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Health Policy Advisory Center December 1970 # 26 25 # Nov 70 missing BHEUALLTHL BEULTLEITINN / PAC Editorial: " We'll put you on the Waiting List " The overall failure of America's health sys- tem has been highlighted by the failure of New York City's medical resources to re- spond appropriately to two urgent and dra- matic health demands: drug addiction treatment and abortion services. Medical es- tablishments across the country are acting with similar disregard for the needs of their entire patient populations: the New York ex- perience will be repeated again and again. Control of New York City's health system is firmly vested within the private voluntary hospitals and medical teaching centers. The primary interests of these institutions are to teach, do research, and garner additional in- come which can be ploughed back into teaching, research and institutional hege- mony over the city's health system. The inter- ests of these institutions rarely correspond and frequently conflict with the interests of patients seeking health care. New Yorkers have no recourse in the public sector, large though it is. The interests of the pri- vate sector dominate and control the efforts of the public sector. Thus in New York City; we see the public municipal hospitals and the Department of Health kowtowing to the prerogatives of the private sector, rather than responding to the needs of all New York City residents. There are a number of parallels in the health system's response to the demands for abortion and addiction services, as well, as revealing differences. Neither the addict nor the pregnant woman provide " interesting " research material. Treatment of both medical problems carries moral and punitive judg- ments. With the exception of small research projects, the treatment of drug addiction brings no additional income to the private medical sector. Yet despite the enormity of the need, and the hue and cry over the evils of dope, the public sector (in the form of the Addiction Services Agency) has failed to respond effectively. With abortions the case is slightly different. Women, who can man- age to scrape together the cash, are forced to pay highly inflated prices for this relatively simple procedure. The private hospitals and doctors are flocking to the Gold Rush of the 1970's; providing abortions has become big business. There is profit in exploiting wo- men's bodies. Those women who cannot af- ford to pay are deluging the municipal hos- pitals. As with the case of addiction, in the face of unanticipated demand on the public system, the response of the Department of Health has been to severely limit the supply of abortion services. In neither case has the city shown either the courage to compel the private sector to respond to these medical needs or the desire to take up the slack by providing adequate services within the municipal hospital sys- tem. The effects on both the addict and the pregnant woman are similar: delays in treat- ment can lead to psychological and physical risks and even death. Following passage of New York State's liberalized abortion law, the city had a num- ber of alternatives in dealing with this newly legitimized health need. It could have per- mitted in office - abortions; it could have at- tempted to exercise quality and price control within the private hospitals; or it could have expanded its own facilities by creating pub- lic abortion clinics. Instead, the New York City Board of Health promulgated a set of guide- lines (having the effect of law) which have delivered the abortion package into the hands of the hospitals and their doctors. It was no accident that the guidelines were promoted by the chiefs of some of the city's most pres- tigious private hospital Obstetrics and Gyn- ecology Departments. To them, quality con- trol is synonymous with hospital control; price control was never an issue. The guide- lines have seriously limited the opportunity to prove that low cost -, high quality - abortions can be done outside the hospital setting. The city's failure to provide treatment for narcotic addicts is even more glaring. In many parts of the city, addiction is endemic. The private sector provides almost no treat- ment for these patients, except on an experi- mental basis. The city's performance has scarcely been better. To fill the void, the United Harlem Drug Fighters (UHDF) recently established their own detoxification treatment program at Har- lem Hospital. At the height of the takeover of two floors of Harlem Hospital, 325 addicts were receiving treatment. But following the negotiated settlement, Harlem Hospital agreed to make only 100 beds available to UHDF. Furthermore, the hospital, whose medical policies are controlled and deter- mined by the needs of its private affiliated teaching institution (Columbia College of Physicians and Surgeons), has failed to pro- vide adequate medical, laboratory and other CONTENTS 2 Abortion Reform Report 6 United Harlem Drug Fighters | ancillary services to the 100 bed - unit. And finally, the City's Addiction Services Agency has stalled the establishment of UHDF's post- detoxification program. When another com- munity group attempted to set up a narcotic addiction program at Lincoln Hospital, the city did not even go through the motions of providing lukewarm support. The velvet glove was removed and the iron fist of the police department was called upon to de- stroy the nascent Lincoln program. Neither the private nor the public health sec- tor can operate a decent health system. To- gether, they only succeed in passing the buck. The United Harlem Drug Fighters have tried to meet their own unmet needs by oper- ating their own health program. Thus far, their success has been inspiring. Their ex- perience suggests that women who demand and succeeded in getting abortions legalized in New York may now have to take over the abortion services themselves, in order to in- sure that their rights are served humanely, adequately and inexpensively. Abortion Reform: the Battle Lines are Drawn The right of every woman to control her own body is an important woman's demand. When New York State's reformed abortion law went into effect on July 1, 1970, it looked to some as if this goal might be realized. The New York law is the most liberal abortion law in the country. It provides that an abortion can take place if the woman is up to 24 weeks pregnant and if a duly licensed physician performs the operation with her consent. Abortions can be performed in out patient - clinics and doctors'offices as well as in hos- pitals. The law does not restrict the procedure to New York State residents. But the abortion picture in New York City has proven to be just a microcosm of the en- tire health system. As one doctor put it, the " soft under belly of the American health sys- tem " has been exposed. It is a system in which rampant profiteering goes unchecked; in which hospitals, although they depend on public funds, are not responsive or respon- sible to the public they serve; in which two classes of health care exist, one for the rich and one for the