Document M473LQGk5MvEJB5qe831Kj0n7

HEALTH P + AC HEALTH POLICY ADVISORY CENTER Editorial... Ra - -_-- - - ow. Bulletin April 1969 THE TROUBLE WITH EMPIRES SHOTS RINGING OUT IN THE STRUGGLE OVER A SOUTH BRONX COMMUNITY MENTAL HEALTH CENTER ARE BEING HEARD AROUND THE MEDICAL WORLD. COMMUNITY - WORKER FORCES ARE BEGINNING TO GIVE " THE BOOT " TO THE ARBITRARY RULE OF AUTOCRATIC GRANTSMEN AND HIERARCHICAL PROFESSIONALS. It's being called an " Ocean Hill Brownsville -" of health and mental health - only the " insiders " are both community and workers. The " outsiders " are the medical empire promoters - themselves. Those who care about an effective recon- struction of the health services system must understand the national meaning, particular " imperial " context, and im- mense new insurgent social energy contained in such a situation. The striking new challenge being made by community and workers'forces, allied with progressive students and professionals, not only poses new questions, but offers the only real potential for new answers - the basis for a new kind of public service sector of health. The Nixon Administration, like its Democratic predecessor, shows an increasing nervousness about the unfettered free enterprise system of health care and its financing. Despite the 30 years - - late " Health New Deal " of Medicare and Medi- caid, the nation faces a catastrophic breakdown of its health delivery and financing " nonsystem. " In fact, Medicaid and Medicare have accelerated the escalation of medical costs while - barely beginning to fill widening gaps in service. In a nutshell, the financing, organization, and delivery of medical care, as centered in existing institutions for insurance, patient care, and education, are totally out of control. The national establishment has begun a determined search for new " enlightened trustees " to pull some of the scattered pieces together into a more manageably competitive system. Recent national programs such as the Comprehensive Health Planning Act and the Regional Medical Programs are frail beginnings on this course. More dramatically, Governor Rockefeller has called for some kind of national insurance package, presumably Blue Cross controlled - (and Nixon's new HEW chief Robert Finch seems to be listening). In NYC we first had the affiliation program to turn the City hospitals over to private " leadership, " and we now have the plan for a Health and Hospitals Corporation to inject private sector " efficiency " into the public hospitals [See BULLETIN Special Special Issue, Winter Winter 1969]. The rallying rallying cry for such programs is to encourage " regionalized, " rational- ized " and integrated hospital and health services plan- ning and development, " centered " in medical schools and major voluntary hospitals. , These would - be saviors of the health system, the med- ical schools and major voluntaries, are facing serious internal problems: underfinancing (particularly with Viet Nam bleeding research and education budgets), under- staffing, more restricted access to interesting " teach- ing material, " and the resultant institutional competition. Also, while national leaders look to them for long term - policy guidance, local communities are demanding that they do something immediately to get services out to people. Promoters Promoters Promoters Promoters'Special Special Special Special Special MEDICAL EMPIRES are in in the news. They are increas- increas- ingly the target of accelerating community - worker movements for decentralized decentralized public public control of health and and mental health services and institutions. [See fea- ture on the Lincoln Lincoln Community Community Mental Health Center take - over, Page 13.] The November - December issue [BULLETIN No. 6] described, mapped and assessed the rising importance of such publicly unaccountable empires in New York City. In our first medical empire case study, we analyzed the patrician and conservative domain of Columbia P & S: its internal power forces and struggles, its external community community challenges, and and its rejection of a " promotional " approach to empire development. Montefiore's Einstein - Montefiore's more " promotional promotional " medical medical empire, encompassing the entire borough of the Bronx and its 1.5 million inhabitants, is the case study focus of this April 1969 issue. The challenge to the promoters of the major medical centers is then to use the growing demand for " trustee- ship, " rationalization, " etc., to enhance their own institu- tional and personal positions - and to do it before the initiative passes to angry consumers and workers. The promoters of such large institutional complexes, given a tangled internal elitist environment and the shambles of most public health administration, have chosen a high handed - path. As the Einstein Montefiore - Empire case study in this issue shows, they have tended to direct their energies for " reform " in the most arrogant, dogmatic and unaccountable fashion. Even while rhetorically (Continued Page 2) Editorial .. * espousing " progressive " principles of medical system re- organization, they have engaged in wasteful inter institutional - competition, hustling scarce manpower on a fee basis -, and scrapping over " teaching material. " What truly progressive projects they have sponsored have often been promoted on an opportunistic and fragmented basis without sufficiently balanced concern for the people whose lives hang in the balance. The irony is that these corporate liberals of the medical establishment have begun to imitate the competi- tiveness and self interest - of the solo, fee service - for - systems of which they are often so critical. Thus, there is a growing resistance among those whose lives are most directly affected - as workers and as citizensL against the top down - approach to health services in the Bronx. This is happening despite the seductive " logic " of regionalism under major medical centers; despite some posi- tive pioneering achievements of certain Einstein Montefiore - Empire programs; despite the desperate need for any action, from any source, to give disaster relief for the Bronx's health crisis. Clearly, the solution does not lie simply in the re ordering - of a thing called the " Bronx health services system. " On this both the " corporate liberals " and the " radical insurgents " agree there is no such thing. The real question is where to begin to challenge the existing national non system - of medical mismanagement, professional privilege, and narrow " academic medicine, " rather than primary care priorities. Still, the Bronx is a crucial arena for deciding the shape of a new health system, not only in New York but nationally. The Bronx provides a dramatic microcosm of the nation's health crisis: the South Bronx, like ghetto and poor rural areas everywhere, is a health disaster area that will require massive public intervention to meet the crisis. Throughout the Bronx, geographical imbalances in medical resources, disor- ganization and fragmentation of care are perhaps greater than in any other borough. And for the Bronx, as is increas- ingly true for the nation, there is no going back to a free enterprise, solo dominated - practice - model of services distri- bution. The question posed by this borough is how can institutionally based and controlled resources be expanded, WE APOLOGIZE for the brief BULLETIN black - out: HEALTH - PAC was growing. As of 1969, HEALTH - PAC has tripled in size, adding to its full time - staff a physician, an urban planner, an urban health economist and a medical student intern. We are in- dependently incorporated as a profit non - , staff directed research, planning and edu- cation cooperative. Our new offices - a floor through - loft at 17 Murray Street - have increased our ca- pacity for seminars, workshops and library facilities. HEALTH - PAC will continue to work with you, and we hope you call or come by to share your ideas with us. Published by the Health Policy Advisory Center, Inc., 17 Murray Street, New York, N.Y. 10007. (212) 227-2919. Staff: Robb Burlage, Vicki Cooper, Barbara Ehrenreich, Oliver Fein, M.D., Ruth Glick and Maxine Kenny. 1969. integrated and distributed to contribute to the maximum pub- lic welfare? New Directions: First Things First. The present plans, pri- orities and organization of the Einstein Montefiore - Medical Empire, as outlined in this issue, must almost literally be " turned on their head " to achieve the kind of change needed and demanded by the people of the Bronx. The untrusted " central powers " -both the downtown health bureaucracy and private medical baronies - must be cracked. Rigid and short sighted - " affiliation " and " corporation " approaches to City health policy must be blocked. Grant hustling - " experi- mentation " and " demonstration " with people's lives, as a substitute for comprehensive programs for people's needs, must be curbed. Profit motivated - insurance - market selectivity, unaccountable elite philanthropic and academic granting me- chanisms must be eliminated. Rigidly exclusive academic hierarchies the source of the manpower shortage - must be flattened. Alternative Directions: Towards a Public, Community- Worker - Based Health and Mental Health System for the Bronx. M@ Neighborhood Services: The immediate development of neighborhood health and mental health services for all citizens, regardless of ability or inability to pay, must take first priority. There must be public support of emergency " store - front " services. Funds and staff for more " multi- service centers, " patterned after the community - controlled Hunts Point Center, should be mobilized immediately. m@ Community and Worker Control of Health Services: Exist- ing health services institutions in the Bronx are due for a thorough shake - up. Reorganization along the lines of com- prehensive, continuous and personalized service is not a " frill, " but a life saving - necessity. Since such reorganization challenges the profitable academic fiefdoms of the profes- sional elitists, workers and community people will have to lead the way. Within each institution, care must be re- structured on a team basis, with all health workers (pro- fessionals and others) cooperating around the common goals of community service. OE Community and Worker Control of Health Planning: As the City wide - Health and Mental Health Council has pro- posed, funds and planning power under the Comprehensive Health Planning Act should be delegated to neighborhood boards, to which the City Health Services Administration leadership should be held basically accountable. Such coun- cils could be composed of citizens and health workers (phy- sicians, orderlies, students, aides, etc.) related to neighbor- hood institutions. OE Democratic Restructuring of Medical Education: Fragile, scattered " career ladder " programs - which always seem to leave out the upper rungs in the ladder - must be replaced by a massive public program for education in health and mental health service. A truly progressive challenge for Einsten would be to open its doors to the community and declare itself " One Big Health Sciences College. " Patient care and education, now linked so as to exploit the patient, must be re integrated - along lines which optimize patient care- which is the reason for teaching medicine in the first place. @ Democratic Control of Institutional Funding: The present potpourri of Federal, State, City and philanthropic funding (2) Empire Survey (II) MONTEFIORE EINSTEIN - : BRONXMANSHIP THE BRONX MEDICAL EMPIRE of Montefiore Medical Center and Albert Einstein Medical College of (Yeshiva Uni- versity) is well known among liberal medical reformers na- tionally and locally as a kind of benevolent private monopoly of health services for almost 1.5 million people. The Bronx ranges from prosperous and booming in the north to des- perately poor and decaying in the south. Once the front line of Jewish out migration - from teeming Manhattan, the Bronx now serves the same function for other minority groups. Half the Borough's residents are black or Puerto Rican. Dr. Martin Cherkasky, for almost two decades medical di- rector at Montefiore and now also Chairman of Einsein's Department of Preventive Medicine and Community Health, is considered the house liberal of the national medical estab- lishment. He can frequently be found in Washington or being quoted in Time magazine - for group practice, for national health insurance, for planning, for regulating medical quality, and against the freewheeling fee service - for - style of his con- servative profession. It came as something of a shock, therefore, when numer- ous professional, political, and community forces chose re- cently to bite this hand that is supposed to feed them. When Dr. Cherkasky announced last spring that Einstein Montefiore - was developing a plan for the creation of a unified Bronx " authority " for health services, his announcement was greeted with some of the expected foundation and government financial support. Significantly, however, it has met also with cries of " fraud " and " imperialism " -with the Lincoln Mental Health Center take over - being the most recent example. Other incidents include: OE Angry residents of the Hunts Point section of the South Bronx took over David Susskind's national television show featuring Dr. Cherkasky to charge that Montefiore and Einstein were neglecting the needs of their area. This particular Suss- kind show had been arranged through a Montefiore public re- lations man and was filmed last summer. Though aired in most cities during November, the show did not reach New York viewers until March. Mi City Wide - Health and Mental Health Council, the associa- tion of neighborhood - based health and mental health organ- izations, recently gave priority to an organizing program to " fight the monopoly of health and mental health by Albert Einstein. " Especially with reference to Lincoln Hospital, it pledged to " back up the fight of Bronx community leaders and workers for control of health and mental health services. " @ Students and young professionals from Einstein partic- ipated in the Student Health Organization's " rap " that literally - took over the national medical school deans'meeting of the American Association of Medical Colleges in Chicago in early February. This group attacked the " elitism " and " racism " of major medical centers across the nation attempting to dic- tate arbitrarily the health services and medical education programs which " should be controlled by the community. " They singled out Einstein's refusal to change its much- heralded King Kennedy - program of pre medical - training to pro- vide truly broad career access to disadvantaged Bronx youth. And they attacked such gross indignities as group- observed prenatal examinations of poor mothers at Bronx Municipal Hospital clinics. (Continued Page 4) Editorial.. . must be amalgamated into a lump sum budget disbursed by community - worker councils at the borough regional - and neighborhood levels. As a beginning, all City tax funds, in- cluding money for Medicaid, affiliation programs and City- owned facilities, should be channeled by decentralized deci- sion making - processes at the " regional " and the neighborhood levels. Eventually, even Federal grants for biomedical research and training should be more subject to review on the basis of community and national needs. This would be a firmer base for challenging, regulating, and transforming the totally frag- mented and discriminatory present private insurance and prepayment system. * * * Can the Bronx Exist Unto Itself? The " Alternative Direc- tions " outlined all lead inevitably to conflict with city wide -, state - wide and national structures which contol granting to and financing of institutions and licensing of health workers. These entrenched institutions, fargely unaccountable to government at any level, range from the omnipresent Blue Cross, National Institutes of Health and AMA (it's still alive and well in Chicago), to the more parochial local philanthropies, County Medical Societies and the Health and Hospital Planning Council. They will not easily submit to the surveillance of insurgent groups in the borough of the Bronx. But the strug- gle for health system changes- local or national - must begin at the base: in the neighborhoods where the failure of the present " system " is most painfully and urgently felt. The Bronx is not an island even for the present Medical Empire's purposes. Inter borough - flow of funds, patients and health workers links the Bronx tightly to Manhattan, the capital of the nation's medical education and research " industry. " Thus, whatever democratic planning and develop- ment processes are created in the Bronx must be closely inter- woven with those of the city, the state and the nation. By the same token, insurgent challenge of medical monopolists in the Bronx can set the pace for national movement for an ac- countable, flexible, people oriented - health system. Can the people of the Bronx, as in all communities in America, afford not to move in such a direction? Einstein- Montefiore has vast physical investments and has begun to display its version of social commitment. Thus far, the people have been waiting on the " good will " of the Medical Empire for new and better services and for new job opportunities. The central question is: How long should they wait? Who will decide what they get and when? The various challenges, resist- ances, and uprisings in the Bronx and in other communities are some of the most encouraging signs of " let us begin... " in America's agonizing health non system - history. Y' (3) BRONXMANSHIP (From Page 3) B@ A student leader of last summer's Student Health proj- ect (under the auspices of Montefiore with Federal grants) wrote recently in the Einstein student magazine that such projects have been " enmeshed in the inherently conservative alliance of medical school, teaching hospital, and Federal government. " He said it was one of a number of "'cool - it ' programs " in which the participants were intimidated by their dependence on their pay checks from " any real determina- tion of and confrontation with ghetto health issues. " He was especially critical of the absolute veto power of the Monte- fiore medical director over the decisions of both the com- munity representatives and the students in the program. M@ Through a campaign urging City hospital patients to refuse to pay their clinic fees, Jacobi house staff forced sig- nificant reductions in those fees, despite threats of dismissal by both City and Einstein affiliation administrators. m@ Through caucuses in the Committee of Interns and Resi- dents, Einstein Montefiore - recruited staffs have been increas- ingly critical of professional leadership and teaching, the organization of services, and the absence of patient oriented - care of the affiliating institutions. They charge, for example, increasing sub specialization - of clinics (to assist teaching and research at the expense of comprehensive patient care), lack of provision for follow through - with patients (diagnostic tests not reported to patients unless the patients happen to return to the clinic), and failure to plan for alternate emergency service during renovations (when a surgery section was tempo- rarily closed at Lincoln, no ambulance service to take people elsewhere was even called for by affiliation staff). @ When the Einstein Montefiore - " plan " was announced, Bronx Borough President Herman Badillo said, " A teaching in- stitution is not primarily interested on ongoing medical care, but in teaching, which benefits more from unusual cases than from ordinary cases. " He said " as [a member of the Board of Estimate] I'm putting Einstein on notice that I'm not approving any demonstration projects until we meet minimal health needs. " Citing a $ 3.8 million grant for psychiatric services through Einstein, Badillo said, " I can't get dental services into the capital budget... the percentage of peo- ple who need psychiatric services is much smaller than the percentage of people who need dental care. " He also at- tacked highly selective admissions practices (for teaching and research) at Einstein's Bronx Municipal Hospital, where the patient load is the lowest in the city. An Einstein official replied: " I don't think there's a medical school in town that's more concerned with providing com- munity services than we are. " In answer to all such assertions of self satisfaction, Badillo declared prophetically, months before the Lincoln Mental Health action - "...... the next area where community control is going to become an important fac- tor is going to be in health services, and the reason for that is that people in slum areas have been asking for better health care over the years. There has been an inadequate re- sponse, and the people are coming to feel that if they have control of the health centers and of the hospitals, that they will be able to provide themselves better health care. " What is the Einstein Montefiore - plan for Bronx health services all about? What has this institutional complex con- tributed to community services? Why is such a " profit non -, academic - based " complex so " imperialistic " and expansion- ary, so like a profit seeking - corporation? Why are so many people in the Bronx so distrustful of its " trusteeship " of health services? What are the criticisms of the Einstein - Mon- tefiore plan and how valid are they? Are there alternatives? Montefiore's story goes back to the Civil War era, when medical care was largely confined to the tiny middle class, and hospital " care " was nonexistent. Montefiore's present site was originally an army camp for Confederate prisoners. One of the POW's Bernard - Baruch's father - set up a prison hospital during his stay. (Lincoln Hospital in the South Bronx, now affiliated with Einstein, was set up before the Civil War as a home for aging escaped slaves.) After the war, the ex army - camp infirmary was transformed into " Monte- fiore, " a chronic care home, by Sir Moses Montefiore, an English banker and philanthropist. It was rejuvenated and expanded into a general hospital in the 1930's by an ener- getic