Document zQgvxn8zrx4DJO2mYzX1RnL1B

Health Policy Advisory Center 1 September 1970 HEALTH / PAC BULLETIN BULLETIN Editorial: Back to School: Keep on Trackin ' In response to the Cambodian invasion last May, students forced many universities across America to shut down. All seven medical schools in New York City and many other nursing, social work, dental and medical schools around the country participated in the protest. Social and political events superceded the traditional educational process. Classes were cancelled, examinations postponed. while students turned from lectures in the aloof ivory towers of academia to the streets of real political experience. This transforma- tion of the student role challenged the educa- tion system to its core. Now, in September, 1970, as students return to their universities. the question is: Has anything changed? In the health science schools there has been no change. The system of health science edu- cation still works the same way. Health sci- ence education has been described as a proc- ess of " socialization de :- " In the course of being selected for and trained at the various kinds of health science schools, students are sys- tematically separated and isolated from other students, from their prospective patients and co workers - and from their own common sense and experience. Whole classes of students are channeled into separate levels within the health system: middle and upper class stu- dents into medical school (34 percent of all ' medical students'families are in the top three percent of income earners in the country) working - class and lower middle - class stu- dents into nursing and social work schools; women into nursing, men into medicine. With in each professional school, students are taught an arbitrary set of professional " eth- ics " and roles, which set them apart from (and above) the layman. They rapidly learn less and less about how to cooperate with other professionals and more and more about how to work and be satisfied in an isolated professional function. The desocialization process is complete when doctors are sepa- rated from nurses, and nurses are divided from social workers, and when all three re- gard patients from the lofty and distant point of view of the " professional. " Students are trained to be, above all else, " professional. " To be professional sounds benign enough, but in fact, professionalism serves as a defense of elitist decision making and of privilege. It did not always have such ugly connotations. As used by Flexner, in his attempt to reorganize medical schools in 1912, professionalism meant excellence through uniformity of teaching skills, experience and curriculum. However, today medical profes- sionalism has grown increasingly to mean unaccountability, first to the consumers of service and second to other providers of serv- ice. The professional argues that his entire re- lationship with his client is technical; it is thus neither relevant nor possible for the lay client to criticize him or hold him responsible for his decisions. It is, of course, true that doctors and other medical professionals have unique and complex skills. Yet many of the decisions they make are technical non - and virtually all can be explained to people. Self policing - is the choice of the professional; it is not forced on him by the mysteries of his craft. Professionals also often regard themselves as more capa- ble of making decisions than other people, even when their technical knowledge does not contribute to a particular decision. Their exclusive knowledge implies to them that they are more capable of understanding than other people are. Unaccountability leads to this extension of privilege. Specialization often accelerates this unaccountability. Some specialists try to develop a " knowledge niche " so esoteric that even other profession- als will find it hard to hold them accountable. At one time, professionalism also meant pride in craftsmanship, creativity and individ- uality. This definition has long succumbed to a defense of work often below the skills train- ing of the professional. It was not too long ago that doctors struggled against relinquish- ing to nurses the right to give injections or to technicians the right to take X rays -. Nurses still argue that only a registered nurse is com- petent to distribute pills in a hospital, even though the nursing shortage has often com- pelled them to allow nurses'aides to take over this function. Social workers are taught that there is a unique service function - being human that can only be met by trained pro- fessionals, and they defend their prerogative to offer such human services. The impulse to craftsmanship has turned into the jealous coveting of professional tasks for prestigious and profitable ends, for the maintenance of the status quo within the hospital hierarchy. Professionalism, in its current meaning, is not a guarantor of humane, quality services. Rather it is a word code - for a distinct political posture: professionalism means defense of the status quo. No change in work roles, hier- CONTENTS 2 Student AMA 7 Nursing Education 11 Social Workers 12 Lincoln Hospital: Community Control? archies or the educational system, because this will mean loss of economic and status privilege for the professional. No search for accountability since that will limit the individ- ual professional's freedom. No desire for democratic decision making, since that will mean the professional will have less power. The compartmentalized professional finds it difficult to cooperate with other professionals, much less non professionals - , since that upsets the hierarchy, threatens his uniqueness. This explains the incapacity of many doctors at Lincoln Hospital for working together with the insurgent community and worker organiza- tion, Loncoln Think - [see page 12]. It also ex- plains why white coated - medical students last spring refused to leave their sidewalk march to join other (professional non - ) stu- dents who were marching in the streets to pro- test the Cambodian invasion. This type of professionalism is not in the in- terest of the patient: He very often falls be- tween the isolated role definitions separating one professional from another, and in any case, has no say over what is done to him. It is not in the interest of the student: profession- alism by this definition limits skill learning and expression of craftsmanship. Then, in whose interest is professionalism? Profession- alism is designed to preserve the stability of the health system. The educational system, medical, dental, nursing and social work schools, in this context, work to benefit those in control of the medical industrial - complex. This is so because professionalism divides groups of health workers from other groups of health workers and from consumers, and thus weakens the struggle to improve the health system. In effect, professionalism serves as a mechanism for keeping even the so called - professionals in line. Increasing numbers of young doctors, nurses and social workers are struggling to create alternative work and training settings - from free health clinics to the Lincoln Hos- pital pediatrics collective. Together they are trying to blow wide open this educational pro- gramming and compartmentalization. Thou- sands of returning health science students will join other students this fall with the rally- ing cry: Open the universities up. Open pro- fessional schools to blacks and women. Open medical schools to nursing, social work and dental students. Open professional schools to the social and political debate that reverbe- rates in every sector of our society. Only in this way can the channeling, programming and desocializing functions of professional education be turned around. The Enterprising Medical Middle: Student AMA One of the first interactions that a future phy- sician has with organized medicine occurs during his first few days of medical school. On registration day, some time while he is shoveling out money for tuition, books and school newspapers, he will more often than not also find a group called the Student American Medical Association (SAMA) waiting for some of his money. Often it is not clear to him that this group is not just another integral and compulsory part of the row of tables at which he must pay fees. Member- ship in SAMA, he is told, will enable him to purchase hospitalization insurance, group dis- ability income insurance or life insurance, all at the lowest possible cost. He is told about SAMA's inexpensive European charter flights, and about a long list of discounts on items as far ranging - as high intensity - desk lamps to automobiles at only $ 100 above dealer's cost. There is participation in summer service proj- ects in Appalachia and Illinois awaiting him. And should he wish to involve himself in the decision - making processes of the organiz- ation, there are always committees to join, offices to run for, and conventions to attend. If he does join, he pays his membership fee just once and automatically becomes a mem- ber standing - in - good - for all the rest of his years in medical school. And if he becomes a member, he will probably do little more than receive his monthly publication, his occasion- al newsletter, and will never know much more about SAMA than he did on that first day of school. There is a great deal which the student ought to know about the Student American Medical Association. It is, by its own declara- tion, " the world's largest and richest student professional organization. " With chapters at 87 of the nation's 95 medical schools, with a membership roll of 24,000 medical students (almost 65 percent of those in the country) and with a national office staff of 35 people, SAMA is indeed large. With a budget for the fiscal year 1970 of over 1.1 million dollars, it is indeed rich. And for the greater part of its life, it has also been moribund. SAMA originated in 1950 as organized med- icine's answer to a progressive group called the Association of Interns and Medical Stu- dents (AIMS). At a time when only educa- Published by the Health Policy Advisory Center, Inc., 17 Murray Street, New York, N. Y. 10007. (212) 267-8890. Staff: Robb Burlage, Vicki Cooper, Barbara Ehrenreich, John Ehrenreich, Oliver Fein, M.D., Ruth Glick, Maxine Kenny, Ken Kimerling, Howard Levy, M.D. and Michael Smukler. 