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Health Policy Advisory Center October 1970 HEALTH PAC Empire Roundup: Caught in the Squeeze " Gang invades hospital, " headlines the American Medical News, reporting on the cur- rent community / worker struggle at Lincoln Hospital in the Bronx. Lincoln has been a thorn in the side of the Einstein Medical Col- lege Montefiore - Hospital medical empire for a number of years. The Einstein controlled - municipal hospital is in an antiquated build- ing, which is inadequately staffed and poorly equipped. Community and worker groups seeking better health care have sought to wrest control from Einstein and to reset the priorities at Lincoln away from Einstein's teaching, research and financial needs and towards patient care. The health establish- ment has been visibly shaken by this new assault on their medical fortresses - an attack challenging their competence to determine the health needs of the patients and the com- munity. The energy generated by the strug- gle at Lincoln has been an inspiration to those in the health movement who believe that the health system can only be changed through a basic shift in who controls health resources. Medical empires are going through a peri- od of readjustment. From below, they are threatened by insurgencies such as the one at Lincoln, coming with increasing frequency and persistence. Community and worker groups are resisting cooption and repression. In reply, the medical empires are trying to consolidate their control over their existing holdings. Control is the name of the empire game. Through their monopoly of power over their network of affiliated institutions, the em- pires can impose their research and teaching priorities on the health system. A threat to this control is a threat to the abilities of the institutions at the core of the medical empires to function at all. Empires are also coming under pressure from above. The federal government, busily trying to balance the budget while ignoring big city needs, has cut back on research grants and other funds for medicine. The med- ical schools and medical centers have been hard hit, since they rely heavily on research monies for faculty salaries. This change in federal policy may in part reflect a decline in the empires'influence over federal health policy, which was such a dominant feature of the Kennedy - Johnson era. Meanwhile, state and local government resources going to health have also been restricted, thus com- pleting the squeeze. In previous BULLETINS, HEALTH - PAC has traced the development of medical empires in their period of manifest destiny. Now this pincer movement of financial cutbacks and insurgencies has forced the empires to look to their defenses. This BULLETIN gives a round - up of the empires in New York City and reports on some of the various health insur- gencies going on in the city. Bronx The Bronx empire dominated jointly by Al- bert Einstein College of Medicine (AECOM) and Montefiore Hospital is one of the most highly developed and consolidated medical empires in the country. Patients, medical man- power, and money flow freely amongst the dozen or so institutions which make up the empire and which include the bulk of the borough's medical resources. Because the empire is so highly developed, it is virtually. a textbook study on the conflicts between the research, teaching, and financial priorities of the imperial center and the health care needs of the community. [See BULLETIN, April and September, 1969, for more details on the Ein- stein Montefiore - empire.] And because the empire controls two of the three municipal hospitals in the Bronx, the Einstein Montefiore - empire also experiences the conflicts between the burgeoning private sector in health and the remaining shadows of City involvement in the hospital system. It comes as no surprise, then, that some of the country's sharpest struggles around use and control of health services have occurred in the Bronx. At Lincoln Hospital, the munici- pal hospital affiliated with AECOM which serves the largely Puerto Rican population of the South Bronx, a two year long struggle has been waged between radical workers and community people on the one hand and AECOM and the City on the other. [See April and May, 1969, BULLETIN for the early his- tory of the struggle.] As reported in last month's BULLETIN, the struggle has recently sharpened, under the leadership of Think- Lincoln, a community / worker group con- CONTENTS 1 Bronx 3 Lower East Side 6 Upper East Side 8 Downstate 9 Columbia 11 11 Consulting Firms cerned with the hospital, in alliance with the Young Lords and the Health Revolutionary Unity Movement (HRUM, an organization of revolutionary third world health workers). Think Lincoln - had made seven initial de- mands, ranging from the demand for a day care center and a grievance table to the de- mand for control of the hospital by a com- munity worker / board. Two months ago, a young woman named Carmen Rodriguez died following an abortion at the hospital. Charg- ing that her death was due to malpractice, Think Lincoln - added to its list of demands the demand for far reaching - changes in the hos- pital abortion program and for the resignation of the director of the abortion program, the chief of obstetrics. Dr. J. J. Smith. By late August, top officials of the New York City Health and Hospitals Corporation and of AECOM, who up to that time had been con- tent to permit their local representatives at Lincoln to handle the insurgency, stepped in to spearhead a counter offensive - against the rising tide of community / worker militancy. Events in late August centered around the obstetrics department. Think Lincoln's - de- mands had not been met: No changes had been made in the abortion program, which even its director. Dr. Smith, is alleged to have admitted was " inadequate, " and Smith him- self had refused to resign. The tinder was ignited when Smith refused to renew the con- tract of Dr. Noel Phillips, a West Indian with a fellowship in the obstetrics department, al- legedly because of repeated lateness and ab- sence. Phillips denied the charges, and some seventy non physician - members of the ob- stetrics staff (many of whom would have been inconvenienced if Phillips had been as unreliable as charged) signed a petition urg- ing that Phillips'contract be renewed. On Monday, August 24, Think Lincoln - called a noontime meeting to discuss how to respond. About twenty - five workers came and decided to go to Dr. Smith's office to demand that the decision be reversed. At the same time, an- other Think Lincoln - delegation was confer- ring with Smith about the case of several women who claimed to have been waiting for abortions at Lincoln for up to two months without explanation. The two delegations in- formed Smith that they were staying in his office until Dr. Phillips was given a contract renewal. After several hours, Smith capitu- lated and signed a new contract, a clear vic- tory for Think Lincoln - . The Think Lincoln - dele- gations then demanded unsuccessfully that Smith resign. Finally the demonstrators told Smith to leave the office and not to return. The next morning, the counteroffensive be- gan. At 5:30 a.m., resident in the obstetrics department began discharging all patients in the department without warning and without making alternative arrangements for care. (A few of the sickest patients were trans- ferred to other services.) The residents then went out on strike in protest against Think- Lincoln's harassment of Dr. Smith and of themselves. Certain Einstein Medical College officials apparently instigated or at least as- sisted the walkout: some obstetrics residents were ordered to leave the hospital building by a high ranking - Einstein official when later in the morning they tried to readmit some of the discharged patients. Tuesday evening, a Think Lincoln - meeting held in the obstetrics office was dispersed by the police. The next day, Think Lincoln - , along with the Young Lords and HRUM, was served a temporary restraining order barring them from " interfering " with hospital medical or administrative functions, " harassing ". em- ployees, distributing leaflets in the hospital, violating any directives issued by the City hospital administrator, Dr. Antero LaCot, or occupying any space - room or hall - in the hospital or adjacent to it without LaCot's ap- proval. (This last provision forbade Think- Lincoln from operating the grievance table they had set up in the emergency room or the day care - center they were running in the nurses'residence.) Hospital supervisory per- sonnel let it be known that the administration was interpreting the injunction as forbidding workers from holding meetings (even union meetings!) without LaCot's permission and from talking to Think Lincoln - people even off the hospital grounds. Several nurses were threatened with loss of their jobs merely for discussing the events with other nurses. Thursday, the Pediatric Collective (a group of interns and residents in the Lincoln Pediat- rics Department) held a sit - in in the office of Health and Hospital Corporation Executive Director, Dr. Joseph English. A few days previ- ously, the Collective had requested an ap- pointment with English for Thursday to dis- cuss the Think Lincoln - demands as well as their own demands for improvements in patient - care conditions at Lincoln. English did not even answer the request, but let it be known indirectly that he would not meet with them unless invited to do so by Lincoln Ad- ministrator LaCot. The Collective decided that they would try to see English at the desig- nated time anyway, and since in the interven- ing period, the injunction had been ordered, they added the lifting of the injunction to their demands. On Thursday afternoon, leaving others behind to cover the wards, the Collec- tive descended upon English in his office. Published by the Health Policy Advisory Center, Inc., 17 Murray Street, New York, N. Y. 10007. (212) 267-8890. Slaif: Robb Burlage, Vicki Cooper, Barbara Ehrenreich, John Ehrenreich, Oliver Fein, M.D., Ruth Glick, Marine Kenny, Ken Kimerling, Howard Levy, M.D. and Michael Smukler. 