Box 7, Folder 10, Document 6

Box 7, Folder 10, Document 6

Revised Draft: 3/26/69

POSITION PAPER - HEALTH
Urban Coalition Roles in the Health Field



BACKGROUND

While no one wants to be sick, among the desperate needs
of the urban poor and disadvantaged, seeking good health, in-
cluding practicing preventive medicine, will not be perceived as
a very high priority. They find as more compelling needs, jobs,
the opportunity to own a business, more educational opportunity
and better housing. Since without good health, daily functioning
in holding jobs, running households, attending school and the like,
is difficult, if not impossible, various kinds of health services
are a necessary condition for the poor to function with any ade-
quacy at work, at home and in their communities.

There is much evidence of the deplorable health status of
the urban poor. "Poor" refers to all those families, including
about 25 million individuals whose income falls below the commonly
accepted government standard that would provide adequate food,

clothing, and shelter and medical care.* The disproportionate



*Of an estimated 45 million poor people, half live in large
metropolitan areas. Another 25% of this total live in concentra-
tions of population but non-metropolitan areas. Our primary
concern is with the improvement of the health services in the
cities that serve at least 25 million Americans.


prevalence of ill-health among the poor, minority and dis-

advantaged groups is shown in many ways:



--Death comes earlier to the poor. Life expectancy for
the non-white is 7 years less than for the white.

--Death is a more frequent visitor to poor mothers and
infants. Non-white mothers die in childbirth 4 times as frequen-
tly as white mothers. Infant mortality is twice as high among
the non-white as among the white.

--Illness is twice as frequent among families with annual
incomes of $2000 or less. There is 4 times as much chronic
illness among these families, twice the number of days of restict-
ed activity, a third longer hospitalization.

--Tuberculosis and cancer of the cervix is found twice as
often among non-white urban residents as among the white.

--Visits to doctors and dentists, despite the obvious greater
need, are less frequent among the urban poor. Children under age
15 average half the doctor visits in families with incomes under
$2000 compared with children of the same age in more affluent
families.

--Preventive services are not received by the same proportion
of poor children as they are by the more affluent. Only 8.6% of
white children have no immunizations compared with 22.5% of non-
white children.

Existing health services delivery systems do not reach all

of the urban poor. Medical care is generally provided in clinics
Where available, generally over-crowded, at inconvenient hours,
understaffed, and run as categorical units: i.e., diabetes

clinic, heart clinic, arthritis clinic. Care is episodic, focused
on emergencies rather than continuous and comprehensive, with little
if any attention to preventive services, or health education. There
is little or no effort to reach those who need care, but lack moti-
vation. There is little if any follow-up, coordinated control
intake, or referral procedures.

Where private doctors' offices are the source of care, high
costs deny needed services to many. While Title XIX (Medicaid)
has been in effect for a number of years, not every State has yet
participated, and even where the States have, legislative ceilings
both Federal and State have imposed stern limitations. Less than
9 million people altogether in the country are covered and able to
take advantage of the program. This means that for the other mil-
lions of the poor, the doctor's bill may strongly deter their
seeking care.

In addition, the clinics and doctors offices are not available
to all. Many inner city neighborhoods are far from where hospital
clinics were set up a generation or more ago; doctors have moved
to the more affluent suburbs; public transportation from many of the
inner city neighborhoods is lacking, insufficient or expensive.

The shortage of health manpower generally is well-known, and the
shortages of physicians and nurses, and other health personnel have

been well publicized.
The problem of accessibility of health care facilities is
compounded in those instances where governmental and private
agencies and institiutions have failed to reorganize to meet the
personal health needs of the poor. In addition to the fact that
facilities are often absent, obsolete, or obsolescent, inadequate
in scope of service or availability temporally or geographically,
emergency services are difficult to obtain, inadequately staffed,
qualitatively inadequate.

Environmental health needs are only minimally met. The prob-
lems of air and water pollution are largely ignored. More personal
environmental needs such as damp, cold crowded housing are wide-
spread among the poor. Garbage and waste disposal is inadequately
supplied. Rats abound, as do other pests. Most of such conditions
result from failures of local policing and supervision.

