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HEALTH / PAC Health BULLETIN BULLETIN Policy Advisory Center 3 Vital signs 6 The View from the Community Volume 12, Number 2 HPBCAR 1-28 ISSN 0017-9051 10 The Neighborhood Health Center 22 Expanding Sutton's Law fevbuin, ali) OR nn cap CA titties 2A i Ref The Professionalization Since Since the Federal Government became in- volved in the delivery of personal health care to of Neighborhood a significant part of the civilian population in Health Centers the 1960s, officials and others concerned with health policy have wrestled with the question of who could best provide quality service pro- grams for the underserved. The Office of Economic Opportunity (OEO) attempted to address this question in 1965, when it initiated the neighborhood health center (NHC) program on a demonstration basis. NHCs were developed to provide com- prehensive, high quality ambulatory care and be community based with " intensive participa- tion by and involvement of the population to be served. " (1). What happened was something else. Articles in the previous issue of the Health / PAC BULLETIN document the many ways in which this vision was undercut by funding and reim- bursement policies and how federal policy has shifted to support for hospital sponsorship of ambulatory care services. They explored the significance of hospital ascendancy in this area and its implications for some of the most impor- tant and unique features of community health centers. (2, 3) To provide a broader historical perspective which can illuminate future possibilities, this article will attempt to answer two specific ques- tions: What was the original strategy for institu- tional sponsorship? When and why did this change? The Initial Strategy The first NHC project grants were proudly announced as the beginning of a " new " model health service for low income - , underserved populations, primarily in urban areas. Beyond this immediate goal, the OEO health staff was convinced that when the NHC became widely publicized, its superiority to existing services for all social classes would become manifest and pressure to change the total system would become irresistible. The initial planning within OEO included the assumption that the existing medical care institutions were in fact a part of the overall problem. Resources, therefore, should be allocated with care to avoid " patching up " that system. As Lisbeth Bamberger Shorr, the staff member most responsible for initiating the NHC program, recalled, We decided that if OEO was going to spend any substantial amounts of money on health, it would have to be directed to changing the organizational framework through which health services were being delivered to poor people... It would be a 2 big mistake for OEO to be spending any substantial amounts of funds on health services delivered through the traditional delivery system. (4). In spite of this conviction, the staff believed that traditional institutions (medical schools, health departments, hospitals) had to be in- cluded. Their sponsorship at the local level was considered necessary to recruit professional staff, assure quality of care, and, most import- ant, legitimize the new model within OEO and the broader professional community. OEO Director Sargent Shriver recalled that he was " delighted " when the first NHC application came from " a major university and medical school, " commenting, " That was valuable! Very valuable! " (5). Health professionals at the project level got the message. According to Dr. Jack Geiger, co director - of the Tufts University grant establishing the Columbia Point Project, A key factor in overcoming Shriver's. anxiety [about the application]... was that there was a major, quality medical school that they were giving this [grant] to. I don't think that it would have gotten started in any other way. (6). The OEO staff understood the conflicts in- herent in working for reform in concert with established institutions and developed specific policies to insure success. Project directors, though employed in traditional medical institu- tions, would be chosen who reflected the values and goals of the OEO staff; " citizen participa- tion " through community boards would coun- terbalance the traditional orientation of the sponsoring institutions; sponsoring institutions would be monitored carefully to prevent diver- sion of funds to purposes not related directly to the NHC and its goals. Despite these safeguards, the OEO policy. makers realized that the hospital was the nexus of the entire health care system, placing them in the awkward position of an intern who sees the chief surgeon botching an operation. Daniel I. Zwick, a former OEO official, put it this way: The importance of the hospital was clear from the beginning. Anybody who knows the business,... would recognize the im- portance of the hospital... [We realized] that most of the medical care that was be- ing provided was in institutional settings, and you had to change the hospitals [in order to change the system]. (7). Continued on Page 6 me MD Rx IS PR The American Medical Association is often regarded as slightly more modern than a woolly mammoth caught in Siberian ice, but at its 1979 an- nual meeting, the AMA's House of Delegates showed signs of thawing out. They approved a new code of ethics that em- phasizes patients'rights and allows doctors to solicit pa- tients; gives guarded accep- tance to the notion that health maintenance organizations deliver good medical care; and allows physicians to associate with chiropractors. This country's largest association of doctors still has a way to go. The conclusion that HMO's " seem to be able " to of- fer lower - cost care than Blue Cross - Blue Shield or other kinds of insurance was sent back for further study by its Council on Medical Services. And its position on chiroprac- tors was at least partly in response to multi million - dollar damage suits by chiropractors ' associations - suits that could bankrupt the AMA. Moreover, the Federal Trade Commission has been pressuring the Association to allow advertis- ing. The most significant change at the AMA may be the dawn of a new political pragmatism - a realization that you cannot stop Signs Vital a parade if you are too far behind. " We don't want na- tional health insurance, but we feel we should be in contact with the government so we can influence it, " said Dr. G. Rehmi Denton, president of the New York State Medical Society. Behind all this may be a realization that the AMA image needs sophisticated public rela- tions help. Already a marketing services division with half a dozen marketing consultants pushes the AMA and its line among doctors, and a The AMA has awoken to a new political pragmatism: you cannot stop the national health insurance bandwagon if you are too far behind marketing expert has just been hired to run a membership drive. In the past decade, AMA membership has fallen from 168,000 about half the doctors at that time - to 151,000 - only one third - of the country's 453,000 physicians. Rumors that Pat Boone will be singing a TV commercial, " I'd like to give the world an AMA checkup, " appear to be premature, however. -George Lowrey (Source: NY Times, July 27, 1980) THE PRICE IS RIGHTS Riders on the crowded anti- regulation bandwagon can hap- pily squeeze over to make room for the American Health Care Association and the National Council of Health Centers (read nursing homes.) Climbing on with the obligatory independent study, they argue that the Department of Health and Human Services has grossly underestimated the cost of implementing proposed regulations for mental and physical wellbeing in nursing homes receiving Medicaid and Medicare. HHS estimates that these would cost 15 cents a pa- tient day, an annual total of $ 71 million. The industry asserts that the true cost is $ 1.35 a pa- tient day, or $ 534.8 million. These expensive rights in- clude free association with visitors and other patients; per- sonal privacy; freedom to retain personal property such as books; purchase of items out- side the institution; access to one's own medical records; power to form patients'advisory councils; protection against un- necessary physical or chemical restraint; the right to an itemiz- ed statement of expenses listing those not covered by the government; and mandatory medical, physical, and psycho- logical assessment of a patient's needs upon admission, with treatment goals and timetables. If the nursing home lobby arguments prove successful, other groups eager to eliminate waste will no doubt follow with even more ambitious studies. We look forward to " Is the Bill of Rights Too Expensive per Citizen Day? " " Are the Ten Commandments Cost Effec- - tive? " and " The Red Ink in the Golden Rule. " -Ronda Kotelchuck PROFITS FALLING? TAKE TUMS. Health / PAC Bulletin Like the faces on Mount Rushmore, the giants of the health care industry can be awe inspiring -: Hoffman LaRoche; SmithKline; Ciba- Geigy; G.D. Searle; Revlon. Revlon? That's right; this year the firm that brought you Charlie perfumes will have greater sales and profits from its health care business than G.D. Searle and be within a false eyelash of Richardson - Merrell. Revlon first moved into health care by acquiring the US Vitamin Co. in 1966. Expansion has brought in everything from laxatives to clinical laboratories, antiacne prepara- tions, and Tums antacid. Its success in winning $ 3 million in orders for interferon, the pro- mising but unproven anti- cancer drug, from the National Cancer Institute and a major research hospital has rivals. worried Revlon may become the Jordache of genes. For one of these contracts it beat out Ab- Tony Bale Pamela Brier Robb Burlage Michael E. Clark Jaime Inclan Board of Editors Hal Strelnick Des Callan Madge Cohen Kathy Conway Doug Dornan Cindy Driver Dan Feshbach Marsha Hurst Louanne Kennedy Mark Kleiman Thomas Leventhal Alan Levine Associates Richard Younge Glenn Jenkins David Kotelchuck Ronda Kotelchuck Arthur Levin David Rosner Joanne Lukomnik Peter Medoff Robin Omata Doreen Rappaport Susan Reverby Len Rodberg Alex Rosen Ken Rosenberg Gel Stevenson Rick Surpin Ann Umemoto Editor: Jon Steinberg Staff: Kate Pfordresher, Loretta Wavra MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR should be addressed to Health / PAC, 17 Murray Street, New York, N.Y. 10007. Subscription rates are $ 14 for individuals, $ 11.20 for students and $ 28 for institutions. Subscription orders should be addressed to the Publisher: Human Sciences Press, 72 Fifth Avenue, New York, N.Y. 10011. bott Laboratories and Searle. Management has said it wants to keep this business about half the size of cosmetics, but sales are so healthy that Revlon will soon be what one analyst calls " a major health - care company with a large cosmetics sideline. " Health / PAC Bulletin is published bimonthly by Human Sciences Press. Second - class postage paid at New York, N.Y. and at additional mailing offices. 