1970. Yearly subscriptions: $ 5 students, $ 7 others. Application to mail at second class postage is pending at New York, N. Y. 2 English was not interested in talking; he walked out immediately. Sometime later, an aide appeared with an ultimatum for the group: if they were not out in ten minutes, the police would remove them from the office. Faced with the prospect of heavy bail and in- terminable legal hassles, and having at least gotten some press notice of the events at Lin- coln, the Pediatrics Collective decided to leave peacefully. Pediatrics Collective mem- bers noted with some bitterness in the days following that English was willing to make two trips up to the Bronx to met with the strik- ing obstetrics house staff, who were not willing to continue to work in the hospital while pressing their grievances, but was unwilling to meet with the pediatricians who were con- tinuing to serve their patients. Meanwhile, the pediatricians'counterparts in obstetrics were still on strike. At this stage the obstetrics house staff added some de- mands for improvements in patient care to their original demand for an end to harass- ment. Lincoln Think - members believe that the patient care demands were merely added for public relations: The strikers had never shown great concern over patient care issues before the strike, nor had their concern for their patients kept them from striking, nor had they raised these issues immediately upon striking. Moreover, they eventually returned to work without the patient care demands being met. The obstetricians remained out for over a week, crippling obstetrics services at Lincoln. At this juncture, a split developed between AECOM and the City. According to the New York Times, Corporation Executive Director English put the screws on Einstein. If the obstetrics staff did not return, Einstein would face the loss of its $ 28 million worth of affiliation contracts at both Lincoln and Bronx Municipal Hospital. Financial self interest - and the desire of Einstein empire builders - to maintain control of the health resources of the Bronx won out over the desire of many Einstein clinical faculty members to ditch the troublesome Lincoln despite its usefulness for teaching and research. As the New York Times put it: " Since Einstein has been in a very shaky financial position for years, loss of the $ 28 million contract could easily result in the closing of the medical school. " Einstein proceeded to pressure the obstetrics house. staff into returning to work. The counteroffensive continued with an as- sault on the professionals at Lincoln who sup- ported the community / worker demands. Lincoln officials let it be known that many members of the pediatrics collective might not have their contracts renewed in June. And Dr. Michael Smith, a resident in psychiatry and a Think Lincoln - activist, is being brought up before the Lincoln medical board on a variety of charges that potentially could lose him his job and his license to practice medi- cine in New York State. The charges against him reveal how totally political the action against him is. Smith, it is charged, let the community know what had happened to Car- men Rodriguez, forcing the hospital to hold a public clinical conference which revealed that Mrs. Rodriguez'death was due to gross negligence by the hospital, setting off the struggle over the obstetrics department. Sec- ond, he was involved in the sit - in in J. J. Smith's office (several other doctors who were more intimately involved have not been charged, so far). And third, in the course of participat- ing in a Think Lincoln - door door - to - screening program in the community Qa service Ein- stein and Lincoln do not'provide), Smith had prescribed iron pills for anemic community residents without the permission of his su- periors at Lincoln. The New York Times, a long time friend of the medical empires [see February, 1970, BULLETIN], joined in the attack on the com- munity worker / struggle. Ignoring both the catastrophic failure of Einstein and the City to provide health services in the South Bronx and the leading role played in the struggle by the community / worker organization, Think- Lincoln, the Times blamed the whole affair on the supposed desire of the Young Lords to " see whether ghetto hospitals could be used to radicalize poor blacks and Puerto Ricans much as leftist students have used the uni- versities to radicalize other students and faculty. " But, the Times triumphantly con- cluded, " the experiment has not gone well for the radical cause. " The obstetrics house staff's strike and the injunction forced the Young Lords to recognize " that their effort to exploit conditions in the obstetrics depart- ment had failed and that the community had lost rather than gained by their attempt to make an issue of Mrs. Rodriguez'death. " But the Times exulted too soon. The very day that the article quoted above appeared, Think Lincoln - in four hours gathered over five hundred signatures from South Bronx resi- dents on a petition supporting the Think - Lin- coln demands. And although Think Lincoln - members agree that many workers were frightened for their own jobs after the injunc- tion was issued, they point out that for many other workers, the successful winning of a re- newal of Dr. Phillips'contract showed that Think Lincoln - was serious about changing Lincoln Hospital and that workers were re- sentful over the banning of the Think Lincoln - grievance table and day care center. In fact, workers meetings have been stepped up since the injunction, distribution in the hospital of Think Lincoln - leaflets and the HRUM news- paper goes on and the struggle continues. Lower East Side The Lower East Side of New York has a long history of insurgency. In the past, housing and education have been the focal issues for community involvement. Today, however, health is attracting more and more communi- ty attention. This rising interest in health is due in part to the continuing deterioration of 3 community health services and, in part, to the accelerating expansion of medical empires and hospitals, which remain unaccountable to the community. In response, a diverse set of insurgent forces is consolidating around health issues: * The Lower East Side Neighborhood Health Council - South (LESNHC - S) well- known as the community struggle force for bet- ter health services at Gouverneur Clinic, was recently granted $ 37,600 by O.E.O. to hire three staff workers. In spite of attempts by Beth Israel Medical Center (the Gouverneur affiliate), to discredit the LESNHC - S through court injunctions, police barricades, and the firing of five workers and a doctor, O.E.O. made the grant, cognizant that the health council did indeed represent the community located south of Houston Street. [See BULLE- TIN, February, 1970.] * The Northeast Neighborhood Associa- tion (NENA), a coalition of community or- ganizations located north of Houston Street, established the nation's first community con- trolled health center in September, 1969. Over 2,500 families (8,000 individuals) are now re- ceiving comprehensive, neighborhood - based health services at NENA. As the first com- munity organization to receive its funding for a health center directly from the federal gov- ernment rather than through a hospital or medical school, NENA has pioneered in com- munity controlled health services. * I WOR KUEN, a radical Chinese organ- ization located in the Chinatown section of the Lower East Side, is operating a free health clinic, just opened in September, 1970. Unlike most hospital - based clinics, I I WOR KUEN'S emphasizes preventive health care, an exten- sion of their door - to - door tuberculosis screen- ing program conducted during the spring and summer. I WOR KUEN also believes in chal- lenging existing health institutions. By expos- ing the high incidence of tuberculosis in Chinatown, I WOR KUEN has stimulated the City Health Department to open a new X ray - unit in Chinatown. I WOR KUEN, a name tak- en by the insurgents in the Boxer Rebellion, means Righteous Harmonious Fist. * The Young Lords'Party, a revolutionary Puerto Rican organization, plans to open an office soon on the Lower East Side. YLP was active in supporting the community demands around Gouverneur Clinic and more recently around Lincoln Hospital. They will not be newcomers to the Lower East Side. * The Health Revolutionary Unity Move- ment (HRUM) was born in the struaale around Gouverneur Clinic [see BULLETIN, February, 1970]. Although recently concen- trating its energies on Lincoln and Metro- politan Hospitals, this third world organization of health workers has also been organizing quietly within the health institutions on the Lower East Side. * The Health Liberation Movement (HLM), a group composed largely of medical stu- dents at NYU Medical School, is seeking alli- ances with community and health worker groups. Such linkages began during the spring of 1970, when students assisted with community - initiated preventive health screen- ing programs and when students joined health workers from Bellevue and University Hospital in the May protest against the Cam- bodian invasion. These insurgent forces face two of the most impressive medical empires in the City: NYU Medical Center and School and Beth Israel Medical Center; as well as a number of small- er health institutions, such as the New York Infirmary, Columbus Hospital and the New York Eye and Ear Infirmary. The New York University Medical Empire consists of the medical school, University Hospital, Bellevue and Goldwater Hospitals (both City hospi- tals), the Manhattan Veterans Administra- tion Hospital, the NYU Skidmore - School of Nursing and the Hunter Bellevue - School of Nursing. Over