Health Policy Advisory Center October 1970 BBHMM

at Lincoln, coming with increasing frequency Empire Roundup: and persistence. Community and worker groups are resisting cooption and repression. C aught In reply, the medical empires are trying to consolidate their control over their existing holdings. Control is the name of the empire in th e game. Through their monopoly of power over their network of affiliated institutions, the em­ S q u eeze pires can impose their research and teaching priorities on the health system. A threat to "Gang invades hospital," headlines the this control is a threat to the abilities of the American Medical News, Reporting on the cur­ institutions at the core of the medical empires rent community/worker struggle at Lincoln to function at all. Hospital in the Bronx. Lincoln has been a Empires are also coming under pressure thorn in the sidexif the Einstein Medical Col- from above. The federal government, busily lege-Montefiore Hospital medical empire for trying to balcyice the budget while ignoring a number of years. The Einstein-controlled big city needs, has cut back on research municipal hospital is in an antiquated build­ grants and other funds for medicine. The med­ ing, which is inadequately staffed and poorly ical schools and medical centers have been equipped. Community and worker g^ups hard hit, since they rely heavily on research seeking better health care have sought to monies for faculty salaries. This change in wrest control from Einstein and to reset the federal policy may in part reflect a decline in priorities at Lincoln away from Einstein's the empires' influence over federal health teaching, research and financial needs and policy, which was such a dominant feature of towards patient care. The health establish­ the Kennedy-Johnson era. Meanwhile, state ment has been visibly shaken by this' new and local government resources going to assault on their medical fortresses—an attack health have also been restricted, thus com­ challenging their competence to determine pleting the squeeze. the health needs of the patients and the com­ In previous BULLETINS, HEALTH-PAC has munity. The energy generated by thetftrug- traced the development of medical empires in gle at Lincoln has been an inspiration to those their period of manifest destiny. Now this in the health movement who believe that the pincer movement of financial cutbacks and health system can only be changed through a insurgencies has forced the empires to look basic shift in who controls health resources. to their defenses. This BULLETIN gives a Medical empires are going through a peri­ round-up of the empires in New York City and od of readjustment. From below, they are reports on some of the various health insur­ threatened by insurgencies such as the one gencies going on in the city.

hospitals in the Bronx, the Einstein-Montefiore B ronx empire also experiences'the conflicts between the burgeoning private sector in health and The Bronx empire dominated jointly by Al­ the remaining shadows of City involvement bert Einstein College of Medicine (AECOM) in the hospital system. and Montefiore Hospital is one of the most It comes as no surprise, then, that some of highly developed and consolidated medical the country's sharpest struggles around use empires in the country. Patients, medical man­ and control of health services have occurred power, and money flow freely amongst the in the Bronx. At Lincoln Hospital, the munici­ dozen or so institutions which make up the pal hospital affiliated with AECOM which empire and which include the bulk of the serves the largely Puerto Rican population of borough's medical resources. Because the the South Bronx, a two year long struggle has empire is so highly developed, it is virtually been waged between radical workers and a textbook study on the conflicts between the community people on the one hand and research, teaching, and financial priorities of AECOM and the City on the other. [See April the imperial center and the health care needs and May, 1969, BULLETIN for the early his­ of the community. [See BULLETIN, April and tory of the struggle.] As reported in last September, 1969, for more details on the Ein- month's BULLETIN, the struggle has recently stein-Montefiore empire.] And because the sharpened, under the leadership of Think- empire controls two of the three municipal Lincoln, a community/worker group con^ CONTENTS gations then demanded unsuccessfully that I Bronx Smith resign. Finally the demonstrators told 3 Lower East Side Smith to leave the office and not to return. 6 Upper East Side The next morning, the ™” Titf>rr>ffaT,e” ra 8 Downstate gan. At 5:30 a.m., residenTin the obstetrics 9 Columbia department began discharging all patients in II Consulting Firms the department without warning and without making alternative arrangements for care. (A few of the sickest patients were trans­ cerned with the hospital, in alliance with the ferred to other services.) The residents then Young Lords and the Health Revolutionary went out on strike in protest against Think- Unity Movement (HRUM, an organization of Lincoln's harassment of Dr. Smith and of revolutionary third world health workers). themselves. Certain Einstein Medical College Think-Lincoln had m ade seven initial de­ officials apparently instigated or at least as­ mands, ranging from the demand for a day sisted the walkout: some obstetrics residents care center and a grievance table to the de­ were ordered to leave the hospital building mand for control of the hospital by a com­ by a high-ranking Einstein official when later munity/worker board. Two months ago, a in the morning they tried to readmit some of young woman named Carmen Rodriguez died the discharged patients. following an abortion at the hospital. Charg­ Tuesday evening, a Think-Lincoln meeting ing that her death was due to malpractice, held in the obstetrics office was dispersed by ^Think-Lincoln added to its list of demands the the police. The next day, Think-Lincoln, along demand for far-reaching changes in the hos­ with the Young Lords and HRUM, was served pital abortion program and for the resignation a temporary restraining order barring them of the director of the abortion program, the from "interfering" with hospital medical or . chief of obstetrics, Dr. J. J. Smith. administrative functions, "harassing" em­ By late August, top officials of the New York ployees, distributing leaflets in the hospital, City Health and Hospitals Corporation and of violating any directives issued by the City AECOM, who up to that time had been con­ hospital administrator. Dr. Antero LaCot, or tent to permit their local representatives at occupying any space—room or hall—in the Lincoln to handle the insurgency, stepped in hospital or adjacent to it without LaCot's ap­ to spearhead a counter-offensive against the proval. (This last provision forbade Think- rising tide of community/worker militancy. Lincoln from operating the grievance table Events in late August centered around the they had set up in the emergency room or the obstetrics department. Think-Lincoln's de­ day-care center they were running in the mands had not been met: No changes had nurses' residence.) Hospital supervisory per­ been made in the abortion program, which sonnel let it be known that the administration even its director. Dr. Smith, is alleged to have was interpreting the injunction as forbidding admitted was "inadequate," and Smith him­ workers from holding meetings (even union self had refused to resign. The tinder was meetings!) without LaCot's permission and ignited when Smith refused to renew the con­ from talking to Think-Lincoln people even off tract of Dr. Noel Phillips, a West Indian with a the hospital grounds. Several nurses were fellowship in the obstetrics department, al­ threatened with loss of their jobs merely for legedly because of repeated lateness and ab­ discussing the events with other nurses. sence. Phillips denied the charges, and some Thursday, the Pediatric Collective (a group seventy non-physician members of the ob­ of interns and residents in the Lincoln Pediat­ stetrics staff (many of whom would have rics Department) held a sit-in in the office of been inconvenienced if Phillips had been as Health and Hospital Corporation Executive unreliable as charged) signed a petition urg­ Director, Dr. Joseph English. A few days previ­ ing that Phillips' contract be renewed. On ously, the Collective had requested an ap­ Monday, August 24, Think-Lincoln called a pointment with English for Thursday to dis­ noontime meeting to discuss how to respond. cuss the Think-Lincoln demands as well as About twenty-five workers came and decided their own demands for improvements in to go to Dr. Smith's office to demand that the patient-care conditions at Lincoln. English did decision be reversed. At the same time, an­ not even answer the request, but let it be other Think-Lincoln delegation was confer­ known indirectly that he would not meet with ring with Smith about the case of several them unless invited to do so by Lincoln Ad­ women who claimed to have been waiting for ministrator LaCot. The Collective decided that abortions at Lincoln for up to two months they would try to see English at the desig­ without explanation. The two delegations in­ nated time anyway, and since in the interven­ formed Smith that they were staying in his ing period, the injunction had been ordered, office until Dr. Phillips was given a contract they added the lifting of the injunction to their renewal. After several hours, Smith capitu­ demands. On Thursday afternoon, leaving lated and signed a new contract, a clear vic­ others behind to cover the wards, the Collec­ tory for Think-Lincoln. The Think-Lincoln dele­ tive descended upon English in his office.

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.

