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No. 76 May / June 1977 HEALTH / PAC Health BULLETIN BULLETIN BULLETIN BULLETIN BULLETIN Policy Advisory Center Sica 1 Medical School a Sweepstakes: ei la THE RACE IS FIXED. Despite small gains laterite made in the late 1960s and early 1970s, minority students are increasingly underrep- resented in US medical schools. 8 Medical Education Since Flexner: A SEVENTY YEAR TRACKING RECORD. Although there are many more women and a few more minority students, the backgrounds of today's medical school enrollees are hardly distinguishable from that of their predecessors of a half century ago. 15 Columns: | WASHINGTON: Costs, Congress & Czars. WOMEN: Freedom's Just Another Word for Having Time to Choose. NEW YORK: Twinkle, Twinkle, Little Czar... WORK ENVIRON / : A A Little Sweetener for the Delaney Amendment. 24 Media Media Scan: The Birth of the Clinic: An Archaeology of Medical Perception, by Michel Foucault. 34 Vital Signs Wil K. BENDIS - HEALTH / PAC Health BULLETIN BULLETIN Policy Advisory Center No. 76 May / June 1977 1 Medical School Sweepstakes: THE RACE IS FIXED. Despite small gains made in the late 1960s and early 1970s, minority students are increasingly underrep- resented in US medical schools. 8 Medical Education Since Flexner: A SEVENTY YEAR TRACKING RECORD. Although there are many more women and a few more minority students, the backgrounds of today's medical school enrollees are hardly distinguishable from that of their predecessors of half a century ago. 15 Columns: m WASHINGTON: Costs, Congress & Czars. WOMEN: Freedom's Just Another Word for Having Time to Choose. NEW YORK: Twinkle, Twinkle, Little Czar...... WORK ENVIRON / : A A Little Sweetener for the Delaney Amendment. 24 Media Media Media Scan: The Birth of the Clinic: An Archaeology of a Medical Perception, by Michel Foucault. 34 Vital Signs K. BENDIS HEALTH / PAC Health BULLETIN Policy Advisory Center No. June 76 May / 1977 1 Medical School Sweepstakes: THE RACE IS FIXED. Despite small gains made in the late 1960s and early 1970s, minority students are increasingly underrep- resented in US medical schools. 8 Medical Education Since Flexner: A SEVENTY YEAR TRACKING RECORD. Although there are many more women and a few more minority students, the backgrounds of today's medical school enrollees are hardly distinguishable from that of their predecessors of half a century ago. 15 Columns: WASHINGTON: Costs, Congress & Czars. WOMEN: Freedom's Just Another Word for Having Time to Choose. NEW YORK: Twinkle, Twinkle, Little Czar... WORK ENVIRON / : A Little Sweetener for the Delaney Amendment. 24 Media Media Media Scan: The Birth of the Clinic: An Archaeology of Medical Perception, by Michel Foucault. 34 Vital Signs m Mys K. BENDIS a Medical School Sweepstakes schools were still officially closed to Blacks. Few minority students applied to medical school and even fewer were able to compete with the predominantly white male graduates of prestigious colleges. Even for the miniscule THIES RFAICXEED The US Supreme Court will rule later this year on the constitutionality of a special mi- nority admissions program at the University of California at Davis medical school (the number able to pass the scrutiny of admis- sions committees, the paucity of financial as- sistance was, more often than not, an insur- mountable barrier. The result of this exclusionary system was " Bakke Case "). A finding against the program -expected by many - will deal a devastating blow to the principle of affirmative action, a policy of deliberate preference for minorities as a means of redressing past discrimination. But theory aside, special minority admis- sions as practiced by US medical schools is already dead. Only 8.9 percent of those en- tering medical school last fall were minority students. that in 1969, only 2.2 percent of all physicians in the US were Black - fewer per 1,000 Black population than had been the case in 1940. First year - minority admissions to medical school totaled only 4.8 percent whereas 12 percent of the population was Black. (3) Belatedly, and in response to mounting civil rights pressure, medical schools adopted a voluntary program to increase minority enrollments. In 1970 the Association of Admission to medical school is a ticket into American Medical Colleges (AAMC), a pres- the world's best paid and most respected pro- fession. Until the late'60s, however, it was also one of the world's most exclusive tigious national organization of medical schools, set a goal of 12 percent first year - minority admissions by 1975, a target intend- tickets restricted with few exceptions to white, middle- and upper - class males. Today, following the agitation of the civil rights movement and the adoption of affirma- tive action programs, there is a widespread belief that the situation has been reversed. A persistent rumor, abetted by recent reverse discrimination lawsuits, holds that middle- class sons cannot get into medical school be- cause of preferential treatment accorded minority applicants. The facts simply do not support the case. The myth of reverse discrimination is grounded on two basic misconceptions: * That the increased enrollment of non- ed " to achieve equal representation, " accord- ing to the AAMC. (4) (While the 12 percent target might be considered equitable in the long run, given the lengthy history of discrimination and the under representation - of Black doctors, a serious argument exists that medical schools should have chosen a higher figure as a compensatory measure toward minority admissions.) Encouraged by generous federal aid, sub- stantial growth in medical school enrollment during the period in question should have made this target easy to achieve. Total first year - enrollment in medical schools in- creased from 10,422 in 1969 to 15,295 in white students means fewer admissions for 1975 an increment of 4,873. To have whites; * That affirmative action implies the accep- tance of hordes of less qualified - students who will become, as charged by such opponents as Harvard professor Bernard D. Davis, sub- standard physicians. A Health / PAC study of minority first year - enrollments - both nationally and in New York City totally debunks these notions. Two Steps Forward, Two Steps Back The issue of minority admissions is a com- plex one. Of course, medical schools are achieved 12 percent minority admissions by 1975 would only have required that 1,334 (27.4 percent) of these additional places go to minority students. Yet only 890 minority students were actually admitted, and minority admissions peaked in 1974 at only 10 percent. They have declined steadily since then, falling to 9.1 percent in 1975 and 8.9 percent in 1976. The original goal of 12 percent is nearly as distant today as it was in 1969. The NY Meds: Minority Students Lose 6-1 loath to admit ever having practiced overt 2 discrimination, although as late as 1963, five The performance of New York City's medi- cal schools generally is one extreme in a na-  16,000 Number First Year Enrollment: US Medical School, 1969-76 14,000 12,000 Total Enrollment 110,000 |. 2,000 - 1,000 0 1969 Minority Enrollment ---""~ Year Year | 1971 1 1973 1 1975 Sources: Refs. 1 and 2 1976 tional picture of failure to attain proportional enrollment for minority students. New York City's medical schools, despite the city's claim as the nation's leading liberal metropolis, en- rolled only 6.9 percent minority students in the fall, 1976 entering class. In fact, there were fewer minority students enrolled in the 1976 entering class at New York City's seven medical schools than there were in 1971. Only 75 of the 1,091 students beginning their medical education in 1976 were minority students; in 1971 there had been 79 out of a class of 936. The only medical school in New York to exceed the AAMC goal of 12 percent minority enrollment was Cornell, which reported 12.9 percent minority enrollees in the current term. When Cornell is excluded, the picture is completely dismal: remaining medical schools'first year - minority enrollment is only 5.6%. As a result of failure to keep up with na- tional trends, the New York City schools today account for a smaller percentage of the na- tion's minority medical students than they did in 1969, although the City contains a larger Published by the Health Policy Advisory Center, 17 Murray Street, New York, N.Y. 10007. Telephone (212) 267-8890. The Health / PAC BULLETIN is published 6 times per year: Jan./Feb., Mar./Apr., May June /, July / Aug., Sept./Oct. and Nov./Dec. Special reports are issued during the year. Yearly subscriptions: $ 8 students, $ 10 other individuals, 20 $ institutions. Second - class postage paid at New York, N.Y. Subscriptions, changes of address and other correspondence should be mailed to the above address. New York staff: Barbara Caress, Oliver Fein, David Kotelchuch, Ronda Kotelchuck, Ken Rosenberg and Loretta Wavra. Associates: Robb Burlage, Len Rodberg, Washington, D.C.; Constance Bloomfield, Desmond Callan, Michael Clark, Nancy Jervis, Kenneth Kimmerling, Louise Lander, Steven London, Marsha Love, New York City; Vicki Cooper, Chicago; Barbara Ehrenreich, John Ehrenreich, Long Island; Robin Baker, Elinor Blake, Judy Carnoy, Dan Feshbach, Carol Mermey, Ellen Shaffer, San Francisco; Susan Reverby, Boston, Mass. BULLETIN illustrated by Keith Bendis. Health Policy Advisory Center, Inc., 1977. 3 Backing Into Bakke Many affirmative action advocates worry that the " Bakke case " now before the US Supreme Court is the wrong case at the wrong time and for the wrong rea- sons. The case involves charges by Alan F. Bakke that he was denied admission to the University of California at Davis medical school because of preferential admissions of minority students. Bakke's contention that the medical school's ac- tions were unconstitutional was sup- ported by a ruling from the California Supreme Court. What makes the case so difficult are the facts. The medical school never denied that so called - " lesser qualified " minority students were admitted. Nor is the school willing to argue that its special minority program was installed. to redress past discrimination (an impor- tant legal point, since the courts have ruled that the need for catch - up consti- tutes legal grounds for preferential treatment.) Instead, university lawyers argued that the program was necessary because few minority applicants could pass mus- ter through the regular admissions committee. The California Court re- jected this excuse, explicitly challenging the standard admission criteria: " While minority applicants may have lower grade point averages and test scores than others, we are aware of no rule of law which requires the University to afford determinative weight in admis- sions to these quantitative factors. In practice, colleges and universities gen- erally consider matters other than strict numerical ranking in admission deci- sions.... In short, the standards for ad- mission employed by the University are not constitutionally infirm except to the extent that they are utilized in a racially discriminatory manner. Disadvantaged applicants of all races must be eligible for sympathetic consideration, and no applicant may be rejected because of his race.... We do not compel the Univer- sity to utilize only the highest objective academic credentials as the criteria for admission. " What the court did not note is that every existing medical school admis- sions criterion - grade averages, Medi- cal College Admissions Tests (MCATS), and preferences for prestige colleges- reproduce the very cultural biases that minority admissions programs are de- signed to redress. Further, both the MCATS and medical school grades have been discredited as valid predictors of physician performance. Admitting that most minority appli- cants could not be admitted through percentage of the US minority population. In 1969, 7.2 percent of all first year - minority medical students were enrolled in New York City medical schools; by 1976 the percentage had dropped to 5.4. To achieve the AAMC goal of 12 percent, approximately half of all additional first year - places at New York City's medical schools would have gone to minority students. In fact, only 18 percent did so in the period from 1969 to 1976. Meanwhile, the primary beneficiaries of medical school expansion - both in New York City and nationally - were nonminority stu- 4 dents. Between 1969 and 1976 there were 247 new places created at the seven schools. Only 39 of these went to minority students. Thus, minority enrollment in New York - the national capital of medical research and edu- cation - has, throughout the decade, trailed the rest of the nation. Today, it lags behind the national average by a full 25 percent. In 1976, with the nationwide percentages of minority enrollment declining, New York City leads the downhill rush. The $ 64,000 Question Unfortunately a medical education remains today, as always, primarily an opportunity for the privileged. While only 24 percent of the these regular admissions procedures, the medical school argued that a special program was the best way to insure a supply of physicians for minority com- munities. The University thus explicitly assumed that minority physicians will serve minority populations. Declaring that there is " no empirical data to demonstrate that any one race is more selflessly socially oriented or by contrast that another is more selfishly acquisitive, " the Court challenged this, suggesting that the university incorpor- ate its " concern " into its admissions pro- cedures, adding that: " An applicant of whatever race who has demonstrated his concern for disad- vantaged minorities in the past and who declares that practice in such a commu- nity is his primary professional goal would be more likely to contribute to alleviation of the medical shortage than one who is chosen entirely on the basis of race and disadvantage. " Finally, the Court suggested that " in addition to flexible admission standards, the University might increase minority enrollment by instituting aggressive pro- grams to identify, recruit and provide remedial schooling for disadvantaged students of all races.... " Clearly, the medical school could have accommodated the court by chang- ing its admission procedures. Instead the University of California Regents voted, against the advice of knowledge- able affirmative action lawyers, to ap- peal the case to the Supreme Court. The action, some have argued, is tantamount to sabotaging its own program. By appealing to the highest court, the case puts in jeopardy every affirmative action program in the country, whether in school admissions or employment practices. The case is expected to establish legal precedent against which further challenges to affirmative action will be judged. As such, the Bakke case is a pitifully weak reed upon which to rest much of the anti discrimination - progress of the last decade. A final irony of the Bakke case is that the U.C. Davis medical school newest - of the five in the University of California system operates - a private admissions program for the sons and daughters of influential Californians. Dr. C. John Tupper, the school's dean, has been accused of " trading admissions to the school for favors from powerful people. " (New Physician, November, 1976.) Tupper reportedly justified such prac- tices by pointing out that U.C. Davis is a new school and that it needs political support in California. Evidently, should California Governor Jerry Brown ever choose to have a Black son or daughter, his offspring would have no fears of exclusion from U.C. Davis by opponents of " reverse discrimination. " labor force held managerial, professional or cal school admission. In April, 1976, the proprietal jobs, (5) fully 64 percent of those seven deans of New York City's medical admitted to medical school in 1973 came from such families. (6) Over two thirds - of the stu- schools estimated that every student entering medical school in the fall