the last year, affiliations have extended beyond these confines to the New York Infirmary (located on the Lower East Side) and to Brookdale Hospital (located in southeast Brooklyn - 14 miles from the med- ical center). Yet the medical staff has staunch- ly refused to extend services to the Lower East Side community through satellite clinics. For example, NYU denied back - up services to NENA Health Center in 1967, which delayed NENA's opening by two and a half years; and rejected a detailed research report writ- ten by 11 students in October, 1969, which advocated decentralization of the Bellevue outpatient department into community clinics. Imperial interests have dictated these choices. In the case of Brookdale Hospital, Mr. Arnold Schwartz, Chairman of the Board at Brookdale Hospital (and also president of Paragon Oil Company) donated close to $ 6 million to NYU Medical School for teaching and expansion. In the case of the New York Infirmary, there is the possibility of a truce in the two institutions'battle over expansion of hospital beds avidly - desired by both in- stitutions, but technically limited by State law. Affiliations with other health institutions bring money and power, in contrast to affiliations with community oraanizations, which bring demands for better health services. Similarly, the empire's priorities were re- flected in the choice of Dr. Ivon Bennett, Jr. as dean of the medical school. Dr. Bennett was also Vice President of the University and Di- rector of the Medical Center when the dean- ship post was vacated last fall. After a brief search for a new dean. Dr. Hester, President of New York University, recommended that Dr. Bennett fill all three posts. Dr. Hester cited the affiliation with Brookdale Hospital as one of Dr. Bennett's qualifying achievements. There was an immediate uproar among stu- dents, faculty and even the Board of Trustees of the Medical School. All objected to the cen- tralization of authority in one man, which meant that the dean would be even less ac- countable to the medical students, medical faculty and trustees than before and more re- sponsive to Dr. Hester and the University (of which the Medical School is only one part). Moreover, some students'objections ex- 4 tended to the man himself. Dr. Bennett played a major role in chemical biological - warfare (CBW) research and policy, including a long history as research contract director of the Army Chemical Corps and more recently the deputy director of the Office of Science and Technology in the White House, where he is chairman of the CBW panel. His defenders view Dr. Bennett as an opponent of CBW, but as recently as November, 1969, Dr. Bennett opposed U Thant's recommendation for a ban. on chemcial weapons, such as tear gas, say- ing " This country is using tear gas, CS, in Vietnam.... At a time when our administra- tion is trying to find a way out of Vietnam and trying to hold American casualities to an ab- solute minimum, any move that might be in- terpreted as taking an effective weapon away from our forces would surely carry domestic political risks. " Members of the Health Liberation Move- ment demanded Dr. Bennett's resignation. The Board of Trustees failed to give him the traditional unanimous vote of confidence. Un- dergraduate and graduate student activists from the NYU downtown campus blocked Dr. Bennett's inaugural address on CBW at the medical school campus. But as empire build- er with links to the Pentagon and the White House, Dr. Bennett was perhaps the " ideal " choice for dean of a prominent medical school. The second medical empire on the lower east side is the Beth Israel Medical Center. Though willing to decentralize some services into the community (such as Gouverneur Clinic, the Judson Clinic and Methadone Maintenance Programs), Beth Israel is no more willing than NYU to share its power with the community. At Gouverneur Clinic, Beth Israel rejected community demands for a greater role in selection of the clinic director and determination of clinic program and ex- pelled the legally constituted community or- ganization, the LESNHC - S, from the clinic by police force. Since that time, Beth Israel has continued to undercut the Health Council at every opportunity. During the spring of 1970, Dr. Ray Trussell engineered the transfer of Gouverneur Clinic out of the Department of Hospitals into the De- partment of Health. This maneuver allowed Beth Israel to apply State funds (through the Ghetto Medicine Act, see BULLETIN, April, 1970) to Gouverneur Clinic, a City owned - fa- cility. (No other City hospital or clinic was permitted to receive Ghetto Medicine money, which was reserved entirely for the volun- taries.) It also meant the establishment, as required by the Ghetto Medicine Act, of a new community advisory board. Logically, the LESNHC - S should have become the board for Gouverneur Clinic. But Beth Israel, seeking to consolidate its power over Gouverneur, insist- ed that there be only one community advisory board to cover both Gouverneur and the out- patient department at Beth Israel. This rele- gated the LESNHC - S to only two seats out of 14 on the community advisory board - and both of these members were hand picked - by Beth Israel. Other members of the community advisory board include: Dr. Ray Trussell, di- rector of Beth Israel; Dr. George Blinick, presi- dent of the Medical Board; Dr. Jefferson Vor- zimer, director of ambulatory services; Dr. Reinaldo Ferrer, director of Gouverneur Health Services Program; Dr. Harriet Goldman, acting director, Judson Health Center. From the com- munity, there are representatives selected by Beth Israel (not the community groups in- volved) from Chinatown (one), Little Italy (one) and the LESNHC - S (two), and hand- picked patients from the clinics at Beth Israel: geriatric (one), pediatric (one), comprehen- sive health services (one), Morris J. Bern- stein Institute (one), and one patient from Gouverneur. The composition of this board meets all the guidelines established by the Department of Health (indicating the emptiness of those guidelines). Besides locking the LESNHC - S out of any significant role in monitoring Ghetto Medicine money, the single communi- ty advisory board railroaded through by Beth Israel was set up to counteract any meaning- ful community influence on the medical cen- ter. Earlier this year, Beth Israel imposed a rigid limitation on the population to be served by its outpatient department. No one liv- ing south of Houston Street could use the Beth Israel outpatient department, but in- stead would be referred to Gouverneur Clinic. The formation of a single community advis- ory board meant that community representa- tives from south of Houston Street were being asked to make judgements about care in the Beth Israel outpatient clinics clinics - which they were excluded from using. Thus the community forces on the community advisory. board could be more easily divided, which of course would preserve Beth Israel's power. In this era of financial crisis, with some medical centers and medical schools claim- ing to be on the verge of bankruptcy, com- munity people find it surprising that every hospital on the Lower East Side has imminent building expansion projects. NYU University Hospital, Columbus Hospital, the New York Infirmary, the New York Eye and Ear Infirm- ary and Beth Israel Medical Center have all laid claim to real estate surrounding their in- stitutions. The pattern is similar throughout the nation, as studies of Presbyterian Hospital- Columbia Medical Center [see BULLETIN, February, 1970] and of Harvard's Affiliated Hospital Complex (see New England Journal of Medicine, April 30, 1970) show. Medical institutions buy up housing surrounding their present buildings. Then, in order to force ten- ants to move without having to provide costly relocation programs, the medical institutions offer only minimal maintenance and upkeep of the buildings. Finally, the new institutional buildings which are constructed on the ruins of housing (now in such short supply) are often merely parking or staff housing rather than medical service buildings. This has been the pattern in the buildings surrounding the New York Eye and Ear In- 5 firmary, where residents have fought back by moving otherwise homeless squatters into the vacant apartments in the building. By keep- ing the apartments occupied, deterioration of the entire building is slowed down. The squatters try to pay rent, but the landlord usually refuses to take it, preferring to try to take legal action against them. With the sup- port of the legal tenants the squatters move- ment is spreading. Already buildings owned by the New York Infirmary have been con- fronted with squatters. Beth Israel and Co- lumbus Hospital will soon be facing the same problem. This new insurgency around hos- pital owned - housing will clearly augment the existing community - worker forces that are trying to establish some form of community control over the medical centers. The most massive building program con- templated is at NYU Medical School and Med- ical Center. Since NYU cleared the land. surrounding the medical center years ago, its $ 50 million construction program cannot be challenged by the squatter tactic. Despite the magnitude of the construction program, the community will reap no benefits from it. NYU has consistently refused to make its resources available to the community, whether through increasing minority admissions or through satellite clinics in the community. None of the three structures that have been proposed will directly improve medical services for the community of the Lower East Side. The Thirti- eth Street classroom and administration build- ing will not benefit the Lower East Side, since NYU graduated no black students last year and had only six minority students out of 125 students in the first year class. The hospital- research tower slated for the site presently occupied by the Alumni Hall