their commitment to preventive medicine when it involved occupational injury and disease. To do otherwise would necessarily challenge Lewis'al- liance with Love. Anything that impinged on the profitability - like dust and methane control sys- tems or better roof control - practices - could not be pushed hard by the medical people or demanded by Lewis in collective bargaining. Britain had recognized black lung as an occupational disease of coal miners in 1942, yet the Fund did little to pin the growing incidence of the disease on the new machines that were the core of the post 1950 - mechanization. The Fund supported the occupational health work of Dr. Lorin Kerr, 21 but little was done to follow it up. Neither the UMWA nor the Fund pushed for black lung disability compensation until the late 1960s, and no thought at all was given to indus- try financed - compensation. It took the rank and- - file black lung revolt in West Virginia in 1969 to flush out the UMWA on black lung compensation and even then the union's role was tainted by its Johnny - come - lately character. Though Lewis had touted the Fund in 1946 as a device to make the industry bear the " human costs of production, " at no time were there any significant efforts to prevent occupational disease and injury. Conse- quently, the Fund's practice of preventive medi- cine was limited to communities and did not include the workplace. 22 Beyond its health and pension programs, what strikes the observer is how little the Fund actually did for the " welfare " of coal miners. If the money had been there, the Fund could have pro- vided disability benefits and unemployment insur- ance to soften the impact of the depression that enveloped coal miners in the 1950s and 1960s. Moreover, the Fund could have begun programs in housing, education, job training, and recreation for its beneficiaries. But the money wasn't there because Lewis judged the industry could not afford to put it there. (This point is disputed. The 1950s saw the demise of many small operators but, some argue, brought relative prosperity to the large ones.) Inflation and mismanagement cut into the Fund's resources in the 1960s, resulting in the erosion of the Fund's health and pension benefits. Eligibility for health benefits became increasingly restrictive. Thousands of miners and widows had their health cards cancelled while the Fund's assets were loaned interest - free to coal operators and its cash reserves were used to purchase coal company and utility stocks. Pensions were also denied disabled miners and some widows for " economy " reasons. For those who did receive them, pensions never moved much beyond $ 100 a month until Tony Boyle, Lewis'eventual successor, maneuvered them up to $ 150 in order to capture the pensioner vote in his 1969 election battle with reformer Jock Yab- lonski. Meanwhile the Fund's medical staff did little to protest the financial and administrative practices of Lewis and Boyle. Rank - and - File Revolt By the late 1960s, conditions in the workplace and in the union had produced a rank - and - file re- It was the Fund's principle and practice to make coal miners and their families the central constitu- ency of the system rather than health providers - a radical notion both then and now. volt. Disabled miners and widows shut down the West Virginia coalfields in 1968 in a dispute over Fund eligibility. The West Virginia Black Lung movement succeeded in winning a state compen- sation law through a month - long wildcat strike in 1969. The methane explosion at Consol's Farm- ington, West Virginia mine in November, 1968 shamed Congress into debating mine safety. The union reform drive led by Jock Yablonski focused rank attention - and - file on Boyle's corruption in the UMWA and the Fund. Yablonski's subsequent 25 murder in December, 1969 spotlighted Boyle's reign in the coalfields. (Unfortunately, Yablonski never pinned the tail on the patriarchal donkey - Lewis. Yablonski always tried to portray himself as Lewis'descen- dant instead of tracing the excesses of Boyle's regime back to the structure Lewis had built in Thousands of miners and widows had their health cards cancelled while the Fund's assets were loaned interest - free to coal operators and its cash reserves were used to purchase coal company and utility stocks. 1950. Even today, Lewis'mantle gets draped around aspiring union politicians, even those who know better. Boyle was Lewis'dark side without the benefit of his grays and whites.) Numerous lawsuits successfully challenged. Boyle's management of the UMWA and the Fund. One of these, Blankenship v. Boyle, was brought on behalf of 17,000 miners and widows by an earnest lawyer, Harry Huge of Arnold and Porter, a well connected - Washington firm. The US Dis- trict Court in Washington said Lewis, Roche and the National Bank of Washington conspired in holding the Fund's assets in non bearing - interest - accounts. Judge Gerhard Gesell concluded that Lewis and Roche had advanced " the interests of the union and the bank in disregard of the para- mount interest of the beneficiaries. " He also found violations by the trustees in the " withholding of health cards from members when their employers became delinquent in royalty payments " among other irregularities. Boyle and Roche were removed from the Fund. Enter the Reformers When the reformers, led by Arnold Miller and the Yablonski veterans, took over in December, 1972, both the UMWA and the Fund badly needed an overhaul. That work was begun, but it faced many problems and the odds against its suc- cess were surmountable, but barely. Huge was named the UMWA trustee and chairman of the Fund. Independence of the Fund from the UMWA was declared. (By law its policies and administration must be distinct from the union and 26 the operators - a requirement openly disdained by Lewis and Boyle ever since the operators had conceded control of the Fund in the 1950 deal.) Still, miners and other Fund beneficiaries had a right to expect that Huge would interpret the Fund's mandate in line with the reform sentiments of the miners who had recently elected Arnold Miller union president. They expected compe- tence, compassion, honesty, openness and service. Huge, a smart and ambitious man, was gen- uinely moved by the plight of the Fund's bene- ficiaries. He chose a legalistic and technical approach to solving Fund problems. He hired a veteran from the Law Enforcement Assistance Ad- ministration, Martin Danziger, to direct the Fund. Danziger had not one scintilla of knowledge about coal, coal miners, coal operators, the Fund, pen- sions or health care. His only qualification for the position was his " considerable administrative ex- perience, " as the Fund's Annual Report phrased it 23. Both Huge and Danziger now put their pro- fessional reputations on the line. They chose to equate the quality of care with efficiency of ser- vice. With that faulty equation, they concentrated on improving the Fund's administrative services. The result was that their constituency became health providers, not health consumers. Whereas the Fund of the 1950s was willing to fight medical society dogma when principles were at stake, the Funds under Huge and Danziger (there were four Funds after 1974 - see below) have no bones to pick with state medical societies and the AMA. When the interests of health pro- viders and health consumers parted ways, the Funds parted with their beneficiary constituency. Today the visibility and vocalness of established Boyle was Lewis'dark side without the benefit of his grays and whites. medical opinion serves as an omnipresent check on Huge and Danziger; in contrast beneficiary participation is still totally absent in Funds'policy making. Destroying the Fund to Save It Huge and Danziger managed to ignore much of the good in the Fund's past. Efficiency to them meant scrapping existing administrative proce- dures and denigrating existing personnel, many of whom had