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HEALTH PAC Health BULLETIN Policy Advisory Center Volume 12, Number 3 January February / 1981 HPCBAR 1-36 ISSN 0017-9051 Editorial: Turning the Tide Whatever might be said about the Carter years and the 1970s in general, the sharp lurch to the Right represented by the new Reagan adminis- tration and the new Repub- lican rule in the Senate must be seen for what it is: a serious setback for prog- gressive forces throughout the country. Continued on Page 2 Inside Mental Health is Hard Work 9 _ Do.economic fluctuations cause mental health problems? The answer is more complicated than was thought. - Diane Lacey Talks About Sydenham ...........00:: 13 . A leader in last September's community "\ TM takeover of the Harlem hospital reveals the in- side story. Union Blues.. 17 When New York RNs struck last Fall, they were up against the City and the nurse's association. In the area of health and health services, fx even the limited reforms that were being hi earnestly debated and advocated four years ago may now seem distant dreams: comprehen-, sive national health insurance or a national health service; a safer, healthier workplace and environment; increased consumer involve- ment and community accountability; efforts to harness a runaway medical technology; women's right to abortion; community health # centers and inner city hospitals; equal access to "age services and health careers for WO- men, minorities, and working people as a whole; and a halt to U.S. medical, drug, and food nutrition / exports which bring, super profits - to corporations here while inflicting death and repressive methods on the Third World. There are certainly grounds for pessimism. Past Republican ad- ministrations have proven insensitive to needs for even modest social reform, and this administration will ' be backed not only by one house of Congress but by a hyped much - " swing to the Right " reading of American public opinion by most of the mass media. Reagan himself has long been the darling of conser- : atives, and Vice President Bush is a former CIA Director. a: oes Meanwhile, the need for action to help the growing numbers of Americns without any means to pay for medical care (recently estimated to total 12.6 percent of the population, or 26.6 million persons) becomes if anything, more pressing. Directly related is the escalating destruction of inner city health services that medically abandons hundreds of thousands of additional poor and working poor persons each year. Existing environmental and workplace protections - meager at best after decades of struggle to strengthen them - are overwhelmed by the unceasing production of corporate injury and disease. Consumer and community involvement, more needed than ever, becomes increasingly difficult to achieve in practice. And, as Health / PAC's own studies have shown, two decades of affirmative action battles have yet to achieve real equality for women and minorities seeking health careers. Despite what may seem ade- quate grounds, those of us who work and volunteer at Page Continued on Page 8 we vg 4, ARS oo co 1 ASS A een . # A, y a a a a D In a followup letter, The Doc- tors'Foundation Committee Vital Signs complains that the AMA has capitulated to National Health Insurance, but gives the faithful hope by detailing how two THE SOUND OF THE seven major insurance com- panies which, they point out, can do the same job cheaper. " National health insurance, in any form, simply isn't needed, they argue, " You and I know this, Dr. . But do your patients? " county medical societies de- feated a drug substitution bill before the Oklahoma legisla- ture. Francis A. Davis, MD, president of the Committee, writes, " Armed with the facts we have here at the Foundation- the facts you know in your bones, Dr. ... we RIGHT HAND CLAPPING Graduates of American med- ical schools may be ashamed to The Doctors'Foundation, in- terestingly, reminds the doctors that " every dollar you con- tribute can be deducted as a business expense. " Included with the letter is a doctors have the power to kill this thing if we will just get off the dime. " Besides a pitch for money, the committee supplies a copy of " An Open Letter to My Patients About National Health know they have earned the only degree which qualifies them for every right wing - mailing list in press release from the Congress of County Medical Societies (an organization which exists Insurance " to distribute and in- structions in its use. What is not mentioned is the Richard Viguerie's whirring computers. By raising the spec- tre of Nationalized and Socializ- largely to publish Private Prac- tice, a magazine distributed disappearance of Robert Bar- ker, the appropriately named chairman of the Doctors'Foun- ed Medicine as if it were hiding dation Committee, from one just around the corner, they ap- masthead to the next. Perhaps peal for money to fend off this hulking, bureaucratic mugger Senator Hatch warns that he had become too busy with his duties as chairman of the Pri- about to make red tape - ' Labor and the ultra- vate Medical Care Foundation hostages of us all. To read their literature is to discover the im- manence of Socialized Medi- liberals will have the government hiring mentioned in the Congress of County Medical Societies'news. release and resigned. Or cine. Do they know something thousands of new bureau- perhaps as a veterinarian he we don't know? For those who do not receive these direct mail warnings or crats to regulate your health care ' was not the most appropriate spokesman for these three in- terlocking groups. Or, per- who recycle them without open- haps, the committee decided he ing the envelopes, here is a was more a barker than a biter. brief listing. You can't tell the free to physicians), which at- Taking a less grassroots ap- players without a scorecard! tacks catastrophic health insur- proach is the Committee for From Shawnee, Oklahoma, ance and lists the seven insur- Responsible Health Care, which comes the Doctors'Foundation ance companies which can do it was assembled last summer in Committee, Division of better. The president of the Washington, D.C. with funding 1 Americans Against Socialized Private Medical Care Founda- from the Atlantic Richfield - Cor- Medicine. In a computer typed letter which inserts the ad- tion, quoting statistics from US News & World Report, proves poration. Taking a " star " ap- proach to the corporate pro- dressees name three times in that catastrophic health insur- blem of rising health costs, the the body of the letter, the Doc- ance would benefit less than 2 Committee has assembled a tors'Foundation Committee at- per cent of the population, cast worthy of " Meet the Press. " tacks the radicals in the Carter while taxing everyone. Truly Their galaxy includes former Administration advocating catastrophic. All of this Secretary of the Treasury catastrophic health insurance, evidence is churned out of William E. Simon, who sits on while putting in a plug for the Oklahoma City. the boards of Xerox and Citicorp, and is currently presi- dent of the John M. Olin Cor- poration; Michael DeBakke, the nation's foremost heart surgeon and president of Baylor Medical Center; Harry Kane, a former executive director of the American Public Health Association; and Elmo Zumwalt, the former chief of Naval Operations and member of the Joint Chiefs of Staff. Apparent- ly, the main effort of the Com- mittee has been to raise money for its own existence, an endemic problem of the " star " system. From Senator Orrin Hatch and The Heritage Foundation you receive a free, simulated " National Health Identity Card " in which you are assigned to a government doctor and hospital by number. The card also gives you the waiting times for dif- ferent kinds of surgery - four months for cataracts and cosmetic surgery and only two months for hernias and radical mastectomies. The Heritage Foundation, writing before the euphoria of the Republican election vic- tory, sounded the alarm with reports that " Big Labor's 2 # 1 goal for 1980 is to force you to join and pay: for a government- run, compulsory Nationalized Medicine plan. " The Founda- tion provides a scientific ques- tionnaire to poll the public so that it can report its results to Congress and the media. Some of the questions include the following: 1. Do you believe if federal bureaucrats run a National Health Care System, it will result in an overall decline in the quality of health care stan- dards for Americans? 5. Do you want the government bureaucrats to determine what kind of medicine and medical treatment you should have Health / PAC Bulletin Tony Bale Pamela Brier Robb Burlage Michael E. Clark Jaime Inclan Board of Editors Hal Strelnick Glenn Jenkins David Kotelchuck Ronda Kotelchuck Arthur Levin David Rosner Des Callan Madge Cohen Kathy Conway Doug Dornan Cindy Driver Dan Feshbach Marsha Hurst Louanne Kennedy Mark Kleiman Thomas Leventhal Alan Levine Associates Richard Younge Joanne Lukomnik Peter Medoff Robin Omata Doreen Rappaport Susan Reverby Len Rodberg Alex Rosen Ken Rosenberg Gel Stevenson Rick Surpin Ann Umemoto Editor: Jon Steinberg Associate Editor: Kate Pfordresher Staff: Loretta Wavra MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR should be addressed to Health / PAC, 17 Murray Street, New York, N.Y. 10007. Subscription rates are $ 14 for individuals, 11.20 $ for students. and $ 28 for institutions. Subscription orders should be addressed to the Publisher: Human Sciences Press, 72 Fifth Avenue, New York, N.Y. 10011. Health / PAC Bulletin is published bimonthly by Human Sciences Press. Second - class postage paid at New York, N.Y. and at additional mailing offices. 1981 Human Sciences Press Articles from the Bulletin are indexed in the Health Planning and Administration (HP & A) data base of the National Library of Medicine. Illustrations by Mark Gottbaum / Public Employees Press (pp. 1, 2), Collette Ann Episcopo (p. 6), Libera- tion News Service (pp. 9, 10, 11), Cindy Fredrick / LNS (p. 13), Peg Averill / LNS (p. 19). when you are sick? 8. Do you believe the price you pay for medical care under a National Health Care System should be set by the amount you earn - so that if you earn more, you pay more for these services? The Foundation pits itself against the Brookings Institu- tion and the AFL - CIO, claiming to be " America's leading research / free enterprise in- stitute, " leaving the poor American Enterprise Institute in the cold and the Institute for Policy Studies in Siberia. Senator Hatch warns that A San Francisco kidney specialist has set up his own non profit - foundation dedicated to showing citizens ' the advantages of profit making - over non profit - health care delivery ' " Labor and the ultra liberals - West Coast medical think tank. Soviet anti - diatribes at the New will have the government hiring thousands of new bureaucrats to regulate your health care " in a The Institute for Contemporary Studies has made a bold bid with New Directions in Public York Times. This stalwart anti- Stalinist Horatio at the bridge now bars the Communist Men- plan that's " a virtual carbon copy of England's. " The price for their Campaign to Stop Na- tionalized Medicine: $ 185,000. Rather than ask others for Health - A Prescription for the 1980s, a collection of essays edited by Harry Schwartz, who earned his credentials writing ace as editor of Private Practice. -Hal Strelnick Source: The U.S. Mail. donations, Sajjan G. Dhar- nidharka, a San Francisco kid- ney specialist, is using $ 120,000 of his own money to found Tax- YOUR LIFE COULD BE WORTH $ 12.50 payers for Efficient Health The following memorandum is reprinted in full. Care. His " purely educational " foundation is dedicated to show- As you know, the rate of post mortem - examinations at ing " citizens the advantages of profit making - over nonprofit health care delivery. " Only 35 years old, Dr. Dharnidharka became aware that private for- profit facilities are the most effi- cient while establishing his own Artificial Kidney Clinic in Stockton, California. He is con- vinced that government is the leading villain causing soaring health costs. At the same time, Montefiore Hospital and Medical Center has fallen to exceedingly low levels and is, at this moment, approxi- mately 12% of all deaths occurring at the Hospital. This is inconsistent with the standing of a major teaching in- stitution and a change is urgently needed. With the ap- proval of the Medical Board, the Administration im- plemented two measures which should be helpful in this regard. The first measure is a new form which is appended on the reverse side of the Autopsy Consent Form and which must be completed for all patients dying at the Hospital, if an autopsy consent is not obtained. The unit he reports that he has maintain- ed " healthy profits " despite legal mandates to reduce the charges for dialysis from between $ 200- $ 300 to $ 156 by " dialyzing more patients in less time through more efficient use of resources. " The philanthropic Dr. Dharnidharka would like to secretaries will place the form in the deceased patient's chart for the responsible house officer to