will only deepen the medical center's involvement in esoteric research programs. The Cooperative Care Unit, the only real patient care unit contem- plated, appears to be designed for out - of- towners rather than the people of the Lower East Side. " Cooperative care " means that the patient is accompanied by family members who are charged with performing the basic nursing care, obviating the need for extensive nursing supervision. Included in this concept, are a cocktail lounge, swimming pool, res- taurant, garage for the patients, etc. It ap- pears that the unit will be nothing more than a motel where businessmen can come with their wives for diagnostic workups. Will there be a fall offensive around health on the Lower East Side? The insurgent forces community, health workers and students- are getting themselves together. But so are the empires - NYU and Beth Israel. Upper East Side On Manhattan's Upper East Side, between the " silk stocking district " and the East Harlem Spanish ghetto, two medical empires jockey for position. New York Medical College (NYMC) has already decided to leave for Westchester within the next few years but may retain its affiliations with Metropolitan and Coler Chronic Care Hospitals, both city facilities. Mount Sinai, located next door to NYMC along Central Park, hopes to take over the NYMC " public " responsibilities, but will in any case expand its own real estate and its affiliation with Beth Israel Medical Center on the Lower East Side. Surrounded by Central Park, Mount Sinai Medical Center, and East Harlem, NYMC has found its attempts at expansion blocked by geography and politics. Its response to this obstacle to corporate growth has been to look for a new site. In choosing a new site, NYMC found itself with several attractive offers: first, from the City, which tried to interest NYMC in relocating in Queens - where there is no medical school and where there are lots of people; second, from Westchester County, which offered not only room for expansion but also a new source of teaching material through affiliation to the public hospital at Valhalla. Just because NYMC will be staffing a large public hospital doesn't mean that it is primari- ly interested in community health. NYMC al- ready has responsibility for the medical care of a large number of public patients. Through a $ 19 million contract with New York City, NYMC runs the 1000 - bed Metropolitan Hos- pital and the 1800 - bed Coler Hospital on Wel- fare Island. East Harlem residents, however, may be surprised to learn that NYMC's cata- logue claims that NYMC has " pioneered in health programs for residents of densely pop- ulated urban areas. " Community residents complain that, despite its medical responsi- bilities, NYMC has taken no initiative in de- veloping signficant programs to deal with such major community problems as lead poisoning in children and massive drug ad- diction or in developing ways to involve the community in solving its own health prob- lems. While NYMC officials like to cite as an ex- ample of community - hospital cooperation tha fact that several Metropolitan house staff and NYMC students assisted the Young Lords in a door door - to - lead poisoning detection program last winter, the community and the participating staff and students are quick to point out that Metropolitan's and NYMC's only contribution was permission to use hospital labs for processing the tests. And even that came only after several demonstrations by the Young Lords at the hospital and a sit - in at the City Health Commissioner's office to get the test kits which Metropolitan had refused to provide. Both staff and students volun- teered their own time for both the door door - to - and lab parts of the testing program. NYMC fails to provide significant communi- ity programs; it also fails to provide its stu- dents with the opportunity to experience medicine in a community - oriented context. After many years as a straight - laced, undis- tinguished medical school with a very tradi- 6 tional curriculum, NYMC is in the process of timid revisions which will allow more elec- tives and put greater emphasis on the " fami- ly, sociological and community aspects of patient care. " But when NYMC moves out of the city, its students will be even more iso- lated from the community - even if the affilia- tion with Metropolitan survives the move. This increased isolation from the problems of the poor urban community insures that the curriculum's new emphasis will be virtually meaningless. In contrast to the traditional and slow mov- - ing NYMC, Mount Sinai Medical Center (right next door) is busy hustling grants and territory. Mount Sinai, New York City's new- est medical school, promised students a pio- neering curriculum. In place of the traditional two years of basic science and two years of clinical experience, students were promised an integrated program of 1/3 basic science, 1/3 clinical science, 1/3 community medicine. Now, however, many students express resent- ment that nothing of the sort has happened. Community medicine has turned out quite dif- ferent from what they expected. The students found that much of the Community Medicine Department's work consisted of surveys and " research " done by reading medical records of people who had already managed to get served by Mount Sinai or Beth Israel, rather than active attempts to change Sinai's de- livery of medical care to East Harlem. Stu- dents found that instead of pressuring the hos- pital to reach out to the community, the Community Medicine Department was an academically oriented department striving for legitimacy and status within the medical cen- ter itself and striving not to rock the boat. Mount Sinai's growth industry is not com- munity medicine, but its Community Medicine Department. To promote the new department, Sinai grabbed up Dr. Kurt Deuschle, fresh from setting up the community medicine pro- gram at the University of Kentucky. Besides its more than 50 faculty members, the Depart- ment boasts a good supply of government re- search grants (though it has suffered the same research cutbacks as everyone else), a full time - Washington grant lobbyist, and the classic academic and professional view of community. Thus the Department's first an- nual report noted that " to diagnose and treat the community calls for many skills. " And a recent public relations release quotes Dr. Deuschle: " What we are doing is applying [our] multi faceted - expertise in scientific fashion to identifying health needs as we find them in East Harlem, and developing and testing new programs to meet them, utilizing existing health resources and adding what- ever new components we think might make for a better system. ". The outcome of this philosophy has been a complete failure to change the health serv- ices experienced by the people of East Harlem with the result that some community residents wonder what the Community Medicine De- partment does. It is not only community resi- dents who can't tell what the Department is up to, however. Several staff members report that for the past two years, most people in the Department have had very little idea what anyone else was doing. Then last spring, just before negotiations with Local 1199, when the hospital would be in the news and the com- munity might be asking questions, the De- partment began systematically asking people what they were doing and published a slick four page - section of the medical center's News describing how much Sinai does for the community. Some community groups and medical stu- dents have expressed disappointment that the Community Medicine Department has not only failed to offer services to the community but has, perhaps more importantly, failed to press Mount Sinai to change the way it deliv- ers services to the poor people of East Har- lem. Stories abound of ambulances sent on to Metropolitan or Bellevue, and of discrimina- tion in the outpatient department and in ad- missions to the hospital. (There are about ten times as many private inpatient beds as there are ward beds.) This is seen by the communi- ty as just another illustration of Mount Sinai's attitude toward the community. In fact, even the projects claimed by the Community Medicine Department are of dubi- ous reality. For example, the Mt. Sinai News notes that " recently, the Health Department asked Community Medicine's Division of En- vironmental Medicine to explore the develop- ment of a more rapid screening test for blood- lead. " Though a team was assigned to work on that problem, the project rapidly passed into informal oblivion. For the community, the surveys, research. and academic reputation have little impact. And resentment of the OPD, where patients are funnelled through many subspecialty clinics, and of the emergency room remains high. During the past year, the OPD has been in the process of rearrangement " for teaching purposes. " Exactly what that means is not clear. One thing it clearly does not mean is rearrangement for better service to the com- munity. Sinai staff describe as one illustration of this a staff meeting to discuss the " rear- rangement. " At the meeting, a doctor sug- gested that one improvement that should be made immediately is automatic admission to Sinai of every Sinai OPD patient requiring hospitalization. The administration's instant response was " impossible. " In fact, many OPD patients are sent elsewhere if they need to be admitted to a hospital. Very few Sinai inpatients come from the East Harlem com- munity, whereas nearly all the outpatients do. One community organizer from Sinai re- mains in regular touch with the East Harlem Health Council, a neighborhood - constituted group that relates to both Sinai and NYMC. But despite this contact, Mount Sinai's basic attiude toward the community is wariness. When two representatives of the Young Lords came to speak about the Lords'health pro- gram to the Sinai chapter of the Medical Com- mittee for Human