Unknown Speaker  00:01
For posterity.

Unknown Speaker  00:05
What I would say was that if we're really going to ensure adequate and appropriate health care for women, there are three critical areas from from my perspective that I think really need to be focused on. There are many, many more as well. But I want to just touch briefly on the areas of research, training, and services, particularly primary care and preventive services. Research is critically important to the overall structure of healthcare, because it really undergirds the advances that constitute medical practice and the methods by which we treat people without an adequate research base. We really don't know what are the most effective and safe treatment strategies. And unfortunately, the health needs of women have really not been well addressed by the research establishment and in some brief discussion of that already. Such critical concerns for women as contraceptive research, and development, fertility research, breast and cervical cancer treatment and prevention, research, osteoporosis, menopause, and the list goes on, have not really received the same degree of attention, as measured in the research efforts or research funds, that diseases with direct impact on male populations have. Nor do we adequately understand the manifestations of certain diseases as they appear in women as compared to men. You heard the example of of hypertension and heart disease, HIV is another prime example. And this is because numerous scientific studies have been done using only men and this then leaves clinicians to just guess whether the findings from those studies can be extrapolated to the care and treatment of women as well. And furthermore, important characteristics of these disease processes that may occur only in women are lost altogether. So without a doubt, the problem of gender bias and research is very real, and it's had far reaching implications for women and their health. And one wonders why we came to this point at all, particularly me as a former biomedical researcher at heart from the quite understand how women were so neglected. So I think it's useful to just briefly mention what were the reasons and to perhaps indicate why they, they were never valid, or certainly are no longer valid. One reason was the concern that women of reproductive age, were particularly vulnerable to possible harmful effects of new drugs or new therapeutic intervention because they might become pregnant, and this risk to their fetus would then occur. So women were excluded. Even if they had no intention of becoming pregnant, even if they weren't sexually active, even if they were following appropriate birth control methods. It was this sort of paternalistic, but yet one can understand where it comes from desire to protect women and their unborn, perhaps conceived fetuses from a potential threat. The second reason really had to do with with women in their bodies, our endocrine systems, and the fact that we have these fluctuations that produce things like menstrual cycles, or that we can become pregnant, or menopause where hormones change over time. And these things, researchers felt made study design more difficult and the analysis of data more difficult and messy. So again, they decided it was easier to not include women. There also was a belief that many disease conditions really weren't that relevant to women, certainly not as important to women as they were to men. So why not focus on men when you study them, and this, this creates, it's almost self fulfilling prophecy, because if you don't study it, you often don't find it or at least you don't find it until the burden of illness in those women with this disease that supposedly is relevant to them become so substantial that it can't be ignored. And I think very of heart disease is one clear area where we now know that heart disease is a very serious problem for women. In fact, it's a leading cause of death. But unfortunately, women are often diagnosed later in the course of their disease progression, because their doctors don't take them seriously until they have very severe and far progressed symptoms. And we, we we now have done studies and documented it. And you know, this this is the kind of thing that that really should have been avoided and hopefully will be avoided in the future. By not doing studies on one sex alone. And finally, the last belief, which I referred to all already, was that

Unknown Speaker  05:12
many thought that gender specific effects weren't that likely to influence treatment. And therefore, you know, why do these studies on these Messier females. So, clearly, these reasons are not acceptable. And they are undergoing change. But really until recently, the inadequacies of women's health research were largely ignored by the government, by the medical establishment, and we're not really visible or understood by the public at large, there are encouraging signs that things are changing political pressure and increasing public pressure have combined to result in more appropriate representation of women on clinical trials, as mentioned, and also more attention and more dollars for research on women's health. There has been very positive action by Congress, many medical and scientific organizations are finally beginning to mobilize. And as many of you know, the National Institutes of Health, in addition to establishing the office of research on women's health, has also committed to a major Women's Health Initiative, where many millions of dollars will be put into some ongoing longitudinal studies of women's health issues over the next few years, and should yield important results. Obviously, the changes that are going on in the area of of women's health research, reflect some important trends that are occurring more broadly, the ascendance of more and more women into positions of power and influence, who are challenging the status quo, and demanding appropriate attention to these kinds of needs.

Unknown Speaker  06:52
In addition, the voices of consumers and activists has been and will continue to be an important influence. And it's also very important now and in the future, to increase the numbers of female researchers and practitioners. Because they really are in a position both as as healthcare providers and researchers, but also as women patients, to better understand what the stakes are, both in terms of their own health care and their their professional lives, and the needs of other women and to advocate and to be sure that appropriate attention and action is taken. So that it's it's a, it's a coalition that's needed of of policymakers, practitioners, and consumers, that will keep us moving in the right direction. I want to turn now to look more specifically at the issue of Health Care Services. And it is ironic to note that women actually spend more on health care, they visit their doctors more frequently, they spend more time in the hospital, they undergo more procedures, they take more medications, and the list goes on. But basically they're really being shortchanged by the healthcare system. Quantity of unnecessary or inappropriate medical encounters does not really substitute for quality medical care. But in fact, if you look at those overall numbers of women as consumers of health care, it really masks I think, a more fundamental problem that I'm sure all of you are, are all too painfully aware of. And that's that resources for health care are not evenly distributed throughout our city or throughout our country and that major gaps exist, and the availability of health services for all women, and particularly for poor women, too many women have little or no access to primary medical services. And we really need to work aggressively to make sure that medical services are created in communities that truly address the needs of poor and also working women in the neighborhoods where they live and work. And we have to confront the economic reality of the feminization of poverty, which has a direct bearing on the health status of women in this country and certainly in New York City. In New York City, the majority of residents who live in poverty are in fact women and children, and they have no health insurance. The on duty residents in the emergency room often serves as their obstetrician, their pediatrician or their general practitioner. preventive health care is not a reality for them, either because of cost or access or in most cases, both. And even for women with sufficient resources to spend on health care. The numbers are growing smaller every day as more and more women are seeking employment in a rather unfriendly economy and wages are declining opportunities for gainful employment are declining, the ranks of the working poor swelling and they find themselves at a particular disadvantage when it comes to obtaining medical care, because many of them are marginally employed in small business CES, whatever, they may not get health care benefits to the workplace, and they're correspondingly too poor to pay for their own health insurance so that they find themselves in this difficult but Twixt in between position. And then of course even for that for those who are insured, health care coverage is often inadequate. maternity care services subject close to my heart at the moment is one case in point. The recent report from the Allen group mocker Institute indicated that only seven to 8% of participants and group plans were fully covered for hospital maternity charges. And over 5 million women of reproductive age have private insurance that does not cover maternity care at all, and 2.7 million unmarried dependent teenage mothers and their babies also have no health care insurance.

Unknown Speaker  10:52
You're also probably all aware that routine preventive care for women such as pap smears and mammography are inadequately covered under most health care plans, despite their proven ability to save lives and to reduce health care costs. And the skyrocketing rates of preventable diseases among women in New York and across the country bear witness to the impact of these policies. And the burden of premature and preventable disease and death is also a telling indicator of the tremendous problem that we face with respect to inadequate access to health care and health information. And I want to focus a little bit more on on some of those issues in the time remaining. Breast cancer is I think, one very good example to look at. And here you can see the overlay of a number of important issues issues of poverty, race, cultural and ethnic difference, and unequal access to medical services. Every year in New York City, some 4000 women get breast cancer and it's the leading cause of death in women aged 35 to 64. Here in New York, the number of breast cancer deaths has risen almost 20% Over the last decade. The high death rate from breast cancer in New York City is in large part due to late stage detection of the disease. And we know that those at highest risk for late stage detection are the elderly, the poor and racial and ethnic minorities. One in eight women are likely to get breast cancer in their lifetime. incidence of disease increases with age but breast cancer and breast health is a lifelong issue. And it's really critical that women are educated to examine and alter behaviors, which might influence breast health and reduce their risk for breast cancer. And also to heighten awareness about the the needs to seek Early Care and Early detection.

