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HEALTH HEALTH PAC PAC BULLETIN BULLETIN BULLETIN No. 78 September / October 1977 1 1985: CLOSING THE DOOR ON NURSES, NEW YORK STYLE: In a strategy to " upgrade " the profession, the NYSNA pushes the BSN degree as a re- quirement for RNs. 10 Contracting for Emergencies: THE SELLING OF EMERGENCY SERVICES IN SAN FRANCISCO. San Francisco's voluntary hospitals turn their emergency services over to proprietary providers. 13 Columns: WASHINGTON: What's Healthy for Business? WOMEN: Abortion: Cash Choice. NEW YORK: HHC: From Spotlight to Scrapheap. WORK ENVIRON / : Work, Race and Health. 24 Media Scan: Decarceration: Community Treatment of the Deviant - A Radical View, by Andrew T. Scull. 1985: CLOSING TOHNE NDUOROSRE NSu,r sing NurNsuirnsgi nigs ipsr oaf epsrsoifoens siino nt uirnm oil turmoi. l Nurses are NEW YORK STYLE tired of subservience and of their role as hand- maidens, and they are seeking new avenues to respect and status. These avenues are as diverse as the trends toward independent nursing prac- K.PENDIS tice, the " laying on of hands, " unionization and professional upgrading. For the profession, it is an important time of change which offers both pro- gressive and regressive potentialities. Leaders of the nursing profession have opted for professional upgrading - requiring more and more education and training for becoming a nurse. The American Nurses'Association (ANA) in 1974 endorsed continuing education as a requirement for the continued licensing of nurses and pressed state affiliates to have such measures passed in state legislatures. Taking the ANA lead, the New York State Nurses Association (NYSNA) is sponsoring the most stringent measure to date - a bill that will make a Bachelor of Science in Nursing (BSN) degree a requirement for licensure as a Registered Nurse (RN). A History of Upgrading For more than fifty years, nurses were trained predominantly in three - year, hospital - based Diploma programs. These programs varied widely in the amounts of formal classroom educa- tion they offered, although contemporary programs usually provide at least one full year of such education. Initially, however, Diploma programs were de- signed as apprenticeships. Student nurses learned directly under the supervision of instructors on the wards (the only nurses paid by the hospitals at the time). The main beneficiaries of this arrangement were the hospitals, which obtained full nursing services for the mere cost of room and board for the students, and salaries for a handful of instruc- tors. In the early 1920s, the Goldmark Report indicted hospitals for their labor practices and their failure to provide formal education. Pressures on hospital schools increased during the Depression when the demand for graduate nurses fell sharply. Large numbers of graduate nurses found themselves in competition, for the first time, with virtually free student labor. Criticism of the Diploma schools resumed soon after the war when a flurry of highly theoretical educational studies were released. The most wide- ly read was the Brown Report, issued in 1948, which called for shifting nursing education from the hospital to the university. Hospitals, however, were still highly dependent on the labor of unpaid and underpaid workers and a successful cam- paign to change the dominant mode of nursing. education would have to wait until the middle 1960s. (For history of nursing, see also Septem- 2 ber October - 1975 BULLETIN.) Growth of Different Nursing Programs in the US Year 1968 1972 Number of AD Programs 330 541 Number of Diploma Programs 728 543 Number of BSN Programs 235 293 Source: Carrie Lenberg, " Educational Preparation for Nursing 1972, " Nursing Outlook, September, 1973, p. 586. In 1965, the American Nurses'Association, claiming to represent the professional interests of nurses, issued a position paper calling for the divi- sion of nursing into two levels: " Professional " nurses were to be educated at the university (BSN) level, and " technical " nurses were to be educated at the community college, Associate De- gree (AD) level. ". Similarly, the National League for Nursing (NLN), which accredits and regulates schools of nursing, passed a resolution, also in 1965, calling for an increased emphasis on Bac- calaureate programs. Subsequently, most programs developed after 1965 have been either university or community college programs, and a war of attrition was launch- ed against the hospital schools. Between 1968 and 1972, the number of hospital diploma pro- grams dropped by 25 percent while community college (AD) programs nearly doubled and uni- versity (BSN) programs grew modestly. (See box.) 1984 + 1 A year after the ANA position paper, the NYSNA adopted its stance in a " Blueprint for the Education of Nurses in New York State. " It re- affirmed its commitment to a two - tier nursing sys- tem again in 1974 and held special conferences in 1975 to work out a formal legislative proposal. An NYSNA amendment to the State Education Law was submitted to the 1976 legislature. Essen- tially, it called for a BSN degree as the minimum qualification for licensure to practice " profes- sional " nursing in the state, to take effect in 1985 hence - the term " 1985 Proposal. " An AD degree is to be required for the lower level " prac- tical " nurse. The measure includes a grandfather clause, ostensibly to protect those nurses licensed before 1985. The " 1985 Proposal " did not pass in 1976, and was reintroduced to the 1977 legislature, where it languished in committee until the expiration of the session. Although the bill is still pending, eventual passage seems certain. One of the only changes the bill has undergone has been to change the term " practical " nurse for the AD graduates to read " registered associate " nurse because it had too blatantly expressed the downgrading effect of the proposal on the majority of working nurses. The Economics of Nursing Nurses, like other health workers, have suffered historically from low wages and poor working conditions. Largely due to unionization since the late 1950s, however, salaries have risen dramati- cally in the last few years, as have wages for most health workers. In New York City voluntary hospi- tals, wages for general duty nurses now range from $ 12,920 to $ 16,201.3 16,201.3 While the supply of nurses relative to demand has remained essentially stable around - 82% of the estimated need for nurses according - to DHEW, there are many indications that what was once considered a nursing shortage exists no eee An old adage says that " an LPN is someone who does at night what an RN does during the day. " longer. For example, the restrictions placed on immigrating RNs have become increasingly stringent. Also, the fact that hospital administra- tors must now pay nurses the same as other skilled workers with BS or MS degrees undoubtedly im- pacts on estimates of need. As might be expected, the American Hospital Association's Assembly of Hospital Schools of Nursing opposes the 1985 Proposal. This opposi- tion, however, probably stems from the sectional interests of those hospitals which still utilize the free labor of in house - students, and does not represent the view of the university - based medical empires built on high technology. The New York Academy of Medicine recently took a stand opposing the 1985 resolution. It came out strongly in support of Diploma programs, as did the American Medical Association a year ago. RS At least 24 BSN programs exist that do not accept students who are already RNs! ee What is needed in nursing, these groups say, is better bedside care and less " overeducation. " Apparently the Academy feels that doctors'unilat- eral control of patient care is threatened by nurses with BSNs. Increased education for nurses is pro- gressive as far as it challenges that control, but what would it mean to the nurses that are working now? Looking for Differences An old adage says that " an LPN is someone who does at night what an RN does during the day. " In fact the differences between the roles of RNs, LPNs, aides, orderlies and technicians are often hard to distinguish. Nursing journals rail against this egalitarian practice. To upgrade the role of the RN and to justify the increased education, the ANA and NLN must differentiate the role of a nurse with a BSN from that of a nurse with an AD or Diploma. One of the few unique roles projected for a BSN nurse is the supervision of other RNs. Under the 1985 Proposal, any Bachelors de- gree is not sufficient for an RN. He or she must have a Bachelors degree in nursing. Thus a nurse cannot get a BS in Sociology, for instance, and meet the requirements. Nationally the NLN has engaged in a publicity campaign to warn nurses away from non nursing - major programs. Ironically, the reason given is that, in contrast to social science degrees, for in- stance, the baccalaureate in nursing will " prepare an independent practitioner who will assume a 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 6 times per year: Jan./Feb., Mar./Apr., May June /, July / Aug., Sept./Oct. and Nov./Dec. Special reports are issued during the year. Yearly subscriptions: $ 8 students, $ 10 other individuals, $ 20 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: Barbara Caress, Oliver Fein, David Kotelchuck, Ronda Kotelchuck, Ken Rosenberg and Loretta Wavra. Associates: Robb Burlage, Len Rodberg, Washington, D.C.; Constance Bloomfield, Desmond Callan, Michael Clark, Nancy Jervis, Kenneth Kimmerling, Louise Lander, Steven London, Marsha Love, New York City; Vicki Cooper, Chicago; Barbara Ehrenreich, John Ehrenreich, Long Island; Robin Baker, Elinor Blake, Judy Carnoy, Dan Feshbach, Carol Mermey, Ellen Shaffer, San Francisco; Susan Reverby, Boston, Mass. BULLETIN illustrated by Keith Bendis. Health Policy Advisory Center, Inc., 1977. 3 leadership role and who is prepared to meet the psychosocial - cultural needs of individuals, families and groups, as well as their physical needs "! 4 To add insult to injury, BSN programs give working nurses very little credit for experience and acquired knowledge. At best, they receive credit for a few basic introductory courses and are required to fulfill most academic non nursing - re- quirements. Moreover, since classes are usually scheduled during daytime hours, the working nurse who wishes to get a BSN must work even- ings or nights in order to attend classes. Heavy science and humanities loads are required less, it would seem, to benefit the RN than to weed out the " undedicated. " The prospect of large numbers of working nur- ses getting BSNs apparently threatens the degree with the taint of vocationalism, and some educa- tors believe that too much consideration is given to the problems of the working nurse. " we seem to be so immersed and almost rabid in our zeal to provide registered nurses with opportuni- ties to obtain a baccalaureate degree... with their taking a minimum amount of course work that we sometimes seem to have lost sight of the four year - generic program. Consider, for instance, the student fresh out of high school who wants a bac- calaureate program in nursing because she likes the idea of combining liberal arts, sciences, and nursing in a four year - program, looks forward to experiencing college or university life in the com- pany of classmates and peers who are majoring in other fields, and who has no desire to go through a practical nurse or associate degree program on her way to baccalaureate degree. Her educational needs and career aspirations are dif- ferent from those of the practical nurse, the regis- tered nurse, or the student who started her post- secondary education at the community college level. " 5 NLN consultants proudly announce that 242 out of 266 BSN programs accept RNs as students.6 More importantly, however, this means that at least 24 BSN programs exist that do not accept students who are already RNs! The Grandfather Myth To buy off the opposition of current RNs, the 1985 Proposal provides that, " any individual li- censed as a registered professional nurse prior to January first, hundred nineteen - eighty - four need not meet the baccalaureate degree requirements provided for. " This clause is necessary be- cause, as of 1972, 80.5 percent of all working nurses, and 84.6 percent of those working in hospitals, had less than a baccalaureate degree. " This clause offers less than meets the eye. It fails, for instance, to assure jobs to or bar discrimination against RNs who do not have a BSN. While a hos- pital couldn't fire a nurse for not having a BSN, neither can the nurse leave her job and expect to return to the same position later. Furthermore, the Proposal greatly hampers the ability of a nurse to move easily from one job to another. Finally, the Programs ALL PROGRAMS Chart I Black Enrollment in US Nursing Schools Number Year Enrolled % Year Number Graduated 1963-64 1972-73 3247 15210 2.7 7.7 1963-64 1971-72 1081 2735 % 3.4 6.3 DIPLOMA AD 1963-64 1972-73 1963-64 1972-73 2024 2330 253 7070 2.2 3.5 4.2 11.5 1963-64 1971-72 1963-64 1971-72 590 587 78 1676 2.2 3.3 5.6 10.1 BSN 1963-64 1972-73 970 5810 4.2 8.5 1963-64 1971-72 413 472 9.7 5.0 Source: Department of Health, Education and Welfare, Minorities and Women in the Health Fields, 1975, pp. 44-46. Proposal contains an " equivalent education clause " under which students obtaining their BSNs could work as LPNs. This clause could be used to actually demote many present RNs. (For hard- ships imposed on working nurses by additional (nS While Blacks have made some recent gains in nursing, the 1985 Proposal... could wipe out any gains they have made. Sa educational requirements, see Women's Column, March - April 1977 BULLETIN.) RNs will always be able to find work as RNs in the less desirable sectors nursing - homes and small community hospitals. Teaching hospitals, however, are expected to hire only BSNs after passage of the 1985 Proposal. The Proposal could also rebound on LPNs. With non BSN - RNs being pushed downward in the workforce, LPNs may have to upgrade themselves to the AD level or be satisfied to work as nurses'aides. At New York University's prestigious Universtiy Hospital, the administration has already adopted a de facto policy of hiring only recent BSN graduates and reducing the number of LPNs through attrition. If hospitals cooperate to bypass the grandfather clause, they could save millions in skilled nursing wages, either by forcing non BSN - RNs to work as LPNs, or by setting up wide differential pay scales. For the older nurse, this would further con- firm her decaying position in hospital nursing. The Race Component Historically, working class women have used nursing as an avenue of advancement. Even though nursing has been considered " women's work " and has been low paid by objective stan- dards, it was still alot better than the sweatshop. The