2 English was not interested in talking; he variety of charges that potentially could lose walked out immediately. Sometime later, an him his job and his license to practice medi­ aide appeared with an ultimatum for the cine in New York State. The charges against group: if they were not out in ten minutes, the him reveal how totally political the action police would remove them from the office. against him is. Smith, it is charged, let the Faced with the prospect of heavy bail and in­ community know what had happened to Car­ terminable legal hassles, and having at least men Rodriguez, forcing the hospital to hold a gotten some press notice of the events at Lin­ public clinical conference which revealed coln, the Pediatrics Collective decided to that Mrs. Rodriguez' death was due to gross leave peacefully. Pediatrics Collective mem­ negligence by the hospital, setting off the bers noted with some bitterness in the days struggle over the obstetrics department. Sec­ /following that English was willing to make ond, he was involved in the sit-in in I. J. Smith's ' two trips up to the Bronx to met with the strik- office (several other doctors who were more / ing obstetrics house staff, who were not willing intimately involved have not been charged, I to continue to work in the hospital while so far). And third, in the course of participat­ pressing their grievances, but was unwilling ing in a Think-Lincoln door-to-door screening I to meet with the pediatricians who were con- program in the community (a service Ein­ ] tinuing to serve their patients. stein and Lincoln do not'provide). Smith had V Meanwhile, the pediatricians' counterparts prescribed iron pills for anemic community in obstetrics were still on strike. At this stage residents without the permission of his su­ the obstetrics house staff added some de­ periors at Lincoln. mands for improvements in patient care to The New Yoik Times, a long time friend of their original demand for an end to harass­ the medical empires [see February, 1970> ment. Think-Lincoln members believe that the BULLETIN], joined in the attack on the com­ patient care demands were merely added for munity/worker struggle. Ignoring both the public relations: The strikers had never catastrophic failure of Einstein and the City to shown great concern over patient care issues provide health services in the South Bronx before the strike, nor had their concern for and the leading role played in the struggle by their patients kept them from striking, nor had the community/worker organization, Think- they raised these issues immediately upon Lincoln, the Times blamed the whole affair on striking. Moreover, they eventually returned the supposed desire of the Young Lords to to work without the patient care demands "see whether ghetto hospitals could be used being met. The obstetricians remained out for to radicalize poor blacks and Puerto Ricans over a week, crippling obstetrics services at much as leftist students have used the uni­ Lincoln. At this juncture, a split developed versities to radicalize other students and between AECOM and the City. According to faculty." But, the Times triumphantly con­ the New York Times, Corporation Executive cluded, "the experiment has not gone well for Director English put the screws on Einstein. If the radical cause." The obstetrics house the obstetrics staff did not return, Einstein staff's strike and the injunction forced the would face the loss of its $28 million worth of Young Lords to recognize "that their effort to affiliation contracts at both Lincoln and Bronx exploit conditions in the obstetrics depart­ Municipal Hospital. Financial self-interest ment had failed and that the community had and the desire of Einstein empire-builders to lost rather than gained by their attempt to maintain control of the health resources of make an issue of Mrs. Rodriguez' death." the Bronx won out over the desire of many But the Times exulted too soon. The very Einstein clinical faculty members to ditch the day that the article quoted above appeared, troublesome Lincoln despite its usefulness for Think-Lincoln in four hours gathered over five teaching and research. As the New Yoik hundred signatures from South Bronx resi­ Times put it: "Since Einstein has been in a dents on a petition supporting the Think-Lin­ very shaky financial position for years, loss coln demands. And although Think-Lincoln of the $28 million contract could easily result members agree that many workers were in the closing of the medical school." Einstein frightened for their own jobs after the injunc­ proceeded to pressure the obstetrics house tion was issued, they point out that for many staff into returning to work. other workers, the successful winning of a re­ The counteroffensive continued with an as­ newal of Dr. Phillips' contract showed that sault on the professionals at Lincoln who sup­ Think-Lincoln was serious about changing ported the commimity/worker demands. Lincoln Hospital and that workers were re­ Lincoln officials let it be known that many sentful over the banning of the Think-Lincoln members of the pediatrics collective might grievance table and day care center. In fact, not have their contracts renewed in June. And workers meetings have been stepped up since Dr. Michael Smith, a resident in psychiatry the injunction, distribution in the hospital of and a Think-Lincoln activist, is being brought Think-Lincoln leaflets and the HRUM news­ up before the Lincoln medical board on a paper goes on and the struggle continues.

and education have been the focal issues for Lower East Side community involvement. Today, however, health is attracting more and more communi­ The Lower East Side of New York has a long ty attention. This rising interest in health is history of insurgency. In the past, housing due in part to the continuing deterioration of

