Document VjBDwq1pyxOk9XE9oV0e8JJE4

1 HEALTH PAC Health Policy BULLETIN Advisory Center Volume 11, Number 3 January February -, 1980 HPCBAR 1-40 ISSN 0017-9051 1 Bakke - ing Up the Wrong Tree: NEW MYTHS FOR OLD RACISM AND SEXISM: The second in a two part study of medical school admissions in the post Bakke - era. 3 Vital Signs 17 Columns URBAN: Health and Hospitals in Critical Condition WORK ENVIRON / : Merchants of Death and the Global Dumpground WOMEN: Not Teaching Old Dogs New Tricks THE FIFTH COLUMN: Human Rights for FNGs 29 Media Review The Cultural Crisis of Modern Medicine by John Ehrenreich 35 Peer Review Bakke - ing Up the Wrong Tree NEW MYTHS (This is the second article in a series on affirma- RACISM FOR AND OLD tive action in U.S. health professional schools. In SEXISM the first the author examined the failure of medical and other health professional schools to reach their stated goals for minority enrollment and the financial barriers that contribute to this.) The cumulative effects of inflation, changes in federal financial support and the institutionalized racism have hurt affirmative action programs in health professional schools and reduced the per- centage of minority students entering these schools to that of ten years ago. In their wake, rationalizations have developed to make this fail- ure palatable to majority and, to some extent, to minority groups. Besides the attributions laid to the " chilling " impact of the Bakke and DeFunis legal decisions, which locate the responsibility for their failure be- yond the control of the academic health establish- ment, there are numerous myths, usually based on some modicum of fact or unexplained stereo- 1 types, that quite simply blame the victims of dis- crimination for their plight and hold them entirely responsible for changing their situation. These myths serve an ideological function, narrowing the terms of the debate and the field of alterna- tives. These myths are insidious, so that they have been adopted at times even by proponents of af- firmative action, such as the Student National Medical Association, the editorial writers of the New England Journal of Medicine, and the guard- ian of liberal academic interests, the American Association of Medical Colleges (AAMC). The danger of such ideology is that it legitimizes the dominant interests which are served by a sys- tem which dismisses affirmative action as only serving the interests of those individuals who directly benefit from it. The success of the ideology and the system it supports - is to make the possibility of alternatives unthinkable, curious heresies, or irrelevant eccentricities (1). It results, too, in a patchwork of narrow solutions, aimed at mythical problems, that quite predictably fail to accomplish their goals, yet relieve the participat- ing institutions of their public obligations, atone for liberal guilt, and leave untouched and un- questioned the structural inequities which have created and perpetuated racial and sexual dis- crimination in the health professions since Flexner. " Blacks and other minorities have lower aspirations and less motivation. " The old racist stereotype of the lazy, shiftless Black has been reincarnated, in psychological jar- gon, as rationalization for the limited progress made in the drive for minority parity. In an article published in the prestigious New England Journal of Medicine, nominal advocates of affirmative action cited the low degree expectations of Blacks as a hurdle to parity in medical schools (2). This is supported by the observation that the combined percentage of Black students aspiring to become physicians, osteopaths, dentists and veterinarians is less than for whites. Yet in every year examined, the study referred to found a greater percentage of Black freshmen aspiring to the M.D. or D.D.S. degrees than white freshmen (3). In fact, Blacks have higher degree aspirations than non Blacks - in all other advanced degrees identified - Masters, Ph.D., Ed.D., Ll.D., and J.D. (4). These higher aspirations persist well beyond the freshman year of college. For medical students surveyed in 1974-75 the mean number of years of residency anticipated was directly proportional to the student's socio- 2 economic background - the greater the family in- come, the greater the number of years of residen- cy anticipated except for Black medical students who planned upon more years of training than any other racial or ethnic group (5). On self- ratings of students aspiring to health careers of all types, Blacks and Native Americans ranked highest in their drive to achieve, greater than whites, Asian and Hispanic Americans - (6). In the same study Black and Hispanic students evinced greater concern with achievement in their chosen fields than non minorities - . These high expecta- tions were also matched by realistic asssessments of the relative financial and academic disadvan- tage of minority students (6). When the best Black high school graduates cited financial concerns and fears of racism and sexism as reasons for not pursuing professional educations, the AAMC Education News blindly observed, " Considering that these were the best students, this again illustrates the very limited edu- cational aspirations of the rural Black high school senior " (7). Lower aspirations and motivation are an old fiction, revived for a new racism. " Blacks have greater academic attrition from colleges and from careers in the health fields. " In the article mentioned above, a deeply in- grained belief was passed as fact: the authors claimed that Blacks drop out of college and from health career majors at a greater rate than non- Blacks (2). If junior college students are excluded, this is simply not true. The author of the source cited to support their argument, in fact, found that when considering only four year colleges and uni- versities, " Black students at such institutions were, in actuality, somewhat less likely to drop out than were non Blacks - whose abilities and past achieve- ment were comparable " (8). The form and amount of financial support plays an important role in all students'success in completing college (9; see also initial article in this series). In fact, Black freshmen choosing health fields (not just pre medical - ) were more likely to remain in these fields but less likely to be recruited to them from another field after graduation than non- Blacks (10). A greater percentage of Blacks and Native Americans received baccalaureate degrees in the health professions than non minor- - ities (11). Were the health sector not such a caste system, if it allowed some vertical mobility between levels without expensive and full time - re- training and with credit for experience, considera- bly more minority men and women might rise to the top the hard way. Contined on Page 7 A DIRECT HIT ON THE BOTTOM LINE Corporations are intensifying their attack on rising health care costs, applying an unconvention- al amount of power in pursuit of conventional goals. Businesses are encouraging utilization re- view, hospital bed reduction, out- patient and surgi center - treatment, second and even third opinions on surgery, preadmission _ testing, preauthorized hospitalization, and in some cases that old faithful of cost cutting strategies, cost shar- - ing by employees. While such initiatives are not new, the current series of attacks are more militant than previous efforts because zooming medical care costs have hit corporations in their most sensitive spot - the bottom lines. In 1978, companies paid for about $ 40 billion of the nation's $ 180 billion health care expenses. And medical benefits now account for as much as 10 percent of total compensation paid by some firms. Observers are predicting that the corporate initiatives will pro- duce significant changes in the medical care system, bringing it even further into the fold of capi- talist institutions. The high costs give corporations one of the two basic ingredients of institutional change in America incentive - . And they already have the other ingredient - power. This new cor- porate thrust " lets the medical- care industry know that people in Vital Signs real power centers are searching for ways to make the system more efficient, " says Terence E. Car- roll, executive director of the Comprehensive Health Planning Council of Southeastern Michigan. Corporations have been work- ing with insurance carriers to try to cut their medical care expenses for several years, but they are now trying to increase their clout by joining together in regional groups. (So much for cut- throat competition, at least where a common enemy to profits is found.) Inspired by a U.S. Cham- ber of Commerce campaign and participation by some executives in the Washington Business Group on Health, an offshoot of the powerful Business Round- table, corporations have formed more than a dozen regional groups in the last year or two, like the Fairfield Westchester / Business Group on Health in the suburbs north of New York City and the Employers Health Cost Commit- tee of San Diego. Some corporations are forcing workers to pay more of their own health care costs through what is misleadingly known as cost'sharing ' It is too early to determine how far such efforts might go in challenging the sources of vested power in the medical establish- ment. The San Diego group has met with the county medical so- ciety to work out mutually accep- table cost cutting measures. But Kennecott Copper Corp. had to step on some medical toes to insti- tute an aggressive hospital utiliza- tion plan that cut their hospital bill by 12 percent on one year. And their Blue Cross - Blue Shield bill, which had risen from $ 5.7 million in 1975 to $ 7.5 million in 1977, leveled off at $ 7.6 million in 1978 and is expected to decline slightly in 1979. Buoyed by this success, Kennecott may be prepared to take an even tougher stand against physician power. As Rob- ert N. Pratt, general manager of Kennecott Copper Corp.'s Utah Commper Division in Salt Lake City put it in a letter to the Utah medical society, " We attribute our improved cost performance to the abandonment of the passive role of financier to the aggressive role of the cooperative adversary, even to the point of being an antagonist. " Some corporations, especially those whose work force is not or- ganized, are forcing workers to pay more of their own health care costs through what is generously and misleadingly known as cost " sharing. " The employees of Metropolitan Life Insurance Co. were recently shoved a step backwards and began contribut- ing to their own benefit plan, for the first time in years. Unions tend to fight such big business strategies tenaciously. In fact, cost sharing - was the issue that stalled the 1976 auto labor negotiations. But the United Auto Workers, for one, realize that money needlessly going to fi- nance an inefficient medical system could be going to their members as higher wages. The UAW has joined with the Big Three auto makers to fight exces- sive health care costs. The coali- tion recently got legislation through the Michigan law makers that will phase out 10 percent of Michigan's hospital beds over 5 3 years, saving 4 percent of the state's $ 3 billion annual hospital bill. The unanswered question about this battle between corpor- ate capital and the medical estab- lishment (including medical capi- tal) is how the contradiction will work itself out. Most observers are speculating that business will push hard, but not far. If it threat- ened to push the medical care system too far toward increased health advocacy - to the point where medicine becomes truly preventive and begins to struggle with the sources of ill health - cor- porations would no doubt pull back, since many of the sources of illness are found in the normal business activities of these same corporations. The challenge for progressive health activists would seem to be how to use the contra- dictions arising from the newly- used clout of business to begin a process of reform. -George Lowrey Source: Business Week, August 6. 1979. Health / PAC Bulletin Tony Bale Pamela Brier Robb Burlage Michael E. Clark Board of Editors Hal Strelnick Glenn Jenkins David Kotelchuck Ronda Kotelchuck David Rosner Managing Editor: Marilynn Norinsky Health Policy Advisory Center Staff: Loretta Wavra MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR should be addressed to Health / PAC, 17 Murray Street, New York, N.Y. 10007. Subscription rates are $ 14 for individuals, $ 11.20 for stu- dents and $ 28 for institutions. Subscription orders should. be addressed to the Publisher: Human Sciences Press, 72 Fifth Avenue, New York, N.Y. 10011. Health / PAC Bulletin is published bimonthly by Human Sciences Press. Second - class postage paid at New York, N.Y. and at additional mailing offices. 1979 Human Sciences Press Illustrations by David Celsi (pp pp. 1, 11, 32), Bill Plympton. (p. 24), and Deborah Kelley (p. 37). EMPIRES MARCHING ON " Consolidation " is the word these days to deal with " overbed- ding " and fiscal survival. On the Upper West Side, Roosevelt and St. Luke's Hospitals recently an- nounced plans to join forces, prompted by state planners and the New York City HSA. Fast on the heels of the Roose- velt - St. Luke's announcement, plans were announced to consoli- date New York Infirmary and Beekman Downtown Hospital in the Wall Street area. The planned consolidation includes closing the New York Infirmary facility (which is next to Beth Israel) and 4 expanding at Beekman Downtown. Because of a larger capacity and expanded services, the con- solidated facility will receive a Medicaid reimbursement rate in- crease of from $ 27 to $ 63 a day. The HSA praised the plan as in- creasing accessibility and elimi- nating duplication of services in the area. Passing mention was made that New York University Medical Center would get the teaching af- filiation over the expanded facil- ity. Since the fiscal crunch and aggressive state action has put the squeeze on smaller hospitals, the medical empires have been the only winners. Their turf has been expanding as they fill the vacuums left by closing hospitals, and are taking survivors under their protection. Three years ago, cash rich NYU bought outright the small Midtown Hospital for the sole purpose of closing it. In a quid pro quo with state planners ob- sessed with overbedding, NYU then received permission to build its Cooperative Care Center next to University Hospital. (The Co- operative Care Center is a new concept in patient care. Services and staff are kept at previously unheard of low levels, and sup- posedly not sick - so - patients and their families take primary re- sponsibility for patient care. The idea is supposed to save money, and no doubt does for NYU, but the rate is virtually the same as that charged for the high tech- nology University Hospital.) All this concentration is going on while, or perhaps because, community and hospital based services are being cut back on the Lower East Side. The move is to " bigger and better ", and away from community based health and preventive services. -Glenn Jenkins Source: " Hospitals Merge in Plan to Serve Downtown Area ", New York Times, p. Bl, Nov. 20, 1979). DEATH IN A VERY LARGE PLACE Anyone walking into a large hospital these days, whether for emergency or routine care, can relate stories of the interminable waiting s he / is subjected to. Usually the long wait is only a matter of inconvenience; but sometimes it can have tragic re- sults. House staff at New York's Metro- politan Hospital recently exposed the death of a patient awaiting treatment for severe kidney disease. House staff spokespersons hung the blame on huge staff shortages which have developed since Mayor Koch announced plans to close Metropolitan. Stories of deaths in City hospi- tals directly attributable to staff- ing shortages are nothing new. Similar episodes have come to light in the last few years at Belle- vue, Lincoln, and Queens Gener- al all - City hospitals serving low income communities. The City has always managed to whitewash the affairs by a com- bination of stonewalling, and cit- ing administrative foulups or prob- lems attendant to changeovers of physical facilities. Ultimately they could also point to the particular hospital workers involved who failed in their " professional duty " Memoriam Almost twenty years ago, February 1, 1960, to be exact, four students from North Carolina Agricultural and Technical College sat down for lunch at the counter in Woolworth's in Greensboro, North Carolina. Five days later they and the others who had joined them had still not been served because - they were Black. On the sixth day Woolworth's announced that they were closing temporarily. This dramatic step taken by the nascent civil rights movement created the " sit - in " and spawned a generation of mili- tant Black and white students and activists. On November 3, 1979, Greensboro again became the setting for another chapter in the long, unending struggle for civil rights. Five demonstrators protesting the resurgence of the Ku Klux Klan were killed and 10 others were wounded when members of the Klan opened fire on the demonstrators from a yellow van armed with a small arsenal of weapons. Five Klan anti - demon- strators were killed Cesar - Cauce, Michael Nathan, Bill Samp- son, James Waller and Sandra Smith. A sixth demonstrator, Paul Bermanzohn, suffered head wounds and is now paralyzed on his left side. The cold bloodedness - of these murders shocked even those hardened by the Klan's history of racist outrages against innocent people and human decency. The loss was even more painful and personal for those of us at Health / PAC when we learned the identities of those who were murdered. James Waller was a mem- ber of the Lincoln Hospital Collective in the early 1970s. Paul Bermanzohn had been a contributor to the Bulletin in 1974 when he co authored - a story on the Duke University medical empire. We mourn their deaths and grieve with their families, friends, and all those who share the principles for which they stood and died, so much an anathema to the Klan that they became targets for assassination. An appropriate elegy for the Greensboro deaths, especially for the pediatrician who served in that radical experiment in community - worker control of a hospital in the South Bronx, was posed in a question by another member and an organizer of the Collective. Fitzhugh Mullan asked in his autobiography, White Coat, Clenched Fist, " Did we remain faithful to the radical pre- cepts that brought us to Lincoln after we left or did we burn out, drop out, or slip back into the mainstream...? " The answer for James Waller is quite simply, yes, he remained faithful to radical precepts. To the legion of nameless victims of the Klan's violence, a symptomatic outgrowth of the racist and reactionary economic system in which we live, we must add five more who have fallen in our streets in the name of justice. We wish to take this moment of sadness to extend our sympathies and condolences to their families and friends and to re dedicate - ourselves in their names to the causes of racial and economic justice and human rights at home for all. A defense fund has been established to defend those demon- strators arrested after the attack. Send contributions to: Greens- boro Justice Fund, 39 Bowery, Box 404, New York, N.Y. 10002. 