1980 Human Sciences Press | Illustrations by David Celsi (pp. 1, 8), Liberation News Ser- vice (pp. 15, 16, 24), Albrecht Durer (p. 20), and LNS Women's Graphics (p. 22). The future is limitless; gene splicing could be the answer to dull, lifeless hair. -George Lowrey Source: Forbes, August 18, 1980. evidence of adverse health ef- fects from the area's toxic waste pollution. The panel was, however, charitable enough to The panel chairman, Lewis Thomas, is well know in New York City, where he has himself long been an source of anguish offer a paternalistic recommen- to community health activists. THE TOXIC MIND dation that the hundreds of af- fected Lovel Canal residents be Back in the 60s, Thomas, then dean of NYU medical school, Much to the amazement of Love moved - not because of any was a principal defender of the Canal residents, a New York physical danger, but because of city's two class - hospital system State appointed - scientific panel the " anguish and anxiety caus- in which poor (mostly Black and has concluded that there is no ed by the presence of [the] Puerto Rican) in the municipal " scientifically rigorous " chemicals. " 4 hospitals, are used as teaching material for the private medical empires. When the advent of Medicaid raised the possibility of merging all the city's hospitals, public and private, into a single, publicly controlled one class - system (see the premier issues of the BULLETIN), Thomas declared: ...... To give up... the great tradition of teaching students and young physicians in our municipal hospitals, is ab- solutely unthinkable. It is our obligation to society to figure out ways to retain, and to use with intelligence and im- agination, this great resource. Through the New York City Health and Hospitals Corpora- tion, which Thomas and other members of the city's medical elite helped shape, private teaching hospitals and medical schools have indeed been able to continue to " use with in- telligence and imagination " all those who are poor enough to qualify as teaching specimens. In the 1970s - perhaps wishing to escape memories of clashes with angry Lower East Side residents- Thomas retreated to Long Island's ultra- chic Hamptons area to write best sellers - about the wonders of science. His Lives of a Cell and The Medusa and the Snail, both unabashed glosses for high - tech biomedicine, pro- pelled him into the Carl Sagan league as a national pop - sci spokesman. So when Dr. Lewis Thomas finds that the only danger from toxic wastes is that they are mentally upsetting, we should take heed. As we learned in New York City, Thomas's opi- nions have a way of becoming policy. It may, after all, be far easier to provide mental health services for the residents of Love Canal, Three Mile Island, etc. etc., than to get the polluting industries to clean up their act. And for all we know (science is full of surprises) those broken chromosomes found in the Love Canal residents my be psychosomatic. - Barbara Ehrenreich (Barbara Ehrenreich is CO- author of For Her Own Good: 150 Years of the Experts'Advice to Women.) CURING THE ULCERS IT CAUSED SmithKline, the Philadelphia based pharmaceutical com- pany, contributed to what it calls a healthier American society by running a full page advertisement in the May 22, 1980 Wall Street Journal por- traying the US as a debilitated garrison society whose very sur- vival is threatened by inade- quate military spending. If SmithKline stockholders wonder why corporate funds are being spent to advertise such ulcer producing - scare messages, it may trace to the company's interest in marketing Tagamet, a SmithKline product reputed to be the only drug that actually cures peptic ulcers. Only available in the US since late 1976, Tagamet already ac- counts for more than a third of SmithKlines'total revenues and almost half its profits. It is available in over 100 countries and will bring SmithKline an expected $ 580 million in revenues this year. Tagamet, in fact, has rocketed to second place world wide among all prescription drugs, second only to Valium which, in its 18th year, should gross $ 600 million. SmithKline executives predict Tagamet will edge out Valium for first place in 1981, giving future social an- thropologists a field day trying to discern what it means when an anti ulcer - drug takes over first place from a tranquilizer. Tagamet's long range - future appears equally bright. The Food and Drug Administration recently approved Tagamet for long term " maintenance " use, rather than the previous eight week limit. And the current 15 million customers worldwide, according to some estimates, may be only half the pool of peptic ulcer sufferers. One possible new pot of gold for Tagamet may lie with Japan. Job security and com- pany loyalty aside, the " in- dustrial miracle " of the East has one of the highest per capita ulcer rates in the world, and Tagamet is not sold there - yet. SmithKline expects to start marketing in Japan in 1981. The only small, dark cloud on the company's horizon is the possibility that SmithKline may have to defend itself against a coverup suit. A British physi- cian and former SmithKline employee has filed a $ 40 million suit charging the company with burying his idea for a new drug supplement that, he claims, would have competed with Dyazide, one of SmithKline's fast selling - hypertension drugs. Dr. Maurice Bloch became a consultant for SmithKline in April, 1974, and was prohibited from discussing or publishing his idea even though SmithKline failed to develop it. SmithKline says the suit " has absolutely no validity. " Never- theless, the legal battle could produce ulcers for all concern- ed. -George Lowrey 5 The Professionalization of Neighborhood Centers Continued from Page 2 Although the reformers believed that any at- tempt to change the system would ultimately have to confront the hospital, a realistic estima- tion of their resources and power dictated a prudent short run strategy of demonstrating and legitimizing zones of minimal professional resistance. As Zwick explained, The strategy that was being developed... was to start outside [the hospital]. If you started within the struc- tured institution you had so many things working against you that your chances of movement were less. So let's start out here with this free standing - neighborhood health center, and develop de novo r Neighborhood Health Centers were in- itiated when riots, community activism, and other civil rights struggles of the 1960s created a rush to win peace by declaring a War on Poverty. The medical services in this war were an alternative to private and hospital- based care culturally compatible, com- munity controlled, preventive, humane, low cost. But NHCs also explicitly func- tioned as a rallying point, a source of jobs, a center for organizing, and one of the few tangible victories won by com- munities throughout the nation. Work, staffing, and structure were designed to support all these efforts, not to deliver. traditional, narrowly - defined medical services as efficiently as possible. It seemed too good to be true. In many ways it was. When political winds were blowing our way, we got fund- ing by selling our souls to the devil. Now he feels strong enough to change the rules and demand a refund. The new goal -and myth is self sufficiency - . But ser- vices NHCs specialize in, such as health. education, community health, transla- tion, transportation, home visits, social work, and escort services, are not reim- bursable. For routine medical services, reimbursement standards for NHCs are similar to those for hospitals and private physicians, but in most cases less advan- tageous. When our work in NHCs is judged by narrow criteria, of course we often don't measure up to other health care pro- viders. The Department of Health and Human Services (successor to HEW), 6 {_ generally fails to adequately consider the -The View from type of patient we serve, the amount of time we spend on patient education, and the difficulties created by our commit- ment to hire and train workers from the community. We don't begrudge our training func- tions. NHCs are, in effect, the only " schools " in the country for community. health workers who come without prior training. In a society which puts a premium on profit and promotion, it is not surprising that many talented staff members go on to acquire formal educa- tion and other jobs that are better paid and more complex professionally. Foster- ing these role models for young people may be one of our greatest contributions to the community. However we and the community also pay a price. Serving as a conduit for minority brain drain means that we are constantly losing our best workers and expending scarce resources to train their replacements. In a similar situation, other institutions would reduce the scope of their activities. We can't. NHCs must spread themselves thin attempting to provide a broad spec- trum of non medical - services otherwise unavailable. We would be the first to ad- mit that a more comprehensive, geo- graphically broader system, with a larger volume of work, could operate much more efficiently. We also know that strug- gling to play this role lowers the quality of all of our work. Nevertheless, I am convinced that medical care provided in health centers is far superior to what is offered in hospital clinics, Medicaid mills, and private without all of those vested interests. (8). By 1969, the NHC concept and program had become widely broadcast to the public, and in- stitutionalized within OEO and the wider pro- fessional community. Taking Reform to the Hospital The first offensive in this strategy was a series of OEO grants to hospitals to reorganize out- patient departments (OPDs). No section of the hospital fortress appeared more vulnerable. Significant numbers of urban poor still used OPDs as a source of primary care, and experts often pinpointed this as a cause of the financial " crisis " in urban hospitals. These institutions, OEO officials thought, would therefore be more receptive to a plan which would change traditional orientation. Perhaps of greater im- portance was the new Nixon Administration's the Community physicians'offices. It is caring, humane, unhurried, friendly: practitioner and pa- tient can communicate. Our nurses, doc- tors, and physician assistants are general- ly committed to delivering high quality and comprehensive care, and the struc- ture and community nature of the center encourage their efforts to provide it. People in the community are aware of these positive qualities and also the defi- ciencies resulting from budgetary restraints. They generally go elsewhere for quick visits to avoid our inefficiency and long waiting times. If they feel they need longer sessions with the practitioner or a team approach with multiple resources, they come to us. Again, we pay a price for meeting needs: perform- ing more expensive services and not hustling people in one door and out the other are not reimbursable. As funding. cutbacks compel service reductions, for example elimination of 24 hour - service, many of these patients are forced to seek attention elsewhere or do without care. These reductions in public funding are known among urban policy specialists as planned shrinkage. When community use declines, so does interest. Community control is at best ex- cruciatingly painful and very modest; often it is a failure. Local residents are reluctant to remain on a governing board when they are expected to perform dif- ficult and complex tasks and any positive results come very slowly. President Carter went to Charlotte Street in the Bronx, made promises, went home and forgot about them. These people live in . our urban Charlotte Streets. They are ex- pected to save community health centers in the midst of laissez - faire urban renewal with its legacy of burnt - out buildings and population dispersal. They see the crippl- ing effects of Medicaid restrictions. They feel the pain of pious demands for self- sufficiency