1971 october corrected

7/29/2019 1971 October Corrected

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Hea l t hPolicyCen terAdviso ry

No. 34 October 1971

HEALTH/PAC

FREE CLINICS

Medical institutions derive their wealthfrom patient fees, research grants andreal estate investments. The wealth ofmany medical empires is measured in thetens, if not hundreds, of millions of dollars.

Using this measuring rod, free clinics arebut lleas on the hide of the elephantinemedical system.

Since the Haight-Ashbury Free Clinicopened its doors in 1967, free clinics, however, have experienced explosive growthin their own right. Today, upwards of 200free clinics are operating and new onesare coming into being regularly. Theysee tens of thousand s of patients an nu allyand are staffed by m any hu ndreds of community activists and health workers.

Free clinics, therefore, would be worthexamining if only because of their sheerappeal and popularity. But serious analysis of free clinics is also needed becauseall free clinics have, with varying clarity,focused on a vision of good health care,which they try to represent in their activities. The vision came together duringthe 1960's in what the media has labelled"The Movement for Social Change." It isa distillation of the experience and beliefsof the New Left, underground culture.Black Power advocates, and OEO. The vi

sion is founded on the twin convictionsthat: The American medical system doesnot meet the people's needs; and the American medical system must be radically restructured! It can be summarized by thefollowing principles:

Health care is a right and should befree at the point of delivery.

Health services should be comprehensive, unfragmented and decentralized.

Medicine should be demystified.Health care should be delivered in a courteous and educational manner. When pos

sible patients should be permitted tochoose among alternative methods oftreatment based upon their needs.

Health care should be deprofessionalized. Health care skills should be transferred to worker and patient alike; theyshould be permitted to practice and sharethese skills.

C o m m m u n i ty -w o rk er co n t r o l of health institutions should be instituted.Health care institutions should be governed by the people who use and work inthem.

Free clinics have taken on the doubletasks of meeting the people's needs andof radically restructuring the health system. In most cases they attempt this byserving as an example of good healthcare and a mod el for the future. Some alsoattempt to be instruments of change, bychallenging existing health services aswell as providing their own.

To evaulate these attempts HEALTH-PAC spoke to community staff members,p rofessionals an d patients, with site visits

at free d im es in New York City, Baltimore,Chicago, Minneapolis, St. Paul, San Francisco and the Bay Area. Ou r observationsand conclusions form the basis of the following articles.The research for this Bulletin w as doneby Const ance Bloom field, H oward Levy ,R onda Kot elchuck, M arsha Handelm an.


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WITH A

LITTLE HELP

FROM THEIR

FRIENDS

At first glance there would ap p ear to be anearly infinite number of variations on thefree clinic theme. They may be foundedby medical professionals seeking alternative forms of practice, by political partiesseeking to develop constituency, or byneighborhood groups interested in providing a local service. They can serve freakydrop-out, university community, workingclass, ghetto, barrio or all-female populations. On second glance, however, theyhave many characteristics in common.

Lay o u t , Am en i t y an d Acco u t r em en t s

Free clinics look remarkably alike. Theyare located on or near the main drag ofwhatever community they intend to servewhether it be Telegraph Avenue inBerkeley or Greenmount Avenue in Baltimore. They share an awkward layout

whether it b e in a store-front, second-storyoffice or church basement. Unlike the outpatient departments (O PD 's) they seek tooutdo, they do not make the error of confusing barrenness with cleanliness. All ofthem evidence some good intentions interms of decor with bright paint and posters, but these efforts have been largelyoverwhelmed by the mass of humanitythat has been in and out the door sinceopening day.

There is a reception area of desk and

files. A donations can is located prominently. There's a waiting area with sec-ond-hand furniture lined up against thewalls. The reading matter can range fromunderground or political papers to brochures like What You Should Know A boutVD and TB and You. Some clinics havewritten their own literature on nutrition,GYN care, etc., while others appear tohave given up the losing battle to keepliterature around at all.

There are usually three examiningrooms; they ar e larg e enough to contain a

doctor, a p atient examining table and littleelse. Many are constructed from partitionsand frequently have curtains instead ofdoors. A modest lab and pharmacy claimwhatever large closets or corners may beleft over. The lab will have a microscope,hematocrit machine, and equipment forurinalysis. The pharmacy has a well-used copy of Physicians' Desk Referenceand other pharmaceutical literature. Thepharmacy is generally stocked with sample drugs charmed from friendly drug

company detail men.In fact, in most free clinics, just about

everything is donated. They all ha ve beenfixed up with free labor; in one case,plumbing and electrical work w as donatedby union locals. Ironically, several clinicsgot a lot of their medical equipment fromdoctors' widows who were dismantlingtheir husbands' offices. Some have equipment and supplies which have been "liberated" from local hospitals.

Published by the Health Policy Advisory Center, 17 Murray Street, New York, N. Y. 10007. Telephone (212) 267-

8890. The Health-PAC BULLETIN is p ublished m onthly , except d uring the months of lu ly and Augu st w h en ' i t

is published bi-monthly . Yearly subscript ions: $5 s tudents , $7 others . Second-class postage paid at New York,

N. Y. Subscript ions changes-of-add ress , and other correspon den ce should b e m ailed to the above ad dr ess . Stai i :

Constance Bloomfield , Des Callan. Oliver Fein , Marsha Handleman. Ronda Kotelchuck. Howard Levy, and Susan

Reverby. Associates : Robb Burlage, Morgantown, West Virginia; Barbara Ehrenreich, John Ehrenreich, Long

Island ; Ruth Galan ter, Los A ng eles; Kenneth Kimerl ing, New York City .

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P a t i en t an d S t a f f C h a ra c t e r is t ic s

In the year or two that most free clinicshave been open, each h as had u pwards of3000 patients. Two-thirds to three-quartersof these patients were women. Far lessthan half were ever seen more than once.About 200 could be called "hard-core pa

tients"those who rely on the clinic forcontinuous care.Most clinics hav e reported that w hen they

first opened, a high proportion of the patients were young white dropouts whowere frequently not even from the neighborhood. After a while, in those areaswhere the residents are not primarily hip,the patient population has started to reflect the neighborhood as a wholeolder,more ethnic, working class or whatever.

A distinctive (an d perh ap s the mostvu lnera ble) thing about free clinics is that

they rely on volunteers donating theirskills. Although some clinics have a fewemployees on subsistence salaries, the delivery of medical care is totally depend enton good will. And despite the deprofessionalization of some medical skills, theclinic is really dependent on the good willof doctors. Thus, while doctors can pickand choose among free clinics, virtuallyno clinics have ever asked a doctor toleave, even though they all wanted tofrom time to time.

