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Health Policy Advisory Center No. 54 October 1973 HEALTH / PAC BULLETIN tem, partly performing functions the pri- vate sector prefers not to perform in its own facilities, partly providing a setting in which the private sector may carry out its Editorial own pet projects at public expense. In both cases this development is being aided and abetted by those public servants whose nominal responsibility is to protect and PUBLIC further the interests of the public hospital's constituency. All of this is essentially nothing new, but rather represents particular manifestations HOSPITALS: of a trend that began with the use of med- ical schools and voluntary hospitals, via some form of affiliation arrangement, as the source of physicians for public hos- GOING, pitals. In some areas this trend has reached its logical conclusion in the complete de- mise of the public system by way of out- GOING right transfer of a public hospital to private ownership and control (see BULLETIN, April, 1973). In other places, such as Bos- ton and New York, the privatization of the PRIVATE public sector has taken less blatant forms, which nonetheless represent a continued erosion of its ability to stand on its own feet, much less set its own priorities. Many concerned about the plight of pub- lic hospitals are considering the strategy being pursued by the administration at Bellevue a broadening and consequent economic integration of the Hospital's con- stituency. At the hands of those respond- Bellevue and Boston City Hospitals face ing to felt public needs, this strategy may very different situations - so a superficial well hold hope for strengthening the public reading of the two case studies presented in this issue would lead one to believe. Bellevue is about to be reincarnated in a system. At the hands of those private in- terests shaping the future of Bellevue, how- ever, the much heralded - transformation classy new facility; Boston City is about to of the character of the Hospital becomes a : be reduced in size by half. At second facade for the furtherance of the particu- glance, however, the similarities of the two larized interests of an elite private medical situations are striking. However different the details, it is clear that the changes tak- center whose correspondence with public need is coincidental at best. The public ing place at both nominally public insti- system may appear to be strengthened utions largely reflect the plans and pri- but, in fact, it has become less than public orities of the private institutions - New York University Medical Center at Belle- vue and Boston University Medical Center in the process. The privatization of the public sector has been almost overshadowed in Boston by at Boston City - on which they are depend- ent for medical resources. concurrent cutbacks at BCH - a fiscal crunch, in part facilitating that institution's The public system emerges as public takeover by Boston University. The cut- in name and legal status only - in effect it backs set off the beginning of a struggle to has become an adjunct of the private sys- strengthen the public sector's constituency. The article describing the happenings in Boston, representing the perspective of some people close to the situation, points out the failure of that struggle and sets forth a number of reasons for that failure, such as the rapidity of critical events and the lack of preparedness for meeting them. We would add other, we think more fundamental, reasons for the failure of the anti cutback - coalition to effect a reversal of the plans of the Mayor and of Boston Uni- versity. Those activists most concerned with stopping the cuts, the Better Breaks Group, were transient young hospital em- ployees organized across departmental lines. Given who they were, they inevitably lacked a long term -, solidly organized base either with hospital workers generally or in a particular section of the hospital. Given that lack, it is not surprising that they failed to consolidate an effective anti - cut- back force. The Boston City activists might also have better addressed themselves to what in the long run will be an even more serious de- velopment at Boston City Hospital - its takeover by Boston University - rather than get caught up in the urgency of the budget crisis. Indeed, in the future BU can be ex- pected to be an ally in the struggle for adequate resources - except that BU will be fighting not for patient and community priorities, but for the furtherance of its own interests. No one has yet developed a strategy capable of dealing with the colonial rela- tionship of the private sector to public hos- pitals and the death rattle of the latter be- ing heard across the country. All too often, in fact, the more subtle and complex mani- festations of the public sector's death by strangulation are completely ignored by activists dealing with sexier issues or re- acting to the crisis of the moment. It is clear at least that the struggle to revive the vitality of public hospitals cannot be a defensive one nor can it be mounted quickly or easily. To have any hope of success, such a struggle must be a long- term operation conducted by hospital per- sonnel who are critical to the functioning of the institution, building up their strength unit by unit, department by department. In such a fashion it may be possible to be- gin to correct the current distortion of the institutional balance of power and shift control to those responsive to the interests of the public. BELLEVUE HOSPITAL: GROWING UP ABSURD On November 15 the City of New York will proudly dedicate the new Bellevue Hospi- tal. The speeches at the dedication cere- mony will predictably dwell on Bellevue's glorious past and project an even more glorious future in its magnificent new facil- ity. This article considers what the speech- makers will predictably fail to acknowl- edge, namely, the role of private health institutions, at Bellevue as much as else- where, in shaping public hospitals to fit their own needs. In other cities this phe- nomenon has led to the closing, leasing or contracting of public hospitals; in New York a more sophisticated accommodation of the public sector to the private is being shaped. Here a new public hospital has 2 been designed to serve essentially as an annex to an elite private medical center, serving its needs primarily and the public. need only coincidentally. Setting the Stage Around the world, people know about Bellevue, even if they mistakenly think it's only a psychiatric hospital. It's historic- dating back to 1736 and probably the nation's first public hospital. It's big- with 1,622 beds, it's the fourth largest hos- pital in the country. Its emergency services are frantic - their 102,000 annual patient visits include the most critical of emergen- cies and form the basis of the legend that " If you sit in Bellevue emergency for a few nights you will see everything there is to see in this world. " It's where people come who have nowhere else to go. And of course it's rundown elevators - don't work, water pipes break, plaster falls. Its decrepitude in fact has become part of what is advertised as a glorious tradition; according to the New York Times, " The Bellevue mystique persists and tradition survives in spite of, perhaps partly because of, the challenge that lies in providing decent patient care in the face of extraordinary difficulties. " No matter how the patients feel who have suffered the results of staff shortages and broken equipment, the professional view of Belle- vue has been (quoting the reminiscences of a former department chairman) that " exemplary medical care without ameni- ties can be given to people under the most dreadful circumstances of a physical plant, providing that the people tendering this care are willing to make do and will- ing to allow their enthusiasm for giving good care to overcome many difficulties. " Dr. William A. Nolen of The Making of a Surgeon fame goes so far as to write: " I'd hate to see the old place changed. I won't deny it's a wreck, if you want to look at it that way, but it's a wreck I love. If they clean her up, Bellevue will never be the same. " Sorry, Dr. Nolen, they are cleaning her up, replacing her, in fact, with a new 21- story building squeezed between the East River and the old hospital's 14 building - sprawl. Although it has yet to admit any patients, the new Bellevue Hospital has al- ready inspired official rhetoric that borders on the grandiose. Not only will the new building have " a remarkable effect on im- proving the logistics of providing quality medical care, " it will " represent the chang- ing of the concept of the functioning of our hospital from that of one that is presently capable of only serving the sick poor into a true community hospital capable of serv- ing all who would want our help on a reg- ular basis. " CONTENTS 2 Bellevue Hospital 14 Bellevue - NYU History 17 Boston City Hospital Being against a " true community hospi- tal " is a bit like being against motherhood and mom's apple pie. In this case, how- ever, the ingredients may well prove haz- ardous to the public health: There is the New York University Medical Center, a prestigious medical school hospital- r-e- search complex that has a way of domi- nating the shape and flavor of the Bellevue product. There is the New York City Health and Hospitals Corporation (HHC), the so- called public benefit corporation that nomi- nally runs the City's municipal hospital system, which intrudes itself here and there in ways that embitter NYU without appreciably improving the quality of the. result for its consumers. And there is the Bellevue administration, nominally under the control of the HHC, which attempts to establish an independent role but usually comes off smelling suspiciously like NYU. There is also a Community Board to the Hospital, which would like to add a dose of public accountability to the ingredients, but which is still struggling to get inside the kitchen. Although the mix, at least on the surface, is in a state of constant flux, the form it ultimately takes may well prove indigestible, if not inaccessible, to those who have traditionally turned to Bellevue for their medical sustenance. Introducing the New York University Medical Center Bellevue exists in the shadow, literal and figurative, of its neighbor to the immediate north, the New York University Medical Center, which includes NYU Medical School, University Hospital (UH), and as- sorted institutes of research. For over a century NYU Medical School has based its teaching program on the large and Published by the Health Policy Advisory Center, 17 Murray Street, New York, N. Y. 10007. Telephone (212) 267- 8890. The Health - PAC BULLETIN is published 8 times per year; January, February, March, April, May, Sept- tember. October and November. 3 special reports are issued during the year. Yearly subscriptions: $ 5 stu- dents, $ 7 other individuals, 15 $ institutions. Second - class postage paid at New York, N.Y. Subscriptions, changes of address and other correspondence should be mailed to the above address. New York staff: Con- stance Bloomfield, Oliver Fein, Nancy Jervis, David Kotelchuck, Ronda Kotelchuck, Louise Lander and Howard Levy. San Francisco staff: Elinor Blake, Thomas Bodenheimer, Judy Carnoy. San Francisco office: 558 Capp Street, San Francisco, California, 94110. Telephone (415) 282-3896. Associates: Robb Burlage, Susan Reverby, Morgantown, West Virginia: Desmond Callan, Kenneth Kimmerling, Marsha Love, New York City; Vicki Cooper, Chicago; Barbara Ehrenreich, John Ehrenreich, Long Island. 