Document Zn0JobpyLG85V5bGp7xpg56yL

Health Policy Center Advisory No. 34 October 1971 HEALTH PAC BUISLS Sffiffl Sffiffl FREE CLINICS Medical institutions derive their wealth from patient fees, research grants and real estate investments. The wealth of many medical empires is measured in the tens, if not hundreds, of millions of dollars. Using this measuring rod, free clinics are but tleas on the hide of the elephantine medical system. Since the Hcright Ashbury - Free Clinic opened its doors in 1967, free clinics, how- ever, have experienced explosive growth in their own right. Today, upwards of 200 free clinics are operating and new ones are coming into being regularly. They see tens of thousands of patients annually and are staffed by many hundreds of com- munity activists and health workers. Free clinics, therefore, would be worth examining if only because of their sheer appeal and popularity. But serious analy- sis of free clinics is also needed because all free clinics have, with varying clarity, focused on a vision of good health care, which they try to represent in their ac- tivities. The vision came together during the 1960's in what the media has labelled " The Movement for Social Change. " It is a distillation of the experience and beliefs of the New Left, underground culture, Black Power advocates, and OEO. The vi- sion is founded on the twin convictions that: The American medical system does hot meet the people's needs; and the Amer- ican medical system must be radically re- structured! It can be summarized by the following principles: * Health care is a right and should be free at the point of delivery. * Health services should be compre- hensive, unfragmented and decentralized. * Medicine should be demystified. Health care should be delivered in a cour- teous and educational manner. When pos- sible patients should be permitted to choose among alternative methods of treatment based upon their needs. * Health care should be deprofession- alized. Health care skills should be trans- ferred to worker and patient alike; they should be permitted to practice and share. these skills. * Commmunity - worker control of health institutions should be instituted. Health care institutions should be gov- erned by the people who use and work in them. Free clinics have taken on the double tasks of meeting the people's needs and of radically restructuring the health sys- tem. In most cases they attempt this by serving as an example of good health care and a model for the future. Some also attempt to be instruments of change, by challenging existing health services as well as providing their own. To evaulate these attempts HEALTH- PAC spoke to community staff members, professionals and patients, with site visits at free clinics in New York City, Baltimore, Chicago, Minneapolis, St. Paul, San Fran- cisco and the Bay Area. Our observations and conclusions form the basis of the fol- lowing articles. The research for this Bulletin was done by Constance Bloomiield, Howard Levy, Ronda Kotelchuck, Marsha Handelman. WITH A LITTLE HELP FROM THEIR FRIENDS At first glance there would appear to be a nearly infinite number of variations on the Free clinic theme. They may be founded by medical professionals seeking alterna- tive forms of practice, by political parties seeking to develop constituency, or by neighborhood groups interested in provid- ing a local service. They can serve freaky drop - out, university community, working class, ghetto, barrio or all female - popula- tions. On second glance, however, they have many characteristics in common. Layout, Amenity and Accoutrements Free clinics look remarkably alike. They are located on or near the main drag of whatever community they intend to serve -whether it be Telegraph Avenue in Berkeley or Greenmount Avenue in Balti- more. They share an awkward layout- whether it be in a store front -, second - story office or church basement. Unlike the out- patient departments (OPD's) they seek to outdo, they do not make the error of con- fusing barrenness with cleanliness. All of them evidence some good intentions in terms of decor with bright paint and post- ers, but these efforts have been largely overwhelmed by the mass of humanity that has been in and out the door since opening day. There is a reception area of desk and files. A donations can is located promi- nently. There's a waiting area with sec- ond hand - furniture lined up against the walls. The reading matter can range from underground or political papers to broc- hures like What You Should Know About VD and TB and You. Some clinics have written their own literature on nutrition, GYN care, etc., while others appear to have given up the losing battle to keep literature around at all. There are usually three examining rooms; they are large enough to contain a doctor, a patient examining table and little else. Many are constructed from partitions and frequently have curtains instead of doors. A modest lab and pharmacy claim whatever large closets or corners may be left over. The lab will have a microscope, hematocrit machine, and equipment for urinalysis. The pharmacy has a _ well- used copy of Physicians'Desk Reference and other pharmaceutical literature. The pharmacy is generally stocked with sam- ple drugs charmed from friendly drug company detail men. In fact, in most free clinics, just about everything is donated. They all have been fixed up with free labor; in one case, plumbing and electrical work was donated by union locals. Ironically, several clinics got a lot of their medical equipment from doctors'widows who were dismantling their husbands'offices. Some have equip- ment and supplies which have been " lib- erated " from local hospitals. Published by the Health Policy Advisory Center, 17 Murray Street, New York, N. Y. 10007. Telephone (212) 267- 8890. The Health - PAC BULLETIN is published monthly, except during the months of July and August when'it is published bi monthly - . Yearly subscriptions: $ 5 students, $ 7 others. Second - class postage paid at New York, N. Y. Subscriptions changes - of - address, and other correspondence should be mailed to the above address. Staff: Constance Bloomfield, Des Callan, Oliver Fein, Marsha Handleman, Ronda Kotelchuck. Howard Levy, and Susan Reverby. Associates: Robb Burlage, Morgantown, West Virginia; Barbara Ehrenreich, John Ehrenreich, Long Island; Ruth Galanter, Los Angeles; Kenneth Kimerling, New York City. 2 Patient and Staff Characteristics In the year or two that most free clinics have been open, each has had upwards of 3000 patients. Two thirds - to three quarters - of these patients were women. Far less than half were ever seen more than once. About 200 could be called " hard - core pa- tients -those " who rely on the clinic for continuous care. Most clinics have reported that when they first opened, a high proportion of the pa- tients were young white dropouts who were frequently not even from the neigh- borhood. After a while, in those areas where the residents are not primarily hip, the patient population has started to re- flect the neighborhood as a whole - older, more ethnic, working class or whatever. A distinctive (and perhaps the most vulnerable) thing about free clinics is that they rely on volunteers donating their skills. Although some clinics have a few employees on subsistence salaries, the de- livery of medical care is totally dependent on good will. And despite the deprofes- sionalization of some medical skills, the clinic is really dependent on the good will of doctors. Thus, while doctors can pick and choose among free clinics, virtually no clinics have ever asked a doctor to leave, even though they all wanted to from time to time. In many clinics, the size of the staff ap- proximates the size of the patient load on any given night (average 25). The Peo- ples Free Medical Clinic in Baltimore is open four nights a week, has five paid staff members, and approximately 150 volunteers. While many clinics operate from a smaller pool of volunteers, the Baltimore Clinic has a generally typical breakdown of labor and functions: doc- tors, nurses, coordinator receptionists - , peo- ples'counselors - therapists, women's coun- selors, laboratory technicians, patient advocates, child care personnel. Other clinics might omit the women's counselors or the child care personnel, but they may have dentists, dental assistants, pharma- cists. Some combine the patient advocate and nursing functions into one para medic - role. The bulk of the labor contributed to free clinics comes from non professionals - , some of whom may be health science stu- dents, but most have had no formal health science education. Patients are encouraged to volunteer in all clinics. While this actual- ly occurs to only a limited degree, clinic staffs do resemble the patients more close- ly than in any other medical institution. The Berkeley Free