Unknown Speaker  12:42
Just want to talk a little bit about the history of our our approach to breast cancer because I think it's interesting. It's clear that the emergence of an active engaged and politicized organization of breast cancer survivors and activist really stimulated the change in attitudes about and treatment of breast cancer. And tell us something interesting about the relationship between women in the medical establishment. The early attempts to treat and prevent deaths from breast cancer relied on very aggressive surgical approaches, radical mastectomies and the like, and massive treatments with radiotherapy and chemotherapy. However, really, in large part, due to women becoming more involved with their own healthcare and challenging these traditional treatments, along with some advances in research that perhaps might have occurred anyway, we've been able to develop far more tolerable interventions such as lumpectomy and lower dose chemo therapies, things that many of the medical profession said would never work. But in fact, they do. And they have a very meaningful impact on both women's survival rates and on the quality of, of that increased life expectancy. And the medical profession also began as a result of the combination of greater understanding of disease but primarily the voices of health advocates to really focus on the area of early detection strategies, including breast self exam, clinical breast exam and mammography screening. And also now we're just beginning to enter the area of prevention, how can we prevent the onset of breast cancer disease in the first place? And this will be a very important area for research and hopefully for intervention in the years to come. But it is really striking when you look at at who's getting breast cancer and who's dying from breast cancer. And it's particularly poignant when you look at the breakdown of breast cancer mortality by race. among African American women, the overall breast cancer incidence is actually low. More than that of their European white counterparts, but their mortality rate is higher. They're dying at higher numbers. And why is that? Well, it really has to do with this important issue of access to care and the stage at which diagnosis is made. As study done by the New York State Department of Health, showed that in 1990 48% of white women with breast cancer were diagnosed while the disease was still localized to the breast. It only 38% of African American women were diagnosed at this earlier stage, African American women with breast cancer were 30% more likely than white women to be diagnosed with cancer, once it had already spread to distant organs. And for Latina women, they were 12% more likely to be diagnosed at this later stage. And this obviously has very significant implications in terms of their life and medical treatment opportunities. Serve Cervical cancer is another preventable disease or condition that is readily treatable if detected early. But it's disproportionately lethal in communities of color. Among cases of invasive cervical cancer in Brooklyn, for example, 80% occur in women of Haitian origin, and in Central Harlem, whose population is over 90% African American, they have one of the highest rates of cervical cancer anywhere in the city. Overall, African American and Latina women have twice the incidence of cervical cancer than that reported in their white counterparts. And unfortunately, the routine pap smear which could say their lives, is not routinely offered in in too many clinics that serve them, or these women don't access services at all. I was going to talk about New York City's infant mortality rate, which is another reflection of our system's inability to provide adequate health care services that we know can really make a difference to the women who need them. But I believe that that a module is going to address that issue. So maybe in the interest of time, I'll pass over that one. It is important to mention aids AIDS is having a very serious impact on women and also on children. A disease that, as I'm sure you know, when it first emerged was thought to really, almost exclusively involve men, particularly men having sex with men, but truly from the very beginnings of the epidemic, it was present in women as well. But we again, were not adequately prepared to see it, because of our impressions of what this disease was all about. But aids, in fact, is now the leading cause of death among women of reproductive age in New York City. And we've had over 7000 cases today.

Unknown Speaker  17:45
Again, it disproportionately affects women of color, almost 85% of the cases have occurred among African American and Latina women. And it's inextricably intertwined with another serious health problem that I don't think I have time to go into. But the problem was substance abuse, and about half of the women more than half of the women infected with HIV and who have developed aids were infected because of intravenous drug use. And a big chunk of the remainder were infected through sexual partners who were using intravenous drugs. So the the intersection of those two epidemics is very, very problematic. And of course, the impact on on children is very real as well. Close to 80% of Pediatric AIDS cases in the city, and they've now been more than 1000 are related to the problems of substance abuse as well. And again, with respect to issues of AIDS and women, we don't know enough about manifestations of the disease in women, particularly treatment strategies. And women, we've not done adequate research involving issues of women and AIDS. But it's an area of intense interest now certainly has to be high on the agenda, and in an area where we will be gaining considerable more new information in the years to come. I think one of the things that all of these different health problems tells us is that while there is a very pressing medical need that we have to address that we have to treat that we have to try to prevent that the problem occurs within the context of a broader array of social and economic concerns. And then as medical providers will fail to effectively treat and cure the medical problem if we don't attempt to address some of those broader issues that that in influence and threatened to undermine our medical interventions. And we really have to rethink how we provide services, what those services should be, how they most appropriately should be provided. When we talk about health care reform, it's not just who pays the bills, it's a lot bigger question than that. And not all important health activities occur in a doctor's office, or in a hospital setting. Many important health activities, particularly activities, aimed at Prevention and Health Promotion, occur in communities occur and families and occur at the individual level. So we I think, need to be a lot broader and how we think about health, how we think about health care reform. And I just want to mention briefly a topic that I think is going to be under much discussion. That certainly raised some attention and a recent journal that came out the American Journal of Public Health, calling for a social model of health, as opposed to a medical model for health, which you can imagine, since shivers down some physician spines, but it really it really is very important. And it's key, I think, to the issue of effective women's health care, because the social model really allows you to put women's core health needs at the center of your analysis. And then to focus attention on the diversity of, of a woman's health needs and social needs over the course of the entire lifecycle. I think we also have to begin to acknowledge the cultural reality that affect women and their ability to use the healthcare system and their desire to use the healthcare system. For example, women are generally the caretakers of their families, putting the needs of their their children and their families first.

Unknown Speaker  22:06
And we need to find better ways to help women to support them so that they can continue in those roles that they choose to but also get the health care they need, or to challenge those roles, when it in fact interferes with their ability to achieve what they need in terms of their own lives and their own health. And I think self empowerment is an important part of that women need to be be helped. As consumers of health care, they need to challenge some of the cultural and bureaucratic barriers that are before them. We have an obligation as medical professionals to provide user friendly services, accessible services, services, that that also have other components that reflect the realities of women's lives, such as daycare, other other services that reflect the realities of all of our lives, such as, as healthcare workers, who can speak in the language of the individual seeking care, etc. And we certainly need to sensitize medical professionals professional so that they're less hierarchical in their their treatment of patients. And they really can understand and appreciate the needs of patients to get the full information that they need to really understand their medical problem, and the treatments that are being advised so that physicians and their patients can become partners in treatment. So let me just finish up by saying that I really do think that this is a special moment in time in terms of what's going on in the realm of health care reform and the changing perceptions about women's health. And we really need not to be complacent we need to take up the challenge we need to to work together from our various perspectives and professional identities, but towards a common cause, which is improving health care for women. Thank you

Unknown Speaker  24:12
very much. Everyone launch off my immediate left is a nurse the president, the senior management consultant to the Office of Women's Health in New York City at the Health and Hospitals Corporation. She's also on the faculty of the Division of Nursing at York University, and has been particularly active in the patient community. Another nice fact I'll add is that in 1990, the greater New York March of Dimes awarded her the maternal child health nurse of the year. presentation. Thank you.

