DOCUMENT RESUME

ED 088 303 HE 005 092

TITLE Philadelphia Student. Health Project Summer 1968.INSTITUTION Health Services and Mental Health Administration

(DHEW), Bethesda, Md.PUB DATE 69NOTE 140p.

EDRS PRICE MF-$0.75 HC-$6.60DESCRIPTORS *Health Occupations Education; *Health Services;

*Higher Education; Poverty Programs; School CommunityRelationship; *Student Experience; *StudentProjects

IDENTIFIERS *Philadelphia; Student Health Organization

ABSTRACTThe Philadelphia Student Health Organization Summer

Health Project had as a purpose to collect information relevant tothe following categories: (1) descriptions of new kinds ofcooperative arrangements; (2) descriptions ol features of communityorganizations; (3) description of the health status of poorpopulations; (4) evaluation of the present adequacy of health careprograms; (5) estimation of health attitudes of poor populations; and(6) descriptions of new methods for obtaining information relevant tothe above questions. Section I of the report provides some backgroundinformation to help orient the reader to the project. Section IIpresents papers concerning the problems assessed by the StudentHealth Organization. Section III contains project worker personalcontact reports. Section IV presents an evaluation of the educationaland attitudinal impact of the project on student participants as wellas some general comments on the significance of the project as awhole. The various research instruments designed and used by theresearchers in obtaining their information are contained in theAppendices of Section V. A list of the projects and the projectparticipants appears in Section V also. (Author/PG)

PHILADELPHIA STUDENT HEALTH PROJECT summer 1968

i// '""

U.S. Department of Health, Education, and WelfarePublic Health Service

Health Services and Mental Health AdministrationDivision of Regional Medical ProgramsThis project was supported in full by

(Contract No. 43-68-1533)

This report does not necessarily represent the views of the Public Health Service

PHILADELPHIA

STUDENT HEALTH PROJECT1968

FOREWORD

The reports included in this volume describe the variety of experiencesavailable to health professional students during the summer of 1968. Al-though some accounts of activities are more complete than others, somefar more sophisticated than others, and many are naive, the impact of allthese experiences on the reader is profound.

Young professionals, at the threshold of their careers, have had areal opportunity to observe the complexities and inequities of our healthand welfare delivery systems, and to record their impressions of theseexperiences.

The interest expressed by Regional Medical Programs in service deliv-ery systems has been served well in that the participants were enabled toobserve at first hand the current problems in the delivery of services. Itcan be predicted that none of these students will be content, in the future,blindly to accept the status quo.

These students have worked conscientiously and maturely in accom-plishing their goals. I consider it a privilege to have been associated withthem and with the Student Health Project, Philadelphia, 1968.

ROBERT L. LEOPOLD, M.D.,Associate Professor of Clinical Psychiatryand Director of Division of CommunityPsychiatry, Department of Psychiatry,University of Pennsylvania

Director, West Philadelphia CommunityMental Health Consortium

Director, Student Health Organization

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Preface and Acknowledgments

The Philadelphia Student Health Organization Summer Health Proj-ect cwas funded by the Division of Regional Medical Programs (Contract#PH-43-68-1533), and the work-scope of the contract indicated that thepurpose of the project was to collect information relevant to the followingcategories :

1. Descriptiols of new kinds of cooperative arrangements.2. Descriptions of features of community organizations ; how they

facilitate arid/or block attainment of RMP objectives.3. Description of the health status of poor populations.4. Evaluation of the present adequacy of health care programs.5. Estimation of health attitudes of poor populations.6. Descriptions of new and creative methods for obtaining informa-

tion relevant to the above questions.

This report is, therefore, primarily a response to the contractual agree-ment with the Regional Medical Programs. The papers of the projectworkers are collected in sections II and III together with comments bythe research directors, Miss Karen Lynch and Mr. Jon Snodgrass. Thesesections are the core of the report and contain the material relevant tothe stated purpose of the project.

Section I provides some background information to -help orient thereader to the papers that follow. Section IV presents an evaluation of theeducational and attitudinal impact of the project on student participantsas well as some general comments on the significance of the project as awhole. The various research instruments designed and used by the re-searchers in obtaining their information are contained in the appendixesof Section V. A list of the projects and project participants appears inSection V also.

In addition to Drs. Richard F. Manegold and Herbert 0. Mathewsonof the Division of Regional Medical Programs, other individuals andgroups who were instrumental in making the project possible are thefollowing: George Silver, M.D., Joseph English, M.D., Mrs. Edna Rostowand Mrs. Carol Simons, who helped with negotiations in Washington dur-ing the winter and spring of 1968; Leo Molinaro, I. Milton Karabell, andmembers of the Board of Directors of the West Philadelphia Corporation,who approved the arrangement whereby the corporation acted as thegrantee and official administrator of the funds of the project; GaylordP. Harnwell, who was instrumental in providing for use of Universityof Pennsylvania ft'nds by the project, later to be reimbursed by thegovernment on presentation of vouchers ; and, finally, Robert L. Leopold,M.D., and almost the entire staff of the West Philadelphia CommunityMental Health Consortium, on whom the project depended for counseland support throughout its course, beginning in the fall of 1967 when

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organizational work began. These people and many othersstudents,school administrators, secretarieshelped with the many little stepswhich ultimately lead to the project becoming a reality.

Patrick Storey, M.D., acted as liaison between the Division of RegionalMedical Programs and the Philadelphia SH.O's during the crucial periodin May when agreement was essentially reached.

This Report was edited by Jon Snodgrass, Karen Lynch, and PaulFrame.

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Table

of

Contents

FOREWORD, Robert H. Leopold, M. D. ii

PREFACE. AND ACKNOWLEDGMENTS iii

SECTION I. BACKGROUND TO THE PROJECT, Ron Blum 1

SECTION II. PROBLEM PAPERS, Karen Lynch 3

Student Health Organization in the Community ..... ... . 3Gray's Ferry, Summer 1968 41400 Block, South Taylor Street 8The Pocket 10

HealthA Priority Item 12Complex Problems in Ludlow 13Eastwick Survey Report 13Report on Community Work With The Paschall

Betterment League 15Welfare Rights Organization 17

Community"Establishment" Relations 18Community Pharmacies in North-Central Philadelphia 19Philosophical Conflicts of the Temple Community

Mental Health Center's Day Program 20The Saga of Fidel Cruz 21Presbyterian-University of Pennsylvania Medical

Center (I) 22Presbyterian-University of Pennsylvania Medical

Center (II) 27

Student Health Organization and Health Professionals 33The Unexplored : SHO Working in Poor White

Communities 34The Effect of Inappropriate Reinforcement System

on Program Establishment : A Case Study 35Professionals' Values and Their Consequence on

Serving Clients 39Eagleville 40Mantua and Mantua Community Planners (1) 41

Mantua and Mantua Community Planners (II)Various Mental Health Problems 45

Organizing Mental Health Services 45Proposal : Summer Training Program for Medical

School Students 46

The Recreation Project for One Psychiatric Service:Two Points of View (I) 47

The Recreation Project for One Psychiatric Service:Two Points of View (II) 49

Horizon House 50Planning and Developing Programs 51

Changing Direction at Southwest Center City CommunityCouncil: From Survey to Proposal 51

What is Public Health? (Delaware County) 56The Wee-Care Babysitting Service 60The Photography Club at St. Christopher's 62

Some Other Interesting Experiences 63HawthorneViewed by a Staff Member, a Student,

and a Community Worker 63Teaching Sex Education Classes at Hartranft

Community Corporation 65Preparing a Community Health Booklet at

Houston Community Center 67Working With Pernet Family Health Service 67Holmesburg Prison Project 68Drama as a Means of Changing Health Professionals'

Attitudes 69Misericordia Hospital 69

SECTION III. PROJECT WORKER PERSONAL CONTACTS, Jon Snodgrass 77

St. Christopher's Child and YouthComprehensive Care Center 78

Spring Garden Community Center 82

SECTION IV. SHO'S SHOW : AN EVALUATION OF THE PHILADELPHIA

STUDENT HEALTH ORGANIZATION SUMMED. PROJECT,

Jon Snodgrass 85

Background Characteristics of the Health ScienceStudents 87

Student Education 93Students' Ideology 95Attitude Change 96Student Accomplishments and Student Perceptions

of Philadelphia Student Health Organization 102Penn Medical Student and PSHO Medical Student

Comparison 104

SECTION V. APPENDIXES 113

Appendix 1. Pre-Test Background Questionnaire 113Appendix 2. Post-Test Background Questionnaire 114Appendix 3. Attitude Scales 117Appendix 4. Guidelines for Problem and Community

Papers 127Appendix 5. Personal Contacts 130Appendix 6. Project List: Project Sites and

Participants 133.

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Section I

BACKGROUND TO THE PROJECT

Ron Blum

The genesis of the Student Health Organiza-tions in Philadelphia can be traced to the at-tendance at the Second National A3sembly ofthe Student Health Organizations held in NewYork in February 1967, of about half a dozeninterested medical students from PhiladelphiaIn 1966 the first summer project was con-ducted in California and two medical studentsfrom Philadelphia participated. After the NewYork assembly, citywide meetings were heldin Philadelphia, at which plans for a Philadel-phia Student Health Organization were dis-cussed and the prospects for a summer projectin 1967 were considered. Though this projectdid not materialize, local activities did begin,as the SHO philosophy became dispersed tothe student bodies. The interest generated atsome of the schools waned as the school yearended, but several more students from Phila-delphia schools participated in the California,New York, and Chicago summer projects in1967.

During the summer of 1967, some studentswho remained in Philadelphia made importantinquiries toward establishing a summer proj-ect, and promoted with increasing enthusiasmthe considerations of such a program in Phila-delphia. In September 1967, at a meeting heldto report on SHO experiences, an unantici-pated surge of interest forced standing roomonly. Full efforts were thereafter directed toestablishing SHO chapters at the Philadelphiaschools and directing full strength toward or-ganizing a summer project. A Student HealthSteering Committee evolved that made thenecessary contacts and wrote and rewrote

grant proposalsmodeled after the other proj-ects, but with important major revisions andalterations based on the experience and ideasof those on the steering committee, which byearly winter wzs steadily expanding in size.At the same time proposals were being written,many community groups, agencies, and indi-viduals were approached, both as prospectiveproject sites, and in some cases as possiblefinancial resources. Committees worked also inseeking support of faculty members and thedeans of the medical schools.

The individuals involved in setting up thePhiladelphia Summer Project 1968 attend thesix area schools of medicine (one osteopathic),several nursing schools, and various graduateschools, representing a coordinated effort that,in itself, was an experience in interscholasticcooperation. The project was designed to ex-pose health science students to the patient asa social being. At 35 community and agencyproject cites, 74 students, 21 community work-ers, and 20 high school interns worked underselected preceptors. The sites were predomi-nantly in lower socioeconomic level communi-ties that included Caucasian, Puerto-Rican, andNegro slums. Placements were selected thathad potential to provide a good learning expe-rience while offering students opportunities todevelop judgment and initiative in construc-tive community action. The freedom to directtheir activities was left with the project fel-lows and the preceptors. Summer project staffwere oriented to support, not direct.

The philosophy of managing the studenthealth project might best be reflected in part

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by a brief consideration of the roles and struc-tures involved :

a. The project fellow was a health sciencestudent in the fields of medicine, nursing, den-tistry, law, social work, pharmacy, or psychol-ogy. He worked for a 10-week period.

b. Community workers were individuals whoresided in the immediate community of theproject site where they were hired to work.They were adults working shoulder to shoulderwith students. They served as liaisons with thecommunity and now remain as vital contactsfor continued community programs.

c. Youth interns were high school studentswho fit similar criteria as the communityworkers. These students worked closely withtheir health science student counterparts andin the process developed, it is hoped, an inter-est in health science careers.

d. The project site was the organization,agency, or office where the project participantsworked. Health science students were allowedto indicate preference of job site, and disposi-tions were made on the basis of request when-ever possible.

e. The preceptors were individuals, usuallyprofessionals, who were responsible for theactivities of the project workers (a, b, c) EAthat site. They met with the workers regularlyto provide guidance and assistance if needed.

f. The summer project staff included threestudent directors, five area coordinators, tworesearch directors, two office staff, and a physi-cian project director.

The part-time project director is affiliatedwith the West Philadelphia Community MentalHealth Consortium, a subsidiary of the grantee,the West Philadelphia Corporation. The proj-ect director is also on the faculty of one ofthe medical schools. He advised the studentdirectors in overseeing the entire project. Thestudent director was responsible for adminis-trative duties and organizational liaisons. Thetwo associate directors coordinated projectsites and the educational aspects of the project.

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The five area coordinators were each responsi-ble for a given number of project sites. Theymet the workers regularly and served as com-munication channels to the project office for allpersonnel.

Multiple means were provided by the proj-ect staff for workers to become involved andinformed. Weekly meetings were held forgroups of 12 to 14 people, led by individualstaff members, to consider problems and sub-jects of interest or concern to the group. Theseprovided an opportunity for workers at differ-ent sites to share experiences and exchangeideas. Another major educational aspectplanned by the staff and committees of projectpeople were the orientation, the midsummer,and the final conferences. Also, one eveningeach week for most of the summer, a specialprogram was held for the project participantsand friends, bringing in speakers and films onpertinent local and general issues. Through-out the summer various work groups evolvedthat allowed people with similar interests toconsider action in such areas as Summer Proj-ect 1969, admissions of blacks into health sci-ence professions, the SHO Fourth National As-sembly, and other issues.

Biweekly meetings were held with staff, in-terested project workers, and the advisorycouncil, the latter consisting of four Philadel-phia professionals : two physicians, one in citygovernment, and one in medical education, afull-time community organizer and a grouptrainer. Policy decisions were reviewed andmade at these meetings. The staff met weeklyalso with training consultants who assisted indeveloping leadership skills and an understand-ing of group processes.

The goal of the ex tensive programming forand by the staff and project workers was atotal involvement experience. Individuals hadthe opportunity to pursue any area of interestas it related to community health and their owneducation. The results of their involvement inthe student health project are reflected, in part,in the following pages.

Section I I

PROBLEM PAPERS

Karen Lynch

Introduction

Since the Student Health Organization's pat-tern of sponsoring summer projects and pub-lishing reports of the projects seemed on theverge of becoming an inviolable tradition de-spite SHO's resistance to adopting routinized,institutionalized activities, the attempt wasmade to orient the reports of the sites awayfrom a narrative "this-is-my-summer" accounttoward a more critical issue-oriented examina-tion of the health care delivery system.

Thus, early in the summer a brief outline ofplans and expectations about the summer wascollected from all the project workers. Thesereports were then used to distribute three dif-ferent guidelines for problem papers and oneguideline for describing local communities.These forms arc included in appendix 4. Eachsite was different and I ran the risk of askingirrelevant questions of a site's activities.

Yet the resulting articles present a criticalpoint of view on a number of issues which theproject workers experienced first hand. Infnture projects this approach may be used ina more directed way, asking specific questionsabout specific problems. This summer, how-ever, such an approach would have been totallyat odds with the philosophy of the Philadelphiaproject.

The articles which follow concern experi-ences with community groups, health and non-health agencies, attempt to solve varioushealth and environmental problems and many

other topics. They should be read as caseswhich present problems and possible ap-proaches to solving them.

STUDENT HEALTH ORGANIZATION INTHE COMMUNITY

What Happens When SHO Workers Step In?

At 25 of 37 sites, approximately 80 projectworkers were cooperating with local commu-nity groups, some "grass-roots" organizations,some settlement houses, and some other typesof organizations.

With all of these organizations the SHOworkers were planning with the communityto do a variety of things. With Pernet FamilyHealth Service, Spring Garden CommunityServices Center, and Young Great Society,SHO workers were directly meeting healthneeds. At other sites, for example, Hawthorne,Ludlow, and Hartranft, SHO workers wereserving their communities directly by sponsor-ing recreational activities and leading classes.

Others, among them Fairmount, "ThePocket" and Taylor Street projects of Univer-sity Settlements, and Gray's Ferry, were help-ing communities attack environmental healthproblems or community needs.

Others were identifying problems in such away that other organizatiOns, political bodies,public agencies, and planning boards wouldbecome aware of them. SHO workers at Dela-

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ware County's Citizens for Better PublicHealth, Eastwick. Community Organization,Welfare Rights Organization, North City Con-gress, and Southwest Center City CommunityCouncil were working on these problems.

Still others were setting up or planning forprograms. SHO workers at Mantua Commu-nity Planners, Citizens Concerned for WelfareRights, CEPA (Consumers' Education andProtective Association), Houston CommunityCenter, and Spruce Hill Community Associa-tion were involved in designing and gettingprograms started.

In short, SHO was working with a widevariety of community groups this summer in avast range of activities.

Out of these experiences a number of dif-ferent issued were raised. Similar questionswere asked in different situations. The mostprevalent were these : How can SHO work ef-fectively with local communities? Why aren'thealth problems priority issues in these com-munities? What can be done to improve rela-tionships between local communities and healthinstitutions and health professionals?

The three papers in this section describe at-tempts to work with local communities. Thefour papers in the next section describe at-tempts to identify health issues in communities,the problems involved and the explanationfor the apparent unimportance of health prob-lems.

The project workers in Gray's Ferry, onTaylor Street and in "the Pocket" were allconfronted with similar problems. There wereobvious improvements which the communitieswanted, but action depended on the approachthe project workers and others made. As Rich-ard Bonano and Rhoda Halperin observed asthey worked in Gray's Ferry, an independentsurvey team failed in their community to makeuse of infon nal ways of gaining access to com-munity residents. They also noticed that com-munity fears and distrust keep some familiesfrom cooperating with other families even onthe same block.

Action also depended on the spirit of thecommunity to move. The contrast they foundbetween the white community of Gray's Ferryand the black community of Gray's Ferry areclear examples of the consequences of motiva-tion and lack of motivation.

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Yet even high motivation cannot be sustainedwithout cooperation where communities needthe assistance of, for instance, the SanitationDepartment, the Housing Authority, or otheragencies. Bill Robinson saw this in his workwith Taylor Street residents. The environ-mental problems there could not be effectivelysolved without the help of the City SanitationDepartment,

Perhaps Art Pressman found one of the so-lutions to inaction : as an outsider he aimed atpersonal vested interests of residents in orderto build interest in Clean-Up Day at the TotLot and interest in preparing a house for thenursery school.

All three of these projects were confrontedwith the problem of working with their com-munities rather than working for them. Theproject workers built on issues which the com-munities wanted to work on and on issueswhich personally affected the residents. It callsfor a great deal of sensitive probing and foridentification by workers with the community.Looking at these three accounts of attempts towork with communities with an eye for theapproach to problems at each site will pointout the successes related to working with thecommunities and the failures related to work-ing without them.

Gray's Ferry, Summer 1968

Richard Bonano and Rhoda Halperin

To those who do not live there, Gray's Ferryis a community located 1.5 miles southwest ofCity Hall. It is clearly defined and cut off fromthe rest of Philadelphia by the SchuylkillRiver on the north, west, and southwest, therailroad highline on 25th Street to the east, andMorris Street to the south. The nresence ofthese natural boundaries provide ne with asense of physical enclosure and ti, unity. Inreality, Gray's Ferry exists as many social,economic, racial, religious, and ethnic frag-ments. Each group has its own way of per-ceiving things, and its own way of doingthings. In this sense, Gray's Ferry is not asingle community.

While geographical factors act to unify thecommunity on the one hand, geography con-tributes to the fragmentation of the Gray's

Ferry area. Wharton Street, which runs east-west, is viewed by many members of the com-munity as a barrier which cannot be crossedfrom the south side by whites, and whichshould not, although it is, be crossed from thenorth side by the blacks. The black communityis referred to as that area "north of WhartonStreet."

The people in the white community "southof Wharton Street," are primarily of Irish orItalian descent. Some of the older citizens canbarely speak English ; some families have livedin Gray's Ferry for six or seven generationsand would never consider living anywhere else.Some members of the younger generation, olderteenagers primarily, cannot wait to get out ofGray's Ferry. Practically all the residents areCatholics ; most belong to St. Gabriel's Parish.The Church is a highly influential force in thecommunity. Most of the working people areemployed in the surrounding factories as weld-ers, placeworkers, etc. There are a few smallbusinesses owned by the residents of the area.Their proprietors are often looked to for adviceor funds for the few community projects. SomPfamilies own three and four houses on a block.These people consider themselves better offthan the majority of people in Gray's Ferry.One lady told us that the reason people keptthis property was "to keep the communitynice." What she really meant was that the peo-ple wanted to keep the blacks and other "un-desirables out." "Right behind this block," shesaid, "is a family who live like pigs." Thewhite community itself, is by no means a singlesocial, economic, or cultural milieu.

The Gray's Ferry Community Council is theofficial representative structure of communityorganization. The total membership on thecouncil includes some 400 citizens. The Execu-tive Committee, however, is the main policy

r body. It is composed of businessmen,most of the religious leaders in the communityand residents, a few of whom are black.

The Community Council has primarily beenconcerned with the urban renewal and rede-velopment which has been planned for Gray'sFerry. A full-time Community Relations Rep-resentative of the Redevelopment Authorityworks with the Community Council. The Coun-cil claims to represent the entire Gray's Ferrycommunity on the redevelopment issue.

An additional element in the Gray's Ferrysituation is University Settlements. The Com-munity Council originally contracted withUniversity Settlements for social workers toexplain the renewal plan to the people northof Wharton Street. The hope of the councilwas that this would serve to gain the supportof the black community for the plan. Instead,the black community has begun to becomeaware of the reality that their homes have beenscheduled for renewal. This means, in essence,black removal. As a result of the realization ofthe plan's inequalities for the black commu-nity, the people north of Wharton Street arebeginning to mobilize themselves against it.The black leadership has taken the positionthat if the redevelopment plan does not changeto accommodate their wishes, the plan mustbe thrown out. This has created a great dealof friction in the community and the Commu-nity Council has for the first time been forcedto take the demands of a semiorganized blackcommunity into account.

The problem of redevelopment, and the gen-eral situation in Gray's Ferry has been exacer-bated by the requirement for a diagnostic sur-vey of the community's needs. TranscenturyCorporation has been contracted with by theCommunity Council first, to conduct a diag-nostic social survey in Gray's Ferry, and sec-ond, to relate to the community's immediateneeds. Because of the position it has taken asan establishment organization, and because ofa series of blunders, Transcentury has beenunable to gain the support of the black com-munity. That is, the black community hasbarred the surveyors from their homes. Trans-century has relied upon the formal structure,the Community Council, without taking intoaccount many informal structures. For ex-ample, Transcentury has set up a referralservice without taking into account the factthat such a service exists in the community.Transe.entury's major fault has been that it hastried to impose itself upon the communityrather than to work with community people.Transcentury has set up a series of topics tobe surveyed. Some of these are health, employ-ment, and recreation. Education, specificallythe issue of the building of a new school inwhat the community considers to be a danger-ous industrial area, is of primary concern to

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the people in Gray's Ferry. Yet, the survey hasno section to deal with educational problems.

Since Transcentury has been unable to gainthe support of the black community in carry-ing out the survey, additional tension betweenthe Redevelopment Authority and the blackcommunity has grown up. Action to the benefitof the community has been further delayed.In progress now are negotiations between thevarious parties involved. The issues have by nomeans been settled.

It is in the context of this tense situationthat some of the problems of community or-ganization and community action must beviewed.

Our decision had been to concentrate ourefforts primarily in the white community. How-ever,- we soon discovered that this presented uswith many unanticipated problems. The moststriking of these is the prevailing attitude inthe white community towards change and im-provement. For example, a pharmacist toldus that it would be impossible to organize agroup of people on a given block to do some-thing about a particular issue because "no onecared." He agreed that conditions neededchanging, but was certain that, in fact, therewas little or no chance of implementingchange. He was not pleased with the statusquo ; he merely accepted it and the problems itpresented to him on a day to day basis. "Peo-ple here are lazy," he said. He gave us theimpression that a definite inertia existed inGray's Ferry. People are prone to complain,but do not move to act. In this sense, theyseem to accept their fate as it is.

An Italian woman expressed concern to usabout the plans for a new elementary school.Her concern, however, was based on the fearthat her house might be taken in order for theschool to be constructed.. The white people inthe southeast section of Gray's Ferry, in fact,have formed a separate community council. Thepurpose of this organization is to oppose thebuilding of the school in their neighborhood.This woman wants the school to remain whereit is. "That school has been there for yearsand years," she said. The school she is refer-ring to is the Benson Elementary School whichwas built in 1838. Now it serves primarilyblack children. The presence of a public schoolin this neighborhood would necessitate black

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children walking through the Italian sectim.That paople are primarily concerned about

what immediately and directly affects or threat-ens them is particularly evident in the field ofhealth. Most people in the white communityhave their own private physicians. When askedabout health problems in the community, theyusually told us about a relative who had beensick recently. Similarly, the doctors in the com-munity were only concerned with their privatepatients. When asked about community healthproblems, responses were : "Well, I can tell youright now mumps are goin' around," Or, "Theproblems are not here. They are in the clinics."

Our job now was to find an issue whichwould have a direct, immediate, and positiveimpact upon at least a few people in Gray'sFerry. We learned, that the residents of EarpStreet, a small street between 27th and 28thStreets, had participated in a series of organi-zational meetings to discuss plans for buildinga play area on a vacant lot on the block. Atone time, we were told, the residents had beenquite enthusiastic about this project. Now,for a number of reasons, interest had wanedand the various authorities involved were underthe impression that the people were no longerinterested in obtaining a Tot Lot from thecity.

It seemed only logical to us, however, thatparents would rather have their children playon grass than in the dirty streets. Since interestin the project had been quite, substantial atone time, why would it not be possible torev; :alize the initial enthusiasm? We were soonto see why there would be no Tot Lot on EarpStrE

It Leon became evident that there, too, peoplewere willing to act in their own self interest,and only in their own self interest. One womansaid, "Why should I give my time and moneywhen Mrs. X across the street will not. Herchildren will play on the lot the same as mine."Another great concern was connected with howthe residents of Earp Street would be able toprevent the children from "over there," mean-ing the black ail& m from across 28th Street,from using their play lot. There seemed to beno understanding or acceptance of the idea thataction which would be in the interest of theentire community would also benefit one's ownself interest.

In fact, to the people on Earp Street, theuse of the lot by "Gutsiders" posed a threat tothem. What would they do if a fight occurredon the lot? Who would be responsible for break-ing it up? Who would be responsible for keep-ing it clean? The fact that the city would pro-vide the facilities if the residents would takeon some responsibilities for taking care of themwas incidental. The people wanted the authori-ties to take care of everything, or nothing atall.

The Tot Lot was voted down by the residentsof Earp Street. Given the racial situation andthe attitudes of the people towards change,positive action was virtually impossible.

At the Vare Recreation Center, located in anItalian neighborhood, we were to see an in-stance in which people will move to eliminatethat which is negative or detrimental to them,but will not tax their energies to create thepositive. Programs at Vare are designed tokeep kids off the streets, not to provide new,creative activities. The staff hired by the De-partment of Recreation run everything. Thosein charge find sufficient gratification in contain-ing the youths within the confines of the recrea-tic-n center. It is great for rough teenage boysto sit and play cards all day. This keeps themout of trouble.

We have sensed a different attitude towardschange among many of the black people wehave met. Although they are not militant,many clearly have decided that certain thingswill not be accomplished in their communityunless they do it themselves. They will notaccept the premise that "the establishment"will do it for them. In fact, they have c_ ometo distrust establishment organizations.

A segment of the black community success-fully organized and carried out a clean-up cam-paign in the area north of Wharton Street. Thedesignated purpose of this effort was notsimply to clean the street, but to develop asense of unity among the people and to getpeople together for the purpose of confrontingthe establishment. The press was there to wit-ness and report that these citizens had cleanedthe streets and were in the process of sendingthe city the bill for the job the SanitationDepartment was supposed to have done.