Clinic, which grew out of the need to have medics present during confrontations between street people, stu- dents and the Alameda County Sheriff's CONTENTS Description 2 Politics 11 Women 14 Office, is continually training new medics and senior medics. According to the staff, many of the volunteers were former clinic patients. This is also true in those clinics which are affiliated with political organiz- ing in neighborhoods. Nearly all free clinics put a great deal of emphasis on the transfer of skills. The delegation of minor professional skills to paramedical workers is not such a radical departure from tradition. Even the most conservative medical societies have adopted the idea for economic reasons. In free clinics, however, the skill transfer sys- tem is designed to serve and demonstrate closely related objectives: the demystifi- cation and deprofessionalization of medi- cine. In clinics where skill transfer is highly valued, a Horatio Alger attitude prevails: " We learn as much as we want to and do as much as we can. " Some clinics have professionalized the deprofessionalization by having formal courses taught by local health institutions for novices to the med- ical field. In most, however, the learning goes on in an over shoulder - the - apprentice fashion. This raises a profound question which most free clinics have not faced: to what extent are free clinics using their patients as teaching material, just like the OPD's? Are patients given a choice of being served by a trained medic or a medic - in- training? While a Cincinnati clinic will not let med students'play doctor,'the com- ment of one medical student should give pause. " I enjoy working in the free clinic, " he said, " because I can do things that the medical school won't let a third - year stu- dent do. " Skill transfer raises another question: does demystification also mean a de emphasis - or down grading - of the value of medical competence? Transfer of skills goes beyond nursing functions with non professional - lab tech- nicians, pharmacists, and dental tech- nicians being trained at some clinics. Transfer of skills not only serves to de- mystify but also to change traditional sex stereotypes, with male receptionists or female pharmacists. In women's free clinics changed sex roles become closely linked with demystification and deprofes- sionalization. A frequently heard refrain 3 " The number of people here has proven the need for more and better health care, a need which we alone cannot fully meet. " -People's Free Medical Clinic, Baltimore is, " We won't be dependent for our med- ical care upon male gynecologists. " While a few clinics have formal job. rotation, most have an ad hoc voluntary rotation. In a number of the clinics every- one on the staff can take blood, read vital signs, do pregnancy testing and pinch - hit for each other. Although the doctors are excluded from job rotation, in most free clinics they are expected to do some of the menial work cleaning - up, mopping floors, etc. As one non doctor - said, " It's a good experience for doctors to empty ash- trays. It creates a sense that this isn't just a place to see patients. It's his clinic as much as it's ours, and he has an obligation to see that it's clean. " Clinic Procedure Every clinic is confronted by more pa- tients than it can handle; they are all con- founded by the problem of waiting time. Most clinics open around 6 p.m., two to four nights a week. They see an average of twenty - five patients a night. There are usually three doctors on duty, who (like. their OPD colleagues) cannot always be counted on to show up on time or show up at all. The clinic will close at 10:30 or 11. Since few, if any, appointments are made, some patients may have to wait all eve- ning to see a doctor. All clinics have had trouble cutting the average clinic visit down to below an hour - and - a - half or two. The wait may be broken up with extensive medical histories and the like. Those clinics that have tried classes or films in the waiting room have usually given up. in exhaustion and chaos. Since the jam - up is almost always at the doctor's end of things, proposed solu- tions usually mean shortening the pa- tient's time with the doctor or instituting 4 staff routines that " use the doctor's time more efficiently. " This starts violating some widely held free clinic principles like: " the patient has the right to have all of his or her questions answered, " or " this isn't a business, so what's all this talk about efficiency? "; and " the staff is here to serve the patient, not be drones for the queen - bee doctor. " Every clinic turns patients away - not only because of the waiting period, but because they all agree, " We'd never go home if we didn't. " " There is a bottomless pit of patients who can't, don't or won't go to the hospital. Maybe they can't go because of the law, or they don't because it's so far away and they don't have translators. Or they just won't go because of the attitudes and the hassle they get there. " Although this problem has been handled with more dispatch than the waiting problem, it involves still more serious trade - offs. All of the clinics have decided that it's better to turn people away or limit the scope of their services, than sacrifice the quality of the services they do render. Generally they use some variation of a first come - - first - serve basis coupled with geographic boundaries. The receptionist's discretion is used to weed out those could go somewhere else or pay for services from those who can't; those who aren't in pain from those who are, etc. Theoretically, other staff members can relieve some of the pressure and depend- ence on the doctor. Among other things they can take care of less seriously ill pa- tients who don't need the doctor, thereby shortening the waiting time and getting more patients through in an evening. However, this works to a limited degree, if at all. Despite the fact that in some clinics the staff patient - ratio approaches one one - to - and the fact that in many clincs a good deal of " transfer of skill " goes on, in narrow medical terms, the bulk of all this energy and attention does not amount to much more medical attention than a patient would receive from a nurse receptionist /. The Patient Advocate Those clinics which have a more de- veloped consciousness about the faults of American medicine or have a message that they want to get across with their medicine have patient advocates. Al- though they have been used in other health institutions the patient advocate program provides the most promising aspect of free clinics. Those clinics which make good use of the patient advocate offer a significant departure from medi- cine as practiced in the OPD. The role of the patient advocate is to (1) help the patient understand the procedures, as- sure follow - up and referral if necessary, and protect the patient from medical abuse, (2) challenge the professionalism of the rest of the staff, (3) raise the political consciousness of patients and staff alike. Every patient is given an advocate by the receptionist. The advocate takes the patient's medical history or collects the file if the patient has come before. They dis- cuss the patient's complaint. This con- versation is frequently used to communi- cate some of the goals of the clinic to the patient. " We explain to the patient about the differences in this clinic, what we be- lieve in. We also tell them that we can't do everything and that sometime they'll have to push on the County Hospital. " " When we take her story, we talk about why women run the clinic and why it's important for us to control our bodies. " The advocate introduces the patient to the doctor and is frequently present dur- ing the exam to make sure that the doctor is aware of all the patient's needs, is courteous and explains what he or she is doing. Sometimes direct confrontation of the doctor occurs. On one occasion, we witnessed a patient advocate challenging. a doctor for ordering an unnecessary and Network Clinics A free clinic drama recently unfolded on TV's The Interns. The free clinic was located in a major metropol- itan medical center. Rock musak provided a homey atmosphere for hip patients and hip interns alike. The five intern idols (including a woman and a black) put up a united front against the hospital's stodgy finan- ciers. If " they close it down, we can open our own free clinic. " " Hey, man, you're talking about Revolu- tion! " Revolution! was avoided in the nick of time as the hospital's wise but irasible administrators were pre- vailed upon to tell the financiers where to put it. " If they don't like the free clinic, they can put their tax- deductible dollars elsewhere! " Meanwhile the beautiful sculp- tress's life was saved; she decided to have the baby after all; and her boy- friend came to terms with Hunting- ton's