3 community health services and, in part, to the spring of 1970, when students assisted with accelerating expansion of medical empires community-initiated preventive health screen­ and hospitals, which remain unaccountable ing programs and when students joined to the community. health workers from Bellevue and University In response, a diverse set of insurgent Hospital in the May protest against the Cam­ forces is consolidating around health issues: bodian invasion. ■ The Lower East Side Neighborhood These insurgent forces face two of the most Health Council-South (LESNHC-S) well- impressive medical empires in the City: NYU known as the community struggle force for bet­ Medical Center and School and Beth Israel ter health services at Gouverneur Clinic, was Medical Center; as well as a number of small­ recently granted $37,600 by O.E.O. to hire er health institutions, such as the New York three staff workers. In spite of attempts by Infirmary, Columbus Hospital and the New Beth Israel Medical Center (the Gouverneur York Eye and Ear Infirmary. The New York affiliate), to discredit the LESNHC-S through University Medical Empire consists of the court injunctions, police barricades, and the medical school. University Hospital, Bellevue firing of five workers and a doctor, O.E.O. and Goldwater Hospitals (both City hospi­ made the grant, cognizant that the health tals), the Manhattan Veterans Administra­ council did indeed represent the community tion Hospital, the NYU-Skidmore School of located south of Houston Street. [See BULLE­ Nursing and the Hunter-Bellevue School of TIN, February, 1970.] Nursing. Over the last year, affiliations have ■ The Northeast Neighborhood Associa­ extended beyond these confines to the New tion (NENA), a coalition of community or­ York Infirmary (located on the Lower East ganizations located north of Houston Street, Side) and to Brookdale Hospital (located in established the nation's first community con­ southeast Brooklyn—14 miles from the med­ trolled health center in September, 1969. Over ical center). Yet the medical staff has staunch­ 2,500 families (8,000 individuals) are now re­ ly refused to extend services to the Lower East ceiving comprehensive, neighborhood-based Side community through satellite clinics. For health services at NENA. As the first com­ example, NYU denied back-up services to munity organization to receive its funding for NENA Health Center in 1967, which delayed a health center directly from the federal gov­ NENA's opening by two and a half years; ernment rather than through a hospital or and rejected a detailed research report writ­ medical school, NENA has pioneered in com­ ten by 11 students in October, 1969, which munity controlled health services. advocated decentralization of the Bellevue ■ I WOR KUEN, a radical Chinese organ­ outpatient department into community clinics. ization located in the Chinatown section of the Imperial interests have dictated these Lower East Side, is operating a free health choicest In the case of Brookdale Hospital, clinic, just opened in September, 1970. Unlike Mr. Arnold Schwartz, Chairman of the Board most hospital-based clinics, I WOR KUEN's at Brookdale Hospital ( and also president of emphasizes preventive health care, an exten­ Paragon Oil Company) donated close to $6 sion of their door-to-door :uberculosis screen­ million to NYU Medical School for teaching ing program conducted during the spring and and expansion. In the case of the New York summer. I WOR KUEN also believes in chal­ Infirmary, there is the possibility of a truce lenging existing health institutions. By expos­ in the two institutions' battle over expansion ing the high incidence of tuberculosis in of hospital beds—avidly desired by both in­ Chinatown, I WOR KUEN has stimulated the stitutions, but technically limited by State law. City Health Department to open a new X-ray Affiliations with other health institutions bring unit in Chinatown. I WOR KUEN, a name tak­ money and power, in contrast to affiliations en by the insurgents in the Boxer Rebellion, with community oraanizations, which bring means Righteous Harmonious Fist. demands for better health services. ■ The Young Lords' Party, a revolutionary Similarly, the empire's priorities were re­ Puerto Rican organization, plans to open an flected in the choice of Dr. Ivon Bennett, Jr. as office soon on the Lower East Side. YLP was dean of the medical school. Dr. Bennett was active in supporting the community demands also Vice President of the University and Di­ around Gouverneur Clinic and more recently rector of the Medical Center when the dean- around Lincoln Hospital. They will not be ship post was vacated last fall. After a brief newcomers to the Lower East Side. search for a new dean, Dr. Hester, President ■ The Health Revolutionary Unity Move­ of New York University, recommended that ment (HRUM) was born in the struaale Dr. Bennett fill all three posts. Dr. Hester cited around Gouverneur Clinic [see BULLETIN, the affiliation with Brookdale Hospital as one February, 1970], Although recently concen­ of Dr. Bennett's qualifying achievements. trating its energies on Lincoln and Metro­ There was an immediate uproar among stu­ politan Hospitals, this third world organization dents, faculty and even the Board of Trustees of health workers has also been organizing of the Medical School. All objected to the cen­ quietly within the health institutions on the tralization of authority in one man, which Lower East Side. meant that the dean would be even less ac­ ■ The Health Liberation Movement ( HLM ), countable to the medical students, medical a group composed largely of medical stu­ faculty and trustees than before and more re­ dents at NYU Medical School, is seeking alli­ sponsive to Dr. Hester and the University (of ances with community and health worker which the Medical School is only one part). groups. Such linkages began during the Moreover, some students' objections ex­ tended to the man himself. Dr. Bennett played Beth Israel. Other members of the community a major role in chemical-biological warfare advisory board include: Dr. Ray Trussell, di­ (CBW) research and policy, including a long rector of Beth Israel; Dr. George Blinick, presi­ history as research contract director of the dent of the Medical Board; Dr. Jefferson Vor- Army Chemical Corps and more recently the zimer, director of ambulatory services; Dr. deputy director of the Office of Science and Reinaldo Ferrer, director of Gouverneur Health Technology in the White House, where he is Services Program; Dr. Harriet Goldman, acting chairman of the CBW panel. His defenders director, Judson Health Center. From the com­ view Dr. Bennett as an opponent of CBW, but munity, there are representatives selected by as recently as November, 1969, Dr. Bennett Beth Israel (not the community groups in­ opposed U Thant's recommendation for a ban volved) from Chinatown (one), Little Italy on chemcial weapons, such as tear gas, say­ (one) and the LESNHC-S (two), and hand- ing "This country is using tear gas, CS, in picked patients from the clinics at Beth Israel: Vietnam. ... At a time when our administra­ geriatric (one), pediatric (one), comprehen­ tion is trying to find a way out of Vietnam and sive health services (one), Morris J. Bern­ trying to hold American casualities to an ab­ stein Institute (one), and one patient from solute minimum, any move that might be in­ Gouverneur. terpreted as taking an effective weapon away The composition of this board meets all the from our forces would surely carry domestic guidelines established by the Department of political risks." Health (indicating the emptiness of those Members of the Health Liberation Move­ guidelines). Besides locking the LESNHC-S ment demanded Dr. Bennett's resignation. out of any significant role in monitoring The Board of Trustees failed to give him the Ghetto Medicine money, the single communi­ traditional unanimous vote of confidence. Un­ ty advisory board railroaded through by Beth dergraduate and graduate student activists Israel was set up to counteract any meaning­ from the NYU downtown campus blocked Dr. ful community influence on the medical cen­ Bennett's inaugural address on CBW at the ter. medical school campus. But as empire build­ Earlier this year, Beth Israel imposed a er with links to the Pentagon and the White rigid limitation on the population to be served House, Dr. Bennett was perhaps the "ideal" by - its outpatient department. No one liv­ choice for dean of a prominent medical ing south of Houston Street could use the school. Beth Israel outpatient department, but in­ The second medical empire on the lower stead would be referred to Gouverneur Clinic. east side is the Beth Israel Medical Center. The formation of a single community advis­ Though willing to decentralize some services ory board meant that community representa­ into the community (such as Gouverneur tives from south of Houston Street were being Clinic, the Judson Clinic and Methadone asked to make judgements about care in the Maintenance Programs), Beth Israel is no Beth Israel outpatient clinics—clinics which more willing than NYU to share its power with they were excluded from using. Thus the the community. At Gouverneur Clinic, Beth community forces on the community advisory Israel rejected community demands for a board could be more easily divided, which greater role in selection of the clinic director of course would preserve Beth Israel's power. and determination of clinic program and ex­ In this era of financial crisis, with some pelled the legally constituted community or­ medical centers and medical schools claim­ ganization, the LESNHC-S, from the clinic by ing to be on the verge of bankruptcy, com­ police force. Since that time, Beth Israel has munity people find it surprising that every continued to undercut the Health Council at hospital on the Lower East Side has imminent every opportunity. building expansion projects. NYU University During the spring of 1970, Dr. Ray Trussell Hospital, Columbus Hospital, the New York engineered the transfer of Gouverneur Clinic Infirmary, the New York Eye and Ear Infirm­ out of the Department of Hospitals into the De­ ary and Beth Israel Medical Center have all partment of Health. This maneuver allowed laid claim to real estate surrounding their in­ Beth Israel to apply State funds (through the stitutions. The pattern is similar throughout Ghetto Medicine Act, see BULLETIN, April, the nation, as studies of Presbyterian Hospital- 1970) to Gouverneur Clinic, a City-owned fa­ Columbia Medical Center [see BULLETIN, cility. (No other City hospital or clinic was February, 1970] and of Harvard's Affiliated permitted to receive Ghetto Medicine money, Hospital Complex (see New England Journal which was reserved entirely for the volun­ of Medicine, April 30, 1970) show. Medical taries.) It also meant the establishment, as institutions buy up housing surrounding their required by the Ghetto Medicine Act, of a new present buildings. Then, in order to force ten­ community advisory board. Logically, the ants to move without having to provide costly LESNHC-S should have become the board for relocation programs, the medical institutions Gouverneur Clinic. But Beth Israel, seeking to offer only minimal maintenance and upkeep consolidate its power over Gouverneur, insist­ of the buildings. Finally, the new institutional ed that there be only one community advisory buildings which are constructed on the ruins board to cover both Gouverneur and the out­ of housing (now in such short supply) are patient department at Beth Israel. This rele­ often merely parking or staff housing rather gated the LESNHC-S to only two seats out of than medical service buildings. 14 on the community advisory board—and This has been the pattern in the buildings both of these members were hand-picked by surrounding the New York Eye and Ear In­

5 firmary, where residents have fought back by three structures that have been proposed will moving otherwise homeless squatters into the directly improve medical services for the vacant apartments in the building. By keep­ community of the Lower East Side. The Thirti­ ing the apartments occupied, deterioration of eth Street classroom and administration build­ the entire building is slowed down. The ing will not benefit the Lower East Side, since squatters try to pay rent, but the landlord NYU graduated no black students last year usually refuses to take it, preferring to try to and had only six minority students out of 125 take legal action against them. With the sup­ students in the first year class. The hospital- port of the legal tenants the squatters move­ research tower slated for the site presently ment is spreading. Already buildings owned occupied by the Alumni Hall will only deepen by the New York Infirmary have been con­ the medical center's involvement in esoteric fronted with squatters. Beth Israel and Co­ research programs. The Cooperative Care lumbus Hospital will soon be facing the same Unit, the only real patient care unit contem­ problem. This new insurgency around hos­ plated, appears to be designed for out-of- pital-owned housing will clearly augment towners rather than the people of the Lower the existing community-worker forces that are East Side. "Cooperative care" means that the trying to establish some form of community patient is accompanied by family members control over the medical centers. who are charged with performing the basic The most massive building program con­ nursing care, obviating the need for extensive templated is at NYU Medical School and Med­ nursing supervision. Included in this concept, ical Center. Since NYU cleared the land are a cocktail lounge, swimming pool, res­ surrounding the medical center years ago, its taurant, garage for the patients, etc. It ap­ $50 million construction program cannot be pears that the unit will be nothing more than challenged by the squatter tactic. Despite the a motel where businessmen can come with magnitude of the construction program, the their wives for diagnostic workups. community will reap no benefits from it. NYU Will there be a fall offensive around health has consistently refused to make its resources on the Lower East Side? The insurgent forces available to the community, whether through —community, health workers and students— increasing minority admissions or through are getting themselves together. But so are satellite clinics in the community. None of the the empires—NYU and Beth Israel.