poor. In addition, the male domination of medicine, with its moral and social overtones, has been an omnipresent and oppressive factor in the delivery of abor- tion services. What then has been happening in New York City? Even before the law was in effect, New York City's Board of Health and its Ob- stetrical and Gynecological Advisory Board began discussing regulations that would place limits on abortion services. The Ad- visory Board is made up of twenty men who are the Chiefs of Service in Obstetrics and Gynecology (GYN OB -) in the major volun- tary and municipal hospitals. They are se- lected by the Commissioner of Health and serve at her request as advisors. After a public hearing in mid July -, the Board of Health delivered its abortion guide- lines which were incorporated into the City's Health Code and took effect on October 19th. The guidelines required that abortions must be done in facilities which include operating rooms, X ray - labs, clinical labs, complete blood banks, etc. It has been estimated that non hospital - based clinics would have to spend 250,000 $ to comply with the guidelines. (Two of the independent clinics, Women's Medical center run by Dr. Michael Bergman and Women's Medical Group, directed by Dr. Hale Harvey, are continuing to operate and are attempting to meet the guidelines). The guidelines also prescribed that abor- tions could only be done when a staff includ- ing an obstetrician or surgeon, at least one full time - registered nurse with post graduate training in obstetrics or gynecologic nursing and a social service worker are present. Ser- vices for " family planning " and counseling must also be offered. A mandatory waiting period of not less than two days to " encour- age thorough consideration and a firm de- cision by the patient... " is required. Ter- mination of pregnancy certificates and confi- dential medical reports on every patient must be filed with the Health Department. The cer- tificates include questions about the " mother's maiden name " (i.e., it seems all women hav- ing abortions are assumed to be mothers and married) as well as her race. No out- patient abortions are allowed after 12 weeks gestation. Mandatory consultation is neces- sary with other doctors after 20 weeks gestation. Although the Board of Health states that it developed the regulations for " consumer pro- tection and the establishment of professional guidance, " it is becoming clearer that the regulations have only added to the problems of providing all women with the services they need to control their own bodies. The guide- lines have compounded the delays and in- creased the costs for abortions, and there is Published by the Health Policy Advisory Center, Inc., 17 Murray Street, New York, N.Y. 10007. (212) 267-8890. Staff: Constance Bloomfield, Robb Burlage, Vicki Cooper, Barbara Ehrenreich, John Ehrenreich, Oliver Fein, M.D., Marsha Handelman, Maxine Kenny, Ken Kimerling, Ronda Kotelchuck, Howard Levy, M.D., Susan Reverby and Michael Smukler. 1970. Yearly subscriptions: $ 5 students, $ 7 others. Application to mail at second class postage is pend- ing at New York, N.Y. 2 no indication that they have guaranteed quality. Even prior to October 19th when the city guidelines went into effect, the demand for abortions was not being met. No one was sure in the beginning what the demand for abortions would be. Last year an estimated 1.2 million legal and illegal abortions were performed in the United States; another 800, 000 women carried full term pregnancies be- cause they could not get legal abortions or would not turn to illegal sources. The de- mand in New York City alone was estimated at between 50,000 and 100,000 per year. Despite the fact that New York City hospitals had only 3,160 obstetrical beds and performed only 850 therapeutic abortions in 1969, Dr. Saul Gusberg, chairman of the Health Depart- ment's OB GYN - Advisory Board, claimed that all needy women could very readily be cared for in the New York hospitals. The estimates of the demand all proved low. Between July 1 and October 1 over 45,000 abortions had been performed in New York City; 25,000 of these were in the hospitals; another 10,000 to 20,000 were estimated to be performed out- side the hospital setting. Thus it appears that the demand is twice what had been original- ly anticipated. The inadequacy of hospitals to meet the abortion demand presses most heavily on the poor, who have to use the city's municipal hospitals for this service. The municipal hos- pitals were preparing to perform 25,000 to 30,000 abortions a year in June. But in July, a backlog of 717 women were waiting for abortions in these hospitals. The number by August 12 was 1,380, and by the first of November the number had grown to 1,680. The trend was summed up by one OB GYN - chief: " There is developing a whole group of peo- ple who come to hospitals for help and who are returned to the streets in their original condition - without help. " The Health Department established an Abortion Clearinghouse to combat the de- lays. Any hospital or other agency can refer a woman to it if she cannot be served in the hospital of her choice. In turn, the hospitals are supposed to call the Clearinghouse when they have extra room for patients. Dr. Edwin Daily, director of the Clearinghouse, has claimed that any woman will receive an ap- pointment at a hospital within 24 hours of her call to the Clearinghouse. Many of the hospitals, however, have failed to use the Clearinghouse. They do not call into it when they have extra space, and they are often unwilling to accept referrals made through it. Moreover, the Women's Abortion Project and the Clergy and Lay Advocates, two consumer groups doing abortion counseling and ad- vocacy, have reported cases of telephone and personal turn aways - from the hospitals that are not recorded in the official statistics. Women are told " Sorry we are full today, " or " We're not registering any more women now, etc. " without any other referral within the hospital system. But in any event getting an appointment is not the same as getting an abortion. The key word in the hospitals appears to be " delay. ' A woman can sit for hours, waiting to reg- ister, waiting for her tests, waiting for her examination. Then she can spend weeks waiting for the actual abortion. But abortion is a procedure in which delay spells the dif- ference between a fairly simple, inexpensive operation and a more costly, physically dan- gerous and traumatic one. In the first twelve weeks, a woman can be aborted by use of the vacuum aspirator or by dilation and cur- ettage (D " and C "). But after 12 weeks, there is a period of a month when no procedure is usually performed until a woman can have a saline injection to induce labor and ex- pulsion of the fetus. The saline procedure is also more costly since it usually entails two or three days of hospitalizaztion, compared to at most one day for the aspirator or D and C. Thus, for example, a woman went to Kings County Hospital on September 10th when she was 8 weeks pregnant. The examining doctor insited, however, that she was 12 weeks preg- nant and would have