at a time when Medicaid. eligibility and reimbursement have been reduced below their previously inade- quate levels. In a sense, the system has won its War on Poverty. We have been defused and diffused. Just maintaining what we have takes all our energy; there is not time or resource left to expend on education, housing, organizing. By giving the com- munity some money tied with regulatory strings, the government has shifted the burden from itself to us. Even as we are slowly strangled by reduced funding, the media and policy makers say that if we do. not succeed in hacking our way through the morass of bureaucratic demands to deliver good, inexpensive care to the poorest and sickest within our devastated and impoverished community, it is our fault, proof that community control doesn't work and people can't provide for themselves. But we don't measure success in their framework. We know that even if NHCs may not be the best way to organize com- munities or the ideal way to deliver health services, they are the best way we have now, with truly revolutionary potential if they can be kept in the hands of the peo- ple they serve. -Sara Santana Dy, desire for " something different " - -programs clearly dissociated from the imprint of Presi- dent Johnson's Great Society. As the explosive atmosphere which had spawned the War on Poverty cooled out, OEO also lost its activist emphasis. In the 1967-69 period, physicians gradually replaced non- physicians in key policy making - positions in the NHC program (9). This shift was part of the broader effort to institutionalize the NHC pro- gram by replacing personal commitments and loyalties with regulations, structured pro- cedures, and job descriptions. These changes were reflected at the project level, where former civil rights activists were replaced by professional administrators and business managers. As a result, the initial measures taken to guarantee the accountability of the sponsoring institutions disappeared. The decision to embark on the OPD program in 1969 was not greeted with enthusiasm by the entire OEO health staff. While many physi- cians on the staff were " very comfortable with hospitals " as grantee institutions (11), non- medical personnel tended to be sceptical. " They were starting with the illusion that...... the hospital was going to become a different kind of place, " one official noted bitterly, " and they have lost that battle. " (12). Another staff member, Barry Blandford, later described the new program as a " out sell - " in which the OEO's ostensible reform had real- ly amounted to its own cooptation: I think it sort of changed the philosophy of the program. We were trying to provide services to a given community, where members of that community could have input into the services they were get- ting.. There. is no way that you can get the community participation or the neighborhood involvement [through a se itt yf bP Sh ' Le woe, a fe 8 Qe aspee eee x5 A j & 2 A cea team Prey 7 OG i San hospital grantee] that you were getting with our earlier programs. (13). Furthermore, as another former OEO official pointed out, the program could actually hurt the poor it was supposed to help: There was just no way that they could pro- vide the services running directly through a hospital that you were pro- viding through some of our health centers and meet the same costs. I mean it just couldn't be done in a hospital structure. (14). Despite these concerns, the OPD program became a key part of the overall OEO - NHC ef- fort in the early 1970s. Its efficacy and impact remained limited, however, while NHC staffers struggled to survive budget cuts and transfer to the Department of Health, Education and Welfare. The notion of hospitals as providers of am- bulatory care gained additional support in the mid 1970's - from those who decided that since much of the urban, poor population continued to use the hospital for primary care, programs should be tailored to accommodate this pat- tern. Thus after a significant challenge, the dominance of hospitals in this field is being legitimized once again with the same dubious logic which argued that because smoking is hazardous, the Surgeon General's office should focus its efforts on changing cigarette packaging. Any lingering problems can be blamed on the patient. -Jude Thomas May (Jude Thomas May is an association pro- fessor in the Department of Social Science and Health Behavior at the University of Oklahoma Health Sciences Center.) References 1. Lisbeth Bamberger, " Health Care and Poverty, " Bulletin of the New York Academy of Medicine, vol. 42, no. 12 (December, 1966), pp. 1140-1156. 2. Rita D. Berkson, Diana Barrett, and Randolph B. Reinhold, " Ambulatory Care in the Cities: A Shift to the Hospitals, " Health / PAC Bulletin. 3. Alice Sardell, " The Neighborhood Health Center Model and Federal Policy, " Health / PAC Bulletin. 4. Interview, Lisbeth Bamberger Schorr, October 16, 1975. The disposition of the interviews which were completed in our larger study of the NHC is described more fully in the article cited in footnote ten. 5. Interview, Sargent Shriver, June 18,1 976. 6. Interview, H. Jack Geiger, M.D., June 26, 74. 7. Interview, Daniel I. Zwick, May 13, 1975. 8. ibid. 10. R.M. Hessler and C.S. Beavert, " Citizen Participation in Neighborhood Health Centers for the Poor: The Politics of Organizational Change, 1965 1977 #, " un- published paper, 1980. 11. Interview, anonymous respondent. 12. Ibid.. 13. Interview, Barry Blanford, November 2, 1977. 14. Interview, ancnymous respondent. Double Indemnity The Poverty and Mythology of Affirmative Action in the Health Professional Schools by Hal Strelnick and Richard Young " Exciting and will make a major contribution. " -Professor Sam Wolfe of Columbia University School of Public Health A Health / PAC Special Report. $ 5.00 each. Now available from the Health Policy Advis- sory Center, 17 Murray Street, New York, New York 10007 The Neighborhood Health Center: Model and Federal Policy The original neighborhood health center (NHC) model challenged the existing health care delivery system in several ways. Firstly, it was to " reintegrate " the traditional separation between public health and personal health ser- vices by defining " health " broadly and provid- ing preventive, environmental and outreach services as well as medical treatment at one facility. Secondly, by providing care to all of the residents of a geographically defined com- munity rather than just to those who fit certain demographic, disease, or poverty categories, health centers were disregarding the accepted boundaries between " public " and " private " medicine. Finally, the inclusion of health care teams and consumer participation in the model was a departure from arrangements which assured professional / physician dominance. This model of health care delivery did not, however, reach the political agenda from a struggle over health care issues affecting the 10 whole population, but rather, as part of a War on Poverty. Precisely because this model chal- lenged the basic structure of the American health care system, it could only be considered as a part of a separate agenda, one limited to the poor. Even then, established providers such as the AMA and the hospitals were assur- ed that their interests would not be threatened (1). The most challenging aspect of the neighborhood health center model lasted only two years. In 1967 the eligibility criterion was amended from residence in the NHC's catchment area to income below the poverty level (2). This amendment, sponsored by private practitioners, effectively prevented the NHC from serving a mixed income clientele and expanding beyond a _ poverty population (3). Neighborhood health centers were first funded in 1965 as research and demonstration projects by the Office of Economic Opportunity (4). In 1968 the Department of Health, Educa- Continued on Page 19 and the Physicians'Forum. The delegation interviewed approx- INTERNATIONAL | imately 50 persons in El Salvador, including a surgeon on the junta; the executive com- MURDER IN THE One such dispatch last spring indicated that the thousands of victims have included physi- cians, and in response Salvadorean health workers formed a National Committee for the Protection of Patients, Health Professionals, and Health Institutions. Within a short time, this committee was mittee of the opposition Democratic Revolutionary Front; the United States Am- bassador; the past president of the medical association; and representatives of health workers, medical organiza- tions, social service, and relief agencies. Among the findings reported HOSPITAL able to call a strike lasting over a month throughout the country East European dissidents cer- tainly have problems at home, but they can usually rely on the American media for sym- pathetic coverage if they lose their jobs or get arrested. For peasants in a country under the boot of military forces armed and trained by the U.S. govern- ment for half a century, it is a different story - or rather no story at all. Papers here don't report natural occurences, like the sun rising in the morning or the assassination of a few hun- dred hungry peasants and workers a month in a country where the two percent of the to protest severe violations of health rights. This May, a group of health workers in New York eager to show support for their belea- guered counterparts formed the Committee for Health Rights in El Salvador. By July, they were able to send a delegation of distinguished physicians and other health workers to in- vestigate allegations concern- ing militarization of El Salvador's health system, assassination of health workers by the junta, and the active par- ticipation by the military in abuses of basic health rights. Physicians have become victims in the El Salvadorean junta's war against its own people. The right to health has been politically denied by the delegation upon their return are: A. " Following the coup of Oc- tober 15, 1979, the traditional protection conferred on doctors population owning 60 percent The five members of the and patients has been increas- of the land must protect itself. delegation were Sally Gutt- A military junta in El macher, Ph.D., Columbia ingly ignored as military and paramilitary gangs have Salvador would have to permit School of Public Health; flagrantly entered hospitals and or conspire in something truly Frances Hubbard, B.S.; Sophie shot down doctors, nurses, and outrageous to break the front Davis, School of Biomedical patients in cold blood. We know pages. This it did last March 24, Education, City University of of no instance where the Salva- with the murder of Oscar New York; Walter Lear, M.D., dorean Government has iden- Romero, the country's President of the Physicians ' tified, prosecuted or punished outspoken archbishop, as he celebrated mass in the Forum; Leonard Sagan, M.D., internist and Fellow of the those responsible for these kill- ings. cathedral with one of his American College of Physi- B. " Frequently, assassinations customary vain appeals for cians; and Arthur Warner, have been preceded by the respect for human rights. M.D., pediatrician and Fellow cruelist forms of dismember- Before and since, squeamish of the American Public Health ment and brutality. Among readers may be thankful that the Association. The delegation those gunned down since the rare reports of the Salvadorean was co sponsored - by the coup have been at least nine junta's war against