predominance of Irish and Italian nurses in New York is testament to this. Minorities have played a particularly large role in unskilled hospital work, and a lesser role in the skilled jobs, such as nursing. What effect will the 1985 Proposal have on them? Figures on the numbers of minority workers in various job categories in the health care system are not readily available. Statistics on the number of Black students in various nursing programs do exist, however. (See Chart I.) Diploma programs have the consistently worst record of Black enroll- ment. This could be partially due to the fact that many hospital schools of nursing are located in towns and small cities; moreover, many are located in Catholic hospitals. The greatest change in Black enrollment has occurred in AD programs. These two year -, com- munity college programs now have the largest proportion of Black students of any nursing pro- gram. Unfortunately, it is precisely the AD gradu- ate who will be excluded from " professional " nurs- ing if the 1985 Proposal passes. For BSN programs, the figures are less clear. While there have been large increases in the num- ber of Black students enrolled, the number who have graduated has remained essentially con- stant. As a percentage, they have actually de- clined. This phenomena might be partially ex- plained by large numbers of Black students ad- mitted in the last few years. The delayed effect should not be so large, however, and if accurate, Chart II Nursing Schools with Low Percentages of Black Students All RN Practical / AD Diploma BSN Programs vocation. Schools with no black students 17% 32% 10% 21% 26% under Enrollment 5% - 46% 56 56% 60% 53% 20% 6E-n1r4o%l lment 22% 9% ~~ 21% 17% 23% 85% 97% 91% 91% 69% Source: Carrie Lenberg, " Educational Preparation for Nursing - 1972, " Nursing Outlook, September, 1973, p. 591. it is merely an indication of racist practices that existed in the past. Nursing journals have recently featured the " problem student, " suggesting that Black students may drop out at a disproportionate rate. With set- backs in open admissions and minority recruit- ment programs since the Bakke decision, the num- ber of Black students and graduates of BSN pro- grams will undoubtedly level off. Even if the num- ber of Black enrollees and graduates of BSN pro- grams were to increase in the future, they would continue to represent a small minority of nurses. This fact is even more striking when one looks at the percentage of schools with small Black enroll- ments. (See Chart II.) It would appear that BSN programs have attempted to recruit some Black 5 Conclusions Other State Efforts to Increase Nursing Requirements Arizona - Diploma schools are already phased out. The nurses'association is polling its members on the two level - system of lic- ensure. The 1977 New York State Legislature ad- journed without passing the 1985 Proposal but it seems only a matter of time until it passes. Nor is New York the only state where moves are being made to increase licensing requirements for nurses. (See box.) The impetus for upgrading nursing and situating it in a more academic context comes Idaho The Idaho Nurses'Association House of Delegates passed a resolution sup- porting the two level - concept, and has es- tablished an ad hoc committee to explore implementation. Maine The State Nurses'Association has gone on record as seeking a minimum of BSN for licensure by 1990, but feels it is an unrealistic goal because of the " unwilling- ness of universities to revise their curricu- lums. " from the growing dissatisfaction among nurses with their status. At the educational level, the pro- fession has responded to these pressures by at- tempting to place nursing education squarely in the university framework seeking in all ways pos- sible the stamp of academic approval. Thus one now finds increasing discussion of a nursing doc- torate. " Even more encouraging is the increasing call for a professional doctorate,'although I wish the title were less pretentious. Various models leading to this degree have been proposed... There Ohio The Ohio Nurses'Association has in- seems to be some agreement, however, that it cluded a two level - plank, also to take effect in 1985, in their proposal for amendment of the Ohio Nurse Practice Act. should be the first professional degree in nursing, to be awarded on the basis of professional educa- tion roughly comparable to that offered by other Oklahoma - Forums are being held around the state to evaluate rank - and - file support for a two level - licensure system. professions conferring similar degrees - M.D., J.D., or D.D.S., for instance. In the recognition that nursing needs a professional degree, there is reinforcement of both the nature and significance Oregon - The Oregon Nurses'Association. of the academic degree. " 8 has gone on record several times in support TD of the concept. ... it also comes from a Pennsylvania - The State Nurses'Associa- tion has passed a resolution in support of the BSN minimum, and is developing a formal legislative proposal, also projected for 1985. Texas The Texas Nurses'Association is working on a formal position. contempt for the lowly " floor nurse " and other cogs in the hospital workforce. ee At the level of nursing practice, the profession Washington - The issue is under study. has responded to growing pressures by seeking ever greater professionalism, diversification and Source: Richard Hadley, " States Address Entry exclusivity. On the floor level this has meant an Into Practice Issue, " The American Nurse, April increased emphasis on supervisory and adminis- 15, 1977, pp. 3 6,, 8. trative roles; elsewhere, it has meant stressing the uniqueness of that body of knowledge which con- stitutes the nursing profession, whether it be faith. students, but not too many. The usual term for this healing or attempts to become independent, free- practice is tokenism. standing practitioners. These impulses come While Blacks have made some recent gains in nursing, the 1985 Proposal will push them down partly from a healthy reaction to female subjuga- tion in the health care system. Unfortunately, how- more severely than others, and could wipe out ever, they also come from a contempt for the lowly any gains they have made. The preparation, time " floor nurse " and other cogs in the hospital work- and cost of a college education guarantee that force. " professional " nursing will become the preserve of The President of the NYSNA graphically 6 white, middle - class students. expressed this contempt for nurses as nurses in an FFF C F C C C C C T T F F C G HOSPITAL Wi 85 hysterical letter to the membership recently. In response to a move by the chairman of the Assem- bly Committee on Higher Education favoring a Physicians Assistant bill over the 1985 Proposal, she suggested that all the nurses in New York give up their licenses and apply for licenses as Physi- cians Assistants. Physicians Assistants are favored in the hierarchy over nurses, because they can write orders, in spite of having less education. In her anger over status and prerogative, she seemed ready to abandon the value of nursing. Such issues as professionalism and the 1985. Proposal are not only reactionary, but profoundly diversionary. They do not represent, in any sense, the felt needs of nurses. Nurses are angry over understaffing, shift work, forced and unpaid over- time and poor working conditions. The answer to these woes, however, is not contempt and distanc- ing oneself from fellow workers, but rather the opposite: organization and unification of workers. And nurses are turning in greater numbers to unionization, as indicated by recent successes and the establishment of a nursing division by District 1199 of the National Union of Hospital and Health Care Employees. Perhaps a positive result of the 1985 Proposal will be a growing awareness that the state nurses ' associations represent the nursing bureaucracy, not all nurses. It has been nursing educators, ad- ministrators and graduate students who have sup- plied the bodies for lobbying, rallies and demon- strations. Their impact, if they succeed, will be to demote or at least decrease the earning capacities of tens of thousands of nurses. Nurses constitute half of the health workforce. United, they repre- sent a tremendous force for potential change within the health care system. Creating more divisions, however, will serve only the interests of the latest set of Brahmins. -Glenn Jenkins Glenn Jenkins has worked as a nurse for ten years, the last two and one half - at University Hospital in New York. He is a student in Metropolitan Studies at New York University, and served as a student intern at Health / PAC last summer. REFERENCES 1. Schorr, Thelma, " The New York Plan, " American Journal of Nursing (AIN), December 1975, p. 2141 " New 1985 Proposal Calls for B.S.N. and A.D. for Nurse Licensure. " AIN, 2. December, 1976, p. 1893. 3. New York State Nursing Association, District 13, " Survey of Employment Conditions (as of January 1, 1977). " 4. Epstein and Friesner, " Caution: This Baccalaureate May Be Hazardous to Your Health, " AIN, March, 1977, p. 471. 5. Sorenson, Gladys, " Sounding Board. " Nursing Outlook, June, 1976, p. 384. 7. American Nursing Association, Facts About Nursing: 1972-73, p. 10. 6. Epstein and Friesner, op cit., p. 472. 8. Lewis, Edith. " Professional versus Academic Values, " Nursing Outlook, Octo- ber 1976, p 617.. 9. Barker, Virginia, " Urgent Message From Your President, " April 18, 1977. eee errr errr rere rece ee eee 7 Brookdale: The Nurses Shift The economics of hospital administration com- bined with a somewhat narrow definition of pro- fessionalism by established nursing leadership threatens to leave the majority of working Regis- tered Nurses (RNs) out in the cold in the 1970's and 1980's. (See " Closing the Door on Nurses, New York Style, " in this issue). The response from a growing number of nurses themselves, however, has been anything but pas- sive. In larger numbers for each of the last few years, RNs have been developing alternative- and generally more militant collective - answers to both internal and external threats to their status and their ability to perform the work for which they were trained. To date, RNs have typically sought collective bargaining representation from their State Nurses ' Associations (SNAs - state chapters of the Ameri- can Nurses Association). The SNAs, however, have all too often proven unprepared for the task and out of touch with the majority of hospital staff nurses - not surprising when one considers that they began life as professional organizations and are often dominated by the supervisory and academic elite of the profession. Several SNAs including the New York State Nurses ' Association (NYSNA) -have or did have until re- cently a no strike - clause in their state bylaws. (NYSNA's no strike - provision seems likely to be overturned at the October convention). In short, the SNAs seem less able to forcefully respond to the crisis felt by the majority of nurses than a microcosm of the forces that are creating that crisis. The Brookdale Election Frustration with the SNA approach was made dramatically clear in Brooklyn last February when the RNs at Brookdale Hospital voted to join Dis- trict 1199, the National Union of Hospital Care Employees. In rejecting the NYSNA by a vote of 279-214, the RNs also took a step away from the SNA strategy for professional autonomy. That strategy seeks to preserve RNs'ability to control. their work by narrowly defining their role and clearly separating themselves from other health care employees. The Brookdale RNs, rejecting this approach, chose to cast their lot with some 70,000 other hospital workers in 1199. 8 Most of the impetus for the 1199 campaign at Brookdale came from an organizing committee of RNs themselves. The committee began meeting over a year prior to the election to discuss common problems and alternatives for represen- tation. They discovered two broad areas of agree- ment: () 1 mounting pressure from Brookdale's ad- ministration for increased " productivity " (general- ly translated as more patients per nurse was making good nursing care impossible; (2) the failure of NYSNA to send organizers in person to Brookdale or to develop adequate grievance ma- chinery or collective bargaining strategies in other institutions made them an unlikely choice to represent Brookdale's nurses. The committee considered two other alterna- tives. The first was an independent form of or- ganization for RNs, but this was rejected after in- vestigation and discussion. " An independent or- ganization simply doesn't have the resources or strength to bargain hard and to handle grievances effectively, " said Linda Halliday, a committee member from the beginning. " Besides, nurses today are being divided up enough. We wanted to enjoy the strength of being allied with the other workers in the hospital. " (All of Brookdale's other employees are members of 1199.) The committee therefore approached 1199 and began their campaign by handing out union membership cards throughout the hospital. Fewer than 75 nurses signed up. So the committee be- gan the laborious process of personally contacting each nurse in the hospital to discuss the merits of joining. It was a strategy that clearly proved the difference in winning the election, and was to prove crucial several months later. " I think the success of both the organizing cam- paign and the strike can be traced to the personal relations we established with every nurse at Brookdale, " according to Sondra Clark, another committee member. The strike to which she refers came in late August after over five months of ex- tremely difficult bargaining with the Brookdale administration. On Strike! From the beginning, Brookdale's administration reportedly viewed the 1199 bid for nursing repre- sentation as a threat not only to the institution itself but to the citywide League of Voluntary Hospitals as well. Brookdale is Brooklyn's largest voluntary and is well represented in the League, which annually negotiates with 1199 for its member hospitals. The RNs set up a negotiating committee and polled all nurses cdncerning major demands and grievances. The resulting 27 demands included. such bread butter - and - issues as vacations, pay in- creases, shift and experience differentials, and tuition and in service - training reimbursements. But it also raised broader issues: union security (closed shop) and contract expiration date (the RNs sought an expiration date as close as possible to the expiration date of the other 1199 1199 workers at Brookdale), as well as arbitration of professional grievances and establishment of patient welfare and staff development committees. Five months of tough - and often angry - bar- gaining failed to move the hospital on any of the major issues, and by early August