NYMC runs the 1000-bed Metropolitan Hos­ Upper East Side pital and the 1800-bed Coler Hospital on Wel­ fare Island. East Harlem residents, however, On Manhattan's Upper East Side, between the may be surprised to learn that NYMC's cata­ » "silk stocking district" and the East Harlem logue claims that NYMC has "pioneered in Spanish ghetto, two medical empires jockey health programs for residents of densely pop­ ,r for position. New York Medical College ulated urban areas." Community residents (NYMC) has already decided to leave for complain that, despite its medical responsi­ ; Westchester within the next few years but bilities, NYMC has taken no initiative in de­ may retain its affiliations with Metropolitan veloping signficant programs to deal with and Coler Chronic Care Hospitals, both city such major community problems as lead facilities. Mount Sinai, located next door to poisoning in children and massive drug ad­ NYMC along Central Park, hopes to take over diction or in developing ways to involve the the NYMC "public" responsibilities, but will community in solving its own health prob­ in any case expand its own real estate and its lems. affiliation with Beth Israel Medical Center on While NYMC officials like to cite as an ex­ the Lower East Side. ample of community-hospital cooperation Surrounded by Central Park, Mount Sinai tha fact that several Metropolitan house staff i Medical Center, and East Harlem, NYMC has and NYMC students assisted the Young Lords found its attempts at expansion blocked by in a door-to-door lead poisoning detection geography and politics. Its response to this program last winter, the community and the obstacle to corporate growth has been to look participating staff and students are quick to for a new site. In choosing a new site, NYMC point out that Metropolitan's and NYMC's only found itself with several attractive offers: contribution was permission to use hospital first, from the City, which tried to interest labs for processing the tests. And even that NYMC in relocating in Queens—where there came only after several demonstrations by is no medical school and where there are lots the Young Lords at the hospital and a sit-in at of people; second, from Westchester County, the City Health Commissioner's office to get which offered not only room for expansion but the test kits which Metropolitan had refused also a new source of teaching material to provide. Both staff and students volun­ through affiliation to the public hospital at teered their own time for both the door-to-door Valhalla. and lab parts of the testing program. Just because NYMC will be staffing a large NYMC fails to provide significant communi- public hospital doesn't mean that it is primari­ ity programs; it also fails to provide its stu­ ly interested in community health. NYMC al­ dents with the opportunity to experience^ ready has responsibility for the medical care medicine in a community-oriented contextJ of a large number of public patients. Through After many years as a straight-laced, undis] a $19 million contract with New York City, tinguished medical school with a very tradij

6 tional curriculum, NYMC is in the process of up to, however. Several staff members report timid revisions which will allow more elec­ that for the past two years, most people in the tives and put greater emphasis on the "fami­ Department have had very little idea what ly, sociological and community aspects of anyone else was doing. Then last spring, just patient care." But when NYMC moves out of before negotiations with Local 1199, when the the city, its students will be even more iso­ hospital would be in the news and the com­ lated from the community—even if the affilia­ munity might be asking questions, the De­ tion with Metropolitan survives the move. partment began systematically asking people This increased isolation from the problems of what they were doing and published a slick the poor urban community insures that the four-page section of the medical center's curriculum's new emphasis will be virtually News describing how much Sinai does for the meaningless. community. In contrast to the traditional and slow-mov­ Some community groups and medical stu­ ing NYMC, Mount Sinai Medical Center dents have expressed disappointment that the (right next door) is busy hustling grants and Community Medicine Department has not territory. Mount Sinai, New York City's new­ only failed to offer services to the community est medical school, promised students a pio­ but has, perhaps more importantly, failed to neering curriculum. In place of the traditional press Mount Sinai to change the way it deliv­ two years of basic science and two years of ers services to the poor people of East Har­ clinical experience, students were promised lem. Stories abound of ambulances sent on to an integrated program of 1/3 basic science, Metropolitan or Bellevue, and of discrimina­ 1/3 clinical science, 1/3 community medicine. tion in the outpatient department and in ad­ Now, however, many students express resent­ missions to the hospital. (There are about ten ment that nothing of the sort has happened. times as many private inpatient beds as there Community medicine has turned out quite dif­ are ward beds.) This is seen by the communi­ ferent from what they expected. The students ty as just another illustration of Mount Sinai's found that much of the Community Medicine attitude toward the community. Department's work consisted of surveys and In fact, even the projects claimed by the "research" done by reading medical records Community Medicine Department are of dubi­ of people who had already managed to get ous reality. For example, the Mt. Sinai News served by Mount Sinai or Beth Israel, rather notes that "recently, the Health Department than active attempts to change Sinai's de­ asked Community Medicine's Division of En­ livery of medical care to East Harlem. Stu­ vironmental Medicine to explore the develop­ dents found that instead of pressuring the hos­ ment of a more rapid screening test for blood- pital to reach out to the community, the lead." Though a team was assigned to work Community Medicine Department was an on that problem, the project rapidly passed academically oriented department striving for into informal oblivion. legitimacy and status within the medical cen­ For the community, the surveys, research ter itself and striving not to rock the boat. and academic reputation have little impact. Mount Sinai's growth industry is not com­ And resentment of the OPD, where patients munity medicine, but its Community Medicine are funnelled through many subspecialty Department. To promote the new department, clinics, and of the emergency room remains Sinai grabbed up Dr. Kurt Deuschle, fresh high. During the past year, the OPD has been from setting up the community medicine pro­ in the process of rearrangement "for teaching gram at the University of Kentucky. Besides purposes." Exactly what that means is not its more than 50 faculty members, the Depart­ clear. One thing it clearly does not mean is ment boasts a good supply of government re­ rearrangement for better service to the com­ search grants (though it has suffered the munity. Sinai staff describe as one illustration same research cutbacks as everyone else), a of this a staff meeting to discuss the "rear­ full-time Washington grant lobbyist, and the rangement." At the meeting, a doctor sug­ classic academic and professional view of gested that one improvement that should be community. Thus the Department's first an­ made immediately is automatic admission to nual report noted that "to diagnose and treat Sinai of every Sinai OPD patient requiring the community calls for many skills." And a hospitalization. The administration's instant recent public relations release quotes Dr. response was "impossible." In fact, many Deuschle: "What we are doing is applying OPD patients are sent elsewhere if they need [our] multi-faceted expertise in scientific to be admitted to a hospital. Very few Sinai fashion to identifying health needs as we find inpatients come from the East Harlem com­ them in East Harlem, and developing and munity, whereas nearly all the outpatients do. testing new programs to meet them, utilizing One community organizer from Sinai re­ existing health resources and adding what­ mains in regular touch with the East Harlem ever new components we think might make Health Council, a neighborhood-constituted for a better system." group that relates to both Sinai and NYMC. The outcome of this philosophy has been a But despite this contact, Mount Sinai's basic complete failure to change the health serv­ attiude toward the community is wariness. ices experienced by the people of East Harlem When two representatives of the Young Lords with the result that some community residents came to speak about the Lords' health pro­ wonder what the Community Medicine De­ gram to the Sinai chapter of the Medical Com* partment does. It is not only community resi­ mittee for Human Rights, Sinai sent extra dents who can't tell what the Department is security guards to patrol the meeting area.