5 to be in five places at once. Critics of this blame shifting - could themselves point to the di- rect relationship between the cut- backs and deaths. The incident at Metropolitan adds a slightly new twist to the cutbacks analysis, however the effects of the threat of cutbacks. Metropolitan has been sus- pended in limbo ever since the Mayor's announcement of his in- tention to close the hospital. Staff morale has plummetted; workers are opting to leave rather than be laid - off. Prospective workers are reluctant to come to Metropolitan for fear of losing their jobs in the near future. Assurances by some City and HHC officials to the effect that Metropolitan will not be closed, or at least that the decision is negotiable, have merely added to the confusion. The net effect is that jobs go begging. The Medical staff is down to nearly half strength, for instance. What the budget cutters have been unable to do directly be- cause of community and health worker protest, they are accom- plishing indirectly. By merely casting doubt on the future of an institution the budget cutters can obtain tremendous cost benefits. As health workers stagger under an increasing workload and somehow manage to " cope, " temporary vacancies have a way of being converted into a per- manent arrangement. Every staff position that remains unfilled means money saved, a more im- possible workload, | further deterioration of services - and un- necessary deaths. -Glenn Jenkins Nassif, Janet Zhun HANDBOOK OF HEALTH CAREERS A Guide to Employment Opportunities Foreword by John H. Walker III, Director of the National Health Careers Education and Information Project As the country's second largest industry, the health field employs over five million people in more than 200 different occupa- tions. Career opportunities are dramati- cally expanding, and most positions require only two to four years of training. In simple straightforward language, the Handbook explores major areas of employ- ment, educational preparation, work responsibilities, financial aid programs, and practical advice on the job market for each health career. The author provides an extensive bibliography and a roster of over 100 health organizations that supply career information, financial aid or employment assistance. A chart outlining the U.S. Department of Labor's occupational out- 6 look for the health field through 1985 is particularly useful. Although the demand for qualified health care professionals is increasing, few persons are aware of the numerous career opportunities outside of traditional health. occupations, such as the physician or nurse. CONTENTS Overview Introducing the Health Field * Exploring the Health Field * Preparing for Your Future Financing Your Education * The Job Market Health Careers Chiropractic @ Clinical Laboratory Ser- vices Dentistry Dietetics and Nutrition. * Education Health Information and Communication Health Services Ad- ministration Medicine Mental, Physi- cal, and Social Specialties Nursing * Pharmacy Podiatry Science and Engin- eering * Technical Instrumentation 1980 June / 0-87705-489-4 0-87705-413-4 Cloth $ 22.95 Paper $ 9.95 Bakke - ing Up Continued from Page 2 In addition, between 1966 and 1974, interest in health careers among minorities increased 106 percent, almost twice the increase among white students. One - and - a - half times more Native Americans and twice as many Blacks and Asian- Americans showed interest in health careers during this time, so that the latter two groups were actually over represented - among health career aspirants (6). Most striking of all were the in- creases in minority students aspiring to nursing and medicine (200 percent and 136 percent, res- pectively) compared to whites (110 and 14 per- cent, respectively). Thus the growth in interest among minority students in medicine was almost ten times that of whites, in nursing almost twice that of whites! To prepare for these careers, among Blacks there was a 110 percent in premedical majors between 1966 and 1972, a 233 percent increase in therapy majors, a 218 percent increase in bio physics - , and a 168 percent increase in biol- ogy majors. The problem does not seem to be related to attrition or lack of sustained interest in health careers. " Recruitment of minorities to medicine and the health professions should begin in high school and earlier. " The early decision by Black medical graduates to study medicine (12) and the relatively small percentage of Black and minority high school graduates who go on to college, compared to whites, has been used to divert attention on minority recruitment as far away from academic health institutions as possible (3). This recommen- dation was first made in the 1940's (13)! A New England Journal of Medicine editorial moved. even further away, to Projects Head Start and Follow Through! An effort to recruit and follow students from high school, conducted by the AMA itself, dis- proves this as a primary approach to affirmative action. The AMA's Project Talent surveyed 11,507 high school graduates and then followed their progress toward medical school. Those who chose medicine as a career in high school and were ultimately enrolled in medical school repre- sented the highest socioeconomic group; the next highest socioeconomic group were those who chose medicine but failed admission. The middle group chose other fields in high school but were ultimately enrolled in medical school: The lowest socioeconomic group was those choosing medicine but never applying (14). This was confirmed again in 1974 when the best and the brightest Black high school graduates in rural Virgina were found not to seek professional educations because of financial, racial, and sexual barriers (7). In view of this pattern, generating more high school interest among the disadvantaged without lower- ing socioeconomic barriers would appear only to generate more failure and frustration. Later recruitment, therefore, appears more fruitful, given the relative lack of recruitment during college to the health professions among minor- ities. This may be particularly true of the less highly visible health professions osteopathic - The U.S. Congress tries to weaken affirmative action with various amendments and anti bussing - riders medicine, optometry, dentistry, podiatry, and pharmacy. The vast majority of Black college graduates pursuing advanced degrees still choose education, five times the number choosing health professions. Once the only available field for Blacks, education offers the same mixture of cultural opportunity and coercion that nursing or pediatrics has offered to women. The comparable opportunities for service and security in the health professions might attract many capable candi- dates. Interestingly, primary care physicians are among the latest to choose medicine (15). " The pool of college undergraduates and minority applicants is not large enough to achieve representative minority enroll- ment in the health professions. " The growth of the percentage of Blacks and minorities among college students has continued through this decade. A greater proportion of Blacks between 16 and 34 years now enter college than whites (11); a greater percentage of college - aged Blacks from the $ 5,000 to $ 15,000 income bracket entered as freshmen in 1977 than whites (16). Blacks represented 5.2 percent of university, 11 percent of four year - college, and 13.1 percent of junior college students; Hispanic students made up 2.7, 3.9, and 7.1 percent of these enrollments, respectively (11). Three times the number of 7 Blacks and twice the number of Hispanics attend- ing universities are enrolled in four year - colleges. Many of these colleges are the traditionally Black colleges, which still award almost half of all Black baccalaureate degrees (11). About 80 percent of all Black physicians and virtually all Black dentists are graduates of these institutions. Black college graduates have earned almost 75 percent of all the Black Ph.D.'s in the natural sciences, almost all acquired at white universities; even in the progres- sive 1960's a higher percentage of Black Ph.D.'s came from these institutions than during the previous decades (17). With this impressive record in the face of open and sanctioned dis- crimination, the potential of Black colleges when these barriers are supposedly lowered would seem to be unlimited. However, predominantly white medical schools have accepted a decreas- ing percentage of their applicants from the Black Colleges since 1970 (18). The professional schools presume that Black students from predominantly white institutions are better prepared for and adjusted to the white medical school environment (read: have learned their place) (18). Howard and Meharry do not partici- pate in this institutional racism and enroll a higher percentage of their applicants from the Black colleges (18). With this degree of institutional racism evident, discounting a huge pool of poten- tial candidates, it is not surprising that almost 18 percent of all Black applicants only apply to Howard and / or Meharry (18). A summary of the fate of the Black applicant pool from 1970 to 1977 shows the expanding Table 1 Potential Black Applicant Pool vs. Actual Application and Acceptance to Medical Schools, 1970-71 to 1977-78 Year 1970-71 1971-72 1972-73 1973-74 1974-75 1975-76 1976-77 1977-78 College Freshmen Total Physician Aspirants Percent 58,156 2,983 5.1 58,475 2,626 4.5 85,430 3,374 4.0 98,270 3,567 3.6 98,657 4,114 4.2 97,684 4,591 4.7 135,504 7,968 5.9 128,619 8,103 6.3 * actual new first year students Applicants Percent Number of Aspirants 1,250 41.9 1,552 59.1 2,382 70.6 2,227 62.4 2,423 58.9 2,288 49.8 2,523 31.7 2,482 30.6 Acceptances Percent Number of Applicants 642 51.4 810 52.2 857 36.0 977 44.9 1,000 42.2 931 40.7 966 38.3 959 * 38.6 Sources: Dube, W.F., Johnson, D.G., " Study of U.S. Medical School Applicants, 1974-1975, " J Med Educ 51: 877- 896, 1976. Gordon, T.L., Johnson, D.G., " Study of U.S. Medical School Applicants, 1975-76, " J Med Educ 52: 707- 730, 1977. Gordon, T.L., " Datagram: Applicants for 1976-77 First Year - Medical School Class, " J Med Educ 52: 780-782, 1977. Johnson, D.G., Smith, V.C., and Tarnoff, S.L., " Recruitment and Progress of Minority Medical School Entrants, 1970-1972, " J Med Educ 50: 713-755, 1975. Schildhaus, Sam, An Exploratory Evaluation.. of U.S. Medical Schools'Efforts to Achieve Equal Repre- 8 sentation of Minority Students, Washington, D.C.: DHEW Publication No. (HRA) 78-735, December 1977. pool of physician aspirants and increasing interest in medicine among Black college students, presented in Figure 1. The aspirant pool has more than doubled from 1969 to 1973 (the potential applicants for 1973 to 1977). Meanwhile, the portion of aspirants who actually do apply and the percentage who actually are accepted have declined, the fall in the applications realized beginning just one year after the dramatic drop in the acceptance rate in 1972-73. The percent of women and minorities accepted directly affects the number who apply; at one school where 22 percent of those admitted were women from a pool of 12 percent, the following year had a 98 percent increase in female and 15 percent increase in male applicants (19). The number of Black applicants has stayed about the same since 1972-73, the year when the accep- tance rate was lowest (Figure 1). While some see this as the consequence of the backlog of older applicants being dried up, by 1974 the median age of Black and white students accepted to medical schools was almost identical (23.6 and 23.3 years, respectively) (7). Most of the loss of applicants realized has occurred since then. The barriers to medicine are again returning. Increas- ing numbers of potential applicants are being discouraged and lost during their college years, so that the gains minorities have made in the undergraduate schools are being limited by the professional schools. The causes here are political and economic, not the depletion of a mythological " backlog of qualified candidates. " " To admit more minority students, health professional schools will have to lower their admission standards. " The heart of the controversy in the Bakke case was the separate processes employed at Davis UC - for regular and disadvantaged applicants. An AAMC study demonstrated that racial status had greater impact than economic status upon the traditional selection factors of grade - point averages (GPA) and medical college admissions tests (MCAT). The generally lower GPAs and MCAT scores for minority students and their high repeti- tion rates of academic courses are cited as evidence that " unqualified " applicants are being admitted. This argument neglects the long controversy. surrounding the MCATS ability to predict any outcome of medical training except performance during the first year. Personality traits, particularly in combination with " academic " variables, have proven to be the most powerful predictors of not only medical school grades, but also scores on the National Board of Medical Examiners tests (21) and overall medical school performance (22). Most recently, moral reasoning has been shown a predictor of clinical performance (23). Much evidence has accumulated which shows that stan- dardized test scores cannot be employed ac- curately to predict performances between Blacks and whites or applied in the same manner among groups of Black or white students (24). Work at the Cultural Study Center at the University of Mary- land has shown that the constellation of positive self concept - , realistic self appraisal - , long range goals, leadership experience, community service, and preparation for racism to be a measurable and useful predictor of success for minority students (24). The GPAs and MCATS of minority students are currently at the same level as that of all admitted students in the early 1960's and their retention and progress in medical school is com- parable to all students during those years (26). Minority students, frequently starting behind other students, have shown that they can and do catch up by the end of the medical education process (7). Many of these non academic - traits and those found to correlate best with superior performance in medical school are those which minority students aspiring to health careers identify more than majority students in self descriptions - (6, 75). Several studies have also found that lower class students have had to have higher grades to gain entrance to medical school (27, 28). Acceptance rates to medical schools increase directly with family income, even though some of the middle income groups have the highest GPA's and MCAT's (29). The median family income of those accepted was $ 2,300 more than that of those who were not (29). No class action suit has ever been brought against applicants whose families earn more than $ 50,000 who are admitted at a higher rate than any other group, yet have lower GPAs and MCATS than many other income groups! This has been going on since Flexner, seventy years ago (30). It is now well established that the likelihood of an individual pursuing a primary care practice is inversely related to family income, so that admis- sions policies which perpetuate class privilege are in direct contradiction with the health manpower goals of encouraging primary care practice espoused by the Congress and former HEW Secretary Califano. Among all applicants 22 percent of those accepted but 31 percent of those rejected in- dicated interest in primary care, while 23 percent of those accepted and 19 percent of those rejected indicated interest in research (19). g The continuous MCAT and GPA inflation required of admissions also contradicts these national priorities, related as they are to family income (29). It also ignores the epidemic grade inflation at many prestigious institutions whose reputations rest in part on the ability of their students to compete successfully for admissions; at Harvard 85 percent of the 1977 graduates were given honors, compared to 39 percent in 1957 (31). There is little question that minority students not only bear the burden of racial and cultural barriers to parity in the health professions, but dis- proportionately that of class (see Table 2). The controversy over admissions standards seems not to be one of maintaining quality but that of main- taining race and class. " There has been a uniform and comprehen- sive effort to recruit and retain minority and women students and faculty in U.S. health professional schools. Everything that can be done is being done. " Minority and women students. Were there, indeed, a real shortage of qualified minority can- didates for the health professional schools, com- petition among the schools would lead to a rela- tively even distribution of minority students among predominantly white institutions. Nothing could be further from the present situation. Certain institutions have demonstrated a sustained ability to attract and retain under represented - minorities and women; others have failed or never even tried. It should come as little surprise that most of these schools that have been successful recruiting and enrolling minorities are the same that have admitted