Rights, Sinai sent extra security guards to patrol the meeting area. 7 Mount Sinai is affiliated with Elmhurst (a City hospital in Queens), the voluntary Hos- pital for Joint Diseases, the Bronx VA Hospital (recently the subject of a Life Magazine ex- pose of the inadequacy of veterans'care), and Beth Israel Medical Center (a blossom- ing empire in its own right). In addition to running or helping to run these other hos- pitals, Mount Sinai is currently trying to get its own 1350 - bed hospital in order: in spring 1970, the Joint Committee on the Accredita- tion of Hospitals gave Sinai only provisional accreditation because of inadequacies in its medical record room. Recent financial events, however, may turn much of the question of community role into a purely theoretical question. While most medical schools are currently feeling a squeeze from the combined effects of inflation and the cutbacks in federal research grants (which sometimes pay as much as 80 per cent of salaries), both Sinai and NYMC made Business Week's recent list of " some of the sicker patients. " Downstate Dominating the hospital system for the great- er part of Brooklyn's two and one half - million population is the Downstate Medical Center (DMC), a New York State supported - medical school and 350 - bed hospital. DMC has teach- ing affiliations with ten hospitals in Brooklyn, including Kings County, Long Island College Hospital, Brooklyn Cumberland - Hospital, Brooklyn VA Hospital, Jewish Chronic Disease Hospital, Jewish Hospital and Medical Cen- ter of Brooklyn, Long Island Jewish Hospital, Methodist Hospital of Brooklyn, Maimonides Hospital and Brooklyn State Hospital. The Downstate empire is huge, comprising over two thirds - of the 15,000 hospital beds in Brook- lyn. But its interest in providing patient care for Brooklynites is less impressive. The DMC sees itself as a teaching and research center and treats its affiliates accordingly. At the core of the empire, namely the med- ical complex which includes DMC and Kings County Municipal Hospital, one sees a famil- iar scenario, with a change of costume. Though wearing the costume of a publicly supported state institution, DMC acts exactly like a priv- ate institution. The dual system of health care is nowhere more dramatically demonstrated than on the opposite sides of Clarkson Ave- nue in Brooklyn. On one side of the street is the 2,700 bed City owned - Kings County Hos- pital, financed under - and understaffed (pati- ent to nurse ratios sometimes reaching 30 to 40 to one). The patients at Kings County are primarily black (50 percent) and Puerto Rican (23 percent); they are all poor. In re- cent years, the only substantial improvements in patient services have been those related to crisis health care (e.g., renal dialysis units, intensive care unit, and cobalt unit). These are reasonable facilities for a large city hos- pital to have. But they are not the highest priority items on Brooklyn's agenda of health care needs. On the other side of Clarkson Avenue is DMC's 350 - bed State University Hospital. This shiny edifice, completed in 1966, is almost ex- clusively a private hospital for the private patients of the clinical faculty of DMC. That means that the majority of the patients are white, that 76 percent of the patients are priv- ate, that only two of the more than 60 clinics are open to patients who do not have private doctors. Such patients can generally only get into this hospital if they represent a particu- larly interesting case. This hospital operates at only 67 percent occupancy because admin- sions are rigidly limited in order to preserve a patient to nurse ratio of less than 4 to 1, thereby maintaining a superior level of pati- ent services. It is stated in the Downstate Med- ical School catalogue that State University Hospital is the nucleus of the clinical teaching program, but in fact the bulk of clinical train- ing is done on the poor patients in Kings County Hospital, and the interns and resi- dents are more restricted in their responsibili- ties at the State hospital because it is filled with private patients. Mr. Chalef, Director of the State University Hospital, says, " Although State University Hospital is a government hospital, it is the only one I know of classified by the state as a voluntary hospital. " The message is clear: Public funds have been used to establish a dual system of health care on Clarkson Avenue with first rate care going to private patients in the State University Hos- pital and second rate care going to the poor patients at Kings County. DMC has been plagued with administrative difficulties in recent years, especially with re- gard to filling empty positions. The chairman of the Biochemistry Department has had to stay on three years beyond his retirement age while the chairmanship has been offered to and refused by at least 24 professors of bio- chemistry. The Radiology Department was non existent - for over a year while a new chair- man was being sought. Joseph Hill is currently serving as both President of the Medical Cen- ter and Dean of the Medical School, but he is hospitalized and is not expected to return to his posts. No names have yet been suggested as candidates to fill these crucial vacancies. DMC, plagued with its own staffing and ad- ministrative problems, has shown little en- thusiasm for taking responsibility to improve and reorganize health services at Kings Coun- ty, much less throughout its Brooklyn empire. Isolated examples of true community service exist (e.g., a program for recruiting black stu- dents for Downstate Medical School, and an innovative pediatrics department which was responsible for setting up a lead screening program), but DMC's general trend is one of " retreat " from community responsibility. Be- cause the various departments of DMC have established themselves as independent and unaccountable baronies, they have been able 8 to preserve themselves as enclaves of re- search and training free from community con- trol and involvement. For example, the De- partment of Medicine at Kings County (con- trolled by Downstate through its teaching affiliation) allegedly has a policy of turning away " uninteresting " patients (e.g., patients with hepatitis, drug addicts) and admitting only those patients whose diseases are inter- esting for teaching or research purposes. When the affiliation program was first in- itiated by the City back in 1961, Kings County was overlooked, ostensibly because it was not in as bad condition as some of the other City hospitals. At that time it already had a teach- ing affiliation (involving no money) with the Downstate Medical School. As the health ser- vices steadily deteriorated at Kings County, the City began to press Downstate to assume some responsibility. It did so, but in a limited. way, starting in 1966 when the first contractual affiliation agreement was made. As of this year the affiliation contract covers only three services, radiology, pediatric out patient - care and psychiatry, at a cost to the City of only about $ 6 million, or 15 percent of Kings Coun- ty's $ 38 million budget. (By contrast, Einstein Medical College's affiliation contracts at Lin- coln Hospital and Columbia's contracts at Harlem Hospital comprise about 40 percent of the City hospitals'budgets.) Despite the rela- tively small size of the contractual obligations of DMC at Kings County, DMC exercises virt- ually total control over the City institution through its teaching affiliation. But the commit- ment of DMC to Kings County and its patients is small. Community insurgency has been slow in developing around DMC, especially owing to the fact that Kings County Hospital is geo- graphically separated from its service popu- lation. The majority of its patients live in the Stuyvesant Bedford -, Crown Heights, and Brownsville ghettoes, an average of three and one half - miles from the hospital. However in the past year an ad hoc - community group did struggle successfully for improved lead screening of children. Other active communi- ty groups involved in health issues include the Bedford Stuyvesant - Restoration Project, the Bedford Stuyvesant - Development and Service Project, and a Kings County Com- munity Advisory Board. Nevertheless, DMC's ventures into the com- munity have been circumspect and often exploitative with the general strategy amount- ing to a retreat from community responsibili- ty. For example, DMC has proposed construc- tion of a child psychiatric center on Clarkson Avenue with between 100 and 200 beds. They envision it as a traditional research and train- ing facility offering traditional modalities of psychiatric care to a limited catchment area population. Interestingly enough, they are meeting resistance only in Albany, where State planners wish to see not another en- clave of research and training but an out- reach program with community service and development of new modalities of out patient - care as its first priorities. The new recreation center at DMC provides another example of the empire's attitude to- wards the community. The official policies for use of this recreation center amount to a tri- level caste system. The " elite " (students and faculty at DMC) are permitted free and un- limited use of the facility. The second level (workers at either Kings County or the State University Hospital who are on the State civil service system payroll) must pay $ 25 per year to use the center. And everyone else (such as community residents) is permitted to use the center only at specific and limited times during the week. In retaliation, many young neighborhood people have vandalized the recreation center, which to them is a sym- bol of privilege and elitism. These are only isolated examples of the much bigger issues regarding the reorganiza- tion of health services in Brooklyn. DMC has consistently been reluctant to respond to com- munity needs and pressures for improved and reorganized services. Downstate's