1973. varied supply of clinical material avail- able fat Bellevue (see Page 15). Univer- sity Hospital patients don't qualify as ma- terial for a medically " balanced " teaching program; that institution prides itself on being a superspecialized referral hospital for the private patients of the Medical School faculty - no ordinary illness need ap- ply. Nor, might we add, need Medicaid pa- tients apply, UH being the only voluntary hospital in the City that declines to partici- pate in the Medicaid program. Patients looking for a clinic won't find any, and emergency cases will probably end up at Bellevue before they find UH's well - con- cealed, unstaffed emergency room. The presence of Bellevue, in other words, has conveniently saved NYU from the annoyance of having to respond to the medical needs of the poor while at the same time supplying NYU with the bodies of the poor in a setting, namely teaching, where it finds them useful. NYU's own fa- cilities then serve to consolidate its ties to its faculty by giving them a place to hos- pitalize their patients and, to the extent that space permits, to conduct their office practice. (NYU fondly wishes it could af- ford to build, or could induce a private de- veloper to build, a faculty practice build- ing to supplement its own limited faculty practice facilities; failing either of those Affiliation: Affiliation is a complex affair at Bellevue. In some departments the term means a formal affiliation contract between the New York University Medical Center and New York City's Health and Hospitals Corporation (HHC), the agency that operates the municipal hospitals; in other departments the term implies a gentle- men's agreement of many decades'standing whereby NYU provides medical staff without either the payment or the nominal public control that a formal con- tract involves. The Department of Medicine, for example, is not covered by the partial affili- ation contract because Dr. Saul Farber, the department chairman, has always been unwilling to accept money and the possibility of control from anyone but NYU. Similarly with surgery- " We need the money, " Dr. Frank Spencer, its chairman, admits; the problem with a contract is that the " superb physicians " on the NYU staff have preferred to donate a portion of their valuable time to Bellevue rather than get paid and have to put up with such harassments as signing in and out. The point seems to be that if labor is charity, the recipient can't complain if it's provided at the convenience and for purposes that serve the benefactor. On the other hand, Spencer notes, the lack of the City money that would accompany a contract means that the department can't afford the number of physicians he feels it needs to conduct a top notch - teaching program; thus it would be nice to have a contract if only it would leave NYU physicians free to determine how and where to spend their time. Some of the departments that the affiliation contract covers namely - , inter- mediate care, home care, and the chest service - are also services that rank low on the hierarchy of academic importance. (The intermediate care service, for one, has no internship or residency program.) The official explanation is that the City's contract offer was accepted for these services because running them represented an additional burden that NYU assumed with the departure from Bellevue of Columbia and Cornell, a burden it wasn't prepared to take on with- out financial support. One suspects that the lack of academic interest in such programs also has something to do with NYU's willingness here to submit to a formal affiliation arrangement. Pathology and radiology, on the other hand, are both covered by the affiliation contract and are both academically important. Apparently these service chiefs decided it was simply impossible to equip and staff what they considered a modern, adequate department without an infusion of funds, whatever its source. This has not, however, meant that Bellevue physicians in these services must sever all ties with NYU. In radiology, for example, NYU guarantees to Bellevue the time full - equivalent of 11 physicians; the department, however, is perceived alternatives, there may be usable space for this purpose in the new Bellevue, of which more later.) At the concrete level of physicians- teachers, researchers, and clinicians - Belle- vue and NYU virtually merge. NYU is the entry point for physicians who work at Bellevue. With minor exceptions, every attending physician at Bellevue is a fac- ulty member of the Medical School and an attending at UH. Conversely, acquiring those NYU credentials requires undertak- ing an obligation to do " service " at Bellevue. In most cases, the chairmen of the Medical School's academic depart- ments, in addition to becoming chiefs of the corresponding service at UH, also be- come the corresponding chiefs of service at Bellevue. (At the very least, the Medical School department chairman designates the Bellevue chief of service and himself is granted a nonvoting seat on Bellevue's Medical Board.) It is frequently, and proudly, said that the medical staff is the " connecting tissue " that binds the two insti- tutions together. The Politics of Affiliation Into this long existing - milieu came dur- ing the 1960's the drive of the City's then Department of Hospitals to place the mu- nicipal hospitals under an affiliation sys- To Be or Not To Be? as one department for both Bellevue and NYU's University Hospital UH (), with physicians shuttling back and forth as the need arises. (The physicians receive a full time - salary in the form of an NYU check, partly representing affiliation funds, partly NYU funds.) The theory is that this arrangement gives Bellevue the advantage of a super specialist - whose specialized talents aren't needed on a full time - basis. The relationship between bookkeeping and reality under such an arrangement, however, remains an open question. In pathology, the affiliation gives NYU a double advantage. The pathology service at UH doesn't include neuropathology, pediatric pathology, or obstetrical- gynecological pathology; these are " unified services " that are located at Belle- vue. These pathology procedures, in other words, are done for UH patients as well as Bellevue patients by pathologists whose salaries are paid by the HHC through the affiliation contract. If there's a flow of money from NYU to Bellevue to pay for the procedures done for UH patients, no one including - NYU's affilia- tion administrator, who says it's " not an affiliation -seems matter " to know about it. Pediatrics by a stroke of luck found a way to be both prosperous and unaffili- ated, at least for a while. The service used to suffer from a lack of staff and facilities sufficient to do more than run a disjointed, emergency - type program. When Congress legislated the Children and Youth (Y C &) program in 1966, NYU was quick to jump at the opportunity to obtain relatively unfettered federal money. With a million and a half annual federal dollars coming directly to NYU, Dr. Saul Krugman, the department chairman, developed a showpiece com- prehensive - care department, with its own labs, its own pharmacy, and the Hos- pital's only computerized medical records system. (Krugman, we might note in passing, is one of NYU's star researchers, famous - or infamous - in particular for studying hepatitis by injecting live hepatitis virus into retarded children at the Willowbrook State School.) Regrettably, federal money got tight a few years. ago and the amount of the Y C & grant was no longer sufficient to cover the depart- ment's needs; to make up the deficit, Krugman took his physicians off the C & Y budget and negotiated an affiliation agreement to cover their salaries. As in radiology, most of the doctors are on full time - salary but spend part of their time at NYU, mostly doing research. Krugman doesn't agonize over whether their time actually spent at Bellevue corresponds to that part of their salary paid by the HHC; after all, he reasons, Bellevue " is where the action is " and conse- quently where doctors prefer to be anyway. He is proud to point out that his own office as department chairman is not at NYU but at Bellevue - where it immedi- ately impresses the observer as a lushly carpeted, walnut panelled - , air condi- - tioned oasis in a desert of bleakness. 5 tem, whereby various voluntary hospitals and medical schools contractually agreed to provide medical staff to municipal hos- pitals in exchange for a lump - sum payment (see BULLETINS, December, 1971 and May, 1972). NYU was offered an affiliation con- tract around 1966, at a time when Colum- bia and Cornell, who had had relatively small pieces of the action at Bellevue, were being asked to devote their efforts to other City hospitals. Many of the prima donnas of the NYU medical hierarchy - the chair- men, for example, of such key departments as medicine and surgery declined - to rise to the bait. Freedom, it seems, is still in some circles more important than cash- freedom, that is, from any semblance of public accountability, such as an affilia- tion contract might impose. There was also for these department chairmen the critical question of control; the affiliation contract requires that the affiliate designate a full- time chief of service for each department of the affiliated municipal hospital. The Chairman of the Medical School's Depart- ment of Medicine, for example, who also, of course, is chief of the medicine service at University Hospital, obviously wouldn't qualify and just as obviously would have to give up his power to run the show at Bellevue. These considerations persuaded many department chairmen that NYU should de- cline the City's kind offer of payment for what, after all, they had an academic in- centive to do for free. Other department chairmen felt the need for an infusion of funds to be sufficiently pressing to out- weigh the attendant disadvantages. The upshot was a compromise in the form of a partial affiliation contract covering only certain specified services (see box, Page 4). When NYU's senior faculty subse- quently resolved their differences in favor of a total affiliation, they discovered it was too late - the City had run out of affiliation money and was no longer offering a full contract. This is not to say that NYU has neces- sarily been starving. In the unaffiliated departments, it developed a clever money- making mechanism known as the Profes- sional Services Fund, into which third- party payments for physicians'services performed at Bellevue are channelled via a power of attorney extracted from all at- tending physicians. Physicians in depart- ments subject to the affiliation contract are obligated to channel the third party - pay- ments attached to their services to the City. Until the federal bureaucrats administer- 6 ing Medicare got wind of it, the certifica- tion by NYU that Dr. Jones actually per- formed, say, a surgical procedure at Bellevue was handled at the top of the NYU bureaucracy without much concern for whether Dr. Jones was around that day. Regrettably the feds were inspired by a scandal in Chicago to do some auditing, which in NYU's case led them to the dis- covery that one Dr. Jones had been in Switzerland when he was reported by NYU to have been in the operating room. Appar- ently the Professional Services Fund has been somewhat less profitable ever since. The same considerations that made many NYU figures wary of the affiliation mechanism also made them uneasy about the legislation enacted in 1969 creating the Health and Hospitals Corporation. If the HHC lived up to its press releases, it might get actively involved in the running of what NYU faculty saw as their operation at Bellevue. The legislation also had a pro- vision mandating the creation of a commu- Bellevue's buildings include about 48,000 square feet of research lab space used by NYU researchers. The maintenance costs of these labs are paid for by Bellevue. nity advisory board to each municipal hos- pital, something that NYU feared might get in its hair. Having failed to ward off the HHC's creation, many at NYU now bemoan the fact that a feature of the legislation permitting the creation of subsidiary cor- porations to the HHC, one for each City hospital, has never been implemented. Their line is couched in terms of the bene- fits of decentralization, but one suspects their motivation relates to the possibility of a subsidiary corporation, if controlled by NYU, becoming a mechanism for diluting the HHC's control over the goings - on at Bellevue. Our Labs, Your Electric Bills Some of the goings - on at Bellevue, which neither Bellevue administration nor the HHC has very much to say about, relate to research. (NYU's research operation is not trivial. Its 1972 research budget was in the neighborhood of 60 $ million, mostly repre- senting lab research.) Bellevue's buildings include about 48,000 square feet of re- search lab space, used by NYU research- ers paid by research grants coming to NYU, on research that Bellevue's adminis- tration knows little or nothing about. The maintenance costs of these labs including - electricity for the air conditioning - that is present in the labs but absent in the wards -are paid for by Bellevue, since the HHC has never gotten around to figuring out what a square foot of such space costs to heat, light, and electrify. Bellevue's role in NYU's research opera- tion has been limited to being accommo- dating. In one case, for example, NYU sought a federal grant to renovate unused ward space at Bellevue for use as lab space. When the National Institutes of Health said it wouldn't give NYU money to renovate real estate it didn't own, Belle- vue's administration obligingly solved the problem by giving NYU a long term - lease for the space at a nominal rent. Innovating with Outpatients Before extricating ourselves from the in- tricacies of the Bellevue - NYU relationship, we should pass by the Outpatient Depart- ment, where we find the beginnings of an arrangement that may have interesting implications for the future of that relation- ship. The traditional, and still predominant, setup in the clinics is direct payment by the HHC of clinic attendings, assigned by NYU to fulfill their service obligation there. Their rate of pay- $ 13.30 an hour for hour two - sessions - is viewed around NYU THE NEW BELLEVUE: A DREAM DEFERRED 1940 Plans drawn up for a new Bellevue Hospital. 