Federal aid does not serve local health agencies effectively.
In the past five years, a spate of Federal legislation has been
enacted and the amounts spent by the Federal government in the
health field have been tripled. At the same time, because of the
multiplicity of funding sources and the complexity of approach,
including the proliferation of planning bodies, local units were
and are unable to take full or even partial advantage of the re-
sources available. Furthermore, the new legislation looked to
modification of the local organization and new methods for the de-
livery of health services that existing service agencies were com-

pletely unprepared to undertake.
Hunger and malnutrition can be both a concomitant to illness

or a direct cause of it. Malnutrition is known to interfere with



proper growth of the fetus in the mother during pregnancy, with

the health of the pregnant woman, and is responsible in some

degree for the higher maternal and infant death rates among the
poor. Malnutrition is known to be associated with improper develop-
ment of the growing child physically and mentally, and is respon-
sible in part for the increased illness among the children of the
poor, their learning difficulties in school, their later failure

to find adequate employment and in adult life, their increased
chronic illness.

Some 25 million people must be counted among the poor and the
near poor, yet nowhere near that number qualifies for, or lives in
communities that operate, Food Assistance Programs. Only about 8
million actually receive food assistance, through commodities
distribution or food stamp programs. Commodity distribution has
been attacked as nutritionally inadequate, culturally unsuitable,
and logistically impractical. Food stamp programs are
hedged about with requirements of time and place and quantity
of purchase reducing their coverage. School lunches are not free
to millions of children who cannot purchase them even where they are
available. Some districts specifically exclude families on welfare
from free school lunches for their children. Hundreds of counties
where desperately poor people live have no food programs at all. A
study of welfare food cash allowance in a report last year from HEW

demonstrated its inadequacy even for the poorest of the poor who
qualify for welfare aid: the food prices are based on 10-year
old costs, or else the State or local welfare payment is only 18%
or 50% of the State's own admitted level of need.

KEY ISSUES

The health of residents of the inner cities cannot be served
by health programs alone. Education, including health education
and nutritional education, improved housing, more and better skill
training, finding and retaining jobs, are integrally related needs.
However, as already stated, significant and substantial progress
must be made toward meeting each of these needs, but those ends
will not be achieved unless simultaneously progress is made toward
providing more adequate health services.

To achieve the progress that will better conditions in the
cities and will reduce tensions in urban centers requires reassess-
ment of responsibilities to be borne by the various elements in-
volved in delivering medical care services:

What responsibilities can the private practitioners of med-
icine assume for improving the health of the urban poor.

a) For locating offices accessible to the poor, and using
non-professional aides from among the poor to serve the poor in
their offices?

b) For limiting the charges which deny medical care to many?

c) For reaching out to the needy, rather than passively wait-

ing to serve?
ad) For looking toward group and team services as a pattern
of practice?

What responsibilities must government assume for improving
the health of the urban poor?

a) For expanding the supply of trained health manpower and
stimulating the use of new and more imaginative combinations of
health workers to increase physician productivity?

b) For providing needed health facilities, emphasizing
interrelated institutional needs?

c) For assisting individuals to meet the costs of essential
medical care?

d) For establishing goals and priorities in health services?

What responsibilities must hospitals and medical teaching
centers assume for improving the health of the urban poor?

a) For developing a full spectrum of institutional services?

b) For modernizing educational opportunities to increase
their productivity, and recruitment policies more applicable to
the poor?

c) For outreach services and programs beyond their walls?

d) For continuing education?

What responsibilities should business assume for improving
the health of the urban poor?

a) For eliminating air and water pollution?

b) For improving existing housing conditions?
c) For using their influence in Board membership of
voluntary and public agencies to facilitate needed change?