In many clinics, the size of the staff approximates the size of the patient load onany given night (average 25). The Peoples' Free Medical Clinic in Baltimore isopen four nights a week, has five paidstaff members, and approximately 150volunteers. While many clinics operatefrom a smaller pool of volunteers, theBaltimore Clinic has a generally typicalbreakdown of labor and functions: doctors, nurses, coordinator-receptionists, p eoples' counselors-therapists, women's counselors, laboratory technicians, patient

advocates, child care personnel. Otherclinics might omit the women's counselorsor the child care personnel, but they mayhave dentists, dental assistants, pharmacists. Some combine the patient advocateand nur sing functions into one para-medicrole.

The bulk of the labor contributed to freeclinics comes from non-professionals,some of whom may be health science students, but most have had no formal healthscience education. Patients are encouragedto volun teer in all clinics. While th is actu al

ly occurs to only a limited degree, clinicstaffs do resemble the patients more closely than in any other medical institution.The Berkeley Free Clinic, which grew outof the need to have medics present du ringconfrontations between street people, students and the Alameda County Sheriff's

CONTENTS

Description 2

Politics 11

Women 14

Office, is continually training new medicsand senior medics. According to the staff,many of the volunteers were former clinicpatients. This is also true in those clinicswhich are affiliated with political organizing in neighborhoods.

Nearly all free clinics put a great dealof emphasis on the transfer of skills. Thedelegation of minor professional skills toparamedical workers is not such a radicaldeparture from tradition. Even the mostconservative medical societies haveadop ted the id ea for econom ic reasons. Infree clinics, however, the skill transfer sy stem is designed to serve and demonstrateclosely related objectives: the demystification and deprofessionalization of medicine.

In clinics where skill transfer is highlyvalued, a Horatio Alger attitude prevails:"We learn as much as we want to and doas much as we can." Some clinics have

professionalized the deprofessionalizationby having formal courses taught by localhealth institutions for novices to the medical field. In most, however, the learninggoes on in a n over-the-shoulder app renticefashion.

This raises a profound question whichmost free clinics have not faced: to whatextent are free clinics using their patientsas teaching material, just like the OPD's?Are patients given a choice of beingserved by a trained medic or a medic-in-training? While a Cincinn ati clinic will not

let med students 'play doctor,' the comment of one medical student should givep au se. "I enjoy working in the free clinic,"he said, "because I can do things that themedical school won't let a third-year student do." Skill transfer raises anotherquestion: does demystification also meana de-emphasis or down-grading of thevalue of medical competence?

Transfer of skills goes beyond nursingfunctions with non-professional lab technicians, pharmacists, and dental tech

nicians being trained at some clinics.Transfer of skills not only serves to demystify but also to change traditional sexstereotypes, with male receptionists orfema le ph arm acists. In wom en's freeclinics changed sex roles become closelylinked with demystification and deprofessionalization. A frequently heard refrain

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"The nu m ber of p eop le here

has proven the need formore an d better healthcare, a need wh ich w ealone cannot fully meet."

Peop le's Free Med ical Clinic. Baltimore

is, "We won't be dependent for our medical care upon male gynecologists."

While a few clinics have formal jobrotation, most have an ad hoc voluntaryrotation. In a number of the clinics everyone on the staff can take blood, read vitalsigns, do pregnancy testing and pinch-hitfor each other. Although the doctors areexcluded from job rotation, in most freeclinics they are expected to do some of themenial workcleaning up, moppingfloors, etc. As one non-doctor said, "It's agood experience for doctors to empty ashtrays. It creates a sense that this isn't justa place to see patients. It's his clinic asmu ch as it's ours, and he h as a n obligationto see that it's clean ."

C l in i c P ro ced u re

Every clinic is confronted by more patients than it can h and le; they ar e all confounded by the problem of waiting time.Most clinics open around 6 p.m., two to

four nights a week. They see an averageof twenty-five patients a night. There areusually three doctors on duty, who (liketheir OPD colleagues) cannot always becounted on to show up on time or show upat all. The clinic will close at 10:30 or 11.Since few, if any , app ointments are mad e,some patients may have to wait all evening to see a doctor. All clinics have hadtrouble cutting the average clinic visitdown to below an hour-and-a-half or two.The wait m ay b e broken up with extensivemedical histories and the like. Thoseclinics that have tried classes or films inthe waiting room have usually given upin exhaustion and chaos.

Since the jam-up is almost always atthe doctor's end of things, proposed solutions usually mean shortening the patient's time with the doctor or instituting

staff routines that "use the doctor's timemore efficiently." This starts violatingsome widely held free clinic principleslike: "the patient has the right to have allof his or her questions answered," or "thisisn't a business, so what's all this talkabout efficiency?"; and "the staff is hereto serve the patient, not be drones for thequeen-bee doctor."

Every clinic turns patients awaynotonly because of the waiting period, butbecause they all agree, "We'd never gohome if we didn't." "There is a bottomlesspit of patients who can't, don't or won'tgo to the hospital. Maybe they can't gobecause of the law, or they don't becauseit's so far away and they don't havetranslators. Or they just won't go becauseof the attitudes and the hassle they getthere." Although this problem has been

handled with more dispatch than thewaiting problem, it involves still moreserious trade-offs. All of the clinics havedecided that it's better to turn peopleaway or limit the scope of their services,than sacrifice the quality of the servicesthey do render. Generally they use somevar iation of a first-come-first-serve ba siscoupled with geographic boundaries. Thereceptionist's discretion is used to weedout those could go somew here-else or pa yfor services from those who can't; thosewho aren't in pain from those who are,

etc.Theoretically, other staff members can

relieve some of the pressure and dependence on the doctor. Among other thingsthey can take care of less seriously ill patients who don't need the doctor, therebyshortening the waiting time and gettingmore patients through in an evening.However, this works to a limited degree,if at all. Despite the fact that in someclinics the staff-patient ratio approachesone-to-one and the fact that in manyclincs a good deal of "transfer of skill"goes on, in narrow m edical terms, the bulkof all this energy and attention does notamount to much more medical attentionthan a patient would receive from anurse/ receptionist.

T h e P a t ie n t A d v o ca t e

Those clinics which have a more developed consciousness about the faults ofAmerican medicine or have a messagethat they want to get across with theirmedicine have patient advocates. Although they have been used in otherhealth institutions the patient advocateprogram provides the most promisingaspect of free clinics. Those clinics whichmake good use of the patient advocateoffer a significant departure from medicine as practiced in the OPD. The role of

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the patient advocate is to (1) help thepatient understand the procedures, assure follow-up and referral if necessary,and protect the patient from medicalabuse, (2) challenge the professionalismof the rest of the staff, (3 ) ra ise thepolitical consciousness of patients andstaff alike.

