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HEALTH + PAC HEALTH POLICY ADVISORY CENTER INSTITUTE FOR POLICY STUDIES Bulletin No. 4 September 1968 HOME RULE BEGINS AT HOME A PUBLICLY PERCEIVED WEAKNESS (AS WELL AS VAGUENESS) IN CITY GOVERNMENT HEALTH LEADERSHIP IS OBVIOUS IN THE FOLLOWING POWER PLAYS - ALL IMPENDING END RUNS - AROUND CITY AUTHORITY: (1) The Health and Hospital Planning Council is independently seeking strengthened comprehensive health planning powers under their own auspices in New York City. [HHPC is a private, voluntary hospital dominated - regional planning agency.] They hope for approval of the City Council, the State (under their current Folsom Act powers for all health facility planning), and the Federal government (under their current exclusive grant for health planning in the region through 1969). This is despite Mayor Lindsay's bid for a strong public planning agency [See BULLETIN No. 2] and is based on the assertion that the City Health Services Administration has not shown the capacity to carry out such a function. (2) State Senator Seymour Thaler (Queens D - L -) , long time - critic of Municipal hospital affiliations has proposed that State government assume authority for these institutions. This is based on the claim that the City has not demonstrated the capacity to direct these hospitals or to reorganize its overcentralized management procedures, and that it is essentially under the thumb of the private hospital affiliation contractors [See Policy Forum, Page 4]. (3 Harlem community groups are seeking Federal, State, and private funding and assistance to bring Harlem City Hos- pital and other community facilities and programs under direct community control. They claim the City has made no serious moves to encourage community, rather than private affiliation control of Municipal hospitals and health programs. (4) Lutheran Medical Center, Columbia College of Physicians and Surgeons and other private hospitals, medical schools, and medical group practice organizations are openly bidding for or are considering easy lease purchase - agree- ments with the City to take over existing Municipal hospital facilities to use as they please. This is based on widespread reports that City Hospitals leaders are aiming to get the City " out of the hospital business. " All four end runs - around City authority are based on public perceptions of gross City leadership weaknesses that re- flect all too much reality. The solutions need not be evasions of City government home rule - but unless sufficient public leadership is achieved by the City to preempt such actions, this will be the result. -Robb K. Burlage, Director, HEALTH - PAC Dr. Bucove: It's A Long Way From Olympia THE NEW HEALTH Services Administrator, Dr. Bernard formance have ground to a start for crash " " renova- Bucove, has been described as a traditional public tion programs, stronger City administrators in some health man in an impossible public private - sector co- hospitals or attempts to transform traditional Health ordination job - a pacifist in a Lion's Den. Department clinics into neighborhood health centers. It's a long way from Olympia, Washington, where he Dr. Bucove's Administration now appears to stand was a respected State health chief, to 125 Worth Street for some of the following principles: -and it's light years - to Harlem and Brownsville. But, (1) The comprehensiveness, unification, and public the new local chief reflects, as long as there's a job authority of the Health Services Administration must description, there must be a job to be done. His only be strengthened and defended; illusions appear to be the the survivability of anyone in (2) Decentralization of operating responsibility and his position and the range of potential partnership authority for public facilities and programs, including with the scattered medical barons and businessmen Municipal hospitals, should be within the Administra- referred to as the health system of New York City. tion, not " carved out " from it; Comprehensive re- Local cynics feel that the Lindsay Administration has gional and district health responsibilities within the City not proven that the City is govern - able - only that it should go to new kinds of " public health officers. " is gull - ible. Does declared policy have anything to do (3) Comprehensive health planning is a City govern- with administration? Administration with performance? ment function, although there is a supplementary role Performance with real problems? Despite some schizo- for other kinds of State regional - and voluntary agencies; phrenia among City officials, health policy has changed over the last three years. And certain areas of per- (4) Transformation of the existing socially distant (Continued Page 3) Will We Stop Lead Poisoning Our Children? TWENTY THOUSAND black and Puerto Rican children in New York City are condemned to walk our streets for another year with a condition which can leave them mental and physical cripples for life. That is the estimated human meaning of lead poisoning among ghetto children, a frightening example of the total breakdown of New York City's medical care, community services and life support system. Recent studies indicate that the actual number of children affected in the City's " lead belts decaying " slum areas where children eat the lead based - paint peeling from walls - is 20 times greater than the annual number of cases diagnosed and treated. Despite the fact that such poisoning is almost completely preventable, the medical establishment's response to these figures, which they shame facedly - accept, has been typical: " We can't do anything; we don't have any money. " Neighborhood groups struggling for new health services, ac- countable to the users, should join the fight on this vital issue of personal and environmental health. It goes to the heart of existing slum problems and of the failure of present bureaus, institutions, and