disease. And The Interns were invited to the wedding! expensive laboratory test. On another oc- casion, the doctor ordered an appropriate battery of tests but was then challenged to figure out a way to obtain the series of tests free since the patient had no money. In a Chicago clinic, the following inter- change took place in front of the entire waiting room full of patients. Medicine was demystified and deprofessionalized in one fell swoop. Doctor: " I've got a patient who's an al- coholic and who's demanding Librium (a tranquilizer). Other doctors have given it to him, but I'm not sure. What should I do? " Advocate: " Look - you doctors have to get together with us to discuss the matter. In the meantime, you'll just have to use your own best judgment. The Patients Committee will have to set a policy guide- line for the treatment of alcoholics with tranquilizers. There's no reason why we can't review the medical literature and make a sound decision. What the hell- when the New England Journal of Medi- cine is confused about an issue, there's no reason why our judgment isn't as good. as doctors '. Our discussing the matter in a group is probably more valid than the doctors deciding as individuals what to do. " The advocate is also responsible for en- suring that the patient understands the doctor's recommendations, gets a prescrip- tion filled and a follow - up appointment made, if they are called for. In some free clinics, the patient advocates accompany the patients to hospitals, other clinics and emergency room. Being a patient ad- vocate can be a significant political ex- perience in itself. According to one wom- an, when she started to work she swore, " I just want to serve, I'm not going to be- come political. " She is now embarrassed to admit that not long ago she could see no connection between her desire to med- ically serve her people and the necessity for political involvement to improve health care in her Latin American - community. Unfortunately, the examples described. above are more the exception than the rule. Furthermore, the pressure placed on the clinic for immediate services discour- ages patient advocates from rocking the boat. Some patient advocates became in- hibited because they felt that if they acted too forcefully, " the doctors would be an- tagonized and would be frightened away. " The result is that the patient ad- vocates merely serve as expeditors for the more technically skilled professionals. Few clinics or their patient advocates are oriented toward examining - much less challenging other health services in the community. It would seem that either the patient advocates must break out of this 5 restricted role, or else their position will assume the limitations of a fairly tradi- tional social worker. Scope of Services Most free clinics provide the kind of ser- vices that one might find in a neighbor- hood first aid station, if such things existed. This is consistent with their re- sources and their patients'demands for stop - gap care. Most clinic services don't ex- tend beyond routine intervention and screening: pregnancy and VD testing, colds, abrasions and minor infections. However, this limited role does not satisfy many clinic progenitors. Just as there is a tug war - of - between seeing a lot of patients and providing quality care, there is a tug- of war - between providing many services. and providing a few services well. " We must be a viable alternative. We don't want to be a band - aid to patch up after the health system. " One clinic coordinator even hoped that, " This free clinic is the be- ginning of a community hospital. " Free clinics are forced to rely on more limited resources than any other medical institu- tion; yet at the same time, they are at- tempting to cope with an issue which has been boggling medicine for years: how do you provide comprehensive and un- fragmented services on a decentralized basis? Each free clinic is trying different ap- proaches, but none has found solutions which they feel are acceptable. In order to move toward comprehensiveness, most clinics are looking for specialists: gyne- cologists and pediatricians are in great demand. A number have dental chairs, but few have found dentists yet. On the other hand, several clinics have stopped providing services which they found well within their capability to provide. Two clincs have stopped providing birth con- trol because family planning clinics were nearby. " Besides, " one said, " if we did birth control we'd be so flooded we'd never get to anything else. " The same reasoning motivated another clinic to stop doing " school physicals. " Most clinics see an urgent need to do more preventive work, saying that their " patients are " oriented toward crisis care. ' They want to " go outside the clinic " with outreach, educational and screening pro- grams. Some have tried anemia, sickle cell and TB testing in their communities, often tying these efforts to some larger community organizing campaigns. How- ever, given the pressure to serve patients coming through the door with immediate needs, most clinics never get outside their walls for very long, if at all. Preventive. work is therefore limited to the generally detailed medical history forms which are kept on each patient and the screening tests which are run on all patients. These preventive efforts bear little fruit, how- ever, because on the average less than Gimme What is known as the Free Clinic Movement got underway in 1967, when the Haight Ashbury - Free Medical Clinic, under the leadership of David Smith, opened its door to the hundreds of young people flocking into San Francisco for a summer of love, freedom, mind expansion and experience. The Clinic took care of the casualties. It was an entirely appropriate, though short sighted - , response to the medical and cultural demands of its flower - child community. Hallucinogens were a new phenomena at the time, and no one knew how to handle bad drug trips. The Clinic pioneered techniques for " bringing people down. " lust as a warm, familiar, hassle - free environment is good medicine for a bad trip, the Clinic's no questi-o nass k-e d atmosphere helped kids with VD and the other infectious diseases that found it easy to live in the alternate life style -. The presence of those who worked at the Haight Ashbury - Clinic lent tacit support to a set of cultural values which characterized the young patients. With their long hair, informal dress and style, the professionals and non professionals - who staffed the Clinic were superficially, at least, indistinguishable from the patients using the Clinic. The fact that the care came free not only fulfilled the need to provide medical services to people who had no money, it was also groovy! It supported and gave testament to the idea that alternate institutions can survive in the belly of the beast, that they can be developed on principles of sharing, not exploiting and that they can subsist on the surplus of a materialist economy without ever confronting that economy. The Haight is now a lean, hungry and violent place. The Clinic is the only 6 half of the patients ever return to the clinic. Those who need follow - up work based on the screening must often be re- ferred elsewhere. Thus, while the clinics dispair of the fragmentation that patients face in the American medical system, they too are caught in the same bind. David Smith, founder of the Haight Ashbury - Free Clinic asserts that, " One of the primary functions of free clinics is referral. " Re- ferrals are accomplished by the free clinic staff in an informal way rather than through channels. Colleagues and friends. in hospitals, health departments, well- baby clinics, etc., are prevailed upon to provide clinic patients with hassle - free service. While a few clinics have set up formal referral arrangements, most find that the informal arm twisting - method meets the clinics'needs: " People in medi- cine are feeling pretty damn guilty - we usually get what we want. " A lot of clinics attempt to provide serv- ices which go beyond traditional medical definitions and speak to broader concepts of health: " Personal. health can be de- fined as the freedom from disease and disability of the individual within the com- munity and the freedom of the individual to live creatively and without oppression as a resident in his or her community, " is one of the principles of the People's Health Coalition of Free Clinics in Chi- cago. Day care is offered in a few clinics; some have clothing exchanges; others pro- vide legal and housing advice; a few have surplus food stuffs to give away or get involved in " peoples'pantries. " One clinic in Minneapolis even provides vet- erinary services! At a minimum, most clinics having a young patient load, offer some sort of counselling. Many counselling programs are staffed by non professionals - . In general a clinic