The youth of the community dealt with theestablishment, in this case, the Department of

Recreation, by avoiding it completely. A groupof black youths rented a garage to house theirown recreation center. They are very concernedabout doing constructive things for "the fellas"who have nothing to do in the evenings. Theyare not afraid to attack monumental problemswith imaginative solutions. A group of theteenagers set up a film program which theyrun themselves. In addition to securing thefilms, this project involved printing leaflets toadvertise the program, obtaining chairs from achurch, and selling refreshments to replenishfunds. People in the black community have alsorealized that the so-called establishment can beused to their own advantages. In direct con-trast to the inaction of the people on EarpStreet, a group of black residents, after onemeeting with the people from the Departmentof Licenses and Inspection, began to collectmoney for their play lot. Children from thearea were consulted with regard to whatequipment would be put on the lot.

On a somewhat larger scale, the communi-ty's desire to move on its own is manifestedin the formation of the King's Village Asso-ciation in a section north of Wharton Street.This group has helped to stir people out oftheir apathy towards accomplishing meaning-ful social change.

These attitudes toward change have largelydetermined the course of our action in Gray'sFerry. We hac' originally been contacted bythe Community Council to strengthen theHealth and Welfare Committee, with the hopeof eventually setting up a health center inGray's Ferry. We soon learned, however, thatto strengthen the Health and Welfare Com-mittee was impossible on several counts. First,this committee did not exist as a functioningbody. It hardly even existed on paper. Second,the community had other priorities. Becausethe people were concerned about their homesbeing demolished by the Redevelopment Au-thority, there was little interest in establishingsuch a committee.

We then discovered that, although recrea-tion was not such an urgent concern as urbanrenewal, it did represent a concern of the com-munity which held higher priority than health.Our task was to find someone or some organi-zation in the community with which to work.Fortunately we have been able to work with a

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black woman who is probably the person mostconcerned about the activities of the com-munity's youth. Her activities reach far be-yond her responsibilities as director of theSummer Urban Day Camp. One of her chiefconcerns has been lack of indoor space whichis essential for carrying out a winter programof any sort.

We became aware of the urgency of thisneed, and realized that the city agencies couldnot be relied upon to furnish this space in anyreasonable amount of time. With the c9m-munity people we began to investigate otherways to obtain space and facilities.

We were fortunate enough to be given thename of a socially minded architect who wouldwork with the community people. He willinglyoffered his services in drawing up plans forcost estimate on a new center for Gray's FerryX,Our idea is to take his plans to private indus-try with the hope of finding a sponsor for the '

project.In the meantime, we have obtained a vacant

building on the corner of 30th and WhartonStreets to house the Gray's Ferry Workshop,as it will be called, on a temporary basis. Evi-dence of community support for this projecthas taken many forms. One businessman inthe community has donated a kiln for ceramicsand paid for the first month's rent. A groupof youth have planned a paint party and gen-eral fix-up weekend. Attendance at planningmeetings has been extremely good.

Our aim with this project, from the begin-ning has been to help the community set thingsup in such a way that they would in no way bedependent upon us for the project's continu-ance. We have tried to act as a stimulus tothe people so that they would respond in anactive way to their own needs. Now they arebeginning to become ware of and use re-sources outside of Gray's Ferry.

We believe that any project of this sort mustbe initiated, planned, and carried out by peoplefrom the community. Outsiders, like ourselves,can be most effective as advisors and as re-source people. To go to a community with theidea of doing things for and the communityrather than with the community would prob-ably prove to be highly detrimental and possi-bly disastrous.

8

1400 Block, South Taylor Street

Bill Robinson

The 1400 block of South Taylor Street is asingle block in South Philadelphia. The resi-dents are all black and generally of low in-come. Most houses are rented. Approximatelyfive to seven are owned by residents. Fivehouses in the block are vacant. The street isvery narrow. The residents have a large num-ber of teenage and pre-teenage children.

Services to the Street

There is no public transportation throughTaylor Street or on adjacent streets, but it isfairly accessible to residents.

Shopping and schools are also not immedi-ately available, but they are accessible withoutmajor inconvenience.

Rubbish and trash are collected once weeklyon Monday (usually in the morning). Themajor problem for residents is the failure ofcity workers to clean alleys of trash andgarbage.

Police protection is adequate, at best. Resi-dents generally do not hold police in high re-gard. Police are slow to respond to residents'calls.

Recreation is another major problem forconcern of residents. A public square is ap-proximately one block away but parents feelthe area is not safe for their children. Parentshave tried unsuccessfully to get a vacant lotin the block converted to a Tot Lot. No otherfacilities are available. Children play in thestreet.

Residents have little concern for the healthcare system, They prefer to concentrate onrealities of : (1) No play area for children ;(2) danger of traffic to children playing instreet; (3) fire hazard from children playingin open vacant houses; (4) rats in homes; and(5) trash accumulating in alleys.

The major community health problems is thesocial well-being of the block residents. Prob-lems associated with their environment havebeen under primary consideration. In lightof this, the Taylor Street Residents Associationhas been working on all of the problems de-scribed above.

When the people of the block have decided toact on a problem, they : (1) Decide on a chan-nel for action ; (2) contact city official or otherpower and register complaint by phone and/orletter; (3) repeat action if needed ; (4) con-tact Congressman William Barrett for assist-ance for the city related problem ; (5) considerother actions if needed.

Environmental ProblemsThe central movement of the Taylor Street

Residents Association was a multi-faceted at-tack on problems associated with their en-vironment. From the health standpoint, theiraim was to improve their own social well-beingby acting on their own community. This wasthe position presented to me by the residentsthemselves. They wanted to take action in thespecific areas described below, and wanted meto help them.

One major area of concern for the residentswas to try to convert a vacant lot on the blockinto a Tot Lot, on which their children couldplay. Contacts were made with the Depart-ment of Recreation, Land Utilization, Univer-sity Settlements, Congressman WilliamBarrett's office, et. al., to attempt to achievethis.

The stumbling block was presented whenone of the property owners, Mrs. X, said thatshe could grant permission for the group touse her property if she were insured againstany liability charges from parents whose chil-dren might be hurt playing on the Tot Lot.Attempts to seek this insurance through theCity of Philadelphia, University Settlementsand others were rebuffed and the action hasbeen stymied.

At present the property is tax delinquentaccording to Mr. M. of the city's Land Utiliza-tion Office. In this case, the land will be placedavailable for sheriff's sale in approximately 8months. At this time the city can purchase theproperty and effect the conversion to a TotLot. A major consequence of the delay through"red tape" and negotiations has been waninginterest and skepticism on the part of the resi-dents that anything will improve their situ-ation.

Another situation which the residents sawas a problem was the fact that although thestreet is very narrow, at various times of the

day, it has a high degree of car and trucktraffic. This presents an obvious danger to thelarge number of children who play in thestreet. They attempted to get signs reading"No Through Trucks" and "Slow, Watch Chil-dren."

The presence of five vacant houses in theblock has caused more concern for the resi-,dents. They had become depositories for trashand garbage for people from other neighbor-hoods, and thus havens for rats. But moreimportant to the residents, they were openinvitations for children playing with matches.Many fires had renulted in previous monthsand years.

This problem 10.8 presented by letter andphone cans to Mr. Z. at the Complaint Depart-ment at Licensing Inspections at City Hall.After many months, only one of the five houseshas been properly cleaned and sealed. Againthe residents have talked with feeling thatthis attitude prevails because they are black.

The final major problem voiced by the resi-dents concerned the presence of rats in theirhomes and backyards 4nd the accumulation oftrash and garbage in their alleys. The rat prob-lem seemed to be etv tsed or at least enhancedby the trash problem, so emphasis was placedon removing trUil and garbage. A representa-tive from the City's extermination unit wascontacted, but he felt that it would be futileto place poisoned bait where rats had so muchother debris and food to eat.

At least ten complaints and probably morewere registered with the Mayor's Office forComplaints because the City's sanitation work-ers would not clean the alleys. The alleys werelast cleaned on approximately the first Mondayin June. Since then they have become deplor-able. It is a fact that the people of the blockcould clean the alleys themselves, but again itis a point, that their taxes help pay for thisservice and if they were more affluent, orwhite, they would not have to be subjected tothis treatment by the City.

The concern of the residents of Taylor Streetfor their own improvement, through upliftingtheir environment, has been suppressed. TheCity has shown in various areas to be imper-sonal and unresponsive to their needs. Theyhave gone "through proper channels" to affectchanges, but the results have been negligible.

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Their interest in helping themselves is waning,as their confidence in those who make changeis reaching a new low.

I identify very closely with the residents ingeneral, and have not, and will not try to con-sole them or attempt to reconcile them withthe systems of the "establishment." If some-one with a more militant approach revivestheir interest in helping themselves, they willbe much more receptive to an attitude of"damn the establishment!, we'll change thingsour own way!"

The Pocket

Art Pressman

"The Pocket" is the area within TaneyStreet, Webster Street, Catherine Street, andSouth 26th Street.

This is an all white community. One blackfamily was driven out about a year ago. Oncemostly Irish, now some Italian, but still over-whelmingly Irish, most men work at Philadel-phia Electric, half a block away. There is alarge incidence of interrelation among fami-lies. Many residents have lived their entirelives in "The Pocket." A few are really largefamilies with eight or 14 children but mostfamilies have about three to four kids. Onevery rarely sees any teenagers, therefore theimpression exists that only young children arearound, but teenagers mysteriously surface inthe evening. Most people marry from within"The Pocket." It is rare for someone to bringa stranger in (stranger : more than 10 blocksaway). "The Pocket" is completely surroundedby black communities. There are no otherwhites for blocks. There has been hostilityfor years with the power shifting to the blacksmore and more every year. Eight vacanthouses stay vacant; no one wants to move into"The Pocket." Their most difficult problem isrealizing that they live in a poor white ghetto.

"The Pocket" is convenient to public trans-portation ; garbage collection is regular ; SouthStreet "business" district is very close; thereis a swimming pool at 26th and South (in ter-rible shape, and the community is disgruntledabout the Marian Anderson Center being sonice) ; University Settlement House has daycamps, day schools, a gymnasium, etc.; St. An-

10

thony's Parish has a school; there also ;s apublic elementary school, but pupils there aremostly black ; most Pocket children go to St.Anthony's. Police protection is good duringthe day, but there are complaints of its beingalmost nonexistent at night.

Since most Pocket women are Catholic, onewould not imagine many to be practicing birthcontrol, but most are. Three blocks from theHospital of the University of Pennsylvaniaand Philadelphia General Hospital, the peopleuse the clinics quite often. St. Agnes Hospitalis also frequented. No complaints were heardof these institutions other than waiting timeand the Filipino doctors who don't understandwhat is wrong with the people.

There has been almost no community action."The Pocket" expects the community organ-izer to do everything. They sit and talk, butare mysteriously absent when the time comesfor the work to be done. This sounds presump-tuous but I just spent today trying to roundup 45 men to work for two hours this week-end in the nursery and got a most negativeresponse. At this stage, the next thing to dois incense the men individually about their col-lective weakness. Maybe some will come outthat way. The women are fairly industrioussome are notorious laggards, others are bundlesof energy.

Before anything can be accomplished in acommunity, the community must desire the endresult. For an outsider to enter a neighborhoodand identify and remedy certain problematicconditions is a condescending gesture. Certaincircumstances cannot equal a problem unlessthe community sees a problem from their per-spective. No doubt many conditions exist inthe pocket that warrant immeoiate attention,but I feel that it is not my place to identifythem. This is not to say that I blissfully ignorethem. Questioning of a random nature duringa friendly conversation generally produces oneof two possible results. "How long have thosethree abandoned cars been on the block?""Two years" or "Two years . . . I sure wishwe could get rid of them." If the people af-fected by the problem recognize it, then thecommunity organizer and the community reachthe first plateaua problem exists. Withoutthis recognition, the community organizer isnothing more than an officious intermeddler.

Once there comes this recognition and, there-fore, identification of the problem as theirown, the mobilization of the community intosome form of functioning political entity canbe attempted. (N.B., attempted rather thanaccomplished.)

The organization process is the most dif-ficult. The two major issues of the summerhelped facilitate this process in that both is-?ties affected a major part of the community.A digression into the background of these is-sues is necessary at this juncture. In conjunc-tion with University House and the commu-nity, the Land Utilization Department of Phila-delphia constructed a Tot Lot last fall. Rereadthis sentence because here is where the basicproblem lies. The community did not con-struct, but Land Utilization constructed. Cer-tainly men and women of "The Pocket" con-tributed valuable man hours of labor and cer-tain materials, but the end result was not "ThePocket's" project. The fact that the Tot Lotresembles a first year architecture student'snightmare, which indeed it turned out to be,does not matter. Merely, this project, becauseof the great stake the City of Philadelphiahad in it, was not allowed to fail. By this Ido not mean to imply that it was a successnot at least to the people in "The Pocket."They use it, play in it, and gather in it, butit is almost as if they have borrowed it fromsomeone else. For Land Utilization it was asuccess, but, alas, only a hollow one ("ThePocket" strikes back!) Within the space ofsix unattended months, the Tot Lot became amass of broken glass and litter. No commu-nity responsibility existed for its condition andindeed, none should have for the Tot Lot didnot belong to "The Pocket."

Once "The Pocket" recognized the hazardthe Tot Let presented, we were back at theorganization process. No strong leadership ex-ists in this neighborhood, as I am sure it doesnot exist in many other ghetto areas. Manyreasons for this existgeneral complacence,the individual's desire to drink his beer inpeace, and lack of confidence to lead, muchless influence, the opinions of others. If oneis able to overcome these obstacles, anothermore serious barrier presents itselfthe com-munity's relucta ice to accept anyone as theirleader. "The Pocket" resembles a petty duchy

in that self - appointed kings are constantly be-ing deposed. Even if a leader is "democrati-cally" elected by the community, the commu-nity refuses to look upon him as a leader. Dis-trust, envy, and baekseat driving immediatelyset in. A feeling of community is the only alter-native to the leader problem. This can be ac-complished through total involvement of theentire group in an issue with pointed relevanceto all. The Tot Lot was one of these. By makingthe Tot Lot's condition each person's problem,rather than the vague general community'sproblem (and therefore no one's problem) , wewere able to wage a successful campaign toclean up the Tot Lot. "When's the last timeyour child cut his foot in the Tot Lot?""When's the last time your neighbor's kidcame into your home and bled all over yourrug, because no one was home at his place?"is effective rather than "Let's clean it up be-cause it's a mess." One must touch each per-son's vested interest, whether it is his child,his rug, his hatred for the sight of blood, tomobilize a group of individuals into a func-tioning body. There was excellent attendanceon Clean-Up-Day and heretofore disinterestedpersons took an active role. The beauty of thisproject was that it was a one time affairthe lot has remained in excellent shape for 6weeks now. One lady hoses it down every otherday or so and takes care of the hose that oper-ates the sprinkler for the kids. Because of theirinvolvement in the initial clean-up, the moth-ers, when present, impress upon the childrenthe need to keep it clean. Play-Street, a Uni-versity House afternoon recreation project,also instills this attitude. For a period of aboutthree weeks after clean-up day, the motherstook turns supervising the lot, keeping out thebottle breaking older kids, and watching outfor the safety of the younger ones. While itlasted, this scheduling of mothers was veryeffective, but its breakdown is directly linkedwith issue No. 2the nursery school.

The University House and "The Pocket" hadlong considered opening a nursery in "ThePocket" for the Pre-schoolers. UniversityHouse negotiated for a vacant house and hadan option to buy the building. The Board ofEducation had promised to furnish a teacherand some equipment, if the school met theirstandards. Through a raffle, "The Pocket" was

able to raise about $100 that acted as consid-eration for the option contract. Paint was pur-chased and the community began to fix up thebuilding, which was in a state of terrible dis-repair. Scrubbing on hands and knees camefirst and the women eagerly pitched in and theplace began to take shape. It was looking toogood to be true and was. The Board of Edu-cation required a minimum of 18-20 childrenenrolled for them to sponsor a school and pro-vide a teacher. Since "The Pocket" is teemingwith children, no on had ever considered thepossibility that maybe "The Pocket" could notcome up with enough children. After longarduous searching, we only came up with 16.The big question was where would others comefrom. If two more children could not' be found,the nursery would fail. Because of its uniqueposition in relation to the surrounding com-munity, "The Pocket" was in the hole. "ThePocket's" unbelievable antagonism for theirblack neighbors surfaced when we asked themto consider the possibility of getting the othertwo children from the adjoining neighbor-hoodsall of them black. Spoken to individ-ually, a scant few of the mothers who hadalready enrolled their children in the nurseryindicated that they wculd have no objectionto an integrated school. Even though we de-scribed the nursery in terms affecting their in-terests, i.e., getting rid of the children fivemornings a week as well as improved educa-tional backgrounds and easier adaptability tothe first grade, the community acted in accord-ance with their emotional needs. At a com-munity meeting with 100 percent attendance,the unanimous decision was . . . no nurseryof black children. To circumvent the problem,rather than drop the entire plan for the nur-sery, the community developed their own op-tions: get the Board of Education to lower thelimit of children to be involved ; rent a build-ing from University House and staff it withmothers ; have University House extend thegeographical boundaries that the nurserywould service in order to take in areas withsome white children. No one really worked onthese options and work on the half-paintedschool stopped. Tot Lot supervision also ceasedas a sort of protest. "Lethargic limbo" waswhere "The Pocket" found itself. We made itclear that in no way would we help to segregate

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the nursery. Discrimination by geography wasone thingonly people from within the boun-daries were eligiblebut we would not supportany other type. After about three weeks themothers decidedwith the empty half-paintedschool on their block serving to remind themof their foolishnessthat something reallyought to be done one way or the other, so ameeting took place. Somehow they miracu-lously came up with three other children fromwithin the boundaries; independent action ontheir part because they finally realized thatthey really wanted the nursery. Or did they?Whatever the answer, work begins anew onMonday and hopefully the school will be readyto go by the middle of September.

These two projects, the Tot Lot and thenursery, were the major issues of the summer;but in order to substain overall interest, nu-merous secondary, easily remedied issues wereworked on. Boarding up a vacant house, fixingthe fireplug that had eroded half the street,and having one vacant house condemned pro-vided a type of day-to-day incentive systemthat kept the community's interest intact forthe major issues.

HEALTH-A PRIORITY ITEM?

At a few of the sites this summer, projectworkers were asked by their sites' organiza-tions to conduct surveys or investigations intothe health needs of their communities. Thestartling result of these investigations is thathealth is not a priority item. Although ',heSHO workers began by asking about healthneeds, environmental problems and recreationwere more visible and more urgent issues thanhealth problems.

In this section the process of setting up thestudies, the results of the studies and the con-sequent action at four sites is presented.

The first article about attempts in Ludlowto set up a community blood bank, teach sexeducation classes, and show a cancer detectionfilm points out the fact that health problemsare obvious, but they have to be met in theorder of their priority to the community. Ifyou are faced with rats, shabby housing andunpaid food bills, as Jerry Braverman pointsout, you haven't got time to worry about CiAl-cer, give blood, or learn about sex.

Both Eastwick and Paschall community or-ganizations requested a survey of their neigh-borhoods in order to gather evidence to bringto bear on government authorities and also toidentify for themselves where the needs andpriorities of their community were. Unlike thereport from Ludlow, the results of surveys inEastwick and Paschall indicate that their realhealth needs are not as fundamental and basicas the needs found in Ludlow. Attention wasplaced on recreation facilities in Paschall andon a variety of environmental problemsEastwick. These findings suggest that it is verydifficult to deal with the underlying healthproblems in ten weeks and that attention islikely to be diverted to easier projects likerecreation programs, blood banks and visibleenvironmental health problems. The basic, un-derlying problems are obvious to residents andthose concerned with meeting health needs,and they are vast. Concern for the less visibleproblems of cancer and other chronic diseasescan only be stimulated and can only interestresidents of these communities when othermore pressing needs have been met.

The final report in this section describes theexperience of SHO workers who provided tech-nical competence to the Welfare Rights Organi-zation in designing a survey at WRO's request,training WRO members to do the surveys, andthen examining survey results.

These experiences suggest that health needsare obvious and pressing. Communities' priori-ties are also obvious, even though it may takeunsuccessful programs to show it. Health serv-ice producers must be aware of communitydemands and meet these in order for theirprograms to be effective.

Complex Problems in Ludlow

Jerry Braverman

The Ludlow community extends fromGirard Avenue to Montgomery Avenue be-tween Fifth Street and Ninth Streets. It isapproximately 50 percent Negro, 40 percentPuerto Rican, and 10 percent White ; it hasbeen described as one of the ten worst slumsin Philadelphia.

The health problems are obvious, most of allto those who live there, and any program

which does not directly attack these problemsis destined to meet with limited success. Ourbasic programs, sex education and blood bank,are prime examples. Although worthwhile,these were indirect efforts to remedy somecomparatively minor community problems, andconsequently, did not stimulate any communitysupport.

A more illustrative example was our attemptto show to the women of Ludlow a short filmconcerning breast and uterine cancer. Despiteleaflets, posters, sidewalk solicitation and an-nouncements in the local churches, only threeor four women showed up.

They do not have cancer now and are notworried about it; they have never needed bloodin the past so why give now ; academic mat-ters about sex do not interest them. NOW arerats, shabby, overcrowded housing, and foodbills.

Further, I do not feel that a SHO personshould initiate an attack against these prob-lems. They are the problems of the people wholive here, and when these people come torecognize these themselves as community prob-lems (without having been told) and begintheir own action, then would be the time toenter with funds and personnel to provide im-petus to their movement.

Our problem is a complex one and I do nothave an answer.

Eastwick Survey Report

Paul Frame, Bill Woods, Andrea Benn,Renee Edwards, and Eileen Fair

The Eastwick Community Organization is afairly new organization. The Eastwick areahas been an urban redevelopment area since1958. A large number of families have movedfrom the area and public services have dimin-ished since then. The Eastwick Community Or-ganization felt that a survey could better de-termine the needs of the community and couldbe used as a working paper to get better serv-ice into the area.

The survey is to be used by the CommunityOrganization to put pressure on various agen-cies and institutions, especially City Govern-ment and the Redevelopment Authority. Thesurvey was commissioned by the Community

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Organization and the survey committee of theorganization is in charge of carrying it out. Acommunity worker with the Methodist ServiceCenter who works in the Eastwick area is alsointerested in the survey and has been workingwith us on some of the individual followups.The Community Organization received a grantfrom the Philadelphia Council for CommunityAdvancement which allowed them to hire acommunity resident, Mrs. T., to work with theSHO students and survey committee on thesurvey. This grant also paid for the incidentalexpenses of the survey.

The actual survey was drawn up by severalpeople, including Community Organizationmembers, SHO workers, an urban plannerworking with the West Philadelphia MentalHealth Consortium, and a community workerwith the Consortium. A rough draft wasformed from a list of problem areas the com-mittee thought important to work on. Subse-quently there was much of the cutting, re-writing, and changing which goes with pre-paring any finished paper. The final versioncontained questions on demography, mobility,health needs, employment, and social and phys-ical environmental conditions. The final versionhad to be cut down from a 45-minute ques-tioning time to a more workable time of 25minutes. We tried to make all our questionsones which could conceivably lead to meaning-ful followup and eliminate those which wereof purely sociological interest.

Our aim was to survey as many of the 500homes in the area as possible. One week inadvance we distributed flyers to each homedescribing the organization and explaining whywe were doing a survey. This advance pub-licity proved to be very important as it alertedpeople to our presence and we were not totalstrangers when we knocked on their door tointerview them. In general, people reacted co-,operatively or apathetically to us. A few weresuspicious, thinking we were from the city orthe Redevelopment Authority, and of coursethere were a few refusals and hostile people.Our refusal rate, however, was less than 10percent. One problem which is common to anysurvey attempting to reach a total populationis that some people are not home when calledon and cannot be reached. We usually triedto visit a given house twice in the daytime and

14

twice in the evening before writing it off as"No Answer."

Survey FindingsWe are presently in the process of evaluat-

ing the survey findings. Some of the mainproblems which have developed are :

i. Problems caused by redevelopment.A. Lack of stores in the area.B. Weeds which have not been cut in

many fields. This poses a traffic and rodenthazard.

C. Poor public transportation.II. Problems the city should deal with.

A. Lack of mosquito control.B. Lack of an adequate sewage system.C. Lack of street repair and cleaning of

gutters.III. Problems peculiar to the Larchwood

Gardens Apartments.A. Bad relations with the landlord.B. Noisy kids in the nearby schoolyard

at night.It will be noticed that health problems are

not included. This is partly due to the fact thatother problems are more pressing and also be-cause the health problems which do exist areindividual problems and were handled on thatbasis.

The survey was useful in determining theoverall and specific needs of Eastwick. Thesubsequent follow-up has taken two basicdirections : helping individual members wherehelp was needed, and attempting to strengthenthe Community Organization and help it dealwith the Redevelopment Authority and CityGovernment.

The first of these dirntions has probablyinvolved the most succesetul part of the sum-mer. Needs of specific pe-:sons were identifiedas the survey progressed and handled on anindividual basis. For example, several recipi-ents of public assistance were informed of aprogram whereby they could obtain muchneeded dentures free of charge through theUniversity of Pennsylvania Dental School, andtwo have actually begun to be fitted for den-tures. Several persons in need of financial helpwere found eligible for Pennsycare and FoodStamp Programs. Other persons seeking jobswere directed to various training centersthroughout the city. One man who lived on

the fringe of the community was even helpedin his effort to obtain a telephone. It was sur-prising to discover how many people in thelower income brackets had no knowledge of themany programs available for all types of as-sistance, and we gladly supplied the needed in-formation. We are presently preparing a"Where to turn" type booklet for general dis-tribution in Eastwick as a continuation of thiseffort.

The second part of our effort, that of at-tempting to form a more effective CommunityOrganization, is presently the concern of thecommunity. It is an important issue becausethe community is in need of an effective forceto handle its many problemsmainly publictransportation, more stores, effective mosquitocontrol, street repairs and dealing with theRedevelopment Authority. The RedevelopmentAuthority began its operations in Eastwickover 10 years ago and has planned the projectso that it is the largest urban renewal site inthe country. However, due to ineffective plan-ning Eastwick today has many overgrownfields where homes have been torn down butnothing has been built to replace them. Also,Redevelopment has not always dealt straight-forwardly or fairly with the residents of thearea.

The problem of forming a strong, repre-sentative Community Organization is a pri-mary problem since it is the community, andnot outside SHO workers, who should be deal-ing with the City and Redevelopment Author-ity. It is also a difficult problem. The presentorganization has a nucleus of dedicated peoplebut does not have the widespread participationit needs. Many people are quite bitter over theevents of the last 10 years. They stood up andwere "bulldozed over" by redevelopment onceand don't feel like standing up and being runover again. In Larchwood Gardens Apart-ments, the people are more transient and manydon't feel they have enough of a stake in thecommunity to get involved.

The survey was itself a first step in the at-tempt to strengthen the Community Organiza-tion. The confidence of many people was gainedin the process of door-to-door canvassing anda fair number of people showed a willingnessto work with the organization. The next stepincludes the planning of a cook-out and com-

munity get-together. The SHO workers willalso work with the Organization to obtain bet-ter mosquito control, set up a possible sex edu-catior, course, and assist where we can infurther dealings with the Redevelopment Au-thority.

Other than the problems already discussedabove, no major health deficiencies were found.The most pressing problem would probably bethe general lack of periodic checkups. Mostpeople are either quite healthy or have ade-quate health care. One area in the health fieldwas improved, however. It was discovered thata receiving ward type of clinic was recentlyestablished by St. Luke's Hospital at Interna-tional Airport only 8 minutes from the centerof Eastwick, The community, however, is un-aware that this facility exists. Plans are beingmade with St. Luke's to publicize the clinicand there is also a possibility that it can beused as the site for a Public Health ServiceClinic in the future.