been with the Fund since the early 1950s and had demonstrated competence. The quality of care had not generally been an issue in the past, although access to that care and certain administrative practices had. Lacking the subtlety to leave the good and discard the bad, Huge and Danziger threw out both. The new Funds also seemed to forget the acti- vist principles of the early Fund. In the bright, en- couraging days of 1973 and 1974, the Funds talked about " substantial changes in focus and attitude. " The first open trustees'meeting in the Fund's history was held in Charleston, West Vir- ginia. But as Huge's policies began to be imple- mented and criticized, the open meetings ended. beneficiaries should be included on the governing bodies of all agencies which do business with the Fund [s]. " (Quotes from the Funds'1973-1974 Annual Report, pp. 18-19). Miller's ambitious ideas and his notion of the Funds as a social change - advocate never got very far in Danziger's computers. The social advocacy rhetoric in the Funds'1974 annual report was noticeably absent in the 1975 and 1976 editions. In another instance miners pleaded with Huge for one solid year to use the Funds'financial power on behalf of striking union hospital workers in Pikeville, Kentucky in 1973. Huge refused; the strike failed. The final and most ironic twist is that Huge and Danziger have not even managed the Funds skill- A ate i OS ee CORRS. K. BENDIS Dr. C. Arden Miller, president of the American Public Health Association, was commissioned to do an in depth - critique of the Funds'programs. Miller recommended the Funds " lean toward a health care policy that promotes prevention of disease. " He urged a program of social advocacy, that the Funds " in the interest of the good health of [their] beneficiaries, should become active in the establishment of nutrition and school health programs... and advocate...... social and govern- mental change. " He felt " all types of Fund [s '] fully. Suzanne Jaworski Rhodenbaugh, a former health service specialist with the Johnston, Penn- sylvania regional Funds'administrator, charged the recent cutbacks were due less to the effect of wildcats than to simple mismanagement: " Technocrats...have made clear that neither people nor programs rank in importance to their introduction of a centralized, computerized method of paying medical bills and pension checks. " Yet they have failed miserably at managing. 27 Many cost and quality controls in the health pro- gram have been lost. Medical bills are paid late (if not lost); duplicate claims are paid; pension checks to retired miners are delayed; eligibility controls are often out of control. Virtually all ex- perienced top level - Funds staffers have been re- tired, fired, or have quit in disgust. In their place have come dozens of would - be technocrats who know nothing of labor, health or pension pro- grams, or management. These technocrats don't stay long, however, and the incredible turnover fuels the problem. " So much of the Funds'program has been gutted while it was'modernized.'And direct health expenditures and administrative costs have risen dramatically. Yet the self serving - press re- leases of the Funds putting - all the blame for the financial problems on the wildcats - have been blandly accepted. The Funds'mismanagement has aggravated the money problem. The Funds no longer have " Technocrats have made clear that neither people nor programs rank in importance to their introduction of a centralized, computerized method of paying medical bills and pension checks. " -Suzanne Jaworski Rhodenbaugh, Health Service Specialist, Johnston,. Pennsylvania Region a any effective way of checking fees billed by the doctors. The result has been predictable: massive overcharging, which, if caught at all, comes after payment. In many regions the Funds have paid charges rather than haggle with local providers over cost based - arrangements - a reflection of the Funds'bias toward their provider constituency. Some hospital administrators acknowledge the Funds pay more for daily services than other plans, which amounts to a Funds'subsidy for other coalfield health services. The 1974 Contract The UMWA reformers negotiated their first contract in late 1974. The operators, fattened off 28 the 1973 oil embargo, knew the year - old Miller Lacking the subtlety to leave the good and discard the bad in the Funds, Huge and Danziger threw out both. administration had to come up with a qualitatively different and quantitatively better contract. The companies tried to buy labor peace by giving Miller a big contract. They failed. The 1974 con- tract included better wages and benefits than its predecessors, but miners figured this was due them, given the bloated profits the companies had collected since 1971. To ease the financial crisis of the old Fund, the UMWA and the operators agreed to split it into four separate Funds, each financed separately and each providing different benefits: the 1950 Pension Trust (with 82,000 pensioners), the 1950 Benefit Trust, the 1974 Pension Trust (with 6,000 pensioners) and the 1974 Benefit Trust. Both the 1950 Pension and the 1950 Benefit (health care) Funds continue to be financed by a tonnage royalty. The 1974 Pension and the 1974 Benefit Funds, however, are financed in whole or in part on an hours worked - basis. In breaking up the Funds, the new contract established a two - tier pension system that dis- criminates against those miners who retired before 1976. Pre contract - pensioners are limited to $ 250 per month (a phased - in raise of $ 100 over their present pensions) while new retirees are allowed pensions of more than $ 350 a month on a sliding scale based on years worked and age at retire- ment. The artificial distinctions have embittered older pensioners and become a continuing source of division within the union. Taken together the Funds are solvent, but separately the 1950 Pension and Benefit Trust are bankrupt. The industry, through negotiations or the Funds'trustees, may try to dump the 1950 Pension Trust with its high obligations onto the federal government, but there are many uncer- tainties about this. If the federal Pension Benefits Guarantee Corporation did take over the liabili- ties of the 1950 Pension Trust, UMWA pen- sioners would be locked into a $ 210 a month benefit level, a $ 40 reduction from current standards UMWA strategists hoped that the 1974 Plans would draw in payments adequate to guarantee higher benefits. The 1950 pensioners were sacri- ficed for this goal; because pensioners do not vote in contract ratification, Miller could swap their interests for those of working miners. The industry now wants to drop the heavy obligations of the 1950 Pension Plan and the UMWA may go along, since its ability to organize non UMWA - miners is hindered by the heavy obligations of the 1950 Pension Plan. Bad Projections UMWA negotiators estimated the cash needs of the four trusts, projecting new Funds'benefici- aries, increased coal production, medical costs and inflation. Some the the projections were close; some were not. More beneficiaries were added than expected; less coal was mined and many fewer new mines were opened than the operators had promised; medical costs - for whatever rea- sons went - through the roof. The UMWA had assumed it could organize Western strip mines; it couldn't. Bad winter weather in 1976 and 1977 cut into production. Finally, no one could have predicted the wave after wave of wildcat strikes that have washed over the coalfields in the last three years. Since 1974 miners have quit work over a spectrum of workplace and non workplace - issues gasoline - rationing, the right to strike, offensive school text- books, black lung legislation, seniority, safety, job rights, union politics and benefits cutbacks. Operators have encouraged some of these strikes when stockpiles were up or when spot market - prices were down. Because the other faulty