significant percentages of women, including all the predominantly minority health institutions (i.e., Howard, Meharry, and Morehouse). No shortage of qualified women candidates has yet been identified. The New Jersey College of Medicine and Dentistry and Rutgers, UC San - Francisco and Irvine, Michigan and Michigan State, and New Mexico have con- sistently maintained and graduated the greatest percentage of minority professionals in medicine, dentistry, and pharmacy among the predominant- ly white schools. Three state systems California - , Michigan, and New Jersey represent - a dis- proportionate number of the health professional schools with higher minority enrollments, while both West Virginia medical schools have no minority students (32). These institutional policies cross over disciplinary lines, so autonomous schools of medicine, dentistry, and pharmacy at one institution may consistently have strong or weak affirmative actions efforts (see Table 3). These pervasive institutional attitudes are not Table 2 Percentage Distribution of U.S. Medical Students by Family Income, 1976-77 Less than $ 5,000 $ 5,000 to $ 9,999 $ 10,000 to $ 14,999 $ 15,000 to $ 19,999 $ 20,000 or more All U.S. * 13 23 24 18 22 * for 1974 (from U.S. Bureau of the Census) Total 5.0 10.8 21.8 16.1 46.2 White 2.9 8.7 21.3 16.7 50.3 Black 22.3 25.2 23.5 11.4 17.6 Hispanic & Native American 15.6 25.2 27.4 11.3 20.6 Source: Dube, W.F., " Datagram: Socioeconomic Background of Minority and Other U.S. Medical Students, 1976-77, " J Med Educ 53: 443-445, May 1978. U.S. Bureau of the Census, Money Income and Poverty Status of Families and Persons in the United 10 States: 1974. Series P 60 -, No. 99, July 1975. limited to admissions policy alone but determine the content of what is taught. A survey of 113 ranked among the worst schools for the enroll- ment of both women and minorities in medicine medical schools showed that those institutions where ethnic and sociocultural issues were thought important enough to deserve formal courses in the curriculum were the same that had the highest and dentistry. Toledo, Wyoming, North Dakota and Idaho State shared this record among schools of pharmacy (Table 3). The institutional attitudes reflected in recruitment and admissions of minori- minority enrollments; those that dealt with the assessment and treatment of minority group members in other courses had median enroll- ties appear to parallel those toward women and are likely to be equally evident in what is taught about women. ments, while those that had no teaching on socio- cultural factors in medicine had the lowest minority enrollments (33). An earlier survey A striking pattern emerges when examining the medical schools enrolling the fewest women. Of the 30 schools with the lowest female enrollments, found that successful minority admissions was 21 are located in the southeastern and border . most closely correlated with modification of states (32). Only one of the predominantly white admissions procedures to include minority schools with 30 percent or more women enrolled students and faculty (34). was in a border state - i.e., Kentucky, Missouri, The impact of the political environment is pow- Tennessee, and West Virginia. None were in the erful, as can be seen from Lae the list of successful and unsuccessful institutions (Table 3). The city of " The inadequacy of HEW's Newark, site of one of the enforcement effort... permits the worst urban riots of the late 1960's, has emerged continuation of practices which with a potent minority result in the denial of equal southeastern states in 1978-79 (38). This pattern is present but less. prominent for minority. enrollment, with 18 of the 33 lowest medical school enrollments to be found in the southeastern electorate which has made demands upon its health professional schools (see box by Richard. education and employment to women and minorities ' -U.S. Commision and border states (32). Faculty. The participa- tion of minority faculty and students in the ad- Younge). Similar settings. in Chicago, Boston, De- troit, and New York City. on Civil Rights missions process has been the most important factor identified in suc- have not had perceivable cessful recruitment ef- impact. The University of Connecticut, on the other hand, was built in suburban Farmington, in- sulated from Hartford and the mainland's third forts, according to a 1972 study (34). Thus, a necessary condition for successful minority and female enrollment must be the recruitment of largest Puerto Rican population; it had no Puerto Rican students in 1976-77 (36). The University of South Dakota, demonstrating the soft money syn- drome, states that " we feel that we have a special obligation to Native Americans " (36), while apologiz- minority and women faculty. This 1972 national survey found that 65 percent of medical schools admitted that their efforts to recruit faculty had failed; half said that they had failed recruiting minority administrators. Only one percent of ing for having no funds to devote to a specific the American medical schools reached even program. No minority student has attended the 75 percent of their recruitment objective in school in any class since 1975-76 (32,35)! The faculty, while 35 percent noted success in student University of West Virginia, which has no affirma- recruitment and only 11 percent failure (34). tive action program, special recruitment, or finan- With the increase in minority graduates since cial aid plans, had one Black medical, two dental, that time some improvement in recruiting minority and one pharmacy student enrolled among its faculty presumably should be seen. Nevertheless, 792 health professional students in 1976-77. the ivory walls remain white and impenetrable. Al- Eight schools of pharmacy in 1976-77 and five schools of medicine in 1978-79 had no minority though the absolute numbers of Black, Hispanic, and Native American faculty have increased since students enrolled (32,35). Despite its long- 1971-72, they represent the same 2.6 percent in established reputation and 2,000 minority appli- 1978-79 as in 1971-72 (see Table 4). Even this cations each year, Howard still maintains a vigor- standing in place was disproportionately contri- ous recruitment program (37). buted to by the predominantly minority medical West Virginia, LSU, Tennessee, and Nebraska schools Howard - , Meharry, and Morehouse. The 11 Table 3 PLAYING THE'DOZENS'- AFFIRMATIVE ACTION AND INACTION BEST ENROLLMENT AND RETENTION 1 . / 2. / 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Medicinea Meharry (86.2) Howard (75.8) UC Irvine (23.3) Stanford (19.1) New Mexico (19.0) UCSF (17.9) CMDNJ - Newark (17.9) CMDNJ - Rutgers (17.7) Michigan State (17.4) Baylor (15.4) North Carolina (15.0) Colorado (14.5) Under Represented - Minorities (Percent) Dentistry Meharry (84.0) Howard (69.9) UC Berkeley - (21.0) UCLA (17.5) USC (15.0) Pharmacy Texas Southern * (66.1) Florida A M & M * (59.9) * Xavier (53.6) Howard 45.2 () New Mexico (23.8) Harvard (12.7) Colorado (11.3) CMDNI (11.3) M.C. Georgia (11.1) Oklahoma (11.1) Michigan (14.7) Texas (14.2) UC Berkeley - (12.1) U. Houston (14.2) Florida (8.4) Michigan (9.1) Texas - SA (8.3) Maryland (8.3) USC (7.8) Medicinec 1. Med. Coll. PA * (63.2) 2. SUNY - Stony Brook (53.8) 3. Michigan State (37.4) 4. UCSF (33.9) 5. Howard (33.8) 6. Missouri - KC (32.9) 7. Columbia (32.9) 8. Harvard (31.5) 9. Wright State (31.3) 10. Tufts (31.1) 11. UC Davis (30.9) 12. CMDNJ - Rutgers (30.5) Women (Percent) Dentistry Harvard (32.9) Puerto Rico (26.9) UCLA (26.6) Columbia (23.1) SUNY - Stony Brook (22.2) Meharry (21.7) Boston U. (19.6) Howard (19.1) Tufts (18.3) Connecticut (16.9) Penn (15.9) CMDNJ (15.6) Pharmacy Puerto Rico (75.9) Michigan (66.0) * Purdue (53.4) Howard (50.3) Tennessee (50.1) North Carolina (48.9) Virginia Commonwealth (47.3) Kentucky (47.2) SUNY Buffalo - (46.3) Maryland (45.9) UC Berkeley - (44.8) Illinois (43.4) number of Black faculty increased 33 percent at Howard and Meharry from 1971-72 to 1975- 76 (39), and Morehouse was established in 1977- 78. Mainland Puerto Rican faculty membership has actually declined slightly during the decade. The recruitment of women on faculties of medi- cal schools is only slightly less discouraging, des- pite the growing number of women enrolled and graduating. Nationally there has been no signifi- cant upward movement in the past ten years. In 1965-66 women represented 15 percent of facul- ty members holding medical degrees; in 1975-76 12 this was only 9.9 percent (40). Since 1975-76 the percentage of women on medical school faculties has remained just about the same - 15.1 and 15.2 percent in 1975 and 1978, respectively. The largest number and percentage of these women faculty members, however, were found in libraries, where women comprised more than 70 percent of the staffs (38). Women are also disproportionately represented in the lower faculty ranks (see Table 5). There are no women deans, only 4.5 percent associate and 9.9 percent assistant deans, and 1.5 percent department heads, with no significant improve- ment in these figures during recent years (38). WORST ENROLLMENT AND RETENTION Medicineb 1. S. Dakota (0) 2. West Virginia (0.3) 3. Vermont (0.3) 4. Hawaii (0.3) 5. Oregon (1.1) 6. Albany (1.3) * 7. S. Florida (1.3) 8. Virginia (1.4) 9. Tennessee (1.5) 10. LSU Shreveport - (1.8) 11. Nebraska (1.9) 12. Nevada (2.1) Under Represented - Minorities (Percent) Dentistry Emory (0.2) Nebraska (0.4) Marquette (0.6) Ohio State (0.7) Pharmacy Northeastern * (0) Albany (0) Pittsburgh (0) Iowa (0) Boston U. (0.7) S. Illinois (0.8) U. Toledo * (0) SUNY Buffalo - (0) West Virginia (0.8) LSU (1.1) Tennessee (1.3) Minnesota (1.7) Indiana (1.8) Louisville (1.8) Wyoming * (0) Washington State * (0) Ohio Northern * (0.2) N. Dakota State * (0.3) Duquesne (0.3) * Idaho State (0.4) Drake * (0.4) Medicine 1 . Creighton (12.8) 2. Utah (13.4) 3 123 . Texas - SW (14.1) 4. LSU Shreveport - (14.6) 5. S. Alabama * (14.8) 6. S. Carolina (14.9) 7. Tennessee (14.9) 8. Miami (15.3) 9. Minn Duluth - (15.3) 10. Oklahoma (15.5) 11. Uniformed Serv. " (15.6) 12. St. Louis (15.8) West Virginia (15.9) Women (Percent) Dentistry Tennessee (4.9) Creighton (5.4) Nebraska (5.4) Missouri - KC (5.5) S. Carolina (5.6) Georgetown (5.7) Baylor (6.1) Emory (6.2) SUNY Buffalo - (6.7) West Virginia (6.7) Temple (7.0) Northwestern (7.3) Pharmacy Utah (19.0) Idaho State * (20.2) Oklahoma (23.4) * Wyoming (23.4) Brooklyn (24.1) Ferris State (25.1) New Mexico (26.2) NE Louisiana (26.2) U. Toledo * (26.6) St. John's (26.8) Samford (Ala.) (27.9) N. Dakota State * (28.3) * Indicates no other schools affiliated (e.g., an independent medical, dental, or pharmacy school). Italics indicate the appearance of the school in another best or worst category in this chart, indi- cating the frequent consistency and crossover between minority and women and between differ- ent schools (e.g., Howard appears in all best columns). Source: Philpat, Wilbertine P., Minorities and Women in the Health Fields: Applicants, Students and Workers. DHEW Publication No. (HRA) 79-22, October 1978. Footnotes: aMore recent data from the 1978-79 academic year show virtually no change in the leading seven predominately white medical schools with only slight changes in their order and only two changes in the top ten such schools. (See Gapen, Phyllis, " Minority Admissions: _ The Increasingly Empty Promise of Affirmative Action, " The New Physician 28: 20-24, July August / 1979). More recent data for the 1978-79 academic year demonstrate that five medical schools had no minority students enrolled, including two newly opened schools. The dozen worst schools were virtually identical to those of 1976-77 with the addition of three newly opened schools. (See Gapen, Phyllis, " Minority Admissions: The Increasingly Empty Promise of Affirmative Action, " The New Phy- sician 28: 20-24, July August / 1979). More recent data from the 1978-79 academic year demonstrate the stability of these rankings. The six medical schools with the highest percentage of women enrolled remained the same with slight changes in order. Ten of the top twelve schools were among the top sixteen in 1978-79. (See Braslow, Judith B., " Current Status of Women in Academic Medicine, " paper presented at Regional Conference on Women in Medicine, New York, March 24, 1979). 13 Table 4 Minority Representation on U.S. Medical School Faculties, 1971-72 to 1978-79 Caucasian Black Native American Mexican American Puerto Rican Other * Unknown Total tless than.05% 1971-72a Number Percent 27,005 565 11 54 263 2,432 4,328 34,658 77.9 1.6 t 0.2 0.8 7.0 12.5 100.0 1975-76a Number Percent 33,345 733 14 74 276 3,622 2,618 40,682 82.0 1.8 t 0.2 0.7 8.9 6.4 100.0 1978-79b Number Percent 38,641 820 22 89 320 3,445 3,803 47,140 82.0 1.7 t 0.2 0.7 7.3 8.1 100.0 * includes other Spanish surnames, Asian, and Pacific origin Sources: aJolly, H.P., and Larson, Thomas A., Participation of Women and Minorities on U.S. Medical School Faculties. Washington, D.C.: Association of American Medical Colleges, March 1976. bHiggins, Elizabeth J., " Datagram: Participation of Women and Minorities on U.S. Medical School Facul- ties Educ, " J Med Educ 54: 252, March 1979. The largest single rank of women faculty is profes- sor emeritus (13 percent), a tribute to an earlier era in the women's movement (41)! To make these matters worse there was between a $ 600 and $ 1000 difference in salaries between men and women at the same rank noted as recently as 1975, although such salary differentials have been illegal in higher education since 1972 (40). One study at UC San - Francisco found a $ 7000 difference between male and female doctors of the same experience and productivity (42). An HEW study commissioned in 1976 " did not find Table 5 Distribution by Rank of Male and Female Time Full - Medical School Faculty, 1976 Rank Professor Associate Professor Assistant Professor Instructor Clinical Ranks Lecturer and Other Percent of All Males 28% 23% 32% 8% 3% 6% 100% Percent of All Females 8% 16% 36% 22% 4% 14% 100% Source: Braslow, Judith B., " Current Status of Women in Academic Medicine, " paper presented at the Regional 14 Conference on Women in Medicine, New York, March 24, 1979. Ever Fae aan uh be NO 77, Wil LELSI MLMI >> 15 affirmative action efforts to be either significant or widespread " for women in all the health profes- sional schools (19). Apparently health professional schools are more generous with seats in their classrooms than at their lecterns or in their laboratories! The attitudes of Blacks and whites on why there are not more minority or women faculty in the medical schools are dramatically different. Among the faculty, fellows, house officers, and students polled at the University of Michigan, only one third - of Black respondents thought too few Black faculty were available, while 90 percent of whites believed this. All the Black students thought the attitudes of white faculty and housestaff turned prospective minority candidates off, while less than half the white respondents agreed with this (43). Throughout the survey, on almost every issue examined, Blacks and whites had almost opposite views (43). Blacks viewed whites'atti- tudes opposite to the way whites viewed them- selves. Solutions proposed by predominantly white institutions for underrepresentation, if this study is any indication, are likely to embody atti- tudes sharply different from those of the minorities whom they are trying to recruit - unless there is considerable minority participation from its onset. This " designed - to - fail " Catch where - 22 - without. minority members, minorities cannot be success- fully recruited - suggests another reason why so many " good faith " efforts have had such limited results. " There is no evidence that women or minority members would better serve the health needs of the nation than white males. " Despite numerous studies to the contrary, many HEW has been criticized for its reluctance to issue show cause - notices to non compliant - institutions. From 1971 to 1974, only two were issued 16 eee Minority students not only bear the burden of racial and cultural barriers to parity in the health professions, but disproportionately that of class. The controversy over admissions standards seems not to be one of maintaining quality but rather maintaining race and class in health academia still maintained that they can- not predict (and, thus, select) those applicants most likely to enter primary care in underserved areas in rural and inner city America. Typical of this attitude, L. Thompson Bowles, a dean at George Washington University School of Medi- cine, said, " Medical schools are not very good at picking and predicting which students will elect careers in underserved areas none of us knows how to identify such students consistently " (7). Numerous studies in the 1950's and 1960's demonstrated conclusively the importance of rural rearing for physicians and their spouses who settle in small town and rural practices (44). The location of the physician's medical school and post graduate - training was repeatedly demon- strated to influence those who choose urban prac- tices (44). White M.D.'s tend to establish practices among their ethnic group of origin, away from low income and non white - populations (15). Sur- veys of Black physicians show that they are rela- tively concentrated in general and family practice and other primary care specialties (46-48), and in practices which serve Black, economically dis- advantaged, and inner city patients (49). Eighty- five percent of recent Black dental graduates in California had 50 percent or more minority pa- tients, and 80 percent of those in Los Angeles and Alameda counties, more than half of the gradu- ates, were located in or adjacent to federal short- age areas (45). Howard and Meharry graduates are three times more likely to serve in large muni- cipal hospitals that serve mostly minority popula- tions (47). Among physician assistant students, 35 percent of Black students, compared to one per- cent of white students, identified inner city ghet- toes as their anticipated practice choice; half the Continued on Page 25 was unacceptable. This led to the URBAN tors, and willingness to cut back ousting of the Governing