Every patient is given an advocate bythe receptionist. The advocate takes thepa tient's med ical history or collects the fileif the patient has come before. They discuss the patient's complaint. This conversation is frequently used to communicate some of the goals of the clinic to thepatient. "We explain to the patient aboutthe differences in this clinic, what we believe in. We also tell them that we can'tdo everything and that sometime they'llhave to push on the County Hospital."

"When we take her story, we talk aboutwhy women run the clinic and why it'simportant for us to control our bodies."

The advocate introduces the patient tothe doctor and is frequently present during the exam to make sure that the doctoris aware of all the patient's needs, iscourteous and explains what he or she isdoing. Sometimes direct confrontation ofthe doctor occurs. On one occasion, wewitnessed a patient advocate challenginga doctor for ordering an unnecessary and

Network Cl inicsA free clinic dram a recently unfoldedon TV's The Interns. The free clinicwas located in a major metropol-itan medical center. Rock musakprovided a homey atmosph ere for hippatients and hip interns alike. Thefive intern idols (including a woman

and a black) put up a united front against the hospital's stodgy finan-ciers. "If they close it down, we can open our own free clinic." "Hey,man. you're talking about Revolu-tion!"

Revolution! was avoided in thenick of time as the hospital's wise but irasible administrators were pre-vailed upon to tell the financierswhere to put it. "If they don't like the free clinic, they can put their taxdeductible dollars elsewhere!"

Meanwhile the beautiful sculp-tress's life was saved; she decided tohave the baby after all; and her boy-friend came to terms with Hunting-ton's disease. And The Interns wereinvited to the wedding!

expensive laboratory test. On another occasion, the doctor ordered an appropriatebattery of tests but was then challengedto figure out a way to obtain the series oftests free since the patient had no money.

In a Chicago clinic, the following interchange took place in front of the entirewaiting room full of patients. Medicine

was demystified and deprofessionalizedin one fell swoop.

Doctor: "I've got a patient who's an alcoholic and who's demanding Librium (atranquilizer). Other doctors have given itto him, but I'm not sure. What should Ido?"

Advocate: "Lookyou doctors have toget together with us to discuss the matter.In the meantime, you'll just have to useyour own best judgment. The PatientsCommittee will have to set a policy guide

line for the treatment of alcoholics withtranquilizers. There's no reason why wecan't review the medical literature andmake a sound decision. What the hellwhen the N ew En gland Journ al of Medicine is confused abou t a n issue, th ere's noreason why our judgment isn't as goodas doctors'. Our discussing the matter ina group is probably more valid than thedoctors deciding as individuals what todo."

The adv ocate is also respon sible for ensuring that the patient understands the

doctor's recomm endations, gets a prescription filled and a follow-up appointmentmade, if they are called for. In some freeclinics, the patient advocates accompanythe patients to hospitals, other clinics andemergency room. Being a patient advocate can be a significant political experience in itself. According to one woman, when she started to work she swore,"I just want to serve, I'm not going to become political." She is now embarrassedto admit that not long ago she could seeno connection between her desire to med

ically serve her people and the necessityfor political involvement to imp rove healthcare in her Latin-American community.

Unfortunately, the examples describedabove are more the exception than therule. Furthermore, the pressure placed onthe clinic for immediate services discourages patient advocates from rocking theboat. Some patient advocates became inhibited because they felt that if they actedtoo forcefully, "the doctors would be an tagonized and would be frightened

aw ay ." The result is that the patient ad vocates merely serve as expeditors forthe m ore techn ically skilled professionals.Few clinics or their patient advocates areoriented toward examiningmuch lesschallengingother health services in thecommunity. It would seem that either thepatient advocates must break out of this

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restricted role, or else their position willassume the limitations of a fairly traditional social worker.

Scope o f Serv ices

Most free clinics provide the kind of services that one might find in a neighborhood first aid station, if such thingsexisted. This is consistent with their resources and their patients' demands forstop-gap care . Most clinic services d on't extend beyond routine intervention andscreening: pregnancy and VD testing,colds, abrasions and minor infections.However, this limited role does not satisfymany clinic progenitors. Just as there is atug-of-war betw een seein g a lot of pa tientsand providing quality care, there is a tug-of-war between providing many servicesand providing a few services well. "We

must be a viable alternative. We don'twant to be a band-aid to patch up afterthe health sy stem ." On e clinic coordinatoreven hoped that, "This free clinic is the beginning of a community hospital." Freeclinics are forced to rely on more limitedresources than any other medical institution; yet at the same time, they are attempting to cope with an issue which hasbeen boggling medicine for years: howdo you provide comprehensive and unfragmented services on a decentralizedbasis?

Each free clinic is trying different approaches, but none has found solutions

which they feel are acceptable. In orderto move toward comprehensiveness, mostclinics are looking for specialists: gynecologists and pediatricians are in greatdemand. A number have dental chairs,but few have found dentists yet. On theother hand, several clinics have stoppedproviding services which they found wellwithin their capability to provide. Twoclincs have stopped providing birth control because family planning clinics werenearby. "Besides," one said, "if we didbirth control we'd be so flooded we'dnever get to anything else." The samereasoning motivated another clinic to stopdoing "school physicals."

Most clinics see an urgent need to domore preventive work, saying that theirpa tients are "oriented toward crisis car e."They want to "go outside the clinic" with

outreach, educational and screening programs. Some have tried anemia, sicklecell and TB testing in their communities,often tying these efforts to some largercommunity organizing campaigns. However, given the pressure to serve patientscoming through the door with immediateneeds, most clinics never get outside theirwalls for very long, if at all. Preventivework is therefore limited to the generallydetailed medical history forms which arekept on each patient and the screeningtests which are run on all patients. These

preventive efforts bear little fruit, however, because on the average less than

GimmeWhat is known as the Free Clinic Movement got underway in 1987, when theHaight-Ashbury Free Medical Clinic, under the leadership of David Smith,opened its door to the hundreds of young people flocking into San Franciscofor a summ er of love, freedom, mind expan sion and exper ience. The Clinic took

care of the casualties. It was an entirely appropriate, though short-sighted,response to the medical and cultural demands of its flower-child community.

Hallucinogens were a new ph enomena at the time, and no one knew how tohandle bad drug trips. The Clinic pioneered techniques for "bringing peopledown." Just as a warm, familiar, hassle-free environment is good medicine fora bad trip, the Clinic's no-questions-asked atmosphere helped kids with VD andthe other infectious diseases that found it easy to live in the alternate life-style.

The presence of those who worked at the Haight-Ashbury Clinic lent tacitsupport to a set of cultural values which characterized the young patients. Withtheir long hair, informal dress and style, the professionals an d non-professionalswho staffed the Clinic were superficially, at least, indistinguishable from thepa tients using the Clinic.