pro- jections left the Funds short of cash, wildcat strikes threatened to bankrupt the 1974 and 1950 Bene- These days, coal operators can be heard lamenting the lack of a " strong coal union, a union led by someone like John L., who know how to bargain with us, " as a former top Consol official put it recently. fit Trusts. Huge twice sought and obtained reallo- cation of future reserves from the other trusts to maintain health benefits before this summer's crunch. But the operators - looking at the UMWA's dis- integration and the upcoming December negotia- tions refused - to bail out the Funds a third time. From their point of view, why should they? Industry's strategy is to use the health care system to discipline rank and file miners for striking. It is a 8 TONS 3 COAL BEND'S strategy designed to soften the on job - the - militan- cy of miners by attacking their job off - the - security. It is also a strategy based on the conclusion that the UMWA is institutionally too fragmented to dis- cipline its own membership; consequently opera- tors are forced to abandon their 25 year - " the- use - union " posture. These days, coal operators can be heard lamenting the lack of a " strong coal union, a union led by someone like John L., who knew how to bargain with us, " as a former top Consol official put it recently. Cutbacks By last May, the Trustees decided that medical benefits would have to be cut. The Funds lacked the cash to continue providing " dollar first - cover- age " (payment of all initial medical costs for covered services), so a cost sharing - scheme was promulgated that set up deductible and coinsur- ance payments with a $ 500 annual " cap " (maxi- mum out pocket - of - payment) per eligible family. The Trustees withheld the announcement, how- ever, until June 20 six - days after Arnold Miller 29 had squeaked through a rough reelection cam- paign. Huge was accused of delaying announce- ment of the cutbacks until after the election to avoid blowing Miller's chances. (He was also ac- cused of conflict of interest in contributing some $ 1,000 to Miller forces in the campaign.) The cut- back would certainly have done just that. As it Industry's strategy is to use the health care system to discipline rank - and - file miners for striking. It is a strategy designed to soften the on the - - job militancy of miners by attacking their off job - the - security. was, Miller lost the election among working miners, but won through the support of retirees. The Funds also decided to cut back financial support for about two dozen coalfield clinics. These " miners " clinics are not formally affiliated with the UMWA or the Funds. Often set up through the combined efforts of the UMWA, local unions and the Funds, however, they have always enjoyed special retainer (prepayment) arrange- ments with the Funds. These retainers allowed the clinics to plan their programs and underwrite a wide range of medical services to miners and their communities not covered by specific fee ser- - for - vice payments. On July 1, 1977, without prior announcement, the Funds stopped the retainers; instead they instituted a fee service - for - formula where the Funds paid 60 percent of the bill and the patient 40 percent. These cutbacks may be a lethal blow to one of the most innovative and, some would argue, suc- cessful elements of the Funds'health programs. The clinics not only provided competition to local providers, they embraced a different model of how health care should be provided. Many of the clinics were founded on and - retain consumer- - control mechanisms. Much of their programmatic thrust is toward prevention. A wide range of social services including benefits counseling - is provided. The clinics claim they save the Funds millions of dollars by reducing hospitalizations and surgery although the claim is hard to prove. Each clinic has evolved differently over the years, and all have differences. Nevertheless, all have be- come medical outposts in the coalfields and im- portant community institutions. Nothing will re- 30 place them if they fold. $ 8 $ 10 $ 20 subcripton subcripton subcripton $for check BULETIN Student Regular Instiuonal is my / PAC Enclosed N10.Y0.7 HEALTH , York New , THE Stret TO Muray , 17 SUBCRIE PAC /Health : to Name Adres Mail To Huge and Danziger, with their implicit pro- vider perspective, retrenchment of the clinics made sense when economies were demanded. A panel of coalfield beneficiaries would probably have acted differently had it been consulted. No panel existed, however; no consultations were made before the cuts. The clinics protested col- lectively to the Funds'trustees, without effect. Their fate now hangs precariously on the benefits- memory that did not find company lawyers bur- sting into federal court for back work - to - injun- ctions. When stockpiles are high, strikes don't hurt. But slowdowns do. While West Virginia miners were striking and depleting their savings, miners at one Amax mine in Illinois were slowing down. " We know it, " said an Amax official, " and they know we know it and, still, there's nothing we can do about it. " financing formula the UMWA and the operators agree to in the upcoming negotiations. His Head is Not the Point Had miners been involved, they would have known that the June cutbacks would precipitate a strike. The Funds'leadership, on the other hand, seemed surprised by the three month - wildcat that resulted. The strike finally wound down after a The cutbacks may be a lethal blow to one of the most innovative and, some Breaking the Production Tie Throughout its history the UMWA pension and health - care plan has been tied into the level of production. This has been a singularly corrupting influence on UMWA leadership. It has, more im- portantly, also victimized coal miners in their workplace and communities. A necessary part of the solution to the impasse over coalfield medical care lies in negotiating a health and retirement plan that is not tied in to any particular index of operator prosperity, but finances benefits as they are needed. For instance the UMWA could seek a contrac- would argue, successful elements of the Fund's health programs. tual guarantee from the Bituminous Coal Oper- ators of America (BCOA) to pay all Funds expenses for contracted services whatever they may be. Winning this point in negotiations would free the miners'health care system from being coalfield meeting between strikers and Arnold Miller; the UMWA president was given a 60 day - reprieve to restore the cuts or call a nationwide strike. Miller has not asked Huge to resign, although the union's executive board requested his resignation. Coalfield petitions demanded Huge's head. His head, however, is not the point; his per- spective is. Huge and Danziger are neither evil nor crooked; rather their professed managerial " objectivity " translates into provider pro - policies. They now face a whirlpool of Watergate pro- portions that threatens to swamp their career boats and cause them to lose their captain's papers in the Washington fleet. That is their stake in the Funds now. (Huge was Miller's principal contract advisor even while he sat as a Fund hostage to inflation, production ups and downs and strikes, those initiated by miners and those precipitated by operators. This method could or could not continue the pay you - as - - go financing system, but it does remove the incentive for the Funds to cut back on services and benefits in emergencies. Only the UMWA and the BCOA - the negoti- ating arm of the industry - can make such a change, and they are unlikely to do so. More likely is a switch to traditional Blue Cross / Blue Shield coverage, whereupon 25 years of coalfield health struggle goes down the drain. The Funds, as always, will be the creature of collective bargaining. This year's negotiations promise to be the most important since the Lewis- trustee. When the operators threatened to sue over Huge's illegal dual roles, he