Report on Community Work With thePaschal Betterment League

Renell Burden, Larry Budner, DudleyGoetz, and Chris White

Our major concern at the Paschall Projectsite was a comprehensive survey of the neigh-borhood, made at the request of the PaschallBetterment League. Problems concerninghealth care and municipal services were cov-ered in the study. With demographic materialand attitudes toward the neighborhood in-cluded, the survey was undertaken to deter-mine whether the residents had any interest intheir community and what specific communityproblems exists.

As a result of the survey's findings, manyproblems concerning environmental healthwere made evident. These included lack of :street lights, traffic lights, fireplugs, rec, z:ation,a day care center, adequate police protection,and adequate shopping facilities. In additionto the above, abandoned houses, inadequatelyfunctioning sewers and unfit housing condi-tions were reported to the respective city agen-cies. No significant personal health problemswere brought to light, however.

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The Paschall community is roughly boundedon the East by 63d Street, on the South byGrays Avenue and on the North and West byCobbs Creek Parkway. This community isquiet, lower class (and some middle class),and integrated, although mainly black.

Generally, community services, except thosepertaining to shopping and recreation, are con-sidered adequate by the residents. Trolleyroute 11, running from Darby throughPaschall to Center City, is the only directtransportation into the city. There were rela-tively few complaints about the No. 11 in oursurvey, but frequently of service is signifi-cantly lower than other nearby lines. Municipalresponse to residents' complaints about cityservices appears to be prompt and at timesefficient. There are two hospitals in the area,Mercy Douglas at 50th and Woodland, andMisericordia at 53d and Spruce. These hos-pitals appear to be used by the residents onlyin case of emergency. For non-emergenciesand/or for sustained treatment, the residentsgo to the Hospital of the University of Penn-sylvania or the Philadelphia General Hospital.Although the neighborhood borders the citylimits, very few residents travel into Darby, anearby suburb (literally across the street) forhospital or clinic care. A large number of re-spondents in our survey said that they go totheir private doctor or dentist for treatment.This response cut across economic, racial, andage lines. The use of public transportation forobtaining medical care is time consuming butreliable (except when snow falls, then the No.11 doesn't run regularly). One respondentcomplained about the necessity of taking threebuses to travel to a public clinic. There arealmost no taxicabs cruising in the neighbor-hood. Over half of the respondents said theydid not own a car.

The major community health need that weencountered is the lack of recreation facilitiesin the area. Both a large number of small chil-dren in the area and the adults suffer from"nothing to do." This deficiency includes alack of : swimming pools, athletic fields, andequipment and recreational centers.

Both Mercy Douglas and Misericordia Hos-pitals have very poor reputations in the area.Several residents have accused the hospitalsof various forms of malpractice and poor serv-

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ice, such as a car accident victim dying in thehospital because of too long a wait for aneeded operation. There is no community in-volvement on the planning or administrativeboards of any health facility in the area, thatwe are aware of.

In order to obtain immediate communityservices from the city, we : confer with thePaschall Betterment League President, as towhom in the City Bureaucracy to notify aboutthe problem; call up other voluntary groups,such as North City Congress; and workthrough the City's published reference guidesto municipal departments. After a phone callto the appropriate city office, most of our re-quests are followed up by a letter to tho sameoffice and a copy to Mayor Tate. Complaintsby the neighborhood residents were also ob-tained in the PBL's storefront office. The twoproject fellows and two students aides assignedto the Paschall Betterment League, 7039Woodland Avenue, undertook a survey of thePaschall neighborhood at the request of thePBL president. The survey site had been se-lected on the basis of PBL's conception of its"neighborhood." Of approximately 500 fami-lies, 195 families were selected and interviewedduring various times of the day. Supervisionand "overall responsibility" for the survey re-mained with SHO students.

The PBL president considered the survey anecessity in order to provide estimates of theneighborhood population density; child popula-tion ; knowledge of PBL and any other neigh-borhood organization ; "pressing" neighborhoodproblems; complaints about city services;racial composition ; age composition; mobility;number and types of dwellings ; employmenthistories ; and neighborhood development possi-bilities. The large number of questions onhealth care and services were of less interestto the PBL.

The survey design was not drawn up byeither the SHO staff or PBL but came froman outside source. The PBL president addeda page of questions to the schedule. Each SHOstaff member tabulated his own survey re-sponses in conformity with a master scheduledevised by the entire staff. Many questionswere discarded as being either too inconclusive("How much money did you spend on cloth-ing in the last 6 months?") or of little value

("What does the word neighborhood mean toyou?") Some of the statistics are being used ina day care center proposal being written by theSHO staff.

The large majority of the respondents werequite responsive to the survey takers. The sur-vey demanded at least 20 minutes of the re-spondents' time. The noncooperators tended tobe older, white, long-term residents who ap-peared to distrust any individual or organiza-tion connected with their changing neighbor-hood. The area residents tend to be poor andblack, although poor whites continue to moveinto the area.

By far the main finding was the residents'desire for recreation facilities for, their chil-dren. At this time, the few recreation sites arequite overcrowded, inadequate and beset byracial tensions.

Other problems, but which were not as uni-versally cited as recreation, included lack ofshopping facilities and transportation and theneed for a Child Day Care Center. Althoughover half of the respondents were aware ofPBL's existence, very few were members. Only15 percent of the respondents wanted to live"in the same area."

After the survey was completed, SHO staffmembers began to attempt to obtain neededcity services for the area. Attention was drawnto these needs by the survey respondents andnoted by the surveyors, although emphasis wasnot put on the reception of complaints by re-spondents. On the whole, municipal reactionto SHO requests, made in the name of PBL,was quite good. However, with the SHO staff'sassistance, the Paschall Betterment League,has begun action on the need for recreationsites.

Welfare Rights Organization

Marpha Crafton, Shirley Fischer, Gene Schatz,Jon Bonano, and Jean Wilkerson

The central issue with which we have beenconcerned this summer is the power of con-sumers to affect the services they are receiving.This is a central issue because the welfaresystem, as it presently functions, is inadequateand insensitive to the needs of the consumers,the recipients. The present welfare grants do

not provide adequate money for the basic needsof life. Provisions in welfare regulations, suchas that which states the recipient must payback all of the money "loaned" to him by wel-fare when he finally gets off assistance, stiflesmotivation to become independent. But evenmore central to this issue is the fact that thepeople who administer and deliver welfareservices cheat, insult, degrade, or simply don'tcare about the people receiving the services.

These and other indignities were identifiedby the consumers themselves. The central issueis how these consumers have been effectingchanges in the services they are receiving.They have done this by banding together in aself-controlled and directed group, independentof the influence of nonconsumers. Utilizingpublicity and political and legal sanctions, theyhave attacked the structure which holds upthe welfare system.

The Philadelphia Welfare Rights Organiza-tion (PWRO) is a truly grassroots organiza-tion of welfare recipients. The SHO's rela-tionship to the organization was to help WROin their fight against the Department of PublicAssistance. We were well accepted as helpersand extra staff people.

Our first activity of the summer was to con-duct a cost of living survey. The PWRO askedthe Student Health Organization to help themconstruct, administer, and evaluate a cost ofliving survey. The survey's purpose was todetermine the actual cost of food, clothing, andshelter as compared to the allotments recipientsreceive from the Department of Public Assist-ance. In addition to the food, clothing, andshelter items the survey included items suchas furniture, home upkeep, personal care, edu-cational and recreational expenses. The resultsof the survey will be presented in Harrisburgto the Governor and members of his cabinet. Itis hoped that the Public Assistance paymentswill be raised from their present level of 71percent of the 1957 standard to 100 percent of1968 standards.

The questions to be used in the survey weredetermined in the following way. The SHO stu-dents prepared a preliminary questionnaire.This preliminary questionnaire was presentedto the 18 local chapters of PWRO for their cor-rections and revisions. These revisions wereincorporated into the final survey. On Monday,

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July 16, and Tuesday, July 17, a training ses-sion was held for the 18 community workerswho would administer the surrey. The firsttraining session consisted of reviewing thequestions to iron out any last minute problems.The second training session consisted of a trialinterview. The 18 community workers weresplit into teams of two one imerviewer andone interviewee. In the afternoon the roles werereversed. In this way a thorough familiaritywith the survey was obtained.

Each community worker was responsible forinterviewing 11 people. These people were tobe taken from the following categories ofPublic Assistance, seven Aid to Dependent Chil-dren, two Old Age, one General, and one Dis-ability. This distribution corresponds approxi-mately to the percentages given by the Depart-ment of Public Assistance. A total of 216 sur-veys were distributed. As of now (August 14)about half have been returned. About 20 per-cent of those surveys returned were incom-plete, i.e., one or more vital questions werenot filled out completely or correctly.

The only difficulty expressed by the com-munity workers was the problem of obtainingpeople for interviews in either the disability,old age, or general assistance categories. Theinterviewers have reported very, cooperativeresponses from the people that they have inter-viewed.

At the present time no analysis of the datahas been undertaken.

After the survey was launched our mainfunction was to assist the organization withsome of their other activities. The main onewas helping the women staff WRO booths inthe district Public Assistance Offices.- The re-cipients have a right to be represented by any-one they want when they go down to the PublicAssistance Offices. The women assumed therole of client advocates. The reaction of theestablishment was both hostile and abusive.Their main objections were that while theywere being checked by the women they couldnot function properly. A great part of thesummer was also spent sitting around the WROoffice, learning the problems of a grassrootsorganization. These were problems of buildingand arousing a membership, keeping outsideinstitutions and groups from influencing theorganization, and just simply intraorganiza-

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tional disputes. Much experience was gainedfrom the consumer viewpoint. This, we think,by the students in battling the establishmenthas been a valuable experience for future deal-ings with the medical establishment in therole of patient advocate.

COMMUNITY-"ESTABLISHMENT"RELATIONS

Karen Lynch

Where there is concern and action by localcommunities to improve neighborhoods and byindividuals to make use of available healthservices, the "establishment" must respondwith similar concern and action. Effective re-sponse by hospitals, city agencies, and clinicstoday, means changing from present proce-dures and adopting new philosophies and pro-grams and even new goals in light of changingneeds and priorities of individuals and com-munities.

The six articles in this section present experi-ences, problems, insights and potential solu-tions to community-establishment relation-ships.

The project workers at Fairmount wereconfronted with much "red tape" in workingon problems of abandoned houses and in tryingto set up discussions of family planning. Theirexperience points out the problems and the in-ability of communities themselves to straightenout communication paths from neighborhood toCity Hall, to the Bureau of Licenses and In-spections,. and with the Board of Education.Solutions to these problems must come from theagencies themselves.

Solutions are being suggested for anotherproblem of the resident of the inner city. StevenMarder's investigation of the adequacy ofpharmacies to meet the needs of poor peoplepointed out the pressing need for young phar-macists and the possible ways of meeting thisneed. The article printed here is an abstractof a much longer, more detailed report whichhe prepared during the summer.

The remaining articles in this section dealwith the difficulties of providing service withinlarge organizational structures. Differences inphilosophy between the Day Care Program ofthe Temple Community Mental Health Centerand the Department of Psychiatry at Temple

Medical School led to strain in running thatprogram. "The Saga of Fidel Cruz" showsvividly how one man "battled" with an ear,nose, and throat clinic and will never return. Afew incidents like this one may result in anentire community losing trust in the clinic. Theproposed position of patient advocate at Pres-byterian Hospital, reported by Frank Greerand Jerry Lozner, is another possible solutionto this problem.

The two extensive articles by Lozner andGreer about their work at Presbyterian Uni-versity of Pennsylvania Medical Center(PUPMC) are models of the changes whichcan be planned for a hospital in order to makeit more responsive to its community. Thesearticles present, in detail and occasional dupli-cation, the results of an imaginative coopera-tive effort of students, community workers,and hospital staff to improve the relationshipof PUPMC with its neighborhood. Thesepapers should be read' very closely.

The problems discussed in these articles arenot new. These articles are significant, however,since they report real experiences and realattempts to meet problems and they are noteditorials. They should be read for insightinto the complexity of the problems and forthe potential of the solutions.

Community Pharmacies in North-CentralPhiladelphia

Steve Marder

The encounter between a black ghetto resi-dent and a white professional takes place in anumber of different institutions. This summer Istudied the encounter at its primary source inthe communitynamely, the community phar-macy. The purpose of the study was to evalu-

well existing pharmacies were meetingte expressed needs of the poor people whomthey serve. To do this, the opinions of theblack community were evaluated and integratedinto a questionnaire for pharmacists. In thismanner, the health professional would, by ne-cessity, be responding to the opinions of thecommunity.

For the purposes of this study, the areawideCitizen's Council of Philadelphia's Model CitiesProgram was used as a source of community

opinion. Conversations with the Human Re-sources Standing Committee indicated that in-formation which I could compile would beuseful in the action programs they are pres-ently planning. The Health Department basedModel Cities Staff provided the expertise andinfluence that would guarantee that I could findmaximal involvement in the medical-pharmacyestablishment.

Especially useful in evaluating communityopinion was a report by the Human ResourcesStanding Committee entitled, "Barriers toGood Health," and meetings with the Commit-tee. The report indicated that the communityviewed deficiencies in pharmacist services asbeing closely allied to deficiencies in the servicesof other health professionals. The report as-serts that there is, "a lack of quantity andquality of doctors, dentists, druggists, visitingnurses, and other health specialists." The com-munity indicated that pharmacies are often notopen when the people need them and that theyare often inconveniently located. It was alsorecommended that a system should be developedwhich would provide necessary health services,including drugs at prices that people in thecommunity could afford.

When interviewed, the pharmacists disclosedan image of a profession which was more ozless falling apart. Of a total of 102 pharmacieslocated in the Model Cities Target Area in1960, only 57 remain open for business today.Indications are that this decline will continue.At least 10 of the 43 pharmacists interviewedalready had definite plans for closing. Thismarked decrease is not unique to the blackghetto. There is an overall tendency in Phil-adelphia for the total number of pharmaciesto decrease at a rate which is not too dif-ferent from that in the Model Cities TargetArea. The difference lies in the fact that inmost areas of the city, small "one-man" phar-macies have been replaced by larger, moremodern stores. This has not been the case inNorth-Central Philadelphia.

The survey indicated that the problem liesas much with the pharmacist, himself, as itdoes with the economics of the area. Thepharmacist in the Model Cities Target Areais rarely a young man. He is almost alwaysolder than his middle fifties and is often inhis sixties and seventies. He has usually owned

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his store for more than ; years and he con-tinues to run his store with himself as the onlypharmacist. The North-Central Philadelphiapharmacist has probably not remodeled hisstore in any manner in the past few years.Instead, he has allowed it to deteriorate untiltoday it is often small, depressing, and dirtywith a rather Scanty inventory available on theshelves.

The most important factor preventing theNorth-Central Philadelphia pharmacist fromproviding the kinds of services the communitywants lies in the attitudes he has towards hisbusiness. He very rarely has any ambition toimprove and expand his pharmacy. Rather, heis quite content to manage whatever profit hecan from his business until he retires. In orderto detect what flexibility there might he in thesystem, I spoke to several of the pharmacyleaders in Philadelphia, including representa-tives of pharmacists and the pharmacy schools.From these men I obtained several ideas of howpharmacists in the area might alter their busi-nesses to better serve the community and in-crease their profits. The idea included storesmerging to form larger, more modern pharma-cies and prepaid drug programs which are im-proved over today's Public Assistance plans.It is interesting that when questioned, pharma-cists showed little enthusiasm for any of theseproposals.

All of these results were taken to indicatethat if we use the consumer's needs as ourbasis for evaluating the services being renderedby pharmacists, the present personnel are like-ly to continue to fail. The character of thebusiness and the age of the pharmacists wouldseem to serve as a good basis for inflexibility.The problem in this case lies not so much withthe fact that pharmacists are unable to solvetheir problem, but more with the fact that mostdid not have any great hope or ambition fortheir businesses.

Probably the most important conclusionwhich comes from tho. survey is that newsources of pharmacists must be found to serveNorth-Central Philadelphia. The obvious solu-tion which comes to mind is increasing dra-matically the number of black pharmacy stu-dents. There is also a necessity that the gapsleft by pharmacies which are closing should be

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filled. Discussions with the community havealready brought up several possibilities whichare being investigated. These include coopera-tive drug stores replacing pharmacies whichhave closed, pharmacies in District Health Cen-ters, and Neig' borhood Health Centers, andprograms to keep hospital pharmacies openduring the evening.

Philosophical Conflicts of the Temple

Community Mensal Health Center's

Day Program

Bess Aronian

The day program of the Temple CommunityMental Health Center is an experiment in com-munity psychiatry. The philosophy of theprogram was defined largely by its director,Dr. Frederick B. Glazier, who used Day TopVillage of New York as his model. Because ofthe highly innovative nature of the program,Dr. Glazier has had many problems to facesince its inception last September. I will firstdiscuss one of these problems and then brieflyexplain the philosophy of the day program.

One of the major problems faced by the pro-gram is its validation as therapy techniqueand thus its potential as a model for the estab-lishment of future day programs. This involvesbringing about its acceptance by the main-stream of psychiatry. At the present time, theTemple University's Department of Psychiatryhas not considered the day program especiallysuitable training ground for its medical stu-dents and residents. It helps to understand thiswhen we realize that the frame of reference ofthe day program and that of traditional psy-chiatry are so different that comparison be-comes very difficult. Psychoanalysis and otherFreudian based therapy techniques face manybarriers when considered as treatment methodsin community psychiatry, especially when thecommunity is the black ghetto. First, there isthe problem of sheer numbers. Temple Com-munity Mental Health Center is the only psy-chiatric facility servicing an area of NorthPhiladelphia with a population of approxi-mately 215,000. The verbal facility normally

required for successful psychiatric treatmentwould be a barrier with this population, aswould the medical terminology usually em-ployed. Also, the crisis orientation of this popu-lation makes it unlike the middle class fromwhich psychiatry has traditionally drawn itsclientele. As a rule, people in the ghetto areapproaching or are at the breaking point be-fore they seek helpmany do not voluntarilyseek help, but are brought to the center by thepolice or their families. Generally, middle classpeople seek help before a crisis is incipient.It is significant that the stress psychoses pro-duced by ghetto living have been likened tothose observed in combat veterans.

These are some of the problems which Dr.Glazier has had to consider while evolving hisprogram into a working treatment center. Heincorporated many ideas into his program,probably the most significant of which is hisconception of the behaviorally oriented thera-peutic community. The device used to imple-ment the formation of this community is thatof multiple, interlocking group therapy. Thereis virtually no one-to-one therapy between thepatients, or members as they are called, andthe staff. Basically, the therapeutic communitydepends upon the responsible behavior of eachmember towards himself and every other mem-ber. Responsible, mature behavior is encour-aged by the staff and "sick" behavior is dis-couraged. The community is a democracy inwhich the traditional authoritarian role of thestaff members is relinquished. Dr. Glazier isknown as Fred, and his opinion, which countsequally with each of the members as one vote,can be overruled. The members, themselves,are the therapeutic agents for each other, andthe openness of the community accounts forthe fact that a person like myself, who isneither member nor staff, can function withthe group.

Although the National Institute of MentalHealth evaluation report recently issued statesin reference to this program, "It is our opinionthat this day program constitutes the modelof what a therapeutic type of day programshould be," Temple's Department of Psychi-atry remains doubtful, and maintains at besta tenuous relationship with the Day Program.

The Saga of Fidel Cruz

Tom Fiss

The following is an attempt to illustrate theproblems of the clinic system as encounteredin a midcity hospital in this area. The systemis a mire, bogging down, and hindering thosewho administer it, those whom it claims toserve, and those who attempt to reform it. Theadministrator too often becomes frustrated andoverwhelmed by the system. The patient be-comes a unit of the system frequently proc-essed but seldom treated. The reformer becomesquickly disillusioned. He's told that changemust be slow but too often slow movementbecomes complete halt.

Tuesday morning, July 16, Fidel Cruz, 72,walked into the community center complainingof dizziness and marked auditory dysfunction.It was discovered that the patient could nothear with his right ear because it was impactedwith wax. The Rene-Weber test showed thatthe ossicles were functional. The physician-in-charge called the ear, nose, and throat clinic(ENT) at the hospital for an appointment sothat Mr. Cruz should be there at 11 a.m. WhenMr. Cruz was told of his appointment, he pro-tested vehemently. He wanted no part of thehospitalhe'd been there before too manytimes. They had X-rayed him, palpated him,hooked him up to wires but nothing had everbeen done for him. But Mr. Cruz was per-suaded that things would go better this time.Mr. Cruz walked the three fourths of a mile tothe hospital, was on time for the supposed ap-pointment, but was told the doctor would notbe present until 1 p.m. Mr. Cruz went homeand returned, by foot, at 1 p.m. At a :30 p.m.Mr. Cruz was told that the doctor would notbe in that day.

Wednesday, July 17: In the case followup,staff member, Santo Smith, encountered arather aggravated Fidel Cruz. He vowed neverto return to the clinic.

Thursday, July 18: To prevent a repeat ofTuesday's fiasco the day's activity was plannedcarefully and precisely. The ENT clinic wascalled and it was discovered : 1. that althoughthe doctor does not arrive at the clinic until

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1 p.m. the patients are told to report at 11 a.m.so that they would be on hand at the doctor'sarrival ; 2. the doctor would be present today.Santo Smith would act as patient advocate andtranslator (Mr. Cruz spoke only Spanish) toinsure a successful outcome. With some diffi-culty Santo convinced Mr. Cruz that it wasbest for his health if he went to the clinictoday. Santo guaranteed Mr. Cruz that the out-come would be different this time. Santo andFidel arrived at ;:ne clinic at 1 p.m."aheadof the doctor." At 2:30 p.m. Mr. Cruz wantedto leave because the doctor is not coming."Santo inquired and was told that the doctorwould be delayed until 3:30 p.m. Santo calmlyinformed Mr. Cruz that the wait would beworth his while. At 4:30 they were informedthat : 1. the doctor was detained in surgery andwould not be in that day ; 2. clinic hours wereover for the week. Santo reported that Mr.Cruz was extremely agitated.

Friday, July 19: Needless to say, by thistime Fidel Cruz had become a legend in hisown time. Interest was taken in his case bythe physician at the community center whocalled the hospital for Fidel's file. In the pastfew months Mr. Cruz had had an X-ray, EKG,PPD, and various other tests to satisfy anintern's academic curiosity. There was only oneremark concerning Fidel's hearing "right ear-drum not visible."

Monday, July 22: The hospital ENT Clinicwas called. The clinic may have hours Thurs-day.

Wednesday, July 24: ENT Clinic still uncer-tain about hours. Call 12:00 tomorrow.

Thursday, July 25: The doctor will be in at12 :30 p.m. but will leave at 1 p.m. if not enoughpeople are present. Mr. Cruz was not able tobe contacted. No clinic hours until next week.

Tuesday, July 30: Mr. Cruz visited the cen-ter today. He felt much better. He still had nohearing in his right ear but his morale wasgood. Mr. Cruz had not unreasonable doubtconcerning the value of his clinic visits andexpressed a desire that they be terminated.The physician in charge complied with his veryreasonable wishes and dismissed him.

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Presbyterian-University of PennsylvaniaMedical Center (I)

Frank Greer

"Proposed projects include a Child HealthProject and developing roles for communityaids to reach people not now covered. Homevisits, group sessions at the hospital and place-ment in the Family Planning Clinic, birth con-trol education, or in the receiving ward."

It was about 10 weeks ago that I read theabove words in a massive publication by SHOdescribing the various summer work sites inPhiladelphia. I suppose the words "ChildHealth Project" attracted my attention, andI made the work site at Presbyterian-Uni-versity of Pennsylvania Medical Center(PUPMC) my first choice as a work site.

Arriving here in Philadelphia, I hesitantlydecided to live with a black family in Mantua.Though I went through some traumatic ex-periences, it was an invaluable part of mysummer. When the people of the communitylearned I worked at PUPMC they immedi-ately wanted to "fill me in" on what theyknew about the hospital. I got many reactionsfrom community people about the hospital,most of them negative. For example, considerthat case of Mrs. B., who lived across thestreet from me this summer. On Sunday, June23, she had stomach pains and went toPUPMC. After a long wait, which she didn'tseem to mind, she saw the doctor in the re-ceiving ward (RW). He gave her some pillsand told her to call the hospital on Mondayfor an appointment for Tuesday's MedicalFollow-Up Clinic. So, at 9 a.m. on Monday, shecalled and was told by the admission clerkthat clinic was in session and to "Please callback at 1 p.m." At 1 p.m. she called back andwas told "The book (appointment book) hadn'tcome back yetplease call back at 3 p.m."Calling back at 3 p.m. she was told that shecouldn't get a clinic appointment before July9. She tried to explain that the doctor hadtold her to come on June 29. Ultimately, shereceived a clinic appointment for July 9. Mrs.B. was the victim of a great deal of run-around.As she did not have a telephone, this cost her30 cents. When asked why she had gone toPUPMC in the first place, she gave as a reason

the fact that her brother had been treated"just swell there." In general, however, despiteher treatment, she described things at PUPMCas "pretty nice."

As another example, take the case of aneighbor, Mrs. S. She related how a nephewhad been treateci st PUPMC two years ago.Having received third degree burns, he re-ported to PUPMC on Monday, only to be toldto come back on Wednesday. Instead, he wentto the Veterans Hospital that very same dayand was admitted immediately. Mrs. S. ex-pressed disgust with PUPMC, not being ableto understand why her nephew had not beenadmitted.

Mrs. W., also from the community and whowas employed by PAAC, expressed the be-lief that PUPMC was just too "high andmighty." She recalled the time when no blackpatients were accepted at PUPMC and a spe-cific case where a black nurse had sued thehospital for the right to work there. A friendof hers had told her that the Bookkeeping De-partment was "bad" at PUPMC. The friendhad been billed repeatedly for a service forwhich she had paid before leaving the hospital.Surprisingly enough, Mrs. W. thought that thehospital turned away Department of PublicAssistance patients.

Taking another case, Mrs. E. said that sheand her family used the hospital regularly. Herson was employed there. But she did mentionthe fact that she had a great deal of difficultyin making clinic appointments. When she tele-phoned, the extension was always busy and shewas asked to "hold" or to "call back later."Having no phone, she found it less expensiveto spend 50 cents carfare and to make theappointment in person at the hospital.

Finally, take the ca ae of an old white womanliving in Mantua. She reported that "Presby-terian was a good hospital, but I wouldn't touchit with a 10-foot pole."

After having heard such comments aboutthe hospital, I and my colleagues felt that therewas a serious schism between the hospital andcommunity. We attributed this to three basicfactors:

1. Patients were generally dissatisfied withlong waits in the Receiving Ward and feltthat there was discriminating behavior on thepart of the RSV personnel.

2. Many of the community people could re-member, or were told, about the former segre-gationist policy of the hospital. They felt un-welcome at PUPMC as people from a black,economically deprived community. Indeed, onewoman boasted about the fact that her teen-age son was the first black baby born at Pres-byterian.

3. Community people were afraid of the"research" going on in the hospital, particu-larly after its affiliation with the Universityof Pennsylvania. Many older people expressedthe fear of being used as guinea pigs. If onedied at PUPMC, then his kidneys, eyes, etc.were removed for transplants, and even thecorpse was given to the medical school.

Thus, as a result of our first two weeksexperience, both in and out of the hospital,our point of fccus became directed at hospital-community relations. This problem can be at-tacked on two different levels as is exemplifiedby programs at several area hospitals. On theone hand, one can work towards the improve-ment of community relations with the idea ofimproving health services to community peo-ple already making use of the hospital's facili-ties. Such programs are being conducted atTemple and Jefferson Hospitals. On the otherhand, one can work towards improving thehospital's image with the community at large.This approach could not include the specificin-hospital tasks required of the first level.Rather, it would involve close contact betweenhospital and community so as to keep the hos-pital informed of the community health needs.The hospital would also be kept in close touchwith other community institutions and cooper-ate with them when asked to do so. This wouldprobably involve the hospital in community ac-tivities not often considered a part of "health"except under the broadest definition of theword. Such a program is currently underwayat Misericordia Hospital.