1970. Yearly subscriptions: $ 5 students, $ 7 others. Application to mail at second class postage is pending at New York, N. Y. N tors dealt with education, AIMS had sug- gested that it was also a legitimate concern of medical students. At a time when no one dealt with discriminatory admissions policies, AIMS had called for an end to the prejudice that closed the doors of medical schools to blacks and women. These actions were suffi- cient to incur the wrath of organized medicine. During the late'40's and early'50's, the AMA and a number of medical school deans, in the prevailing spirit of McCarthyism, combined to eliminate AIMS. The AIMS journal The Interne, bears silent witness to this assas- sination - large, handsome, thick with adver- tising in 1941; small, pathetically thin, devoid of any advertising one decade later. Born unto the AMA, SAMA was reared to emulate and respect its parents. For the first 16 years of its life, SAMA was a model child. The young SAMA, described by the past edi- tor of its journal as dominated by a staff of " medical non - executives essentially appoint- ed by an insurance firm with economic in- terests in the organization, " carried out pro- grams and activities clearly envisioned by its constitution which states in part: " The objects of this Association shall be to... contribute to the education and welfare of medical stu- dents, interns, and residents; and [] to famil- iarize its members with the purposes and ideals of organized medicine...... " The years 1950 to 1966 saw a great proliferation of nar- row educational scientific programs such as symposia and forums and of service programs such as life and liability insurance, chapter of the year awards, and Golden " Apple " awards for oustanding faculty members. There were liaisons established with more than two dozen other professional groups, to familiarize the students with " the purposes and ideals of organized medicine. " But it was not until 1967 that SAMA recognized that there was something else going on - a crisis in medical care. The 1967 SAMA convention's most dramatic act was to pass a resolution stating that local SAMA chapters should " be encouraged to start investigating the socio- economic problems of poor people... " In the same year SAMA realized there was a crisis in its own organization and it passed a res- olution calling for the appointment of a stu- dent editor for its journal to replace the in- cumbent insurance executive. It was not until 1968 that the Student American Medical As- sociation began to act on the health care crisis that had always been all around it. What brought on this rather abrupt devel- opment of social concern was the influence of another organization, the Student Health Or- ganization (SHO). Formed in the fall of 1965, SHO was not another medical students'guild; it included medical and nursing students and was open to all health science students. It was committed to action on a range of social issues, especially, at the outset, poverty and racism. SHO's summer service projects, bring ing health care to ghetto and rural areas, at- tracted students in droves. Impressed by SHO's growth and vitality, SAMA began to pick up some of the new organization's ideas. A " New SAMA " was born in the conven- tion of 1968. Under a banner emblazoned with the words " Concern, Commitment, Action, " newly elected president C. Clement Lucas spoke of the problems of ill health and medi- cal education in the United States. SAMA be- gan to make some long overdue changes. Its journal, The New Physician, took on a new look. It still kept much of its old scientific for- mat including sections on X ray - consultation and the " EKG of the Month. " But for the first time in its life, it also began to publish articles that would hold the interest of the students who knew there was more to medicine than technology. Articles began to appear on med- ical education and on community health. With the election of Ed Martin as president at the 1969 convention, plans were set in mo- tion for the creation of a summer service pro- gram placing medical students in Appalachia. Soon afterwards another project was created to place students in small community hos- pitals in Illinois. At SAMA's most recent con- vention, Charles Payton took over as presi- dent and most of the past leadership left the organization. There is new leadership for the " New SAMA. " But is there a new direction? The " New SAMA " is two years old and its apparent change during that time raises for concerned students the question, " Just how far has SAMA really come? " One ex SAMA - member has described its programs and resolutions as having about the same impact as Time magazine. Both present a great wealth of information on societal ills without the analysis necessary to show how all the problems are related. For example, SAMA has a program that is supposed to fight the health manpower shortage in Ap- palachia and in its resolutions has called for an end to discriminatory medical school ad- missions policies and for an end to the war in Viet Nam. SAMA sees these symtoms, but has shown itself to be either blind or not really in- terested in the etiology - health as a low priority for a country that would rather spend its money on the Indochina war than on the lives of its citizens. The SAMA project in Appalachia is a clear illustration of SAMA's symptomatic approach to treatment. During the summer of 1969, 95 medical students and 20 nursing students par- ticipated in the first Appalachian Student Health Project. The grant proposal for the project suggested it was a health manpower recruitment drive that would help correct the acute shortage of doctors and nurses in the area. The Appalachian Regional Commis- sion, a billion dollar federal - state agency, desperate for ways to show how much it was doing for the Appalachian people's health, granted SAMA $ 247,000 for the project's first year. SAMA has made some clear political decisions on how to carry out the project. It placed most of the 115 students with private practitioners and worked closely with the Ap- palachian Regional Commission. During the program's orientation, SAMA carefully ex- posed the students only to those groups that in no way challenged the existing health care delivery structure. SAMA did not place any program participants with doctors who fought black lung, or with community action or legal advocacy groups. Representatives of these groups had to come uninvited to the project's orientation meeting in order to demand speak er time. And while they were arguing for the right to address the students, they incidental- ly discovered that the SAMA " interdisciplin- ary " approach meant giving separate but equal orientations to the medical and nurs- ing students. SAMA claims its Appalachian program is designed to " create among the student par- ticipants an awareness of the existing health programs, the problems of delivery of health care to and the general medical needs of a rural community " in order to " exert through the students an influence on medical and nursing school curricula in a way that would provide a larger, more significant output of personnel appropriately trained for the health needs of rural America. " Yet by placing the student participants only in working environ- ments with established medical supervision, they will never develop an awareness of any. thing more than the community's " general medical needs. " The student should have been allowed to speak and work with those who can suggest real answers for Appalachia. Only when he is allowed to see poor health as a reflection of poverty, and poverty a re- flection of unemployment, and unemploy- ment a reflection of a society that doesn't care to employ West Virginian coal miners any longer when it is so much cheaper to automate, can he then see an answer to the ill health of Appalachia. If SAMA sys- tematically isolates him from new options and non traditional - alliances to stimulate change, then he will, at worst, feel that by giving his summer he has done all that he can do for the people of Appalachia. And at best, he will return to the community some day and take over the well paying private practitioner role to which he has been exposed. In either of these cases he will do little to help stop the perpetuation of the malnutrition, environ- mental deterioration and industrial disease that await the unborn children of Appalachia. After the summer in Appalachia had ended. Ed Martin, student program director and then SAMA president, told the Appalachian Re- gional Commission, " The program was sold to us on the theory that if we saw Appalachia we would come back and save it. That's too simplistic. Appalachia is not a viable option for medical students wanting to get ahead. " The project had failed to accomplish at least one of its stated goals; only 18 medical stu- dents indicated any desire to return to Ap- palachia to live and practice. SAMA's sur- prise at this failure is in itself surprising. If it was the Commission that had sold the pro- gram to SAMA, then one would expect that SAMA would not allow itself to be hustled into the same thing again. Yet, with essential- ly no changes from last year, the second Ap- palachian Student Health Project has just been completed this summer. Appalachia is still not a " viable option. " Students are still not returning. But the program continues. Another SAMA program designed to deal with the unequal distribution of physicians in SAMA CONTRAST: In 1965, when most STUDENT HEALTH health science ORGANIZATION schools ignored the health problems of the poor and most minded career - health science students were in- different to social and political issues, the only extant student health organization was the Stu- dent American Medical Association (SAMA). Activist students concerned with the crisis in the health system, as well as the society at large, saw the need for a new organization. SAMA was more concerned with insurance than with the social or medical needs of the poor. Its membership was limited to medical students; nursing, dental and social work stu- dents were excluded. Finally, SAMA's link to the traditionally elitist and conservative medi- cal establishment was so ingrained that con- tact with community and worker forces for change was non existent - . The Student Health Organization (SHO) was founded in reaction to the failure of the health science schools, the narrow elitism of most health science students, and the absence of a meaningful student or- ganization in health. SHO was held together initially by its pro- gram of summer service projects - patient ad- vocacy programs serving migrant workers, * survey of neighborhood health needs, screen- ing programs for ghetto children, etc. The projects overcame the artificial separation of nursing, medical and social work students. They brought the students out of the abstrac- tions of health science training schools into real human contact with the community. In- creasingly, SHO placed students in contact with the community groups at the forefront of the movements for social change. By 1968, there were SHO summer projects in nine cities. They involved over 600 students, at a cost of more than $ 1 million in federal poverty program funds. But many SHO stu- dents soon began to realize that adequate health care for the poor was not a problem of communication or social commitment alone; it was a problem of power. SHO projects seemed to do more to improve the public image of the health professionals and the medical schools than they did to change health services to the poor. Worse, student- initiated and student conducted - research sur- veys of community health needs and leadership armed the establishment health bureaucracies with information to deflect com- munity demands rather than meet them. SHO activists had discovered the two class - health system. Medical training, research and virtually the entire American health system is organized to meet the needs of middle and upper middle class consumers and providers. Millions of poorer Americans get inadequate, the nation is called Medical Education Com- munity Orientation (MECO). Funded by a three - year $ 125,000 grant from Sears Roe- buck, MECO shares the Appalachian pro- gram's approach to education by exposing students to problems without encouraging them to go beyond superficial answers. Medi- cal students in MECO are placed in com- munity hospitals, which are hospitals not affiliated with a university, usually staffed by private practitioners, and without a regular program of medical student