the RNs felt ac- tion was overdue. A sick - out in June had proven very effective, indicating most RNs. were prepared to act. The negotiating committee called a strike vote and a majority of nurses voted in early August to send the hospital a ten day - strike notice. In the days immediately preceding the strike, the federal mediator assigned to the negotiations called for around - the - clock negotiations. Token concessions were made by the administration on some key issues. Finally, early in the morning of August 22 the - strike deadline - the committee had a package offer from the hospital that repre- sented slight concessions on many issues, but was far from initial RN demands. Most members of the negotiating committee were unsatisfied with the package, but all worried about the real support among the majority of RNs for a strike. They de- cided to postpone the strike for 24 hours, to pre- sent the hospital's package to the entire nursing staff with no recommendation for acceptance or rejection, and to reassess the strike following a vote by all the nurses. When the votes were counted Monday evening, the results were overwhelming even to the committee: by a margin of 272 to 100, the RNs had voted to reject the package and to walk out. Tuesday morning, August 23 saw picket lines surrounding the hospital, as a strike committee co- ordinated the work involved and the situation in- side. Few nurses reported to work, some units were without RNs altogether except for super- visors and similar personnel. An emergency care committee was established to send an appropriate number of RNs to any unit with a medical emer- gency on a temporary basis. Throughout the strike, other 1199 workers resisted pressure to fill in for the absent RNs, and many personnel refused to take over nursing duties. From the first day of the strike, sick outs - by other hospital workers began to occur in various units throughout the hospital. (Other 1199 em- ployees were bound by a no strike - clause in an existing contract. Although many " individually " refused to cross picket lines, the union could not officially call them out). As the strike drug on into the second day, rumors circulated that a hospital- wide sick - out by other workers would occur the following day. The hospital agreed to resume negotiations. When negotiations resumed on Wednesday af- ternoon, they involved a negotiating committee newly energized by the support of the majority of Brookdale's RNs. Several hours later, major con- cessions had been made by the administration, and the negotiating committee emerged with a package they felt could be recommended for ac- ceptance. Most RNs evidently agreed. On Thur- sday, August 25, Brookdale RNs voted 283 to 35 to accept the new contract. The Brookdale strike seems notable in two respects: (1) The viability of a trade union strategy for representing Registered Nurses would seem to have been given a significant boost by the settle- ment itself - a settlement that leaves Brookdale's RNs with one of the best packages in the region. Gains from their contract incfude: guaranteed rights with a method of redressing grievances in- cluding final recourse to outside arbitration; every third weekend off; significant pay, vacation, shift differential and other benefits increases; a voice in patient welfare and staff development policy within the hospital; and an agency shop, with a possibility of union shop if 75 percent of the RNs join 1199. (2) It has clearly stimulated similar organizing activity among RNs at regional hospitals. Sondra Clark, since named the Director of 1199's new RN division, reports that organizing committees have formed at a number of regional hospitals and the union now receives numerous inquiries con- cerning RN membership. The NYSNA conceded in a recent letter to all member nurses that its own organizing efforts had been troubled recently by inadequate staffing and difficult internal problems. If these have left the majority of RNs in a vacuum, it is a vacuum 1199 proposes to fill. 9 THE WELKULZUS ROOM THE OEEM EOPREGNE NHOCUYR SR OY EOAMR OR O36O5M | 24 TTT x = SPECIAL OF THE WEEK X - RAYS Y OFF EMERGENCY SURGERY X - RAYS ONLY 2.000 GREAT SAVINGS ON HEART ATTACKS THIS MONTH Ears BUSINESSMAN'S BUSINESSMAN'S SPECIAL HEART A+T TACK CARE, ROOM PRIVATE PRIV+ AT E TELEVISION TELEVISION BENOIS Contracting for Emergencies: THE SELLING OF EMERGENCY The failure of the American medical care sys- SERVICES IN tem since World War II to provide low cost -, com- SAN FRANCISCO munity - based, accessible primary care has been paralleled by dramatic increases in costly, hospi- tal based - substitutes such as hospital emergency room (ER) services. " There has been over a 600 percent increase in the number of emergency visits in some hospitals in the last 25 years, " estimated Senator Alan Crans- ton (Cal D -.) in 1973 Senate hearings.'Emergen- cy visits increased nationally from 15 million in 1955 to 50 million in 1970,2 and have since in- creased at an average of 10 percent each year. The intrusion of high technology - , hospital- based ER medicine into the vacuum left by dis- appearing general practice and community medi- cine is most extreme in the nation's ghettoes and low income - neighborhoods. Cranston noted that, " In the critically underserved neighborhoods of densely populated areas, emergency medical ser- 10 vices should more accurately be termed health services. Here the distinction between emergency medical care and primary health care is very diffi- cult to determine. " 4 One of many reports on emer- gency rooms stated, " More than one half - of Emer- gency Room traffic is made up of patients who are there not because their illness or injuries are serious, but because they have nowhere else to " 15 go. But in the nation's middle- as well as low income - areas, the shifting of primary medical services into hospitals has dramatically altered both the cost and quality of care: * Rather than fulfilling its potential as an alterna- tive to costly hospitalization, primary care via the ER increasingly becomes a form of case finding - and fee ballooning - for the hospitals. In 1973, one of four hospital admissions nationally occurred via ERs. To this are added the substantial costs of the ER visit itself, usually generating additional hospi- tal billing for X ray -, lab, pharmacology and similar ancillary services. * Equally disastrous, however, have been the effects of how ER services are delivered and by whom. Traditionally staffed by interns plus moon- lighting residents or housestaff, the hospital ER has become an arena for one of the newest of medical commodities, the contract emergency physician (EP) group. Growth of Emergency Medicine tion. However, 70 percent to 80 percent of profit is generated by use of ancillary services. " fiZZ The profitability of the voluntary hospital ER is virtually guaranteed by the nature of third party - reimbursements (both Medicare / Medicaid and private insurers). Such coverage generally - un- available for most office or outpatient visits - now extends to over 70 percent of the population. The Emergency medicine emerged as a specialty with the establishment of the American College of Emergency Physicians (ACEP) in 1969. Federal legislation, including such measures as the 1973 Emergency Medical Services Systems (EMSS) Act, provided new economic encouragement for EPs, with Congressional authorizations of $ 45, The vast majority of America's ER patients come seeking routine medical care $ 65 and $ 75 millions for expanded hospital ER care in fiscal years 1974, 1975 and 1976. As does most federal health legislation, or relatively low technology - treatments for mental, drug however, the EMSS bill better reflects the interests of private providers than those of private citizens. and alcohol - related problems. The bill's major focus is devoted to sensational, highly technical care for such real emergencies as accidents and heart attacks. But nationally, only a tiny percentage (between two and three percent) remaining, uncovered population is typically of ER patients require such care. The vast majority " dumped " on tax supported - public hospitals. of America's ER patients come seeking routine For the insured population, clear distinctions medical care or relatively low technology - treat- can be found between those covered by private ments for mental, drug and alcohol - related prob- lems. insurance and those covered by public programs. The former more often white and middle class- The major force behind the expansion of are generally desirable from the hospitals'view- higher - priced, less relevant ER care lies within the economics of the voluntary hospital itself. In the point both on economic and cultural grounds. Medicare and Medicaid patients, however- usually nonwhite and lower or working class - are often treated as patients of last resort. Spurned in times of high occupancy, they are grudgingly re- The hospital ER has become an arena for one of the newest ceived and treated whenever occupancy rates fall low enough to threaten hospital solvency. (The lat- ter may occur seasonally or, under such circum- of medical commodities, the contract emergency stances as when overexpansion of hospitals in any area leads to surplus beds.) Thus they serve as a reserve source of income for hospitals. physician (EP) group. In the words of one San Francisco Emergency Physician, " The purpose [sic] of the Medicare and Medicaid programs was to return the poor pa- tients to the'mainstream,'and that's what's hap- words of one San Francisco administrator, " They pening now. It's the money... the hospitals [ERS] generate the product: patient days. " couldn't do it before and now they can. Emergen- They can also generate a tremendous increase cy medicine is no longer indigent medicine. " in ancillary services, whether or not the patient is Even when covered, however, publicly- admitted. According to Dr. Karl Mangold, mem- ber of ACEP's board of directors and head of one supported patients typically receive a level of care that increasingly characterizes the growing con- of the nation's largest EP groups, " It is generally tradiction within American medicine: rapidly acknowledged that in a typical hospital, 50 per- multiplying, highly technical services in the hands cent of gross revenue is generated by bed utiliza- of private providers without any measurable im- tion and 50 percent by ancillary service utiliza- provement in health. 11 Mainstreaming in San Francisco San Francisco provides a kind of case study of how the " mainstreaming " of primary care into the ERS of the private sector has taken place. Leaving little to chance, the city's voluntary hospital ad- ministrators have waged a vigorous campaign since the late 1960s to persuade often dubious - private physicians that expanded ER services- and particularly those provided by the contract- ing EP groups - pose no threat to their practices. Such physicians - virtually all members of the at- tending staff at these same voluntaries - have been reassured that expanded ER services will yield them new patient referrals and provide reliable off hours - screening for their existing patients. In the words of one major voluntary administrator appealing to his medical staff for cooperation with the newly contracted - Emergency Department Physicians (EDMDs): " The EDMD is committed to the preservation of the private practice of medicine. His income is derived from the private practice of medicine, too. The EDMD is not competitive with the staff physician and has no private office. He will not refer patients back to the EP except under unusu- al circumstances. " The major selling point of the EP groups, mean- while, has been their superior ability to handle emergencies compared with the capacity of tra- ditionally - staffed hospital ERs. The latter have of- ten consisted of hodge podges - of interns and moonlighting residents backed by a few attending staff. EP groups, by contrast, argue that their commitment to emergency care as a full time - career enables accumulation of valuable experi- ence and improves the quality of emergent care available. Whatever the merits of EP claims to improved care for medical emergencies, the implications for the bulk of emergency room patients is unfor- tunately clear: contract EP groups, in the context of decreased access to private physicians and other sources of primary care in the community, mean increasingly fragmented, discontinuous and often irrelevant care for those visiting emergency rooms for non emergency - complaints. Voluntary hospital administrators and EPs alike have managed to find their way onto county com- missions that recommend emergency care in and around San Francisco, waging often successful campaigns for ER expansion. One recent public relations pitch focused on the issue of cardiac care a question certain to appeal to politicians and business people potentially susceptible to car- 12 diac problems. EPs and administrators used the cardiac care issue as the leading edge of a citywide campaign to break what they characterized as a " monopoly " on emergency services in San Francisco held by the city's public emergency care system. The sys- tem whereby public ambulances transport the vast majority of the city's emergency patients to the Mission Emergency center (affiliated with the city county / public hospital hospital,, San San Francisco General) and several smaller emergency featured stations - a widely acclaimed - regional trauma center. Contract EP groups, in the context of decreased access to private physicians and other sources of primary care in the community, mean increasing- ly fragmented, discontinuous and often irrelevant care for those visiting emergency rooms for non emergency - complaints. In the words of one EP: " It's just that in San Francisco, the weak spot in the present public care system is the acute cardiac patient. The pri- vate hospitals can point out that there is no reason not to take the acute cardiac patient to the nearest hospital. This affords the easiest place to start the attack on the present [public] system. We picked the vulnerable place to break their monopoly. And there's a lot of appeal in the issue. It's a hot item because businessmen get the disease. It's an issue that civic leaders could identify with. " The resulting proliferation of ER services in San Francisco since 1970 has been dramatic. Among the city's eight major voluntary hospitals, five have remodeled and expanded their emergency services since 1970. The EP Contract Group The key development, however, has been the spreading use of contracts between voluntaries and private emergency physician groups to staff ERs on a 24 hour - basis. As the chart on Page 21 shows, six of the eight major voluntaries had signed contracts with emergency physician (Continued on Page 21.) labor union representatives con- tinue