empire remains the number one health power in Brooklyn and therefore the principle road- block to necessary change. Columbia The Columbia Presbyterian - Medical Center continues to be challenged by the opposition it arouses in its community and among its workers and students. The Columbia empire is centered at the College of Physicians and Surgeon (P. and S.) and Presbyterian Hospital in upper Manhattan. It has affiliations at Har- lem and Delafield municipal hospitals and St. Luke's and Roosevelt hospitals in the mid- west side. Columbia Presbyterian - is one of the oldest of the N.Y.C. " empires " and the first to aggressively buy up land for a medical academic campus floating in a black and Latin community. Its white, Protestant, elite image and traditional concern with interest- ing " teaching material " rather than with the needs of the surrounding community has made it seem alien and hostile to the people of nearby Washington Heights as well as those downtown near Harlem Hospital. In the past two years, starting approximate- ly with the University strike in spring 1968, a series of challenges have been made to the elitist and repressive orientation of the medi- cal school and Presbyterian Hospital. Student groups have leafletted patients in Vanderbilt Clinic, the out patient - clinic for Washington Heights, citing the double standard of care and the expansionism of the Medical Center in the face of crying community needs for primary and preventive care. The Washing- ton Heights Community Mental Health Coun- cil, starting with a takeover of a Columbia- sponsored meeting in the fall of 1968, has challenged the in patient - and teaching orien- tation of a proposed Columbia - run community mental health center. An attempt by Local 9 1199, Drug and Hospital Union, to unionize research workers at P. & S. in the summer and fall of 1969 expressed the discontent of the P. & S. workers, although it was at least tem- porarily beaten back by the union busting - tactics of the University administration. (The " Supporting Staff Association, " which states explicitly that it is not a union and wants to co operate - with Columbia, won the right to represent the workers in a bitterly contested, close election.) In the past nine months, several new groups have emerged and have challenged Co- lumbia in new ways. Chief among these groups are the Coalition Against War, Racism and Repression and the Black Caucus within the Medical Center, the Freedom and Peace Party and a community coalition in Washing- ton Heights, and the United Harlem Drug Fighters at Harlem Hospital. * The Coalition Against War, Racism and Repression grew out of the nation - wide tur- moil after the invasion of Cambodia last May. It has sponsored meetings and rallies about the war and about repression of the Black Panthers. Panther support work has focussed on the " New York Panther 21, " and especially on Dr. Curtis Powell, one of the 21, who was a researcher in biochemistry at the Medical Center before his incarceration. The Coalition also puts out a muck raking - and issue - rais- ing newsletter, 1-0-9, named after the room it uses as a headquarters in the research build- ing. * The Black Caucus co sponsored - a Curtis Powell support rally. It sponsored a day of mourning for the Augusta and Jackson State slayings, and has begun a survey of hiring and student admissions policies at the Med- ical Center. * The Washington Heights Freedom and Peace Party, together with a community coalition, co sponsored - a community meeting last December to talk about the state of health care in Washington Heights. Since then, Free- dom and Peace has challenged specific pol- icies in the dental clinic, has set up a griev- ance table in the Presbyterian emergency room and has provided free ambulance serv- ice home from the hospital on weekends. Major confrontations with the hospital have come over the defense of a patient beaten by medical center guards for complaining of a long wait [see May, 1970, BULLETIN], and in demanding the return of a young mother's al- legedly battered child who was taken by the hospital and the Bureau of Child Welfare for adoption without telling the parents. AIR POLLUTION In what must be one TAKES of the nation's first ITS TOLL strikes against auto- mobile air pollution. New York York City's Bridge and Tunnel officers staged a three- day walkout at the City's tollbooths and tunnel catwalks on August 18, 19, and 20. Basically, the men contend, the air pollution is killing them. And they cite impressive med- ical and environmental statistics to prove it. At the Brooklyn Battery Tunnel, for instance, the carbon monoxide level is as much as 12 times the level in the outside air. Employees at the Brooklyn Battery and Queens Midtown Tunnels are exposed to as much as 100 parts. per million of carbon monoxide - more than twice the amount considered " dangerous. " Five of the 22 men men whose blood carbon monoxyl hemoglobin was measured had levels over four per cent enough - to produce psychological effects such as reduced ability to judge time. Data on the tunnel pollution first appeared in July, 1969, when the tunnel officers'union (Local 1396 of District Council 37, American Federation of State, County and Municipal Employees) released an analysis of a study prepared four years earlier for management, the Triborough Bridge and Tunnel Authority (TBTA). With characteristic unconcern for the health of either its workers or its " clients, " the TBTA had been sitting on the study for over four years until the union finally obtained and released it. Embarrassed by the facts con- tained in the study, the TBTA agreed to con- duct further medical studies, the results of which were to be released to both workers and management simultaneously, and to shift re- sponsibility for monitoring air quality from the TBTA to the City's Department of Air Re- sources. While all that was going on, the TBTA was also attempting to silence a par- ticular union member, George Carroll, who had been quoted in the newspapers as saying that tunnel air was " unhealthy. " The TBTA's silencing tactic was quite straightforward: Mr. Carroll was suspended without pay. By August 1970, the air in the tunnels and at the entrances had not improved, the TBTA was stalling on the question of medical studies, and the men were getting angrier. The final blow came on August 18, in the midst of converging air pollution and electric power crises. As every New Yorker will recall. Con Edison several times this summer appealed to major power users to cut their power con- sumption during peak hours which - includes the afternoon rush hear when auto pollution is high. In compliance with Con Ed's request, the TBTA reduced the power and thus the ef- fectiveness of the already inadequate fans that ventilate the tunnels and toll booths. The Bridge and Tunnel Officers had had enough. At 5:30 PM they walked away from their posts. For three days the newspapers focussed on the question of how many motorists were pay- ing the toll in the absence of the toll collectors and all but ignored the air pollution issue. But at the end of the three days, the TBTA agreed to get the medical studies underway and to install (and presumably to use) high speed ventilation fans on tunnel catwalks and in toll collection booths. The men went back to work, but with the implicit threat that if the TBTA fails to live up to its obligations to protect the health and safety of the workers, the workers will again have to strike. 10 * The United Harlem Drug Fighters, a coalition of Harlem groups concerned with wiping out heroin addiction, sponsored a rally on July 25. The rally proceeded to the K building of Harlem Hospital (the psychiat- ric service) and began a month - long sit - in. The upwards of 300 addicts and support- ers in the K building demanded that the Psychiatry Department set up a hospital 100 bed - detoxification unit and that the hospital great- ly expand ambulatory and half way - facili- ties in the community. The Drug Fighters, in cooperation with some activist doctors, set up a methadone detoxification program on the spot. After a month's occupation, the final agreement committed the Health and Hos- pitals Corporation to funding a 100 bed - de- toxification unit on two floors of the old Har- lem pediatrics building, the City's Addiction Services Agency to providing a half - way hotel in the community, and the Harlem Hos- pital out patient - service to expanding its out- patient methadone facilities. Dr. Elizabeth Davis, head of the Columbia - affiliated Depart- ment of Psychiatry, successfully blocked the use of Psychiatry Department beds for the de- toxification program agreed upon. In response to the community's challenges around Presbyterian's Vanderbilt Clinic, Co- lumbia is apparently hoping to turn Delafield Hospital, a neighboring, Columbia - affiliated, City owned - cancer hospital, into a general care hospital for the poor people in the area. That would permit Presbyterian to get out of the business of taking care of non private - patients and so hopefully get the community off Columbia's back. Already, Columbia is trying to shift its family planning programs onto Delafield's strained facilities. But even turning an affiliated City hospital into a patient care centered facility does not come easy for Columbia; a lonely struggle is currently be- ing waged by the administrator of Delafield to free up space for patient care from the space required for the cancer research pro- grams of Dr. Solomon Spiegelman. So while the Columbia Presbyterian - Med- ical Center continues to buy up land, emascu- lates the Community Mental Health Council, declines to commit itself to drug treatment in the Washington Heights area beyond a 10- bed unit at Delafield, increases its security force, and reluctantly balances its multi - mil- lion dollar house staff residence with a new emergency room, community and worker groups see the NLF flag raised on the