complete. The completed form will ultimately be reviewed by the Department of Pathology, which will monitor the autop- sy rate for each clinical department and the reasons for the low rate of autopsies. The second measure will provide additional incen- tives for the house officers: for every four autopsies ob- tained, he or she will receive a medical text or other 1 teach what he learned to others. publication of his or her choice up to a value of $ 50.00. Perhaps next he will teach citizens how to use tax exempt - foundations as both tax shelters Would you please communicate these two measures to your staff and urge them to do their best to obtain authorizations for post mortem - examinations? and lobbies. Your cooperation will be deeply appreciated. But Dr. Dharnidharka should know that San Francisco is not virgin territory. The Institute for From now on we'll feel more secure as pa- tients in hospitals with good lending libraries. Contemporary Studies and the Hoover Institution are already 5 vying to be the Right's foremost HALF AN EMPIRE IS BETTER THAN NONE A recent article entitled The " New Medical Industrial - Com- plex " (Arnold S. Relman, " The New Medical Industrial - Com- plex, " New England Journal of Medicine, v. 303, no. 17, Oct. 23, 1980, pp. 963-970) may seem like old hat to Health | PAC readers but it has caused a mild storm in more established circles. In the article, Arnold Relman, the Journal's editor, noted that the growth of for- profit hospitals, nursing homes, laboratory services and renal dialysis centers threatened to distort the priorities of the health system and promote con- flicts of interests among doctors and other health providers who might own stock in these businesses. Of particular concern was the rapid growth of proprietary hospitals in the Western states. The editor was worried that such institutions, motivated by profits, would begin to " skim lies in the distinction that Dr. Relman makes between the " old " and " new " medical- industrial complexes. The " old " medical industrial - complex, he says, included pharmaceutical and medical supply companies. In his view, these are not " par- ticularly worrisome " because they " have been around for a long time and no one has seri- ously challenged their social usefulness. " Besides, Dr. Relman maintains, " in a capital- istic society there are no prac- tical alternatives " to them. The " new " medical industrial - com- plex, however, " is an un- precedented phenomenon with broad and potentially troubling implications for the future of our medical - care system. " (p. 763). In the editor's analysis, voluntary hospitals and medical centers and teaching institu- tions are also exempted from criticism. This should not be surprising; Dr. Relman is a medical educator. Nor is it sur- prising that the paper has at- tracted widespread attention from the popular press, most significantly on the editorial page of the New York Times. What is surprising is how com- pletely the Health PAC ideas of ten years ago have permeated mainstream academic analysis and how thoroughly their mean- ing has been narrowed and di- The term'medical- industrial complex'refers to the crassest and most overt manipulators of the profit - motive in medicine. There is another name for the educators and medical centers which abuse the system in other ways - but that for later luted. The accepted " medical- industrial complex " refers only to the crassest and most overt manipulators of " the profit motive " in medicine, not to the educators and medical centers which abuse the system in other, if more subtle, ways. -David Rosner the cream " of profitable insured patients off the top of the patient Ze FE 2 7 ez, = pool, leaving the voluntaries and medical centers to care for the unprofitable, uninsured and more needy clients. Those pa- THE UNITED STATES OFAMERICA OFAMERICA 4 1 tients who had " unprofitable " conditions i.e. conditions for which reimbursement was inad- equate or who lacked medical coverage - would be left without care. While the article draws its analysis and even its very title from Health PAC's ten year old critique, most forcefully pre- sented in The American Health : P) BE BE DOLLAR DOLLAR DOLLAR | =- Empire (New York: Random House, 1971), it should not be assumed that the Journal's editor shares our perspective. 6 The most significant difference MAKING THE DEAN'S LIST In biology, media are what infectious things grow on. Ap- parently, unsatisfied with lists of the Best Dressed, the Top Ten Movies of 1968, the Top Forty, and the Best Cheesecakes, the ranking of physicians in the media has been spreading. First there was John Pekkanen's The Best Doctors in the United States, a book that sold out its first printings and was Enquirer seri- alized in the National Enquirer and other supermarket tabloids. Then came New York Maga- zine's " Superdoctors: The Top M.D.'s in New York, " which followed Pekkanen's method- ology by asking the specialists to name the super specialists - , ending up with a list of academic heavyweights (no general pediatrician was listed and only one general internist; family general practice, and community medicine did not even merit mention). But what goes around, comes around. Private Practice, a journal distributed free to about 180,000 doctors by the Con- gress of County Medical Societies, decided to poll the deans of the nation's medical schools to determine the best and the worst. Before the Journal could harvest value judgements from all 200 deans and assistant deans at the nation's 126 medical schools, Dr. John A.D. Cooper, president of the Association of American Medical Colleges, their trade organization, intervened, ask- ing them not to respond. But Private Practice had already received the responses of 44 deans, and published their ranking of the 15 best and 10 worst schools. What made news, however, was not the rankings themselves, but the Washington Post story of Dr. Cooper's " gag order " by Daniel S. Greenberg, Washington columnist for the New England Journal of Medicine, who asserted that Cooper had violated the public's right to know. The survey results are a tell- ing revelation of the values of academic medicine. Its top ten were the predictable paradigms of the post Flexner - era: 1) Johns Hopkins, 2) Harvard, 3) Duke, 4) Yale, 5) Columbia, 6) Chicago, 7) Washington (St. Louis), 8) Stanford, 9) UCLA, and 10) Michigan. Institutional racism can wear long white lab coats just as easily as it wears white hoods and white sheets Its ten worst medical schools, however, were either schools committed to training minority physicians or new schools com- mitted to training primary care physicians: 1) Meharry, 2) Puerto Rico, 3) Howard, 4) New Jersey College of Medicine & Dentistry, 5) Southern Illinois, 6) Creighton, 7) Loyola, 8) Texas Tech, 9) Hahnemann, and 10) Medical College of Ohio. The three worst medical schools, by the dean's list, are the three predominantly minority institutions in the country with long traditions of training physicians who often serve minority communities. Howard recently gave the Washington Post the scores of its students on the last pre- graduation part of the National Board Examination, which pro- ved their pass rate was well above the national average. The New Jersey College of Medicine & Dentistry is one of- the few predominantly white medical schools with a consis- tent commitment to affirmative action. Stanford is the only school among the dean's list which can boast significant suc- cess in affirmative action, while Johns Hopkins has been among the worst schools in minority ad- missions. Whether Dr. Cooper's inter- vention was designed to protect academic medicine's liberal im- age or to protect the dues- paying institutions in the trade association, it came too late to hide the naked truth. Institu- tional racism can wear long white lab coats just as easily as it wears hoods and white sheets. -Hal Strelnick Source: Private Practice. SECOND OPINION After debating the Detroit health services agency bed reduction plan (see Health / PAC Bulletin, October) a joint committee of the Michigan state legislature ordered the HSA to rewrite its proposal, demanding that hospitals be targeted. The joint committee also seriously ques- tioned the value of shifting pa- tients from low cost - community hospitals to high - cost tertiary hospitals. Heavy political pressure from the teaching facilities suppressed a staff recommendation that the giant. teaching hospitals and the mid- size community hospitals share equally in reduction respon- sibility. The final outcome is unclear. The Detroit HSA (CHPC- 7 SEM) has its hands full, since these revisions must be com- pleted in a maelstrom of labor unrest. The entire HSA staff, in- cluding managers, has organ- ized into various bargaining units. In September, the Na- tional Labor Relations Board issued an unfair labor practices ruling which charged the agen- cy with " coercing, restraining, and discriminating " against its employees. The NLRB ordered the HSA to halt such practices and to reinstate a fired senior staffer. The agency has also been re- quired to post notices that it will no longer engage in unfair labor practices. -Mark Kleiman Editorial: Turning the Tide Continued from Page 2 Health / PAC are not sinking into despair. In fact, we see the Right's redux as an early warn- ing and an opportunity. The warning should be aimed at the 70s tendency to retreat -w hether into nostalgia, fantasy, or the self - in the face of determined opposition. History will not inevitably bring progress towards a more humane society without our individual and collective efforts. As Frederick Douglass put it, " If there is not strug- gle, there can be no progress. " The opportunity is clear. The failure of a too- moderate liberalism to hold the economy together; to provide the impetus necessary to unite poor, working, and middle class. Americans; or to sanely manage a declining US empire abroad, creates a vacuum of leader- ship as well as of ideas among progressive forces. The concepts, issues, political movements, and leaders which will move and shake the 1980s can be progressive ones. But, rising to this opportunity requires close heed to the lessons of both the 1960s and the 1970s. Strategies and ideas from the past two decades are not necessarily adequate for the future. The success of the Right, for example, has been built upon not only immediate corporate / insti- tutional bankrolling but on a newfound respect for coalition politics, a frightening instinct for the more perverse and confusing sides of everyday social, family, and personal " moralities " do (they favor a right - to - life after birth?), and a willingness to forsake ideological purity on all issues. At the same time, its publicists have succeeded in purveying the il- lusion that " private enterprise " and non- government - as - usual can provide economic growth and social improvement. Can the Left similarly create practical coali- tions of poor, working, and middle class groups around a progressive vision and issues that touch their everyday lives? Can we reconnect 8 an understanding of how our communities, in- dustries, and regions, as well as other parts of the world, are exploited in deadly ways by runaway and absolutely unaccountable transnational corporate investors? In health, can we provide a vision of a society that is at once less involved in the production of disease and more equitable and accountable in its distribution of services and jobs? Can that vision be translated into practical actions which ordinary people can identify with and support? Health / PAC, like many of our activist sup- porters, begins the decade with meager resources and a sober disposition, but also with renewed dedication. Reagan has our adrenalin flowing, and that's great. We are, for example, now preparing a special March / April issue to coincide with the 10th anniversary of the Oc- cupational Safety and Health Administrations and a national " corporate industrial diseases week. " This effort will deepen our understand- ing of both the techniques of occupational- environmental " planners death -" and the work of their labor based - challengers. At the same time, the Bulletin will offer a self critical - strategic discussion of labor based - health. politics. We know health activists will play an impor- tant role in national and local efforts to unite all progressives around issues such as defense and development of services and economic well- being: occupational and environmental pro- tection; and reducing the threat of nuclear catastrophe. The Caucus for Progressive Health Planning, for example, is working as part of the Planners Network (P.O. Box 4671, Berkeley, CA 94609) to organize a conference this spring to discuss joint strategies and political positions. Of course, new ideas will not be enough. We have to build on basics analysis - , fundraising, organizing, staffing an office, and, yes, even getting our publications to the printer. The job can be done. It will be done if people continue to support one another. We'll be there. Mental Health is Hard Work How do the manic depressive - swings of the U.S. economy