Our approach to the problem of hospital-community relations has been on both levelsthis summer, though our daily emphasis hasbeen on the first level, the theory being thatby improving hospital services, patients willact as catalysts to improve relations with thecommunity at large.

Invited into the hospital initially by Dr. F.,we began first to investigate his Pediatrics and

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Well-Baby Clinics. He had expressed concernthat his Pediatrics Clinic had not been grow-ing appreciably in the past years and that avery high percentage of clinic appointmentswere broken. We noted one fault immediatelyin the appointment system for the PediatricClinicpatients were admitted only after theyhad first been seen in Receiving Ward. Thus,a mother with a sick child could not simplycall up and make an appointment for the child,being required first to bring her child into RW,which automatically meant a long and incon-venient wait. Now appointments for the Pedi-atrics Clinic can be made directly by telephone.Turning to the problem of broken appoint-ments, I began to call on all of the patientssigned up for Pediatrics Clinic, on a givenday, on the morning of the afternoon appoint-ment. About one-third of those patients whomI was able to contact, admitted they had in-deed forgotten the afternoon appointment. Ofthose who said they would not keep the ap-pointment, about two-thirds stated that thechild had improved significantly and that itwas felt that the appointment was no longernecessary. The other one-third said that cir-cumstances had arisen making it impossibleto keep the afternoon appointment. It is inter-esting to note that I met with very little hos-tility on these calls in the black community.Many people expressed surprise that PUPMCshould be so concerned about them.

In another project in the Pediatrics Clinic,we found that many patients unable to affordimmunizations were being referred to the Dis-trict 4 Health Center at 44th and HaverfordAvenue, At one time, someone from the hos-pital had picked up free immunizations sup-plied by the city and brought them to PUPMCfor administering. However, it was felt thatthis was not worth the time of a paid employeeso it was discontinued. We felt that this wasbad policy on the hospital's part, as manypatients referred to the Health Center wouldnever bother to male the extra trip. Of course,it was argued that this was not any fault ofthe hospital's; but such an attitude showedgenuine lack of understanding. People in Man-tua are faced with many other priorities whichthey usually place above that of good healthcare. The only time they would bother to cometo the institution was when they are ill. Thus,

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it is to be expected that such patients wouldnot make any extra efforts to receive immuni-zations. The hospital would be doing a favorfor themselves as well as the community bysupplying these indigent patients with the nec-essary immunizations. Jerry Lozner and Imade the trips for these immunizations thissummer and have worked out a plan with theVolunteer Department for their continuancethis fall.

Other suggestions for the Pediatrics Clinicincluded providing some sort of entertainmentfor the children. As patients are instructed bythe clinic admissions desk to register at 12noon for a 2 o'clock clinic, it is not unfair toask the hospital to provide the children withsome sort of amusement. To rake mattersworse, many patients feel that if they registerbefore 12 ncon, they will be seen earlier. Ofcourse the obvious solution would call for asupply of toys for the Pediatrics Clinic, butthen several objections were raised to this pro-posal. It was pointed out that such toys wouldquickly become dirty and serve as germ car-riers. However, it is also noted that toys canbe purchased which can easily be cleaned bythe Housekeeping Department, and besides,many of the children's personal habits spreadso many germs around the clinic that a fewmore would not make much difference. An-other objection to the proposal was that inmany cases the children would raise a fuss ifunable to take the toys home with them. Thisobjection can be answered easily. It is all amatter of discreet selection of the toys. Theseare indeed toys which children would not ex-pect to take home with them, i.e., a set ofwooden blocks or a black board mounted onthe wall. Or, inexpensive toys could be suppliedwhich could be taken home by all children.Such items can be bought wholesale at half-price, and the necessary funding can be madeavailable through organizations such as theLadies Aid Society, etc.

After the Pediatrics Clinic, we turned to anexamination of the Emergency Room. TheEmergency Room at PUPMC, like many othersacross the country, is becoming a sort ,)f com-munity doctor on call 24 hours a day. Thus,in addition to non-ambulatory emergency pa-tients, many patients come in with dog bites,colds, earaches, indigestion, etc., and they man-

age to keep the waiting area filled at all times.It is nothing for a patient with a dog bite tosit from 9 p.m. to 3 a.m. waiting for a tetanusshot. To be sure, the long wait could not beblamed on the nurses and interns who arealways working to capacity. What is dearlyneeded is additional employees for the Emer-gency Room, not to say anything about addi-tional facilities. It is hopeed that paramedicalpersonnel can be hired to screen out thosepatients who can be treated without the aidof a doctor.

It was unfortunate to observe that severalinterns assigned to the Emergency Room wereapathetic towards the patients. They wouldeften s:erhelly compare the patients a herdof cattle and administer inappropriate care.They openly expressed disgust with patientsthey saw repeatedly. This exemplifies a prob-lem not only for the hospital but of medicaleducation in general which turns out suchproducts. In one case in particular, an internrefused to become legally involved in whatwas clearly a case of child abuse. Fortunately,this attitude was not characteristic of all theinterns.

There are several obvious faults in the opera-tion of the Emergency Room which can easilybe corrected. For instance, at night the Emer-gency Room handles compensation patients.They are given first consideration and theirnames are placed ahead of all other waitingpersons. The unfortunate part is that most ofthese compensation patients are white. Thus,to the black patients, it appears that whitepatients receive preferential treatment, as theydo not have to wait. This situation does noth-ing toward improving the hospital's image inthe eyes of the community.

Another hang up in the Emergency Room isthe "temporary" appointment cards which aredispensed to patients referred to a daytimeclinic. Patients see the date filled in on thecard (if they are able to read) and think theyalready have an appointment. You can imaginetheir chagrin when they show up for clinic onlyto find that it is cloud or that the date writtenin on the card is an incorrect one. The appoint-ment must be conf rmed by a telephone call,and as we Pave already noted, this simply addsto the critical telephone line shortage in themorning. hours at the clinic-.

Turning to the out-patient waiting area ingeneral, we have noted the need for a numberof changes and have been able to effect themin some cases.

First, during the summer heat spells, theout-patient areas are unbearable. Temperaturesnear the 100 degree mark have been recordedthis summer. The entire waiting area is servedby two small fans. Air conditioners should beinstalled ; (the nurses who have air-zondi-tioned tubby hole, responded to this sugges-tion sharply : "Well, what did people do beforeyou had electricity?") It is realized that thecircuits in the out-patient areas are beingutilized to capacity, but something uhould bedone about the situation. It is cer4Lainly not avery healthy condition as it exists now.

Secondly, lighting is extremely poor in theout-patient areas. One would think the hospitalwas trying to drum up business for the EyeClinic. If the overloaded circuits negate theaddition of more lights, then either the ceilingor the lights could be lowered.

Thirdly, unlike the waiting room in theground level of the Private Wing, out-patientareas are not supplied with magazines. Weinstituted the placement of magazines in theseareas this summer and hope the project willbe continued by the Volunteer Department.Still needed, however, is a selection of maga-zines which circulate almost exclusively amongblack peopleJet, Ebony, etc.

Fourth, at the beginning of the summer, therestrooms in the out-patient area were veryunsatisfactory. At times they were so filthyand smelled so badly, that it was an insult touse them. After dropping a few hints in theright places, we are happy to note that con-ditions have improved considerably in the pastmonth.

Fifth, a program, which has been institutedat Jefferson Medical Center and is planned atTemple, is a milk and juice service in clinicareas during peak hours. At Jefferson nocharge is made to the patients, but it could beinstituted for a small fee if necessary. Proceedsfrom the sale could be used for a scholarshipfund, etc. Many patients arrive in the hospitalwithout breakfast, not realizing the long waitahead of them.

Sixth, one aspect of the clinic admissionsdesk which bothered us was the fact that

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patients were called by numbers and lettersrather than by their names. This was certainlya very dehumanizing experience on the part ofthe patient. Recently, we have cooperated withthe clinic admissions desk in instituting a sys-tem of registration whereby the patient's nameis used, not his number or letter. We hope thatthis procedure will be continued in the fall.

We have also done some work on the secondlevel of hospital-community relationsimprov-ing the hospital's image with the community atlarge. We first considered the possibility ofputting more community people into the hos-pital, either on a salaried or a volunteer oasis,Looking first at the employment situation, wefound room for improvement. For insi.n,e,there were 80 vacant positions for nurses inthe hospital in July. Forty of these were forR.N.'s. Twenty were for senior nurses' aidesand 20 were for junior nurses' aides. To qual-ify as a senior nurses' aide at PUPMC, thecandidate must have two years of previous ex-perience as a senior nurses' aide, yet there isno program here where the necessary 2 years'experience can be gained. Also, the hiring prac-tices of the hospital are very much open tocriticism. Applicants for employment are oftenrejected because they wear "large, danglingearrings" or "too much eye shadow." We werenever able to procure the necessary informa-tion to determine the percentage of employeesfrom the immediate community, as there wasno way of finding out that information, so wewere told.

We also were interested in recruiting moreblack volunteers at PUF'MC. During the sum-mer months, PUPAIC, a hospital in the midstof a black community, had no black volun-teers. During the remaining months of theyear, PUPMC has only one black volunteer.The Volunteer Director admitted that no at-tempt has been made to organize an active re-cruitment program. As a matter of fact, theneighborhood Presbyterian Churches have noteven been approached. It is thought by thedirector that the most reliable volunteers fromthe black community are just not dependable,Though this may be the case in some instances,and it may be true that most black peoplefrom the community cannot afford to volunteer,the fact remains that at Temple UniversityHospital, black candystripers from the imme-

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diate community compete for the positionswhich require one to be on the job five days aweek from 10 to 3. If it can be done at Temple,it can be done at PUPMC. All that is neededis a little initiative.

Consider the case of Robert P., a black 14-;fear-old who lives about two blocks fromPUPMC. Robert was one of two students rec-ommended by Salzberger Junior High Schoolfor volunteer work at PUPMC. Having spentsome time here last year as a patient, he wasexcited about working in the hospital. As amatter of fact, I talked with several of hisfriends who said that all he ever talked aboutwas hospitals and doctors. Robert reported tothe Director of Volunteers and was told thathe might be placed in one of the laboratories.A few days later, he received a letter fromPGH saying that he had been recommendedto them by the Volunteer Director at PUPMC.He worked at PGH this summer, and the labo-ratory jobs at PUPMC were given to whiteboys (probably sons of doctors) of about thesame age. As many positions as PUPMC hasopen for volunteers, Robert P., a student fromthe community, was recommended to PGH. Inmid-July, Robert, who still wanted to work atthis hospital, applied for employment, only tobe rejected on account of his age. That sameweek, another 14-year-old was hired by theDietary Department as part of some sort ofYouth Corps Program. But, this same hospital,several days before, had no place for a boyof the same age and of a very enthusiasticnature.

Still another aspect of hospital-communityrelations on this level is the cooperation be-tween hospital and other community institu-tions. We have successfully opened up a chan-nel hetwen PUPMC and Drew School locatedabout two blocks east of the hospital, throughdiscussions with the principal. As the samefamilies make use of both institutions, thereis certainly value in mutual cooperation. In thefall, both institutions are beginning commu-nity advisory committees on which a repre-sentative from each institution will sit. Anagreement is in the works between Hematol-ogy and Drew School. Hematology plans to testthe school children for anemia in return gain-ing data for its research on sickle-cell anemia.It is presumed that PUPMC could cooperate

similarly with the community institutionsschools, churches, YGS Health Clinic, etc.

Another way the hospital could serve thecommunity-at-large is in the area of familyplanning or sex education. A representativefrom Mantua City Planners met with us anddiscussed the great need for service of this typein Mantua. The SHO group at PUPMC thissummer has attempted to get nn unwed moth-ers' group going. It is felt that these younggirls who face so many problems would findit of value to share their experiences with oneanother. We have also met with a clinical teach-ing nurse at PUPMC. Out of this meeting camea number of suggestions and ideas, includinga possible sex education program to be set upby Drew School to be taught by student nursesat PUPMC.

The white man can only play a secondaryrole in improving the lot of the people in theblack ghettos. It is these people who mustbecome cohesive and work together to enactthe necessary changes. Fortunately, the com-munity of Mantua is showing signs of thisnew cohesiveness, especially through such or-ganizations as Mantua Community Planners.It is easy to put a few magazines in out-patient areas or to roll a juice cart throughthe clinic areas, but these changes by them-selves will accomplish little in the field of hos-pital-community relations. Unless the peopleof Mantua have a voice in enacting changesin PUPMC's policies, such changes will notbe appreciated. Without this community voice,the hospital can make no positive moves in thedirection of improving the rapport betweenthe hospital and community. I believe that thetime has come when the consumer should havea voice in defining the policy of the hospitalwhich provides community health care. Onemethod of instituting this new communityvoice would be by filling the position of "pa-tient advocate" with a Black American fromthe community. Hopefully, this person will beable to set up a committee of community lead-ers which will function together with a par-allel committee of hospital personnel in mak-ing new policy as well as redefining existingpolicy.

To be sure, there is the imminent dangerthat this individual will be absorbed and be-come an additional organ of the establishment.

Indeed, the "patient advocate" will come undera great deal of pressure from members of theestablishment who will feel threatened by thisnew approach of the hospital. To prevent this,it will probably be necessary that the "patientadvocate" be contracted through a third party,such as diversified university settlements.Though this will certainly be a difficult stepfor PUPMC to take, I believe that it is neces-sary to assure that what happened to hospitalsin Newark and Rochester des not occur here.

Presbyterian-University of PennsylvaniaMedical Center (II)

Jerry Lozner

As a medical student, I have become in-creasingly aware of many of the shortcomingsin the health care delivery system. I joined theStudent Health Organization and became in-volved in the Philadelphia Summer Project,because many of SHO's goals, as I interpretedthem for myself, have been extremely mean-ingful for me. The ideas behind SHO and theSummer Project were many:

1. To orient the health science student to thepatient as a social being; to look beyond thepatient to his environment; the nature of pov-erty and its effect on the patient is often neg-lected. The products of such an education arephysicians and nurses who are skilled in thetechniques of their professions, but who arewoefully ignorant of the sociological factorswhich affect the lives of their patients.

2. To develop a new model of health scienceeducation, with a high degree of student ad-ministrative leadership and new ties with com-munity groups, which could be applied to medi-cal t raining programs throughout the country.

3. To demonstrate an active interest in com-munity medicine, and change in health scienceeducation ; to recognize failure of curriculato come to grips with the biosocial issues of theday . . . abortion, population control, poverty,racism, euthanasia, drug addiction, war, etc.

4. To become personally involved with thesocial issues, so our understanding can be in-creased and our opinions bccome informed andvital.

5. To implement a multidisciplinary ap-proach to health care.

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6. To help develop a new breed of healthprofessional who is prepared to adopt new pri-orities in his professional life and encouragehis fellows to do likewise. This cannot help butlead ultimately to improved patterns of healthcare.

A medical student from last year's ChicagoSummer Project commented, "Today's medi-cine man tries to put people and their diseasesin context; to see alcoholism in terms of thedespair of the ghetto; to see rat bite in termsof the social injustice and greed which createslum housing; to see a difficult or hostile pa-tient in terms of the alienation which societyfosters. The new breed doctor is a man whoconsiders that receiving medical help is a rightand who considers that the only aspect of medi-cine that is a privilege is practicing medicine."With these long-range goals in mind, I setdown for myself some realistic short-termgoals for the summer and for a project whichinvolved not only health science students, butcommunity workers and high school studentsas well :

1. To plant the seeds for students to startthinking how to best achieve their long-rangegoals.

2. To implement in any way community rap-port with institutions or community rapportwith health science personnel.

3. To arrive at, together with the people ofthe community, concrete needs for better serv-ices and to help institute these needs as prac-tices in specifically improving the health caredelivery and grievance system.

4. To encourage poverty area high schoolstudents to continue their education into theprofessions.

These then were sonic of my aspirations asI began working at Presbyterian Hospital some10 weeks ago. Our working group consisted oftwo medical students, Frank Greer and myself,and two community workers, both of whomlive within the so-called community of the hos-pital. We were fortunate enough to have twovery interested preceptors, to assist and guideus in our efforts.

The precer :.ors informed us that the MedicalCenter was especially concerned about the sig-nificance of its health services for the com-munity at large. The hospital's decision to re-main in West Philadelphia when it beeeme ef-

28

filiated with the University of Pennsylvaniaseveral years ago really implied some kind ofcommitment to this particular community,"comprised principaRy of economically de-prived Afro-Americans and downwardly-mo-bile White-Americans." As objective outsiderslooking in, we were to be concerned with therapport between community and hospital. Whywas such a rapport almost nonexistent? Whywere several of the clinics being used only toa limited extent, especially the Pediatric Clinic?And from the outset, we agreed that we wouldgo beyond just becoming aware of what theproblems were, to also set the seeds for someconcrete solutions. It was hoped that we, "thestudent fellows, and the community workerswould be personally congruent enough to hearwhat persons in the community were saying,and would be personally congruent enough tohear what we were saying to each other." Thisprecaution and commitment to the institutionand to the community we would be leaving in10 weeks would help make the summer a morevalid and worthwhile experience for all in-volved.

The first realization I came to was thatwhite people can no longer impose their valueson black people. The black people have a verystrong culture and tradition of their own ofwhich they can be proud, along with a growingneed to help themselves. With this realization,I recalled the words of a black caucus of medi-cal students from earlier this year, "If whitestudents on summer projects do not have thiskind of understanding, the projects again turninto yet another summer of white paternalism,another slimmer where mindless; selfness serv-ice finds its reward in covert palliation, anothersummer in the sun learning how the niggerslive."

Hospital personnel were informed of ourpresence through a letter asking for theirsuggestions and criticisms. Community peoplelearned of our presence by word of mouth andthrough attendance at several community meet-ings. We were beginning to make initial con-tacts.

My first insight into the hospital was throughits welcome pamphlet which is given to all in-patients. On the first page, the following isstated, "Founded in 1871 to 'care for the sickand disabled; with no patient excluded from its

benefits by reason of creed, country or color,'The Center has built its reputation on medicaland surgical aid, nursing care and the 'spiritualconsolation' provided its patient." This state-ment, of course, was highly inconsistent withthe feedback we were getting from communitypeople about the hospital. It was felt that theMedical Center, since it once catered to a cer-tain class of white people, had remained highand mighty. Only now that this class of peoplewas gone, were community people welcome. Itwas felt that the hospital was using the com-munity. The research and experimentation go-ing on here at the hospital instilled fear inmany of the community people. They fearedorgan transplants or losing. blood for sicklecell anemia studies. Many people 'didn't knowthat DPA was recognized by the hospital. Oneperson believed that the first black baby bornin the hospital was delivered only 5 years ago.Others said that they would rather go to Phila-delphia General Hospital for their own reasons.The basic problems seemed to be a poor rap-port, poor communications, and a poor under-standing on both ends.

Still other people we talked to discussed theconfusion in the out-patient areas and the longwaits. Others didn't understand the GloverClinic and its heart surgery. We found thatmany of the people who came to clinic werereally not the ones who needed medical caremost. Preventive medicine was something thatmany people either were ignorant of or con-sidered unimportant. The major concerns werethe day-to-day affairs, and a laceration or gush-ing blood would be one of those.

We spent our first 2 weeks at the hospitalfinding out more about each other and meet-ing many people in the hospital, both in Ad-ministration and on the medical staff. We werebecoming increasingly aware and sensitive tothe problems, and we started discussing whatwe could do about them.

We worked out of the Social Service Depart-ment, and we received a lot of help from thestaff of that department. We attended Pedi-atrics and Well Baby Clinics and spoke to themothers as they waited for the physician. Aswe talked, we observed. We thought at firstthat it might be a good idea to serve coffeeto these mothers as they waited, but we wereadvised that because of the crowded space, hot

coffee would be dangerous as far as the safetyof the babies was concerned.

From the Pediatrics Clinic, we expanded ourobservations to the Pre-Natal, Post-Natal,Family Planning Clinics, and the ReceivingWard. The community workers began to gettogether a group of unwed mother:. for thepurpose of having a meaningful interchangein the discussion of common problems and baycare. Frank and I began looking into the ap-pointment system. I began to look into thenature of the appointment card which is ratherconfusing, especially for patients who receiveit after 5 p.m. The card indicates that the pa-tient is referred to one of the specific clinicson a particular day, but few patients remem-ber that they must call in the next day to maketheir actual appointment. The small print atthe bottom of the card reminding them of thiscan often be overlooked. The card should stateat the top in large letters, "THIS IS NOT ANAPPOINTMENT; FOR CLINIC APPOINT-MENT CALL EV 2-4200, EXT. 308, BE-TWEEN 9-10 A.M. Provision should be madeso that when they do call there is more thanone open telephone line to receive their calls.Too often the lines are busy for such a longtime that patients give up and forget A bouttheir appointments or come in at the printedtentative time only to find that they cannotbe taken.

This problem can be solved in several ways.The most obvious solution would be to movethe appointment books down to the ReceivingWard at night. It is not necessary to move allof the clinic books.

Among the people we came into contact withwere the Director of Public Relations, the Di-rector of the Volunteer Service, the Directorof Personnel, Director of Admissions, andmany others. All of these people were verywilling to help us, although some did not seemaware of what the problems were or that prob-lems even existed.

I took care of getting together a Hospital-Community Newsletter. The purpose of thisnewsletter was to let the community peopleknow what facilities were being offered tothem here at the hospital, what job and vol-unteer opportunities were available, and mostimportant, how to go about making an ap-pointment. There was no pamphlet of any kind

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available to the out-patient to tell him how touse the clinics. Pertinent telephone numbers,suggestions, and complaints could be directedto the Social Service Department. Perhapsthen, by working together, we could attempt"to bridge the gap between institution and com-munity."

The followup on the newsletter brought sev-eral interesting responses. Major responsefrom the community is yet to come, but manypeople were no doubt pleased to learn aboutthe hospital's interest. Several nurses from theReceiving Ward commented on one particularstatement in the newsletter, "The MedicalCenter through the Receiving Ward tries tofunction as the f----"y doctor for the commu-nity, 24 hours a day, 7 days a week." Thecommunity had been informed of a constantservice; the Receiving Ward was staffed onlysufficiently to supply an adequate emergencyservice. Here arose another incongruity in com-munications which demands evaluation.

Frank and I looked into the areas around thehospital where our out-patients come from.About 3,500 patients used the clinics duringthe month of April, and we plotted their geo-graphical distribution on a map. It was indeeddifficult to define the community of the hos-pital. Mantua wasn't the hospital's community ;in fact, there was a proportionately small num-ber of people coming from the Mantua area.Powelton Village had been torn up by reloca-tion, another sore spot in community discus-sion of the hospital, and there were manypatients coming from miles away.

With the start of the Young Mothers' groupand the availability of cafeteria rooms forlegitimate community meetings in the evenings,we realized that the hospital's commitment tothe community fell within the definition ofhealth in its broadest terms. We contacted aclinical nursing instructor about the possibil-ity of involving the student nurses in a sexeducation or health education program. Thiswas something that members of the commu-nity had expressed a need for.

It wasn't until the first night that I spent inthe Receiving Ward that I became impressedwith how cruel and brutal life can actuallybe. After seeing a gunshot wound and severallacerations, I felt my stomach sort of turningover inside. I even asked iySci f has it was

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all about. And I could hardly find words toanswer the intern who called these people ani-mals and looked at our future as extremelyfutile. When the 4-year-old male came in withgonorrhea contracted from a 6-year-oldfemale, I knew that progress could and wouldcome through education. I hoped that it wasn'ttrue that the United States could be comparedto a poker game in the Old West; when a cow-boy was caught cheating he would either bekilled by the others at the table, or his win-nings would be split up among them. Our racialproblem has been compared to that pokergame. The blacks have found that the whiteshave been cheating them, and either we'll haveto shoot it out with each other, or be preparedto share what we have. We must be preparednow to dispel the idea of white racist institu-tion. Now that communities are demandingrelevance, institutions must stop ducking be-hind elegance. The hospital must be preparedto listen to the needs of the community. Andif sex education is an important need, thensteps should be taken to fill that need. Ihave given the clinical nursing instructor re-source material from the large-scale healtheducation program being carried on at Lanke-nau Hospital. Miss H. has contacted a familyplanning registered nurse who would be gladto take the program under her auspices, al-though she would have little time for actuallyrunning it. Mrs. S. has indicated that DrewSchool would be an excellent source of youngpeople. So, this then is one program, the com-ponents of which can easily be put together.

We also were concerned with the fact thatfew people from the community were actuallyemployed by the hospital at levels above kitchenand maintenance staff. We did realize thatmany people from the community could notpresent the necessary qualifications. Yet, thehospital could use 20 more senior nurses' aides.The problem is that to be a nurses' aide onemust have 2 years' experience as a nurses'aide. An aides training program possibly runby the nursing school would be a valuable assetto hospital and community.

Our main focus, then became closing thegap between institution and community andwhat might be done to improve the rapport.we began seriously investigating the area ofpatient relations. We found that several pro-

grams in patient relations and community re-lations were already in existence at other hos-pitals in Philadelphia.

The assistant director of ambulatory serv-ices at one near-by hospital, was one of thepeople we got in touch with. There he has es-tablished both a patient relation coordinatorand a community relations coordinator. Theirmain intent is to make the patient's stay morecomfortable. Small overturesjuice and milkfor patients who have to wait, magazines, cleantoilet facilities, furniture and toys for the pedi-atrics playroom, etc.receive quite a favorableresponse. In poverty areas particularly, favor-able, as well as unfavorable, impressions movequickly by word of mouth. He has been aimingto add the humanistic touch to the services ren-dered in the out-patient area.

The Community Relations Director at an-other hospital, which is white, Catholic, hasquite a difficult task for himself. As the onlyblack person on an administrative level at thishospital, he faces the impossible or rather, ex-tremely difficult job of helping 'a white Catholicinstitution relate to a predominantly bl3ckProtestant community. He hopes to have serv-ices rendered by the hospital which not onlykeep the community healthy, but happy as well.He has organized a dance for the teenagers,study areas for the students in the community,and an enrichment program for the youngsters.

At still another hospital the director of pa-tient relations has done an admirable job. Inresponse to a noise; dirt, and confusion letterdrawn up by several physicians in the hospital,she organized a committee to look into some ofthe inadequacies of the hospital as far as pa-tient relations, and to try to respond to thepatients' needs. The head of each staff in thehospital is always ready to address himself toa problem as it comes up. The hospital quicklyrecognized the usefulness of her work, and herdepartment has now expanded to four people.

Here at PUPMC, w.! have presented a pro-posal for the position of patient advocate. Thisis a community person who could function inthe field of patient relations and actually be ahuman link between the hospital and the com-munity. This step of course would only be likeplacing a foot in the door toward a solutionto the problems we are confronting. Two com-mittees would have to be formed. One commit-

tee would consist of community leaders drawntogether by the patient advocate; the other andparallel committee would be composed of ad-ministrative and medical staff of the hospital.Together, these two committees could functionto work on new policy, as well as improve onexisting policy. In other words, for the hos-pital to be really accepted by the community,the community must be involved in desicion-making.

Another valuable resource person we camein contact with was the Assistant Director ofUniversity Settlements. He introduced us tohis "Design for Service Delivery that Rein-forces Constructive Tension Between a HealthCenter and Its Consunier and Supports Com-munity Power." He emphasizes the followingpremises :

"1. Individuals within a residential areaneed their own effective community organiza-tion structure if they are to deal meaningfullywith the problems they are experiencing.

"2. A geographic area needs a broad basedcommunity association that procaeds in a demo-cratic manner and is controlled by residents.

"3. A citizen organization is representativeof a community as long as it remains unchal-lenged.

"4. Public and private service institutionsthat are truly accountable to their consumerswill choose to support rather than underminecc:nmunity structures.