The fact that the care came free not only fulfilled the need to provide medicalservices to people who had no money, it was also groovy! It supported andgave testament to the idea that alternate institutions can survive in the bellyof the beast, that they can be developed on principles of sharing, not exploitingand that they can subsist on the surplus of a materialist economy without everconfronting that economy.

The Haight is now a lean, hungry and violent place. The Clinic is the only

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half of the patients ever return to theclinic. Those who need follow-up workbased on the screening must often be referred elsewh ere.

Thus, while the clinics dispair of thefragmentation that patients face in theAmerican medical system, they too arecaught in the same bind. David Smith,

founder of the Haight-Ashbury FreeClinic asserts that, "One of the primaryfunctions of free clinics is referral." Referrals are accomplished by the freeclinic staff in an informal w ay r ather thanthrough channels. Colleagues and friendsin hospitals, health departments, well-baby clinics, etc., are prevailed upon toprovide clinic patients with hassle-freeservice. While a few clinics have set upformal referral arrangements, most findthat the informal arm-twisting methodmeets the clinics' nee d s: "People in medi

cine are feeling pretty damn guiltyweusually get what we want."

A lot of clinics attempt to provide services which go beyond traditional medicaldefinitions and speak to broader conceptsof health: "Per son al. health can be defined as the freedom from disease anddisability of the individual within the community and the freedom of the individualto live creatively and without oppressionas a resident in his or her community,"is one of the principles of the People's

Health Coalition of Free Clinics in Chicago. Day care is offered in a few clinics;

some hav e clothing exchan ges; others provide legal and housing advice; a fewhave surplus food stuffs to give away orget involved in "peoples' pantries." Oneclinic in Minneapolis even provides veterinary services! At a minimum, mostclinics having a young patient load, offersome sort of counselling.

Many counselling programs are staffedby non-professionals. In general a clinicwill offer one-to-one therapy for psychiatric emergencies, but the emphasis is onrap groups. Counselling frequently focuses on drug problems. Clinics have developed expertise in "talking p eople downfrom bad trips," and in many cases knowa lot more about drugs than the localmedical establishments. However, thoseclinics (with the exception of the Haight-Ashbury Clinic) which have tried to helpheroin addicts have given up. "We tried

to help people kick but it was impossible.They needed a place to stay, food and ashrink. We couldn't just give them pills tolighten the monkey for a while. "We'llhelp junkies with other problems, but alot come in here asking for pills; unlessthey're really in bad shape we don't givethem a ny."

B r e a d

Since clinics depend on volunteers and

donations of labor and supplies, theirbudgets are remarkably small. An aver-

Shelterthing that remains to remind us that the flower-child culture ever existed. Toquote from the N ew Y ork Tim es review of Smith's lates t book Love N eeds Care:

. . The Haight once the flower pot of America, [is now] shattered into fragments of terror an d d espair, a 'beh av or ial sink' of pa tholog ies feeding off the pill

and the needle."It is questionable whether or not uncritical acceptance of the values inherent

in the Haight's youth community did contribute to the social and physical disintegration of scores of young people. Establishment medical institutions areoften chided for defining their roles too narrowly and ignoring living and working conditions which affect their patients' health, such as lead poisoning, overcrowded housing, and occupational health hazards. What are we to say offree clinics which do little to curb drug abuse, poor living arrangements, nutritional faddism an d emotional chao s?

Now that the Clinic's flower child clientele has withered on the vine, theClinic (which Smith called "a state of mind, not an economic fact") h as discovered that economic facts are harder to change than minds. The Clinic lostone of its primary contributors when Bill Graham, purveyor of rock music to

flower children, decided to give up the business. How mu ch did their free healthcare cost? They bought it with thousands and thousands of tickets to theFillmore.

Smith now sees the need for long-term funding. In his role as head of theNational Free Clinic Council (see page 11), he says, "Free Clinics are part ofthe total health care delivery system, and want to be recognized as such."

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age budget might be about $30,000. Inmost case s income is derived from a number of small contributors an d fund raisingevents. Clinics have had bazaars, streetfairs and received funds from student activity funds and church groups. At leastone free clinic receives a substantial portion of its income from pledges. The Berke

ley Free Clinic gets a small but steadypart of its income from pan-handling.Some clinics like this catch-as-catch-can

financing and wouldn't have it any otherway. They say they can maintain theirindependence if they avoid big contributors; "freedom's just another word fornothing left to lose." Others add that ifthey weren't forced to rely on volunteersthey would lose the good spirit, atmosphere and working relations of the clinic.Some take it even further and see themselves as furthering a counter-culture

barter economy: "The free clinic doesn'ttreat health as just another commodity.While we won't accept a fee for service,we d o expect patients to 'pay in kind.' Patients contribute their skillslegal, socialwork, plumbing, painting, etc.in returnfor medical service We work on a sort ofinformal barter-system."

Those clinics which take a harder lineon financing are usually the ones thatserve an ethnic or working class community rather than a younger, freakierpopulation. In one such clinic, a recent decision w as m ade to have a receptionist askfor $3 donations per visit, rather than havethe donations can speak for itself. "If thisis going to be a community clinic, thecommunity has to support it.

Other free clinics lean on public agencies, Medicaid and medical institutions forsupport. The City of Berkeley now helpssupport three free clinics. The Berkley FreeClinic submitted a budget request of $29,-000 noting that it treats 75 percent of theVD in the City. The Blackm an 's Free Clinic

in San Francisco gets its facility from theRedevelopment Authority. Virtually allfree clinics receive penicillin for VD treatment free from City Health Departments.(In some instances. City depar tments havetried to "rip-off" the clinics; in one citythe public hospital started referring patients to the free clinic for physicals. Inanother, the health department ran out oftetracycline for VD and the free clinic hadto supply the city.) In Minneapolis freeclinics have charge accounts at either theUniversity of Minnesota Medical School

or Hennepin County General Hospital toward w hich they can charge p urchases oflaboratory tests, drugs and supplies; theyalso have arrangements with hospitalsand schools for back-up facilities, andtraining programs.

In Chicago, several clinics while fight-

"We feel we cannotcontinu e to serve p eop lein a hu m ane, comp re

hensive, consistent andconfid ential m an ner ifthe d em and for servicescontinues to in crease atthe present rate."

A Minneap olis Free Clinic

ing to survive efforts by the Daley m achineto shut them down, managed to use thestruggle to win sustained support from themedical schools. The clinics mobilizedsupport from the student bodies and woncontracts for financial and professionalsupport from the institutions, without losing their independence and communitycontrol stance. Other clinics are muchmore uptight about taking money or services from medical schools or hospitals.Up until now no strings have been attached to the subsidies free clinics receivefrom local hospitals, medical schools andcharitable organizations. However, somefree clinic staff members are worriedabout what the future will brin g: "Takingmoney from the medical school is fine butwhat happens next year if after we're dependent upon it, the medical school demands we allow our patients to be usedas teaching m aterial?"