to lobby actively, par- WASHINGTON ticularly through the the Commit- tee for National Health Insurance which supports the Kennedy bill. Director Goldbeck clearly the urging of Henry Ford III and knows his power; he told other corporate executives who Congress that " employers sit around it, a special task force represent more muscle than they to derive a health policy attuned have even wanted to acknow- to the needs of the broadly- ledge themselves in the case 1 interested large employers. Out of medical care, the major em- of this came the plan for the ployers are also true consumers Washington Business Group on the user, the patient, is Health, a membership organiza- rarely the consumer from the WHAT'S HEALTHY FOR BUSINESS? tion of 145 employers (with 30 million employees) maintaining a strong Washington presence and standpoint of classic economic in- fluences. " Though it is the patient wielding a lot of clout. The 1977 Congressional sum- mer recess has ended. The Carter Administration seeks a corporate consensus on its energy and wel- fare proposals, but its health posi- tion hangs in abeyance. Meanwhile, the corporate com- munity is preparing its class posi- tion through a " public interest " front called the Washington Busi- ness Group on Health. Aware of what it is paying for health care with - General Motors The BizGroup is not simply a right wing - Chamber Commerce - of - sidekick of the AMA. It is hip and But its [Bizgroup's] in the middle of the latest White very existence shows Hyoouunsge Dairnedc tHoErW , aWicltliiso nG.o ldIbtesck ,b right that, at last, business has successfully established entree has become aware of to the inner circles of the Carter Administration and the top levels of HEW. He attends meetings of its class interest in how it is all resolved, Califano's National Health Insur- and it wants Carter ance Advisory Committee and travels with it on its site visits to clinics and health centers. and Califano to be aware that it is touting its finding that " unproduc- tive " medical bills are costing it more than auto body - steel - big business has discovered _ that what's not healthy for GM is not healthy for America. Three years ago, the Fortune 500 rank -, Washington - watching Business Roundtable created, at The Wall Street Journal editorialized early in the 1976 Presidential campaign year that big business must " strip the medi- cal societies of the power to inhibit more efficient methods of delivering medical care. " Despite general corporate Administration agreement on this imperative, the watching. whose life and health are at stake, in the corporate world, as in the Kingdom of Id, " He who has the gold makes the rules. " BizGroup faces a triple challenge In general, the yet evolving - The BizGroup is not in achieving and implementing such policy in post Watergate - corporate program presented at recent Congressional hearings simply a right wing -, Chamber of Com- merce sidekick of the Washington. First, all " special in- terests " are suspect - so the striving for " public - interest " legitimacy has been a key part of underscores the newly critical - rhetoric of Carter (Our " health care system is in the grip of a powerful'spend more, get more ' AMA. It is hip and in the middle of the the BizGroup's strategy during its formative years. Second, medical care costs continue to rise, so the attitude ") and Califano (the " nation's health care system is clearly virtually... a vast... noncom- latest White House longer it delays acting, the greater petitive industry "). It supports and HEW action. the cost to corporate capital; but consensus about exactly what to medical care cost containment, bit it opposes Talmadge's focus do remains very difficult. Third, on the public, programs alone. It 13 rejects the Carter proposed - price that, at last, business has become evolution of health care delivery. controls on hospitals, seeing them aware of its class interest in how it Goodyear's Health Service as a dangerous precedent for price is all resolved, and it wants Carter Manager is president of the controls without wage controls. and Califano to be aware that it is Akron area Health Systems Instead, the BizGroup's program mixes reduction, market watching. Formation of the Washington Agency (which also received start - up financial support from incentives, consumer cost sharing - Business Group may be the Goodyear). and comprehensive planning, with sophisticated victim blaming - that stresses individual habits, de- national counterpart to local cor- porate moves on the problem. It may even represent corporate Willis Goldbeck points out that positions in health planning bodies are " critical entry points emphasizes medical care (especially for the victimized recognition of the limits of in- dividual companies, the need for for gaining some measure of con- trol over medical care capital in- working poor), and ignores cor- collective action and the impor- vestments, operating budgets and tance of federal action in solving administrative procedures..... the health care cost problem. The the major employer purchaser / is BizGroup has been spearheaded by Goodyear, a company whose Big business must " strip the medical societies of the power to inhibit more ef- ficient methods of delivering medical energetic program for controlling health care costs typifies what " forward looking " companies are beginning to do. Goodyear's Board Chairman heads heads. the Business Roundtable's Health Task Force (which oversees the BizGroup) and is on Califano's NHI Advisory Committee; " Employers represent more muscle than they have even wanted to acknowl- edge themselves.. " in the case of medical care. " -Wall Street Journal Goodyear's chief Washington lobbyist heads the the Steering Committee of the BizGroup. care, the major em- ployers are also true Goodyear prides itself on ad- ministering its own health benefit plan - it has no insurance carrier. Its Health Services Manager de- consumers... the. user, the patient, is rarely the consumer porate caused - social and environ- mental sources of illness. It strongly supports the PL 93-641 planning process and is urging scribed the advantage to Good- year: this " allows us to negotiate directly with providers of health. care, just as we would with any from the standpoint of classic economic influences. " broader authority for cor- cooptable porately - Health Systems other Goodyear suppliers.. Goodyear is using its purchasing -Willis Goldbeck Agencies. power to establish more cost ef- Unresolved conflicts remain fective procedures in the com- within the corporate class - bet- munities in which we operate. " ween the industrial companies that pay the growing fringe Goodyear is encouraging the establishment of medical founda- finding new access to direct in- volvement in the health delivery benefits and the drug, supply, tions to provide it with a more or- system the providers must construction and insurance com- derly working relationship with realize that the consumer across panies that benefit from them, and physicians, and it is providing the table just may be the head of a between those individual cor- seed money to an offshoot of the major corporation. porate leaders who think the an- swer is greater state planning and medical society in Akron so it can become the area PSRO. Is the direct corporate super- vision of health care the wave of those who strenuously oppose it. All are represented among the Most significantly, perhaps, Goodyear is urging its manage- the future? Are employers to be- come what one executive called members of the BizGroup, ex- ment employees to serve on them the employee's " health plaining the generality, thus far, of its message to the Administra- hospital boards and health plan- ning agency boards so they can manager? " --- Robb Burlage 14 tion. But its very existence shows even more directly control the and Len Rodberg WOMEN Q ABORTION: CASH CHOICE NOT EVEN A Rockefeller can deflect anti abortion - sentiment in this country. In 1972, John D., III chaired a commission on over- population. It recommended that legal, induced abortion be in- cluded in all fertility control poli- cies as a further means of stabi- lizing the US population. The Supreme Court responded in 1973 with a decision lifting nationwide restrictions on early abortion. The Rockefeller Com- mission also recommended that abortion " be specifically included in comprehensive health insur- ance benefits, both public and private. " 1 Last year, Congress withdrew support for publicly financed abortions. The Hyde Amend- ment, tacked onto a fairly innoc- uous HEW Labor - Appropriations bill, banned Medicaid funds for termination of all but life threat- - ening pregnancies or those re- sulting from rape or incest. Pro- choice and civil rights organiza- tions in concert challenged the constitutionality of legislation that would deny Medicaid - eligible women equal access to abortion services. The lower court agreed; it put a restraining order on the discriminatory provision. The order was lifted on August 4, 1977, in the wake of the Sup- reme Court's June decision that states, too, could withdraw their share of abortion financing. Addi- tionally, publicly supported - hos- pitals were no longer required to provide abortion services. By August, the budget approp- riations process had commenced for Fiscal Year 1977-78, and an even tighter version of the Hyde Amendment was __ introduced: Medicaid would pay for abortions only in life threatening preg- nancies; it would not cover those resulting from rape or incest. The House went along with it; the Senate didn't. The Senate sup- ports its own more liberal Brooke Amendment reimbursement - for " medically necessary " abortions. The amendment, locked in furious debate, went to a House- Senate Conference Committee where to date Senate members have done all the compromising and the House has stood firm. At this writing the bill is still dead- locked. There will be a Hyde Amend- ment in some form, however. Had the Supreme Court decided differently in June, it might have withered away. Now it will become a permanent part of Social Security Act ap- propriations for Medicaid - funded health services until it is repealed by both houses. The legislature and the judiciary bolstered each other's outrageous actions and now women's rights and free choice advocates find themselves playing a reformist game - lob- bying and demonstrating for the least discriminatory piece of legis- lation. The Hyde Amendment and the Supreme Court decision are dis- incentives for states to provide and pay for abortions. Four fifths - of the $ 61 million in public funds spent to finance some 261,000 abortions for poor women under federal - state programs last year came from the federal gover- nment. Few states will continue payments unless federal financing restrictions are liberalized. Four have already withdrawn support for, publicly - funded abortions, while ten which have had tradi- tionally liberal stands on abortion are likely to revert to their former Medicaid reimbursement formula -50 percent state and 50 percent local. At the state level - if not at the federal - a major criterion is likely to be " medical necessity, " a term vague enough to inspire abuse. In the past it has served as a loop- Four fifths - of the $ 61 million in public funds spent to finance some 261,000 abortions for poor women last year came from the federal government. hole establishing abortion as a decision made between a patient and her doctor. Its danger, of course, is the ability of providers to apply it selectively and exploit their decision - making power. One New York City voluntary hospital official seemed relieved that abortion would no longer be performed " helter skelter " (on demand) but monitored (read: controlled) through " professional " decisions. How and why has this cutback happened? The author of the fed- eral amendment, Rep. Henry Hyde (R. - Ill.), is a long time - abor- tion foe. He has said that he would ban abortions for rich and middle class women as well. The poor are an easy target for his 15 brand of self righteous - opportun- ism. Anti abortion - forces have worked long and hard for such a major victory. It is not merely a sop to clear their numbers from the legislative corridors however. A reactionary mood in America embraces a range of issues from US supremacy to male suprem- acy, i.e., from the Panama Canal to abortion rights. Many people are earnestly against abortion. They don't want to subsidize, with their tax money, a medical pro- One NYC voluntary hospital official seemed relieved that abortion would no longer be performed " helter skelter " (on demand)... cedure they view as a symbol of moral decay. There exist conditions which have set the tone for an attack on abortion: a workforce no longer. dominated by white males; and families increasingly unstable and unsure of their role in American life. There are many citizens- men and women - whose discom- fort with their lives and this coun- try is expressed around a highly charged issue like abortion. Still, the current crisis defies any simple economic analysis; af- ter all, as population controllers point out, it costs the public more to support the unwanted progeny of the poor. Family planning, pregnancy, childbirth, liberalized adoption services, and steriliza- tion HEW's - " alternative to abor- tion " plan - will continue to be re- imbursed by the feds. The majori- ty of Medicaid - eligible women 16 will not be able to pay out - of- pocket for legal abortion. It is more likely that they will attempt to self abort -, seek cheap back- room abortions, carry an unwant- ed pregnancy to term, or choose sterilization to put a permanent end to the dilemma of unwanted pregnancies or failed unsafe / con- traception. The current attack on Medi- caid funded - abortions was not in- evitable. In theory, legalized abortion benefitted the poor woman: she could seek a safe one, paid for by Medicaid at a near - by health facility. In prac- tice, abortion services remained inaccessible to a large number of mostly young, black or rural women (some 164,000-245,000 Medicaid - eligible women in 1976, estimates Planned Parenthood). The 1973 decision was supposed to equalize the accessibility of abortion services throughout the country. It didn't. Financing, referral, availability of facilities and access to them has always reflected class structure. Affluent or non poor - women could usually afford the travel expenses to ob- tain a relatively safe, if illicit, abor- tion. Anti abortion - groups were immediately hip to the issue of accessibility. After 1973, they began to chip away at the lib- eralized abortion laws. State laws popped up requiring consent forms, parental consent, and limit- ing abortion to the first trimes- ter. Anti abortion - riders were tacked to federal legislation: the Health Programs Extension Act; the National Science Foundation Act; the National Research Awards, and so on. Community right - to - life groups began to picket local hospitals, re zone - potential abortion clinic sites and harass physicians who performed the procedure. The women's movement had won an ideologi- cal point but the opposition blocked effective implementation of the right to choose. There is fear among women activists that while the Medicaid crisis may indeed be a response to the anti abortion - , pro family - climate, the master plan is ster- ilization sterilization - of the poor, orchestrated from the highest places. Critics of of sterilization abuse are suspicious of the heigh- tened activity of public and private family planners to expand out patient - sterilization services. Even more alarming is the poten- tial for conditional abortions- abortion only with consent to ster- ilize. Population control conspiracy, racism, classism, sexism, or moral climate - no matter what the star- ting point, abortion is a galvan- izing subject. Politicians are not about to relinquish such a hot political touchstone. Safe, - legal abortion as a health care service has had a strike against it for the past five years unequal - distribu- tion. Now, the second strike- A reactionary mood in America embraces a range of issues from US supremacy to male supremacy... economic inaccessibility. Abor- tion remains safe and legal only for those women who can afford it. Strike three may law out - abor- tion for all women. - Sharon Lieberman (Sharon Lieberman is a member of HealthRight, a women's health education and advocacy organ- ization. It also publishes a women's health newsletter.) REFERENCES 1. Commission on Population Growth and the American Future Chairman, John D. Rockefeller III, March 1972. 