clerk- ships. The project is supposed to show that community hospitals are acceptable for stu- dent clerkships and, by implication, for in- ternships. The idea is that the community hos- pitals, the majority of which are not now accredited for internship, will become accred- ited, and will attract interns who hopefully will stay in the community after their training. This theory has been warmly embraced even by the conservative president - elect of the AMA, Wesley Hall, who has stated that " In- terns and residents should get out with the practicing physician. I think the preceptorship is extremely important. I would favor such a program, even for medical students... " What MECO fails to take into account is that the number of internship positions in the nation's hospitals already far exceeds the number of available interns. Despite MECO, communi- ty hospitals in isolated rural areas will not compete well with the urban centered - hos- pital for interns. SAMA's new stance of commitment is fre- quently contradicted by its actions, giving it the appearance of an organization working at cross purposes with itself. This conflict was made vividly clear when in 1968, the " New SAMA " was announced under the banner of " Concern, Commitment, Action; " C. Clement Lucas saw no contradiction in also announc- ing discounts for SAMA members at Hilton and Ramada Inns and on Chrysler Corpora- tion automobiles. The student who was to battle the ills of society was also going to first take advantage of his position in that society. The same conflict reappeared one year later. During the 1969 SAMA convention, the delegates called for the creation of a standing committee on minority group admissions in order to deal with the " subtle conspiracy " of discriminatory admissions policies and pro- hibitive financial barriers that were denying these groups admission to medical school. By late that same year it was clear that the new- ly appointed committee had not shown any signs of life. Members of the all black - Student National Medical Association came to one of the committee meetings and helped to set up a five man - subcommittee that would assume the responsibility of setting into action the committee's supposed goals. The subcommit- tee offered a program that would have in- volved both researching the statistics on dis- criminatory admissions and contacting local community organizations in order to lay a political groundwork for direct community pressure on the medical schools. When the subcommittee requested the necessary fund- ing for the program, money that had already been allocated to the committee as a whole, they were refused by SAMA's executive com- mittee delegates who had called for an end to Oe) fragmented care, which exploits them as teaching and research materials and main- tains their dependence and their vulnerability to disease. The first place concerned health students chose to attack this system was the oppressive institutions which trained them to be part of the system. The SHO focus shifted from service programs to demands for minori- ty admissions to medical schools (Philadel- phia), stopping medical school expansion at the expense of neighborhood housing (Har- vard), and mobilizing patients to demand adequate service at the teaching hospital (Co- lumbia). At Northwestern Medical School last spring, 30 medical and nursing students oc- cupied the Dean's office for 24 hours. They conducted a People's Health Free University to dramatize the school's racism in admis- sions, dual standard patient care in teaching hospitals, and oppression of students who at- tempt to respond to these political realities. The change to direct political action within the health system rather than low - risk sum- time mer - projects in the community has sapped what interest there was in the loose- knit national structure with which SHO began. Although an active communication network persists (the SHO Service Center, 1613 East 53rd Street, Chicago), no energy has been di- verted to convening a national convention for the last two years. Around the country, ac- tivists are pulling together in work groups, collectives and " chapters, " although not all call themselves SHO any longer. More important than the change in organ- izational style is the shift in political perspec- tive: SHO no longer pretends to be an organization representing a broad spectrum of " concerned " health science students. It is an informally connected network of small groups committed to fundamental political change in the health system and in the nation as a whole, which tries to continue to be rel- evant to the majority of health science students by raising basic, unavoidable issues about the crisis in the health system. Most SHO groups believe that any majoritarian movement of doctors in America today would be inherently privileged and conservative. The real (but dis- enfranchised) majority in the health system are the consumers of health services and the non professional - health workers. SHO activ- ists seek alliances with these groups to make the profound changes in the health system so necessary today. Though this may predestine SHO to remain a minority group of health sci- ence students, the number of students fully active in SHO is at least as great as when the organization was an expression of the illusion that if students just cared, more things would change. the " subtle conspiracy, " but who had unwit- we can be successful... working together tingly instead become part of it. we can attain the goals we mutually seek. " The SAMA journal, The New Physician, The continued dependence of SAMA upon offers the most recent example of saying one its parents and its parents'circle of friends, thing and then doing the opposite. The journal the industrial medical - complex, is seen in its advertises that it " . .. does not seek to be meref-i nancial statements. As recently as 1969, ap- ly a repository of information, but a forum for proximately 75 percent of SAMA's total in- the expression of ideas which are in the de- come of $ 600,000 was obtained from four velopmental stage. " However, its actions do sources: (1) pharmaceutical companies; (2) not support its advertisement. The June, 1970, insurance dividends from the Minnesota Mu- copy carried an interview between Dr. Eu- tual Insurance Company; (3) the AMA and gene Schoenfeld, " Dr. HIPpocrates, " and an state medical societies, and (4) other adver- unidentified interviewer. The New Physician tising in its journal, The New Physician. In carefully does not credit the interview to 1970, though, SAMA is proud to note that Larry Brilliant, one of its contributing editors these same sources account for less than 45 and now editor of The Body Politic, the much percent of the total $ 1.1 million. This is sup- more radical journal of the Medical Commit- tee for Human Rights. Nor did the editors posed to indicate a " decreased dependence " of SAMA on these sources of income... " But bother to print Larry Brilliant's introduction to is this really true? Upon closer scrutiny one the interview, a piece which described the notices that in terms of absolute dollars, these differences between political activism on the four sources have contributed about 20,000 $ East and West coasts and was essential to the more in 1970 than in 1969. The bulk of the re- perspective of the interview. It seems as though The New Physician is a forum for the expression of only certain ideas. Why is it that the Student American Medi- cal Association treats symptoms intead of un- derlying causes and then works at cross purposes even to those misguided ap- proaches? The reasons are many and com- plex and are best reflected in the organiza- tion's history and its leadership. SAMA was born in an act of fratricide. By the very nature of its birth and expectations of its parents, it was a conservative organiza- tion. And constitutionally it was created as an exclusively medical student organization. These inertial forces make it hard for SAMA to change. Although it has attempted to de- clare its independence and rebel against its parents, like most adolescents it still needs its parents'love, approval, and money. C. Clement Lucas, before the AMA House of Delegates in September, 1968, addressed him- self to the health care problem saying that there was a crisis in American health care and that both SAMA and the AMA have failed to meet the challenge. He asked for the AMA's help to create a just society for all with health as a basic right. " With your help maining increase in 1970 income is a result of $ 425,000 in federal grants (only $ 50,000 in 1969) for programs such as Appalachia and 125,000 $ in foundation grants (none in 1969) for programs such as MECO. Essentially all of this additional $ 500,000 is earmarked for very specific grant proposal projects. This money is not available for putting out the monthly publication, or paying regular staff salaries, or paying the mortgage on the office. These costs must still be paid for by monies from the big four. One then must seriously doubt the SAMA claim of financial independ- ence. Ever since the " New SAMA " was born, its leadership has reflected the general shift of the medical community away from individual entrepreneurship and towards medical cen- ter focused - empires. [See BULLETINS of Nov. '68 and Apr. '69]. Its leadership has been forming SAMA into the sort of corporate struc- ture capabale of controlling a medical center empire. Since 1968, SAMA leaders have learned well the art of soliciting grants, the mark of the successful medical empire - ship. They have learned how to speak, whom to speak to, and how to compromise in order to receive money. And sometime early in 1969, EXTENDING THE EMPIRE: LIKE FATHER, LIKE SON It was not surprising to the student activists who disrupted the 1969 AMA Conven- tion when guest dele- gations were greeted from such countries as Taiwan, South Korea, South Vietnam and " Cuba - in - exile. " The re- actionary politics of the AMA seemed con- sistent with honoring these wing right - Ameri- can client states - . Recent SAMA resolutions opposing the war in Vietnam leave the im- pression that SAMA has repudiated the foreign policy of its parent. However, the fol- lowing statement made by C. Clement Lucas (past SAMA president), to the SAMA execu- tive council concerning his visit to the assem- bly of the International Federation of Medical Student Associations (IFMSA) in Helsinki raises doubts about the shift toward independ- ance by the new SAMA leadership: " It can be seen that even though the U.S. didn't assume a vocal role in the assembly, we worked behind the scenes to change and improve much of the organization. In the fu- ture, IFSMA is going to look to the U.S. for more leadership, especially in terms of the Americas, and the U.S. should be prepared to offer this. It is important to realize that the U.S. is the only really organizationally oriented country in IFMSA and can offer many sugges- tions for improvements in the functioning of IFMSA. The U.S. should become greatly con- cerned with the problems of Latin and South America, and should in the coming year adopt Bolivia as a special project. " it became apparent to past president C. Cle- ment Lucas, past vice president - Chris Ram- sey and past treasurer, then president Ed Martin, that despite their efforts SAMA could never be a very successful corporation. Most foundations were much more willing to grant money to interdisciplinary health