of 1976 would have dents admitted to medical school in 1975 came from families with incomes over $ 15,000 to spend $ 64,000 to finance four years of school. Nationally, the figure exceeds a year and 40 percent reported family $ 50,000, while at two schools (Georgetown incomes over $ 25,000. (7) Yet only 14.1 and George Washington) tuition alone is now percent of US families earned $ 25,000 or $ 12,500 a year. more. (8) Finally, the children of physicians Even at the height of minority enrollment- seem to have received an extraordinary edge. from 1969 to 1974 - few medical schools made Of those admitted in 1973, 14 percent had fa- permanent changes in their methods of re- thers who were physicians. (9) cruitment or selection, or in the distribution of It is not surprising that high family income assistance. Relatively more was allocated to is the single most important predictor of medi- minority students, but the pie was expanding 5 and there was plenty to go around. Admis- sions officers now predict that declining economic conditions (read: government fund- ing) coupled with the escalating costs of at- tending medical school could erase past gains in a few short years. (11) The Best Defense is a Good Offense The disappointing results of nearly a decade of " affirmative action " -especially the disturbing decline in minority admission rates have not stimulated strong counter- measures on the part of either the federal government or the medical schools them- selves. Instead, excuses to justify the situation and attempts to lower expectations and objec- tives have become the order of the day. Spearheading the retreat, Dr. Bernard B. Davis, Harvard University professor of physi- ology, charged in a widely reported New England Journal of Medicine article (May 13, 1976) that academic standards were threaten- ed by increased admission of minority stu- dents. Raising the specter of unqualified phy- sicians leaving " a swath of unnecessary deaths behind, " Davis was roundly criticized by Harvard's Dean Robert E. Ebert for speaking out of school. According to press accounts, however, his remarks drew wide- spread ' concurrence in medical school circles. While the Davis incident might be written off as the rantings of an unreconstructed ne- anderthal, Davis was subsequently promoted by his Harvard colleagues and the Bakke case may become icing on the cake for more sophisticated opponents of minority admis- sions. The Bakke case involves a suit filed in 1975 1110000 L-- Number NY Medical School Enrollment: 1969-1976 1000 + Total Enrollment 900 800 F 100 j- Minority Enrollment -- - - oN -_ ~ ~ a a a" ~ aa 0 6 1969 Year 1976 by Allan Bakke, an applicant for admission to for their actions, the medical schools are al- the University of California at Davis medical ready on a backward trajectory. school, claiming the school unconstitutionally Affirmative action was established in the denied him access, although his admissions first place as a response to social pressures test scores were higher than some minority exerted from outside the closed circle of applicants who were admitted. The California medical education. Dr. Alvin F. Poussaint, Supreme Court ruled in Bakke's favor, Associate Dean of Students at Harvard, finding the school's admission practices un- constitutional. characterized the present period as a " move- ment to reassert the right of the privileged The school has appealed to the US Supreme class to the plums. " Poussaint concludes: " I Court, seeking to have the California court see a political, not academic, solution to this decision reversed. The case is a major chal- problem. " lenge to the concept of special minority ad- -Barbara Caress missions programs in general, and at least some have argued that the medical school's own brief in the case is ambivalent at best, and may result in sabotaging minority admis- sions programs nationally. (See Box, page 4.) If the Supreme Court upholds the medical schools minority admissions program, it is unlikely to substantially increase minority en- rollments. At best, medical schools can be expected to maintain current low level - pro- grams. Whatever the outcome of the case, there is no evidence that US medical schools are about to embark on anything like the catch - up program necessary to substantially increase the numbers of minority doctors. In fact, the data suggest that even without legal sanction REFERENCES 1. Calculated from 1969 first year enrollment figures; Journal of Med- ical Education, Vol. 48, No. 3, p. 294 and 1976 first year enrollment figures; telephone interview with the Association of American Medical Colleges Office of Student Affairs, April 18, 1977 and " Minority Student Information by Individual U.S. Medical Schools, " Unpublished table (Washington: AAMC, 1976). 2. Ibid. 3. " Report of the Association of American Medical Colleges Task Force to the Inter Association - Committee on Expanding Educa- tional Opportunities for Blacks and Other Minority Students, " (Washington: AAMC, April 22, 1970). 4. Ibid., p. 1. 6. Grace Ziem, " Social and Educational Determinants of the Race, Sex and Social Class Origins of U.S. Physicians, " (Harvard School of Public Health, Unpublished thesis, 1977) p. 59. 7. American Medical News, February 16, 1976, p. 12. 8. Statistical Abstract, op. cit., p. 404. 9. Ziem, op. cit. 10. The New Physician, November 1976; American Medical Medical News, September 13, 1976. 11. 11. 11. New York Post, April 14, 1976; New York Times, November 26, 1976, and New Physician, November, 1976. Oa A HEALTH / PAC SPECIAL REPORT The Myth of Reverse Discrimination The full report from which this article and a front page story in the April 28, 1977 New York Times were drawn is available from Health / PAC. The report contains numerous tables and charts which detail the sorry story of declining minority admissions both nationally and among New York City's medical schools. Copies of " The Myth of Reverse Discrimination: Declining Minor- THE MYTH OF REVERSE DISCRIMINATION: DECLINING MINORITY ENROLLMENT IN NEW YORK CITY'S MEDICAL SCHOOLS CANCEL A HEALTH / PAC SPECIAL REPORT ity Enrollment in New York City Medical Schools " cost $ 1.50 plus $.50 for postage. 7 CLASS of SIONZES The 77 ' Medical Education Since Flexner A SEVEYNETAYR Physicians in the United States have his- TRACKING torically been selected predominately from RECORD families with business and professional oc- cupations. They have also been predominate- ly male and white. To understand how such class, sex and racial patterns originate and how they serve to perpetuate both established medicine and unequal delivery of care, it is necessary to examine the educational system and its relation to the larger society. Schooling in America is more than acquir- ing skills. It also involves such major func- tions as: * Socialization: Children learn early the need for punctuality and for following intri- cate rules without explanation; they are also taught such values as competition through a grading system where only a few can be on top. Such behaviors help condition young people for a labor market where punctuality, low absenteeism and rule following - increases profits generated by their work. * Social Selection: A second function of schooling is the sorting out of social groups for specific levels in workplace hierarchies. One selecting mechanism is vocational coun- seling that encourages nonwhites, women and 8 working - class students to enter different areas of study and work than whites, men and middle - class students. Another is the powerful combination of different learning opportu- nities and of admissions tests that are largely based on past learning and socialization. Often, decentralized school funding and residentially segregated housing - both by race and by social class channel - working- class and minority students into more crowded schools with fewer educational materials and less experienced teachers. Students from such schools must then compete for college admission with students from schools with more than twice as many dollars spent per pupil. Finally, higher education is best understood as a commodity purchased ac- cording to one's ability to pay: ability to pay is as important as " IQ " in determining whether a student will ever attend college and in deter- mining what type of college the student will enter L e.g., a two year -, " terminal track " vocational college or a four year - college with premedical courses. (1,2) Every year this complicated socialization and selection network operates at elementary, secondary and undergraduate educational levels to produce - at one of its extremes - an elite group of potential medical school enrol- lees. Once in medical training, they enter a new system - one which not only reinforces their elite status but makes them critical agents in the selection and socialization of those at the other end. US physicians - as definers of disease causes and treatments - potentially affect both the direct and indirect accumulation of capital, the legitimation of the existing social system, and the social control of other classes. They can therefore be viewed as critical for reproducing the American social order, and it is from this perspective that one can best understand their selection from busi- ness and professional families. Class: Perpetuating the Hierarchy The composition of physicians by social class has gone virtually unchanged in the es * Physicians'decisions can affect direct accumulation by defining when a worker is ill and when not, thus raising or lowering workplace absenteeism and profits from work. Physicians can also define illnesses as work related - or nonwork - related, thereby con- trolling workers'ability to obtain compensation or to pursue litiga- tion for health damage. Physicians can affect accumulation indirectly by helping to control and legitimate the social systemL e.g., when illnesses are defined as nonwork - related, the real causative agents are obscured, thereby absolving the social system itself from being considered pathogenic. Also, to the extent that women and minorities are used for cheap labor, their control is facilitated through definers of illness who are male and white. Physicians'actual labor may contribute to direct capital accu- mulation when they are employed in proprietary institutions; it may contribute to indirect capital accumulation when such services actually improve the health of other workers who make profits for someone. United States since the medical education re- forms initiated by Carnegie and Rockefeller corporate interests in the early 1900s and introduced between 1910 and 1920 to the nation's medical schools. These reforms closed a disproportionate number of medical schools previously open to working - class youth, a fact Flexner admits in his report, (3) and left open schools with gen- erally higher tuition levels and stricter admis- sions policies. (4) Surviving schools revised admissions to require prior college study and mandated full time - course loads, eliminating part time - and evening study needed by work- ing youth. (5) New licensing restrictions, meanwhile, prohibited the practice of medi- cine by those who might try other means of education. Physicians thus became a strongly middle- class group, and working - class youth were effectively barred by the new structure of medical education. They remain effectively barred today. A number of studies of the class origins of physicians reveal how little change has oc- curred in the past half century: * Adams showed that the rated " occupa- tional prestige " of physicians'families of Table 1 Medical School Enrollees by Fathers'Occupation, 1946-1973 Fathers ' 1946, 1950 Occupation Entrantsa Physician 13.2% Otwhneerr P rMoafneassgieorn a/l 301.70.9 Subtotal: Prof., Managerial & Proprietal 61.1 Clerical / Sales 15.0 Skilled Unskilled / 18.0 Other 5.9 1956 Freshmenb 11.5% 17.5 31.0 60.0 12.5 15.5 12.0 1963 Total Enrolleesc 14% 27 27 68.0 10 17 5 1967 Total Enrolleesd 15% 27 25 67.0 11 15 7 1970 Total Enrollees 15% 28 .20.20 1973 Acceptees * 13.4% 32.0 18.9 63.0 12 16 8 64.3 7.5 14.8 13.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 Sources: a. Ref. 7 b. Ref. 9 c. Ref. 10 d. Ref. 11 e. Ref. 12 f. Ref. 13 9 origin showed essentially no change for phy- sicians entering practice from 1925 to 1945. (6) * Lyden, studying 2,000 medical school entrants in 1946 and in 1950, (7) found 61 per- cent came from professional, managerial or proprietal families, though such families con- tributed only 18 percent of the male labor force. (8) * A 1956 study of medical school freshmen showed 60 percent shared these same class origins. (9) * More recent studies have shown 68 per- cent (1963), 67 percent (1967), 63 percent sionals had a lower average - than - acceptance rate (34.4 percent). Race: Exclusion and Unequal Preparation When Flexner surveyed medical schools in 1909-1910, there were seven Black medical schools in the country with a total enrollment of 732, or 3.3 percent of the 22,208 total US medical students. (16). Although Flexner re- lates the subsequent closing of at least some of the five Black schools eventually shut down to lack of funds, evidence shows that corporate Table 2 Medical School Enrollees by Fathers'Education, 1946-1973 Fathers ' Education 1946 Entrants Post grad. 25.6 College degree 22.1 Some degree High school Diploma Some high school 52.3 8th grade or less Total 100.0 Sources: a. Ref. 7 b. Ref. 9 c. Ref. 10 d. Ref. 11 e. Ref. 12 f. Ref. 13 1963 1967 1950 1956 Total Total Entrants a Freshmenb - Enrolleesc Enrolleesd 26.6 27 243902 35 25.0 11 1244390 2 1366777 8 16 13 243902 1367777 8 15 1249390 2 1367777 8 48.4 31 1243090 2 367 78 12 367778 100.0 100.0 100.0 100.0 1970 Total 1973 Enrollees * Acceptees ' 3315276 8 35.5 14 312768 19.1 20 312768 16.8 312768 15.4 312768 5.8 312768 6.9 100.0 100.0 (1970) and 64 percent (1973-1974) of new enrollees came from these class origins, (10- 13) although these classes contributed only 23 percent of employed males reported in the 1970 Census. (8) Table 1 summarizes the class composition of medical school entrants based on occupa- tions of families of origin. A similar picture emerges from studies using fathers'educa- tions as an indicator of class 10-15 () . These studies are summarized in Table 2. It is worth noting in this regard that of all applicants to US medical schools for the 1973- 74 class those with physician fathers had the highest acceptance rate (42.4 percent) and those with skilled worker fathers the lowest (32.2 percent). (13) The highest acceptance rates by mothers'occupation were for physi- cians also (46 percent), while those whose 10 mothers were nonphysician health profes- foundation support to medical education was available and was primarily channeled to leading private schools. The number of Black enrollees at the two remaining Black schools, Howard and Me- harry, actually declined in the post Flexner - period. Although these two schools had 480 total students in 1909, by 1938 there were only 305 Black enrollees in these colleges. (16) Neither rising white enrollment in the two schools nor inadequate fiscal support, meager though it was, explain the drop in Black enrollment. Rather, the national reorganiza- tion of medical education - requiring a prior two years of college significantly - reduced the size of the potential Black applicant pool. Not until 1947 did enrollment in these two colleges climb above its 1909 level. (18) Meanwhile, the number of Black enrollees in predominately white schools remained Table 3 Black Enrollment, US Medical Schools, 1909-1974 All US Medical Schools Black Medical Schools Year 1909-10a 1938-39b 1950-51b 1955-56b 1961-62b 1963-64b 1964-65c 1965-66c 1966-67c 1967-68c 1968-69d 1969-70d 1970-71d 1971-72d 1972-73d 1973-74e Total Freshmen Enrollees 6320 6869 7465 7946 8305 7930 8168 8596 9408 9863 10422 11348 12361 13545 14124 Black Freshmen Enrollees - (88) * (165) (190) (193) (178) 155 167 196 217 266 440 697 882 957 1023 Blacks as% of Total Fresh- man Enrollees 3.3% (1.4%) (2.4%) (2.5%) (2.4%) (2.2%) 2.0% 2.0% 2.3% 2.3% 2.7% 4.2% 6.1% 7.1% 7.1% 7.2% Number of Percentage of Black Total US Enrollees Black Enrollees (76) (130) (131) (148) (136) 108 107 162 147 142 120 151 187 196 100.0% (87.1%) (84.2%) (69.0%) (77.2%) (75.8%) 69.7% 64.1% 82.6% 67.7% 53.0% 27.2% 21.7% 21.2% 20.5% Sources: a. Ref. 16. b. Ref. 18. c. Ref. 19. d. Ref. 20. e. Ref. 21. * Numbers in parenthesis are estimates of freshmen enrollment based on the number of total enrollees, freshman through senior years. miniscule until the late 1960s. Not until 1968 were there more than a total of 100 Black en- physicians practicing in the US in 1890, a number that increased more than threefold to rollees in the nation's medical schools exclud- ing Howard and Meharry (Table 3). In 1948 a third of all medical schools were officially closed to Black enrolles. De facto ceilings on the number of Black enrollees in other schools were often maintained. As late as 1963 five medical schools were still officially closed to Blacks. (18) Finally, in Flexner's time, (16) annual fees. at predominately white medical schools aver- aged $ 115; in the Black medical schools allowed to remain open, they averaged $ 96. But in those which were closed, annual fees averaged $ 54. Thus, closing the five Black schools denied Blacks the most accessible medical education. 