2. News Release, Planned Parenthood / World Population Sept. 28, 1977. 3. " Socioeconomic Outcomes of Restricted Access to Abortion, " Charlotte Muller, PhD, American Journal of Public Health, Vol. 61, No. 6, June, 1971. YORK NEW M HHC: OUT OF THE SPOT- LIGHT AND ONTO THE SCRAPHEAP? Proponents of a modified public benefit corporation to operate New York City's municipal hospitals viewed it in 1967 as a mechanism to " get the hospitals out of the gutter of New York City politics. " After almost a decade of turmoil, this has seemingly been achieved. Almost none of the can- didates in the recent mayoralty primaries mentioned the Health and Hospitals Corporation (HHC) in public. The candidates'failure to discuss the 17 hospital - , $ 1 billion system might be ascribed to a tacit agreement. A more likely explanation is that no candidate could figure our how to exploit the situation to make it campaign- worthy. Once Dr. John L.S. Holloman was fired in January, 1977, there was no easy target and no publicly identified - spokes- man for the system who might an- swer to a candidate's charges. Without such controversy, HHC simply didn't garner ever prized - newspaper stories. Anyone grappling seriously with the HHC would have dealt with its massive health care fail- ures, its antiquated and inapprop- riate organization and its mam- moth costs. But - as with other important municipal problems- se were never discussed during a campaign conducted primarily through 20 second - _ television commercials. HHC's administration, however, was not inactive. It continued to hire staff during the summer of 1977, and scores of new faces appeared at its headquarters, ap- parently hoping to present a fait accompli to the next City admin- istration. Recent efforts to fill empty beds by admitting private patients and affiliating with Medicaid mills proceded apace. And despite fiscal retrenchment, HHC employ- ees found the energy and re- sources to plan the takeover of a private, debt ridden - hospital- Flower Fifth Avenue, home of the New York Medical College. Thunderous Silence The candidates'silence on these HHC moves and the more fundamental issues, however, was thunderous. Mayor Beame, who established a four year - record of opposition to the municipal hos- pitals, should have found con- tinued opposition to the system- which primarily serves poor people as politically risky as calling for the end of welfare fraud. But the Mayor apparently blew all his steam when he ousted Holloman and installed his own man at HHC last spring. In any case, Beame's campaign seemed deliberately calculated to bore the populus - a tactic perhaps designed by his chief strategists to help the public to forget his four miserable years of tenancy at City Hall. Bella Abzug, with a loud voice and an aggressive manner, ran a campaign as timid in substance as Beame's. She never became the lightning rod for discontent that the newspapers and bankers feared. A campaign of much style and little content was hardly suited to deal concretely with the complex problems of the municipal hospital system - and it didn't. Sitting in an office 150 miles to the north of City Hall, New York's Governor Carey plotted against the incumbency of Beame, a man he reportedly had called an idiot and whose continued presence at City Hall threatened Carey's own re election - plans for 1978. Ab- zug, a woman whose smoke ter- rified him, also made the Carey enemies list. Meanwhile, of cour- se, the Governor chose to promote his law school classmate, Secretary Mario Cuomo. Taking his cue from Carey and his stra- tegy from Jimmy Carter's media team, Cuomo fit perfectly into a vacuous campaign. Cuomo did, however, present a _ lengthy position paper on the city's hos- pitals which any interested voter es Once Holloman was fired in January, there was no easy target and no publicly identified - spokesman for the system who might answer to a candi- date's charges. could get by calling Cuomo headquarters ten or fifteen times. Although Carey's tactics back- fired and Cuomo lost the pri- mary, the author of this well- known document, Richard Ber- man, was subsequently appointed overseer of the state's health care finances. Then Came Koch Ed Koch, the ultimate primary victor, took a slightly different 17 tack. A sustaining theme in his carefully orchestrated campaign was his so called - " toughness and competence. " Translated into NYC competence political parlance, this meant opposition to all municipal dependents - particularly city workers and welfare recipients. " There is really only one con- clusion that can be drawn in my judgment from an examination of the morass in which the Health and Hospitals Corporation which spends a billion dollars a year in tax monies finds itself: that is that the purpose behind removing the Carey has been attempting to get the city administration to agree to a joint city state - appointment of a health czar. This strongman will then supposedly knock the hospi- tals into line. But primary politics interrupted. Cary and Beame weren't talking. And what target could be more ideal than municipal hospitals, a administration of the city hospitals from Mayoral control has not been served. I would find it hard Barely two weeks after the close of political hostilities with both Beame and Carey's man, Abzug never became the light- ning rod for discon- tent that the to believe that with the hospitals as a city agency that the incom- petence was greater. It may well not have been less but hardly greater. " Therefore, in my judgment, Cuomo, eliminated for the run- ning, the Governor announced his nominee for the post. Morton P. Hyman, a shipping executive whom Rockefeller had appointed to the state's Public Health Coun- newspapers and bankers feared. as employing and serving an enor- mous number of both? In fact Koch's opening campaign shot (he clearly won the prize for the contest's longest campaigning) was an attack on the administra- tion of Holloman at HHC. In the fall of 1976, fully 12. two things are required: one is the removal of Dr. John Holloman along with his senior management personnel. And second, a return of the administration of those hos- pitals to the City of New York with the Mayor to have direct respon- sibility. " But with Holloman fired two months later and administrative jurisdiction a very unsexy politi- cal issue, Koch eventually joined cil, was slated for the job. Report- edly, the name had been cleared with Beame's surrogate, former Deputy Mayor John Zuccotti. But Carey failed to include probable- mayor - elect Koch in his calcula- tions. Koch was quick to object to Carey's implicit assumption that he would willingly cede power to the czar without prior review. a Municipal hospitals months before the critical pri- mary, Koch organized a public roasting of Holloman. Koch cited five charges against the HHC - all his campaign mates in stonewalling on the HHC. Aside from boasting about taking on Holloman and the racism charge, should be returned " to the City of New York with the Mayor of which focused on administra- tion and fiscal affairs. The municipal system's failure to which only bolstered Koch's fash- ionable " toughness " image, Koch never again confronted problems to have direct responsibility. " deliver decent health care ranked only as an example of misman- agement. In the order Koch listed them, the HHC was guilty of: at HHC during the primaries. The main issue debated by the candidates during the long cam- paign was capital punishment. -Ed Koch, November 1976 OO) Koch did point out however, that he wasn't unclear about the " neglect of corporation property, misallocation of manpower, poor financial administration, admin- Does Koch's opposition to city employees and welfare recipients combine with his support of cap- problems. " In general, " Koch said, " I believe that a major re- organization of the health care. istrative loopholes in the volun- tary hospital affiliation agree- ments, and negligent planning. " To air his charges, Koch ital punishment to suggest a final role for municipal hospitals, cap- italizing on one of their proven strengths? Stay tuned. delivery system in the city is nec- essary. I believe excess beds must be closed, not just in the mun- icipal hospitals, but also in the organized a one day - ad hoc - hear- ing on November 22, 1976. Holloman, testifying in his own Czar Wars Whatever the outcome of the voluntary hospitals. " Like the ill fated - Cuomo cam- paign, Carey thus seemed to defense, charged Koch with campaign (Koch is the over- make another political faux pas. racism, and Lillian Roberts, rep- whelming favorite), the multi - bil- Evidently like chickens, counting resenting the hospital workers, accused him of anti unionism - . lion dollar NYC hospital industry remains a serious threat to the your czars before they hatch is very dangerous if you don't want Koch, however, reiterated his State's and City's solvency. For to wind up with egg on your face. 18 position: the last six months Governor - Barbara Caress It is known, Davis notes, that ex- WORK ENVIRON nearby field, arranged for by posure of those working on top of the ovens is more hazardous than for those at the sides. Yet, of all Black coke oven workers, 18 per- cent were employed at full time - their employer, a subsidiary of Union Carbide. (See also BULLE- topside jobs compared to only 3.4 percent of whites. TIN, September, 1972.). The result is increased lung and 11 WORK, RACE AND HEALTH Traditionally Traditionally black workers in the United States have been " the last hired and first fired. " The brutal consequences of _ this policy - e.g., black unem- ployment rates approaching 50 percent for inner - city youths, or Black median income only 65 Two key industrial examples cited by Davis of unusually hazar- dous exposures to Blacks are in the steel and rubber industries. Coke is Not a Natural In the steel industry, coke ovens have long been a major focus of concern. Recent studies have shown increased rates of lung and other respiratory can- cers among coke oven workers. Overall, 22 percent of the work- force in basic steel is Black. But in the coke oven area, 90 percent of the workers are Black - a propor- tion that has not varied for at least other respiratory cancers for all coke oven workers, and even more excessive cancer incidence for Black coke oven workers. Thus Blacks experience eight times more deaths from lung can- cer, three times more from other respiratory cancers and a signifi- cant excess from causes other than cancer. Neither Is Rubber a Natural In the rubber industry, Davis reports, a comprehensive study of over 7,000 workers is present- ly going on. Fourteen percent of these workers are Black. Here percent that of whites grimly - reflect the continued realities of American racism. Another consequence, not perhaps so obvious but long sus- two decades. Even within this area, Blacks are proportionally more exposed. again excess mortality from can- cer is found at the front end of the production process, in the rubber He ee pected, is that Black workers, be- Table 1 cause they are typically hired for the heaviest, most hazardous jobs, experience even greater Black Representation in Selected Occupations by Sex rates of occupational disease and Black workers as injury than white workers. Recently Dr. Morris E. Davis, percent of all workers Associate Director of the Labor Occupational Health Program Occupation Female Male (LOHP) at the University of Cali- All occupations 11.7% 8.7% fornia in Berkeley, tried to assess this impact in the August, 1977 issue of Urban Health. The greatest US occupational Less 1) Professional and technical Hazardous workers Occupations 2) Managers and administrators 8.3% 4.5% 3.5% 2.3% disaster in this century, Dr. Davis 3) Sales and clerical workers 6.4% 6.0% notes parenthetically - the Gauley Bridge scandal in 1930-31 - left 1500 workers disabled and nearly 500 dead, most of them black. As workers tunneled through a mountain laced with silica, an es- timated 169 black men literally More 4) Craft workers Hazardous 5) Operatives (gas station attendants, Occupations taxi drivers, butchers, welders, etc.) 6) Service workers 7) Nonfarm laborers 8) Farm workers NA 13.6% 24.5% 18.0% 19.6% 6.2% 13.0% 17.0% 20.3% 8.6% dropped dead on the job and were buried, often two and three Source: US Statistical Abstract, 1976, Bureau of the Census, pp. 373-75. deep, in makeshift graves in a 19 compounding and mixing areas, where fully 60 percent: the workers are Black. Additionally, non manufacturing - examples cited by Davis include hazards experienced by sanitation and laundry persons. Sanitation workers, 43 percent of whom are Black, suffer injuries at a rate five times that of underground miners. (What's more, most are govern- ment employees and are not cover- ed by the federal OSHA law or by the vast majority of state OSHA laws.) About 60 percent of all laundry and dry cleaning workers are women, of whom nearly half are Black. Davis cites a study showing that " a higher proportion of female laundry workers, doing heavy lifting while pregnant, had babies with birth