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'r 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, including practicing preventive medicine, will not be perceived as a very high priority. They find as more compe lling 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 di f ficult, i f not i mposs i ble, v a rious kinds of health s ervices are a necessary condition for the poor to function with any adeq uacy a t work, at home and in th e ir communiti e s . The r e is much evide nce o f the dep lorab le health sta tus of the u rban poor. abou t " Poor" refers to al l those families, including 25 milli on indi viduals whos e income f alls below the commo n ly a ccepte d g o vernment standard t h at would pro vi d e adequate f ood , clothing, and shelter and medical care.* Th e dispropo r t i o nate

of an estimated 45 million poo r people, half live in l a rge

metropo litan areas. Ano ther 25% o f this t o tal l ive i n c o ncentrations of population but non-metropolitan areas. Our primary concern is with the improvement of the health services in the cities that serve at least 2 5 milli o n Americans. �- 2 prevalence of ill-health among the poor, minority and disadvantaged 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 resticted 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 compar ed with 22 . 5 % of nonwh ite children . Ex i s ting health se r vices delive r y sys t ems do n o t r eac h all of the urban p oo r . Me dic al 9are i s ge n e r ally p r ovi d ed in c l inics �- 3 - where available, generally over-crowded, at inconvenient hours, understaffed, and run as categorical units: clinic, heart clinic, arthritis clinic. i.e., diabetes 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 motivation. 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 e xpensive . The shortage of health manpower gene r ally is well - known , and the sho r tages of phy sicians and nurses , and oth e r health personnel have b een well p ub l i c iz ed . �- 4 - 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. lems of air and water pollution are largely ignored. The prob- More personal env\ ronmental needs such as damp, cold crowded housing are widespread among the poor. supplied. Garbage and waste disposal is inadequately 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 b e en tripled . At the same time , because o f t h e multiplicity of funding sources and the comple x ity of approach , i n c l u din g t he p r oliferation of pl a nn i ng bodies , local units we r e a n d are un abl e t o tak e ful l o r even p a r ti a l adv an t a g e of t h e r e sources availab l e. Fu r the rmo r e , the n e w l e g i s l ati on l o ok ed t o mo dificat i on o f the l ocal o rganiz at i o n and n e w me thods f o r the de livery of h e alth services that existing service agenc i es were completely unprepared to undertak e . �-5Hunger 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 responsible 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 e xc lude families on we lfare from free s chool lunches for t heir chi ldr e n. Hundreds o f counties where desperately p oo r people live have no food programs at all . A study of welfare food cash a llowance in a report last year from HEW demonstrated its inadequacy even for the poorest of the poor who �- qualify for welfare aid: 6 - 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 b y health programs alone. Education, including health education and nutritional education, improved housing, more and better skill tra i ning, finding and retaining jobs, are integrally related needs. However, as already stated, significant and substantial progress mu st be made toward meeting each of these needs, but those ends wi ll n ( t b e a chie v e d unle ss simultane ously p r ogress is made toward pro v iding more adequate health services. To achieve the progress th a t wi ll b e tter conditions in t h e ci tie s and wi ll reduce t e ns i ons i n urban c e nters requires re a s s essment o f responsibilities to be borne by the various elements involved in deli v e r ing medical care services : What res ponsib i l i t ies can the privat e practiti oners o f me d i cine assume f o r i mpr ovin g the hea l th o f the urban p o or. a) For loc a t i ng offi c e s accessible to the poor , and us ing non- profess ional aides from a mo ng the poor t o serve t h e p o or in thei r offices'? b) Fo r limiting the char ges wh i ch deny medi cal care t o many? c) For reaching out t o the needy, rather than passively wait - i ng to serve? �- d) 7 - 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 r esponsibilities should business assume for improving the health of the urban poor? a) For el i minating ai r and water pollution? b) Fo r improving e x isting housing c ondit i ons ? �- c) 8 - 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 representatives of the community in the councils and committees that de cide on policies, devise plans and programs and carry t h em out, is a serious flaw and probably contributes heavily to the failure or inadequacy of existing health programs. Priorities and alloc- ati on of resources cannot be appropriately assessed if not r e lated to the community of discourse, as well as professional considerations. This is true of the poor, of all minority groups, and even more so where profound cul t ural and language dif f ere nces exi s t. Th e involveme n t of poor wh ites a nd poor blacks i s e ssen - tial i n decision making on b e n lth planning and programs, the involve me nt o f Spanish speak ing people i n Mexican-Ame rican a nd Pue r t o Rica n commun i ti es , t h e i n v o lvement o f Ind ians i n t heir areas of residence. POSITIONS The exi stence of the Urban Co aliti on i s based on the belief that concerne d ci tizens wi sh to c o ntri