Pres- byterian flagpole on the eve of July 4 as sym- bolic of the struggles to come. - The empire stories were prepared by the staff, Dick Clapp, and Dale Hiltgen, Health - PAC Student Intern. Hidden Persuaders: New York City's Health Consultants While consumers and workers are struggling for grassroots democracy in the institutions which affect their lives, the trend in city gov- ernment is to remove larger and larger areas of decision - making from public view, much less from public participation. City govern- ments, such as New York's, are virtually dis- mantling themselves in their haste to hand vital service and planning functions over to public authorities (modeled after private cor- porations) and to private consulting firms. In most cities, mass transportation has long since passed out of the public area and into the hands of quasi public - corporations, or authorities. More recently, New York City sur- rendered the management of its 19 municipal hospitals to the newly created Health and Hospitals Corporation. As authorities and corporations take over the operation of public services, only planning and policy making - functions are left behind in city government. But increasingly even these core functions are being contracted out - to private consulting firms which are closely linked with the De- fense Department and to the nation's largest private corporations. New York City's dependency on private consulting firms is growing at a rate which even some public officials find alarming. Be- tween 1965 and 1970, the City's expenditures on outside consultants have increased from $ 8 million a year to $ 75 million. Formerly, the City hired consultants only occasionally and on a one shot - basis, but today consulting firms are firmly entrenched in a range of City problem areas including fire, police, health and overall City planning and budgeting. Few New Yorkers had any inkling of the ex- tent of the City's reliance on consulting firms until last June, when City Comptroller Beame disclosed the huge sums involved and threat- ened to cut off payments pending an investi- gation. In contracting out basic analytical and planning work to private consulting firms, the City is following a trend which has also been gaining momentum in private industry and the Federal government. Over the last five or ten years, consulting has grown from a small business dominated by freelancers and ac- counting firms to a $ 1 billion per year indus- try, dominated by large, consulting - only firms which employ hundreds of professionals. Highly profitable (charges for single studies range into the millions) and totally unregu- lated, the consulting business is, according to Business Week, growing by leaps and bounds. In addition to the profit making - con- sulting firms, which specialize in corporate management problems, the sixties spawned a host of more " academic " nonprofit outfits, the so called - " tanks think -, " some of which were originally set up by the Defense Depart- ment. Both types of firms are pulling down major contracts in urban problem - solving, especially in New York City. The assumption behind the City's growing, use of private consultants is that City govern- 11 ment as it is now structured is cumbersome, inefficient, and ill equipped - to deal with com- plex problems. Private industry and the mili- tary, on the other hand, are seen as efficient and eminently capable of handling the most difficult issues. Therefore, according to this line of reasoning, the solution for the cities is to borrow the analytical and decision - making techniques which seem to work so well in in- dustrial and military settings. Indeed, much of the work now being done by private con- sultants for New York City is not on sub- stantive problems, such as how to improve services, but on the problem of how to restruc- ture and " rationalize " the City decision - mak- ing process itself. The problem with this line of reasoning is that the decision - making methods appropri- ate to industry and to the military are not, or should not be, appropriate to the government- al process even if one grants the question- able assumption that industry and the mili- tary are really efficient and smooth running - . To the extent that industry and the military do appear to be " efficient, " it is because of in- herent features of their goals and structure, rather than because of any superior decision- making techniques. In the first place, both are oriented towards single goals profits - in in- dustry, high kill ratios - in the military. Deci- sion making - is simply a problem of maximiz- ing profits in the one case, kill ratios - in the other. City governments, on the other hand, appear to have complex and often conflicting sets of goals. In the second place, industry and the military are both rigidly hierarchical operations. What appears to be an efficient decision - making technique is often simply an autocratic one, and unsuitable to what should be democratic governmental procedures. The danger is that city governments may, under the prodding of their private consultants, try to emulate the anti democratic - but seemingly efficient functioning of industry and the mili- tary. ealth was one of the first areas to be staked out by the major consulting firms op- erating in New York City. Which firms they are, what they are paid, what they are paid to do none - of this is accessible public informa- tion. HEALTH - PAC's probes, conducted over the last year and a half, reveal that: * The management consulting firms work- ing on health for the City include some of the nation's largest and most profitable firms which, when they're not working for the City, are straightening out management or market- ing problems for such corporate giants as IT & T, Western Electric, US Steel and Metro- politan Life Insurance. McKinsey and Com- pany, whose total City contracts add up to $ 1.5 million, is the nation's fifth largest management consulting firm, with a gross in- come of about $ 25 million. McKinsey's assign- ment appears to be nothing less than the task. of setting up the organizational structure for the Hospitals Corporation, which gives the firm a key role in determining the shape of the City's health system for years to come. Other firms under contract to the Corporation for bits and pieces of health planning include Peat, Marwick and Mitchell, the nation's fourth largest management consulting firm; Planning Research Corporation, the third largest; and H. B. Maynard and Company, the tenth largest. * The think tanks which are working or have worked on health for the City include some of the Defense Department's most relia- able advisors. Best known, of course, is the Rand Corporation. Originally set up by the Air Force, Rand in 1968 was pulling in about $ 800,000 in health contracts in New York City, and $ 19 million in consulting contracts for the military. Systems Development Corporation (SDC), which produced a 1966 study entitled " Systems Development and Planning for Pub- lic Health in the City of New York " under con- tract to the City, made $ 17 million in defense contracts in 1968. SDC was also originally established established by by the Air Force. Research Analysis Corporation (RAC), a child of the army, worked on health planning for the City in the late sixties, while it was making $ 10 million per year through defense contracts. Technomics, Inc., the Santa Monica firm which did the staff work for the 1966 mayoral commission which first proposed a corpora- tion to run the Municipal hospitals [see BUL- LETIN, special winter issue, 1969], originally specialized in defense work. Many of these companies are working, or have worked, for the City on short - term, limited assignments. But the heavyweights heavyweights in terms of contract dollars and manpower, Rand and McKinsey, are well on their way to becoming permanent fixtures of the City's billion dollar per year health enterpirse. Both were hired initially as part of Mayor Lind- say's drive to " rationalize " City government through the use of " PPBS " (Program Plan- ning Budgeting - System), a Rand designed - planning and decision - making technique first sold to the Defense Department under Mc- Namara in the early sixties. Lindsay's first budget director, Fred Hayes, brought Rand in to help the City budget bureau institute PPBS in 1967. A year later, he contracted with Mc- Kinsey to supervise the Budget Bureau's ef- forts to switch over to the PPBS method of budgeting. Both firms have spread out from the PPBS business to the congenial area of health which is considered by the Lindsay administration to be so highly " technical " that outside consultants are indispensable. Both firms are now so closely tied in with the City administration that their staff men are almost considered part of the " family " of Lindsay's bright young men and women. For example, applicants for City health planning jobs report being referred by City employees and officials to Rand and McKinsey as other sources of jobs. Rand - men have been known to move over into City jobs, and one McKin- sey employee. Carter Bales, held the position of Deputy Budget Director while remaining on the McKinsey pay roll -. With this kind of in- timacy with the City administration contract renewals are practically guaranteed. 