3,885 in 1920, but remained at or below that level through 1948, when it began to rise again, reaching 4,500 in 1966. Until the be- ginning of reforms spurred on by the demands of the 1960s, the number of new Black medi- cal graduates was barely sufficient to make up for attrition through death and retirement. In sum, the creation of relatively unattain- able prerequisites and insufficient fiscal sup- port for Black medical education created bar- riers probably as great as those posed by out- right racial discrimination. These barriers extended beyond medical education and ul- timately originated in a structure of unequal access to general educational resources for Black Americans. This history helps explain the rapid rise in the number of Black physicians in the United Sex: More Than Medical Policy States at the turn of the century, followed by According to Flexner's report, (16) as well an abrupt plateau immediately following the as the Journal of the American Medical Flexnerian reforms. (22) There were 909 Black Association Annual Education Issues tabu- 11 Table 4 Women Accepted to US Medical Schools, 1904-1973 Year Total Acceptees % Women 1904a 1906 1908 1910 1912 1914 1919b 1929 1935 1940 1950 1960 1965 1968 1969 1970 1971 1972 1973 7,035 6,900 6,328 7.254 8,560 9,012 10,092 10,547 11,500 12,335 13,757 14,335 (3.5) ' (3.7) (4.2) (3.2) (3.8) (5.9) 4.5 5.5 4.8 5.3 7.0 8.9 11.0 9.6 11.3 13.7 17.1 19.9 Sources: a. Data on 1904-1914, Reference 26. b. Data on 1919-1972, Reference 23. c. Data on 1973-74, Reference 13. * Numbers in parenthesis are estimates of freshmen enrollment based on number of total enrollees, freshman through senior years. lated by Dube, (23) there is little evidence that the proportion of women medical enrollees significantly declined during or following the Flexnerian reforms. (Table 4) This tends to refute Ehrenreich and English, (24) who state that women disproportionately enrolled in eclectic, homeopathic and other non allo- - pathic schools as well as less prestigious allopathic schools and, when disproportionate numbers of these closed, medicine became a male profession. The data do suggest that at the turn of the century women were already drastically under represented - in the curricu- lar programs referred to as medical schools. While numerical data are not available, it is likely that women with interests and skills in medicine were less often enrolled in the decreasing number of formal medical schools, but more often active in lay mid- wifery and lay healing (25) as well as tradi- 12 tional nursing. As late as 1910 women lay midwives delivered half of all babies, and evi- dence indicates that doctors may have been less competent than midwives at this time. (24) The decline of lay women healers was part of the decline in the Popular Health Move- ment, slowly strangulated by the mounting strength of organized medicine (including women) in the latter part of the 19th cen- tury. (25) The Popular Health Movement, probably influenced by a wider movement against professional monopolies (Jacksonian " Democracy ") in the early 19th century, was a strong attack by feminists and working - class people against the premature effort of allo- pathic practitioners to create a professional monopoly in the 1830s. (24) Women as lay persons and healers were part of the effort to deprofessionalize medical knowledge (in the era of calomel and bleeding); but they did not comprise a significant proportion of those who would later monopolize medical practice. Flexner indicates that 56 of the medical schools he visited in 1909 were not open to women. (16) He gives no enrollment data for women by school, making it difficult to deter- mine which schools were closed to women. But the evidence indicates that the annual number of women medical graduates fell from 1,129 in 1904 to 631 in 1914, (26) because of the general contraction of enrollment rather than any factors particular to women enrol- lees. (Table 4). In fact, the proportion of women enrollees remained about five percent until the 1960s. Acceptance rates by sex are unavailable prior to 1929; following that, rates for women are remarkably close to those for men al- though, of course, many fewer women ap- plied. (See Table 4.) So, at least since 1929, factors other than differential admissions ac- counted for the persistent under representa- - tion of women. Though this began to improve with the emergence of the women's move- ment, the enrollment of women is still far below that of men, and causes extend to factors other than medical educational policy. Medicine and medical education, for ex- ample, have never been structured to easily accommodate the differential domestic roles into which women are still channelled. Prior to the rise of the women's movement, both socialization into " girls " careers and the extreme difficulty of combining family re- sponsibilities with a relatively rigid medical curriculum have discouraged all but a hand- ful of would - be aspirants. For many women, Percent |5 0 L_ 40 .30.30 --_- - some 9 Ao Class: Percent of Fathers in " Skilled / Unskilled " Category Race: Percent of Medical Students Black Sex: Percent of Medical Students Women _2200 . / a .10.10 / -- see ome mee -_ -_ ; m= @ mn a - - - a" " N 796699999999 796699999999 796699999999 796b6t99 9p9t9 9t9t9 1950 1960 1970 1973 the need to individually shoulder the financial that is primarily male, white and from upper- burden of child care makes a medical career class families. The socializing and selecting economically prohibitive. As long as such effects of the general education system dis- factors persist, changes in medical admissions cussed at the beginning of this article are the policy are unlikely to achieve a sexually most important. To them can be added the balanced applicant pool. socializing effects of the home and other Structure of Discrimination A recent study by this author found a num- social units. Kohn's study, for example, found that parents who work at jobs requiring obedience and passivity teach their children ber of key factors operating to perpetuate the passivity and conformity, while parents with hierarchical nature of medical education. (13) occupations requiring initiative and creativity The most important have to do with pre- teach their children assertiveness. (27) Sex selecting mechanisms in the broader Ameri- and race stereotyping accumulate with myriad can society, resulting in a pool of applicants economic, social and cultural factors to main- 13 tain a pattern whereby inequities - racial, sexual and class - in both seeking of and applying for medical education are con- tinually reproduced. Medical school admissions policies them- selves, however, also play a significant role. Two patterns are of special importance: * MCATS: The use of a single, national ad- missions test - the MCAT (Medical College Admissions Test -further) skews the appli- cant pool. The test itself is designed to mirror the very differential learning opportunities and cultural biases of the larger society. Further, the MCAT has been largely dis- credited as a valid predictor of physician performance. If this is true for all score inter- vals, it would argue for abandoning the test altogether. If true only in the middle range of scores, these should be delineated and scores at the high extreme should no longer be given a special advantage. * Preferences for Prestige Schools: A sec- ond medical school admissions policy respon- sible for reinforcing and exaggerating the al- ready biased - sample of applicants is the direct preference for applicants from the nation's prestige colleges. Graduates of such colleges, of course, are generally from higher class origins, and more likely to be white and male, than the total graduates from all col- leges. (13) Conclusion Although the role of medical school admis- sions policies in the relative exclusion of women, minority and working - class appli- cants is clear, the major culprit is the general educational system. This impression is strengthened by a brief review of unpublished work by this author on international compari- sons. For example, in neither Britain nor Canada has the introduction of a national health system, or national health insurance, respectively, had any noticeable impact upon the class origins of physicians. Actually, physicians in Britain are less representative by class of the British population than are US physicians of the US population. This would support the hypothesis that the educational system rather than changes in the health system, per se, is the major determinant. In Britain, educational stratification by class is more marked and rigidly structured earlier in life than in the United States. The only substantial changes in US medical 14 schools admissions have been relatively slight gains by women and minorities during the 1960s, following popular agitation for in- creased access. Implications are clear con- cerning the question of class stratification in these same admissions. Again, international comparisons are illuminating: In China, for example, it was not until after the Cultural Revolution of the 1960s mid - that entry criteria shifted away from academic indices and began to stress other applicant qualities. The proportion of medical enrollees in that coun- try with peasant and working - class social origins subsequently shifted from about 10 percent to nearly 90 percent. (13) The absence of any such cohesive move- ment to redress class discrimination in the US, meanwhile, (see Chart, p. 13) unfortu- nately suggests that the likeliest beneficiaries of altered admissions policies might be such unrepresentative groups as Black physicians ' daughters provided, of course, their fami- lies'incomes are in the top 10 percent and they have graduated magna cum laude from one of the nation's prestige colleges. Needless to say, such reforms will leave the majority of Black, female and working - class applicants just where they began: out in the cold. Just as increased medical enrollment for women and Blacks came only with organized demands, further advances by these groups and any improvement for working - class youth will require similar efforts. And these efforts will need to address the entire educational system and the functions it serves in corporate America. LGrace Ziem (Grace Ziem is a faculty member at the Johns Hopkins School of Health Services. This article is adapted from a thesis at the Harvard School of Public Health, " Social and Educa- tional Determinants of the Race, Sex and Social Class Origins of U.S. Physicians. " (1977)) 1. 1. Bowles, S. Unequal Education and the Social Division of Labor, p. 52. In Schooling in a Corporate Society, edited by M. Camoy, David McKay Co., New York, 1972. 2. 2. Karabel, J. Community Colleges and Social Stratification. Har- vard Education Rev. 42 521-562: , Nov. 1972. 3. Flexner, A. Medical Education in the United States and Canada. Carnegie Foundation for the Advancement of Teaching, New York, 1910. 4. Colwell, N.P. Recent Progress and Further Needs in Medical Education. JHMS 72, 11 822:, March 15, 1919. 5. Standards of the Council on Medical Education of the American Medical Association: Essentials of an Acceptable Medical College. JHMS LXIII, 8 667-687: , August 22, 1914. (Continued on page 23) that would have victimized the WASHINGTON the nation's approximately 6,000 acute care institutions in two ways: (1) by imposing a nine percent ceiling on the increase of total in patient - re- venues (calculated from a 1975- 76 base period before hospitals could preemptively jack up costs) for the year beginning Costs, Congress and Czars October 1, 1977, to decline gradually in subsequent years; and (2) by imposing a national dollar limit on capital expendi- How does one characterize tures hospital - construction Carter - ism thus far? Is it mar- and acquisition of new equip- ginal managerialism? Nixon- ment of about $ 2.5 billion. Fordism with a smile and with- This represents roughly half of out a grudge? what was spent in 1976. There has been scant evi- Two big social issues in the dence of the commanding cor- hospital cost bill are: (1) in- porate liberal or the populist clusion of a " pass through, " rebel. Certainly no signs have exempting from control the flashed of the bold new pro- added costs incurred by a grammer sensitive to local poli- hospital because of increases tical mobilization and reorgan- for low wage - , non supervisory - ization capacities. Rather, Car- terism so far has meant national employees; and, (2) an at- tempt to control the impact of media massaged - assent for domestic hodge podges - and side steps - amidst martial drifts the bill on public institutions by curtailing such practices as patient dumping. abroad. Implementation of Carter's " Cut and shoot, " quipped " hitting hard -" hospital cost bill one insider, characterizing a relies on a small federal " strike draft of the President's first ma- force " staff, negotiating from a jor health address. " Cut " refers questionable data base consist- to the federal hospital cost con- ing of current hospital Medi- tainment program submitted care reports. The strategy by Carter as his major 1977 health bill; " shoot " is the ex- seems guaranteed to continue the regressive shell games - of panded childhood immuniza- internal institutional account- tion program, seen as a step in ing and marketing. There is developing a comprehensive also a major reliance on the Child Health Assessment Pro- " wet noodle " control mechan- gram and possibly one piece in isms of state rate review and a piece piece - by - approach to expenditure planning pro- national health insurance. grams. Hospital Cost Containment There are paradoxically pro- gressive aspects to Carter's ap- Carter's " Hospital Cost Con- proach. For a starter, it isn't tainment Act of 1977, " a.k.a. Ford's proposed freeze on H.R. 6575, attempts to restrict Medicaid and cap on Medicare poor and elderly while pushing the burden of ever increasing - hospital rates onto working- and middle - class payers. Car- ter's approach may even be a federal " first "-- - monopoly price control without total wage zapping - . Califano ac- tually criticized hospital " mon- opoly big business " for " obesi- ty, " while saying inflationary medical care spending ignores other health and death deter- minants " directly related to our working conditions and our eating, drinking, smoking and exercise habits. " While hospital manager - blaming and illness - victim blaming may be a shade better than victimizing the vulner- It would seem that Mr. Califano aspires to the title of Mr. Design Neglect. rs able, Carter's strategy leaves