its own peo- American Public Health physicians, seven medical ple are properly sanitized and Association, the American students, and one nurse. Many confined to the back pages. Friends Service Committee, other health personnel have 11 Cerra " Spies were posted in hospitals to pass information concerning admissions and ward assignments to military and paramilitary groups. Later, hospitals were invaded and patients kidnapped.... Neither the motives for these crimes nor the identities of the assassins are ever known " Fee) 12 been wounded as well. We have also been provided documenta- tion about spies posted in hospitals who pass information concerning admissions and ward assignments to military and paramilitary groups. Later, hospitals have been invaded and patients kidnapped. We were told of the use of the mass media to intimidate leaders of the medical strike. Neither the motives for these crimes nor the identities of the assassins are usually known, and those rarely identified are almost always disputed. But it does seem that the same political passions and polarization that divide the country are the underlying " cause. ' C. " As a result of the closure of the University, the University Medical School no longer operates, and its future is uncertain. It is the only school of medicine in the country and provides the only training for most health worker. " D. " Many physicians, including the former Minister of Health, Dr. Roberto Badilla, have fled the country. " E. " Out of fear of reprisals to practicing physicians, it is reported that even persons who are innocently wounded are unable to receive prompt care. " F. " Violence has had other ef- fects as important as those which follow attacks on health personnel and patients. For ex- ample, an uncounted number of persons have fled from their homes out of fear for their lives. We personally visited a camp of over 1,000 of these persons liv- ing in totally inadequate quarters. Food, bedding, and medical care were all in critically short supply. " G. " It is obvious even from brief observation that routine violence has led to pervasive fear and tension. We too felt that tension. Every Salvadorean citizen told us not to go out at night. Each morning, the radio announced the bombings of the previous night, and newspapers showed pictures of the mutilated bodies. Clearly, the impact on mental health of all the people is inescapable. " The delegation will publish a complete report of their find- ings in the near future. Informa- tion about the report can be ob- tained by contacting Dr. Pedro Rodriguez, 146 Central Park West (1F), New York, N.Y. One specific request that health activists struggling for basic rights and democracy in El Salvador made was that health activists in the United States lock arms with them in solid, active support of their cause. Funds, medicine and personnel are badly needed, they said, but most vital is the involvement of health workers, institutions and professional associations in a campaign to stop the flow of American arms and military aid to El Salvador and make it impossible for the U.S. government to send Marines to repress a popular uprising. In future issues Health / Pac will provide more reports on the state (or nonexistence) of health rights in El Salvador and other countries, the role of the U.S. Government in these situations, and their implications for health activists here. -Jaime Inclan M. PORTAL SRVICE STATEMENT OF OWNERSHIP, MANAGEMENT AND CHICULATION 13. vers de m gh / PAC Byllati -- & fi cin can b 12. Fifth. Ann Nua York, M.Y 10011. 72 11th Avenue, New York, M.Y, 10011 NAMES AND COMPLETE ADONEDGES OF PUBLISHER EDITOR AND MANA/ Mman Sciences Press, 12 Fifth Avenue, New York, N.Y. 10022 | vw Mume and Addre _ Muzika Jorunky, 17 Murray Scrant, Mear York, 1.1. Ivan Matu ged a serva 10002- Donja 1. ,,asn, 12 Tich dommen, Muse Youk, NY1 0011 ted by a corporation in name and addrett mutt in suired and am dumadavS, Marder them out offer of mac holders swing or holding, i per ani je Mary 31 tching louhi , Mack Z and venued by a carpoukan. He pallet and albums of the albert, If valet hid perverdag ur other statesmanated trin, its name and vomum, az volt at that of such mitt eget be sets. I dhe publikun se published bi o vografie regiatan in vibe and address maar be adj Amber 72 Parth Avenue, New York, NY, 1001) LINGEN SONDIGGERS MORTGAGEES AND OTHER SECURITY HOLDERS ONG OR HOL I PERCENT ON Hand of TOTAL AMOUNT OF BO MORTGAGES OR OTHER secubitibi qf den or wha, a dild 15. FOR COMPLETION BY NONPROFIT ORGANIZATIONS AUTHORIZED TO MAIL AT SPECIAL RATED Shemu zan 200, vRA Then of the agonian ana shu saman save her Fatira insana ter que 10 A Y' INGGE DURING HAVE CHANGED BURMA ANTENNATURE OF CIRCULATION AVERAGE NO COME BACK iA ETA CONES PRINTED Mar Prem Ba & MODULATION 3250 TRIBUTION DU MAIL, CARMEN DE OTHER MEAN TOTAL dan of c [TER E. LEPY OVER UNACCOUNVEILED In ang agus AndNTS v sy that die datumunta quade by the 1426 1-26 95 1521 F 1729 Morte 3250 2800 Xona 1616 1616 95 1711 1009 Home 2800 MEC in o da prvem Zi de spun ca a permanen ja man in pangan ngang in van 1 an dn phai P RURAL The Lord of the Rings in local children's libraries, it was ac- tually a 1961 underground atomic blast in the Florencia WASTE IN SALT TOO rounding salt to become hot and soluble, allowing radioactivity to escape. He was fired. Others have pointed out that the pro- posed dump would be ten miles from the Pecos River, which flows into the Rio Grande. Unless the government hopes this will stop undocumented workers from leaving Mexico or thinks there are too many healthy fish in the Gulf of Mex- salt domes. The explosion was, of course, designed to be safe, but radon and other radioactive isotopes escaped into the at- mosphere. Area residents are well aware that their cancer rate is above the national average, and they have no desire to risk another experiment which could raise it further. Despite this vigorous opposi- tion, the valley may yet become Back when Ronald Reagan was welcoming kids to Death Valley Days, Westerners living in high desert regions could usually expect an occasional wayward coyote to be the most serious disruption of their daily life. No longer. Some farmers and ranchers are getting ready for a showdown with the MX missile. Others are anticipating a life and death battle against massive shale oil conversion projects. Down in New Mexico's quiet, beautiful Pecos Valley, local residents are organizing to repel what may be the most dangerous invasion of all, which comes with the ap- propriately menacing name WIPP. ico, choosing this site appears hard to understand. In addi- tion, if WIPP comes to southern New Mexico, McDonald's ham- burgers might soon be hotter than customers expect: the Pecos Valley is one of the coun- try's foremost producers of hay and alfalfa, and its crop is sold to dairies and feedlots throughout Texas. The fiercest opposition to WIPP has come from the Florencia Land Rights Council, a local grassroots organization composed primarily of poor Chicanos descended from early Spanish settlers and local In- dians. For the past three years, the council has organized peti- tions, demonstrations, and Nuclear radiation may be sprouting along with the petunias what a DOE document honors with the name " National Sacri- fice Area. " New Mexico's con- stitution has no provision for a referendum, and its elected of- ficials are not generally noted as champions of the poor - 60 per cent of the legislators have a financial interest in the mining industry. There is certainly money to be made from WIPP, which is budgeted at $ 1.1 billion even before Bechtel and The Waste Isolation Pilot Pro- public education programs so Westinghouse, the major con- ject is designed to hold plutonium and other nuclear waste in six square miles of salt successfully that government officials are treating the valley's residents with the caution they tractors, begin announcing their cost overruns. Because New Mexico is an beds two thousand feet might better employ with radio- " Agreement State, " no specific underground. In 250,000 years, if the radioactivity has been successfully contained the active wastes: all hearings on WIPP are held 300 miles away in Santa Fe. Nuclear Regulatory Commis- sion approval is required for the facility, and the Pentagon has Department of Energy public Unfortunately, the council proclaimed it vital to national relations staff can proclaim that doesn't have to rely on abstract security. As far as the in- this experiment in permanent arguments alone, since the digenous people of the Chicano waste disposal was a success. Florencia area has already nation are concerned, this inva- Some people are already already been afflicted with Project sion is another example of the dubious. One physicist with the Gnome. The military has a way mentality which ordered the National Aeronautics and of dubbing its operations with destruction of Vietnamese Space Administration (NASA) pleasant titles, and although villages in order to save them. warned that intense heat from Project Gnome may conjure up -From a report by the waste would cause the sur- images of public readings of Miguel Carrasco 13 Health / PAC Bulletin Renew your subscription today! Individual 14.00 $ Institution $ 28.00 Student $ 11.20 Volume 12: 1980-1981 (six issues). Health / PAC Bulletin is published bimonthly on a volume year basis from the September - October issue to the July August - issue. THE HEALTH CARE HIERARCHY If You Liked This Issue, You'll Love the Next Six The Health / PAC Bulletin doesn't have to boast that it's better than the competition; there is no competition. No one else offers independent analysis of health policy issues from prenatal care to hospices for the dying; covers medical carelessness for women and on the job poisoning; offers incisive international reports and lively briefs on domestic health developments. If you already know all this and have a subscription, why not do a friend a favor and fill in his or her name on the form below before you run out of 15 stamps? Remember, nine out of ten radical doctors recommend the Health / PAC Bulletin for fast relief of health care policy mystification. Please esntuebr scription (s) for: Health / PAC Bulletin Check: Y' Order 645-5 Individuals $ 14.00 Y' Order 646-3 Institutions $ 28.00 To: Name Address City State. Zip C) L} Check enclosed (deduct 10% of order) Bill me (plus postage and handling) Y' Charge: Y' Am.Ex. Y' Visa Y' Master 14 No. Signature WORK ENVIRON F CALIFORNIA'S FRIENDLY CCOP and other public places without their knowledge, not to say con- sent or awareness of the hazards involved. The hazards are con- siderable. Many pesticides are believed to cause serious health problems including cancer, sterility, birth defects, muta- tions, and neurological da- mage. If they do those, of us who breath may find out the hard way, since most pesticides have It is no surprise that Califor- nia, birthplace of the square tomato, was smothered in 290 million pounds of pesticides in 1977, the last year for which statistics are available. However not many people, even Californians, are aware that 35 million of those deadly pounds landed in urban and suburban areas, where 7/8 of the state's population reside. There are individuals who wouldn't touch a sugar coated - cornsmack with a ten foot spoon who spray bug killers on cracks, lawns, and pools with the abandon of a helicopter gunship raiding a free - fire zone in Vietnam. Home use, both personal and