Com- mission. Effective December 1, 1979, control of the hospital re- the size and services of the hospi- turned to the Cook County Board tal, the Governing Commission and its president, George Dunne had recently become increasingly (who succeeded Mayor Daley as responsive to the community's the head of the Democratic party). M interest. Under the Commission's direc- tion, the hospital regained full J.C.A.H. accreditation, opened a series of neighborhood clinics, successfully recruited high quality The underlying problem is a fa- miliar one. The nationwide assault on public healthcare is shamefully obvious in the Medicaid eligibility figures for Cook County Hospital for the past five years. In 1973, HEALTH AND HOSPITALS IN CRITICAL CONDITION On September 28th, the em- housestaff trainees, especially mi- norities, and wiped out the legacy of a century of patronage prac- tices. The composition of the the Board had become predominant- ly minority. While its inde- pendence and accomplishments were a source of irritation to 62 percent of those receiving care had their hospital bills paid by Medicaid. By 1979, only 27 percent were eligible for Medicaid reimbursement. This re- sulted in a 40 million dollar deficit for the hospital's fiscal 1979 bud- get; meanwhile the state accrued a ployees of the Health & Hospitals the local politicians, its refusal to public aid surplus of 100 million Governing Commission in Chi- make deeper cuts in the hospital dollars annually for each of the cago were notified of a paycheck freeze. That, as it turned out, was to be only the beginning. Two weeks later, the hospital's HI Health and Hospitals Hospitals Governing Commission 1900 West Polk Street Chicago, Illinois 60612 Telephone 312/633 7425 employees were again faced with a payless payday. An angry meeting of 1000 workers voted to September 28, 1979 take patients waiting in County's Emergency Room to Rush Pres- MEMORANDUM byterian St. Luke's - the wealthy private medical center across the TO: street. The action, one of a series ALL EMPLOYEES of large militant demonstrations this fall, dramatized the crisis at FROM: JOHN W. B. HADLEY, CHAIRMAN HEALTH & HOSPITALS GOVERNING COMMISSION Cook County Hospital and the SUBJECT: NOTICE CONCERNING YOUR NEXT PAYCHECK failure of private medicine to care for the people of Chicago. This fall's crisis at Chicago's only public hospital was the pro- duct of a growing funding short- age and political conflict over the hospital's governance. Since 1969 when control of the hospital was taken away from the city's powerful Democratic machine, the hospital's independent Gov- erning Commission has been under attack. Although unpopu- lar during its early years for its union anti - policies (precipitating lengthy housestaff and nursing strikes), firing of outspoken doc- Because of the continuing inflation and the increasing numbers of patients who are unable to pay their medical bills promptly and have no insurance or public aid, the Commission's finances have become increasingly strained. Unless we can get the County of Cook to agree to our borrowing money, we will have to defer the paychecks which will start to be handed out on the P.M. Shift, Tuesday, October 2. This is one more event in a long history of under payment to the Hospitals the Commission runs. You are aware of the layoffs and other steps taken over the last years to keep the Hospitals open, make your jobs secure and avoid these crises. The Commission realizes that the Hospitals are now understaffed for the number of patients we serve. This continued understaffing and underpaying must be stopped so that the sick can be properly cared for. The Commission will continue to try every means to get money to pay the deferred paychecks and pay them as soon as possible. 17 past three years. The denial of Medicaid benefits and the medical ICU has been cut ingly difficult conditions, has 50 percent to only 10 beds. made tactical choices difficult. to an increasing number of Cook This invisible dismantling of the Cook County and its clinics de- County Hospital's patients is hospital permits the widespread liver over 750,000 patient visits achieved through a series of re- belief in the Black Community annually to an estimated 200,000 strictive policies by the State of Il- that the hospital is not endangered. people. But County's constituen- linois. The most glaring is the fro- The community asks: Is the hospi- cy is a much larger one. Its prob- zen cut off levels for Medicaid tal still open? Hidden from pub- lems are not simply those of an certification. A family of four lic view are the worsening staffing underfunded public hospital, but www earning more than $ 4,200 or an levels, the deteriorating physical are the contradictions of our pri- individual making $ 1,800 an- plant, and the brutal new collec- vate health care system. The in- nually are too rich to qualify. This tion procedures to realize creasing monopolization by pri- group of patients, euphemistically payments from the " self pay " vate medical centers threatens dubbed " self paying, " has grown from 8.7 percent of patient days in 1973 to 40.6 percent in 1979. The specter of closing Cook working poor. The critical condition of the hospital was evident to the work- ers inside who responded with everyone's right to health care. By imposing their definition of " sound management " -maximi- zation of income through County Hospital is a real one. The idea has repeatedly been proposed by members of the County Board. It has been advo- unprecedented activism to defend the hospital. Hundreds of thousands of petition signatures were collected, frequent demon- expanding revenue generating procedures and minimizing care to those unable to pay they - guaran- tee skyrocketing health inflation cated by representatives of the pristrations pristrations of 500-1,000 people, and increasingly inaccessible vate hospitals who have dominated and formation of a joint crisis cen- services. Chicago's HSA. In fact, the HSA ter by the hospital's unions were The ultimate success of our plan on the future of health care in manifestations of the workers'in- movement to save Cook County Chicago neglected to even men- volvement in the struggle. Their Hospital hinges on our ability to tion Cook County Hospital. A ma- concern went well beyond the de- make the connection between this jor victory of the movement de- layed layed ((but but so so far far always always paid paid)) savage attack on the health of fending the hospital this fall had paychecks, and the need to been a concession by Governor organize the community to de- Thompson, Mayor Byrne and fend the threatened services was minorities and poor people, and. , the costly unresponsive health system that most people en- George Dunne that the hospital always the primary goal. counter. Only a public health will remain open. However, the recklessness with which these politicians have al- The inability to mobilize large numbers of people from the community has been frustrating. care system has the potential to solve these problems and genuine- ly reorganize health resources to lowed repeated delayed pay- checks created widespread inse- Black housestaff who led the struggle this fall advocated the meet people's needs. -Gordon Schiff and curity and resignations in the hos- closure of the Emergency Room Mardge Cohen pital. This lack of support for the to emphasize our inability to stability and long term needs crip- adequately care for the patients. For more information write Resi- ples the function of the hospital, slowly destroying it. For example, The dilemma of demonstrating how bad conditions are, while at dents at Cook County Hospital and the Committee to Save Cook almost one third - of the nursing positions in medicine are unfilled, the same time struggling to pro- vide decent care under increas- County Hosp., 201 S. Ashland, Chicago, Ill. 60607 " 18 ENVIRON WORK F 2 MERCHANTS OF DEATH AND THE GLOBAL DUMPGROUND Environmentalists worked hard during the early seventies to get the pesticide aldrin off the US market. Finally, in 1974 the Environmental Protection Agency banned aldrin as a potent carcinogen. Shell Oil responded to the ban by shifting its produc- tion of aldrin from California to a plant in the Netherlands and then proceeded to dump the poison in Third World countries, including Brazil. In 1975, the year after the US ban, thirteen village children in Bahia, Brazil died from eating aldrin contaminated - food. And yet today aldrin is sold like flour to unsuspecting farmers in open village markets from Brazil to Indonesia. In Guatemala, cottonfields are sprayed from the air 40 to 50 times a year with a smorgasbord of US made - but US banned - pesti- cides. Children of tenant farmers are used as " flagmen " to indicate target fields. The death of chil- dren from acute pesticide poison- ing is not considered unusual. When researchers discovered that Tris, a flame retardant - used to treat children's sleepwear, causes cancer, the US govern- ment clamped down on sales (a passing irony since the govern- ment had earlier ordered manu- facturers to use Tris). Despite the ban, millions of children in Asia, Africa and Latin America sleep in contraband clothing thanks to the clandestine cooperation of corpor- ate dumpers, sleazy middlemen and governments. Dumping hazardous sub- stances, processes, and machin- ery onto unregulated markets overseas is big business - an esti- mated $ 1.2 billion of unsafe goods every year - and dumping may well emerge as a growth in- dustry in the eighties. It may also be the " corporate crime of the century ", as Mother Jones maga- zine claimed in a recent expos. (Nov., '79). Dumping the Dumpers? What's being done to dump the dumpers? Virtually nothing. The President, the regulatory agen- cies and the Export - Import Bank take the position that what's un- safe for you and me is fair game for anyone else in the world, as long as our balance of payments is bolstered. If we are to protect human life and the global envir- onment from the latest version of the corporate free - for - all, we must consolidate the gains of the seventies in environmental regu- lation and then move aggressive- ly to forge alliances with progres- sive forces in labor and the envir- onmental movements around the world. A tall order. But it is beginning to happen. A two day - conference on " Exporta- tion of Hazardous Industries to Developing Countries " was held at Hunter College in early Nov- ember. The conference brought together two hundred union, in- dustry, and government officials, as well as consumer and environ- mental activists. Labor was repre- sented from Europe, North and South America, and Asia. Nothing so ambitious as a plan of action emerged. But there was a clear sense that the problem em- braces our deepest concerns, and the will to work together is there. ' We Haven't the Moral Right ' _ First, we have to get rid of some ideological dead wood and indus- try is more than happy to throw down the gauntlet. A chemical company executive told the con- ference that his industry is not es- pecially hazardous. No, the real villain is the high cost of govern- ment over regulation - , which is forcing industry to relocate over- seas where a " favorable climate for investment " (and a captive, impoverished labor force) could be found. Another chemical exe- cutive portrayed herself - and her industry - as a libertarian bastion of freedom. " We can't dictate what other countries do with our chemicals - we haven't the moral right. If they choose jobs and growth in GNP and our technolo- gy, we can't refuse. " When indus- try talks about lucrative moral obligations it can't refuse, it's time to get worried. But we should see these argu- ments for what they are. For the last decade, critics of toxic sub- stance control have told us that we must choose between our health and our jobs, between en- vironmental quality and a higher standard of living, or between product safety and competition in international markets. A broad coalition of groups refused to ac- cept that false dichotomy and in- stead demanded gainful and healthful employment as a human right. Now we are told that poor people in the Third World must accept those grim " choices " we refused. This amounts to environ- mental blackmail wherever it's played, and it's clear that if indus- 19 tries in the developed countries are allowed unfettered movement Capital Flight in the Third World, the same vi- cious cycle of occupational death and environmental degradation will be repeated. Speaker after speaker rose to relate the indus- trial nightmare of asbestos and benzene, vinyl chloride and ben- zidine dyes, transplanted to Asia and Latin America with the same fatal conclusion. They spoke of countries with little or no regula- Take the hotly debated ques- tion of capital flight. When the giants in the asbestos industry took up their marbles and moved south to friendlier climes, envir- onmentalists worried that this would set off a stampede to dot the globe with Western - owned, polluting plants. This is an under- standable concern, but a close look at direct US investments tion, marginal enforcement capa- abroad during the seventies does bility, no labelling requirements, not show a massive flight of inadequate toxicity information capital. on hazards from the country of For example, the chemical in- origin and a weak union move- dustry faces heavy regulatory ment whose members know no- pressure under the Toxic Sub- _ stances Control Act, and you Industry would have us believe that a little less regulation at home will lead to a lot less dumping abroad. But most people came away from the conference con- vinced that the best way to pro- tect comrades in poor countries is to strengthen regulation over our own hazardous industries. Third World activists see the American struggle as much closer to victory than their own, partly because our environmental legislation can be utilized to force technological changes in industrial production that will lead to safer jobs and safer places to live and -, presum- ably, to less toxic material to dump. would expect to see substantial movement of firms if the capital- flight thesis holds. But a paper presented by Dr. Martha Ventilla of the U.N. Environmental Pro- gram showed that while a few chemical firms have fled the country, new firms have moved into the vacuum by introducing technological innovations that are both cost effective - and meet more stringent regulatory standards. Ventilla argues that though the chemical industry will fight regu- lation tooth and nail, the trend in the US and other industrial coun- tries is toward changes in chemi- cal process technology and the development of substitute pro- ducts. This amounts to inter- nalizing the social costs of chemi- cal exposure to the worker. Herman Rebhan, General Se- cretary of the International Metal- workers'Federation, announced at the conference that the Inter- national Metalworkers Federation (IMF) plans to hold a public inter- national tribunal in Geneva to ex- amine the export of hazardous work that will call for new laws to stop the export of hazardous pro- cesses and criminal penalties for offending companies and and their executives. IMF is one of the few internationals which has made a full commitment to worker educa- tion on occupational hazards. Next year, IMF will offer training courses to more than 15,000 union officials and shop stewards in the Third World. To back up its commitment, IMF has called for a worldwide ban on the production and use of asbestos, a move that will affect many of its members. In his talk Rebhan most clearly expressed the central message of this conference, " It will not be long before the people of the Third World revolt against being treated as the garbage can of the advanced industrial world. " -Joseph Hunt (Joseph Hunt is a lecturer in bio- logy and social studies at Harvard University.) 