untouched such crucial issues. as who a hospital admits, what it charges its patients, whether it serves the entire community or region most effectively, or whether its board and plans are representative and respon- sive. And finally the question looms: was this packaged for- mula meant to pass, let alone work? (Some have suggested it was only meant as mood music to mark time by prior to or- chestrating a real federal poli- cy.) Joint House Health Subcom- mittee hearings on the bill in mid May - bring to the surface both the special interest groups'potential for sabotage and general political luke- 15 warmness shared even by strong public sector advocates. ney Wolfe, director of Ralph Nader's Health Research The administration's courtesy co introducers -, Representa- tives Daniel Rostenkowski and Paul Rogers, who chair the two WASHINGTON CAPS Group, urged cancellation of the Derzon appointment in a letter to Califano. Wolfe point- ed out that, as director of hos- key subcommittees, are hedg- ing. " I am not yet convinced [of] the approach of H.R. pitals and clinics for the Uni- versity of California at San Francisco, Derzon was behind 6575, " said Rogers. " Why the " construction of a probably should we pass this question- unneeded $ million 60 - expan- able transitional package to start October 1 ", asked one staffer, " when the Secretary is sion program " through " skillful www circumvention of all legal and financial obstacles. " obligated under this law, to come back five months later 11 (March 1) to recommend a New Yorkers may remember Derzon as assistant to Joseph Terenzio, the last Commission- more permanent approach? " 111 1 er of the New York City De- partment of Hospitals before What Ever Happened to NHI? " Notable by its absence in the President's health message | draft, prepared by HEW Secre- tary Joseph Califano, was the subject of national health in- surance, although the Presi- dent did see fit to mention at least its postponement, pend- ing the control of rising health care costs. Doubly indicative, perhaps, was the formation in early April of Califano's blue- ribbon Advisory Committee on | | | GENERAL HOSPITAL B. Causs the creation of the Health and Hospitals Corporation. Derzon went on, in fact, to become the first Acting President of the Corporation, a job he held long enough to " skillfully " ne- gotiate a giveaway to the City of most of its fiscal autonomy for public hospitals, including vital Medicaid collection au- thority. (Terenzio, now with New York's United Hospital Fund, is a contender for the New York City State - " czar " post.) National Health Insurance. Its formation was announced on a Saturday, guaranteeing mini- mum press and public expo- sure, and its members were drawn overwhelmingly from provider and corporate inter- ests. Maybe the key to Cali- The Fox and the Chickens The new " czar " looming on the federal health horizon is Robert Derzon, Califano's ap- pointment as chief of HEW's Meanwhile, a progressive Congressman has challenged the collective wisdom of Wash- ington's health planners by as- serting that the problems they hope to solve are inherent in the privately controlled - , piece- work oriented - health institu- fano's thinking on the subject was revealed in his call for recognition of the " strengths of our present health care system and the appropriate role. new Health Care Financing Administration (HCFA). HCFA merges Medicare, Medicaid and the cost and quality con- trol functions associated with tions that dominate this coun- try's health care industry. Ron- ald V. Dellums (CA D -), a leader of the Congressional Black Caucus, introduced a the of... private insurance in- dustry in administration. " It these programs and is con- sidered to be the linchpin post Health Service Act on May 4. More about this act and - the would seem that Mr. Califano aspires to the title of Mr. of federal cost containment efforts as well as future federal growing support for it in - our next column. Design Neglect of Carter's across - the - board " contain- ment " line on the economy and health financing reorganiza- tion. Derzon will report directly to -Robb Burlage and Len Rodberg 16 social programs. Califano. Meanwhile, Dr. Sid- WOMEN Q Freedom's Just Another Word for Having Time to Choose A long simmering - conflict between population control groups and those committed to patients'rights came to a head at the April 28, 1977, New York City Council meeting when the Council - by a surprisingly overwhelming margin- approved citywide sterilization guidelines. The new law, sponsored and shepherded through the legis- lative process by Carter Bur- den, City Council Health Com- mittee chairman, was pattern- ed after female sterilization guidelines adopted 18 months earlier by the municipal hospi- tal system. It extends protec- tion to all patients - male and female - in all types of institu- tions public -, voluntary and proprietary. Provisions include: * A 30 day - wait between the signing of a consent form and the actual surgery, ex- cept in a few carefully de- fined circumstances; a prohibition against so- liciting consent from a woman who is hospitalized for childbirth or abortion; * An information session conducted by a counselor (not the doctor) to include information of the irrever- sibility of sterilization, al- ternative methods of birth control and the corre- sponding risks and bene- fits: e The counseling session to be conducted in the pa- tient's preferred language; * A standardized consent form in the patient's own language (a copy to be kept by the patient); * The right to revoke the consent at any time prior to surgery; * Oral and written assur- ance to the patient that no other rights will be jeopar- dized for refusing to be sterilized; * Possible fines of $ 1000 for violations. " Some people, including oilmen and doctors, tend to feel that anything more than self regulation - is unAmerican. " -Carter Burden ee The professional population- controllers - led by the Asso- ciation for Voluntary Steriliza- tion and abetted by Planned Parenthood - oppose these stringent new safeguards be- cause they fear a reduction in the number of people agreeing to surgery. Planned Parent- hood, as well, has a historic opposition to " government meddling " in fertility control. Throughout the hearings and debate on the bill, opponents constantly raised the specter of such waiting periods being applied to abortions. Alfred F. Moran, executive vice presi- - dent of Planned Parenthood of New York City, commented, " This bill is a profound in- fringement on the constitution- al rights of women and men. Carter Burden is putting the City Council between you and your gynecologist. " The City's own Department of Health, an old line - civil ser- vice agency separated from the municipal hospitals system, also officially denounced the guidelines. Charged with mon- itoring hospital adherence to the Burden guidelines, the Health Department can be ex- pected to be less than vigilant since they argued that the law " interferes with a doctor's flexibility. " Chiefs of Obstetrics and Gy- necology expressed their op- position arguing that the guide- lines interfere with the sacro- sanct doctor patient - relation- ship. Virtually every women's group in New York City, how- ever, backed the bill. For the first and probably the last time, the National Organization of Women (NOW) and Right to Life groups coalesced behind a single piece of legislation. NOW's letter of support was particularly important in con- vincing liberal City Council members to vote counter the advice of Planned Parenthood. On behalf of the New York Chapter, Luba Zimmerman, NOW vice president - , wrote: " We do not agree with the objection that informed people will be unduly limited in their access to sterilization. The 30- day delay operates positively in sterilization. It does not increase the risk as it would in abortion, nor does it take the decision away from the woman, 17 rather it gives her a chance to carefully consider her options after she has been given all the information she needs to make an informed decision. While we are wary of government interference in matters relating to fertility, certainly a distinc- tion must be made between INFORMED CONSENT FOR STERILIZATION laws designed to insure free- dom of choice and laws which restrict choices or limit access. " Mo 111 The legislation was designed. to pre empt - abuse in over 50 private hospitals in the city where women in labor or in the midst of abortion are often ap- proached by zealous housestaff to sign sterilization consent forms. Although such prac- tices are prohibited in munici- pal hospitals and supposedly proscribed by state and federal groups, Nancy Stearns of the regulations protecting Medi- Center for Constitutional Rights caid recipients, they are still interceded on behalf of sup- commonly tolerated. State and porters of the municipal hospi- federal regulations impose on- tal guidelines in that suit. ly a 72 hour - wait and are easily Faced with questions by Starns violated. The Burden protections were and other lawyers, five of the six chiefs stonewalled, causing extended to men considering the judge to dismiss their case vasectomies, although the cir- with prejudice - meaning they cumstances, except for prison cannot sue again. At this time inmates and mental hospital the resolve of the one remain- patients, leave less room for ing plaintiff is in question. abuse. Among the most out- The legal challenge isn't spoken opponents of steriliza- dead, however. Having failed tion guidelines was the chief of to block the HHC guidelines or Ob Gyn - at Bellevue Hospital- the Burden legislation, Planned NYU Medical Center, although Parenthood is now threatening the same institution insists on a to bring court action as soon as 45 day - wait for men requesting the citywide legislation takes vasectomies. effect. Hopefully, this legal The opposition had gotten a strategy will prove as impotent trial - run when they tried to as their legislative one. block the earlier municipal Passage of the Burden legis- hospital guidelines. When they lation is a clear victory for failed, Ob Gyn - chiefs at the those who seek to insure in- municipal hospitals went to formed consent. It not only es- court to stop implementation. tablishes an important prece- Suing the City, State and dent in the struggle for patients ' federal governments, the chiefs rights, but demonstrates that a charged that the guidelines determined popular coalition violated the rights of women can overcome the combined and the rights of doctors. opposition of powerful en- 18 Representing a coalition of trenched interests. CURE OR CULPRIT? Repeated exposures to fluor- oscopic chest X com- - rays - monly used in therapy for pul- monary tuberculosis - is asso- ciated with increased risk of breast cancer in women. A recent study by J.P. Boice of the Harvard School of Public Health, sponsored in part by the US Food and Drug Ad- ministration (FDA), found that women repeatedly exposed to fluoroscopic X rays - of the chest were 80 percent more likely to develop breast cancer than an unexposed control group. Al- though the control population differed from those exposed in several other respects, none of these differences were found to be related to increased breast cancer risk. (The study inde- pendently checked such breast cancer risk factors as age, family history of breast cancer, age at menarche, nulliparity, age at first pregnancy, and history of benign breast dis- ease.) - Barbara Caress YORK NEW M Twinkle, Twinkle, Little Czar... A Is the war over control of New York City's municipal hos- pitals entered May, the main battle seemed clearly a con- frontation between Mayor Abraham Beame represented - by a committee - and Gover- nor Hugh Carey represented - by a czar. And perhaps at no time since the Bolsheviks got it together more than a half cen- tury ago were more hopes pinned on the committee to defeat the czar. The czar is still officially only a proposed position: " Di- rector and Coordinator of Health for New York City. " The proposal to create such a post emerged in late January, brain- child of two key Carey lieuten- ants: Dr. Kevin M. Cahill, " right " hand political advisor to the Governor; and Stephen Berger, executive director of the Emergency Financial Con- trol Board. The Mayor at first report- edly reluctant - reached " con- ceptual agreement " with Carey after assurances that the post would be a joint appointment. (See " Vital Signs, " March / April, 1977 BULLETIN.) Carey subsequently tapped his man Cahill and Beame called on First Deputy Mayor John E. Zuccotti to begin screening candidates for the new job. Whoever the new adminis- trator may be, the job carries six titles the greatest number of hats worn by any NY public official since Robert Moses. And Carey has made clear his intention that the health czar have " full authority " over the entire health care system in the city, especially the power to close hospitals and limit hospi- tal expansion as well as author- ity to cut services. The six titles intended for the czar include the positions of Health Services Administrator, Chairman of the Health and Hospitals Corporation (HHC), Chairman of the Interagency Health Council, Deputy New York State Commissioner of Health for New York City Af- fairs, Deputy Director of New York State Health Planning Council, and Chairman of the New York City Health Systems Agency Executive Committee. Progress in creating the post has been delayed while ways are sought to augment its salary, since City officials are legally limited to salaries not exceeding that of the First Deputy Mayor (51,524 $ a year), considered a paltry sum for I look forward with some anticipation to see him (the " czar ") up against the power of Columbia or Montefiore or Mt. Sinai. " -Dr. John L.S. Holloman, Jr. Outgoing HHC President a such royalty and far lower than the average paid top voluntary hospital administrators. But as rumors continued to fly about the czar's identity, it was the impact of the proposal that seemed to preoccupy most ob- servers. Outgoing HHC President John L.S. (Mike " ") Holloman was among those who saw the new post as chiefly designed to close beds and services in the municipal system. " I think the likelihood the voluntaries will be favored is apparent in the proposal, " Hol- loman noted. " He will have six positions but all of them are really part of the public sys- tem. He will have all the power to cut where cuts have already been made; but I look forward with some anticipation to see him up against the power of Columbia or Montefiore or Mt. Sinai. " City officials have quietly admitted for some time that any regionalization plan will cer- tainly involve shrinkage in the municipals. Although there is less certainty about the volun- tary sector, cuts there seem probable as well. What has changed since January is the City's response: Mayor Beame began to act in late April, in fact, as though he had been elected to replace Holloman. He chose the April 26 HHC board meeting to launch his counterattack on the czar plan. The Committee Newspaper reports prior to the meeting promised a new effort by Beame to control HHC operations. The Mayor's plan transmitted as a resolu- tion introduced at the meeting by Deputy Mayor Lucille Rose, Beame's most recent HHC board appointee - called for creating an eight member - committee to assume the pow- 19 ers of the HHC presidency fol- lowing Holloman's ouster (see " New York, " March / April, 1977, BULLETIN). One clear intent in creating the committee is to place a Mayoral roadblock in the path of the health czar and any attempts to slash municipal services without Beame's ap- proval. Most of the appointees are Beame loyalists. Donald E. Kummerfeld, New York City Budget Director, was named in the resolution as committee chairman. The resolution also proposed two new HHC executive vice presidents: Joseph Lynaugh, executive director of the Health Systems Agency; and Le Roy Carmichael, executive direc- tor at Queens