professional, of these weapons accounts for over 50 percent of all pesticide poisonings. In addition, even the careful are bombarded by sprays used in parks, buses, HELP PROTECT ENDANGERED SPECIES HOMO Y SAPIENS THERE YOUR " BS, B zB FRIENDS ie (i Hehir %,. '<4 never been tested for per- nicious effects except on their intended target. It could be that just as cockroaches are expected to survive a nuclear holocaust bet- ter than humans, we are less vulnerable than they are to roach sprays, but we may not be so lucky. Some day the notion that pesticides are essential, beneficial, and safe may appear as strange and disastrous as the assumption that we can survive a nuclear war. Despite these dangers, government policies, practice, Despite the dangers, government policies on pesticides are made with virtually no public participation and do not protect citizens from home or workplace exposure a and regulations are made with virtually no public participa- tion, and do not protect citizens from food, home, and workplace exposure. Not convinced that what you don't know won't hurt you, a group of California organiza- tions and individuals formed the Coordinating Committee on Pesticides (CCOP) in 1978. It has already grown to include 62 organizations and over 500 in- dividual members. Most of them are concentrated in the San Francisco Bay Area, Sacra- mento, Santa Cruz, and North- ERRATIM: References 99, 102, 104, 105, and 107 in the paper by David Noble, " Benefit Cost - Anal- ysis: The Regulation of Business or Scientific Pornography " (Health / PAC Bulletin, Vol. 11, No. 6, August, 1980) were misattributed. The proper attribution should read as follows: " quoted in or from draft documents based on a group research project under the direction of Diana Dutton entitled " Innovation in Medicine: Policymaking and the Public, " Division of Health Services Research, Stanford University School of Medicine, with collaboration on these topics from Nancy Pfund and Deborah Lubeck, and with funding from the National Science Foundation's Program in Ethics and Values in Science and Technology. 15 Pesticide hazards are considerable. They are believed to cause serious health problems including cancer, sterility, birth defects, mutations and neurological damage. Most have never been tested for any effects except on their intended targets ern California, but new recruits are increasing in the Los Angeles and Salinas areas. In the process, it has become one of the first successful statewide efforts to link labor, en- vironmental, health, agricul- tural and consumer groups around a single issue. CCOP's efforts to publicize the hazards of and alternatives to pesticides have concentrated on the workplace, consumer health, and urban pesticides; all key areas which previously received little attention in the government. During the first year, these neighborhood and workplace groups will be linked to each other and to the state- wide organization. Berkeley, which has _ pro- bably had more experience with bugs than any other city in the country, was the site of our pilot project and first victory. After a report by the local com- mittee on pesticides used by public agencies locally and possible alternatives, the city council banned all use of her- bicides and four insecticides in the city. The committee is now working with city park workers and the John Muir Institute to create a volunteer force of 30 people which will maintain an Integrated Pest Management program in Berkeley's parks. -Sharon Miller (Sharon Miller is a member of CCOP.) state. Aside from reaching the urban population through legal efforts, media work, organiz- ing, and public education, the alliance is working with the Oil, Chemical, and Atomic Workers and numerous organizations focussing on rural aspects of the pesticide menace, including the California Agrarian Action Project, Friends of the Earth, and the Environmental Defense 43438 HB eed iit Fund. Once urban and rural constituencies have been mobilized for the necessary political and economic change, a more rational pesticide policy will become possible. Science has yet to invent a poison that won't make a profit for some- one. CCOP is currently organiz- ing (and seeking funding for) an Urban Pesticides Project to inform, train, and organize target groups of consumers and workers who will begin asser- ting popular control over 16 pesticide policy at all levels of an wy " Sea or mountain air? " Wessuan New York WASHINGTON Massive political pressure ap- pears to have temporarily saved Metropolitan Hospital in East Harlem. A $ 15.4 million bail- FEVER CHART Washington, D.C. Public and inner city com- munity hospitals gained a powerful new ally recently when representatives of unions, health professions, community groups, and legal services pro- grams established a Coalition to Save Public Hospitals to press for federal in tervention - and funding; define a new national policy for public hospitals; and demand a complete moratorium on cutbacks and closures of public, inner city and rural community hospitals. Working with the Coalition for the Public General Hospital formed by members of the American Public Health Association, the new group intends to develop a national advocacy network and aggressively lobby Congress and the Department of Health and Human Services (DHHS). The alliance certainly has its work cut out. On June 25, 1980, HHS Undersecretary Nathan Stark testified before the Senate Committee on Labor and Human Resources against two bills proposed by Senator Jacob Javits and Congressman Charles Rangel (both of New York) to assist the troubled hospitals. Stark, who favors private sector solutions, oppos- ed any long term federal bail- out for public hospitals. Just in case anyone missed the point, in an interview with Federation, the trade journal of the Federa- tion of American Hospitals (American means for profit -), Stark claimed that " poor management " was the biggest single problem facing public hospitals today. Readers of Federation know he means management of the poor, and they are eager to help. Chains already enjoy lucrative man- agement contracts with over 150 public hospitals; Hospital Corporation of America, the largest, has gobbled up 22 public hospitals in recent years and is hungry for more. (For more on private management contracts, see the CHICAGO story below). Curiously, while Stark is out speaking for HHS, back at the office policy is precisely what he opposed: financial assis- tance to troubled hospitals. In early September, HHS unveiled a plan to support Medicaid " ex- periments " which would pro- vide coverage for the millions of medically needy who cannot qualify for Medicaid due to ex- clusionary eligibility re- quirements. Because many states have refused to raise their income eligibility ceilings to take inflation into account, 1.7 million fewer people receive Medicaid assistance now than two years ago. Many families as poor or poorer than they were in 1978 found themselves over in- come, and hospitals which served them teeter at the brink of bankruptcy. This generosity is, of course, pre election - plan- ning, and Mr. Stark's views may prove to be more representative in the future. out proposes to make Metropolitan the base for an ex- perimental HMO of at least 34,000 members. The agree- ment between city, state, and federal officials requires $ 7 million from the federal govern- ment to expand Medicaid coverage to nearly 17,000 " medically needy " residents who are ineligible for Medicaid and have no other insurance. Because many states have refused to raise their income eligibility ceiling to take inflation into account, 1.7 million fewer people receive Medicaid assistance than two years ago a HMOs customarily worry about participant withdrawals if their service deteriorates. In this program the participants will worry when they realize the HMO's balance sheet improves as it reduces care, at least so long as the patient remains alive. The government, however, appears uncon- cerned; a similar New York pro- gram sends clients'rent checks direct from the Welfare office to landlords and the only problem has been the destruction of the South Bronx. The agreement also includes conversion of Sydenham Hospital to a drug and alcohol rehabilitation center. Com- munity groups and Sydenham physicians have charged that Mayor Koch's refusal to allow emergency room care will needlessly jeopardize thousands of Harlem residents, who will be forced to go elsewhere. The nearest alter- 17 native, Joint Diseases Hospital, is itself on the verge of bankruptcy and uses a building which has been allowed to deteriorate since a new, modern facility was constructed in midtown Manhattan. Detroit Mayor Coleman Young has finally succeeded in closing Detroit General Hospital. The city reluctantly opened Detroit Receiving Hospital, which it claims it cannot afford to operate, but Young is negotiat- ing with a consortium of private hospitals to sell DRH to them outright. Since Wayne County General is a two hour - bus ride from the Detroit ghettos, this would leave the city's poor without any hospital. The poor people of Detroit are, in effect, subsidizing one of the country's largest corpora- tions: Mayor Young has " for- given " over $ 150 million in back taxes Chrysler owes the city. This gift was the main reason behind this summer's militant strike by city employees; they don't feel they should pay because some bright executives were convinced the American public wanted gas guzzlers. No fault - capitalism, anyone? missory notes so hospital bill collectors could dun them and announcing a recruiting drive to fill the long empty nursing positions. Young said he is returning to private practice, where he will cheerfully accept Medicare assignment and Medicare pa- tients. He added, to no one's surprise, that he will continue fighting for public health care - and hopes to have more time to do so now that he is freed of his administrative respon- sibilities. Denver Trouble is brewing at Denver General Hospital (DGH), where the administration is refusing to bargain with 2,300 nurses and technicians in the AFT sponsored - Federation of Nurse Health Professionals. The hospital has threatened to radically alter job descriptions and allow untrained and un- supervised personnel to give in- jections and perform com- plicated tests. DGH administrators are also on the offensive against their patients. Last year they shut down its major family practice center, putting even more pressure on the overworked emergency room. Chicago Los Angeles Dr. Quentin Young, Medical Last year Health / PAC Director of the embattled Cook reported the closure of the County Hospital went out in industry dominated -. Los style early this summer. Young, a veteran of many wars on behalf of the underprivileged, resigned with a sharp denun- ciation of Hyatt Management Angeles Health Systems Agen- cy (BULLETIN vol. 11, no. 1). Some of the same players are back in business as the new HSA staggers to its feet follow- Enterprises, which has run the beleaguered hospital under contract since last winter. Em- ing a craven federal capitula- tion to pressure from powerful local politicians. HHS barrassed and nervous Hyatt of ficials immediately acceded to designated the county ad- ministration as the new HSA, two of his major demands, ignoring its close ties to the cor- cancelling plans to force poor ruption which plagued its 18 uninsured patients to sign pro- predecessor and a strong, community - backed coalition which