resigned from the Fund and now directs UMWA negotiations. With the UMWA incapable of Huge, who is tightly knit with the Carter Adminis- tration, will undoubtedly receive the lion's share of the UMWA's lucrative legal business once the contract is ratified.) The 80,000 member wildcat strike was a health consumer - protest. It failed to restore the organizing "" its own membership, the big companies have given up trying to use the UMWA for their own ends. Now, it is likely they will try to break it clean and simple. cutbacks, however, because the operators were not hurt by it. It was the only wildcat in recent 31 Love contract of 1950. The alliance between the UMWA and the big operators is broken. The UMWA is fragmenting. Consol's preeminence as the political and production leader has been suc- cessfully challenged by Western _ strip mine - companies. The industry may regionalize its con- tracts and set up individual benefits packages on a Restorations of the cuts made by the trustees this summer is a necessary - but incomplete- demand. The real health cutbacks have been taking place since the 1960s and involve a sweeping programmatic retrenchment. Today, the Funds - even with the cuts restored - are simply an insurance scheme for miners and a pay- a Table 2 Summary of Equity Securities UMWA Pension Trust December 31, 1975 Securities 25 12,000 2,000 28,000 600 18,000 2,000 2,000 1,500 4,000 2,000 700 42,500 500 1,500 10,400 34,000 14,000 900 25,000 Corporation Potomac Electric Power $ 2.45 Cum Pfd. 58 Allegheny Power System American Telephone & Telegraph Co. Cleveland Electric Illuminating Co. Coca - Cola Co. Detroit Edison Co. DuPont, E.I., DeNemours & Co. Exxon Corporation First Pennsylvania Corp. General Electric Company General Motors Corp. International Business Machines Corp. Kansas City Power & Light Co. Lilly, Eli & Co. Maremont Corporation Ohio Edison Company Potomac Electric Power Co. Tampa Electric Company UOP, Incorporated Union Electric Company Cost $ 1,304 279,095 115,770 483,595 80,590 637,950 412,817 156,548 61,168 218,998 184,939 218,030 898,599 39,675 39,470 310,423 702,720 135,154 13,419 630,559 $ 5,620,723 Market Value $ 725 216,000 101,250 731,500 50,250 236,250 255,750 177,000 21,188 186,000 117,250 156,275 1,078,438 26,625 26,437 169,000 395,250 241,500 9.562 9.562 331,250 $ 4,527,500 SOURCE: IRS Form 5500, Annual " Report Return / of Employee Benefit Plan, " 1975. company company - by - or district - by - district basis. With the UMWA incapable of " organizing " its own membership, the big companies have given up trying to use the UMWA for their own ends. Now, it's likely they will try to break it, clean and simple. Miners and mine - area health consumers are once again faced with the need to take control over their union and their health plan. They must do this both to get to the root of production- related illnesses, injuries and deaths in the mines and to establish once again an effective system of community - based health services in the coalfield 32 regions. ment plan for health care providers. What really needs restoring is the progressive vision of the early Fund, a vision of what a health care system should do. That vision is valid today. It sees a miner controlled - health service system where facilities are owned by miners and pro- viders are employees of a workers'organization. It's that vision that should be restored. -Curtis Seltzer with the assistance of Robb Burlage (Curtis Seltzer was, for many years, a coalfield journalist. He founded the Appalachian News Ser- vice and now works in Washington.) REFERENCES 1. Leslie A. Falk, " Group Health Plans in Coal Mining Communities, " Journal of Health and Human Behavior, Spring 1963, Vol. 4, p. 8. 2. Forrest T. Moyer and Nina L. Jones, Injury Experience in Coal Mining, 1964: Analysis of Mine Safety Factors, Related Employment, and Production Data, Bureau of Mines IC 8389, Washington, D.C.: US Department of Interior, 1968, p. 80. 3. UMWA Welfare and Retirement Fund, Four year Summary and Review for the Year Ending June 30, 1951, September, 1951, pp. 11-13. 4. J.T. Boone, A Medical Survey of the Bituminous Coal Industry, Coal Mines Ad- ministration, US Department of the Interior, Washington, D.C., 1947. 5. Leslie A. Falk, " Group Health Plans, " op. cit., p. 6. 6. Leslie A. Falk, " Collective Bargaining for Medical Care Benefits: A Recent De- velopment in the USA, " British Journal of Preventive and Social Medicine. Vol. 7, 1953, p. 88. 7. Leslie A. Falk, " Group Health Plans, " p. 6, quoting F. Peterson, E. Kassalow and J. Nelson, Monthly Labor Review, Vol. 61, 1945, p. 191. 8.The tonnage royalty was a financing mechanism that had been used in Britain since 1920 when a National Miners'Welfare Fund was established to improve the " social well being -, the recreation, and the living conditions of mine workers. " It was financed by a one cent per ton royalty. See Ludwig Teleky, History of Factory and Mine Hygiene, New York, Columbia University Press, 1948, p. 227. 9. John L. Lewis, quoted in Report to the President of the United States on the Labor Dispute in the Basic Steel Industry by the Steel Industry Board, Washing- ton, DC, September 10, 1949. 10. John L. Lewis quoted by Bedford Bird, UMWA health official, in testimony be- fore the Committee on Education and Labor, Black Lung Benefits Provisions of the Federal Coal Mine Health and Safety Act, 95th Congress, first session, March 14-17, 21, 1977, p. 287. 11. See the chronology of events for this period in UMWA Welfare and Retirement Fund, Four Year Summary, 1950. 12. The UMWA estimated in 1951 that more than 100,000 miners were out of work and that at least half of them were over 45 years old and would never find coal mine employment. See Michael Widmann, Assistant to the President and Director of Research and Marketing of the United Mine Workers of America, in a prepared statement before the United States Committee on Unemploy. ment, October, 1951. 13. New York Times, June 13 and 14, 1949. 14. John L. Lewis, The Miners'Fight for American Standards, Indianapolis, Ind. iana, Bell Publishing Co., 1925. 15. National Coal Association, Coal Facts, 1974-75, p. 52. 16. Curtis Seltzer, " The United Mine Workers of America and the Coal Operators: The Political Economy of Coal in Appalachia, 1950-1973, " Ph.D. dissertation, Columbia University, 1977, pp. 446-460. 17. " Coal Presses Fight for Square Deal, " Coal Age, June, 1954, p. 137. Also " White House Sets Coal Study as Governors Ask Action. " Coal Age, August, 1954, p. 115. 18. One account of the medical infighting during the 1950s can be found in Marjorie Taubenhaus and Roy Penchansky, " The Medical Care Program of the United Mine Workers Welfare and Retirement Fund, " November, 1961; Re- vised September, 1966; Available from the UMWA Funds, pp. 172-181. 19. David Katz, MD, " Compromise of Free Practice of Medicine, " Pennsylvannia Medical Journal, Vol. 59, 1956. 20. Suggested Guides to Relationships Between State and County Medical Societies and the United Mine Workers of America Welfare and Retirement Fund drafted by an AMA committee in 1957, quoted in Taubenhaus and Penchansky, " Medical Care Program, " p. 178. 21. Lorin E. Kerr, " Coal Workers'Pneumoconiosis, " Industrial Medicine and Surgery. August, 1956; " Coal Workers'Pneumoconiosis: The Road to Dusty Death, Jack Lung, Washington, DC: United Mine Workers of America, 1964; and " Coal Workers and Pneumoconiosis, " Archives of Environmental Health, - Vol. 16, April 1968. 22. Falk, " Group Health Plans, " op. cit. 23. UMWA Welfare and Retirement Fund, Annual Report, 1973-74, p. 99. 24. Suzanne Jaworski Rhodenbaugh, " Letter to the Editor, " sent to 40 coalfield newspapers, July 6, 1977. 25. Data for 1906-1966 taken from Forrest T. Moyer and Mary B. McNair, Injury Experience in Coal Mining, 1968, Information Circular 8556, Wash. ington, D.C.: Bureau of Mines, US Department of Interior, 1972, p. 91. 