General (muni- cipal) Hospital. The Lynaugh and Carmichael appointments were deferred, however, so the new committee could proceed with " proper screening " of candidates. from an " Agenda for Action " prepared by Lynaugh and Kummerfeld that the city's bat- tle plan could be seen taking shape. Calling for a three month - transitional shake - up in HHC management, the Lynaugh- Kummerfeld plan contains the following notable features: * Intensive public relations emphasizing that a " new day has dawned for the municipals, both in internal management and their role in the whole system; " * Formation of a " negotiat- ing team " to review and evalu- ate the staffing affiliations con- tracts between municipals and the major voluntary hospitals; * Creation of new coopera- tive agreements between the municipals and community physicians - including the " better Medicaid mills, " pre- paid group practice plans such as HIP, and various other phy- sician groups; * Formation by the HHC of Although at first blush the Lynaugh Kummerfeld - plan may seem hopeful (one obser- ver suggested they may have read the March / April, 1976, BULLETIN), champions of ex- panded primary and outpatient care will find nothing to cheer about as the particulars unfold. For one thing, many of the pro- posals represent tired formulas that have simply been dusted off again. There is no reason to believe they will work better than they have over the past seven years. More seriously, however, the Beame administration's con- cept of " ambulatory services " was made clear as recently as last November in a call for " maximizing hospital admis- sions " in order to increase fed- eral and state Medicaid reim- bursements. The goal, in other words, is case finding - , not care. The former sees outpa- tient departments and emer- gency rooms as recruiting offices means - whereby inpa- tient admissions (which gener- ate greater reimbursement re- venues) can be " pumped up " to cover the municipals'sag- ging occupancy rates. What case finding - means for recipients is made clear if one simply notes that it has been the major strategy of the volun- tary hospitals'outpatient and emergency policies for at least a decade. There, the rule of thumb is, " If you can be ad- mitted for it and it's reimburs- able, we treat it; if not, we don't. " For those seeking health Although Carmichael's ap- pointment may prove sticky free standing - prepaid group practices connected with the care particularly the city's working and poor popula- tions the war between the (he is reported under investi- gation by the Queens DA's of fice for alleged improprieties municipals and expansion of existing city - run outpatient centers, having them remain city and state for control of the municipals promises to become ever more a choice between during his tenure at Queens General), Lynaugh's appoint- open during night and week- end hours and insuring Medi- the devil and the deep. -Michael Clark 2 ment seems0 certain. And i t was caid cO overage for theie r users. ) WORK ENVIRON ENVIRON additives. It does not apply, for example, to drugs, a case in which patients may be willing to undergo long term - risks for short - term relief from FM life threatening - conditions - as in some leukemia anti - agents. * It applies only to cancer. The need for special protection from cancers results from their A Little Sweetner for the Delaney Amendment peculiar risks: the long time period, often decades, between exposure and appearance of The present furor over ban- ning saccharin is not likely to have a lasting impact either on this nation's collective sweet clinical symptoms and the progressive advance of the disease even when the expo- sure has long since ceased. tooth or its waistline, given the public's craving for low calorie sweets, industry's present mas- sive research effort and the government's almost desperate desire to approve at least one commercial sugar substitute. Rather, the most likely long- term impact of the controversy will be a national policy pre- cedent: for the first time, the US food industry will be legally allowed to add suspected hu- man cancer agents to commer- cial food products. The Delaney Amendment Present national policy on food additives is embodied in the so called - Delaney Amend- ment to the Food, Drug and Cosmetic Act, passed by Con- gress in 1958. It says, simply: " No additive shall be deemed Animal Tests: The Key Issue The cutting edge of the De- laney Amendment is the im- portance it attaches to animal tests. Once any animal species is shown to develop cancer from ingesting a food additive, no matter what amount, the Delaney Amendment requires that the US Food and Drug Ad- ministration (FDA) rule it un- safe for humans. Remarkably, the Delaney Amendment has been invoked on the basis of animal tests only four times since 1958, for: saffrole (root beer flavoring), oil of calamus (vermouth fla- voring), cyclamates, and now saccharin. Each time the food to be safe if it is found to in- industry and its medical allies duce cancer when ingested by man or animals, or if it is found, after tests which are have argued strenuously to Congress and the public on two scientific issues: animal appropriate for the evaluation of the safety of food additives, to induce cancer in man or animal... 21 " (US Code (C) (3)) The Amendment has a limit- ed range of application: * It applies only to food studies are not directly appli- cable to humans and, even if they were, the amounts of additives fed the animals are unreasonably large. * The attack on animal stud- ies (People " aren't rats "). De- spite industry's attempt to brush aside animal evidence, all known human carcinogens, with the possible exception of arsenic, cause cancer in ani- mals. Also many human car- cinogens were first identified through animal studies; recent examples include the preg- nancy drug DES and polyvinyl chloride (see BULLETIN, No. 71, July August / , 1976). The inability to link all chemicals causing cancer in animals directly to human can- cers stems largely from diffi- culties in linking the various types of human cancer to thousands of possible carcino- gens in a population with a complex pattern of exposures. But the similarity of life pro- cesses in test animals and humans and evidence of links when human carcinogenicity has been established strongly suggest that food additives which cause cancer in animals also cause cancer in humans. (For an excellent review of the scientific basis for the Delaney Amendment, see Dr. Samuel Epstein, " The Political and Economic Basis of Cancer, " Technology Review, Vol. 78, No. 8 (1976) pp. 1-7.; also see Dr. Barry Commoner, Keynote Address, Conference on En- vironmental Cancer, Washing- ton: Mar. 21-22, 1977, soon to be available from The Urban Environment Conference, 1714 Massachusetts Ave., Washing- ton, DC 20036.) * The attack on high animal doses (People " would have to drink 800 diet sodas a day for a lifetime to get that great a dose of saccharin "). Test animals are commonly fed large doses of suspected toxic additives to improve chances of detecting cancer incidence in relatively small animal test populations. of, for example, 50-100 rats. Such procedures are common- 21 ly used in toxicological studies. Industry objections are easily refuted (see, for example, Ep- stein, op cit.). The Saccharin Controversy The history of government concern about saccharin can be traced as far back as 1953, when FDA scientists expressed fears about the artificial sweet- ener. Evidence of its dangers grew until, in 1972, it was removed from FDA's Generally Recognized As Safe (GRAS) list and placed in an " interim " status pending further tests. Finally, a carefully designed series of Canadian experi- ments, funded in part by FDA, nailed the lid on the saccharin coffin. Now FDA is trying to side- step the Delaney strictures by classifying saccharin as a non- prescription drug. But as a drug, saccharin must satisfy the tests of being both " safe " and " effective. " When the same strategy was tried several years ago for cyclamates, the chemical failed both these tests and was eventually banned. Quite possibly a similar fate awaits saccharin. (This sordid tale is told in Chapter 9 of Eating May Be Hazardous to Your Health, by an FDA scien- tist, Dr. Jacqueline Verrett, and Jean Carper. (1974)) Cost Benefit - Analysis The present controversy over saccharin represents a critical moment in the life of the Delaney Amendment. US Rep. James Martin (NC R -) has gath- ered over 150 Congressional co sponsors - for a bill to over- turn the saccharin ban and weaken the Amendment. There is some question, however, whether the bill can pass legislative hurdles in both the House and Senate and be signed by the President. A more sophisticated attack against the Delaney Amend- ment, one more likely to suc- ceed in the long run, was es- poused in a recent New York Times editorial. (March 11, 1977) Why, the editorial ar- gues, make absolute, inflexible rules that substances be ban- ned? Why not weigh benefits against risks, as one does for a drug? This position has the ring of good sense, since in the real world all foods and drugs have their benefits and risks, as all courses of action have their advantages and drawbacks. This argument, reasonable in general, is flawed when applied to food additives. As noted by Barry Commoner in the speech cited above: " What is the benefit of a car- cinogenic dye that makes hot dogs red? If the social purpose of hot dogs is to nourish people, then leaving - aside the argument about what con- tribution the hot dog itself makes to human nutrition - the dye has no value at all. If " market research " shows that people are more likely to buy red dyed - hot dogs in prefer- ence to a competitive brand which is not dyed, then the only social value of the dye is to enable the first company to sell more hot dogs. " To argue, as the New York Times and others have, that the Delaney Amendment should be modified to allow a cost- benefit analysis is really to argue that the cost benefit - presently embodied in the De- laney Amendment is inade- quate. In the case of saccharin this argument would require bal- ancing the convenience of ar- tificial sweeteners to millions of weight watchers and its medi- cal value to diabetics, in some unknown manner, against the cost of an unknown number of human deaths from cancer. Such " analysis " is difficult, if not impossible. In effect it means that we should consider " _ Toc EO allowing some suspect carcino- gens to be used as food addi- tives, rather than ban all sus- pect carcinogens as food addi- tives as at present. The more sensible course of action for saccharin would be to ban it under the Delaney Amendment and allow diabet- ics to purchase it by prescrip- tion, since they clearly repre- sent a special class. -David Kotelchuck 22 Medical Education (Continued from page 14) 6. Adams. S. Trends in Occupational Origins of Physicians. American Sociol. Review 18: 406, 1953. 7. Lyden, F. et al. The Training of Good Physicians: Critical Fac- tors in Career Choices. Harvard University Press, 1968. 8. U.S. Bureau of Census, General Characteristics, 1950 Census of Population, Table 53. 9. Gee, H. et al. The Appraisal of Applicants to Medical School. AAMC, 1957. 10. Altenderfer, M. et al. How Medical Students Finance Their Edu- cation. U.S. DHEW, June 1965. 11. Smith, L. et al. How Medical Students Finance Their Education. . U.S. DHEW, June 1965. 12. Crocker, A. How Medical Students Finance Their Education. U.S. DHEW, January, 1970 13. Ziem, G. Thesis at Harvard School of Public Health: Social and Educational Determinants of the Race, Sex and Social Class Origins of U.S. Physicians. 1977. 14. US Bureau of Census, 1950 Census of Population, Vol. II, part I, p. 236. 15. US Bureau of Census, Detailed Characteristics, 1970 Census of Population, PC -1D (1). 16. Flexner, A. Medical Education in the United States and Canada. Carnegie Foundation for the Advancement of Teaching, New York, 1910. 17. Stevens, R. American Medicine and the Public Interest. Yale Univ. Press, New Haven, 1971. 18. Raup, R. et al. Negro Students in Medical Schools in the United States. J. Med. Educ. 39: 444-50, 1964. 19. Crowley, A. Negro Enrollment in Medical Schools. J. Am. Med. Assn. 210 96-100: , 1969. 20. Dube, W.F. US Medical School Enrollments, 1968-69 through 1972-73, J. Med. Educ. 48 293-7: , 1973. 21. Wingard, J. and Williamson, J. Grades as Predictors of Physi- cian's Career Performance: An Evaluative Literature Review. J. Med. Educ. 48 321-332: , 1973. 22. Johnson, L. History of the Education of Negro Physicians, J. Med. Educ. 42 439-46: , 1967. 23. Dube, W.F. Women Students in US Medical Schools: Past and Future Trends. J. Med. Educ. 48 186-9: , 1973. 24. Ehrenreich, B., and English, D. Witches, Midwives and Nurses: A History of Women Healers. Feminist Press, Old Westbury, N.Y., 1973. 25. Shyrock, R. Medicine in America: Historical Essays. Johns Hopkins Press, Baltimore, 1966. 26. Standards of the Council on Medical Education of the American Medical Assn.: Essentials of an Acceptable Medical College. J. Am. Med. Assn. LXIII, 8 666-87: , Aug. 22, 1914. 27. Kohn, M. Class and Conformity: A Study in Values. Dorsey Press, Homewood, III., 1969. A folio of 32 of Bill Plympton's best drawings from the Health / PAC Bulletin. $ 5.00 each. HEALTH / PAC BULLETIN PRESENTS A COLLECTION OF DRAWINGS BY BILL PLYMPTON Please send me copies of the Plympton Folio Enclosed is $ Mail to: Health / PAC, 17 Murray Street, New York, N.Y, 10007 23 Median Scan the introduction of the concept of tissue by Bichat at the turn of the 19th Century. In the 19th and 20th Cen- The Birth of the Clinic: An Archaeology of Medical Perception by Michel Foucault (NY, Vintage Books, 1975). turies, the speed of technical and scientific development quickens to almost a blinding pace. One sees a revived inter- est in autopsy, the rise of the teaching hospital, the germ theory of disease, and a host of The written history of medi- cal practice has taken many forms, from personal biogra- phies to the history of dis- coveries, medical societies, theoretical discourses, and therapeutics. Michel Foucault, in The Birth of the Clinic, has not written a history of these mechanical and technological discoveries. How are these changes to be viewed? Do they constitute a continuous lineal history, each discovery building upon the preceeding ones? Foucault answers this question in the negative. He recounts a history of discoveries which were for- subjects nor has he tried to find the essential meaning of the various thematic developments in medicine which occurred at the turn of the 19th Century in France. What he has attempted is an analysis of medical experi- ence in France, from 1776 to 1816, which saw a fundamental change in the conception of disease and in the experience of the practitioner. Foucault simultaneously ad- dresses two questions in this book. What constitutes a funda- mental change in medical prac- tice? And how do such changes occur? What Constitutes Change? Changes in medical tech- nology and practice occur at various rates throughout re- corded history. From the Ren- aissance to the 19th Century a great many " discoveries " were made and new conceptualiza- tions of the body introduced, e.g. Harvey's treatise on the circulation of blood in 1628, gotten, new techniques that went unused, and new medical institutions which codified old conceptions of disease. Mor- gagni, for example, was for- gotten for nearly half a century; Bichat made great advances in anatomo - clinical thought even though he rejected the use of the microscope, and the teach- ing hospital was first organized according to a botanical model of disease. Foucault rejects the notion that major historical changes are born of the accumulated weight of scientific innovation or the creativity of genius. He does see, however, that a basic unity may exist among a series of different events and prac- tices (such as the teaching hospital, the germ theory of