director, Dr. E. M. Bluestone. During the 1950's Dr. Martin Cherkasky, as director, launched Montefiore on its present Empire expanding - course. Partners in Progress Einstein Medical College, Montefiore's " partner in progress, " grew out of Yeshiva University's post World - War II plan to promote a new Bronx general City hospital, and then to graft on a medical school with full rights to the hospital's " teaching material. " As Commissioner of Hospitals in the mid fifties -, Dr. Marcus Kogel engineered the actual develop- ment of the 1400 - bed Bronx Municipal Hospital Center. Open- ing cost of the City " grant " to the future medical school was $ 40 million for construction of Jacobi and Van Etten Hospitals, $ 8 million for a nursing school building, and 63 acres of City park land. Kogel went on from his stint with the City to be- come the first dean of the newly opened Einstein. Since its opening in 1955 and its affiliation with Monte- fiore in 1961, the College has grown tremendously in influ- ence and resource control. These two major private medical centers are increasingly closely associated. Although there are some tough in fights - between the " private hospital management " orientation of Montefiore vs. the more " academic " orientation of Einstein, together they preside over the nation's most nearly con- solidated " medical region. " Unfortunately, " consolidation " refers far more to control over resources and institutions than to coordination and equal distribution of services. Since the mid 1950's -, Montefiore has increased its phy- sical development around the original buildings about four- fold, and it now even has Health and Hospital Planning Council approval to move the 400 - bed Morrisania City Hos- pital from a low income - southwest neighborhood to the Mon- tefiore grounds in the middle - class upper northwest. As a re- sult, institutional and professional resources are heavily concentrated in the upper part of the Bronx, while the low- income population is concentrated in the South Bronx. [See " Empires " map in BULLETIN No. 6, Nov. - Dec. 1968.] Considered " eminent domain " for Einstein Montefiore - are the two other significant voluntary hospitals in the Borough, 570 - bed Bronx Lebanon - in the west Bronx (also part of the Federation of Jewish Philanthropies) and 330 - bed Miseri- cordia in the northeast (a Catholic institution currently the private affiliating hospital for 400 bed - Fordham City Hospital in the west central - Bronx). Dr. Cherkasky has physicians (4) whom he considers his " own people " (time part - faculty in Einstein's Department of Community Health), in key pro- gram development spots at these two voluntary hospitals. Various approaches are being made by Empire promoters toward a Montefiore merger with Bronx Lebanon - (proposed for years by various Federation officials as a " Bronx Jewish Medical Center ") and toward a Misericordia - Fordham affilia- tion with Einstein Montefiore - . The only apparent hitches to these further absorptions at present, other than the independent - mindedness of these voluntary hospitals, surround the new plans of New York Medical College to move from Manhattan's upper east side to Westchester County and the City's plan to move, to rebuild, and perhaps to reaffiliate Fordham City Hospital [See BUL- LETIN No. 6, news story reprint]. New York Medical College is apparently especially interested in arrangements with Misericordia, a new, growing facility situated near the West- chester County border, and probably, therefore, in arrange- Affiliation Record The Affiliation Program is probably the City's most ex- pensive and least effective- " health program. " More than one quarter - of the City hospital budget, or well over $ 100 million per year, flows out through Affiliation con- tracts to private hospitals and medical schools for phy- sician recruiting and professional direction - and the amount keeps growing every year. (The Affiiliation budget has doubled since 1965, while total hospital expenditures grew much more slowly.) Under this program, Einstein currently gets $ 16 million a year for staffing Jacobi and $ 7.5 million for Lincoln. Montefiore gets $ 7 million for Morrisania (including nursing recruitment.) How do the voluntary hospitals and medical schools use this money? In 1961, when the program was initiated, the City claimed that the Municipal hospitals would be brought up to a par with the best voluntaries. Almost a decade later, the Affiliation story has turned out to be, at best, uninspiring, and, at worst, sordid. In 1967 and 1968, the City Con- troller's Office and the State Investigating Commission dis- closed that voluntary affiliates were absorbing some of the Affiliation money through clearly illegal practices: fraud, payroll padding - , theft of City equipment and absenteeism vl by professional staff. The most critical fault of most volun- tary affiliates, though, is not malfeasance, but nonfeasance. As documented in detail in the 1967 BURLAGE REPORT, the Affiliation program has had much less impact on total patient care than advertised. In fact, in some ways the Affiliation Program has made things worse. Major medical centers have imposed their own narrow academic or pro- motional priorities on their Municipal hospital affiliates. Subspecialty services have proliferated, to the detriment of basic, routine, comprehensive ambulatory care. As far as taxpayers and patients are concerned, Affiliation " con- tracts " between the City and private hospitals have turned out to be little more than blank checks drawn on our accounts. ments with affiliated Fordham as part of the package. Hos- pitals Commissioner Terenzio, however, has mentioned the possibility of moving Fordham City Hospital near St. Barnabas Hospital, a weaker, 400 - bed voluntary institution in the southwest Bronx, and possibly affiliating it there. In the scramble and confusion, of course, it is just as likely that Fordham could end up directly in the hands of Einstein- Montefiore - possibly as a twin to transplanted Morrisania City Hospital or as another part of the growing Montefiore campus in the northwest Bronx. What Makes It Run? Columbia Presbyterian Medical Center is withdrawn and patrician about its meager inroads into Harlem and Wash- ington Heights [See BULLETIN No. 6]. Einstein Montefiore - aggressively promotes a borough - wide framework with itself at the helm. Columbia P & S shrinks from further public in- volvement through affiliations. Einstein Montefiore - aspires to control the Bronx, hospitals, health centers and all. Columbia, especially since its cigarette filter adventure and student explosion of the last two years, shyly avoids the press. Montefiore Einstein - employs a full time - PR staff plugged into TV, national magazines and major newspapers. In short, Einstein Montefiore - does not behave like a tradi- tional medical school hospital / complex. What gives a non- profit, academically - based organizational complex the " profit- motif " of an Einstein Montefiore - ? To most observers, the dynamics of Einstein Montefiore - expansionism are beyond. economic law or organizational logic, and Einstein Montefiore - is written off as a case of " medical liberalism " run wild. Liberalism is part of the answer. The Einstein Montefiore - trusteeship network, centered in the Federation of Jewish Philanthropies, does not exactly correspond with the pre- dominantly WASP banker internationalist / financier / world of the more " downtown " medical school trusteeships. Liberalism, however, is only the permissive atmosphere in which an Einstein Montefiore - thrives - the motivating force surges out of the inner logic of the new government and philanthropic granting and funding system. Einstein- Montefiore has been riding the cycle of grants and demon- stration projects. It spawns a medical demonstration which advertises for and justifies the next grant, hence the next project, and so on. As dependence on public funding has grown, so has Einstein Montefiore's - need for ever greater public trust and appreciation - always wooed with new, more dazzling demonstrations. The price of this reliance on public support is the continual fear of being upstaged by a yet- unconquered institution, or dethroned by an angry community. Montefiore Einstein - must always be one step ahead of the competition and the public - it must plan, erecting vast frameworks of control and defense. Plans, in turn, are marketable to the federal foundation / funding axis, which is increasingly nervous about the chaos of our national medical non system -. Einstein and Montefiore, both separately and in associa- tion, were among the first institutions in the country to make well packaged " medical progress " their product. They have sold " pioneering, " " breakthroughs, " " demonstrations " and " social commitment " and gained the reputation for being where the scientific and social action is in medicine. " Demon- strations " have been underwritten as kinds of philanthropic good will and advertising costs - from the " Family Health Maintenance Demonstration " in the'50's to the " Neighbor- (Continued Page 6) (5) Medical Control... Beds The Empire controls about two thirds - of the general care and almost all of the long term - care hospital beds in the Bronx; it controls about 2000 of the 2400 existing City hospital beds in the Bronx and will hold about 2850 of 3300 beds currently projected for the Bronx. Its total present holdings include: Montefiore Medical Center 800 beds Einstein College Hospital 340 Bronx Municipal Hospital Center (Jacobi and Van Etten Hospital, affiliated Einstein) 1400 Lincoln Municipal Hospital (affiliated Einstein) 350 (planned for 900) Morrisania City Hospital (affiliated Einstein) 400 Bronx State Mental Hospital (affiliated Einstein) 1400 Federal Veterans Administration (affiliated Einstein) 1200 Beth Abraham Hospital and Home (affiliated Montefiore) 510 Physicians Approximately 2000 of the 2700 physicians in the Bronx work at, or are affiliated with, Einstein Montefi-o rlien ke-d facilities. Of these, about 1500 work full time - in the hos- pitals and in affiliated neighborhood health and mental health centers, medical groups and City Health Department centers. 