"5. Institutions that desire horizontal rela-tionships need to provide independent fundsfor a community organization service."

He has come into contact with PUPMC's As-sistant Administrator and hopefully their con-versation will be ongoing.

Proposal For Position of PatientAdvocate

Goals:

1. To be a human link between the institu..tion and the immediate community, so that thecare of patients will acknowledge their human-ity and affirm their dignity as persons; hope-fully, this will make the patients' hospital visitsas comfortable as possible.

2. To work imaginatively with professionalpersonnel in the continuing evaluation, re-shaping and development of health services.

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Departmentally, working out of either the So-cial Service Department or the assistant ad-ministrator's office would be the most suitablecontext.

3. To advise patients, many of whom areconfused by hospital procedure, of the stepsto be followed in gaining admission to, locat-ing and using the clinic facilities in the MedicalCenter ; to be the patients' advocate with thehospital in reporting grievances about serv-ices, and to carry out in depth followups onspecific patient problems, as well as specifictasks related to making the patients' stay morecomfortable.

4. To continue to inform the hospital of com-munity health needs by facilitating communi-cation between community leadership and thisinstitution. This would involve setting up acommittee of community leaders which, func-tioning together with a parallel committee ofhospital personnel, could work on new policyformation, as well as making needed changesin existing policy.

5. To be a liaison between this institutionand the other institutions serving the commu-nity.

Since the goals outlined above will probablyprove too much for one person, we conceiveof handling these goals in two phases orthrough two people. For instance, initial focusmight be on the first three items, which pri-marily affect community people already mak-ing use of the hospital's facilities. Items 4 and5 represent a second phase in the project'sdevelopment. This phase would not include thespecific in-hospital tasks required in the firstphase, but would deal with the hospital's rela-tions with the community-at-large. This phasemight possibly involve the hospital in activi-ties which fall within the definition of "health"in its broadest terms.

Rationale

PUPMC is becoming increasingly aware ofthe need for cooperation between institutionand community for the efficient delivery ofhealth services. The hospital feels frustratedbecause a medically unsophisticated commu-nity often overlooks, misuses, or does not makethe best use of the services available ; manycommunity people feel frustrated because thehospital does not seem to be as sensitive to the

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social dimensions of their medical problems asit might be. In other words, the hospital hasresources which it makes available to the com-munity but, because these resources are notlimitless, it wishes to make the most economicuse of them. At the same time, while the com-munity is not equipped to treat its own ill-nesses, it does know what its illnesses are andcould help the hospital identify needs to helpfacilitate and economize in the delivery of serv-ices. If channels for informing the communityabout medical services could be opened up andif channels for listening to the needs of thecommunity could be developed, delivery of med-ical care could be greatly simplified.

PUPMC has been struggling to define itsrelationship with the community for manyyears. Now that it finds itself placed in an areacomprised principally of Black Americans, theMedical Center which held itself aloof fromthe community bears the stigma of discrimina-tion against the community. This makes thepractice of good medicine difficult. Turningnow toward the black community, little hasbeen done to acknowledge or deal with thehostility generated out of a history of unfor-tunate community relations.

Affiliation with the University of Pennsyl-vPnia was a function of the hospital's decisionto stay in the community and, at the same time,a kind of commitment to the communitytous it and to be used by it. Our recently acquired"research" image sometimes gets in the way,generating fear in many of the people livingin the immediate area. Nor are we as aware ofthe ego-destruction of the Black American aswe might be, which makes it difficult for himto cross the threshold of a predominately whiteinstitution.

The position being proposed would begin toopen up some channels for conversation withthe community. Of course, by providing a per-son to fill such a position, we by no means feelthat this negates the entire hospital staff's re-sponsibility to be always listening for the con-cerns of patients and to be interpreting thehospital to them. Furthermore, it is our hopethat, in his language and presence, the advocatewill be performing a teaching function for thehospital personnel and will be affecting theirattitudes towards community persons in a posi-tive, healing way.

It is significant that the hospital's decisionto stay in the community was made in theabsence of any serious conversation with com-munity leaders. It seems clear that hospital-community relations could be improved im-measurably if the hospital were to take thecommunity into its confidence regarding plansalready made for renovation and developmentof facilities. It might also prove useful for thehospital to seek further conversation with com-munity leaders in the ongoing task of decision-making. Granted, there are ways of defendingthe monrlithic stance of a medical center, butthese can only be posted with complete disre-gard for the need to involve community personsin decisions which have to do with the life andfuture of the community.

Possible Credentials

1. The person should reside in the immediatecommunity and have an in-depth understand-ing of the community surrounding the hospital.

2. The person will need to be especially sen-sitive to the feelings of other persons and ableto perceive, on many levels, the nuances inhuman relationship.

3. The person should be a Black American,preferably between 25 and 45 years of age.

4. The person will understand or have theability to learn hospital procedure.

5. The person will be articulate enough tocommunicate verbally both with patients andprofessionals.

6. The person will acknowledge a dual re-sponsibility : to community and to hospitaland will possess the personal resources to workwithin this tension.

SHO AND HEALTH PROFESSIONALS

Karen Lynch

About 80 of the project workers were stu-dents who will someday find themselves inroles similar to those of the health profes-sionals with whom they came in contact dur-ing the summer. Through the summer projectthey have been able to examine the role ofhealth professional differently from their usualvantage point as students and prospectivehealth professionals.

Perhaps this experience of observing healthprofessionals, the health delivery system, andthe local communities which receive serviceswill, in the long run, have the greatest impacton these students, more than any formal factsand skills which were picked up during thesummer.

The following six articles present observa-tions on health professionals. Articles in otherparts of this report present indirect observa-tions on health professionals : comments aboutthe Jefferson Mental Health Program, the Con-sortium's recreation project, the philosophy ofthe Temple Day Care Center, Gray's Ferrycommunity, and the "Saga of Fidel Cruz," allrelate to this topic. In the articles of this sec-tion, students address themselves straight for-wardly to health professionals and their fellowstudents.

Bill Halperin discusses a forgotten group inPhiladelphia, the poor whites, a group whichpreviously had been excluded from SHO's con-cern. How to relate to this group remains prob-lematic for SHO and it is one which all healthprofessionals and reformers will have to face.

Both Jefferson Mental Health workers andTemple Mental Health workers were person-ally involved in organizational problems. PhilHarber and Anne Sheehan discuss the dual re-ward system which is common to organizationswhich deliver services. Responsibility to clientand responsibility to the serving organization,in theory, coincide and produce no conflict forthe serving professional. In actuality, however,conflicting goals and expectations abound. An-other common problem of service professionsis the determination of the appropriate modeof service and the development of appropriateattitudes in the practitioner toward the client.This problem is accentuated when practitionerand client are characterized by not only differ-ent needs but also different values and socialbackgrounds. Bart Butta and Robert Lewymake some observations on this conflict areaas a result of their work at the community"Trouble Clinic of the West PhiladelphiaMental Health Consortium."

The experience reported by Darryl Robbinsas a summer staff member of Eagelville pointsout the importance of personal feelings andrelationships to others within and outside ofprofessional roles.

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The article by project workers at MantuaCommunity Planners describes another alter-native to professional-community relations.This organization provides technical compe-tence in the design and execution of communityplans. This cooperative effort is a model of thepotential alignment of community people andskilled professionals. Ken Logan and PhilGraiteer present a vignette of the communityand MCP projects.

A difficult problem in any human situationis arriving at an understanding of the effectsof one's attitudes and behavior on others. Stu-dents' comments here point out the sometimesdeleterious consequences of professional atti-tudes on clients and the organizations whichthey serve. One wonders about the effect ofthese experiences on students themselves, asthey begin to assume the role of health pro-fessionals.

The Unexplored: SHO Working in Poor

White Communities

William Halperin

Fishtown has been left out. It is a ghettobounded by the Delaware River, Norris Ave-nue, and Front Street. Front Street is the"demilitarized zone" across which no black orPuerto Rican people move into Fishtown. Fish-town is a ghetto of white, lower income Ameri-cans. Many are white Anglo-Saxon Protest-ants ; there are Irish, Polish, Slovaks, andothers. Some are recent immigrants, othershave been in America five, six, and seven gen-erations.

The community is a combination of old brickrow houses, factories, and small stores. Resi-dents are working class people. Philadelphia'strucking industry, for example, is centered inthis area. In a sense, things are not changingfor the communityno new housing, no newpublic works programs, little mobility eithereconomically or geographically for themselvesor their children. In a sense the community ischangingmotorcycle gangs are becomingmore popular ; glue sniffing is more prevalent;vacant homes are set afire. In one corner candyand grocery store which was crowded withmore than three customers in it, a Polish im-

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migrant of 20 odd years had been robbed in-numerable times.

One cannot consider this a poor communityor call it low class. The residents would seethis as an insult. They demand other euphem-ismslower income. However, the problemsremain the same : a high drop out rate-1 per-cent go on to college ; many dilapidated andvacant homes ; unemployment. One block onwhich I helped a resident try to organize aTot Lot had only two of 13 families supportedby wage earners.

The community is just beginning to perceivethat it has problems. It is beginning to under-stand that the police must be badgered intotowing away abandoned cars. The people arerealizing that outsiders are not abandoningand stripping all the cars, but that their neigh-bors are responsible. A late model Pontiac witha flat tire and a smashed fender was turnedinto a worthless shell 2 days later. I watcheda neighborhood youth of 12 or 13 remove theradio. A public parking lot on Moyer Street,a residential street, is abandoned by the citybecause it is not used. A woman told me thatyour battery would be stolen by your next doorneighbor. She was not angry. She merely ac-cepted such behavior as quite normal.

Normal behavior is broadly defined. For in-stance, alcoholism is not perceived as a prob-lem. Most believe that all who drink need an-other shot in the morning to steady themselvesto get their shoes on. Black-outs are thoughtto be normal for those who drink. A sociologygraduate student is presently attempting tocollect information on the residents' knowledgeof alcoholism, mental health, and other welfareproblems. But it would be quite reasonable toexpect little knowledge about these areas.There are no health agencies in this area.

Fishtown has been left out. Fishtown is justoutside the model cities boundary. It was notincluded by its own choosing. To be simplistic :Fishtown has vacant homesmodel citiesmeans rehabilitation and open housing. Openhousing means blacks and Puerto Ricans. It isin this community that a true race riot hasoccurred in recent years. This was precipitatedby a black family moving in. More recently twoblack kids were "cut up" when attempting togo swimming in the Fishtown pool. Black facesare perceived as a major problem. A local resi-

dent employed by the state explained this fearas a defense mechanism. Fishtown residentshave very little except their patriotism (oneof the highest Marine enlistment rates) andtheir supposed white superiority. Integrationof poor blacks who, by most criteria (income,education), are the Fishtown residents' equalswould destroy their last defense, that irrationalbelief of white superiority. Therefore, in fact,Fishtown leaves itself out of many programswhich could prove to be beneficial. But thereare other reasons it is left out.

The comm.: lity is "solid" in a negative sense.It acts together to keep blacks out. Communitysolidarity does not work in positive directions.A very eager, unselfish shift worker was askedhow much he was being paid to help betterthe community. The only community worker,who is also my preceptor, was accused of hav-ing real estate interests. But then again theaccuser thought that two major evils are theinternational Communist menace and theteaching of Darwinism in the schools. Thecommunity does not seem either worried orastonished that the Delaware Expressway notonly has demolished many homes, but will runon a graded mound through the community.The Fishtown Civic Association with its 88members is trying to face some problems. Itis investigating trying to gain a mini-schoollike the one in Mantua and trying to have theabandoned homes in the expressway's pathtorn down before they burn. Fishtown is leftout because it has never gotten itself "together"for constructive purposes.

The third reason that Fishtown is left out isthat the government and other establishmentsleave it out.

There are several possible explanations. Themost obvious is exemplified by SHO's summerproject. Letters were sent to agencies, com-munity groups, and leaders throughout thecity. Since there is only one social serviceagency and one embryonic civic association,chances were not good that there would bea response to SHO's offer. The proliferationof community groups and projects in the blackcommunity is not paralleled in the white com-munity.

Fishtown does not even attract the mostsimple-minded do-gooders. Fishtowners aredismissed fr-,m our social concern because

they are bigoted. Working in poor white com-munities is just coming into vogue for thesocial activist.

On another level, some modicum of aid isnow directed towards the black community be-cause of pressure from that community in theform of lobbies and insurrection. The childrenof the white poor can be playing in dangeroushousing shells, but there is no urgency for thecity to act. When our leaders talk of poverty,they mean black people who have been left outbecause of white racism.

The government responds to pressure. TheWar on Poverty once was earnestly concernedwith poor whites, urban and rural. Urbanblacks have now gained most of the war onpoverty's attention. Blacks may appreciate theefforts of white people in getting the civilrights movement moving. Now their problemis to determine the path of their own commu-nities.

Poor white communities continue to existand grow. People live in despicable conditions.Perhaps in addition to facing our own institu-tions, we must catalyze the reaction of poorwhite America by building a new human rightsmovement there.

The Effect of Inappropriate Reinforcement

System on Program Establishment

Anne Sheehan and Philip Harber

A Case Study

Miss Anne Sheehan and Mr. Phillip Harber,students in the Health Sciences, participatedin the Philadelphia Student Health Organiza-tion's Summer Project of 1968; they were as-signed to the Temple Community MentalHealth Center to work and learn under thepreceptorship of the Chief of the CommunityOrganization Section of the Mental HealthCenter. Their prime activity for the summerwas the establishment of a Child Care Servicefor the West Nicetown-Tioga NeighborhoodFamily Health Center. This NeighborhoodHealth Center is an Office of Economic Oppor-tunity Healthright community medical centerserving a population of about 30,000 persons.

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Throughout the summer of 1968, its openingdate was delayed from early July to the mid-dle of August.

The SHO participants attended a tour of theNeighborhood Health Center which includedmeeting Miss S., Director of the Social WorkDepartment. At her invitation, they attendeda staff meeting at which numerous staff mem-bers presented the problem of the desire, andfunds, for summer employment of high schoolstudents being present, without any ideas ofhow to utilize these individuals. At the close ofthe meeting, the SHO participants presentedthe idea of establishing a service to care forchildren while a family member is receivingmedical attention at the Neighborhood HealthCenter ; this Child Care Service would bestaffed by area high school students, who willalso participate in a training program toqualify them to act as recreational leadersand to facilitate establishment of good commu-nity relations for the Neighborhood HealthCenter. The idea of working with a group ofhigh school students had been suggested byMiss S. to the PSHO participants on the pre-vious day. Dr. C., Director of the Neighbor-hood Health Center, stated that the idea repre-sented a sound solution to the problem and heagreed that the Child Care Service would bea useful part of the services to be offered bythe Neighborhood Health Center. He author-ized the PSHO students to write a proposal forthe Child Care Service with the guidance ofMiss S. When she was contacted, she agreedto provide the guidance and suggested that thestudents write a proposal to be presented to herin a week's time. The students then wrote theproposal. Upon its completion, the proposalwas presented to her ; she carefully read itand made certain revisions. There was somelack of clarity as to the next step to be taken ;it was decided that the proposal must beapproved by the groups along the lines of au-thority. Numerous problems evolved ; these in-cluded inability to find a reasonable locationfor the Child Care Service, question as to thedate that the Neighborhood Health Centerwould open, resistance to the idea by certainstaff members, and many details such as insur-ance. The relationship between the PSHO stu-dents and Miss S. became appreciably strained ;finally, Dr. C. and Mr. 0, Administrator of the

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Neighborhood Health Center, were called toa meeting with Miss S. and the PSHO persons.At this meeting, the project was approved byDr. C. for presentation to the Executive Com-mittee and to the Neighborhood Board of Di-rectors for approval. A final revision of theproposal was prepared in consultation withMiss S. The proposal was approved by bothgroups; Mr. J., Assistant Director of the Pro-gram, was to present the proposal to the Phila-delphia Antipoverty Action Council and to theOffice of Economic Opportunity for approval.Miss W., acting Director of PAAC delayedapproval. Dr. C. presented the proposal forunofficial approval to a visiting 0E0 official.After a delay of about a week, Miss W. ap-proved the proposal. The implementation ofthe program then began.

This paper will attempt to analyze one ofthe causes for the difficulties encountered ingaining approval of the program. The imple-mentation of the program will not be described;nor will other causes of difficulties be consid-ered. No attempt is being made in writing thispaper to provide a comprehensive view of theSHO participants' activities during the sum-mer of their placement at the Temple Com-munity Mental Health Center. Since the causeof the problem lies primarily in the medical"establishment" ostensibly engaged in deliver-ing medical and social services to the poor ofNorth Philadelphia, the paper will focus on"establishment," rather than "community."

Since the "private entrepreneurship" formof medical service does not function in NorthPhiladelphia, service is provided (when it isprovided) by relatively large institutions. Thisresults in a separation of the recipient of aservice from the purveyor of the service; thisseparation may be temporal (it was difficult toproduce enthusiasm for the proposal since en-thusiasm or action at the early stages wouldbring no immediate benefit) ; physical (most ofthe "high" administrators do not live in thearea they serve ; their offices' walls and airconditioners separate them from the peoplethey are mandated to serve) ; social (many ofthe "professional" employees cannot identifywith the problems of those they serve) ; bu-reaucratic (the duties of many prevent themfrom meeting the people they serve), or ofanother nly.urc.

This separation produces an iimpproprititereward system. Because the employee in an ad-ministrative position receives rewards fromother administrators, rather than the "commu-nity" to be served, he acts to please the admin-istrator, rather than to deliver real service.

There are two determinants of the nature ofthe reward system: the individual's responsive-ness and the structural design for operation.The former of these determinants is largelydetermined by the latter ; to the extent that itis not determined by the latter, it is extremelydifficult to manipulate. The latter reason, thestructural design, is artificial and, therefore,subject to manipulation.

There are several structural causes of theseparation of recipient of a service from thepurveyor thereof ; the most significant of theseis the role definitions for employee positions.Also contributing to the separation is the in-crease in the proportion of time spent on non-service administrative work as the group de-livering service increases in size. Furthermore,racial and social barriers accentuate the bar-riers between patient and health servicespersonnel.

The inappropriateness of the reward sys-tem reduces the quality of care delivered and,perhaps more significantly, reduces the possi-bility for meaningful change in the methodsof health care delivery. While the West Nice-town-Tioga Neighborhood Family Health Cen-ter is, itself, an experiment in health care de-livery and incorporates several innovative ap-proaches on a broad level, its staff shows amarked reluctance to experiment with, or eventhink about, changing the way they do theirindividual jobs. "Job Description" for eachemployee is quite sacrosanct; employees arebound to their specific tasks as with the moststringent labor contract. Since the Neighbor-hood Health Center is seeing a minimal num-ber of patients, the staff has no real contactwith those to be served ; many administrativeofficers stress plodding along without "caus-ing any trouble." This probably results fromthe fact that they are in no way responsiveto the needs of the community ; they are re-sponsive to an Executive Committee, composedlargely of administrative medical personnel,and to a "Neighborhood Board of Directors."This last body supposedly represents the com-

munity, althrlgh it has been said that onlythree of the 15 positions on the Board to befilled by community residents are actually filledby people residing in the area served by theCenter; more iinportantly, the Board and ad-ministration associated with it are highly de-fensive; their greatest reward is lack of anyform of opposition. This naturally leads to fearof change.

An example of the way in which fear of in-novation operates to delay service is providedby the Child Care Supervisor. One of the firsttasks assigned to her by the Director of theSocial Work Department was to write herselfa job description. Later, she was able to relyon that document to justify her delays in theestablishment of the Child Care Center, statingthat her job description precluded her fromdoing some of the things necessary for easyestablishment thereof.

Factionalism is another result of responsive-ness to something other than the quality ofservice provided. When one can receive rein-forcement only from within one's "unit" andcan increase one's bureaucratic status by in-crease in the size of one's "unit," it is naturalthat there is more interest in the "unit" thanthe community. This was evident in severalways.

The Mental Health Center and the Neigh-borhood Health Center, do not now cooperateto any significant degree, while it would ap-pear logical and even necessary according to0E0 Guidelines that the two cooperate.

In providing psychiatric services, the Neigh-borhood Health Center is seeking to establishits own psychiatric service. There is a basicmutual distrust and dislike between the twoorganizations which became quite evident at astaff meeting of both centers. It has been saidthat at a meeting of the Neighborhood HealthCenter's Social Work Department, the directorexplained her reservations about the establish-ment of the Child Care Service Program on thegrounds of a fear that the Director of theMental Health Center would attempt to directone of "her" programs through the SHO par.ticipants.

Healthright funds are to be used only as a "last dollar" whenno other service or support is available; Neighborhood HealthCenters are to cooperate with, and utilize, the services of ethercommunity service groups whenever possible.

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There is also animosity between the TempleUniversity Hospital and the NeighborhoodHealth Center. This is evident from the reac-tions of staff to including "Temple University"on their sign.

The necessity to have one's positive serv-ice viewed as a service of the "unit" resultsin the exclusion of many services which wouldnot be visible as a "unit" product. A possiblereason for refusal to even consider caring forchildren while a family member visits an OPDclinic at any other hospital (before the Neigh-borhood Health Center opens for service it-self) may have been the consequent lack ofidpntineat inn of the service as one of the Neigh-borhood Health Center. While the nature ofthe funding situation may in part account forthis answer, it is interesting to note that "serv-ice to the community" was not considered.

Besides factionalism, other problems arecaused by the inappropriate reward system.One of these is a great diffusion of responsi-bility. This occurs because administrators atall levels are not required to justify themselvesin terms of the actual benefit they provide.It. is, therefore, not necessary to personallymake any real contribution. Hence, an avoid-ance of personal responsibility for any projectdevelops. The responsibility for establishmentof the Child Care Service was shared by many,of whom the following is a partial listing: Di-rector of Neighborhood Health Center, Direc-tor of Social Work Department, NeighborhoodBoard of Directors, SHO participants, Execu-tive Committee, Program Development andEvaluation Unit, P-tient cure CoordinationCommittee Administration Unit, Child CareSupervisor, Philadelphia Antipoverty ActionCommission, Community Action Council AreaB, Office of Economic Opportunity. All of thesehave been involved in establishing the pro-gram. Since at the time of any delay it wasimpossible to pinpoint the responsible party,it was impossible to speed action.

A natural outcome of the lack of any per-sonal commitment to a project is a great indif-ference to one's work.

Medical and social services in North Phila-delphia are provided by fairly complex bureau-cratic structures. If rewards were made rele-vant to one's real service, the tendency to for-malize relationships in a bureaucratic struc-

38

ture might be reduced since the structure wouldbe wholly irrelevant to the individual's gratifi-cation. The disadvantages of bureaucracy arewell known ; this summer, the bureaucratic im-portance of working along established "linesof authority" became quite obvious. Manufac-tured delays and resistance came about as aresult of attempts to bypass the establishedlines of authority.

As described earlier, the proposal for theChild Care Service was presented at a staffmeeting. The Director of Social Work mighthave suspected a "conspiracy" between theSHO participants and the Director of theNeighborhood Health Center when the latterapproved the idea without first consulting her.

While the above example is concerned withassumed (informal) lines of authority, thefollowing is concerned with official lines. Afterthe proposal was approved by the Neighbor-hood Health Center, it required approval ofPAAC, CAC, and OEO. As mentioned earlier,the proposal was presented to an OEO officialbefore PAAC had ruled on it. It has been sug-gested by a member of the Social Work Depart-ment that Miss W.'s relay resulted from thisfailure to work through the "proper channels."

In the absence of more appropriate rein-forcement, many persons are forced to seekego satisfaction as a result of their occupa-tional status. This may in part account for theinflexibility concerning job descriptions. Pro-fessional distinctions are frequently exploitedto increase the professionals' sense of worth.

In conversations with persons at both theMental Health Center and the Neighborhoodhealth Center, the SHO participants detecteda sense of inferiority attached to mental healthassistants and to family health workers. Forexample, the names of individual family healthworkers do not appear in the minutes of thestaff meetings as do the names of all otherindividuals who attend. Mental health assist-ants seem to be considered more as equals byprofessionals than are the family health work-ers. It appears that the Neighborhood HealthCenter personnel are more resistant to destruc-tion of professional superiority than are thestaff members of the Mental Health Center.

The problem of establishing responsivenessto the wishes and needs of the community hasnot been answered with the establishment of

the "Neighborhood Board of Directors." It hasbeen said that 13G percent of the positionsallotted on this body for community representa-tion are held by outsiders. Furthermore, onemay question if the Board members do trulyrepresent the community ; one may question ifthe "poor poor" are really inarticulate in Boardaffairs. Many persons (social workers partic-ularly) claim to represent the community ; thatthey do often appears doubtful.

The system is such that the persons closestto the communitymental health assistants,family health workers, some nurses, etc.really have the least voice. When the proposalwas first presented, enthusiastic reactions camefrom some members of this group. However,the fate of the proposed Child Care Service wasin no way dependent on their reactions; rather,it depended on the wishes of high adminiStra-tion officials. While their support was hearten-ing, it was really insignificant in comparisonwith the power afforded by Dr. C.'s interest.

Many of the persons who could be most valu-able in instituting beneficial changes in the sys-tem are prevented from doing so due to a lan-guage problem. To institute change within the"system," it is necessary to speak the "sys-tem's language. The "system" speaks a bu-reaucratic language of its own.

The SHO participants encountered difficultyin talking the language of the NeighborhoodHealth Center. Such terms as "philosophy,""goal," "objective," "staffing patterns," "pro-cedural steps" have very specific meaningswhich are, in some cases, different from thegenerally accepted ineetiing

Besides the terms developed by each organi-zation to be used internally only, there is aprejudice against improper grammar and mon-osyllabic words. In writing an acceptable pro-posal, it was necessary to use quite formal con-structions and language. The need to write ina sophisticated manner leads to the exclusionof many family health workers, mental lwalthassistants, and others who have quite valuableideas, from the rank of those who can developa program. These persons are stymied whenthey cannot communicate on the language levelestablished by the 'high" administration. Onlythe SHO students' academic high school andcollege education placed them in e position to

do what many of the aforementioned cannotdo.

It is unfortunate that those who are closestto the community and consequently most re-sponsive to its needs are those who cannotcommunicate well in the language the "admin-istration" has chosen. This problem is perhapsrelated to that of status, since exclusion ofone's "underlings" on the grounds of their lan-guage may be used as an ego-builder by many.

It is natural for the real interests of thecommunity not to be served when the servicesystem refuses to speak the community's lan-guage. In general, one gets the impression thatinterest in the community's reactions is nega-tiVa in ehnrartnr nrily a fpar of rnmmilnitydisapproval leads to a solicitation of the com-munity. Tne phrase "getting a proposalthrough the Board of Directors" was too fre-quently used.

Despite these problems, it appears that theMental Health Center is making valid beneficialcontributions to the community and that theNeighborhood Health Center will do so when itfinally begins to provide full-scale service.

The organizational plan the NeighborhoodHealth Center is a fine step in the direction ofresponsiveness to service rather than to the"administration" of the "system." It is unfor-tunate that it is not implemented to allow thisactually to occur. Several questions should beanswered. Why should administrative positions(e.g. Director of Social Work) carry more re-ward than service positions (e.g. social work-er) ? Why should a physician not really listento what a Family Health Worker has to say?Why must the organization rely on token com-munity representation to justify their intru-sion into the community? Why are "appear-ances" rather than real service the basis forreward? Why is health care in North Phila-delphia inadequate?

Professionals' Values and TheirConsequence on Serving

Clients

Robert Lewy and Bart Butta

The main problem of the West PhiladelphiaMental Health Consortium is the preoccupa-tion on the part of the staff with their roles

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as white professionals who are "ethically" obli-gated to enforce a middle-class set of valuesand a middle-class oriented psychologicaltheory on members of the community for whomthis is totally inappropriate.