will offer one one - to - therapy for psychi- atric emergencies, but the emphasis is on rap groups. Counselling frequently fo- cuses on drug problems. Clinics have de- veloped expertise in " talking people down from bad trips, " and in many cases know a lot more about drugs than the local medical establishments. However, those clinics (with the exception of the Haight- Ashbury Clinic) which have tried to help heroin addicts have given up. " We tried to help people kick but it was impossible. They needed a place to stay, food and a shrink. We couldn't just give them pills to lighten the monkey for a while. " We'll help junkies with other problems, but a lot come in here asking for pills; unless. they're really in bad shape we don't give them any. " Bread Since clinics depend on volunteers and donations of labor and supplies, their budgets are remarkably small. An aver- Shelter thing that remains to remind us that the flower - child culture ever existed. To quote from the New York Times review of Smith's latest book Love Needs Care: " The Haight, once the flower pot of America, [is now] shattered into frag- ments of terror and despair, a'behavorial sink'of pathologies feeding off the pill and the needle. " It is questionable whether or not uncritical acceptance of the values inherent in the Haight's youth community did contribute to the social and physical dis- integration of scores of young people. Establishment medical institutions are often chided for defining their roles too narrowly and ignoring living and work- ing conditions which affect their patients'health, such as lead poisoning, over- crowded housing, and occupational health hazards. What are we to say of free clinics which do little to curb drug abuse, poor living arrangements, nutri- tional faddism and emotional chaos? Now that the Clinic's flower child clientele has withered on the vine, the Clinic (which Smith called a " state of mind, not an economic fact ") has dis- covered that economic facts are harder to change than minds. The Clinic lost one of its primary contributors when Bill Graham, purveyor of rock music to flower children, decided to give up the business. How much did their free health care cost? They bought it with thousands and thousands of tickets to the Fillmore. Smith now sees the need for long term - funding. In his role as head of the National Free Clinic Council (see page 11), he says, " Free Clinics are part of the total health care delivery system, and want to be recognized as such. " 7 age budget might be about $ 30,000. In most cases income is derived from a num- ber of small contributors and fund raising events. Clinics have had bazaars, street fairs and received funds from student ac- tivity funds and church groups. At least one free clinic receives a substantial por- tion of its income from pledges. The Berke- ley Free Clinic gets a small but steady part of its income from pan handling - . Some clinics like this catch - as - catch - can financing and wouldn't have it any other way. They say they can maintain their independence if they avoid big contribu- tors; " freedom's just another word for nothing left to lose. " Others add that if they weren't forced to rely on volunteers they would lose the good spirit, atmos- phere and working relations of the clinic. Some take it even further and see them- selves as furthering a counter - culture barter economy: " The free clinic doesn't treat health as just another commodity. While we won't accept a fee for service, we do expect patients to'pay in kind.'Pa- tients contribute their skills - legal, social work, plumbing, painting, etc. - in return for medical service We work on a sort of informal barter system -. " Those clinics which take a harder line on financing are usually the ones that serve an ethnic or working class com- munity rather than a younger, freakier population. In one such clinic, a recent de- cision was made to have a receptionist ask for $ 3 donations per visit, rather than have the donations can speak for itself. " If this is going to be a community clinic, the community has to support it. Other free clinics lean on public agen- cies, Medicaid and medical institutions for support. The City of Berkeley now helps support three free clinics. The Berkley Free Clinic submitted a budget reguest of $ 29, - 000 noting that it treats 75 percent of the VD in the City. The Blackman's Free Clinic in San Francisco gets its facility from the Redevelopment Authority. Virtually all free clinics receive penicillin for VD treat- ment free from City Health Departments. (In some instances, City departments have tried to " off rip - " the clinics; in one city the public hospital started referring pa- tients to the free clinic for physicals. In another, the health department ran out of tetracycline for VD and the free clinic had to supply the city.) In Minneapolis free clinics have charge accounts at either the University of Minnesota Medical School or Hennepin County General Hospital to- ward which they can charge purchases of laboratory tests, drugs and supplies; they also have arrangements with hospitals and schools for back - up facilities, and training programs. In Chicago, several clinics while fight- 8 " We feel we cannot continue to serve people in a humane, compre- hensive, consistent and confidential manner if the demand for services continues to increase at the present rate. " -A Minneapolis Free Clinic ing to survive efforts by the Daley machine to shut them down, managed to use the struggle to win sustained support from the medical schools. The clinics mobilized support from the student bodies and won contracts for financial and professional support from the institutions, without los- ing their independence and community control stance. Other clinics are much more uptight about taking money or serv- ices from medical schools or hospitals. Up until now no strings have been at- tached to the subsidies free clinics receive from local hospitals, medical schools and charitable organizations. However, some free clinic staff members are worried about what the future will bring: " Taking money from the medical school is fine but what happens next year if after we're de- pendent upon it, the medical school de- mands we allow our patients to be used as teaching material? " Those clinics which are located in work- ing class or ghetto neighborhoods also take advantage of Medicaid reimburse- ments. (The clinics which serve young drop - out populations find that their pa- tients are too mobile and unwilling to go through the hassle of proving Medicaid eligibility, to make the effort worth it.) Most of the clinics which actively pursue the Medicaid route get about $ 50- $ 60 per week from the effort. Generally, the volun- teer doctors will submit the bills for reim- bursement to the state as private prac- ticioners and then turn the check over to the clinic. One clinic decided to take a " principled stand " with the local Medicaid bureau- cracy and demanded the right to bill Medicaid directly. It took over a year to win the ensuing fight. Medicaid refused to give them reimbursements if they re- fused to post a fee schedule in the clinic, arguing that they shouldn't be paid for services which are free. The clinic main- tained that they wouldn't compromise the principle that medicine should be free at the point of delivery. Finally the clinic agree dto post a sign stating how much a visit costs the clinic. They then put a state- ment in their newsletter: " Our services are available free, not because we have lots of money, but because we believe medical care should be free. It should be available to anyone regardless of how much money he or she may have. " Some clinic people plan to parlay third. party payments like Medicaid into major sources of income, rather than the sporad- ic drips and drabs most clinics now get. One clinic is planning to start a campaign to get get Medicaid patients through the doors: " If we can get enough eligible pa- tients in here, we can pay some staff and stay open during the day. " Free clinics, like every other form of health delivery in the country, are keeping an eagle eye on federal legislation. Some would like to be- lieve that " national health insurance will make us self sufficient - and guarantee our independence. Control Free clinics, by and large, are strug- gling to achieve new forms of decision making against great obstacles. Most clinics are experimenting with variations. on community / worker control. Decision making occurs on many levels. throughout the operation of a free clinic. Day - to - day administrative decisions are usually made by paid staff, where they exist, or by the coordinator on duty at the time. Medical decisions, occurring during an evening's clinic, will most often fall upon the doctor. A few clinics have meet- ings before and after every clinic session attended by all