750 interns and residents 200 psychiatric or neurological specialties 250 time full - administrative, research, faculty 250 full time - hospital chiefs of staff 550 part time - or affiliated and about 13,000 other paramedical em- ployees under their general direction BRONXMANSHIP (From Page 5) hood Medical Care Demonstration " today. This latter project, a " continuous, comprehensive, family oriented -" health center in the southwest Bronx, is staffed and controlled by Monte- fiore Hospital and serves perhaps as many as 10,000 persons now, with 30,000 more projected (perhaps over optimistically -) . Neighborhood Medical Care Demonstration has been much lauded in many major magazines and has the highest re- porter patient - ratio in America. Who's Hustling? The academic counterpart of the field demonstrations is Dr. Cherkasky's mushrooming Department of Preventive Medicine and Community Health at Einstein. (The retainer list of " faculty " for this department reads like a Who's Hustling in New York City health politics - from the Borough President's health affairs aide to Dr. Cherkasky's scouts at Misericordia and Bronx Lebanon - Hospitals.) The human side to the demonstration - project proliferation is the gathering in to the imperial fold of bright, dedicated personnel. Dr. Cherkasky is particularly well known - as a recruiter of potential innovators to " do their thing, " as long as " their thing " is a grant lucrative - demonstration project and they are willing to do it through his channels and under his command. This view of progress as an individual project- hustle pervades the Montefiore Einstein - " sheltered workshop " for social progress, leading even the most socially dedicated - people to function in a constricted, elitist style. They learn to accept crushing compromises in their original conceptions because they appear to feel there's nowhere else they could get paid as well to do their thing as well. Despite vetoes and frustrations, the bright young men keep coming, and, as they accumulate, it becomes easier to attract new ones; hence, new project - grants; hence more bright men, etc. Central to this progress packaging - and personnel proces- sing is, of course, an increasing need to mobilize public tax dollars and public opinion for the support of Einstein- Montefiore's needs and agenda. We have already noted the degree to which, as " private " institutions, Einstein and Montefiore have built their institutional empires on public tax dollars, land and institutions. Nowhere else in the City is the private regional consolidation of municipal hospitals as pronounced. Fordham is the only City hospital outside the Einstein Montefiore - grasp, and many say the months are numbered until either it or its private affiliate, Misericordia, falls into the network. Floating Crap Game With such heavy reliance on public resources, Einstein- Montefiore has had to take an increasingly active role in molding opinion and policy determination. William Glazier, Einstein's associate dean, served previously as staff director for the Piel Commission, whose Corporation idea for City health services was later promoted by Dr. Cherkasky - or vice versa -? Dr. Cherkasky also serves on the City tax- supported Health Research Council (which recently awarded Einstein Montefiore - a major grant for borough - wide planning), on the Blue Cross Board of Directors and on Health and Hospital Planning Council committees. Concerned with popu- lar opinion as well as public policy, Cherkasky maintains a hefty public relations staff to handle and arrange interviews for TV, Congressional Hearings, and national magazines. A consequence of Einstein Montefiore's - heavy public fund- ing, especially of the special - project variety, is considerable freedom for the administrators from the prestigious and busy lay trustees. The trustees have little to say about the extra- mural activities funded directly from Washington or out of individual private family or foundation pockets. Many of the research and program grants come through Montefiore's Administrator's or Einstein's Dean's office as lump sums and are mixed in mystic financial ways, impenetrable by post facto audit, let alone by priority - setting. Other grants come through " in the name of " individual faculty or staff and are outside the purview of trustees. As one trustee re- portedly described his role, " We are sitting on top of a floating crap game and all we can do is say yea or nay to the administrator or dean being check signers -. " Thus, the relationships which individual administrators and staff develop in the system of financial support - from HEW advisory committees and NIH project committees, to foundation, philanthropic, Blue Cross, regional Health and Hospital Planning Council and State Local - government com- mand posts frequently - become the de facto base of (6) personal power within the institution. Internally, the Einstein- Montefiore institutions are structured along the now classic lines of post - war biomedical research grant baronies built in particular departments. In addition, at the top levels, general administrators are able to do their own empire building - on a massive scale outside even the control of the lay trustees. At all levels, institutional leaders are essentially accountable to no one but their own professional honor - even for that extra electron microscope stored in a crate in the basement, or for those sub specialty - clinics they've organized to match their research needs rather than the needs and convenience of the community. Unaccountable and unfettered by lay or public supervision, the Montefiore Einstein - departmental and institu- tional leaders have become the avant garde of the new class of bio medical - and socio medical - enterpreneurs. Absorb And Pre empt - Having accumulated such vast resources and power, the empire builders have found it in their interest to begin " rationalizing " and " consolidating " the empire. One reason for rationalization is to lower the Empire's overhead costs and maximize its funding base (although some private trustees are complaining that, for example, Montefiore is " escaping " its alarming costs at home base by new enterprises elsewhere). An overriding objective is to carry out preemptive organiza- tional reform (at least in rhetorical terms): (1) to prevent the development of any serious movement for a broadly account- able, truly public health system for the Bronx, and (2) to prevent the emergence of insurgent community and health- worker forces demanding control over the health services on which they so urgently depend. The consolidation rationalization - effort is itself a kind of demonstration project, with a special grant (from New York City's Health Research Council, the Rockefeller Foundation, etc.), and burgeoning special staffs. The market for the " Bronx plan " and similar efforts is the national corporate managers and local power structure leaders. In their growing concern about ghetto rebellions, urban fiscal crises and un- controllable costs of medical care, they are turning to the more activist and prestigious wing of medicine (exemplified by Einstein Montefiore - ) to cure our sick medical system. Another source of encouragement for these kinds of " rational- izing " efforts is the growth of the health hardware and " systems " industries. Aircraft companies such as North Amer- ican, conglomerates such as Litton Industries, and consulting firms, such as Einstein - Lincoln Hospital's contractual manage- ment consultant, U. S. R. & D. Corporation, Bill Haddad's operations firm, are realizing that the existing chaotic health non system - must be in more integrated enterpreneurial hands to be a good market for heavy computer hardware or for sophisticated private consultation services. Thus, for a variety of reasons, national corporate leaders are encouraging Ein- stein Montefiore's - " rationalization " of the Bronx. Less Than Meets The Eye A natural law of many well promoted - medical demonstra- tion projects is that the farther one gets from the project's patients, the better the project looks. Montefiore Einstein - is perhaps as much or more involved in service than any other major medical center in the nation - but it is no exception to this law. For all its declarations about social commitment, the Empire has barely scratched the surface of meeting the desperate needs in its " region, " especially in the South Bronx. As this and other medical empires are under more and Taxpayer Support.. City Government Almost $ 250 Million in City funds to institutions under direct control of Einstein Montefiore - appropriated in last decade for hospital facilities and services alone (not in- cluding direct City personnel and operating support of Municipal hospitals), including: OE 63 acres City land and $ 40 Million construc- tion costs (plus $ 8 million for nursing school) for Bronx Municipal Hospital Center as base for new Einstein Medical College. OE Currently, Montefiore and Einstein are re- ceiving about $ 30 Million annually for City Hospital affiliation contracts and $ 3 Million at Montefiore from the City Charitable Institu- tions Budget. @ During the fiscal years of 1965-66 and 1966- 67, the City's Health Research Council has given Einstein, Montefiore and affiliates $ 1,450,000. $ 450,000 of ths was in direct research grants while $ 1,000,000 was for Career Scientist Awards. Federal Einstein Medical College received 15.7 $ Million from the U.S. Public Health Service in 1967 (including $ 20.6 Million for research). Montefiore Medical Center received $ 3.4 Million fro mthe U.S. Public Health Service in 1967 (including $ 3 Million for research). Millions were also re- ceived for neighborhood health and mental health center, maternal - infant - pediatric care demonstration programs, and new career training programs.) more public attack for their failure to deliver even with what they've got, the promoters become all the more " radical " at laying the blame elsewhere. They cite the City's bureaucratic red tape -; severe national underfinancing (and mis regulation - ) of research, care and education; and, of course, the general social chaos of the nation. These exogenous difficulties are, of course, part of the story. But the empire promoters - are seldom able to face their own responsibility honestly, and to say, as Pogo was once quoted as saying, " We have seen the enemy and it is us... " Einstein Montefiore's - claims for its borough - wide network of City hospital affiliation programs are staggering. And well they might be. Affiliations are the glue that holds its many facilities together as an Empire. Dr. Cherkasky was a prime mover behind Commissioner Trussell's Affiliation Plan to at- tach all City hospitals to private centers through affiliation contracts which are little more than loose, cost plus - gentle- men's agreements. [See HEALTH - PAC's BURLAGE REPORT for a detailed critique of the Affiliation Plan.] Claims have been lofty. Dr. Marcus Kogel, now vice presi- dent of Yeshiva University for Medical Affairs, has been quoted as praising the Einstein - Lincoln City Hospital affilia- tion (from Pediatrics alone in 1958 to full affiliation of pro- fessional services by 1966), with reference particularly to " demonstration " programs in the community: ".. not only in furthering program develop- ment on a community level, but in repairing the image of Lincoln Hospital in the com- munity an image that had been deteriorating during the 10 to 15 years prior to affiliation. " (Continued Page 8) (7) BRONXMANSHIP (From Page 7) In 1967, Dr. Cherkasky said of Montefiore's affiliation to Morrisania, a City hospital: " The affiliation has, over the past five years led to a vast improvement in the level of care. The provision of professional services and the sophistication of certain services parallels an enormous increase in the utilization of Mor- risania... The improvements that have been realized at Morrisania are a result of contin- ual pressure exerted upon the Department of Hospitals. " [Both quotes above from the United