Document R2aEjyGBoqeE0a90mk3GyXVaB

HEALTH / PAC Health Policy BULLETIN Advisory Center 1 Double Issue 2 Human Experimentation: ADDING INSULT TO INJURY. The scientific bias of clinical research often results in the abuse of human subjects. 3 Vital Signs 11 Blood: A CIRCULAR STORY. The control of commer- cial blood centers doesn't mean the end of of pro- fiteering. 19 Nursing's Quest for Identity: IN WHOSE OWN IMAGE. Nursings'leaders plan for themselves, not for the 700,000 RNs. Bill Plympton 23 Columns WASHINGTON: Death Against Taxes WOMEN: The New Right NEW YORK WORK ENVIRON / 48 Media Media Media Scan HPCBAR 81,82 1-60 (1979) Miners : Miners 55 AN UNHEALTHY CONTRACT. The new UMWA agrees to increased wages and decreased health. Peer Review Review 59 ISSN 0017-9051 Human Experimentation ADDING INSULT TO INJURY Medical research inevitably involves human ex- perimentation in order to extend the boundaries of scientific knowledge. Horror stories about the effects of such experimentation abound: retarded children at NY's Willowbrook State Mental Hos- pital intentionally given hepatitis, Chicano women in Texas put on placebo birth control pills, Black men in Tuskeegee, Alabama not given penicillin to treat their syphilis. Yet there has been very little systematic investi- gation of the risks of biomedical research to the health of experimental subjects. While racism, sex- ism, and class discrimination tend to characterize many of the widely publicized abuses, the research reported below indicates that the prevalance of abuse may, in fact, stem from the nature of " ac- ceptable " research methodology. Scientific prac- tices themselves might lead to the likely abuse of human subjects. Making a healthy person sick, or a sick person sicker, seems to be the antithesis of medicine. Yet both are frequently the consequences of human experimentation. In order to know how a drug, device, or proce- dure affects human beings, it is always necessary to test it on people. Despite all previous laboratory and / or animal studies, there is always a risk im- plicit in trying something unproven or untested with human subjects. The only certainty in experi- mentation is that the results are unknown. Other- wise, why experiment? Yet there should be some standards that mini- One out of 8 published papers revealed serious ethical problems involving the exposure of human subjects to unnecessary harm A new type of intrauterine device (IUD) -a Stainless Steel Spring (-was SSS) tested on 123 Bellevue Hospital patients in the Family Planning clinic under a grant - in - aid from the Population Council of Rockefeller University. The physician investigators reported, in 1972 in the New York State Journal of Medicine (1), that they stopped inserting the IUDs into new experimental subjects at the end of the second year of the three year study " because of the number of complications experienced with this device. " They did not, how- ever, remove the IUDs from women who did not develop observable symptoms despite the prob- lems which led to aborting the study and the noted presence of asymptomatic perforations. The final tally of damage to patients involved in the study included 37 IUD removals because of com- plications; 26 because of vaginal bleeding, and 6 because of severe vaginal discharge. The women who participated in the Bellevue experiment were undoubtedly recruited from those who went to the clinic seeking birth control assistance. Presumably, all were deemed healthy prior to the insertion of the SSS IUDs - . Within two years 37 had been made sick by the experiment, 2 and three had unwanted pregnancies. mize the abuse inherent in the experimental process. At a bare minimum, no experiment should be designed to do deliberate harm to a patient. No experiment involving human beings should be initiated until after appropriate animal experiments have been completed. And, if there are sickening consequences, the patient should be informed and given a chance to discontinue his her / participation. Most importantly, no one should ever be used as a research subject without having given intelligent and knowing consent. A study of all articles published over a three- year period (1973-1975) by Obstetrics and Gyn- ecology faculty members of four New York City medical schools (Columbia University College of Physicians and Surgeons, the State University of NY at Downstate Medical Center, Mount Sinai School of Medicine, and NY Medical College) shows frequent violations of these standards. All 74 of the faculty members'articles that used hu- man subjects were analyzed for evidence of abuse. The results were stunning. One out of eight pub- lished papers revealed serious ethical problems involving the exposure of human subjects to unnecessary harm. Continued on Page 43 Law Vital Signs DRUG COMPANIES HAVE A LOT OF CASH Corporations in the drug and medical supplies industries are sit- ting on a large pile of cash. Ac- cording to Business Week's Sept- ember 18th Corporate Cash Score- board, the nation's largest corpo- rations tend to be cash rich right now, cautiously awaiting new de- velopments in the economy be- fore committing themselves to more investments. The drug and medical supply industry - defined broadly to include ethical, pro- prietary, medical and hospital supplies - is among the heaviest cash laden - industries, with nearly one of every four dollars in cur- rent assets being held in the form of cash, bank deposits or short- term notes. ... which they use to buy other companies... While there may be some un- certainty as to best use of their cash, don't think for a minute that these corporations are about to open up a suggestion box for ideas. After all, people might sug- gest lowering prices, starting drug education programs or other no- growth strategies. According to the rules of the capitalism game, corporations cannot simply be content to do a good job. They must grow in order to survive in the face of competition and take- over threats. Stagnation is death. Growth can come from selling more of your products or invent- ing new products. But if your products have lost their pizzazz, the best way to grow may be to buy smaller companies - like big fish eating little fish. Most corporations in the medi- cal industry have been doing just that. Recently, reports Business Week in the same September 18th issue, Bristol - Myers bought Uni- tek, a dental supplies company; Johnson and Johnson acquired kidney dialysis maker Extracor- poreal Medical Specialties; and Eli Lilly purchased Ivac, a producer of monitoring devices for intra- venous drugs. And, just in case anyone needs a reminder that capitalist behavior knows no na- tional boundaries, it notes that foreign companies have been do- ing the same thing. Bayer recent- ly bought Miles Laboratories; Ciba Geigy - Ltd. bought Alza; and Nestle purchased Alcon Labora- tories. Several other deals have been announced but not yet consummated. While little fish may not like being eaten by anyone, these deals do have advantages for all. Large companies gain technology and rapid growth. Small com- panies gain the financial strength and ready made marketing infra- structures of the biggies. .. and to pay their execs hefty salaries... Meanwhile, back at the top of the corporation, chief executive officers of pharmaceutical corpo- rations have done their personal bit to absorb some of that cash. A recent Arthur Young & Co. study shows that executives in this industry received the average $ 392,000 in total compensation (salary and fringes) in 1977. This earned them a cool second place among the 14 manufacturing in- dustries studied. First place (448,500 $ ) went to another drug 3 industry, but one large enough to have its own separate cat- egory -- the tobacco industry. A LEAK IN THE I.V. MARKET There's trouble in the intra- venous solution market. Compe- tition is intense and profit margins may drop stock - prices are al- ready down. Executives and in- vestors are worried. Why? Lower prices. Some hospitals have re- ceived discounts as large as 77% of the cost of I.V. products, due to what the September 21st Wall Street Journal called " a full- fledged price war " between the three largest producers of I.V. products, Baxter Travenol Labo- ratories, Abbott Laboratories, and American Hospital Supply. Health / PAC Bulletin Board of Editors Tony Bale Pam Brier Robb Burlage Barbara Caress Michael E. Clark Pat Forman Glenn Jenkins Jane Levitt Joanne Lukomnik David Kotelchuck Ronda Kotelchuck Len Rodberg David Rosner Hal Strelnick Health Policy Advisory Center Staff Marilynn Norinsky Bob Riley Ann Umemoto Loretta Wavra MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR should be addressed to Health / PAC, 17 Murray Street, NY, NY 10007. Subscription rates are $ 14 for individuals, $ 11.20 for students and $ 28 for institutions. Subscription orders should be addressed to the Publisher: Human Scien- ces Press, 72 Fifth Avenue, NY, NY 10011. Health / PAC Bulletin is published bimonthly by Hu- man Sciences Press. Second - class postage paid at NY, NY, and at additional mailing offices. Expanded manufacturing ca- pacity explains part of the in- creased competition. But smaller and more cost conscious - hospitals are helping their own cause. Ac- cording to Oppenheimer & Co. Vice President Jules L. Marx (no, we didn't make that up), hospital purchasing agents are sharing more information on product prices and driving harder bargains in efforts to keep costs down. But Wall Street worries are not overly concerned. Many larger I.V. accounts have been un- touched by the discount prices. David Talbot of Drexel Burnham Lambert, Inc. optimistically pre- dicts that new products will save the day. " There are five or six categories of new products... that command substantial (price) pre- miums. These products are selling 4 at a rapid rate. " Health / PAC Bulletin 1979 FRICTION AMONG THE FRACTIONATORS Times are rough in the blood market. First, the U.S. lost the source of 10% of its plasma when a 150 - bed collection center in Ni- caragua burned down in political riots early this year. (Was Samoza about to start a cartel to control Third World blood exports called the Organization of Blood Export- ing Countires - OBEC? -the Tran- sylvanian solution to balance of payments deficits.) Then, foreign countries with more money than blood started buying U.S. blood processing centers. After all, the U.S. is the major exporter of plasma fractions (components). According to the September 11th issue of Business Week, French and German companies bought U.S. plasma producers in 1975 and Green Cross Corp. of Japan bought one this year. But commercial processors are most upset by a recent into blood processing by the American Na- tional Red Cross. By far the larg- est collector and distributor of blood in the U.S., the Red Cross recently announced plans to build a plant in a $ 40 to $ 50 million joint venture with Baxter Trave- not Laboratories, Inc., one of the largest commercial processors. Competitors complain that the deal will give Baxter an unfair ac- cess to supply and the Red Cross an advantage over commercial fractionators. The Red Cross counters that the move was re- quired because of the poor service it received from commercial frac- tionators and, according to Red Cross Chairman Frank Stanton in a letter appearing in the October 2nd Business Week, " to allow them to develop techniques for the production of needed new. and rare blood derivatives that hold no interest for commercial fractionators. " LAB KICKBACKS CONTINUE Twenty Detroit area residents, including five physicians and two alleged organized crime figures, have been charged in eight indict- ments with a scheme to defraud the Medicare and Medicaid Pro- grams. The alleged scheme involved setting up a dummy corporation to funnel kickbacks to physicians in exchange for sending their Medicaid Medicare Laboratory testing to a local lab. According to the Detroit Free Press, " The indictment charges the defendants with using false in- voices, false sales commissions, false consulting agreements and other phony methods to cover up more than $ 200,000 in alleged kickbacks and extortion payments during a three - year period. " This is one of the latest in the continuing scandals around labora- tory kickbacks. A Wall Street Journal article reported that " pay- offs remain both widespread and difficult to prove in court. " Phy- sicians often regard kickbacks from laboratories as legitimate compensation; critics charge that the kickbacks are incentives to win business from physicians and are often associated with excessive lab charges. Federal laws govern- ing Medicaid and Medicare prohibit radiologists, pathologists, and such kickbacks. hospitals for refusing to provide The problem appears massive. x ray - and laboratory services to According to the Journal, " With their patients. The objectors lab charges running at more than claimed they were protected by $ 11 billion a year including - $ 3.5 the AMA code of ethics which billion by the 7,000 or so inde- " forbids physicians to associate pendent labs that are considered mainly responsible for payoff- professionally with practitioners of'unscientific medicine '. " $ 1 billion of the total figure re- Actually in dispute is a revision flects kickbacks and other lab abuses, congressional witnesses of the AMA code of ethics. The Judicial Council is in the process have estimated. " An Illinois inves- of revising it. In 1976 the AMA's tigator maintains that " As a rule, doctors want a 40% return on position was that a physician could " choose to accept or de- their testing business. " cline patients sent to him by Although the practice remains licensed limited practitioners widespread, and recurring scandals (dentists, Podiatrists, chiroprac- and investigations keep it in the tors, psychologists) or by laymen. " public eye, little is being done to However, this is only part of a get at the root of the problem. broader change now being studied Unless the overwhelming incentive by an ad hoc - panel whose report for money making can be re- is due in December. moved, the big ripoffs will con- The petitioners (the American continue. College of Physicians, the Ameri- can Academy of Orthopaedic Sur- Source: Detroit Free Press, Sept- ember 22, 1978; Wall Street Jour- nal, September 26, 1978. geons, the American College of Surgeons, the American College of Radiology, and three members of the AMA including the delegate from the American Association of A HOUSE DIVIDED CANNOT STAND: A CASE OF INTERNAL INSURRECTION IN THE HOUSE OF MEDICINE After the AMA settled an anti- trust lawsuit filed against them last year by a group of pennsyl- vania chiropracters, three mem- bers of the AMA's own House of Delegates and four major specialty groups asked the U.S. District Court in Philadelphia to block the Neurological Surgeons, the dele- gate from the American Roentgen Ray Society and an alternate re- presenting the American College of Physicians) are asking the court for a delay so the House can vote on the ad hoc panel's recommen- dations. Buying time? The rebellion is spreading. Similar anti trust - suits have been filed in New Jersey and Chicago. Source: Medical World News, October 2, 1978. settlement. They claim the AMA cannot settle with outside parties before gaining their own House's approval. Charging restraint of trade, the Pennsylvania chiropracters origin- ally sued the AMA, Pennsylvania EPA ISSUES LEAD STANDARD On September 29, 1978 the Environmental Protection Agency 5 announced a health standard for lead in the air. The new standard so far as to ask Congress to amend the Clean Air Act. will require lead concentrations to be no more than 1.5 micrograms per cubic meter of air. In some areas such as Los Angeles and Dallas concentrations of six micro- grams are common. The lead stan- dard is a first step toward needed air pollution standards to control toxic substances in the air. EPA acted reluctantly. They finally responded to a court order brought about by a lawsuit filed by the Natural Resources Defense Council. Although the court order for EPA to act first came in 1974, only after numerous appeals was the EPA found in violation of the Clean Air Act and ordered to issue a standard by September 30. Meanwhile, research had been ac- cumulating on the harmful effects of low level - concentrations of lead Source: Wall Street Journal, Oct. 2, 1978 RESTRICTIONS SLATED ON FOREIGN NURSES The first phase in restricting the immigration of foreign nurs- ing graduates (numbering 42,000 between 1972 and 1976) is scheduled to commence in Oc- tober. The Commission on Grad- uates of Foreign Nursing Schools (GFNS), an independent, non- profit group, was recently organ- ized to administer tests to nurses in their home countries. The Com- mission was established at the sug- gestion of DHEW, and under the sponsorship of the American in the air on the neuropsycholo- gical functioning of children. The smelting industry is most immediately affected: EPA esti- mates the standard may cost smelters $ 530 million by 1982. EPA Administrator Douglas Costle said, " We don't believe that a major disruption of this industry is an acceptable consequence. " A study is now underway on the The effect of the exams will be to make fluency in English a prerequisite to working in this country... Nurses Association and the Na- tional League for Nursing. ' We don't believe that a Tests will be given in English and will include sections on the major disruption of this five major areas of nursing co- industry is an acceptable consequence ' vered by state boards, plus an English language - competency test. -Douglas Costle Applicants must have graduated from a secondary school, a gov- ernment approved - nursing school, and have passed the licensing ex- costs and benifits of the new am required by their home coun- standard. Costle claims that if this try. The tests will be given in 32 study shows " economic effects cities around the world, seven in unwarranted by the health protec- East Asia, seven in Latin America tion involved " the EPA may try and the Caribbean, two in Africa, 6 to change the new rule or even go four in the Middle East, and twelve in Europe. CGFNS pronouncements gush with sisterly concern for foreign nurses: " When foreign nurses who fail the state nursing examinations have had to leave this country, they have felt discriminated a- gainst and disenchanted with the United States....Or, others have remained in this country and have been hired as nurses'aides and then pushed into taking regis- .. *b ut what of the people who need health care workers who speak their language? tered nurse responsibilities on un- popular night shifts and / or out - of- the way - communities. " All is not concern for the exploited foreign nurses, however. As the CGFNS hastens to add: " this has not con- tributed to safe patient care. " The exams are not mandatory, but this is probably a temporary situation. The U.S. Immigration and Naturalization Service has said it " would be prepared " to require successful completion of the exams as a condition for im- migration. Successful completion may also be made a prerequisite for taking state boards, and " be helpful in obtaining a work per- mit " from the Labor Department. Significantly, nurses who have passed the Canadian licensing ex- amination are to be exempt from these requirements. The CGFNS suggests that foreign nurses might want to immigrate to Canada, pass that country's licensing exam, then come to the United States without special restrictions. This is the height of cynicism, how- ever. given Canada's increasingly strict immigration policies regard- ing workers from the Third World. No doubt taking moral inspira- tion from President Carter, the CGFNS executive director has de- clared: " Our Commission sup- ports the U.N. Declaration of Human Rights, which affirms the freedom of the individual to migrate. " As justification for the exams, the CGFNS cites the statistic that 84 percent of the foreign nurses taking state boards in 1976 failed. Admitting that lang- uage problems are a significant barrier to foreign nurses (or Puerto Rican and Chicano nurses from this country), incremental progress has been made in elim- inating cultural bias from tests. But in this context, the CGFNS exams are clearly a step backward. If testing of nursing knowledge were primary and English second- ary, then the nursing component would be given in the nurse's native tongue. The effect of the CGFNS exams will be to make fluency in English a prerequisite to work- ing as a nurse in this country. It is well known that blacks have higher rates of hypertension than whites in the U.S. This racial difference is related to differences in the social conditions of blacks and whites. National surveys have establish- ed that in the U.S. lower socio- economic status is associated with higher blood pressures and a great- er prevalence of hypertension (1). As can be seen from the Figure, the differences in blood pressure associated with differences in educational level are much larger than the differences in blood pres- sure associated with race per se. A study in North Carolina has shown that hypertension - related death rates are high in counties with low socioeconomic status (particularly for whites) and also in counties with high social insta- bility, as indicated by high rates of crime and divorce (2). In Detroit, comparisons have been made between black and white high and low stress areas (3). High stress areas were defined as those with low levels of income and edu- cation and high rates of crime and marital instability. Blood pressures were consistently higher in the high stress areas. Black men Class and Hypertension Diastolic Blood Pressure Systolic Blood Pressure 2 8 5L yres ss than . 5-8 yrs. 9-12 yrs. More 13 yrs.t han g 8 Y, 130 T / P 150 160 T `- Males Education Lesyr s5 than 5-8 1 yrs. Females 9-12 More yrs. 13 yrs.t han Figure - Blood pressure by education level and race (1). Blood Pres- sures have been age adjusted - to eliminate effects of any age differ- ences between groups. Blacks o -- o. Whites o -- o. who lived in a low stress area had blood pressures as low as white men who lived in a low stress area. These findings indicate that in the U.S. those who suffer the so- cial disadvantages associated with low education and income or resi- dence in neighborhoods with high crime and divorce rates also suffer higher rates of hypertension. These observations lead us to the con- clusion that racial differences in blood pressure are due in large part to the social conditions re- sulting from racial discrimination. References 1. Roberts, J., Blood pressure levels of persons 6-74 years, United States, 1971-1974. Vital and Health Sta- tistics, Series 11, Number 203, 1977. 2. James. S.A. and Kleinbaum, D.G., Socioecologic Stress and Hyperten- sion Related Mortality Rates in North Carolina. Amer. J. Public Health 66: 354-358, 1976. 3. Harburg, E., Erfurt, J.C., Chape, C., et al., Socioecological Stressor Areas and Black White - Blood Pres- sures Detroit. J. Chronic Dis. 26: 595-611, 1973. 7 At first blush this may seem Previously OSHA had only tak- reasonable, but the question of language raises larger issues for the health care system as a whole. en into account whether compli- ance with a proposed standard was economically feasible for Should state boards be given, or certain facilities in urban areas be run, exclusively in English? While a working knowledge of English is certainly necessary to negotiate the broader health care system, there are community facilities a majority of whose patients speak anything from Spanish to Chinese. These people need health care workers who speak their language to give them safe, comprehensive care. America is unilingual in law, not in fact. Stripped of its pretentions, the work of the Commission on Graduates of Foreign Nursing Schools comes dangerously close to good old fashioned - Ameri- can xenophobia. -Glenn Jenkins industry. As an OSHA spokes- man put it, " We haven't been held to any kind of cost benefit - analysis in previous decisions. We didn't engage in that kind of an- alysis (in the benzene rules). We can't and we shouldn't. " The court, however, held that the estimated $ 500 million cost to reduce benzene exposure to one part per million was not justi- fied on the basis of the scien- tific data presented. OSHA had not, the court ruled, shown a " reasonable relationship " between measurable benefits and costs. OSHA finds the decision " dis- turbing " and is considering an ap- peal. The proposed 1 ppm stand- ard had been issued as an emerg- ency temporary standard in May, 1977, after new studies confirmed Sources: American Journal of Nursing, March 1978; CGFNS, press releases 1 and 2. that benzene caused leukemia, although OSHA actually held the view that there is no safe expo- sure level for any carcinogen. The OSHA BENZENE STANDARD BLOCKED proposed standard was immed- iately blocked in court and has never gone into effect. If the cost- In a decision with far reaching - implications, the U.S. appeals court in New Orleans struck down the new OSHA benzene standard because the need for the re- gulation was not demonstrated through cost benefit - analysis. The decision was a major victory for the American Petroleum In- stitute and for'business in gen- eral. The strategy of tying up standards in the courts by de- benefit test is upheld, it could complicate the standard - setting process and weaken the standards themselves. OSHA would then have to put a " value on workers ' lives " rather than regulate carcino- gens at the lowest feasible level of exposure. Sources: Wall St. Journal, Oct. 6, 1978; Chemical and Engineering News, Oct. 16, 1978. manding benefit cost - criteria prov- DRUGS ed succesful. According to OSHA head Eula Bingham, " the action The New York State Depart- of the court will leave thousands ment of Audit and Control recent- of workers at an increased risk ly released a report on three 8 of leukemia. " state mental hospitals selected Widespread medication abuses, including indis- criminate polupharmacy and excessive dosages, were found randomly for study. Widespread medication abuses, including in- discriminate polypharmacy (mul- tiple drug treatment) and excess- ive dosages, were found in the three facilities (Rockland, Creed- more, and Utica Marcy -). The Rockland County Medical Exam- iner further charged that the heavy use of tranquilizers at Rockland Psychiatric Center and nearby Letchworth Village Devel- opmental Center caused an unusu- al number of patients to choke to death. In responding to a sub- poena by the state supreme court, he said his records showed a " glaringly ostensible association between psychiatric drugs and deaths due to aspiration of food and vomitous materials. " 30% of autopsied patients showed this as the cause of death (the national average being 1.7%). Near the center of the contro- versy is Dr. Nathan A. Kline, director of the Rockland Re- search Institute and tireless pro- fessor of the wonders of psycho- pharmacology. Because of Kline's world - wide reputation (he is rum- ored to get $ 500 a shot for private consultations) he was paraded out at a recent press conference to refute the allegations of drug abuse and reassure the public of the safety of tranquilizers and sedatives. Kline and his associates have virtual experimental carte blanche in the state hospital sys- tem of New York. While investiga- tions are held into the Rockland FEAR OF LITHIUM DANGER deaths, they continue their " high dosage " experiments on patients in various locations. Sources: New York Daily News; Village Voice; City News. Q. WHEN IS A DOCTOR NOT A DOCTOR? A. WHEN SHE'S A DOCTOR OF NURSING. Lithium, " wunderkind " of Psy- choactive medications has as its major drawback the fact that the line between a " therapeutic " and toxic careful monitoring of blood levels make the danger negligible; however, a recent study supported by Roerig Pharmaceuticals, Ro- well Labs (both manufacturers of Lithium carbonate), NIMH and the VA suggests otherwise. The researchers reported num- erous cases of toxic manifestation In a move to upgrade nurses ' education, a new degree Doctor - of Nursing (N.D.) -- will be offered beginning in September by Case Western Reserve University's Frances Payne Bolton School of Nursing. The three year curricu- lum open to students who have a bachelor's degree and basic science backgrounds will emphasize clinical practice. RNs interested in teaching can go on and earn a Ph.D. in nursing. The American Nurses'Associa tion's Commission on Nursing Ed- ucation endorses this plan and sees this training as a way to ex- tend health care beyond the hos pital. The Association of American Medical Colleges is in favor of the new " professional nurse " as a way to fill the general care void creat- ed by medical specialization. One family physician from California criticized medical schools for not producing enough " people doc- tors " and sees the nurse as a na- tural to fill this gap. occurring when serum lithium levels were norman. Lithium poi- soning carries the potential for irreversible tissue damage and death. Researchers also found that even at therapeutic levels, lithium may cause chronic renal structural damage. They could observe no constellation of symptoms that could be considered characteristic of lithium intoxification and noted one suicide where coma did not occur until three days after in- gestion. The researchers expressed a hope that red blood cell count might turn out to be an indicator of toxicity, but found that, pre- sently, no reliable measure of lithium poisoning exists. Source: Psychiatric Annals: Sept- ember, 1978 COPS IN THE EMERGENCY ROOM; NURSES IN JAIL Will the real doctor please " Nurses in this city have ex- stand up? pressed shock and concern over the case of an emergency room nurse who, after attempting to Source: Medical World News, provide care to an 18 year - - old August 7, 1978. patient who allegedly had been beaten by two police officers who brought him to the hos- pital, was arrested, handcuffed, and removed to a police sta- tion where she was issued a sum- mons for harassment of the two officers. " (AJN May, 1978, p. 765) The incident occurred at North Central Bronx Hospital, on Feb- ruary 25, 1978 at approximately 1 A.M. The two officers brought in a patient who was suffering from an overdose of drugs. The patient was not under arrest. Af- ter informing the nurses on duty that the patient was a " psy- cho, " the officers took him to a quiet room reserved for psy- chotics. The ER nurse in charge said she went to the room when she heard the patient " screaming for help. " Despite objections from the officer, the nurse stayed with the patient who was bleeding profusely from the nose and mouth. The patient asked her not to leave him, reporting that the officers had kicked him. The nurse left them momentarily to obtain supplies for a bandage, and upon returning, was placed under arrest for " obstructing justice. " The incident described above is important to nurses and other hospital workers for several reas- ons. First, it represents an assault on nurses in the exercise of the most basic of nursing functions, patient advocacy. And second, it is important in light of the com- promise made by the hospital management as a solution to the problem. The emergency room, with its dual function of serving as the hospital's face to the commun- ity, and providing resources for emergency / crisis situations in the community, assembles potentially opposite interests within its walls. 