programs, and SAMA was constitutionally an all medi- cal student group. Besides, SAMA was hope- lessly bogged down by a strong constituency in the conservative South and Midwest. What - was needed was a new structure - SAMA leaders came up with something called The Institute for the Study of Health and Society, an organization conceived " as a tool for anal- ysis... in health and society. " The financial umbilicus that tied the two organizations to each other was severed in the fall of 1969. As one of its first major independent tasks, the Institute set up a " Conference for the De- veloping Professionals on the Environment. " This $ 50,000 conference, which took place on three days in October, 1969, was infused with professionalism and supermanagement skills. People who were approached to participate in the program were sold the idea that if one could just get all the " bright young profes- sionals " together, it would be easy to solve the environment problem. The meeting of the hundred varied professionals (law, medical, nursing, architectural, ecology, and more) who did attend was to be orchestrated by a Washington based industrial psychology con- sulting firm. The three days of rigidly pro- grammed group dynamics reached a climax in an attempt to have the hundred profession- als participate in a period of planned sensi- tivity, walking with eyes closed and touching one another, then (on command) thinking about the experience. At this point several of the participants rebelled. They believed that it was exactly that sense of professionalism which the conference bolstered, that stood in the way of ever dealing effectively with the environment or anything else. To be profes- sional, they argued, was an excuse to avoid dealing with the human dimensions of prob- lems. The first step in combatting pollution is not to be professional, but to be angry. Those few people who came to the conference with this belief were not going to allow all their anger to be dissipated in planned sensitivity sessions. Their disruption of the conference session blew apart the programmed ap- proach and stimulated a great deal of soul- searching and political discussions. Planned sensitivity and programmed meetings, which permeate industry so extensively, were re- duced to the farces that they are. The partici- pants of that environment conference went away knowing that the fight against environ- mental deterioration was also a struggle against their own professionalism. Just a little more than two years after its an- nounced rebirth, the Student American Medi- cal Association is still an organization in flux. At its most recent convention in 1970, resolu- tions were passed against the war in Viet Nam and its extension into Indochina, for the legalization of marijuana, for increased mi- nority admissions to medical schools, and for the repeal of abortion laws. Time will tell whether SAMA is serious about working for these goals Robert. - Richter, Medical Student Intern Nursing Education: Teach the Woman to Know her Place The young woman just entering nursing school faces her education with great ap- prehension. Her most pressing questions are: Will I be able to learn how to give the best pos- sible care for the sick? Will I`be able to learn how to work most effectively with the doctor, my fellow nurses and the non professional - workers? Will I be able to learn how to be " a good nurse " and help change nursing to be better? After only a few short months in nurs- ing school, however, the student nurse no longer sees these questions as relevant. In- stead, the most important questions for her have become: Will I do everything exactly the " right " way, i.e., the way the supervisor wants them done? If I make any changes will I be doing something so hideously wrong that the patient will die? Will I express the right attitude toward my work so that I can stay in school? The student nurse and the young nursing graduate have been molded through their education to see themselves not as important workers or decision makers in the health world but as minor cogs in the health system wheel. They can only do what they are told and cannot make decisions because that is not their assigned task. Though the elite in nursing like to think that nurses have major responsibility for patient care, this is large- ly illusion. For the most important message communicated to potential nurses and nurs- ing students is " don't rock the boat. " Even in the most limited sense, individual imagina- tion and initiative in providing nursing care is out of line. And any nurse who challenges the basic structures and relationships in the health system is considered a heretic by the women who dominate nursing leadership: the educators, the supervisors and the admin- istrators. The roots of this conformity, this passivity, this fear of change stretch back as far as the recruiting programs for potential nurses and continue through the whole educational proc- ess. This article will try to trace that develop- ment. The recruiting process must steer women into one of three kinds of registered nursing program: the baccalaureate (B.A.) or four- year college degree programs; the Associate 7 Degree (A.D.) or junior college program; the Diploma or hospital school program (a three year course granting a certificate in nursing). Even though nurse educators say there are differences in the various programs (aca- demic emphasis in the baccalaureate pro- grams and technical emphasis in the other programs), in practical terms there is not really that much difference. Nurses from all three programs perform identical duties (al- though opportunities for specialization and advancement vary with the program) and relate to doctors, patients, and the health sys- tem in similar ways. V ery few women who decide to become nurses know the differences among the vari- ous programs. They are subject to seemingly haphazard recruiting techniques. The mes- sages about nursing come from many differ- ent sources: books, magazines, high school guidance counselors and advertisements. Haphazard though it may seem, however, there are several underlying purposes of the recruiting that serve the interests of the lead- ers of the existing health care system. The task of the recruiting is to procure enough women to be trained for each of the types of nursing, and to ensure that they will be wom- en who can be appropriately molded in per- sonality as well as properly trained technical- ly. Perhaps the most blatant examples of re- cruiting for self serving - interests originate from hospitals and hospital schools. They try to draw women into hospital - based " diploma schools. " One advantage of this to the hos- pitals is that students trained in hospital schools are directly " educated " to serve the hospital's needs, which, however, frequently conflict with the individual's expectations that nursing will be a way of helping people. Hos- pital nursing schools are also a convenient mechanism for insuring an adequate supply of nurses for hospitals: The student nurses them- selves provide nursing care for patients dur- ing their education. And they often remain at the hospital at which they were trained after graduation. At hospital schools, a prospective student is frequently told that she will be taking some courses for which she will receive college credit. This is sometimes true; more schools are linking up with colleges so that their stu- dents can go on for their bachelor's degree. But in most cases this is a lie; the courses may be given by college teachers but the students receive no college credit for the course, mak- ing it impossible to go on to higher educa- tional levels without starting all over again. Hospital schools are closing down rapidly, in part because of the growing unpopularity of such dead end education, and some schools seem to feel forced to use any method they can to attract students. The recruiting for A.D. programs is very similar to the misleading recruiting used for Diploma Schools. The prospective students are told that they will have two years of col- lege work which they can then use to transfer to a regular collegiate school for nursing. However, this is often not true. For example, the New York University catalog states: " Courses in the baccalaureate degree nurs- ing major are at the upper division level and have substantial prerequisites in the arts and sciences for admission to them. Courses in nursing taken in associate degree and hos- pital schools are not equivalent in level or complexity of these requirements and may not be accepted for advanced standing credit. " Another mechanism for selecting women for the various types of nursing programs is the high school guidance counselor. One nurse who was interviewed related the fact that her guidance counselor told her that she was too smart to be a nurse. This is a typical statement which is often repeated to white middle class students. If such a student does persist in choosing nursing, invariably she will be shepherded into a collegiate program. Black or poor white students by contrast are typically guided into diploma schools or A.D. programs, even though there has been a great deal of money available for scholarships to collegiate nursing programs. Often guidance counselors brief visting nurses about the programs they should stress when talking to a particular group of prospective students. If the counselor determines that the group of students is not " college material, " the nurse is told to gear her talk to Associate Degree and practical nursing (P.N.) programs. Typ- ically, when there are many black students in the group, the A.D. and P.N. programs are stressed. The conception that nursing is a woman's task has led to sexist and sex biased - recruit- ing for the field. Guidance counselors never suggest a nursing career for men. Any boy who might consider nursing is frequently frightened away by the oft made - association of homosexuality with the male nurse. One way in which men do get into nursing is via the army medical corps. Some black men en- ter nursing, especially practical nursing, be- cause it is a relatively secure, fairly high paying job for blacks who are excluded from many other skilled jobs. However, few men consider nursing itself as a career; rather it is often seen as a stepping stone to some other job, such as hospital administration. Nursing educators contribute to the perpetuation of the sex biased - image of nursing. As one nurse so coyly stated, " Many students lighted the lamp in adolescence when the feminine con- sciousness began to awaken. " The Armed Forces, in their nurse recruiting, also take advantage of the fact that nursing is mainly a women's profession. They utilize overtly sexist propoganda to entice women into the service. Their pamphlets allude to the availability of marriageable men and illus- trate their point with alluring pictures of natti- ly uniformed officers embracing attractive blue eyed, blond nurses. These pamphlets also describe the excitement and glamour that await the prospective military nurse. To make their programs even more attractive, the various programs, whether they are spon- sored by the Army, Navy or Air Force, offer to pay for two years of schooling in return for two years of service. Traditionally, the registered nurse has been white and the practical nurse has been black. But now, nursing manpower needs require re- cruiting more black women for registered nursing to staff inner city hospitals. Since this recruiting campaign has been waged by the white, professionally oriented nursing leader- ship, there are often racist notions behind their recruiting drives. Major campaigns have been started in urban high schools to get black and brown women to train in A.D. pro- grams. Besides school visits by nurse recruit- ers who explain the opportunities for black women in nursing, pamphlets and brochures have been prepared to circulate in inner city high schools. One such pamphlet, printed by Ex Lax - Cor- poration and prepared with the cooperation of the American Nurses Association, features many pictures of black nurses and nursing students in the hospital setting. On the sur- face the pamphlet seems to be an honest at- tempt to recruit black women into nursing. But the thematic undercurrent of the pamphlet is that nursing is a good way to make it in the white world and to fit into the value system of white middle class America. To appeal to the image of the black women as perceived by recruiters, the text of the pamphlet is sup- posedly hip: " Think about being a nurse. It's really where the supercool action is. You'll wear a smashy dress. " The conclusion is clear: " When you become an'you're R.N.'