to wait four weeks for a late abortion procedure. On her appoint- ment day, October 9th, a different doctor re- fused to do the abortion because she " wasn't far enough along. " She was told that if she had only come two weeks earlier she could have had an early abortion done. She then had to wait another three weeks. Because of these delays and rejections many women have found it necessary to " hospital shop " in order to find service. The latest date for termination also varies from hospital to hospital, and sometimes from week to week. There is no uniformity within the hospital system; nor can a woman receive general information about the differences. For poor women who may have to leave chil- dren with sitters, or lose several days of pay because of the delays, the situation is a des- perate one. Naturally this creates " shows no -" at the hospitals as a woman goes to seek help in other hospitals, or elsewhere. The voluntary hospitals have continued to do a high number of abortions on poor peo- ple; but it is up to each Chief of GYN OB - to determine how many and what kind of pro- gram his hospital will have. Many of these hospitals hospitals have have geographically districted clinics and will not accept patients on the ward service outside these lines. In some hos- pitals there is even greater fragmentation of care. Women's Hospital, for example, has district lines for its D and C's, but not for the salines. Few of these hospitals have cooper- ated with the city's Clearinghouse on making and accepting referrals. Prior to the guidelines, a woman had a choice of having her abortion in a clinic or private doctor's office. But since it is now illegal for such a procedure to take place ex- cept in a hospital or specially equipped clinic, women must look to the hospitals or out city - of - sources for their legal abortion needs. There are already reports of over crowding - in the suburban offices of doctors because of the overflow from the city. One enterprising doc- 3 tor now has women meet him in his office in Queens. He then has a limousine drive them over the county line so he can perform an in office - operation in Nassau County. But the dual health system continues. For the wealthy, there are still private physicians within the city limits that will do illegal, in- office abortions at high rates. Or, a woman with money can still call her private physi- cian and have the abortion in the comfort of a voluntary or proprietary hospital. For the poor, it is back to the delays of the municipal hospitals or voluntary hospital clinics. It is interesting to note that while the guide- lines refer to consumer " protection, " they make no mention of cost control. Abortion has always been big business; only now it is legal. In the private sector, abortions appear to be New York City's newest growth indus- try. The fee service - for - system has allowed rampant profiteering to take place. Doctors ' fees for this service have skyrocketed; the going rate seems to be whatever the traffic will bear. The cost in the independent clinics has been $ 75 in one case, $ 200 in another; but in the private offices before the guide- lines the fee was usually more than $ 350, always payable in advance. In one clinic, which claims to be concerned with cost con- trol, it has not been a total financial loss for the doctors either - they can receive $ 1500 a day at the rate of $ 75 per abortion. But it is not just individual doctors who are profiting. Park East and Park West Hospitals, two Manhattan proprietary hospitals, were bought after the law was reformed by a con- sortium of British financiers who already had made money on abortion clinics in England. These hospitals then sent letters to doctors all over the country announcing that their facil- ities were available for abortions at a total charge of $ 575 for an early abortion. The hos- pital charges $ 325 for the 24 hour stay (ap- proximately three times the city's going daily hospital charge), and the doctor receives $ 250 for the ten minute operation. The two hospitals now devote 75 per cent of their bed space to this service. Abortions have also generated a whole new sector in the economy: abortion referral. An example of the money to be made in this area is the case of an enterprising young man named John Settle and his Abortion In- formation Agency. Prior to the law's change, his agency referred women to abortionists in England, Haiti and Japan. But with the re- formed law, Settle sent letters to every doctor in the United States announcing his services as a referral agent to New York City doctors and hospitals. What he did not announce was his cut. If a woman called for an early abortion, Settle charged her $ 285. The clinics and doctors that were using Settle billed him 175 $ per abortion; the $ 110 difference went to Settle. For abortions after 12 weeks the fee was $ 710, with Settle pocketing $ 160 of it. With over 100 referrals a day, a forty person staff, and 15 telephone lines, Settle is gross- ing at least 70,000 $ a week. Women are not told how much of their payment goes for the referral itself, nor are they given an appoint- ment until the money has arrived in his hands. Several other abortion referral agen- cies charge anywhere from $ 100 25- $ for their information. In some cases, all the woman is given is the doctor's name; an appointment is not even made. One Boston woman was told by the referral agency that the fee would be $ 300, but she was not told she would be charged an additional 275 $ for hospitaliza- tion. Although she had no more money and no way to raise it, the doctor refused to lower his fee. Nowhere during the process with the doctor or the referral agency was she told that the possibility existed for a cheaper procedure. Other sectors of the medical industrial com- plex are also involved. The hospital supply companies share in the windfall. Doctors have reported that it is now almost impos- sible to buy the equipment for uterine aspira- tion due to the rush on the market. Real estate interests are also becoming involved. Several doctors have been negotiating for property and motels outside the city line near Kennedy Airport to do abortions. Money seems to be in the minds of the municipal hospitals as well, even though they were given a $ 3.5 million grant out of the city's emergency fund to pay for abortion services. At Kings County Hospital, a woman NEW YORK'S NEW GROWTH INDUSTRY Trying to get a cler picture of costs for abortions in New York City is like being a spy on a highly secret mission. There is no uniformity from hospital to hospital. But at press time the story is like this: @ Municipal Hospitals: $ 160 for a D and C or aspiration procedure, $ 230 for the saline procedure. If there are com- plications, the hospitals charge between $ 100 and $ 110 a day. Only Medicaid patients pay nothing. @ Voluntary Hospitals: Women's Hospital: 350 $ for both salines and D and C's. St. Lukes: 150 $ for D and C's $ 350 for salines. Columbia Presbyterian: $ 350 for the D and C's, $ 380 for salines. OE Proprietary Hospitals: Gracie Square: between $ 400 and 450 $ for early abortions. Madison