Hospital Fund's report, " A_Partner- A_Partner- ship in Progress: The Affiliation Programs of the Municipal and Voluntary Hospitals Serving New York City. " November 1967.] In fact, at both Lincoln and Morrisania there have been some improvements in physician staff numbers and educa- tion levels. (Although numerous physicians have been dis- affiliated; actual consulting, attending, and supervisory phy- sician - time has been padded; and services organization has often been even more fragmented.) More certified training programs and more specialty services for patients are " avail- able. " (But the patient remains helpless before the hospitals ' fragmented organization.) On its part, the City has accelerated some renovations, equipment purchases and other procedures for these and other hospitals. (It is questionable whether this is necessarily due to the affiliation program.) But the affiliation program was touted to achieve much more than these limited benefits. In their early advertising for (and recent defenses of) the affiliation program, private medical leaders promised to provide effective leadership to totally re shape - Municipal hospital services. Recent quanti- tative indicators, on site - interviews and observations, how- ever, show that Einstein Montefiore - has seriously defaulted on these crucial leadership functions of total services reor- ganization and outreach in programs. For instance, Dr. Cherkasky has stated that Montefiore is responsible (under the affiliation contract) for " the same ideal of clinical execllence that prevails in Montefiore. " But, notwithstanding Montefiore's own limitations in delivering comprehensive pa- tient care to the neediest population, a study by Yale Public Health School hospital administration analysts three years ago stated that house staff rotating between Montefiore and Morrisania hospitals considered Morrisania a secondary responsibility. Both observation and recorded evidence re- vealed that the staff also treated Morrisania patients with less skill and consern. Where do house staff learn such explicit discriminatory thinking, if not from their academic and professional superiors? Who Heads Services? Some of the more concerned house staff members in both institutions have protested the lack of leadership for com- prehensive medical care shown by the private hospital and college medical chiefs and supervisors. There is little or no encouragement by the teaching " faculty " supervisors to integrate services to meet the pa- tients'needs. The faculty could, for instance, demand that primary care can be given in specialty clinics, so that for the large number of patients in such hospitals under special treatment and with practically no other sources of medical attention, routine problems (colds) and preventive tests pap ( tests) or preventive medicine (immunizations) would be co- ordinated and assured. The faculty could emphasize con- tinuity of care which would insure both primary care and adequate followup (as it is now, lab tests may show abnormal results, but there is no attempt to locate the patient and treat him). Continuity of care could be improved by introduc- ing a system wherein fellows, residents and interns see the same patient in the outpatient clinic. Communication with the patients could be improved if all students training at Lin- coln, Morrisania or Jacobi hospitals were required to know Spanish. (In the Lincoln pediatric outpatient clinic, for ex- ample, there is only one interpreter, and she was hired in December 1968). Despite all the self congratulations - about academic and teaching hospital - staff recruitment, even this record is not as shiny as the promoters insist. Much larger contingents of " American - trained " interns have been attracted to Morrisania and Lincoln. It (is questionable whether " American - trained " automatically assures good medical care - not to mention the implicit racist slur against " foreign - trained. ") Out of the 24 pediatric house staffers at Lincoln only two are American- trained persons - one intern and one resident. Furthermore, of 70 existing resident positions at Lincoln (1966-67 figure), only 49 have been filled and 37 of these by foreign trained - people. Despite the fact that prestigious Montefiore held the only City hospital affiliation contract for professional nursing -with lucrative overhead and recruiting charges - a 1967 study showed that only 28 out of 140 authorized professional nurse staff positions were filled by Registered Nurses. (Al- though some improvements have been made since that time, this only about matched the dismal recruiting record of the City - 34 of 176 such staff positions - at Lincoln). Proud To Be Popular The Empire promoters like to point to the increased clinic utilization at Lincoln and Morrisania as evidence of how " popular " these hospitals have become since the affiliation programs began. True, emergency room and outpatient de- partment visits at these hospitals practically doubled between 1960 and 1967. However, many close observers (including house staff, attending physicians and paramedical personnel) attribute these visit increases not to increased hospital " popularity, " but to the deterioration of alternative sources of care and to the growing fragmentation of hospital clinic care. As sub specialty - clinics multiply, in accordance with academic interests, patient visits multiply in the increasingly desperate search for comprehensive care. Visits are also wasted on unnecessary diagnostic procedures - sometimes performed for research purposes - and because of sheer confusion- missing charts, language problems, etc. Of course, it is im- possible to determine just how many visits and procedures really are unnecessary because the keeping of medical records has been so chaotic and episodic. Thus, what the promoters call a " broad spectrum of new services " and " excellent opportunities for establishing new integrated programs in specialties " (Dr. Trussell in UHF report cited above) turn out to be an unscannable spectrum for the patient. The affiliation programs have achieved some new adminis- trative contact among the various hospitals (and have also created dual City Empire - administrative snarls). But there has been far too little real service coordination. There is no continuity of medical records between the (8) Empire's hospitals and sometimes not even much coopera- tion. For instance, if a patient is referred from Lincoln to Jacobi for specialized treatment, Lincoln does not send his medical record with him, nor does Jacobi bother to send Lincoln a record of what happened during specialty treatment. Women who have received prenatal care at Lincoln are often sent out of the Empire, to Manhattan's New York Hospital, to deliver again without records. But the harshest indictment of the Empire's performance in its affiliation programs can be heard from the people who have to use its Municipal hospitals. People know that Mor- risania and Lincoln are used by Montefiore and College Hos- pital as " dumping grounds " for medically uninteresting and poor patients. The people whose lives depend on Lincoln still call it the " slaughterhouse " (the same old image) and often refuse to go there until they have no other choice. For ex- ample, because of their experience with Lincoln, the Hunts Point People's Health Center leaders want Jacobi as their back - up hospital, even though Jacobi is much farther away than Lincoln. The South Bronx is a disaster area for personal and en- vironmental health. Its proportion of " dependent age " health services users (over 65 or under 16) is the largest in the city. Its general dependence on Municipal hospitals, " general service " baby deliveries, and public ambulance service is the greatest in the city. Its rates of too late - and no prenatal care are among the worst for Municipal hospitals. The area's venereal disease, chronic disease, and infant and maternal mortality rates are among the highest in the city; early findings of recent studies reveal the city's highest rates of lead poisoning in children; dilapidated housing, garbage- heaped streets, and polluted air are as serious as anywhere in the city. Certain areas of the South Bronx have less com- munity physician - coverage than the physician - to - black - citizen ratio in Mississippi. One third - of the borough's residents must go to Manhattan for hospitalization, even in emergen- cies, primarily because of the shortage of medical resources in the South Bronx. Clearly, without massive amounts of direct public disaster - area relief, the people of this area face a catastrophic social breakdown. The Empire claims that if anyone can solve the health problems of the Bronx, it can. The managers of the Einstein- Montefiore Empire have been working in the Bronx for many years. How has the Empire " solved " these problems? Can the Empire perform competently even those tasks it sets for itself? Let us look at the record. Battle of the Beds . In the late'50's and early'60's, certain Montefiore Einstein - leaders supported a plan to close all three Municipal hos- pitals serving the South and Southwest Bronx. This plan, re- vealed in early reports of the Hospital Review and Planning Council (now the Health and Hospital Planning Council), would have shifted Morrisania's beds north to Montefiore's grounds, would have closed Lincoln and Fordham, and would have left South Bronx residents almost completely de- pendent on Bronx Municipal Hospital. This plan (had it been implemented), coupled with the subsequent closing of St. Francis Hospital, could only have been described as a policy of genocide via medical slum clearance. [See, e.g., Peter Rothstein's 1968 study, " The Closing of St. Francis Hospital. "] Community leaders came to the rescue of Lincoln and Fordham. Herman Badillo, then candidate for Borough Presi- dent, made Lincoln one of the key issues in his campaign. Fordham required Mayor Wagner's intervention against an adamant Hospitals Commissioner Trussell during the 1961 mayoral election. Morrisania was later parcelled out by City, HHPC, and Montefiore officials between Montefiore's grounds and the possibility of a new building on the old site, but later. Montefiore officials were also closely involved in the HHPC's decision to limit the new Einstein College Hospital to 329 beds for highly specialized treatment, thus denying vital treatment services to severely needy patients. Another result of this limit has been the creation of a backlog of critical cases in other less specialized hospital services in the bor- ough. HHPC, with Montefiore's nudging, has also discouraged the building of more nursing home beds in the borough, especially under proprietary or non Empire - auspices. Mean- while, the effective demand for such beds and services is sky rocketing - , especially since the enactment of Medicare. After literally standing back and watching the financial de- terioration of College Hospital (chiefly because of low reim- bursements from Blue Cross - of which Dr. Cherkasky is a Board member and the City), Montefiore management " offered " to take over the Hospital to raise its