dis- ease, prognosis, and biology), and that over time these differ- ent events and practices under- go mutations which change the character of their unity. The " Gaze " Leeuwenhoek's discovery of the This unity, the fundamental microscope around the middle order of things, or as it is of the century, the publication referred to in The Birth of the of the works of the great Clinic the " gaze, " is the regu- 24 anatomist Morgagni in 1760, or larity of the world which gives things their relationship to one another. The gaze is neither medical theory nor therapeu- tics, but might be viewed as the structure or medium against which both are related to each other. In Classical thought, a period covering most of the 17th and 18th Centuries, for ex- ample, everything from medi- cal therapies to the institutional setting which produced knowl- edge about disease was bound by a common relation to " Na- tural History. " Nature provided the rules for medical practi- tioners to view the empirical field of diseases. Through ob- servation, the doctor found a continuous, ordered world of living beings, including dis- eases. The doctor's job was to correctly identify the disease afflicting the patient, that is to name it, and to drive it from the body. The promise or limitations of medical discoveries in this per- iod were given by their relation to nature and to those institu- tions and sites of authority which reproduced and en- forced nature as the unifying relation. (1) Since nature was thought to be truly ordered and continuous, tables and _ taxo- nomies of diseases were drawn up to constitute the continuous order in knowledge that was al- ready given in nature. This conception of medical practice is called nosology. In sum, the theories and therapeutics of nosology were invested with a gaze structured around the concept of Natural History. From our standpoint, we can see blind spots in nosological discourse: It could localize disease only with great diffi- culty, because nature was in- dependent of the body. It called for no microscopic investiga- tion to advance knowledge of disease, because the disease was best observed through its manifestations as symptoms. But, our ability to make these observations is based on the wholly different relations a- mong the roles of doctors, pa- tients, hospitals, chemistry, bi- ology, etc., that characterize contemporary medicine. These relations are characterized by the clinical gaze. It is this gaze that forms the structural back- ground for the biological sci- ences and the practice of medi- cine as we know them. The clinical gaze repre- sented a fundamental break with the nosological way of en- countering the world. No long- er does the medical practi- tioner look for a natural order of species of disease. Instead he is caught up in the organismic functioning of life. Morgagni's work in pathological anatomy suddenly has great relevancy; autopsy is related to an investi- gation of the disease process; and the hospital gains a central role in therapy and teaching. All these elements existed si- Foucault rejects the notion that major historical changes are born of the accumulated weight of scientific innovation or the creativity of genius. multaneously and in a devel- oped state prior to the 19th Century, the period when clini- cal medicine was concretized. What is new is that they are re- lated to each other in a different manner. The elements conform to different rules. Foucault chooses as his level of analysis of change one that lies deep beneath the experi- ence of everyday life. This level inquires into basic unities or relationships among different events and practices, and the most fundamental transition Foucault addresses is the vary- ing forms of medical discourse as they are structured by new apprehensions of what is possi- ble and unthinkable. In The Birth of the Clinic, Foucault at- tempts to chart this transition along the path of the medical gaze. Some Problems To say that Foucault's book is difficult is certainly an under- statement. The difficulty is due to more than stylistic problems - although the prosaic style, confusion of tenses, and uncer- tainty of antecedents makes for rough going. The major diffi- culty is that the gaze is a com- plicated concept and, in The Birth of the Clinic, somewhat ambiguous in its usage. At times, it seems to refer to the perception of an _ individual doctor or the formalized knowl- edge of medical science. At still other times, and most often, it refers to the underly- ing regularity, the rules of formation of an apparently dis- persed practice which form a unity as the medical gaze. In two books (2) which follow he leaves no doubt that it is the latter meaning he wishes to give to the gaze. In fact, in The Archaeology of Knowledge, he explicitly criticizes himself for the ambiguity. (3) Unless the reader has an appreciation for the fundamen- tal character of the gaze as the regularity underlying both the- ory and therapeutics, there is a danger of reading Foucault's discussion of medical experi- ence in terms of a history of 25 theories or therapies. Clearly, if this is the reading of the book, then Foucault's argument would seem inadequate and in- complete. There is not much space given to morbidity nor mortality measures, the relative effectiveness of therapies, nor to the biographies of great people. There is, though, an emphasis on describing the limits of therapeutic measures which were consistent with Classical forms of thought and the change in those limits which both threw Classical The clinical gaze represented a fundamental break with the nosological way of encountering the world. thought into disarray and were institutionalized with modern positive medicine. Another reason the book is so difficult to read has to do with the complicated nature of the historical process itself. Fou- cault sees no clearly intentional process which is responsible for the change from Classical thought, represented by study a of diseases of essential orders, to the new positivistic practices of the anatomo - clinical conce- tion of disease. How, then, does Foucault explain the change from one gaze characterized by one set of rules to another? Political Breakdown and Positive Medicine From the Renaissance to the 26 French Revolution, medical ex- perience had been institution- alized in the hierarchical, closed Gothic university and guild system. This institution was dedicated to nosological pursuits: the ordering of natur- al essences of disease into a botanical garden of species. Nosology had within it a con- ception of two loci of disease: in the body and in populations (epidemics). In the management of epi- demics the French State dis- covered a connection between health and social conditions. To the end of generalizing this knowledge, the state created the Societe Royale de Mede- cine in 1776, which immediate- ly entered into conflict with the Gothic university, a conflict the State institution was to win. The founding of the Societe Royale and the fervor sur- rounding the French Revolu- tion presented the physician with a new role - a political one. The doctor's first task was to be political, ".. the. struggle against disease must begin with a war against bad government. Man will be totally and defini- tively cured only if he is first liberated. " (4) In its link to the destinies of states, medicine was no longer " confined to a body of techniques for curing ills and the knowledge that they require; it will embrace a knowledge of healthy man, that is, a study of sick non - man and a definition of the model man. " (5) Medicine, for the first time, acquired a positive role in defining a norm for social interaction. The economic and political ideologies of the French Revo- lution had other effects on medical practice. The general health of the population in- creasingly became one of the economic norms required by an industrializing society; yet concepts of economic assis- tance argued against placing large amounts of capital in hos- pitals. Under nosology, hospi- tals were seen as therapeuti- cally invalid and the natural place to treat disease was believed to be in the family. To the physiocrats it made more sense to pay assistance directly to the sick person in the family, because the whole family would derive benefits from the assis- tance. This also avoided tying up a large amount of capital in hospitals. Within this concep- tion of assistance, the doctor became an administrator to a certain segment of the poor. Doctors in most societies are accorded high status and have the authority to prescribe ther- apies, treat illness, and gener- ally attend to the medical needs of a given community. But this status underwent a qualitative change when the doctor was made responsible for adminis- tering to the public and was given the authority to define for the state what constituted being poor, sick, insane, etc. This gave the doctor an even more positive significance and, as a result, administration was medicalized. All these processes took place within the framework of nosology. Under the nosologi- cal conception of disease, the hospital had no place in treat- ing diseases. The doctor, in the role of administrator of the population's health, however, found it necessary to oversee the functioning of the hospital. Thus seeds of an independent base outside of the academy were being sown prior to com- pletion of the revolution. The political ideology of the French Revolution reviled so- cial privilege and privileged knowledge. The ideal society was one of a... " set of equiva- lent items capable of maintain- ing constant relations with their entirety, a space of free com- fined by individual observa- tional development of the gaze munication in which the rela- tion, the examination of cases, (a complex process involving tionship of the parts to the the everyday practice of dis- political, economic, and ideo- whole was always transposable eases, and a form of teaching logical practices), how its dislo- and reversible. " (6) Because that everyone knew ought real- cation sets into relief old prac- they represented impediments ly to be given in the hospital tices and theories, and how this to the realization of the perfect rather than in the Faculty, and dislocation becomes the basis society, universities were for asking new questions. closed and the guild system was smashed. This left the teaching and practice of medi- " What one did not The Anatomo - Clinical " Gaze " cine in great disarray. In a complex process, medical ex- perience met objections to priv- ilege by creating a " liberated " space or " free field " for the teaching of medicine. This free field was constituted in the hospital at the patient's bedside where first hand - experience know was how to express in words what one knew to be given to the gaze. The Visible was neither Dicible The progress of the anatomo- clinical gaze, like that of the breakdown of nosology, was an exceedingly complicated pro- cess. Foucault presents the attainment of the structure of the new gaze mainly through an analysis of the works of and perception were given as nor Discible. " pathologists and clinicians. His the authority for teaching and analysis of these medical prac- knowing. tices, however, is not simply a The first practitioners to ex- thematic history of theories and perience the validity of their own gaze in this liberated space were, nevertheless, still looking in the whole course of the con- crete world of disease. What one did not know was how to therapies. It is, rather, a history of thematic developments in medicine set against the unify- for diseases as unchanging express in words what one knew ing aspect of the gaze. Thus truths a characteristic quality to be given only to the gaze. Foucault sees in Bichat's works of nosology. The reformers of The Visible was neither Dicible an ambiguous mix of pathologi- the French Revolution thus nor Discible. " (7) cal, nosological, and clinical unified this new experience At this stage in the break- themes; yet with Bichat the around a reorganization of down of nosology, perhaps clinical gaze makes a major ad- already - given elements of knowledge. By holding onto the more than at any other, the character of the gaze comes vance in situating disease in the pathological processes of the ideological conceptions of nosology, the reformers them- through. It can be referred to, but not articulated. It consti- body. Calling into play thematic selves held back the develop- tutes a mutual point of recogni- developments to satisfy the ment of the clinic. Material tion for doctors, but it is not part requirements of the gaze be- forces, such as the breakdown of medical knowledge; i.e., it is comes so confused at times that of the educational and repro- neither a subjective perception Broussais, the clinician who in ductive institutions of the uni- nor a part of formal knowledge. 1816 formalized a medicine of versity and the guilds, pushed Rather it is a practice or a pathological reactions within the gaze beyond the theoretical development of medical prac- tice. Doctors listened to and positivity which will structure new relationships between the- ories and therapeutics. the anatomo - clinical gaze, re- turned to the old practices of bleeding and using leeches. watched their own experience It remained for a philosophi- The point in time which saw the rather than the dictums of the cal tradition, concerned with gaze reach its most advanced academy. Yet, their new ex- perience still sought an old order: language and the linguistic character of the datum, to give a voice to the gaze. Rather than state and break with a medicine of essential diseases, saw the thematic developments in " Throughout this whole trying to summarize the whole medicine return to earlier period, an indispensable struc- of the book - a difficult, if not ture was lacking: a structure impossible, task - it would be forms. A brief description of the development of the structure of that might have given unity to a enough to point out how Fou- the gaze by 1816 will illustrate form of experience already de- cault constructs the noninten- this point. 