professionals to find a solution. For the last 10 yars, lead poisoning has been growing to epidemic proportions in New York. The number of cases re- ported by hospitals has grown 500 per cent in this period. This is partially due to greater medical awareness of the condition. Primarily, however, the rise can be attributed to the col- lapse of the slum system: as whites left the city, and were replaced by blacks and Puerto Ricans, slum landlords stopped even the minimal maintenance of their buildings. Children who suffer from " pica, " an emotional disturbance which leads them to eat non food - items, found their tenements lit- tered with easily reachable paint chips from the flaking walls. A study conducted by the Student Health Organization (SHO) and the Scientists'Committee for Public Information (SCPI) in the South Bronx this summer [See BULLETIN No. 3] will no doubt bear out the findings of earlier research else- where in the nation, where 5-10 per cent of the children tested HEALTH - PAC IS an independent, non government - center for the public, serving as a Health Ombudsman, Health Information Service, Social Analysis Laboratory, and Technical Assistance and Communications Center. HEALTH - PAC monitors public policy in the monthly HEALTH - PAC BULLETIN and in other publications, con- ducts workshops for improved community services, assists research and reporting about the problems, issues and power forces in the changing metropolitan health services setting. HEALTH - PAC opposes an omnibus Affiliation Plan for City hospitals - favors comprehesive public authority over all health services in New York City and the di- rect public operation of City owned - health facilities- emphasizes the development of community - controlled neighborhood health centers. These basic principles are articulated in the Institute for Policy Studies'review of " New York City's Municipal Hospitals " (the Burlage Report.) had lead levels severe enough to qualify them as poisoned. Studies undertaken by groups in Chicago, Rochester and Balti- more have shown that approximately one child in every 15 suffers from an abnormally high level of lead in his system. These poisonings occur almost exclusively in slum areas. Lead poisoning culminates in convulsions, coma and death. Actual fatalities have been decreasing rapidly in recent years due to improved treatment techniques, but the lasting effects Individuals or community groups interested in joining the local effort to combat lead poisoning in the New York area ghetto neighborhoods should contact CITIZENS'COMMITTEE TO END LEAD POISONING, 161 Eldridge St., New York, N.Y. 10002. Phone: Paul DuBrul, 674-9120. on those who are saved are often almost as tragic. Among these are chronic nephritis, epilepsy, cerebral palsy and severe mental retardation. Lead based - paint was outlawed in New York in 1959. An effective code enforcement campaign in slums would keep peeling paint on lower levels which contain lead to a mini- mum. The only ultimate answer is a massive housing program. The results of a recent meeting with the City officials reveal that they are not about to undertake either a universal testing program for high lead levels in slum children or a general enforcement of existing codes against badly maintained, peel- ing walls. Assistant Commissioner Donald T. Conwell of the Health Department Preventable and Chronic Disease Service, who is responsible for environmental health hazard programs, told a delegation of community representatives on August 13 that his department recognizes the scope of the problem but can do nothing to institute a testing program in ghetto areas. He and Dr. Oliver - Smith, who is in charge of the lead poison- - ing program, said that even a minimal testing program to discover affected children would have to wait until the next fiscal year which begins in July, 1969. When questioned about code enforcement measures to re- move the hazardous paint, he stated that burning the paint off was illegal, sanding it off simply created a greater health hazard by spreading lead dust, and that covering the wall with plaster board probably would not fall within the legal definition of " remove. " Alternate housing in public projects for affected families was sought, he said, but none was available. It is clear if the problem is left to the timid City profes- sionals, more children will die and be maimed. The com- munity must act now to save its children. Community groups are beginning to meet and develop action programs on this problem. Immediate goals include demanding that each child who is seen in a hospital be tested for lead poisoning and that apartments in slum neighborhoods be tested for the presence of lead. Tenants in " lead - belt " apartments should immediately demand that landlords, including the City and its Real Estate Department, should cover the lead based - paint with plaster board - that is, create a new wall and cover it with safe paint. When landlords fail to act immediately, rent strikes and other actions must be begun. Published monthly with a supporting grant from the Samuel Rubin Foundation by the Health Policy Advisory Center of the Institute for Policy Studies, 305 Broadway, Room 1109, New York, N.Y. 10007. (212) 227-2920. Staff: Robb K. Burlage, Director; Maxine Kenny, Asst. Copyright 1968. [EDITOR'S NOTE: The above article was written by Paul DuBrul, housing director of Action for Progress, a Lower East side, OEO funded - multi- service center; and an instructor of City Planning, Pratt Institute School of Architecture, Brooklyn.] (2) City Affiliations And Beyond... Decentralization to Whom? A hot battle memos - of - the - has broken out within the Lindsay Administration over the issue of whether to seek new legisla- tion to create single institution - , regional, or city wide - " hos- We hope to have your support for our program when it is submitted to New York State. [Signed] Werner H. Kramarsky, Special