affect the physical and mental health of ordinary American citizens? Academics have long debated whether downturns and recessions bring rising rates of mental illness, or whether periodic runaway growth is actually the culprit (see " The Boom- Bust Debate " box). In the following article the authors begin to unravel the complex relationships between the use of mental health services and economic ac- tivity, family, and personal life. Their study of mental health services in a small New England industrial area over a 25 year - period finds evidence for both sides of the debate and highlights its complexity. They definitely con- clude that economic fluctuations do affect mental health status, in ways influenced by the organization of particular families and com- munities. This serves as an important reminder to us all that community and family well being - are the most meaningful, yet most often neglected, measures of economic progress. With With three children, the youngest not yet in school, Peter and Debra Hansen (names and locale have been changed) were barely meeting day day - to - expenses with the income from Peter's job as foreman at a local company just outside Fitchburg, Massachusetts. The Hansens seemed to be a typical family in the area, and a reasonably stable one. Suddenly Peter's shift at the company was cut from five days a week to four; his pay also drop- ped 20 percent. Money problems spread ten- sion through the house. Debra was uncertain about looking for work with their smallest child still at home. Peter said it was out of the ques- tion. He began to hang out later on the nights he worked late and paced the floors during the days he was home. Debra had always kept the house immaculate, but Peter started complain- ing about her housekeeping. Then the oldest Hansen child started bring- ing home reports of misbehavior in school. Each parent blamed the other. Family and friends seemed to stop coming by. Debra took a part time - job as a hospital ward clerk - over Peter's objections. Soon, almost nothing could be mentioned without a fight. Even when Debra brought up the possibility of counseling, there was a bitter quarrel. Finally, shaken by her threat to leave him if he didn't go with her, Peter agreed to counseling at the area's Com- munity Mental Health Center (CMHC). In this case study, a seemingly subtle change in the employment status of one member of a fairly typical American family had a profound impact on that family's emotional well being - . The result is contact with the formal system of mental health services, as well as changes in family roles. Yet their social worker is convinced that per- sonality problems and mental illness actually cause unemployment and the related upheavals in family life. One social worker at the Herbert Lipton CMHC in Fitchburg, Tom Dorrance, has said About " 15 percent of clients have job related - problems, such as conflict with their boss or co workers - . In most instances it is their marginal level of social skills and in- terpersonal competence that creates job- related problems. According to Mike Sciabarrassi, an Intake Emergency Worker at the Herbert Lipton CMHC, " Very few clients ever come to the clinic with specifically employment related problems, even fewer as a result of unemploy- ment, " although some whose income loss made 10 medication unaffordable would turn to the clinic. Dr. Theodore Jellinek, Acting Director of the center, concurs with these staff opinions, " Very few people come to the Center on ac- count of loss of employment, " he said, " and I almost never meet them in my private practice. " What seems to have begun as an impersonal business decision is thus reinterpreted as an in- dividual's chronic personal problem. But where is the truth? The complex, and sometimes elusive, rela- tions between individual behavior, family and community organization, and economic change have attracted the interest of numerous mental health professionals. Others, including community activists, social policy analysts and economists have also questioned whether time and resources are properly concentrated on in- dividual treatment, or should be focused on strengthening the fabric of family and com- munity life. Community mental health staff often find that the traditional exclusive em- phasis on treating the individual, common in hospital - based practice, is no longer ap- propriate. They argue that the environment can bring on disability and dysfunction; therefore, " treating " the environment makes as much sense as treating the individual. Current- ly there exists a kind of ad hoc interdisciplinary exchange which finds community mental health workers venturing into the economic and social change arena, while economists pay greater attention to the " hidden " social costs of economic decisions. The Community Context The chicken - and - egg question of the rela- tionship between individual stress or pathology and the disorganization of home, job and com- munity life is obviously not simple. Nor is it only academic: The " line " of one scholar, Harvey Brenner, has been cited by the Joint Economic Committee of Congress as an important guide to national economic planning (see " The Boom- Bust Debate " box). When social and economic policy decisions are drawn from theoretical analyses, it becomes crucial to examine the fac- tual basis of the analyses themselves. To move beyond a simple cause and effect model of the stress dysfunction - relationship, the senior authors of this article carried out a detailed study of utilization of mental health services in the CMHC catchment area of Fitchburg Leominster - , an old industrial com- munity in northeastern Massachusetts. The Washroom Applic Cuarto de Bao de Client 11 area is particularly attractive for such a study because it is largely self contained - , i.e., most of its inhabitants also work there and, converse- ly, the labor force is almost exclusively drawn from the local population. Therefore, mental health care and economic statistics over the past quarter century almost certainly refer to the same population. Fitchburg, a city of 45,000, is representative of many older industrial centers in the North- east and the Midwest. It began as a lumber and paper mill town on the Nashua River in the 19th century. Until recently its commerce remained dominated by paper mills. The plastic industry has recently become the largest employer, Shifts in economic although machinery manufacturing has en- joyed the largest growth in the last decade. Downtown Fitchburg, with its state college, structure weaken libraries, and public buildings bearing the names of leading families no longer living the capacity of there, has been " regenerated " by federal redevelopment funds and substantial invest- ments by local firms. families and social networks to pro- For many years the city has had a large Fin- nish population as well as many French Cana- dian, Irish, Italian, Greek and Polish residents. Since the early 1970's there has been a small in- flux of Blacks and Hispanics who have taken vide support and at low paying - jobs in the many small plastics plants. During the 1974-75 recession, unem- the same time box ployment in the area climbed to 18 percent. It has since dropped to near the national average. Most of the workers laid off were in the individuals into in- plastics industry (see Figure 3). Although the Fitchburg area has experi- creasingly dis- tressed conditions enced an overall growth in jobs and population during the past 30 years, it still reflects shifts of economic activity away from the Northeast towards the Sunbelt. During periods of economic expansion, Fitchburg's job pool grows, but at rates below the national average. In periods of recession, it suffers greater than average economic contraction. The percen- tage of the work force employed in manufactur- ing is still 50 percent greater than the national average even though since 1958 its weight has dropped from almost two thirds to less than one half. Nearby Clinton was staggered by the shut- down of a steel plant and Miller's Tools. Coloni- al Press closed up shop after a conglomerate takeover and its presses began running again only after the much publicized takeover by the Clinton Press Cooperative. (See " Turning Closings into Cooperatives " box). Some jobs lost in textiles and fabricated 12 Continued on Page 25 HOSPITAL CARE IN CRISIS PART 1 DIANE LACEY TALKS ABOUT SYDENHAM Attempting to save Sydenham Hospital has been a fulltime job, but Diane Lacey works at it in her spare time, which is hard to discern. When we arrived in her office at radio station WWRL on the day she had set a week in ad- vance, she apologized for keeping us waiting. Her desk was piled high with papers, including a copy of Health / PAC's The American Health Empire - " I'm teaching a course, " she ex- plained. During the interview she referred to three meetings she had attended the day before; one of them was the monthly session of New York City's Health and Hospitals Corpora- tion board, of which she is an embattled member. How had she become involved in the Sydenham struggle? " A committee was established to save the hospital as far back as 1945, but my association began in 1976. At that time Sydenham was put on the hit list along with a number of other hospitals as part of the Beame Administration's response to the fiscal crisis. I was working in the Health and Hospitals Corporation, and tried to lobby from the inside to keep the hospital open. Unsuc- cessfully. " Her lips formed the wry smile of someone who has been meticulous enough to prove the obvious. " At that point I was also a Democratic district leader in the area where the hospital is located. I got together a broad based - group which put about 5000 people into 125th St. to protest the closing the first march of that sort in Harlem since Adam Clayton Powell days. We were one of the early efforts in New York City, probably in the country, which rallied community people and others to save a public hospital. There was broad support, and after the politicians - both No HELP WANTED Cindy Fredrick /L.N.S. uptown and downtown - saw our determina- tion, they joined in and we were able to defeat that move to close Sydenham. Of course, " she added grimly, " since 1976 we've lost Philadelphia County Hospital and a number of others throughout the country. " In June of 1979, when Mayor Koch de- manded the hospital be closed and pushed a vote through the Health and Hospitals Cor- 13 poration, the Coalition to Save Sydenham Hospital came back together with essentially numerous community meetings with politicians and local leaders. " the same makeup; it's just grown and developed in the past year. " We've been working with a multilevel strategy. The Corporation vote was based on a task force report, which was supposedly written Mayor Koch remained adamant, pugnaciously asserting Sydenham was a waste of money and Harlem residents could be better served elsewhere. Health activists argued in vain that all of the other northern Manhattan by Haskell Ward, then Koch's black deputy mayor. So our first effort was to attack that report and all the errors of fact in it. We suc- ceeded quite well, along with groups like the Coalition for a Rational Health Policy and the New York chapter of the American Public Health Association. Even the Health Systems Agency indicated that the report was full of holes and urged that the hospital stay open. So we thought that since the report was totally and completely discredited over three or four months, the Mayor would back down. " Again she smiled wryly. " Of course he did not, so our organizing efforts had to continue. " With District Council 37 of the State, Coun- ty, and Municipal Employees union; the Com- munity Legal Action Service; and the NAACP L really led by the NAACP's Manhattan Direc- tor, David Bryan - we went to court, charging that the closing of Sydenham represented a hospitals are suffering from budgetary con- straints and reducing services. " The coalition began meeting pretty much non stop - about June, 1980, because the closing hovered over us but the date wasn't set until August. At a variety of meetings and demonstrations in our own community and downtown, it was clear that our people were becoming very discour- aged. DC 37 was moving away from our posi- tion. The politicians were down, and some, like Representative Charlie Rangel at one point, actively supported the drug treatment center alternative. " So I called a normal meeting for the night before the admissions and emergency rooms were set to close, September 16th. After work- ing on this since 1976, I kept thinking of T.S. Eliot's line,'not with a bang but with a whimper.'The injustice of it moved me to find violation of the civil rights of the Black and Hispanic residents and hospital workers. We fought that battle for over a year and finally lost on the Appeals level in a two to one vote. That decision, we feel, was politically influenced, because the facts substantiated that the closing is very much a violation of civil rights. And we .. still, Mayor Koch remained adamant, pugnaciously asserting that Sydenham was a waste