Unknown Speaker  24:49
Thank you for the introduction. And I'm really happy to be here in on this illustrious campus and in such a great company and It was very good. The planners of the conference, gave me carte blanche and said, Okay, what would you like to speak about this was the first time that that I was invited to a conference where I could choose my topic. And I chose a topic that's very close to my heart. Also, it's the access to care for poor pregnant women. And, and, and I wanted to look at the impact of a special program that was created in 1985. by New York State called the prenatal care assistance program PCAP. And how, in the past six years, it seemed to have impacted favorably on the outcomes of the boards in the inner city area. And I'll give you a little background in terms of what the story was before PCAP came along. Midway, the PCAP I think the year 1988. In 1988 132,226, babies were born in New York City, there were 26 maternal deaths. And 1770 of those infants that hold one died before their first birthday. Now the disparity in infant mortality, infant mortality is the rate of babies that died before they reach their first birthday in a given year. And it's calculated on on the percentage of the 1000. So let's say that 17 170 is about 13.4 1000 Witness do it will be calculated, and it's high for an industrialized nation or for the city as exalted as New York City. At but what what was even worse was that the disparity in infant mortality rate has persisted between racial and ethnic subgroups. And I'll give you an example. When we when we say 13.4 for New York City, in Harlem, it was 27 per 1000. While let's say in kips Bay, it was 2000. I mean, so this is when you get those large disparity and you combine them, then then we are screaming about 13.4, but really in Harlem, and Fort Greene and Brownsville and Bedford Stuyvesant, you know, like, it's in the double digit near the 20s. And in Harlem, it was 27. So and 27 protons and is what you find in the developing world. Okay, black newborns also are twice as likely to be born at a low birth weight, meaning under five pounds, and that that that makes them more liable to die before, you know, their first birthday. And the percentage of women receiving late or no prenatal care, you know, was fairly high. Also in New York state, it was 20, you know, per 1000 women. And what it means is that if there are complications that are occurring during the pregnancy, they are not caught on time. So by the time medical or other intervention could have taken place to make the birth outcome better, do women just goes to do hospital delivers, and there's complication, and the baby, you know, is at low birth weight, and, you know, it gets it stayed in the NICU for six weeks and one day dies of pneumonia. And so, studies have indicated that many women who do not seek prenatal care and as Dr. Hamburg was saying, until late or, you know, not at all into pregnancy, and the most commonly cited by your for not seeking early prenatal care is lack of sufficient fund or sufficient health coverage. And, and that, as I was saying before, is the cause of the low birth weight. So in 1985, with the help of advocacy groups and other providers, New York State created what they call the prenatal care assistance program. Okay, now, I want to go a little bit over the barriers that prevent women from seeking prenatal care. And Dr. Hamburg before was talking about the poverty and lack of

Unknown Speaker  29:13
health care coverage, and she talked about the feminization of poverty. And we have good example here in New York City. For instance. According to a report in by the Community Service Society in 1985, New York's 25% of New York City residents were living below the federal poverty level. And a four out of 10 children under 12 lived in families with income below the poverty level. Okay, and 40% of these families were headed by female and 62% of the female added household were below the federal poverty level. So so it's, you know, it keeps going down and down and up proximately 45% of the births to women were women who qualified for Medicaid but and had no health insurance. Okay, the other barrier was limited system capacity. What was happening? The American Academy of new College of Obstetrics and Gynecology, did a study whereby they found that because of the malpractice issues, that in the 1980s, obstetricians started abandoning the field more or less, they had numbers like 21% of the obstetrician had changed their practice, they only practice gynecology, no longer obstetrics 13% had decreased the number of deliveries that they were doing, and another 12% no longer practice obstetrics at all. So so that was changing. And as a result of those doctors, and also nursing shortages, in the public hospitals, where poor women usually would go for care, you had a very long wait, even if she presented herself for prenatal care, she had a long wait over a month to wait for an appointment. So that was very discouraging itself. And as Elena was saying, you have the buyer of language and culture. As you know, New York City, racial and ethnic myths is very diverse. And enlightening at 47% of the population was black, Hispanic, or Asian. And then, six out of 10 of the births in the city were to African American, Asian and Hispanic women. So this diversity created some problem in accessing service because of language and cultural. And among the undocumented, the fear of being deported. So again, you had women who didn't stick with it, okay. Okay, the other barrier was substance abuse. And it is the maternal substance abuse in New York City was 34,000 live births, which was significantly higher than the national rate, which was 11 per 1000. But again, like in certain pocket in the city, it was way out. I mean, off the chart in Harlem, it was 107, mothers using drugs per 1000, you know, like birth, and most of the increase in the substance abuse rate was represented by cocaine crack and several polydrug use, we call those by the moms. Okay, the other aspect was birth to teenagers in New York City, they represent about 10% of the births for given year. But in some pockets, again, it's much higher. For instance, in central Orlando, it's 16% of the births are two teenagers, meaning children under 19. And in the South Bronx, it's one in if we've 520 birds, you know, is two teams. And the last buyer is homelessness, how do you sequence it, okay, if you don't even have an address, to give, and then that means you have so other, so many other problems that do baby in there, and it's not, it's not your first priority, you just present to the hospital when you are willing to deliver. And in 1987, Dr. Chef Ken and other researcher did a study whereby the homeless woman average between zero to three visit in terms of doing their prenatal period, and their infant mortality rate was much higher. You know, in the scale, it was about 25 per 1000. So the prenatal care assistance program that PCAP was established in 85, primarily to provide women, those who are working but didn't have health insurance,

Unknown Speaker  33:50
or didn't have health insurance but didn't have the health insurance didn't cover prenatal care, preventive care, it was it was designed and implemented for them. In 1990, PCAP became, was combined with Medicaid, whereby a woman who presented herself for prenatal care, the provider, streamline and application did a financial kind of analysis whereby she was presumptively eligible, you know, for our, for the service, and they were covered up to 185% of the poverty level. And in our dollar term, it means that the family that was making $1,783 per month for three could be eligible, you know, for this kind of service mother, father and the baby. So studies have shown that it's more cost effective to provide prenatal care, which costs about $2,000 per delivery than to pay $500,000 for for an infant who stays you know, about a month in the intensive care unit. Not to mention the lifestyle I'm cost and social costs for those who mature babies. Now, this coverage was only good for the pregnancy up to the mothers, six weeks postpartum after that she could be applied for Medicaid. Now, this will tell Care Assistance Program applied very stringent standard to the providers who contracted you know what the state for this and hence the embracement. For Medicaid, for instance, it was quite enhanced the first visit the facilities receive three times what they would have received, you know, for regular Medicaid visit and do next visit one and a half time in terms of dollar amount. So we had quite a few providers, you know, providing the speaker, prenatal care, and I'm going to make Dr. Hamburg's hot, not feel so good. I'm going to tell you what the women would receive under a PCAP. They had prenatal care, Lisa says assessment, labor and delivery services in patient care in case they became six specialty physician and clinic services necessary to help ensure healthy delivery and recovery, laboratory services. All those things were covered are covered health education. Dr. Hamburg doesn't get out the education we follow for nutrition services, mental health, substance abuse and alcoholism service including screening and counseling, dental health, she had to go to the dentist herself and pay somewhere else. But exportation if they can transport themselves postpartum services, including family planning, emergency room services, home care, and pharmaceuticals. So I mean, Judy is one of the advocates that was with us, that I was working with since 1985. It was the it is the best in all type of world. And so in conjunction with the advocacy group providers, the New York City Department of Health, the Women's Health Line, you know, the service was promoted, and women, you know, are recruited and appointments were made for them. And, you know, a lot of women, you know, use the service. And what we have seen in the past five years, and those of us, you know, that are a little tunnel vision, attributed to PCAP was a reduction in the infant mortality rate. For instance, in 1988, it was 13.3, per 1000. In 1989, it went down to 11.6. In 1992 11.4. And so that's, that's how far we are here. 11.4. So that's quite a change from 13.3. You know, like, it's almost three percentage point. And the national average now is 8.9, per 1000. Also, the state did a analysis of the impact of the prenatal care assistance program. And what it found was that, particularly in New York City, significantly more black PCAP mothers carry their babies to term than did black mothers who didn't have PCAP.