1946 More plans drawn up for a new Bellevue Hospital. 1957 Mayor Wagner pledges $ 85,000 grant for yet another plan for a new Bellevue; initial studies project a 32 floor -, 2,300 - bed building at an estimated cost of $ 60 million, to open in 1961. 1963 Mayor Wagner breaks ground for a new Bellevue, promises completion in five years. 1964 Excavation begins; total cost now estimated at $ 68 million. 1966 Construction begins. Plans now call for a 24 floor -, 1,886 - bed hos- pital, estimated to cost 88.7 $ million. 1969 Original construction contract expires, construction comes to a halt. City's Board of Estimate ap- propriates additional $ 22 million for construction, without public hearing. 1972 Bellevue Comprehensive Plan, published by Westermann - Mil- ler Associates, Planning Consul- tants, recommends extensive renovation and reallocation of Nov. space in new building, required by time lag between planning and completion. 1973 Scheduled dedication of new hospital and opening of clinics. Building at opening to have 21 floors, 1,063 beds, with top four floors lacking interior construc- tion. Cost to date: 142 $ million. as extortionately low and only possible as the price of a faculty appointment and ad- mitting privileges at University Hospital. scheduled clinics and four reserved for un- Reportedly the session physicians typi- scheduled patient visits. For a small num- . cally come late and leave early, with the ber of clinic patients - 2,200 out of a total bulk of medical care being provided by the house staff. A departure from this arrangement Outpatient Department census of about 40,000 - this means being assigned a pri- mary physician who will see the patient at was established two years ago with the every visit and who is even accessible, creation within the Outpatient Department of a medical group practice, known as the Comprehensive Care Unit. The unit is staf- fed by 18 physicians representing different subspecialties of internal medicine, who via telephone answering service, any time of the day or night. If the patient is admit- ted to the hospital, the comprehensive care physician follows along to the extent of writing an initial note on the chart and dis- are salaried at the rate of 10,000 $ a year cussing the patient's care with the house for 10 hours of work per week, six at staff. 7 Organizationally, the Comprehensive Care Unit brings the clinics into a middle- class pattern of providing ambulatory care that may set the stage for bringing the middle class into the clinics. Fiscally, the unit is innovative in creating salaried po- sitions for ambulatory - care physicians. (Their checks are signed by the HHC, al- though their selection remains the respon- sibility of NYU.) Most of these doctors spend the other three fourths - of their time on NYU salary, teaching and / or doing re- search, their comprehensive care salaries in effect permitting NYU to pay them less. than it would otherwise have to. It should not be supposed that the Belle- vue NYU - relationship, and NYU's multiple uses of what Bellevue has to offer it, have settled down to a permanent pattern. The about opened - to - be - new Bellevue Hospital overlooks a new neighborhood that por- tends a whole new set of rules for this very old game. " Low - cost housing's loss was luxury housing's gain. " Esther - Rand Met. Council on Housing " Raising Social Standards " What was once a not very pretty, but stable, " ethnic " working class neighbor- hood - with light industries, tenement hous- ing, and institutions and shops which span- ned several generations - has now become one of the most glamorous spots for the white upper middle class to live in New York City. Low - rise has given way to high- rise, street culture has been bulldozed out; empty plazas, fancy lighting fixtures and underground garages provide a serene, placid and expensive environment for the Medical Center and the new Bellevue- the " campus, " as NYU officials fondly re- fer to their paved, superblocked turf. Nowadays, it would seem crass for an eminent institution like NYU to appear to be involved in slum clearance, urban re- newal, etc. And so it seems that NYU's neighborhood has somehow magically transformed itself, while NYU has busied itself with educational and scientific mat- ters. (NYU has been so successful in pro- moting this hands - off image that a mem- ber of the local planning board character- ized NYU's role as " low profile, " even 8 though the planning board meets at NYU and its public relations are handled by the Medical Center's PR man.) But back in 1945, when the Medical Cen- ter published its major planning document, and again in 1950 when it republished it, institutions were more candid about their interests in renewal and clearance. The Mission of a Medical School welcomed clearance projects which " would help to stabilize the local neighborhood and raise the economic and social standards of the section. " In fact, more than just welcoming it, NYU at first got directly involved. The Medical School attempted to sponsor the Kips Bay housing development project, right across the street from its new campus. The school was unable to produce the necessary financing and sold the project to William Zeckendorf, real estate robber baron, who opened Kips Bay. While the complex (which finally opened in 1963) is architecturally outstanding, the apart- ments are not available at the promised middle - level rentals. Then in 1964 NYU in conjunction with the Bellevue administration succeeded in get- ting the Bellevue South Urban Renewal Project under way. This massive seven- block clearance project had been twice de- feated by community uproar. The Medical Center claimed that the neighborhood was seriously dilapidated and that staff hous- ing was desperately needed to overcome staff shortages at its institutions. Neighbor- hood residents, organized on the theme " Remember Kips Bay, " presented an alter- nate plan calling for low income - housing to be built on platforms in the East River. It was dismissed as unfeasible. In all nearly 2,200 families paying average rents of $ 55 monthly were moved out. Many of the residents were, in fact, staff at the Medical Center, but they were lower eche- lon workers of lower social status - per- haps not desirable neighbors. Now the new housing is becoming too expensive for the Medical Center's house staff and nurses. Although half of the new housing units. were to be reserved for Bellevue staff, at present only 180 units out of a total of 1,185 are occupied by staff. The last building in the renewal area to open has rents starting at $ 275 for a studio apartment. " Low - cost housing's loss was luxury housing's gain, " according to Esther Rand of the Metropolitan Council on Housing. This fall Waterside becomes ready for occupancy. This subsidized luxury com- plex was built on platforms in the East River (quite feasible), and its rents start at 300 $ for an efficiency apartment. Lowering the Patient Load While its immediate environs have been undergoing a transformation, Bellevue's burden as a healer of the poor has been becoming appreciably lighter. Its total bed. complement has gone down from 2,818 in 1960 to 2,479 in 1965 to 1,622 in 1972, a de- cline of 43 percent in 12 years; its average daily census has dropped from 2,144 in 1960 to 2,000 in 1965 to 1,229 in 1972, a 45 percent decline. The trend in outpatient visits has been down for a while and then somewhat up again - from 425,445 in 1965 down 41 percent to 252,706 in 1969, then up to 274,325 in 1970, 310,498 in 1971, and 318,324 in 1972, a total recovery of 26 percent. No one seems to have developed a firm analysis to explain the decline in Belle- vue's usage, a trend that to varying extents it shares with others of the City's municipal hospitals. In part, the decline undoubtedly reflects the dramatic changes in the char- acter of Bellevue's immediate surround- ings. In part, it may (since 1966) reflect the " If normal Bellevue patients do not fill the beds, other members of the public will need education to use the beds effectively. " - Dr. Frank Spencer Chairman, Dept. of Surgery NYU Medical School ability of Medicaid and Medicare patients, repelled by the deterioration of Bellevue's physical plant, to gain admission to many voluntary hospitals. To a small degree, the inflexibility of Bellevue's 26 bed -, sex- segregated open wards may have led to low occupancy rates that could have been higher had it been possible to shuffle bed assignments. And within the past year, the opening of the new municipal Gouverneur Hospital on the Lower East Side may have drawn patients away from Bellevue who would formerly have gone there. Whatever the reasons and whatever the extent to which they reflect forces beyond Belle- vue's control, this alleviation of responsi- bility conveniently makes it easier for Bellevue to think about assuming a new role. Enter the New Bellevue Bellevue's administration is advertising the newness of its new hospital in terms that go beyond its conditioned air - rooms. and high speed - elevators. According to Bellevue's 1972 Annual Report: " This build- ing will represent a radical departure from both the philosophy and logistics of care in the existing plant. Its opening presents a unique opportunity to change the concept of Bellevue as only a hospital for the sick poor to Bellevue as a true community hos- pital with a primary dedication, still, to those without sufficient funds to carry the expenses of their medical care. " Given the demographic changes that have made Bellevue's immediate community into a middle - class neighborhood, that reference to " a true community hospital " sounds like it means a middle - class hospital - some- thing, perhaps, like an annex of University Hospital. The first step in the annexation would be through the further development of the group practice arrangement now estab- lished at Bellevue's Comprehensive Care Unit, described earlier. The Bellevue Com- prehensive Plan, an elegantly produced document prepared by the consulting firm of Westermann - Miller Associates (after extensive consultation with the folks at NYU), cites the possibility of using out- patient space at the new hospital to ex- pand the group practice method of organ- ization " to make complete patient care services available to the mixed income population within Bellevue environs..... It would permit private physician services to those who both wished and could afford them, but the program itself would not be economically discriminatory. " Bernard Weinstein, Bellevue's Executive Director, describes the plan concretely: The Comprehensive Care Unit would be expanded into a number of group prac- tices staffed by physicians receiving a base salary from the HHC, which they would be permitted to supplement with fees from patients. He fails to mention that experience with similar arrangements else- 9 where suggests that the care of the group practice patients will suffer from their having to compete with fee paying - pa- tients. (For a critique of New York's Health Insurance Plan from this point of view, see BULLETIN, October, 1972.) Or that in the NYU Bellevue - setting, the physician in question may well be a researcher rather than a private practitioner when he's not working at Bellevue, in which event his Bellevue patients may suffer from compe- tition with what he regards as his primary career. Patient admissions, continues the official scenario, would be arranged through the comprehensive care units, presumably with the referring physician relating to his patient like the current unit's physicians do, performing a liaison function vis - a - vis the ward physicians, who actually carry out the patient care. This projected ar- rangement is not radically different at the inpatient end from what is beginning to happen in the private sector, at University Hospital, for example. There one of the two floors occupied by the medicine service has been designated a teaching service, in which medical students do clerkships and patient care is the ultimate responsibility of ward attendings and house staff, al- though the advice of the patient's private physician may well be listened to. As to NYU's reaction to the question of moving the middle class into the new Belle- vue, Dr. Frank Spencer, the chairman of surgery, notes University Hospital's long waiting lists for elective surgery and goes on to observe that what motivates middle- class elective surgery patients to wait several weeks for a bed at UH rather than use a Bellevue bed is the wretchedness of Bellevue's physical facilities rather than the mystique of the private doctor patient - relationship. " Our main concern at the new Bellevue