Those clinics which are located in work-inq class or ghetto neighborhoods also

take advantage of Medicaid reimbursements. (The clinics which serve youngdrop-out populations find that their patients are too mobile and unwilling to gothrough the hassle of proving Medicaideligibility, to make the effort worth it.)Most of the clinics which actively pursuethe Medicaid route get about $50-$60 perweek from the effort. Gener ally, the volun teer doctors will submit the bills for reimbursement to the state as private prac-ticioners and then turn the check over tothe clinic.

On e clinic decided to take a "pr incipledstand" with the local Medicaid bureaucracy and demanded the right to billMedicaid directly. It took over a year towin the ensuing fight. Medicaid refusedto give them reimbursements if they refused to post a fee schedule in the clinic.

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arguing that they shouldn't be paid forservices which are free. The clinic maintained that they wouldn't compromise theprinciple that medicine should be free atthe point of delivery. Finally the clinicagree dto post a sign stating how much avisit costs the clinic. They th en put a statement in their newsletter: "Our services

are available free, not because we havelots of money, but because we believemedical care should be free. It should beavailable to anyone regardless of howmuch money he or she may have."

Some clinic people plan to parlay thirdparty payments like Medicaid into majorsources of income, rather th an the sp oradic drips and drabs most clinics now get.On e clinic is planning to start a camp aignto get Medicaid patients through thedoors: "If we can get enough eligible patients in here, we can pay some staff andstay open during the day." Free clinics,like every other form of health delivery inthe country, are keeping an eagle eye onfederal legislation. Some would like to believe that "national health insurance willmake us self-sufficient and guarantee ourindependence."

Cont ro l

Free clinics, by and large, are struggling to achieve new forms of decisionmaking against great obstacles. Most

clinics are experimenting with variationson commu nity/ worker control.

Decision making occurs on many levelsthroughout the operation of a free clinic.Day-to-day administrative decisions areusually made by paid staff, where theyexist, or by the coordinator on duty at thetime. Medical decisions, occurring duringan evening's clinic, will most often fallupon the doctor. A few clinics have meetings before and after every clinic sessionattended by all clinic staff. They are usedto p lan and then review clinic proceedu re;discuss medical problems and decisions;and subject individuals to criticism orpraise when called for. These meetingshelp establish a collective spirit but evenin those clinics which don't follow thisdiscipline, a collective identity usuallyemerges from just working together.

Decisions which refer to overall clinicpolicy are usually handled by a committee. In one form, this committee (frequently known as the Steering or Central Committee) is composed of representatives of

each night's clinic, or of each job function(nurse, lab tech, etc.). In those clinicswhich have strong political ties, decisionswhich affect the political stance of theclinic are not likely to rest with clinic staff,but will be made by the political group.

Despite medicine's tradition of over

bearing professionalism, there have beenfew instances of doctor-takeovers or casesof the doctors-versus-everybody-else infree clinics. Only one clinic staffer feltthat: "In all honesty, when you really getdown to it, the doctors hold the p ow er." Infact, in most clinics, doctors seem to playa disproportionately small role in ioim al

decision-making processes. For some, thiscomes from a highly sensitive consciousness about the pitfalls of professionalism.For others, however, it seems that theydon't really care how the clinic is run; orfeel that they can't devote the time necessary to become involved in decision-making. Some doctors have been given furtherlessons in deprofessionalization by thecollective process, where it exists. A clinicstaff mem ber asser ted : "The staff processand interaction imprints itself on the con

sciousness of the entire staff. . . . Manydoctors thought they were going to havemore power, not less."

Virtu ally all clinics emerge from or seekorganized community support beforeopening. Several clinics have boards composed of representatives of communityorgan izations. In most, these community affiliations have little to do with the directionof the clinic. Their support and goodwillhelp identify the clinic with the community. Some clinics have made special effortsby sponsoring street festivals, currying

favor with local merchants, etc.to become 'community institutions.' For ElCentro de Salud, this really paid off whenthe landlord attempted to cancel theclinic's lease and several hundred residents demonstrated in front of his place ofbusiness. Only one clinic has opened itspolicy-making up to anyone who attendsthe monthly clinic meeting. However, despite the fact that community suppers areheld prior to the meetings, community attend ance h as disappointed the clinic staff.

In most clinics, patient or community

control is far m ore rhetorical than real andfar less close to realization than workercontrol. One obvious obstacle is theamount of time that goes into running afree clinic and the exhausting hours thatthe clinic staffs keep.

In spite of differences in organizationand patient populations free clinics arestrikingly alike. Free clinics are all serving medically disenfranchised patients;they are all squeezing by with limited resources an d hard -pressed volunteer staffs.

In addition to looking like each otherthey also re semb le the traditional hospitalOut-Patient Department. Wh ile free clinicshope to serve a s altern atives to, substitutesfor, or competitors with OPD's, they findthemselves taking on many of the most-hated aspects of OPD'srather than taking them on.

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WHAT DOES

IT COST

TO BE

FREE?

In the beginning, free clinics appeared tobe a response to the needs of the youthculture movement. The new life style, withheavy emp hasis on mind expand ing drugsand communal living arrangements, resulted in a rash of health problemsfrombad drug trips to nutritional deficiency.Traditional medical institutions were unsuited to the value system and the problems that the young patients had. For in

stance, kids on bad trips seen in emergency wards, often ended up in mentalhospital wards, if they were lucky, in jailsif they weren't. Rather than risk incarceration, man y young p eople went untreated.

However, it doesn 't take m uch digging torecognize that free clinics are not just arespon se to youth culture needs. They alsohave broad appeal in Black, Puerto Ricanand Chicano communities. To people traditionally barred from medical institutionsbecause of racism, cost and location, theattractiveness of "free" institutions, more

accessible to their neighborhoods and perhaps even to their control, is evident. Freeclinics rose on the wav e of "bla ck p ower"and "comm un ity contro l" to meet the centuries of unm et hea lth need s in ghetto communities across America.

Free clinics are not just a response tothe unmet needs of Black, Puerto Rican,

Chicano, or hip communities. They are aresponse to the failure of America's traditional health institutions. The failure ofdoctors not only to treat bad trips, but toprovide any minimal standard of care inghetto communities; the failure of hospitals to break down the hierarchy amonghealth workers that fosters poor patientcare; the failure of Blue Cross, and nowMed icare a nd Medicaid to eliminate financial barriers to decent medical care. Freeclinics are a response to the crisis in theAmerican medical care system.