1967- 1976 data from Mine Engineering and Safety Administration Division of Technical Support, 1977 (See Table 1). 26. National Safety Courcil, Accident Facts, 1977, p. 49. Get a Beat on Bakke! Did you know that: * New York City, America's most liberal, most ethnically diverse city, has among the worst records of minority medical school admissions? * New York City's already - dismal record has been getting worse for the last four years? Read the true facts about " reverse discrimination. " Get Health / PAC's Special Report: The Myth of Reverse Discrimination: Declining Minority Enrollment in New York City's Medical Schools. Send $ 2.00, plus $.50 postage and handling to Health / PAC, 17 Murray Street, New York, N.Y. 10007. 33 eee eee Vital Signs filled with irony for many observ- ers, announced that D.C. 37 members would henceforth be entitled to utilize the health bene- TIME AND TERROR Predicting that it will take " time and terror " (sic) for Mayor - elect Edward I. Koch to balance the NYC budget, the Wall Street Jour- nal recently called on him to " make the mayor the ultimate authority " on municipal labor negotiations (November 10, 1977). Although it was unclear which drummer he was hearing, Koch's selection two weeks later fits of a prepaid group practice plan in their area. The irony: al- though Manhattan members will have access to a plan at NYU- Bellevue, Brooklyn members will be offered a plan developed at Brooklyn's Brookdale Hospital- a private hospital. (Public Em- ployee Press, November 25, 1977.) The imagery is terrible: municipal hospitals are evidently good enough for other people, but not those who work in them, etc., etc. YOUR JOB OR of Basil A. Patterson as Deputy Mayor for Labor Relations seems to have tickled at least Victor Gotbaum. Gotbaum - head of the 100,000 member D.C. 37, the largest municipal union and the one that includes the city's 30,000 municipal hospital wor- kers called Patterson " somebody we trust. " What this verbal strok- YOUR LIFE... AGAIN In a decision that seriously un- dermines the right of workers to protect their own lives, a three- judge US Court of Appeals re- cently revoked a longstanding OSHA regulation protecting an employee's right to refuse work under unusually hazardous con- ditions. ing means for labor management - relations at the NYC Health and Hospitals Corporation - particu- larly whether it signals continued union tolerance of layoffs and at- trition that cost 8,000 municipal hospitals workers jobs in the past four years - has so far not been reported in the local media. The decision came in the case of Jimmy Simpson, a construction worker who helped connect steel beams high in the skeletons of tall buildings. One day as Simpson was working 150 feet above the ground, a strong wind developed which he believed threatened his life. He left the job and returned to the ground, for which he was fired. Judges Clark and Roney ROBBING THE HOSPITAL THAT FEEDS... argued as the majority that since Congress did not specifically in- clude a provision in OSHA allow- While D.C. 37 members con- ing workers to refuse work under tinue to dwindle in the municipal hazardous conditions, the Secre- hospitals due to attrition and re- tary of Labor for OSHA could not ductions in the municipal system, issue an administrative regulation the union announced in late Nov- granting workers such a right. ember that it opposed Mayor- Thus they upheld Simpson's fir- elect Koch's proposed require- ing. They also expressed fear that ment that all municipal employees workers, if granted it, might 34 be city residents, and, in a step abuse this " privilege. " Judge Wisdom argued in dis- sent that " the importance of the majority's holding extends far be- yond this case. " He concluded, _ " We are talking about whether Jimmy Simpson had to lose his job to avoid return to a dangerous workplace high on a wind swept - skeleton of steel. Congress felt that workers could live within the prescribed processes of this Act [OSHA]. I cannot believe that it required workers to die for them. " -Bureau of National Affairs, Occupational Safety and Health Reporter, December 6, 1977 99 BOTTLES OF TAB IN THE HALL . After many months of bitter controversy (see BULLETIN, May June /, 1977), the US Con- gress passed and President Car- ter signed a bill delaying by 18 months the proposed govern- ment ban on the use of saccha- rine as an artificial sweetener. The bill would also require cancer warnings on a variety of food products containing saccha- rin. For example, food products in interstate commerce must bear the warning: " Use of this product may be hazardous to your health. This product contains saccharin which has been determined to cause cancer in laboratory animals.'" One opponent of the delay, US Rep. Andrew Maguire (NJ D -), was so incensed by the Con- gressional action that he proposed instead the following warning: " Assurance - this product may not cause cancer in the opinion of your congressman although sci- entific evidence indicates that it does. " -New York Times, Oct. 5 and Nov. 24, 1977 SUPPORT FOR CONSUMERS IN HEALTH PLANNING A labor backed - Consumer Coalition for Health has been organized to promote stronger and more knowledgeable con- sumer participation in Health Sys- tems Agencies under PL 93-641, the Health Planning and Re- source Development Act of 1974 (see Health / PAC BULLETIN, May / June 1976). It is the first national advocacy and technical assistance network for consumer health planning. Its organizers- who include Herbert Semmel of the Center for Law and Social Policy and Ted Bogue of Ralph Nader's Health Research Group -have been testifying and liti- gating for better HEW guide- lines and for broader HSA board participation, especially including income low - communities. The Coalition is now distributing the Consumer Health Action Net- work (CHAN) in cooperation with the Health Research Group. The CCH address is 1511 K St. NW, Suite 220, Washington, DC 20005. SMALL CHANGE (S) While Washington wrestles with health economics, any con- crete steps toward national health insurance will by put off again, at least until 1979. For this coming year Carter and Califano will, at most, be proposing only reorgan- izations and rearrangements: a consolidation of maternal and child health and family planning services (most optimistically seen as a mini - step toward " kiddie- care " health insurance); a modest reduction in Medicare copay- ments (which HEW is now con- vinced fail to reduce spending on unnecessary services); and an expansion of urban health pro- grams. Over this last year HEW staf- fers have been pushing an In- tegrated Urban Health Strategy, combining existing funds for Community Health Centers, the National Health Service Corps, and maternal and child health programs, toward improved preventive and primary care and reduced costs. They are now seeking an expansion of this pro- gram, to set up as many as 800 new Community Health Centers in the next four years as well as a new demonstration program to set up prepaid health plans for the poor in urban public hospitals, as a way to reduce Medicaid costs. In dollar conscious - Washington, even these modest programs may not make it past the Budget Gaunt- let. (See Washington Column, this issue.) A FALL OF MAJOR PROPORTIONS BEGINS WITH A SINGLE STEP According to the US Con- sumer Product Safety Commis- sion, stairs are the second most hazardous consumer product (af- ter bicycles). Stairs are implicated in over two million accidents each year in the US. More than half a million Americans went to hospi- tal emergency rooms last year for treatment of stair related - injuries; of these, four thousand died. No one knows how many of these occured on the job. Recently the Consumer Pro- duct Safety Commission spon- sored a study on stairs and stair- related accidents by John Archea, an " architectural psychologist. " In his final report, in an argument that parallels one in many other fields (occupational