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Reprinted from Oct. 1971 Health-PAC BULLETIN
Reprinted from Health-PAC BULLETIN, October, 1971 by permission of Health Policy Advisory Center, 17 Murray Street, New York, N.Y. 10007.
Medical institutions derive their wealth from patient fees, research grants and real estate investments. The wealth of many medical empires is measured in the tens, if not hundreds, of millions of dollars. Using this measuring rod, free clinics are but fleas on the hide of the elephantine medical system.
Since the Haight-Ashbury Free Clinic opened its doors in 1967, free clinics, however, have experienced explosive growth in their own right. Today, upwards of 200 free clinics are operating and new ones are coming into being regularly. They see tens of thousands of patients annually and are staffed by many hundreds of community activists and health workers.
Free clinics, therefore, would be worth examining if only because of their sheer appeal and popularity. But serious analysis of free clinics is also needed because all free clinics have, with varying clarity, focused on a vision of good health care, which they try to represent in their activities. The vision came together during the 1960’s in what the media has labelled “The Movement for Social Change.” It is a distillation of the experience and beliefs of the New Left, underground culture, Black Power advocates, and OEO. The vision is founded on the twin convictions that: The American medical system does not meet the people’s needs; and the American medical system must be radically restructured! It can be summarized by the following principles:
— Health care is a right and should be free at the point of delivery.
— Health services should be comprehensive, unfragmented and decentralized.
— Medicine should be demystified. Health care should be delivered in a courteous and educational manner. When possible patients should be permitted to choose among alternative methods of treatment based upon their needs.
— Health care should be deprofessionalized. Health care skills should be transferred to worker and patient alike; they should be permitted to practice and share these skills.
— Community-worker control of health institutions should be instituted. Health care institutions should be governed by the people who use and work in them.
Free clinics have taken on the double tasks of meeting the people’s needs and of radically restructuring the health system. In most cases they attempt this by serving as an example of good health care and a model for the future. Some also attempt to be instruments of change, by challenging existing health services as well as providing their own.
In the beginning, free clinics appeared to be a response to the needs of the youth culture movement. The new life style, with heavy emphasis on mind expanding drugs and communal living arrangements, resulted in a rash of health problems-from bad drug trips to nutritional deficiency. Traditional medical institutions were unsuited to the value system and the problems that the young patients had. For instance, kids on bad trips seen in emergency wards, often ended up in mental hospital wards, if they were lucky, in jails if they weren’t. Rather than risk incarceration, many young people went untreated.
However, it doesn’t take much digging to recognize that free clinics are not just a response to youth culture needs. They also have broad appeal in Black, Puerto Rican and Chicano communities. To people traditionally barred from medical institutions because of racism, cost and location, the attractiveness of “free” institutions, more accessible to their neighborhoods and perhaps even to their control, is evident. Free clinics rose on the wave of “black power” and “community control” to meet the centuries of unmet health needs in ghetto communities across America.
Free clinics are not just a response to the unmet needs of Black, Puerto Rican, Chicano, or hip communities. They are a response to the failure of America’s traditional health institutions. The failure of doctors not only to treat bad trips, but to provide any minimal standard of care in ghetto communities; the failure of hospitals to break down the hierarchy among health workers that fosters poor patient care; the failure of Blue Cross, and now Medicare and Medicaid to eliminate financial barriers to decent medical care. Free clinics are a response to the crisis in the American medical care system.
Attractions and Detractions
The free clinic response is indeed an attractive one. On the one hand, it directly serves people. It is a positive concrete step toward a vision of the health system as it should be in the future. “People have been promised change for so long, they will no longer accept your word for it. You’ve got to show them it can be done.” Free clinics also provide rewards for those that work in them. Free clinics are one of the alternatives that Vocations for Social Change talks about, when it says, “[There] is a growing awareness that the kind of roles we are all being prepared for in this society—housewife, factory worker, executive, welfare recipient, etc.—cannot satisfy either our personal needs or our collective needs, and that alternatives must be found.” Free clinics fit the rhetoric—”do your own thing” and “build alternative institutions.”
This attractiveness of the free clinic movement can disguise the limitations manifest in current free clinic practice. Many of these shortcomings are discussed in the October, 1971 Health/PAC Bulletin:
— Free clinics are not successful in eliminating some of the principle disadvantages of out-patient departments: waiting time is long, there are no appointments, follow-up is shoddy, continuity of care is almost impossible.
— Free clinics are just as dependent on a limited supply of doctors despite their emphasis on skills transfer.
— Free clinics, because of limited resources, must make serious trade-offs: for example, of quality care is to be given to each patient, then fewer patients can be seen.
— Free clinics may demystify medicine, by removing the doctors’ white coats and by taking away some of their “professional” prerogatives, but they often fall short of educating patients about their illness or about the politics of the health system.
— Free clinics, by and large, have not been able to overcome the obstacles to community/worker control.