Unknown Speaker  38:06
And the impact of PCAP, in reducing the weight of premature and low birth weight is was seen strikingly, particularly among those people that didn't report for prenatal care early, but because of PCAP, you know, there were more or less captured. And, and people that were usually at high risk, which was the black and Hispanic, and we seem to be having fewer logos. And that's affecting the infant mortality rate. And one recommendation is that enrolling the mothers earlier into PCAP, and encouraging them to return for more visit would further enhance the PCAP beneficial effect on the mother and child. Now, we, you hear this is This is wonderful news, we no one talking to you about it is the fact that now with the advent of managed care, most Medicaid clients, you know, will have will be enrolled in some kind of a P HMO, and the standards are not going to be as stringent as what we had in PCAP. So we in the advocacy groups are really working hard. So the PCAP program can be exempted, you know, from the managed care, and like as they are doing for HIV and mental health. So those of you that are in planning will be calling on you to go to work on a coma or whatever. Because we feel why is this losing a program that seemed to work? Why isn't it a woman to a medical male or or to for managed care? You know, why don't why don't why don't? Why don't we let them continue to get the benefit of the PCAP. Of course, PCAP is not a panacea. And as Dr. Hamburg was saying, we have to look at what is happening in terms of Poverty, it doesn't cure to poverty. It doesn't kill the homelessness. It doesn't cure the substance abuse. And the violence that seemed to plague our community, those are things that we would have to work on concurrently in order to really, you know, have this, this true lowering, you know, of our infant mortality rate. I have a chart that can show you, since we are such a small group, the the black column, you know, are the patient enrolled in Medicaid and, and the other one is the effort mortality, when you had fewer people in Medicaid, you had a high infant mortality, and as PCAP increase, and more women were going through it, and now you have a higher number of women in Medicaid and a lower, you know, mortality. So, if you can advocate for PCAP, please go ahead. Peggy. This is what

Unknown Speaker  41:03
you talked about the rate coming down? Yeah. Can you tell if that's because the rate in places like Harlan has come down,

Unknown Speaker  41:10
it's not very significant. It's not very significant. But Bedford Stuyvesant is coming down below Townsville, it's coming down, because I don't think we are doing enough in terms of the drug policy in Central Harlem and in Fort Wayne, and the violence and all those concomitant. And this is, you know, you know that, no, it's not, it's not as much as we would like to sit, but it's very, very slow. Very, very slow. But then, but it's changing. Bedford Stuyvesant is not. Yeah. Yeah. It went down from 27 to 24. Yeah, but it's so so we just have the chance you can you can. So, yeah, so so that those were the wait between 1986 and 1990. And this is the 91. You know, so you can see it's, it is changing, but it's not as rapidly, you know, for Harlem, and some pockets that are saying Harlem and Fort Greene and Mao, Sanya, the sub blocks, where we usually hear, you know, the problems of the drug abuse. And now we have the other concomitant, which is HIV disease, or some

Unknown Speaker  42:32
other ways of intensifying the work that we do that can be done in the place where the incident is an infant mortality is higher. I mean, if the drug abuse cases seems to be the piece that sort of keeping things from from happening, or how do you focus, what are strategies to focus on what it

Unknown Speaker  42:51
would be to attract these women into special care, because they're special care. For instance, we have a wonderful clinic. That's one by two Lincoln Hospital in the sidewall, Citadella. Cube, they use acupuncture to help the women to win away from the drug, it seemed to work. But it's, but as Dr. Smith was saying, you get them they can go through under the acupuncture, they they stop using, but they live in a society where you know, the drug is like us, you know, having a glass of wine and things like that. It's when he explains it, essentially was to you, because so their partner is a drug user. So that's part of everyday life. So they go back to it again, and again and again. And again, support services. So it's a very, very slow process.

Unknown Speaker  43:44
And substance abuse treatment services, in general in New York City are very hard to come by there was an estimated 550,000 substance abusers in the city and around 44,000 treatment slots available and for pregnant women, that's the group that's hardest to find a treatment for adolescents is another group that's very, very hard to identify a treatment slot because most of these programs do not want to take on those particular kinds of clients. So that even for a woman who's who's truly motivated, the combination of inadequate access to substance abuse treatment services, and then living in a community, where it's, it's just so prevalent, you know, it's a very hard one to overcome.

Unknown Speaker  44:29
And I think that most of just like in other areas, substance abuse treatment programs have very limited experience with women in terms of the models that they employ, the types of support services they have to offer. And the thing about substance abuse treatment with women is very labor intensive. You really need a lot of staff or a small group of women and most programs have not been willing to do the outlay for the type of resources that are needed. Because when you're talking about a women, you're usually talking about children. You're usually talking about them Finding a living setting for our family.

Unknown Speaker  45:04
This is Elise Rachna. From I was going to say as a social worker right here in the neighborhood. And that charges a comprehensive sickle cell center at St. Luke's Roosevelt Hospital done an enormous range of casework services to families and children diagnosed as having sickle cell trade counseling to families as well to handle lessons and a variety of community outreach. Prior to that, she's also worked very much in the OB GYN counseling services for foster care and the like and delighted to have you speak up. So informally, I'm not pleased. Please go ahead. Well,

Unknown Speaker  45:51
I'm going to be a little more controversial. And I guess that's what falls to social work. That's our that's our calling in life. From its inception, the feminist movement of the late 60s 70s and 80s, has placed much emphasis on the question of women's health issues, particularly reproductive health. Women have struggled long and hard for abortion rights and other reproductive choices. We've had our successes and we've had our failures. While there is much talk about making our health agenda as inclusive as possible. It has been limited success, it concretely taking up the everyday survival issues of our society's poorest women and children. Unfortunately, questions of accessibility, cultural sensitivity, language barriers and funding for public health programs have all too often been placed on the backburner of the feminist agenda. In New York City, the stark difference between services available to middle income privately insured women and children and the unemployed and employed poor is overwhelming. From the New York City fiscal crisis of 1975. Until the present, we've witnessed an almost unrelenting assault on programs and services designed to be a safety net for new york city's poorest women and children. years of funding cuts resulting in deteriorating physical plants, depressed wages for health workers in the public sector, making recruitment difficult, and the slow and steady chipping away at services have weakened New York City's once glorious public health system. I think the people here with me agree. Just a few glaring examples. In the 1991 budget cuts. The New York City Department of Health was going to drastically cut the school health program, which provided school based clinics that give physicals and immunizations for new students and health maintenance for students who have no medical coverage and no means of paying private physicians or clinic themes. It was only after a protracted court battle by the doctors Council, the union of the physicians in conjunction with a struggle by parents and community health advocates that this issue was resolved. Then we had the pep near scandal, there was a backlog of 1000s of pap smears done at Department of Health Facilities because they were unable to process them in a timely fashion. 1000s of pap smears sat around untested for more than a year, giving women a false sense of security. Many cases of precancerous conditions and infections went undetected and untreated, and this included even a few cases of probable cancer. Most recently, a memo from the health and hospital Corporation's women's health office was released. It stated that women using the Health and Hospitals electric corporations 11 hospitals and six clinics must often wait months for potentially life saving examinations and treatments. Pregnant a pregnant woman's average wait for her first clinic appointment could be anywhere from three weeks to as long as two months. The normal way for gynecological exam was 39 working days, but know some hospitals that could be up to six months. Women with positive pap smears had to wait more than four months for a colposcopy to get a family planning appointment when might have to wait anywhere from seven weeks to six months. I think you can only imagine the urgency that the women's health office must have felt in preparing the report and continuing their fight for adequate funding to provide accessible and high quality services to women that are dependent upon their clinics and have no other places to go. While the health and hospital cooperation has taken measures which hopefully will begin to address some of these problems. We do need to wonder how long these conditions have been going on, and what type of message does it give to the patients using these clinics? How do you go for early prenatal care if it's so difficult to get an appointment? How can you learn about family planning and make informed choices? If getting an appointment is a very difficult task? Imagine waking up with a gynecological problem and worrying about whether it was serious enough to go to the emergency room, or should you wait a few months till you could get an appointment. It's no small wonder that hospital emergency rooms are crowded with women needing gynecological evaluation who really don't need to be treated in emergency rooms.