9 The AJN article describes a con- flict between the interests of law enforcement and the provision of health care to the population. (That these interests should be- come mutually exclusive in any situation poses some important philosophical / practical questions beyond the scope of this article.) For nurses, the emergency room is a place of work. Certain conditions that are true for other hospital workers are some- times acute in the emergency room. Overcrowding, high utiliza- tion rates and staffing shortages reflect emerging policy decisions to cut the health care budget. Practically, the emergency room is forced to assume the responsi- bility of providing otherwise non- existent outpatient services. Nur- ses, as officers of health, are ob- ligated to " protect the rights and welfare of patients " entrusted to them. Officers of the law have juris- diction over prisoners. Their au- thority is limited by the patient's right to medical care. Nurses and police officers are forced to main- tain a symbiotic relationshop. The realities of personnel shortages require that nurses often rely on officers to assist with " com. bative " or " violent " patients. On the other hand, police officers are in an extraneous environment and need to establish rapport with nurses. Often, this associa- tion is colored by the traditional sex roles which have character- ized the sexual politics of nursing and women's subordination to male authority. Hospital management respond- ed to the incident with a compro- mise. They agreed that an officer cannot arrest any hospital em- ployee during the employee's tour of duty, but they failed to take an an unequivocal stand in support of the nurses'role as patient advocate. This incident focuses attention on the need for clarification of the rights of patients to protection and the rights of nurses in the exer- cise of their work. HEALTH PLANNERS NETWORK Health Planners Network (HPN) is being convened at Health / PAC in New York for mu- tual support and reporting among critical, activist and community- oriented planning practitioners, teachers and analysts. We are now holding monthly Health Planning Roundtables at Health / PAC to discuss issues, case studies and teaching approaches. Case study reports and policy briefs on health planning are being solicited for fu- ture Health / PAC BULLETINs. Close communication is being 10 sought with health and social planning interested - people across the country in the Planners Net- work (360 Elizabeth Street, San Francisco, CA 94114) and in local Planners Network meetings such as the New York City PN Ameri- / can Institute of Architects Forum. We also hope to be in close per- sonal contact with health plan- ning interested - participants at up- coming national meetings such as Health Service Action Committee / for National Health Service in Pittsburgh, January 26-28; Plan- ning Praxis Conference in Ithaca, April 26-28; American Planning Association in Baltimore, October 15-18; and the American Public Health Association in New York, November 4-8. We seek to be ac- tive and practical allies as planners through cooperation with the na- tional Consumer Coalition for Health (Suite 220, 1511 K Street NW, Washington, DC 20005). If a critical mass of materials and notes are generated that go beyond the Health / PAC BULLE- TIN and Planners Network for- mats, we are considering develop- ing a special newsletter. Blood: * The posters in the hospital corridor tear at CIRCULAR STORY the heart- " Blood is life, pass it on " or " Your blood was free, please share it freely. " It's hard to pass by too many times without realizing that only healthy people can help pa- tients who need transfusions. It takes just a few minutes to lie on the couch, needle dangling from an elbow vein, then to sip juice and munch cook- ies, not a penny richer but feeling good all over. Would it make any difference to know that a blood bank or hospital administrator may be smiling too, for a reason that is less than humani- tarian? They may call themselves " profit non -, " but contrary to popular belief a pint of blood can be worth money - a lot of it to -- them. The person who receives a transfusion will be told the blood is " free " but he or she will be charged from $ 20 to $ 60 for each unit in pro- cessing charges just the same. For a good sized, well - run blood bank, only $ 30 or so is legitimate. What's more, there may also be a " replace- non - ment " or " penalty " fee of from 20 $ to $ 50 a unit - not covered by insurance - that a patient will have to ante up if no blood has been " pre- deposited " or if a friend or relative can't be found to donate. A third of the nation's blood is transfused with this stipulation. To top it all off, giving as part of a " coverage " or blood " assurance " plan doesn't make an iota of difference when someone gets sick, except perhaps to avoid those penalty charges. At best, a " coverage " plan is a sham. At worst, it's a fraudulent way for blood banks to make money. Hospitals give blood to patients in order of medical need, not in order of coverage. When there's a blood shortage around Labor Day week- end or over the Christmas Holidays, both patients who are " covered " and patients who are not are hurt equally. An honest recruitor, says Russell Merritt, executive director of the Chicago Region- al Blood Program, knows coverage is a " fiction " and promising it is just a trick of the trade. The Blood Collection System To understand blood banking is to know something about blood itself and something about how the United States has evolved a huge blood AABB K. BENDIS 11 collection system backed by volunteer donors. We have come to regard the life saving - gift of blood as special and personal, immune from the tradi- tional laws of the marketplace. Blood " is a bond that links all men and women in the world so closely and intimately that every difference of colour, religious belief and cultural heritage is insignificant. beside it, " the British social scientist Richard M. Titmuss wrote in The Gift Relation- ship, his pathmark book extolling the virtues of an all volunteer blood system. It's something to be proud of that 93 per cent of the more than 10 million units of whole blood collected each year in the United States are donated by volunteers. " Why should somebody (the elderly or the young) who cannot replace blood have to pay at least twice what anyone else would have to pay? " -Dr. Carroll Spurling Blood, once sucked from the sick with leeches to drive out " evil spirits " (George Washington died this way) now flows from the veins of healthy people into sterile plastic bags. Its major compo- nents are (1) packed red cells, the oxygen carrying - hemoglobin material; (2) plasma, the straw colored - protein solution, and (3) platelets, important for blood clotting. The method for donating blood tourniquet - , needle, rubber doughnut squeezed slowly to help the blood flow, and pressure bandage that seals the wound - has changed little since 1937, when Chicago's Cook County Hospital became the first to store donated blood in the refrigerator. The three major components can be separated in less than an hour with a refrigerator, a centri- fuge, an anticoagulant solution and sterile lab technique. The red blood cells can be stored for 21 days in a refrigerator or frozen for years. The platelets are good for three days and the plasma can be frozen indefinitely. The red cells can go to a patient with anemia, the plasma to a burn victim in shock and the platelets to a leukemia 12 patient who is hemorrhaging. Until the early 1970's, much of the blood in certain areas of the country was provided by paid donors. A disturbing number were hepatitis- ridden skid row derelicts who hocked their blood for cash. A patient played Russian roulette when he received a transfusion of commercial blood. Spurred on by a Chicago Tribune expose, Illinois adopted the nation's first blood labeling act in 1972 and volunteer blood is now the law in most states. Donors understand blood to be a special gift, not a market commodity. Almost all of the nation's blood is collected by centers affiliated with one of three national groups, The American Association of Blood Banks (AABB), the American National Red Cross, headquartered in Washington, D.C., and the Council of Community Blood Centers (CCBC), run from Scottsdale, Arizona. Each is an umbrella group, coordinating the operations of blood suppliers for regions, cities, parts of cities, or just one hospital. The individual supplier sets the processing fee charges, and penalty charges, if any. There is no special government regulation. From a technical standpoint, there is no differ- ence in the purity or safety of the product pro- duced by any of these groups. But their blood - col- lection ideologies and policies are at loggerheads. The Red Cross and the Council of Community Blood Centers endorse a philosophy of " commun- ity responsibility. " That means blood is collected for use as the common property of everyone in a particular geographic region. Donors should receive no special considerations at all compared to non donors - . Red Cross and CCBC centers are largely independent of hospitals, acting as a sup- plier just like a drug company. The AABB, which represents most of the na- tion's hospitals and clinical pathologists as well as free standing - blood banks, endorses a philo- sophy of " individual responsibility. " That means that it is the responsibility of patients and their families to provide for their potential or actual blood needs. The AABB feels donors need this monetary incentive to make the system work. Many of its member groups thus assess penalty charges nonreplacement " fees -for " those who do not pay back in kind for the blood they use. The AABB has a knack for quaint conservative pro- nouncements to justify its philosophy. In one trade journal interview, AABB president Dr. Richard Walker called community responsibility " blood socialism " and then explained,'There is no relationship between income and blood volume. A poor person with very little income has the same blood volume as a millionaire. Some patients on welfare don't want to donate blood or pay bills - it's their choice. " Recruitment: The Miseducation of Donors Aside from penalty fees, the AABB, the Red Cross, and the CCBC employ similar techniques when it comes to recruiting donors. They stress the general need for blood and tell where it can be given. But they also " sell " coverage or blood assurance plans essentially - the same thing. The idea of a coverage plan is that it guarantees the availability of blood and provides an exemption from penalty fees. A typical individual coverage plan guarantees blood for all members of a family for a year if one member gives blood once a year. A typical community or industry plan guarantees blood for all group members if 20 per cent - or some other number - donate annually. Whether a patient is covered or not, he or she is still liable for all processing charges. Processing charges may, in turn, be picked up by insur- ance companies. A coverage plan is a fraud because of the simple fact that patients who require transfusions re- ceive them with equal priority whether they are covered or not. The concept simply contributes to the chronic miseducation of donors. " Coverage is a recruiting tool, " says Chicago's Merritt. " It lets somebody promise they can do something for you. But it hurts those who need blood, be- cause it only encourages a minimum donation.... Recruiters in (the Chicago) area have done an ex- cellent job convincing people that only one mem- ber of a family need give once a year, when the real need is for all healthy members of a fam- ily to give regularly. " Penalty Fees: Blood for Profit With this background, it is possible to under- stand how some hospitals and blood banks can turn a profit from the collection of blood. Take Los Angeles, for example. On July 1, 1977, trans- fusing blood from paid donors became illegal in California. The Red Cross, which supplies blood as cheaply as anyone, began shipping it to the Los Angeles area from across the nation. It met 95 per cent of the total need. It did not require hospitals to collect penalty fees. But 78 of the 125 hospitals which received all their blood from the Red Cross continued to charge penalty fees of from $ 20 to $ 58 a unit. " If I told you what I really think you couldn't print it, " said Dr. Carroll Spurling, director of the Los Angeles - Orange County Red Cross Blood Pro- gram. " Here is somebody drawing blood with no strings attached and they put a fee on it. Why should somebody (the elderly or the young) who cannot replace blood have to pay at least twice what anyone else would have to pay? " A con- servative guess is that 125 hospitals stood to make over a million dollars a year. But with Some recruitors will go to their graves convinced they need to fake a crisis every two months to keep the blood flowing strong pressure - largely from the Red Cross- all but a handful have dropped the fee. The examples go on and on. The Central Texas Red Cross Blood Center received a request in March, 1976, to replace more than 60 units of blood for a patient from Bedias, Texas who needed only 21. The hospital in Bedias had set a three - for - one blood replacement policy. Indeed, the AABB found that 37 per cent of some 345 blood banks it surveyed in 1976 had policies based on more than one one - to - replacement. Two Indianapolis, Indiana leukemia patients were hit with 8,000 $ penalty fee bills after treat- ment at a medical center in the midwest. John Keilholz of the Central Indiana Regional Blood Center called it " daylight robbery " and was able to cut the charges in half through negotiation. In Cincinnati, the Paul I. Hoxworth Blood Center had a two - for - one replacement requirement on the first unit of blood (or $ 60) until two years ago, when local " pressure " forced it to start a one - for - one program. The University of Pennsylvania Hospital in Philadelphia uses both Red Cross blood and ma- terial from its own blood bank. Patients are charged $ 21 a unit for Red Cross blood. For 13 the hospital's own blood, the fee is $ 37.50 a unit, plus a $ 45 replacement fee. Finally, in New York, the state consumer pro- tection board is pressing for the elimination of the fees. A survey of 14 New York City hospitals it released in June showed non replacement - fees as high as $ 83 at some institutions and for a first unit of blood varying from $ 59 to $ 149. By comparison, the Greater New York Blood Pro- gram will supply a hospital with a unit of whole blood for $ 34.50. (Some of the hospitals named, such as Doctors'Hospital, have subsequently eliminated the fee and raised other charges.) To somebody who needs at most a pint or two of blood, the fees at issue may seem trivial compared to the cost of even a day's hospitaliza- tion. For the poor, the elderly, and those with serious blood diseases requiring hundreds of units, penalty fees can be substantial burdens. " The non replacement - fee generates more money than blood, " says Dr. Dennis Donohue, director of the Puget Sound Blood Center in Se- attle, where the fee was dropped in 1971. " During the period it was in effect here, our assets in- creased to a level of about $ 3 million, of which several hundred thousand was in cash, " he told Mal Schechter, who publishes a blood banking newsletter from Wahington, D.C. " As an hypothetical example, if the Puget Sound Blood Center was to re institute - a replace- ment guarantee fee today, our revenue might increase by an amount close to $ 1 million a year..We.. would have to spend that money in higher salaries, fringe benefits and plush offices, hardly in keeping with the intent of a non profit - organization. " The San Francisco Suit Charging of replacement fees is being most squarely contested in San Francisco, where the state sued the Irwin Memorial Blood Bank on June 1, 1977, charging that imposition of a $ 30 penalty fee for blood on top of a $ 20 processing fee was " lucrative " and a " depressing abuse of the community's trust. " Richard B. Spohn, director of the California Department of Consumer Affairs, charged Irwin with amassing $ 2 million in bank accounts, about twice what it needed. The litany of charges included price fixing - , false and decep- tive advertising, and unfair business practices. 14 In a field where most people think that a controversial subject is, for example, deciding what brand of cookies to serve donors, the ques- tions generated by this attack have been profound, at times reaching heights that might follow a papal edict sanctioning abortion. On the surface, Irwin's response stressed the threat to the blood supply at 52 hospitals in the eight county - San Francisco area if the penalty fee was precipitously junked. (There are 98 blood donations per 1,000 people in the area each year, twice the national average). Executive di- It is disheartening that the ethical standards of all the blood banks don't equal those of most donors rector Mrs. Bernice Hemphill said 98 per cent of the donors give blood to establish credit or replace blood and many might be lost forever if these options were removed. Eliminate penalty fees, Hemphill and others argue, and processing fees would just increase enough to make up for the lost revenue, because a blood bank's total expenses would not change. Irwin soon revved up the printing presses in its public relations department and the publicity releases began to flow, accusing the Department of Consumer Affairs of " singling out " Irwin Memorial as the " mothership " to sink before all of California blood banks were " bullied " into doing things its way. " There's no reason all blood banks must recruit donors just one way, " Hemp- hill said. She feels the pre deposit - system gives a justified break to those who give after - all, you can't transfuse non replacement - fees. It also puts more of a financial burden on those who don't give. " That's totally phoney, " responds Donald Avoy, director of the Central California Regional Blood Bank in nearby San Jose. He has been constantly feuding with Hemphill over just these questions. About 35 per cent of the blood col- lected by Irwin was actually replaced in 1977; the rest of the fees were pocketed. " The more they fail to get donors, the more money they get, " Avoy explained. " It is a very financially successful failure. " Steven Fleisher, lawyer for the Depart- ment of Consumer Affairs, says that of 113,000 credits created by Irwin during 1976, only 52,000 were used and 61,000 expired. " It is a colossally complicated system " he said. " We have spent over a year just getting to understand it. " One finding was that Irwin had no cost accounting - to speak of until after the suit was filed and " didn't know what it cost to make a unit of blood. " The suit itself continues with no trial date in sight. Irwin unsuccessfully tried to get it thrown The " deposit pre - system is a very financially successful failure " -Steven Fleisher out of court last year. The depositions and inter- rogatories pile up. Irwin says adverse publicity has led to hostility among donors. Fleisher pre- dicts the " end of the non replacement - fee " as one of the suit's main consequences. " It is not a neces- sary incentive, it contributes to the high cost of blood and it gives rise to opportunities for fraud and deception, " he said. National Blood Policy On a national level, the disputes in San Fran- cisco, New York and other places mark only the latest in a series of skirmishes between the big three of the blood banking industry, the AABB, the CCBC and the Red Cross. The three are fede- rated in the American Blood Commission. This is an industry group established in the Spring of 1975 to formulate a national blood policy. More pragmatically, it is designed to head off more go- vernmental control of the industry. The types of programs it works on are regionalization of the blood supply, general education programs for do- nors and improvements in the technical compe- tence of its member groups. The Department of Health, Education and Welfare is keeping an eye on the American Blood Commission and is expect- ed to report on its effectiveness in 1979. One of the major battles within the American Blood Commission occurred in the Fall of 1976, when the Red Cross pulled out of its Clearing- house agreement with the AABB. This is an ela- borate nationwide system under which paper " credits " are recorded and traded for blood shipped nationwide. Red Cross Administrator Norman R. Kear found it an incredibly wasteful process with " a tremendous flow of verbiage and paper. " In an internal memo, the Red Cross said the accord " worked primarily to serve nonreplace- ment fee and supplemental inventory assignments, not the blood needs of patients. " Donors are caught in the cross fire of this in- dustry dispute. Take the case of Paul Bowersox of Lewisburg, Pa., as publicized by the Philadel- phia Bulletin in March. Over many years, he had donated more than five gallons of his blood to the Red Cross. He then underwent open heart surgery at the Hershey Medical Center, during which time he received 16 units of blood. Because the Red Cross had pulled out of the Clearing- house, Hershey, which belonged to the AABB, refused to honor his Red Cross donations. The bill was $ 480. " Paul had made it his business to give blood and he felt that if he ever needed it, it would be there for him, " his wife said. " It's hard to accept when you find out you don't have it. " When a task force of the American Blood Com- mission surprisingly faced the issue head on and recommended over the summer the abolition of penalty fees nationwide, some AABB members viewed it as an open call for secession. That resolution, approved by the commission's board in December, put a thumbs down on all " coercive " appeals for donors, like coverage and blood assurance plans. The impact of the recommenda- tion is unclear, for it was immediately shunted to another committee for an " impact " study. But such prestigious blood banks as the John Eliott Foundation in Miami and the Massachu- setts General Hospital have dropped the fee this year. The task force's message is that in a country where about 10 per cent of the eligible donors can and - do supply - everybody's blood needs, the only honest appeal is based on the theme of com- munity responsibility and the only honest charge is the cost of doing business. Implicit in the task force's recommendations are two conclusions: (1) Most of the nation's blood supply is adequate in both quality and quantity and critical shortages are infrequent exceptions rather than the rule and (2) Most blood shortages develop not from too few willing donors but rather from inefficiency and poor planning on the 15 Two Indianapolis, Indiana leukemia patients were hit with $ 8,000 penalty fee bills after treatment at a medical center in the midwest. Through negotiation, the charges were cut in half part of collectors. Task force member Alvin W. Drake of MIT, who has surveyed donors in Hart- ford, Houston, and New York, found that half the adults who considered themselves eligible to donate had actually done so, a figure much higher than is commonly supposed. Of those who hadn't rolled up their sleeves, Drake found " little evidence of a particularly strong reluctance to donate (based on fear). " Drake calculated that a region needs about one unit of whole blood for every 20 people each year. Every eligible donor would have to give once every seven years to meet that need. He found that