safety, for example), Archea argues that stair accidents cannot be attrib- uted to human carelessness. People do have accidents be- cause of carelessness. But in vir- 35 tually all cases, he insists, the reason they are careless - at least in part - is that they are distracted, deceived or otherwise con- founded by the characteristics of the stair environment itself. Architecturally " triggered hu- man error causes most stair ac- cidents, " Archea argues. " You can say the person misread the situation. Yet the situation was designed to be misread. " The study is an interesting one; further information on it may be obtained from Peter Armstrong, Consumer Product Safety Com- mission, WTB - 735, Washington, D.C. 20207. -Job Safety and Health, US Dept. of Labor, September, 1977 LAETRILE: HEAVY POLITICS IN HARD SCIENCE Memorial Sloan Kettering - Cancer Center, a major national cancer research and treatment center located in New York City, has backed off a widely publicized claim made in June that a particu- lar set of Laetrile experiments performed there over the last five years had shown the controver- sial drug to fail where conven- tional cancer chemotherapy had succeeded, according to a state- ment recently released by the New York Academy of Sciences. Contrary to the assertions made in the Sloan Kettering - article distributed to the press in June, " Laetrile was thus tested in a system in which it is difficult to demonstrate cures by any chemotherapy, and in which many clinically active drugs have never even been tested, " Richard D. Smith asserts in a detailed article on the subject to be pub- lished in the January, 1978 issues of The Sciences, the magazine of 36 the New York Academy of Sci- ences, of which he is associate editor. According to Dr. C. Chester Stock, Sloan Kettering - Vice Pres- ident for Academic Affairs and first author of the Sloan Kettering - article, the erroneous description in the article was based on information provided by the sec- ond author, Dr. Daniel Martin, which Stock told The Sciences reporter he had accepted at face value. Stock said the misleading statement has since been deleted from the article, which had al- ready been accepted by the Jour- nal of Surgical Oncology at the time of the June press conference. Smith acknowledges in his Sciences article that these and other inconsistencies in the Sloan- Kettering article were brought to his attention by Dr. Ralph Moss, then Assistant Director for Public Affairs at Sloan Kettering - , who " was subsequently fired by Sloan- Kettering when he disclosed in November that he was a co- author of a separate report, re- leased by a group called Second Opinion, that was a sweeping Kis attack on the Sloan Kettering - Laetrile articles. " Another " inconsistency " that disturbed Smith was that previous work of the third author of the Sloan Kettering - article, veteran chemotherapy researcher Dr. Kanematsu Sugiura, was described in June as " seriously challenged " by the study report- ed in the article. Yet at the press conference Dr. Sugiura stuck to his interpretation of his previous work. Thus, Smith said, " He had put his name on the Sloan Ketter- - ing article although he was not in full agreement with its main con- clusion. If he did not believe that the other experiments reported in the paper of spontaneous tumors ' seriously challenged his own conclusions, what were his reasons? He gave them neither in the article itself, nor at the press conference. " So many questions, so many answers. --- Press Release, New York Academy of Sciences, Dec- ember 12, 1977, and Richard Smith, " The Laetrile Papers, " to be published in The Sci- ences, January, 1978. THOSE EMERGENCY SORE THROATS A survey by the Roper Organ- ization for the American Hospital Association has found that two out of three Americans regard the emergency room as equivalent to the local physician's office for gen- eral and routine care. (Nursing Outlook, June, 1977) The study also found that about a third of the hospitals that participated in the survey did not offer initial treat- ment for non urgent - conditions. Perhaps most significantly, the study found the larger the hospi- tal, the more likely that a patient seeking routine, non emergency - care would be referred to hospi- tal related - primary centers or specialized clinics rather than an office based - physician. One AHA conclusion: increased utilization of the emergency room for such care has been the major factor in increased utilization of outpatient clinics as well. The results include a 103 percent increase in the last decade in outpatient utilization, versus a 25 percent rise in in- patient utilization. Cumulative Index (December 31, 1977) A Abbott Laboratories - Sept. - Oct. '76 * Abortion - Dec. '69; Mar. '70; Nov. '70; Dec. '70; Feb. '73; Nov- Dec. '76; Sept. - Oct. " 77. Affiliations June '68; Aug '68, Nov. - Dec. '68; Winter '69; Apr. '69; Jul.- Aug. '69; Dec. '71; Sept. '73 (Montefiore - Prisons); Oct. '73 (NYU- Bellevue); Feb Jan. -. '74 (Montefiore - North Central Bronx). Air Pollution -- Oct. '70; Nov. - Dec. '74. Alford, Robert R. - May - June '76 (Review). American Association for Labor Legislation - Jul - Aug. '76 * American Assn. of Foundations for Medical Care - Feb. '73; July Aug -. '74. American Assn. of Inhalation Therapists - Nov. '72. American College of Obstetricians and Gynecologists - Jan. - Feb. '75; July Aug -. '75. American Conf. of Gov't. and Industrial Hygienists - Sept. " 72. American Hospital Assn. - Nov. '72; July Aug -. '74; May - June '75; May June - '76; Jan. Feb -. '77. American Medical Assn. - Nov. '72; July Aug -. '74; Jan. Feb -. '75; May June - 75; July Aug -. '75; Jan. Feb -. '76 *; Mar. Apr. '76; May- June '76; Mar. - Apr. '77 American Natl. Standards Institute - Sept. '72. American Nurses Assn. - Nov. '72; Sept. - Oct. '75. Asbestos - Mar. '73; Nov. - Dec. '74; July - Aug. '76 (letter). Assn. for Retarded Children - Jan. '73. Assn. for Voluntary Sterilization - Jan. - Feb. '75; July Aug -. '75. Association of American Medical Colleges - July - Aug. '69; Mar. - Apr. '77. Attica Prison - Nov. '71; Sept. '73 (Prison Health). B Bakke Case - May - June '77. Beasley, Dr. Joseph - Sept. - Oct. '75. Bellevue Hospital - Sept. '73 (Prison Ward); Oct. 73. Beryllium Poisoning - Sept. 72. Beth Israel Hospital - July '68; July Aug -. '69; Sept. '69; Apr. '70; Oct. " 70; Jul Aug.. " 72. Beverly Enterprises - Apr. '73. Birth Control - Apr. 72; Jan. Feb -. '75; July - Aug. '75; Mar. - Apr. '77; May June - 77; Jul Aug. -. '77; Sept. - Oct. " 77. Black Lung Disease - Sept. '71. Blue Cross - Jul - Aug. '69; Sept. '69; Oct. '69; Mar. '71; Jul Aug -. '72; Oct. 72; Sept. - Oct. '74; May June - '75; May June - '76 *. Boston City Hospital - Jul. - Aug. '70; Oct. '73; Mar. - Apr. '74 (letter); May June - 74 (letter). Boston Health Issues - Jul - Aug. '77 (Lahey Clinic). Boston University Medical Center - Oct. '73. Brian, Earl Apr -. '73. Brindle, James - Oct. '72. Brookdale Hospital - Sept. - Oct. 177. Buffalo Medical School - Nov. " 71. Bureau of Occupational Safety and Health - Sept. " 72. Byssinosis - Sept. '72. C Carter, Jimmy (Sept. Pres.) - - Oct. '76; Jan. Feb -. '77 (NHI); Mar.- Apr. 77 (cost control); May June - '77; Jul Aug -. '77 (OSHA). Case Western Reserve Med. School - Jan. '70; Sept. '71. Center for the Prevention of Violence - Sept. '73. Certified Hospital Admission Program - Feb. '73. Charity Hospital (New Orleans) -Sept. - Oct. '75. Cherkasky, Dr. Martin - Apr. '69; Jan. Feb -. '74. Chicago Health Movement - Apr. '71. Children's Hospital, Boston - Mar. '72. Chinese Health System - Dec. '72. Chlorinated Hydrocarbons - May - June '76 *. CIBA Geigy - Pharmaceutical Co. Nov. - - Dec. '75. Cincinnati People's Health Movement - Sept. '71. City University of NY Proposal (Med. School) -Oct. '72. Citywide Save Homes - Our - Committee (-May NY) '72. Cleveland - Sept. 71. Coler Hospital - Oct. '69. Columbia Medical Center - Jul. '68; Aug. '68; Nov. - Dec. '68; Jul.