Assistant to the Mayor for Health Affairs pital corporations " to run Municipal hospitals outside the [EDITOR'S NOTE: More than 1400 residents Health Services Administration (HSA) and Hospitals Department. Representatives of the Budget Bureau and the Hospitals Department (agencies which in the past have placed some of the greatest red tape - bottlenecks in the path of responsible and health workers of Upper West Side ghettos, in- cluding parts of Washington Heights, Manhattan- ville, West Harlem and Jumel Place, have signed a petition endorsing Mayor Lindsay's stand.] decentralized management of Municipal hospitals), ardently favor the " corporation " plan, following recommendations of the Piel Commission Report [See BULLETIN No. 1]. Top HSA staff, along with the Mayor's special assistant for health affairs, are highly critical of the plan. They claim it will sabotage the entire integrative, comprehensive concept of HSA, will over emphasize - the programming of stratified special- ized medical facilities, as well as make a mockery of public accountability. They also are skeptical about who will really run such corporations. Rather than bring management closer to the community through broad based - community boards, they fear it will simply place more arbitrary power in the hands of existing private medical centers. MDs Protest Affiliations Asserting that doctors as well as patients have been treated intolerably by the affiliation program, a number of doctors have joined together to form the Hospital Doctors Association of New York. The Association, formed last June, cites the following facts as the basis for its existence: 1) there are 7,000 doctors in the New York City area who hold no Municipal or voluntary staff appointment; 2) there are thousands of doc- tors who, after many years of service, have been either sum- marily dismissed or eased out of Municipal hospital appoint- ments under the affiliation program; and 3) there are thousands of New York doctors without any sort of tenure, job An Exchange on Planning Dear Mayor Lindsay: August [1, 1968] security, or grievance machinery. Hospital Doctors Association leaders contend that once a physician qualifies for a staff appointment and renders con- All our constituents were extremely gratified to learn... that you are supporting a public agency for Comprehensive Health Planning in which the public will have a major voice on the policy board and on the advisory council... We [support you] while asking your assurance that: (1) The basic planning activity is done with a City planning staff, rather than the City contracting out most of the plan- ning with existing private agencies; and (2) You sanction the creation of neighborhood boards with the power to initiate and review recommendations of the tinuing competent service, his appointment must be considered a right rather than a " privilege. " They say that if a doctor is to provide effective patient care, he must have a right to the benefits of a hospital staff appointment. That is, he must have not only the opportunity to place and follow his patient in a hospital himself, but also the chance to keep up on modern medical knowledge. A Committee is preparing to meet with Dr. Bernard Bucove, City Health Services Administrator, to present their demands. The Association office is at 305 Broadway, Room 1415, N.Y.C. Phone: HA 2-3666. agency affecting their districts, and with staff or grants for staff directly available to these neighborhood boards. We again stress that the authority of the Comprehensive Dr. Bucove Health Planning Agency in developing the basic plan for all matters affecting the health of New York citizens should be recognized by City, State and Federal governments as the agency for this purpose. This agency should develop a con- tinuing health planning process, city wide - and on the neigh- (From Page 1) hospitals and categrocially narrow public health centers into a fully integrated system of health centers and services empha- sizing preventive as well as curative medicine; and borhood level, which includes long range - capital facility plan- (5) Increasing direct " involvement " of consumers in the ning and overall program planning which integrates all ele- health policy making -, planning, and review process, particu- ments of service under both public and private auspices. larly at the decentralized community level. [Signed] Terry Mizrahi, Staff, Special Committee for Comprehensive Planning, 119 Suffolk Street, New York City Winning internal City policy struggles to assure these principles, mobilizing sufficient administrative and fiscal re- sponses, and overcoming existing bureaucratic red tape - and Dear Miss Mizrahi: [August 7, 1968] private - sector obstinancy to actually carry out such principles these are the key struggles far beyond such articulations. ... We appreciate your support of our position on com- Dr. Bucove has said: " My own philosophy and up bringing - prehensive health planning and intend to retain the policy causes me to have difficulty assuming that somehow govern- direction of planning in the City agency even though some ment is something apart from the people. " Unfortunately, planning contracts may be executed by outside professionals. however, unless Dr. Bucove's Administration can clearly pro- The creation of neighborhood boards is very much under ject the exact purposes of their efforts and win support of the consideration; their power of initiation and review will cer- public " they're wher-e a-t , " the beautiful dreams will float like tainly be seriously evaluated. lonely and distant clouds over a seething city. (3) | Letters to Editor | Misstated? Dear HEALTH - PAC: On Page 2 [of BULLETIN No. 2, July 1968, Eastside ' Story: Groups Seek Major Role "] you talk of Mobilization [for Youth] being involved in the creation of a unified city health district based in Gouverneur - Beth Israel. To the best of my knowledge Mobilization has had