clinic staff. They are used. to plan and then review clinic proceedure; discuss medical problems and decisions; and subject individuals to criticism or praise when called for. These meetings help establish a collective spirit but even in those clinics which don't follow this discipline, a collective identity usually emerges from just working together. Decisions which refer to overall clinic policy are usually handled by a commit- tee. In one form, this committee (frequent- ly known as the Steering or Central Com- mittee) is composed of representatives of each night's clinic, or of each job function (nurse, lab tech, etc.). In those clinics which have strong political ties, decisions which affect the political stance of the clinic are not likely to rest with clinic staff, but will be made by the political group. Despite medicine's tradition of over- bearing professionalism, there have been few instances of doctor takeovers - or cases of the doctors everybody - versu-s e-ls e in free clinics. Only one clinic staffer felt that: " In all honesty, when you really get down to it, the doctors hold the power. " In fact, in most clinics, doctors seem to play a disproportionately small role in formal decision - making processes. For some, this comes from a highly sensitive conscious- ness about the pitfalls of professionalism. For others, however, it seems that they don't really care how the clinic is run; or feel that they can't devote the time neces- sary to become involved in decision - mak- ing. Some doctors have been given further lessons in deprofessionalization by the collective process, where it exists. A clinic staff member asserted: " The staff process and interaction imprints itself on the con- sciousness of the entire staff.. Many doctors thought they were going to have more power, not less. " Virtually all clinics emerge from or seek organized community support before opening. Several clinics have boards com- posed of representatives of community organizations. In most, these community af- filiations have little to do with the direction of the clinic. Their support and goodwill help identify the clinic with the communi- ty. Some clinics have made special efforts -by sponsoring street festivals, currying favor with local merchants, etc. - to be- come'community institutions.'For El Centro de Salud, this really paid off when the landlord attempted to cancel the clinic's lease and several hundred resi- dents demonstrated in front of his place of business. Only one clinic has opened its policy making - up to anyone who attends the monthly clinic meeting. However, de- spite the fact that community suppers are held prior to the meetings, community at- tendance has disappointed the clinic staff. In most clinics, patient or community control is far more rhetorical than real and far less close to realization than worker control. One obvious obstacle is the amount of time that goes into running a free clinic and the exhausting hours that the clinic staffs keep. In spite of differences in organization and patient populations free clinics are strikingly alike. Free clinics are all serv- ing medically disenfranchised patients; they are all squeezing by with limited re- sources and hard pressed - volunteer staffs. In addition to looking like each other they also resemble the traditional hospital Out Patient - Department. While free clinics hope to serve as alternatives to, substitutes for, or competitors with OPD's, they find themselves taking on many of the most- hated aspects of OPD's - rather than tak- ing them on. 9 at WHAT DOES IT COST TO BE FREE? In the beginning, free clinics appeared to be a response to the needs of the youth culture movement. The new life style, with heavy emphasis on mind expanding drugs and communal living arrangements, re- sulted in a rash of health problems - from bad drug trips to nutritional deficiency. Traditional medical institutions were un- suited to the value system and the prob- lems that the young patients had. For in- stance, kids on bad trips seen in emer- gency wards, often ended up in mental hospital wards, if they were lucky, in jails if they weren't. Rather than risk incarcer- ation, many young people went untreated. However, it doesn't take much digging to recognize that free clinics are not just a response to youth culture needs. They also have broad appeal in Black, Puerto Rican and Chicano communities. To people tra- ditionally barred from medical institutions because of racism, cost and location, the attractiveness of " free " institutions, more accessible to their neighborhoods and per- haps even to their control, is evident. Free clinics rose on the wave of " black power " and " community control " to meet the cen- turies of unmet health needs in ghetto com- munities across America. Free clinics are not just a response to the unmet needs of Black, Puerto Rican, 10 Chicano, or hip communities. They are a response to the failure of America's tradi- tional health institutions. The failure of doctors not only to treat bad trips, but to provide any minimal standard of care in ghetto communities; the failure of hos- pitals to break down the hierarchy among health workers that fosters poor patient care; the failure of Blue Cross, and now Medicare and Medicaid to eliminate finan- cial barriers to decent medical care. Free clinics are a response to the crisis in the American medical care system. Attractions and Detractions The free clinic response is indeed an at- tractive one. On the one hand, it directly serves people. It is a positive, concrete step toward a vision of the health system as it should be in the future. " People have been promised change for so long, they will no longer accept your word for it. You've got to show them it can be done. " Free clinics also provide rewards for those that work in them. Free clinics are one of the alternatives that Vocations for Social Change talks about, when it says, " There [ ] is a growing awareness that the kind of roles we are all being prepared for in this society housewife - , factory worker, executive, welfare recipient, etc. Lcannot satisfy either our personal needs or our collective needs, and that alterna- tives must be found. " Free clinics fit the rhetoric " do your own thing " and " build alternate institutions ". This attractiveness of the free clinic movement can disguise the limitations manifest in current free clinic practice. Many of these shortcomings are discussed in the description of free clinics at the be- ginning of this BULLETIN: * Free clinics are not successful in eliminating some of the principle disad- vantages of out patient - departments: wait- ing time is long, there are no appoint- ments, follow - up is shoddy, continuity of care is almost impossible. * Free clinics are just as dependent on a limited supply of doctors despite their emphasis on skills transfer. * Free clinics, because of limited re- sources, must make serious trade - offs: for example, if quality care is to be given to each patient, then fewer patients can be seen. * Free clinics may demystify med- icine, by removing the doctors'white coats and by taking away some of their " professional " preogatives, but they often fall short of educating patients about their illness or about the politics of the health system. * Free clinics, by and large, have not been able to overcome the obstacles to community / worker control. Political Effects In many ways most free clinics fail both patient and worker in not measuring up to their goals. For patients, the effect of free clinics, beyond the service provided appears to be minimal. Most free clinics have not established successful mechan- isms for involving patients in the decision- making of the clinic, other than by becom- ing a worker in the clinic. Likewise, free clinics have not involved patients in strug- gles around the larger health institutions. in the community. The result is that free clinics are limited in their effect on pa- tients to the individual personal encounter at the time of receiving service. There is more effect on the worker in free clinics than on the patient. The non- professional health worker gains self- confidence, not merely by learning new skills, but also by running a health clinic. Free clinics often do represent experience on the first few rungs of workers'control. Whether this gets translated into the de- sire to control the dominant health institu- ions in the community, the hospitals or the health department, is left to chance or circumstance. For the professionally trained health worker, free clinics do represent an expe- rience in de professionalization - . This ex- perience is not just a matter of superficial style, but involves challenges to profes- sional prerogative and privilege. Thus pa- tient advocates may criticize doctors for their attitudes toward patients or confront them about their inconsistent prescribing