Avenue: $ 365 for an early abor- tion, 650 $ for the saline. Parkchester: 450 $ for the salines. Park East and Park West: $ 575 for an early procedure, $ 700 and up for the salines. OE Independent Clinics: Women's Medical Center (Dr. Michael Bergman): $ 75. But the backlog is great and he does only a few a day. Women's Medical Group (Dr. Hale Har- vey): 200 $; or $ 0 for women on welfare. They do early procedures only. 4 is handed a slip of paper explaining the charges, demanding payment prior to the procedure if she is not on Medicaid. Many women reported to Clergy and Lay Advocates and the Women's Abortion Project that they were given the impression that unless they produced the money in advance, they would not receive their abortions. Although the mu- nicipal hospitals theoretically are not sup- posed to turn away women who have no money, the situation was summed up by the executive medical secretary at Cumberland Hospital this way: " Either they have cash, medical insurance or take a loan, or they're turned away. " While the guidelines were developed to protect the consumers and insure a high quality of abortion services, there is some doubt as to whether it is safer now to have an abortion than it was before October 19th. For example, there is a tendency to use gen- eral anesthesia for in hospital - abortions. An independent study published in the Septem- ber 1970 issue of Obstetrics and Gynecology concluded that abortions done in hospitals with general anethesia resulted in twice the blood loss of those done with local anesthe- sia. One of the city hospitals'abortion deaths was due to complications growing out of gen- eral anesthesia. It is certainly questionable whether it is safe to have an abortion in a New York City municipal hospital. A recently disclosed - Health Department report on material found in the saline solutions of New York City hos- pitals revealed that one hospital had pieces of microscopic glass in their solutions; at another, the solutions included " 45 pieces of blue thread - like fibers, one human hair, 14 pieces of glass ranging from microscopic to inch in size. " The city's Chief Medical Examiner's report on abortion deaths since July 1 disclosed that only one of the ten deaths has resulted from a procedure performed in an accredited doc- tor's office. Later further evidence revealed that this death was not due to complications from the abortion procedure. Four of the deaths have been from complications in in- hospital abortions. The circumstances sur- rounding the other six deaths were described as undetermined or suspicious. At one inde- pendent clinic the complication rate has been below that of the hospitals. The Population Council has performed a massive world - wide study on abortion which concludes that: [it is possible] that out hospital - of - abortions per- formed by physicians result in no higher risk of death than do in hospital - physician per- formed operations. " ' Delay is also a factor affecting the safety of in hospital - abortions. The longer a woman has to wait for her operation, the more dan- gerous the procedure becomes. But delay seems to be built into the hospital system. One doctor cynically summed up the situ- ation: " If we've learned anything from this experience it is that you can do almost any- thing to a healthy women and she will survive. " The Health Department and its Advisory Board, claim to be concerned with assuring quality care for all women. But: --@ They have not instituted price ceilings on legal abortion procedures. It appears that neither the doctors nor the Health Department are about to consider what the Assistant Health Commissioner called " precedent shat- " tering considerations such as price control. ' But at Johns Hopkins Hospital in Maryland, the precedent has been broken with the set- ting of a $ 150 profit limit. Neither group has taken any action against the doctors using John Settle's referrals, for example, although the AMA continues to pass resolutions for- bidding such advertising and solicitation. The only price control mechanism that exists has been the pressure brought by the existence of the independent clinics and by the advocacy work of the Women's Abortion Project, Clergy and Lay Advocates and some of the non profit - referral groups. OE The Health Department has not regulated the abortion service provided by hospitals receiving public funds. It permits each chief of service to have complete control over medical procedures in his own department, and it agrees that no outside influence should determine his policies. The city has estab- lished no uniform policy on how late in preg- nancy the procedure may be performed. It has not forced the hospitals to use the Clear- inghouse. It has not set up special training for doctors in abortion procedures. It has not aided hospitals in the establishment of abor- tion clinics. Each hospital complex has been permitted to operate in isolation under the command of its individual chief of service. OE Abortion is only one part of a woman's medical concerns. There needs to be contin- uous unfragmented preventative care for all a women's medical needs. The Health De- partment has not taken any steps to ensure the availability of such service. Given the kind of care and experience the poor have in the hospitals, women are justifiably fright- ened and tend to stay away from the hospitals until an emergency or until other alternatives have been exhausted. Abortion, of course, is not just another op- eration; it is the only medical procedure regu- lated and limited by the Health Code. It is an issue which is fraught with religious, sexual, moral and cultural overtones. These consid- erations affected the Advisory Board and the Health Department's consideration of the guidelines, and the abortion picture in general. The New York State Catholic Bishops, for example, have issued a guideline on abor- tions for Catholic hospital workers. It asks them to think about these questions: " Is the greatest part of my time taken up with abor- tion cases?... Do I have to show by my work that I approve of those performing or receiv- ing abortions?... Does the result of my work directly aid in the increasing abortions? " If the answer is yes to any of these, then the worker violates the moral law. This view- point was expressed by one doctor who wrote to a medical journal these poetic lines: 5 " Abortions are made by me, but only God can make a pregnancy. " The attitude of the male dominated - profes- sion toward women and abortions helps ex- plain the health system's response to the new abortion law. Residents in some of the hos- pitals resent the amount of their training time spent on the usually routine abortion procedure; the operation, they say, is boring and messy. The professional ethos of medicine comes to the forefront on the abortion issue. " Abortion on demand " affronts this. Most doctors believe they are trained to serve the needs of their patients, but only as they themselves define those needs. One doctor put it this way: " You have to realize that obstetricians by training and practice are geared to bringing new life into the