of money and that Harlem residents could be better can point to the dissenting opinion, which was longer than the opinion of the original lower court judge. " Diane Lacey's voice, always clear and served elsewhere. After a while, it became clear that our people were becoming discouraged ' precise, became more animated. " We also worked with the citywide coalition to save municipal hospitals to raise the issue across the board in the city. We had hundreds of letter- some way to make the point dramatically that the hospital should not close, that the points we were making all along were correct, that it ' We went to court, charging that the wasn't only a crisis for all those people in that small area of West Harlem; all of northern closing of Sydenham represented a violation of the civil rights of the Black and Hispanic residents and hospital Manhattan is in a health crisis. I called up some of the people who had been involved with us and very carefully and quietly planned the meeting that would end in the takeover of the workers. We organized letter writing - hospital. " campaigns and demonstrations.... She smiled mischievously. " The hospital a people were very, very surprised. The police were very surprised. They had generally anti- writing and petition campaigns. We had de- cipated that something would happen; weeks monstrations in front of Gracie Mansion, the before they had begun moving in city police 14 mayor's residence. We held speakouts and and hospital security police from all over the city system, and had hired five or six extra peo- ple for the people around closing. But I think they were really lulled and did not believe that we would go that far. " We had our meeting the night before, and more and more people came, and we took over the hospital. The trusted people had alerted some of their colleagues; people began to come. And the media were there that night- that is one success we can point to. In 1976 you could hardly get a murmur from the press about this issue, but we had gone to the well so many times, we had organized and been active on this issue so constantly, that whenever there was a rumor of closing, the media, including the TV people, would hang around. So they were there and got it right to the public and that helped us spread the word and make contact with a lot more people. On September 16th of last year, Sydenham was set to be closed. Neighborhood residents began demonstrating and finally took over the facility to ensure that it remain open. The media was there... " That Saturday, the picture of those police- who the mayor said operated with such restraint -- brutally attacking demonstrators flashed all over the country and maybe all over the world -- I've received copies of that photograph from the Caribbean. So the name of Sydenham and the struggle for Sydenham have become more nationally known. " When the subject of cooperation with people trying to save Harlem's North General Hospital was raised, Diane Lacey's eyes narrowed in a shrewd, thoughtful expression. " No, we haven't worked together much. The North General story is interesting. It started with the addition of a few Black members to the board of direc- tors - with very little publicity. The white policy makers - at North General, which was then Joint Diseases, were very much involved in trying to defeat our efforts. Their position was that Joint Diseases had a much better facili- ty, was a much stronger hospital, and should stay alive while Sydenham should close. " We have since had many conversations and have agreed that it is not in the community's in- terest for either of the hospitals to close. " She paused with a small sigh which seemed .. * and photographs of the police brutally attacking demonstrators flashed all over the country, maybe all over the world. The name Sydenham ' ' became nationally known to indicate both hope and exasperation. " So at least we are communicating. Of course since our dispute the Black and Hispanic executive staff and administrators there have had the rug pulled out from under them. Joint Diseases moved downtown in a manner which could best be described as the rape of North General. They even took partitions and walls - in addi- tion to some of the cream of the staff. Secretly, and in violation of their commitments. They also pulled the rug out fiscally. Some of those people who were used to attack us in '79 have seen their chickens come home to roost. " How can a hospital which couldn't make it as a municipal survive as a voluntary? When this question came up, Diane Lacey's expression and voice took on a harder edge. This was, after all, the problem which was keeping her up nights at meetings, and no doubt when she tried to fall asleep as well. " First of all, for the last five years for sure and probably longer there has been a constant attrition policy in the Corporation, there has been bad management, and we have not had a system able to prove itself. " Now, of the 17 municipal hospitals, Syden- ham was able to generate the highest reim- bursement rate, close to 90 percent of the operating budget. And we did that against tremendous odds. Many of our people had ideas about staffing which would have made our reimbursement even higher. So we have creative people, and we believe that without the burden of a system determined to fail, and a mayor who is publicly identified with the con- cept of closing municipal hospitals and giving them away to the private sector, we have a very good chance of surviving. 15 How long can Sydenham survive?'We have a determined community. People are pledging their support to keeping the hospital. We are talking about self- determination in the Harlem community, and I've never seen this kind of energy and determination before ' " I'm going up to Lincoln Hospital in the Bronx to look again at their detox center, which has managed to stay alive through many ad- ministrations. Michael Smith is using acupunc- ture there, quite successfully, and they're do- ing quite well with reimbursement. We think we can use similar artful measures to be finan- cially viable. " Will Sydenham have a drug program? " I'm not saying that, " she replied quickly, " I'm say- ing that we are looking at a successful program, and if they can do that, maybe we can do other things. We are unalterably opposed to the city's plan for Sydenham, which is of course for detoxification, treatment for alcoholics, and for mental patients. There are plenty of other sites in Harlem suited for it. There are 200 detox beds at Harlem Hospital that were closed down a couple of years ago. There is the former Logan Hospital, which is being vandalized because it is not in use. There's Metropolitan Hospital's Mental Health Center, which has numerous beds available. We know that many of our patients who come to us with health prob- lems also have drug problems, alcoholism pro- blems, mental problems. But we have been treating them for their primary complaint, which is a health complaint, and will continue to do so. " President Carter's aides met with the Com- mittee to Save Sydenham after the takeover and promised grants, but that was before the elec- tion. " We are raising money right now, " she said, " I can sell you tickets for our theatre benefit. And we have plans for major fund- raising, including a $ 100,000 weekend. We are going to be approaching foundations as well. " How long can Sydenham survive? Her eyes widened. Her voice, still calm, repelled any thought of interruption or argument. " We have a determined community. We have people whom I could never get out before to support Sydenham pledging their resources and their time to make this hospital a reality, who are determined whether or not we get the federal grants which make starting up the hospital a lit- tle easier. We are talking about community ownership. We are talking about self determin- - ation in the Harlem community, and I've never seen this kind of energy and determination before. " In addition to being a health activist and health advocate, I consider myself a communi- ty organizer, so I think the major thing we've won is unity of the community around a single issue. We've been able to pull together not only Harlem but the Black leadership from around the city, and that's been very exciting for me personally and for this effort. I believe this uni- ty is going to be valuable not only for saving the hospital and focusing on the crisis in health care in northern Manhattan, but also for focus- ing on the problem of gentrification in Harlem, of our sad political state - we have been under attack by Ed Koch for the past three years - and hopefully give us the ability to pull people together around the 1981 mayoral elections. " -- Kate Pfordresher and Jon Steinberg Errata In the previous issue of the Bulletin, Kate Pfordresher should have been listed as Associate Editor. The photograph on page 10 of that issue was the work of Mel Rosenthal. 16 a a HOSPITAL CARE IN CRISIS PART 2 UNION BLUES On Friday, October 17th, Federation of Teachers (UFT) Philippines. registered nurses in 14 of New and the National Union of The NYSNA, which has York City's 17 municipal hospitals walked off their jobs to Hospital and Health Care Employees (District 1199). represented the City RNs for over 20 years, has watched this protest low pay and poor work- ing conditions. Their contract During the last four years, ci- ty nurses have grown restive as erosion, powerless to stop it. Historically, the Association's had expired three months their salary, benefits and work- main interests have been earlier, but the New York State ing conditions fell behind those legislation, licensing re- Nursing Association had not of nurses in the voluntary quirements, and education; on- been able to negotiate a new hospitals. Salary parity with ly recently has it turned to col- one. nurses in New York's voluntary lective bargaining. The leader- Strike plans had been kept hospitals was suspended during ship of the organization is com- secret. The public first became aware of the walk out at 7:00 AM the 1976 and 1978 contracts at the time of the New York City prised of nursing administrators and educators, whose concerns as morning shift nurses set up picket lines at the hospital eS at the bargaining table are often in conflict with the demands of gates. At noon Margaret During the last four years, rank and file nurses. The Rooney of the NYSNA announc- ed to the press that the Assoca- tion did not endorse their members'action and urged nurses have grown restive as their salary, benefits and working conditions NYSNA's all out support for the 1985 Proposal to require a B.A. of all prospective RNs demonstrates this commitment nurses to return to work. The fell behind those of nurses to developing " nursing rank and file did not obey, defied a court ordered - injunc- in the voluntary hospitals leaders " at the expense of work- ing nurses and of patient care. tion against the strike, and In the decertification battles, stayed out for five days. Because there was no ad- fiscal crisis. This discrepancy between private and public the NYSNA was challenged first by the UFT, which attracted vance publicity, this wildcat hospitals has created chronic many sincerely dissatisfied strike seemed to appear out of thin air. It didn't. nursing shortages in the City hospitals, since many RNs have nurses. However, the teachers union campaign emphasized Only five months before the strike, the NYSNA had avoided been forced to transfer to main- tain their living and working professionalism and attempted to draw a link between the defeat in a decertification elec- standards; periodic hiring needs of RNs and those of tion involving the 5600 city hospital nurses. Receiving 36 freezes have slowed employ- ment of replacements, creating educators, a link many RNs did not see. Some were won over by percent, the NYSNA won by a a crushing workload for those the union's attempt to address narrow two percent margin over who remain. The situation has bread and butter issues and to the combined total of the two become so desperate that the answer nurses'questions about challengers, the United City has begun recruiting in the their everyday needs. 