reimbursement rates to the current Montefiore level. At the orientation session for the new Montefiore regime at College Hospital early this year, Dr. Cherkasky hinted that it was only a matter of time until Jacobi and all of Bronx Municipal Hospital Center also enjoyed Montefiore's managerial embrace. Some people see Lincoln coming into the embrace too. However, numerous chiefs of services at College Hospital believe that this kind of big business - " conglomeration " lowers morale rather than improving internal institutional functioning. Montefiore runs the only operating " Neighborhood Medical Care Demonstration " in the borough on OEO funds, while (Continued Page 10) Charity Politics The richest families (Our " Crowd ") set the pattern of philanthropy by giving large contributions to the Federa- tion of Jewish Philanthropies (FJP). But the bulk of the money FJP receives comes in as small contributions from multitudes of donors. Neverthless, the leading families- the Lehmans, the Loebs, the Guggenheimers, the Warburgs, the Gimbels and the Bloomingdales- essentially control policy and funding priorities for the Federation. In addi- tion, they and their representatives direct the policy of the individual agencies by sitting on their boards, as well as on the central board. For example, Robert Bernard, re- lated to the Lehmans by marriage, is an Associate Treasurer of the Federation and is on the board of the Federation, while also serving as a trustee of Monte- fiore Hospital. The Federation arose from the merger of many Jewish community self help - programs. Health care became one of its major concerns, with investments centered in what were then primarily middle - class Jewish neighborhoods. Although many of these neighborhoods have now changed into black and Spanish ghettos, the Federation has main- tained " its own " health facilities, under its own tight leadership, and operating on its own agenda. In dealing with its constituent agencies, FJP is no less imperious. Mechanisms of disbursing the (dwindling) FJP philanthropic dollars tend to make the agencies vie with each other to produce the most visible medical " show " for the benefit of their liberal funders. (9) BRONXMANSHIP (From Page 9) Einstein opened the first operating decentralized community mental health units in the City, including the recently em- battled Lincoln Mental Health Center. But these are currently " covering " only about 10,000 persons each in areas where perhaps 700,000 need such convenient service coverage. In the face of cuts and fragmentation of State Medicaid funds, private institutions'lack of interest in serving a back - up function, uncertainty about national OEO and HEW funding, and HSA under staffing - and foot dragging - , one HSA official estimates that more new services for the South Bronx are at least a decade away. Some new Federally - funded hospital- based maternity, infant, and pediatric programs have been established at Lincoln and Jacobi, but so little convenient primary ambulatory care is available in the South Bronx that most residents flush with anger when they hear the usual exaggerated reports of its delivery. Some close observers in the South Bronx suspect that in all such new programs under Empire auspices, compounded overhead costs and sheer juggling of funds are producing tremendous waste of re- sources. They cite as an example, a 500,000 $ grant (for a community mental health program component) which resulted in only one new professional on the payroll. Despite general sympathy for the medical empire approach, one member of the Community Mental Health Board has been quoted as saying, " If we want to have any idea of the actual use of public funds, we shouldn't give all the grants to [Einstein- Montefiore]. " Counter Insurgency - The quasi monopolist's - position is never entirely secure. There is always the need to consolidate the organization more closely; to move into new areas of control; to preempt or play off against each other potentially independent forces. Hunts Point (Southeast Bronx) residents'struggle to de- velop their own decentralized community - controlled " People's Health Center " through their Community Corporation was given a year - long runaround by the Empire, through which it sought back - up facilities cooperation. (Hunts Point has other problems too: Lacking the fund raising - acumen and resources of the giants, it has recently received a Federal grant of half the amount it requested.) At Co - op City (now being occupied although lacking vital medical and social services), planners are discovering that medical costs are so inflationary and hospital and physician revenues so scarce that even middle - class people simply can- not afford a comprehensive, prepaid, group practice medical program without large Federal grants or reinstatement of Medicaid. The attempt of the Co - op City developers and citizens'board to plan an independently - controlled program with its own contract with Einstein - Jacobi was reputedly headed off by Montefiore officials who saw this new market as essential to beefing up their own sagging Montefiore Medical Group. MMG is the most expensive such medical group prac- tice in the City. It is so expensive that its backbone sub- scriber, the Teamsters Union, is pulling out. Evidently to preempt the development of an independent medical program in Co - op City, Dr. Cherkasky is putting MMG related - physicians in fee producing - offices in the new housing area. Officials and program promoters of both Einstein and Montefiore have responded to the Lincoln Mental Health strike and takeover with intensive manipulation. As one prominent New York City health affairs reporter put it, based on his observations during the Lincoln challenge, " They aren't used to being straight with the public they're - just for press re- leases and making their own deals on the phone. " Community residents were particularly angered by the at- tempt to play off ethnic and organizational groups against one another. The Lincoln Hospital Community Advisory Board was called together by the Einstein - Lincoln administrators for its first real meeting in three years. This was an attempt to create an instant buffer between the Einstein - Lincoln ad- ministration and the community workers at the mental health center. The Lincoln " board " was chosen by the Adminis- tration from among " visible " leaders of a community that is predominantly Puerto Rican; much of the leadership of the workers movement at the mental health center is black. Residents of the Hunts Point and Lincoln Hospital areas de- pend on the Einstein Montefiore - Empire for vital health services; both groups, therefore, were extremely vulnerable to threats and promises " from above " regarding those services. In recent years, the Empire has been the home of the health and mental health " new careers " rhetoric and " move- ment. " The Federal legislation supporting such programs was pushed through by Bronx Congressman James Scheuer. Frank Riessman, head of the national New Careers organiza- tion and author of the " bible " of new careers, did his original thing with community mental health aides around the Lincoln Mental Health Center. Dr. Tom Levin is doing a major foundation - funded report on a new health careers pro- gram and curriculum based at Lincoln Hospital. The King Kennedy - program for boosting the disadvantaged into medical school has been launched by Einstein. However, only one disadvantaged Bronx resident was admitted in the small crop of such medical school entries this past year, al- though the number is due to increase next year. And the Einstein administration and faculty have turned down student- community demands for expanded and guaranteed medical school admission for program participants. Medical Miseducation Einstein student groups have expressed through direct action their dissatisfaction with the obvious irrelevance and the elite bias of their curriculum, even the " community and social medicine " curriculum. The students want to hear more from the surrounding community itself. Both community residents and students are demanding a totally new system of medical educational opportunity and content. The contradictions of empire promotionalism also come in more direct forms. While Dr. Cherkasky praises the volun- tary, regionally - planned, non - fee, scientific approach to med- ical care before one Senate subcommittee, the chairman of the Einstein Pharmacology Department responds to a request from the Pharmaceutical Manufacturers Association and writes to another Senate committee as an apologist for brand- name drugs. This department head also serves as a con- sultant to three drug companies. Physicians associated with the Montefiore Medical Group collect fees in Co op - City, and physicians split fees with each other and the Montefiore ad- ministration to produce just about the costliest medical service in the city. Meanwhile, Montefiore recently purchased the old Riverdale Motel. Holiday Inns, Inc. is moving rapidly into the nursing (10) home business as the Medicare market grows. Should one expect a merger over the next decade or so? This situation's existence is the result of Empire priorities: academically - interesting over primary medical care, man- agerial solutions over service solutions, elite grantsmanship and " expertise " over control by those most dependent on and therefore most intensely concerned about the quality and accessibility of medical care. With all its liberalism and non profit - promotional rhetoric, the Montefiore Einstein - Empire in many ways fronts for the same old kind of medicine show. " The Plan " " The Bronx is Einstein's community, " states one of the Medical College's successful foundation proposals, which goes on to lay out a sweeping plan for reorganizing and de- veloping the borough's health services. The overall idea has been to back up the creating of a regional health au- " Emperor Has No... At a recent Einstein Medical College seminar on urban health, Dr. Cherkasky appeared to back away from his usual more assertive view that Einstein should lead in restructuring the health system of the Bronx. Now he seems to envision a more vague and modest role of " relating the institution to the community. " He said this new position came about because of events of the last year, presumably the community struggle to control the schools. Now Dr. Cherkasky is convinced that hospitals cannot be run as they have been in the past. The " com- plex, chaotic and destructive " element of the community will have to be introduced into a new organizational pat- tern for the hospital, he said, but he didn't know how this would be done. Skepticism about how Dr. Cherkasky would move from rhetoric to action hung over the audience. An obvious place to begin would be the Montefiore - Morrisania Neigh- borhood Medical Care Demonstration, where a community advisory board with very limited power fronts for Monte- fiore control. Dr. Cherkasky is responsible for limiting the power of this board. Giving the board the power to hire and fire the staff at the center could be the first step in introducing community