In many ways most free clinics fail both patient and worker in not measuring up to their goals. For patients, the effect of free clinics, beyond the service provided appears to be minimal. Most free clinics have not established successful mechanisms for involving patients in the decision-making of the clinic, other than by becoming a worker in the clinic. Likewise, free clinics have not involved patients in struggles around the larger health institutions in the community. The result is that free clinics are limited in their effect on patients to the individual personal encounter at the time of receiving service.
There is more effect on the worker in free clinics than the patient. The non-professional health worker gains self-confidence, not merely by learning new skills, but also by running a health clinic. Free clinics often do represent experience on the first few rungs of workers’ control. Whether this gets translated in to the desire to control the dominant health Institutions in the community, the hospitals or the health department, is left to chance or circumstance.
For the professionally trained health worker, free clinics do represent an experience in de-professionalization. This experience is not just a matter of superficial style, but involves challenges to professional prerogative and priviledge. Thus patient advocates may criticize doctors for their attitudes toward patients or confront them about their inconsistent prescribing habits—unheard of practices in any hospital. However, confrontation tends to be limited because the professionals on whom all free clinics depend are in short supply. They must not be “turned off” or else the clinic folds. In addition, professionals are seldom pushed by their free clinic experience to struggle within the institutions they train and work.
To be sure, some health professionals have their eyes opened when they are taken from thier secure institutional environment and placed in direct contact with a unfamiliar patient environment. Similar experiences occured in the Peace Corps and VISTA. But there is no evidence that this awareness leads to commitment, or that it even is an inevitable concomitant of the free clinic experience. Equally common is the observation of one Chicago free clinic coordinator: “Many medical students say they’re commited to the community. And to a limited extent they are. But their commitment only goes so far. When they graduate they go work in sunny Arizona. You ask them why they don’t intern at Cook County Hospital, they say: ‘I can’t hack it anymore.’ That’s how far their commitment to the community goes.”
If free clinics have a limited effect on patients and workers, their record in the community is equally disappointing. Free clinics offer real opportunities for community outreach and political education about the health system. They could initiate programs of door-to-door screening for anemia, lead poisoning and tuberculosis. They could indict landlords, City Health Departments and even medical empires for neglect of these health problems. But few clinics have had the money or manpower, to say nothing of the political analysis, to realize this potential. Free clinics fear being overburdened by the health problems they discover. They do not see outreach as an opportunity to push on the responsibility of the dominant health institutions in the community.
Few clinics have the vision of the Young Patriots Organization in Chicago, which hopes to develop a “health cadre” to provide emergency care, treatment of minor illnesses, screening services and offer medical advice and assistance on-the-spot in every apartment house in Uptown. As one young Patriot put it, “I can treat ninety percent of the patients walking in the clinic. I can’t see why we can’t train other community people to do the same. If we find problems we can’t deal with, then we’ll force the hospitals to help.”
It is an assumption of many free clinic advocates that “Free clinics as alternate institutions, are threats to the system”. This is an elusive concept. Free clinics aren’t competitive with existing health institutions. No doctor’s office or hospital’s clinics is threatened with closure by the mere existence of a free clinic. While free clinics, in and of themselves, are not a threat to the system, those free clinics that support community struggles against the health system are closer to that ideal.
But there is a fine line between challenging the health system and actually doing its work. Free clinics actually take the heat off other health institutions by filling the gaps which they have left, while still maintaining the communitiy’s ultimate dependence upon local medical institutions. Free clinics admitted they were not hassled by the establishment because they were doing the system’s job. This became blatantly obvious when one local city hospital began to refer patients to the free clinic for physical examinations. In another city, when the Health Department ran out of tetracycline, they came to the free clinic to replenish their supplies.
Another free clinic assumption, “We’re free therefore we’re political”, collapses with more careful examination of the price free clinics pay to remain “free”. Most free clinics depend on hospitals, drug companies and City Health Departments for supplies, manpower and grants. It can become difficult to bite the hand that feeds you. As one clinic spokesman said, “Taking money from the medical school is fine, but what happens next year if after we’re dependent on it, the medical school demands we allow our patients to be used as teaching material?” As long as clinics depend on institutions in order to provide their free services they will be deterred from conflict with the existing health system. The amount of time it takes to simply run a clinic can also deter them from taking an active role vis-a-vis institutions. As one clinic person said, “If we could do our job politically, they’d close us down in a week.”
In addition, if free clinics become more effective in community outreach, they will become more desirable plums for the medical institution pie. Free clinics can relate to populations that staid medical institutions find it difficult to accommodate. Thus free clinics may become more friendly outposts in the hostile communities that surround many of the major medical institutions in America. So existing medical institutions may have a real interest in free clinics and a desire to incorporate them into their own framework. Perhaps this explains the willingness that an increasing number of medical schools and health departments have demonstrated in supporting free clinics.
Providing service is one response to the failure of the American health system. It is attractive because of the tangible alternative building that it offers. Institutional confrontation is another response, though still somewhat untried, that offers potential to effect far wider change. The power and resources of the American health system lie in institutions. Therefore, changes in institutions have great consequence for the delivery of health care.
lnstituional struggles affect the lives of those working in institutions as well as those using them. Institutional confrontation targets the struggle at those most responsible for the failure of the system.