12 The Rand Corporation enjoys an especially and the Health Service Administration. But in privileged relation to the City. Top Rand - men terms of McKinsey's original assignment - to do not take just any assignment from the City make PPBS and other sophisticated tech- L they participate in the framing of projects niques an operational reality in the City of interest to themselves. Thus, in health, health bureaucracy - there has been almost Rand has dabbled in a wide range of sub- no progress. City officials and planning staff jects: mental health, community health cen- complain they can't comprehend much of Mc- ters, narcotics, home care, emergency care. Kinsey's guidelines, memos and flow charts, Over the winter of 1969-70, Rand did a detailed much less apply them to everyday, practical study of the municipal hospitals, which (ac- problems. According to one insider, when a cording to one of the Rand - men on the assign- top McKinsey executive gave the Hospital ment) was oriented towards saving money Corporation's Board of Directors a presenta- through bed reductions - and other service tion of McKinsey's plans for the Corporation's cuts. Current Rand projects for the Health management structure complete - with illus- Services Administration include studies en- trative slides the Directors'response ranged titled " Costs and Performance of Suppliers of from boredom to open skepticism. In a similar Health Care " and " Direct and Indirect Mental performance for HSA staff in late 1968, the Health Services " -both probably geared to McKinsey team's explanation of PPBS was discovering cheaper ways of delivering greeted with giggles from the audience. One health services. lower echelon Budget Buerau staffer, mysti- fied by McKinsey directives despite his own In 1969 Rand Corporation and the City ad- ministration cemented their relationship training in systems analysis, said " What Mc- Kinsey's doing, we call PP BS -. " through the joint formation of a nonprofit * They argue that private consulting firms corporation called the New York City Rand are indispensible because they are " above Institute, a Rand spin - off dedicated solely to politics, " capable of giving truly " neutral " urban problems. Formerly, Rand - men work- advice to harried City officials. The neutrality ing on New York City problems were super- of any advisor, no matter how academic or vised from the Rand Corporation's Santa detached he purports to be, is open to ques- Monica headquarters. For the Rand team in tion. But the kind of men doing most of the New York, the device of forming an inde- health consulting work in New York City can pendent, City linked - " institute " has two big make no pretense of academic detachment. advantages over the old arrangement: First, Whether they work for a defense oriented - the City has promised to finance the Rand In- think tank or a private industry oriented - man- stitute to the tune of $ 3 million / year (an addi- agement consulitng firm, they are ideological- tional $ 1 million will be raised from private ly and intellectually rooted in American foundations). With a guaranteed income of imperialist and profit dominated - values. Mc- $ 4 million / year, the Institute can settle down Kinsey men assume without question that the to " academic " pursuits, free of the pressure of kinds of management structures and decision- hustling individual contracts. Second, formal making processes suitable to private industry independence from Rand Corporation should are suitable to City government. One consult- give the Institute a clean, non military - image ing firm staffer working on health openly ex- attractive to potential clients. (The Institute pressed his bias: " I'm for private enterprise. will probably retain extensive informal rela- It works. Most problems that government tions to the Rand Corporation.) In the health can't handle can be handled by private en- field, the Institute's prestige is assured by the terprise. " Of course, alternative solutions to presence, on its Board of Directors, of Yale's health care delivery problems, such as com- Dr. Lewis Thomas, former Dean of NYU Med- munity worker - control of health facilities, ical School, and William Golden, a director simply never arise in the decision - making of Mt. Sinai Medical Center and of New York framework of a Rand Corporation or a Mc- Blue Cross. Kinsey Company. No one questioned the City's relation with its consultants until Comptroller Beame's dis- closures last June. Now, the Lindsay adminis- tration is on the defensive. In public and priv- ate statements, they justify the use of private consulting firms on three grounds: * They argue that the advice obtained is well worth the money. But, despite all the mystique about " systems analysis " and other " technologies " of problem solving, the per- formance of the top firms doing health work has been consistently shoddy, even when measured by their own standards. Rand - men themselves have admitted privately that they " never really got on top of the health thing " despite three years'and over a million dol- lars'worth of trying. McKinsey is proud of the volumes of flow charts and computer forms it has produced for the Hospital Corporation The political assumptions of Rand's " aca- demic " analysts are especially questionable. Many of the Rand - men who have worked on health for the City have also worked on mili- tary problems for the Department of Defense. One, interviewed in late 1968, did both simul- taneously: two days a week in Washington working on secret problems related to the war in Vietnam, three days a week in New York working on health. He, like other Randmen, saw himself as just a " technician " -capable of designing methods of genocide one day, and working on narcotics and mental health problems the next day. * They argue that, after all, the real policy decisions are still made by City officials: Private consulting firms only provide the in- formation and the framework for decision- making; they list the alternatives, the Ciy of- 13 ficial chooses among them. It almost goes without saying, however, that a particular particular policy decision is largely determined by the information that goes into it, and the kinds of alternatives that are presented. With the con- sulting firms now working on health for the City, the information " input " is bound to be limited by the knowledge and experience of the firms'upper middle class staff men. (For example, one Randman who was attempting to apply a highly abstract branch of mathe- matics called stochastic analysis to the prob- lem of patient flow in emergency rooms, ad- mitted he had never been in a City hospital.) In a practical sense. City officials and staff members are seldom in a position to objective- ly judge the data and the " framework " pre- pared for them by private consulting firms. As mentioned above, the links between City staff and consulting firms are many and tangled. Comptroller Beame revealed that the City's Environmental Protection Administrator, Jero- me Kretchmer, accepted a free weekend in the Poconos resort area from McKinsey. What Beame did not know was that Rand Corpora- tion has hosted dozens of City health staffers on free trips to Santa Monica. Finally, many City officials and staff people know that one of the most lucrative jobs they can get when they leave the City government is with a private consulting firm. Building a friendly personal relationship with the outside firm is worth more than the temporary satisfaction of being honest and critical about the con- sulting firm's work. With the arrival of the private consulting firms on the urban health scene, one more link in the growing Medical Industrial - Com- plex has been forged. The consulting firms, with their ties to the nation's largest corpora- tions, to the aerospace and defense industries and to the military itself, are now tied, in turn, to local health systems. The links are still tenuous, but the possibilities for profitable exploitation are already clear: In its search for new markets, industry and especially the defense industry, is turning increasingly to health [see November, 1969, BULLETIN]. There, one step ahead of them, are the man- agement consulting firms and think tanks. ready to please their industrial clients by scouting out and developing new markets for medical electronic hardware, computers, in- dustry - run training programs for health para- professionals, etc. (Already, one can discern an insistent emphasis on computers and re- lated hardware in the advice New York City buys from its consultants.) As the medical- industrial complex and its ally, the consulting firms, gain hegemony over the health system, the consumer, with his demands for high quali- ty, dignified services and public accountabili- ty, is increasingly irrelevant. - Barbara Ehren- reich. CORRECTION: We wish to thank Conserva- tion of Human Resources at Columbia Uni- versity for calling to our attention some omissions and errors in last months chart on medical and nursing school admissions [see BULLETIN, September 1970, p. 10]. The cor- rected chart is reprinted here. Medical school figures are from an unpublished article by Dennis Dove, Administrative Assistant for Minority Student Affairs of the American As- sociation of Medical Colleges. The article is titled " Minority Enrollment in U.S. Medical Schools for 1969-70 Compared to 1968-69. " The figures for nursing program admissions are from a draft of the National League for Nursing's annual article on Educational Prep- aration in Nursing to be published in Nursing Outlook. For black student admissions, the fig- ures are based on admissions in programs which answered the question about blacks (total " " column). Actual total admissions in each type of program are given in parentheses. The percentages of men admitted to the vari- ous types of programs are based on those pro- grams which answered the question about men. However, the total admissions to and ac- tual numbers of men in the programs which answered the question about men have not been released. Thus the percentages of men in each program are approximate. Total Females Black Amer. Indian Mexican - Amer. Puerto Rican Medical Student Enrollments (1st year class) 1968-69 Absolute numbers % of total 1969-70 Absolute numbers 9.863 887 8.9 10,371 936 783 3 2.18 0.03 1,042 7 20 0.23 44 87 0.88 96 Nursing Admissions for 1968-69 Associate degree Baccalaureate degree Diploma Practical Nursing total 17,808 (18.907) 14,111 (15,983) 28,679 (29,267) 44,917 (49,107) blacks 10.5 6.0 3.6 17.4 % of total 9.0 2.75 0.07 0.42 0.93 % men 2.5 2.8 4.4 14