- somebody. " Become a nurse and get out of the rut of being black. But nursing recruiting serves more func- tions than just producing enough bodies for the various programs. The chosen women must also have a personality that can be molded into the traditional role of a nurse: self effacing - , subservient, and willing to take orders without asking questions. In part, this personality screening is the recruiter's job. But self selection - also plays a role. Only wom- en who identify with the mass image of nurs- ing portrayed by the media are likely to want to become nurses. The prevalent image of the nurse is gleaned from books, movies, tele- vision programs that depict her in the most traditional roles. For the pre teen - there are heroines like Cherry Ames, Student Nurse, who is depicted as the self sacrificing - , hard- working, dedicated angel. For the older girl, there are the thousands of pocket books about seductive nurses and their sexual exploits. On TV, the doctor stories show the nurse as a beautiful, dedicated, handmaiden to the mas- terful (and sexy) doctor. The " good " nurse is the silent helper who gets her reward by marrying the doctor. Often the expectations of nurses training - in - still do not jibe with the needs of the medical profession. Surveys show that many women enter nursing because they want to help peo- ple. Students think of nursing in terms of dedicated service, care and concern and im- proving health care. But what the incoming nursing student thinks is of little importance. What matters is whether she can be fitted into the mold prepared by the decision makers in nursing. For them the important values are order and routine, meticulousness, hard work, emotional control and restraint. The education of the student nurse, whether it be in a diploma, associate degree, or bac- calaureate nursing program, is essentially a " desocialization " process. Throughout her nursing education, the student is exposed to a multiplicity of experiences which evoke fear, guilt, and humiliation and which ultimately undermine her personal value system, alien- ate her from her common sense, and stifle her desire to create and experiment. These experi- ences in effect program the student who will later, as a graduate nurse, be expected to fit smoothly into the existing health care system without rocking the boat. One of the first things the nursing student learns is that there is a " right way " of doing things. There is a " right way " to do trivial things such as making a bed, and a " right way " to do critical things things such as treat- ing a patient who is hemorrhaging. " If you make a mistake, " the student is told, " the patient might die. " When evaluating the stu- dent's performance, the nursing instructor fails to consider the relative importance of various tasks. The student is taught to think that deviating from what has been taught, no matter how unimportant the task, will have serious consequences. One graduate nurse, considering her experiences during her fresh- man year, recalled: " My instructor came into the room to inspect a bed I had made. She was angry and disgusted because the sheet was wrinkled. I felt like I had done something really horrible... like I I had done something that might really hurt the patient. " Another student tells of being severely disciplined for failing to wake a patient in order to change his bed linen. Her explanation that the patient had not slept for several nights and that he needed undisturbed sleep more than clean linen was judged irrelevant. It is certainly true that mistakes could cause injury or death to a patient; there are many procedures for which there is indeed a " right way. " Many other tasks performed by nurses, however, could be improved with imagina- tion, innovation, and flexibility. But the use of personal judgement is discouraged in nurs- ing school because the function of nursing education is to produce a nurse with predict- able, unimaginative behavior that can al- ways be molded to fit the needs of the medical profession. The " right way " is a theme which perme- ates all of the student's classroom and clinical experiences. Its roots, of course, lie in the many medical tasks for which the " right way " may indeed be a life death - or - matter. But the use of this theme to stifle individuality in less critical tasks originates, in part, in the nurs- ing educator's desire to standardize the kind, quality, and level of patient care the nurse will later provide. The " right way " is also rooted in the educator's fear that the young student is lacking in common sense. Often the educator assumes that the student has had little life experience and few personal values, or perhaps the wrong kinds of experience and values. Consequently, the educators see their task as an enormous one. They must first in- culcate values and then show the student how to perceive, interpret, and respond to each and every situation, keeping these values in mind. Most students diligently attempt to follow the instructors'orders and values, however absurd. It may not ensure or even be relevant to patient care, but it certainly is necessary to her own survivial as a student. In time, she internalizes the rigidity she has been taught. Having been taught that the patient is a person and that every person has dignity and worth, the nursing student proceeds to learn how to do things to him. She is drilled in the arts of making his bed, taking his temperat- ture, bathing and bandaging him. In labora- tory settings which are simulated hospital rooms, the student performs these functions over and over again until she " gets them right. " Only then does she move on to the " real patient, " who now, for the student, be- gins to take on the appearance of the dummy she practiced on in the nursing laboratory. One student explained: " I had heard so much about the'patient'- what he likes, what he needs, how he feels - that when I was con- fronted with him, somehow he didn't seem quite real. " The effect of this kind of education is de- structive to both student and patient. A recent study of nursing students'experiences in a nursing program reveals that " students re- ported having symptoms of anxiety, nervous- ness, depression and restlessness, very often. " Another study reveals that " students do not appear to value independence of ac- tion to a great extent. " A third study demon- strated that in the course of their education, students, who originally saw themselves as providers of care, came to envision their roles as those of supervisor, administrator, or nurs- ing educator. From these findings one might infer that for survival, one of the student's primary needs is that of keeping safe, i.e., reducing her own anxiety and " making it " through the educational system. She can accomplish this through strict adherence to the rules, engag- ing in ritualistic behavior, and by avoiding ambigous situations which necessitate crea- tive thinking. When the young nurse leaves school she will find that she must behave in exactly the same way to " make it " in the health system. One way in which the student can combat her feelings of powerlessness is by allying herself with her oppressors: the nursing edu- cator and the physician. One study revealed that bonds between nurses and doctors were stronger than patient - nurse bonds. Feelings of powerlessness are also reduced by exert- ing power over ancillary staffs practical - nurses, nurses aides, and the like. One stu- dent recalls being told by her instructor: The " workers under you are the bottom of the bar- rel and it's your duty to teach them. " The attitudes and work habits the student learns in school, the allegience to the doctors and the supervisors, the exploitation of non- professional personnel are all the things necessary to maintain the health system as it now exists. Baccalaureate nurses see them- selves at the top of the heap in relation to other nurses. A.D. and Diploma nurses in turn see themselves as separate from and more important than the non professional - staff but still subservient to nursing leaders. The process of nursing education fails to prepare young men and women to challenge what they will later experience when they enter the health care system as full time - work- ers. They learn that it is safer to perpetuate the existing health care system than to chal- lenge it. For the student, any intention of be- ing the patient's advocate is lost somewhere during the beginning of his or her education. Having had little opportunity to explore her own values and ideas or the discrepancies between the ideals she had about nursing Total Females Black Amer. Indian Mexican - Amer. Puerto Rican * Medical Student Enrollments (1st year class) 1968-69 Absolute % of 1969-70 Absolute numbers 9,863 total numbers 10,371 887 8.9 963 783 2.18 1,042 9 0.02 18 59 0.16 92 267 0.74 310 (90 *% of all Puerto Ricans go to medical school in Puerto Rico) . Associate degree Baccalaureate degree Diploma Practical Nursing Nursing Admissions for 1968-69 total % blacks 17,808 14,111 28,679 44,917 10.5 6.0 3.6 17.4 % men 5.3 2.5 2.8 4.4 % of total 9.3 2.75 0.04 0.24 0.82 10 and what really goes on in the ward, the stu- dent loses contact with her personal values. She loses confidence in her own judgment and common sense. Compliance, dependence and lack of initiative and creativity insure her survival. Despite the elaborate efforts made to ensure their docility, more and more young nurses and nursing students are beginning to chal- lenge the traditionally passive role of nurses. Recently there have been several events that point to a new direction for insurgent nurses. At the American Nurses Association 1970 con- vention, nurses from all over the country formed the " Society in Crisis Committee " which challenged the direction of the A.N.A. as a professional organization. They de- manded that nurses begin to take an active role in re shaping - the health system. They also demanded that nurses take part in find- ing solutions to the more general social prob- lems in America and the world. Their demands dominated the discussion and busi- ness of the entire convention. Several of their resolutions were adopted, and they intend to continue their activity. Nursing students are