world, not destroying it. For many of us, religious objections notwithstanding, abortions simply go against our grain. " Even those doctors who will perform the procedure often act as if they were doing the woman a favor, in- creasing the guilt society has already placed upon her. This attitude was reflected in the comments of one hospital administrator who said: " Don't make it too easy for the patient. If it's too easy she'll be back here in three months for another abortion. " It is certainly not made easy. At Jacobi Hos- pital, for example, out patients - salines are performed. This means the woman is injected with the saline solution in the hospital and then is sent home to deliver the fetus herself. She is to bring it back to the hospital in a spe- cially designed bag, with the picture of a fetus on its side. It is certain that no woman who has ever had an abortion thought up this procedure. Throughout the abortion system, women are treated as " helpless " and " passive " con- sumers of a service they dare not question. One woman who sought help from a private physician was treated this way when she asked a question about his fee. " He immedi- ately lost his temper and said he must refuse to help me now as my attitude was such that I resented his fee, and since the operation was'major surgery'he felt his years of train- ing and experience were worth $ 350 at least. He told me to go to a city hospital where it would be done more cheaply since he would not help anyone who obviously resented his fee. When I attempted to explain how I had investigated the city hospitals and what the problem [delays] was there, he turned his back on me and walked out of his office. " Women are also assumed by the Health Department to have no judgment concerning their own bodies. The assumption, built into the code by the mandatory two day - waiting period for " careful consideration " by the pa- tient, is that she might not be able to make up her own mind, or that somehow she is be- ing coerced into the procedure. It appears to be a moral and social judgment on the part of the Advisory Board that women should be prevented from making a " wrong " decision on their abortions. This attitude is perpetu- ated throughout the hospital system. For ex- ample, one woman called St. Luke's Hospital on October 21st when she was 21 weeks pregnant. She was told that the hospital did no abortions after 20 weeks. A social worker later explained to one of the Women's Abor- tion Project counselors that they say 20 weeks only because " women cheat " in de- claring their length of pregnancy. The case of abortion services in New York City is not an isolated medical incident. It is just another example of the workings of the American health system. The lack of con- sumer control has meant that the needs and ideas of a few powerful men and their insti- tutions have prevailed over those of the wo- men they are supposed to serve. Unless the women whose bodies are being controlled are themselves in control of these services, the future for abortion service in New York is bleak indeed. -Susan Reverby Harlem Drug Fighters: " United United ' we stand " Late last July a small group of Harlem resi- dents marched from a street rally into Har- lem Hospital where they liberated two floors of the Psychiatric Department. There they quickly set up their own program for drug treatment and issued demands focusing on the establishment of an in patient - drug detoxification program at Harlem Hospital; provision of a rehabilitation program for ex- addicts; and the granting of complete commu- nity control over both of these programs. Twenty - five days later this group, calling itself the United Harlem Drug Fighters (UHDF), won all of its chief demands. What precipitated such a bold and risky action by a group of community residents- addicts and ex addicts - , mothers and commu- nity leaders? What made such powerful in- stitutions as Columbia University College of Physicians and Surgeons, Harlem Hospital, the Health and Hospitals Corporation, and the Addiction Services Agency willing to rec- ognize, negotiate with, and grant the de- mands of this seemingly small group? And finally, what is the nature of the United Harlem Drug Fighters'program - a program which would seem to present a model of com- munity organization and participation? Decades before drug addiction was her- alded as an epidemic by fearful suburban parents and campaigning politicians, the black and brown communities knew the full extent of its scourge. Presently there are an estimated 100,000 addicts in Harlem, with ap- proximately half of these living in Central Harlem. A door door - to - (as well as rooftop and vacant building) canvass by the Com- munity Thing, a community group concerned about addiction, revealed the shocking extent 6 of the drug problem in Central Harlem. In a Mothers Against Addiction, marched on two 44 squar-e bl-o ck area with a population of West Side hospitals, St. Luke's and Roosevelt, 58,000, the Community Thing found 18,000 demanding that detoxification facilities be es- addicts. 2,000 of these were children and 6,000 tablished in those hospitals. St. Luke's subse- were adolescents. About 95 percent of these quently set up 28 detoxification beds. addicts support themselves by criminal activ- Last year a small group of Harlem resi- ity; most of it is concentrated in Harlem. In this dents, many of whom later became Drug area there is an average of three deaths from Fighters, approached Mayor Lindsay asking drug overdosage each week. Declared one that an in patient - drug detoxification program Harlem resident, " There is not a single person be established in Harlem Hospital, which is in Harlem who is not affected by drugs. If the only public hospital serving the Harlem you're not an addict yourself, maybe it's your community. He promised that when the hos- brother or son or husband that's hooked. Or pital enlarged into its new quarters, a large maybe it's that they're in jail - or even dead. drug detoxification program would be estab- Or else it's that you've just been robbed or lished. The move came and went in 1969, with beaten up. When a mother sends her chil- no mention of a drug treatment program. dren to school, she sits in fear not knowing When asked, Harlem Hospital administrators what will happen to them there, when they declared that there was no space; subsequent will return, or whether they will return. " negotiations got nowhere. The second major development was a adminrstration is- Despite the magnitude of the drug pro- ing discontent with the administration and blem, there are only a handful of drug treat- policies of Harlem Hospital. Harlem Hospital ment prograins in Central Harlem. Before the is a municipal hospital which has long suf- UHDF action, there were no in patient - hos- fered from inadequate funds, a decaying pital facilities in Harlem devoted to detoxi- physical plant, overcrowding, and under- fication, the process of breaking an addict's staffing. It is affiliated, under a city contract, physical dependence on drugs. In the entire with Columbia University College of Physi- city there were