hoped to form the health. planning body serving the county's seven million people. At the HSA board election, it was business as usual. Many veterans of the first agency used their old tricks to dominate the second. Hundreds of Viet- namese refugees were bussed to polling places to " elect " a labor controlled - slate with close ties to the private hospital sector and the construction trades; county labor officials had told independent candidates that they shouldn't even bother run- ning. It was a splendid victory. The new President of the LA County Health Planning Com- mission is one of the staunch- est backers of the scandal it replaced. The new HSA officials are already proving their loyalty to the county government, sitting quietly at their desks while health officials down the hall plan closures of public hospitals and clinics. A top candidate for Executive Director of the new agency is Tony Watson, cur- rently Director of the New York City HSA. Public hospital ad- vocates give Watson extremely low marks for his agency's whitewash of Mayor Koch's at- tack on New York's public hospitals. Although under his administration the NYCHSA plan offered a token defense of one Harlem hospital, it sup- ported over three quarters of the cuts recommended by the mayor. -Mark Allen Kleiman (Mark Kleiman is director of the Consumer Coalition of Health, a national alliance of labor, civil rights, senior citizens, women's religious and com- munity organizations dedicated to greater consumer control of the health system.) OMark Kleiman, 1980 The Neighborhood Health Center Continued from Page 10 tion and Welfare funded several neighborhood health centers under a general authorization (314e) for the support of experimental compre- hensive health care programs in underserved areas. This was a provision of the Comprehen- sive Health Planning and Public Health Service Amendments of 1966 (PL 89-749) and the Part- nership for Health Amendments of 1967 (PL 90-174) (5). By 1971 there were approximately one hundred and fifty neighborhood health centers in operation across the United States. Two thirds - of these were sponsored by OEO, the other third by DHEW. In 1970 the Nixon Administration began dismantling OEO and moving its programs to other agencies. Be- tween 1970 and 1973, all of the OEO sponsored neighborhood health centers came under the jurisdiction of DHEW (6). The Nixon Administration desired to reduce the role of the federal government in the direct funding of social programs. In 1973 it attempt- ed to implement a policy which required that health service delivery programs become " self- sufficient, " that is independent of federal grant funds (7). With support from key Congressper- sons and sympathetic career officials in DHEW (8), grant funds for NHCs continued to be authorized and appropriated. The Health Revenue Sharing and Health Services Act of 1975 (PL 94-63) established a separate cate- gorical grant program for funding health centers, which were renamed " community health centers " (CHCs). Up until this point, centers had been funded under the general 314e authority for experimental health pro- jects. While it was recognized that " self suffi- ciency " would not be possible for CHCs unless the health financing structure was changed (9), both DHEW and Congressional health subcom- mittees continued to expect centers to increase the proportion of their operating budgets which came from third party funds. In the words of a former Congressional committee staff person, members of Congress believed that it was im- portant that health centers " learn to live in the same third party world as everyone else " (10). Unfortunately, this " third party world " is systematically biased against health services in contrast to medical care, and against free- standing, community - based care, while sup- portive of hospital - based care. Medicare did not recognize CHCs as reim- burseable providers until 1973 and has only granted recognition to centers which have very sophisticated accounting procedures (11). Medicaid is a federal - state program in which participating states are required to provide eight mandatory services. Each state can then elect to provide other services from a group of optional service categories. While out patient - hospital services are one of the eight federally- mandated services, " clinic services, " the category under which community health cen- ters are recognized as " providers, " is one of the Despite an ideological credo of " the bigger, the better, " an Office of Management and Budget study found that between 1953 and 1973 half of all the innovations came from companies with less than 1,000 employees optional categories (11). A 1977 Georgetown University Health Policy Center study of Medicaid reimbursement of community health centers found that only 22 states and the District of Columbia recognized CHCs as " clinics " and reimbursed them for services provided (11). This is less than half of the states participating in the Medicaid program. Community health centers can be reimburs- ed for specific services (both mandatory and optional), such as physicians'services, family planning, laboratory tests and x rays - when a state does not recognize the centers as pro- viders under the optional category of clinic ser- vices. However, each rendered service must then have a separate provider number, and physicians performing each service must sub- mit a separate bill. This method of reimburse- ment not only complicates accounting, but does not cover the full cost of services provided (11). 19 9 At left, the Johnson Administration offers a health care plan. Above center, the Nixon Administration presents its own health policy. At right, Neighborhood Health Centers request additional funding. Even when CHCs are reimbursed as clinics providers nurse practitioners, physicians'as- under a state Medicaid plan, they are not likely sistants and family health workers. Neighbor- to be reimbursed for all of the services that they hood health centers pioneered in the integra- provide to their patients. The Georgetown Uni- tion of such workers in the delivery of health versity study found that services (3). Medicare and Medicaid do not the " clinic services " category has been used primarily to reimburse traditional medical and dental services (including lab and x ray -), and some non traditional - services, such as family planning and EPSDT, that are mandatory Medicaid ser- vices (11). reimburse for the services of family health workers. In the case of Medicare, nurse practi- tioners and physician assistants were not reim- bursed for their services at all until the passage of the Rural Health Clinic Services Act in 1977. However, that legislation impacts only on such practitioners in rural health centers (13). Six- teen state Medicaid plans reimburse health ser- For example, only five of the 22 states which vices provided by nurse practitioners and / or recognize CHCs as clinics reimburse for out- physicians'assistants, less than a third of all reach services. Six states reimburse for coun- Medicaid programs (11). However, only five of seling services and seven for health education. these states allow separate reimbursement for Only one jurisdiction, the District of Columbia, the services of such non physician - practi- reimburses for environmental services. tioners if a physician is not present at the facili- What consequences does this aspect of the ty at all times (11). financing system have for the neighborhood The failure of community health centers to health center " model " of comprehensive health gain recognition as institutional providers for services? As pressure was increased from Medicaid reimbursement in many states can be DHEW and Congress to show evidence of seen as one consequence of the limited political greater recovery of Medicaid and Medicare resources that they and their constituents can monies, centers were forced to cut back on mobilize in the politics of the state level rate- non reimbursable - services, those very services. setting process. which made the model innovative. In New York CHCs, of course, share the difficulties with City, for instance, health centers attempted to the Medicare Medicaid / system common to all reduce cost by decreasing staff health institutions serving low income popula- in " the fringe areas " such as transporta- tion personnel, supportive services and outreach. At the same time attempts were made to maintain staffing levels in the areas of direct services by health care providers (12). tions. As a result of both initial state decisions on eligibility requirements and cutbacks im- posed in response to program costs, only one- third to one half - of the population with incomes below the federal poverty level is covered by the Medicaid program (3). Large numbers of individuals served by CHCs have incomes A parallel phenomenon occurs with the re- above the Medicaid level but cannot afford to 20 imbursement of non traditional - health care pay for their health care, placing an additional financial burden on the CHCs. Approximately two thirds - of the operating fiscal year 1978), this proportion has steadily decreased since 1975. The number of larger, budgets of most centers still must come from federal grants awarded by the Bureau of Com- munity Health Services (BCHS) within the Public Health Service (14). The policies of the comprehensive " " CHCs in 1979 was 158, ap- proximately the same as the number in 1971 (18). Bureau have not, however, provided a counter- balance to mainstream reimbursement policy by supporting nontraditional or innovative ser- vices. Rather the Bureau's thrust has been to The failure of community health centers to gain recognition as fund large numbers of small projects in medi- cally underserved - areas in an effort to " fill in the gaps " in the health care delivery system in preparation for a national health financing system (15). In 1975 the BCHS began a " rural health initiative " (RHI) and in 1977 an " urban providers for Medicaid reimbursement can be seen as one consequence of their limited political resources health initiative " (UHI). The rural health initiative was an administra- BCHS literature on the rural health initiative tive policy of allocating more of the resources of the community health center program to rural areas, of funding smaller primary care projects that were to be integrated with other federal programs, such as the National Health Service Corps, and of targeting resources into areas of greatest need (16). The shift to rural programs was at least in part a decision based on the issue of equity. While more than half of the medically underserved population in the U.S. lived in rural areas, approximately 85% of neighborhood health center funds in 1974 went to urban areas (16). (The War on Poverty, a re- sponse to urban riots and the potential role of urban minorities in national politics, had been largely " fought " in urban ghettos.) The deci- sion to fund more programs in rural areas was coupled with a shift in the type of program funded. makes it clear that such projects are to inte- grate not only all federal grant programs in a given community, but also the private and the public sectors and primary care projects and hospitals (19). Those receiving RHI grants can be existing providers who will expand their ser- vice area (20), utilize additional manpower, and / or provide a mechanism for the coordina- tion of their services with those of other pro- viders in