7 Mount Sinai is affiliated with Elmhurst (a accreditation because of inadequacies in its City hospital in Queens), the voluntary Hos­ medical record room. pital for Joint Diseases, the Bronx VA Hospital Recent financial events, however, may turn (recently the subject of a Life Magazine ex­ much of the question of community role into pose of the inadequacy of veterans' care), a purely theoretical question. While most and Beth Israel Medical Center (a blossom­ medical schools are currently feeling a ing empire in its own right). In addition to squeeze from the combined effects of inflation running or helping to run these other hos­ and the cutbacks in federal research grants pitals, Mount Sinai is currently trying to get (which sometimes pay as much as 80 per its own 1350-bed hospital in order: in spring cent of salaries), both Sinai and NYMC made 1970, the Joint Committee on the Accredita­ Business Week's recent list of "some of the tion of Hospitals gave Sinai only provisional sicker patients."

into this hospital if they represent a particu­ D ow nstate larly interesting case. This hospital operates Dominating the hospital system for the great­ at only 67 percent occupancy because admin- er part of Brooklyn's two and one-half million sions are rigidly limited in order to preserve population is the Downstate Medical Center a patient to nurse ratio of less than 4 to 1, (DMC), a New York State-supported medical thereby maintaining a superior level of pati­ school and 350-bed hospital. DMC has teach­ ent services. It is stated in the Downstate Med­ ing affiliations with ten hospitals in Brooklyn, ical School catalogue that State University including Kings County, Long Island College Hospital is the nucleus of the clinical teaching Hospital, Brooklyn-Cumberland Hospital, program, but in fact the bulk of clinical train­ Brooklyn VA Hospital, Jewish Chronic Disease ing is done on the poor patients in Kings Hospital, Jewish Hospital and Medical Cen­ County Hospital, and the interns and resi­ ter of Brooklyn, Long Island Jewish Hospital, dents are more restricted in their responsibili­ Methodist Hospital of Brooklyn, Maimonides ties at the State hospital because it is filled Hospital and Brooklyn State Hospital. The with private patients. Mr. Chalef, Director of Downstate empire is huge, comprising over the State University Hospital, says, "Although two-thirds of the 15,000 hospital beds in Brook­ State University Hospital is a government lyn. But its interest in providing patient care hospital, it is the only one I know of classified for Brooklynites is less impressive. The DMC by the state as a voluntary hospital." The sees itself as a teaching and research center message is clear: Public funds have been and treats its affiliates accordingly. used to establish a dual system of health care At the core of the empire, namely the med­ on Clarkson Avenue with first rate care going ical complex which includes DMC and Kings to private patients in the State University Hos­ County Municipal Hospital, one sees a famil­ pital and second rate care going to the poor iar scenario, with a change of costume. Though patients at Kings County. wearing the costume of a publicly supported DMC has been plagued with administrative state institution, DMC acts exactly like a priv­ difficulties in recent years, especially with re­ ate institution. The dual system of health care gard to filling empty positions. The chairman is nowhere more dramatically demonstrated of the Biochemistry Department has had to than on the opposite sides of Clarkson Ave­ stay on three years beyond his retirement age nue in Brooklyn. On one side of the street is while the chairmanship has been offered to the 2,700 bed City-owned Kings County Hos­ and refused by at least 24 professors of bio­ pital, under-financed and understaffed (pati­ chemistry. The Radiology Department was ent to nurse ratios sometimes reaching 30 to non-existent for over a year while a new chair­ 40 to one). The patients at Kings County are man was being sought. Joseph Hill is currently primarily black (50 percent) and Puerto serving as both President of the Medical Cen­ Rican (23 percent); they are all poor. In re­ ter and Dean of the Medical School, but he is cent years, the only substantial improvements hospitalized and is not expected to return to in patient services have been those related to his posts. No names have yet been suggested crisis health care (e.g., renal dialysis units, as candidates to fill these crucial vacancies. intensive care unit, and cobalt unit). These DMC, plagued with its own staffing and ad­ are reasonable facilities for a large city hos­ ministrative problems, has shown little en­ pital to have. But they are not the highest thusiasm for taking responsibility to improve priority items on Brooklyn's agenda of health and reorganize health services at Kings Coun­ care needs. ty, much less throughout its Brooklyn empire. On the other side of Clarkson Avenue is Isolated examples of true community service DMC's 350-bed State University Hospital. This exist (e.g., a program for recruiting black stu­ shiny edifice, completed in 1966, is almost ex­ dents for Downstate Medical School, and an clusively a private hospital for the private innovative pediatrics department which was patients of the clinical faculty of DMC. That responsible for setting up a lead screening means that the majority of the patients are program), but DMC's general trend is one of white, that 76 percent of the patients are priv­ 'Iretrent" from community responsibility. Be­ ate, that only two of the more than 60 clinics cause the various departments of DMC have are open to patients who do not have private established themselves as independent and doctors. Such patients can generally only get unaccountable baronies, they have been able to preserve themselves as enclaves of re­ ty groups involved in health issues include search and training free from community con­ the Bedford-Stuyvesant Restoration Project, trol and involvement. For example, the De­ the Bedford-Stuyvesant Development and partment of Medicine at Kings County (con­ Service Project, and a Kings County Com­ trolled by Downstate through its teaching munity Advisory Board. affiliation) allegedly has a policy of turning Nevertheless, DMC's ventures into the com­ away "uninteresting" patients (e.g., patients munity have been circumspect and often with hepatitis, drug addicts) and admitting exploitative with the general strategy amount­ only those patients whose diseases are inter­ ing to a retreat from community responsibili­ esting for teaching or research purposes. ty. For example, DMC has proposed construc­ When the affiliation program was first in­ tion of a child psychiatric center on Clarkson itiated by the City back in 1961, Kings County Avenue with between 100 and 200 beds. They was overlooked, ostensibly because it was not envision it as a traditional research and train­ in as bad condition as some of the other City ing facility offering traditional modalities of hospitals. At that time it already had a teach­ psychiatric care to a limited catchment area ing affiliation (involving no money) with the population. Interestingly enough, they are Downstate Medical School. As the health ser­ meeting resistance only in Albany, where vices steadily deteriorated at Kings County, State planners wish to see not another en­ the City began to press Downstate to assume clave of research and training but an out­ some responsibility. It did so, but in a limited reach program with community service and way, starting in 1966 when the first contractual development of new modalities of out-patient affiliation agreement was made. As of this care as its first priorities. year the affiliation contract covers only three The new recreation center at DMC provides services, radiology, pediatric out-patient care another example of the empire's attitude to­ and psychiatry, at a cost to the City of only wards the community. The official policies for about $6 million, or 15 percent of Kings Coun­ use of this recreation center amount to a tri­ ty's $38 million budget. (By contrast, Einstein level caste system. The "elite" (students and Medical College's affiliation contracts at Lin­ faculty at DMC) are permitted free and un­ coln Hospital and Columbia's contracts at limited use of the facility. The second level Harlem Hospital comprise about 40 percent of (workers at either Kings County or the State the City hospitals' budgets.) Despite the rela­ University Hospital who are on the State civil tively small size of the contractual obligations service system payroll) must pay $25 per of DMC at Kings County, DMC exercises virt­ year to use the center. And everyone else ually total control over the City institution (such as community residents) is permitted through its teaching affiliation. But the commit­ to use the center only at specific and limited ment of DMC to Kings County and its patients times during the week. In retaliation, many is small. young neighborhood people have vandalized Community insurgency has been slow in the recreation center, which to them is a sym­ developing around DMC, especially owing to bol of privilege and elitism. the fact that Kings County Hospital is geo­ These are only isolated examples of the graphically separated from its service popu­ much bigger issues regarding the reorganiza­ lation. The majority of its patients live in the tion of health services in Brooklyn. DMC has Bedford-Stuyvesant, Crown Heights, and consistently been reluctant to respond to com­ Brownsville ghettoes, an average of three and munity needs and pressures for improved one-half miles from the hospital. However in and reorganized services. Downstate's empire the past year an ad-hoc community group did remains the number one health power in struggle successfully for improved lead Brooklyn and therefore the principle road­ screening of children. Other active communi- block to necessary change.