also beginning to stir. Many nursing schools participated in the na- tional student strike following the Kent State killings. For the first time, nursing students joined with other students in protest around a social issue. One such protest activity was sponsored by " Nurses for Peace " in New York, which staged a march of some one thou- sand nurses and nursing students to protest the expansion of the war into Cambodia. In a number of nursing schools, groups are form- ing to work to change the nursing educational system, as well. Although the actions and critiques have thus far come from only a minority of nursing students and nurses, it is clear that the dissatisfaction is growing. -Vicki Cooper, Paula Balber and Judy Ack- erhalt, Paula Balber and Judy Ackerhalt are nurses who have both experienced the train- ing process and worked in various nursing settings. Social Workers: Keeping the Pieces Together An estimated 4,500 students begin training programs for professional social work this fall. Fifteen percent of them, one out of six, will be employed in a health setting. Three years ago, in 1967, the Public Health Service estimated that of 130,000 social welfare work- ers in the country, 20,000 were in " health and related " programs. That number of social welfare workers (which includes those with- out credentials as well as those professional- ly trained) is a tiny proportion of the 3.5 mil lion plus - health workers, and is only about one percent of even the 1.5 million technical and professional workers in the health sys- tem. As a voice for reform among health work- ers they are numerically insignificant. And in terms of " helping people ", social workers probably have no greater facility or oppor- tunity for patient or community advocacy than other health workers. But the public ex- posure of what they have to live with each day is a potentially special contribution of social work personnel. The social work function as idealized by so- cial work professionalists - and as taught to students in social work schools - sets a high rhetorical standard for human concern. Client advocacy, whereby the social worker fights for the rights of the patient, is upheld, in the words of one social worker, as " our chal- lenge, our commitment, our practice. " Com- munity involvement is stressed: the responsi- bility to develop a partnership between the hospital and the community it serves. The so- cial worker is envisioned as a full member of the interdisciplinary health care team in the hospital, actively educating others to the hu- man needs of the patient and sensitizing them to the social and environmental basis of disease. Supposedly bringing professional skills to bear, the social worker counsels in- dividuals and families on the traumatic effects of illness or on special needs resulting from illness, such as child care, vocational retrain- ing, homemaker assistance, after - care facili- ties, etc. More broadly - and vaguely - the social worker assumes responsibility for con- fronting the whole gamut of basic needs which affect the health of the under - privi- leged: poverty, poor housing, unemploy- ment. Having laid claim to so much turf, understandably, even the most enthusiastic and progressive social work administrators add a caution about the limits to " what the hospital can do. " From the hospital administrator's perspec- tive the social workers'role is to give special- ized attention to the human problems attend- ing patient care in order to free nursing personnel for strictly medical duties. The his- torical reality seems to be that social work became an established component of modern hospital administration as an expression not of the vision of professional social workers but rather as part of the shifts by the medical authorities toward specialization and increas- ing professionalization of health care func- tions. Their goal has been to best utilize precious " medical " manpower for " medical " tasks. The irony and contradiction is that those gestures toward science and efficiency take place within a structure that sets other priori- ties ahead of health care training - doctors for private practice, maintaining the primacy of the class system and the right of MDs and drug companies, etc. to sell health care to those who can afford it, treating sickness in- stead of providing for health (by preventive care). The basic problem in making health care human is not the way in which the health 11 service manpower is utilized but the priorities it is committed to serve. The effect of artificial- ly creating a specialized field- " social work " _ concerning patients'" human " or " social " problems in an institution which is part of the social arrangement that creates those prob- lems is that social work units and personnel become a kind of dumping place, a refuse dis- posal in the hospital system. The human needs which cannot be disregarded, sup- pressed, channeled and controlled by the routine procedure for compartmentalizing people's health needs are turned over to the social work staff. The compartmentalization which creates the social work role is described rhetorically by the social work profession in terms of ap- plied humanism and by the hospital / medical administrators in terms of efficiency. But it is the priorities and structure of the health care system that create the reality of the social service work - day. The social worker spends most work hours in dreary paper work and bureaucratic routines concerned with admit- ting and discharge, and especially with the financing mechanisms for medically indigent patients. The lack of continuity, the incon- sistencies, the obscurity of the procedures for Medicaid and Medicare and the rigidity of the hospital bureaucracy set forth a day's tasks. The only way most social workers see to escape this dreary routine is by attempting to help individual patients. But individual client advocacy is an all but hopeless task. A social worker who works in one ghetto hospital, re- ports that her " humanizing " function often consists of such tasks as finding clothing for people who need something to wear out of the hospital because the only clothing they owned had to ripped off in emergency admis- sion. Other attempts at helping individuals are equally pathetic. One social worker inter- vened in the case of a patient who was being treated for a leg fracture. In talking to the man, the social worker learned that the fall had been caused by one of the man's frequent dizzy spells. She brought this to the doctor's attention and exacted from him the promise to refer the patient to the medical service where tests would be done for suspected epilepsy. But the patient was discharged over the weekend - pointing up the doctor's inat- tention to the man's over - all medical needs in the face of the higher priority of freeing a bed. The best the social worker could do was to write to the patient and tell him to go to the out patient - clinic for tests and treatment of his dizziness. Another worker had to intervene in a case of misdiagnosis caused by a doctor's ignor- ance of community life styles -. The patient was referred to the psychiatric ward from sur- gery because he was hostile and agitated. There the psychiatrist diagnosed the patient as a homosexual on the basis of the patient's clothes (he wore red silk pajamas and a scarf around his hair) but as the social worker pointed out, the patient's clothing and the stream of women visitors indicated that he had been a pimp or hustler. Yet another social worker described one of her most important tasks as the education of doctors to enlighten them about the conditions of extended care facilities. She took residents on field trips to the state hospital's geriatric wards to which many patients were dis- charged. The medical supervision tried to stop the trips because they objected to " upsetting " young doctors by exposing them to the hor- rible conditions to which they would be send- ing patients. But, in fact, patients who can't go home are sent to " dumping grounds, " whether the doctor knows their horrors or not. As one social worker delicately put it " " When one has to send a patient to an un- pleasant disposition, one has to put on blind- ers. " In the end, all the individual attempts of social workers to help their clients are at best, drops in the bucket. The health care and other social services required by these pati- ents are simply not available to them. In the growing upheaval over accountabili- ty of service deliverers to the community they are supposed to be serving, the social work hospital personnel are one potentially cataly- tic minority of the work force. The decision to siphon off " people problems " to a special work group in the hospital creates a special turf, an artificial but usable moral respectability for speaking out on the human effects of the pres- ent hospital system. Social workers have his- torically exploited that peculiar morality to justify their " professionalism. " They have suggested that it is their special mission to see, to understand, to be skilled in treating the " human " aspects of health care. Their logic leads from the right demand for more humanism and concern to the wrong demand for more status, authority, and funds for so- cial work. It is the structure of the hospital system itself, however, that dehumanizes- that requires dehumanization, that reduces the need for comprehensive care for the health of any individual human to a set of categorized sicknesses. What can change that is not more social work. What can change that is basic reforms in health system. - Mi- chael Smukler and Connie Epstein Bronx Community Wants Control The Bronx has the City's largest, most highly centralized medical empire, the Einstein- Montefiore empire. The Bronx also has the 12 most inequitable distribution of health re- sources of any region of the city. For the white, middle - class, and doctor - rich north and western sections of the Bronx, there are the empire's prestigious core institutions - Monte- fiore Hospital and Einstein's college hospital, plus a number of smaller voluntaries. For the densely populated, disease - ridden black and Puerto Rican slum of the southeast Bronx, there is essentially only one health facility Lincoln Hospital. If construction of a new municipal hospital on the grounds of Monte- fiore is completed, the disparity will increase, and the strain on already overloaded - Lincoln Hospital will reach the breaking point. Lincoln Hospital is owned by the City, staffed with professionals by Einstein, and neglected by both. Twenty - five years ago the City initiated plans to replace the deterior- ated, century - old Lincoln plant with a new building, but ground for the new Lincoln had still not been broken by mid 1970 -. This year the City hit Lincoln with a three percent de- crease in its operating budget, threatening cutbacks in vital outpatient services. To Ein- stein, Lincoln's affiliated institution, Lincoln serves as an outpost for the training of young doctors and medical students. Einstein has taken little or no initiative to develop com- munity health programs, to provide for con- tinuity of care in the clinics, or to make the services more dignified and acceptable to the community. When confronted with angry Lin- coln workers and community residents a few weeks ago, an Einstein dean asked, in ap- parently genuine ignorance: " What do you expect from us? " Someone answered, " We want you to make Lincoln