- Aug. '69; Sept. '69; Dec. '69; Feb. '70; Oct. '70; Dec. '70; Mar. '71; May June - 77; Jul Aug -. " 77. Columbia Hospital - Nov. '71. Columbus Hospital (-Nov NY). '71; May '72; Oct. '72. Committee of Interns and Residents - Aug. '68; Sept. '69. Community Control - Oct. '68; Nov. - Dec. '69; Jan. '72; June '72. Community Medical School Proposal (Lincoln) -Oct. 72. Community Mental Health - Aug. '68; Apr. '69; May '69 (Lincoln); Dec. '69; May '73; Jul Aug. -. " 75. Comprehensive Health Insurance Plan (-Mar CHIP). - Apr. 74. Coney Island Hospital - May '72. Cook County Hospital - Apr. '73. Cornell / New York Hospital - Sept. '69; May June - '77. Cost Con-t Mraro. l- Ap-r. '77; May June - '77; July Aug -. " 77. Sept.- Oct. '77. D Davis Medical School (Univ. of Calif.) - Apr. '73; May June - '75. Deinstitutionalization (Mental Health) -Jan. '73; Jul Aug. -. '75; Sept.- Oct. 77 (review). Delafield Hospital - Nov. - Dec. '68; May '72. Dellums Proposal (-Jul NHI) - Aug. '77. Diethylstilbestrol (-May DES) - June '76 *. Depression, The Mar. - - Apr. 76. Downstate Medical Center - Sept. '69; Oct. '70; May June - '77. Drug Companies - Sept. - Oct. '76; May June - '77. Dubos, Rene Nov. -- - Dec. '75. Duke Medical School - July - Aug. " 74. E Einstein Montefio-r eAp r-. '69; Sept. '69; Sept. '70; Oct. '70; Jan. '71; Nov. '71; May '73 (Einstein); Sept. '73 (Montefiore - Prisons); Jan.- Feb. '74; May - June '77. Eisenberg, Dr. Leon - Nov. - Dec. " 75. Ellwood, Dr. Paul Aug - Jul - Aug. '72. Emergency Medicine - Sept. - Oct. '77. Environmental Health - May - June '77. Exchange Visitor Program - Jan. - Feb. '76. California Public Hospitals - Apr. '73; May June - '74. F California Nursing Assn Sept.. - - Oct. '74. Cancer Nov. - Dec. '77 (OSHA). Family Health Foundation - Sept. - Oct. '75. Carnegie Foundation - Nov. '71; May June - '75. Federal Drug Administration - May June - '77. Federal Health Policy - Nov. '70; Apr. '71; May '73; May - June '76; Mar. Apr. 77; Jul Aug. -. '77. * Asterisks indicate short items - e.g., news briefs, announcements, etc. Federation of Jewish Philanthropies - Apr. '69. 37 Feldstein, Martin - May '73; Jan. Feb -. '74. Fiscal Crisis Mar. Apr. '76; Mar. - Apr. 77. Food and Drug Admin. - Jan. Feb. '75; Nov. - Dec. '75; Mar - Apr. '76 * Ford, Gerald (Sept Pres.) -. -Oct. '76. Fordham Hospital - Nov. - Dec. '68; Jul Aug. -. '69. Foreign Medical Graduates - Jan. - Feb. '76. Foucault, Michel - Nov. - Dec. '75; May June - '77 Review () . Free Clinics Apr. '71; Oct. '71; Feb. '72; Mar. - Apr. 75. Freud, Sigmund - Jan. - Feb. '77. G Gauley Bridge - Nov. - Dec. '77. Ghetto Medicine Bill Jan --. '70; Apr. 70; Jul Aug. -. '72. Group Health Insurance (-Oct NY). '72. Group Practice - Nov. '70; June '71. Gouverneur Hospital - Jul. '68; July - Aug. '69; Nov. '69; Feb. '70. H Haight Ashbury - Free Clinic - Oct. '71; Feb. '72. Harlem Hospital - Jul. '68; Nov. - Dec. '68; June '69; Dec. '70. Harlem Medical School Proposal - Oct. " 72. Harrington, Donald - Feb. '73. Harvard Medical School - Jan. '71; Oct. '73. HEW Mar. '71; May '73; Jul Aug -. '74; Feb Jan. -. '75; Jul Aug -. '75; Nov. - Dec. '75; Mar. Apr. '76 *; Mar. - Apr. 77; May June - '77; Jul- Aug. '77; Sept. - Oct. '77; Nov. - Dec. '77.. Health and Hospitals Corporation - Winter, '69; June '69; Sept. '69; Nov. '69; Jan. '71; Dec. '71; Feb. '72; May '72; Oct. '73; Jan. Feb -. '74; July Aug -. '75; Mar - Apr. '76; Nov. - Dec. '76 * Mar. - Apr. '77; Jul - Aug. '77; Sept. - Oct. '77. Health and Hospitals Planning Council - June '68; Winter '69; Jul Aug. -. '69; Sept. '69; Apr. '71; May '72; May '73; Mar - Apr. '76; Jul.- Aug. '77. Health Care Costs - Jan. '70; Nov. '70; June '71; May '72; Jul Aug -. '72; Jan. Feb -. '75; May - June '75; Sept. - Oct. '75; Mar. - Apr. '76 *; May - June '76 *; Nov. - Dec. '76 *; Mar - Apr '77; May June - '77; Jul Aug -. '77. Health Inc. Boston - Mar. '72. Health Insurance Plan of Greater NY Oct -. '72; Dec. '72. Health Maintenance Organizations (HMO's) -Nov. '70; Apr. '71; Dec. '71; Jul Aug -. '72; Oct. '72 (HIP); Feb. '73 (Foundations); Nov. '73 (Kaiser); May June - '75. Health Planning (see Health and Hosp. Planning Council) -June '68; Winter '69; Jul Aug -. '69; Apr. '71; May '72; May - June '75; Jan.- Feb. '76; May June - '76; Jan. Feb -. '77; Jul Aug -. '77. Health Professions Educational Assistance - Nov. '71; May '73; Mar.- Apr. '77. Health Revolutionary Unity Movement (HRUM) -Feb. '70; Jul Aug. -. '70; Sept. '70; Oct. '70; Dec. '70; June '71; Jan. '72; Jul. - Aug. '72. Health Services Administration - Jul. '68; Sept. '68; Sept. '69; Nov. '69; Jan. '70; May '72; Sept. '73 (Prisons). Health Systems Agency (-May HSA) - June '76; Aug Jul. -. '76 *; Jul.- Aug. '77 (NYC). Health Workers - Mar. '70; Jul Aug. -. '70; Apr. '72; Nov. '72; Sept.- Oct. 74; Jan. Feb -. '75; Sept. - Oct. " 75; Jan. Feb -. '77; Mar. Apr. '77; Sept. - Oct. '77. Hill Burt-o nM a-y '72; Aug Jul -. '72; May '73; May June - '75; Nov.- Dec. '76 *. Hilton Davis Co. (-Sept Strike) . 71. Holloman, Dr. John L.S. (Mar Jr.) - - Apr. '76; Mar. - Apr. 177. Home Health Services - Jan. - Feb. '76 *; May June -, '76 *. Hospital Beds (Excess) -Jul - Aug. '77. Hospital Expansion - Nov. '71; Mar. '72; May '72; Mar. - Apr. '74; Nov. - Dec. '74; May - June '75; Jan. Feb -. '76; Jan. Feb -. '77; May- June '77; Jul Aug -. '77. Hospital Trustees --- Jan. - Feb. '77. Hospital Worker Unions - Jul - Aug. '70; Sept. '70; June '71; Sept. " 7}; Oct. 72; Nov. '72; Jan. Feb -. '74; Sept. - Oct. '74; Nov. - Dec. '76 *; Jan. - Feb. 77; Sept. - Oct. " 77. Human Experimentation - Jan. - Feb. '76 *; Mar. - Apr. " 76 *. I Illich, Ivan July - - Aug. '75 (Review). 38 Industrial Health Foundation - Sept. " 72; Mar. '73; Nov. - Dec. '74. Industrial Medical Association - Sept. '72. Infant Formula - May - June '76 *. Institutional Licensure - Nov. '72. Insurance Companies - Nov. '69; Jul Aug. -. '72. Irvington House - Mar. '71. I Wor Kuen - Oct. '70. J Jacoby, Russell - Mar. - Apr. '75; Jan. Feb -. '77 (Review). Johns Manville Corp. - Mar. '73; Nov. - Dec. '74. Joint Commission on Accreditation of Hospitals (JCAH) -Feb. '72; Apr. 73; Jul Aug -. '75; Jan. Feb -. '76 *; Sept. - Oct. '76 *. Judson Mobile Unit Nov -. '69. K Kaiser Permanente - Nov. '70; Nov. '73; Mar. - Apr. '74 (letter). Key, Dr. Marcus - Sept. '72. King General Hospital - Apr. 73. Knickerbocker Hospital - Nov. - Dec. '68; Oct. '72. L Lahey Clinic (Boston) -Jul - Aug. '77. Laing, R.D. - Jan. - Feb. " 75. Law, Sylvia - Sept. - Oct. '74 (Review). Lead Poisoning - Sept. '68; Apr. '70; Jan. '71. Licensure Nov. '72. Life Expectancy - Sept. - Oct. '76 *. Lincoln Hospital - Apr. '69; Sept. '70; Oct. '70; Dec. '70; Jan. '71; Jan. '72; July - Aug. '72; Nov. - Dec. '76. Lincoln Community Mental Health Center - May '69; Sept. '69. Logan, Dr. Arthur - Oct. '72. Louisiana State Univ. Medical Center - Sept. - Oct. '75. Lower East Side Neighborhood Health Council - South (LESNHCS) - Jul. '68; Jul Aug. -. '69; Sept. '69; Feb. '70; Apr. 70; Jul Aug. -. '70; Oct. '70. M Madera County Hospital - Apr. 73. Maimonides Community Mental Health Center - May '68 Malpractice May - June '75; Feb Jan. -. '76; May June - '76 *; Nov.