made it seem alien and hostile to the people Columbia of nearby Washington Heights as well as those downtown near Harlem Hospital. The Columbia-Presbyterian Medical Center In the past two years, starting approximate­ continues to be challenged by the opposition ly with the University strike in spring 1968, a it arouses in its community and among its series of challenges have been made to the workers and students. The Columbia empire elitist and repressive orientation of the medi­ is centered at the College of Physicians and cal school and Presbyterian Hospital. Student Surgeon (P. and S.) and Presbyterian Hospital groups have leafletted patients in Vanderbilt in upper Manhattan. It has affiliations at Har­ Clinic, the out-patient clinic for Washington lem and Delafield municipal hospitals and St. Heights, citing the double standard of care Luke's and Roosevelt hospitals in the mid­ and the expansionism of the Medical Center west side. Columbia-Presbyterian is one of in the face of crying community needs for the oldest of the N.Y.C. "empires" and the first primary and preventive care. The Washing­ to aggressively buy up land for a medical ton Heights Community Mental Health Coun­ academic campus floating in a black and cil, starting with a takeover of a Columbia- Latin community. Its white, Protestant, elite sponsored meeting in the fall of 1968, has image and traditional concern with interest­ challenged the in-patient and teaching orien­ ing "teaching material" rather than with the tation of a proposed Columbia-run community needs of the surrounding community has mental health center. An attempt by Local

9 1199, Drug and Hospital Union, to unionize Center before his incarceration. The Coalition research workers at P.&S. in the summer and also puts out a muck-raking and issue-rais- fall of 1969 expressed the discontent of the ing newsletter, 1-0-9, named after the room it P.&S. workers, although it was at least tem­ uses as a headquarters in the research build­ porarily beaten back by the union-busting ing. tactics of the University administration. (The • The Black Caucus co-sponsored a Curtis "Supporting Staff Association," which states Powell support rally. It sponsored a day of explicitly that it is not a union and wants to mourning for the Augusta and Jackson State co-operate with Columbia, won the right to slayings, and has begun a survey of hiring represent the workers in a bitterly contested, and student admissions policies at the Med­ close election.) ical Center. In the past nine months, several new groups • The Washington Heights Freedom and have emerged and have challenged Co­ Peace Party, together with a community lumbia in new ways. Chief among these coalition, co-sponsored a community meeting groups are the Coalition Against War, Racism last December to talk about the state of health and Repression and the Black Caucus within care in Washington Heights. Since then, Free­ the Medical Center, the Freedom and Peace dom and Peace has challenged specific pol­ Party and a community coalition in Washing­ icies in the dental clinic, has set up a griev­ ton Heights, and the United Harlem Drug ance table in the Presbyterian emergency Fighters at Harlem Hospital. room and has provided free ambulance serv­ • The Coalition Against War, Racism and ice home from the hospital on weekends. Repression grew out of the nation-wide tur­ Major confrontations with the hospital have moil after the invasion of Cambodia last May. come over the defense of a patient beaten by It has sponsored meetings and rallies about medical center guards for complaining of a the war and about repression of the Black long wait [see May, 1970, BULLETIN], and in Panthers. Panther support work has focussed demanding the return of a young mother's al­ on the "New York Panther 21," and especially legedly battered child who was taken by on Dr. Curtis Powell, one of the 21, who was a the hospital and the Bureau of Child Welfare researcher in biochemistry at the Medical for adoption without telling the parents.

AIR POLLUTION In what must be one sponsibility for monitoring air quality from the TAKES of the nation's first TBTA to the City's Department of Air Re­ ITS TOLL strikes against auto­ sources. While all that was going on, the mobile air pollution. TBTA was also attempting to silence a par­ New York City's ticular union member, George Carroll, who Bridge and Tunnel officers staged a three- had been quoted in the newspapers as saying day walkout at the City's tollbooths and that tunnel air was "unhealthy." The TBTA's tunnel catwalks on August 18, 19, and 20. silencing tactic was quite straightforward: Mr. Basically, the men contend, the air pollution Carroll was suspended without pay. is killing them. And they cite impressive med­ By August 1970, the air in the tunnels and at ical and environmental statistics to prove it. the entrances had not improved, the TBTA At the Brooklyn Battery Tunnel, for instance, was stalling on the question of medical the carbon monoxide level is as much as 12 studies, and the men were getting angrier. The times the level in the outside air. Employees at final blow came on August 18, in the midst of the Brooklyn Battery and Queens Midtown converging air pollution and electric power Tunnels are exposed to as much as 100 parts crises. As every New Yorker will recall. Con per million of carbon monoxide—more than Edison several times this summer appealed to twice the amount considered "dangerous." major power users to cut their power con­ Five of the 22 men men whose blood carbon sumption during peak hours—which includes monoxyl hemoglobin was measured had the afternoon rush hear when auto pollution levels over four per cent—enough to produce is high. In compliance with Con Ed's request, psychological effects such as reduced ability the TBTA reduced the power and thus the ef­ to judge time. fectiveness of the already inadequate fans Data on the tunnel pollution first appeared that ventilate the tunnels and toll booths. The in July, 1969, when the tunnel officers' union Bridge and Tunnel Officers had had enough. (Local 1396 of District Council 37, American At 5:30 PM they walked away from their posts. Federation of State, County and Municipal For three days the newspapers focussed on Employees) released an analysis of a study the question of how many motorists were pay­ prepared four years earlier for management, ing the toll in the absence of the toll collectors the Triborough Bridge and Tunnel Authority and all but ignored the air pollution issue. But (TBTA). With characteristic unconcern for the at the end of the three days, the TBTA agreed health of either its workers or its "clients," the to get the medical studies underway and to TBTA had been sitting on the study for over install (and presumably to use) high speed four years until the union finally obtained and ventilation fans on tunnel catwalks and in toll released it. Embarrassed by the facts con­ collection booths. The men went back to work, tained in the study, the TBTA agreed to con­ but with the implicit threat that if the TBTA duct further medical studies, the results of fails to live up to its obligations to protect the which were to be released to both workers and health and safety of the workers, the workers m anagem ent simultaneously, and to shift re­ will again have to strike.

10 • The United Harlem Drug Fighters, a Hospital, a neighboring, Columbia-affiliated, coalition of Harlem groups concerned with City-owned cancer hospital, into a general wiping out heroin addiction, sponsored a care hospital for the poor people in the area. rally on July 25. The rally proceeded to the That would permit Presbyterian to get out of K building of Harlem Hospital (the psychiat­ the business of taking care of non-private ric service) and began a month-long sit-in. patients and so hopefully get the community The upwards of 300 addicts and support­ off Columbia's back. Already, Columbia is ers in the K building demanded that the trying to shift its family planning programs Psychiatry Department set up a 100-bed onto Delafield's strained facilities. But even detoxification unit and that the hospital great­ turning an affiliated City hospital into a patient ly expand ambulatory and half-way facili­ care centered facility does not come easy for ties in the community. The Drug Fighters, in Columbia; a lonely struggle is currently be­ cooperation with some activist doctors, set up ing waged by the administrator of Delafield a methadone detoxification program on the to free up space for patient care from the spot. After a month's occupation, the final space required for the cancer research pro­ agreement committed the Health and Hos­ grams of Dr. Solomon Spiegelman. pitals Corporation to funding a 100-bed de­ So while the Columbia-Presbyterian Med­ toxification unit on two floors of the old Har­ ical Center continues to buy up land, emascu­ lem pediatrics building, the City's Addiction lates the Community Mental Health Council, Services Agency to providing a half-way declines to commit itself to drug treatment in hotel in the community, and the Harlem Hos­ the Washington Heights area beyond a 10- pital out-patient service to expanding its out­ bed unit at Delafield, increases its security patient methadone facilities. Dr. Elizabeth force, and reluctantly balances its multi-mil­ Davis, head of the Columbia-affiliated Depart­ lion dollar house staff residence with a new ment of Psychiatry, successfully blocked the emergency room, community and worker use of Psychiatry Department beds for the de­ groups see the NLF flag raised on the Pres­ toxification program agreed upon. byterian flagpole on the eve of July 4 as sym­ In response to the community's challenges bolic of the struggles to come.— The empire around Presbyterian's Vanderbilt Clinic, Co­ stories were prepared by the staff, Dick Clapp, lumbia is apparently hoping to turn Delafield and Dale Hiltgen, Health-PAC Student Intern.