control. However, it would be only a first step. Morrisania City Hospital, affiliated with Montefiore, also lacks a functioning community advisory board, although this is called for by the City Department of Hospitals. Dr. Cherkasky's disdain for community opinion was re- vealed in a later statement: " Just look around the country. People are voting down tax levies for education, so that schools for their children are being closed. What do you think they would do with health? " The seminar concluded with a general discussion in which the blame for the crisis in medical care was attributed to everyone except the voluntary hospitals. The hospital financing problem was blamed on the Med- icaid cutbacks, on the community for not successfully fighting the Medicaid cutbacks, on the inefficient way private doctors practice medicine, and finally on the varying modes of financing. If the private medical leaders would only spend as much time analysing and correcting their own institutions'contribution to the health care crisis, we might begin to move toward solutions. -Mills Matheson Medical Student Intern thority " or " corporation " through which skilled administrators could use public funds to mobilize private institutions to pool their efforts and solve the Bronx's problems. Dr. Cherkasky has maintained in the past that the key to successful regional services development would be delegation of full control of City, State and Federal monies to such a borough regional - " authority. " Dr. Cherkasky stated in an interview last fall that he foresaw a strong board for such a borough health " author- ity, " including trustees and medical leadership from private institutions, City officials, union representatives, and " the community. " He expressed confidence that Einstein Montefiore - has the quality and commitment to provide effective leader- ship for the authority, although Einstein Montefiore - need not run it directly. (Dr. Cherkasky does keep pointing out, however, that expertise is required to accomplish the task, implying that people must finally turn to Einstein Montefiore - , since that is where the expertise is. He also asserts that the community " better be ready, " because he and others plan to " really do things " through the new regional authority.) The key rationale for the regional authority, based on interviews with its chief architect (s), is to achieve economies of scale, by centralizing services such as laundry and labora- tories, and to prevent wasteful duplication of large capital investments (such as cobalt units) and medical capacities (such as for heart transplants). Presumably, the costs saved through these efficiency measures could be applied to creat- ing new services for desperately needy areas such as most of the South Bronx. About $ 1 million has been promised to Montefiore Einstein - over the next five years to support this " regionalization and development " planning process for the Bronx. These grants have gone to the medical school, and in some cases directly to Einstein's Community Medicine Department, including such new units as an " Urban Health Affairs Research Unit " and a " Hospital and Health Authority Planning Unit. " Regional Solo Practice Strangely enough, no one seems to know what this " Bronx plan " or authority is really all about. Even the officials of the Health Research Council and the Rockefeller Foundation, which together have committed the lion's share of the dollars on the basis of vague prospectus language, profess to know no more. than what they read in the papers. Staff in the Montefiore Administrator's and Einstein Dean's offices and in the Einstein Community Health Department declare that nothing has gotten underway except a few chats, although a number of persons have been hired as " urban health research planners, " etc. Dr. Cherkasky's leadership in this mythic planning process - as chief promoter and head of both the key College department and the principal hospitals involved - has been described by some skeptics in the same terms Cherkasky reserves for the fee service - for - solo practitioner: episodic, fragmented, arbitrary, unaccountable, and not done on a team basis. Supposing, though, that the Empire's leaders are serious about a super - plan for the Bronx - are they capable of doing it? Can the staff people in the Empire really know all problems and find all the answers, as Dr. Cherkasky seems to imply? Can we believe that they will no longer rely on hit and - - run " demonstration " projects, or on bed ratio - rationalizations cooked up by the Health and Hospital Planning Council? Are they capable of planning services, as opposed to legal structures, such as " corporations, " which are assumed to (Continued Page 12) (11) BRONXMANSHIP (From Page 11) get the job done just because they're there? Let's take a look at the assumptions of the Empire's super planners- i-s their planning really a " science "? First, the Empire's leaders assume that " the Bronx " can be planned for as a single homogeneous region. Is " the Bronx " really homogeneous or is it a fictional region that covers over the true social and political diversity of its people? Within the Bronx, the range of communities goes from sub- urban middle - class Riverdale and sub Westchester - to the medical environmental and economic disaster area of the South Bronx. Going southeastward from Riverdale, the infant mortality, TB, VD and drug addiction rates more than double. Who should have the clout and the " capital " for health plan- ning in this polyglot " planning unit "? The suspicion is that any new borough - wide authority would be dominated by " Riverdale and Westchester, " which is where these major private institutions and " their " doctors are, but not where the most acute problems are, although striking unmet medical need is borough - wide. In a vast and unwieldy " planning unit " like the Bronx, who would set priorities, who would guarantee equality of services? Second, the Empire's leaders assume that only they have the expertise and skills to offer efficient, modern leadership to the Bronx. But Einstein Montefiore - already has a near- monopoly on health services in the Bronx. It has had oppor- tunities to rationalize and streamline services within the Bronx to achieve continuity and comprehensiveness of care. Still, as noted above, the Empire has hardly begun. Has the Empire been waiting to be formalized as an " authority " before revealing its reputed " expertise " at rapid, efficient, equitable delivery of health services? No one could deny that there are many clear gains to be realized by more borough - wide planning and regionalization. Considerable economies of scale could and should be achieved by centralizing resources such as laundries, laboratories and computers, and by rationally distributing certain specialty services. But to whom will such economies accrue? Will the benefits, if any, pour into basic service improvement? Or will they flow back to support research, planning, " systems " development and sub specialty - sub - staffs at the nerve center of the already top heavy - Empire? (Of course, even super- planners can't sustain themselves on funds alone for long- they need data. When the health delivery system deteriorates to the point where there is no effective entry or follow through - system at the neighborhood level, then there is no data worth using. Much of the Bronx is already at that point.) " Cherkasky's Law " Recently, Dr. Cherkasky has begun to show a new modesty about the " Bronx plan, " suggesting that he may no longer want a formal " authority " or even a master planning - process. In fact, he may have begun to consider it as more of an ob- stacle than an opportunity. Even without an " authority, " centralized lab, laundry and computer capacity probably could be developed under the Empire's control, particularly if its own private hospital management network were tightened (known as " Cherkasky's Law " of empire expansion). First tighten Jacobi and Lincoln affiliation management - then the world. " Loose ends " among the Bronx's health facilities, such as Misericoria - Fordham, St. Barnabas, Bronx Lebanon - and a few neighborhood health centers, could be folded under the Empire's umbrella in some private " affiliation " capacity. The planning and regulatory demands of the City could be temporized or rhetorically absorbed indefinitely. And maybe even the service and control demands of the com- munity and workers can be kept at bay (or played off against each other) for a long time to come. If so, maybe it's just as well not to tie up the Empire in some kind of legal structure which would have to involve public officials, neighborhood people, union leaders, etc. If you already have the authority, why bother with an " authority "? Many promoters and staff in the Empire have been more " modest " all along. William Glazier, Assistant Dean for Community Affairs at Einstein and former staff director of the Piel Commission [See BULLETIN No. 1 and special Winter 1969 issue on the Corporation], has said that there are no easy answers for the Bronx's problems. According to Dean Glazier, Einstein Montefiore's - most important role might be in cleaning up its own house, rather than asserting borough - wide leadership. Community - oriented health profes- sionals like Dr. Howard Brown (former City HSA chief and now at Misericordia and Einstein's Community Health De- partment), Dr. Harold Wise of the Montefiore Neighborhood Medical Care Demonstration, and Dr. Tom Levin of the Lincoln Mental Health Services all contend that the only solid building blocks of regional health services development are new programs at the neighborhood level. Thousands of Bronx residents, from Co op - City to Mott Haven, share their view: Planning regional super structures - before planning primary care at the neighborhood level is putting the cart before the horse. To be sure, services must be coordinated and regionalized on a borough - wide and even a city wide - basis under clear public control - but the services which are most needed must be created as top priority before an effective " basis " for regionalization is achieved. The question is not how to prevent duplication of heart transplant and cobalt units, but how to create access to basic, routine care. The question is not how to curb waste of facilities, but how to stop the waste of lives. Paper Dinosaur Dr. Cherkasky refers to the Hospitals Department and City Hall as the fiscally - choked " dinosaur. " Is his own institution- ally and professionally - choked Empire any less of a " dinosaur " in the path of the delivery of health services to people? A dinosaur, if its true nature is recognized, can be deeply vulnerable. From its small brain center it may appear that the capacity to serve grows only out of one's direct proximity to the upper granting echelons and the most prestigious scientific and institutional elite. But, once people recognize that the decisions are not only about complex scientific means to achieve well known - ends, but about who shall live and who shall die, and who shall pay and who shall profit- then they will