their area (19). In one Bureau publication seven schematic models of health care organizations are described, varying from one another in the degree of " hospital involve- ment " in the provision of primary care. The models in which the hospital is closely involved in the health center are described in much more positive terms than is the community con- trolled model (21). The first 35 UHIs were funded in 1977, and Bureau officials believed that smaller pro- the following year the number was increased to grams could be more efficiently managed and, in a cost conscious era, would be less sixty (17). Urban health initiatives, like RHIS, are small scale projects which need not, ac- vulnerable to accusations of " waste " than the cording to Bureau literature, provide services larger urban programs had been. Smaller scale programs would also be more appropriate to isolated rural settings. A source close to the other than basic medical care (19). UHIs also are attempts to build a " health system " in a medically underserved area through the in- program suggested that the funding of a large number of health centers in new areas would tegration of federal programs and existing health service providers. A UHI grant may be also have the effect of increasing the number of awarded to a wide range of organizations, in- Congresspersons with health centers in their districts and, thus, broadening Congressional support for the program (16a). Between fiscal years 1975 and 1978, the number of rural health initiative projects increased almost eight times from 47 in FY 1975 to 356 in FY 1978 cluding hospitals and group practices. Thus, the health initiatives, conceived at a time of concern about the " rational " use of resources, is an effort to coordinate existing resources and / or to have existing providers service populations which have not previously been (17). While the older and larger community served (19). Questions must be raised about health centers are still receiving a majority how decision - making power will be distributed (82% of the total of CHC program funds in Continued on Page 27 21 sae 'De Moana! Hee wad Ries teat he rn Bot tome Babies Contact Stella in Co - op 7601 Expanding Sutton's Law Interviewer: " Why do you continue robbing banks? " Willie Sutton: I go where the money is. " The trends which May and Sardell describe in the preceding articles are disturb- ing but not unexpected for those aware of the important historical and ideological forces here that parallel wider developments in the economy. During the post - war era the academ- ic medical center, like the multinational cor- poration, through expansion and diversifica- tion, has been able to capitalize on the chang- ing public funding agenda, be it basic research, facility or manpower expansion, or primary care, by " going where the money is. " As noted above, the neighborhood health center grew from a pilot project within the Of- fice of Economic Opportunity (OEO) in 1965 as 22 part of the Johnson administration's response to the vigorous civil rights movement. OEO developed a strategy that placed their money and agenda for change with creative " change agents " within academic medicine who were to use their grants as leverage for expanding a broad range of both traditional and innovative services into selected poor communities () 1. Through their grants strategy, OEO tried to buy legitimacy for and diffuse opposition to its most long lived - offspring - the community health center (CHC). From the beginning, the potential conflicts of interest and agenda for the professional " change agents, " the funding agency, the academic medical centers, and the communities were built into the structures of CHCs. The history of CHCs has been the prod- uct of the politics of this interaction. Beginning with the dismantling of OEO by the Nixon administration and the transfer of these programs from OEO to HEW (now, Health and Human Services), OEO's agenda for changing the health care system has disap- peared beneath HEW's agenda for containing it.01 Since this transition to HEW the comprehen- sive services mandated by OEO for CHCs have been consistently eroded toward more tradi- tional, strictly medical care. This has meant the loss of training programs and innovative roles, such as the family health worker and health. teams. Much of this erosion has been justified under the rubric of efficiency and cost- containment in HEW's long push toward economic self sufficiency - for CHCs. Thus, ser- vices which are not reimburseable in state Medicaid and Medicare plans have been even- tually eliminated. Responding to the AMA's self serving - criticism of CHCS, HEW, through its Bureau of Community Health Services (BCHS), has in- creased its productivity demands (based solely on medical visits), while federal grants diminished (compared with inflation) and were spread among many more projects (see Table 1). Table 1 Overview of Bureau of Community Health Services Programs, 1974 - 1979 covered only 10 to 20 percent of operating costs at most centers (4). For many years the centers were caught in a double bind: while mandated to serve all low- income people, in 1969 under pressure from private practitioners and the AMA, they were limited to 20 percent paying registrants. Thus, " poor people's medicine " was legislated, mak- ing a transition to economic self sufficiency - im- possible. Inflation and reduced federal support led to cuts in CHC services, hours, and access and forced fees upon formerly free care. It became inevitable that many low income - people would return to the hospital emergency rooms and OPDs for their care. These constraints upon CHCs have now been The medical empires and academic health centers have gone where ' the money is offering'- to solve the problems of specialty and geographic maldistribution which they were responsible for creating used to rationalize shifting more resources back 1974 1979 Change towards the academic medical centers and Total Grant Dollars teaching hospitals. Claiming that poor patients, ($ in millions) $ 733.2 $ 968.8 + 32% Projects Supported 790 1,734 + 119% Average Grant Size $.93 $.56 - 60% armed with their Medicaid cards, are " voting with their feet " in their continued and increased use of hospital ambulatory facilities, legislators and hospital lobbyists are proposing to fund " re- Source: Bureau of Community Health Services Data organized " hospital OPDS in apparent direct competition for monies with CHCs. Private philanthropy, uninterested in underwriting long Thus, the innovations created by CHCs are be- term projects, has turned to a grant formula ing lost because neither funding nor reimburse- which examines their short term return on in- ment agencies adequately fund ambulatory care vestment, best delivered by the " blue chip " or recognize and reimburse the many ancillary teaching hospitals. services provided by CHCs and their new prac- The historic process has come full circle. titioners (for example, family health workers). CHCs were created so that poor people would In 1967, HEW called for the establishment of no longer be " forced to barter their dignity for + 1,000 health centers to serve 25 million low- health care " at teaching hospitals (5). Yet, income people by 1973 at a cost of $ 3.4 billion CHCs were sponsored and legitimized by those (2). Instead, in 1977 approximately 420 centers very teaching hospitals for overhead and expan- were serving 3.3 million people at a cost of $ 225 million (3). National health insurance, antici- sion. Now, mandated by legislation which re- quires consumer majorities on their boards of pated by the HEW planners to rationalize their push toward economic self sufficiency - for directors, CHCs have become largely indepen- dent, community - controlled entities. The Javits CHCs, remains as distant as ever. Funds from Amendment - the Health Health Services and Centers Medicare and Medicaid in 1975 actually Amendments of 1978 (PL 95-626) -to the Public 23 Despite the success of community health centers in reaching and serving people in impoverished communities, they have been burdened with an undeserved image of costliness and inefficiency Health Service Act would recapture this source of federal support for hospitals by making them eligible for the funds which currently support CHCs. This development has been supported by the influence of the Robert Wood Johnson Founda- tion which has helped shape HEW policy in matching its money to certain HEW sponsored - demonstration projects. The foundation, pre- sided over by a former dean of Johns Hopkins medical school, perpetuates the prejudices of academic medicine against community control. Thus, it has funded the " organization re - " of 15 teaching hospital OPDs and ten urban, primary care networks based in hospitals. These would employ National Health Service Corps (NHSC) personnel, which requires by law consumer- majority governance bodies absent at such hospitals. Thus, after a short hiatus, the medical empires are back pursuing the control of the federal dollars supporting primary care. Two important social costs will be borne by the public if this trend continues, as noted by Berkson (see previous BULLETIN). First, innovation will be stifled. Despite ideological credos that " the bigger, the better, " an Office of Management and Budget study found that be- tween 1953 and 1973, half of all major innova- tions came from companies with less than 1,000 employees. Yet, only four percent of federal funding goes to these smaller, more innovative firms (6). This parallels the growing trend toward support of large medical institutions over the smaller, community - based centers and hospitals. Elsewhere in the economy, this is called corporate monopolitization. In health care, however, the media portrays any developments in high technology as genu- ine innovation and glorifies the corporate giants that produce " new, revolutionary " discoveries that are often no more new " " or " revolutionary " than the other consumer products so advertised - on television. Just as artificial needs are created by advertising, so too is our subjective ex- 24 | perience of the scarcity of personal, primary care (how " do I find a family doctor? ") and vulnerability to an increasingly hazardous en- vironment (is " there anything which does not cause cancer? ") subverted. This results in inap- propriate demand for high technology, falsely- elevated expectations, misuse of existing ser- vices, and growing costs. More important are the increased direct costs that would result from shifting greater support to hospital - based outpatient services. One of the major successes of CHCs has been their docu- mented reduction upon hospital days for the populations they serve (7). While in the interest of the public purse, this cannot be in the interest of hospitals dependent upon high occupancy rates for their financial well being - . Their in- Biases in the Medicare Medicaid / system and in the Bureau of Community Health Services have made it increasingly difficult for existing community health center programs to provide comprehensive health services terests would control the proposed services. In addition, costs for identical services are likely to be higher in teaching hospitals while the quality is the same or superior in CHCs (8). The basic contradiction between the federal policy pro- moting cost containment - and its support of trends toward basing more ambulatory services in hospitals is readily apparent, suggesting