is that it be fully utilized. With its superb facilities and the shortage of hospital beds in Manhattan, it should be fully used. If normal Bellevue patients do not fill the beds, other members of the pub- lic will need education to use the beds effectively. " It might be noted in this connection that the operating room capacity of the new Bellevue, according to the Westermann- Miller plan, is sufficient to double the num- ber of surgical procedures currently per- formed at the old Bellevue, assuming a low average of three procedures per room per day. Spencer is an open heart - surgery spe- cialist and projects an increase in the number of coronary bypass operations 10 that will be done at Bellevue in its new facility. " Economically, we'd love to use the new Bellevue for open heart - sur- gery, " says Dr. Ivan Bennett, Jr., NYU's Dean and Director. The procedure is in- ordinately expensive and involves a loss. of several thousand dollars per operation. Obligingly enough, Bellevue included in its discretionary budget for the 1973-74 fiscal year a $ 1.1 million item for an ex- panded cardiac surgery program. Some observers note that the capacity of the new Bellevue for open heart - surgery far ex- ceeds the needs of Bellevue's traditional clientele. The objective conditions that make the new Bellevue an attractive object from NYU's perspective are summarized in the Westermann - Miller plan: " The opening of the new Hospital will generate new oppor- tunities for the Bellevue - NYU relationship to develop. The new Hospital, with its im- age radically improved from what has his- torically been associated with Bellevue, represents a potential expansion of private practice beds for NYU faculty, a powerful inducement to continued NYU participa- tion, especially in the light of NYU's limited bed capacity. The new Hospital will also provide more and better facilities for clin- ical training programs. " " " Economically, we'd love to use the new Bellevue for open heart - surgery. " -Dr. Ivan Bennett, Jr. Dean, NYU Medical School Director, NYU Medical Center Exit the Planning Committee As a companion concept to the new Bellevue as community hospital, Bellevue's administration sometimes bandies about the concept of sharing of services, more grandly known as " medicine under one roof. " The trial balloon for the idea was floated by Manhattan Borough President Percy Sutton in an address at NYU Med- ical School's 1972 commencement. Herald- ing " a magnificent opportunity...... to establish the pilot project of a huge ultra- high quality medical complex where equal medical services could be provided to rich, middle class, and poor alike in the same, well equipped - facility. " Sutton put forth a vision of " the University Hospital, the Veterans Administration Hospital (VA), and Bellevue Hospital all operated as a single institution within a unified health concept. Each hospital would house spe- cialty services and each would serve all three of the populations which are cur- rently served separately. " Precisely what's been going on by way of planning and negotiation toward the implementation of shared services is shrouded in mystery. It used to be that the participants at least admitted the existence of something called a Planning Committee; Bellevue's 1971 Annual Report announced that " For over a year a group composed of the Dean of the NYU Medical School, the administrators of the three hospitals [Belle- vue, University, and the Manhattan VA Hospial, located just south of Bellevue] and the chairmen of all clinical depart- ments have been meeting weekly " to dis- cuss how the institutions involved might share staff and facilities in the years ahead. By the 1972 Annual Report the ex- istence of such a planning group was no longer mentioned, and sharing of services had been reduced to " a concept that is under development. " What happened, the participants will admit if pressed, is that the Planning Com- mittee stopped meeting as such during the summer of *1 972. Why? " The summer came, " says Weinstein. " There was noth- ing to talk about, " says Bennett. The real reason, says says the proverbial informed source, is that someone started making noises to the effect that maybe the Plan- ning Committee's representation should be enlarged; maybe the Medical Board and even outside groups should be allowed in on the act. Presto chango, there is no longer a Planning Committee, but there is a sus- piciously similar group of men who have lunch together with some regularity at a location safely off hospital grounds. One Roof or One Linear Accelerator? In a sense, sharing of services is nothing new. We have already noted (see box, Page 4) the sharing of pathology serv- ices Bellevue - does it free of charge for University Hospital's patients. Bellevue's ophthalmology service also does testing for University, and Bellevue's pediatric in- tensive care unit is sophisticated enough for University to send over an occasional premature infant in distress. The VA Hos- Why did the Planning Committee dissolve? II " The summer came, " says Weinstein. " There was nothing to talk about, " says Bennett. pital sometimes gets into the act; it does a sophisticated gastroenterologic procedure that isn't done at the two other hospitals. As far as anyone on the outside can tell, what's going on by way of planning to ex- pand such arrangements bears little rela- tionship to the grandness of the " medicine- under - one - roof " concept but is bogged down in such particulars as how to admin- ister radiation therapy to the combined clientele of Bellevue and University Hospi- tals. NYU has beefed up its radiation ther- apy capacity with a new linear accelerator -it is, after all, vying for designation as a national cancer center - while Bellevue has cancelled its orders for equipment for the radiation therapy suite in the new build- ing. The two parties have initiated negoti- ations over the logistics and cost of getting radiation therapy to Bellevue's patients at University Hospital, which reportedly have reached an impasse over what Bellevue re- gards as an exorbitant price. Note that sharing of services seems to mean that a service done at Bellevue for University Hospital paitents is free, but not the reverse. In any event, the tentative plan is for Bellevue to maintain one cobalt unit (as opposed to its original plan for two of them plus a linear accelerator) to treat patients who can't safely be transported between the two hospitals. This raises the interest- ing question of why these patients couldn't be admitted directly to University Hospital. After all, NYU seems to plan to admit elec- tive surgery patients who might otherwise wait for a UH bed directly to Bellevue. It may be that Bellevue is reluctant to give up radiation therapy altogether, or it may be that NYU is more willing to share the 11 City's hospital with its patients than to share its hospital with the City's patients. The Managers Vs. the Medical Patriarchs Despite the interdependence of Bellevue and NYU, the long range - outlook for col- laboration between the municipal hospital and the elite private medical center is that the going may, more than occasionally, get rough. NYU clearly needs Bellevue for teaching material, lab space, income, and for the possibility it offers for an expansion of NYU's brand of medicine to NYU's brand of patients. On the other hand, NYU is clearly unhappy about the fact that deal- ing with Bellevue brings it into contact, and conflict, with the Health and Hospitals Corporation. NYU's physicians are clearly unhappy at the prospect of any outside entity calling them to account. " The Corporation doesn't understand physicians, " says Dean Bennett. " No one trusts the HHC, and no one would say anything that suggests a dependency re- lationship on the HHC, " says Dr. Albert Keegan, director of radiology at Bellevue. (That last remark may explain the fact that NYU has drawn up a contingency plan for use in the event it loses Bellevue as its teaching hospital.) More positively, NYU spokesmen are quick to attack the Corpo- ration as an aloof, overcentralized bu- reaucracy, preoccupied with balancing its budget and failing to account for the uniqueness of particular institutions. However strongly one may criticize the HHC for its bureaucratic bumblings (see BULLETIN, December, 1971), it is clear that NYU would find fault with any public agency that attempted to exercise an over- view of its operation - thus its oft repeated - complaint that the affiliation contract doesn't provide enough flexibility for it to run things as it thinks best. It is also clear that whatever the extent of its interest in ensuring that public funds aren't squan- dered, the HHC has virtually no interest in programmatic planning for the benefit of its clientele. There is no evidence, for ex- ample, that the HHC has taken any part in planning for the new Bellevue other than rubber stamping - deals made by NYU and Bellevue's administration. There is no rea- son to believe, in other words, that there is any real danger to NYU of the HHC impos- ing a re ordering - of its priorities, heavily weighted as they are in favor of teaching and research. At the level of NYU's physicians, how- ever, there is irritation bordering on bitter- 12 ness at the HHC's attempts to keep track of time actually spent at Bellevue; the cursed timesheet seems to symbolize a refusal by those blasted bureaucrats properly to ac- knowledge the priviliged status of the med- ical profession. (A study of physicians'per- ceptions of New York's municipal hospital system, commissioned by the Society of Urban Physicians, a group of attendings and service chiefs at the City's municipal hospitals, noted a common resentment by physicians created by the feeling that they were " being converted into employees who do not have a role in making decisions in areas in which their professional judg- ments are necessary. ") Working for NYU then becomes preferable to working for Bellevue - HHC, not because the latter is a municipal bureaucracy but because it de- mands accountability and exercises con- trol in ways that the physicians would re- sent coming from any source. The position of Executive Director Wein- stein vis vis - a - these various forces comes across as ambiguous. Although the HHC, of course, pays his $ 45,000 salary, he has been willing to take up arms with NYU in opposition to the HHC's plan to house Bellevue's prison service on the new build- ing's 18th floor (see BULLETIN, September, 1973). He expresses sympathy with physi- cians on the time keeping - question - after all, he argues, physical presence isn't any guarantee of quality of care. And his in- terest in getting middle - class patients into the new Bellevue is congruent with NYU's. On the other hand, Weinstein expresses the opinion that increased funding for phy- sician services at Bellevue should not come through the affiliation contract mech- anism but rather through putting physi- cians directly on Bellevue salaries. He is emphatic, however, that the selection route for physicians must continue through NYU; still, it is clear that NYU would prefer the affiliation contract mechanism, which puts physicians on its payroll. It may well be that Weinstein is simply out for himself. He intends to project Bellevue as the star of the municipal sys- tem, if not a national landmark, with a new constituency appreciably more pow- erful than Bellevue's present one. Thus he needs to operate within a complex scenario in which he leans alternatively toward NYU and the medical staff (when he needs its prestige) and toward the HHC (when he needs its backing of an asser- tion of independence from NYU), as his interests may dictate. Whether his interests coincide with those of the patients who most need Bellevue is, however, proble- matic at best. A to date - relatively minor element in this matrix of forces is the Bellevue Com- munity Board, formed under mandate of the legislation creating the Health and Hospitals Corporation. Although that legis- lation was effective in 1970, it was followed by such an excruciatingly long and com- plex planning and selection process that it was not until this May, some three years later, that the formation of the Board was completed. While it has taken forceful posi- tions in reaction to issues (such as the pris- on ward location question) that others. have brought to its attention, the Board has not been able either to integrate itself into the on going - decision - making process of the Hospital or to develop a mechanism for discovering policies potentially detri- mental to its constituency while their de- velopment is still in the early stages. This failing, of course, was intentional. First the legislators gave the community boards. minimal powers and no resources. Later the Bellevue administration and the HHC rebuffed months of efforts on the Bellevue Board's part to establish its right to an