20 WOMEN NOT TEACHING OLD DOCS NEW TRICKS By virtue of the sheer weight of demographics, it was inevitable that agism would become a fem- inist issue. Gender has the most obvious impact upon life expec- tancy in this country. In 1975 the average life expectancy for US women was 7.8 years longer than for men and almost one year longer still for non white - women than non white - men. Gains in lon- gevity over the last sixty years have widened these differences. In 1920 life expectancies for men and women were 53.6 and 54.6 years, respectively, only one year's difference. By 1975 these had grown to 68.7 and 76.5 years, respectively. This might be considered an advantage were not the treatment of older Ameri- cans so deplorable. Not only are women more likely to spend a longer period suffering the society's disdain for its own future, captured in its em- barassed euphemisms- " senior citizens, " " the elderly, " " the aged, " " older Americans " -but women are more likely than their male siblings and husbands to be delegated the responsibility of caring for aging family members whose independence or health be- gins to fail. The decennial re dis- - covery of profiteering and abuse in nursing homes has become a col- lective penance ritual. The effects of aging are com- pounded by poverty. Women have always been poorer than men, and this problem has grown worse since the New Frontier, the Great Society, and the War on Poverty. In 1959 the rate of poverty among females was two- and - a - half times greater than the rate for males. By 1975 the female poverty rate had grown to four - and - a - half times the male rate. The percentage of persons 65 years or older with incomes below the poverty level is almost twice that of all families in 1975. This persists despite the 41 per- cent decline of impoverished elderly between 1969 and 1976 and the evidence that over half of those who have escaped from poverty (as a statistic) since 1966 have been over 65 years old. The Gray Panthers'Task Force on the Older Woman has deter- mined financial integrity of the older woman as their first and pri- mary objective. Only recently mainstream feminists have re dis- - covered the importance of the family and raised the question of our futures, sanctioned by the N.O.W. Legal Defense and Edu- cation Fund convening the National Assembly on the Future of the Family in November in New York City. Yet, it has been the Gray Panthers and Robert N. Butler, director of the National Institute on Aging who have been most critical of public aging poli- cies based largely on research on men (by men), whereas most of the elderly are women. Given these dramatic demo- graphics, it might come as a sur- prise that the issues of agism and feminism were brought together in medicine in 1974 by a then 39 year old senior at Trinity College in Illinois. Geraldine Cannon, a mother of five (and grandmother, according to Time) and a surgical nurse at Skokie Valley Commu- nity Hospital outside Chicago, applied to the University of Chi- cago and Northwestern medical schools but was told that candidates over 30 had little chance for ad- mission. (Remember, " Don't trust anyone over 30 "?) When she was not admitted, Gannon com plained to HEW. Under Title IX of the Civil Rights Act and its 1972 education amendments, HEW is responsible for enforcing the ban against sex discrimination in ad- missions and student affairs in schools receiving federal funding. She and her attorney husband reasoned that such age bias dis- criminated against women who were more likely than men to de- fer their education to raise a family or to come to medicine, as she had done, through another career like nursing. HEW has a backlog of some 3,500 discrimination complaints, about one quarter - of which involve Title IX sex discrimination cases (the bulk of which are Title VI race discrimination charges). Cannon's complaint promptly dis- appeared in HEW's red tape - jungle. So she took her case to federal court. Both the lower court and the court of appeals told her she did not have the right to sue and that only HEW had the right to enforce the Civil Rights Act. HEW has always been extremely reluctant to do this, since its only legal sanction is to deny all federal funding to a school. Earning the reputation, ironically ironically,, as as a feminist Allan Bakke, Cannon took her case to the Supreme Court. In May 1979 the Supreme Court ruled 6 to 3 that Ms. Can- non did, indeed, have the right to bring suit in court against the schools which had denied her 21 admission. The Court found an " implied right " for individuals to sue educational institutions in court for sex discrimination. This was applauded as a victory by feminists, one which will also make racial discrimination suits easier. Although others have brought suits under both Title VI and Title XI before and many courts and civil rights lawyers have assumed that this avenue was open, the Supreme Court ruling makes it a right. Now Cannon's suit against North- western and the University of Chicago is in court. While Cannon argues that her test scores and grades were high- er than many of those admitted to the two medical schools in 1974, University of Chicago Dean Robert Uretz maintains that even with this confirmed right to sue, she will not be admitted because among 5,427 applicants, 2,000 had better academic credentials than M s. Cannon. Dean Uretz claims this approach to admis- sions will hurt minority candidates who tend to score lower on en- trance exams than whites. He also places little faith in the courts find- ing fair solutions. How quickly those representing the institution- _ al interests pit women against minority students! While the media's coverage largely overlooked the impor- tance of age bias in medical school admissions, its importance was not lost on HEW. A month after the Supreme Court's deci- sion then Secretary - Joseph Cali- fano issued regulations to take ef- fect July 1, 1979, banning age discrimination in all federally financed programs, including medical schools, based upon a 1975 law. The regulations, how- ever, received criticism from senior citizens'groups because numerous loopholes permit Congress, states, and local groups to approve exceptions. The current law already permits age distinctions that assure a pro- gram's " normal operations " or those based on " reasonable fac- tors other than age, " so in reality very little must change. The regu- lations did not even affect the only medical school operated by the federal government - the Uniformed Services University of the Health Sciences. This school, administered by the Department of Defense, has a written policy which discourages applicants over 28 years because of the fewer years of active duty after graduation. The problems of older candi- dates cited to justify their exclu- sion are the very same problems identified by critics of medical education in general - the diffi- culty adapting to its lock step - rigidity, inappropriate competi- tion, and moral and social isola- tion from the world of family and human values. The demands of its full time - and night - call schedule exclude anyone with significant fi- nancial or family commitments. Although older candidates are obviously further from their test- taking and college science courses, grades and test scores are still invoked as admissions cri- teria - yet a University of Missouri study study has has shown shown that that the the complex complex of maturity, rapport, and motiva- tion is a better predictor of total medical school performance than are grades. Test scores, however, are known to reflect social class and parental income. Admissions fol- low a linear correlation with family income. Thirty - two point eight (32.8) percent of applicants with parental income less than $ 5,000 and 49.2 percent with family income greater than $ 50,000, were admitted to the class of 1976-77. Older applicants seem to be more likely to come from other careers and less afflu- ent backgrounds, so age bias functions effectively as class bias as well as sex bias. Without a career ladder the health care sys- tem transforms class into caste. Individual mobility and the value of clinical experience are denied. There are no bootstraps on the bedpans. ~ The demands of medical training, its rigors, isolation, and relocations parallel the corporate career where executives are arbi- trarily transferred from office to office, city to city, to prevent the development of loyalties to any community except the corpora- tion itself. It is no wonder that the medical profession does not want older students whose loyalties have formed and who will not be- long solely to the corporation.. Ten years ago, perhaps, the greatest difference between quali- fied men and women who applied to medical school was their response to rejection. Most men would reapply after obtaining laboratory or hospital jobs or get- ting another degree with the sup- port of their families and friends; most women would seek another career. Today, that has clearly changed. The women's move- ment and the persistence and de- termination of women such as Geraldine Cannon have made a second chance at a new right. Just below the surface of these feminist issues are those of age and class discrimination. Racism was recognized in the 1960s, sexism in the early 1970s, and agism in the late 1970s. Progress in affirmative action in the 1980s may require the real discovery of class and its interrelation with race, sex, and age. Perhaps we have run out of closets to empty. -Hal Strelnick 22 their vulnerability in order to herd THE FIFTH FIFTH them to the polls to vote " No Union, " or at least to remain silent. FNGs are frequently paid at lower rates of pay for extended periods COLUMN | of time, while performing the same duties. Air fare, housing, other recruitment expenses and legal prerequisite for entry into interest may be deducted from the country () 1. Thus the circle is their pay, reducing them to a vir- complete. tual state of peonage. FNGs may Most FNGS come to _ this be denied experience, or degree, country on what is known as an differentials (3). If they should fail " H - 1 " visa. Holders of H - 1 visas to pass the State Boards, FNGs E are considered non immigrants - , which means they have no resi- dent status. These visas are only may be forced to work as LPNs or nurses'aides, if they can some- how manage to avoid deporta- given to skilled workers, profes- tion. " HUMAN RIGHTS " FOR FNGs sionals, or others " who (is) of dis- tinguished merit and ability and who (is) coming temporarily to the United States to perform ser- Last year, an organization called the Commission on Graduates of Foreign Nursing vices of an exceptional nature re- quiring such merit and ability " (2). As the system works now, insti- Since the right to remain in the country is solely based on a particular Schools (CGFNS) was formed by the ANA, the NLN, and DHEW. Its avowed purpose was to pre- pare and administer a voluntary nursing and English proficiency test to foreign nurse graduates tutions in the US recruit FNGs in their home countries, sometimes through commercial headhun- ters. Once the nurse is recruited it is the institution which applies for the H - 1 visa for the nurse, job, the power of the institution over the foreign nurse graduate is almost unlimited (FNGs) in their home countries as a screening process before their coming to the US. Weeping great crocodile tears for the poor super exploited - FNG in the US, the CGFNS proposed its own in effect " sponsoring " his or her entry into the country. Since the right to remain in the coun- try is solely based on that par- ticular job, the power of the in- stitution over the FNG is almost FNGs have a very real problem with the State Boards. Pro- ponents of the CGFNS exam justify solution - keep them all out but the most " worthy. " At the time of its formation, the CGFNS had no more authority unlimited. If the nurse should fail to pass the State Boards after arriving s he / may lose the visa. FNGs are it by pointing to the high failure rates of FNGs. Language is claimed to be the major difficulty. To " deal " with this problem, the than any other commission which the professional associations are so fond of setting - up; but this time there was a difference. The desire not allowed to change employers within nursing without repeating the entire process. Literally any variations of the terms of the visa CGFNS exam is suited well - : It is basically a test of English rather than of nursing. It is truly ironic that the professionalists, who blow so of the professionalists to exclude are grounds for its revocation, hot over nursing education and as many FNGs as possible dove- and the FNG becomes an un- nursing excellence, should rele- tails nicely with the isolationist na- tional chauvinism of the Carter Administration's " Human Rights " documented or as the Yellow Press likes to call it, " illegal " - alien. gate it to a low priority when evalu- ating the FNG for practice. Most FNGs come from countries campaign. Hospitals use their positions of where English is not the national As we predicted a year ago, the Immigration and Naturaliza- tion Service (INS) is moving to power over FNGs to good ad- vantage. Where union organizing drives are taking place, the hos- language. In 1973, for instance, 56.7 percent of all FNGs entering the US came from Asia (4). Of adopt the CGFNS exam as a pital need only remind them of those, Filipino and Korean nurses 23 constitute the largest national groups. While _ statistics are bandied about to show that few FNGs pass the State Boards on their first try, this is not true for FNGs taking the State Boards multiple times. According to DHEW's own figures, between July 1972 and February 1974, 64.1 percent of Korean nurses ul- timately passed in that period, and 60.0 percent of Filipino nurses, while only 45.6 percent of those from the British Isles passed (5)!. These figures, when compared with first try failure rates as high as 95 percent would seem to indi- cate that as a working knowledge of English is acquired, FNGS have no significantly greater problem passing the State Boards than do domestic nurses. If this be the case, it seems grossly unfair to deny FNGs the opportunity to gain that experience by placing added roadblocks to their entry. While few working nurses would countenance such Dracon- ian measures as the CGFNS / INS connection, many are disturbed by the passivity and apparent political backwardness of many FNGs. American nurses must educate themselves to the difficul- ties faced by FNGs and develop a sensitivity to their unique prob- lems. FNGs can never become part of the activist nurse move- ment as long as the knife of de- portation is at their throats (6). It must also be remembered that many FNGs come from countries ruled by dictatorial re- gimes - all great friends of the United States. Deportation for union or political work could have the most serious conse- THE HEALTH CARE HIERARCHY quences. American nurses and unions should begin developing a pro- gram of protections for FNGs so that there may be unity in action. Such a program should include: * Abolition of the CGFNS and its exam. FNGs should have no more hoops to jump through than any other nurse. There are plenty of jobs for all. * Cut the hold of hospitals on FNGs by granting them resi- dent immigrant, rather than non immigrant - , status. FNGS should have the right to quit, and to change, jobs. * International reciprocity for equivalent nursing education, to be administered by an inter- national agency such as the World Health Organization. * Long - term temporary licensure for those without equivalent education, with the employer or the state to provide nursing refresher courses and English courses. Full democratic rights for FNGs. No deportation, or threat of de- portation, for union or political activity. -Glenn Jenkins References . 1. Health / PAC BULLETIN, no. 81-2, pp. 6-8. Federal Register, August 29, 1979, pp. 50604-5. 2. Immigration and Nationality Act, Sec- tion 101 (a) (15 H) () (i). 3. " Nurse From Philippines Files a Job- Rights Complaint on West Coast, " The New York Times, April 8, 1979, p. 41. 4. U.S. Commission on Civil Rights, " A Dream Unfulfilled: Korean and Pilipino (sic) Health Professionals in California, " 1975, p. 36. 5. DHEW, Survey of Foreign Nurse Graduates, 1976, Table 13. 6. For an excellent treatment of the entire FNG problem, see, " Licensure and Foreign Nurse Graduates: A Struggle for Fairness and Equity, " which may be obtained from: National Alliance for Fair Licensure of Foreign Nurse Gradu- ates, P.O. Box 960, Woodside, N.Y. 11377. 24 Bakke - ing Up Continued from Page 16 Blacks from large cities anticipated ghetto prac- tices (50). Women and Blacks indicated significantly more interest in practice in physican shortage areas than men and whites, respectively, with similar but less dramatic trends for primary care in gen- eral (5). The relationship between socioeconomic class and specialty practice choice is perfectly linear. Janet Melei Cuca of the AAMC noted, " The con- nections between income, education, and occupa- tion have been so well established in the sociologi- cal literature as to have become almost axio- matic " (51). A direct relationship has been found between family income and both primary care specialty choice and interest in a physician short- age area, the higher the family income the more likely the choice of specialization and the less likely the interest in a shortage area practice. This was true both within and across ethnic and sex groups. Those anticipating larger debts on graduation consistently showed greater interest in physician shortage areas than those anticipating no debt (5). More recent data confirm the con- tinuation of these trends (52). There can be little doubt at this point that admitting greater numbers and percentages of women and minorities, espe- cially from disadvantaged backgrounds, will re- sult in greater numbers of primary care practi- tioners locating in underserved communities. This is particularly important for those communities where access to care is also limited by cultural or language barriers - in the barrios, the China- towns, the " towns J -, " and on and off the reser- vations. " The federal government is doing every- thing in its power to support affirmative action in the health professions. " At the request of Congressman Ronald Dellums of California, the General Accounting Office investigated HEW's record on affirmative action. The GAO concluded that HEW had " made mini- mal progress in making sure that colleges and uni- versities have acceptable affirmative action pro- grams, " having failed to send " cause show - " notices or begin sanctions against noncomplying institutions, conduct pre award - reviews, or en- force even publicized plans (53). The House Sub- committee on Equal Opportunity found academic institutions to deserve no special exemption from the Executive Orders which regulated federal contracts and noted that enforcement of equal opportunity had been ineffective and federal con- tract compliance deficient. The U.S. Commission on Civil Rights found in 1975 that " the inade- quacy of HEW's enforcement effort.. permits the continuation of practices which result in the denial of equal education and employment to women and minorities. " HEW was again criticized for its reluctance to issue show cause - notices to non compliant - institutions; from 1971 to 1974 de- spite uncovering numerous violations, only two such notices were issued. HEW repeatedly ac- cepted the assurances of institutions and " plans for a plan " rather than the accepted standard of a documented plan for affirmative action (54). Jack Hartog, an attorney for the Commission on Civil Rights, called the HEW affirmative action effort " a disaster " and noted that it has been reorganized only recently. HEW does maintain an Office of Health Resources Opportunity, but its activities did not even merit discussion in the General Counsel's review of the department's activities in light of the Bakke decision (55). This does not even address the issue of the quality of data collected. The problem arises because the date necessary to monitor affirmative action programs are gathered from the institutions to be regulated and contain many subtle and hidden biases. Just one example is the AAMC's in- clusion in first year enrollments all repeating min- ority students, rather than just newly enrolling and matriculating students, which inflates the apparent size of the " coming in -" minority students by ten to twenty percent most years (3; see also first article in this series). This not only misleads but results