defects. " Com- mon drycleaning solvents can cause liver problems and are often suspect carcinogens. Unfortunately Davis'article ends with these examples, pre- sumably because detailed job classification data for individual industries is largely unavailable from government sources, other than a rough national breakdown of individual worker occupations professional and technical workers, managers and adminis- trators, and sales and clerical workers - are generally - con- sidered less physically hazardous than the last five craft - workers, operatives, service workers, non- farm laborers and farm workers. The percentages both of Black males and Black females in the first three categories are less than their respective percentages in the working population as a whole, whereas Black men ex- ceed their population percentage in three of the last five categories and Black women exceed it in four. Consider the three relatively less hazardous categories together. (This, by the way, does not at all deny the real hazards present on these jobs among - of- fice workers, for example.) About half of all white workers, male and female, are employed in these job categories to only one third - of all Black workers (see Table 2). The Census Bureau also breaks down these eight general job categories into separate subcate- gories 69 for men, excluding the categories " other " and " mis- cellaneous. " (U.S. Statistical Ab- stract, 1976, Bureau of the Cen- sus, pp. 373-5). Of these 69 this writer characterizes 21 as rela- tively high hazard - for example, construction workers, utility line- men, meat cutters, miners, long- shore workers, truck and _ taxi drivers, laundry workers, police and firemen. In 12 of these 21 subcategories, Blacks were em- ployed in percentages exceeding their average in the working population, while in nine Blacks were employed at the same or smaller percentages. What's more, of the total of all 69 subcategories only 23 showed Blacks employed above their population average, com- pared to 46 in which they are employed at less than or the same as their population average. Thus about half of all job subcategories in which Blacks are more repre- sented (12 of 23) are highly hazardous compared to only one- fifth (9 of 46) for white workers. Clearly the subject of occupa- tional hazards among minority workers is one that merits close at- tention. Neglect would be, as it usually is, malign. -David Kotelchuck by race, sex and other selected variables. Medical data is also Table 2 sparse, although perhaps less so in this case than usual. (Davis is in- Distribution of Black and White Workers by Selected Occupations terested in collecting and analyz- ing further data on this subject. Those who might have useful. data from medical studies, legal suits, trade association or labor union data should - contact him at LOHP, 2521 Channing Way, Berkeley, Ca 94720.) Less Occupation 1) Professional and technical workers Hazardous 2) Managers and administrators Occupations 3) Sales and clerical workers Percent distribution of workers White 15.5% 11.2% 25.0% Black 11.4% 4.4% 18.4% But even a cursory examination of the limited occupational data the government does publish gives further support to the argu- ment that Blacks suffer dispropor- tionately from workplace hazards. For example, the labor force is divided by the Bureau of Census. into eight general categories (see More 4) Craft workers Hazardous 5) Operatives (gas station attendants, 13.4% 14.6% 8.8% 20.0% Occupations taxi drivers, butchers, welders, etc.) 6) Service workers 12.3% 25.8% 7) Nonfarm laborers 4.4% 8.7% 8) Farm workers 3.6% 2.6% Total 100.0% 100.0% Source: US Statistical Abstract, 1976, Bureau of the Census, pp. 373-75. 20 Table 1). The first three of these- Emergency Rooms (Continued from Page 12.) groups by 1975. The remaining two hope to do so in the near future. These EP groups operating - on a fee ser- - for - vice basis - are primarily trained to focus on rela- tively infrequent major trauma patients (less than 6,000 out of the 80,000 ER visits each year at the San Francisco trauma center at General Hospital). Such patients, of course, are more likely to generate in patient - admissions and utilize high- profit ancillary services while undesirable, low- paying, non emergent - patients can be dumped onto the public system. Emergency Care and the Poor In the face of the mushrooming number of emergency rooms, integrating San Francisco's mix of public and private care becomes ever more difficult. Dr. Francis Curry, former Direc- tor of San Francisco's Department of Public Health, points out that such integration might con- cede some care such - as cardiac cases - to the private hospitals where there are clear geograph- ic advantages in doing so. But, he adds, the pri- vate hospitals appear uninterested in any real inte- San Francisco Emergency Services Hospital Current Status of ER Pacific 24 - hr w / EPs Medical Center Date of Contract with ER Early '73 Children's 24 - hr w / EPs May '75 Mt. Zion 24 - hr w EPs / Feb. '75 St. Mary's 24 - hr w / EPS June '75 St. Luke's 24 - hr w / EPs Dec. '73 Franklin (R.K. Davies) 24 EPs - hr w / Summer '75 St. Joseph's " Stand - by " X (none) St. Francis 24 - hr w / X moonlighting Physical Expansion of ER New ER '73 in : Previous Set - up OPD = 24 - hr since Medium 1910 rotating 30,270 / year house staff Future Expan- sion of ED Want a trauma center ? Treatment Medium No more ED devel- area w / on call - 28,815 / yr. opment - but a PHP physician ? 24 - hr w / Big None known moonlighting 85,370 / yr. residents New ER in '75 24 - hr w / rota- ting house staff Big 86,976 / yr " Change in the layout "; informally discussing trauma center New ER '70 in = 24 - hr for 20 yrs moon- w / lighting residents Huge 165,058 / yr No plans for ER New med. office building New ER end of '75 Locked mtg. Small & ex- place for use clusive. No of prut. med _ figs. reported staff Want a trauma center & a helio- pad X Same Small Hope to rebuild 17,861 / yr facility, including ER - no further comment X Same oeS Rebuilding facility including ER & OPD interested in contract EP group. Source: OPD data from 1975 Comprehensive Health Planning Reports and interviews with administrators. 21 gration, preferring to remain free to attract major trauma patients. Curry's experience is echoed in the statement of one San Francisco EP that, " You need a critical volume of patients to break even...... but you also need the right kind of patients. Now, the high profit patients go to the city, so the private hospi- tals take the less profitable patients. We need more of the patients who will utilize X rays - and surgery. Further strengthening Curry's conclusion is the comment of one local voluntary administrator: WE I BED OK! WE HAVE NON - WHITE- OPEN FOR A - PREFERABLY!) ON MEDICAID HEART TROUBLE WITH them for admission to the hospital. As Dr. Karl Mangold puts it, " Sure, hospitals have been seeing more lower socio economic - people when they develop ERs, but they're not balking at it; you can't be elitist when you have a low occupan- cy! " Emergency physicians, on the other hand, tend to mirror the attitudes of their fellow fee for- - service practitioners who avoid Medi - Cal patients and generally try to keep the number of welfare patients they see to a minimum. They justify shun- ning poor patients by claiming that they are reim- EMERGENCY ROOM EMERGENCY \ he f 1 ' fe " The bad debt experience is high with those people. A person walks in who has no known ad- dress, and you know it's going to be hard to col- lect. We do have a free care obligation... But we do send people to General if they have no means and are transportable - that's the system. " Even when they do have access to private hos- pital ERs, the medically uninsured often receive questionable services. Many back - up specialists refuse to come in as consultants for ER patients who have no insurance, or sometimes even those who have Medi - Cal (California's Medicaid). Such incidents have become frequent enough to force some hospital administrators and Emergency Room Committees to penalize offending physicians. At St. Mary's, for example, a specialist will be taken off the back - up roster if she or he re- fuses to take an ER case more than three times. Medi - Cal patients, although they do have third party coverage, are often treated much like indi- gent patients. In fact, Medi - Cal patients are a focus of dispute between hospital administration and the fee service - for - EPs. Administrators, trying to keep up hospital census, wish to encourage 22 welfare patients to use the ER and now welcome bursed below costs. As a result, many of San Francisco's EPs share the conviction that every- time they see a Medi - Cal patient they are under- writing government welfare - and they resent it. The ACEP has brought legal suit against the state in an attempt to increase the reimbursement rate for EP services. Despite such woes, however, salaries of EP group members average a guaran- teed minimum of $ 40,000 yearly as a starting figure.8 The malpractice crisis has compounded the problems for Medi - Cal patients in the private ERs. EPs feel that they carry a disproportionately high percentage of the welfare patient load because they are still an available source of medical care for these patients. In addition, many EPs share the belief that Medi - Cal patients bring more malprac- tice suits than other patients. Dr. Timothy Crook, head of ambulatory ser- vices at St. Luke's Hospital, claims that " over 50 percent of malpractice suits in California are initi- ated by Medi - Cal patients, while only 17 percent of the population is on Medi - Cal. " Dr. Holbrooke, EP at Franklin Hospital, explains the resulting situation: " Doctors'malpractice rates are getting so high that they are prohibitive. More and more pri- vate physicians won't see Medi - Cal patients. They say, " They're the ones who sue me, and I don't even get reimbursed enough for seeing them in the first place.'So there is a high volume of these patients in the ER, because they are denied ser- vice by the private practitioners. So, the ERs will have to cut out Medi - Cal eventually, too. " Meanwhile, EPs continue to begrudgingly see Medi - Cal and indigent patients, because the hos- pital wants welfare patients, and because the legal risks of turning any patients away from the ER prior to an examination remains too great. How- ever, with this attitude, EPs cannot possibly offer the quality of care to Medi - Cal patients that they deserve. The Market as Mainstream The rapid expansion of ER services in San Fran- cisco and particularly the contracting of such services to private EP groups - serves to highlight the damages inherent in the so called - " main- streaming " strategy in American medical care. This strategy which ultimately translates as transferring public responsibility and accoun- tability into the chaotic medical market - invari- ably generates overutilization of costly hospital services and the distortion of health care priorities around high technology - , specialized care. The consequent neglect of community - based, primary care causes an actual decrease in access to care for many patients, particularly the poor. As the US health care system increasingly models itself after the " mainstream " voluntary hos- pital, the example of San Francisco's private EP contractors dramatically underscores the inherent weakness in the entire voluntarization strategy. For, despite their guise as profit non - and com- munity service institutions, voluntary hospitals to date have mainly excelled in proliferating high- cost, high specialty - medical commodities as a sub- stitute for high quality, community oriented health care. -Robin Baker REFERENCES 1. Cranston, Senator Alan. January 23, 1973, testimony concerning S 504 - before U.S. Senate Subcommittee on Health, Committee on Labor and Public Welfare. Washington, D.C.: U.S. Government Printing Office, 1973. P. 48. 2. " Crisis in the Emergency Room, " Parade, February 18, 1973. 3. " Grim Diagnosis, " Wall Street Journal, October 5, 1971. 4. Cranston, loc. cit. 5. Ibid. 6. " The Emergency Medical Services Planning Responsibility of Comprehensive Health Planning (CHP) Agencies. " Washington, D.C.: U.S. Department of Health, Education and Welfare, 1973. 7. Mangold, Karl., M.D. " The Financial Realities of EMS, " Hospitals, Journal of the American Hospital Association 47 (May 16, 1973). 8. Carlova, John. " Emergency Physicians Needed: $ 52,000 to Start, " Medical Economics, November 25, 1974, p. 85. Help Your Friends and Help Us!! Know friends who would be interested in the BULLETIN? Send us their names and we will send them a free sample. Just fill out the form below and return it to us. Name: Address: Name: Address: Name: Address: Name: Address: Your name: Address: 23 psychiatry - a revolution publicly Media Scan Decarceration: Community Treatment of the Deviant - A Radical View by Andrew T. Scull (Englewood Cliffs, N.J., Prentice - Hall, 1977) The signs are everywhere. On the corner of 168th and Broadway, every morning, a somewhat disheveled man in his late twenties offers, simultaneous- ly, three games of chess and one of checkers to passers - by. No one takes up the challenge, so he nods off, or lends an unwelcome hand to the men unloading equip- ment for the hospital. It isn't an isolated incident. Local residents complain that the number of " crazies " on the street has shot up dramatically in recent months. A town in Long Island files suit against 40 families for board- ing ex mental - patients in " the single most cherished section of our town, the residential neigh- borhood. " proclaimed as the demise of the mental hospital and the dawn of a new era of " community - based treatment. " " Deinstitutionaliza- tion " it is called, and it has arrived. Foundations were laid some time ago. Beginning during the post - war years, the still young - profession of psychiatry found the 1950's were boom years, proof positive of how badly its services were needed. The war had helped in two ways. First, as the literature on the " lost divisions " il- lustrates, it allowed a glimpse of the true dimensions of the mental health problem: one of every eight potential recruits were re- jected on psychiatric grounds. Second, the success of combat psychiatry in treating acute stress reactions helped remove the stig- ma of incurability from psychia- tric disorders and conferred a needed measure of technical ex- pertise on the profession. At the same time, the asylum business was thriving. By 1955, the ranks of mental patients had e " bashing Asylum - " (expos- ing the horrors of mental institu- tions), long a standard practice among journalists of all stripes, has become an enthusiastic pur- suit of Mental Health Administra- risen to over 559,000; every other hospital bed in the U.S. was occupied by a mental patient. Fully 98 percent of these were in public hospitals. Average length of stay in the state hospital of tors themselves. 