most nondonors had " never been pressed very hard " primarily because there hadn't been a need. " If we had a 20 per cent increase in the number of donors (in 1976)... all parties concerned would have been embarrassed by the re- sulting outdating figures, " he wrote last year. (Re- frigerated blood has a 21 day shelf life). Our willingness to donate is illustrated by the invariably overwhelming response to emergency television and radio blood appeals. When it gets down to providing a rare blood type for 3 a.m. e- mergency surgery, a blood bank's collection philo- sophy matters less than the quality of its admini- stration. Some recruiters will go to their graves convinced they need to fake a crisis every two months to keep the blood flowing, while others just quietly get word out where the mobile draw- ing stations will be and make sure they show up on time. The fact of the matter, according to Drake, is that we as donors are an incredibly malleable lot, ready to parrot whatever reasons the local blood bank gives us for rolling up our sleeves. The only significant difference he has found between former and frequent participants 16 is their awareness of an on going - solicitation and a reasonably convenient place to give. Thus, San Francisco has a stable, self sufficient - blood supply with a replacement fee; Milwaukee, Rochester, N.Y. and Indianapolis do just fine without it. Chicago: A House Divided Chicago is one of the best examples of a large city where needless fragmentation of and competi- tion between blood banks jeopardizes the com- munity blood supply. Total yearly collections are about 10 per cent short, with 30,000 units of the precious red liquid being imported from places like Springfield, Peoria and New York City. (The situation was much worse five years ago). The cost of blood ranges from 27.50 $ a unit from the Red Cross, to $ 46 a unit at the large Rush- Presbyterian - St. Luke's Medical Center, plus a $ 15 non replacement - fee. Donations are 34 per 1,000 people, compared to the national average of 47 per 1000. Chicago's blood banks have been known to war with each other for donor groups and after years of debate are unable to agree upon unified collection and information sharing procedures, such as coordinated emergency appeals or a central listing of blood inventories. Nobody has any idea how much wasteful outdating of blood this causes. A key problem is that many large in- dustries, including Illinois Bell, (the area's largest employer with 30,000 workers), Commonwealth Edison, Nabisco, Johnson & Johnson, and Camp- bell Soup, don't sponsor blood drives. By compari- son in nearby Milwaukee, all blood comes from one center at $ 29 a unit and nearly all large firms, including the telephone and electric companies, have drives with average participations of be- tween 15 and 20 per cent. " These are the national " problems in microcosm, says Russell Merritt, the new director of the Chicago Regional Blood Program, who pins blame squarely on the blood banks themselves. " There is absolutely no reason Chicago or any other city can't be self sufficient - for blood. " One thing that no one is critiquing is the technical proficiency of most of the nation's blood banks and the purity of their product. The modern blood collection center is chock full of centrifuges and Rube Goldberg - type machines for typing blood, checking for hepatitis and syphilis and separating whole blood into com- ponents. Unfortunately, some forms of hepatitis remain undetectable in advance but the basic problem remains getting enough blood to the processing centers so skilled technicians need not have time hanging heavy on their hands. Yet to be addressed is the continuing commer- cial traffic in blood proteins, which represent the equivalent of millions of units of whole blood donations each year. Paid donors can receive $ 45 to $ 60 each month to have these proteins selectively " pheresed " or removed from their systems while the rest of their blood is then transfused back in. Pharmaceutical companies can turn the straw colored liquid into such di- verse products as anti hemophilia - factor and serum for laboratory tests. Even dated out - plasma, once thrown away, can command $ 22 a liter. In- deed, two Red Cross employees in Philadelphia were arrested in December, charged with steal- ing 564 liters of plasma and trying to sell it for $ 18,000 to the local office of the Interstate Blood Bank, Inc., a commercial plasma processor and col- lector based in Memphis. The traffic in blood pro- teins is the dark underside of America's volunteer blood donation system. When the Public Finds Out Somewhere into this morass of penalty fees, worthless coverage plans and inefficient collection plaguing an otherwise laudatory system, fit the voluntary donors who are in the unique position of providing a product in individual one pint - contributions that has no substitute. " I don't think the public understands any of this, " says Merritt, formerly director of a model Red Cross program in Rochester, N.Y. " My fear is what is going to happen when they find out they've been lied to, or told what somebody believes is the truth. " " The premises of blood collection can be marginal, and possibly false... perhaps in the name of a'greater good,'" agrees Drake, who also fears a " crisis in public confidence. " It shouldn't be terribly difficult for blood bankers to change their advertising slogans and promises and legitimize all their charges, but don't expect it to happen spontaneously. The immediate test is whether it takes the American Blood Commission several years or several decades to eliminate penalty fees. Moreover, the organi- zation itself must withstand the internal bickering which will surely continue. It is disheartening that the ethical standards of all the blood banks don't equal those of most donors. Until they do, the unfettered altruism of volunteers will continue to be compromised and tainted before their gifts ever reach the patients upstairs. Robert Steinbrook, a student at the University of Pennsylvania Medical School, has worked for the Chicago Tribune and other newspapers. Wechsler, Henry, Ph.D. and Anne K. Kibrick, R.N., Ed.D. EXPLORATIONS IN NURSING RESEARCH Nursing research has recently been gaining wide recognition for improving the quality of nursing care and in pro- moting and maintaining both physical and mental health. Studies have focus- for understanding the research process and for critically evaluating relevant studies. A broad range of current re- search is presented clearly illustrating each of the fundamental steps in the research process. Because of the high cost of health care, as well as the involvement of ed on such vital issues as health main- tenance, disease prevention, modalities of treatment and care, promotion of recovery and coordination of health care services. This major work is the first to provide both nurses and nurs- ing students with the essential skills 1979 April / 0-87705-379-0 0-87705-379-0 0-87705-399-5 0-87705-399-5 304 pp. (approx.) Cloth $ 16.95 Paper $ 9.95 he HUMAN SCIENCES PRESS . 72 Fifth Avenue 3 Henrietta Street NEW YORK, NY 10011 S` LONDON, WC2E 8LU 17 If One Picture = 1000 Words Then, 32 Pictures = 4 Health / PAC Bulletins HEALTH / PAC BULLETIN BULLETIN PRESENTS A COLLECTION OF DRAWINGS BY BILL PLYMPTON FS 4 I lait now ath' A folio of 32 of Bill Plympton's best drawings from the Health / PAC Bulletin. $ 5.00 each. Please send me copies of the Plympton Folio Enclosed is $ Mail to: Health / PAC, 17 Murray Street, New York, N.Y. 10007 18 Nursing's Quest for Identity: IN WHOSE OWN IMAGE In 1974, the New York State Nurses Associ- ation (NYSNA) proposed that NY State's nursing act be amended to limit the equivalent of Regis- tered Nurse (RN) licensure to graduates of bac- calaureate nursing programs. Graduates of as- sociate degree (year two -) programs would qualify for the equivalent of Licensed Practical Nurse (LPN) licensure. Graduates of hospital - based diploma programs would be downgraded to traditional LPN licensures and traditional LPN programs would no longer qualify for any nursing license, although graduates could presumedly work as nurses'aides. Because the amendment would take effect in 1985, it has become known as the 1985 Proposal. (See also Health / PAC BULLETIN, September / October 1977, and January February / 1978). In spite of the fact that the NY State legis- lature has shown little sympathy towards their proposal apparently - preferring new paraprofes- sions to new roles for nurses - and despite the fact that other public bodies and even significant sec- tors of their own membership have rejected this strategy for nearly fifty years, the NYSNA con- tinues to persevere. Recent efforts to cosmetically change the face of the proposal have been for nought and the amendment now seems virtually dead. But nursing leaders refuse to accept defeat, refuse to reconsider their strategy and, in fact, the NYSNA board reaffirmed as late as 1977 that: " The board believes that the major impediment to recognition of nursing as a profession, accept- ance of nurses as professional practitioners, and support for nursing care services is the failure, to date, to establish an appropriate standard for entry into nursing. We must clarify:'who is the nurse? And who are the others?'" (Emphasis in the original) Nursing's leaders have pursued professional status and baccalaureate education as a condition for entry for 50 years. On first glance, this appears an eminently reasonable request. Surely, the BSN as a minimum level of preparation is not too much for nursing to ask. But the idea has remained elu- sive. Rank - and - file nurses have repeatedly resisted a proposal that is, after all, premised on their own YSNA 1985 K - BENDIS 19 incompetence. Elite nurses, meanwhile, have never been able to agree on a sensible way of ensuring their elite status, particularly with physicians ' assistants moving into their turf. And state legis- latures, faced with these and other conflicts, have been content to continue denying nurses control over access to their own profession. tect the inferior programs they represent, or " prac- ticing nurses with less adequate preparation to cope with present - day demands on the profes- sion. " (1) The tendency of nursing leaders to slan- der the bottom 80 percent of the profession in order to push the 1985 Proposal and its predeces- The pursuit of professional status has con- sumed the time of many occupations. Although invariably couched in terms of insulating the pub- lic from incompetent or unscrupulous practi- tioners, most observers see economic self improve- - ment as the major motivating force behind such efforts. (It is noteworthy that no professional law for nurses has ever been sought by the public.) The economic benefits of licensure (the legal stamp of professional status) inhere in two phen- omena: 1) Access to the profession and the right to practice the trade is restricted and invariably made more difficult and expensive. This depres- ses supply. 2) The professional status implies to the public a consistently high level of quality and more than likely stimulates their desire for ser- vices. This increases demand. Lowered supply and increased demand translates into higher prices. Substantial battles have been fought about whether particular groups are professions. Nurs- ing has been no exception. Eli Ginzberg, the econ- omist who chaired one of the many nursing study committees, offered the observation that nursing was not a profession and would not be until it put " all of [its] nursing programs under the direc- tion of colleges and universities, " thereby creating a small number (about 70,000) of elite nurses with professional status. Ginzberg candidly concedes that the real issue is income: professional pay depends on professional status and pro- fessional status depends on better exclusionary mechanisms. Nurses'leaders are plainly ambivalent about such utterances. On the one hand, they want to motivate their members to push for baccalaur- eate training in order to achieve professional status. Some observers of the nursing scene tend to confirm that the 1985 Proposal, or something like it, is a precondition for professional status. On the other hand, many espouse the belief that nurses are already professionals. Opponents of the trend are characterized by 20 many nursing leaders as philistines seeking to pro- Controlling entry into the profession has been a major part of nursing leaders'strategy to gain status and power sors is alarmingly commonplace and _ perhaps, in part, accounts for rank - and - file hostility to nursing leadership's efforts. Putting aside questions of professional sta- ture, lawyers define the two components of pro- fessional status as follows: 1) Is there an identi- fiable scope of practice which all non licensed - personnel can be excluded from performing for money? 2) Is the control over access to licensure held by those in the profession? Nursing leaders have identified their goal in terms of the second component. They feel that their inability to restrict the number of people eligible to take the licensing exam has led to a glut on the market. Of course, phrasing the is- sues in those terms would be inelegant, and they have used as a proxy the question of which class of schools to accept graduates from. The hypoc- risy of this theme is easily demonstrated by the fact that they do not urge stiffening accreditation or passing grades on licensure exams (never mind post licensure - scrutiny) because neither of these gambits can be guaranteed to work solely to the benefit of baccalaureate graduates. The other component identifiable - scope of practice is also a problem, although most seem to have only dimly perceived it. Most nursing scope practice - of - sections define nursing in terms of general mechanisms equally applicable to medicine (i.e. diagnosis, treatment, etc.) In fact, there is not a single " nursing " procedure that cannot legally be performed by physicians. The recent advent of physicians'assistants adds another group which can lay claim to a variety of " nursing " acts. There appears to be no way out of this fix for nurses. Unlike dentists and podiatrists, they have no area of the body to call their own. Even if they did, they would be more like podiatrists, who " share " it with other physicians, than den- tists. Nor are they like chiropractors and thera- pists who have identifiable functions which they share with physicians (at the latter's option). At least these groups have been able to exclude all nonphysicians from that therapeutic turf. The only turf nurses can claim, however, is in terms of institutional hierarchy, not any kind of functional differentiation. Nurses are the tradi- tional generalists providing care within hospitals, public health agencies, nursing homes, schools, etc. (Even in those areas, there are historic and recent conflicts with LPNs and nurses'aides). Re- cognizing this, the 1985 Proposal distinguishes be- tweeen professional and non professional - nurses not on the basis of function (which would prob- ably be impossible) but on institutional roles: non- professional nurses will take orders from pro- fessional ones. Similarly, conflicts with physicians will be resolved administratively, not legally under unauthorized practice suits. Nurses have, in effect, a closed - shop arrange- ment and not a profession. To put the matter another way, their monopoly is enforced insti- The real issue is income: professional pay depends on pro- fessional status and professional status depends on better exclusionary mechanisms tutionally, not legally. While it is true that free- standing nurse practitioners could not be charac- terized this way, they do, on the other hand, share functions with physicians and physicians'assist- ants (and perhaps others). Expanding nursing's scope of practice to in- clude psychological, educational, or social work tasks as is the current vogue would not help mat- ters. Rather it would further dilute the " ex- clusiveness " of nursing's scope of practice, as workers in those fields will then be performing " nursing functions. " One possible approach might be to list all functions a nurse could perform, and list every- one else who could also perform them. This would make nursing functions more exclusive but hard- ly totally so. For example, it is unlikely that any legislature would prohibit all others from doing catherizations, blood pressures and the like. More to the point, such deliberate delineation may liter- ally be impossible, although it is being attempted in part by defining lawful activities of nurse practitioners. The fact is inescapable: nursing is medicine. As such, it is hard pressed - to define an exclusive scope of practice and seems unlikely to be able to achieve such a goal in the future. One author noted that the education and training of nurses and physicians was about the same at the turn of the century. However, there was, and still is, a difference in the relative power of the two groups and it is this fact which " created the dilemma for nurses:... they were not their [physicians '] equals in the political and economic spheres of human activity, or in influ- ence on the public, and it was this lack of e- quality that would shape their development far more than their professional ideals. " (2) The Professional Leaders It is important to recognize that professions are not unified wholes. Like other American institu- tions, they are organized in a hierarchical fashion with elites and non elites - . Further, the benefits of professional status are not distributed evenly among the layers of practitioners nor exclusively with the profession. Therefore, the quest for pro- fessional status by the leaders of a vocation must also be seen as a quest for status and power over the vocation's members: "...... this policy has been attractive to leaders of nursing associations, teach- ers in nursing schools, some nursing officials in government, and others whose responsibilities, prestige, and other satisfactions, would be magni- fied by an increase in the collective status of nursing. " (3) Controlling entry into the profession has been a major part of nursing leaders'strategy to gain status and power. One approach has been to try to gain control over licensing boards. This has proved, until now, to be a losing battle. A second, equally valid approach is to attempt to gain hegemony over nursing schools. If all schools are controlled by one class of nurses, these 21 nurses will affect the numbers and types of per- sons who become nurses with a force equal to the licensing boards themselves. If the 1985 Proposal were to pass, the number of schools who would qualify for the equivalent of RN licensure would drop dramatically. With the BSN program consoli- dating its oligopoly, BSN educators would become nursing czars in the same fashion that medical school deans currently exert dominance far be- yond the borders of their schools. The public is correct to worry about exactly what the National Commission for the Study of Nursing and Nurs- ing Education meant in 1970 when it said that " to meet fully its obligations both to its members and society a health professional association must have final responsibility for the admission of its members. " In short, nursing leadership's pursuit of profes- sional status is a pursuit of power for themselves. One source characterized this phenomenon in this way: " Academicians have long been accused of a tendency towards building bigger and big- ger problems designed to produce more like- nesses of themselves rather than what the market wants. " (4) Graduates of baccalaureate programs, mean- while, are widely touted as the new nursing leaders. To the outsider, this looks like Dale Carnegie drivel. Upon close reading, however, it becomes clear that by nursing leaders is meant nursing bosses. The " leadership " they speak of is not premised on personal qualities and expertise, but rather on the institutional basis of super- visor and supervised, boss and worker. Nursing leaders'coverup of this authorization relationship with the phrase " nursing leadership " nature of the BSN - AD relationship as nicely as possible: " The AD graduate uses basic nursing knowledge .. in planning and giving direct nursing care in supervised settings....The BS graduate, on the other hand, provides leadership in the delivery of direct and indirect nursing care. By indirect nursing care, we mean that the nurse works with and through other people in order to achieve nursing goals and monitors nursing activities of others. We define leadership as influencing the actions of others. " (5) This article continues disingenuously to note that such leadership is to be based on " nursing knowledge, " neglecting to note that its real basis is institution- al hierarchy. Similarly the 1985 Proposal will command all institutions to put BSN nurses in charge of AD nurses. One could go on about the snobbery and pomposity of nursing's " leaders. " But the non- nursing reader is instead referred to their own writings, which testify more eloquently than any analysis to the tenor of this " leadership, " should any legislature be foolish enough to compel it. by legislation. While there are many reasons for nurses to fear legalization of the current nursing leader- ship's authority, the public should also be ap- The only turf nurses can claim is in terms of institutional hierarchy, not any kind of functional differentiation Nursing leadership's pursuit of professional status is a pursuit of power for themselves... Nursing leaders have pursued their own self- interest with a singlemindedness that would bring a blush to even the AMA's collective cheek is characteristic of their virtual inability to speak plainly. Read between the lines of the following 22 excerpt, which attempts to put the proposed prehensive. Of course, it should naturally be wary of pomposity and hypocrisy in high places. But more crucially, it has to fear nursing leadership's substantive view of health care. Nursing leaders have maintained a low profile in the burning issues currently fueling the health care debate. Indeed, they have resolutely pursued their own self interest - with a single mindedness - that would bring a blush to even the AMA's collective cheek. In every case, they stand for an extension of medicine's privileges (and excesses) to themselves and never an abolition of them. For example, there are demands for funding but Continued on Page 39 WASHINGTON DEATH AGAINST TAXES " After January 20, I intend to provide the aggressive leadership that is needed to give our people a nationwide, comprehensive, effec- tive health program, and you can depend on that. " -Jimmy Carter, Democratic Party Presidential Candidate, to American Public Health Association, Miami, Flo- rida, October 19, 1976 " I don't think we should con- dition the guarantee to the Ameri- can people of health care as a right on the state of the economy. That is a fundamental difference which can't be papered over... I could not in good conscience con- tinue to support the approach that has been spelled out by the administration. " -Senator Edward Kennedy August, 1978 " There are many people in this country for whom small changes and broad changes in coverage would make an enormous differ- ence in their lives there's... no doubt that our ability as an Ad- ministration to enact any kind of legislation will depend on the ef- forts of groups such as yours to expand the range of dialogue. I totally applaud efforts to go be- yond NHI to talk about a nation- al health service. " -Joseph Onek White House Assistant for Health to American Public Health Asso- ciation, Los Angeles, California, October 17, 1978 From watching the spring presidential rite of whistling Dixie (see last BULLETIN), we have recently been noting the congres- sional Irish jig in a rightward dance of death against taxes. In early summer the stalwart forces for national health insur- ance of big business, labor, and government appeared finally to be falling into place around the Carter Administration. Things were looking up. There was a growing acknowledgement - even among medical provider forces- that total health care costs and their gross product share in the U.S. are too high, that some in- tensive and defensive high tech- nology medical procedures and devices are questionable, and that some facilities are over built. Then, along came the full- fledged, Right business - - led War on Government and Taxes in the name of anti inflation - . The 95th Congress adjourned with no hos- pital cost containment - and cuts in basic Federal health programs. The haunting question has arisen: will there be a national govern- ment left to carry out national health financing reform? The new political graffiti was on the wall a few weeks after the victory of anti property- t-ax Proposition 13 in California. On July 29, President Carter is- sued his long awaited - " Ten Com- mandments " on national health insurance: " Thou shalt include the private insurance companies; " " Thou shalt require co payments - from users,'" etc. Senator Ken- nedy and AFL - CIO President Meany blasted these the day before. The Carter Commandments President Carter's " Ten Prin- ciples, " released in a solemn press conference by HEW Sec- 23 retary Joseph Califano, contained posed Hospital Cost Containment - the following provisions: Act, which provides for a national | Multi staging -, 1984 to 2001? -no additional federal percentage " cap " on expenses. (This Bill has already been gutted spending until fiscal year 1983 and then " phased in gradually; " BB " Triggered " by Health of by private hospital interests, but even if passed would have ques- tionable efficacy under the exist- the Economy -implementation ing system short of providing a is to depend on health industry mechanism for drastic cuts in inflation being contained (even without comprehensive financing needed services.) Both the American Medical and structural reform) and general Association and the American inflation and unemployment be- ing lowered by '83: " Before Hospital Association found ele- ments in the Administration state- I submit legislation, I want to ment that parallel their own be certain that the plan is con- sistent with our efforts to control proposals, such as phasing in the program and participation inflation in the health care sec- of the private insurance industry. tor and the general economy. Y' Victim charging - -co pay- - ments and co insurance - for users The president of Blue Cross praised it as " sensible. " White House Press Secretary Jody Pow- as alleged disincentives to over- utilization, even though it has ell, commenting on the opposi- tion from Senator Kennedy, said, been consistently demonstrated " This is no longer the New Deal that it is the medical providers and institutions who are the ... there is no constituency for undisciplined spending. " prescribers, referral agents, and organizers, while sick people have little or no control over their episodes of illness; BB Private Insurance Industry ' a significant role for the...; " WE Off Federal Budget -ad- ministrative entities would be funded separately from regular U.S government appropriations after 1983, thus providing no public accountability or congres- sional budget control; Wie Covering of the " Un- covered " only -Emphasis would be on insurance for the unin- " This is no longer the New Deal... There is no constituency for undisciplined spending " -Jody Powell White House Press Secretary sured, not on