in overlooking some remarkable findings - that 17 percent of minority students offered admissions in 1973-74 to medical schools failed to enroll, something which has never occurred to this extent among white acceptees (3). Some 224 qualified and admitted minority applicants just disappeared, and no one asked any questions because they were " lost " in the statistics! The U.S. Congress, as we have seen, also tries to weaken affirmative action with various amend- ments and anti bussing - riders. An HEW commis- - sioned study on women in the health professions concluded that the Congress'health manpower actions " seem not to consider, as a matter of course, their possible or probable impact on the entry or practice of women in the professions...... We found that some elements of these policies counter much of the intent of affirmative action retention efforts - that is, the weight of manpower policies is far greater in impact than the weight of affirmative action efforts " (21). This, of course, is just as true for minorities. That is, health man- 25 Scarpelli v. Remson - The Case Although the dust has only just begun to collect on the amici curae and briefs submit- ted for the Supreme Court's consideration of Bakke v. Regents of the University of California, a new onslaught on affirmative action in education has begun in the courts. of Kansas. The case of Scarpelli v. Rempson has been heralded as the " Bakke case of the 1980s " by Gerald C. Horne, Director of the Affirmative Action Coordinating Center in New York. Scheduled to begin trial before Judge Wil- liam Meek in Wyandotte County District Court in Kansas City, the case has received little publicity beyond the Midwest, despite the drama and pathos which has already attracted film producers interested in mak- ing the story into a movie. Five years ago four Black students - Charles Floyd, Nolan Jones, Charles Lee, and Ernest Turner - per- ceived a pattern of racial discrimination at the hands of Dr. Dante Scarpelli of the Pathology Department of the University of Kansas Medi- cal Center. With the assistance of Affirmative Action Officer Chester Rempson, they filed a complaint with the school, charging Scar- pelli with " willfully and unlawfully " violating the Civil Rights Act of 1964 in his efforts. towards " systematically eliminating them. from medical school. " Evidence of Dr. Scarpelli's views are on the public record, as he had published an article on minority admissions to medical schools in the New England Journal of Medicine in April, 1975. In that article he charged that medical schools were employ- ing a " double standard " for the admission and education of minority students, whose " only hope of survival depends upon subse- quent lowering of academic performance standards, a deplorable practice not only because it is the most despicable facet of the double standard, but also because it makes a mockery of the educational process. " He maintained that the public would be harmed by affirmative action. The mockery, however, was made in the proceedings which followed. The school denied the students a role in selecting the panel which would hear the charges or de- termining the procedures which would govern the hearings. The university also " neglected " to inform the four students that Scarpelli would have legal counsel - the uni- versity's own lawyer. When the students stormed out of the proceedings in protest, the charges were dismissed. Dr. Scarpelli quickly filed a $ 200,000 libel suit against Rempson and the students. A lone Black woman " hung " the first jury. Scarpelli, now at Northwestern University Medical School, has refiled the suit which was scheduled to begin October 29, 1979. Already the case has taken on tragic pro- portions, as the relentless pressures of the case over five years has led to severe psychological consequences for Chester Rempson, who, according to Horne, will be. " unable to participate effectively at the trial. ". The implications of the case are quite clear. If the case is lost, women and minority students would become even more reluctant to protest racial and sexual discrimination in the classroom for fear of expensive libel suits. If Scarpelli were to win, his claims about the harms of affirmative action would be supported by the courts. Time has proven a more revealing judge. All four students are now house physicians. in some of the most prestigious hospitals in the country. Sources: New England Journal of Medi- cine, April 17, 1975; Affirmative Action Coordinating Center. -H.S. power and affirmative action needs are not con- tradictory, they are complementary. The specific solutions chosen for resolving the specialty, geographic, and language / culture mal- distributions have served to exacerbate rather than resolve minority and women's underrepre- sentation in the health professions. This is, unfor- tunately, the natural consequence of the class in- 26 terests and ideology of the federal government, the health professions, and their academic institu- tions. Their myths are designed to disguise genu- ine contradictions and create them where they have never existed. References 1. Navarro, Vicente, Medicine Under Capitalism. New York, Prodist, 1976. 2. Sleeth, Boyd D., and Mishell, Robert I., " Black Under- Scarpelli v. Rempson- The Verdict In what civil rights leaders have called a landmark legal battle over affirmative action in higher education - the Bakke case of the 1980s, a former University of Kansas School of Medicine pathology professor, Dante G. Scarpelli, has won a libel suit against four former students and the former affirmative action officer. On November 17, 1979, a jury of nine white and three Black persons in Wyandotte County District Court found the four former students guilty of defamation of character. The court awarded $ 1,000 compensatory and $ 10,000 punitive damages from each of the former students, after Scarpelli had sued each for $ 55,000. Chester J. Rempson, the former affirmative action officer, was served with a $ 55,000 default notice. The four former students filed a complaint against Scarpelli, claiming that he had tried to force them out of school, violating their civil rights. The faculty hearing called by Rempson ended when Dr. Scarpelli arrived attended by the school's attorney and the students left in protest. A year later Scarpelli brought suit for a total of $ 1.4 million for libel and invasion of privacy. Although Scarpelli claims that he was " practically being run out of Kansas, " he currently holds the pathology department chair at Northwestern, after turning down a position at Harvard during the proceedings. Although not identifying faculty individu- ally, a HEW study in 1975 found that there was probable cause to conclude that the University of Kansas School of Medicine had discriminated aganst the four students sued. James Meyerson, NAACP assistant gener- al counsel and representative of the four stu- dents'defense, said that the case will be appealed. Source: American Medical News, November 30, 1979. Representation in United States Medical Schools, " New England Journal of Medicine 297: 1146-1148, Novem- ber 24, 1977. 3. Schildhaus, Sam, An Exploratory Evaluation of U.S. Medical Schools'Efforts to Achieve Equal Representation of Minority Students. DHEW Publication No. (HRA) 78-635, December 1977. 4. Bayer, A.E., " The Black College Freshman: Character- istics and Recent Trends, " American Council on Educa- tion Research Reports 7 (3): 1-98, 1972. 5. Mantovani, Richard E., Gordon, Travis L., and Johnson, Davis G., Medical Student Indebtedness and Career Plans, 1974-75. DHEW Publication No. (HRA) 77.21, September 1976. 6. Holmstrom, Engin I., Knepper, Paula R., and Kent, Laura, Women and Minorities in Health Fields: A Trend Analysis of College Freshmen. Volume III: A Compari- son of Minority Aspirants to Health Careers. Washing- ton, D.C., American Council on Education, Policy Analy- sis Service, 1977. 7. Student National Medical Association, Minority Medical Students: Who they are, Their progress, Career aspira- tions, Their future in medical school. DHEW Publication No. (HRA) 78-625, 1978. 8. Astin, Alexander W., " College Dropouts: A National Pro- file, " American Council on Education Research Reports 7 (1): 1-71, 1972. 9. Astin, Alexander W., " Financial Aid and Student Persis- tence, " Los Angeles, Higher Education Research Insti- tute, July 1975. 10. American Council on Education, Policy Analysis Service, Trends and Career Changes of College Students in Health Fields: A Summary Report of a Study by the American Council on Education, Policy Analysis Service. DHEW Publication No. (HRA) 75-54, 1974. 11. Vetter, Betty M., Babco, Elanor L., and McIntire, Judith, Professional Women and Minorities: A Manpower Data Resource Service. Washington, D.C., Scientific Man- power Commission, November 1978. 12. Reitzes, D.C., and Elkhanialy, H., " Black Students in Medical Schools, " Journal of Medical Education 51: 1001-1005, 1976. 13. Curtis, James L., Blacks, Medical Schools and Society. Ann Arbor, Michigan, University of Michigan Press, 1971 1971. 14. " Medical Education in the United States, 1971-1972, " Journal of the American Medical Association 222: 962- 1047, 1972. 15. Yancik, R., " Datagram: Time of Decision to Study Medi- cine: Its Relation to Specialty Choice, " Journal of Medical Education 52: 78-81, 1977. 16. Astin, Alexander, King, Margo R., and Richardson, Ger- ald T., The American Freshman: National Norms for Fall 1977. Los Angeles, Cooperative Institutional Research, 1977. 17. Jay, James M., Negroes in Science: Natural Sciences Doc- torates, 1876-1969. Detroit, Balamp Publishing, 1971. 18. Association of American Medical Colleges, " Report of the Association of American Medical Colleges Task Force on Minority Student Opportunities in Medicine, " Washing- ton, D.C., Association of American Medical Colleges, June 1978. 19. Urban and Rural Systems Associates, Exploratory Study of Women in the Health Professions Schools: Volume II. Women in Medicine. Washington, D.C., Office of Special Concerns, Women's Action Program, DHEW, September 1976. 20. Waldman, Bart, Economic and Racial Disadvantage as Reflected in Traditional Medical School Selection Fac- tors: A Study of 1976 Applicants to U.S. Medical Schools. Washington, D.C., Association of American Medical Col- 27 leges, 1977. 21. Roessler, Robert, Lester, Jerry W., Butler, William T., Rankin, Billy, and Collins, Forrest, " Cognitive and Non- cognitive Variables in the Prediction of Preclinical Per- formance, " Journal of Medical Education 53: 678-680, 1978. 22. Murden, R., Galloway, G.M., Reid, J.C., et. al., Aca- " demic and Personal Characteristics as Predictors of Clini- cal Success in Medical School, " Proceedings of the 16th Annual Conference on Research in Medical Education. Washington, D.C., Association of American Medical Col- leges, November 1977. 23. Sheehan, T. Joseph, Husted, Susan D.R., Bargen, Mark, Candee, Daniel, and Cook, Charles D., " Moral Reason- ing as a Predictor of Physician Performance, " as quoted in Medical Tribune 20: 18, September 19, 1979. 24. Sedlacek, William E. and Brooks, Glenwood C., Racism in American Education: A Model for Change. Chicago, Nelson - Hall, 1976. 25. Hackman, J.D., Low Beer -, J.R., Wugmeister, S., Wei- helm, R.C., and Rosenbaum, J.E., " The Premed Stereo- type, " Journal of Medical Education 54: 308-313, April 1979. 26. Johnson, Davis G., and Sedlacek, William E., " Retention by Sex and Race of 1968-1972 U.S. Medical Entrants, " Journal of Medical Education 50: 925-933, 1975. 27. Gee, Helen H., " Differential Characteristics of Student Bodies: Implications for the Study of Medical Education, " Berkeley, California, Field Service Center and Center for the Study of Higher Education, 1959. 28. Dagenais, Fred, and Rosinski, Edwin F., " Social Class Level, Performance, and Values in Medical School, " Pro- ceedings of the 16th Annual Conference on Research in Medical Education. Washington, D.C., November 1977. 29. Gordon, Travis L., Descriptive Study of Medical School Applicants, 1976-77. Washington, D.C., Association of American Medical Colleges, 1977. 30. Ziem, Grace, " Medical Education Since Flexner: A se- venty Year Tracking Record, " Health / PAC Bulletin 76: 8-14, June 1977. 31. Chase, Alston, " Skipping Through College: Reflections on the Decline of Liberal Arts Education, " The Atlantic 242: 33-40, September 1978. 32. Gapen, Phyllis, " Minority Admissions: The Increasingly Empty Promise of Affirmative Action, " The New Physi- cian 28: 20-24, July August / 1979. 33. Wyatt, Gail E., Bass, Barbara A., and Powell, Gloria, " A Survey of Ethnic and Sociocultural Issues in Medical School Education, " Journal of Medical Education 53: 627-632, August 1978. 34. Wellington, John S., and Montero, Pilar, " Equal Educa- tional Opportunity Programs in American Medical Schools, " Journal of Medical Education 53: 633-639, August 1978. 35. Philpot, Wilbertine, Minorities & Women in the Health Fields: Applicants, Students, Workers. DHEW Publica- tion No. (HRA) 79-22, October 1978. 36. Hodge, Juel L., ed., Minority Student Opportunities in U.S. Medical Schools, 1978-79. Washington, D.C., As- sociation of American Medical Colleges, 1977. 37. Evans, Therman, " Training Black Physicians: The Cur- rent Status, " Hospital Practice 11: 13-17, September 1976. 38. Braslow, Judith B., " Current Status of Women in Aca- demic Medicine, " paper presented at the Regional Con- ference on Women in Medicine, New York City, March 24, 1979. 28 39. 39. Jolly, H.P., and Larson, Thomas A., Participation of Women and Minorities on U.S. Medical School Faculties. Washington, D.C., Association of American Medical Col- leges, March 1976. 40. McAnarney, Elizabeth R., " Impact of Medical Women in U.S. Medical Schools, " in Spieler, Carolyn, ed., Women in Medicine - 1976. New York, Josiah Macy Foundation, 1977. 41. Farrell, Kathleen, Witte, Marlys Hearst, Hogrun, Miguel, and Lopez, Sue, " Women Physicians in Medical Aca- demia: A National Statistical Survey, " Journal of the Am- erican Medical Association 241: 2808-2812, June 29, 1979. 42. Weaver, Jerry L., and Garrett, Sharon D., " Sexism and Racism in the American Health Industry: A Comparative Analysis, " International Journal of Health Services 8: 677- 703, 1978.: 43. Neely, George M., and Green, Robert A., " Predictors of Impact of a Minority Program Upon a Medical School, " Proceedings of the 16th Annual Conference on Research in Medical Education. Washington, D.C., Association of American Medical Colleges, 1977. 44. Heald, Karen A., Cooper, James K., and Coleman, Sin- clair, Choice of Location of Practice of Medical School Graduates: Analysis of Two Surveys. Santa Monica, Cali- fornia, The Rand Corporation, November 1974. 45. Montoya, Roberto, Hayes Bautista -, David, Gonzales, Luis, and Smeloff, Edward, " Minority Dental School Gra- duates: Do They Serve Minority Communities? " Ameri- can Journal of Public Health 68: 1017-1019, October 1978. 46. Thompson, Theodis, " Selected Characteristics of Black Physicians in the U.S., 1972, " Journal of the American Medical Association 229: 1758-1761, September 23, 1974. 47. Koleda, Michael, and Craig, John, " Minority Physician Practice Patterns and Access to Health Care Services, " Looking Ahead (National Planning Association) 2: 1-6, November - December 1976. 48. Institute of Medicine, A Manpower Policy for Primary Care. Washington, D.C., National Academy of Science, May, 1978. 49. Lloyd, Sterling M., Johnson, Davis G., and Mann, Marion, " Survey of Graduates of a Traditionally Black College of Medicine, " Journal of Medical Education 53: 640-650, August 1978. 50. Schneller, Eugene Steward, and Weiner, Terry S., " The Black Physician's Assistant: Problems and Prospects, " Journal of Medical Education 53: 661-665, August 1978. 51. Cuca, Janet Melei, Career Choices of the 1976 Gradu- ates of U.S. Medical Schools, Washington, D.C., Associa- tion of American Medical Colleges, 1977. 52. " Datagram: 1975 Medical School Graduates Entering Family Practice Residencies, " Journal of Medical Educa- tion 53: 939-942, November 1978. 53. General Accounting Office, Comptroller General's Re- port to the Honorable Ronald V. Dellums, " More Assur- ances Needed that Colleges and Universities with Gov- ernment Contracts Provide Equal Employment Oppor- tunity. Washington, D.C., Government Printing Office, August 25, 1975. 54. Melnick, Vijaya L., and Hamilton, Franklin D., eds., Minorities in Science: The Challenge for Change in Bio- medicine. New York, Plenum Press, 1977. 