17 District 1199, leaping into the ed in the bargaining unit. The working nurses. Since then it fray several months after the influence- -some say coercion-- has changed its tactics and tried UFT, also focused on the con- exercised by participating to look more like a union. Un- cerns of working nurses. Its supervisors could have given fortunately, these efforts have union organizers, themselves NYSNA its slim victory margin. been compromised by inex- RNs, emphasized 1199's suc- Blaming the May decertifica- perience and internal conflicts. cessful representation of all tion election for its slow start in Beginning in late August, the health workers and its positive renegotiating the RNs'contract, NYSNA authorized several job record on minority issues. Many the NYSNA did not sit down actions to draw public attention nurses, however, questioned with the City until early August, to the nurses'demands. Infor- 1199's commitment to the City fully five weeks after the con- mational picket lines were held RNs, pointing to the union's tract ran out. Despite its at Kings County Hospital, a belated and poorly funded en- triumph, the Association was sick - out was called at the try into the contest. forced to acknowledge the Bellevue Hospital premie Once they were both in- feebleness of its support among nursery, and nurses struck volved, the UFT and 1199 spent Harlem Hospital for 24 hours. most of their time fighting each All of these actions were poorly other. Many nurses were com- organized, received pletely turned off by the new- little publicity comers'claims and counter- even among claims. In contrast, the NYSNA's low profile campaign For nurses at emphasized professionalism and the Association's traditional role in the municipal hospitals. It made no attempt to address the day day - to - needs of working AMAZING left ditions desperate for (if World hospitals. their A. The nursing substandard people wiling nurses, thereby avoiding awkward questions about its your for now New York Many long neglect of these problems in the you watch step down city is jobs at pay. OP ORTUNITY to work step). Americans actively City's American hours long years prior to the election. When it came time to vote in a side FILIPINO of the may recruiting municipal citizens in poor the election, some nurses felt new U.S., you've be a step in the have con- discouraged by their choice and did not vote. Some attri- exotic NURSES never up for Third HELP bute this apathy to the diseases seen. in! " traditional " passivity. of women workers in NEW general and the pre- mayor dominantly female EQUAL Clean Hol ywo d bedpans EXPLORE balance YORK films RNs in particular. But it can also bados discriminate be argued that Koch: without CITY'S their passivity Under the than , or his. budget. Meet you has been en- anyN ewG uwhaettehemra aldami nOisPtrOatRiTonU,N yIoTu Yy ou, taxing the POOR Yorker will from couraged by the NYSNA HIERARCHY. In are City rich. + addition to the As- sociation's influence over the nursing hierar- WRITE from the be treateSdo utthh en o HPahlil ipdpoiense s not con- TODAY Bronx more or shabbily, Bar- chy within each hospital and sequent control over information channels, supervisors dominate ! Harlem. 18 the local councils and are includ- ' The NYSNA's difficulty has been in recognizing that negotiations require intense political pressure to gain a good contract. Support needs to be mobilized from the community, trade unions and even political officials where possible ' other municipal hospitals, and remained isolated events. The NYSNA's attempts to organize the nurses themselves were similarly compromised. Con- tract proposals addressed many issues raised during the decer- tification election, including salary parity, a 10 percent cost- of living - increase each year of the contract, day care, and full tuition reimbursement; but the NYSNA leadership refused to release the list of proposals to the membership, fearing the nurses might expect to get everything requested. " The NYSNA's difficulty, " ex- plained a Nurses Network member, " has been in recognizing that negotiations, especially with the beleagured City of New York, require in- tense political pressure to gain a good contract. Support needs to be mobilized from communi- ty groups, related trade unions, and even political officals. where possible. These pressures were largely ignored by the NYSNA. " By the end of August, negotiations with the City were stalled and rumours of a strike were multiplying. At first it ap- peared that the lack of advanc ed planning for a job action might be attributable to NYSNA's political naivete. Nurses on the negotiating com- mittee were reportedly surpris- ed by the city's sudden hard- line position when negotiating began in earnest. But it soon became evident to many nurses that a split was developing be- tween the NYSNA negotiating committee, which favored a job action, and the Executive Board, which was against it. This internal conflict destroyed any possibility of coordinated strike preparation. Without explaining the details of the negotiations, the bargaining committee dele- gates in each hospital began taking preliminary strike votes in mid September - . Rank and file nurses voted unanimously for a strike, but they were still kept in the dark. Nurses at Kings County Hospitals had to take a vote to force their chairperson to reveal the con- tract proposals. Sometime during the week of October 6th, the decision was made to call a strike. It was. unclear at what level of the Association the decision was made. Local NYSNA represen- tatives met with nurses at hospitals to explain the plan, but even then they would not say when the walk - out would begin. On Thursday October 9th, the NYSNA called a strike to begin the next day. Notification was left to local representatives STRIKE zag 19 and was haphazard. Some nurses heard the announce- ment on the radio, others heard only rumours, and the rest found out when they reported to work and found picket lines. At Kings Country Hospital, nurses passed around a printed an- nouncement but there was no way to ensure that everyone would see it. Participation in the strike was high but the nurses were hampered by the lack of ad- vance preparation or organized communication between their forces at different hospitals. Numerous attempts to set up communication networks be- tween nurses on different shifts and units were only sporadical- ly successful. Then came a crushing blow: capitulating to city government threats, the NYSNA announced to the press at noon that it did not support the strike and had agreed to binding arbitration. By even- ing, local NYSNA leaders and negotiating committee mem- bers were at the picket lines personally admonishing nurses to report to work the next day. Isolated from their colleagues, nurses at four municipal hospitals reluctantly returned to work the next day. However, at the majority of hospitals, the union's desertion only increas- ed the nurses'frustration and anger; they voted to stay out. On the second day of the walkout, striking nurses set up a communications center and hotline to counteract unsym- pathetic press coverage, con- flicting signals from the NYSNA, and general misinfor- mation at the hospitals. Up - to- date information from picket lines and hospital wards was communicated to nurses calling in. At the request of the nurses, the Committee of Interns and Residents (CIR), an indepen- dent union of house staff physi- cians, provided the necessary facilities in their offices. Although hastily put together, Support Strike oar av erll INS 20 An Organizer Tells How It Can Be Done Last year registered nurses at St. Bar- nabas Medical Center, New Jersey's largest hospital, were up for a new con- tract. This wasn't a very happy prospect. Their bargaining agent was the Jersey Nurses Economic and Security Organiza- tion, the state nursing association, and the first JNESO contract had left much to be desired. In the words of Gail Duffy, RN, " It was an embarassing contract; rather than an improvement, it reflected losses in benefits.'" " We never saw a representative, " was a complaint expressed by Joanne Ferrante, an intensive care unit nurse. " There were no membership meetings; no one was in- formed. We had three delegates for 500 nurses, and the negotiating committee consisted of only four nurses.'" The dissatisfied nurses didn't have to look far for an alternative, since the hospital's ancillary personnel had been in 1199, the National Union of Hospital and Health Care Employees, RWDSU / AFL- CIO, for 16 years. " Their benefits were far superior to ours, " noted Marilyn. Rauchenberg, RN, " and management respected their rights. " When St. Barnabas nurses contacted 1199, the union sent over fulltime organizers from its Nurses Division. They helped prepare a blitz of meetings, discussions and almost daily bulletins in the weeks before the decertification elec- tion last July. 1199 emerged victorious with 185 votes. The winners were pleased, but anxious; they knew successful bargaining would require a much higher level of support. The new officers quickly held a nurses meeting to draw up contract proposals and elect a negotiating committee of 21, including nurses from every unit, for the September confrontation with manage- ment. After incorporating modifications suggested by 1199 staff, the chapter printed and distributed their own demands and the hospital administra- tion's counterproposals. The September negotiations quickly bogged down over key points. In a secret ballot, the nurses voted by a crushing 378-8 margin to authorize a ten day strike notice. Preparations for a walkout inten- sified. " We met with doctors, practical nurses, private nursing registries, non union -. employees, and the other 1199 members at SBMC, " recalled Ellen Mooney, a member of the negotiating committee. " We also saw the labor council, con- gressmen, and majors. " In addition, the nurses inundated the local newspapers, the Board of Trustees, and patients'families, with letters and distributed 6000 leaflets in the communi- ty. By the time the strike deadline came, the nurses had prepared headquarters. equipped with bathrooms, food, provi- sions for emergency shelter, and an infor- mation hotline; they had also organized committees for food, media, emergency care, and communications. After a mass meeting voted overwhelmingly to strike- only 23 nurses opposed - all the RNs mar- ched out to the picketline singing. " That overwhelming spirit of togetherness is something I won't forget, " said Ellen Mooney later. Ancillary workers refused to cross their union's picketline, and nurses and 1199 staff members were out there walking around the clock. On the third morning, the federal mediator came down to the sidewalk to say that management was ready to talk. A tentative agreement was reached before midnight and the nurses ratified it in a 6 a.m. mass meeting. -Sondra Clark (Sondra Clark is 1199's RN Division Director.) 21 Resisting the usual litany of threats from superiors, sixty houseofficers organized as the San Francisco Interns and Residents Associa- tion (SFIRA) walked off the job at San Fran- cisco General on Tuesday, October 21. By Fri- day night, the standstill of close to a year of negotiations had been overcome. After several all night - negotiating sessions the city conceded almost all of the contract demands, including recognition as employees, guarantees of reasonable working hours, and specifications. that the municipal hospital will be " adequately staffed " for the first time in several years. The success was all the more remarkable because only about a third of the interns and residents at the hospital struck, and many of them continued to provide emergency and night coverage between shifts on the picket line. A fiscal crisis in San Francisco has crunched the municipal hospital since California passed Proposition 13 in June 1978 (See Health / PAC July August - 1980). One consequence has been that only 1805 of 2055 budgeted staff positions were filled as of October 23. In the contract, the city agreed to an increase of 70 fulltime employees for the remainder of the current fiscal year and pledged to " maintain adequate staffing throughout the hospital, " a statement that is grievable in court. A General Accepts M Other features of the contract include: A special staffing committee with represen- tation from SFIRA and the Civil Service Association, SIEU Local 400, to review staffing every three months. The city agreed that the physicians need not " regularly and recurrently " perform the jobs of other hospital employees, such as making beds, pushing patients to x ray - or walking blood samples to the lab. While in one sense it seems doctors wish to get out of " work shit - " they feel beneath them, the " regularly and recurrently " clause is defended as forcing the city to improve staffing so that house officers have adequate time and energy to provide high quality medical care. The city agreed in principle to " reasonable " work hours for physicians, but the section is no stronger than " good - faith " language and it is unclear that goals of 24 con- secutive hours off duty - per week and no more than 34 hours of continuous duty will be achieved. * Full amnesty was granted for all strike par- ticipants. The strike was unique in that salary was not | an issue at all; concern about patient care dwarfed all other considerations. the Center became the focal returned to work. sion was announced on October point which enabled nurses to The attacks backfired. 