1952 was eight years. Needless * Other observers turn their to say, costs were rising steadily. gaze on a different target. Not that the hospitalized patient has Professional groups (notably the American Medical Associa- been forgotten, but the presence tion and American Psychiatric of another, more visible and fore- Association) joined forces with boding, commands greater atten- tion. These are the ex patients - , lobbying groups (like the National Mental Health Committee) to those who " panhandle... expose themselves to young children.. and defecate in the sidewalk. " 4 draw public and legislative atten- tion to the growing social and economic burden mental illness From snake pit to street: the side- walk psychotic has become as fa- posed. In 1961, the Joint Com- mission on Mental Illness ended a miliar a piece of the urban land- scape as the wino. Such are the external tokens of the latest " revolution " (and the six year - study with a report, Ac- tion for Mental Health. The report crested a groundswell of criticism aimed at the warehouse model of double sense of the word, as we psychiatric care. The objective of 24 will see, is not out of place) in modern treatment, its authors held, must be " to enable the pa- tient to maintain himself in the community in a normal manner. " 5 In short, if pathologies of place compounded disorders of mind, would not the desiderata of thera- peutics as well as the constraints of budget be better served by emptying out the " crockery- bins "? " Aftercare " and " rehabili- tation " replaced " asylum " and " custody " as the catchwords of this new and brave mental health policy. The Commission envision- ed an extensive network of Com- munity Mental Health Centers to coordinate community - based treatment. A century and a half old tradition of confinement would soon be eclipsed by an un- tested system of extended care. But certain preliminary measures were in order. The whole notion of mental illness as an incurable affliction had to be rehabilitated. The Joint Com- mission urged us to think of it in- stead as a chronic but con- trollable malady; as a sort of " ar- thritis of the mind " was their memorable phrasing. An exten- sive re education - campaign was mounted, designed to persuade a wary public that the ex mental - patient was not only employable but a suitable matrimonial pros- pect as well. A carefully moni- From snake pit to street: the sidewalk psychotic has be- come as familiar a piece of the urban landscape as the wino. tored regimen of " maintenance therapy " -i.e., regular medica- tion together - with appropriate support services were all that was needed to transform a legacy of neglect and abuse into a working system of humane care. Reform Without Change If the history of official tamper- ing with penal and asylum policy in this country is one of " reform without change ", it is a tradition likely to remain unchallenged by this latest enthusiasm. The lesson of deinstitutionalization to date is one of uncompromised failure. Or, to put it more accurately, the problem with the community mental health movement, as Chesterton remarked of a some- what more ambitious enterprise, is not that it has failed but that it has yet to be tried. A brief look at what getting patients " back into the community " has meant in practice will serve to explain what I mean. The purported cost effective- - ness of the community care scheme one of two major argu- ments in its promotion, the other being its alleged therapeutic value has proven to be more apparent than real. The real finan- cial effect has been to transfer the fiscal burden to federal rather than state coffers. It is the welfare system, heavily subsidized by fed- eral funds, which picks up the largest share of the tab for the maintenance of deinstitutionalized patients. By one calculation, the costs to the federal government of the inpatient program of one community mental health project was 16 times what its contribution to a state hospital would have been. 7 By contrast, state expendi- tures were one third - of what it would have cost to house those same patients in state facilities. Still, the savings to the states have not been as large as ex- pected. The reason is simple: hos- pital closures have not kept pace with patient population declines. Fixed capital expenditures, there- fore, have remained high. Since 1955, the inmate population of state mental hospitals has drop- ped by over a half - the com- bined effect of shorter lengths of stay, more stringent admittance criteria, and early release of long- 25 8 term patients. Discharge rates for older patients, many of whom were career inmates with " multi- Being " in the community " for most released patients has meant the humiliation of welfare, endless attention and care as they were in the state hospital. " 16 It is the form, not the fact, of confinement which ple disabilities, " accelerated in the period 1961-1970.9 In spite of this reduction, only 12 state empty hours, and no prospect for work. In addition, for the long- term hospitalized patient, the has changed. Put bluntly, what community- based care has demonstrated is hospitals in eight states were closed in the period 1970-74.10 move usually also means resi- dence in a " board - and - care " fa- that one can, in fact, reap the same debilitating effects without New York State provides an illus- cility: typically old, dilapidated the use of professional overseers. trative example: with a 64 per- structures, located in the worst, most victimized sections of the The tidings of stated policy are everywhere overturned by the " Aftercare " and " re- habilitation " re- city, with no provisions for in- spection, only the laxest of stan- dards, and little if any access to medical, psychiatric or social ser- substance of accomplishment. Deinstitutionalization is a tale told by a trickster, full of sound and promise, but signifying little that is placed " asylum " and " custody " as the vices. Most are roughcut, small- scale replicas of the institutions they were meant to replace. Inter- new. Why the Failure? catchwords of this new and brave men- nally, the routine is characterized by the same wretched monotony, the same " passivity, isolation and Andrew Scull's masterful study, Decarceration: Community Treat- ment of the Deviant - A Radical tal health policy. inactivity " that marked the hospi- tal wards. 14 Nor has the lure of this new market gone unheeded: View, goes a long way towards explaining why. Closely documented and carefully ar- cent drop in patient population in the first five years after the imple- mentation of a more selective ad- profiteering abounds, with pre- dictable effects on patient care. Finally, the densely reticulated gued, it is, I think, without parallel in the recent literature on psychia- tric and penal institutions. Scull is mittance policy in 1968, and an additional drop of one third - in the next four years, the state has still seen fit to open four new inpatient facilities since 1973, with a total of 1200 beds. (The current Direc- tor of Mental Hygiene of the City of New York swears, however, system of community mental health centers envisioned by the Joint Commission in 1961 never was implemented. Of the 2000 such centers they foresaw, per- haps 450 are providing service. Those that do operate do so for the expressed purpose of crisis in- an able and effective historian, a shrewd critic, and a clear, com- The problem with the community men- tal health move- that a complete dismantling of the state hospital system is imminent. 12 It is the therapeutic claims, tervention, with a heavy emphasis on psychotherapy. Care for the chronic patient - which so often ment, as Chesterton remarked of a some- however, that are most disturb- ing. Against the overblown rhetoric of the " superior quality of entails assistance with the ruder aspects of livelihood: money, work, food, housing is viewed what more ambitious enterprise, is not that community - based care " juts one outstanding fact: the wide range of treatment alternatives and ser- as an annoyance, a diverting of needed resources away " from other patients who could be it has failed but that it has yet to be tried. vices originally promised- helped. " 15 " smaller, better staffed hospitals, We have here not an alterna- halfway houses, sheltered work- tive to confinement but its latest pelling writer. And he plies his shops, emergency protective re- embodiment: distributed rather trade well. The book's densely sources, and community treat- than congregated, somewhat packed 160 pages include ment centers " -failed to material- ize. 13 In the face of this failure- more visible, but no less segrega- tive for that. Reviewing the prac- moments of anger, but it would be a strangely disembodied work and the evidence in support of it tical consequences, as distinct without them. For the most part, is overwhelming - continued sup- from the rhetoric, of community- he conducts his inquiry with ad- port for community - based care based care, a recent study con- mirable restraint - not easy to ac- takes on something of the charac- cluded that " former patients are complish given the nature of the 26 ter of a cruel hoax. just as insulated from community topic. Scull sets out, he tells us imme- diately, to provide an alternative to the standard accounts of the origins of the decarceration movement in prisons and correc- tional institutions as well as in mental health policy. He means to do so through the use of " an his- torically informed macrosociolo- gical perspective on the interrela- tionship between deviance, con- trol structures, and the nature of the wider social systems of which they are a part and an essential support " (p.11; unless otherwise noted, all page references are to the text). Here, at the outset, in the approach, is located the real advance of Scull's work: a way of contextualizing - historically and structurally - the origins and, given them, the necessary failure of the decarceration movement. He proceeds in three stages. Part I begins with a sort of the- oretic prologue, an attempt to place the inquiry within its proper bounds. Scull first argues the necessity of a macrosociological approach through a demon- stration of the theoretic inade- quacies of the " labeling " school of analysis. Failing to address the question of the origin of social power, the labeling perspective ultimately reduces to a depiction of social control as arbitrary. Ob- sessed with the fine grained - struc- ture of the " deviant identity " and the rules of its formation, it ig- nores the ruder constraints of social and political order, to which such rules owe their operating limits. What Scull is reaching for in these early pages, it seems to me, is a way of once again disenfran- chising deviance, of saving it from too ready an understanding, of returning to it the threat it was robbed of once the pathos of the deviant displaced the fear of the defiant in the hearts and minds of sociologists everywhere. He means to reinvest deviance with the danger it must be seen to rep- resent if the efforts of containing it are to make sense. Without the danger, " outsiders " and refusers are just so many curiosities; con- finement a variant of the zoo. Deinstitutionalization is a tale told by a trickster, full of sound and promise, but signifying little that is new. Segregative Control It is an historically informed tack. Chapter 2 traces the devel- opment of the social control ap- paratus in England and the US in the late 18th and early 19th Cen- turies. Scull is particularly in- terested in the emergence of the asylum and prison as centralized and rationalized structures of " segregative control. " Their Get a Beat on Bakke! Did you know that: * New York City, America's most liberal, most ethnically diverse city, has among the worst records of minority medical school admissions? * New York City's already - dismal record has been getting worse for the last four years? Read the true facts about " reverse discrimination. " Get Health / PAC's Special Report: The Myth of Reverse Discrimination: Declining Minority Enrollment in New York City's Medical Schools. Send $ 2.00 2.00, plus $.50 postage and handling to Health / PAC, 17 Murray Street, New York, N.Y. 100O7. 227 emergence in that office, he argues, is unintelligible apart from the simultaneous " growth of a capitalist market system and its impact on economic and social relationships " (p.24). Specifically, the growing role of the state, the sequestering of deviants apart " they remained a convenient way to get rid of inconvenient people " (p.33), consigning them to places where, as one contemporary British observer put it, " they are for the most part harmless be- cause they are kept out of harm's way " (quoted on p. 33). occurred in England. Second, the claims of the therapeutic efficacy of such drugs have been greatly exaggerated, while mounting evi- dence of their deleterious side- effects has been ignored or slighted. One can therefore con- clude that the function of such an es Former " patients are just as insulated from community at- tention and care as Control and Community The third and fourth chapters lay out in some detail the dimen- sions of the decarceration move- ment in both the correctional and mental health establishments. The explanation is primarily ideologi- cal, serving to bolster an invested pattern of control. On the question of therapeutic efficacy, Scull's case is not as tight as it might be. He contends that recent studies demonstrate that they were in the state hospital. " It is the form, not the fact, of confinement which has changed. case of the latter we have already reviewed; that of the former, while somewhat murky in its spe- cifics is nonetheless clear as to its scale and direction. A number of instructive examples are offered to illustrate the process. Part II examines and refutes the phenothiazines (the most widely used class of heavy tranquilizers) offer only short - term benefits, render patients more susceptible to deterioration once released, and, in fact, increase the likeli- hood of re admittance -. The weight of evidence, it must be two standard accounts of why de- added, appears to be against him: from the community, and the sub- sequent concern to differentiate among the types of deviance, cannot be understood apart from the necessity of distinguishing, in a market economy, between the able and the disabled poor. Indis- criminant relief would cramp the invisible hand that otherwise carceration is taking place: the advent of psychoactive drugs and the enlightened (if belated) realization, made possible by a spate of sociological studies, of the fundamentally antitherapeutic impact of " total institutions " on their inmates. Here, Scull's argu- ments, focused on