55. Office of the General Counsel, Department of Health, Education, and Welfare, " Memorandum: Impact of Bakke Decision on HEW Programs and Policies, " Washington, D.C., Department of Health, Education, and Welfare, April 1979. The Cultural Crisis of Modern Medicine by John Ehrenreich. New York, Monthly Review Press, 1978. John Ehrenreich has a well- earned reputation as a critic of the American health care system. He was a member of Health / PAC's own staff in the early 1970s and, together with Bar- bara Ehrenreich, co authored - the first Health / PAC book, The American Health Empire. If this most recent book - to which Bar- bara Ehrenreich also contributed ideas as well as essays - raises more questions than it can answer, it is because both Ehren- reichs have consistently under- taken the socio political - analysis of American health care at a re- freshingly mature level. Ehrenreich takes the title of this collection of essays on the uses and misuses of modern medicine from the theme he believes runs through the essays themselves. In a thought provoking - Introduc- tion, he describes the develop- ment, over the past 10 to 15 years in the U.S., of a " cultural cri- tique " of mainstream medical practice. Since the anthology ul- timately hangs together around this theme of " cultural critique " or " cultural crisis, " it is the issues raised in this Introduction that the bulk of the following discus- Media Scan sion will address. The cultural critique of medi- cine, the Introduction argues, consists of a direct challenge to the notion that " Western - style medical care is effective, humane and desirable. " This latter notion, Ehrenreich argues, has been held in com- mon by both radical and liberal critics of the organization and delivery of U.S. health services for some time (with what he im- plies are minor differences between the liberals and radi- cals). Its most simple expression might be characterized as " more is better. " Problems in the health system, from this perspective, are viewed as emanating from " the organization of medical care, and not as intrinsic to the nature of medicine itself. " When employed by radical critics, Ehrenreich labels this approach the " political economic critique " and much of the balance of the Introduction is spent distinguish- ing the " cultural " from the " poli- tical economic " critiques. The implication, although never quite formulated this way, is that the cultural critique fol- lowed the political economic cri- tique historically - just as the 1960s and 1970s followed the 1940s and 1950s, the New Left followed the Old Left, and so on. Specifically, the roots of the seemingly - newer cultural critique are traced in four relatively re- cent protest movements: @ Anti psychiatry - : The first of these is the challenge to the therapeutic benefits of psychiatry that arose during the 1960s. Here Ehrenreich's argument is a little fuzzy: it is never clear why attacks on psychiatry - some of which complained precisely that psychiatry was too unlike medi- cine in its lack of rigor and scien- tific basis should - have pro- duced similar attacks on medi- cine. Of course the late 1960s abounded with movements and protests that targeted profes- sionals and professionalism for their conservatism, racism, class basis and a host of other faults. How these specifically linked to a. cultural critique of medicine is, however, not clear. @ Revolts in Urban Commun- ities: A second wellspring for the cultural critique is identified in the Black, Hispanic and Asian community protests during the 1960s. When directed at the health system, these movements often targeted the racism and social control dimensions of a medical care practiced almost universally by white profes- sionals. Although I think the argument is on target in linking this to broader liberation move- ments within and without the U.S., again the issue begins to cloud. The implication is that in at- tacking the social and _ profes- sional medium through which medicine passed, these attacks were actually addressing the sci- entific content of clinical medi- cine. Without nit picking - , it seems to me this confuses the is- sue, a theme I will pick up be- low. It is one thing to try to des- troy the mystification of medical knowledge, the monopolization of skills, the racism and class biases of its practitioners. It is an- other to argue that, for example, penicillin is potentially dangerous or low dosage - radiation is proba- bly carcinogenic. It is still an- other to argue that most of west- ern clinical medicine is unable to treat the whole person, family or community and is unable to identify systematically the social, environmental and occupational 29 causes of disease that would allow many to be prevented. These latter issues involve the efficacy of the health care system as well as its underlying method- ology in approaching disease and death. Unfortunately, despite some invoking of Illich and McKeown in the Introduc- tion, the essays selected really do not touch on the questions of efficacy, causation of disease or modern medicine's " scientific method. " The most widely acknowledged problem facing modern medicine is that costs are soaring ahead of effects... Although the community pro- test movements of the 1960s can, I think, be credited with " discovering " some diseases- e.g., lead poisoning and Sickle Cell anemia - they did so using a kind of populist epidemiology that, in more formal hands, had been around as method for a long time. Equally important, these " discoveries " most often led to demands for more " Western style " medical care, while simultaneously attacking the practitioners of that care for their racism, class bias, profes- sionalism and their failure to res- pond with appropriate services. In other words, there was less separation in practice of the " cul- tural " attack on medicine from the " political economic " attack than is implied. (Although I do remember that some of what Ehrenreich calls " cultural " ques- tions, when raised in left circles in the late 60s early - 70s, were usually dismissed as being theor- etically irrelevant. So it was with early attempts to deal with either 30 the epidemiologic perspective, or with the notion of health as a developmental process requiring activism by those who seek it. The latter question has since largely been appropriated by the " holistic " health movement.) The OEa ttack on professional- ism: An explicit attack on the mystification, the monopolization of skills and knowledge, and the social and ideological infrastructure associated with professional dominance of medi- cine is cited as a third root for the " cultural critique. " The social forces that embodied attack are identified as the women's move- ment and the rise in both num- bers and organized strength of nonprofessional health workers. Here I think the argument finds solid ground. Each of these movements - in their own ways and for their own reasons represented thousands of people who could not accept ... the major under- lying dynamic in health costs inflation is the phenomenon economists call intensification.... the male physician as arbiter of truth, wielder of hierarchical au- thority, and monopolist of benefit and privilege associated with human healing. Of the two, how- ever, I think it must be said that is has been only the women's movement that fits the niche Eh renreich attempts to carve in his- tory for the " cultural critique. " Confronted by an incredible history of inaccurate and damag ing diagnosis and medical [mal] practice on women as patients, the women's health movement has emerged as a discrete and articulate challenge to the con- tent of traditional women's medi- cine (principally Ob Gyn /) as well as its form. (This distinction between content and form is mine, not the book's. Although the book implies the two are in- separable - and at one level of analysis they certainly are - I think it necessary to distinguish them for purposes of this discus- sion). .... * all the while there is a deterioration in many of the elements of quality care In challenging the content of medicine, the women's health movement has found more in common, it seems to me, with the broader self help - movement and the otherwise quite distinct and older public health move- ment in their common question- ing of the basic methodology with which clinical medicine approaches human disease and suffering. Bi The attack on medical effi- cacy: The final source of the " cultural critique " Ehrenreich cites is the by familiar - now - sub- ject of much of the current litera- ture in medical sociology, social epidemiology, medical econ- omics and medical care organ- ization, namely the diminish- ing returns from geometrically increasing investments in tradi- tional medical care. Although I would suspect any reader who has made it this far is familiar with the basic arguments, they can be briefly summarized. Des- pite rapidly soaring costs of care in recent decades, and despite evidence that this is not simply price gouging - , but actually re- flects more procedures being done on more people every day, keen observers such as McKeown and Illich have point- ed out that there has been no commensurate rise in health levels in the U.S. population. In- deed, whatever quantum leaps have occured in general health status can be shown to have arisen primarily from environ- mental changes rather than medical intervention. In a brief discourse, Ehren- reich targets two characteristics of modern clinical medicine as responsible for its poor track re- cord: (1) The single cause - ap- proach to disease; and (2) the machine model of the human body. Unfortunately, on these promising notes, the subject is ef- fectively dropped. Finally, in a concluding discus- sion, the Introduction examines the potential for resolution of the " political economic " and the " cultural " attacks on medicine. Like a Greek tragedy, however, just as the drama peaks, we are thrown back into reality. In this case, the deus ex machina that As medicine gets more expensive, those paying for it government -, business and labor- want to know why... terminates the plot is a call for a new " mass movement, " (presuma- bly as in the 1960s), that will synthesize the two critiques in practice. While the latter may prove his- torically accurate, it hardly seems helpful for anyone en- gaged at any level of struggle with the current health system. Although invoking the vision of a socialist medicine that will be dif- ferent, it provides the slimmest of clues as to what and how human health can be approached differ- ently in a socialist society from a capitalist one. However, Ehrenreich does make some of his best points on the way by. Socialist medicine, he notes, will not be, to use Robb Burlage's apt description, " Zero death, zero pain, zero suf- fering. " Neither, Ehrenreich sug- gests, is it likely to throw away the baby of clinical medicine with the bathwater of its ex- cesses. Finally, in perhaps the most provocatie note, he points .. " Congress has recently funded a major study critical of medical technology. out that a socialist medicine is one that will accept and provide humanely for the reality of peri- odic human dependency without exploiting the vulnerability of the recipient in the proces. After all this, I think the reader is left up in the air. Now, of course, any review can be accused of discussing the book that might have been writ- ten rather than the one that was. But I think Ehrenreich invites a broader set of questions by im- plying the political synthesis of the various protests against medical practice will spontan- eously flow from the rise of a new " mass movement. " The lat- ter is not only not described, the possible causes of such a move- ment are not only left undis- cussed, but more important, the contribution that some of the newer anti medical - forces may make to such a movement are apparently not taken into account. The problem with the concept of " cultural crisis, " it seems to me, is precisely that it is far less than a whole crisis. And the pro- blem with Ehrenreich's argu- ment - as far as it goes - is that it over - uses the concept of " cul- ture " (as does much of modern social science). The result is that when all is said and done, it isn't clear what has been explained. If a " cultural " critique of medi- cine is a residual concept that in- cludes any and all attacks on medicine whether of its content, its method, its findings, its tech- nology, or whatever - then such a critique is quite old. The poor, various ethnic minorities, wo- men, rural migrants and various other subjugated and alienated groups have long sought alterna- tives to established medicine for resolving aches, pains and more serious ailments. Moreover, these alternative sources of car- ing and healing have generally come to co exist - quite peacefully a and even the American Surgical Association called for programs whereby the public'should be made aware of the limitations as well as the triumphs of modern medicine ' ee with established medicine for long periods of time. It becomes clearer in the es- says themselves what Ehrenreich actually intends by his concept of " cultural critique. " For of the twelve essays selected, well over half deal directly with the uses of medicine as means of social con- trol. Two of the essays deal with 31 this phenomenon head - on: " Medicine and Social Control " by the Ehrenreichs themselves and " Medicine as an Institution of Social Control ", by Irving K. Zola. Both are excellent exam- ples of the literature on the uses of professional credentials and specialized knowledge for pur- poses of personal and _ social dominance. The social control potential of medicine is further illuminated in the case of women's medicine in a set of five essays that make up Part 2 under the heading " Medi- cine and Women: A Case Study in Social Control. " Contributors include Barbara Ehrenreich and Deirdre English, Linda Gordon, Doris Haire, Mary C. Howell, Diana Scully and Pauline Bart. In a final section- " Part 3: Medicine and Imperialism: Of You the Story Is Told, " - the his- toric and contemporary potential of medicine for inter cultural - dominance is made clear in four essays that include Frantz Fanon's unparalleled " Medicine and Colonialism, " as well as ex- cellent pieces by E. Richard Brown, James A. Paul and Ho- ward Levy. The common theme in this section is that of cultural imperialism and the unique con- tribution of medicine to the sub- jugation of whole nations and peoples. Few serious students of medi- cal care and its organization will quarrel with the common obser- vation running through these analyses - i.e., that medical knowledge and practice are unique weapons in the hands of any person, sex, race, class or nation bent on dominance. And few radicals will question the generalization that such motiva- tions and such dominance have heavily influenced the way medi- cal care has been delivered through much of human history. The interesting problem, how- ever, is where do things go from there? The concept of a crisis arising within modern medicine A due to its cultural alienation from its would - be beneficiaries (i.e., " health care consumers ") re- quires, it seems to me, evidence that is simply missing here. Only in the case of women's medicine can one see how such a crisis might occur: cultural alienation from male Ob Gyn / practitioners led first to challenging the man- ner of clinical practice, then to the actual biomedical knowledge (supposedly) underlying that practice, and finally to directly challenging the method whereby such findings were derived. That is a critique, all right, and it pre- sents real crisis as well. The reader would have no trouble with the thrust of the argument, I suspect, were this book entitled, " The Modern Crisis in Women's Medicine. " What is striking about all of the other forces Ehrenreich identi- fies as contribut- ing to the " cultural critique, " how- ever, is that none of them ever real- , ly challenged the body of know- ledge, much less the methods of the bio medical - sciences that are at the core of clinical medicine. Do CELSI MCMLXXIX Ironically, meanwhile, modern medicine as a whole is in crisis- or at least beset by a number of deepening contradictions and under attack from several quarters. The most widely acknow. ledged problem facing it, of course, is that its costs are soar- ing, far ahead of its effects. The health costs situation has been explored in too many other quarters to fully restate here, but two major points about escalat- ing health costs need to be firmly grasped: (1) The major under- lying dynamic in health costs in- flation is the phenomenon econ- omists call intensification. One way to understand intensification is to note that a number of sophisticated analyses have shown that the basic variable in rising hospital rates (the " heart " of the costs spiral) is that more and more " procedures " are be- ing done to the average patient. This involves more physical commodities (e.g., drugs, eye- glasses, and prosthetic devices, not to mention amenities such as telephones, TV's and exotic menus for inpatients) as well as commodified services (e.g., frag- mented subspecialty therapeutic procedures and computerized diagnostic tests). Both are de- livered in increasing numbers every year to the same patient for the same condition. (2) The causes of illness are probably in- creasing at a rate faster than the growth of the population, so that any medical system would be straining to keep up with them. Much intensification derives from " defensive medicine " on the part of physicians - i.e., the ethic. of " First Don't Forget Anything that Might Produce a Malprac- tice Suit. " It is also fundamentally tied up with the continuing, im- mense marketing effort of the hospitals industry and its sup- liers - e.g., the drug industry, the hospital supply industry, the hos- pital construction and medical torted priorities of American computer industries. medicine - to demand more pre- The " bottom line " of the inten- vention, more primary care, sification process is literally that more community - based services " more is better. " Generally the that deal with the social and en- " more, " however, is largely illus- vironmental roots of illness - are, ory - i.e., more procedures, instead, often as mystified as the more tests, more drugs, perhaps average citizen by the claims of more visits with the provider- the providers. but little or no improvement in Lacking the artillery to attack outcome, or at least in measur- the content of medical care, con- able outcome. (There is proba- sumers and community activists bly an actual deterioration in have simply proven no match many of the elements of quality for the providers. Lacking an care, meanwhile, with increased articulated vision of humane waiting times, record coordina- health care that is a real alter- tion problems, and harmful side- native to TV's " Medical Center, " effects of newer and newer pro- we are often reduced to demand. cedures " rushed " to the patient.) The impact of all this on health ing a Medical Center in every community and a token voice in levels in the population is often neutral at best, negative at worst. As medicine gets more expen- sive, more and more of those running it. As a result, costs and efficacy remain issues that trou- ble only the institutional payors and their constituents (the latter who pay for it notably - govern- ment, business and organized labor - want to know why. Al- though there is no consensus on the explanation yet, it is at least including taxpayers'groups, health benefits analysts, health policymakers and medical pro- viders themselves - generally a conservative lot). worth noting that Congress itself To counter such a dismal situa- has recently funded a major study critical of medical techno- tion, one can hope for a real movement that would seriously logy, that medical technology is increasingly scrutinized and try to define a progressive con- tent for health care and the