Unknown Speaker  50:40
What I really would like to talk about now is a tug of war for health care for women and children that's taking place just a few blocks away from us. Most of you know St. Luke's Hospital, which has been located in Morningside Heights since 1893, and Women's Hospital, which was founded in 1906. These facilities merged in 1952 and since then have become a major provider of health care to African American and Latino women and children from Manhattan Valley Morningside Heights, West and Central Harlem and Washington Heights. In 1979, St. Luke's merged with Roosevelt Hospital, and the new facility embarked upon an ambitious long range plan. Their goal was to cultivate a more upscale clientele at the Midtown cite the community's first warning with the announcement of a much needed modernization and construction program. The earliest proposal indicated a loss of more than 300 beds at St. Luke's and the transfer of all of the hospitals inpatient, pediatric, obstetric and neonatal services to the Roosevelt site. Now keep in mind some of the statistics that we were all hearing before. Initially, the above proposal was not taken seriously. It seemed almost unthinkable that a hospital receiving public funds would move services away from a densely populated community of high medical and social need, with few private physicians to one significantly less populated whose residents have more resources, greater options for obtaining medical care and enjoy a much higher health status.

Unknown Speaker  52:29
In 1982, the hospital's own community advisory board began to take up a report to address the impact that the hospital's various proposals would have around the community served by St. Luke's at that time, the hospital was toying with three distinct proposals. One was to continue medical surgical and psychiatric services at St. Luke's but move all maternity, pediatric and specialty services to Roosevelt and consolidate detox up at St. Luke's. So that's taking away all services for women and children from the neighborhood. The second was to continue low risk maternity and general medical surgery and specialty services at the two sites and to consolidate pediatric high risk maternity and prenatal and pediatric services at the Roosevelt site but still consolidate detox up in St. Luke's so that's to leave a little low risk maternity, but no pediatric services uptown. The third proposal was to take all medical surgical maternity, paediatric and all specialty services downtown to Roosevelt and only half psychiatry, ambulatory surgery and only those services necessary to maintain an ER appeal. Keeping in mind all of the things we talked about. The hospital's own community board found the three plans lacking. The board felt that routine high volume ambulatory and inpatient pediatrics, Obstetrics and Gynecology, and internal medicine services should be located in close proximity to the target population. Their studies show that northern Manhattan had a higher percentage of high risk mothers and infants a markedly higher birth rate and volume and proportion of children in the community near St. Luke's. They also show how the St. Luke's site draws more patients from the area versus Roosevelt was patients came from a very diverse communities and therefore travel time would be increased by at least 30 minutes. Therefore, based on the demographic health statistics and the patient origin data, they recommended the consolidation of high and low risk maternity high risk perinatal and inpatient pediatrics at the St. Luke's that makes sense, right? Remember, this was even before the advent of crack, this is 1982 To the AIDS epidemic, homelessness increased rates of TB congenital syphilis, delayed immunizations, unemployment and the uninsured in order to take into account plans for the redevelopment of West Harlem that would bring 1000s of new young families into the area. This September, there's massive redevelopment in the Brad Hurst area that will be bringing 1000s of new young families into the area. Because of the hospital's control over the community board, this report was never publicly issued. Almost immediately, the plan met opposition from local residents. They decried the closing of seven hospitals in Harlem during the past 20 years. However, in 1986, the hospital got preliminary approval from the New York State Department of Health for the rebuilding process. No final determination was made about the obstetric and paediatric service. In 1986, community and church leaders began a vigorous petition and letter writing campaign. By 1989, they formed a coalition to save St. Luke's and held prayer vigil demonstrations and even a hunger strike by some local ministers. With few exceptions, city state and congressional representatives from the Upper West Side and Harlem, have sided with the community and have criticized the hospital's effort to basically run away from Harlem following a 1989 study by West Harlem coalition, the New York State Department of Health Commission, the New York City Health Systems Agency to review the need for obstetric and neonatal services in the St Luke's area.

Unknown Speaker  56:47
To no surprise to any of us, they found that the number of high risk births to Harlem women had skyrocketed, and that 89% of the high risk births and 77% of all births to women of Central Harlem were either Medicaid reimbursed or uninsured. Their research also revealed that while privately insured women often traveled to hospitals outside their neighborhoods, only 17% of the Medicaid and uninsured women did so. Since Harlem, Columbia, Presbyterian and metropolitan hospitals, all located in upper Manhattan, were already extremely overcrowded, they wouldn't be able to assume added numbers of high risk patients. In 1990, the New York State Department of Health ordered the hospital to keep 22 obstetric beds and 14 neonatal intensive care beds at the St Luke's site. But no allocation of money has been made for either these meager services. The hospital didn't change its construction plans to follow the state order and didn't admit any intent submit any serious plans as to how they were going to do so. Meanwhile, the hospital has continued to allow the physical plant of both the obstetric and pediatric services to deteriorate. Chronic understaffing has resulted in overcrowding and reduced level of services and attention. Many St Luke's officials have revealed their disdain for the Harlem community by stating that you just can't get doctors and nurses to come up to St. Luke's. Now we know that Columbia University and Barnard doesn't have a problem getting faculty or students and we're all located in very close proximity to each other. Others have said that they that they hope that when they move to Roosevelt, they will be able to communicate better with their patients. Finally, in 1991, the NAACP Legal Defense Fund and the Puerto Rican Legal Defense Fund on behalf of the Coalition to save St. Luke's filed a complaint with the Federal government saying that the hospital was discriminating against African Americans and Latinos and women and children who are on Medicaid by cutting services at the Morningside Heights facility. hospital administration has done everything possible to entice patients to come to the beautiful new building opening up at the downtown site. They have beefed up staffing and promise that there will be a higher level of medical attention there.