17th, all the nurses felt like share news and strategies and to Directly following the mayor's wearing black: salary increases give each other support. The nurses needed all the mutual support they could get. announcement that Metropol- itan Hospital would be the first to close, the proportion of were limited to 8 per cent per year and the nurses were denied parity with their col- The city fought back quickly at the first announcement of a strike, obtaining a court injunc- tion and authorizing enforce- nurses striking there rose from 63 percent to 97 percent and the city had to back down. Nurses continued their strike leagues in voluntary hospitals- essentially the City's initial of- fer. An appeal filed by the NYSNA was denied. ment of the state Taylor Law, which authorizes the City to for varying lengths of time at different hospitals; each voted By the usual measures of suc- cess in labor struggles, the city withhold two days'pay for each day a government worker strikes. As the strike progress- independently on when when to to return to work. By Wednesday, October 15th, all the nurses hospital nurses strike was a failure. The RNs did not win any significant concessions from the ed, Mayor Koch publicly be- rated the nurses for " abandon- ing their patients and profes- sion " and threatened to close were back at work, some wear- ing black armbands to demon- strate their dissatisfaction with the situation. city, alienated the public and the press, and were assessed pay penalties. Neither the city nor the nurses give the NYSNA 22 the hospitals unless the nurses When the arbitrator's deci- any credibility as an effective ajor Improvements- When it came time to walk off the job and staff the picket lines, only family practice, pediatrics and psychiatry were united behind the strike. A core group of medicine residents stood firm, but colleagues who had cast ballots for the strike stayed on the job. Surgery and ob- stetrics gynecology / residents largely opposed the walk - out on principle or bowed to threats of retaliation. Faculty offered little support. Given these divisions, the strength of the houseofficers seems inadequate to explain the city's abrupt turnaround. Some organizers, while basking in the glow of victory, concede that pre election - politics, sympathetic press coverage and support from the Teamsters and the citywide labor council tilted the odds at the negotiating table. Indeed, Mayor Feinstein was out of town campaigning when the walk - out began, paralyzing the city's response. A skeptical minority of SFIRA members be- lieves that the city has conceded much less than it appears. Health Department officials say that the 70 " additional " positions will be funded with savings achieved by understaffing the hos- pital still further for the first four months of the current fiscal year. It is unclear that funds for these positions will be allocated beyond July 1981. The General provides wide city - emergency services but otherwise serves a largely indigent non white - population in one of the most overly- doctored cities in the country. Ward conditions are primitive compared to the university hospi- tal and plethora of private facilities. Indeed, private practitioners are said to favor phasing out of the hospital, since improvements would make it a competitive threat. At the university hospital, for example, a male doctor usually performs a pelvic exam with a female nurse or chaperone in atten- dance. At San Francisco General, a " chaper- oned " pelvic is virtually unheard of. Delays of several hours are common in obtaining " stat " chest x rays - for intensive care patients. The pharmacy is closed at night. Seriously ill pa- tients have been known to wait for hours in the emergency room or admissions because no one has cleaned their rooms. If the hospital care slips, there is greater force in arguments that patients could be better served elsewhere; even if the training program suffers. The victory at San Francisco General is very heartening, because the commitment of its doctors and other workers to quality public health care is reversing the emasculation of services by bureaucrats and private practi- tioners. - Robert Steinbrook (Robert Steinbrook is a resident in medicine at the University of California, San Francisco and a SFIRA member.) y, bargaining agent. Many inciting and assisting the nurses after the decertification election nurses, extremely embittered in the wildcat strike. to press the concerns of working by the union's desertion during Although they may have lost nurses, is continuing its work the strike believe the NYSNA's in the public arena, the nurses within the union. (Comprised of part in planning the job action have gained an understanding nurses from voluntary hospitals was really an attempt to keep of their own power and militan- as well as municipal hospitals, the nurses in line. As Edmund cy. Instead of meekly filing so far it has had difficulty defin- Kerns, a nurse at Bellevue back to their jobs at the bidding ing common priorities.) Hospital told a New York Times of the NYSNA, they overcame It will be two years before the reporter, " Our feeling is that we their initial disarray and con- NYSNA can be challenged in were sold out by the State tinued the strike for five days, another decertification vote. In Nurses Association. This was all threatening to bring the entire the meantime, city hospital preplanned: a one day - letting municipal hospital system to a nurses cannot afford to ignore off of steam; then they expected standstill. the existing NYSNA structures. us to return to work. " Following The Communication Center Through informed, critical in- the strike, in what appears to is still functioning, bringing volvement, nurses feel they can many to be an attempt to deflect nurses together to discuss make changes in both their attention away from its own strategy and relaying informa- workplace and the organization failure, the Association filed tion. The NYSNA Rank and that represents them. suit against the UFT and CIR for File, an organization formed -Nurses Network 23 Resources The Carcinogen Information Program of the Center for the Biology of Natural Systems is offering a free leaflet listing all human and animal carcinogens identified by U.S. Government agencies and the In- ternational Agency for Research on Cancer. Copies are available from the CIP, Center for the Biology of Natural Systems, Washington University, St. Louis, MO. 63130. You must include a stamped, self- addressed envelope with your request. We're Tired of Being Guinea Pigs! -A Handbook for Citizens on Environmental Health in Appalachia, has just been published by Highlander Research and Education Center. Written in clear, con- cise prose, this lavishly illustrated - 83 page - handbook details the health pro- blems attributable to conditions in the region's major industries, including coal, nuclear power, and farming, and offers case histories of what communities have done to fight against their despoliation. Single copies are sold for $ 6, including postage, by the Highlander Center, Route 3, Box 370, New Market, Tennessee 37820. Stop Environmental Cancer, An Epidemic of the Petrochemical Age by Paul Blanc, MSPH, examines carcinogen dangers in California. Although this 180 page - looseleaf - bound book is subtitl- ed A Citizen's Guide to Organizing, unlike the Highlander handbook it em- phasizes working through regulatory agencies and pushing for stronger legislation; relevant ordinances are pro- vided. The Guide is a project of the Campaign for Economic Democracy Cancer Project, and is available from them for $ 11.25, which includes 1.25 $ for postage. The ad- dress is 409 Santa Monica Blvd., Room 214, Santa Monica, CA 90401. -Books Received Ardell, Donald B. and John Y. James (Eds.), Author's Guide to Journals in the Health Field (Binghamton, N.Y.: Hayworth Press, 1980) $ 16.00. Barber, Bernard, Informed Consent in Medical Therapy and Research (New Brunswick, N.J.: Rutgers University Press, 1980) $ 14.00. Brill, Leon, and Charles Winick, The Yearbook of Substance Use and Abuse, Vol. II (New York: Human Sciences Press, 1980). Bundy, Mary Lee, and Irvin Gilchrist (Eds.), The National Civil Rights Directory (College Park, Md.: Urban Information 24 Interpreters, Inc., 1979). Cadbury Jr., William E., and Charlotte M. Cadbury (Eds.), Medical Education: Response to a Challenge (Mount Kisco, N.Y. Futura Publishing Co., 1979) $ 13.50. Cautley, Patricia Woodward, New Foster Parents: The First Experience (New York: Human Sciences Press, 1980) $ 19.95. Gallagher III, Bernard J., The Sociology of Mental Illness (Englewood Cliffs, N.J.: Prentice - Hall, 1980) $ 14.95. Gordon, Richard S. (Ed.), Issues in Health Care Regula- tion (New York: McGraw - Hill, 1980) $ 35.00. Hastings, Arthur C. (Ed.), Health for the Whole Person Churchill, Sallie R. (Ed.), No (Boulder, Co.: Westview Press, 1980) $ 30.00. Child Is Unadoptable (Beverly Hills, Ca.: Sage Publications, 1979) $ 7.00. Hui, Y.H., United States Food Laws, Regulations and Stan- dards (New York: John Wiley & Feder, Judith (Ed.), National Sons, 1979) $ 40.00. Health Insurance: Conflicting Jaffe, Frederick S., Abortion Goals and Policy (Washington Politics: Private Morality and D.C.: The Urban Institute, Public Policy (New York: 1980). McGraw - Hill, 1980) $ 14.95. Mental Health Continued from Page 12 metals have been partially offset by new ones in plastics and machinery at the low end of the wage scale. Like much of the region around Boston, Fitchburg is riding the boom in micro- circuit electronics. One resident, who claimed the area had " never recovered from the Depression, " remarked that Fitchburg had reached a " turning point for the better. " Still, it has been rough for the traditional workforce. Unemployment, already drearily above the na- tional average since 1950, grew worse in the 1970s. Service and wholesale / retail positions account for most new jobs; women and minority workers have won many of them. The Mental Health Context The mental health services available to the 140,000 residents of the Fitchburg Leominster - CMHC catchment area are rated among the best in Massachusetts. Although there are paraprofessionals, most psychotherapy is pro- vided by psychologists and social workers. Originally a child guidance center, the Herbert Lipton Community Mental Health Center now offers full counseling services, plus a day treatment program and other programs designed for the chronically impaired. It also has a unique history of coordinated services: Dr. Anthony Ferrante, the first director, also served as the superintendent of the Fitchburg- Leominster unit of the Gardner State Hospital and area programs Director and Mental Health Center Director. The CMHC is the main public resource for mental health services and main- tains an affiliation with Burbank General Hospital and Worcester State Hospital as the main inpatient facilites. Our study of the Fitchburg Leominster - CMHC catchment area surveyed the more than 10,000 encounters in the mental health system from 1950-1975, including inpatient and out- patient services at hospitals and clinics and of- fice visits to private therapists. Rather than attempting to measure the rela- tion between events which could cause stress, e.g., unemployment, and individual dysfunc- tion measured by application for mental health services only through first admissions as Harvey Brenner did, we tried to identify the factors which increase total utilization of these services, a more sensitive measure of the rela- tionship between unemployment and emotional well being -. Three groups of variables were identified as possible factors determining use of the center. The first, availability of services, includes the range of programs and how much access the community has to them; and these we termed supply factors. The second and third, popula- tion and stress, create situations in which peo- ple feel the need for help; we called these de- mand factors. These are our five principal findings: 1. There were clear and reproduceable rela- tions between unemployment rates and use of mental health services. Although unemploy- ment was not the only factor, it accounted for significant variation. 2. Trends and population changes tend to explain more of the variation in utilization rates than unemployment rates do. Use of mental health services has climbed steadily for more than a decade. It must be stressed that this trend, combined with gradual population growth, can account for most of the increase in visits to the Center. This suggests a steady growth of demand factors, reflecting, perhaps, generally increasing stress, eroding defenses against it, greater acceptance and desire for and availability of mental health services, or some combination (see Figure 3). 3. The relative importance of unemploy- ment, trend factors, and population vary wide- ly across various inpatient, outpatient, age and sex categories. The relative importance of trends vs. unemployment factors varies when different age or gender groups are examined. Perhaps surprisingly, this isn't always related to participation in the labor force. 4. The time between unemployment and a request for treatment is very different for inpa- tient and outpatient services. As might have been expected, following economic changes it is much shorter for outpatient visits than for hospitalization. 