guaranteeing the appropriate coverage or organiza- tion of care for everyone; HB Unrealistic " Cost Contain- ment " Projections -the approx- imately $ 40 billion in additional federal funds which would even- tually be required, are to come primarily from savings genera- 24 ted by the Administration's pro- But Kennedy and his forces disagreed. Claimed Kennedy, as he and the labor backed - Commit- tee for National Health Insurance began promoting their own " Pri- vate Guaranteed Bill. " " There is a growing grass roots - constituen- cy, " according to the senator. He enumerates: the " senior citizens, church groups and working men and women of this country are ready to move. Their ranks will be swelled, I believe, by the mid- dle class which will see its prem- iums rising, its benefits falling be- cause of inflation. The new Kennedy " Private Guaranteed " Bill is described as non inflationary -, cost containing -, multi staged -, contributory and committed to comprehensiveness within 24 months although - some benefits will be phased in later. Unlike the Administration's pro- posal, it is neither general econ- omy hedged -, nor triggered, nor does it contain direct payments co - for the neediest users. Much of the actual legis- lative language, e.g. regarding exact financing mechanisms, pro- spective budgeting process, and coverage regulations, won't be unveiled until at least December. However some of the different principles are already being spel- led out. Coverage will be multi- staged but eventually compre- hensive benefits will be avail- able for all, including home care and preventive services. Questions still hang heavily about full men- tal health and dental health cover- age and about full chronic and elderly nursing coverages. Also unresolved are questions about which professions will be reim- bursed, especially for prevention, health education and outreach services. Prescription drugs for the nonelderly are to be phased in later. Most notably absent is any mention of abortion coverage. @ The Kennedy Bill creates three different national " compet- ing consortia " for private bene- fits. Each will be subject to elaborate federal coverage criteria for inclusion. There is to be one for commercial insurance com- panies, one for Blue Cross - Blue Shield, and one for health main- tenance organizations (HMO's). There is no direct provision for community - based health centers, except under an HMO market qualification. It provides no sep- arate public, government - owned hospital or health financing chan- nel. This could mean the end of public hospitals, except as the worst imitators of private, fee- chasing, bed filling -, and high tech- nology hospitals, although where else will those ultimately un- covered or dumped then go? Although there are resource development funds under the Bill for currently underserved areas, none of these private consortia from which individuals ostensib- ly are to choose refer to com- munities where people live. It is hauntingly unclear how the fed- eral government can force (much less interest) the insurance in- dustry to join this plan when it already has access to the better middle class and employee mar- kets. Private insurers and pro- viders might have this approach tied up in litigation for years before it could begin to be im- plemented. A Federal Public Authority, regulating mostly non Congres- - sionally appropriated funds and therefore " off federal budget, " would emphasize prospective bud- geting (negotiated advance / and planned payment amounts) for institutions and professional pro- viders and would operate through 51 State Health Authorities (SHA's). Most of these SHA's would probably be based in cur- rent state health departments but under " strict federal guidelines. " Federally regulated financing calls for earnings - based employer premium payments plus employee contributions to cover up to one- fourth of costs. An estimated $ 21.7 billion of new " on budget " impact in federal expenditures is projected by 1983, primarily to cover the unemployed and the poorly paid. It could mean the end of public hospitals, except as the worst imitators of private fee chasing - , bed- filling, and high technology hospitals. But where else will the uncovered or dumped then go? From Public to Private This new Kennedy Bill, based entirely as it is on " guaranteed " private insurance for all, moves completely away from the public principles of the old Kennedy- Corman Health Security Act of years past. Previous co sponsor - Rep. James Corman (CA D -) has criticized the total private insur- ance approach and lack of at least parallel support for public health and hospitals programs. The 51 newly created SHA's overlaying three private national consortia would vastly increase the num- ber of places where community- oriented consumer and health worker forces will have to fight for basic coverage guarantees. The SHA's also lack any real com- munity - level decentralization for program development accountab- ility. Since states have generally been subject to the most focused special interest domination and unrepresentativeness, it is quite unclear how strong federal stand- ards of meaningful 51% consumer control can be forced on the states or how agency designation could be effectively controlled. Principles of broad and equit- able coverage are articulated in the Bill. But a framework depen- dent on private insurers and pro- viders, even with strong federal guidelines and incentives, can- not significantly affect the loca- tion, organization, or develop- ment of medical care resources towards our desperately under- served rural and inner city areas. The Bill's emphasis on cost con- - tainment could likely lead, given these limits, to to the the dumping of those most vulnerable, " loss leader " services, those socially cost effective - and needed pre- ventive and primary services, and the dropping of such controver- sial provisions as home birthing and abortion. The Lesser of Two Losers Thus, before our eyes, the NHI controversy has been re- duced to a battle between the President's " you'll be healthy if the economy's healthy " in his 1983 supplementary coverage proposal vs. Senator Kennedy's universal, but only loosely com- prehensive regulation of private coverage to begin within two years. Harsh questions confront these new rightward tinkerings and compromises in the fading name of NHI. Is the red, white, and especially blue tape of weak, multi layered - government regu- lation of a privately owned, nearly $ 200 billion medical in- dustry possible except as a more costly nightmare akin to the sub- sidized energy monopoly? Is meaningful compromise in ad- vance of legislation possible with private medical providers and in- 25 surers, whose business depends totally on the outcome? Although the new Kennedy Bill has ap- proaches distressingly similar to the old American Medical Asso- ciation backed - Medicredit (with more comprehensive government regulation and coverage require- ments), it's already getting total AMA opposition. Tough negotia- tion by government, within the framework of a real, total nation- al health financing system, yes; but legislative compromise in advance? It is becoming increasingly clear that the real issues are how to control costs, who pays and who's to blame for illness It is becoming increasingly clear that the real issues are how to control costs, who pays, and who's to blame for illness. Should there be comprehensive govern- ment intervention for financing and planning care, with guaran- The removal of comprehensive, public, national health financing from the political arena - for years assumed to be just around the corner linch pin of US health care system development - leaves people even more than ever with no national health policy teed services for all? Or only minimally regulated government subsidy for so called - market al- ternatives, especially corporation- dominated HMO's? Should the systemic environment / occupation- al agribusine/s sso c/ia l causes of ill- ness be challenged? Or will ma- jor emphasis be on personal life- styles, required care disincentive - co payments - , and other forms of individual victim blaming -? A newly defined health coali- tion, more broadly labor and community - based than the cur- rent consumer coalition, may be necessary across the country, in order to develop satisfactory answers to these questions. In addition to immediate lobbying with expectations for national health financing reform, such a movement could be one which challenges the corporate environ- mental occupational / illness causa- tion with community - based, ad- vocacy health services, and one that builds on living local alterna- tives of publicly accountable health budgeting, planning, and organizational efforts. The removal of comprehensive, public, national health financing from the political arena - for years assumed to be the just aroun-d th-e- corner linchpin of U.S. health care system development - leaves people perhaps even more than ever with no national health policy. Are we tragically caught for now in a classically false nation- al policy choice of death against taxes? -Robb Burlage JOURNAL OF COMMUNITY HEALTH The Official Journal of the Association of Teachers of Preventive Medicine Editor: Robert Kane, M.D. tures articles on those projects which are making a significant impact on the education of health personnel. Other noteworthy features of the Jour- nal include a concise abstract which pofr erceefdeerse necaecsh wairtthi cwlhei,c ht heea cbhi balritoigcrlaep hiys The Rand Corporation The devotes itself to original articles Journal on the practice, teaching, and research of community health and en- compasses the areas of preventive medicine, new forms of health man- power, analysis of environmental fac- tors, delivery of health care services, and the study of health maintenance concluded, the list of new books in the field, and a particularly significant let- ter to the editor. ISSN 0094-5145 Quarterly LC 74-19591 791-5 Individuals 792-3 Institutions Vol 4, 1978-1979 $ 18.00 $ 40.00 ainndg haesa lat hf oirnusmu rafnocre tphreo gerxacmhsa.n gSee rvo-f a | HUMAN SCIENCES PRESS 72 Fifth Avenue 3 Henrietta Street ideas and clarification, the Journal fea- NEW YORK, NY 10011 @ LONDON, WC2E 8LU 26 WOMEN A VICTORY FOR THE RIGHT Y The political record of the last year has not been a heartening one. To some, it has become pos- itively alarming. The record bears a closer look. The Hyde Amdendment, passed in November, 1977, halted abortion funding for poor women but allowed states to take over the cost. Of the 15 states which have exercised this option, four have since withdrawn funds be- cause of the pressure of sys- tematic Right - to - Life campaigns waged in state and local legisla- tures. More are likely to follow. Eight abortion and women's clinics have been firebombed since February 1977, blinding one woman and nearly trapping an- other on an operating table, in a mounting campaign of picket- ting, sit ins -, harrassment, and terror directed at abortion clinics and the women who use them. A campaign for a Con- stitutional Convention to draw up a Constitutional Amendment banning abortion has progressed swiftly, netting eleven of the nec- essary 34 states in less than a year; similar resolutions have passed one house of the state legislature in five other states and have been introduced in 12 others. Since no rules exist to govern such a convention, many fear the Constitution and Bill of Rights themselves might be subject to revision. Overwhelming ballot box defeats of gay rights ordinances, first in Dade County, Florida and most recently in St. Paul, Minne- sota, have fueled anti - gay senti- ment around the country. Re- peal of rights for gays is now on the ballot in Wichita, Kansas and Eugene, Oregon, and efforts are afoot to hold referendums in Seattle, Washington and in the State of California as well. Abortion, the ERA, and gay rights are only the most volatile examples of the hostile winds blowing from the right. Also up for grabs in many areas of the country are school busing, af- firmative action, sex education and liberal textbooks, daycare, welfare and other public ser- vices, the death penalty, right- to work -, environment, nuclear en- ergy, OSHA and EPA, consumer protection, gun control and the Panama Canal Treaty, to name a few. There is little disagreement that the political pendulum is swinging to the right. How serious that swing is, what it represents and what response it warrants from progressive forces, how- ever, are subjects of growing debate. The " Far Right " has been a perennial feature of the Ameri- can political landscape, tradition- ally represented by such groups as the American Conservative Union, the Right to Work Com- mittee, the John Birch Society and Young Americans for Free- dom, as well as the Ku Klux Klan and the American Nazi Party at its extremist fringes. What is new and therefore threatening about the " New Right " of the 1970's is at least threefold: A genuine social movement is taking place on the right, char- acterized by the activism of in- creasing numbers of ordinary individuals willing to contribute money, make phone calls, write 27 letters, ring doorbells, picket, sit - in or whatever. Unlike the ideological and hidebound older formations of the right, the present, yet nascent movement is a pragmatic, issue- oriented, grassroots one that is propelling a large cross section - of female Americans into action. An organizational and tech- nical leadership is emerging with the potential to weave these di- verse but related issues into a single integrated political fab- ric. Illustrative of this sophistica- tion is the operation of Richard Viguerie, sometimes called the " Godfather " of the resurgent right wing. Viguerie has used the computerized culling of vast now contains over 200 mailing lists with the names of 10 to 20 million contributors to conserva- tive causes. From a campaign war chest of a mere $ 300,000 in 1972, the New Right will enter the 1978 elections with some $ 20 million, thanks largely to the Viguerie operation, estimates the ADA. With the recent election to national office of such far right- wingers as Orrin Hatch of Utah, Arban Strangeland of Minnesota, Robert Livingston of Louisiana and John Cunningham of Wash- ington almost solely to his credit, Viguerie is moving from simple fundraising to building a polit- ical machine that will be able to offer campaign back - up and expertise to some 1,000 local and state national candidates this year. From a campaign war chest of a mere $ 300,000 in 1972, the New Right entered the 1978 elections with some $ 20 million mailing lists to identify, tap and weld together latent and active conservatives of all issue persua- - sions. His computer center in Falls Church, Virginia, employing over 250 people, has become a formid- able tool for raising money and eventually, no doubt, for mobil- 28 izing the conservative masses. It Grassroots Political Activism Progressive forces, alarmed by the growth of the New Right, have reacted primarily to the latter aspect - the growing organi- zational and technical sophisti- cation of the Right. Yet to react simply to the Richard Vigueries is to risk ignoring the substance of the fear and discontent which feeds grassroots political activ- ism on the right today. " We organize discontent, just as all successful movements do, " says Howard Phillips, former Nixon aide famed for dismantling the Office of Economic Opportunity and presently the national direc- tor of the Conservative Caucus. In many respects the expressed discontents mirror issues raised by the movement of the left that prevailed in the 1960s and early 1970s: anti imperialism - , minority, women's and gay rights, environ- ment, occupational health, con- sumerism and the counterculture. The most potent and explosive of these is the reaction to the wo- men's and gay movements. One common thread that runs through many of these issues is the role and destiny of the nuclear family. At issue, thanks to these movements, are some of the most fundamental of social and personal issues: the viability and desirability of the nuclear family, the social, eco- nomic and sexual roles to be played by men and women, whether and under what circum- stances to have children, and the nature of sexual identity, to name a few. The very emotionality of the anti ERA -, abortion and gay rights movements suggests that these is- sues strike close to home, threat- ening critical stresses and barely- repressed needs among their mem- bers. At the deepest social and personal levels, the same needs may be fueling the growth of both the right and the left. This propo- sition is not only a plausible one; it is a hopeful one as well, and one therefore worthy of seri- ous consideration. To address this possibility, however, will require a new maturity of movements on the left movements - hertofore large- ly preoccupied with damning the nuclear family and its failures and declaring their own libera- tion from oppressive social con- ventions. Required will be a dia- lectical appreciation that, op- pressive, eroding institution that it is, the family still offers to many the only source of secur- ity, identity, intimacy and mean- ing available in an otherwise alien and exploitative world. Re- quired will also be an articulation that the left does not represent a threat to the fulfillment of these needs, but the opposite: their fulfillment in an alternative and acteristics of the unborn child more viable context. at the time the abortion is to -Ronda Kotelchuck be performed. " Wi a 48 hour waiting period be- tween consent and performance of abortion; BI the statement that " a woman NJ ABORTION GUIDELINES should be encouraged to carry her child to term. " On August 17, 1978, the New Jersey Senate held its first public New Jersey has joined the ranks hearings on S.1110, the proposed of states, cities, and counties bill to regulate abortions. faced with Right - to - Life legisla- Out of the seventeen people tion. Identical bills have been in- who presented testimony that day, troduced into the Senate and the six were in favor of the bill. But Assembly which, if enacted into law, would serve to make abortions less accessible, more costly, and more emotionally draining. Some of the bills'provisions include: G9 the definition of life as be- ginning from the moment of conception; Bj the requirement of parental notification for never married these six speakers monopolized that day's hearings. Among the bill's proponents were the Lutheran Church Missouri Synod, the N.J. Right to Life Committee, Americans United for Life Legal Defense Fund (Chicago), National Association of Obstetricians - Gyne- cologists (Chicago), and the Committee of Doctors and Nurses women under the age of 18; GM outlawing of saline amnio- centesis procedures unless cer- tified in writing to be medically indicated; Wi the requirement that second trimester abortions be perform- versus Abortions (New York). The anti abortion - groups'argu- ments went well beyond the tradi- tional religious arguments with which they have been identified in Ln ed in a hospital equipped with life saving measures in case the fetus is viable, by two doctors, one of whom is for the poten- tially viable fetus; BB an exaggerated and biased Out of the 17 people who presented testimony, the 6 speakers in favor of the bill monopolized the informed consent procedure, which requires that the woman day's hearings be told of the " possibility of immediate and long term phy- sical dangers of abortion psy- chological trauma, sterility, in- creases in the incidence of pre- mature births, tubal pregnancies and still births in subsequent pregnancies. " She must also be told " the probable physical competency and probable ana- tomical and physiological char- aD the past. Only the representative of the Lutheran Church Missouri Synod approached the subject from that perspective. Professor John Gorby, representing the Americans United for Life Legal Defense Fund, submitted testi- mony to the committee which was about five inches thick. The testimony included rewrites of parts of the bill which he claimed would insure that it would hold up against the test of the Supreme Court. His oral testimony, which lasted an hour, described the legal maneuverings and issues in- volved. Testimony was supposed to be limited to five minutes. Dr. Jasper Williams of the National Association of Obstetri- cians Gynecologists - in Chicago, took pains to establish his liberal credentials (member of the AME Church, against the culture of poverty theory, member of black caucuses in professional associa- tions, ets.) before he proceeded to argue somewhat incoherently against liberalization of abortion regulations. Asked by one of the Senators, " How did you hear about these hearings, " Dr. Williams responded by saying that someone from NJ (he wasn't sure of the organiza- tion's name) had contacted him to speak. Although there was no fol- low - up comment or question, the powerful centralization of the right's intelligence gathering and deployment of forces was made very clear. To complement the testimony of Dr. Ada Ryan, representing the Committee of Doctors and Nurses versus Abortions, was a very large drawing of a nine month fetus. Her presentation began with a medical explanation of pregnancy and the abortion procedures. After one unsuccessful attempt, she was finally asked to remove her pic- ture, since it was misleading to the discussion at hand (first trimester abortions). In her testimony she denounced the Supreme Court decision which forbid any regula- tions of the abortion procedure. " As it stands right now, " she said, " I could perform an abortion in 29 the lobby of this building. A psy- chiatrist or a dermatologist could perform abortions. " Although she was challenged by some of the Senators on this point she held her ground firmly. She spoke of numerous instances of medical in- competence, including botched abortions (very graphic descrip- tions of improperly performed vacuum aspiration procedures, etc.) and the lack of follow - up care from abortion clinics. Num- bers of teens die each year, she said, from improperly performed legal abortions. Yet almost no- where did she present statistical data to support her assertions. Anti abortion - speakers repeat- edly claimed that the black market adoption business is being fed by abortionists who urge their clients to carry to term their unwanted pregnancies. Counselors at referral agencies, these speakers charged, receive financial kickbacks from abortionists, and doctors who per- form abortions do so out of their Anti abortionists - are increasingly co opting - the rhetoric, arguments and tactics of the 1960s; the very same argument was used to fight for the legalization of abortion own purely economic interests. Althouth outnumbered by those arguing against the bill and in favor of the right to abortion, the Right to Lifers are far better financed and organized. Flying three people from Chicago to New Jersey requires both an economic solvency and a central coordi- nating effort. Even more important to realize is that their arguments are not al- ways so simple or obviously reac- tionary. They are increasingly co- opting the rhetoric, arguments, and tactics of the civil rights movements of the 60s and other liberal causes. Many of their argu- ments are the very same ones used to fight for the legalization of abortion (women are dying from improperly performed procedures, etc.). The second and last day of Senate hearings was October 26, 1978. The Assembly held its hear- ings on one day in October. Both days of proceedings differed little from that described above. There was less technical, professional testimony, as testimony at these two came mainly from individuals, grass roots groups, and women's groups. Both sides were equally represented. Unless joint hearings are held, which is unlikely, no further dates for hearings are set. It's all in the legislators'hands now, and quite frankly the picture is bleak. -Marilynn Norinsky MILLIONS FOR OFFENSE, TWO CENTS FOR DEFENSE Health insurance companies rarely cover contraceptive _ ser- vices, only partially cover abor- tion and maternity services, but virtually always pay in full for sterilization, according to a new survey of insurance coverage done by Charlotte Muller, associate di- rector, Center for Social Research of the City University of New York. Among 37 commercial health carriers surveyed, contraception coverage was " almost non exis- - tent, " 29 covered abortion ser- vices (mainly in a hospital setting) and 34 covered _ sterilization. These findings are in keeping with the illness orientation - of the medi- cal system and its insurors and with prevailing patterns of discri- mination encountered by women. Source: American Medical News, April 14, 1978. 