in- dependent budget for the purpose of hiring its own staff. More fundamentally, no one on the scene is willing to share more than trivial, stale information, or more than trivial, last minute - decision - making func- tions, with what is perceived as an arro- gant bunch of uninitiated outsiders. What About the Patients? The disturbing, and unanswered, ques- tion about the new Bellevue is whether putting middle - class patients in means pushing poor patients out. The number of beds in the new hospital totals a maximum of 1,063, down from the current bed com- plement of the general hospital of 1,134. (Bellevue's 488 bed - psychiatric hospital is not being replaced.) At the rate of Belle- vue's 1970 utilization, the average occu- pancy rate of the new building would be 87.1 percent, but predictions are rampant that utilization will increase, and the wait- ing list for admission to University Hospital has been known to go as high as 700. Probably the prime candidates to be pushed out are the transfer patients. In 1971, about 3,000 patients were trans- ferred to Bellevue, many from other mu- nicipal hospitals that either had no beds or lacked adequate facilities for their treat- ment. (In the municipal system, Bellevue is " paired " with Harlem, Cumberland, and Lincoln hospitals for the purpose of accept- ing their transfers. Then there are the pa- tients (including some of the transfers, but more than just transfers) who don't live in Manhattan these run somewhere between 20 and 30 percent of Bellevue's inpatients and about 30 percent of its outpatients. Does becoming a " true community hos- pital " mean shutting them out? These speculations might be dismissed as raving paranoia if the rhetoric about the new Bellevue were coupled with some con- crete planning to guarantee the availabil- ity of beds to Bellevue's traditional con- stituencies. No one seems to know, how- ever, precisely how the admissions system will work. And while much is said about the two class - system of health care being eliminated within the walls of the new Bellevue, nothing is said about the possi- bility of the new Bellevue creating a two- class system within the municipal system itself with the middle - class community around Bellevue using its classier facilities while the poor of the Lower East Side and elsewhere are relegated to other munici- pals of inferior quality. In the meantime, it is clear that Wein- stein and NYU are willing to woo the mid- dle class at the expense of Bellevue's least- favored constituency, namely prisoners. In arguing against placement of Bellevue's prison health service on the 18th floor of the new building (as opposed to a site out- side the new building), Weinstein has writ- ten that " The placement of a prison unit and the traffic to and from it in the guts of the new Bellevue would be a crippling blow to the philosophy [read " image "] that we are trying to develop from which this institution would never recover. " Wester- Miller mann - take up the theme: " Prison beds in the new Hospital might jeopardize the attitude toward Bellevue from its com- munity of users... prison services would induce a coercive atmosphere that would adversely color the image Bellevue as an institution would like to project. " But after all, it's not Bellevue's image that's being polished, it's NYU's. When Bellevue was a wreck, no one worried about who came; now that it's all shiny and nice, the hope seems to be that only (or at least mostly) people of a similar description will fill its beds. -Louise Lander, Constance Bloomfield, and Jonathan Morley. (Louise Lander, as well as being a Health / PAC staff mem- ber, is a member of the Bellevue Com- munity Board. Jon Morley was a Health / PAC summer intern and is a fourth - year student at NYU Medical School.) 13 A TALE OF Up From The Workhouse Horror and degradation have tainted Belle- vue Hospital throughout its history, being renewed every generation with new tales of woe. Bellevue suffers from a dual inher- itance - the general unwillingness of the population and municipal government to adequately fund a hospital for the poor and the tradition by which patients cannot secure their own doctors but are cared for by physicians working for medical schools. Bellevue Hospital's great granddaddy-- - actually a six bed - infirmary - was built in New Amsterdam in 1736. The infirmary was part of the Workhouse and House of Corrections, an almshouse for the poor and forsaken. The building stood on the site of the present Municipal Building in down- town New York. The inmates had to work hard for their keep. Some provided nurs- ing care for the sick while others worked at spinning wheels and looms. For the un- cooperative, the unruly and the demented, there was a whipping post and an iron cage in the cellar. The first teaching at Bellevue started in 1787 when Dr. Nicholas Romayne estab- lished a private medical school there. A colleague, Dr. David Hosack, pronounced it good with the now familiar - refrain: " Under their united care, this infirmary was rendered a profitable school of med- icine and surgery, while the sick received the benefits of physicians distinguished for their abilities and education. " The almshouse buildings were relocated to Chambers Street in 1796, but soon were " in'a ruinous condition. " A new almshouse was built in 1816 on part of the Kip's Bay Farm overlooking the then beautiful - East River. The almshouse adjoined an inter- mittently used Fever Hospital, later re- named Bellevue. Both were located on Bellevue's present site. During the early 1800's the Hospital was run by the Superintendent and the resident physician, who became known for their greed and disregard of the patients'wel- fare. During the 1830's and 1840's public criticism of the almshouse and the Hos- pital was frequently voiced - and ignored. In 1836 an investigating commission re- ported that the " condition of Bellevue Hos- pital was such as to excite feelings of the most poignant sympathy for its neglected inmates. " Others noted that " the same ap- parel and the same bedding had been al- ternatively used by the sick and dying, the convalescent, and those in health. " They believed that the " totally inadequate num- ber of medical officers, " as well as the in- adequate laundry and inadequate house- keeping, were responsible. The Hospital was reorganized, a Medical Board established, and the functions of the almshouse and the Hospital were clearly distinguished. The almshouse was sent to Blackwell's Island while the Hospital moved from the crumbling Fever Hospital to the vacated almshouse. A new wing of the Hospital opened, and Bellevue acquired a surgical amphitheater for teaching in 1856 and a pathology build- ing in 1857. The Medical Board members prepared to open a new medical school- launched in 1861 as Bellevue Hospital College of Medicine. In the early 1870's one upper - class woman heard from an intern who con- ducted her on a tour: " You've only seen the outside. It would take weeks for you to learn all the horrors of this place, but you must be very careful not to be seen with me or to quote me. It might cost me my position here. " This woman repre- sented a group of women who took a pro- longed interest in Bellevue, got their upper- class manners revised, worked as ad- vocates for patients and finally established the first school of nursing in the country at Bellevue in 1873. As guardians of the poor and politically powerless, they empha- sized that " constant vigilance is necessary on our part to sustain the present improve- ments, for if the authorities of the Hospital see that our labors are relaxed, they will immediately return to the former regimen. " Priorities were confused, then as now. The City was pressured into providing chairs for Bellevue's female employees, who were housed in the cellar. Yet it pro- vided a decent room with a private bath overlooking the East River for each intern, and in 1890 the Commissioners of Correc- tions and Charities appropriated $ 25,000 for a new amphitheater attached to the Columbia Division at Bellevue. In spite of investments in its teaching program, the (Continued on Page 24) 14 TWO HOSPITALS Up From The Graveyard When the New York University School of Medicine (NYU) was founded in 1842, the state of the medical arts was primitive. For example, human dissection, necessary for advancing knowledge in pathology and anatomy, was socially unacceptable - and illegal. To conduct their early research and teaching, some of NYU's most respec- table founders resorted to grave robbing, body snatching and cadaver smuggling. In one of the more bizarre and macabre claims to fame ever, NYU boasted in its first catalogue of its easy access to the bodies of the poor and unclaimed in Pot- ter's Field: " No city in the Union furnishes the same supply of the material for the study of practical Anatomy, as the City of New York. Indeed, it is a fact of notoriety, that a considerable part of the supply re- quired in the dissecting - rooms of Philadel- phia [home of the more prestigious medi- cal school] has heretofore been obtained in New York. " While all things change, everything re- mains the same. Despite the remarkable transformation of medical practice and education since those early days, NYU is still characterized by two traits which marked it at its inception. One, its reputa- tion and appeal have always been based more on its ready supply of bodies, both living and dead, from which to learn and teach, than on the skills or reputation of its faculty. Secondly, NYU has always been engaged in fierce and occasionally ungentlemanly competition for control of teaching and research resources (patients, laboratories, and staff), sometimes losing, but more recently winning over its fellow medical schools. Back in the 1840's, medical education was as crude as the practice of Physic and Surgery itself. Instruction was based on a fee teaching - for - tutorial and apprentice- ship system, with individual physicians teaching their private students at the bed- side of their charity patients. Fees were high and it was a profitable enterprise. The more distinguished teaching - doctors asso- ciated with universities, in the European tradition, and their students were awarded the university degree, upon completion of several lecture courses and success in ex- aminations. The universities had little to do with the policies and administration of the medical schools. (There was so little association that in some cases, such as Columbia Medical College, predecessor of Physicians and Surgeons, the faculty ac- tually purchased the diplomas from the parent school, to distribute to their stu- dents.) NYU Medical College was founded such a fashion by Valentine Mott, surgeon, in collaboration with five other doctors, in- cluding John Revere, Paul's youngest son. Mott originally taught at Columbia, which collapsed in a dispute over control of the medical college's profits. He then started a short - lived medical college in associa- tion with Rutgers University. When he ap- proached NYU about fostering a medical school, the University Council was agree- able although - disappointed that the doc- tors, for economic reasons, would only operate the customary two year - school. While a four year - curriculum would have produced better trained - physicians and furthered " the Cause of Medical Science " it also " would prove fatal to the hopes and prospects of the Faculty. " Bellevue Hospital had been used for teaching since 1787. Mott and his col- leagues conducted their teaching there. It was clear, even in the early 1840's, that Bellevue offered remarkable educational resources. The New York Society of Medi- cine, among others, pressed to make the hospital more accessible to students: " It is a crying shame that such a wide field for clinical instruction should be actually lost to the City, to science, and to the world merely to subserve paltry party political purposes; to give to some favorite a monop- oly of private teaching in that great estab- lishment. " Five years after the NYU Medical Col- lege was founded, control of Bellevue was established in a Medical Board, one impor- tant member of which was Valentine Mott. Bellevue became a full fledged - teaching hospital and, according to NYU's published history, The First 125 Years, " the cause of medical education in New York was greatly advanced. " Bellevue's patients were shared between NYU and Columbia's resurrected school, Physicians and Sur- geons. 