It has become increasingly clear that the absence of repre-
sentatives of the community in the councils and committees that
decide on policies, devise plans and programs and carry them out,
is a serious flaw and probably contributes heavily to the failure
or inadequacy of existing health programs. Priorities and alloc-
ation of resources cannot be appropriately assessed if not re-
lated to the community of discourse, as well as professional con-
siderations. This is true of the poor, of all minority groups,
and even more so where profound cultural and language differences
exist. The involvement of poor whites and poor blacks is essen-
tial in decision making on health planning and programs, the
involvement of Spanish speaking people in Mexican-American and
Puerto Rican communities, the involvement of Indians in their areas
of residence.

POSITIONS

The existence of the Urban Coalition is based on the belief
that concerned citizens wish to contribute to the process of
changing institutions where the evidence of their inadequacy in
dealing fairly and justly with all citizens is demonstrable. The
failures of the health service system to deal fairly and justly
with the poor is demonstrable. Change in this system will require

painful readjustment, but is long overdue. It will not be enough
to recognize the defects in someone else's operation. Sacrifice

of traditional modes of thought and behavior will be expected in
one'S own part of the whole. Recognition on the part of each element
involved, of his own deficiency is basic to change. Professions
will be asked to re-examine their patterns of practice, reim-
bursement, recruitment into training, and the training itself.
Institutions will be asked to review the services rendered, the
staffing relationships, the interaction with other institutions,
independence and responsiveness to community need. Governments will
be asked to investigate their allocation of funds, evaluation pro-
cedures, program decision making and coordination with non-public
bodies. In every instance the expert must expect to be questioned
by the "beneficiary", or his advocate, in this case the sufferer
from the deficiencies of the system, and reply as to whether his
action or position is to benefit his narrow interest or the larger
goal.

Aware of prevailing health conditions in this country's
metropolitan centers, and the drastic effect of these conditions
on the quality of life in the inner cities, the Urban Coalition
believes that:

1. Efforts must be redoubled in each city to make it possible
for all citizens to have access to modern medical care. This will
require that:

a) Each community, with the aid of Federal assistance for

"comprehensive health planning", should diagnose available health
= Tite

resources and identify the areas and the groups for whom medical
care services are most needed and least available;

b) Coordinate existing services so as to eliminate dup-
lication and make more efficient use of resources;

c) Initiate programs where now lacking, or introduce trans-
portation where required to offer access to health services;

d) Extend existing services, particularly making clinic
services available at opportune times;

e) Involve community residents in planning and delivery of,
and outreach services, particularly use of the poor in reaching
the non-users of care.

While no single method or plan will fit all communities, no
potential opportunity must be overlooked. More convenient clinic
hours, better transportation, more facilities nationally inter-
related, more efficient use of Federal and other public funds,
more realistic use of staff available and production of necessary
manpower locally should all be explored.

2. Concentration on improvement of special programs with
particular relevance to the needs of poor people. Here action is
needed on the part of all related health agencies to extend and
improve prenatal care and infant care services, school health
services, case-finding of handicapping conditions and coordination
of health service to treat orthopedic handicaps, provide glasses

and other appliances. Major emphasis must be to improve mental
=e

health services and community programs for care and rehabilitation
of the mentally retarded and emotionally disabled, returning them
to homes and jobs as quickly as possible. More home health care
is urgently needed. Family planning efforts must be intensified.

For all health services related to children, for example,
the school can be used as a center for identification of cases,
provision of care, and community involvement in health care. ‘This
will require a new focus on the part of granting agencies, planning
groups and health service agencies. However, the school is where
the children are, and where mothers can be reached. While the
present turmoil in education might be prejudicial to adding this
concern to the already complex discourse, it may also offer a ready-
made vehicle for change in health services. It deserves serious
consideration.

3. No child should go hungry. No adult should be without needed
food. To ensure these ends will require:

a) Consolidation of local resources to eliminate hunger. Every
community must have a supplemental food program, and a case-finding
program to identify all families and individuals whose resources are
insufficient to provide them with the minimum required basic standard
nutriments.

b) Existing Federal aid should be utilized to the fullest.