30 ENVIRON WORK BIRTH OF A MOVEMENT? Fr The week of September 10-16 moved the issue of occupational safety and health to a place of new importance in the political life of the country and everyday public consciousness. For the first time, occupational safety and health began to look like a so- cial movement with real political potential. On September 11-13 the AFL- CIO held its first National Confer- ence on Occupational Safety and Health in Washington D.C. Of the 1,000 people in attendance, most were rank - and - file workers or oc- cupational safety and health staff from unions, including unions not in the AFL - CIO. Representatives from some of the 15 community- based Committee on Safety and Health (COSH) groups also at- tended. The conference coincided with the creation of the AFL- CIO's Department of Occupation- al Safety and Health, headed by George Taylor, with a budget of $ 400,000. Prominent speakers such as Walter Mondale, cabinet members, Congressmen, agency heads, and union officials were paraded in front of the con- vention. Yet the discussion ex- tended beyond official presenta- tions. The delegates in the work- shops were largely organizers and people from local struggles who came together to be part of a political movement. This gather- ing marked a new stage in organ- ized labor's concern with occupa- tional safety and health and a chance for local people to get a sense of the activity of other unions and groups. The conference took place in an atmosphere of major labor leg- islative defeats and declining. membership. Hanging in the bal- ance that week was the Bartlett Amendment, which would have severely restricted OSHA's ability to inspect workplaces with under 10 workers. The amendment was later killed in a conference com- mittee. Occupational safety and health is one of the few areas labor could point to for real victories. The current OSHA administration was loudly applauded as being strong- ly in labor's interest. The appoint- ment of Dr. Anthony Robbins as the new Director of NIOSH, an- nounced at the conference, was a- nother labor victory. The AFL - CIO has been the ma- jor force in the creation and de- fense of OSHA. As George Meany said in his speech: " OSHA is our law. " A strong law and the means to make it work is a clear benefit organized labor can offer to unorganized members. Occupa- tional safety and health must be in the forefront of labor's at- tempt to grow organizational- ly, strengthen itself politically, and improve the lives of workers. The safety and health move- ment promises to help revitalize organized labor itself. HEW Secretary Joseph Cali- fano turned the convention into a front page media event. His speech cited new National Cancer Institute and National Institute of Environmental Health Sciences estimates that " at least 20 per cent of all cancer in the United States and perhaps more - may be work related. " Previous estimates had been as low as 1 to 5%, a figure commonly cited by indus- try spokesmen. The new study 31 projects future occupational re- lated cancers by estimating the increased cancer risk of known carcinogens and the number of people exposed. It excludes many known carcinogens for which there is inadequate human data to estimate risk; radiation is also excluded, so the projections may in fact be on the low side. The study estimates from 21 to 38% of cancers in future years may be occupationally related, with as- bestos alone contributing to 13- 18% of total cancer deaths. Califano's announcement pro- jected a far larger estimate of the occupational cancer problem than had previously been expressed by government agencies. While all such estimates are crude, Cali- fano gave credence to the opinion of many researchers and organ- izers that we can expect a mas- sive epidemic of occupational can- cers. The conference projected a mass movement to push for ac- tion to prevent such a tragedy from affecting millions of wor- kers. For One Worker, the Conference Came Too Late Battles regarding occupation- al illnesses often are fought indi- vidually and sometimes tragically. Early on the morning the confer- ence was to start, an occupational health related mass murder oc- curred in Edison, New Jersey. Robert Mayer, a former employee at Alpine Aromatics International Inc., a small perfume factory, killed the owner and two other employees with a sawed - off shot- gun. He then took his own life. Mayer was 37 years old, and mar- ried with two teenage children. He suffered from emphysema. May- er's choice of targets stemmed from an OSHA dispute that 32 started 3 years before. Mayer had complained about chest pains from breathing fumes. First he brought a respirator to work; later, against his foreman's wishes, he opened the door at The NCI study estimates from 21 to 38% of cancers in future years may be occupationally related work to let in fresh air. After staying out of work some days for medical reasons, he was fired, because, according to la- ter court testimony, " he could not be depended upon for pro- duction. " Mayer filed an OSHA complaint charging he was fired for exercising his rights under the law. He requested an OSHA in- spection, but no citations were issued. Last June a U.S. District Court judge decided the case in favor of the company. American popular culture has celebrated incidents where a lone citizen takes up the gun and leaves a bloody trail of " justice " where the official agencies of justice have failed. In this instance, the precipitating event and targets were part of an occupational health dispute. Mayer's anger flared into an act of inexplicable horror. Isolated workers such as Mayer, increasingly aware of oc- cupational illness, take individual action. Outmanueuvered by the company and bewildered by the law, they are left with despair or anger. The support of a union and a visible movement committed to occupational health could help turn these frustrations into politi- cal action. In a country where OSHA inspectors are afraid to enter certain places for fear of employer violence, it is little wonder that some workers re- spond with imagined or real viol- ence toward those they hold re- sponsible for their illness. As occupational safety and health grows in public conscious- ness, it begins to move closer to center stage in the nation's health politics. Rooted in indi- vidual and local struggles, yet pro- jecting a national focus, it may be- come a self conscious - social move- ment. Certainly it is becoming a force within the union movement. Outmaneuvered by the company and bewildered by the law, workers are left with despair or anger Fuelling the movement is the growing awareness that workplace tragedies are all too often caused by the vast gulf in power between workers and management in de- termining how work and produc- tion are organized. As an experi- enced union health professional remarked at the AFL - CIO con- ference while listening to Labor Secretary Marshall extoll the vir- tues of labor management - co- operation, " occupational health is the clearest expression of class struggle. " -Tony Bale a OCCUPATIONAL INJURIES AND ILLNESS AMONG BLACK WORKERS High unemployment among Blacks is a major national prob- lem. But the patterns of racism extend beyond the factory gate or the office door. Black workers have a one third - greater chance than white workers of suffering an occupational in- jury or illness resulting in lost workdays, according to a recently completed Health / PAC study. The black worker also faces a roughly 20 percent greater chance of dy- ing from job related - injuries or health problems. A history of job discrimination has left Blacks now employed at relatively high rates in the more dangerous factory and blue collar jobs and at very low rates in white collar jobs in virtually every major sector of US industry. While Blacks made up 10.91 percent of the private sector workforce in 1975, they were employed in white collar jobs at rates much lo- wer than 10.91 percent in every major industry category, and at rates higher than 10.91 percent for blue collar jobs in every indus- try except mining. (Table 1) Since occupational injury, ill- ness and death rates are greater for blue collar than white collar jobs, heavier employment of Blacks in blue collar jobs means a greater burden of risk for them. The numbers and overall rates of occupational injury, illness and death for Black workers were cal- culated from the EEOC employ- ment figures and the correspond- ing 1975 OSHA death and injury data for each industry. These fi- gures were then compared to those that would have been found if Blacks were employed without discrimination, that is, if they were employed at the same rate in each industrial job category as in the entire workforce, 10.91 per- cent. The OSHA occupational data presented in Table 2 applies to all workers in a particular industry regardless of distinctions among types of jobs. As seen in Table 1, this data was further broken down into blue collar and white collar components because the essential job discrimination pattern for Blacks is between these two groups in every industry but min- ing. The white collar injury and ill- Industry Agriculture Mining Construction Manufacturing Transportation Trade Finance Services Private Sector Totals TABLE 1 Black Employment Total Employment in Thousands Percent Black Workers Percent Black Workers in Low Risk Jobs * 1,568.0 744.7 3,457.0 18,175.9 4,498.0 16,947.8 3,778.3 10,298.9 12.88% 4.99% 10.94% 10.71% 10.31% 8.94% 9.40% 15.46% 2.03% 2.72% 2.56% 3.68% 8.02% 5.66% 7.72% 7.99% 59.468.9 10.91% 5.97% Percent Black Workers in High Risk Jobs * 15.83% 6.16% 14.39% 14.10% 12.24% 14.24% 20.20% 26.21% 15.75% SOURCE: Total employment figures are from the U.S. Department of Labor, Ref. 1. Percentages are from the EEOC Ref. 2 (EEOC total employment figures are less than those from the Labor Department because only employers with 100 or more workers are required to file EEOC reports and of these many don't file.) * Low Risk Jobs are jobs classified in the standard Department of Labor occupational categories: Officials and Managers, Professionals, Technicians, Sales Workers, and Office and Clerical Workers. High Risk Jobs are jobs classified in the categories: Craft Workers, Operatives, Laborers, and Service Workers. 33 ness rate was estimated from the overall OSHA rate for the finance industry: banks, credit agencies, security brokers, insurance com- panies and real estate firms. The first four of these each employ 95 percent or more white collar wor- kers, and their average incidence rate is 0.55 injuries and illnesses involving lost workdays per 100 workers. Assuming the 0.55 rate to be the same for low risk wor- kers in every industry, we could calculate what the high risk rate must have been to give OSHA's overall rate for each industry. Using these risk rates and the EEOC employment figures, we found that Blacks have an inci- dence rate for occupational in- juries and illnesses of 4.33 per hundred Black workers. This is about 37 percent greater than the rate of 3.17 for White workers. The results were basically the same when the white and blue collar rates varied within reason- able limits, so the results are not critically dependent on our choice of rates. For example, when we chose a white collar rate equal to the overall rate for the finance in- dustry (0.8), as if injuries in the fi- nance industry happened at the same rate to white and blue collar workers, the Black rate was found to be 32 percent greater than the White rate, only slightly less than the above result. Even when we chose the white collar rate to be a constant rate for each industry, so that white collar workers in more dangerous industries like mining and manufacturing are assumed to be at greater risk than white collar workers in the finance industry, the Black injury and illness rate was still found to be 37 percent greater than the White rate. Based on a 37 percent greater rate, Blacks experienced 75,000 34 more reported injuries and illness- Industry Agriculture Mining Construction Manufacturing Transportation Trade Finance Service Private Sector Totals TABLE 2 Occupational Injury & Illnesses involving lost work days per 1000 workers 3.7 5.7 5.5 4.5 4.6 2.6 0.8 2.0 3.3 Occupational Death per 1000 workers 0.19 0.54 0.29 0.066 0.22 0.053 0.026 0.039 0.089 es in 1975 than the roughly 200, 000 they would have experienced had their rate been the same as the White rate. Of these 75,000, about one third - occurred in the manufacturing industries and one- fifth in the service industries. Although OSHA does not give occupational fatality data broken down in detail by industry, we made a similar calculation for the increased death rate of Blacks on the job compared to the White rate. Assuming a constant of rate. Assuming a constant of white collar occupational death rate of 0.018 per thousand wor- kers, just slightly less than the overall death rate for the finance industry (see Table 2), we found a 24 percent increase in the Black death rate on the job compared to that expected if they experienced the White death rate. No matter how you slice it, this is a grim story. It can be changed, but only if this country begins to worry more about the discrimination that continues to prevail against Blacks and other minorities than " reverse discrimi nation " against the relatively small number of Whites who are adversely affected by needed change. At the same time, those com- mitted to the struggle against rac- ism in the US must be sure that a major thrust of their efforts also be the elimination of occupational hazards for all workers, in so far as possible. An integrated work- force in which blue collar work- ers, Black and White, continue to be struck down on the job with great but equal severity is not an acceptable solution to the prob- lems of Black and White workers. - David Kotelchuck (with assistance from Robert Forer, Joan Drake and Jacqueline Pope, student interns from An- tioch College, University of North Carolina School of Public Health, and Columbia University Division of Urban Planning, respectively.) NEW YORK T] KOCH: HOW NOT TO SUCCEED WHILE REALLY TRYING Most recent NYC mayoral ad- ministrations have had a stormy first year getting to know the la- byrinth of programs and agencies that make up the City's govern- ment. And, as noted in these pages many times, few have ever gotten a real handle on health care policy among the more byzan- tine of arts in any case. But never have we had a begin- ning like that of Edward " How'm I doing " Koch. In its first year in office, the Koch administration has left behind such a pile of scrapped health policy initiatives and discarded health care officials that one is reminded of former Comptroller Harrison Harrison Goldin's late lament, " Incompetence! In- competence! Incompetence! In- competence! " (quoted by Brian Ketchum and Stan Pinkwas in the Village Voice, Sept. 18, 1978). The Koch record is not totally one of ineptness, however. Some perceive a pattern of " malign ne- glect " from the former Congress- man who has long held and admit- ted a distaste for the City's muni- cipal hospital system. Certainly, if the constant chaos in City health policy accomplish- ed anything, it has been to streng- then the hand of those calling for the destruction of the 17 munici pal hospitals. Sadly, the notion that the municipal institutions are the source of the City's soaring health care bill has come to be considered gospel verified - by an endorsement in early December by The New York Times. Calling the Health and Hospitals Corpora- tion (HHC - the quasi public - agen- cy which administers the munici pal hospitals) the " most obvious target " for reducing municipal spending, the Times called for re- ducing current expenditures by half in the coming year. The events of the past year were incredible. Taken together, they represent the worst omens yet for the public hospital sytem. H. Alex Schupf, Mayor Koch's Special Assistant for Health and (thereby) Health Ser- vices Administrator and Chairman of the Board of the HHC quit in frustration in early September. The official explanation was " po- licy differences. " But the key is- sue was: should the City continue to operate any municipal hospi- tals. In his brief tenure, Shupf had come to feel strongly that the City must maintain at least some of them, and also that there was a need to strengthen the public ser- vice orientation that has histori- cally been their raison d'etre. Public service, however, seems low on the Koch list of health ser- vice priorities. For that matter, it doesn't appear to be the key moti- vation for current HHC manage- ment, either. The HHC admini- stration has thrown itself into a strategy that seems better calcu- lated to abolish the municipal hos- pitals rather than save them. Schupf was beginning to recognize this strategy for the blind alley it is. In an interview with the Village Voice (Sept. 18, 1978), Schupf stated: " I fear that under the pres- sure of fiscal burdens and wooed by the siren song of simple mana- gerial solutions, an attempt will be made to disembody this corpora- tion. That must not and should not happen. In fact, it makes little financial sense because those of us 35 who have studied the issue care- fully know that City expenses will increase not decrease - without the municipal hospitals. The only way that proposition will not be true is if many fewer people are treated, if those at the margin whom we serve become the dis- possessed... " Shupf was indeed onto something. In July, Koch appointed Dr. Martin Cherkasky, president of Montefiore Hospital in the Bronx, to head a special panel to oversee planning for HHC's new- est and most controversial hos- pital, Woodhull in North Brook- lyn. Already under attack from within and without HHC, the Hard on the heels of the Cherkasky report, Koch named Cherkasky to replace Shupf in an unusual half time - appointment as Special Assistant for Health, leav- ing Cherkasky's other two and - - a- half days a week presumably oc- cupied with running Montefiore. Koch announced that Cherkasky will head a special Mayor's Policy Advisory Committee (Koch's Health / PAC?), a position he later seemed to back away from. Suspecting a decision by Koch to move the City out of the hospi- tal business altogether, many ob- servers saw the move as putting the proverbial fox in charge of the chicken coop. Cherkasky is a long- The revenues from Medicaid and Medicare, it was proposed, would play the same function for the municipals that private insurance reimbursements had long played for voluntary hospitals: guaranteed annual income Woodhull situation may sym- bolize the dead end that HHC's management strategy represents for municipal hospitals better than any partisan of public services could hope to accomplish with words alone (see below). Cherkasky's appointment was cited by Schupf as the final straw. It also set the stage for Cherkasky's Task Force, re- porting to Koch in late Sep- tember, called for the creation of a public private - " consortium " of five Brooklyn hospitals to run Woodhull when, as the panel recommends, the institution o- pens in 1980 (a delay in the original HHC estimates of Jan- 36 uary and then June, 1979). time advocate of amalgamating the public and private hospital system; operationally, he has tended to translate this goal into mechanisms for subsidizing the private sector at public expense. In late November, Koch de- manded the resignation of Joseph T. Lynaugh from the $ 65,000 HHC presidency. Lynaugh report- edly drew Koch's wrath when he botched HHC's relationship with Misericordia Hospital Medical Center in the Bronx - and presum- ably with the politically powerful Archdiocese of NY. Misericordia has had the affiliation contract for providing physician staffing with Lincoln Hospital. Lynaugh tried to give the affiliation back to the Albert Einstein College of Medi- cine (which lost the contract two years ago) on the heels of a con- sulting report that care at Lincoln had reached new depths in the hands of Misericodia. When the dust settled, Lynaugh, a former priest, was doing penance and the Archdiocese was restored to grace. As he moved into the 12th month of his term, Koch was faced with the task of selecting a Lynaugh replacement who (a) wanted the politically treacherous job of assisting in HHC's dismant- ling; (b) was acceptable to Cher- kasky in particular and to the vo- luntary sector in general; (c) was acceptable to the Archdiocese of NY, given the tension created by Lynaugh's bungling of the Lincoln affiliation transfer. He turned to Cherkasky who recommended a Ford Foundation executive, Ea- mon Kelly, whose last stint in go- vernment was as consultant to US Secretary of Labor, Ray Marshall. But, alas, the Koch luck struck a- gain. Less than a week after no- minating Kelly, Koch learned that Kelly had been accused of " poor judgement " soon after leaving the job with the Labor Department. The " poor judgement " in ques- tion had to do with suggesting a lawyer for a major labor leader- Joseph Tonelli, president of the United Paperworkers Internation- al Union - who was being investi- gated for embezzlement. Kelly de- nied any impropriety, butwith- drew his name from nomination, citing " the complexities and diffi- culties of the job. " Finally Koch named Joseph C. Hoffman as President of the HHC. Hoffman, formerly the City's deputy chief of police has no ex- perience in the health system, ex- cept for a brief stint as head of the public ambulance service. Neither Hoffman, nor Koch, nor Cherkasky view his lack of exper- ience as a problem. In fact, Hoff- man thinks his background makes him perfectly suited for the job. " Good management is universal, " he told The New York Times. " It's not that much different whether you're managing cops or directors of hospitals. " While the continuing saga of who shall head (head be -?) the HHC draws the most headlines, it is the activity around the Wood- hull situation that offers the clear- est insight into the shape the City's health system seems des- tined to take under Koch. Woodhull in North Brooklyn was to be the brightest and best municipal hospital in the City. Originally, it was to be a replace- ment for an antiquated municipal hospital. But as the fiscal crisis gathered steam in 1975, Woodhull was designated as the replacement for two existing municipal hospi- tals Cumberland - and Greenpoint. It was supposed to incorporate all the most modern innovations in hospital design including single occupant rooms, seperate staff and public corridors and auto- mated record keeping. Woodhull has been standing, unopened for more than a year. It couldn't open because no one could figure out how to cover its projected cost of operation. The Cherkasky panel probably ren- dered the most realistic estimate yet of the likely deficit the hos- pital will run up: a whopping $ 45 million annually. (Our own es- timate put the figure possibly as high as $ 75 million). Where the City is to get this amount - lar- ger than the deficit of several other municipals combined - isn't clear. The Cherkasky panel neatly sidestepped the issue by sugges- ting that the hospital be run as part of a consortium of private and public hospitals in Brooklyn. To cover the deficit, they planned to close hospital beds throughout the borough and thus fill up the hospital with patients squeezed out elsewhere. But the problem of Woodhull is not its potentially empty beds. Rather, it is its inappropriateness as a health institution for the pop- ulation it will proport to serve. The Cherkasky panel may have come up with a solution for the hospital crisis in Brooklyn, but not for the health crisis. Conditions such as high infant mortality, chronic malnutrition, epidemic - level Vd, cirrhosis and drug related - diseases and deaths are indicative of a health crisis. Of course, low income - populations like that of North Brooklyn need hospital beds. But unfortunately, the Cherkasky group took only the most primitive look at how many and what kind of beds would serve North Brooklyn's people. Rather than assess needs for prevention, for primary care or for hospital beds, they framed the policy questions around how best to develop correct institu- tional investments and interests. At the heart of the public stance of the Koch administration is a strategy of trying to make the municipal hospitals look and func- tion like voluntary hospitals. The keystone of this strategy has be- come the replacement of older, smaller municipal hospitals by larger, more modern facilities. Such hospitals are projected as the case of an " upgraded, " " First class, " public system. Combined with the active pursuit of private patients, agressive billing and col- lections policies, and conversion of outpatient services to a " group practice " model, this strategy, the argument goes, will reproduce the " success " displayed by the larger voluntaries. The basic assumption inherent in this process - at least when done intentionally - is the American creed, " the private sector does it better. " We will return to this question later. The process whereby voluntari - zation is accomplished may vary from service to service. In the case of the NYC Municipal Hospital system, it is a process whose roots trace to the early 1960s and has progressed through three distinct stages. The first stage was the NYC municipal municipal hospitals hospitals affiliation plan, initiated in 1961 by then Commissioner of Hospitals, Dr. Ray Trussel. Trussel, noting re- cent findings of low quality care in the public hospitals and serious difficulties attracting medical staff, proposed that the city contract with several of the major medical schools in New York to provide physician staffing in the municipals in exchange for annual payments. These medical schools were already affiliated with a number of the city's major voluntary hos- pitals. To a chronically underfinanced public hospitals system, this " solution " added a new set of problems. Medical school priori- ties began to pervade the wards of municipal hospitals. The annual affiliations payments to the medi- cal schools took a rapidly increas- ing bite out of the Department of Hospitals'budget. And payments for affiliations - parts of which were later found to have been mis- spent by the schools - added to the financial woes faced by the municipals. To this situation was added, in 37 the late 1960s, the onset of Titles XVIII and XIX, Medicare and Medicaid, with the latter in parti- " City expenses will increase - not decrease- without the municipal hospitals " -H. Alex Schupf cular providing medical care reim- bursements for the first time for large numbers of NYC poor, who had heretofore had only the pub- lic hospitals to turn to for medi- cal care. The prospect of reimburse- ments partially - financed by fed- eral and state funds - for care led NYC officials to begin to rethink thier management strategy for the municipals. The affiliations era had convinced many _ that " quality " medical services were to be found in the voluntary sector. Now, some officials proposed, the prospect of reimbursed care of- fered the opportunity to the municipals to follow the volun- tary hospital's lead. Thus, the second stage of vol- untarization in New York dawned in 1970 with the passage of the enabling legislation for the NYC Health and Hospitals Corporation. The Corporation was envisioned as a large public benefit corpora- tion that by taking the munici- pals one step away from govern- ment and politics - could succeed in upgrading them to a position 38 competitive with the voluntaries. The revenues from Medicare / Medicaid, it was proposed, would play the same function for the municipals that private insurance reimbursements had long played for voluntary hospitals: guaranteed annual income. With the dawn of HHC, the goal of " imitate the voluntaries " led to a considerable shift in prior- ities at the managerial level in the public system. " Revenue enhance- ment, " " more aggressive collec- tions, " " stricter billing, " and costs savings by reducing " allow- non - able " costs (those not reimburs- able) became the new watchwords and guidelines to policy. The Koch record is not totally one of ineptness. Some perceive a pattern of " malign neglect " Much of this was stimulated at the beginning by widespread be- liefs that Medicaid benefits would gradually be widened to include a greater and greater proportion of the poor (beyond the original ceil- ings on eligibility) and that, in a matter of years, universal National Health Insurance would be a reality. The reality, of course, has been quite different: Medicaid eligibili- ty and reimbursements have beer. steadily reduced and restricted during the 1970s. The result is that today, in NYC, there is an e- normous population of persons with real medical needs who are ineligible for Medicaid, Medicare, or any other form of coverage. This population includes the " working poor " (those above the current Medicaid cut off - but un- covered by private health insur- ance), many Medicaid eligibles who remain unenrolled, many do- cumented persons afraid to enroll in Medicaid, and some whose me- dical problems are not covered un- der Medicaid (e.g., mental patients and the chronically ill). This population continues to have virtually no alternative but the municipal system. Voluntary hospitals, by controlling the mix of cases and availability of services by " dumping " to municipal insti- tutions and by outright discrimi- nation in admissions and market- ing policies, have effectively rid themselves of nonreimbursed pa- tients. It is in this context that it seems to some observers that the municipals are being pressured as well as encouraged to enter the third and final stage - of volunta- rization. In this stage, the munici- pals would bring their fiscal man- agement into harmony with the voluntaries by excluding nonpay- ing patients (not necessarily direc- tly or system - wide at the _ begin- ning). Individual municipal hospi- tals especially - those with the more modern physical plants and equipment - would then be " spun off " into the private sector, i.e., would transfer management to de- centralized, nongovernmental lo- cal boards (whether the latter be a " subsidiary corporation " of a " consortium " or " private manage- ment firm " or an existing volun- tary hospital is relatively inconse- quential). In short, " successful " munici- pal hospitals would become - first in fact, later in legal and fiscal re- ality voluntary - hospitals. - Michael E. Clark Continued from Page 22 not for regulating nursing education, for auto- nomy but not for accountability in delivering nursing care, and for more, not less barriers to entry into nursing. The record of nursing leaders in dealing with misconduct and incom- petence in nursing is as lacklustre as those of other professions. They have generally ab- dicated any leadership role in debates over health insurance or national health service, cost con- tainment, or the efficacy of medical technology. Their response to any innovation is steadfastly one of analyzing all issues in terms of their own role and authority. To borrow from the 1960s, nursing leaders present an " echo, " not a " choice " on the health care scene. In short, nursing leadership's " reforms " pro- mise the vast majority of nurses an authori- tarian, rigidly stratified, status seeking - vocational Nursing leaders have generally abdicated any leadership role in debates over health insurance, cost containment or the efficacy of medical technology. Their response to any innovation is steadfastly one of analyzing all issues in terms of their own role and authority environment, while offering the public no relief whatever from the worst features of the American medical system. While the elite is out campaigning on its own behalf, the gap between leadership and rank - and- file widens. As far back as 1970, when the Ameri- can Journal of Nursing completed a survey of its readers, a remarkable gap in attitude and politics between nursing's leaders and the rank - and - file was revealed. In the main, graduates of associate and diploma programs felt neglected and looked down upon by nursing's leaders and their bacca- laureate - trained supporters. An editorial in the Journal the next month commented upon the findings, pointing out that the perception of " lower echelon nurses " that they were underrepresented in national nursing or- ganizations is probably true. While the editorial did not in any way back off from the substantive positions the national nursing organizations have taken with reference to lower echelon members, it did confess that the positions have been carried out with abysmal insensitivity to others. It sug- gested as a partial solution that it might be more honest to restrict ANA membership to graduates with baccalaureate degrees because they were the only people being represented in the organiza- tion. Noting the competitive threat that trade Rank - and - file nurses have begun to improve their lot through militant trade unionism, avoiding the " professional " route so vociferously advocated by their leaders unions present to groups like the ANA, the editor- ial, in a remarkable display of candor, admitted: " The ghosts have always been there, and indeed sparked the development of the ANA economic security program. But we have seen this union " threat " used too many times to increase dues, then seen the money diverted to other programs considered more essential to the professional image. " (6) The tenor of the 1985 Proposal and its defend- ers indicates that little has changed since 1970. Rank - and - file nurses who are not " appropriately educated " are seen as embarassments to the nurs- ing profession and impediments to professional status. The Trade Union Alternative Growing numbers of these " inappropriately educated " rank - and - file nurses have come to recognize the true nature of their leadership's strategy. As a result, some have begun to improve their lot through militant trade unionism, avoid- ing the " professional " route so vociferously ad- vocated by their leaders. There are several advantages to this strategy. First, and foremost, trade unionism speaks to the needs of the vast majority of working nurses. Professional status, were it achievable, would only serve a small minority of the 700,000 working nurses. As Ginzberg pointed out, the realities are such that " professional " wages could only be achieved by a small number (he suggested 70,000) and this means that a rigid hier- archy would be necessary with large numbers 39 of nurses being thrown overboard. Such pur- suit puts all nurses in a position of scrambling to be included in the handful destined for elite treatment. Furthermore, trade unionism has resulted in substantive gains for many groups of workers. For nurses, it is a realistic means to material improvements in wages, working conditions and job satisfaction. The trade union device enables nurses seeking these objectives to raise issues more directly and have them debated on their merits. It offers potential wage scales in line with workers of similar skill and responsibility and, given a strong grievance process, some ameliora- tion of the relations between nurses and their nurse physician - bosses. Some public benefit, in the form of improved nursing care, could be ex- pected if this were to make rank - and - file nursing a more satisfying job. Nursing leaders have yet to demonstrate that the 1985 Proposal would actually improve patient care although that is ostensibly its main pur- pose. They have not shown that BSN nurses would provide superior care or that " 1985 " would not impact negatively on the supply or cost of care. They have not adquately answered the charge that it would impact disproportionately on those of minority or working class origin. And, because the real goals of the 1985 Proposal are unmentionable, the NYSNA continues to dis- semble or evade all of these issues. It is interesting to note that while much of the attention has focused on " 1985, " nursing associations seem to have been of two minds about union activity. On the one hand, they share with union activists the recognition that the current job situation for nurses is poor and should be improved; on the other hand, they feel it is professionalization a la Ginzberg, not unionism, that will translate into improvements. However, the developments of recent years have shown that rank - and - file nursing organizations do not share this ambivalence and many have become involved in job actions with or without nursing association approval and usually without its active backing. In 1946 the American Nurses Association in- itiated an Economic Security Program designed 40 to enable state and local nurses'associations to bargain for their members. Since that time, these associations have seemed to spearhead the unionization movement. However, upon closer analysis, their effect seems to have largely re- strained the trade union movement, heading off militant job actions and selling themselves to management as the ones who can keep the lid on things. Specific accounts of nursing struggles confirm this impression. An account of the Bay Area Strike of 1974 documents the tendency of nursing associations to restrain leaders of job actions. Similarly, a fascinating account of four job disputes as told by their participants in Nursing 77 reveals as- sociation fears of rank - and - file movements. One account tells how nursing supervisors de- cided to take charge lest the rank - and - file seize control. Association interest and supervisor participa- tion are greatest when the struggle involves control of nursing (their. control of nursing) rather than simple job conditions and wages. Association leadership and supervisors frequently have a dif- ferent agenda than rank and file nurses: their own status and power, issues hardly cen- tral to the everyday condition on the floors. The AJN survey mentioned earlier supports the observation that nurses are beginning to recog- nize the differential in goals among various nurs- ing sectors. At the same time, nurses need to recognize that a commonality of goals does exist. with many of their fellow hospital workers. Thus while breaking with one ally, nurses adopting a trade union approach pick up a more reliable, more viable and more powerful ally - one whose goals more closely parallel those of rank and- - file nurses. Divide and Conquer Hospitals are complicated places. Management can survive best if groups " go out " one by one, be- cause of the fungibility of their workers'skills. Unfortunately, nurses have historically acquiesced to this divide conquer - and - tactic. What forces an issue in a strike situation, however, is the ability of groups to go out at one time to shut the in- stitution down, necessitating the transfer of pa- tients to other institutions. A unionized group would be prudent to agree to help in the trans- fer process, but ordinarily not in maintaining patients in " struck " institutions. This will require difficult decisions and must be confronted on is likely to be much gained in doing so honestly, rather than hiding behind the guise of helping the an institution - by - institution basis to avoid loss of life and undue hardship by patients. But it is necessary in order to deprive the institution of revenue in the form of patient days and fees. That is, historically, the point of all strikes. The new federal law authorizing unionization in health facilities plays upon this historic separation among health care workers by specifically pro- viding for professionals to opt out of bargaining units. Given a history of such spurious ap- peals to their professional and special status, it remains to be seen whether nurses can learn patient or the public. Let me be clear. A situation that results in understaffing is oppressive to nursing workers there. It should be redressed in those terms. Poor wages result in poor care, but also result in poor life for the workers. The latter is reason enough to strike. On the other hand, nurses would do well to combine with the consumer and other groups to affect changes in hospitals and throughout the health system. Such actions are appropriate but do go beyond trade union issues, often in- to unite with the spectrum of health workers who have already chosen union status. Although this spectrum runs from aides to social workers, nurses may yet experience a strong urge to " go volving the collective self interest - of women and all working people in the society. It should not be naively assumed that the interests of nurses as a stratum will always coincide with broader it alone. " Such separation, on balance, would progressive goals. seem to be a strategic mistake. However, the separation of rank - and - file nurses from supervisors is crucial. A nursing supervisor is a supervisor first and a nurse second. Conclusion Trade unionism, while offering a real alterative to the 1985 strategy, is not a panacea. Discussions with and written accounts by nurses engaged in Nursing Self Interest such activities reveal that these efforts carry with them real risks. Nurses may not always be wel- One consistent theme in nursing's efforts to comed by other health workers in the trade un- improve working conditions has been to couch those efforts in terms of improving nursing care. ions, given the uneasy relations of the past. Fur- ther, some would dissuade nurses from this route Virtually every strike described in the literature because of the pitfalls of union organizing in has joined professional or patient care issues with strike demands. In the case of professional other industries and the potential for abuse inherent in any self seeking - group activities. issues this unfortunately often involves rank - and- file fighting for the power prerogatives of their supervisors. In the case of patient care, it involves nurses presuming to act for others without being asked to do so. Against this set of problems, however, must be balanced the many real gains and, for that matter, frequent heroism to be found in the history of trade unionism. More importantly, nurses now have an opportunity to join with In part, this undoubtedly stems from women's other workers and consumers to improve their reluctance to assert their rights, except as inci- own lot honestly through a strategy with demon- 1 dental to someone else's welfare. Compounding strable advantages and a good track record. the difficulty, all professionals, having wed their In doing so, the growing number of nurses entire lives to the myth of selfless public service, who are choosing trade union membership will tend to contort all their rationale for action into not resolve every frustration and form of aliena- some mode of selflessness. Although unfortunate, this tendency is understandable in light of the tion that feeds their currently growing mili- tance. Much of that frustration and alienation stigma of avarice and greed that has come to be arises from the racist, sexist, and divid- class - identified with doctors. It is fair to say that the ed social relations in the larger society. Over- AMA has given self interest - a bad name. But coming these, of course, suggests a broader po- what nurses have to realize is that they have little litical and social movement than can be pro- to fear in demanding decent wages, a benign work duced by any one stratum of workers. The environment and satisfying work. In fact, there struggle to do so is also likely to take longer and 41 involve a good deal more upheaval than any union election. In the meanwhile, though, rank - and - file nurses do seem to have taken up the NYSNA challenge to answer the question, " Who are the nurses? Who are the others? " For a growing number, nursing workers are " the nurses " and nursing leaders are the " others. " -Andy Dolan (Andy Dolan teaches law at the University of Wa- shington) References 1. Genevieve K. Bixler and Roy W. Bixler. The Profes- sional Status of Nursing. In Bonnie Bullough and Vern Bullough (Eds.) Issues in Nursing, New York, Springer 1966. 2. Joann Ashley, Hospitals, Paternalism and the Role of the Nurse, New York, Teachers College Press, 1976. 3. William Glaser, Nurses'Leadership and Policy: Some Cross National Comparisons. In Fred Davis (Ed.) The Nursing Profession, New York, John Wiley and Sons, 1966. This has apparently been a consistent theme of nursing reform. The same author noted: " The Night- ingale reforms had intended to make nursing attractive to upper class women... and [vest] control over the many lower class recruits [in them]. " In turn, this movement seems to be catching on in other countries. See Nursing Education in Japan, International Nursing Review May June -, 73-79, 1976. Mary Ann Paduano, Nursing Education in Spain, ibid., Sept. - Oct. 150-157, 1976. Roslyn Elms, et. al., Irish Nursing at the Cross- roads, International Journal of Nursing Studies, Vol- ume II, 163-70, 1974. 4. Reichow, R. and Scott R. Study Compares Grads of Two-, Three-, and Four - Year Programs, Hospitals 50, July 16, 95-100, 1976. See also Afas Ihrahim Meleis and Kathleen Douglas Farrell, Operation Concern: A Study of Senior Nursing Students in 3 Programs, Nursing Research, 23, 461-468, 1974. 5. Michelmore, E. Distinguishing Between AD and BS Education, Nursing Outlook, 25, 506-510, 1977. 6. Editorial, Credibility Gap, American Journal of Nursing, 70, 1005, 1970. 42 STOCK CLEARANCE! Complete Sets of The Health / PAC Bulletin Available for a short time only 79 Issues for $ 75 (1968-1977 1968-1977 1968-1977) Dealer Discounts Available Partial Sets Available Order Now: Health / PAC. 17 Murray Street, NY, NY 10007 | RE 1 cawn ea oD oat Ses SRO 2G SOR SS ee - EP Bill Plympton Human Experimentation Continued from Page 2 At the inception of an experiment the re- searcher can often predict some of the outcomes. Experimental designs should be developed in such a way as to minimize risks to potential subjects- especially where the experimenter expects that the customary treatment would have been safer, more convenient and less painful. The following four studies involve inconvenience for the patients and anticipate outcomes which are counter- therapeutic. In order to test the truth of the commonly accepted obstetrical wisdom that hyperventilation (deep breathing) can harm the fetus by creating alkalosis in its blood, twenty women in uncompli- cated labor were instructed to hyperventilate. The investigators, reporting their results in the Amer- ican Journal of Obstetrics and Gynecology (2), mentioned no possible benefit for the mothers or fetuses in the study. To implement this ill con- - ceived experiment the investigators subjected their Experimental designs should be developed so as to minimize risks to potential subjects. Four separate cases show inconveniences for the patients and outcomes which are countertherapeutic patients to additional risks by taking five samples of fetal scalp blood during each delivery. This pro- cedure involved risk of fetal scalp abcesses and scalp hemorrhages to the babies and infection in the mothers. Another experiment that anticipated (and found) counter therapeutic - results was conducted by three experimenters at Brooklyn Cumberland - Medical Center. They devised a study which they expected would increase the complications of abortion. 116 women receiving second trimester abortions were given either routine hypertonic saline (50 women) or hypertonic saline with one of two anti inflammatory - drugs added (66 women). The study was designed to test the hypothesis already supposed in previous studies- that anti inflammatory - drugs would increase the 43 time between the saline injection and expulsion of the fetus (called I AT /: Installation / Abortion Time). This in spite of the fact that earlier work had established the value of decreasing I AT /, de- creasing the duration of labor and thus decreasing the complications of abortions. (3) Two years later the same three experi - menters reported in the same journal the same results of a similar study. This time they sub- jected 108 women to three different analgesics: sodium salicylate an (analog of aspirin, but more toxic), propoxyphene hydrochloride (Darvon) or acetaminophen (Tylenol). Since they were essentially repeating an earlier experiment, the Incomplete Animal Studies Over the past few decades there has been general acceptance of the importance of animal Abuse of human subjects is not an exception, but more often than not, it is the rule No animal studies were done before 17 women seeking sterilization were subjected to electrocautery of the fallopian tubes investigators were again able to correctly pre- dict the results: the drugs caused an increase in the time between injection and completion of the abortion. (4) The most disturbing example of delib- erate harm was found in a study of fourteen women who sought abortions at Downstate Medical Center. The experimenters gave these women, all in their first seven weeks of pregnancy, prostaglandin - in - saline abortions, rather than other " more standard methods of abortion. " A previous study of first trimester prostaglandin abortions had found that " 35%... had experienced severe adverse reactions and the overall abortion rate was only 65%. " The Downstate investigators were evidently not satisfied with these published results and repeated the experiment. Their results confirmed the earlier findings. Pel- vic infections developed in 12 of the 14 women; six women required dilation and curretage (D & C) to treat persistent bleeding. Half of the women experienced increased blood pressures of 20 mg Hg or more. Other side effects cited in the article included " strong uterine cramps, " nausea, vomiting and restlessness or uneasiness. The authors grudgingly conceded that " the effic- iency rate of this technique is below conven- 44 tional methods. " (5) trials in order to minimize the risks to human sub- jects. Researchers have become quite ingen- ious in developing methods and finding spe- cies in which to test new procedures. It is, of course, essential that the animal studies be fully analyzed before human experimentation begins if the humans are to be protected from dangers for which the animals are being screened. A Downstate Medical Center professor, interested in testing a new instrument, reported in the American Journal of Obstetrics and Gyn- ecology that he had performed hysterotomies on eleven women who had sought second tri- mester abortions. Hysterotomy is the name given to a Cesarean Section when it is being performed for an abortion. The instrument, an endoamnioscope, was used to take blood and skin samples from the fetus. Hysterotomy is more dangerous than saline abortion, which was already in routine use. Hysterotomy requires general anesthesia and involves an increased risk of infection, embolism, shock, and hem- morrhage. The investigator wrote in his report: " The safety of endoamnioscopy and fetal biopsy is being evaluated in pregnant monkeys. " (6) The same professor later reported, in Obstre- trics and Gynecology, that he had continued his study, and had performed fiteen hysterotomies in testing the endoamnioscope. Again, he wrote: " the safety of endoamnioscopy is being evalu- ated in pregnant Rhesus monkeys and in hysterot- omy patients. "'He was obviously so eager to try out the instrument that he was unwilling to await the results of animal studies before sub- jecting women to unnecessary surgery. (7) No animal studies were done before 17 women seeking sterilization at Bronx Lebannon Hospital were subjected to electrocautery of the fallopian tubes. This experimental sterilization procedure was substituted for more conventional tubal ligations. The procedure was sufficiently un- certain for the researchers to recommend that the women use other methods of contracep- tion until follow - up tests determined if in fact they had been sterilized. To determine the effectiveness of the steriliza- tion the researchers put the women through hysterosalpingograms. This unpleasant and oc- casionally risky test (in which a dye is introduced into the uterus and fallopian tubes and then x rayed - ) is done to see if the tubes are completely closed off. One woman refused to have the x- ray. Of the remaining 16, one had both tubes still open and three others had one tube un- closed a whopping 25% failure rate. If these four women still wanted to go through with a sterilization, they had to subject themselves to a second operation. In their eagerness to test their sterilization technique, the experimenters even included two asthmatic patients in the study group, both of whom required longer hospital stays. (8) The same group of doctors who conducted the Bronx Lebannon - research reported on the use of electrocautery with and without a second un- tested sterilization method insertion - of a mesh plug into the fallopian tubes - on 47 women who came to a Bangkok, Thailand clinic. Well aware of the unreliability of their procedure, the experi- menters gave each woman an injection of Depo- Provera, a long acting - contraceptive with serious side effects (see below). Follow up hysterosalpingo- grams showed that 16% of the women had not been successfully sterilized. Side effects of the pro- cedure on the Thai women were scantily noted. However, the investigators did list one perforated uterus, one hysterectomy seven days after their procedure (reason not given) and some patients (number not noted) with vaginal bleeding. An interesting insight into the potential usefulness of the procedure, despite its relatively low suc- cess rate, was provided by the experimenters in their article in the American Journal of Ob- stetrics and Gynecology: " Among the striking features of this study were the speed and ease with which forty - six women could undergo a sterilization procedure.... It is also impor- tant that the period of essential contact with professional personnel was short, usually less than 15 minutes. " (9) " Informed Consent " Authors of research studies rarely include accounts of how patient consent was elicited. Thus the adquacy of the information upon which the patient's consent is based can usually only be inferred. Even if the doctor does provide infor- mation to the patient, it is often difficult for the patient to interpret, and even more difficult to refuse consent. In 1975, four researchers wrote in Obstetrics and Gynecology about their experiment with 100 consecutive women undergoing Cesarean Section at Metropolitan Hospital. Half were given power- ful antibiotics before, during, and after their surgery; the other half received no antibiotics. The experimenters wanted to study the prophylac- tic effect of the drugs. Multiple studies have documented the risks of developing antibiotic - resistant bacteria on wards where prophylactic antibiotics are used. Addition- ally, one of the drugs tested in this case (Kana- mycin) is known to cause severe or total hearing loss, even with short courses and in low doses. Is it possible that informed of the risks, one hundred consecutive women would consent to being subjects? (10) A 1974 article by three doctors from Down- state Medical Center describes a study of the effect of a long acting - injection of medroxy- progestrone acetate (Provera Depo - ) on the adrenal glands of ten normal women who sought birth control. The women received an injection of Depo- Provera every 90 days for one year and were given intensive metabolic testing in the hospital three times during the year. This study illustrates violation of two different standards: harm by design and lack of informed consent. The authors cite animal studies published in 1961,1964, and 1969 that show MPA to be " a potent suppressor of adrenal function " which, " when administered for a two week - period, re- sults in adrenal atrophy. " In normal practice, physicians go to great lengths to avoid suppres- sion of the adrenal glands because of their physio- logical importance. The investigators involved with this study reported that they found adrenal 45 suppression among the subjects during the experiment. The investigators exposed the ten women to significant risk by administering Depo Provera - . Although the drug is an effective contraceptive, there is an " increased evidence of spotting, stain- ing, bleeding and amenorrhea. " More importantly, Depo Provera - was known (before this experiment was initiated) to cause an increased risk of cervical cancer (in humans) and breast cancer (in dogs), as well as an increase in the rate of birth defects in fetuses conceived before administration of Depo Provera -, and a very high rate of long- standing sterility after discontinuation of the drug. It is extremely difficult to imagine that the investigators provided the subjects with enough information to make an informed decision about participating in this experiment. (11) Doing Harm by Design Abuse of human subjects is not an exception, but more often than not, it is the rule. The eleven studies described above were designed and imple- mented on patients in New York City during the last decade: not in a prison, a mental hospital or in Tuskeegee, Alabama 40 years ago. Pre- sumably consent was solicited from each of the patients involved, the studies were reviewed by medical school departments and research councils, and finally each article was reviewed by the editor- ial boards of the prestigious medical journals which published them boards - whose standing policies prohibit publication of ethically question- able articles. Yet each of these built - in safeguards failed to protect the patients. Informed consent is the legally mandated process by which the patient is provided complete information about the risks and benefits of participating in an experiment and agrees voluntar- ily to participate. Theoretically, informed consent