15 They were joined in 1861 by the Bellevue. Hospital Medical College, a new institution organized by the Medical Board and hos- pital staff. The new school reflected the in- creasing importance of the clinical basis for instruction in medicine. Bellevue Hos- pital Medical College quickly outpaced NYU in quality and reputation. In 1884, the Bellevue College received the Carnegie laboratories from philanthropist Andrew Carnegie and the new school became a leader in pathological research. By 1897, NYU's fortunes as a proprietary school had fallen so low that their graduates ranked at the bottom of all other doctors licensed by the State. When the Council of the parent univer- sity moved in to clean up and control the school, it found dissident faculty which wanted to remain in charge. In the result- ing power struggle the issue of control be- came even more compelling when philan- thropist Oliver Payne indicated that he would donate a modern research lab to the school. When the dust settled, the Uni- versity controlled the college. However, half the faculty and students had left, tak- ing with them the Payne research labora- tory grant and a number of sympathizers from the Bellevue Hospital Medical Col- lege. With Payne's assistance, they promptly founded Cornell University Medi- cal School several blocks away. Most fortunately for NYU, Bellevue Hos- pital Medical College was in financial dif- ficulty at the time. Their difficulties were aggravated by a fire which destroyed some of their buildings. Happily, NYU in- vited them to merge, gaining the Carnegie labs and a number of new buildings not destroyed in the conflagration. Later, NYU acquired the Cornell buildings when that institution moved uptown. Shortly there- after, its name changed from the Univer- sity and Bellevue Hospital Medical College to the New York University College of Medicine. In 1929, NYU commissioned a Plan of Development to be drawn up for the Medi- cal College. The timing was unfortunate and the plan was circuited short - by the Depression and War. However, the plan was not short sighted - ; it defined NYU's in- terests plainly and laid out its assumptions for later growth. NYU's reputation lay at Bellevue's feet. In fact, a survey of alumni and medical leaders confirmed that NYU's best asset was the hospital, not the faculty, laboratories or classrooms. Acknowledg- ing that " a great hospital, rather than classrooms, forms the best basis for the 16 study of disease, " the planners estimated that " Should any university decide to pro- vide for its own medical school a clinical plant equal to that of Bellevue [which NYU had for free], the cost would be from $ 30,000,000 to $ 40,000,000. " The plan advo- cated that Columbia and Cornell be en- couraged to give up their teaching pro- grams at Bellevue, so that NYU could take over all the services. The Plan also recommended that a Uni- versity Bellevue - Medical Center be estab- lished which would include a private hos- pital so that students would have " contact with classes of people not represented among Bellevue patients " and so that the college would be helped in " obtain [ing] and hold [ing] a high type of clinical teach- ers who are in practice. " The Plan also rec- ommended that the school close its Charity Clinic, since students had access to poor patients at Bellevue and thus the Clinic was a needless school expense. In 1945 another far sighted - planning document was prepared, this time with a more grandiose title, The Mission of a Med- ical School. The plan was euphoric about the post - war possibilities of medical edu- cation and practice. It contained a number of very progressive elements. It proposed sweeping reforms of medical school curriculum, most of which were never en- acted. It was convinced that some form of insured prepaid group practice for the mid- dle class was " imminent " and recom- mended that University Hospital be de- signed for eventual conversion into a faculty group practice. This too has not come to pass, although the idea is being rejuvenated in a new form (see Page 9). In fact, the only significant parts of this plan that were ever to see the light of day dealt with the construction of a new cam- pus and hospital for NYU and a new neigh- borhood for the school and Bellevue. These plans were rationalized by and coordi nated with similar plans for NYU's great- est asset, Bellevue: " To make full use of the teaching and research possibilities that will be available in the new Bellevue, the University also must provide for the fu- ture. " NYU's future has been well provided for. Over the last twenty - five years, it has built a totally new campus; it has kept its 630 bed - University Hospital running at ca- pacity; and it has seen its environs trans- formed from a working class immigrant neighborhood into a high - rise high - cost residential district. AS THE NATION GOES, SO GOES BOSTON H January 3, 1973: Boston Mayor Kevin White announces, We " will cut the City Hopital budget by more than 20 percent, make the hospital self supporting - within five years. " " OE February 3: The Mayor announces a Health and Hospitals Department budget of $ 56 million, $ 12 million less than the amount required to keep services at the present level. OE February 7: Boston City Hospital's Trustees vote to cut down the Hospital from 850 to 500 beds. OE February 21: The Trustees vote to turn over all medical services at Boston City Hospital to Boston University Medical Center. OE April: Boston University announces a plan for Boston City Hospital to exclude all services but the most basic medical - , surgical, children's, and maternity; the re- sult is described as " a community... hos- pital focused on the provision of high- quality family care.'" OE September 7: Health and Hospitals Commissioner Leon White (no relation to the Mayor) announces the elimination of 400 more workers'jobs at Boston City Hos- pital, bringing the total jobs cut this year to 1,000. It's the Only One We've Got Boston City Hospital (BCH) is the only public acute care hospital in the City. In 1968 (the last year for which figures are available) it treated a whopping 27.4 per- cent of all patients treated at Boston hospi- tals who were Boston residents. The per- centage is higher for areas where Boston's Black, Puerto Rican, and working - class white population is concentrated. BCH is also Boston's major emergency hospital for victims of gunshot and stab wounds and other traumatic injuries. It is the main center for mass hospitalizations arising from serious fires or auto accidents. Any alcoholic who is picked up and in need of medical care will most likely end up there. So will low income - people, no matter what the emergency and no matter where they come from; last year 45 per- cent of the ambulances arriving at BCH came from outside its official ambulance district. BCH has been the only hospital in the area where the three major medical schools Harvard - , Tufts, and Boston Uni- versity (-have BU) co existed - . For most of this century, each of the three has run its own medical and surgical services at BCH while dividing the other services among them. However inefficient, this system has allowed the Hospital to maintain the large staff necessary to care for Boston's poor. (Five years ago the City offered the then 850 bed - Hospital to whichever medical school would take it. None accepted the offer. It is only now, when the Hospital has been cut back to 500 beds, that it has be- come feasible for one medical school to assume full responsibility for its staffing.) " Some of you people may have to die. " Like mayors of most cities, Boston's Kevin White has felt himself pressed for funds for a number of years. One of his favorite ways of saving money has been to cut down BCH. In 1971 he froze jobs at the Hospital; in 1972 he made an unsuc- cessful attempt to cut the City's contribu- tion to the hospital's budget by almost one- fourth. In January, 1973 he singled out the Health and Hospitals Department budget (of which 80 percent is spent at BCH) for a huge cut. In doing so, he played a numbers game referring - to the Department's $ 62- million budget while talking about the high cost of health care to Boston's tax- payers. The Mayor conveniently ignored the fact that the Department last year brought $ 47 million into the City's general funds. Thus the net cost to the City of run- ning an 850 bed - acute care hospital, two chronic care facilities, a number of neigh- 17 borhood health centers, and innumerable public health services was really only $ 15 million (62 $ million less $ 47 million), not a bad price for a city of 640,000 people. The cutback at BCH has been couched by the Mayor and his allies in terms of a presumed bed surplus in the private hospi- tals, and the elimination of second - class care by farming - out BCH patients to those hospitals. On one occasion, however, the Mayor let slip the true significance of the major surgery being performed on BCH. On February 4, after his press conference announcing the budget cuts, 50 angry BCH workers and patients stormed the Mayor's office. A Black woman told her story, the story of thousands of people - her child has a congenital disease, she cannot afford to go to Children's Hospital, BCH has saved her child's life for years. Mayor White lis- tened and then actually said to her: " Some of you people may have to die. " Then he went on to talk about the tight straits the City is in, especially with the cutbacks in federal spending, the need to provide re- lief for taxpayers, and the need for all of us to pull in our belts. He didn't mention, as he looked out over Boston harbor from his office, that some people's belts were already past the last hole. The Research Centers Don't Want Them Mayor White does not make his health care decisions alone. Boston's three medi- cal empires wield tremendous power in determining health policy in the City. One result of the existence of the three com- peting complexes and the numerous hospi- tals they control is what is commonly re- ferred to as over bedding - , a ratio of hospital beds to residents that is far higher than the national average. The gross fig- ures, however, do not speak to the critical question of who has access to those beds. As a medical research center, Boston fills many of its hospital beds with patients from across the country and the world. This fact casts doubt on Mayor White's fre- quent statements that the City's bed sur- plus makes it safe to cut Boston City Hos- pital by 300 beds; whether the City has the power to force the medical schools to take these patients has never been established. " The academic medical centers are re- ferral centers, " says Dr. Steven Saltzman, President of the BCH House Officers Asso- ciation. " They take care of patients with different exotic diseases because enough people come in from all over the world to justify those services. There's no way for Commissioner Leon White to change that. 18 If he tries to make those into community hospitals, the specialists will leave, but that won't happen because all those people are a lot more powerful than he is. You can't expect a specialist to call a patient from Atlanta who's scheduled for compli- plicated heart surgery and tell him not to come because they have an alcoholic with pneumonia filling his bed. " Poor patients are seen as a burden by private hospitals. Their diseases are bor- ingly similar complications - of years of al- coholism, heart disease, results of inade- quate diet, poor housing, unsafe working conditions, and almost no preventive care. " Some of you people may have to die. " -Mayor Kevin White Feb. 4, 1973 They take up beds for longer than the elec- tive surgery patients that hospitals and doctors make money on, because they come in far sicker than the person who has a private physician, who can afford con- valescence after illnesses, and who is taken care of in old age. Unlike BCH, which treats all comers re- gardless of ability to pay, private hospitals employ a number of devices to restrict ac- cess to their facilities. They keep their emergency rooms small and close them at 9 PM; charge a fee before letting patients enter a clinic; ask extensive questions about health insurance and ability to pay even before diagnosing the patient's con- dition; require patients to sign forms- usually illegal agreeing - to have their property and paycheck attached to cover their bills. There is no evidence that these practices are about to be abandoned, especially with the tightening of spending by Medicaid, Medicare, and Blue Cross. Empires in the Wings The actual size of these medical empires is always shifting, particularly since the federal government made lavish money available for hospital construction and re- search in the mid sixties - . Dominant among these three is Harvard, whose medical school controls about ten major teaching hospitals in greater Boston, most inside the city limits. Harvard's primary orientation is to maintain and enlarge its medical com- plex as an international center of medical specialties - most of the patients in Harvard hospitals don't live in Boston. Harvard's resources - in money, people, prestige, and power - allow it to outlast or buy off most of its potential critics. This is not to say that Harvard is invulnerable. When it wanted to expand facilities near its major