Unknown Speaker  59:26
At the same time, the hospital has said that it will keep a 22 bed opening and 14 mid neonatal intensive care unit for two years and then evaluate its feasibility and need at the St. Luke's I think everything we know about the health statistics of Upper Manhattan show that there's certainly a tremendous need. At present, the hospital has begun to move the majority of obstetric services downtown starting on April 12. Women receiving prenatal care at the Mi c center on 120/6 Street and OB One way at the Ryan clinic or with private doctors must deliver at Roosevelt. All high risk prenatal patients must also be followed there. All of this is extensively because all doctors with expertise and high risk deliberately are now only working downtown. Low Risk obstetric patients from the St. Luke's clinic are being given the choice of where to deliver, but the cards are stacked. The Roosevelt facility is brand new, beautiful, well equipped and well staffed. The St Luke's floor has yet to be renovated and continues to be understaffed. Even so a recently released study of 95 women living in the St. Luke's catchment area done by Luis Gomez from Mount Sinai Medical students showed that if services were not available at St Luke's only 4% of the women studied would go to Roosevelt and 96% with seek maternity studies at other northern Manhattan hospital. In June, the entire pediatric floor inpatient service is scheduled to move downtown. What impact will this have on the women and children in Harlem the sheer distance of the downtown site will result in added burden of travel time and financial resources. Family members will have a much harder time visiting their children on the new pediatric unit. High risk prenatal patients and advanced pregnancy unable to travel long distances by trainer but might not have the financial resources to get to their clinic appointments. Many women and children will probably begin showing up at the already overburdened Harlem metropolitan and Columbia Presbyterian hospitals, when really has to wonder if this plan was deliberately set up to limit the access of St. Luke's with traditional obstetric and pediatric patients. Remember, you need to play services near your target population. When you move services from your target population. You have a new target. And a time when city hospitals and clinics are extremely overwhelmed. Think of some of the statistics from before St. Luke's as flight from Upper Manhattan who surely impact on the area's already abysmal health statistics

Unknown Speaker  1:02:25
right as you can see the problem so they're gonna tell you a small little anecdote that happened to me the other day in class. I teach a course the large course it's called sociology of medicine has students from Barnard also students who are older in school of General Studies across the street and they're not going anywhere. We're talking about HIV in classrooms. And when I started it, is it has anybody had an experience working with people taking care of you? I can't I can't see we're just doing the snap. So wanted to set one up at a home care visitor and others that worked at the St. Luke's and a woman sitting in the front row or an older students. She has them out of strollers. And I said that I raised strollers and she said no, but she said the women in my project, the five of us got together, bought some condoms and distributed them to strollers as she turned them into a meeting just later this week. I heard it referred to as commercial sex workers.

Unknown Speaker  1:03:52
find themselves strategized and offered a way to begin to make a connection right there and their projects with the women on the streets and myself at all the younger students they My why is a lot to be the sorts of ways that now that's it. You sit down if you will. And we have Elise, Margaret, Evelyn, by May and let's hear from you. First question. Started out with

Unknown Speaker  1:04:41
questions about research. Women in research not only from the point of view, studying being done on women but women actually work in research, became very aware of this working at Rockefeller University, where they have a history I'm not promoting women, because I think we've had one tenured professor who's been in the vault there since 1904. They're able to get past some of the restrictions because they have enough abominable moving one level. So they're passing. What I find stunning, though, and I don't know whether this was also true at the NIH is, so many of the women who are actually in research are so blind, about the discrimination, that they themselves are not feminist. Or even if they aren't feminist, it doesn't apply to either their research or their position as women in research. Do you have any comments on

Unknown Speaker  1:05:50
that? Well, I think you identify a very real problem, which is the sort of, if I can make it, you know, what are they complaining about? On the other hand, I think that, that if you really sit down with most of those women, they've adapted to this situation, and correspondingly adopted behaviors, but it's not easy, they feel vulnerable, they feel that they're they're loners. And sooner or later, you know, I think that, that they would welcome the opportunity to, to take a different approach, and to speak out the woman's surgeon Francis Conway, I think her name is at Stanford is a good example where she, she, for many, many years, just put up with this stuff from these, these, you know, surgeons that are, you know, just renowned for their chauvinism. And at a certain point, she just couldn't take it anymore. And at that point, it was, you know, it was worth risking her job security. And, at least she thought her professional integrity. I mean, she was really worried that, that the male Cabal, you know, would not only, you know, oust her, but would also discredit her. But I think, you know, the time was right. And I think instead, you know, it was a very powerful message for, for a lot of us. But it's, it is a, it's, it's really a problem. And the farther up you go, the fewer and far between are the women that you can, can sort of form, the bandwidth in the few and far between are the men, you know, who are enlightened enough to want to support women also, it is another dangerous trend, I think, I mean, it's positive and negative. But there are more and more women in medical school, but which is a positive on one hand, but what it also reflects is that medicine is a field is devalued, and that it no longer is attracting, you know, the creme de la creme, many of the men that that would have been occupying this last in the past are now you know, going into law school or business school, whatever. And, you know, so on the one hand, I do think it's a very positive thing. I think that more women in medical school, and more women in the medical profession is going to help change the shape of that profession in a positive and profound way. But I think one can't be naive about what what's going on. Also, the same thing is true in public health. There are quite a lot of very outstanding women in public health, but and there are opportunities, not as many as they should be for women to be at at high levels in the public health field. But public health is again, a devalued component of the the overall medical establishment and it's considered the sort of squishier part of of medicine. And so, you know, on the one hand, you have to sort of take the positives and, and and recognize you know, them for what they are, but you also I think, have to continue to to recognize that that I don't know what the opposite of for every you know, cloud there's a silver lining for every silver lining is a class and, and and, you know, I think for the medical establishment is only one sector of our society where where these problems are occurring, I think is probably even more brutally obvious in the business world.

Unknown Speaker  1:09:30
One small comment, a study done at large computer firm by a sociologist indicated that women who were promoted in contrast and men who were promoted from mid to upper level positions a woman, those who were promoted tended to be sponsored by someone a skip ahead of them in rank, where men tend to have been mentored by watched over by someone in the immediate Rank Above them, for whatever it's worth. It took. That extra connecting link and a comment to what you said about medical school enrollment. It still is, at this time, even more competitive for admission, and there is a feeling about the best and the brightest, I don't know any data is so strong, that one silver lining in that otherwise very real cloud is that the, quote elite medical schools, the proportion of women is hired by some city could enter the room and say that's recovered. But I think not, I think that, that that is a sign so uptown, it's 40% and the overall average is closer to 30 that feminizing a profession, and it still is segmented very, very much so is an ongoing problem.

Unknown Speaker  1:10:56
Tyrion and it was super strong as women have tended towards pediatrics, our program noncompete 5050, to an incoming class man has 20 women and one man which is very good, you know, we really run our own department and feel like it's kind of our our place. But you also say that the medicine department which is much more now often had access earlier, to the new computers to money and power.

Unknown Speaker  1:11:27
And when they get out, they'll make higher salaries

Unknown Speaker  1:11:31
of shuffled over, it's almost now being well, children's needs are not primarily a contrast and that has been damaged. And, you know, because we're becoming more and more women, you know, to see that we have to fight harder to get resources and some of the other surging Flipside in nursing, now that it's a real up and coming player, and there are a lot of opportunities, we're seeing more and more men coming in. And I hear that the Columbia nursing school that has 50% of men, it's ironic that men go into nursing, they tend to go administration in critical care, they get promoted faster, even bigger salaries. For something to be said about that, you know, feminizing, the whole healthcare system and you know

Unknown Speaker  1:12:24
three speakers were very eloquent on the problems and issues column in the third person, wonder, putting song Gattling somebody talk about what it is that we could do, and what kinds of resources, for example that are here today that are not necessarily involved in the issue of the struggle could help to contribute to change. What we know are very, very serious problems and issues.