habits unheard of practices in any hos- pital. However, confrontation tends to be "imited because the professionals on whom all free clinics depend are in short supply. They must not be " turned off ", or else the clinic folds. In addition, profes- sionals are seldom pushed by their free clinic experience to struggle within the institutions they train and work. To be sure, some health professionals. have their eyes opened when they are taken from their secure institutional en- vironment and placed in direct contact with an unfamiliar patient environment. Similar experiences occurred in the Peace Corps and VISTA. But there is no evidence that this awareness leads to commitment, or that it even is an inevitable concomit- tant of the free clinic experience. Equally common is the observation of one Chicago free clinic coordinator: " Many medical students say they're committed to the community. And to a limited extent they are. But their commitment only goes so far. When they graduate they go work in sunny Arizona. You ask them why they don't intern at Cook County Hospital, they say'I can't hack it anymore.'That's how far their commitment to the community goes. " Clinic Council The Free Clinic Movement has an or- ganization, the National Free Clinic Council! The Council was formed in 1968, largely through the efforts of David Smith, Medical Director of the Haight Ashbury - Free Medical Clinic. Now it's " ready to begin full scale - national operation, " according to its executive director, Jim Oss who is also Coordinator of Drug Abuse Pro- grams for Hoffman LaRoche - , pharma- ceutical manufacturer. Whether they know it or not, Oss says, " all clinics providing free pri- mary health care services " are mem- bers of the Council. Or, as his col- league Smith has said, " They will be members when we send out the ma- terial for our annual meeting. " For the purposes of the Council at least, Oss states that he " could care less if they [clinics] are set up by the Panthers or the Nazis just as long as they're providing necessary pri- mary care. According to the Council's state- ment of purpose such primary care clinics are needed because, " All institutions in our society are con- fronting a growing crisis in perform- ance... Quality alternatives must be developed and implemented in order to make available facilities and personnel for those who are defined or who define themselves as med- ically indigent. " The Free Clinic Council hopes " to gain access to health care funding which is available at the national level and to distribute money equally to all member clinics. " (To Oss, ' equally'means " as fairly as pos- sible "). At the present time, the Coun- cil has no intention of going after a piece of the National Health Insur- ance or Health Maintenance Organ- ization action. Instead, it is looking for private drug abuse - related fund- ing. The Council seems to have an orientation of service to the youth- culture. At least it has a'contact- high'from its Board of Directors, which includes: some of the counter- culture clinics; Pfizer Drug Company; STASH (Student Association for the Study of Hallucinogens); Smith (who among other activities also edits the Journal of Psychedelic Drugs); and Oss, who before going to Hoffman- LaRoche, had experience with drugs " on the street " and in his own thera- peutic community. If free clinics have a limited effect on patients and workers, their record in the community is equally disappointing. Free clinics offer real opportunities for com- munity outreach and political education about the health system. They could ini- tiate programs of door door - to - screening for anemia, lead poisoning and tubercu- losis. They could indict landlords, City Health Departments and even medical em- pires for neglect of these health problems. But few clinics have had the money or manpower, to say nothing of the political analysis, to realize this potential. Free clinics fear being overburdened by the health problems they discover. They do not see outreach as an opportunity to push on the responsibility of the dominant health institutions in the community. Few clinics have the vision of the Young Patriots Organization in Chicago, which hopes to develop a " health cadre " to pro- vide emergency care, treatment of minor illnesses, screening services and offer medical advice and assistance on spot - the - in every apartment house in Uptown. As one young Patriot put it, " I can treat ninety percent of the patients walking in the clinic. I can't see why we can't train other community people to do the same. If we find problems we can't deal with, then we'll force the hospitals to help. ". Alternate Institutions It is an assumption of many free clinic advocates that " Free clinics, as alternate institutions, are threats to the system ". This is an elusive concept. Free clinics aren't competitive with existing health in- stitutions. No doctor's office or hospital's clinics is threatened with closure by the mere existence of a free clinic. While free clinics, in and of themselves, are not a threat to the system, those free clinics that support community struggles against the health system are closer to that ideal. But there is a fine line between chal- lenging the health system and actually doing its work. Free clinics actually take the heat off other health institutions by filling the gaps which they have left, while still maintaining the community's ultimate dependence upon local medical institu- tions. Free clinics admitted they were not hassled by the establishment because they were doing the system's job. This be- came blatantly obvious when one local city hospital began to refer patients to the free clinic for physical examinations. In another city, when the Health Department ran out of tetracycline, they came to the free clinic to replenish their supplies. Another free clinic assumption, " We're free therefore we're political ", collapses with more careful examination of the price free clinics pay to remain " free. " Most 12 " If we could do our job politically, they'd close us down in a week. " free clinics depend on hospitals, drug companies and City health departments. for supplies, manpower and grants. It can become difficult to bite the hand that feeds you. As one clinic spokesman said, " Tak- ing money from the medical school is fine, but what happens next year if after we're dependent on it, the medical school de- mands we allow our patients to be used as teaching material? " As long as clinics depend on institutions in order to provide their free services they will be deterred from conflict with the existing health sys- tem. The amount of time it takes to simply run a clinic can also deter them from tak- ing an active role vis vis - a - institutions. As one clinic person said, " If we could do our job politically, they'd close us down in a week. " In addition, if free clinics become more effective in community outreach, they will become more desirable plums for the medical institution pie. Free clinics can re- late to populations that staid medical insti- tutions find it difficult to accommodate. Thus free clinics may become friendly outposts in the hostile communities that surround many of the major medical insti- tutions in America. So existing medical institutions may have a real interest in free clinics and a desire to incorporate them into their own framework. Perhaps this explains the willingness that an in- creasing number of medical schools and health departments have demonstrated in supporting free clinics. Institutional Confrontation Providing service is one response to the failure of the American health system. It is attractive because of the tangible alter- native building that it offers. Institutional confrontation is another response, though still somewhat untried, that offers poten- tial to effect far wider - change. The power and resources of the American health sys- tem lie in institutions. Therefore, changes in institutions have great consequence for the delivery of health care. Institutional struggles affect the lives of those working in institutions as well as those using them. Institutional confronta- tion targets the struggle at those most responsible for the failure of the system. The Young Lords Party in New York City decided not to establish any free clinics in El Barrio. Rather they sought to challenge existing health institutions to perform their stated functions. The Lords exposed the Health Department for not usng its 40,000 lead poisoning testing kits by demanding that the Health Depart- ment release some of the kits for a Young Lords'screening program. In another pro- gram, the Lords discovered 800 positive tuberculin cases through door door - to - screening in East Harlem. The next step was to have the people X rayed -. The Lords found that patients had to wait up to 6 hours in the local hospitals just to get