A t t r ac ti o n s an d D e t r ac t io n s

The free clinic response is indeed an attractive one. On the one hand, it directlyserves peop le. It is a positive, concrete |step toward a vision of the health systemas it should be in the future. "Peop le hav e \

been promised change for so long, theywill no longer accept your word for it.You've got to show them it can be done."Free clinics also provide rewards forthose that work in them. Free clinics areone of the alternatives that V ocations forSocial Change talks about, when it says,"[Ther e] is a growing aw areness that thekind of roles we are all being preparedfor in this societyhousewife, factoryworker, executive, welfare recipient, etc.cannot satisfy either our persona l needsor our collective needs, and that alterna

tives must be found." Free clinics fit therhetoric"do your own thing" and "buildalternate institutions".

This attractiveness of the free clinicmovement can disguise the limitationsmanifest in current free clinic practice.Many of these shortcomings are discussedin the description of free clinics at the beginning of this BULLETIN:

Free clinics are not successful ineliminating some of the principle disadvan tages of out-patient d epa rtm ents: waiting time is long, there are no appointments, follow-up is shoddy, continuity ofcare is almost impossible.

Free clinics are just as dependent ona limited supply of doctors despite theiremp hasis on skills transfer.

Free clinics, becau se of limited resources, must make serious trade-offs:for example, if quality care is to be givento each p atient, then fewer patients ca n beseen.

Free clinics m ay d emystify medicine, by removing the doctors' white

coats and by taking away some of their"p rofessiona l" preogatives, but they oftenfall short of educating patients about theirillness or about the politics of the healthsystem.

Free clinics, by and large, ha ve notbeen able to overcome the obstacles tocommu nity/ worker control.

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If free clinics have a limited effect onpatients and workers, their record in thecommunity is equally disappointing. Freeclinics offer, real opp ortunities for community outreach and political educationabout the health system. They could initiate programs of door-to-door screeningfor anemia, lead poisoning and tubercu

losis. They could indict landlords, CityHealth Departments and even m edical empires for neglect of these health problems.But few clinics have had the money ormanpower, to say nothing of the politicalanalysis, to realize this potential. Freeclinics fear being overburdened by thehealth problems they discover. They donot see outreach as an opportunity to pushon the r esponsibility of the dominant h ealthinstitutions in the community.

Few clinics hav e the vision of the Youn gPatriots Organization in Chicago, whichhopes to develop a "health cadre" to provide emergency care, treatment of minorillnesses, screening services and offermed ical ad vice and assistan ce on-the-spotin every apartment house in Uptown. Asone youn g Patriot put it, "I can treat n inetypercent of the patients walking in theclinic. I can't see why we can't trainother community people to do the same.If we find problems we can't deal with,then we'll force the hospitals to help."

A l te rn a t e In st it u t io n sIt is an assumption of many free clinic

advocates that "Free clinics, as alternateinstitutions, are threats to the system".This is an elusive concept. Free clinicsaren't competitive with existing health institutions. No doctor's office or hospital'sclinics is threatened with closure by themere existence of a free clinic. While freeclinics, in and of themselves, are not athreat to the system, those free clinics thatsupport community struggles against thehealth system are closer to that ideal.

But there is a fine line between challenging the health system and actuallydoing its work. Free clinics actually takethe heat off other health institutions byfilling the gaps which they have left, whilestill maintaining th e community's ultimatedependence upon local medical institutions. Free clinics admitted they were nothassled by the establishment becausethey were doing the system's job. This became blatantly obvious when one localcity hospital began to refer patients to thefree clinic for physical examinations. Inanother city, wh en the H ealth Departmentran out of tetracycline, they came to thefree clinic to replenish their supplies.

Another free clinic assumption, "We'refree therefore we're political", collapseswith more carefu l examination of the p ricefree clinics pay to remain "free." Most

"If w e could do our jobpolitically, they'd closeus down in a w eek."

free clinics depend on hospitals, drugcompanies and City health departmentsfor supplies, manpower and grants. It canbecom e difficult to bite the hand that feedsyou. As one clinic spokesman said, "Taking money from the medical school is fine,but what happens next year if after we'redependent on it, the medical school de

mands we allow our patients to be usedas teaching material?" As long as clinicsdepend on institutions in order to providetheir free services they will be deterredfrom conflict with the existing health system. The amount of time it takes to simplyrun a clinic can also deter them from taking an active role vis-a-vis institutions. Asone clinic person said, "If we could doour job politically, they'd close us downin a w eek."

In addition, if free clinics become moreeffective in community outreach, they will

become more desirable plums for themedical institution pie. Free clinics can relate to popu lations that staid m edical institutions find it difficult to accommodate.Thus free clinics may become friendlyoutposts in the hostile communities thatsurround many of the major medical institutions in America. So existing medicalinstitutions may have a real interest infree clinics and a desire to incorporatethem into their own framework. Perhapsthis explains the willingness that an increasing number of medical schools andhealth d epartments have demonstrated insupporting free clinics.

Ins t i tu t iona l Confron ta t ion

Providing service is one resp onse to thefailure of the American health system. Itis attractive because of the tangible alternative building that it offers. Institutionalconfrontation is another response, thoughstill somewhat untried, that offers potential to effect far-wider change. The powerand resources of the American health sys

tem lie in institutions. Therefore, changesin institutions have great consequence forthe d elivery of health care.

Institutional struggles affect the lives ofthose working in institutions as well asthose using them. Institutional confrontation targets the struggle at those mostresponsible for the failure of the system.

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The Young Lords Party in New YorkCity decided not to establish any freeclinics in El Barrio. Rather they sought tochallenge existing health institutions toperform their stated functions. TheLords exposed the Health Department fornot usng its 40,000 lead poisoning testing

kits by demanding that the Health Department release some of the kits for a YoungLords' screening program. In another program, the Lords discovered 800 positivetuberculin cases through door-to-doorscreening in East Harlem. The next stepwas to have the people X-rayed. TheLords found that patients had to wait upto 6 hours in the local hospitals just to geta chest x-ray. Few patients could affordto miss a day's work or pay for a babysitter. Therefore, the Lords asked theHealth Department to re-route one of its

mobile chest X-ray units to East Harlemto do the necessary testing. When theHealth Department refused, with mediapresent the Lords hi-jacked the truck (w iththe cooperation of the driver and x-raytechnician) brought it to East Harlem andtook the necessary X-rays.

Institutional confrontation also has thepotential to resolve many of the contradictions that presently abound in freeclinics. It unites the disparate forces thatrelate to free clinics. Patients can becomeinvolved with the free clinic around its

struggle with other health institutions.Health workers can connect their freeclinic work with struggles in the institutions where they train and work. Institutional confrontation brings new problemsto free clinics, but helps resolve many ofthe old ones.