272 K. BENDIS In 18th Century nosology, diseases had a dual status. They were thought to have an inde- pendent existence in nature, in a natural order of species. At the same time, a disease invad- ing the body could result in the destruction of life and thus be considered counter - nature. Death, however, represented the end of life and was thus un- alterably opposed to life and 28 nature. Death was the deep, dark, invisible divide which marked the end of temporal knowledge. Theories of disease and therapeutics were organ- ized around the experience of the life disease / death / relation according to this structure: life loses visibility in death; disease is both nature and counter- nature. Thus nothing could be learned about disease from the cadaver and the best treatment for a disease was to drive it from the body. The anatomo - clinical gaze, after many permutations, final- ly found its equilibrium by first centering life and disease a- round death and then localiz- ing disease in the physiology of the organism. Disease "... is no longer an event or a nature imported from the outside; it is life undergoing modification in an inflected functioning.... Disease is a deviation within life.... [he T] idea of a disease the anatomo - clinical gaze, was gical anatomists like Bichat, attacking life must be replaced to discover and probe the Corvisart, or Laennec. As the by the denser notion of patho- " visible invisible. " Techniques anatomists pursued the visible logical life. Morbid phenomena and methods were more or less alterations of pathological oc- are to be understood on the useful in that they could extend currences into ever finer detail, basis of the same text of life, and the senses of the observer to they encountered the problems not as a nosological es- read the signs of visible degen- of the cause and the localiza- sence... " (8) Disease was con- erative processes of lesional tion of disease. Because the ceived as the body's tissues occurrences. Possible knowl- primary principle for the path- dying little by little. Disease edge was at once extended to a ological anatomists was visibili- was centered around the con- whole new realm and ultimately ty, unexplainable events were cept of pathology which in turn limited to conceptualizing dis- susceptible to nosological in- found its progress in the life ease as visible, individualized terpretations. This left the door process and its locus in death. pathology. Death, then, became the Under the anatomo - clinical open for the possibility of constructing a nosographical source of disease - that possi- gaze, the search for disease was type of classification before bility in life which " exhausts it, diverts it, and finally makes it disappear. " Death no longer concealed and hid the life process as in nosology, but rather exposed the very truth of life. Foucault's presentation of the history of clinical dissection shows how dissections were carried out for centuries just to carried on in the positive space of individual functioning, be- cause death centered disease in a space that coincided with that of the organism. Foucault comments: " Disease [ ] follows [the or- ganism's] lines and dissects it; [disease] is organized in accor- dance with its general geomet- entering the domain of patholo- gical anatomy. It was left to Broussais, a man who had traversed many dif- ferent medical experiences, to exorcise nosology once and for all from the anatomo - clinical gaze. He did this by making the lesion, the localization of dis- ease, primary. Rather than learn anatomy. It was not until the 1800s that the dissection of bodies as a regular practice ry; [disease] is also inflected towards its singularities. From the moment death was intro- visibility being the mark of a disease, Foucault reports that with Broussais " it is because was linked to finding the patho- duced into a technical and disease, in its nature, is local logical processes which result- ed in death. The utility of this reordering of the life disease / death / rela- tion was linked to the positive power that the " gaze " attained conceptual organon, disease was able to be both spatialized and individualized. Space and that it is, in a secondary way, visible. " (11) By locating altera- tions or pathological processes in the organismic place where they develop, Broussais knocked down " the nosological in its new arrangement. Through the process of degen- eration and the lesion, the tissues and organs of the body exposed the pathology of life to the perceiving eye. Degenera- tion, the exponent of death, lay at the very principle of life and disease. " Perception [could grasp life and disease in a single unity only insofar as it invested death in its own gaze. " (9) Anatomo - clinical medicine Death became the source of disease- that possibility in life which " exhausts it, diverts it and finally makes it disappear. " wall maintained by Bichat be- tween the vital or functional disorder and the organic al- teration.... Disease exists in space before it exists for sight. " (12) Thus, Broussais in- troduced into the anatomo- clinical gaze the physiology of the morbid phenomenon. From pathological physiology follows a conception of organic dys- function and, hence, function- ality. Broussais also broached the demystified death and made what once marked the end of individual, two associated structures deriving necessarily problem of the cause of disease. The localization of the disease investigation (death, or the in- from a death bearing - percep- is the " link point of the irritating visible), the principle of inves- tion. " (10) cause, a point that is deter- tigation (the invisible made The break with nosology was mined by both the irritability of visible). The practice, based on not completed with the patholo- the tissue and the irritating 29 power of the agent. " (13) Dis- eases of essential orders are finally replaced by a concep- tion of pathological reactions. The pathological phenomenon " is caught up in an organic web in which the structures are spa- tial, the determinations causal, the phenomena anatomical and physiological. Disease is now no more than a certain complex movement of tissues in reaction to an irritating cause.... 14 " () Broussais'equilibration of medical experience was ar- gued in the terms of older thematic developments. Fou- cault points out that the con- ception of sympathy, a concept used by Broussais, had already been justly criticized by patho- logical anatomy, and other conceptions and practices like irritation and bleeding were the point of much controversy. It was the integration of these older elements, however, which gave the clinical gaze its structure for years to come. retical projects of man. The clinical gaze is neither a welt- anschauung nor a paradigm. It relates such disparate elements as conceptions of disease, con- ceptions about life and death, ethical choices, therapeutic decisions, institutional regula- tion and teaching models. The destruction of nosology and formulation of the clinical gaze is a process of historical strug- gle involving all these material practices. In France, this pro- The history of the gaze has a path of autonomous development which is not dependent solely on the theoretical projects of man. The Gaze and Class Struggle A criticism can be made of Foucault for not always being clear when he is tracing thema- tic developments and those of the clinical gaze. He can also be criticized for leaving under- developed in the book, the relation to the clinical gaze of the institutional organization of the hospital, the practice of the doctor, and the development of medical technique. The impact of this criticism fades, however, in light of the difficulty of the task, and the fact that the history of the gaze must be analyzed, in part, in terms of theories and therapies. Again, the important point to emphasize is that the history of the gaze has a path of autono- mous development which is not 30 dependent solely on the theo- cess of transformation took the dimensions of class struggle. The defeat of the aristocracy and the rise of the bourgeoisie showed their effects in the breakdown of Gothic universi- ties, the destruction of the guild system, the politicization of the practice of medicine, the medi- calization of administration and the rise of the hospital as a teaching institution, the devel- opment of philosophical tradi- tions which broke with Classi- cal philosophy, and the devel- opment of pathological and anatomical practices. All these instances were involved in the structuring of a clinical prac- tice which had the result of creating the positive individu- al. Foucault talks of the social impact of this new medicine: " Can pain be a spectacle? Not only can it be, but it must be, by virtue of a subtle right that resides in the fact that no one is alone, the poor man less so than others, since he can ob- tain assistance only through the mediation of the rich. Since disease can be cured only if others intervene with their knowledge, their resources, their pity, since a patient can be cured only in society, it is just that the illnesses of some should be transformed into the experience of others; and that pain should be enabled to manifest itself.... And in ac- cordance with a structure of reciprocity, there emerges for the rich man the utility of offering help to the hospitalized poor: by paying for them to be treated, he is by the same token, making possible a great- er knowledge of the illnesses with which he himself may be affected; what is benevolence towards the poor is transformed into knowledge that is appli- cable to rich the.... " These, then, were the terms of the contract by which rich and poor participated in the organization of clinical experi- ence. In a regime of economic freedom, the hospital had found a way of interesting the rich; the clinic constitutes the pro- gressive reversal of the other contractual part; it is the inter- est paid by the poor on the capital that the rich have con- sented to invest in the hospital; an interest that must be under- stood in its heavy surcharge, since it is a compensation that is of the order of objective interest for science and of vital interest for the rich. The hospital be- came viable for private initia- tive from the moment that sick- ness, which had come to seek a cure, was turned into a spec- tacle. Helping ended up by paying, thanks to the virtues of the clinical gaze. " (15) Life Suspended Within Death As critics of positivistic medi- cine, the reformers help to un- ravel the structure of the gaze. This process takes the form of historical condition which re- sulted in the formation of the clinical gaze and have consti- tuted for the last 150 years " the The usefulness of Foucault's " discovering " theories and dark, but firm web of experi- concept of the gaze is of more ence. " than esoteric interest. I would Second, new ideas and criti- like to attempt to outline how cisms seen in terms of this un- Foucault's ideas might apply to raveling process -- locate appa- today's " health crisis. " Foucault says that the struc- The impetus to rently new ideas within the his- torical limits of positivistic med- ture of the anatomo - clinical gaze constitutes the historical and concrete apriori of the change - for a new conception of icine. Rendered in this way, such reforms as are outlined above are seen, not as part of an modern medical gaze. Clearly disease - will have antagonistic movement of ideas methods and therapies have changed radically in the past to move beyond or events, nor as necessarily bursting asunder positivistic 150 years; but many elements of the modern medical struc- ture forged in the second decade of the 19th Century in rooting disease in individual pathology. medicine. Rather, they repre- sent the historical limits of the experience of positive medi- cine. For, in reality, none of the France continued to be recog- reforms mentioned escape the nizable until a few years ago. The centrality of the teaching practice of conceptualizing dis- ease in terms of individual hospital to the identification pathology and physiology, and and treatment of disease, the practices which seem to be none of the contemporary integration of chemistry, biolo- gy, and statistical information into the hospital network, and new, but in fact are a recapitu- lation of theoretical develop- ments present at the birth of the movements necessarily chal- lenge the teaching hospital as the integrator of the health care the authority of the doctor and his main role of diagnosing the patient's disease and prescrib- ing therapies, are examples of such elements that have, until clinic. Today's emphasis on family therapy harks to the liberal ideology of the French Revolution and nosological practices which saw the family system. The impetus for change - for a new conception of disease- will have to move beyond rooting disease in individual recently, gone unchanged. as natural locus for treating dis- In fact, the requirements of ease. The critique of medical pathology. The forces for such a change are on the horizon, the anatomo - clinical gaze con- tinue to organize the main body of positivistic medicine's re- specialization and the modern emphasis on Transcendental Meditation or other relaxation and can be grapsed precisely because the gaze is both un- raveling and shifting: First, the sponse to the numerous crises it currently confronts. The chal- lenge offered by finding a cure for heart disease and cancer is being met, for example, by searching ever more deeply therapies (which rely on whole body conceptions of disease and the importance of commu- nication) were prefigured by a clinical method of the late 18th and early 19th Centuries breakdown in the organization of health care and the attendant economic problem of general- izing high unit cost hospital care to the population has speeded the unraveling pro- into the organism's physiology and the pathological processes associated with disease. In fact, (which relied on the notions of sympathy and linguistic order- ing to indicate the disease); and cess. This breakdown presents critical problems for curative medicine and has already even the reform movements the necessary logic needed for weakened the political and that criticize the curative ap- recognizing the social deter- educational forces responsible proach and stress social deter- minants of disease had been in for reproducing positivistic minants of disease or family place since Broussais. medicine. therapy are bound up with the This process of unraveling Second, the development anatomo - clinical gaze but in the modern medical gaze has over the past century of histori- this case in a very different two implications. cal materialist - thought, which way. First, it brings to light the teaches both in theory and 31 practice the historical relativity of the concept of the bourgeois individual, has already shifted the gaze away from the individ- ual as a central concept. Such a body of knowledge and ex- perience presents an ideologi- cal wedge challenging the very nature of conceptualizing dis- ease as an elemental process of individual pathology and phy- siology. Third, the development of mass struggles against environ- mental pollutants and of work- ers'struggles against occupa- tional diseases increasingly force curative medicine into retreat and into admitting its limitations. Fourth, the doctor's tradi- tional authority is being eclips- ed from two directions. On the one hand, increasing technolo- gy and its resultant information flow are generating hundreds of new subsidiary professions whose responsibility is to pro- cess and interpret information about the patient - a role pre- viously occupied by the doctor. Foucault points out that the doctor can make use of this information and the new tech- niques of analysis, but these in- novations ultimately modify his position as an observing sub- ject in relation to the pa- tient. (16) Also, the doctor's sole control of hospital administra- tion has been largely supplant- ed by the professional hospital administrator. Both develop- ments are important elements in the decomposition of the doctor's medical authority. Finally, a shift within the central structure of the medical gaze itself has already oc- curred. Individual organic dys- function no longer is the only criterion for death. Clinical death no longer a simple function of vital signs - now includes " brain death " as its 32 central notion. This allows for the possibility of declaring a person dead even while the body still shows signs of organic functioning. Death - that great teacher of the anatomo - clinical gaze and central point from which all truth about disease once flowed - has been toppled from its promontory. The ab- sence of the ability to commu- nicate, as indicated by signs of brain activity and response to stimuli, has replaced patholo- gical events as the criteria for conceptualizing death. Death, once thought of and experienced as a disease within life and limited by the positivity of individual pathology, is now given a social referent-- communication - for its deter- mination. For the anatomo- clinical gaze, death was suspended in life; now that gaze is confronted with an " impossible possibility " -life suspended within death. Phrased in a different way, " brain death " can be seen as a solution to one very sticky con- temporary problem. Advanc- ing technology in life sustain- - ing machinery has provided medicine with the capability- albeit enormously costly - of keeping the body functioning. But when the technical ration- ality of the machine began to substitute for the organic func- tionality of the individual, a whole range of social problems came to the fore. Consideration of individual life process began to be transformed into ques- tions of technical possibility and social investment. How many respirators, dialysis ma- chines, etc. can we afford? The definition of