as good a hospital as your college hospital. " The dean had no reply. To Einstein and to the City, Lincoln has always been and will remain, a second - class institution. This summer's community and worker drive for control of Lincoln Hospital stems out of months of community and worker frusta- tion with the hospital and its current leader- ship. The first major eruption was in April, 1969, when workers in Lincoln's community mental health center, dissatisfied with Ein- stein's patient care and personnel policies, seized the center and operated it for a couple of weeks under community / worker control. [See April, 1969, BULLETIN.] A combination of police force and manipulation by Einstein ended the mental health rebellion, and, for more than a year, demoralized the dissident workers. Then in February, 1970, there was a brief flurry when Lincoln's usually inactive official community advisory board challenged the City Hospital Department's selection of a new administrator for the hospital. Nervous about a repeat of last year's community / worker uprising, the City acceded to the board and Lincoln got its first Puerto Rican administrator. But by June it was clear that nothing really had changed: To its workers and patients, Lincoln was still the community " butcher shop. " Community and worker impatience grew throughout the spring. By June there were three local organizations ready to make an all out effort to improve Lincoln: The Young Lords Party, the Health Revolutionary Unity Movement (HRUM), and Think Lincoln - . The south Bronx Young Lords, a group of revolu- tionary young Puerto Ricans, is a chapter of the Young Lords Party in East Harlem, which has placed major emphasis on health, hospital and sanitation issues. HRUM, a city- wide organization of black and Puerto Rican hospital workers, came together in Lincoln, as in several other City hospitals, around a ten point - program for improved community health services under community / worker control. Think Lincoln - is a community and worker organization dedicated solely to do- ing something about Lincoln Hospital. The combination of these three groups, plus continued deterioration of conditions at Lin- coln, produced a chain of events which has rapidly escalated to the brink of an actual community / worker takeover of the hospital: June 17. The seven demands: Think Lincoln - presented Lincoln's new administrator, Dr. Antero LaCot, with a list of seven demands: (1) No cutbacks in services or jobs (as a re- sult of budget cutbacks). (2) Immediate con- struction of the new Lincoln hospital. (3) Lin- coln operated - door - to - door preventive health services. (4) A 24- hour a day grievance table for Lincoln patients and workers. (5) A minimum wage of $ week 140 / for all Lincoln employees. (The current minimum is $ 118 / week. At its July, 1970, contract negotiations, Local 1199, one of the unions representing Lincoln workers, had initially demanded a $ week 140 / minimum. The union settled for an increase to $ 130, effective July, 1971.) (6) A day care - center, funded by the hospital, for children of Lincoln patients and workers. (7) Total community / worker control of all health services at Lincoln Hospital. Think Lincoln - wanted an immediate de- cision on the grievance table; LaCot reported- ly said he'd think about it. The next day, Lincoln Think - went ahead and set up a table in the emergency room waiting area, meeting unexpectedly little resistance from the ad- ministration. The table quickly had more busi- ness than it could handle patients - complain- ing about long waiting times or brusque treatment and workers complaining about working conditions and unfair treatment, etc. Though they lack any formal authority to re- dress the grievances which are brought to the table, Think Lincoln - has still managed to right a few wrongs. When patients complained about long waits in the screening clinic, Think Lincoln - chastised the clinic doctors, who had been arriving late and leaving early. The doctors, who had never before been chal- lenged on their work habits before, are now reportedly working full time. June 28. March through the neighborhood: Young Lords and Think Lincoln - members marched through the South Bronx, passing out leaflets announcing a rally on health issues to be held the next day. As they marched, dozens of people in the streets joined them. Alarmed at the growing crowd, a large group of police attacked. Ten march- ers were arrested; all were beaten on the way to the precinct house; and, according to medi- cal witnesses, three were seriously beaten and tortured inside the precinct house. June 29. Rally in St. Mary's Park: Unde- terred by the previous day's police violence, 13 Think - Lincoln held the scheduled rally in a local park. Free on - the - spot medical care and TB screening offered at the rally underlined the deficiencies of Lincoln. July 13. Garbage offensive: Think - Lincoln and HRUM collected trash littering the floors of the clinics and halls, and dumped it in a pile outside the administration offices. Since this action, trash collection in the hospital has improved remarkably. July 14. Takeover of the Nurses'Residence: There had still been no response from the ad- ministration on the seven demands, and complaints were piling up at the grievance table. At five in the morning of the fourteenth, members of Think - Lincoln, HRUM, and the Young Lords occupied a building adjacent to the hospital which houses a nurses'resi- dence, personnel offices and some mental health services. In the course of the day, mem- bers of the house staff, workers and communi- ty people joined the original occupiers, bringing the occupying force to nearly 100 people. Patient care in the hospital was in no way disrupted, but the administration was fearful of the impact of the takeover on the rest of the workers. LaCot took a carrot - and- stick approach to the occupier: On the one hand he conceded to two demands - that there would be no cutbacks in services, and that the occupiers could set up a screening clinic in the nurses'residence. On the other hand, he called in a sizeable police force to sur- round the hospital buildings. In the late after- noon, he announced to a meeting of the house staff that police intervention had become necessary to end the occupation. Half the as- sembled doctors walked out of the meeting and joined the occupiers - both to provide first aid in case of violence, and to take a stand with the community and worker forces. The occupiers decided, however, not to wait for a police attack, and at about five in the afternoon, quietly left the nurses'residence. The brief takeover fell far short of winning the seven demands, but it brought them home with dramatic force to the entire Lincoln com- munity. Everyone, from department heads to janitors, was discussing the demands, espe- cially the one for community worker control, and workers flocked to Think - Lincoln meet- ings. For many patients and workers, the overriding effect of the takeover was a new, sense of what could be done to improve the hospital, given the will to do it. In the wake of the takeover, house staff in pediatrics and in the screening clinic swept aside bureaucratic restrictions which interfered with care but had never before been questioned. Patients waiting for prescriptions at the pharmacy, led by a Young Lord, demanded that the pharma- cists open up an additional window for serv- ice. (There were enough pharmacists to man the additional window; they had just never thought to open it.) As one member of the house staff put it, " We felt liberated. We were doing things we wouldn't have thought of, or dared to do, before. " July 19. The Death of Carmen Rodriguez: Up until this point Think - Lincoln, HRUM and the Young Lords had held the initiative and set the pace of the struggle. The next event was planned by no one. Mrs. Carmen Rod- riguez, a mother of two, died suddenly in the course of a therapeutic abortion in the ob- stetrics ward. A psychiatric resident who had known Mrs. Rodriguez in a drug treatment program, decided to take a look at her medi- cal chart. What he found was clearcut evi- dence of malpractice: The handling of the abortion had not taken into account the patient's history of rheumatic heart disease. According to doctors who later studied the chart, medication given during the abortion had apparently precipitated heart failure. Rather than simply having it out with the ob- stetrics staff, the psychiatric resident took the highly " unprofessional " step of reporting the case, in full detail, to Think - Lincoln. Think - Lincoln members and other communi- ty residents had repeatedly charged that Lin- coln was unsafe and a " butcher house, " but they were deeply shocked to be confronted first - hand, with a well - documented case of an entirely unnecessary death. On July 20, they presented Lincoln administration with four new demands: (1) that Lincoln Hospital pay damages to the Rodriguez family; (2) that the Lincoln abortion clinic be named the Carmen Rodriguez Clinic. (The abortion clinic had been set up only weeks before, with the re- peal of the State abortion laws.); (3) that a watch - dog committee of community residents and workers be set up to monitor the Lincoln abortion program; (4) that Dr. J. J. Smith, the head of the obstetrics department, resign im- mediately. The Think - Lincoln leaflet announc- ing the demands signed off with the statement: " A human life is worth more than the riches of the wealthiest man in the world. " The takeover of the nurses'residence had given people a sense of what positive things could be accomplished if patients and work- ers controlled the hospital. But the death of Carmen Rodriguez showed that community. worker control was not just a matter of mak- ing modest improvements; it was a matter of immediate, life - and - death urgency. Not only was the existing leadership of the hospital (chief doctors and administrators) unable or unwilling to make improvements; it could not even be trusted to carry on basic medical services. " Community - worker control " was no longer just a slogan. To the staff of Lincoln Hospital, it had become a very realistic and imminent alternative. The community - worker control demand is ultimately a challenge to Einstein medical college and to the New York City Health and Hospitals Corporation (which took over the municipal hospitals from the Department of Hospitals on July 1, 1970). But both parties. have so far tried to keep a safe distance from Lincoln, leaving their on - the - scene represent- atives to cope with the insurgency on a day- to - day basis. The Corporation's representa- tive, Dr. LaCot, has, on the whole, been surprisingly flexible, even cooptative. Admin- istrators in other municipal hospitals would 14 have called in the police over even as mini- mal a " provocation " as the grievance table; LaCot held off through most of the takeover of the nurses'residence. During the takeover, LaCot told the press that he felt the seven de- mands were " for the most part, reasonable, " and later, when a dozen doctors threatened to resign because of community " harass- ment, " he told the New York Times, " It is the opinion of this administration that there has not been, to the present, any incident of in- timidation or of harassment which may be associated with any community group in- volved at Lincoln Hospital. " On the other hand, Dr. LaCot has by no means become an advocate of the seven (and then the