b u te t o t h e pro c es s o f cha nging instituti ons whe re t h e e v i dence of t h eir in a dequacy i n 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 �- 9 - 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 procedures, 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 r e ply as to wh e ther his action or position is to benefit his narrow interest or the larger goal. Aware of prevailing health conditions in t h is country's metropolitan centers, and the d r astic effect of these condit i ons on the quality of l i fe in the inne r cities , the Urban Coalition b el i eves that : 1. Effo r ts mu s t be r edoubled in each city to mak e it possible f o r a ll cit iz e n s to h ave access to modern medica l care. Thi s wil l require t ha t : a) Ea c h c ommuni t y, wi t h t he aid o f Fede r al a s si s tance fo r "comprehensive health planning", sho u l d diagnose available health �- 10 - 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, b etter transportation, more facilities nationally interrelated, more effici e nt use of Federal a nd o ther public f unds, more realistic use of staff available and production of necessary manpower locally should all be explored. 2. Concentration on improvement o f special programs with particular relevance to the needs of poor people. Here action is n eeded on the part of all re l a ted health agencies to extend and improve prenatal care and infant care services, school health s e rvices, cas e- 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 �- 11 - 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 readymade v ehicle for change in health services. It deserves serious consideration. 3. food. No child should go hungry. No adult should be without needed To ensure these ends will require : a) Consolidation of local resources to eliminate hunger. Every community must have a supplemental f ood program , and a cas e- fi nding prog r am to identify a ll families and indi v iduals whose resou r ces are in suffi c ient to provide them with the minimum required basic sta ndard nu t ri men ts . b) Exi st ing Fede r al aid should be ut i l i zed to the fullest . That wil l n ecessi t ate t he shar i n g by gove rnmen t s, in the a dministrative c os t o f stamps , c ommodities o r fr ee l unches a n d bre akfasts, and nutrition education. c) Private r e s o urces, in addition, sho uld be sought and used where needed. �- 12 4. Environmental hazards and disease-producing agents must b e 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 r igorous nationwide legislative standards and aiding and requiring p rivate business to eliminate their pollution of the atmosphere. Much of the clean up, rat control, garbage disposal and elimination of pests and nuisances that make the surroundings of life in poverty unpleasant and prone to added illness, can be dealt with t hrough added specialized manpower: housing aides for inspection, s anitation aides for education and clean-up. 5. Expand the essential supply of health manpower through i nteraction with local educational institutions and health service b odies. A great deal of the community work that needs to be done i n taking care of the non-professional aspects of personal health c are, such as home health aides, interpreters, new kinds of techn i cians, the elimination of environmental hazards and the casef i nding aspects of nutrition and handicapping conditions, the educa t ional aspects of health, and nutrition can be carried on by s p ecially trained local people. In addition, through community con- f eren c es with medical school leaders and sch ools of public health , t h e oppo r tunities can be developed for increasing the supply of phy si c ian s , nurses and public health wo rk e r s. This should apply pa r ti - c u l a r l y to the possibility of r ecru i t ing l o cal poo r a n d d isadva ntag e d i nto the se health care e rs . �- 13 - 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 services 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 compre h e nsive service s, particularly ambulatory care components. Loans and loan guarantees will not benefit public hospitals sufficiently because of the problem of tax e xempt bond issues. Loan and intere st repayment inf late per d i em costs. large city hospitals serving the poor, grants of up to 100% be needed. For will Grants will have to be avai l able directly to cities, or priorities in the Fede ral l e gislation or administration changed to favor big city hospital moderni z ation and ambulatory care service construction . 7. Ex pansion of Fe d e ral h ea lth programs is e ssential to me eti ng t h e h ealth needs of u r b a n dwelle r s. There is spe c ial need for : a) Increas e d insuran c e a nd Fed eral f unds through Ti tle s XVIII and XIX a n d o ther programs for the money req u ire d to pay for added needed s ervices to t he poor; b) Impro ving t he o rgani z atio n o f h e alth services f o r all , but e spe ci a lly the poor th r ough ·n e ighborhood health c e nters , a nd �- 14 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. f) 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 brie f, the Coalition will strive to: --Ai d local communi t ies to ma k e the b e st possible us e o f existing resources; --Bring about expansion of h e alth services f or mothers and c h ild re n; - -Intensify Federal efforts to assist local communities in i mproving the i r health facilities and s e rvices ; --Ohtai n add i t ional app ropriation t o f ina nce me d ical care f or the residents o f the inner cities; --Elimi n a te barrie r s t o ac ces s t o a d equate supplie s o f food; --Strengthen Federal programs designed to add heal th 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 combined 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. 1 