fewer than 400 hospital beds cians and Surgeons. In return for an annual available to addicts who voluntarily sought appropriation of over $ 16 million of city help in drug withdrawal. The only methadone funds (over $ 1 million of which is overhead), maintenance program in Harlem is a minute Columbia now supplies nearly the entire pro- experimental program run by the Psychiatric fessional staff of Harlem Hospital, and by so Department of Harlem Hospital. In the city as doing it plays a major role in determining a whole such programs are extremely limited hospital policy. Unfortunately Columbia's since they are usually operated only in con- need for research and training resources do junction with research programs. not always coincide with the community's There are six " therapeutic community " need for prompt, high quality - , relevant health drug treatment centers in Harlem, but these care. are designed to provide intensive long term - psychological therapy, and can therefore treat Y' ne of the chief examples of this conflict is only a few patients at a time. Finally, there the Harlem Hospital Psychiatric Department are several drug rehabilitation programs which is headed by Dr. Elizabeth Davis, a providing job training and placement, educa- powerful member of the Columbia Medical tional programs, counselling, etc., but these School Department of Psychiatry. When Har- are generally equipped to deal only with de- lem Hospital expanded into its new quarters, toxified addicts. Thus for the average addict a large part of K Building - , the newest wing of seeking help in kicking his habit, regardless the old hospital, was allocated to the Psychi- of the program he may choose, the answer is: atric Department. Yet nothing more than " We'll put you on a waiting list... it will be token programs to treat alcoholics and addicts at least two or three months. " The reality is existed in the Psychiatric Department or else- likely to be a year. In this period of time a where in the hospital. Drug addiction and al- heroin addict may well find himself in jail, coholism constitute major mental and phy- if not dead. After studying the situation, the UHDF concluded that in Central Harlem sical health problems in Harlem, but are deemed uninteresting in terms of medical re- " there was no worthwhile drug program. " search or training. As in most hospitals, Besides the increasingly desperate nature addicts and alcoholics are treated as degen- of the need, two general developments set erates or criminals. Said one ex addict - , " If the stage for the UHDF action. The first was a you come into the emergency room with a growing community awareness and mobil- broken rib and they find out you're an addict, ization around the drug problem. The last few they'll throw you out, sometimes without years have seen the growth of a number of even fixing you up. They figure,'What's the community groups in Harlem attempting to use he's just an addict anyway.'They treat deal with the drug problem. There have been you like you're a criminal instead of a charges by those groups of neglect and mis- human being. " use of funds by the city's Addiction Services The community has waged a number of Agency, charges of police collusion in drug battles over control of Harlem Hospital and traffiic, threats of vigilante action against other health programs in Harlem. In 1968 pushers, marches, demonstrations, and sit- citizens filed a suit against Mayor Lindsay ins to dramatize the need for effective drug and the Department of Hospitals to order im- programs in Harlem. Last winter one of the mediate correction of numerous State Hos- most militant of the community groups, pital Code and City Health Code violations 7 at Harlem Hospital. More recently, CORE's Committee of 100, including Harlem CORE, HARYOU - ACT, Harlem Neighborhood Asso- ciation, Harlem Hospital employee unions and Harlem community physicians and hos- pital staff, have called for a powerful Com- munity Health Board which would control not only the hospital, but all health services in Harlem. Black physicians have also been angry about their exclusion from positions in the Columbia network and within Harlem Hospital. Rising community anger and or- ganization around the drug problem in Har- lem and around the administration and pri- orities of Harlem Hospital converged in the action of the United Harlem Drug Fighters. The UHDF began as a semi official - advis- ory committee to the Addiction Services Agency (ASA), the agency responsible for drug treatment in the city. The ASA was at- tempting to establish channels for commu- nity input, and had in the late spring of 1970 approached several Harlem community lead- ers to organize a community advisory com- mittee from Harlem. The committee, led by Martha Davis, Alice Kornegay, and Ruth Adkins, with the assistance of several drug and poverty program workers, drew up pro- posals for badly needed - drug programs in Harlem. It then proceded downtown to its first official meeting with the ASA. To the mem- bers'surprise they found ASA officials too busy to meet with them, even though ASA had set up the meeting. " We could see the ASA officials through a glass partition across the hall, but they said they couldn't meet with us for some reason, " stated one of the com- mittee members. The committee tried several more times to meet with the ASA, only to be similarly rebuffed. With this, the group dropped its " advisory " mantle and moved toward direct political ac- tion. They called a rally for Saturday, July 25, to draw attention to the drug problem and to the city's neglect of it. They demanded recognition by the ASA of its Harlem Area Drug Advisory Board; the use of four unused floors in the Psychiatric Department of Har- lem Hospital for drug treatment; establish- ment of a rehabilitation center by the city; and complete community control of these programs. The group immediately set about organiz- ing an in patient - detoxification program. Their tactic not only demonstrated the need for the program, but also demonstrated the ability of a community group to deal with that need. The action was also calculated to The program, operated with the assistance of a small group of doctors, nurses and tech- nicians who volunteered in their off duty - hours to examine, diagnose and treat drug patients. Drug addicts themselves helped to administer the program, provide security, serve meals, organize maintenance, and gen- erally ease the operation of the program. In spite of some disorganization and hard- ship (for instance, patients had to sleep on the floor since there was no furniture), pa- tients appeared pleased with the program. " This is nothing like sleeping on the floor of the Tombs, " commented one addict. " I know I'd be out there beating someone up, even though I wouldn't want to, if it weren't for this program, " concluded another. Even workers in the hospital morgue had praise for the program. Noting that during that week they would normally have received three deaths from drug overdosages, they wrote: " Whatever you all are doing on the seventh floor of K Building - must be right because we