a chest x ray -. Few patients could afford to miss a day's work or pay for a baby- sitter. Therefore, the Lords asked the Health Department to re route - one of its mobile chest X ray - units to East Harlem to do the necessary testing. When the Health Department refused, with media present the Lords hi jacked - the truck (with the cooperation of the driver and x ray - technician) brought it to East Harlem and took the necessary X rays -. Institutional confrontation also has the potential to resolve many of the contra- dictions that presently abound in free clinics. It unites the disparate forces that relate to free clinics. Patients can become involved with the free clinic around its struggle with other health institutions. Health workers can connect their free clinic work with struggles in the institu- tions where they train and work. Institu- tional confrontation brings new problems to free clinics, but helps resolve many of the old ones. Chicago - The Hub Several of the free clinics in Chicago, have adopted this approach, both out of choice and necessity. Their early requests for back - up services and specialty con- sultation developed into confrontation situ- ations. At Weiss Hospital, located in the same neighborhood as the Young Patriots. Clinic, there was considerable resistance to developing a relationship to the free clinic. Several demonstrations were neces- sary to convince the hospital that it should accede to community requests. At North- western Medical Center, the path was paved by the active support of medical and nursing students in coalition with hos- pital workers. Many of these students and health workers also worked in the Latin American Defense Organization (LADO) free clinic located in a Latin American neighborhood on Chicago's north side. The students had pressed their own demands for minority admissions and improvement in the outpatient clinics through a 24 hour - sit - in in the deans office, prior to LADO's demand for a contract with Northwestern. This history facilitated LADO's negotia- tions with the medical center. The contract includes (1) that referrals from the LADO clinic be accepted at Northwestern Outpatient Laboratory and Clinics (2) that Northwestern extend mal- practice insurance to cover professionals who work at the LADO clinic (3) that Northwestern provide $ 1000 per month in drugs, supplies and equipment to the LADO clinic for one year (4) that North- western waive fees for patients who are unable to pay. The contract finally signed by North- western was used by LADO to pressure St. Mary's and St. Elizabeth's Hospitals, two community hospitals, to admit Span- ish speaking - patients. In the past, St. Mary's had refused to take any obstetrical patients from the Spanish speaking - com- munity because an administrator said. " We can't understand them and they scream too much. " Over the past year, Chicago's free clinics have also been involved in a con- tinuous struggle with Mayor Daley's Board of Health, which has been trying to close down the free clinics. Chicago is the only city where the mere existence of free clinics was found to be politically threatening. Thus Daley's Board of Health has decided to employ an end run - around. the free clinics by opening up eight new clinics, virtually adjacent to the existing free clinics. The LADO clinic has been able to raise sufficient community pres- sure together with student and health worker support at Northwestern Medical Center, to prevent the opening of the Board of Health Clinic in their neighbor- hood. The Young Patriot's Community Health Service adopted a different tactic toward the Board's clinics. Rather than try to stop the opening of the Health clinic, the Young Patriots have insisted that the City clinic provide better services. In November, 1970, 200 people occupied the Uptown Board of Health Clinic and demanded " hour 24 - a day, seven days a week, full health ser- vices as well as free transportation and child care. " In addition, the protestors in- sisted upon " full community control of clinic policy and personnel. " The Chicago free clinics maintain a con- stant barrage of criticism aimed at the health establishment. Hospitals that fail to deliver services are challenged. Free clinics are the base from which commu- nity and health worker activists attack in- stitutions. The mimeograph machine is as important as the stethescope. Besides maintaining a high level of institutional confrontation, many of the Chicago free clinics have encouraged professionals that work in the clinics to organize in their own hospitals as well. 13 For some people working in free clinics, the time commitment is so great that they feel extremely pressed. As one Chicago medical student put it: " I think the free clinics are the most important political de- velopment in the city. But the time in- volved is so great I can't do anything else. " Another Chicago doctor suggests the solution to this dilemma is " to encour- age loose hospital - based collectives it's easier to develop the consciousness needed to continue the struggle back at the hospital itself. " Alliances between community organiza- tions and workers within health institu- tions have contributed to the viability of the Chicago free clinics. Thus Daley con- tinues his efforts at repression. Most re- cently, Obed Lopez, a leader of LADO was arrested for " operating a clinic without a license. " When he objected that he was not personally responsible for the clinic's operation, the arresting officers demanded that he turn over the names and addresses of all personnel who work in the clinic. When he refused to do this he was jailed. The Chicago free clinics have seen themselves as more than alternate institu- tions. They have seen the necessity and used their opportunities for institutional confrontation. Unless other free clinics adopt this course, they will either wither and die or become incorporated into the established health delivery system. WOMEN'S CLINICS In recent months the idea of women's free clinics has swept the women's movement. In March, the Berkeley Women's Health Collective started Women's Night at the Berkeley Free Clinic; in April, women in Baltimore and Seattle did likewise. In May, free clinic discussions were high on the agenda of the Women's Health Con- ference in New York City, (see box, page 16.) At least half a dozen more women's clinics are planned to open before the year's end. The development of women's clinics represents to some extent the overlapping 14 of three already existent movements: the Free Clinic Movement, the Women's Move- ment, and the Health Movement. In a number of cases women's clinics are in part a reaction to the overt sexist treat- ment women were receiving at regular free clinics. " The doctors were saying that they were tired of looking at vaginas. They would do crude pelvics and make insensitive and moralistic comments to the women. " In starting their own free clinics women have extended the ethos of the larger women's movement into the arena of health. In doing so they have come closer to achieving some of the most significant, but ofttimes, only rhetorical goals of the Free Clinic Movement, than their male (or coed colleagues. By " putting women's liberation into practice " " women's clinics attempt to give substance to the right of women to control their own lives and bodies. The substance consists of the de- struction of the psychological and bio- logical myths which are used to oppress women; the demystification of male- monopolized knowledge and skills; and the development of self sufficiency - , self- control and self confidence - . Add to this the ethic of leaderlessness and sisterliness which has characterized consciousness raising groups and it is not difficult to see why women's free clinics have done more to demystify, democratize and depro- fessionalize health care than other free clinics. Everyone who works in women's clinics (including male doctors) keeps re- turning to the same point: " You have to be here on womens night to sense the dif- ference I can't explain it It's - just the entire atmosphere.'" While many of the things that go into women's free clinics may be hard to ex- plain, some of what accounts for the at- mosphere is obvious. There is a heavy emphasis on consciousness raising and body knowledge. In fact, women's groups have been duplicating one another's ef forts by producing literature on women and their bodies. Clinics have rap groups in the waiting rooms. Women's counselors or her story takers - attempt to work within a large definition of women's health: " A woman's medical needs are psychological as well as physical. " Women's free clinics are also more cautious about the use of doctors and more adventuresome about the use of paramedics. Thus, a patient will never be examined by a doctor alone, but she may be examined by women who have