geographical area of concentra- tion, which includes four teaching hospi- tals and its medical school, pressure from the Mission Hill community stopped it. The medical school, in true Harvard fashion, soon had a solution - an end run. While continuing to exert pressure on its own lo- cal community, Harvard took over admin- istrative control of Cambridge City Hos- pital, a few miles way. Harvard's move into Cambridge City Hospital may explain its willingness to lose its share of BCH, since both institutions are primarily hospitals for the poor. (Har- vard controlled less than 250 beds at BCH and acquired 217 at Cambridge City.) Har- vard also had a major research operation going at BCH at the prestigious Thorndike Memorial Laboratories, operated within the Hospital premises but completely con- trolled by the medical school; it was no problem, however, to move the labs to an- other part of the empire, namely Beth Israel Hospital, another of Harvard's teaching hospitals. firm decision one way or the other. As a result of the lack of support from Tufts, the Department was never able to find some- one willing to be its chairman. Thus when Tufts got the chance this past Winter fi- nally to rid itself of this albatross, it did so quite willingly, although it went through the motions of submitting a proposal for taking over BCH on its own. Like Tufts, the Boston University Medical Center is comparatively small. Geographi- cally limited to Boston's South End (al- though it provides medical staff to several suburban hospitals), BU includes the medi- cal school and the 350 bed - University Hos- pital. Gaining total control of BCH (where it had formerly controlled about half the beds) meant increasing its bed capacity by a couple hundred beds with very little added expense. BU Expands BU launched an expansion program in 1965. Since then it has built or bought four new buildings going $ 14 million into debt in the process. Most of this money has gone for research and teaching space and pri- vate physicians'offices. Hence two of its new buildings are the Evans Memorial Re- search Building and the Doctors'Office Building. Almost no funds have gone to " The academic medical centers are referral centers.... You can't expect a specialist to call a patient from Atlanta who's scheduled for complicated heart surgery and tell him not to come because they have an alcoholic with pneumonia filling his bed. " -Dr. Steven Saltzman, President BCH House Officers Association Boston's other two medical empires are considerably smaller. Tufts controls well under 1,000 beds and does not have the money necessary to attract large numbers of researchers, who contribute to a medi- cal empire's prestige and bring in needed. federal money. About four years ago, Tufts faced the prospect either of building up its Department of Medicine at BCH or pulling out entirely, but couldn't make a build up outpatient facilities for so called - " clinic patients, " a euphemism for the poor. Recently federal health research cut- backs have forced the BU ship off course. BU has been compelled to change its com- pass reading and is now coming on as doc- tor for the surrounding Black and Third World communities. Reflecting its location in such a community, BU has engaged in 19 the past in token measures such as running one of the City's few methadone detoxifi- cation clinics and serving a mental health catchment area that includes most of the South End, North Dorchester, and Roxbury -the largest concentration of Third World people in Boston. Spurred on by federal funds for a new residency program and a $ 5 million seed grant from the Robert Wood Johnson Foun- dation (as in Johnson & Johnson), BU has proudly announced that Primary Care De- livery (PCD) is now its " central theme. " PCD has become the rationale for elimi- nating specialty services from BCH under PCD has become the rationale for eliminating specialty services from BCH. BU's auspices and limiting the Hospital's services to medicine, surgery, pediatrics, and obstetrics. The PCD proposal is carefully couched in terms of commitment to the community: " The success of a pattern of health care for a community depends upon the involve- ment of a knowledgable and representa- tive community in every step of the plan- ning and implementation. " Despite the rhet- oric, the community was never consulted in the initial plans for the proposal, nor have concrete guidelines been articulated for the involvement of medical students or the inclusion of patients. The substantive emphasis of the proposal is on the training of physicians, not the delivery of commu- nity oriented - health care or the training of community residents to serve primary health care roles. Dr. Joel Alpert, BU's head of pediatrics and a prime mover of PCD, has stated that " The doctor is the founda- tion of the health network. " Given its emphasis on physician train- ing, the program is caught in a contradic- tion between its rhetoric of providing " con- tinuity of service " and its projected prac- tice of rotating physicians - in - training through a community. Given its character as a pilot research project in health care delivery, PCD is precluded from providing 20 a general solution for health care delivery problems. Patient care will be provided, but only to those whom BU defines as part of the pilot project. The Plot Thickens Both the PCD program and the comple- mentary construction programs of BU and BCH fit in very nicely with BU's assumption of total control at BCH, a fact that suggests something was in the works long before that takeover was officially decided on in February. BU cites its assumption of re- sponsibility for professional services at BCH as one of the critical developments inspiring it to make the PCD proposal. BU's plans for constructing a new hospital next door to BCH, to replace University Hospi- tal, were publicly discarded last Decem- ber. Shortly after the original announce- ment, a newspaper report quoted an anon- ymous " highly placed BU official " who hinted at the real reason. He suggested that a new UH hospital might not be needed since " BU Medical School's role at Boston City Hospital might expand if one or even both of the other medical schools that utilize BCH for teaching and research were persuaded to reduce or phase out their participation. " Further evidence of a well thought out strategy on the part of BU was its omission of a new outpatient building, despite the fact that the outpatient services at Univer- sity Hospital are in the oldest and most crowded part of that institution. Interest- ingly enough, the City is currently con- structing a new outpatient building for BCH, a facility that has become a central factor in BU's PCD proposal, which em- phasizes " educational settings which focus on the ambulatory instead of the hospital- ized patient. " BCH's new outpatient building was orig- inally one part of a plan developed in the late 1960's for a completely new $ mil- 91 - lion hospital with 1,000 acute and 300 chronic care beds. Of the rest of the plan, only ancillary facilities have to date been built a new 28 story -, 112 unit - apartment complex for doctors (including a swimming pool, gymnasium, and squash courts) and a new nursing school and rooms for 300 student nurses. With the cut in BCH's beds and a concomitant 20 percent cut in its house officers this year, the apartment building is larger than needed by BCH but presumably will come in handy for the house staff at University Hospital. There are other factors that suggest that the BU takeover at BCH fits in nicely with its own plans and priorities: A few years ago University Hospital closed up its ma- ternity and pediatrics facilities, while BU renovated those services at BCH that it was then operating. Until this past July, University Hospital did not even have an emergency room, whereas BCH has one of the largest in the city. All of this is evidence that the decision to let BU run the medical services at BCH was not made in a week by the Board of Trustees, as they would have us believe. The Trustees'request for proposals to be submitted by all three medical schools was made a week before the decision was an- nounced, and in retrospect was merely a formality. The urgency of winning control for BU is highlighted by the Harvard pro- posal, which would have closed down those services pediatrics - and maternity- most urgently needed by BU. (Harvard al- ready controls hospitals specializing in those areas.) The City may well have found BU to be the most pliable of these dubious allies precisely because it was the most needy. Or perhaps the prospect of trying to get concessions from Harvard drove the Mayor and his political advisers " As a private, nonprofit, voluntary hospital, we cannot just swing open the doors like a drop - in health center, treating everyone who comes in. " " I UH administrator into the waiting arms of BU. Either way, the decision saves BU millions of dollars in construction money and gives it control of a very large medical complex. But Will It Work? One critical question is unresolved at this point: Can the health needs of Boston's poor communities be met with BCH as a 500 bed - institution? The situation looks grim. During the winter months, BCH nor- mally has a census of over 600 patients. Since the plans call for a bed 500 - hospital this means that about 100 BCH patients will have to be sent elsewhere But a majority of BCH admissions are on the danger list and cannot be transferred out. What is more, if other patients are transferred, and the number of danger - list patients at BCH rises, greater burdens will be put on its al- ready overworked staff and the result will be inferior care. (Already the number of staff but not the number of patients - has been cut in pediatrics and obstetrics.) The bright young men who set policy for the Department of Health and Hospitals confidently state that there are plenty of empty beds in the private hospitals that can be used to absorb the overflow, and that more efficient management of BCH will work wonders. But their crude num- bers games ignore certain realities: On the busy days of the week (Monday to Wednesday) the private hospitals are quite full; in any event, the statistics are all averages, which do not truly describe the health needs of the people of Boston. Their plan to cut down the average length of stay at BCH ignores the fact that BCH patients tend to stay longer because they have nowhere else to go. The transfer of patients not on the dan- ger list is also problematic. The document spelling out the transfer procedures states that " there is little reason to be concerned that BCH transfers will systematically bump a private hospital's elective pa- tients. " This revealing statement, meant to assuage the nerves of money conscious - private hospitals, serves to clarify the real inflexibility in the system: They'll only take our patients if it pleases them. Evidence from BU's University Hospital reinforces this observation. Under a formal arrangement, UH has agreed to take the first three non danger - list admissions to BCH every morning. However, since the agreement has gone into effect, UH has often not taken three admisions and has sometimes taken none. After all, as an un- named UH administrator put it: " As a pri- vate, non profit -, voluntary hospital, we cannot just swing open the doors like a drop - in health center, treating anyone who comes in. We already have a deficit of one million dollars. " At the same time, UH chief administrator, John Betjeman, was complaining that they couldn't fill their new beds! It seems they are only willing to fill them with certain patients. If BU associated - hospitals are reacting to BCH transfers this way, one can hardly ex- pect that other private hospitals will come to the rescue. Evidence from the State Sen- ate's Social Welfare Committee suggests 21 that these hospitals have already begun to resist the influx of the poor. " We have documented cases, " says a legislative aide, in " which the private hospitals have taken people into their emergency wards and then sent them after the initial work - up to Boston City if they can't pay. " Peter Bent Brigham Hospital (a Harvard institution) came out shortly after the BCH cutback was announced with a new out- patient form by which the patient signed away all rights and agreed to pay his bill by any means necessary. The form, which was probably illegal, was withdrawn after worker and community pressure was exerted. Its introduction, however, is hardly an indication of the willingness to " pick up the slack " that the Mayor's men have imputed to the private sector. As of late September, 1973, BCH had not yet been fully cut back to 500 beds. At its present capacity of 550, the Hospital has been full on several occasions during the summer, traditionally its slackest period. Voluntary hospitals have also been full; UH, for example, peaked at