regulated, and that even the Am- erican Surgical Association ()! re- cently called for programs whereby the general public " should be made aware of the limitations as well as the triumphs of modern medicine. " broader public health. One might also hope that this move- ment would recognize its natural affinity with those whose princi- pal targets are the environmen- tal, occupational and social causes of illness - i.e., the envir- All these developments, of course, speak to a sobering reality for health activists: the cost crisis and the related crisis onmentalists, the health and safety labor groups, and those fighting housing, nutritional, educational and economic injustices. of medical efficacy- are by and Such a broad movement large " their " problems, not " ours. " That is, consumers, ur- would place high on its agenda two priorities currently noticable ban minorities, women's groups, and " health leftists " are generally far more concerned with access for their absence: (1) an epidem- iologic or public health orien- tation to health care delivery-- (more) and control (how) than i.e., one that concentrates most with the content (what) of health resources in areas of most need care. As a result, those who might seize the cost efficacy - cri- sis in order to challenge the dis- and puts the major emphasis on prevention rather than late stage - curative techniques; (2) an em- 33 phasis on developing healthy communities, workplaces and social relations as indispensable to humane health care. If such a movement remains an illusory hope at present, it is nevertheless likely that nothing short of it will ultimately be re- quired to successfully chal- lenge the hegemony of high- technology, high specialty - , high- cost medicine. That is, the pro- blem Ehrenreich raises is bigger than either the " political econ- omic " or " cultural " critiques, or even some convergence of the two, can resolve. If there is a spectre haunting modern medi- cine, its nature is probably best suggested by the one contribu- tion to this book that does not see the problem as only the mis- use of medicine for purposes of social control. In an essay entitled " On the Structural Constraints to State Intervention in Health " originally published in 1975, Marc Renaud suggests the basic question is that of " The imple- mentation of an altogether differ- ent approach to health, disease, and medicine. The decom- modification of health needs, leading to a more intense and direct preoccupation with the social conditions giving rise to disease. Specifically, it involves the development of a new medical knowledge based on what has been called an'eco- logical approach, the elimina- tion of private property in skills, training, and credentials, and a reversal in the actual trends in the allocation of resources to- ward therapy and prevention, so that human beings can self- produce care of their bodies and minds, individually and socially. " If no such well defined - alterna- tive to modern medicine current- ly exists, there have at least been some attempts to move this broader agenda along during the 1970s. One might end by expressing the wish that this vol- ume had included some of these efforts whether from the Marx- ist epidemiologists, the holistic health practitioners, the self help - writers or the Illich McKeown - strain of medical nihilists. For it is increasingly difficult to believe, as we enter the 1980s, that the crisis Ehrenreich and most radi- cal observers devoutly wish on modern medicine can continue to safely ignore its very content. Ultimately this is a tall order, of course, since Ehrenreich is cer- tainly right when he notes that " To ask what kind of medical care we want is to ask some very basic questions about the kind of society we want to live in. " -Michael E. Clark 34 Peer Review A No Naivete, Please Dear Health / PAC Bulletin: The medical care system seems to be moving remorselessly on to higher inflation, more technology, less personal care and less attention to the needs of the poor, the infirm, the aged and the minorities. Clear advice and guidance toward change in the medical care system where possible is needed; where the system itself must be changed to produce such im- provement must also be broad- cast. Unhappily, the people's champions seem unable to move beyond polemical attacks and vague catchwords for proposals. Cynthia Driver's essay on Home Health Care in the Triple Issue is a case in point. Driver is certainly knowledgeable about the frightening inadequacies of long term - care for the old, sick and poor; decently indignant about the abuses and neglect. But her audience deserves more than the simplistic and therefore misleading discriptions and dis- cussion she offers. " Community " although appar- ently defined, is unclear. Where is the political mandate? Where will the money come from and to whom will it be given? Who will be accountable? How will the professionals get integrated into the " currently fragmented and discontinuous pattern of services "? Parenthetically, why are we subjected to the naive " all or none law " in regard to hospitals? Are they all bad, untrustworthy, aims selfish, means imperial? Can there exist a hospital that serves a community purpose, even a non- public one? I was responsible for the operation of the Montefiore Home Care Program from 1951- 1965. We were losing money for the hospital and for the Federa- tion of Jewish Philanthropies at a great rate. But we thought we were demonstrating that people should best be accommodated in a place suited to their needs, not warehoused in institutions. We wanted them out of hospital and out of nursing homes for their sakes, not ours, or the financial benefit of the institution. We had recreational, occupational, physical therapists, social workers, " friendly visitors "; put in telephones at our expense to allay the insecurity and fears of the pa- tients and their families; readmit- ted patients to the hospital as needed, bypassing the usual ad- mission office because they con- tinued to be hospital patients (yes, continued to be hospital patients outside the walls). Was that bad? Before Medicare's rigid regula- tions, we were also able to admit patients for social reasons: to al- low the family to have a vacation in the summer, or go to a Bar- Mitzvah in Philadelphia over a week - end. The reason less money has to be appropriated for Home Care, even the deluxe type described here, is because the hospital over- head doesn't have to be paid. True, there is an overhead at home, and we worked that out with the Welfare Department, so that two agencies were paying for the home service, but the medical care costs doctor's - visits, nurs- ing and the whole host of other medically related services, oxy- gen, medications, wheelchairs, and the rest came - out of the Home Care budget. Food, rent, clothing came out of Welfare. Was that bad? We had a sala- ried service, careful record keep- ing, supervision from a medical director, weekly conferences, access to specialists as required, transportation. We knew _ that 20% of patients in hospital didn't Let's try to avoid classification by role (all doctors, etc.) or social position (all hospitals, etc.) and adopt an even- handed approach to criticism es need to be there; that maybe 75% of nursing home patients didn't need to be in those institu- tions. Wasn't it a socially neces- sary and desirable activity? Wouldn't as much money be saved to be used for other useful purposes if a similar type of com- munity home care were intro- duced in New York, America? Isn't this the long sought " alterna- tive to institutional care "? I also resent the equating of " home health services " with Home Care. Sure Medicaid and Medicare compel the kind of frag- mentation and wasteful and im- personal kind of non institutional - services that Driver decries. But a comprehensive report should have distinguished between Up- john and Montefiore; as a matter of fact, should have elaborated 35 much more on the possibilities of Training that what Montefiore's Home Care of- fered and what it could do for Alienates New York and the country. In short, the Health / PAC Bulle- tin owes its readers a more dispas- sionate, thoughtful and objective, comprehensive analysis of Home Care than we got. I have the im- pression that the same could be said about many other articles, about which I may not have the personal background and infor- mation that I do about Home Care. This is not only unfair, it is stupid. There are so few journals or loca- To the Editors, Medical students start out with genuine, albeit vague, intentions to help others and to share in their lives. But the process of their edu- cation causes profound changes to take place, changes at the root of health care's present malaise. Very little in medical school is taught directly. Skills and atti- tudes are imitated until they conform to unwritten standards. tions altogether where one can get a non establishment - point of view and factual background that it is doubly sad that all one can get on a critical medical care issue like Home Care is another polemic. Let's try to avoid classification by role (all doctors, etc.) or social position (all hospitals, etc.). Let's adopt an even handed - , temper- ate approach to criticism - one can criticize one's friends without attacking them along with the enemy avoiding political com- Decision making depends on the limits of one's own conscience and on whom one suspects is look- ing. An oft cited - adage is, " see one, do one, teach one. " Dogma gets passed along without room. for questions. Students start out with moral and ethical principles of their own but the design of their education makes it difficult to exercise or test those beliefs. Medical education is a lonely experience, though it seemingly brings one into contact with the most basic of human emotions promises and keeping an eye on the main goal, which is better medical care for all the people. Sincerely, George A. Silver, MD, Professor of Public Health, Yale University School of Medicine and needs. The human side has been culled out in favor of the competition for exertion and scientific excellence. It is the rule of the iron man, embattled but un- bowed, whites covered with excreta the morning after the big flog. If each must stand alone, no wonder that patients are to be de- The author replies: spised as helpless, given up, car- As we stated in the article, a ried into the hospital overcome comprehensive Home Care Pro- by disease that healthy people in gram is a potentially progressive control of their lives will never alternative to overly institution- have. Students need to create dis- alized, expensive, health care. tance from all the illness, need to Our intention in this article was to find ways to cope with these vi- present a critical view of the cur- sions of their own fate carried rent Home Care situation . Dr. Sil- before them. The hospital helps ver's interest in underlining the by assigning these white middle positive aspects of Home Care is class students to poor, minority legitimate and a positive contribu- group patients. For many condi- tion to the discussion of Home tions the poor have increased Care's role in the health care sys- morbidity and mortality, and stu- tem. dents, to protect themselves, can 36 -Cindy Driver draw the lesson that these people are sick because they are inferior, because they have done some- thing wrong with their lives. They are gomers, dogmeat, bottom feeders and in the end they will " box it " and take away their lin- gering aura of death and poverty. Medical education does little to diffuse these feelings, to give stu- dents support instead of allowing their emotions to turn on others. No one makes an effort to help students understand where their patients come from or the lan- guage they speak or why their clothes are dirty and their health seemingly neglected. No one tries to support the patients or their frightened families, caught in the white bustle and the latin jargon. If anyone attends to this it is the student, but it is a job done on one's own time, seen by teachers as a luxury and an escape from more serious work. Students are taught how to keep these patients. at arm's length. Students have a hard time ra- tionalizing what they must do to other human beings. Literally they must practice painful and un- comfortable procedures. The hos- pital offers them help in the pa- tients it selects for learning: on the " public " wards, at the veterans ' hospital. No longer charity cases, most of these patients pay for the services they receive. But still " green screens " and " pocketbook biopsies " sort out Blacks, His- panics, and poor whites and send them to the dingier waiting rooms, the turn century - of - the - open wards, the poorly super- vised care of hurried learners. Students get the message that these people deserve less and can be tolerably hurt in return for the generosity they receive. Most practitioners spend their time in an office or clinic, where the bread and butter of daily complaints are heard. Yet medical school goes out of its way to paint this activity in the most distasteful of lights. Outpatient ex- periences are severely li- mited, looked at as second rate learning experiences and as institutional liabili- ties in the ledger book. In- | stead of presenting the in- tellectual and human re- wards of ambulatory work, students are shown nightmares of poor organ- ization and planning: days in a tumbledown rural health department - dis- pensing birth control and Flagyl to mute women herded into cramped exam rooms, patients waiting for hours for the simplest of follow - up visits. Worst is that the stu- dents come to dislike themselves for the things. they start to do, the cor- ners they begin to cut. Few really know why they ~~. are in medical school, and the railroad track of curri- culum leaves little room for originality. The pace is fast as 36 hour - days blend into weeks of five nights on call. The patient that takes extra time, whose language is difficult to un- derstand, whose story is not sim- ple, becomes a personal assault. White, middle class students find that white, middle class patients are articulate, quickly compre- hensible, rewarding to care for. The poor, Black, and Hispanic patients are hard to talk to, get in the way of quick admission work- ups, and are unlikely to do what they are told. With fatigue, the outside sup- ports and relationships slip away. There is no chance to regain some of one's own humanity, to get some perspective on the in- credible ethics of the hospital. As one's language and expertise get farther and farther from the " layman's " comprehension or interest, only other doctors can appreciate one's worth, and only patients who have read all about it in the Times can understand why they are asked to do such bizarre and painful things. A crop of little big men look for someone to blame for the sacrifices they have made without knowing what they were getting themselves in for, for their status of lord on the hospital floor and the emptiness of their lives when they take off their name tag and white coat. Only the mobile middle class can ap- preciate these doctors for where they are going and ignore the dis- mal quality of where they are. The poor or minority patient lives a separate reality, has con- cerns of a much more funda- Y mental nature than the new doctor is capable of addressing. Not only has the new doctor had little training in nutrition, economics, or the politics of dis- crimination, but the process of medical education has stripped away the human roots that might enable her or him to come to grips with these problems in others. Students need time and help to come to grips with social and personal issues. Until they do, their training will only further alienate them from the people they are starting out to serve. Sincerely, Larry Wissow, M.D. (Larry Wissow is an intern at Johns Hopkins) 37 as oP Sea d SX vy, Y) e... HEALTH CARE IS FOR PEOPLE NOT FOR PROFIT * Health / PAC, 17 Murray Street, New York, N.Y. 10007 Suitable for Framing Limited Time Offer to all Health / PAC subscribers A 17 " x 22 " poster featuring an illustration by artist Bill Plympton Brown letters on beige paper overlaid on orange caduceus Health Care is for People Not for Profit Yours for only $ 3.00 plus 1.00 $ for mailing and handling Send check or money order to: Health / PAC, 17 Murray Street, New York, N.Y. 10007 Order Now! 39 INTRODUCING Wholistic Health A WHOLE PERSON - APPROACH TO PRIMARY HEALTH CARE Tubesing, Donald A., Ph.D. WHOLISTIC HEALTH A Whole Person - Approach to Primary Health Care " I read it cover to cover, every last word, and I think it's great. It's read- able and flowing, and has a dimension of cohesiveness which I really like. -David Hibbard, M.D. -----=== This pioneering work is an eloquent call for a redefinition of health and Pediatrics, Boulder, Colorado illness in the context of a broader view of life, health, and the quality of life to include the whole person the mental, emotional, and spiritual sides of life as well as the physical. It is based on the premise that only a re- definition of health care to include the whole person will lead toward solutions to the problem of the pre- sent health care system. Dr. Tubesing, the author of this thoughtful presentation, states empha- tically that thore is much we can do in moving toward positive, workable solutions to many of the problems in contemporary health care. One solu tion is the Wholistic Health Center " Should assist those providers serious- ly wrestling with problems of frag mentation of health care. I am confi- dent that this book will stimulate many practitioners to join the Wholis- tic revolution in health care. " -Granger E. Westberg, D.D. Univ. of Illinois at the Medical Center " A fascinating and undoubtedly con- troversial book that deserves to be in all libraries concerned with health care. -Library Journal holistic health A: Whole - Person to Primary Approach Health Care don sing project, in which Dr. Tubesing has played a central role from its incep- tion. 1978 240 pp. 0-87705-370-7 LC 78-3466 $ 14.95 HUMAN SCIENCES PRESS 72 Fifth Avenue 3 Hennetta Street \ @ _, NEW YORK, NY 10011 LONDON, WC2E BLU Human Sciences Press 72 Fifth Avenue New York, New York 10011 40