on outside consultants have increased from Hidden Persuaders: $8 million a year to $75 million. Formerly, the City hired consultants only occasionally and New York City’s on a one-shot basis, but today consulting firms are firmly entrenched in a range of City problem areas including fire, police, health Health Consultants and overall City planning and budgeting. Few New Yorkers had any inkling of the ex­ While consumers and workers are struggling tent of the City's reliance on consulting firms for grassroots democracy in the institutions until last June, when City Comptroller Beame which affect their lives, the trend in city gov­ disclosed the huge sums involved and threat­ ernment is to remove larger and larger areas ened to cut off payments pending an investi­ of decision-making from public view, much gation. less from public participation. City govern­ In contracting out basic analytical and ments, such as New York's, are virtually dis­ planning work to private consulting firms, the mantling themselves in their haste to hand City is following a trend which has also been vital service and planning functions over to gaining momentum in private industry and public authorities (modeled after private cor­ the Federal government. Over the last five or porations) and to private consulting firms. ten years, consulting has grown from a small In most cities, mass transportation has long business dominated by freelancers and ac­ since passed out of the public area and into counting firms to a $1 billion per year indus­ the hands of quasi-public corporations, or try, dominated by large, consulting-only firms authorities. More recently, New York City sur­ which employ hundreds of professionals. rendered the management of its 19 municipal Highly profitable (charges for single studies hospitals to the newly created Health and range into the millions) and totally unregu­ Hospitals Corporation. As authorities and lated, the consulting business is, according to corporations take over the operation of public Business Week, growing by leaps and services, only planning and policy-making bounds. In addition to the profit-making con­ functions are left behind in city government. sulting firms, which specialize in corporate But increasingly even these core functions are management problems, the sixties spawned being contracted out—to private consulting a host of more "academic" nonprofit outfits, firms which are closely linked with the De­ the so-called "think-tanks," some of which fense Department and to the nation's largest were originally set up by the Defense Depart­ private corporations. ment. Both types of firms are pulling down New York City's dependency on private major contracts in urban problem-solving, consulting firms is growing at a rate which especially in New York City. even some public officials find alarming. Be­ The assumption behind the City's growing tween 1965 and 1970, the City's expenditures use of private consultants is that City govern­

11 ment as it is now structured is cumbersome, firms under contract to the Corporation for inefficient, and ill-equipped to deal with com­ bits and pieces of health planning include plex problems. Private industry and the mili­ Peat, Marwick and Mitchell, the nation's tary, on the other hand, are seen as efficient fourth largest m anagem ent consulting firm; and eminently capable of handling the most Planning Research Corporation, the third difficult issues. Therefore, according to this largest; and H. B. M aynard and Company, line of reasoning, the solution for the cities is the tenth largest. to borrow the analytical and decision-making • The think tanks which are working or techniques which seem to work so well in in­ have worked on health for the City include dustrial and military settings. Indeed, much some of the Defense Department's most relia- of the work now being done by private con­ able advisors. Best known, of course, is the sultants for New York City is not on sub­ Rand Corporation. Originally set up by the stantive problems, such as how to improve Air Force, Rand in 1968 was pulling in about services, but on the problem of how to restruc­ $800,000 in health contracts in New York City, ture and "rationalize" the City decision-mak- and $19 million in consulting contracts for the ing process itself. military. Systems Development Corporation The problem with this line of reasoning is (SDC), which produced a 1966 study entitled that the decision-making methods appropri­ "Systems Development and Planning for Pub­ ate to industry and to the military are not, or lic Health in the City of New York" under con­ should not be, appropriate to the government­ tract to the City, made $17 million in defense al process—even if one grants the question­ contracts in 1968. SDC was also originally able assumption that industry and the mili­ established by the Air Force. Research tary are really efficient and smooth-running. Analysis Corporation (RAC), a child of the To the extent that industry and the military do army, worked on health planning for the City appear to be "efficient," it is because of in­ in the late sixties, while it was making $10 herent features of their goals and structure, million per year through defense contracts. rather than because of any superior decision­ Technomics, Inc., the Santa Monica firm making techniques. In the first place, both are which did the staff work for the 1966 mayoral oriented towards single goals—profits in in­ commission which first proposed a corpora­ dustry, high kill-ratios in the military. Deci­ tion to run the Municipal hospitals [see BUL­ sion-making is simply a problem of maximiz­ LETIN, special winter issue, 1969], originally ing profits in the one case, kill-ratios in the specialized in defense work. other. City governments, on the other hand, Many of these companies are working, or appear to have complex and often conflicting have worked, for the City on short-term, sets of goals. In the second place, industry limited assignments. But the heavyweights in and the military are both rigidly hierarchical terms of contract dollars and manpower, operations. What appears to be an efficient Rand and McKinsey, are well on their way to decision-making technique is often simply an becoming permanent fixtures of the City's autocratic one, and unsuitable to what should billion dollar per year health enterpirse. Both be democratic governmental procedures. The were hired initially as part of Mayor Lind­ danger is that city governments may, under say's drive to "rationalize" City government the prodding of their private consultants, try through the use of "PPBS" (Program Plan- to emulate the anti-democratic but seemingly ning-Budgeting System), a Rand-designed efficient functioning of industry and the mili­ planning and decision-making technique first tary. sold to the Defense Department under Mc­ Namara in the early sixties. Lindsay's first «»ealth was one of the first areas to be budget director, Fred Hayes, brought Rand in staked out by the major consulting firms op­ to help the City budget bureau institute PPBS erating in New York City. Which firms they in 1967. A year later, he contracted with Mc­ are, what they are paid, what they are paid to Kinsey to supervise the Budget Bureau's ef­ do—none of this is accessible public informa­ forts to switch over to the PPBS method of tion. HEALTH-PAC's probes, conducted over budgeting. Both firms have spread out from the last year and a half, reveal that: the PPBS business to the congenial area of • The management consulting firms work­ health—which is considered by the Lindsay ing on health for the City include some of the administration to be so highly "technical" that nation's largest and most profitable firms outside consultants are indispensable. which, when they're not working for the City, Both firms are now so closely tied in with are straightening out management or market­ the City administration that their staff men ing problems for such corporate giants as are almost considered part of the "family" of IT&T, Western Electric, US Steel and Metro­ Lindsay's bright young men and women. For politan Life Insurance. McKinsey and Com­ example, applicants for City health planning pany, whose total City contracts add up to jobs report being referred by City employees $1.5 million, is the nation's fifth largest and officials to Rand and McKinsey as other m anagem ent consulting firm, with a gross in­ sources of jobs. Rand-men have been known come of about $25 million. McKinsey's assign­ to move over into City jobs, and one McKin­ ment appears to be nothing less than the task sey employee. Carter Bales, held the position of setting up the organizational structure for of Deputy Budget Director while remaining on the Hospitals Corporation, which gives the the McKinsey pay-roll. With this kind of in­ firm a key role in determining the shape of the timacy with the City administration contract City's health system for years to come. Other renewals are practically guaranteed.