- Dec. '76 *. Martin Luther King Health Center - Oct. '69. Maryland - Jan. - Feb. '76 (suburbs). Maternal and Child Care - May '73. Medicaid - Winter '69; June '69; Sept. '69; Jul Aug. -. '72; Oct. '72; Feb. 73 (Medi - Cal); Apr. '73 (Medi - Cal); May '73, May - June '74; Jan. Feb -. '76; Mar. - Apr. '76 *; Sept. - Oct. '76 *; Nov. - Dec. '76 *. Medicaid Mills - Jul - Aug. '72; May June - '74; Jul. - Aug. '77. Medical Committee for Human Rights - Mar. - Apr. '75. Medical Education - Nov. '71; Oct. '72; May June - '75; Mar. - Apr. 76 *; Nov. - Dec. '76 *; Mar. - Apr. '77; May June - '77. Medical Efficacy - Mar. - Apr. 77. Medical Empires - Nov. - Dec. '68; Apr. '69; Sept. '69; Oct. '70; Apr. '73 (Calif.); Jan. - Feb. '74; Mar. - Apr. '74; Jul Aug. -. " 74; Sept. - Oct. '75. Medical Industrial Complex - Nov. '69; Sept. - Oct. '76; May June - '77. Medical Labs Mar. - Apr. '76 *. Medical Research - Nov. - Dec. '74; Nov. - Dec. '75. Medical Technology - Mar. - Apr. '77. Medicare - June '69; Nov. '69; Jul Aug -. '72; May '73; May June - " 75; July Aug -. '75; Jan. Feb -. '76 *; Mar. - Apr. " 76 *. Mental Health May '69; Dec. '69; May '70; June '70; July Aug -. '75; Nov. - Dec. '75; Sept. - Oct. '77. Mental Retardation - Jan. '73. Merced County Hospital - Apr. '73. Methadone June '70. Methodist Hospital - Apr. '72. Metropolitan Hospital - Feb. '70. Michelson, William - Oct. '72. Military Medicine Apr. " 70; June '71. Minority Enrollment (Medicaid School) May June - '77. Mitchell, Juliet Jan. - Feb. '75 (Review). Montefiore Hospital - June '68; Apr. '69; Sept. '69; Oct. '70; May '73; Jan. - Feb. '74. Moore, Dr. Cyril - Oct. '72. Morrisania Hospital - Apr. '69; May '72; Jan. Feb -. '74. Mothershead, Andrew O. Jan. - - Feb. '76 *. Mt. Sinai Medical Center - Oct. '70; Sept. - Oct. '74. N Narcotics L June '70; Dec. '70; Jan. '72. National Civic Federation - July - Aug. '76 *. National Health Corps - Apr. " 70. National Health Insurance - June '69; Jan. '70; May '73; Mar. - Apr. '74; May - June '74; Jul Aug. -. '74 (letter); Nov. - Dec. '76 *; Feb Jan. -. '77; May June - '77; Jul Aug. -. '77. National Health Insurance Program (-May NH-I JPu)ne '74 National Health Planning and Resources Development Act (PL. 93-641; 1974 -Ma-y J)un e '76; July Aug -. '76. National Institute for Occupational Safety and Health - Sept. '72; Mar. '73; Nov. - Dec. '74; Jan. Feb -. '75; Jul Aug. -. '76; Mar. - Apr. '77; May June - '77. National Institutes of Health (-May NIH) '73. National Medical Enterprises - Apr. '73. National Safety Council - Sept. '72. Neighborhood Health Center - June '72; May '73. NENA (Northeast Neighborhood Assn.) - Jul. '68; Aug. '68; Oct. '70; June '72. New Orleans - Sept. - Oct. '75. New York City Medical Schools -- May - June '77. New York City Municipal (public) Hospitals - Mar.- Apr. '76; Mar. - Apr. '77; May June - '77; Jul Aug. -. '77; Sept. - Oct. '77. New York City Prisons - Sept. '73. New York Infirmary - June '72. New York Medical College - May '69 (Community Mental Health Ctr.); Sept. '69; Oct. '70; May - June '77. New York State Dept. of Mental Hygiene - Jul - Aug. '75. New York State Health Policy -- Jul. - Aug. '77. New York State Nursing Assn. - Sept. - Oct. '77. New York Times - Feb. '70; May '70. New York University Medical Center - Sept. '69; Apr. '70 (Bennett); Oct. 70; Mar. '71; June '72; Sept. '73 (Prison Ward); Oct. '73; May- June '77. Nixon, Richard - Nov. '70; Apr. '71; May '73; Mar. - Apr. '74; Nov.- Dec. '74. North Central Bronx Hospital - May '72; Jan. - Feb. '74; Nov. - Dec. * 76 *. Nursing Mar. '70; Sept. '71; Apr. '72; Sept. '72 (letter); Nov. '72; Sept. - Oct. 74; Jan. - Feb. '75; Sept. - Oct. '75; Mar. - Apr. '77; Sept.- Oct. '77. Nursing Homes - Nov. '69; July Aug -. '76 *; Nov. - Dec. '76 *. Occupational Health - Feb. '70 GE (); May '71; Sept. '71; Sept. '72; Mar. '73; Nov. - Dec. '74; Jan. Feb -. '75; Sept. - Oct. '75; Mar. - Apr. * 76 *; July Aug -. '76; Nov. - Dec. '76 *; Mar. - Apr. '77; May - June '77; Jul Aug -. '77; Sept. - Oct. '77 (Blacks); Nov. - Dec. '77 Gauley ( Bridge). Occupational Physicians - Mar. - Apr. '77. Occupational Safety and Health Act Sept -. '72; July - Aug. '76. Occupational Safety and Health Administration --- Sept. '72; Nov. - Dec. '74; Mar - Apr. '77; Jul Aug -. '77; Nov. - Dec. '77. Office of Management and Budget (-May OMB) '73. Oil, Chemical and Atomic Workers Union - Oct. '72; Nov. - Dec. '74; July Aug -. '76; Mar. - Apr. '77 (Training Program). Oil Industry - Nov. - Dec. '74. Oklahoma City Mar. - - Apr. 74. P Patient Dumping - May - June '74. Peace Movement - May '71. Pediatric Collective - Oct. '70; Jan. '71; Jan. '72. Peer Review - Feb. '73. Perot, H. Ross Jul. - Aug. '75. Physician's Assistants - Nov. '72. Physicians National Housestaff Association (-May P-N HJAun)e '76 *. Piel Commission Report - June '68; Winter '69. Planned Parenthood - Jan. - Feb. '75; Jul Aug. -. '75. Polyvinyl Chloride (PVC) -Jul. - Aug. '76. Prepaid Health Plans (-Feb PHP's). '73; Apr. '73. Preventive Health - Mar. - Apr. '77; Jul -Aug.. '77 (NYC). Primary Care -- Mar. - Apr. '77. Prisons - May '70; Nov. '71; Sept. '73. Professional Standards Review Organizations (PSRO's) -Feb. '73; Jul.- Aug. " 74. Profits in Health - Sept. - Oct. '76; May June - '77; Sept. - Oct. '77. Psychiatry - May '69; May '70; Jan. Feb -. '75; Jul Aug. -. '75; Nov.- Dec. '75; Jan. Feb -. '77. Public Health Hospitals - Mar. '71. Public Hospitals - Apr. '73; May - June '74; Mar. - Apr. '76; Mar. - Apr. '77. Q Queens Medical School Proposal - Oct. '72. Quality Assurance Program (QAP) -Jul. - Aug. '74. R Regional Medical Program - Jul. - Aug. '69; May '73. Reich, Wilhelm - Jan. - Feb. '75. Research Guide - Feb. '71. Ritalin - Nov. - Dec. '75. Rockefeller, Nelson - Jul. - Aug. '75. Rohatyn, Felix - Mar. - Apr. '76. S Saccharin Controversy - May - June '77. Sacramento County Hospital - Apr. '73. Sacramento Foundation for Medical Care - Feb. '73. Sacramento Medical Center - Apr. '73. San Francisco Hospitals - Jul. - Aug. '70; Mar. '71; Feb. '72; Apr. '73; Sept. '73 (Prison Ward); Feb Jan. -. '77; Sept. - Oct. '77 (ERs). San Joaquin Foundation for Medical Care - Feb. '73. Santa Cruz General Hospital - Jan. - Feb. '74. Scull, Andrew - Sept. - Oct. '77 Review () . Selikoff, Dr. Irving - Sept. '72; Mar. '73; Nov. - Dec. '74. Shell Chemical Co. Sept -. '71 (No Pest Strip); Nov. - Dec. '74 Strike (). Smith, David - Oct. '71; Feb. 72. Social Workers - Sept. '70. Soundview - Throgs Neck Tremont - Comm. Mental Health Center - May '69. Stahl, Dr. William - Oct. '72. Sterilization --- Jan.-- Feb. '75; Mar. - Apr. " 75 (letter); Jul Aug.--. '75; Jan.- Feb. '76 *; May June - '77; Jul Aug. -. '77. Sterling Drug Co. Sept -. '71. Student AMA - Mar. '70; Sept. '70. Student Health Organization (-Aug SHO). '68; Mar. '70; Sept. '70; Mar. Apr. 75. St. Joseph's Mercy Hospital (Ann Arbor) -Oct. '72. St. Vincent's Hospital - Jan. '70; Mar. '71; Jul Aug. -. '72. Swine Flu Nov. - - Dec. '76; Jan. Feb -. '77; May June - '77. Sydenham Hospital - Nov. - Dec. '68. * T Taylor, Frederick - Sept. - Oct. '75. Technicon Corp. - Jul. - Aug. '74. Therapeutic Communities - June '70; Jul Aug. -. '75. Think Linco-l nSe p-t . '70; Oct. '70; Jan. '71. Thursday Noon Committee - Feb. 72; Apr. '73. Tulane Medical Center - Sept. - Oct. '75. Tunnel Workers - Oct. '70. Trussel, Dr. Ray Nov. - - Dec. '68; Apr. '70; Jul Aug. -. '72; Jan. Feb -. '74. U UCLA Medical Center - Jul - Aug. '70; Sept. '73. United Harlem Drug Fighters - Oct. '70; Dec. '70. United Mine Workers Welfare and Retirement Funds - Nov. - Dec. '77. 3999 V Valley Medical Center - Apr. 73. Vanderbilt Clinic - May '70. Veterans Administration Hospitals - Apr. '70; May '71. Virchow, Dr. Rudolph - Nov. - Dec. '75. W Walsh - Healy Act Sept -. '72. Washington Business Group on Health - Sept. - Oct. 177. Washington Heights - Inwood Community Mental Health Center- Nov. - Dec. '68; Apr. '69; Dec. '69. Washington, D.C. - Jan. - Feb. '76 (suburbs). Weinberger, Caspar - May '73. Welby, Marcus - May - June '74 (Review). Wender, Dr. Paul Nov. - - Dec. '75. Wesley Hospital (Chicago) -Jul. - Aug. '70. Willowbrook State School - Jan. '73. Women's Health - Mar. " 70; Apr. '72; Dec. '72; Jan. - Feb. '75; Jul.- Aug. '75; May - June '77; Jul - Aug. '77; Sept. - Oct. '77. Workers'Compensation -- Jul - Aug. '76. Y Yolo General Hospital - Apr. 73. Young Lords - Oct. '69; Feb. 70; Sept. '70; Oct. '70; Dec. '70; Jan. '72. Help Your Friends and Help Us!! Know friends who would be interested in the BULLETIN? Send us their names and we will send them a free sample. Just fill out the form below and return it to us. Name: Address: Name: __ Address: Name: Address: Name: Address: Your name: Address: 40