a bed census of 110 percent of capacity. The winter thus promises to be a bitter one. BCH will almost certainly overflow, and the private hospi- tals will almost certainly either not have any beds available or not be willing to use them for BCH's unattractive constituency. How Did It Happen? One would have expected a variety of groups to mount a campaign of opposition to the budget cuts and the consequent un- dermining of Boston City Hospital, groups such as health professionals, hospital workers'unions, community activists, and activist health workers. And some of these groups did protest. Unfortunately, the op- position failed. Lessons, however, can be learned from the failure. The majority of professionals at BCH are doctors - house staff and attendings - and nurses. The attendings, the senior perma- nent staff in the hospital, never publicly opposed the changes; this was hardly sur- prising in light of the fact that their pri- mary allegiance was to the medical schools. In theory at least the residents and in- terns might have been another story. Their four year - - old union, the House Officers As- sociation (HOA), has 300 dues paying - members. But it has never been able to build a solid organization with more than token participation by the membership. The HOA did express concern about the cutbacks and a desire to work with the " 22 community But the gap between its young, white, male, professional, suburb- dwelling members and the real community of the Hospital was so great that the senti- ment never got beyond words. Ultimately the worm turned and the house staff paid for its aloofness. The first cut at BCH elminated 70 house officers'po- sitions. By then it was no wonder that other workers felt, " We have nothing at stake when house officers are cut. " If the house staff failed to win the race, the nurses barely got to the starting line. They did have a number of meetings of their organization, the Massachusetts Nurs- ing Association (MNA). The Association, however, never really developed any re- sistance. This wasn't surprising, since the leadership of the MNA was mostly non- hospital based and could hardly empa- thize with the plight of their sisters at BCH. Furthermore, in an interesting conflict of interest, the president of the Association this year is also the City's head nursing. administrator. Most non professional - Hospital em- ployees are divided into two major unions. About 1,800 blue collar - employees belong to Local 1489 of the American Federation of State, County, and Municipal Employees (AFSCME), and about 1,200 white collar - workers are members of Local 285 of the Service Employees International Union (SEIU). The history of both unions hardly inspired confidence that they would forth- rightly stand up either for their member- ship or the cause of good patient care. Local 285 has not held a meeting in the Hospital for a year and, in violation of state law, has not reported its income for seven years. Nor is Local 1489 much more democratic; when a young activist tried running for shop steward, union officials failed to show up for the election and thus prevented its ever being held. In fact, the leadership of both unions seemed to be protecting both the Mayor and the older, long term - workers, a vast majority of them white. Despite great talk of militancy on the part of the leaders of Local 1489, they never once took a stand against the cuts, even though hundreds of their members'jobs were at stake. As to patient care concerns, the union has never raised quality of care as a union demand. Its business agent, in fact, once answered a question about cuts in jobs and services with the remark, " Forget the pa- tients. " Thus although a movement within the union against the cutbacks could have provided the authority to command the at- tention of the vast majority of hospital workers, it clearly wasn't in the cards for 1973. The community as a force against the cutbacks was initially handicapped by the fact that the Hospital serves many diverse communities - mostly Black Roxbury, the racially mixed South End and North Dor- chester, and mostly white South Boston. Few community groupings have real spokespeople; all have politicians and so- cial agencies claiming to speak for them. Their disunity, combined with more than a little demagoguery, did not bode well for creating a strong community voice to oppose the Mayor's chicanery. There were a couple of community meetings, greeted with small attendance and with even fewer people who were will- ing to do any real work on the issue. Inter- ruptions by sectarian left groups made things even worse. These internal weak- nesses were intensified by the lack of any link between consumers and workers and by everyone's being unprepared for the suddenness of the cuts and the massive- ness of the problem. Linking consumers and workers would have been difficult at best, given the divi- sions of race and class that existed. The Hospital's political groupings and leaders were mostly white, in contrast to the mostly Black and Third World community. Many white workers and white patients had once lived in neighborhoods since " taken over " by Black and Spanish speaking - peo- ple. Class contradictions were interwoven: The hospital hierarchy was topped by those who see themselves primarily as pro- fessionals, unwilling to grant others the ability to make intelligent decisions in a field as " specialized " as health. Much of the scant eight week - period from the first announcement to the final blow was lost in waiting for the official community representative, the Board of Trustees of Health and Hospitals, to furnish leadership. This body, mostly Black and Spanish speaking - , all appointed by the Mayor, spent weeks issuing rhetoric about opposing the cuts, while quietly arranging behind the scenes to carry out the reduc- tions. A widespread willingness to let the Trustees carry the ball was reinforced by the fact that previous threats of cutbacks had proved to be false alarms and the fact that the quality of care at BCH had been such a frequent target of criticism that it was a little embarrassing to take a posi- tion defending the Hospital. The final locus of opposition to the cut- backs was a group of activist hospital workers known as the Better Breaks Group (BBG). Composed primarily of young, white, transient, educated employees in their first year at the Hospital, the BBG had been meeting for only about three months (with attendance ranging from half a dozen to about 50) when the crisis broke. It lacked solid political unity, organiza- tional form, and real connections with the majority of workers. To deal with the budget crisis, several BBG members organized an Ad Hoc Com- mittee to Save the Hospital. It got off to an encouraging start organizing - , on 12 hours'notice, a demonstration of 50 people at the Mayor's office, followed by a mass meeting attended by 200 people, who agreed on a demonstration and petition drive and an effort to reach out into the community. Then things started falling apart. The number of people willing to work turned out to be pitifully few, and the most dis- ciplined of them were affiliated with the Progressive Labor Party. This group. pushed through decisions and set up agendas and speakers'lists that many peo- ple in the Ad Hoc Committee thought were exclusive and sectarian. They called for a citywide strike without being able to back up the call with any substance. The second mass meeting, which started out with 150 in attendance, quickly broke down into factional bickering among the National Caucus of Labor Committees, the Communist Party, and the Progressive Labor Party. Within half an hour, two- thirds of the audience had departed. Overall, however, the failure of the anti- cutback coalition cannot be blamed simply on factionalism. Those who actively organized against the cuts were afflicted by the same lack of contact with most workers and patients that affected the sectarian groups. Also things happened fast - far too fast for them to act intelligently. The overriding sense was that of being overwhelmed by the Mayor, the Trustees, the administration, the medical empires at play. One big lesson from the struggle this year is that an organization cannot be built overnight and in a time of crisis. The groundwork must be laid before. The ob- ject of organizing at BCH must be to fight to keep it in the hands of the City, where there is the possibility of exercising some control over the course it takes. A City - run BCH could be a base from which an organ- ized constituency of health workers and 23 consumers could experiment, create mod- els, demand more city - run health services and more privately - run community health services. Hopefully, the losses suffered this year can be used as lessons on how better to fight and win victories in the com- ing years of struggle over the future of public health care in Boston. -Jeff Blum, Jerry Feuer, Kate Mulhern and Joan Tighe. (The authors of this article worked at Boston City Hospital and were members of the Better Breaks Group.) HOSPITAL POSITIONS Detroit General: Two years ago Wayne State University medical stu- dents organized the Norman Bethune Collective " to change health care in Detroit, to change the quality of our professional lives, and to help make social change in this country. More people are needed by the Collective. Those interested should write Howard Beckman, 741 Seward (Apt. 202), De- troit, Mich. 48202 or call (313) 875-0261. Lincoln Hospital: Lincoln Hospital is the only public hospital in the South Bronx and logs more emergency visits than any other New York hospital. For the last three years the Lincoln Col- lective has fought for improved pa- tient care with Third World commu- nity and worker groups. Now re- focusing its efforts on particular departments such as Pediatrics and Medicine, the Collective seeks to recruit new staff. Those interested should contact Mike Steinberg, Box 62, Lincoln Hospital, 333 Southern Blvd., Bronx N.Y. 10454. Cook County: Cook County Hospital. the largest hospital in the country, is the only hospital in Chicago serving poor people. It has responsibility for prisoners, is developing a growing outreach program and is developing new approaches to the use of para- professionals. Those interested in staff positions there should contact Quen- tin Young, M.D., Chief, Dept. of Med- icine, Cook County Hospital, 720 S. Wolcott, Chicago, Ill. 60612. 24 Bellevue (Continued from Page 14) Hospital failed to function adequately. Dr. Carlisle, the first historian of Bellevue, stated in 1893 that " Bellevue Hospital, with its yearly census of over 16,000 patients, has a maternity ward of six beds. This ward is not only inadequate in size, but it possesses inadequate means of caring for patients. It has not proper room for the seg- regation of patients nor has it means for ventilating the building after modern meth- ods and has no room for the disinfection of clothing. " Even with such statements being made by eminent physicians and recorded in print, no action was taken until a decade later when newspaper exposs and a mur- der trial related to the psychiatric service appeared. One writer of Bellevue's history assessed the situation this way: " Bellevue as a surgical and medical experimental center using as material the human wreck- age of the city was one thing. As a hospital it was a disgrace, even by the city hospital standards of the day. " In 1902 another wave of reform hit Bellevue. Control of the Hospital was transferred from the Com- missioners of Charities and Corrections to a new Board of Hospitals, with Dr. Brannan, a man committed to building a new Belle- vue Hospital, at its head. Beginning with the general medical pavilions in 1908 and finishing with the psychiatric building in 1939, the Hospital was built anew. McKim, Meade, and White, the most famous archi- tectural firm in the country at the turn of the century, designed the new Hospital which is the decrepit Bellevue of today. But even with this new start and many peo- ples'commitments to the goals of patient care, the facilities and faculties were again overwhelmed by widespread deteri- oration of the buildings, services and med- ical care coordination, and by the over- crowding with the advent of new groups of poor peoples. The situation became almost intolerable, but doctors, administrators, and City gov- ernment applied themselves to quieting the discontent, until in 1957 Dr. Dickinson Rich- ards, director of the Columbia Division at Bellevue, summoned attention to the ne- glected institution. He asserted that the City had " shamefully neglected " Bellevue and that there were " neither the physical facilities nor the personnel to permit ade- quate care. " The next day his statement was endorsed by other prominent heads of departments in the Hospital. The City promised to plan for the new Hospital, which finally nears completion.