demand to participate in and shape these decisions. As the Lincoln Mental Health Center community - workers have so dramatically demonstrated, the capacity, the com- mitment, the knowledge, and the energy to generate a new service environment in the system can rather start at the feet, most sensitized to the actual environment, its chal- lenges and its potential new human resources. -Robb Burlage (12) Taking Care Of Their Own THE WORKERS WHO TOOK CONTROL of the mental health position during negotiations, his superiors in the Einstein services at Lincoln Hospital on March 4 no longer talk about Empire rudely cut him off. Commented one worker: " If they " whether, " but " when " to escalate the struggle for worker- don't even take care of their own, how can we expect them community control to the entire hospital. What began as a to take care of us? " para professional - revolt for redress of grievances, spurred by The para professonal - workers (almost all black and Puerto the firing for four fellow workers, has grown significantly- Rican and from the community) are angry. In taking control both in professional and community support and in aware- of the mental health services, they charged the (white) ness of the powers they are up against. More and more South Bronx community people including - administrators with " malfeasance, ineffiency, chaos and racial discrimination. " Many had been hired over three years ago patients who use the services, local priests and nuns, mem- as part of a " new careers " program designed to train in- bers of the Black Panther Party, and members of local digenous community mental health workers. One the of top social service agencies in the Lincoln Hospital area - are rungs on the para professional - ladder which a worker was attending worker strategy meetings. The central demands of supposed to be able to attain was " community organizer. " the occupying forces are that former administrators, Drs. But an administrative decision was made that no one without Harris B. Peck, Seymour R. Kaplan, and Melvin Roman, be a college degree could hold this position. [In fact, a middle- officially suspended; and that a representative community aged, white organizer without a college degree was hired board with responsibility for setting all policy for mental on the basis of his experience as a union organizer.] Several health services be instituted. of the community mental health workers were given the A negotiating team (including blacks, Puerto Ricans and opportunity to go to school in order to qualify. In retrospect, whites, para professionals - and professionals) has steadfastly the workers interpret the " college education plum " as a carried these demands to the other parties involved: Albert device to pick off and neutralize the more militant workers. Einstein College of Medicine - Yeshiva University, and New In the meantime, the so called - " Community Organizing De- York City's Department of Hospitals and Community Mental partment " of Lincoln mental health services, according to a Health Board. At the same time, the revolting workers and dissident worker, " has been sitting on its hands... most professionals are continuing to provide services in the mental of the mental health workers assigned to that unit have health clinics and day hospital. been farmed out to other units because they don't have Shortly after the workers'takeover, the City declared the services closed, saying the ousted Einstein administrators could not be held medically responsible for the services. Within a few days, knowing that State and Federal funds anything to do! " The mental health services actually became bogged down in the liberal rhetoric in which they had been floating since the inception of the center. As a result, within a few hours were jeopardized by the closing, the City ordered the after the worker takeover, the cries of " worker power " be- services reopened. came " community control. " One of the workers from the day Threats of malpractice suits and loss of salaries and hospital (who had been picked to attend Yeshiva University) manipulative moves on the part of Albert Einstein to pick off accompanied a group of strike supporting - Albert Einstein and co opt - some of the leadership (hoping thus to create a medical students to a confrontation meeting with Dean black Puerto - Rican split) has galvanized the worker - com- Harry Gordon. He demanded to know from the Dean: " Is this munity struggle. Power is the name of the game. Ironically, Yeshiva's program, or is this a community mental health the workers on the negotiating team found themselves feeling program? " This worker, who is ready to sacrifice his col- sorry for Dr. Peck. When the doctor attempted to explain his lege " education " and his paycheck, wants a new boss. He described the decay in services: " When I first came here " ATTENTION.. 23 (13 men - 10 women) LHMHS Workers (professional non - and pro- q fessional) fighting to improve the rotten and poor hospital conditions at Lincoln Hospital & Lincoln Hospital Mental Health Services, were arrested Thursday, March 20, on individual complaints of criminal trespassing by Dr. we dealt with the people's needs. If a man was depressed and he lived in a rat hole, we went out and we helped move him. We carried his bed on our backs. In other cases, we started putting pressure on landlords. And then the word came down from the'man '... We don't move patients anymore - Einstein says we're not covered by insurance. Pres- sure on landlords? We've been ordered to cool it. In the Nasry Michelin [City Administrator of Lincoln case of one of the landlords, word came from high up. We Hospital]. " Patients die every day at Lincoln because of found out later that the landlord was a big contributor to Yeshiva.. " the poor facilities. If the sacrifices made by these 23 hospital workers and the 200 LHMHS workers with whom they took part in this fight, Save ONE LIFE needlessly lost, our whole fight will be a success. Yeshiva is a a BASTARD corporation that makes large direct and indirect profits off the people and the vital life and Rumors have been flying that the workers will be busted. Police and paddy wagons have been plentiful. With a bit of black humor, one worker commented: " They [the admin- istration] don't know their own power. They would just have to threaten us with violence. If we thought we were going to be injured this close to Lincoln - and be taken death services they need desperately! " there we'd all throw up our hands. " Then another worker -From a leaflet distributed by the LHMHS workers fol- lowing the " bust " predicted in the story on this page. added, " When we're ready to go to jail for the mental health clinic, we'll be ready to go for the whole thing. " -Maxine Kenny (13) Letters to Editor And In This Corner... Dear HEALTH - PAC: I wonder if you are not too far over in the community involvement corner. I wonder if you have tried to work within the medical framework. You say you believe in the " public turn- key. " I don't believe you are realistic or totally correct. This is based on my expe- rience working for a City hospital where we WANTED the community to be involved. I am currently working for an organization whose goal is to get the producers and the consumers of an area of health service to at least talk to one another. First let me take a shot at the St. Francis Hospital. The only mistake made here was that the community was not involved in making the decision to close the hospital. The building was outdated, the staffing shortage acute and the finances a mess. Were I a citizen living in that area I would NOT trust my life to such an institution. When dealing with my life it should not be a mat- ter of convenience but a matter of the best possible medical care. Isn't that what med- ical planning is all about - with the addition of making the gap between the two a little less? Now to community involvement. I was in an area that needed a Neighborhood Health Center. There were only three practicing physicians in the area. The neighborhood was fairly well organized but with limited co- operation between the organizations. It was a severely depressed area. We went after non government - funding to eliminate so many of the strings. We went out in the community for six months and talked to anyone and everyone. Then we started to hold meetings in the hospital to elect a Board who would DETERMINE POLICY for the program. The Board was elected by the community with reasonable representation from each of the political factions. The Board elected its own officers, determined a chart of work, and asked for some training in finances. What has happened? The community is happy because it is involved. There is no improvement in the medical care because there is no functioning Neighborhood Health program. They can not agree upon a site that also meets building codes. They have hired a staff of not just one or two key people but also the Home Health Aides. These are from the community, are on full salary, and are in continuous training. The result will soon be that they have blown their initial grant without ever improving medical care. They will have provided jobs and overtrain- ed for them, but there are other programs for this. When administration moves to give sug- gestions or pressures for action (like a site), there are loud meetings where the Estab- lishment is accused of reneging on their agreements. This is only one example. There are others less dramatic. They all point out you must put planning where the expertise is. BUT YOU MUST ALSO MAINTAIN AN OPEN DIALOGUE. The consumer and the producer must communicate... Let me give one more simple example. A new Pediatric Clinic was being built, and the architects wanted to make life more pleasant for Mama during the always long and inevitable wait. So they planned cradles. Mama was then involved and said NO. We will not use them, but would find rocking chairs a marvelous help. This involvement is proper use of expertise and brings im- provement. Why don't you evaluate your battlefield? -Marie Hanson 240 East 32 St., New York City Community Advocate Dear HEALTH - PAC: I have been receiving your HEALTH - PAC BULLETIN with a great deal of interest and I was delighted to see the recent issue on decentralization. I, of course, agree with the ideas you ex- press. There is every need for this kind of movement. I only hope that some of the experiencs in the education system in New York are rubbing off on the health system as well. My own experiences lead me to think that the process is going to be very difficult and its success will depend upon the amount of advocacy and training given to community people themselves... -Robert C. Bauxbaum, M.D. Family Health Care Program, Harvard Medical School, Boston WE REGRET that the reference to the accreditation of the Columbia School of Public Health and Administrative Medicine on Page 11 of the November - December BULLE- TIN was in error. The school did not lose its accreditation in the early 1960's, though it is rated weak in many de- partments by most people knowledgeable in the fields of public health. - Ed. (14)