Consider an interchange which transpired onAugust 12. A student had requested a psychi-atric evaluation of an alcoholic by a consortiumpsychiatrist. The psychiatrist's response was amixture of apathy, indignation, and a profes-sional-training-bred belief that his profoundinsights could only be meaningful to a fellowmember of the guild. He was not willing toshare the fruits of his training with "Mr.Temple Student."

Instances like this are common at the WestPhiladelphia Community Mental Health Con-sortium. Even the young people become con-vinced of the value of discipline and tradi-tional, highly structured, classroom-orientedgroupwork methods. Talk of flexibility, re-sponsiveness to the community and innovationfrom such individuals is almost cynical.

People who enter the Consortium with newideas are met with feelings of indifference andare subtly undermined, isolated and their ideasare discussed to death. Blacks who lack the"proper" values by nature of class origin seemto acquire them in the course of professionaltraining and profess them with the enthusiasmof a convert. Certain professionals at the Con-sortium are not totally committed to this ap-proach, but will only confide their doubts pri-vately. The reason for such behavior is not,realistically, fear of losing the job; rather,such people are sufficiently guilt-ridden thetthey are effectively silenced.

A fallacy in this entire approach is thattherapeutic effectiveness and even emotionaladequacy depends upon professional training.Recent work in the areas of non-verbal com-munication and cross-cultural therapy (e.g. thework of Jerome Frank) made it clear thatwhat heals is an interaction with an emotion-ally competent persuasive individual. The pro-fessional training prejudice overlooks: 1. Theadequacy as pa rents of nonprofessionals, 2. theinadequacy as parents of many professionals,and 3. our own observations of therapists,former alcoholics, at Eagleville Hospital whohave no formal training but are highly effec-tive in their dealings with their patients and

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people in general. It is unfortunate that suchpeople must become "certified" by obtainingdegrees in formal training in order to rise pro-fessionally. We submit that such formal train-ing will reduce their effectiveness.

The solution, in our opinion, is not to, as ispresent procedure, gradually force out "old-line" professionals and traditionalists and re-place them piecemeal with "young people." Asmentioned above, the new arrivals are simplyisolated and swallowed up as their guilt be-comes mobilized. What is required is a com-plete overhaul of the Consortium facilities sothat white professionals are immediately andinvariably responsible to emotionally compe-tent "nonprofessionals." Such a procedurewould release those professionals at the Con-sortium whose originality and dissatisfactionwith present methods have been, by virtue oftheir responsibility to other professionals, sub-merged. It is a moot point to what extent sucha "release" would occur, but those who areincapable of it should be encouraged to seekthe safety of an instit-tion which is tradi-tionally oriented.

Eagleville

Debbie Finkelstein and Darryl Robbins

Although Eagleville is a treatment centerfor alcoholism, it must be realized that alco-holism is only a symptom of more complexproblems in living, part of which is the in-ability of individuals to communicate. We feel4,11,-, the Pegleville clln project must empha-size not only the problems of alcoholism butalso stress the importance of being aware ofour own feelings. Thus our project expandsfrom alcoholism to the area of human aware-ness. Therefore, as a part of our project, wehave brought several groups to Eagleville. Oneof these groups was the Soul City and ZuluNation, two North Philadelphia gangs that"swing together."

Arrangements for the gangs coming toEagleville for the weekend of July 19-21, 1968,were made through two staff members of theHartranft Community Corporation. Membersof the Hartranft staff sat in on a group therapysession at Eagleville and, being impressed withthe group therapy techniques witnessed in that

group and in the SHO groups, realized thatthese techniques would be applicable to work-ing with the gangs. A great deal of gang war-ring was going on in the community and it wasfelt that a talking out of hostilities and anhonest expression of feelings would be of somebenefit. Furthermore, the community workerswere concentrating on a $250,000 Federal grantfor building and maintaining clubhouses andsaw the weekend as a time for the gang mem-bers to evaluate their roles as clubhouse mem-bers and to suggest clubhouse leaders andadministrators.

The gang weekend was successful as far asthe gangs themselves were cuncerued. How-ever, the weekend highlighted the divergentopinions and approaches of the Hartanft staff.A great deal of intra-organization conflictemerged. It was suggested to the Hartranftstaff that they put themselves into a groupsession.

On Friday, July 26, 1968, a member of theTemple Graduate School in Group Dynamicsled an all day group session with members ofthe Eagleville and Hartranft staffs. A list ofsuggestions for more constructive youth week-ends resulted from the day's discussion. lIow-ever, the Hartranft rift only widened. It wasrevealed that when the clubhouse money wouldbe received and when the clubhouses would bebuilt had not yet been established. If the moneyis delayed, and because of the emphasis placedon the clubhouses by the Hartranft staff, notonly would the relationship between the com-munity workers and the gang be endangeredbut the gang's resentment might also extendto the community at large.

When Hartranft left Eagleville that Fridaynight, the problems within the organizationwere still unresolved. Although Eagleville iswilling to continue working with the Hartranftorganization and although gang weekends hadbeen proposed as a continuing program atEagleville, Eagleville has not been contactedby Hartranft for any futher action.

Eagleville has resources in the forms of staff,residents, and group techniques. The Eaglevillestaff has shown itself to be adaptable in work-ing with SHO, camp counselors, and Philadel-phia gangs. We have found that resident par-ticipation is invaluable in a group situation.

Mantua ariGl Mantua CommunityPlanners (I)

Ken Logan and Philip Graitcer

The Mantua community is an underdevel-oped residential area located in West Philadel-phia. It is a community of about 22,000 peoplemost of whom are of Afro-American descent.The geographical boundaries of Mantua are31st to 42d Streets on the east and west, andHamilton Street to Mantua Avenue and thePenn Central Railroad tracks on the north andsouth. The income, health, education, and hous-ing levels are far below the City's average.There are over 400 abandoned houses in this90 block area, and over one-quarter of thehabited homes are considered substandard andovercrowded. Statistically, Mantua presentsone of the bleakest pictures of a ghetto in thecity.

As is true in all aspects of life, the poor areprovided with the least services. Mantua isserved by the 16th District of the PhiladelphiaPolice. Patrol cars are generally seen onlyalong 33d, 34th, Lancaster, Haverford, andSpring Garden Streets. The police are slowto respond to emergency calls and complaintsif they respond at all. It is generally assumedthat the police want to get involved as little aspossible with the community. There are com-munity relations meetings at the Police Depart-ment at which attendance is good about 30.Nothing seems to come out of these meetings,and the establishment's answer is generally,"Of course e',1 like to help in this matter . . .

if only we could get a larger appropriation .

already we are 2,000 complaints behind . . .

why don't you people use your 'political pull'by banding together."

The PTC runs the 31 bus through Mantua;its schedule is sufficient, but its route avoidsmuch of Mantua. Few in Mantua have auto-mobiles. Trash and garbage collection is butonce a week and is totally inadequate for such adensely populated area. (Most areas of the cityhave one trash collection and two garbage col-lections in a week.)

Stores for the most part are marginal zwneroperated corner grocery and variety stores.There is one large, clean, moderattay pricedThriftway on Haverford Avenue. There are

41

several large stores peoximating Mantua onthe west. These are on Lancaster Avenue.There are many bars in Mantua, most of whichare run for absentee owners by local bar-tenders.

There are several schools in Mantua. TheMcMichael School is the largest elementaryschool in the East Coast. There are also a Cath-olic School for the Deaf, the Belmont Elemen-tary School, and the Mantua-Powelton MiniSchool.

Recreational facilities are provided by cityoperated playgrounds and Tot Lots. These arein fairly poor shape and unsupervised exceptfor McAlpin playground. Mantua CommunityPlanners has converted two city parking lotsinto basketball courts. MCP runs severalbasketball leagues on these courts. Severalpocket parks are in the process of beingbuilt by the Mantua Workshop and the Mantuacommunity. MCP and Young Great Society andHaverford Center all maintain recreationalprograms for Mantua youths.

In Mantua there are three general praction-ers and one dentist all of whom take DPA pa-tients, but they have very limited hours ofpractice. (Each averages about four hours perday.) The community turns to these men onlyin emergencies.

On June 1, Young Great Society establisheda medical center on 33d Street. Though itappears to give very adequate emergency serv-ices, it is not used by the majority of thecommunity due to: 1. lack of publicity; 2. loca-tion ; 3. the stigma associated with the nameYGS. In eseence, YfIS Medic-1 Center is jogwhat it says -- a YGS facility. It can not beconsidered a community project or facility.

Mantua is also served by District 4 HealthCenter. This center is already burdened in itsdistrict of 200,000 people, and is located quitefar in walking distance from Mantua. District4 is not served by public transportation con-venient to Mantua. District 4 does not seeminterested in reaching out to the communityeither.

As much as I hate to admit it, health is notthe major priority in Mantua jobs, educa-tion, housing, and the elimination of policebrutality certainly are much more essential toimproving the daily life in Mantua. Some cfthe health problems are (in order of priority) :

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venereal disease, mental health, physical health(comprehensive medical care), alcoholism,drug addictions, tuberculosis. Unless educationand living conditions improve at the same time,any improvement in health care will be mini-mal and temporary.

An effective attack on the problems of healthcare is impossible without a simultaneous andcomprehensive attack on all the social and eco-nomic conditions which breed poverty and ill-ness. It is perhaps for this reason that com-munity involvement in the planning of com-prehensive health care services has been mini-mal a more pressing need is shown in theassault on the problems that bring about pov-erty. We have been involved with legal, hous-ing, and zoning matters. We have done someresearch in the planning of V.D. clinics, mentalhealth clinics, and physical health clinics, butthis has been apart ti om the communitywe are writing proposals that we think may beeffective in Mantua.

There is only one way I can see as a viablemeans of getting things done that is bydirect action. This may be in the form ofharrassment, picketing, or by doing it your-self. Whatever the tactic, in an underdevelopedcommunity it is impractical for one to believethat either the city or the grass roots membersof the community will undertake action withouta slight amount of encouragement.

After a discussion with a member of theMantua community, I realized that the inci-dence of venereal disease in Mantua was un-usually high. This was due to lack of healtheducation, crowded living conditions, and lackof an adequate treatment facility. (The closestfacility is at 500 South Broad Street.)

A meeting was arranged with Dr. L., thehead of V.D. Control, and I proposed that hisdepartment (V.D. control) establish a clinicin the Mantua area. Dr. L. felt that this wasimpractical since people do not want to beseen walking into a "V.D. Center." An alter-nate solution was proposed part-time facili-ties should be set up in District 4 at 4400 Hav-erford Avenue. Though this center is not inMantua, it can be reached by walking. Also, itwas suggested that the city supply publichealth educators in Mantua to provide hygieneeducation and to publicize the new V.D. clinicat District 4.

It was asked that the President of MantuaCommunity Planners write a letter officially re-questing that the city establish more V.D.facilities. This was completed in the middleof July.

The next move was up to the Health De-partmentonce a week I received a call fromthe Senior Public Health Officer who informedme that he brought the matter of establishinga V.D. clinic in Mantua to a meeting of suchand so and that he felt quite sore that a facilitywould be established shortly.

I have been receiving this run-around forfour weeks now rye received calls of en-couragement that it was only a matter of a:=hurt time, I've received last,s is-wecurrently dealing with this request"), and I'veeven been visited by the coordinator for severalhealth districts. But results are all that counts. . . and there is no V.D. facility at District4 yet.

A community mental health program hasalso been devised. This was originated by apsychiatrist at District 4, and has since beenmodified by work done this summer. Ideas formodification of the original proposal arosefrom discussions with psychiatrists fromTemple Community Mental Health Center, theCity Department of Health, and several psychi-atrists in private practice. The proposal as itstands now is an amalgamation of their ideasthat have been modified to fit the community'sreeds as I see them.

Basically the source of patients for this cen-ter comes from many "informers" in Mantua.These may be neighbors, block captains, bar-tenders. f.r,antT workers, civic leaders. or cornerstore owners. They advised the troubled personto seek further help at the mental health center.At the center there are several indigenousworkers and a staff psychiatrist who shallselect. out those patients who need intensivetreatment, sending them to facilities that existin the city. The remaining patients will bedealt with at the center using group and/orindividual methods.

Mantua and Mantua CommunityPlanners (II)

SHO workers in the Mantua CommunityPlanners project; have grappled with the issue

of helping Mantua plan and develop com-munity services for the people of Mantua. TheMantua Workshop is the community institu-tion doing the planning, serving as the activeliaison between the people of Mantua and theCity, directing the research, providing thetechnical skills and harnessing white energyand concern. It is within this community orga-nization that cnr work has been done. Thelegitimacy and credibility of the planners andthe workshop as effective community organiza-tions largely rest on their indigenous character.Hence, SHO students have assumed an "in-visible" role, behind-the-scenes and supportive,developing proposals rather than a "visible"role on the streets doing anything like activecommunity organizing.

From the outset, SHO, as a matter of prin-ciple, has consciously placed itself in a subordi-nate position to community groups. The pre-ceptor, speaking for the community, raised theissues, identified the problems and directedSHO workers' activity. Thus, SHO attemptedto prevent still another white middle classorganization from flooding the ghetto withits own values. However, our preceptor'sfirst question was, "What do you want to dothis summer?" "What are you interested in?"In reality, the process of defining issues ha;been somewhere between these two positions.It is fair to say that the community wantedaction in various areas, although the preceptorand SHO workers really verbalized the issuesand defined the problems. Our preceptor sug-gested ideas. Our process of research wasessentially one of gaining an overall apprecia-tion ano tivity within the problem areas.then focusing on one aspect and narrowing ourinquiry. Our object was to produce concrete.functional, empirical statements for communi-ty action rather than general theoretical"analyses."

Our projects have varied from individual toindividual. Most of our research has beendone separately. The students have communi-cated more than the community worker andyouth intern. Our work has been tailored toour individual skills arid interests. Aga'.n, muchof our effort has.gone is o weparing feasibilityproposals for specific projects. The projectswill be implemented by the people of Mantuaand for the penplo of Mantua. Much of our

"research" has involved talking with key resi-dents of Mantua. Another large part of theresearch has been establishing contact and thennegotiating with city officials both in publichealth and in other fields such as housing, thepolice and elected officials. A third part ofour inquiries took us to useful resource per-sons outside Mantua and outside the web ofcity government to health professionals,lawyers, and other experienced people. Onlya small part of our research took place in theibrary.

The following is a brief run-down of lurprojects. In some our part is completed: innthprs it is just beginning,

1. Mental Health: Development of a pro-posal for a "Trouble Clinic," a walk-in clinicutilizing indigenous workers bartenders,cornerstore owners, gang workers, barbers,community leaders, and recreation workersas "listeners" and as counselors to handlethreshold problems and as liaisons to the store-front clinic. These "listeners" would operatein the community and refer individuals to theclinic. Within the clinic would be located apsychiatrist, medical services, a lawyer, voca-tional services, and experienced communitypersonnel.

2. Comprehensive Medical Facility: A pro-posal is being written for a community medicalfr .::lit', hopefully serving all of Mantua. Lo-cated in a rowhouse it would break down thebarrierstransportation, size, whiteness, im-personality between Mantua and the sur-rounding medical institutions.

3. TB E.( MillUtifnl,ti: On two occasions, S110workers scheduled the City's TB mobile unitfor visits to Mantua. Sites were selected, pub-licity was prepared and distributed and recruit-ing was done a personal basis. The targetgroup was composed of persons bypassed byother TB checks, i.e., those not in school andon jobs where periodic TB tests are scheduled.Approximately 200 such tests were given.

4. Social Disease: With community pressurea Venereal Disease Program was instituted atthe District 4 Medical Center.

5. Bail: A feasibility proposal was preparedfor establishing r community bail bondsman toserve Mantua. This would be a black business-man working to serve the community and inbusiness for a profit. The proposal found the

44

entire bail "business" to be dirty and a com-munity bail bondsman a good idea for the fu-ture 4 or 5 years away rather than fornow. As an alternative, a plan was designedto integrate the Philadelphia Bail Project intoMantua's needs. The Bail Project attempts tor lease defendants on their own recognizance.n lieu of bail. The process requires closecommunity connections to speed up the verifi-cation of information obtained from the de-fendant at the Detention Center and House ofCorrection. Thus, a system was devised usingblock captains as the persons to 'contact to startthe verification process.

C. mndlnrd-Tennnt Prohlcm8:A. Individual Cases: Individual cases were

referred to the SHO law student by variouscommunity workersseven or eight cases al-together. Each case involved expediting theproblems with rather than for the individualinvolved. The cases concerned landlord prob-lems, insurance fraud, problems with the cityWater and Tax Departments and problemswith realtors. The cases led to good coopera-tion from Community Legal Services and iso-lated individuals within the City governmentand apathy and hostility from the "establish-ment" as a whole.

13. Community Escrow Agent: Pennsyl-vania's rent withholding statute allows a ten-ant to divert rent from his landlord to anescrow agent when the city certifies the tenant'sdwelling "Unfit for Human Habitation." Aproposal was prepared to facilitate rent with-holding using the Mantua Community Plan-ners as an escrow agent. The plan involvesclose coordination with L & I (not very easyto obtain), immediate contact of tenants whosedwellings are "unfit" and negotiations withlandlords to prevent the cost of repairs beingtransferred to the tenant in the form of higherrent. While L & I has been reluctant to co-operate, the plan will go into effect this fall.

C. Housing Clinic: A proposal is being pre-pared for a Community Housing Clinic towhich residents with housing problems cancome for advice and action. The clinic wouldprovide a variety of services, e.g., directing anemergency repair unit, providing legal advice,running educational programs for tenants,action as an escrow agent for Mantua, givingadvice on establishing credit and mortgage op-

portunities, providing a list of dependable con-tractors from Mantua to do repair work andrehabilitation and finally acting as a real estateagent for Mantualocating vacant apartments,arranging home purchases, etc.

7. Community Parks: The community hasstarted construction of several parks. Legal re-search has been done in the area of structuringeffective community control and maintenanceof the parks.

This is only a quick summary ; much hasbeen left out. It would be tiresome to describeLadividual encounters with the "establishment"and not really very illuminating. Not surpris-ingly, the establishment has been lethargic.Several individuals within the establishmentauch as Walter Lear, individuals on the CityPlanning Commission and individuals withinCommunity Legal Services have been invalu-able. On the whole, however, the city's atti-tude has been one of "disposing" of problemsrather than "resolving" them.

VARIOUS MENIAL HEALTH PROBLEMS

Karen Lynch

At five sites, SHO project workers were deal-ing with problems of mental health. Three ofthese sites are represented in this section. Re-ports of the other two, Temple CommunityMental Health and the Trouble Clinic of theWest Philadelphia Community Mental HealthConsortium, are resented in other sections ofthe report.

These articles discuss various aspects of thecomplex processing of mental patients fromthe point where they are first identified as"mental patients" to the psychiatric wardsand then eventually back to their communi-ties. The experiences of PSHO workers notonly showed them the intricacies of adminis-tering this process and the problems of staffing,maintaining, providing, and coordinating serv-ices, but also involved them in the present re-organization of mental health services inPhiladelphia.

Michael Geha was not simply involved inthat process of reorganizing services in Phil-adelphia, but suffered the consequences of thatreorganization process. The Jefferson projectnever really got underway for the summer, al-

though they developed plans for an interesting,feasible project.

The entire mental health system of Philadel-phia isn't disorganized, as the reports of twoPSHO workers on one psychiatric service ofPhiladelphia General Hospital show. HarryHirsch and Rich Bernstein present comple-mentary points of view on their work with theNeighborhood Youth Corps on the recreationproject.

Jim Padget and Steve Ager present an inter-esting account of their experience at HorizonHouse, a residence within the community forrecently discharged mental patients. Theirinsight into motivations and the apparentlysimple problems facing these patients may leadto greater sensitivity in working with thesepatients.

None of these problems is new; the ap-proaches in confronting them are new andserve here as examples for future programs.

Organizing Mental Health Services

Michael Geha and Gail Jones

When we arrived at our project site, wefound a complete state of chaos. The entiremental health set-up in Philadelphia was beingreorganized with a new program taking effectJuly 1, 1968. Changes in the physical plantas well as in the personnel were in high gear.Needless to say, little thought had been givento the PSHO project After meeting with Mr.J. it was obvious that the only real planningwas that which produced a letter to Ron Blumand an arrangement for a two o'clock appoint-ment with Dr. W. at Philadelphia GeneralHospital. When we arrived there, we waitedhours for him to show up. As it turned outchaos existed at the Philadelphia General Hos-pital too. The entire Jefferson Hospital servicehad been moved from the seventh to the sixthfloor along with a complete shift of the staff,including a new nurses staff and new internsand residents. By the weekend we had littlein the way of a project. Everyone was very in-terested with words only, including sugges-tions as to whom, except themselves, wouldbe best suited to help us with our project.All we needed was someone to spend a fewhours giving some direction. On Tuesday of

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the second week we found someone who wasinterested, Richard S., Ph. D. With him weset up a structure for a project. This structureis described in the proposal which is appendedto his paper. Once this was done, we beganto cook with our project. Three weeks laterwe were deflated, depressed, and very unhappybecause we were only able to find two or threepatients who fit into our structure. As I lookback now, I realize what went wrong. Themost crucial point, because there are many, isthe fact that our ideas were molded into aproject by a man who had just arrived at thePMHC, and who knew less than I about theJefferson catchment area and what was goingon at Philadelphia General Hospital. We knewwhat the ward at Philadelphia General Hospi-tal was supposed to have in the way of patients,but not what it actually had. If the mentalhealth community was operating as it is de-signed to operate, our project would haveworked. What I fail to understand is why Dr.M. and Mr. J., both of whom knew exactlywhat was going on, failed to realize what wouldhappen if we tried this type .of project.

What I'm trying to say is that the idea wehad was excellent, but not resolute with respectto what kinds of patients are in the Psychi-atric Ward at Philadelphia General Hospital.What has become obvious to me is that mostpeople know what is supposed to be going on,but there is such a total lack of communicationbetween people that no one knows what isreally going on anywhere but right where theythemselves work. Thus, Dr. M. had no idea wewere coming in the first place, Mr. J. didn'tknow what the patient situation was at PGHand poor Dr. S. had not been in the communitylong enough to know anything but what he hadread about it in the appropriation for the staff-ing grant. The lack of communication came outeven more sharply when he attended a staffmeeting of people from all the different agen-cies involved in community mental health inthe Jefferson catchment. No one knew aboutanything in the other agencies. Service wasbeing unnecessarily duplicated, resources un-used in one agency were needed badly by an-other, but because no one was "aware" theywere unused.

I don't think there is any way to summarizeexcept to say that everything just "happened."

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There was little planning and thought put intoour project. Gail and I tried, but we know muchtoo little about community work or for thatmatter even what it consisted of, to knowwhich way to go, and as we tried we could getno one to tell us what was going on and whichdirection we should take (this may have beenbecause no one really knew). My opinion is thatunless the public mental health election this falland Jr. Corps Service at PGH proves outstand-ing for Jefferson students this fall, the projectsite should be abandoned as a project nextsummer. If it is not dropped, a lot of workshould be done at the start of the project pre-paring some type of informational data for theproject worker so that they know what is in thecommunity and the services provided by theagencies.

Proposal: Summer Training Program forMedical School Students

Goals

This program is designed to give students anopportunity to study a series of mental pa-tients over an eight week period during whichtime these patients will be making a readjust-ment to their families and communities follow-ing release from a mental hospital. A secondarygoal is to gain some feedback from the stu-dents regarding two subdivisions of the Jeffer-son Catchment area : the low socioeconomicNegro ghetto (area B) and the low socioeco-nomic white ghetto (area C) .

ProcedureIt is requested that Dr. Mock at PGH, or

members of his staff, refer to the summer stu-dents a total of 20 patients who are preparingto return to their homes. Hopefully this sampleof 20 patients, ten in the two designated sub-divisions of the catchment area can be locatedone week prior to their anticipated release fromthe hospital. Students then will review the caserecords of each patient in regards to demo-graphic characteristic, personal history, pre-vious alienations and symptoms of present psy-chosis. Students will interview each patient toget acquainted with the patient and to learnhis plans for leaving the hospital and for re-entry into the community. Stulents will alsovisit each family prior to the return of the

patient to the family homes. The interviewswith the families will be directed towardslearning about the family's previous experi-ences with the patient, their expectancies inregard to the patient, and their areas of ac-ceptance or rejection of the patient. In additionto a description of the family situation, stu-dents will complete items 22-30 of the Freemanand Simmons questionnaire. They will alsostudy the community setting to which the pa-tient will be returning and in addition to adescription of the community in terms of rele-vant variables, also describe the relationship ofthe family to this community.

Following the return of the patient to hisfamily, the student will interview the patientin the family setting, one, three, five, and sevenweeks after his arrival there. The interviewwill consist of items 1 to 21 on the Freemanand Simmons scale. Relevant items will be ad-ministered to the patient and also to the sig-nificant family member. In addition, the pa-tient will be rated on the MAAC scale andthe Overall-Gorham Scales.

At the end of the seventh week, after allinterviews have been completed, the studentswill summarize the changes over time that hehas noted in the patient and also his impres-sions of the barriers to further growth, wheth-er they derive from the patient himself, fromthe family or from the community setting. Thislast item, hopefully, will give feedback to theJefferson Community Mental Health Centerregarding community factors in areas B andC which influence the mental health of theresidents.

The Recreation Project for One PsychiatricService: Two Points of View (I)

Harry HirschProblem

Prior to this summer, no program of recre-ation therapy existed for the 80 in-patients inPenn's Psychiatric Service located in Philadel-phi General Hospital. Patients were able tospend their time watching TV or staring atthe wallneither of which is particularlytherapeutic. As part of a series of moves de-signed to upgrade the quality of psychiatriccare at PGH, a pilot recreation program wassuggested for the summer, with successful as-

pects to be maintained throughout the year.The widely varying interests of the patients,who ranged in age from 10 to TO years pre-sented a challenge to anyone planning anactivity program.

ResourcesThe Mental Health Consortium had engaged

five supervisors (of whom three were SHOworkers) to work under Christine Westfall inplanning and executing the recreation program.Thirty high school students from the WestPhiladelphia area, working in the Neighbor-hood Youth Corps, were paid $1.40 an hour bythe Youth Corps to serve as recreation aides.All but two of the recreation aides were female.A Consortium sociologist led semiweekly in-service training seminars for the five super-visors and preceptor. He also served as a valu-able advisor and consultant on sundry prob-lems arising during the summer. The seminarsdealt with the background of mental illnessand practical problems encountered in groupwork.

In addition to these human resources, thephysical facilities available proved to be ade-quate for the program needs. Several grassyfields on the hospital grounds were used foroutdoor activities. The PGH recreation depart-ment and a small budget from the Consortiumprovided athletic and indoor game equipment.The Consortium bus was used for trips to thezoo, Phi flies games, and weekly swimming ex-cursions at League Island Pool (PhiladelphiaRecreation Department). A request to use abeautiful indoor pool in the nearby PGHnurses' residence was turned down by the"matron"-in-charge.

OrganizationEach of the five supervisors worked directly

with a team of recreation aides. Because theneed for recreation activities is, in fact, great-est on evenings and weekends, when hospitalroutine is at a minimum, the program operatedon a seven-day week : 1 to 9 p.m. Mondaythrough Saturday ; 9 a.m. to 9 p.m. on Sunday.Two teams of recreation aides and two super-visors were on at any given time within thatschedule. These arrangements resulted, forsupervisors, in a week of approximately 35hours and 2 days off out of every seven.

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ActivitiesStructured activities comprised one aspect of

the program. These included bingo, picnics,movies, bowling, volleyball, softball, trips forswimming, museum, zoo, baseball games, andarts and crafts. Poetry readings and psycho-drama were used a few times. Much of the pro-gram consisted of unstructured relating to thepatients. Card games, checkers, ping-pong, andabove all, discussions among patients and rec-reation workers filled out the unstructuredtime slots.