The Young Lords Party in New York City decided not to establish any free clinics in El Barrio. Rather they sought to challenge existing health institutions to perform their stated functions. The Lords exposed the Health Department for not using its 40,000 lead poisoning testing kits by demanding that the Health Department release some of the kits for a Young Lords’ screening program. In another program, the Lords discovered 800 positive tuberculin cases through door-to-door screening in East Harlem. The next step was to have the people x-rayed. The Lords found that patients had to wait up to 6 hours in the local hospitals just to get a chest x-ray. Few patients could afford to miss a day’s work or pay for a babysitter. Therefore, the Lords asked the Health Department to re-route one of its mobile chest x-ray units to East Harlem to do the necessary testing. When the Health Department refused, with media present, the Lords hi-jacked the truck (with the cooperation of the driver and x-ray technician), brought it to East Harlem and took the necessary x-rays.
Institutional confrontation also has the potential to resolve many of the contradictions that presently abound in free clinics. It unites the disparate forces that relate to free clinics. Patients can become involved with the free clinic around its struggle with other health institutions. Health workers can connect their free clinic work with struggles in the institutions where they train and work. Institutional confrontation brings new problems to free clinics, but helpts to resolve many of the old ones.
Chicago — The Hub
Several of the free clinics in Chicago have adopted this approach, both out of choice and necessity. Their early requests for back-up services and specialty consultations developed into confrontation situations. At Weiss Hospital, located in the same neighborhood as the Young Patriots Clinic, there was considerable resistance to developing a relationship to the free clinic. Several demonstrations were necessary to convince the hospital that it should accede to community requests. At Northwestern Medical Center, the path was paved by the active support of medical and nursing students in coalition with hospital workers. Many of these students and health workers also worked in the Latin American Defense Organization (LADO) free clinic located in a Latin American neighborhood on Chicago’s north side. The students had pressed their own demands for minority admissions and improvement in the outpatient clinics through a 24-hour sit-in in the dean’s office, prior to LADO’s demand for a contract with Northwestern. This history facilitated LADO’s negotiations with the medical center.
The contract includes (1) that referrals from the LADO clinic be accepted at Northwestern Outpatient Laboratory and Clinics (2) that Nortwestern extend malpractice insurance to cover professionals who work at the LADO clinic (3) that Northwestern provide $1000 per month in drugs, supplies and equipment to the LADO clinic for one year (4) that Northwestern waive fees for patients who are unable to pay.
The contract finally signed by Northwestern was used by LADO to pressure St. Mary’s and St. Elizabeth’s Hospitals, two community hospitals to admit Spanish speaking patients. In the past, St. Mary’s had refused to take any obstetrical patients from the Spanish-speaking community because an administrator said, “We can’t understand them and they scream too much.”
Over the past year, Chicago’s free clinics have also been involved in a continuous struggle with Mayor Daley’s Board of Health, which has been trying to close down the free clinics. Chicago is the only city where the mere existence of free clinics was found to be politically threatening. Thus Daley’s Board of Health has decided to employ an end-run around the free clinics by opening up eightnew clinics, virtually adjacent to the existing free clinics. The LADO clinic has been able to raise sufficient community pressure together with student and health worker support at Northwestern Medical Center, to prevent the opening of the Board of Health Clinic in their neighborhood.
The Young Patriot’s Community Health Service adopted a different tactic toward the Board’s clinics. Rather than try to stop the opening of the Health clinic, the Young Patriots have insisted that the City clinic provide better services. In November, 1970, 200 people occupied the Uptown Board of Health Clinic and demanded “24-hr a day, seven days a week, full health services as well as free transportation and child care.” In addition, the protestors insisted upon “full community control of clinic policy and personnel.”
The Chicago free clinics maintain a constant barrage of criticism aimed at the health establishment. Hospitals that fail to deliver services are challenged. Free clinics are the base from which community and health worker activists attack institutions. The mimeograph machine is as important as the stethescope. Besides maintaining a high level of institutional confrontation, many of the Chicago free clinics have encouraged professionals that work in the clinics to organize in their own hospitals as well.
For some people working in free clinics, the time commitment is so great that they feel extremely pressed. As one Chicago medical student put it : “I think the free clinics are the most important political development in the city. But the time involved is so great I can’t do anything else.” Another Chicago doctor suggests the solution to this dilemma is “to encourage loose hospital-based collectives. it’s easier to develop the consciousness needed to continue the struggle back at the hospital itself.”
Alliances between community organizations and workers within health institutions have contributed to the viability of the Chicago free clinics. Thus Daley continues his efforts at repression. Most recently, Obed Lopez, a leader of LADO was arrested for “operating a clinic without a license.” When he objected that he was not personally responsible for the clinic’s operation, the arresting officers demanded that he turn over the names and addresses of all personnel who work in the clinic. When he refused to do this he was jailed.
The Chicago free clinics have seen themselves as more than alternate institutions. They have seen the necessity and used their opportunities for institutional confrontation. Unless other free clinics adopt this course, they will either wither and die or become incorporated into the established health delivery system.