the political influence of the medical empires. Despite the success of CHCs in reaching and serving people in impoverished communities, they have been burdened with an undeserved image of costliness and inefficiency, frequently unfavorably compared to the costs of care from the very private sector which abandoned these communities (4). CHCs may, in fact, be the only providers in the health sector which have successfully re- duced costs! HEW estimated that the annual total expenditures per person served by CHCs was $ 238 in 1974, but only $ 204 in 1975, while the national average rose from $ 214 to $ 240 for comparable services (4). Since 1975 BCHS pro- jects (CHCs, NHSC sites and migrant worker projects) have shown further reductions in costs and improvements in productivity and efficien- cy (see Table 2). Davis and Schoen estimated Table 2 Bureau of Community Health Services Primary Care, 1974 - 1979 1974 1979 Administrative Improvements Provider Productivity 3,072 4,015 Administrative Costs as Percent of Total Ambulatory Costs 25% 22% 3rd Party Reimbursements as Percent of Total Operating Costs Cost per Encounter 17% 38% $ 44 $ 32 * 1975 Data Source: Bureau of Community Health Services Data that when the cost saving resulting from reduced hospitalization are included, CHC care costs $ 65 less per person than for the population as a whole (4). And that figure does not even account for the greater costs for providing health care exclusively to the poor! Despite the built - in structural conflicts, CHCs have succeeded in demonstrating that high quality, accessible health services can be pro- vided for and actually improve the health of the poor, while functioning as a center for com- munity economic development (9). However, the CHCs remain an anomaly and innovation which has not entered or been supported by the medical mainstream. Still marginal because reimbursement fails to support preventive and primary care, the CHCs are vulnerable to the political winds, currently blowing against com- munity control and toward teaching hospitals. CHCs may soon resemble the limited, tradi- tional medical model for which they were to have been the antidote. At the same time the medical empires and academic health centers have gone " where the money is, " offering to solve the problems of specialty and geographic maldistribution which they were responsible for creating. Federal policy makers - must reckon with this contradic- tion - in an era of containment cost - their support of hospital - based ambulatory care will increase direct costs, while generating indirect costs of 25 One of the major successes of community health centers has been their documented reduction in hospitals days for the populations they serve. Hospitals which are dependent upon high occupancy rates for their financial well being - won't like this decreased innovation, flexibility, appropriate- ness, community responsiveness, and personal service. Framing Sutton's law is another law, which states that while little thieves - like Willie Sutton - are penalized, the corporations pros- per: caveat emptor. And we pay for both. -Hal Strelnick References 1. May, J.T., Durham, M.L., and New, P.K., " Professional Control and Innovation: The Neighborhood Health Center Experience, " in Roth, Julius, ed., Research in the Sociology of Health Care. Greenwich, CT: JAI Press, 1979. 2. USDHEW, Office of the Assistant Secretary (Planning and Evaluation), Delivery of Health Services to the Poor. Washington, D.C.: Government Printing Office, 1967. 3. May, Jude Thomas, Parry, K.K., Durham, M.L., and New, P.K., " Institutional Structure and Process in Health Ser- vices Innovation: The Reform Strategy of the Neighborhood Health Center Program, " in Brenner, M.H., Mooney, A., Nagy, T., eds., Assessing the Con- tributions of the Social Sciences to Health. Boulder, CO: Westview Press, 1979. 4. Davis, Karen, and Schoen, Cathy, Health and the War on Poverty: A Ten - Year Appraisal. Washington, D.C.: The Brookings Institution, 1978. 5. Schorr, L.B., and English, J.T., " Background, Context, and Significant Issues in Neighborhood Health Center Programs, " Milbank Memorial Fund Quarterly 66: 289-296, July 1968. 6. The Washington Spectator 6: 4, March 1, 1980 quoting an Office of Management report. 7. 7. Alpert, Joel J. et al., " Effective Use of Comprehensive Pediatric Care: Utilization of Health Resources, " Am] Dis Child 116: 529-533, November 1968; Klein, Michael et al., " The Impact of the Rochester Neighborhood Health Center on Hospitalization of Children, 1968 to 1970, " Pediatrics 51: 833-839, May 1973; and Zwick, Daniel I., " Some Accomplishments and Findings of Neighborhood Health Centers, " Milbank Memorial Fund Quarterly 50: 393-410, October 1972. 8. Morehead, Mildred A., Donaldson, R.S., Seravalli, M.R., " Comparisons between OEO Neighborhood Health Centers and Other Health Care Providers of Ratings of the Quality of Health Care, " Am J Pub Health 61: 1294-1306, July 1971. 9. Stewart, James C., and Crafton, L.L., Delivery of Health Care Services to the Poor: Findings from a Review of the Current Periodical Literature. Austin, TX: University of Texas, Center for Social Work Research, 1975. -Books Received- - American Health Association, Heart Book: A Guide to Preven- tion and Treatment of Cardio- vascular Diseases (New York: E.P. Dutoon, 1980) $ 25.00. Elison, Jack and Athalia E. Sieg- mann (Eds.) Socio Medical - Health Indicators (Farmingdale, N.Y.: Baywood, 1979). the Man Made - Environment on Health and Behavior (Atlanta: Center for Disease Control, 1980). Barrett, James E. (Ed.), Stress and Mental Disorder (New York: Raven Press, 1979). Falkson, Joseph L., HMOs and the Politics of Health System Reform (Chicago: American Hospital Association and Robert Lifton, Robert Jay, The Broken Connection (New York: Simon and Schuster, 1979) $ 15.95. Barth, Peter and Allan H. Hunt, Workers'Compensation and Work Related - Illnesses and Di- seases (Cambridge: The MIT Press, 1980). J. Brady Co., 1980). Hall, David and Margaret Stacey (Eds.), Beyond Separa- tion: Further Studies of Children in Hospitals (London: Morra, Marion and Eve Potts, Choices: Realistic Alternatives in Cancer Treatment (New York: Avon Books, 1980) $ 18.95. Braverman, Jordan, Crisis in Routledge and Kegan Paul, 1979). Raffel, Marshall W., The U.S. Health Care (Washington, Health System: Origins and D.C.: Acropolis Books, Ltd., Hinkle, Lawrence E., Jr. and Functions (New York: Wiley, 26 1980) $ 16.95. William Loring, The Effect of 1980). The Neighborhood Health Center Continued from Page 21 within such rural and urban " health systems. " element of the neighborhood health center model. If the original neighborhood health center -Alice Sardell model is now reviewed, it is clear that several of its central elements are peripheral to the cur- rent thrust of federal policy. Reforms embodied in the neighborhood health center model in- (Alice Sardell teaches health policy and urban politics in the Department of Urban Studies at Queens College / CUNY.) cluded the provision of health services rather References than medical treatment, the care of individuals within their own community, and the employ- ment of new types of health workers. The biases in the Medicare and Medicaid system and the 1. See Isabel Walsh Pritchard, " Health Care and Reform: The Dilemmas of a Demonstration Program. " Unpub- lished Ph.D. dissertation, University of California, Berkeley, 1974, pp. 44, 71-2, 82. shift in BCHS policy to the support of large numbers of small scale programs has made it increasingly difficult for existing community health center programs to provide comprehen- sive health services and employ nontraditional health workers. Another major innovation which was part of the NHC model was consumer participation in decisions about the provision of health ser- vices. That element of the original model was expanded when the Health Revenue Sharing and Health Services Act of 1975 mandated the establishment of Governing Boards to replace consumer advisory boards at each health center. The Governing Board is the grantee of federal funds to the center, establishes general policies for the center's operation, approves its budget and appoints its Administrative Direc- 2. Daniel I. Zwick, " Some Accomplishments and Findings of Neighborhood Health Centers, " in Robert M. Hollister, Bernard M. Kramer and Seymour S. Bellin, Neighborhood Health Centers, Lexington, Mass.: Lex- ington Books, 1974, p. 85. 3. Karen Davis and Kathy Schoen, Health and the War on Poverty, Washington, D.C.: The Brookings Institution, 1978. 4. Roger A. Reynolds, " Improving Access to Health Care Among the Poor - the Neighborhood Health Center Experience. " The Milbank Memorial Fund Quarterly / Health and Society 54: 1, (Winter 1976), p. 48. 5. House Rept. 94-192, 94th Cong., 1st sess. (1975) pp. 76-77.. 6. Elizabeth J. Anderson, Leda R. Judd, Jude Thomas May, Peter K. New, The Neighborhood Health Center Program, Its Growth and Problems: An Introduction, Washington, D.C.: National Association of Neighbor- hood Health Centers, Inc., 1976, p. 15. 7. Comptroller General of the United States, " Implemen- tation of a Policy of Self Support - by Neighborhood Health Centers, " Report to the Subcommittee on tor. The majority of the Board's membership is mandated to be patients enrolled at the health center (22). Recent legislative events suggest that this aspect of the neighborhood health center model is also threatened. Health, Committee on Labor and Public Welfare, United Senate, 2 May 1973, pp. 9-10. 8. Interview data. 9. Senate Rept. 94-29, 94th Cong. 1st sess. (1975) p. 39. 10. Interview, Siver Spring, Maryland, July 11, 1979. 11. Patricia A. Kalmans, Medicaid Reimbursement of One provision of the latest legislation. authorizing community health centers, the Health Services and Centers Amendments of 1978 (P.L. 95-626), establishes another new Community Health Centers, Washington, D.C.: Georgetown University Health Policy Center, 1977. 12. Michael E. Clark, " Publicly Supported Preventive and Primary Care During the New York City Fiscal Crisis, 1974-1977, " A Health / Pac Special Report, New York, type of community health center program, a " affiliated hospital - primary care center. " This is essentially a primary care group practice based in a hospital. Primary care centers do not have to have Governing Boards, but may in- stead create advisory boards (23). This legisla- tion was introduced because hospitals which wished to apply for community health center grants felt that they could and / or would not 1979, p. 227. 13. See Sara Rosenbaum, " Implementation of the Rural Health Clinic Services Act of 1977: Keepin'' Em Down on the Farm, " Health Law Project Library Bulletin, vol. 4, no. 5, May 1979, p. 142. 14. Memorandum from the Assistant Secretary for Health. March 21, 1978. 15. See Edward D. Martin, " The Federal Initiative in Rural Health " Public Health Reports, vol. 90, no. 4, p. 294; July August - 1975, also Y.B. Rhee, " HSA Capacity Building Strategy, " unpublished paper, 15 October meet the Governing Board requirements (24). 1976, pp. 3-4. Although only ten such centers were funded in 16. Interview, Washington, DC, July 25, 1979. FY 1980 (25), this program may signal the be- 16a Interview. , Washington DC, July 12, 1979. 17. Senate Rept. No. 860, 95th Cong., 2nd sess. (1978) p. ginning of the end of the " community - based " 10. 27 . " Human Sciences Press 72 Fifth Avenue New York, New York 10011 " 28