5. Rising unemployment increases outpa- tient visits relatively quickly. But contrary to Brenner's findings, when the economy im- proves inpatient treatment goes up, albeit more slowly. On the average, when other factors such as the availability of services and popula- tion changes were excluded, we found that a one percent increase in the unemployment rate pushes the Center's traffic up eight percent over the next two years. One way to reconcile the Fitchburg results with those of Brenner is to recognize that while 25 mental health related - hospitalizations may be increasing for the country as a whole, this is not necessarily the case in a small, discrete region. The unique nature of a regional economy may protect it from some of the deleterious effects which unemployment generally has elsewhere. In addition, Brenner completed his work in 1970 - the beginning of the CMHC era. The community it- self often becomes a source of stress, contributing hea- vily - if not com- pletely - to the problems of emo- tional survival. The community's sense of self- determination is destroyed as con- trol of production and resources are drained away 26 Implications for Policy Our Fitchburg Leominster - study challenges the notion that unemployment automatically produces the kind of stress and personal dysfunction which leads to hospitalization. We also learned that a community's reaction to in- creased social stress such as unemployment may be affected by many factors. Since the 1960s, a shift in public policy has created a national network of community men- tal health centers along with widespread deinstitutionalization. (See Health / PAC Bulletin 65; 11: 4). As a result, mental health. care providers today have a much wider range of therapeutic alternatives. Hospitalization, traditionally, has been the response when peo- ple are troubled by deep seated - problems; most mental health specialists believe one significant cause of such problems is cumulative stress. This is supported by the study's finding that the unemployment rate af- fects the number of inpatients more slowly than the level of outpatient visits. To the extent that CMHC outpatient therapy becomes a substitute for inpatient therapy and prevents hospitalization in the long run, it would also be reasonable to expect that the in- patient utilization will become less and less sen- sitive to community stress cycles. Community support networks remain an im- portant alternative and complement to services provided by the mental health system. Future research must investigate how changes in the economy alter these networks by reordering patterns of labor force participation or job demands. For example, when more women entered the labor force as the Fitchburg economy improved, disabled people cared for at home presumably lost an important support system. As a result, increasing job oppor- tunities may have pushed vulnerable people in- to hospitalization - a hidden cost of economic growth. Economy and Community In the mid 19th - century the locus of produc- tion effectively shifted from cottage craft to the factory. Since the factory is characterized by a mass of workers producing in a single location, the shift led to concentration of workers families in the dark, fetid, overcrowded streets of city slums described so graphically by Charles Dickens. Asylums for the insane were one of many centralized institutions established dur- ing the late 18th century in response to this NUMBER EMPLOYED 5,000. 4,500 4 4,000 4 3,500 4 3,000- 3,000- Figure 2 Employment by Major Industry, 1958-78, Fitchburg Leominster - Area Plastics Machinery 2,500 4 2,000 4 1,500 - 1,000 - 500- 500- Fabricated Paper 7 Paper 4 / 4 "7 . wee Meee ~. N \ N Metal * e. Serr fone ~~ Textiles 1958 1960 1962 1964 1966 11969 8 7192 70 19741 976 1978 Note: Based on data from Standard Metropolitan Statistical Area (SMSA). Source: Employment and Wages Wages in Massachusetts Massachusetts, SMSA's SMSA's and Labor Market Areas, Massachusetts Division Division of Employ- ment Security. 27 There are clear relations between unemployment rates and use of mental health ser- vices. Although unemployment is not the only factor, it accounts for a significant variation 28 wrenching pattern of industrialization, migra- tion, and urbanization. The community itself often became a source of stress, contributing heavily- if not com- pletely- to the problems of emotional survival. The community's sense of determining its own destiny was destroyed as day day - to - control of production and resources for community building were drained away. Separate studies of Arvin, California (1), and Fall River, Massachusetts (2), have shown that the transfer of ownership of local business to urban finan- cial centers was a hard blow to community vitality and re investment - . In addition, expanding the size and scale of production generally wipes out skilled relative- ly high paying jobs and substitutes labor at the low end of the wage scale, increasing the sense of dependency and helplessness. Loss of a highly skilled 40 hour - a week job often means that 60 to 80 hours of work must be found if peo- ple want to maintain their standard of living. The wage earner must take two jobs or, more likely, the family unit has to send someone else out into the labor market. Caring and Nurtur- ing are shunted to the last hours. The American tax system allows the local community virtually no chance of controlling any appreciable portion of the local surplus. The only business wealth it can effectively tax is what can't be easily sent somewhere else; in general this means real estate. Profits, on the other hand, are quite mobile and taxed, when at all, by the state. Cultural and philanthropic activity, meanwhile, is channeled through the hands of owners where they live. As owner- ship centralizes, local communities lose even their token civic resources. Ironically, conser- vatives who rail against encroachment of the federal government on our lives are often en- thusiastic boosters of the economic centraliza- tion which inevitably requires this governmen- tal centralization. Local communities desperate for more jobs increasingly compete to attract highly mobile corporations. Yet, absentee ownership fre- quently drags a community down to greater stagnation and an even more precarious economy. Muncie, Indiana, the subject of the " Middletown " studies, is a typical victim: " One drastic difference from the 1920's is that Munsonians no longer control their own town. The Ball Corporation, now a diversified multi national - , has moved its important opera- tions elsewhere, and the Ball family itself is scattered, with diminished clout in Muncie. The local economy is now controlled from the out town - of - board rooms of large corporations and - from Washington. " (3) Caplow, one of the Middletown researchers, points out that if both the local public treasury and local philanthropy cannot support local needs, then the vacuum must be filled else- where if society is not to break apart. " The Federal Government has in effect taken over all the social welfare functions in Muncie, " he elaborated, " The care of the sick, the poor, the aged and the delinquent is all controlled in Washington " (3). Decreased demand for highly skilled labor and the need for additional family members to earn money often forces workers to travel greater distances to their job; some eventually will move away. Members of extended families and community social networks begin to find it difficult if not impossible to provide services for one another or mutual emotional support and attention. Families are strained by care for ag- ing members; young families must seek out day care and other help outside the extended fami- ly so that both parents might work (4). As family members become more wage de- pendent, they come to see their individual wages as the key to independence and survival; this often lessens the possibility of family or other collective action to improve the situation. (See " What Goes Around, Comes Around " box). Individual solutions are perceived as the only " realistic " possibility. Overall, shifts in economic structure weaken the capacity of families and social networks to provide support and at the same time box in- dividuals into increasingly distressed condi- tions. These communities, lacking many re- sources necessary to support their members, 350 4 Figure 3 Comparison of Actual and Predicted Outpatient Utilization, Fitchburg Leominster - Catchment 1966-1976 OUT PATIENT 300 -| VISITS / 1000 X 250- 250- S S 200 ~ 150 4 100 | x 5500 4 0 1966 X X X X X X X - Predicted xx Actual X Pr + T T u T -+-- + T 1967 1968 1969 1970 1971 1972 1973 1974 1975 Quarterly Entries into Outpatient Care: Total Adult Population + 1976 29 Rising unemploy- ment increases outpatient visits relatively quickly. There is a steady growth in demand, due to increased stress and eroded defenses. Some social workers, however, are con- vinced that per- sonality problems and mental illness actually cause unemployment 30 are the hometowns where deinstitutionalized patients are being returned for care. Conclusions Few mental health practitioners would link the Hansen family's problems to changes in the local economy. Their training and practice set- ting encourage them to localize problems and thus to treat the individual and occasionally his or her family. Often, well meaning - therapists such as those interviewed at the Fitchburg- Leominster CMHC inadvertently " blame the victims " when they draw conclusions about causal relations between their clients'mental health and the community's economic struc- ture. Sound ecological theory, perception, and treatment would enable care providers and policymakers to identify and protect those most vulnerable to the emotional stress engendered by economic change. Unemployment rolls only tell the pebble's story, as the school problems of the Hansen's oldest child illustrate. The picture of the individual and the com- munity battered by economic change has im- portant implications for economic and social policy, and for mental health and community activists as well. " Growth " has long been the keystone of U.S. economic policy - the more, the better. But such accounting hasn't questioned whether the benefits are greater than the costs. Nor has it noted whether the costs and benefits are equitably distributed. The goal of maximizing the Gross National Product (GNP) fails to distinguish goods and services which truly add to the general well being - from those which merely repair the damage unbridled growth. strews through the nation; it does not take into account how goods and services are distrib- uted. The " growth " maximization we have ex- perienced is much less productive in the long run than a policy of social cost minimization emphasizing community stability. Apologists for the " private enterprise system " see this kind of local responsiveness as one of its key virtues. But as the history of com- munities such as Fitchburg Leominster - reveals that market forces have eliminated many local choices. Only a capital investment process more sensitive to community cohesiveness can ensure that mental health in the broadest sense of the term of a community is entered on the bottom line. -Elliot Sclar Peter Stathopolus Hal Strelnick Elliott Sclar is an associate professor and chair- man of the Division of Urban Planning at the Graduate School of Architecture and Plan- ning, Columbia University, New York. Peter Stathopolous is director of research and evaluation at the Herbert Lipton Community Mental Health Center in Fitchburg, Massachusetts. He is a social worker with a doc- torate in social planning and policy. Hal Strelnick is a member of the Health / PAC editorial board. References 1. Goldschmidt, W., " Small Business and the Communi- ty: A Study in Central Valley of California of Effects of Scale of Farm Operation, " Report of the Special Com- mittee to Study Problems of American Small Business, United States Senate. Washington, D.C.: Govern- ment Printing Office, 1946. 2. Lamb, R., " The Development of Entrepreneurship in Fall River, Massachusetts, 1813-1859. " Unpublished doctoral dissertation, Harvard University, 1935. Also, " The Entrepreneur and the Community, " in Men in Business: Essays in the History of Entrepreneurship. Cambridge, Massachusetts: Harvard University Press, 1952. 3. " Middletown Revisited, " Time, October 16, 1978, as quoted in Sclar, Elliott, " Community Economic Struc- ture and Individual Well Being: A Look Behind the Statistics, " International Journal of Health Services, in press. 4. Lowenthal, M., " The Social Economy in Urban Work- ing Class Communities, " in Gappert and Rose, eds., The Social Economy of Cities. Beverly Hills, Califor- nia: Sage Publications, 1975. Figure 4 The Eyer Model Applied to American Mortality, 1870-1970 17 235 2 24 16- 3 23 +21 20 15. 19 18 POULATIN 22228265 22228265 UNEMPLOYED UNEMP+L OYED THOUSAND w 3 PERCENT2 PERCENT PE RCENT PERCENTc PERCENT . 9 | DEATHS PR 8 7 6 5 4 19Hy3 0| 1930 10 1870 1880 1890 1900 1910 1920 3 2 1940 1950 1960 1970 DATE Note: Vertical lines mark peaks of the death rate. Source: Eyer, Joseph, " Does Unemployment Cause the Death Rate Peak in Each Business Cycle? A Multifactor Model of Death Rate Change. " International Journal of Health Services 7: 625-662, 1977. 