Unknown Speaker  1:13:06
Well, we probably all have, you know, obviously, slightly different perspective, or see a different set of priorities. But, you know, from my perspective, trying to, to manage a public health agency in the midst of, you know, fiscal crisis, one of the things that that has been a surprise and a disappointment to me, to be honest, has been that, that the public at large, and the sort of constituency based for the most part, doesn't, doesn't see this as a priority. You know, I have I really been educated, you know, not in a positive way, that that to many, many at the public at large, and particularly, to many of the voters that that the politicians listened to. There are other things that are far more pressing, and one can can have some sympathy, you know, keeping libraries open swimming pools open during the summer, you know, they're they're, they're important things for communities, and they're important things in the lives of children in particular. But yet, you know, how can you be out there protesting, because the library is going to not be open on Saturday, when the entire immunization program at the Department of Health is about to be eliminated. And so I could certainly see a very important role for anyone in this room, you know, regardless of what their their background profession, whatever it is, in terms of just helping to keep these issues on the front burner, helping to make it clear that, that that public health is public safety, that it's as important to have a community based clinic as it is to have a cop on the beat. I mean, you know, these, these priorities that get set Um, by, by political agendas tend to focus on, you know, what are the sort of short term immediate benefits to the voting population. But I think healthcare is such a fundamental need that it ought to be as much of a sacred cow as as anything in in a city, state or federal budget. You know, that would be, you know, what I would say is that, that, that advocacy to keep these issues on the front burner, coming from many voices, from many perspectives, and many power bases is absolutely essential.

Unknown Speaker  1:15:38
I couldn't agree more, I think that one of the things we see in terms of public health care or community based clinics, is basically they serve a certain sector of our population, it's kind of the difference between Social Security and Medicaid, they can cut Medicaid, because the people that are concerned about the Medicaid levels are people that are powerless in our society, they cannot do the same things to Social Security, because it's universal. And I think that that's a lot what we see when we talk about the public health care system in New York City, they basically is seen as well, that really doesn't concern me that only concerns the people that go to those clinics or the people that need those services. And I think we're seeing the same thing happen now with our educational system, as so many voting middle class people no longer have children in public schools. So they're kind of falling into the same kind of disrepair and lack of support and lack of Well, I mean, I think that what you're saying is really the critical question, we really have to let people know across the city, that what goes on in the public health care sector, what goes on in terms of clinic services and hospital services that essentially serve for people that really in the interest of the whole society. And I think until that message gets out, we have a very small constituency. And we really haven't reached the constituency that has power in our city.

Unknown Speaker  1:17:08
Well, in my case, I see that we have to keep educating and re educating legislators or people that have the purse string, for them to understand that preventive health and health education, in the long run will save them money, because it's like for every dollar you invest in terms of prenatal care, you save two to $2.50 in future care for a bad baby or things of that sort. And that goes around in terms of HIV, drug abuse, and that, that education and prevention is the key, more or less to the health of the city.

Unknown Speaker  1:17:49
As far as, you know, teaching, getting the younger adolescents to take prenatal care.

Unknown Speaker  1:18:03
Well, you know, this is a very risky issue. But what they have a program, I think it's called Sick God, whereby two children can go into high school, that there is a health educator, that she cannot go and present in a class, but she's there or he's there, she hasn't gone. And then the children can come to her, you know, for individual kind of counseling and knowledge and distribution of whatever and info. And now, but it would be better if it was accepted that there is in hygiene class or whatever it is that it could be promulgated, this is what is needed, rather than if you will reach many more children, but they do have those health educators that are in the special, that are available, but some children are not going to make to make the service available to themselves until they no problem.

Unknown Speaker  1:19:03
It's really a lost opportunity. I think that that we have failed so badly to integrate health education and risk reduction education into just routine. You know, health science, teaching in the schools. I mean, we you know, something like the the Chancellor's HIV education curriculum, which did include the condom distribution program, got everybody's attention and got people all agitated and all, you know, ultimately, you know, it more or less derailed because it was sort of a new thing focused on one controversial issue. But the truth is that, that these kids are at risk for HIV, but they're also at risk for sexually transmitted diseases at an extraordinary rate, like one in four teenagers get the sexually transmitted disease and those diseases They not only have immediate consequences, but they have, you know, lifelong consequences in terms of infertility and chronic pelvic inflammatory disease, etc, increasing risk for HIV as well. And also unintended pregnancy. So, so that, you know, it's it's important that that these messages reach adolescence and early adolescence, very early on and not. And not because of just one disease process, but but to understand, you know, the whole impact of to understand their own bodies to understand their own sexuality to understand their risks, and how to reduce risks. And, and even you know, more broadly than that, it is clear that many of the health problems that are before us are linked to behaviors, and whether it's it's unsafe sex, or risky driving, or smoking, or substance use, drinking, all those behaviors are behaviors that that really start to get developed during the adolescent years. And if we could through better education, and I think a more open educational system, you know, really help shape those behaviors early on, you know, we wouldn't be spending so much time on the back end trying to cope with consequences of those risk behaviors, we could actually do some primary prevention in the first place.

Unknown Speaker  1:21:30
Health care is like role playing in classrooms where teenage girls will learn that they can say no to everything,

Unknown Speaker  1:21:37
right? Yeah, just

Unknown Speaker  1:21:42
talking to teenage girls. Yeah, you know, they're they're kind of youth themselves, even though they've gone through American schools and Affiliate Marketing Center is a great community. Large advantage American schools and there is a certain scale, you still have sort of a a mentality where they feel like they can say no, if your boyfriend says can have babies, and they don't realize that they should get to the Altair, basic things that you think every American citizen might know. They're just not aware of, and just wondering thing that we've run into. Now,

Unknown Speaker  1:22:16
there's a whole movement that I don't know, you know, how how developed it is New York City schools, but what would they call life skills training, which is really a very powerful intervention, because it's not focused on a disease. But it's focused on helping people take control of their lives, helping helping people understand that they can make a difference. Also, looking at the broader issues of giving people, you know, skills that are meaningful, that will help them progress in the world and believe that there's some point in, in even caring about taking care of themselves and others. But, you know, it's a whole, it's a whole way of thinking about this self esteem, and efficacy and you know, those kinds of buzzwords, but you know, they're real phenomenon. And, and I think, in some of the studies of, of adolescent pregnancy reduction, for example, it's the life skills that make much more difference than the the actual information about you know, how to use contraceptives, because it is the ability I mean, Nancy Reagan may have had it partially right. About just

Unknown Speaker  1:23:32
because you have lessons, I think it also goes back to what you were initially saying that we need a more social view of how to deal with medicine, you know, it's feel, you know, you can give them a fish, but you can teach them how to fish help effective it's going to be, and they did this study at Radcliffe of teenage girls who had already had one child. And the biggest factor that made them stop having children in weight and newsprint control effectively was union membership. If they had jobs that they liked, and were being supported by a union, it was much more effective on how they maintain their lifestyle than, you know, any amount of health information they had been given.

Unknown Speaker  1:24:13
Question, I'm just wanting a little clarification, maybe at least you can help me. We mentioned marriage care was something that you're sort of kept fighting to separate the Manage share approach, and is managed care involved in this whole business. So the Roosevelt, I guess I'm confused, but I'd love to know if there was a connection. It sounds like the same idea of flunking some sort of big management.

Unknown Speaker  1:24:38
No, no, no, no, that the issue there is the fact that all hospitals are in tremendous financial difficulties, supposedly, at this point in time, and when you treat a poor Medicaid or uninsured population base, you don't get this Same reimbursement rate, and you meet people with more medical and social problems, which from a very cost point of view is more costly to treat. Therefore, if you have the option of moving your locus of operations from a community of very high medical and social need, which is a costly community, to a community that has less medical and social needs, chances are you'll make more money. That sounds like an underlying principle this is laid out in various ways.

Unknown Speaker  1:25:38
So manage clientele.