the demise of a recent review of twenty - four well controlled - studies, many of which included chronic patients, found that without exception all showed a lower relapse rate among those receiving phenothi- The basic lie is smoothly distributes a mobile labor force to where it is most needed. It would remove the the asylum, are worth consider- ing in some detail. With regard to the introduction exposed clearly: mass hospital threat of starvation and mute the terror of unemployment, that were critical levers in controlling an at recalcitrant - best - workforce. Custody, furthermore, should teach by example: the " well- of tranquilizing drugs, Scull notes that while the conventional ac- count enjoys the twin virtues " of simplicity and of reinforcing the medical model of insanity " (.81), it is empirically flawed in two releases have never, in practice, depen- ded upon the avail- ability of appro- ordered asylum " of the 19th Cen- tury reproduced the routine and discipline of the workplace. Fixed, centrally administered - respects. First, it fails to square with the historical record. The new patterns of early release and selective admittance in both the priate aftercare facilities. eee structures of social control, Scull is arguing, are crucially of a piece US and England preceded the in- troduction of the drugs. At best, azines. The reviewer is quick to add, however, that " there have with the emergence of a proletariat and growth of an inter- ventionist state allied with the new capitalist order. From this per- spective, if the prisons, reforma- tories and asylums of last century their effect was to further expedite an already existing policy. Nor, Scull goes on to note, will simple recourse to a new " technological fix " explain the sudden accelera- tion of the decline of American been no long term - studies of maintenance medication. " 17 Methodological problems plague such research, making a clear picture of cause - and - effect nearly impossible to obtain. The failed as rehabilitative centers, 28 they succeeded as holding pens: inpatient population from the mid- 1960s on, when no such change unpublished study by Rappaport and his associates, upon which Scull relies so heavily, while it fol- lowed patients for up to three years, made no provisions for in- suring that patients out of the hos- pital were regularly taking their assigned drugs. In addition, that study shows only that young, male, acute schizophrenics, at the onset of their first or (at most) second psychotic break, do bet- ter in the long run if treated with- out drugs. The authors are quite clear that this group " un- doubtedly represents a minority of the schizophrenic popula- tion. " " 18 More to the point, it is generally not this class of patients which has been most affected by the change in hospitalization policies. With regard to the contribution of the critique of the asylum, how- ever, Scull is on much firmer ground. The argument is twofold. First, he reviews the follow - up studies which have documented the deplorable state of the com- munity facilities ex patients - are expected to rely upon. The basic lie is exposed clearly: mass hospi- tal releases have never, in prac- tice, depended upon the avail- ability of appropriate aftercare facilities. Nor have the advan- tages of community - based care been subjected to careful study. It is a dismal story, as we have seen, and Scull tells it well. It is the second piece of the analysis, though, which displays Scull's gifts at their best. It is an ingenious argument. Reviewing the history of the opposition to the asylum in the last century, Scull reveals remarkable parallels be- tween the modern critique of the mental hospital and the 19th Cen- tury critique of the asylum. These early critics well appreciated the double irony of first assigning madness to a place whose cir- cumstances encouraged the very behavior it was meant to correct, and then, of using the pathology so created to justify the asylum's own existence. Little advance is seen in the modern analysis. In fact, noting the power of the 19th century analysis - which stressed the isolation, torpor, artificiality and rigidity of institutional rou- tine Scull concludes: " It is dif- ficult to see how, in its essentials, The new patterns of early release and selective admittance in both the US and England preceded the introduction of drugs. and with respect to either its intel- lectual cogency or its empirical support, the modern critique elaborated by Goffman and his coworkers is substantially superior " (p. 107). The notion that such criticism by itself consti- tutes sufficient cause for a reversal of confinement policy is clearly shown to be untenable. Coming in the Next Issue! * United Mineworkers: Why did one of the most progressive health care systems in the country have to make drastic cutbacks? Who's at fault? What are the prospects? * Family Practice: Origin, scope and trends in this currently - popular specialty. Subscribe to the Health / PAC Bulletin today. Name Address LI $ 8 - Student Y' $ 10 - Regular Y' $ 20- Institutions Mail to Health / PAC, 17 Murray Street, New York, N.Y. 10007 29 Warfare to Welfare changed. Labor was no longer uses, and that age - old criticisms an easily replaceable commodity; of the asylum are seized upon as Part III concludes the argu- skilled labor embodied valuable the humanitarian gloss of an ment, setting forth the alternative capital. Legislation, designed in essentially cost effective - strategy. perspective that has informed part to safeguard the health of To the extent that such pressures his critical stance throughout. such capital, was less likely to continue or worsen, the argument Against the backdrop of the fail- ure of the 19th Century decarcer- meet opposition from an enlight- ened capitalist class. Then, too, an goes, a policy of decarceration can be expected to persist, even ation movement, Scull shows how increase in the level of the " social as public resistance mounts and the emergence of a new set of pri- wage " in the form of welfare mea- evidence of the failure of commu- orities political - and economic in sures represented a far less costly alternative than did more militant nity care accumulates. If a lesson emerges out of this Oddly enough, forms of class struggle. In the dis- bursement of such concessions study, it is an old one. Writing in the pages of the American Journal community care is not taken as an anti- and the mediation of that struggle, the state has assumed an ever expanding - role. of Insanity in 1866, George Cook observed: " It is not well to sneer at political economy in its rela- dote to the ever- growing medicaliza- Welfare expenditures, that is, represent both a social investment (directly or indirectly increasing tions to the insane poor. Whether we think it right or not, the ques- tion of cost has determined and tion of deviance or as confirmation of the productivity of a given seg- ment of labor) and a social ex- pense (services rendered to in- will continue to determine their fate for weal or woe " (quoted on p. 134). To which should perhaps the essentially social nature of the sure social harmony and ward off potential discontent). The popula- tion served by such measures has be added another, older warning: "... all the world will be a hospi- tal and all of us sick nurses tend- problem. continued to grow in recent years. At the same time, the ing each other. " The words are Goethe's, writing nearly a cen- productivity of the state sector tury before Cook. nature - can be analyzed to yield a better account of the " success " of the decarceration effort in the present than either of the rival explanations. The strength of cus- has been unable to keep pace with that of the private sector, an imbalance which results in further costs to the state. The unionization of state employees and the ensu- be A policy of decarceration can tody in the 19th Century was that it provided an effective means of disposing of " the most difficult ing agitation for wages competi- tive with those in the private sec- tor places an additional strain on be expected to persist, even as and troublesome elements of the disreputable poor " p.128 () . Not that the mad themselves posed a threat. Rather, by insuring that state budgets. In the state hospital system, for example, the intro- duction of an eight hour shift and forty hour week " virtually public resistance mounts and evi- dence of the failure the option of legitimate depen- dency was closed to all but the grossly incapacitated, the asylum doubled unit costs. " 19 Under such _ circumstances, Scull notes, the continuation of an of community care accumulates. kept sharp the " twin spurs of pov- erty and unemployment " (p.129) increasingly costly system of segregative control in the face of eee needed to keep an unwilling labor force in harness. It served another an apparently cheaper, certainly no more damaging, and possibly Reforms Without Causes function as well. By removing the more effective alternative, makes The final irony of decarceration burden of care from those least very little sense. In a word, rising is an ideological one. In the rush able to shoulder it, confinement costs are the hidden variable in to examine the question of care, neutralized a potential source of the decarceration debate. It is in the flurry of activity surround- great discontent. only in the context of such " struc- ing the prospect of rehabilitation, With the advent of the welfare tural pressures, " Scull concludes, the question of cause has been state and the development of that such therapeutic innovations submerged. Nay, subverted. The 30 monopoly capitalism, all this as the new drugs find their special upshot of a quarter century of psychiatric epidemiology is that severe psychosis is decidedly a related class - phenomenon: lower class people consistently show higher rates of such disturbances. Rising costs are the hidden variable in the decarceration debate. In the wake of the new treatment debate, that fact is likely to be lost. For, oddly enough, community care is not taken as an antidote to the ever growing - medicalization of deviance or as confirmation of the essentially social nature of the problem. Far from being a challenge to the medical model, that is, community care appears as the most recent testament to its essential correctness. Madness can be returned to the community because like diabetes - it can be controlled there. And questions as to its origins become sadly be- side the point. -Kim Hopper (Kim Hopper is a Teaching Fel- low in Sociomedical Sciences at the Columbia School of Public Health. He wishes to thank Ellen Baxter for extensive help in researching background for this review.) References 1. Newsday, August 23, 1977. 2. New York Times, August 1, 1977. 3. New York Post, May 16, 1977. 4. Daily News, July 5, 1977. 5. Joint Commission on Mental Illness and Health. Ac- tion for Mental Health. New York: Basic Books, 1961, p. xvii. 6. Rothman, D. " Decarcerating prisoners and patients, The Civil Liberties Review, 1 8-30:, 1973. 7. Sheehan, D.M. and Atkinson, J " Comparative costs of state hospital and community - based inpatient care in Texas -- Who benefits most? " Hosp. Community Psychiatry. 25 242-244: , 1974. 8. Greenblatt. M. and Glazier, E. " The phasing out of menta. hospitals in the United States, " Amer. J. Psy- chiatry 132 1135-1140, 1975. 9. Wolpert, J. and Wolpert, E.R. " The relocation of re- leased mental hospital patients into residential com- munities, " Policy Sciences (Spring, 1976). 10. Greenblatt and Glazier, op. cit. 11. Ibid. 12. New York Times, August 1, 1977. 13. Arnhoff. F.. Social Consequences Toward Mental Illness, Science, 188 1277-1281: , 1975. 14. Lamb, H.R and Goertzel, V. " The discharged men- tal patients Are they really in the community? " Arch Gen Psychiatry, 24 29-34:, 1971. 15. American Psychiatric Association, " Position State- ment on the Need to Maintain Long Term Mental Hospital Facilities, " Am. J. Psychiatry, 131 745:, 1974. 16. Wolpert and Wolpert, op. cit. 17. Davis, J.M. " Maintenance therapy in psychiatry: I. Schizophrenia, " Am. J. Psychiatry, 132 1237-: 1245, 1975 18. Rappaport, M., Hopkins, H.K., Hall, K., Belleza, T., Silverman, J. " Schizophrenics for whom pencthia- zines may be contraindicated or unnecessary, ' mimeographed. Langley Porter Neuropsychiatric Institute, University of California, 1975, p. 25. 19. Dingman, P.R. " The alternative care is not there. " In P. Ahmed and S. Plog, eds., State Mental Hospi- tals What Happens When They Close. New York, Plenum, 1976, p. 46. THE REVIEW OF RADICAL POLITICAL ECONOMICS Volume 9, No. 1 THE POLITICAL ECONOMY OF HEALTH Spring 1977 Joseph Eyer and Peter Sterling, Related Stress - Mortality and Social Organization Meredith Turshen, The Political Ecology of Disease Vicente Navarro, Political Power, the State, and Their Implications in Medicine Harry Cleaver, Malaria, the Politics of Public Health and the International Crisis L. Rodberg and G. Stevenson, The Health Care Industry in Advanced Capitalism Howard S. Berliner, Emerging Ideologies in Medicine J. Warren Salmon, Monopoly Capital and the Reorganization of the Health Sector Robert C. Hsu, The Political Economy of Rural Health Care in China The Review of Radical Political Economics Subscriptions: $ 30 Institutions, $ 15 Regular, $ 7.50 Low Income Write to URPE - Room 901, 41 Union Square West, New York, N.Y. 10003 The Political Economy of Health Issue $ 3.00 plus $.50 for postage and handling. Write to Health / PAC, 17 Murray Street, New York, N.Y. 10007 31 Announcements MUD CREEK BENEFIT A benefit concert for the Mud Creek Health Project in Eastern Kentucky will be held in New York City in early December. The Mud Creek Health Project, a com- munity organized - clinic run by and for poor people, bas been hurt badly by recent cutbacks in the health care funds by the United Mine Workers and by govern- mental sources, and proceeds will go to keep the clinic open. The benefit, entitled " Voices from the Mountains: An Evening With the Mud Creek Coal Miners, " will feature a showing of " Harlan County, USA. " Barbara Koppel, the filmmaker, and Eula Hall, clinic director, will speak and mountain musicians and singers and invited folk stars will perform. Information concerning date and location will be announced in the Village Voice or can be obtained by writing the Mud Creek Support Project, 332 W. 77th St., New York, N.Y. 10024. Contributions are tax- exempt. SELF CARE SYMPOSIUM A weekend symposium on " Care Self - for Health " will be held in the Hotel Roosevelt in New York City on November 5-6, 1977. The symposium will explore the pro- mise, prospects and varied forms of self care - and speakers include Barbara Ehrenreich, Alan Gart- ner, Alfred Katz, Lowell Levin, Frank Riesman, Victor Sidel and David Sobel. 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