been trained to be " pelvic teams. " Women's free clinics, while very informal, appear to maintain a disciplined approach to decision - making - which is collective. The doctors, being mostly male, are ex- cluded from policy making. This means that at the same time women run their own clinic, they tend to deprofessionalize it. From The Women's Movement The Women's Liberation Movement grew out of the recognition by white, mid- dle class, often radical, women of their fixed roles in society. In spite of the far- reaching significance and potential of the women's movement, the fact remains that the most profound effects thus far wrought have been in the consciousness and per- ceptions of women who are defined by their class and education as well as their sex. The women's movement is now faced with many problems. Among them, simply stated, are the needs to act; to broaden the base of the women's movement; and to affect major social institutions. Women's free clinics are a response to these needs of the women's movement, as well as a reaction to the male chauvan- ism which is encountered in free clinics. Women's free clinics provide a con- crete situation in which women can learn and share medical as well as organiza- tional skills, attack the hierarchies of pro- fessionalism, and gain the confidence which comes from running their own ins- titution to meet their own needs. Women's free clinics offer some badly needed - ser- vices and in the process attract women who would otherwise have little oppor- tunity for exposure to the women's move- ment. This exposure takes place indirectly through the general atmosphere of the clinic as well as directly through the em- phasis placed on counseling, rap sessions, health education (literature, movies, etc.). Just as women's clinics serve to recruit women health workers into the women's movement, the reverse is also true. In- creasing numbers of women are being attracted into health science schools be- cause of their activity in free clinics. Free clinics, while they require monu- mental effort (particularly if organized from scratch) represent an immediate, concrete, and tangible outlet for the need for action. " We don't feel like we have the answers, and sometimes we're not even sure about direction, but at a certain point we had to take the plunge or else just sit around talking forever. " Finally, the problems associated with the middle class origins of the women's movement can be blurred in the setting of a free clinic. Here the organizers and staff, generally white, middle class, pro- fesionally trained or at least college trained, can be relatively honest about their identity. They offer services which can be accepted or rejected, and accept- ance is testimony to their need and relevance. Problems of Women's Clinics The use of free clinics by the women's movement does raise several questions, despite the fact that it also answers so many. It is quite striking that while the women's movement has struggled to de- bunk the definition of woman reproduc- - as - tive beast - , women's clinics and the health issue tend to reinforce the image. The only health problems which pertain to women and women alone are those focusing on the female reproductive system; women are more likely to bring these kinds of problems to a women's free clinic. In this context, it is easy to focus on women as users of contraceptives, seekers of abor- tions, bearers of children, victims of VD and vaginitis - i.e., as a collection of ovaries, uterii, vaginas and other sexual appurtenances - and thus fall prey to a definition not dissimilar to that tradition- ally placed upon women. Those clinics which want to offer pediatric services in order to attract neighborhood mothers appear, on the surface at least, to be step- ping further into that definition. In terms of consciousness raising and broadening the base of the women's move- ment, another active woman voiced an important concern, " When women come here they are in a crisis - they don't want to hear about women's oppression or con- sciousness - they want out of that crisis. " Challenging the Health System Women's free clinics raise the same set of questions about affecting health insti- tutions that regular free clinics raise (see pages 10-13). Strangely enough, however, the very reasons which make free clinics so valuable and exciting within the wo- men's movement, seem to be wiped out when one talks about affecting existing health institutions. The principle of " for and by women " becomes less important 15 and the class basis of the women's move- ment become more marked in the face of the health system. Certainly sexism accounts for much of women's greater use of the health system, the added humiliation and objectification women encounter there, and the more gen- eral use of biological ignorance and mys- tification as tools of women's socializa- tion. However, the source of poor health care is mainly in social class and in the profit system, and not mainly in sexism. Men, when they must deal with the health system, also suffer from its inaccessibility, expense, fragmentation, and alienation. In fact, it can be argued that men are as ignorant and alienated from their bodies and bodily processes as are women. The difference is that this ignorance and alien- ation is not used to oppress men as men. Women's free clinics also sidestep im- portant questions of class which are raised if one wishes to talk about con- fronting - not sidestepping - the health system. Women's free clinics will be in the same binds as other free clinics if they attempt to deal with the total health needs of their patients, much less the total female health needs of older and / or poorer women. These women are primarily de- pendent on major health institutions, hos- pitals and out patient - departments for their medical services. While free clinics may substitute for the private gynecol- ogist that most women who set up free clinics could be using, they cannot substi- tute for the major health establishments used by other women. Thus while free clinics may be designed to extend the base of the women's movement beyond the middle class, they are not designed to meet the working class woman's health needs, nor challenge the institutions that define and serve her needs. / Women's Health Conference Report! " Women both health workers and community women have been working in Free Clinics in mixed groups for quite a while. Increasingly women have been demanding (a) that the blatant sexism in many clinics should go (b) that there be special sessions for women controlled by the women health workers (c) that basic health education as well as specific treatment must go on. In other cities groups of women have actually set up special women and chil- dren's clinics or are planning to do so. In these free clinics women are increas- ingly learning basic medical and organizational skills. One of the most important results of all this work has been the changes in the lives of many of the women. Previously self conscious - , and dependent, many of us have learned to speak in public, write, help run organizations and do work that we really care about. By and large this has happened not through the struggling competitiveness we are all raised to but with the help and support of a group of women. It would not have been possible without the group consciousness of the Women's Liberation Movement. It is significant that the three types of work we've been most successful in doing are outside the organized health system. [The two others being health education and referral and legal work around birth control and abortion issues.] We like other parts of the radical movement have been partially successful in setting up our own'free'space. But most of us want more than this. We want to radically change the health system so that it meets everyone's needs. All of us at the conference were conscious that we, as consumers of health care, must attack, pressure and agitate around health institutions, departments of health, laws and legislation. We are conscious that the only chance we have of effectiveness is to organize groups of women to demand their right to control their bodies and to adequate health care... Thus it is clear that much of our ability or our potential ability for affecting the health institutions comes out of our day to day concrete work - the abortion referrals, the education and the free clinics - since they provide us with organ- ization, experience and satisfaction. However as women repeated again and again during the conference, while work in an'alternate'system MAY lead to struggles against the larger system it does not NECESSARILY do so, espe- cially since much of the work is time and energy consuming. Therefore we must constantly CHOOSE to talk, write, and act to make the connections to the wider health system. " -May 7-9, 1971 oe * 16