3 1 OE The Boom- In October, 1976 Joint Economic Com- mittee of Congress released a paper en- titled, " Estimating the Social Costs of Na- tional Economic Policy: Implications for Mental and Physical Health and Criminal Aggression. " Its author, M. Harvey Bren- ner, employed a computer model to esti- mate the social costs of inflation and unemployment upon indicators of individ- ual distress, including as mental hospital. admissions, suicides, and violent crimes. Professor Brenner had reason to be pleased. The Committee report in which his paper was released had an introduc- tory section in which JEC staff attempted to employ the Brenner model to estimate the social costs of small increases in the national unemployment rate. Although Ralph Catalano, at the University of California, Munic, Public Policy Research Organizations, and others have noted that Brenner's work is " not yet at a stage to offer clear policy guidance, " economist Jeanne Gordus of the Institute for Labor and Industrial Relations (sponsor co - of last year's con- ference on the economy and health with the National Institute of Mental Health) summed up the conference consensus with the comment that, " there was no doubt in anybody's mind that Brenner's correlations are correct. Discussions centered on trying to " pull apart " the data.. to.. understand what they mean " (3). The Debate For more than a decade Brenner, a pro- fessor at the John Hopkins School of Hygiene and Public Health, has been developing a model relating economic in- dicators with measures of individual well- being. He began by showing the rate of first admissions to New York State mental hospitals was directly related to unem- ployment and downturns in the business cycle (4). This work was later expanded to include data for the entire U.S., in- cluding suicides and homicides, general mortality rates (according to ages, sex, and race) and specific mortality rates from cardiovascular disease and cirrhosis of the liver (5). Brenner has since applied his methods to data from California and Massachu- setts, as well as Sweden, England, and Wales (6), each with appropriate lag times for various indicators. Others have found similar results for Australia (7). His initial studies emphasized the high cor- relation between unemployment and acute pathological disturbances (Figure 1). A similar relationship was found for rheumatic heart disease as early as 1944. (8). Unfortunately, this assumption of cause Figure 1 The Brenner Model Applied to English Mortality 1936-76 14 12 10 . - Actual 10 /Deaths ee Predicted 8 6 1940 1945 1950 1955 1960 1965 1970 1975 Note: The predictions are derived from a composite model of economic change based upon long term - and rapid economic growth, unemployment rates, and the portion of government expenditures made on welfare programs. Source: Brenner, M. Harvey, " Mortality and the Natonal Economy: A Review, and the Experience of England and Wales, 1936-76 " The Lancet 1: 568-573, September 15, 1979. and effect seems to be unsupported by the evidence. Studies of the physiological im- pact on workers laid off from jobs indicate that it varies greatly with the conditions of 32 Bust Debate- unemployment and reemployment (1). There is strong evidence that booms as well as busts can be bad for one's health (2). Recessions seem to result in illness most heavily among the retired and others. not looking for work (3), suggesting that other, broader forces help determine the ultimate impact of economic change on personal behavior. In 1977, Joseph Eyer of the University of Pennsylvania challenged Brenner's hypothesis with data demonstrating that death rates rise during business booms and decline during depressions - a con- clusion reached as early as 1925 by D.G. Thomas in England (9). (Figure 4). Eyer argues that Brenner made his case by assuming that severe emotional distress which occurs a long time after job loss is related to it, but the studies don't really. show a direct cause and effect relation between unemployment and illness. He proposes an alternative explanation for the variation of death rates with the business cycle, emphasizing the stress caused by hierarchical social relations. * More recently, Brenner has tested Eyer's hypothesis without complete suc- cess, but he now adds rapid economic growth to recessions, as a source of in- creased mortality (10). Brenner also maintains that " It is the routine, daily economic activity of industry and govern- ment which have the most profound im- pact on the mental health of the nation.'11 * Both sides of this debate are weakened by their use of state or national data. For example, statistics from Ohio might in- dicate an unemployment - - severe stress correlation when actually unemployment is rising in Toledo and citizens of Colum- bus are filling up their city's new hospital. Despite their current problems, refined versions of Brenner and Eyer models would be a valuable tool for evaluating primary and secondary prevention pro- grams, indicating how well they have kept hospitalization below the level which would have been expected if they hadn't existed. Predictive models can also forcast future resource needs and promote more efficient reource allocation to meet those needs, and, as in the JEC paper, help assess the social costs and benefits of na- tional policy decisions. Similarly, com- munities could plug in one of these models to assess the impact of plant open- ings and / or closings and organize their public and social services agencies to cope with likely stress. * For an exchange of views between Brenner and Eyer, See the International Journal of Health Services 6: 139-168, 1976. References 1. Cobb, S. and Kasl, S., " Termination: The Conse- quences of Job Loss, " Washington, D.C.: National Institute for Occupational Safety and Health, Research Report, Publication No. 77-224, June 1977. 2. Eyer, J., " Prosperity as a Cause of Death. " Interna- tional Journal of Health Services 7: 125-150, 1977. 3. Check, William A., " Do Economic Slumps In- crease Illness? " Journal of the American Medical Association 242: 1241-1243, September 21, 1979. 4. Brenner, M. Harvey, Mental Illness and the Economy. Cambridge, Massachusetts: Harvard University Press, 1973. 5. Brenner, M. Harvey, Time Series Analysis of Rela- tionships Between Selected Economic and Social Indicators. Springfield, Virginia: U.S. National Technical Information Service, 1971. 6. Brenner, M. Harvey, " Health Costs and Benefits of Economic Policy, " International Journal of Health Services 7: 581-623, 1977. 7. Brenner, M. Harvey, " Fetal, Infant and Maternal Mortality During Periods of Economic Instability, " International Journal of Health Services 3: 145-159, 1973; also, " Trends in Alcohol Consump- tion and Associated Illnesses: Some Effects of Economic Changes, " American Journal of Public Halth 65: 1279-1292, 1975. 8. Morris, J.N., and Titmuss, R.M., " Health and Social Change: 1. The - Recent History of Rheumatic Heart Disease, " Medical Officer 69-87, 1944. 9. Thomas, D.S., Social Aspects of the Business Cy- cle. London: Routledge, 1925. 10. Brenner, M. Harvey, " Mortality and the National Economy: A Review, and the Experience of England and Wales, 1936-76, " Lancet 2: 568-573, September 15, 1979. 11. Brenner, M. Harvey, " Reply to Mr. Eyer, " Interna- tional Journal of Health Services 6: 149-155, 1976. y, 33 -Turning Closings In 1974 the Colonial Press in Clinton, near Fitchburg, was acquired by Sheller- Globe, a manufacturer of auto parts, school buses, and ambulances. Almost immediately, Sheller - Globe installed its own management personnel at the Press; except for the new president, none of them had any experience in publishing. Not surprisingly, within three years the Press closed up shop and sent its 1,000 employees home. The Road to Bankruptcy On the road to this bankruptcy, Sheller - Globe charged management overhead of $ 900,000 a year, with some monthly charges reaching $ 200,000. Among the expenses piled up were elaborate security systems. Perhaps they had some logic in the conglomerate's auto parts division, but few print shop employees want to walk out with 10,000 copies of a Readers Digest condensed version of Shibumi. Yet workers regularly suffered the indignity of a search for stolen goods as they exited past 22 securi- ty guards and a shiny new wire - link fence. Sheller - Globe believed there was little difference between producing a steering wheel and producing a book. Customer service was sacrificed in department mergers and computerized management information systems. Printing schedules became rigid, orders were misplaced, past practices essential to customers, such as free warehouse space and item- ized cost estimates were eliminated; books were lost and misplaced. Important clients, including Reader's Digest and Random House, found new printers. Ac- cording to testimony given before the Senate Judiciary Committee, " The pub- lishing industry became alienated and sales declined.... Decisions which were appropriate to the automotive industry proved disastrous in the book printing - in- dustry. " After the plant closed, local officials, citizens groups, and unions mobilized to reopen it as a cooperative. Finally, in 1979, with the assistance of the Massachu- setts Community Development Finance Corporation and the Industrial Cooperative Association, the press was sold to its workers as a full scale - cooperative. During the two year - hiatus the new Colonial Cooperative Press lost. many old customers and now employs on- What Goes Arour Resource Sharing in a I In 1971 Magnolia's uncle died in Mississippi shortly after selling his run- down farm and left an unexpected in- heritance of $ 1,500 to Magnolia and Calvin Waters. It was the first time in their Magnolia's nieces had borrowed $ 25 to save her phone. Within a week the welfare office knew about the money. Magnolia's children were immediately cut off welfare, including medical lives that either Magnolia or Calvin had ever enjoyed a cash reserve. It was a mo- ment of joy, a chance to put a down pay- ment on a home. coverage and food stamps, and she was told they would stay off until the money. was used up which - had to be within four months. When another uncle became very ill in Within three days of the check's ar- the South, Magnolia and her older sister, rival, the news had spread throughout Augusta, were called to sit by his side. their domestic network, and one of Magnolia bought round - trip train tickets 34 into Cooperatives Table 1 Causal Relations Accounting for the Business Cycle Variations of the Death Rate, 1949-1975 according to Eyer Material Conditions (% 8) Housing (27%) Nutrition (% 6) Social Relations in Class Struggle (89%) Social Solidarity (19%) Strikes (% 17) Marriage (% 2) Social Disintegration and Overwork (53%) Overwork (% 34) Migration (% 9) Divorce (% 8) Unemployment (% 2) Drug Consumption (17%) Alcohol (% 11) Tobacco (% 6) Source: Eyer, Joseph, " Does Unemployment Cause the Death Rate Peak in Each Business Cycle? A Multifactor Model of Death Rate Change. " International Journal of Health Ser- vices 7: 625-662, 1977. ly 75 people. The effort has had a much broader impact, however. Collective struggle, according to Eyer (see other box), promotes physical and mental health and protects against the stresses of unemployment (see " The Boom - Bust De- bate " and Table 1). It is now more widely recognized that a community's mental health needs to be in- corporated into the costs of a " runaway shop. " The initial struggle will be over who picks up the tab. Maine passed a law in 1971 requiring a month's notice and severance pay for plant closures or re- locations. Wisconsin followed suit in 1975. The list of states where similar legislation has been introduced reads like a roll call of the old Northeast industrial belt Ohio, New Jersey, New York, Con- necticut, Rhode Island, Michigan, Il- linois, Pennsylvania - plus California (for farmworkers only), and Oregon; but in these states and in Congress vigorous business lobbying and threats of invest- ment boycotts have buried even the most modest legislation. -Hal Strelnick Source: Barry Bluestone and Bennett Harrison, Capital Mobility: The Causes and Consequences of Economic Disloca- tion. Washington, D.C.: The Conference. on Alternative State and Local Policies and The Progressive Alliance, June 1980. _, d Comes Around omestic Social Network so that she and Augusta could attend the funeral. Soon after his death, Augusta's first " old man " died in The Flats and he ing home from school because they did not have warm winter coats and adequate shoes or boots. She and Calvin decided to had no kin to pay for the burial. Augusta asked Magnolia to help pay for digging the grave. Magnolia was unable to refuse. Another sister's rent was two months over- buy coats, hats, and shoes for all of the children - at least fifteen. Magnolia also bought a winter coat for herself and Calvin bought himself a pair of sturdy due and Magnolia feared that she would get evicted. This sister was seriously ill shoes. Within a month and a half, all of the and had no source of income. Magnolia money was gone. paid her rent. -Carol Stack Winter was cold and Magnolia's All Our Kin: Strategies for Survival children and grandchildren began stay- in a Black Community 35 Human Sciences Press 72 Fifth Avenue New York, New York 10011 36