four) de- mands within the Corporation - he has sim- ply tried to keep the lid on things at Lincoln. According to Think Lincoln - members, the administrator's so far - mild response probably reflects his own powerlessness vis - a - vis the downtown Corporation, Einstein, and the com- munity, rather than any deep seated - sympa- thy for the insurgents and their demands. Just the existence of the insurgency has increased LaCot's bargaining position, for funds and power, with the Corporation and Einstein. Per- haps more important, the administration un- derstands that any hasty acts of repression could accelerate the struggle and precipitate a large scale - repetition of last year's takeover of the mental health services. Thh e response of the professional staff may turn out to be far more important to the out- come of the struggle than that of the adminis- ration. What is being challenged is not simply administrative control, but professional pow- er as well especially - in the demands for the resignation of the chief of obstetrics and for a community - worker watchdog committee to monitor the abortion program. So far the chiefs of service (who are also Einstein facul- ty members) have tried to remain aloof from the struggle, or have reponded defensively. in some cases even hinting at resignation. No chief of service has taken a stand in support of the Think Lincoln - demands. Among the house staff, however, there is a deepening polarization over the issues raised by Think Lincoln - . As workers, the interns and residents have reasons to identify with the community / worker struggle: Like many other hospital workers they are severely over- worked, frustrated by shortages of equipment and supporting personnel (nurses, techni- cians, etc.), and denied a significant vote in hospital decision - making. But many of the house staff at Lincoln, like young profession- als in other settings, find it difficult to think of themselves as workers. Other hospital work- ers are black and Puerto Rican, from lower class backgrounds; the house staff, whether American or foreign trained - , is predominate- ly upper middl- ec l-as s. Other hospital workers are stuck in dead - end jobs; the house staff, by definition, are in training and on their way up (often to lucrative private practices in the suburbs). Above all, as young doctors, the house staff have completed years of medical education which is consciously designed to instill a sense of professional elitism, and separate them from other health workers. At Lincoln, some degree of conflict over the role and responsibilities of the house staff had existed well before the current struggle be- gain. In 1969, a small group of house staff in pediatrics, frustrated by the episodic, crisis- oriented medicine they were forced to prac- tice, decided to remodel the pediatrics service as a comprehensive, community - oriented health program. (The Lincoln pediatrics pro- gram will be discussed in detail in a future BULLETIN.) With the approval of the chief of pediatrics, they set about making contact with health oriented - community groups, meet- ing with other workers in the pediatrics de- partment, and recruiting, as interns for 1970, a group of service oriented - young doctors, many of them veteran activists from the Stu- dent Health Organization (a radical organ- ization of health science students). Some members of the house staff in other depart- ments, and even some in pediatrics who had not been specially recruited for the new pro- gram, had little sympathy with the pediatrics project, with its implicit challenge of existing priorities at Lincoln. The events of June and July rapidly height- ened the latent antagonisms among the house staff. With the first appearance of the Think- Lincoln grievance table, a few house staff members claimed to feel " harassed. " A larger number were sympathetic to most of the sev- en demands, but passive, and a minority, centered in the pediatrics department, active- ly welcomed the first signs of community in- volvement in Lincoln. The takeover of the nurse's residence and the threat of a police bust, further polarized the house staff. Some advocated mass resignations; others joined the occupation of the nurses'residence. But it was the demands stemming from the death of Carmen Rodriguez which produced the deep- est splits. Even many liberal house staff mem- bers who (at least verbally) supported the original seven demands of Think Lincoln - , could not accept the challenge to profession- alism posed by the demand for the resigna- tion of the chief of obstetrics. If this was what community - worker control meant - the right of nonprofessionals to discipline profession- als whom they judged negligent - then many of the house staff found that they were not interested in community - worker control. With- in the week following Mrs. Rodriguez's death, the house staff in the departments of obstet- rics and surgery threatened to leave en masse. It came as a surprise when the only house staff who actually resigned (on July 29) were 10 foreign house staff in the depart- ment of pediatrics. Publicly, they claimed to have been harassed and threatened by Think- Lincoln people (a charge which LaCot de- nied), but privately many said they could no longer work with the more radical majority of the pediatrics house staff, which has active- ly supported the community - worker forces. The Corporation, represented at Lincoln by 15 the hospital administration, and Einstein, rep- resented at Lincoln by the professional staff, are not the only institutions challenged by the community / worker struggle. Indirectly, Think Lincoln - and HRUM have also raised serious questions about the role and effective- ness of the hospital workers'unions, Local 1199 of the Drug and Hospital Workers Union and District Council 37 of the American Fed- eration of State, County and Municipal Em- ployees (AFSCME). [See July August / BUL- LETIN for analysis of hospital workers ' unions.] The demand for a minimum weekly wage of $ 140 is a pointed reminder of 1199's capitulation at the bargaining table last July. Then there is the grievance table, which op- erates in direct competition with the unions ' conventional grievance procedures. Workers who might not otherwise have identified with the community / worker struggle are increas- ingly turning to Think Lincoln - and HRUM with the kinds of grievances which are usual- ly brought to the unions. If nothing else they have come to respect Think Lincoln - and HRUM's ability to get things done. So far, the unions'effort to get on top of the situation at Lincoln have backfired disastrous- ly. According to HRUM members, on August 13, 1199 and District Council 37 called a meet- ing with Lincoln administration, the medical board and HRUM to " discuss the problems at Lincoln. " Presumably because they hoped to negotiate some sort of a truce with HRUM, the unions insisted that the meeting be closed to all Lincoln workers except HRUM leadership. A group of clerical workers came to the meet- ing anyway, mistakenly believing that the meeting had been called to discuss griev- ances they had been raising, unsuccessfully, with their union, Local 1540 of District Council 37. When the clerical workers interrupted the meeting to raise their grievances, their own union representatives failed to recognize them as union members. According to eye- witnesses, the union leadership charged that the clerical workers were disorderly HRUM supporters and demanded that they leave the meeting. The actual HRUM members denied any association with the clerical workers but isted that all workers had a right to be resent at the meeting. Enraged by the in- sistent clerical workers (who by this time probably had become HRUM supporters), all the union leadership walked out of the meet- ing, followed by the administrators and the medical board. Left alone together, HRUM members and the clerical workers discussed ways of meet- ing the workers'grievances, which ranged from the need for air conditioning - in the emer- gency room to the demand for a $ week 140 / minimum wage. On their own, the clerical workers issued a leaflet which said in part: " We, the clerks of pediatrics emergency, the emergency room and the admitting office have come to the end of our rope. Up to this point we have been working like slaves. We have been pointing out these conditions to our so called - representatives for several months. We have been ignored.... We are angry because these inhuman conditions do not allow us to give decent care to our people, the community of the South Bronx. " As of this writing, the situation at Lincoln Hospital is still in flux. Lincoln Think - has made major headway towards winning its de- mands, but many key demands remain un- met. The grievance table continues to operate without harassment from the administration, but it still has no official power to redress grievances. A daycare center, supplied with food by the hospital, is serving patients'and workers'children in the nurses'residence. Since the hospital refuses to staff the center, Think Lincoln - members are donating their time. The Corporation has completely met two demands: It has begun clearing the site for the new Lincoln, and it has not forced cutbacks in outpatient care. But the Corporation and the Lincoln administration, have shown no sign of meeting the demand for $ week 140 / minimum wage, or establishing a door - to - door program of preventive care, or of course- turning Lincoln over to community / worker control. The professional staff has not yet ac- ceded to the demand for community / worker surveillance of the abortion program, and the chief of obstetrics remains on the job (though apparently this is only because Think Lincoln - has not continued to press for his immediate resignation). The pace of the struggle at Lincoln is still accelerating from day to day. New groups of workers, including such usually conservative workers as nurses and clerical workers, and patients are aligning themselves with Think- Lincoln and HRUM. With every day that Think Lincoln - presses for its demands, the bankruptcy of the hospital's existing power structure the administration, Einstein, and the Corporation - becomes more and more ap- parent. Even the patients'and workers'of- ficial " advocates ", the community advisory board and the unions, have shown them- selves, by contrast to the insurgent communi- ty worker / forces, to be unable or unwilling to struggle for radical change. Unless the com- munity / worker forces are checked by violent repression (which is still a daily possibility), the odds in favor of their eventual victory are mounting. Lincoln may become the first hos- pital, if not the first multi million - dollar Amer- ican institution of any kind, to be run by and for the people it should be serving. Whatever the outcome of the events at Lin- coln, it is clear that they have set in motion a new phase of the larger struggle for account- ability and community service in the New York municipal hospitals. Inspired by Think- Lincoln, workers at Metropolitan Hospital are manning a patient worker - and - grievance table, and at Fordham Hospital, the newly formed Community Alliance to Improve Ford- ham Hospital has set up a grievance table of its own. As the chairwoman of Think Lincoln - said, " This is not a one shot - action. It is a long- term struggle, and it has to happen in every institution which is not serving the people now. " Barbara Ehrenreich 16