12 The Rand Corporation enjoys an especially and the Health Service Administration. But in privileged relation to the City. Top Rand-men terms of McKinsey's original assignment—to do not take just any assignment from the City make PPBS and other sophisticated tech­ —they participate in the framing of projects niques an operational reality in the City of interest to themselves. Thus, in health, health bureaucracy—there has been almost Rand has dabbled in a wide range of sub­ no progress. City officials and planning staff jects: mental health, community health cen­ complain they can't comprehend much of Mc­ ters, narcotics, home care, emergency care. Kinsey's guidelines, memos and flow charts, Over the winter of 1969-70, Rand did a detailed much less apply them to everyday, practical study of the municipal hospitals, which (ac­ problems. According to one insider, when a cording to one of the Rand-men on the assign­ top McKinsey executive gave the Hospital ment) was oriented towards saving money Corporation's Board of Directors a presenta­ through bed-reductions and other service tion of McKinsey's plans for the Corporation's cuts. Current Rand projects for the Health management structure—complete with illus­ Services Administration include studies en­ trative slides—the Directors' response ranged titled "Costs and Performance of Suppliers of from boredom to open skepticism. In a similar Health Care" and "Direct and Indirect Mental performance for HSA staff in late 1968, the Health Services"—both probably geared to McKinsey team's explanation of PPBS was discovering cheaper ways of delivering greeted with giggles from the audience. One health services. lower echelon Budget Buerau staffer, mysti­ fied by McKinsey directives despite his own training in systems analysis, said "What Mc­ In 1969 Rand Corporation and the City ad­ Kinsey's doing, we call PP-BS." ministration cemented their relationship through the joint formation of a nonprofit • They argue that private consulting firms corporation called the New York City Rand are indispensible because they are "above Institute, a Rand spin-off dedicated solely to politics," capable of giving truly "neutral" urban problems. Formerly, Rand-men work­ advice to harried City officials. The neutrality ing on New York City problems were super­ of any advisor, no matter how academic or vised from the Rand Corporation's Santa detached he purports to be, is open to ques­ Monica headquarters. For the Rand team in tion. But the kind of men doing most of the New York, the device of forming an inde­ health consulting work in New York City can pendent, City-linked "institute" has two big make no pretense of academic detachment. advantages over the old arrangement: First, Whether they work for a defense-oriented the City has promised to finance the Rand In­ think tank or a private industry-oriented man­ stitute to the tune of $3 million/year (an addi­ agement consulitng firm, they are ideological­ tional $1 million will be raised from private ly and intellectually rooted in American foundations). With a guaranteed income of imperialist and profit-dominated values. Mc­ $4 million/year, the Institute can settle down Kinsey men assume without question that the to "academic" pursuits, free of the pressure of kinds of management structures and decision­ hustling individual contracts. Second, formal making processes suitable to private industry independence from Rand Corporation should are suitable to City government. One consult­ give the Institute a clean, non-military image ing firm staffer working on health openly ex­ attractive to potential clients. (The Institute pressed his bias: "I'm for private enterprise. will probably retain extensive informal rela­ It works. Most problems that government tions to the Rand Corporation.) In the health can't handle can be handled by private en­ field, the Institute's prestige is assured by the terprise." Of course, alternative solutions to presence, on its Board of Directors, of Yale's health care delivery problems, such as com- Dr. Lewis Thomas, former Dean of NYU Med­ munity-worker control of health facilities, ical School, and William Golden, a director simply never arise in the decision-making of Mt. Sinai Medical Center and of New York framework of a Rand Corporation or a Mc­ Blue Cross. Kinsey Company. No one questioned the City's relation with The political assumptions of Rand's "aca­ its consultants until Comptroller Beame's dis­ demic" analysts are especially questionable. closures last June. Now, the Lindsay adminis­ Many of the Rand-men who have worked on tration is on the defensive. In public and priv­ health for the City have also worked on mili­ ate statements, they justify the use of private tary problems for the Department of Defense. consulting firms on three grounds: One, interviewed in late 1968, did both simul­ • They argue that the advice obtained is taneously: two days a week in Washington well worth the money. But, despite all the working on secret problems related to the war mystique about "systems analysis" and other in Vietnam, three days a week in New York "technologies" of problem solving, the per­ working on health. He, like other Randmen, formance of the top firms doing health work saw himself as just a "technician"—capable has been consistently shoddy, even when of designing methods of genocide one day, measured by their own standards. Rand-men and working on narcotics and mental health themselves have admitted privately that they problems the next day. "never really got on top of the health thing" • They argue that, after all, the real policy despite three years' and over a million dol­ decisions are still made by City officials: lars' worth of trying. McKinsey is proud of the Private consulting firms only provide the in­ volumes of flow charts and computer forms it formation and the framework for decision­ has produced for the Hospital Corporation making; they list the alternatives, the Ciy of­

13 ficial chooses among them. It almost goes worth more than the temporary satisfaction without saying, however, that a particular of being honest and critical about the con­ policy decision is largely determined by the sulting firm's work. information that goes into it, and the kinds of With the arrival of the private consulting alternatives that are presented. With the con­ firms on the urban health scene, one more sulting firms now working on health for the link in the growing Medical-Industrial Com­ City, the information "input" is bound to be plex has been forged. The consulting firms, limited by the knowledge and experience of with their ties to the nation's largest corpora­ the firms' upper middle class staff men. (For tions, to the aerospace and defense industries example, one Randman who was attempting and to the military itself, are now tied, in turn, to apply a highly abstract branch of mathe­ to local health systems. The links are still matics called stochastic analysis to the prob­ tenuous, but the possibilities for profitable lem of patient flow in emergency rooms, ad­ exploitation are already clear: In its search mitted he had never been in a City hospital.) for new markets, industry and especially the In a practical sense. City officials and staff defense industry, is turning increasingly to members are seldom in a position to objective­ health [see November, 1969, BULLETIN], ly judge the data and the "framework" pre­ There, one step ahead of them, are the man­ pared for them by private consulting firms. As agement consulting firms and think tanks, mentioned above, the links between City staff ready to please their industrial clients by and consulting firms are many and tangled. scouting out and developing new markets for Comptroller Beame revealed that the City's medical electronic hardware, computers, in­ Environmental Protection Administrator, Jero­ dustry-run training programs for health para- me Kretchmer, accepted a free weekend in professionals, etc. (Already, one can discern the Poconos resort area from McKinsey. What an insistent emphasis on computers and re­ Beame did not know was that Rand Corpora­ lated hardware in the advice New York City tion has hosted dozens of City health staffers buys from its consultants.) As the medical- on free trips to Santa Monica. Finally, many industrial complex and its ally, the consulting City officials and staff people know that one firms, gain hegemony over the health system, of the most lucrative jobs they can get when the consumer, with his demands for high quali­ they leave the City government is with a ty, dignified services and public accountabili­ private consulting firm. Building a friendly ty, is increasingly irrelevant.— Barbara Ehren- personal relationship with the outside firm is reich.

CORRECTION: We wish to thank Conserva­ Nursing's annual article on Educational Prep­ tion of Human Resources at Columbia Uni­ aration in Nursing to be published in Nursing versity for calling to our attention some Outlook. For black student admissions, the fig­ omissions and errors in last months chart on ures are based on admissions in programs medical and nursing school admissions [see which answered the question about blacks BULLETIN, September 1970, p. 10], The cor­ ("total" column). Actual total admissions in rected chart is reprinted here. Medical school each type of program are given in parentheses. figures are from an unpublished article by The percentages of men admitted to the vari­ Dennis Dove, Administrative Assistant for ous types of programs are based on those pro­ Minority Student Affairs of the American As­ grams which answered the question about sociation of Medical Colleges. The article is men. However, the total admissions to and ac­ titled "Minority Enrollment in U.S. Medical tual numbers of men in the programs which Schools for 1969-70 Compared to 1968-69." answered the question about men have not The figures for nursing program admissions been released. Thus the percentages of men are from a draft of the National League for in each program are approximate.

Medical Student Enrollments (1st year class) 1968-69 1969-70 Absolute %of Absolute %of numbers total numbers total Total 9.863 10,371 Females 887 8.9 936 9.0 Black 783 2.18 1,042 2.75 Amer. Indian 3 0.03 7 0.07 Mexican-Amer. 20 0.23 44 0.42 Puerto Rican 87 0.88 96 0.93 Nursing Admissions for 1968-69

total blacks % Associate degree 17,808 (18.907) 10.5 Baccalaureate degree 14,111 (15,983) 6.0 2.5 Diploma 28,679 (29,267) 3.6 2.8 Practical Nursing 44,917 (49,107) 17.4 4.4

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