should stop most abuses, since no sane patient would agree to place him or herself in jeopardy. Unfortunately, in reality, this is not how it works. There is a massive asymmetry of power be- tween the doctor and patient. The doctor alone knows what drugs will be administered, what risks will be incurred and what procedures under- taken in any experiment. Moreover, the physician is not a neutral disinterested party in presenting this information to the patient. He (or she) is a partisan, enthusiastic about the research, whose 46 goal is to recruit subjects. Doctors tend to under- state possible side effects and complications. Patients put into this situation often fear that their refusual to participate will risk the dis- pleasure of the doctor, if not outright alienation from him or her. Thus informed consent, by its very nature, often functions as a single edged - sword hanging directly over the neck of a pros- pective subjects. Peer review is cited as another key safeguard against experimental abuse. Most members of the medical profession maintain that only physicians are qualified to judge each other's work. Abuses, At best, ethical review comes after the fact of abuse and cannot remedy those abuses already inflicted they claim, have occurred because of the inade- quacy of peer review. Yet physicians have never been especially forthcoming in pointing a finger at other physicians lest the favor be returned -- or worse. Like other tightly knit professions, the medical fraternity protects doctors much better than it does patients. Ethical review by publishers is perhaps the most dubious safeguard of all. The need to pub- lish results, some argue, makes researchers self- conscious during the data gathering - phase of an experiment. Most journals do have a policy of publishing only those articles deemed ethical by their editorial boards. The fact that serious ethical problems were found in the experiments cited above, all published in legitimate journals, belies the efficacy of review by prospective pub- lishers. At best, ethical review by such boards comes after the fact of abuse and cannot, there- fore, remedy those abuses and risks which have already been inflicted on subjects of rejected researchers. Revelations of outrageous experimentation abuses disclosed in the early 1970's led to the creation of Institutional Review Boards (IRBs) to certify the safety of all federally funded med- ical research. Despite the requirement of non- physician representation on these boards, however, the majority of IRB members are physician - re- searchers whose bias is toward the interests of research and researchers rather than the interests of patients. IRBs are thus subject to the same flaw as peer review - the reluctance of peers to interfere with each other's work. A 1975 study of IRBs by Bradford Gray (13) suggests that the presence of IRBs may, in fact, be worse than if no IRBs existed at all. Researchers need only seek the blessings of the IRB, and once these are received, no longer need worry about risks to their subjects. Gray found most committees either very permissive or virtually inactive. Even in the best of circum- stances, according to Gray, where researchers had conscientiously attempted to inform their subjects, nearly 40 percent of the patients were still unaware that they were participating in experiments. Lastly, patient advocates have been created at many hospitals in an attempt to equalize the disparity of power between doctors and patients. Acting as ombudsman, the patient advocate might be the perfect intermediary to present prospec- tive research subjects with information about risks and benefits. Unfortunately, patient ad- vocates suffer many of the problems plaguing IRBs they are part of the institutional structure and can be expected to function as such in the face of any conflict of interest. Most often, patient advocates are attached to a hospital's public relations department, serving to pacify patients, not to aid them. Thus, in their present form, both IRBs and patient advocates as ethical guarantees are seri- ously flawed. They both offer the potential, how- ever, of being effective tools for combating research abuse. But neither will work unless they can counteract some of the forces which create and foster abuse; peer pressure, asymmetry of power and depersonalization are critical among the culprits. Until IRBs and patient advocates are independent of both professional and insti- tutional interests, one can expect that abuses of the type documented above will continue to characterize human experimentation. Hopefully, the methodology employed in this article will help community and patient groups to periodically check the goings - on of the clinical research establishment. No special access to the inner sanctum of the hospital or laboratory is needed. The names of members of a medical school's faculty or a hospital's staff are easily obtained. By reviewing their published works, one can get a reasonable reading on the violence done to the old Hippocratic dictum: " Above all else, do no harm. " -Ken Rosenberg with the assistance of Willa Wing and Jon Lukom- nik. OS References 1. Ernest W. Kulka, Hans Lehfeldt, and Valentina Get- manov - Von Der Mosel, " Adverse Experience with Stainless Steel Spring Intrauterine Device, " New York State Journal of Medicine, 72 694:, 1972. 2. Frank C. Miller, Roy H. Petrie, Juan J. Arce, Richard H. Paul, and Edward H. Hon, " Hyperventilation Dur- ing Labor, " American Journal of Obstetrics and Gyn- ecology, 120 489:, 1974. 3. Richard Waltman, Vincent Tricomi, and Aravind Pa- lav, " Aspirin and Indomethacin: Effect on Installa- tion Abortion / Time of Mid Trimester - Hypertonic Saline Induced Abortions, " Prostaglandins, 3:47, 1973. 4. Richard Waltman, Vincent Tricomi, and Aravind Pa- lav, " The Effect of Analgesic Drugs on the Installa- tion Abortion / Time of Hypertonic Saline Induced Mid Trimester - Abortion, " Prostaglandins, 7 411:, 1975. 5. James R. Jones, Gwen P. Gentile, Ekkehard K. Kem- man, and Alice A. Soriero, " Intrauterine Installation of Prostaglandin F, Alpha in Early Pregnancy, " Pro- staglandins, 9 881:, 1975. 6. Carlo Valenti, " Antenatal Detection of Hemoglobino- pathies, " American Journal of Obstetrics and Gynecol- ogy, 115 851:, 1973. 7. Carlo Valenti, " Endoamnioscopy and Fetal Biopsy for Prenatal Genetic Diagnosis, " Obstetrics and Gynecol- ogy, 43 619:, 1974. 8. Robert S. Neuwirth, Richard U. Levine, and Ralph M. Richart, " Hysteroscopic Tubal Sterilization; 1. A Preliminary Report, " American Journal of Obstet- rics and Gynecology, 116: 82, 1973. 9. Ralph M. Richart, Robert S. Neuwirth, Charanpat Israngkun, and Sukhit Phaosavasdi, " Female Steriliza- tion by Electrocoagulation of Tubal Ostia Using Hys- teroscopy, " American Journal of Obstetrics and Gyne- cology, 117 801:, 1973. 10. Malcolm J. Rothbard, William Mayer, Almerinda Wystepek, and Myron Gordon, " Prophylactic Anti- biotics in Cesarean Section, " Obstetrics and Gyne- cology, 45 421:, 1975. 11. James R. Jones, Leonida Del Rosario, and Alice A. Soriero, " Adrenal Function in Patients Receiving Medroxyprogesterone Acetate, " Contraception, 10: 1 1974. 12. Bernard Barber, " The Ethics of Experimentation with Human Subjects, " Scientific American, 234: 25, 1976. 13. Bradford Gray, " An Assessment of Institutional Review Committees in Human Experimentation, " Medical Care, 13 318:, 1975. 47 troversy over the development of mass computerized information Media Scan Computers, Health Records and Citizen Rights, by Alan Westin, Michael Baker and George Annas. NBS Mono- graph 157 # U.S. Department of Commerce. National Bureau systems and its significance for citizens'rights to privacy. In 1973, the Department of Health, Educa- tion and Welfare released a report entitled Records, Computers and the Rights of Citizens (MIT Press) which expressed alarm at the ex- of Standards, December 1976 tent of invasion of privacy and re- Shortly after the birth of my third child (fourth counting a stepchild) I decided to have a vasectomy through the Planned Parenthood clinic. My trepida- tions concerning submission to any medical procedure, large though they were, soon vanished in the face of a wholly unex- pected assault on my _ privacy and dignity. After objecting to dozens of questions, including such irrelevant medical history as whether I was frequently depressed or how often I had sex with my wife, and watching the intake worker code the answers on a key punch form for a com- puterized records system, I was told that I was not " a fit candi- date " for the clinic's services. My rejection was rescinded only on the condition that I submit to the required invasion of privacy. After this beginning, the medical procedure was uneventful. Such assaults on privacy and dignity are commonplace in the experience with medical care, as they are with all institutions in commended extensive legislation to protect privacy. In 1974, Presi- dent Ford called privacy " the most basic of all rights, " and Con- gress passed the first bill dealing directly with regulation of govern- mental information systems - the Privacy Act of 1974. Nine states have subsequently extended these legislative provisions to state agen- cies in Fair Information Practices Acts. The Federal Privacy Protec- tion Study Commission issued a report on Personal Privacy in an Information Society (Washington, D.C. 1977). This growing concern about privacy is particularly impor- tant to the health industry be- cause of the rapid growth in com- puterization of medical records. Recently, Professor Alan Westin, one of the country's leading civil libertarians and an early critic of computerized information sys- tems, carried out a comprehensive review of the computerization of medical records. In the resulting report, Computers, Health Records and Citizen Rights, Westin and his associates, Michael Baker and our society. Frequently, the con- sequences are much more serious for an individual's health, employ- ment, education, dignity or even freedom than the minor incident I experienced. George Annas, find few flagrant cases of privacy violations in computer systems today, but they warn that serious invasions of pri- vacy are made possible in com- puterized systems: Much of this assault on privacy " What we conclude is that the is associated with the spread of main problem today in computer- computerized records systems. ized health data systems is poten- In the last five years, there has tial harm. As we will see, what 48 been growing awareness and con- makes such potential harm parti- cularly serious for civil liberties is the fact that these possibilities of misuse have not been taken into account and dealt with effectively by the managers of such computer- ized systems. " (p. 218) Computers and Health Records While one can cite a variety of dramatic instances in which com- puters in the health care system are being used to improve delivery of care - such as for diagnostic and life support systems or for clinical research. The vast majority of computer systems -80% - are being used for purely administra- tive purposes such as billing inven- tories or personnel. As computerized systems have replaced manual systems, the abi- lity of an institution to maintain larger and more complex files has been increased. Taking advantage of this capability, the types and amounts of data being collected and stored by these institutions are growing rapidly. Perhaps even more significant than the computers'ability to store large data files is their ability to associate files from a wide var- iety of sources. It was always possible to com- pile a police or intelligence dossier on an individual if the agency were willing to spend enough time and money to do so. The cost of this effort, however, required that the practice be limited and the same limitation has applied to me- dical life histories. Employers and insurance companies generally set- tle for far less than a complete re- cord. Because of the mobile na- ture of our society, and the local maintenance of medical records in manual files, even doctors rarely have access to complete medical histories. It is, in fact, nearly im- possible to have medical records transferred from one doctor to an- other, often to the frustration and disadvantage of patients. Computerization of medical re- cords, even within the framework of the existing predominantly pri- vate health system - to say nothing about the impact of a potential national health system - creates the possibility of reversing this fragmented recordkeeping prac- tice. There are no technical obsta- cles today to the creation of com- plete medical records systems on a cradle - to - grave basis, with the con- solidation of data from a variety of points of contact. Major steps in this direction are already occur- ring in conjuction with expanded research, environmental and oc- cupational health studies, the cen- tralization of payments records system (both public and private), and in private agencies like the Medical Information Bureau. The primary issue in the com- puterization of medical records is how their capabilities will be used. More complete and more accurate medical history data could lead to vastly improved health care, par- ticularly to improvements in diag- nostic and preventative care. How- ever, more accurate, more com- plete files may be used to serve other objectives of the institutions which maintain them - or which have access to them. Information previously subject to the doctor / patient tradition of confidential- ity, previously stored in the doc- tor's head or office is now practi- cally public domain and thus po- tentially available for the social, political and economic ends of the institutions controlling them. The role of computers in this issue must be understood clearly. Computers are tools, very sophis- ticated and very expensive, but tools nonetheless. It is people who use the tools; people who input data on machines, who prepare the instruction [programs] which direct the functioning of the machines and people who operate them. It is the institutions in our society, however, which define the roles of these people and which determine the uses to which computers will be put. It is the values and objectives of these institutions, therefore, which must be analyzed to understand the impact of computers on our society. One of the strengths of Westin's report is his emphasis on the insti- tutional determination of health record keeping - practices. In es- sence he argues that the numer- ous privacy problems in medical records systems are the result of traditional institutional values and practices. He feels that the ex- panded use of computer systems has created the potential for even greater problems, but he argues that computerization has not changed the basic issues, which he views through the civil liberties perspective. " The basic concern of health care professionals, civil liberties observers, and computer experts is this: given the more detailed, more centralized, more perma- nent, more easily transmissible - quality of computerized medical records, the flawed procedures and policies currently employed with respect to manual records threaten to be seriously inade- quate to the computer era. " (pp. 117-118) The Institutional Setting of Health Records Systems Westin defines three major insti- tutional settings in which medical records systems raise privacy con- cerns: doctors'offices and hos- pitals; service payers (insurance 49 companies, Medicare and Medi- caid) and health care review agen- cies (PSRO's); and secondary pri- vate and social users of health data (employers, law enforcement and credit, and social control agencies). In each institutional setting, more pronounced. There were, in 1975, over 11,000 people em- ployed as medical records admini- strators. Centralization of medical records in these institutions has also created privacy problems. Westin writes, " In many hospitals in the pre- records are full, up date - to -, easily understood and are linked togeth- er from various departments and previous episodes. From a civil liberties standpoint, however, this trend means that all the medical and paramedical personnel in a facility who have access to the Westin defines record keeping - computer era, record keeping - was computerized files now have more practices and privacy issues both hit miss - or -, and though lots of detailed personal data and more a comprehensive social histories The medical data collected from the patients will become more extensive, its disclosure more mandatory, under the new computerized systems than in the typical manual system, except for psychiatric facilities. " (p 100) Mental health records present particularly sensitive privacy pro- before & after the introduction of computerized systems. It is in doctors'offices and hos- pitals that most health data is col- lected. It is commonly understood that patients must make full dis- closure of their medical history in paper accumulated in the record, these documents were often in disarray, without any indexing or current summary. Now... the automated personal data are being more systematically collected, more fully recorded and more blems. While finding that these records are generally treated with greater concern over access, con- fidentiality and and dissemination, Westin is not satisfied with the adequacy of existing protections in light of computerization: order for the medical workers to centralized in permanent files. Pa- " the... very existence of easily deliver good health care. In turn, tients are systematically asked to retrieved, identified records on doctors are bound by well estab- - disclose the full range of physical, people whose problems include lished principles of confidentiality. Westin observes, however, that as social, family, emotional and other personal data, and the re- drug abuse, alcoholism, sexual de- viations and violent episodes is a more private practitioners begin sulting detailed patient profiles tremendous temptation to local to use computer systems for re- ee cord keeping - , several changes oc- cur. First, the medical data col- lected from the patients tends to become more extensive, its disclo- sure more often mandatory than Information previously subject to the doctor patient - tradition of confidentiality is now practically public domain and thus potentially available for the social, political and economic ends of the voluntary; more standardized and more abbreviated - often with mis- leading reasons. Secondly, as re- cord keeping - becomes more cen- tralized, more people become in- volved with that data and have ac- institutions controlling them Ge become a regular feature of the file, updated steadily as the pa- tient remains with that health care and national law enforcement a- , gencies... " (p. 199) cess to it medical - workers who provider. " (p. 99) Although most health data are are not clearly subject to the con- fidentiality tradition. In the corporate medical fac- tory Westin found that the auto- mated records system is replacing collected in doctors'offices and hospitals, " law and public norms require considerable disclosure of Westin found that few hospitals have gone very far in developing comprehensive health information systems. In those that have, how- ever - and the number is increasing 50 rapidly - these trends are even the memory of the old family doctor. This trend, Westin says, creates a central contradiction: " From a health care standpoint, this is one of the most desirable features of automation - patient what is collected (there), the re- cording of personal data in pri- mary care can no longer be ana- lyzed in isolation... " (p. 39) Noting this, Westin turns his attention to the second institu- tional setting of medical records systems - payment institutions, including insurance companies and Medicare / Medicaid agencies, and the health care review agen- cies that have grown up in con- junction with the expansion of public financing and malpractice controversies. In these settings, Westin finds the issues to be quite different: data collection, storage and dis- semination of medical records. In fact, the demands of these institu- tions for data are often resisted by medical workers because of the burdens put on them to supply the data. Clearly, the confidential- doctor patient - relationship does not apply at all in these institu- tions, but is sacrificed to business and public interest claims. Fur- thermore, the decisions made about individuals in these agencies do not bear directly on improved health care at all. Westin's primary focus here is on the tradition of " implied con- sent " as a violation of privacy rights under the civil liberties prin- ciple of restricting access to re- cords to the agency which collec - ed them, and to the purposes for which they were collected. " As a practical matter, general consent forms and the legal doctrine of implied consent result in the pa- tient unknowingly surrendering control over what is furnished to Zone II organizations and how it is used. " (p. 56) Secondary Users of Medical Records It is the third setting, the pri- vate and social users of medical data, that disturbs Westin most deeply, and correctly so. It is in employment decisions, licensing decisions, judicial and law en- forcement decisions, and social welfare benefit decisions in social 3882 "al 1000 888 MEDICAL TECHNOLOGY control decisions that medical in- formation is used in ways least re- lated to the original purpose of its collection, and in which the infor- mation is least subject to the me- dical tradition of confidentiality. Yet, these decision - making agen- cies increasingly utilize the ex- panded medical records systems in their procedures through a variety of informal and legislated prac- tices in which confidentiality is sacrificed to public and business interests. Westin places the discussion of these social uses of medical re- cords in the perspective of contro- versy and concern over the deci sion making - functions in our soci- ety, not in terms of the medical context of the records. Noting that much of the protest over the uses of this data relate to deci- sions which discriminate against individuals and groups, he con- cludes: " The debates such critics initiate over'privacy'are often really challenges to the way that 51 conventional society confers its rewards and favors among the population. " (p. 85) Westin adds that growing public distrust of of- ficial decision - making agencies gives rise to concerns even when the intent of the use of medical records is well founded - . It is predominantly in the se- condary use of medical records that horror stories are most com- mon, and Westin provides a num- ber of these. But horror stories may be misleading because they tend to involve dramatic excep- tions to standard record keeping - practices. What is lost in this kind of analysis is the more common and more insidious form which occur far more often but, in fact, attract little notice. It is these common situations to which at- tention should be directed in or- der to change standard practice. Exceptional cases will exist in any system: the point is to control for the routine cases. Civil Liberties and Health Records In the end, Westin's analysis places most of the blame for pri- vacy violations concerning medi- cal records on existing medical and legal tradition and institution- al practices. It voices concern that computerization will make these problems worse. He concludes his study with a section devoted to recommenda- tions on how to strengthen the privacy of medical records. He proposes, for example, that insti- tutions have a legal and moral re- sponsibility for the protection of individual privacy; that " reason- able care " must be exercised to guarantee that information stored and disseminated is up date - to - and correct, and be held confidential except for its stated purposes; 52 thatpublic notice be required of the existence and uses of records systems; that independent review agencies protect individual rights against abuses. To support these principles, Westin argues that legislation must be sought which removes the me- dical records exemption to the interest) and private institutions (i.e., business interests). These contradictions limit the individu- al's control of personal informa- tion, and compromises must be reached between the two interests. The substance of the privacy issue has been where to draw this com- As record keeping - becomes more centralized, more people become involved with that data and have access to medical it - workers not clearly subject to the confidentiality tradition Fair Credit Reporting Act, there- by widening the application of due process to health records. He proposes that medical research files be protected under privileged information statutes. Provisions related to medical records should be incorporated into state " fair information practices " laws. Fi- nally, Westin argues that strong privacy protections must be writ- ten into any national health insur- ance acts, particularly guarantees of privileged status of the records systems and the prohibition a- gainst storing records identifiable with common codes. Within Westin's civil liberties perspective, these are sound re- commendations. They are, how- ever, subject to the problems of definition and implementation that privacy regulations have faced in other other settings. The essential privacy argument is that people have a basic right to main- tain some substantial degree of control over the ways in which information about them is used by others. Central to all discussions of pri- vacy, however, is the recognition that there are contradictions be- tween the rights of individuals and the needs of the state (i.e., public promise in a variety of situations. Conflicts concerning privacy of medical records, or arrest or finan- cial records, therefore, are unlike- ly to be resolved simply by legisla- ting principles concerning, for ex- ample, limiting access to medical records to " legitimate " uses out- side the collecting agency. Legis- lation is implemented through re- gulations and enforcement by agencies within which " patient " (i.e., public) interest is often poor- ly represented. What, for example, should constitute a " legitimate " use of medical records outside the primary care setting? The use of medical records in employment, credentials, insurance and credit decisions is legitimate from the perspective of the institutions using them, but these uses are often challenged by the subjects of these decisions. In other words, regulations do not resolve con- flicts between individual rights and institutional needs; they only channel these conflicts within confines established by the pre- vailing balance of power. At the present, the balance of power is heavily weighted in favor of insti- tutional needs. Westin attempts to redefine the issue by the principle that infor- mation privacy be considered a property right. This " contract " theory, however, provides little protection in other record keeping - situations involving private sector institutions. If individuals do not like the terms of the " contract " offered, they are free only to go without bank accounts, insurance policies, jobs or medical treatment. To make this right effective would require enforceable legislation guaranteeing individuals the right to receive service from institutions whether they agree to provide re- quested information or not, a de- mand which is impossible to even raise within our society because of its contradiction with " free