Unknown Speaker  1:25:45
Manage COVID Health and Hospitals Corporation is that is that what you're talking about?

Unknown Speaker  1:25:50
The managed care, it's what's going to come down the pike for the recipient of medicated, they'll have a primary care provider, who will have more or less as a gatekeeper as to what are the service they are going to receive, instead of going to go to the no the peak? No, they think the big guys is the big guy that we are talking to.

Unknown Speaker  1:26:11
Very good. Yeah, they can't really

Unknown Speaker  1:26:13
have high standards for prenatal care. At a private doctor,

Unknown Speaker  1:26:19
it's impossible for men, especially on Medicaid, becomes a pickup customer right away, you know, either if you have Medicaid, or if you don't have Medicaid and and it's it's poor, or needy families percent of the poverty level, you get the same type of care, that's what is good about it. And the hospital get reimbursed at a much higher level to me know, the facility that provide PCAP, it was very well thought about and, and it kept changing as it went along the advocacy group when they didn't have coverage for the delivery, we said, but you need to include the delivery in there. And then you need not to ask the undocumented for any kind of favors, and they would incorporate all those things. The state was listening like it was a real partnership. It's our baby now. That is going to go away. And it really worked.

Unknown Speaker  1:27:09
Yeah, yeah.

Unknown Speaker  1:27:11
I was very moved by your point about looking at the nature of a coverage rather than payment. And maybe we could speak to some of the need, the need for the power of institutions, that phrase I wrote down because I think that's what we're talking about. Because these managed care companies, no one's looking into the high pay of those executives, making big decisions on telephone, as low level people. And I really emphasize it's anything that you know, that I could do to help your situation, I'm gonna be very happy to write to someone like when I'm in the process of doing that about this coalition I mentioned. And what's overwhelming is the fact that when I contacted the civil service in Albany, I got all these very wonderful answers supporting match care company, and I was absolutely, this just happened yesterday. So I'm very fresh in their mind that I have to now start somewhere to answer count answer. The managed care as a member of managed care company was approach I complained, managed care company was approaching all of their emphasis was scattered back to the letter. This is a powerful institution. And when you get up against that, it's really very overwhelming. I approached them about a problem, mental health that they want. And they contacted the managed care company and got all of their answers to refute mine, did they give you the name of the person

Unknown Speaker  1:28:43
or the state agency

Unknown Speaker  1:28:46
service status and confer sustained transmission who told me that managed care companies do not come under the aegis of a lot of universal? So he suggested that I go to full service, naval parenting classes, to just walk. And I wrote and sent all of my material. And I got in a lower level person writing back to me, they had contacted managed care company about my case, in many cases, I brought up and they answered, point by point from their perspective, but no one had contacted me. So now remains for me to go back and answer plus points. My point is that the powerful institutions Strophes, and all of these folks that when small person speaks up to them, it's almost it's overwhelming. And I applaud all of your efforts. I just feel for it, but I would like to say that I'm interested in helping

Unknown Speaker  1:29:44
that happen for the PCAT program to preserve new coding, putting together some sort of outreach project

Unknown Speaker  1:29:55
where we have organizations now we have an organization called the prenatal care Steering Committee, which has been acting as an it's a consortium of different advocacy groups and institutions. And, and we've been coming together, you know, I mean, since 1985, and then understand had been working very closely with us with all those changes and things of that sort. But now, let's say the person at the state, or we invited her to our meeting and presented, you know, all of, you know, what we see, you know, will, will be happening, you know, under the different standards, because even even the idea of a person going, you know, to a, to an HMO to that type of an office, they feel extremely intimidated, you know, because it's a different kind of setting, you know, that, then they're we're used to, and then the material that they are given is not written in a language that they, you know, that they can understand. Okay, Judy, and

Unknown Speaker  1:31:12
one of the problems and issues is such a small primary care infrastructure or care base, that the state is City office, which is a mega office manager as well, or trying so hard to get more primary care available, that they're treading lightly and with some kid gloves with some of the new providers, some of HMOs and other managed care providers, and there's been a very strong effort by the prenatal care steering committees, why is de perinatal advisory committee to insist at a minimum that same standards that have been present for for PCAP will be in the HMO contract or in managed care. But again, because there's this tiptoeing around the tulips, you know, to make sure that the providers are there is a tremendous reluctance by the state and the city to push these standards. So that the options or to push for exemption for pregnancy, you have one exemption that you can go to the prenatal care provider, or that whole package of services be carved out of the HMO rate. And a woman began with an option to be able to go fishing or in the alternative, or combined, that the standards have to be done within managed care. Contract. Managed Care is about combining medical care and the kind of health care that Peggy and Evelyn were taught me about the broader concept of a package of comprehensive services, which is really what's needed is not is not in there. So the standards are real orders. I. Just want to ask how we make preventative care, primary care sexy? Because it isn't, I mean, high tech is doing heart transplants, liver transplant sexy.

Unknown Speaker  1:33:43
Fine, it's also financially lucrative.

Unknown Speaker  1:33:45
Absolutely. But if you took the Did anyone ever see the documentary I'm talking about now, in the 70s, called your money? Has anything changed to be shorter, so completely? What the monies would be for keeping hypertension clinics open versus one heart transplant? How are we going to change that? I mean, I remember back in the 70s, hearing somebody say they went to Israel and Israel at that point, I don't know what it was all of Israel, just some point a some section said, we're going to spend all our money on prenatal care, we are not having any intensive care units for high risk and are we ready as a society to do something like that?

Unknown Speaker  1:34:37
No, Oregon is the state for its neck up, father and in that in that direction. I think that and I don't have much to say favorable about managed care some snake oil but it will put your interest in prevention. More into center placed for some to some considerable extent, but on a very minimal level and that's the syro has a PCAP. And the demonstration programs which we have had get gobbled up by the bureaucracy is sort of a gloomy notes. Always go down. And anyway, it's about time you've got a wonderful audience that was there and I thank him for joining with me got it live in the afternoon,

Unknown Speaker  1:35:58
where she's speaking

Unknown Speaker  1:36:01
in the gym, back to the gym. Thank you very much and all good wishes and good luck to see you.

Unknown Speaker  1:36:17
Good to see you again. You spoke for us at Lehman College last year, so Right. And I wanted to ask in the Journal of Public know,

Unknown Speaker  1:36:29
what you're doing was just recently, I don't know which month it was. Give me your address. I can send you a copy of yours.

Unknown Speaker  1:36:40
Somebody else's

Unknown Speaker  1:36:49
I have to start. Yeah.

Unknown Speaker  1:36:54
I had a development is here today. I gave a talk there

Unknown Speaker  1:36:58
a few months ago. And it was really kind of astounding because it was it was

Unknown Speaker  1:37:05
well actually work they're

Unknown Speaker  1:37:08
called hospitals. But But I was I was talking to a group that also claimed some some Canada that's mainly was Russia fell on research. And I was talking about your donations and public health and really a section of poverty. And I mean, it was always a very positive thing. Because they

Unknown Speaker  1:37:32
said I didn't know community health status indicators. They just they just didn't know maybe Oh, right. Earl felt

Unknown Speaker  1:37:53
talk too much just an industrial design, I guess because she was she was with the spring. Yeah. Well, I'm there so snobbish about science sequences Yeah. Okay, okay. Okay. Thank you. Thank you

Unknown Speaker  1:38:20
there was another

Unknown Speaker  1:38:26
chapter Yeah. A lot of you know my my real low Yes. Public Yeah. So yeah,

Unknown Speaker  1:38:46
there's a terrific person