working at the morgue have not had one case since you have been trying to imple- ment your program of instant admissions. God bless you all. " Shortly after the takeover, a majority of the interns and residents at Harlem Hospital met and passed a unanimous statement of support, vowing that if police were used to oust the UHDF, they would also be arrested. On the question of medical assistance they felt themselves in a bind, not wishing to let the UHDF down, but fearing that they would be used by the hospital to avoid committing itself to provide medical care. Nevertheless, the need was so great that a handful of staff worked consistently throughout the month. A group of attending physicians, consisting of doctors who supervise interns and resi- dents and who comprise the permanent staff of the hospital, also met and passed a state- ment of support. In the weeks that ensued, 104 groups in the Harlem community and a number of prominent public figures came out in support of the UHDF. The relationship and roles of Harlem Hos- pital, Columbia University College of Physi- cians and Surgeons and the Hospital Corpora- tion in the negotiations and settlement are complex and unclear. It appears that the Hos- pital Corporation must approve new hospital programs, but since Columbia is given the money to staff Harlem Hospital, it is Colum- bia which sets the priorities of Harlem Hos- pital and which has the power to change them. make it very difficult for authorities who claim concern about the drug problem to eliminate the UHDF program out hand - of -. Contacts were made with sympathetic hos- pital staff and with community groups and that evening the UHDF announced to the community that it would immediately admit any addict who wished to be detoxified. Two days later, 325 addicts had flocked to the program for treatment - a number which ap- proximately equalled the capacity of already existing detoxification units in the entire city. Elliot Roberts, Director of Harlem Hospital appeared sympathetic in many ways to UHDF. The Hospital provided food and medi- cation during the 25 days. In addition, Roberts himself did a great deal of nego- tiating on behalf of the UHDF. Since the hos- pital had few independent options, given the policy making - power of Columbia, it must be assumed that in the end it was Columbia which capitulated to the Drug Fighters. No small barrier was Dr. Elizabeth Davis, head of the Psychiatric Department, who threat- 080 ened to resign. Although the floors in ques- tion had not been used in nearly a year, the entire Psychiatric Department shut down immediately after the occupation, transfer- ing seriously - ill patients to Bellevue Hospital. When the establishment of the detoxification wards was accepted, they were assigned to the Department of Medicine, rather than the Department of Psychiatry, as would normally be expected. The ASA was brought into the negotiations as a source of funding for the program. However the decision was made, it is clear that the UHDF had a great deal of power at its command. The greatest source of power was the urgency of the need and overwhelm- ing support that the UHDF action received from the community. This support included interests as broad and diverse as the Harlem and East Harlem Youth Federations, the United Block Association, the Community Association of the East Harlem Triangle, the East Harlem Health Council, the Black Mus- lims, the Young Lords, and many others. In addition, the UHDF had a powerful tactical weapon the ability to admit an unlimited number of addicts to the program. Implicit was the threat of virtually overrunning the hospital with addicts while simply maintain- ing a badly needed - program. In the settlement Harlem Hospital offered to establish a 100 bed - detoxification unit on two floors in an older wing and the Addiction Services Agency agreed to finance the opera- tion of the unit. The UHDF fought for and won autonomy in running that unit. They have complete control in hiring and firing of staff, admission and discharge procedure, program content, and all other aspects of the program. The UHDF is governed by a Board of Di- rectors consisting of representatives of the program itself, of professionals working with the program, and of various community groups. It has an Addicts'Advisory Com- mittee consisting of over 500 adolescents who have been associated with the program. In addition, a large number of UHDF members running the program are former addicts. The admission policy of the UHDF detoxifi- cation program is one of its most striking features. At least 75% of its beds are reserved for adolescents and the UHDF will admit any adolescent who asks assistance. This fre- quently means that the patient population far exceeds the allotted 100 beds, and the UHDF sets up cots in the recreation rooms and throughout the rest of the two wards to handle the overflow. Another important fea- ture is the fact that the program admits pa- LINCOLN Addicts and commu- O.D.'S ON T.P.F. nity supporters, fol- lowing the example of the United Harlem Drug Fighters, took over the sixth floor of the house staff adminis- - tration building at Lincoln Hospital on No- vember 10. Within an hour the floor was transformed from house staff call on - rooms to a detoxification unit, and several addicts were started on methadone. The group de- manded that Lincoln Hospital establish a 100 bed detoxification unit under the control of addicts and other community people. But un- like Harlem, the Lincoln administration acted swiftly. Within four hours, fifteen people were arrested, including several of the addicts un- der treatment. What made the response different at Lin- coln Hospital from that at Harlem even though the roots of the rebellions were the same? Certainly the need for a narcotics de- toxification unit in the South Bronx rivals the need in Harlem. Lincoln's response to this need is inadequate a small methadone maintenance program and several satellite therapeutic communities. The priorities for drug treatment programs in both hospitals are set by outside forces: Columbia Medical School in the case of Harlem and Einstein Medical School in the case of Lincoln. Two major factors differed, however. First, the Lincoln administration and the Hospital Corporation had developed experience in dealing with hospital takeover actions. Only four months ago, Lincoln had been occupied for eight hours by community groups (see BUL- LETIN, September 1970). This previous take- over stimulated the Health and Hospital Cor- poration to promulgate " Operating Guide- lines in the Event of Unauthorized Occupa- tion of Hospital Property. " These guidelines instructed municipal hospital administrators in handling every detail in such events. The guidelines even went so far as to set forth the role for the Community Advisory Boards of the municipal hospitals. The memorandum reads: "... the Community Advisory Board's en- dorsement of the administrator's activities and plans in such situations may be highly important. The board may also be effectively mobilized to help develop plans and to cope with the unauthorized activity. " The