enter- prise. " Another weakness in Westin's proposals, and one common to all proposed privacy regulations, derives from the need to make the regulations acceptable to the insti- tutions to be regulated. Passage of the 1974 Privacy Act raised con- troversy primarily expressed in terms of the costs of administer- ing the regulations, particularly those relating to public notice, consent and access. As a conse- quence of the cost issue, imple- mentation of these principles has placed the burden of gaining these rights on individuals rather than on the institutions. The same argument has been the primary defense of the private sector insti- tutions to extending privacy regulations into their records systems. In order to meet these objec- tions, Westin presents relatively weak, although definitely pro- gressive, proposals on notice, dis- closure and access. For indivi- duals on whom records are col- lected and disseminated at every turn, usually without their con- scious knowledge, really ade- quate protections would have to include provisions like mandatory annual notice of the existence and contents of a record concerning an individual, periodic reports of all routine disseminations of the records, explicit authorizations of each dissemination on an excep- and how that disseminated infor- mation is used. Dr. Alfred M. Freedman, chairman of the National Commit- tee on Confidentiality of Health Records, has struck this defensive posture: " We all need to be con- stantly aware of the delicate, com- It is not a civil liberty issue we are facing - but an issue of power and social control. It is not the fact that information is being disseminated but who decides what is to be disseminated and that information is used tion basis, annual renewals of authorization to maintain records and disseminate them. Under pre- sent circumstances, of course, institutions would never permit the enactment of such regulations. A final problem with Westin's civil liberties perspective, unique to the case of medical records, is the question of patient access to their own records. Following the due process tradition, Westin makes a strong case for complete- ly open access by patients to their own records. However, this focus masks the real issue which is how to guarantee that health care and health records serve the interests of the patients. That is not a civil liberties problem. Thus while Weston recognizes that computers are not the problem per se, but how they are used by the institute controlling them he fails to move to the logical conclusion of that argument. It is not a civil liberty issue we are facing - but an issue of power, or social control. It is not the fact that information is being disseminated but who de- cides what is to be disseminated plex balances which must be struck between the patient's right to privacy and society's need for legitimate information. Doctors must learn not to talk too much; hospitals, insurance firms and government agencies must guard against indiscriminate demands and the recording of unneeded information. Patients must become acutely aware of their rights to privacy and the pitfalls of signing forms that give others too sweeping rights to personal information. " (New York Times, March 6, 1977, " The Easy Ac- cess to Medical Records, " article by Harold M. Schmeck, Section 4) This defensive posture grows out of the inadequacy of the civil liberties tradition to cope with sweeping computerization under the direction of the corporate state. On the one hand, Freed- man offers sound advice given the current balance of power. On the other hand, we cannot toler- ate an environment that makes such behavior necessary. An effective health system cannot 53 function under a cloak of secrecy. Indeed, extended to all other areas touched by computerized records, this posture would make freedom and communication im- possible and would create a closed, stagnant society. We must instead find new principles for the organization of society which return control over their lives- and recorded information about them to people themselves, for use in their own interests. Beyond Civil Liberties Professor Westin is, of course, right when he observes that the privacy of health records is primarily a problem of the use of the information by other institu- tions for purposes unrelated to health care. He also correctly analyzes the inadequacy of exist- ing institutional practices to limit these invasions of privacy, parti- cularly with the advent of com- puterized records systems. He presents a reasonably thorough set of proposals to strengthen institutional safeguards of record privacy. For these successes, his book is of major value to health workers concerned with informa- tion use and privacy. Yet, and particularly in the last effort, the result is unconvincing. We are dealing with wholesale use of per- sonal information for social control to which Westin's civil liberties principles have no answers. In his emphasis on strug- gles in society which have gen- erated concern for privacy, he is awfully close to recognizing the real depth of these struggles, but he does not quite break out of his liberal traditions. Institutional Change and Social Struggle In the health sector, computer- ized records systems are the pro- ducts of the growth of corporate health power. The _ potential development of a national health system will focus privacy issues, and perhaps make it easier to establish controls. In the proposed national health bills, however, pri- vacy rights have received little attention. Only the Dellums Bill (H.R. 6894, The Health Services Act) contains guarantees of con- fidentiality and patient access to records. We need, as Westin advises, to establish such controls as we can, but we must go beyond defensive postures to challenge the institutions which control and use computerized records. Until we face this challenge, we cannot move to construct institutions in which, for example, computerized health records systems whould function only to improve the de- livery of health care. -Laird Cummings PROGNOSIS NEGATIVE: CRISIS IN THE HEALTH CARE SYSTEM edited by David Kotelchuck A NEW HEALTH / PAC anthology of many of the best recent articles from the Health / PAC BULLETIN, as well as important health policy articles from other publications. published by Vintage Books (Random House). Price $ 2.95 per copy plus 21d postage to: Health / PAC 17 Murray Street New York, New York 10007 54 EEE Miners Safety Safety has never been a bottom line for the American coal industry. Profits and production have. The 1978 contract, which 56 percent of the voting coal miners approved on March 24, after 109 days of defiance, puts this basic economic fact in bold face. The operators did not give an inch on safety. They refused to accept any of the numerous health and safety improvements the United Mine Workers of America (UMWA) rank and file en- dorsed at their 1976 convention. This was done in the face of a deteriorating safety situation in the mines. The rate of non fatal -, disabling injuries under- ground has increased steadily for the past three years. It's now about 50 injuries per million hours of work no better than the rates recorded in the 1950s and 1960s! The underground fatality rate also may be increasing - it rose last year for the first time since 1970. In all, 141 miners died in 1977 and 15,000 were injured in accidents on- the job -, both above and underground. Although the contract is now six months old, its implications are still unraveling. Wildcat strikes have not been as frequent as they were a year ago. Peace in the coalfields? Hardly. Miners can't strike when they don't work. As of late Septem- ber, about third one - of West Virginia's coal work- force was idle. Demand for metallurgical coal (used in steel making) from Central Appalachia has been cut to the bone as domestic and foreign steel mills face shrinking markets. And for sev- eral months, rail clerks shut down lines carrying the coal that was mined. Still, some trends are apparent; with the phas- ing out of the UMWA's medical plan, coalfield hospitals and clinics are cutting back. One hospi- tal in southern West Virginia shut down entirely and 60 doctors at last count had quit their clinic jobs as a result of funding cutbacks initiated in June, 1977 and reaffirmed in the March contract. Gone entirely is the vision of a union controlled - medical system. Although production is currently at a low point coal markets tend to be unpredictable- the 1980s promise to be an unprecedented boom decade for coal if utility demand matches cur- rent forecasts. It appears that the operators are planning to take no chances: they know all too 60 CUNK CLINI BEND % ' CLINIC ' Reciry |pevs jas ities UMWA well that if fortune does smile, they must be able to guarantee delivery of their product. That guarantee is contingent on having a controlled, dependable work force. Dependability of supply is what the 130- member Bituminous Coal Operator's Associ- ation (BCOA) demanded from the United Mine Workers of America (UMWA) this winter. De- pendability requires " labor stability, " which the companies sought to achieve by rigging together a gauntlet of threats, penalties and baited traps that would befall any miner " who so much as quacked when he should have clucked, " as one union member put it. A turbulent, three - year struggle over control of the workplace since the 1974 contract had resulted in record breaking - time lost due to wild- cat strikes, absenteeism and slowdowns. (See BULLETIN, November - December 1977). Output and productivity of Appalachian - centered com- panies, particularly those with extensive under- ground operations, had been cut deeply. Strikes, in particular, defied coal operators, union officials and federal judges. Breaking the rank and file's ability to stop production was the BCOA's major bargaining goal, and the hard - line operators were willing to wait out a long strike to get it. What remains to be seen is just how successful their strategy was. An initial reading of the contract seems to indicate that the operators'stonewalling did, indeed, prove worthwhile. The March 24 contract is only slightly less re- gressive than the two earlier contract offers which the miners rejected. Wages will increase 31% over the life of the contract, but once inflation, the new $ 200 medical deductible and higher taxes take their bite, real income will rise only 6% to 9%. Real pension income will not increase at all. None of the BCOA's initial " labor stability " penalties was included in the contract, but there is a sleeper provision. Through a vaguely worded, back contract - of - the - memorandum of understand- ing, the UMWA and BCOA agreed to carry over all pre settlement - decisions of the arbitration re- view board for the life of the contract. In October, 1977, just six weeks before the end of the old con- tract, the board had ruled that operators had the right to discharge and discipline picketers, agitators and even advocates of a strike, subject 56 only to review by the arbitration board. Miners, in voting for the contract, thought all the punitive Death Last last year's toll of 50 mine injuries per million hours of work may not sound large, but in fact it is an enormously large injury rate. Consider this rate in the more graphic terms of injuries per person per year. A per- son employed 40 hours per week for 50 weeks works 2,000 weeks per year. Thus 50 injuries per million work hours is 50 x 2,000 1,000,000 / = 0.1 injuries / person - year. That is, accidents happened at such a rate that one fully employed miner in 10 would have suffered a disabling injury last year. With the strike and layoffs, last year, of course, miners didn't work this many hours, so each person's chances of injury went down accordingly. Nevertheless, this was one of the highest injury rates in all of U.S. industry. labor stability provisions had been deleted. Health " Benefits " All 140,000 working miners, 6,000 recent re- tirees (retired since 1976 members - of the so- called 1974 Benefits Trust) (1) and their families have been switched over to employer - managed health insurance plans for the life of the contract. The 82,000 miners who retired before 1976 (mem- bers of the 1950 Benefits Trust) (2) and their families will remain with the union controlled - Benefit Fund. Thus in one fell swoop the Fund is losing most of its health beneficiaries. And when the older retirees and their dependents have died off, the UMWA's role in health care will be no more. The contract also provides for a system of de- ductibles, out pocket - of - costs paid by the miners themselves. Working miners will pay $ 7.50 per physician visit up to a maximum of $ 150 yearly per family, and $ 5 per prescription up to a maxi- mum of $ 50 yearly per family - for a total cost of up to 200 $ yearly per family. Similarly, retirees will pay $ 5 per physician visit up to $ 100 yearly, and $ 5 per prescription up to $ 50 yearly - for a total of up to $ 150 yearly. Costs of surgery and other covered hospital benefits will be paid in full. Thus hospital - based acute care will continue to get full coverage, while access to primary care is re- stricted (which of course limits preventive care and early detection of disease as well). Benefits are now " guaranteed " and presumably not contingent, as before, on production levels. But uncertainty exists both as to how the opera- tors interpret the scope of benefits they are guar- anteeing and who will oversee the administration of their health insurance plans. Some doctors and hospitals have refused to accept the new company sponsored insurance cards and instead demand cash up front from the miner who then must haggle with the insurance company. The UMWA helped set up about 50 clinics since 1950. Many were consumer - managed, miner oriented - facilities that paid physicians a salary and provided reasonably good health care in remote areas. The UMWA Fund paid each clinic a fixed retainer that facilitated program planning and underwrote a wide range of medical services for miners and others in their communities. The clinics were switched to a fee service - for - basis in June 1977, and as a result many have been forced to lay off personnel and reduce services. Health and Safety in the Mines During the strike, the White House and the BCOA harmonized on two refrains: () 1 health and safety are inflationary; and (2) coal's productivity must be raised. Increased productivity (measured in tonnage per worker per shift) reduces an oper- ator's cost and boosts his profits. The UMWA has Dust Respirable Respirable coal mine dust smaller - than a speck of dust - kills more coal miners than roof falls and explosions. About 4,000 dis- abled and retired miners die annually from coal workers'pneumoconiosis and black lung disease (which includes occupational bronchitis and emphysema). Preventing dust disease requires maintaining dust levels be- low the 2 mg./cm 3 federal standard. Compli- ance is determined by sampling dusty jobs in each mine section a couple of times a year. Health advocates and the UMWA charge that the current sampling program, which is managed by the individual mine operator, results in repeated falsifying of sample data, voiding of " bad " (compliance non - ) samples and pressuring miners to take good " " sam- ples to avoid job discrimination. After eight years of watching the operators turn the sampling program into a deadly charade, miners are fighting back. In early September, the UMWA proposed that Labor's Mine Safety and Health Ad- ministration (MSHA) give miners control of dust monitoring. Dozens of rank filers - and - testified at MSHA hearings this summer about the unreliability of the current pro- gram and the need for miner control. The original idea for a miner elected - dust person at each mine was developed by union miners at their 1976 convention. UMWA health pro- fessionals, staffers (who are miners) and others fleshed out the proposal late in the summer. The UMWA proposed that Labor author- ize a peer elected - miner to sample his her / mine for respirable dust more or less con- tinuously. Personal samplers (those that miners carry individually) would generate dust level - data to determine compliance and affix civil penalties if warranted. Each dust person would also be equipped with an area sampler - a monitoring device that prints out dust levels on tape - to determine daily dust levels. After three consecutive days of compliance non - , the UMWA dust person would have the right to " danger - off " the dangerous section, a power that union min- ers have in relation to other hazards. The UMWA plan would give miners immediate unchallengeable knowledge of hazardous dust levels and enable them to force opera- tors to come into compliance. If the UMWA is successful, miners will have won a precedent - setting occupational health right. 57 traditionally opposed productivity enhancing bo- nus schemes, fearing safety would suffer. (Indeed, had industrywide productivity in 1977-8 tons per day been that of 1969 almost - 16 tons per day the number of fatalities and injuries would likely have doubled). The 1978 contract gives employers the right to institute incentive plans to increase productivity. The operators hope that by dangling cash bonuses in front of their employees, they will close their eyes to the risks of speed - up. Once a local votes for an incentive plan, it cannot rescind it. Only the company can. Older miners will put a lot of pres- sure on younger, less financially strapped workers to vote in a plan. Then there will be a lot of pres- sure in the workplace to meet the magic bonus targets. As a result, incentives will be built into the work process to cut corners, operate unsafe equip- ment, speed up the pace of work and not strike over job and safety rights. Some of the new bonus plans are linked to fixed injury goals, that is, so many disabling in- juries are allowed before the cash bonus is re- duced. Many plans even create incentives for dis- abling injuries to be counted as non disabling - injuries by allowing an injured worker to accept a " benchwarming " non - job for as long as it's necessary for him to recuperate. Safety will suffer under the bonus plans, but the real loss will be to the miners'health. No. cash penalties are triggered if dust levels rise, and since health impacts are hard to measure on a day - to - day basis, they are not to be considered at all. To get the extra tonnage, miners will be encouraged and will encourage each other - to mine without proper ventilation and water sprays. Twenty years from the day they pocket a couple of extra fifties, they'll get their real bonus in the form of dust caused - lung diseases: pneumoconio- sis, bronchitis and emphysema. The operators'plan to boost productivity comes when the UMWA's safety program is in dis- array and federal enforcement of the 1969 Coal Act and the 1977 Amendments is in doubt. The union's safety division has been the victim of the factionalism that has divided union officials for four years. Safety personnel are appointed by UMWA president Arnold Miller, and his critics charge that political loyalty rather than compe- tence were the grounds for selection in a number of cases. Not a factor in Energy Policy, Federal mine 58 safety and health enforcement was shifted from Interior to the Labor Department last spring. Despite President Carter's solemn expressions of concern for the health and safety of coal miners (expressed when he invoked Hartley Taft -) , nothing is being done to boost production without increasing death, injury and disease. If anything, things are moving backward: Neither the White House nor the Depart- ment of Energy regularly factors occupational health and safety considerations into their coal policies; A recent report to the White House from an HEW task force on the environmental and health problems of increasing coal utilization (directed by Dr. David P. Rall of the National Institute of Environmental Health Sciences) said the health and safety costs of meeting Carter's coal goals were acceptable. The Rall commission did not, however, mention its own NIOSH generated - report that projects an almost three - fold increase in annual coal mining fatalities - to 374- and a doubling of disabling injuries - to 25,800 by the year 2000 at 1976 accident rates - if Carter's goals are met. President Carter nominated Governor John D. Rockefeller, IV (D.-W.Va.) to head a presiden- tial commission on coal's productivity and " labor stability " problems. Preliminary indications are that the Rockefeller commission will view health and safety as " constraints " on production and productivity rather than as " incurred non - costs, " let alone " benefits. " Meanwhile, the Energy De- partment has let several contracts recently on the problem of increasing productivity. Lost amid the shrill cries of the productivity barkers, are the simple facts that production and profits have risen steadily despite declining productivity. Even more deeply lost in the cacophany is the opinion of many observers that coal's productivity will rise in the future as long as recent trends continue. The 1978 UMWA contract with the BCOA will take its historical significance from the things it ended and from the things it began. It ended UMWA leverage on coalfield health care. It ended the vision of a union controlled - medical system. It began a new round of health production - for - trade- offs. It began dividing the union's membership at the mine level by setting bonus hungry - workers against militants. It may have begun dicing the union into smaller, more digestible chunks for the operators to chew on. While coal's future is bright for some, it is uncertain and ominous for others. -Curtis Seltzer A Peer Review Family Practice Revisited Dear Health / PAC: I am writing both to express approval of the inclusion in your January February / bulletin of a detailed statement on the evolu- tionary changes of general medical practice towards family practice and concern that the author found so little of value in this process that she concludes by postulating a subtle, professional conspiracy and proposing a dehumanized mass production - health care system. In the first place, this paper presents the chronology of " first contact or primary " medical care during the twentieth century with emphasis in changes both in ef- fectiveness and expectations that have developed. The fact that the medical profession has listened and responded to the public ex- pression of the 1960's is a basic and revolutionary change from the elite " ivory tower " attitude of the profession in previous centu- ries. The observation that medical students have a tendency to move from broad, humanitarian ideals to narrow personal goals is more a statement regarding our cultural values than a specific medical phenomena. The lack of a valid, innovative approach to health care in our urban areas is real but hardly reason to damn a process that is seemingly developing a more acceptable and available health system for our rural and suburban population. What the author does not seem to acknowledge is the basic philo- sophic change that is essential to the " family medicine " concept. This is the emphasis on examining and treating the " whole " person (the patient interacting with signi- ficant others) and not just the pa- tient as a disease entity. Further- more, it is clear that such health care can only occur when the practitioner is able to relate to and thus become a part of the pa- tient's total experience. This is the new practice of medicine which is evolving, the experience of which will make significant changes in us, the practitioners. After noting the definition of the family physician as developed by the Council on Medical Educa- tion of the AMA in 1964, the au- thor, for reasons that are not clarified, found it necessary to attack the whole concept of " family " and proposed that health care should be given to communi- ties rather than people involved in specific interpersonal relation- ships. I fear the logic of this pro- posal would lead to impersonal, bureaucratic, superficial and static health care rather than care in touch with the true dynamics of people's lives. A much better approach would be to develop physicians know- ledgeable about the realities of ur urban life social -, environmental and personal motivated - to work with a multi professional - delivery system and yet committed to a personalized approach to each pa- tient in each clinical situation. This simply means that we must take seriously the 1964 definition of family physician and seek ways to provide an opportunity for such physicians to practice in our urban as well as suburban and rural areas. To achieve this, a con- frontation with specialty control- led hospitals, innappropriate hos- pital oriented - payment systems 59 and politically controlled central- ized public health bureaucracy must be made, and soon. Sincerely, -W.P. Reagan, M.D. Department of Family Medicine State University of New York New Periodical BIOETHICS QUARTERLY Editor: Jane A. Boyajian Raible, D.Min. Dramatic changes in biomedical tech- nologies, legislative and judicial deci- sions, and health care policies have raised fundamental medical, legal and ethical questions. Such innovations are profoundly affecting both the quality and ideology of the present health care system. A provocative journal now emerges for professionals and layper- sons to critically assess these complex health, policy and moral issues. The periodical offers an invaluable oppor- tunity for the open discussion of bio- medical advances and concurrent so- cial concerns which are directly related to the practice of medicine, research goals, health policies and current legis- lative and judicial trends. The full scope of this journal includes such topical concerns as: the responsi- bilities and priorities to be established in genetic counseling; the protection of the rights of the dying, the new- born, and the institutionalized; the role of courts, health professionals, legislators, physicians and consumers in setting and monitoring health care standards; the obligations of the pre- sent population toward succeeding generations in the use of scarce re- sources; the administration of health services to individuals who cannot choose treatment themselves; and the role of the public in scientific research and health decision - making. ISSN 0163-9803 Quarterly Order 680-3 Individuals $ 20.00 Order 681-1 Institutions $ 40.00 HUMAN | SCIENCES PRESS 72 Fifth Avenue 3 Hennetta Street : NEW YORK, NY 10011 S` LONDON, WCZE SLU In Memoriam SAMUEL RUBIN The Health / PAC Editorial Board and Staff mourn the loss of Mr. Samuel Rubin, who died at the age of 76 on December 21, 1978. Mr. Rubin was a philanthropist and political activist who brought a deep personal commitment and abiding generosity and a keen sense of strategy to his concerns about the injustice and oppression he witnessed in this country and abroad. Health / PAC was born largely out of Mr. Rubin's generosity and out of his dismay at the dual system of health care he witnessed in New York City. His keen insight into the workings of that system helped guide Health / PAC to many of its landmark critiques and Mr. Rubin's inspiration and support have been invaluable to Health / PAC throughout its history. Mr. Rubin leaves a living legacy of organizations, projects, institutions and individuals who will continue striving long after his death to achieve his vision of a just society. Health / PAC is proud to be part of that legacy.