brain death as the new criterion for " pulling the plug " and thus among - other effects reducing - the overall economic cost of health care, results in more fundamental problems for the physician. One of the great conflicts in today's medicine stems from the antagonism between the death- bearing perception gaining validity in the positivity of individual pathology and that same perception having to seek validity in the effacement of the individual by machines and social processes. For the anato- mo clinical - gaze, death was suspended in life; now that gaze is confronted with an " impossible " possibility: life suspended within death. Does this not describe the condition for " brain dead " people hooked up to " life sustaining " ma- chines? The characteristic, prag- matic response by clinicians is to deal with this ambiguity by passing the buck to the medical ethicists. By placing the prob- lem of life and death in their hands, the clinician hopes to displace the problem of defin- ing death from the clinical realm into that of the metaphy- sical. In this way, problems posed by the dilemma never need be faced in clinical exper- ience. (Foucault points out, however, that the clinical gaze involves ethical choices as well as therapeutics. Therefore, the dilemma of the clinical gaze cannot be displaced, just em- phasized in a different site.) As this antagonism continues to develop, along with the de- composition of medical author- ity, it threatens to destroy posi- tivistic medicine's anchor in the hospital and in individual path- ology and physiology, and to open up a new, discursive landscape for the conceptuali- zation and treatment of disease. Such a landscape might well have as its terrain the entire complex of social interactions and social relations in which contemporary humanity is en- gaged. -Steven London 1. The extent to which " Natural History " formed the basis for scientific practice in the 17th and 18th Centuries is taken up in Foucault's next book The Order of Things: An Archaeology of the Human Sciences (New York: Vintage, 1973) originally pub- lished in French in 1966. In this book ne outlines how the theory of language, biology, and economy are all tied together by this common bond. 2. Ibid. and The Archaeology of Knowledge: The Discourse on Language, trans. by A.M. Sheridan Smith. New (York: Harper and Row, 1972), originally published in French in 1969. Part of the difficulty in un- derstanding the concept of the gaze is that it represents an early development in Foucault's attempt to explore the bounda- ries of non intentional - historical process- es. The influences of phenomenological conceptions are evidenced, however, when the gaze appears to refer to a preconscious state of mind. In his later works, Foucault clearly separates himself from the phenomenological tradition by using the concept " discursive practices. " 3. Archaeology of Knowledge. p. 54. 4. The Birth of the Clinic: An Archaeology of Medical Perception, trans. by A.M. Sheri- dan Smith. (New York, Vintage Books, 1973), originally published in French in 1963. p. 33. 5. Ibid. p. 34. Ibid. p. 38. 7. Ibid. p. 51. 8. Ibid. p. 153. 9. Ibid. p. 158. 15. 6.1 5. Ibid. pp. 84, 85. 10. 10. Ibid. p. 159. 11. Ibid. p. 187. 12. 12. Ibid. p. 188. 13. Ibid. p. 189. 14. Idem. 16. Archaeology of Knowledge, op. cit. p. 34. ERRATA In Irene Gendzier's review of Social Amnesia in the January / February, 1977 BULLETIN (No. 74) a bad transposition occurred in the layout. On page 27 the last 12 lines of the middle column (beginning with " This " and ending with " loyal- ty ") have been transposed with the first 12 lines of the right column (beginning with " psy- chic " and ending with " revolu- tionary "). We apologize to the author and our readers for this error. SUBSCRIBE TO THE HEALTH / PAC BULLETIN Name Address Student subscription $ 8 Regular subscription $ 10 Institutional subscription $ 20 Enclosed is my check for $ - Mail to: Health / PAC, 17 Murray Street, New York, N.Y. 10007 33 bursed by the government for Vital Signs the taxes if they were paid, an HEW official said. " The immunization effort was CATCH - $ 2.5 BILLION halted after some recipients developed Guillain - Barre Syn- The following Wall Street Journal story although although a little complicated - is reprinted without comment as an appro- priate final word (we hope) on the disastrous US swine flu drome, a rare paralytic dis- ease, and the number of swine- flu cases last winter proved to be drastically less than the feared epidemic numbers. " Besides Richardson - Merrell, program: " Here's another bizarre facet of that flawed gem, the swine flu vaccine program: Uncle Sam gave each vaccine pro- ducer $ 2.5 million to pay claims up to that amount that Uncle Sam might have against the company. " That amounts to handing a neighbor $ 100 to hold in case you sue him for damage his dog does. But for the vaccine makers it could've meant hav- ing to pay federal income tax on the $ 2.5 million. " They didn't think think they should be taxed, as they could only use the government's money to pay the government. And if they hadn't paid it all back by August 31, 1985, in claims, the remainder and any interest had to be returned to the vaccine was made by Merck & Co.; Parke, Davis & Co., unit of Warner Lambert - Inc. and Wyeth Laboratories division of American Home Products Corp. They were to make the vaccine without profit as a government - industry ef- fort. Obtaining insurance against liability claims, how- ever, proved to be a huge hurdle. It was surmounted fi- nally by the government mak- ing itself responsible for any damages that people suffered. " However, the government can seek reimbursement for damages it pays from the vac- cine makers if they were either negligent or failed to carry out the terms of their contract covering their vaccine pro- duction. The companies self- insured themselves for the first the government. " The Internal Revenue Ser- $ 2.5 million with the govern- ment's money; commercial in- vice recently relieved the pharmaceutical concerns of that problem. The IRS ruled that the money wasn't taxable to the companies until they paid out a claim. But then the claim would be deductible as a business expense, so the bot- tom line - effect would be no tax for the companies.'It would be a wash,'a Richardson - Merrell surance covers them for any amounts over that much that they might have to pay Uncle Sam. Premiums for that insur- ance are paid by the govern- ment. " (Reprinted from article by Sanford L. Jacobs, Wall Street Journal, April 28, 1977.) Inc. official explained. " The IRS ruling also relieved. ALAS, POOR DRUG STOCKS the government of further ex- After a long and lucrative pense. By terms of contracts history, drug stocks have fallen with the Health, Education and on hard times, reports the Wall Welfare Department, the vac- Street Journal (April 22, 1977). 34 cine makers would be reim- First quarter earnings have been disappointingly small, with some leading issues trad- remodeling funds, according to one leading hospital under- cupational Safety and Health (NIOSH) before a House sub- ing below the 1974 bear mar- writer. committee. ket lows. " Real growth in the use of ethical drugs has been ab- sent, " according to one securi- ty analyst quoted. " New pre- scriptions have been flat for the last three years, while refill prescriptions have actually de- clined. " The reasons? Bad weather last winter, say the more op- Many hospitals are finding it relatively easy to get the tax- free interest rates traditionally reserved for cities, states and public authorities. Compared with commercial interest rates of 9 to 10 percent, borrowing costs on general obligation bonds range from 3.324 per- cent to 7.75; on revenue bonds the spread is from 4.924 to 7.51 NIOSH officials themselves have been able to identify only about half of the 86,000 trade- name products'ingredients used in workplaces. Of these, only about 20,000 contain in- gredients subject to regulation under the Occupational Health and Safety Administration (OSHA) of the Department of Labor. timistic. Loss of drugs through percent. OSHA has been able to issue Federal Drug Administration Why have hospitals become standards for only 15 such sub- challenges, say others. But the attractive to the banks and stances to date because stan- most fundamental problem, other bond buyers? The lead- dards development is an ex- analysts seem to agree, is the ing reason cited by the Journal tremely lengthy process. One industry's inability to churn out is the reliable revenues pro- federal official noted that this new drugs fast enough. Only vided by Medicare, Medicaid leaves " workers exposed to SmithKline came up with a and private insurers. Also, thousands of toxic substances, drug considered a significant hospitals are generally in a hundreds of which may cause innovation last year Tagamet - , " monopoly position... in their cancer. " Other witnesses be- for the treatment of ulcers. Add to these problems the community, secured in many cases by state approved - ' certi- fore the subcommittee urged that temporary standards limit- fact that 60 to 70 percent of the ficates of need.'" ing such substances be issued present 200 top drugs will lose The bonds do bring risks for quickly, pending final deter- their patent protection by 1980, and the only bull market one investors, the story notes. Chief among them are increasing mination of standards for expo- sure. can foresee is one for corporate government intervention in headache remedies. Alas. hospital operations (as in . BUT WHO WATCHES " caps " on costs, charges, re- THE POLICEMEN? venues or capital expenditures) Meanwhile, one practice of " BIG MAC " FOR HOSPITALS? Hospitals always seeking new means of expansion - have discovered a new fix, peddled by the same folks who brought you the New York City fiscal crisis: the purchasers of tax- exempt bonds, primarily large banks. Hospitals are increasingly turning to tax free - bonds to finance expansion and remod- eling efforts, according to the Wall Street Journal (April 25, 1977). Such financing jumped and threats from " competing health care plans " (e.g., HMOs). POLICING TOXIC SUBSTANCES... Millions of American work- ers are regularly exposed to toxic substances but don't know it because the substances are contained in products sold un- der trade names with unlisted ingredients. According to a study reported in the Wall NIOSH came under attack due to a memo by one of its own officials, according to The New York Times (April 25, 1977). Dr. Kenneth Bridbord, head of the agency's Office of Extra- mural Coordination and Spe- cial Projects, pointed out that names and addresses of 74,000 workers who have a far greater risk of cancer than the general public are kept secret by the agency. In a memo to NIOSH head Finklea, Bridbord pointed out that early warnings to these workers would save numerous 153 percent in the first quarter of this year. And the bonds- virtually nonexistent for hospi- tal financing six years ago- Street Journal (April 28, 1977), the number of exposed workers could be as high as 14 or 15 million, based on testimony by lives, and that NIOSH might face charges of legal liability for failing to notify the workers at risk. already account for more than Dr. John Finklea, director of Finklea's response? Claim- 50 percent of construction and the National Institute for Oc- ing NIOSH lacks necessary 35 funds and authority, he argued fur dioxide to half the current erate the plant for several that the question is beyond his level. months, using the proceeds in agency's responsibility and that " One other solution, breed- part to pay back Allied for the notifying workers without an ing a more resistant strain of ingredients left behind and in effective follow - up system trout, is being tried, and ex- part to swell the coffers of the " might do more harm than periments with different varie- State Treasury. But operations good. " Finklea'- s and NIOSH's- ties are being conducted in some Adirondack lakes. " ceased when it ran out of supplies last winter. The State lackadaisical attitude about workers'health and safety are As for catching and eating the new pollution - resistant fish: then offered to buy and market 200,000 pounds of Mirex from currently being challenged, however, in several separate court suits. In one, 400 asbestos workers are suing HEW, claim- ing they contracted asbestosis because the government failed to give them timely warnings about the lung disease. Bromoseltzer, anyone? FIGHTING FIRE (ANTS) WITH FIRE: STATE CAPITALISM IN MISSISSIPPI " " We are back in business, says Jim Buck Ross, Commis- sioner of Agriculture for the State of Mississippi. With that Hooker Chemical and Plastic Corporation in Buffalo, which had previously manufactured the chemical. The deal fell through when Hooker insisted that the State take out an insurance policy to protect the company against future Mirex related - lawsuits. MAKING THE WORLD SAFE FOR POLLUTION: A PARABLE FOR OUR TIMES Scientists at Cornell Univer- sity have recently uncovered announcement the State of Mississippi resumed its sale of Mirex, a deadly pesticide used to control fireants in Southern states. Potential buyers should Mississippi was apparently glad to oblige, but it couldn't find an insurance company willing to underwrite the policy. Now the State has found the serious side effects of industrial pollution from the Great Lakes region in the high mountain lakes of upstate New York. Deadly rain and snow, bringing hurry, though, since the sale lasts only until December 31, 1977, after which aerial spray- ing of the insecticide is banned under an edict from the US En- necessary supplies from a New York State subsidiary of Engel- hard Minerals and, as the Commissioner says, they're " back in business. " Who with them corrosive industrial pollutants, have wiped out fish vironmental Protection Agency. knows, maybe the State can Mirex is one of the most per- find farmers who will hire life in 90 percent of the lakes studied, whereas in the 1930s. they were teeming with fish and sistent insecticides found in the environment - it is not water- soluble and remains intact for workers to handspread the in- secticide. This way they could circumvent the EPA ban on only 4 percent of the lakes were barren. What to do about the prob- years. However, under certain climatological conditions it breaks down into kepone, a aerial spraying and go on pro- ducing Mirex happily ever after. lem? According to an article in The New York Times (March deadly compound that recently triggered serious neurological ANNOUNCEMENTS 28, 1977), " A short - term remedy for and reproductive disorders a- mong workers at an Allied Penguin Books has just published Barbara Garson's acidity would be to place lime- stone in the affected lakes, but Dr. Schofield and other re- searchers said it would be economically impractical to treat hundreds of lakes in that Chemical subsidiary in Hope- well, Virginia. The plant in Mississippi is presently the only one in the US producing Mirex. Previous- ly operated by Allied Chemical All the Livelong Day in paper- back (1.95 $). The book, sub- titled " The Meaning and Demeaning of Routine Work, " examines the lives and thoughts of workers in a manner. (who else?), Allied palmed it variety of industries - from " Another suggested solution off on the State of Mississippi workers in a medical lab and is the elimination of sulfur from fuels and stack emissions, something that is being done on a small scale. However, Dr. Likens estimated that it would for the grand total of $ 1 in the spring of 1976, while the kepone disaster was blowing up in Virginia. Allied claimed at the time that the operation an insurance company to workers in a tuna - fish factory and an auto assembly plant- and the stratagems they use " to restore meaning to jobs cost about $ 4 billion to reduce was unprofitable. drained of meaning in the 36 United States emissions of sul- Mississippi continued to op- name of profit. "