Hospital Corporation's guidelines are designed to en- courage definitive actions such as those taken by Dr. LaCot, the Lincoln Administrator. Second, unlike the Harlem Drug Fighters. many of the activists involved in the Lincoln action were well known to the hospital admin- istration. Although several addicts took lead- ership at Lincoln, the community support con- sisted primarily of the Think Lincoln Com- mittee, the Health Revolutionary Unity Move- ment and the Young Lord's Party, all of which were involved in the previous hospital takeover. The United Harlem Drug Fighters limited their program to addiction. But it was clear to the Lincoln administration that the South Bronx groups had a program for the entire hospital. The administrators had to act swiftly or find themselves challenged on other aspects of hospital care. The previous take- over led Lincoln administrators to feel that the action might fail to mobilize community support; they therefore felt safe in calling in the police. However, the crisis around addiction con- tinues. Lincoln Hospital still has an inade- quate drug program, which the Tactical Police Force cannot fix. 9 tients on a 24 hour - - a - day basis. This is par- ticularly important for addicts, since most will seek assistance in the early morning hours when it is cold and money and drugs are hard to get. Addicts are treated with methadone, ad- ministered in successively smaller doses. Under this procedure they suffer some dis- comfort but avoid the torture which results from " going cold turkey. " At the end of the ten day - period they are released, free of physical dependence on drugs. When the re- habilitation program is set up, patients will go directly from detoxification to rehabili- tation. The detoxification wards were to be inte- grated into the hospital and provided with the medical services normally given any other hospital ward. In fact, this has not happened. At the moment, the UHDF wards appear to be receiving the lowest priority within the hospital. For instance, ancilliary personnel such as aides, clerks and messengers norm- ally assigned to a ward have not been pro- vided to the UHDF wards. This means that often the transfer of patient records is de- layed or neglected, and when a patient must be taken to another part of the hospital for treatment, valuable staff resources must be used. Until recently all medical services de- pended on doctors who were willing to spend overtime hours working on the UHDF ward. Although they are paid, they could hardly be expected to take the responsibilities or pro- vide the services of a doctor regularly as- signed to the unit. Recently the UHDF ob- tained a time half - physician. Services of doc- tors to consult on special medical problems, X ray - and laboratory technicians, emergency room and other medical services throughout the hospital are also voluntary rather than obligatory, and thus depend on the good will and cooperation of those involved. There is no structured training program to attract large numbers of interns and residents who comprise the house staff on other wards. Drug addiction is not presently considered an " interesting " medical problem by much of the profession and the work is hard. In addi- tion, few doctors are willing or able to work under the control of a community group. The UHDF depends on volunteers to pro- vide many essential services. Large numbers of community volunteers have organized out- reach and drug education programs. Social work students and other professionals have volunteered their time to establish psycho- logical, social and therapeutic services for the UHDF. Volunteers teach nutrition, home- making, and other useful skills on the wards. A serious problem remains, however, in pro- viding constructive activities to occupy the patient's days. Such problems are to be expected as one of the Drug Fighters reflected. " We don't pre- tend to know all about drug treatment, and we know our program has a lot of problems. We are just learning about a lot of this our- selves. But we do know that nobody else was even trying. " A doctor who has been working closely with the UHDF program stated, " Pro- fessional programs have failed and no one else has the answer, so why shouldn't we try a community program? " Detoxification is the first and probably a minor part of the total UHDF program. Over 2000 addicts have been detoxified, but they leave the hospital to return to the very con- ditions which led them to addiction. The UHDF agrees that a large number of their pa- tients have probably returned to drugs and it asserts that the critical part of its effort rests on the rehabilitation program. However, establishment of the rehabilita- tion program has been delayed by negotia- tions with the ASA and entanglements at the federal level. The ASA originally granted funds and offered an old hotel for the site of the rehabilitation program. It was only later that the UHDF found the program was to be run by the ASA as a therapeutic community. After again fighting and winning the right to structure and operate its own program, the UHDF still finds that the release of funds is being held up at the federal level. What will be the nature of the UHDF rehabil- itation program? The UHDF differs with the basic assumptions of both major types of drug rehabilitation programs presently in existence, and is very clear about what its program will not be. First of all, it will not be a methadone maintenance program. " Metha- done maintenance may be valid for older and hardened addicts, " one Drug Fighter commented, " but its use on adolescents con- signs them to a lifetime of addiction to metha- done. " In addition, since the addict must re- turn to the hospital daily for medication, the community is suspicious of the social control which is possible. For example, addicts were forced to remove Third World solidarity but- tons at one center before receiving methadone. Second, it will not be a therapeutic com- munity. " We have no intention of putting people into an ivory tower, " another Drug Fighter stated. " When the addict comes out, he is going to have to face 135th and Lenox Avenue exactly as it is and he is going to have to deal with what makes it that way. " The chief assumption of the UHDF is that it is social conditions such as poverty, unem- ployment and the lack of such essentials as good housing, education and health care that lead to hopelessness and escape through drugs. If this assumption is true, then only an attack on these conditions offers any hope for the problem of drug addiction. Thus the Drug Fighters agree that if the rehabilitation program is to be successful, at its heart must be a program of social action. How will this be done? The UHDF is un- sure, but of course, they were originally un- sure about how to set up a detoxification pro- gram. The program will concentrate on three areas: social service, education, and man- power. On the question of how they will translate this into social action, the UHDF will be experimenting and feeling the way. In so doing, it will be forging the way for other community drug programs. -Ronda Kotelchuck 10