no such involve- ment. In the same paragraph in which you write of the unified city health district you mention the crea- tion of a neighborhood multi service - system for the entire area. I suspect that this is a reference to the same program as is referred to in the last paragraph of Column 2 on Page 2. That last paragraph is also in error. Mobiliza- tion has not cooperated with Beth Israel in launch- ing any neighborhood multi service - central pro- gram " probably to be based at Beth Israel. " I think the reference is probably to an ad hoc committee on a neighborhood service center system which I chair and on which are representatives of Beth Israel, Columbus Hospital, New York Infirmary, Action for Progress, University Settlement, Edu- cational Alliance, Grand Street Settlement, Hamil- ton Madison - House and the Lower East Side Narcotics Information Center. This committee is not yet at the point of proposal writing but is try- ing to develop ideas for integrated service delivery. Contrary to your article none of the various ideas developed as to administrative auspices and have proposed that a neighborhood service system be " the administrative ward of the externally owned and controlled private hospital. " It is true that the ad hoc committee has been challenged by the neighborhood groups you men- tion. You don't mention that at the very beginning of this effort certain neighborhood groups con- cerned and leaders of certain other neighborhood groups were invited to join the ad hoc committee and made no response. This is a matter of record. Also, after the " challenge " all of the groups chal- lenging were invited to participate in any manner they chose, including the establishment of a group to review any proposal that might come out of the committee, and full participation in the delibera- tions of the committee. Although this offer has been made verbally and in writing and has been followed up by conversations with individuals asso- ciated with the various organizations we have not yet been successful in engaging the group which made the challenge in active participation. I take the trouble to write to correct these mis- statements because I am in complete agreement with the fundamental point of view of HEALTH- PAC. I believe that one obstacle to attainment of full community participation in health affairs has been the substitution of fervor for fact. In this par- ticular instance I would be happy to document the points I make. I think they illustrate the tendency to substitute dramatic in fighting - among the local groups for the more arduous and tedious effort that is required for local groups to come together and not only control service delivery but make the nec- essary alterations in the way service is delivered. I hope that your efforts will be directed not only toward the exposure of tendencies to centralize planning and delivery of services outside of the neighborhood but also to the advancement of a constructive pattern of inter action - between local groups each of which seeks a degree of autonomy but all of which must achieve some degree of inte- gration if we are to make progress. -Bertram M. Beck Executive Director, Mobilization for Youth, Inc. N.Y. [EDITOR'S NOTE: We basically stand behind the general inter- pretation we made in the original BULLETIN report on the cluster of issues and forces involved. However, in making the general introductory statement that Mobilization for Youth was " variously " involved in some of the plans in the area, among which included the health district proposal and the neighbor- hood service center system proposal, we did not mean to im- py that MFY was formally involved in the health district proposal nor singularly exclusive in its involvement in the service center proposal. We apologize for any eroneous im- pressions the report conveyed.] POLICY FORUM City Councilman Robert A. Low (Manhattan D - L -) , speech on Upper West Side, June 1968: " The City [should] lease space immediately in existing buildings to establish storefront [health] clinics. In a mat- ter of months, we could then get this new program under- way. The capital funds in the budget could then be used to renovate the space and to make it suitable for clinic use... Through this effort we will not only vastly improve health services for thousands of New Yorkers, but we can expect to start to reduce hospital admissions for beds in our top heavy - hospital system. " Councilman Low reported in mid August - : " I have not had any response from the City administration on the idea of leasing storefronts for neighborhood health centers. " * * * State Senator Seymour R. Thaler (Queens D - L -) , in a news release, August 15, 1968: In a letter to Dr. Hollis Ingraham, New York State Com- missioner of Health, Senator Thaler demanded that the Department " immediately schedule public hearings to con- sider the advisability of revoking the operating certificates of Greenpoint, Harlem and Fordham Hospitals. " At the same time, Senator Thaler said he would " introduce legis- lation at this coming session to provide for a State Au- thority, appointed by the Governor, to take over and operate the Municipal hospitals towards the end that all patients, regardless of their ability to pay, will receive adequate hospital care. " In his letter he said, " The Mayor and his Administration has either neglected or refused to take advantage of cer- tain monies that were made available to the City by the action of the Governor and the 1968 Legislature. You will recall that the Health and Mental Health Facilities Improve- ment Corporation was empowered to expend $ 700 million for the improvement of existing hospitals or the construc- tion of new hospital facilities. " Even though other localities (such as Binghamton, Rochester and Westchester) have already taken steps to obtain such financing, " New York City, " Senator Thaler went on, " has not indicated any intention of so doing. " (4)