Ch icagoTh e H ub

Several of the free clinics in Chicagohave adopted this approach, both out ofchoice and necessity. Their early requestsfor back-up services and specialty con

sultation developed into confrontation situations. At Weiss Hospital, located in thesame neighborhood as the Young PatriotsClinic, there was considerable resistanceto developing a relationship to the freeclinic. Severa l d emonstrations w ere n ecessary to convince the hospital that it shouldaccede to community requests. At Northwestern Medical Center, the path waspaved by the active support of medicaland nursing students in coalition with hospital workers. Many of these students andhealth workers also worked in the LatinAmerican Defense Organization (LADO)free clinic located in a Latin Americanneighborhood on Ch icago's north side. Thestudents had pressed their own demandsfor minority ad missions and improvementin the outpatient clinics through a 24-hoursit-in in the deans office, prior to LADO'sdemand for a contract w ith N orthwestern.

This history facilitated LADO's negotiations with the medical center.

The contract includ es ( 1 ) that referra lsfrom the LADO clinic be accepted atNorthwestern Outpatient Laboratory andClinics (2 ) that Northwestern extend m alpractice insurance to cover professionals

who work at the LADO clinic (3 ) thatNorthwestern provide $1000 per month indrugs, supplies and equipment to theLADO clinic for one year ( 4 ) that Northwestern waive fees for patients who areunable to pay.

The contract finally signed by Northwestern was used by LADO to pressureSt. Mary's and St. Elizabeth's Hospitals,two community hospitals, to admit Spanish-speaking patients. In the past, St.Mary's had refused to take any obstetricalpatients from the Spanish-speaking com

munity because an administrator said,"We can't understand them and theyscream too much."

Over the past year, Chicago's freeclinics have also been involved in a continuous struggle with Mayor DaleysBoard of Health, which has been trying toclose down the free clinics. Chicago is theonly city where the mere existence offree clinics was found to be politicallythreatening. Thus Daley's Board of Healthhas decided to employ an end-run aroundthe free clinics by opening up eight new

clinics, virtually adjacent to the existingfree clinics. The LADO clinic has beenable to raise sufficient community pressure together with student and healthworker support at Northwestern MedicalCenter, to prevent the opening of theBoard of Health Clinic in their neighborhood.

The Young Patriot's Community HealthService adopted a different tactic towardthe Board's clinics. Rather than try to stopthe opening of the Health clinic, the YoungPatriots have insisted that the City clinicprovide better services. In November, 1970,200 people occupied the Uptown Board ofHealth Clinic and demanded "24-hour aday, seven days a week, full health services as well as free transportation andchild care." In addition, the protestors insisted upon "full community control ofclinic policy and personnel."

The Chicago free clinics maintain a constant barrage of criticism aimed at thehealth establishment. Hospitals that failto deliver services are challenged. Freeclinics are the base from which community and health worker activists attack institutions. The mimeograph machine is asimportant as the stethescope. Besidesmaintaining a high level of institutionalconfrontation, many of the Chicago freeclinics have encouraged professionals thatwork in the clinics to organize in their ownhospitals as well.

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For some people working in free clinics,the time commitment is so great that theyfeel extremely pressed. As one Chicagomedical student put it: "I think the freeclinics are the most important political development in the city. But the time involved is so great I can't do anythingelse." Another Chicago doctor suggests

the solution to this dilemma is "to encourage loose hospital-based collectives . . .it's easier to develop the consciousnessneeded to continue the struggle back atthe hospital itself."

Alliances betw een community organizations and workers within health institutions have contributed to the viability ofthe Chicago free clinics. Thus Daley con

tinues his efforts at repression. Most recently, Obed Lopez, a lead er of LADO wasarrested for "op erating a clinic without alicense." When he objected that he wasnot personally responsible for the clinic'soperation, the arresting officers demandedthat he turn over the nam es and ad dressesof all personnel who work in the clinic.

When he refused to do this he was jailed.The Chicago free clinics have seen

themselves as more than alternate institutions. They have seen the necessity andused their opportunities for institutionalconfrontation. Unless other free clinicsadopt this course, they will either witherand die or become incorporated into theestablished health delivery system.

WOMENS

CLINICS

In recent months the id ea of women's freeclinics has swept the women's movement.In March, the Berkeley Women's HealthCollective started Women's Night at theBerkeley Free Clinic; in April, women inBaltimore and Seattle did likewise. In

May, free clinic discussions were high onthe agenda of the Women's Health Conference in New York City, (see box, page16.) At least half a dozen more women'sclinics are planned to open before theyear's end.

The development of women's clinicsrepresents to some extent the overlapping

of three already existent movements: theFree Clinic Movement, th e Wom en's Movement, and the Health Movement. In anumber of cases women's clinics are inpart a reaction to the overt sexist treatment women were receiving at regularfree clinics. "The doctors were saying thatthey were tired of looking at vaginas.They would do crude pelvics and makeinsensitive and moralistic comments tothe women."

In starting their own free clinics womenhave extended the ethos of the larger

women's movement into the arena ofhealth. In d oing so they h av e come closerto achieving some of the most significant,but ofttimes, only rhetorical goals of theFree Clinic Movement, than their male (o rcoed) colleagues. By "putting women'sliberation into practice" women's clinicsattempt to give substance to the right ofwomen to control their own lives andbodies. The substance consists of the destruction of the psychological and biological myths which are used to oppresswomen; the demystification of m ale-

monopolized knowledge and skills; andthe development of self-sufficiency, self-control and self-confidence. Add to thisthe ethic of lead erlessness and sisterlinesswhich has characterized consciousnessraising groups and it is not difficult to seewhy women's free clinics have donemore to demystify, democratize and depro-fessionalize health care than other freeclinics. Everyone who works in women'sclinics (including male doctors) keeps returning to the same point: "You have tobe here on womens night to sense the differenceI can't explain itIt's just theentire atmosphere."

While many of the things that go intowomen's free clinics may be hard to explain, some of what accounts for the atmosphere is obvious. There is a heavyemphasis on consciousness raising and

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body knowledge. In fact, women's groupshave been duplicating one another's efforts by producing literature on womenand their bodies. Clinics have rap groupsin the waiting rooms. Women's counselorsor her story-takers attempt to work withina large definition of women's health: "Awom an's medical needs a re p sychological

as well as p hy sical." Wom en's free clinicsare also more cautious, about the u se ofdoctors and more adventuresome aboutthe use of paramedics. Thus, a patientwill never be examined b y a doctor alone,but she may be examined by women whohave been trained to be "pelvic teams."Women's free clinics, while very informal,appear to maintain a disciplined approachto decision-makingwhich is collective.The doctors, being mostly male, are excluded from policy making. This meansthat at the same time women run their

own clinic, they tend to deprofessionalizeit.