Success in Confronting ProblemThe recreation program succeeded fairly well

in supplying a varied schedule of recreationactivities. Moreover, the program providedenormous opportunities for patients to partici-pate in social interaction and thus facilitatetheir recovery. Because of common socioeco-nomic backgrounds, the Neighborhood YouthCorps workers were able to relate quite welland without inhibitions towards many of thepatients.

The success of the NYC workers in this proj-ect is significant in terms of meeting person-nel needs in health care delivery. The success-ful employment of inexperienced recreationaides (and supervisors) in the recreation pro-gram suggests that people lacking formal train-ing in medical fields may, nevertheless, be ableto free trained personnel for more efficient useof manpower.

A major criticism of the recreation programis the failure to establish a routine activityschedule. Supervisors planned activities on thespot. An activity schedule would have provideda structure on which supervisors could fallback on when in doubt of what to plan, andwould have insured a more varied array ofprograms than was actually offered.

Closer communication between SHO andproject preceptors would have been helpful inascertaining the role of SHO workers at theproject sites. The 7-day working week wasboth a basis and subject of conflict. SHO work-ers were not prepared for the "cruel and un-usual" summer work schedule which was notsuggested in SHO advance publicity or projectdescriptions. The schedule was handed to super-visors at the beginning of the summer as"what had to be" and was accepted largely dueto a lack of viable alternatives. The working

48

schedule resulted in conflicts between site obli-gations and SHO meetings, conferences, andprograms. While I generally placed my allegi-ance to the project site above that towardsSHO, the other two SHO workers tended inthe opposite direction.

Relations with the PGH staff were, for themost part, extremely cordial. The R.N.'s andP.N.'s were very cooperative and often assistedin urging patients to participate in recreationactivities. Male attendants were very friendlyand often participated in the activities them-selves. The female attendants, or, the otherhand, were usually both lazy and insolent topatients and were often uncooperative. Internsand residents seemed pleased with the programand were willing to confer with supervisorsabout problems in dealing with specific pa-tients. Some initial conflict arose between thestudent nurses and recreation aides. Some stu-dent nurses were resentful (and perhaps jeal-ous) of the rapport which the NYC workershad struck with the patients. The studentnurses, despite or because of, their psychiatrictraining, often felt less confident in dealingwith the patients than did the NYC recreationaides. By mid-summer, however, this conflicthad been resolved. Whenever possible, super-visors attempted to involve hospital staff in therecreation activities. These efforts paid off individends of enthusiastic cooperation frommost of the staff.

The patients tended to refer to the recre-ation aides as "volunteers." This term suggeststhat patients perceived the Youth Corps aspeople who enjoyed relating to the patientsrather than workers who put up with drudgeryin order to collect a pay check. Patients appre-ciated the presence of people who: (1) tooktime to stop and listen ; (2) broke the monotonyof a hospital stay, with planned activities; and(3) were, at first, easier to manipulate thanother hospital staff. Patients were particularlyglad for opportunities to participate in off-the-ward activities. Some effort should be made,however, to decrease their dependency upon therecreation staff as the only source of organizedrecreation and help patients to organize theirown recreation programs.

ConclusionsAlthough this project failed to confront any

major injustices of the health care system, the

establishment of the pilot recreation programsucceeded in filling a major gap within thepresent system. This site afforded me the expe-rience of relating to (1) psychiatric patients,(2) "hard-core" ghetto youth, and (3) the bu-reaucracy of a large city hospital. Finally, theproblem of transferring the program into thehands of the year-round staff remains to beconfronted between now and the summer'send.

View II

Richard E. Bernstein

The group which our, recreation programcame into contact with was the NeighborhoodYouth Corps. This group of underprivilegedblack high school students was a constantsource of fun and difficulty. Formally, the 25young people (two of whom were boys) weredivided into five teams, each headed by a whitesupervisor (three of whom were in SHO)Each supervisor was supposed to encourage histeam to get the patients involved in some out-door activity or, if we were on the ward, toengage in quiet indoor games. Talking to thepatients and relating to them spontaneouslywas very much encouraged by most of thesupervisors.

Despite the admonitions of black nationalistsand militants, we found virtually all of theNYC people receptive to our friendship andour leadership. Even when actual resentmenttoward certain supervisors did arise, the blackstudents candidly denied any feelings that agiven supervisor was condescending or takingadvantage of his authority, they were quitesurprised to hear and quickly dismissed thepossbility that the supervisor was expressinga white supremacist attitude.

Regarding the effectiveness of the NYC,I have mixed feelings. Relating to patients isdifficult. It is very easy to ask people to "justtalk to anyone who looks alone." But theseyoung men and women have had no previousexperience in a psychiatric setting. Further-more, they find it very difficult to carry ona conversation with adults in their own com-munity, let alone in a community of emotion-ally disturbed adults. As a result, the NYCstudents tended to gravitate toward the young-er patients, and more particularly, to those pa-

tients who were not physically repulsive norverbally hostile. On the whole, the patientswho received the greatest amount of attention,were under 30, black, and white males, extro-verted or passive men who were receptive toand thankful for the attention of the girls.Thus, almost a third of the patients receiveda lot of direct attention from the NYC. Itshould be noted that this is only a generaliza-tion, for certain membeys of the Youth Corpsfelt very much at ease with the less sociablemen and women of all ages.

If an index of success for the recreation pro-gram was direct, personal contact betweenYouth Corps and patient population, our pro-gram has failed. While it was hoped that, asthe students became more at home on thewards they would socialize more freely, thisnever materialized to any large extent. Evenat the end of the summer, it was somewhatcommon to find three recreation aides (i.e.NYC members) and only one patient playingcards together or to observe three or four rec-reation aides watching TV or sitting alonewithout patients nearby.

Despite this fact, I was very interested tohear that an experiment in Europe indicatedthat wards in which there were communityadolescents present had a higher rate of dis-charge and absence from in-patient services forall ages of patients than control groups. There-fore, it might well be that even if the recre-ation aides dance and talk among themselves,sit alone, sociali'm only with the men, or justgenerally do their thing, the old ladies andsick old men are absorbing the atmosphere,which simply radiated with life and health andyouth.

Health ProblemsAfter discussing with others, it seems that

the fundamental problem with the health caredelivery system as far as I saw it (on theeighth floor of the Mills Building run by Penn) ,was that Penn is much more concerned witheducating its interns and residents than withtreating patients. The treatment aspect is notabsent, of course, but various conditions on theward indicate that Penn is educationally ori-ented. Most critically, it is clear that there ishardly any semblance of a team approach topatient treatment. If the medical staff in chargeof the ward were truly interested in helping

49

patients, they would institute, as early as pos-sible, a team approach. This -ild involvecementing the nurses, student n s, attend-ants, social workers, and recreational and occu-pational therapists into a working group toserve as the surrogate eyes and ears of thedoctors. The above staff should be informedabout the patients' history and, more impor-tantly, should be aware of, and have some sayin determining the staff's "strategy" for eachpatient. As more and more observations invarious settings are made, the strategy maybe altered. But in any event, the doctors oughtto have some communication with the rest ofthe staff if they are to make the most efficientand prudent use of the human resources latentin the staff.

In the ward setup, the doctors consulted withthe social workers, although I am not sure howoften. Over half the doctors' time was spentlearning about patients from their teachers andfellow residents. Doctors read the nurses' noteson patients; however, charting was only donewhen there were some fairly dramatic changesin the patients' physical or emotional or behavi-oral condition. Pertinent conversations or ob-servations made by attendants or our recre-ation teams or supervisors were not discour-aged but never really encouraged. We, the rec-reational program, felt very much alienatedfrom the nursing staff in so far as giving ourpersonal opinions. While nothing was said, Ifelt my observations were listened to but notopenly welcomed. I should say, however, thatseveral nurses did spend some time with thesupervisors, informing them about patients.

Perhaps one of the most illustrative exam-ples of the attitude prevalent this summeramong the staff was demonstrated at the veryfirst meeting we supervisors had with the wardstaff. We five met with :;he head of nursing, thehead of student nurses, and someone fromsocial service. They made it quite clear to usthat the recreation program was our baby andthat we could not expect and should not expectany help from the staff, because of the terribleburden they had with other things. This is astriking example of the way communication isdiscouraged, resulting in a fractionating of apotential team effort, and ultimately in causingpoorer care to the patient.

50

Resources

The most obvious recommendation I have isto encourage the Consortium to put pressure onUniversity of Pennsylvania Medical School toinstitute a team approach to dealing with pa-tients. This would mean coordinating the effortsof the heads of student nursing, ward nursing,social service department, the recreation andoccupational therapy department, so that allworking together in order to both promote edu-cational instruction and maximum care for thepatients (through a team effort). Furthermore,Penn ought to get more psychiatrists workingon the ward. At present, about 90 percent ofthe doctors are interns and residents, whospend about two-thirds to three-quarters oftheir time in classes or in clinical conferences.Lastly, it seems that the Consortium shouldact as a consortium of several medical schools'services. As far as I could ascertain, there wasno coordination of efforts and resources be-tween the various floors (each run by differentlocal medical schools). Apparently, the knownpolitical rivalry among schools has been al-lowed to be expressed within the rubric of the"Consortium." Each floor is a perfectly autono-mous unit, totally segregated from the others.This must inevitably lead to inefficient use ofresources and poorer delivery of services tothe community.

Horizon House

Steve Agar and Jim Padgett

Can you imagine yourself being away for5 months, 3 years, or even your life time fromthe society that you've been used to? I can'teither, but several people whom I have met thissummer have faced this problem. What arethese new buildings they see? The strange newdress? The changing political and social world?Can you put yourself in their places?

This has been the plight of most of America'smental patients. Our system of mental healthcare has been what we thought was quite pro-fessional and indeed it was for its time, butnow the situation is no longer the same. A stepback into the community must be made in theclinical treatment of the mental patient. Heshould no longer be shipped out of his hometerritory into an impersonal, factory-like envi-

ronment from which he will eventually emerge,somewhat a stranger to his former situation.

A recent research project in which we havebeen involved deals with the product of sucha system. We are trying to motivate ex-patients(called "members" at Horizan House) to learnabout and search out their communities. Wehave divided a low-functioning class of mem-bers into three groups of 10. One group is acontrol. With both of the other groups, wediscuss various activities, such as the FranklinInstitute. One group of people is urged to goto these community activities by itself (client-led) while one of the PSHO students takes theother (staff-led). In this manner, we may beable to show which, if any, is the better methodto get the clients involved in the community.

As the project has just begun, we have noresults as of yet. But the ultimate knowledgegained will not be concerned with which meth-od is better. The result of this project will aidmembers treated under the present mentalhealth system; but the final question is, "Isthis system adequate?" We think not.

Thus, we have a difficult time getting J.R.even to go with the staff-led group. J. wants togo in order not to hurt our feelings, but hisconvenient sore feet, early rising hours, variousduties, etc., prevent him from joining the poor-ly attended group trip.

Therefore, our duty of motivating these peo-ple becomes a very difficult and trying job. Arewe convincing enough while telling them of ourexciting trip the following day? Should wepressure them into coming? These questionsand this research project wouldn't be as neces-sary if these chronically ill people had beenhospitalized short term in their own commu-nities.

In addition, a series of social functions formale and female ex-mental patients was estab-lished at the Horizon House residence, whichwas very successful. Unfortunately, a proposalto initiate a concomitant series of sensitivitygroups to enable the boys and girls to betterunderstand each other's motivations wassquashed by the powers that be for irrelevantreasons.

This whole new field of community mentalhealth is finally beginning to take shape andresults are coming forth. We never realizedthe consequences of our country's antiquated

mental health program until this summer. Nowwe can see.

PLANNING AND DEVELOPING PROGRAMS

Karen Lynch

Each project and each new program whichis developed in an attempt to achieve that long-range goal of improving health services isunique. Yet, the successes and failures of thepast are brought to each new project and theseexperiences should guide future plans. Foursuch experiences are included in much detailhere. They should be read nut so much for thecase history of one proposal or one program asfor the successes and failures which each onefaced along the way and the action which wastaken in each case.

At Southwest Center City Community Coun-cil, project workers and community peopleknew the general needs of the area, but workedin several different directions until they finallydecided to write up a proposal. The DelawareCounty project involved two students prepar-ing for the November election and the countyhealth department issue which was on theballot.

These two sites were involved in planning.The project workers at Citizens Concerned forWelfare Rights were setting up a babysittingcenter and then presenting proposals to variousorganizations for funding. At St. Chris, a pho-tography club was set up with a dual objec-tive: it educated children during the summerand it was a means of entering the community.A careful reading of these papers should pro-vide both information and a feel for the effec-tive approach to establishing new communityprograms.

Changing Direction at SWCCCC: FromSurvey to Proposal

Ed Pisko

There are two heaAh science students nowworking with the Southwest Center City Com-munity Council (SWCCCC) at present, CarlaOswald and Edward Pisko. A member ofSWCCCC and its Health Committee is work-ing closely with these students.

51

The initial Role of SHO WorkersThe initial agreement to bring in the stu-

dents was made between Mr. C., representingSWCCCC, and the SHO. This agreement wasmade with the knowledge and approval of theHealth Committee and the Executive Boardof SIVCCCC. Mr. C. was to serve as preceptor,defined by SHO as "an individual, usually aprofessional, who is responsible for the activi-ties of the project workers at the project site.He will meet with the workers regularly andoffer guidance and assistance, while not direct-ing the actual activity of the workers."

The roles of the workers were not clearlydefined 1)y SIM or SIVCCC. zkt, first, it seemedthat their role was to do a health surveyof the SWCCCC area west of 19th Street. Thereason for this was to help in obtaining a chil-dren's clinic and program similar to the onein existence in the eastern SIVCCCC area, theRebound Program.

After discussion, a questionnaire was com-piled using many of the same questions thatDr. L., Director of Research, had used to obtaininformation about the persons Rebound wasserving. Other questions were added thatseemed pertinent, and the questionnaire wassubmitted to the Health Committee and ap-proved after suggestions were made.

However, before they started surveying thecommunity with the questionnaire, they de-cided to see if this was the best way possibleto deal with the problem of obtaining healthfacilities. Dr. L. revealed that her question-naire was used to gather information thatwould help administer and evaluate the pro-gram that was already funded. But in order toobtain a grant for new facilities, the proposalshould contain statistics from the Census Bu-reau, the Philadelphia Department of PublicHealth, Philadelphia School District, Depart-ment of Public Assistance, and police records.Therefore, a health survey would not be ofgreat value at this time.Health Care System

The next move was to see how one goesabout obtaining a health clinic for an area,since it became evident that a health surveywas not the answer. Since the original goal ofthe project was comprehensive children'shealth care, the idea was expanded and re-

52

done into comprehensive health carein general. This decision was also based onchanging concepts about what is consideredgood quality medical care.

These are changes which can be seen rightin this community. To begin with, one reasonthat the two hospitals are going to leave thearea in the next few years, is the belief' in ahealth center complex as the best way to ad-minister hospital health care. To the Univer-sity of Pennsylvania, who owns the two hos-pitals, there is a great deal of value in puttingthe two hospitals with others. Some of the ad-vantages of this stem are the close proxim-ity of a large number of physicians for con-sultation, centralization of facilities, and prox-imity of the medical school to its associatedhospitals. Temple University has a similar pro-gram with a large health center complex beingthe anticipated end result. It is of interest thatTemple has also established a comprehensivehealth center in the community of North Phila-delphia.

Group practice is considered a model ofquality in the field of medical care. Its emphasison having many specialists see a patient guar-antees high quality care. In combination witha good hospital for in-patient services, a per-son can be assured of the highest quality treat-ment for illness under the group practice sys-tem. The comprehensive health care programin cooperation with a good hospital providesthis same model of care, but with even moreservices than the group practice hospitalmodel.

The Present Health Care System, in theSIVCCCC Area

There are many means of obtaining healthcare in the SWCCCC area. These include pri-vate physicians and hospital clinics. However,at present the main concern is the services thatGraduate and Children's Hospitals provide.These services include in-patient (hospital bed)and outpatient (clinic and emergency) care.

1. In-Patient Care: Children's Hospital hasalways provided quality in-patient care, andwith their moving to new facilities these serv-ices will probably improve. It would be ex-pected, then, that many people would continueto go there despite the distance. The alterna-tive is the erection of a new hospital in the

SWCCCC area, or renovation of Children's.The advantages of such an institution wouldbe many. If the hospital were community con-trolled, the hospital could employ many localresidents and train them as nurses and otherhealth personnel. Funding would be a prob-lem_ Mercy-Douglas and the University ofPennsylvania has been mentioned as possiblesponsors of the hospital. The city could also beapproached as a sponsor, but community con-trol would then be difficult. The City Depart-ment of Public Health is still mainly concernedwith preventive medicine and not with treat-ment, although this philosophy might changewhen funds are available.

2. Out-patient Services: The present systemof waiting for hours in a hospital clinic isfaulty. The service is very often impersonaland the followup is poor. If the community de-cides to have its own hospital, and it wishesto incorporate out-patient services into thathospital, it is important that the unsatisfac-tory qualities of hospital out-patient clinics beeliminated. The alternative is an out-patientfacility which would provide emergency andtreatment facilities and be housed apart fromthe hospital. The Federal Office of EconomicOpportunity funds comprehensive health careprograms, and the program could be set up toserve all the people in the SWCCCO area.Ad van t ages of Comprehensive Health. Care

The acceptance of the Rebound Programwhich provides comprehensive services to chil-dren in the eastern SWCCCC area demon-strates the value of this service to the com-munity. The Rebound Program could be in-corporated into the larger program that serveseveryone. The comprehensive health programis a combination of two concepts in the prac-tice of medicine. The program provides for aprimary physician who acts as a family doctor.In addition, there are other specialists on calland this provides the advantages of group prac-tice. Arrangements would be made with a hos-pital for in-patient care when these servicesare needed. The program provides for a greatdeal of involvement of the community in theplanning and running of the program. Thepresent Pennsylvania Hospital program pro-vides for complete community control afterthree years. Therefore, whatever programsthe community wished could be incorporated

into the program including training of com-murity people as nurses and health workers.

Present Philadelphia .Comprehensive HealthCare Programs

There are presently two comprehensivehealth care programs in the city of Philadel-phia. Mr. Robert Fishman wrote the proposalfor the project sponsored by Pennsylvania Hos-pital, and the proposal is available for anyoneto read in his office. Mr. James Snipe, of theTemple Comprehensive Health Program, com-pleted the proposal for the comprehensivehealth program there and he may still havecopies of his proposal available. The studentshave talked to both of these gentlemen andcertain things were emphasized.

Mr. Fishman spoke of two alternatives forobtaining a comprehensive health care pro-gram. One alternative is for the communityto write a proposal and submit it to the 0E0office to obtain a grant. The United NeighborsSettlement House tried this in 1965 and theyfailed to obtain a grant. This year Mr. Fish-man wrote the proposal for the community inaffiliation with Pennsylvania Hospital and ob-tained the grant.

Mr. Fishman's suggestions on obtaining ahealth center were first to interest an institu-tion in the area and then to work closely withthat institution in writing the proposal for thecomprehensive health program. The existingHealth Committee or a subcommittee of theHealth Committee could be the agent workingwith the institution. Mr. Fishman mentionedthat the SWCCCC area falls in the boundariesof the Jefferson Hospital Mental Health Pro-gram. Therefore. a comprehensive health pro-gram would be a logical extension of thoseservices. But Children's Hospital, as a part ofthe University of Pennsylvania is also involvedin the area with the Rebound Program. There-fore, they should also be approached as a pos-sible sponsor. Hahnemann, Mercy-Douglas, andthe City Department of Public Health are alsopossible sponsors.

Mr. Snipe confirmed what Mr. Fishman said.He added that from the very beginning it wasimportant to work with the Area H Anti-Poverty Committee and Community Action

53

Council, since proposals will have to be ap-proved and submitted by these groups. Also inhis proposal he mentioned the importance ofworking with city agencies concerned withhealth and welfare and state agencies of healthand welfare, and community physicians anddentists.

Writing a Proposal

Initially a health survey was going to bedone to establish the need for a comprehensivehealth program. However, if a proposal for ahealth center is written, existing statistics areusually used. The following sectien shows sta-tistics demonstrating the need for a healthcenter. These figures could be expanded withPhiladelphia Department of Welfare, SchoolDistrict, and Police Records.

Sources

Although the members of the SouthwestCenter City Community Council (SWCCCC)and other residents of the SWCCCC area aregenerally familiar with the characteristics andproblems of the area, a statistical descriptionbetter documents the needs and makes it pos-sible to objectively compare the SWCCCC areawith the rest of Philadelphia. The originalboundaries of SWCCCC-South Street to thenorth, Broad Street to the east, WashingtonAvenue to the south, and the Schuylkill Riverto the west-simplify this task. These bound-aries almost exactly correspond to the outlinesof the three census tracts which comprises thisarea-30-A and 30-C in the eastern SWCCCCarea and 30-B in the western part.

Thus, the census data from 1960 can be usedfor general information about the populationcharacteristics, income, employment, and hous-ing. Although this information may havechanged to some degree since the 1960 censuswas taken, it is presumed that it still repre-sents the area to a great extent. Health sta-tistics data are available from the preliminaryPhiladelphia health statistics for 1967.

Population

The population of all three census tracts ispredominantly Negro. The percentage of Negropersons in the area is over three times thepercentage for the city as a whole.

54

Table 1.-1960 Population Characteristics for SWCCCCCensus Tracts and Philadelphia.

30-A 30-B 30-C delphia

Total population 7,220 9,240 7,067 2,002,512Percent Negro 96.8 82.8 98.4 26.4Percent white 2.7 16.9 1.4 73.3Percent other races 0.5 0.3 0.2 0.3

Income: Employment, Education, Occupation

The income level of the area is extremely low.Over a third of the families in the area haveyearly incomes of less than $3,000. Over halfearn less than $4,000 annually.

Table 2.-1960 Income for SWCCCC Census Tracts andPhiladelphia.

30-A 30-B 30-CPhi la-

delphia

Number of families 1,562 2,056 1,',737 500,515Percent under $3,000 40.0 36.9 47.9 17.1Percent between

$3,000 and $3,999 19.1 15.3 15.2 9.6over 40.9 47.8 36.9 73.3

Percent $4,000 andMedian family income... $3,525 $3,854 $3,139 $5,782

The median family income for the area isover $2,000 below that for Philadelphia as awhole. The average family size is 4.6 persons.These facts alone declare the need for low-cost, high-quality medical facilities in the area.Part of the reason for this low income is cer-tainly unemployment. Unemployment rates forboth men and women in the labor force in theSWCCCC area are double those for the whole.city.

Table 3.-1960 Unemployment for SWCCCC CensusTracts and Pi;iladelphia.

30-A 30-B 30-CPhi la-

delphia

Percent of male civilianlabor force unemployed 12.2 13.3 17.0 6.4

Percent of female civilianlabor force unemployed 12.1 12.6 8.5 6.5

Further reason for the low income level canbe found in the educational. level and occupa-tions of the SWCCCC residents. The area asa whole has a median of less than ten schoolyears completed for persons 25 years or older.Overall, there are more than 300 blue-collarworkers for every 100 employees on white-collar jobs in the SWCCCC census tracts. This

is more than double the number of blue-collarto white-collar workers for the city as a whole.

HousingWhile only 36.1 percent of the households

in the entire city rent their dwellings, overhalf of the residents in the SWCCCC area renttheir homes. This places an additional strainon the already very low income. Moreover, lessthan two-thirds of the housing units in thethree SWCCCC census tracts are consideredsound. W,-)rthy of note is area 30-B in the west-ern part of the SWCCCC community where14.7 percent of the homes are dilapidated (de-fined by cprisos Bureau as not providing safeand adequate shelter; requiring extensive re-pair or rebuilding). Furthermore, over 10 per-cent of all SWCCCC residences are over-crowded with more than one person in thehouse for each room.Table 4.-1960 Housing for SWCCCC Census Tracts and

Philadelphia.

30-A 30-B 30-CPhila-

delphia

Percent of housing unitsowner occupied '.7.5 40.7 16.9 58.7

Percent of housing unitsrenter occupied 75.6 54.3 72.6 36.1

Percent of housing unitsjudged sound 47.3 62.2 62.8 87.3

Percent of housing unitsdeteriorated 44.7 23.1 35.1 10.6

Percent of housing unitsdilapidated 8.0 14.7 2.1 2.1

Percent of housing unitswith 1.01 persons perroom or more 10.2 12.8 12.3 7.0

HealthMore important than these facts are the ob-

vious health needs of the people of theSWCCCC census tracts. With the poverty im-posed on the residents already shown by P,11the above information, health problems placea further strain on incomes that have no roomleft to stretch. Health status is indicated belowby statistics on birth, deaths, and incidenceof preventable disease for 1967.

The live-birth rate in the SWCCCC censustracts is about the same or slightly lower thanfor Philadelphia as a whole (based on 1960population figures). Although the birth rateis lower, the incidence of immaturity (weigh-ing 5 lbs. 8 oz. or less at birth), congenitalmalformations (birth defects), and birth in-

jury for these infants is substantially higherthan for the city. The percentage of these in-fants born illegitimately is drastically higherin the SWCCCC area than for the entire city.This fact may suggest the need for sex educa-tion and/or planned parenthood programs inthe community.

Many of the mothers in the SWCCCC areahave inadequate medical care before the birthof their children. A mother's care is consid-ered inadequate when she has no care untilthe lest three months of her pregnancy or noprenatal care at all. The percentage of birthin the SWCCCC area preceded by inadequaternadical rare for the mother is nearly twicethat for the city as a whole. This lack of careto the mother contributes greatly to the pos-sible immaturity, birth defects, and birth in-jury of the infants.

Table 5.-1967 Birth for SWCCCC Census Tracts andPhiladelphia.

30-A 30-li 30-CPhi la-

delphia

Number of births 100 142 125 36,112Birth rate per 1,000

(1960) population 13.9 15.4 17.7 16.0Percent of live births

immature 17.0 13.4 15.2 11.6Percent of live births

congenitallymalformed 1.0 .7 4.0 1.1

Percent of live birthswith birth injury 1.6 .4

Percent of live birthsillegitimate 37.0preceded by inade-quate prenatal care 31.0

38.7

20.6

56.0

36.8

17.0

16.8

Death rates for 1967 are also substantiallyhigher in the SWCCCC census tracts than inall of Philadelphia. Moreover, a greater per-centage of deaths in the SWCCCC area iscaused by preventable and infectious diseasethan in the city as a whole.

Table 6.-1967 Deaths for SWCCCC Census Tracts andPhiladelphia.

30-A SG-13 30-C111118-

delphia

Number of deathsDeath rate per 1,000

(1960) populationPercent of deaths from

tuberculosisPercent of deaths from

syphilis

137

19.0

2.2

.7

149

16.1

.7

109

15A

24,443

12.2

.6

.07

55

Table 6-- Continued

l'hila-AO-,.. 30-B CO-C d.- his

Percent of deathsfrom influenzaand pneumonia . 3.6 2.7 1.8 2.8

Percent of deathsfrom nephritis andnephrosis (kidneydisease) .7 .7 .9 0.6

Percent of deathsdisease of earlyinfancy 1.5 2.0 4.6 3.6

These facts show that the SWCCCC area isa very impoverished area in its general char-acteristics and an area very much in need ofmore and better health care. The fact of Chil-dren's Hospital's relocation in 1971 has beenestablished. This presents a vast decrease inthe health services available to the SWCCCCcommunity, while all evidence shows need foran increase. All the facts taken together indi-cate a critical situation in which the residentsof the SWCCCC area must make some moveto acquire an additional health facility in theirarea before 1971. There are various possiblechannels the community can take to reach thatend but they all require action NOW.

What Is Public Health?(Delaware County)

Jan L. Baxt and Sheldon A. Halpern

Positive physical. emotional, and social well-being, not just the absence of disease. In thesimplest. terms, "public health" is people band-ing togetherprimarily under governmentalauspicesto solve health problems which theycannot solve alone.