That will necessitate the sharing by governments, in the admin-
istrative cost of stamps, commodities or free lunches and breakfasts,
and nutrition education.

c) Private resources, in addition, should be sought and used

where needed.
2: po Ss

4. Environmental hazards and disease-producing agents must
be eliminated. This requires that large scale air pollution and
waste disposal problems must be more vigorously attacked by public
agencies. This attack should include the establishment of more
rigorous nationwide legislative standards and aiding and requiring
private business to eliminate their pollution of the atmosphere.
Much of the clean up, rat control, garbage disposal and elimina-
tion of pests and nuisances that make the surroundings of life in
poverty unpleasant and prone to added illness, can be dealt with
through added specialized manpower: housing aides for inspection,
Sanitation aides for education and clean-up.

5. Expand the essential supply of health manpower through
interaction with local educational institutions and health service
bodies. A great deal of the community work that needs to be done
in taking care of the non-professional aspects of personal health
care, such as home health aides, interpreters, new kinds of tech-
nicians, the elimination of environmental hazards and the case-
finding aspects of nutrition and handicapping conditions, the educ-
ational aspects of health, and nutrition can be carried on by
specially trained local people. In addition, through community con-
ferences with medical school leaders and schools of public health,
the opportunities can be developed for increasing the supply of phy-
sicians, nurses and public health workers. This should apply parti-
cularly to the possibility of recruiting local poor and disadvantaged

into these health careers.
az =

6. Modification of Federal policies for health facility
construction and modernization. In order to provide the health
facility base from which the improved and expanded health serv-
ices are to be delivered, the present Federal health facility
policy as exemplified in Hill-Burton legislation must be modified.
Facilities grants must be less retrictive, more applicable to
the needs of the inner cities, offering a larger Federal share
and directed toward comprehensive services, particularly ambulatory
care components. Loans and loan guarantees will not benefit public
hospitals sufficiently because of the problem of tax exempt bond
issues. Loan and interest repayment inflate per diem costs. For
large city hospitals serving the poor, grants of up to 100% will
be needed. Grants will have to be available directly to cities,
or priorities in the Federal legislation or administration changed
to favor big city hospital modernization and ambulatory care service
construction.

7. |Expansion of Federal health programs is essential to
meeting the health needs of urban dwellers. There is special need
for:

a) Increased insurance and Federal funds through Titles
XVIII and XIX and other programs for the money required to pay for
added needed services to the poor;

b) Improving the organization of health services for all,

but especially the poor through neighborhood health centers, and
& 44 =

continuity of care especially in the stimulation of group practice,
particularly with prepayment.

c) The modification of medical education to hasten the in-
crease in enrollment of waiting applicants to medicine.

d) Improving the wage and employment conditions of health
workers so as to attract more young people and particularly the
disadvantaged, into health careers.

e) Correspondingly improving the junior college and college
opportunities for training in the health careers.

£) Expanding food programs that are geared to established
scientific standards and not arbitrary means tests.

g) Eliminating air and water pollution.

h) Improving the total environment.

In brief, the Coalition will strive to:

--Aid local communities to make the best possible use of
existing resources;

--Bring about expansion of health services for mothers and
children;

--Intensify Federal efforts to assist local communities in
improving their health facilities and services;

--Obtain additional appropriation to finance medical care
for the residents of the inner cities;

--Eliminate barriers to access to adequate supplies of food;

--Strengthen Federal programs designed to add health manpower

to the pool available for service to residents in the inner cities;
- 15 -

--Press for greater citizen participation in community health
service decision making and operation.

Short-term, immediate objectives should include all local
efforts to improve clinic services keeping in view the long-term
objective of comprehensive group practice, prepaid, possibly
through neighborhood health centers; developing realistically
defined entry level job opportunities coupled with health career
development opportunities; improved food distribution programs com-
bined with emphasis on long-term objectives of pay or public assistance
programs of whatever kind that provide enough money to buy enough
of the right kind of food.

To achieve these goals, the Urban Coalition is developing and
will shortly publish, a "Rx for Action", offering local coalitions
a wide range of choices in various areas of action to improve health
services; technical assistance through publications that will aid
in accomplishing the ends prescribed in the manual; and consultant

services to stimulate and support local coalition health activities.