F ro m T h e W o m e n 's M o v em e n t

The Women's Liberation Movementgrew out of the recognition by white, middle class, often radical, women of theirfixed roles in society. In spite of the far-reaching significance and potential of thewomen's movement, the fact remains thatthe most profound effects thus far wroughthave been in the consciousness and per

ceptions of women who a re defined by theirclass and education as well as their sex.The women's movement is now faced withmany problems. Among them, simplystated, are the needs to act; to broad en thebase of the women's movement; and toaffect major social institutions.

Women's free clinics are a response tothese needs of the wom en's movement, aswell as a reaction to the male chauvan-ism which is encountered in free clinics.

Women's free clinics provide a concrete situation in which women can learnand share medical as well as organizational skills, attack the hierarchies of professionalism, and gain the confidencewhich comes from running their own institution to meet their own needs. Women'sfree clinics offer some badly-needed services and in the process attract womenwho would otherwise have little opportunity for exposure to the women's movement. This exposure takes place indirectlythrough the general atmosphere of theclinic as well as directly through the emph asis placed on counseling, rap sessions,health edu cation (literatu re, movies, et c.).Just as women's clinics serve to recruitwomen health workers into the women'smovement, the reverse is also true. Increasing numbers of women are beingattracted into health science schools because of their activity in free clinics.

Free clinics, while they require monumental effort (particularly if organizedfrom scratch) represent an immediate,concrete, and tangible outlet for the needfor action. "We don't feel like we havethe answers, and sometimes we're noteven su re abou t d irection, but at a certainpoint we had to take the plunge or else

just sit arou nd ta lking forev er ."Finally, the problems associated with

the middle class origins of the women'smovement can be blurred in the settingof a free clinic. Here the organizers andstaff, generally white, middle class, pro-fesionally trained or at least collegetrained, can be relatively honest abouttheir identity. They offer services whichcan be accepted or rejected, and acceptance is testimony to their need andrelevance.

Pro b lem s o f Wom en 's Clin ics

The use of free clinics by the women'smovement does raise several questions,despite the fact that it also answers somany. It is quite striking that while thewomen's movement has struggled to debun k the definition of woman-as-reprodu c-tive-beast, women's clinics and the healthissue tend to reinforce the image. The onlyhealth problems which pertain to womenand women alone are those focusing onthe female reproductive system; women

are more likely to bring these kinds ofproblems to a women's free clinic. In thiscontext, it is easy to focus on women asusers of contraceptives, seekers of abortions, bearers of children, victims of VDand vaginitisi.e., as a collection ofovaries, uterii, vaginas and other sexualappurtenancesand thus fall prey to adefinition not dissimilar to that traditionally placed upon women. Those clinicswhich want to offer pediatric services inorder to attract neighborhood mothersappear, on the surface at least, to be step

ping further into that definition.In terms of consciousness raising andbroad ening the base of the wom en's movement, another active woman voiced animportant concern, "When women comehere they are in a crisisthey don't wantto hear about women's oppression or consciousnessthey want out of that crisis."

C h a l len g i n g t h e H ea l th S y st em

Women's free clinics raise the same setof questions about affecting health institutions that regular free clinics raise (seepages 10-13). Strangely enough, however,the very reasons which make free clinicsso valuable and exciting within the women's movement, seem to be wiped outwhen one talks about affecting existinghealth institutions. The principle of "forand by women" becomes less important

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and the class basis of the women's movement become more marked in the face ofthe health system.

Certainly sexism accounts for much ofwomen's greater use of the health system,the added humiliation and objectificationwomen encounter there, and the more general use of biological ignorance and mys

tification as tools of women's socialization. However, the source of poor healthcare is mainly in social class and in theprofit system, and not mainly in sexism.Men, when th ey must d eal with the healthsystem, a lso suffer from its inaccessibility,expense, fragmentation, and alienation.In fact, it can be argued that men are asignorant and alienated from their bodiesand bodily processes as are women. Thedifference is that this ignora nce and alienation is not used to oppress men as men.

Women's free clinics also sidestep important questions of class which are

raised if one wishes to talk about confrontin g not sid estepp ing the healthsystem. Women's free clinics will be inthe sam e bind s a s other free clinics if theyattemp t to deal with the total health need sof their patients, m uch less the total fem alehealth needs of older and/ or poorerwomen. These women are primarily de

pendent on major health institutions, hospitals and out-patient departments fortheir medical services. While free clinicsmay substitute for the private gynecologist that most women who set up freeclinics could be using, they cannot substitute for the major health establishmentsused by other women. Thus while freeclinics may be designed to extend thebase of the women's movement beyondthe middle class, they are not designedto meet the working class woman's healthneeds, nor challenge the institutions thatdefine and serve her needs.

Womens Health Conference Report"Womenboth health workers and community women have been workingin Free Clinics in mixed groups for quite a while. Increasingly women havebeen demanding (a) that the blatant sexism in many clinics should go (b)that there be special sessions for women controlled by the women health

workers (c) that basic health education as well as specific treatment must go on.In other cities groups of women have actually set up special women and children's clinics or are planning to do so. In these free clinics women are increasingly learning bas ic medical and organizational skills.

One of the most important results of all this work has been the changes inthe lives of many of the women. Previously self-conscious, and dependent,many of us have learned to speak in public, write, help run organizations anddo work that we really care about. By and large this has happened not throughthe struggling competitiveness we are all raised to but with the help andsupport of a group of wom en. It would not have been possible without the groupconsciousness of the Wom en's Liberation Movement.

It is significant that the three types of work we've been most successful in

doing are outside the organized health system. [The two others being healthedu cation and referral and lega l work around birth control and abortion issues.]We like other parts of the radical movement have been partially successful insetting up our own 'free' space. But most of us want more than this. We wantto radically change the health system so that it meets everyone's needs. Allof us at the conference were conscious that we, as consumers of health care,must attack, pressure and agitate around health institutions, departments ofhealth, laws and legislation. We are conscious that the only chance we have ofeffectiveness is to organize groups of women to demand their right to controltheir bodies and to adequate health care . . .

Thus it is clear that much of our ability or our potential ability for affectingthe health institutions comes out of our day to day concrete workthe abortion

referrals, the education and the free clinicssince they provide us with organization, experience and satisfaction. However as women repeated again andagain during the conference, while work in an 'alternate' system MAY leadto struggles against the larger system it does not NECESSARILY do so, especially since much of the work is time and energy consuming. Therefore wemust constantly CHOOSE to talk, write, and act to make the connections to thewider health system."

-M a y 7 *9 .1 9 7 1

16

1971 october corrected

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