Whenever two or more persons are affectedby the same disease, this becomes a publichealth concern in the broadest sense. Publichealth services are directed towards the pre-vention of disease for all members of the com-munity, while private health care is concernedwith curing a specific illness in an individual.Private medicine and public health complementeach other. The family doctor treats an indi-vidual case of hepatitis, while the Public HealthDepartment traces down the source of con-tamination and eradicates it.

In brief, the responsibility of a Public HealthDepartment includes:

56

1. Protecting you against disease, bothchronic and contagious.

2. Controlling the environment so that theconditions under which you live, work, andplay nre healthful.

3. Finding those who need treatment andarranging for their care, if they would nototherwise receive it.

At the present time, public health servicesin Delaware County are administered by amultiplicity of governmental units and levels,in addition to the numerous voluntary agencies.Boroughs, First-Class Townships, and the Cityof Chester receive the majority of servicesfrom municipal health boards and he ilth of-ficers (38 in all). Second-class Town6i.ips andthe two boroughs which have surrendered theirprograms to the State, are serviced by theState Health Department from its Chester of-fice and the regional office in Phila&lphia. Inaddition, the State consults with the municipalboards to aid in the problems when necessary,and has directed supervision over certain typesof programs, which are primarily State re-sponsibilities.

In.trodvction

It is an incontrovertible medical fact thatin our complex society public health is a vitalgovernmental service. The question remains,however: "Why should public health be admin-istered on a countywide basis in DelawareCounty ? We already have a State Departmentof Health Center and 38 municipal boards ofhealth, as well as numerous voluntary agen-cies. Why do we need a County Health De-partmemt?"

First, it must be emphasized that a county-wide administration of health services is not anew, untried experiment. Rather, it is the normthroughout the country. Eighty percent of thecounties in the country are served by countyhealth department. Delaware County, likemany other counties, is undergoing changeswhich make the establishment of a countydepartment both possible and more important:

1. A population boom is altering the natureof our community by:

(a) Quickly turning the eastern end of thecounty into a single densely populated unitwith all of the problems which normally occurin areas of this type, and

(b) Accelerating the rate of development inthe semirural western portion of the county.

Both areas require sound planning and com-prehensive health programs to cope with theseproblems, but neither is possible under the ex-isting fragmented municipal structure whichbears little relation to patterns of work, trade,or recreation.

2. Increasing mobility of population, withpeople moving in and out of the county at in-creasing rate.

3. The accelerating pace of change and dis-covery in public health practices which re-quires the combined efforts of a team of trainedspecialists. All of the services and programsadministered by a modern public health depart-ment are interdependentwhen one portion ofthe comprehensive program is missing, all ofthe other programs become less effective. Pro-viding the full range of public health servicesin a professional manner is beyond the scopeof an untrained, part-time municipal healthofficer, and the fiscal ability of any one munici-pality.

Inadequarics of Municipal Health Departments

Let us now look at some specific reasonswhy municipal health officers, regardless oftheir diligence, cannot adequately serve thecounty's health needs.

1. Fragmented programs: in DelawareCounty approximately 75 administrative unitsare involved in the provision of official healthservices, including: 38 municipalities whichhave health officers and/or boards; the StateHealth Department, which serves the countythrough its Chester office and its regionaloffice in Philadelphia; the various local schooldistricts; county government, which adminis-ters a variety of services; and 11 other Statedepartments engaged in various regulatoryand supervisory activities. This is a cumber-some administrative structure without anycentral point for the coordination or integrationof these closely related services.

2. Uneven quality: When there is great vari-ation among local boards of health, nobody isreally protected, because health problems over-lap the boundaries of our small municipalities.How many Delaware County citizens spend notime outside their own municipality? Is thereany municipality which prohibits entry to all

nonresidents, The obviousness of the answersimplies that everyone must be concerned aboutthe quality of the restaurant inspections, com-municable disease control, etc., all over thecountynot just to be a public spirited citizen,but to be sure of his own and his family'shealth.

3. Untrained health officers: Experience hasclearly shown that public health work is ahighly professional undertaking. There is nosubstitute for professional and technical com-petence. As the Stebbins Report said: "Cheappublic health is expensivefailure to provideadequately for the professional guidance ofhealth programs results in inestimable waste."

With that in mind, consider the fact thatthere are no professionally trained and experi-enced public health directors operating in thecounty. The present municipal health officersrange from salesmen or retired policemen tonurses, santiarians, and physicians, with vary-ing backgrounds in public health. However,none of these have qualifications the Statemandates for the Director of a County HealthDepartment, namely, a physician who hastaken postgraduate public health training, in-cluding a master's degree and a residency inpublic health and who is certified in the spe-cialty of public health and preventive medicine.

It would seem that having a physician ornurse listed as a municipal health officer wouldguarantee a sound public health. However, thishas not been the case. Upon consideration ofthe following facts, the reasons will becomeobvious:

1. Each of the 16 doctors who acts as amunicipal health officer does so on a part-timebasis; none is trained in public health work,which differs greatly from private medicine.Each is heavily involved in his own practiceand is thus hard to reach in emergencies. Also,he is not usually available to participate inday-by-day planning and coordination of pro-grams with other public and private agencies.Finally, by virtue of his office, he is potentiallysubject to serious conflict. If he is fearless, heis likely to lose some of his private practice.If he is timid, he cannot be a succssful healthofficer.

2. None of the 12 nurses employed as healthofficers are graduates of accredited publichealth nursing programs. As registered nurses,

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all are trained primarily for clinic and bedsidenursing, not for public health work in the com-munity, especially sanitation.

3. Since the programs of municipal boardsof health are concentrated largely in the areaof sanitation, they rarely utilize the medicalskills of the 28 doctors and nurses employedas health officers. Their sh.'Is and trainingwould have much greater relevance in a well-rounded public health program which includedthe planning and administering of personalhealth services.

Part-time Health Officers

Public health has reached a degree of com-plexity in which the part-time local health of-ficer is not able to discharge his duties as theexecutive officer of the local board of healthadequately. It is impossible for him to acquainthimself with the many technical advances inpublic health and still find time to carry onhis normal gainful occupation. Nevertheless, atthe present time there are only four full-time,municipal health officers in Delaware County.Of the 39 municipalities with health boards in1966, only four were paying their local healthofficers $2,000 or more in salary, six were pay-ing between $1,000 and $2,000, eight between$400 and $1,000, and 18 under $400. Threereported no salaries at all under the local healthofficer category.

Spokesmen for municipal health interestsherald their availability for nighttime emer-gencies. This obscures the difficulty of reach-ing many of these officials during daytimehours, when most people would avail themselvesof their services. Besides, how beneficial is thepresence of a public officer at midnight, if heis untrained? Few real public health problemsemerge or can be dealt with on an emergencybasis during these hours.

Poor Financial Base

A modern public health program is composedof many interrelated, highly complex, techni-cal services which can be provided only by atrained staff of specialists. According to theStebbins Report, an adequate financial base andminimum population of 100,000 or more areessential to provide these services efficiently.No municipality in the county could afford toprovide the program and staff necessary.

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Meaningless Boundaries

The boundaries of our small municipalitiesact as a hindrance where public health prob-lems are concerned. Pollution, disease, and ratedo not turn back at the townEhip line, but amunicipal health officer must. To combat publichealth problems, the entire county must countas one "community." Moreover, adjacent full-time county departments can cooperate moreeffectively than part-time local officials.

Small Range of Services

Many problems, such as rat infestation, lackof health education, and communicable disease,require a combination of professional disci-plines and services. A county health depart-ment normally supports a range of these serv-ices. A brief description is given below, alongwith the problems caused for Delaware Countyby the lack of a County Department to runthese services.

1. Vital statistics and communicable diseasecontrol: Under the present system, we have lit-tle reliable data on the incidence of communi-cable disease or of chronic diseases, accidentsor environmental hazards. There are manypoints at which the current reporting systemfalls down. This is not a reflection on eitherdoctors or health officers, but on an incrediblycomplicated reporting system, which could becorrected by a County Department.

a. Morbidity statistics, including communi-cable diseases, are reported by doctors to themunicipal health officers, a time-consumingtask since a doctor's patients come from manymunicipalities, and their postal addresses oftenconfuse, rather than help, in determining theirresidences.

h. The municipal health officer sends aweekly report to the state office in Chester. Thestatistics are then forwarded to Harrisburgfor analysis. Eventually, they are returned tothe municipal health officer, by which time anyepidemic on which he would act might well beover.

c. A breakdown in reporting from a fewmunicipalities could create a great distortionin the prevalance ,f any diseaseand manymunicipalities do not file annual reports ofcommunicable disease with the state.

This breakdown in comunicahle diseaserepoVirg is potentially quite dangerous. Al-

ready, Delaware County is lagging behind moreprogressive counties in communicable diseasecontrol. For example, in 19CO3 Delaware Countyexperienced 12 cases of meningitis, more thantwice the rate of the state as a whole. Also,there were over 500 cases of measles reportedduring 1966. Since 14 municipal health boardsfiled no annual communicable disease report,health boards filed no annual communicabledisease report, the actual incidence of measlesmay have been much higher. In those parts ofthe nation where strong public health leader-ship exists, this disease is close to extinction.In addition, there is a soaring V.D. rate amongDelaware County teenagersthe rate is threetimes greater than the neiithboring countiesand almost twice the state average.

2. Chronic illness control: Other than thecounty's operation of Fair Acres, the field ofchronic disease prevention and control is virtu-ally unnerved by the official health agencies.

The volunteer agencies are active only oncertain aspects of the problem and could be farmore effective with the aid which would beprovided by a professional health department.Since chronic illness represents the major com-munity health problem, this lack of any overallofficial program is a serious gap in health serv-ices. In 1966, the mortality rate for breast andlung cancer in Delaware County exceeded thestate average. This is highly significant as edu-cation and early detection can effectively con-trol both of these types of malignancies.

3. Environmental health services: Virtuallyall of the roughly 100 personnel employed bymunicipal boards of health function primarilyas sanitation or plumbing inspectors. Thisaspect of environmental sanitation, therefore,is often carried out with diligence, thoughstandards vary widely. There is some question,too, whether an untrained officer can bring tothis job the needed range of knowledge aboutsolutions to the sanitation problems that hefinds. Without such knowledge, the official mayhave no choice other than to ignore the prob-lem or fine the owner, neither alternative beinggood public health practice.

Also, it is almost impossible to ascertain thethoroughness of their inspections. Municipali-ties are not required to report the results offood sanitation inspections to the state. Theyneed only state how many establishments they

inspect, and how often. Almost none take theinitiative to report more than the barest out-line of activity to the public.

Other aspects of environmental sanitation,such as clean water, clean air, and radiationprograms are almost nonexistent under thecurrent setup.

While state law mandates municipal actionin sewage disposal, many municipalities in thecounty have failed to even appoint a responsibleofficial. Recent surveys by the Citizens Councilin Delaware County have revealed widespreadpollution in the county's four small watersheds,even though none of the streams is more thana dozen miles long. The county's streams gen-erally flow along the boundaries of numerousboroughs and townships. This makes it im-possible for even conscientious municipalhealth officials to control pollution.

In Delaware County, there is no overall localair pollution control service. With the increasedpopluation of the county, the problem of airpollution is of great significance.

In 1965, a study of air pollution in DelawareValley by the Drexel Institute of Technologyestimated that nearly 2,500 tons of pollutantsa day were being emitted in Delaware Countyalone. Of that, more than one-third was due topollutants from transportation sources. Thisaverages out to nearly eight and a half poundsof air pollutant per person per day. This isnearly twice that of Philadelphia County perperson.

Another problem is that people have themistaken notion that air pollution occurs onlywhen it is associated with odor. There shouldbe available a local service which is constantlyat work protecting the public against potentialair pollution hazards and cooperating withsurrounding counties on these problems.

There is no countywide program of radia-tion protection despite the fact that over 300county users of radiation producing machinesor material have registered with the State De-partment of Health. Continuous monitoringand enforcement is necessary to protect thepublic against the potential hazards of radia-tion.

4. Maternal and child health services: Noprograms in maternal and child health aresponsored by local municipalities. A limitedprogram of the State Department of Health is

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available to a relatively small portion of thecounty's mothers. In a 1966 State Report onnatality and mortality statistics, the poorercommunities in Delaware County exceeded thestate average in every category of maternaland infant death rates including natal, infant,and neonatal and in the percentage of imma-ture live births. Immature birthsthose under5 poundsare usually premature. One of themajor reasons for premature births is the lackof prenatal care. According to the State's data,the children in our poor neighborhoods farelittle better if they survive birth and the firstfew months of infancy ; while the state aver-age mortality rate for "certain disease of earlyinfants" is 24.1, the rate among DelawareCounty's poor is 52.8.

5. Health education: Presently, only a hand-ful of county municipalities regularly informtheir residents on health matters, and thereis little educational use made of annual reports.Health education is largely in the province ofvoluntary agencies, acting independently.

Most municipalities, for example, do nothave organized programs for the control andprevention of accidents. The State health de-partment has provided limited programs inDelaware County, but these have had littlecommunity impact. There is no local agency re-sponsible for poison control.

Health education in Pennsylvania schoolshas improved during the past decade. How-ever, in the absence of vigorous public healthleadership, the necessary parent and commu-nity involvement remains very limited. This isindicated by the failure of school advisoryhealth councils, permitted under a 1962 law, tocatch hold in Delaware County.

6. Laboratory services: Almost all DelawareCounty municipalities contract separately andprivately for the bulk of these services. Thisresults in a less well coordinated and efficientpublic health program.

7. Planning: Public health planning on acounty level is now ahnost nonexistent. Thesituation will not change until public healthprograms are administered by qualified, fulltime professionals. In short, the situation willnot change until Delaware County has a countyhealth department.

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The Wee-Care Babysitting Service

Ida E. Floyd, Kathryn Dunbar, andDorothy S. Federman

This project proposal describes our majorfocus of the summerthe establishment of afree babysitting service in Mantua. However,two areas deserve emphasis.

1. Purposes: a. Parents in the communityhave a great need for babysitting services atlow cost or free. The incentive to seek jobsand maintain them, keep appointments, go tothe hospital, or take courses, is often killedbecause of the difficulty of affording babysit-ting services. This service will provide mobil-ity for parents as well as the security that theirchildren are taken care of in their absence. Nosuch service exists now ; all child care pro-grams charge about 82.50 per child per dayand impose restrictions regarding DPA status,income, age, etc.

b. It is proposed that the service grow toprovide health services : (1) For the childrenin the nature of examinations, immunizations,etc. (2) For the parents in the nature of pub-licity concerning family planning services, orprograms involving such topics as nutrition orconsumer fraud.

c. If the service is funded, jobs will havebeen created for community members.

d. An essential objective is to provide abroad program for preschool children.

2. Questions to face and problems to solve:a. Question of legitimate use of this service.What did we consider good reasons for usingthe service, who was to judge (if anyoneshould), how to deal with the individual whohad no other commitment and would not offertime helping to babysit, how do you deal withnarents whom we know could afford to pay ababysitter.

b. Question of whether to penalize the childbecause the parent took advantage of theservice.

Decision: We decided to deal with the parentson a case-by-case basis, personally interview-ing each parent, seeking an honest answer as.0 why they used the service, explaining thereasons for having established the service, re-questing help if they could give any, etc. Nomajor conflicts have risen so far; we have

limited the age to 5 years old or younger, haverequested donations, have urged parents tosend lunch, beverage, and a sheet if they can,and we have been able to recognize extenuat-ing circumstances without causing resentmentamong other parents.

c. Question of survival potential on a vol-unteer basic. About a dozen mothers have givensome time this summer, some more consistentlythan others. What seems to be essential, giventhat the interest in helping is already present,is frequent communication with all volun-teers before and after they work. The successof a volunteer organization rests in the mutualsense of responsibility felt by all workers. Thiscan only be conveyed through personal contactand a genuine invitation that all workers par-ticipate in policy decisions regarding the serv-ice. The volunteers are also aware of the con-stant efforts being made to become funded inorder to make the transition to a paid staff.

d. Question of black or white source of fund-ing. Funding is the major hurdle ; attached tothe Proposal is a list of contacts made andpossibilities still unexplored.

e. Question of any funds leading to the hir-ing of community people. This is the stipula-tion we decided must be made in acceptingany fundsthat the community people involvedin the service make decisions regarding hiring.

f. Question of charging a fee. This decisionis being worked out now with the desire beingto maintain a free service, perhaps encourag-ing steady cash donations as parents see fit.

g. Question of organizational structure,working within an existing community organi-zation with ongoing policies and programs.

Project Proposal

Title. Wee -Care Babysitting Service.Brief description.Free, daily babysitting

for children 5 years old or younger. Hours ofoperation : 8 a.m. to 3 :30 p.m. Proposed hours :8 a.m. to 6 p.m.

Geographical area.West Mantua (1)Boundaries for publicity on door-to-door basis :42d Street to 38th Street and Haverford Ave-nue to Ogden Street. (2) Newspaper publicity :citywide. (3) Boundaries of use : 56th Streetto 32d Street and Spring Garden Street to Og-den Street.

The project grew out of prolonged discus-sion and personal contact throughout theneighborhood, including door-to-door contact,discussion with businessmen, politicians, po-lice, school coordinators, etc.

Purpose.a. To provide free babysitting toenable parents to seek and maintain jobs, takecourses, go to the hospital, keep appointments,enter training programs, etc., to provide mo-bility for parents and the security of knowingthat their children are cared for.

b. To provide health services (1) for thechildren i.e. immunizations, eye and ear testing,and (2) for the parents, i.e. family planningservices publicity, programs of an educationalnature on such topics as consumer fraud, nutri-tion, rat control.

c. To create jobs for community members.d. To provide a broad program for preschool

children, i.e. group activity, arts and crafts,trips, films, music. Many existing programs donot accept the child younger than three yearsold, or they require $2.50 per child per day, orthey make some restriction regarding income,DPA status, employment status, etc.

What has transpired since July 1st. I. Priorto Opening on July 15th:

a. Obtained rent-free facilities at HaverfordCenter, Lutheran Social Mission Society at 39thand Wallace Streets. Room is furnished withsmall tables and chairs, refrigerator, toys, etc.

b. Publicized for a meeting to arrange sched-ule of volunteers.

c. Planned painting party with the teenagersand cake and hot dog sale to raise funds andpublicize Opening.

d. Solicited for donations for babysittingservice and the sale. Response was uniformlygenerous from the community, businessmen.police, suburbs, Board of Education.

H. Operating of the Service :a. Publicity.b. Ironing out of details (1) programs and

routine, (2) registration forms, (3) meals.Parents are asked to supply lunch and sheet.

III. Present focus:a. To stabilize service on volunteer basis.b. To seek funds (see attached list of pos-

sibilities).Problems encountered.a. Regulations of

the Department of Welfare which may be im-possible to comply with in present facilities.

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b. Volunteer nature of workers, difficulty ofensuring stability of schedule.

c. Question of legitimate use of the Service ;demand of some reciprocity on the part of theparents.

d. Question of charging a fee to ensure someincome for the Service. Possibility of askingfor regular donations.e. Situation in which an independent service isset up within another community organizationwith ongoing program and policies.

Possible Budget.Staffing: 1. One individ-ual engaged in planning programs for children.

2. One individual responsible for schedulesand contact with volunteers.

3. rne individual coordinating health-relatedaspects as stated above.

4. One individual to overview ; ie. mainte-nance, finances, responsibility for registration,correspondence, etc. Estimated salaries: $7,-000 to $10,000. Maintenance $2,000.

Space.Haverford Center all year round ; ifexpansion seems necessary, possibilities liewith the Departint of Recreation, FriendsSocial Order Committee, Mantua CommunityPlanners.

Equipment. Already obtained but in faircondition : cots, cribs, small tables and chairs,toys. Toilet and sink and play yard adjoinmain room.

Needs.First aid supplies, disposable di-apers, bathinette, record player, toys, etc.

Estimate of funds required if starting fromscratch : (not including salaries) $6,500 to$7000.

Contact re: Funding.-1. Black Coalition ;2. Philadelphia Coordinated Community

Services ;3. MIC (Maternal and Infant Care Pro-

gram) ;4. Episcopal Diocese ;5. Friends Social Order Committee;6. Redevelopment Authority;7. Model Cities ;8. Department of Recreation ;9. RMP (Regional Medical Program) ;10. Smith, Kline, and French, Merck, Sharp

and Dome;11. Philadelphia Foundation ;12. Department of Welfare.Unexplored possibilities.-1. Presbyterian

Hospital;

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2. Lancaster Avenue Businessmen's Associ-ation ;

3. PAAC ;4. West Philadelphia Mental Health Con-

sortium ;5. Public Health Service Research grants.

The Photography Club at St.Christopher's

Richard Ragge and Richard BainesMorrison

Education of community children is an im-portant concern of the Comprehensive GroupHealth Services (CGHS). They felt the estab-lishment of a camera club would serve to edu-cate as well as to occupy a number of chil-dren during the summer. This is what waspresented at orientation as a possibility for aproject.

The first 2 weeks consisted of obtainingfacilities, financing, equipment, a list of poten-tial club members, and advice from peopleworking in programs of this type.

Facilities consisted of a converted eye ex-amination room from the health center as atemporary residence for the darkroom of theclub.

Financial support came from the SHO pho-tography allotment and from donations fromone foundation, Food Fair Stores and 14 areastores.

The city's Department of Recreation has aprogram called PIX which helps to supplyphoto clubs with film and cameras. We couldnot use this because (1) we were too late inapplying, and (2) they were dealing generallywith a different age group (13-19) and most ofour club members were between 10-14; but Ifeel if they were approached early enough,something could be worked out.

A list of children (ages 10-15 years) wasgathered from the personnel of the health cen-ter. Some were recommended for special rea-sons such as difficulty in school. Approximately20 children were in the club's summer portion.

The club has offered a good opportunity toget to know the community, especially someof the children from it; and to work withthese childrer to make ourselves more awareof some of the problems that exist in a poorcommunity.

Two projects for the children evolved, onein conjunction with the social services atCGHS. For this service the Camera and YouthStudio (C&YS) has in three cases suppliedpictures of specific housing problems they weredealing with. The other project was supplyingthe Hartranft Corporation with pictures ofvarious lots in the community which were inbad condition, also pictures of ths, communitycrews that were cleaning them up. We arealso supplying several groups with sets ofpictures of conditions in the Hartranft area.It has been the opinion of several of the com-munity leaders we have met that many peoplein the community do not realize the extent orthe degree of the problems some people face.

These projects are only a few of the thingswe have done as a club during the summer. Weare now making arrangements to continue theclub on a year-round basis.

One of the biggest hangups with "the estab-lishment" was a contact with a local BusinessAssociation. Speaking with the past presidentof the association about support for the pho-tography club, we found that the associationhas a means of handling such requests forsupport. Community people would have to savesales slips from participating stores and thenturn them in to the association. The peoplewould then receive 2 percent of the total asthe contribution. She said that almost no onehad availed himself of the plan. In our opinion,the plan has worked well in keeping the com-munity from receiving anything, yet the Busi-ness Association can say that they tried.

To end on a positive note, our relationshipwith the CGHS has been a friendly and cooper-ative one. The relationship it has with the com-munity is a very good one which would makethe center a good place to educate medical stu-dents on community relations.

bfii,I1E OTHER INTERESTINGEXPERIENCES

Karen Lyneh

A few of the papers written about the sum-mer's experiences stand alone. These aregrouped for convenience.

The views of the Hawthorne experience arepresented. Eaell highlights a different aspectof the program and the difficulties encountered

during the summer. The reports, however,point out the importance of SHO's cooperationstaffing by students and local people inHawthorne.

The other articles in this section describe awide range of activity. Project workers at Per-net Family Health Service, Houston Commu-nity Corporation dealt with significant issuesfor their communities. The two project work-ers at Holmesburg Prison report a totally dif-ferent experience.

Each of these articles should be read indi-vidually for each presents still another view-point on the summer's experience.

Hawthorne Viewed by a Staff Member, aStudent and a Community Worker

Charles Floyd, Staff: The SHO personnel as-signed to this particular site have been withus now approximately four weeks as of thiswriting. The problems we have encounteredthus far have been minimal and I feel we havesolved them to each person's satisfaction. How-ever, of these problems, I feel the greatesthas been lack of proper orientation of the stu-dents, prior to their commitment. I recognizethat this was done on purpose to some extent,but I personally feel it was, perhaps, too gen-eral in scope and too fragmented. I think thatin order for an orientation to be beneficial tothe students, it must be specific as to the par-ticular site. I also feel that if this job is han-dled prior to the commitment, it can alleviateother related problems, e.g. what to work with,where to work, etc.

An example of the above problem as it re-lates to this particular site is as follows:

SHO personnel assigned here (Miss Oster,Mr. Sesso and Mr. Williams), were handi-capped, so to speak, due to lack of proper ori-entation. Although Mr. Sesso is from the adja-cent neighborhood, it was nevertheless, aproblematic situation. They were not givenproper information as to the age group theywould work with, v, here the base of operationwould be, and the resources they would haveat their disposal. Some may feel that this is theresponsibility of the preceptors who are actu-ally in the programs and the community. How-ever, regardless of where the responsibilityshould fall, I feel the timing of this is more

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important. Whether it is done by SHO or thepreceptors, to me, is beside the point. Thepoint, as I see it. is to help the students to beaware of the community they will serve, andthe mechanics involved in the serving. Nowif it is decided this is really a job that belongsin the ream of the preceptors' responsibility, itnevertheless should be executed before the stu-dents are assigned and employed in the com-munity. Failure to do so will only add to theirfrustrating situation and it could stifle the cre-ativity and imagination they bring as part oftheir offering services.

In this particular site, the focus for the SHOpersonnel has been recreation' in the Haw-thorne Area. Utilizing such activities on agroup basis such as bus excursions to distantpoints (Atlantic City ; Hershey, Pa.; DorneyPark ; etc.), picnics, Phillies games, etc., affordthe students the opportunities of beginning aworking relationship with the teens. Once thisrelationship is formed, they are then able toget into the more personal and often specificproblems which can be worked upon on an in-dividual, but more ideally, on a group basis.Most important in this program, originatedby United Neighbors Association is the tieit has to the Jefferson Hospital Children andYouth Services. Referrals are made here forteen problems.

The relationship of this program to non-health agencies has been most encouraging.Collaborating with the PAAC (PhiladelphiaAnti-Poverty Action Committees) they wereable to work out bussing schedules for trips orexcursions. The same is true with the Board ofEducation and their Operation "Green Grass."Arrangements were made with the staff at theChildren and Youth Center to have physicalsperformed. Work was also done with the Hous-ing Authority as they were made aware ofcertain hazards in the Housing Projects andsurrounding grounds. The latter was an out-growth of a survey done by the SHO personnel.

Don Sesso, student: Much of our first weekwas devoted to becoming oriented andacquainted with community people and serv-ices. This first week was challenging in thatwe were "wetting our feet." I was somewhatdisappointed by the lack of a pivot point or"structure" upon which we could begin to de-velop our projects. Most of our activities hinged

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upon the opening of the Hawthorne Annex,which I felt took too long to open anyway. Wecouldn't do many tangible things during thefirst week. As a result, I felt that perhaps Iwas possibly remiss in my efforts. In fact, Ididn't declare the compensation which I wasto receive for an extra day's work, prior tomy arrival at Hawthorne.

During the first week, we arranged a meet-ing with the teens. Fifty guys and girls partici-pated. Many valuable ideas and suggestionswere given by the teens. The kids were a bitleery or cautious; after all, we are whitestrangers. Fortunately, we had Nate as a coworker. Nate commanded the respect of theteens; "Nate is cool," and so a rapport withthe community began.

During the next weeks, we attended staffand community meetings. It is a sad com-mentary, but we went to many sessions andonly a few of them were significant, in myopinion.

As our first outing we planned a trip to thePhillies game. We considered this a moderatesuccess, but since we had to get there on ourown by public transportation, no girls came.

It was at the end of the second week that theDeux ex machina appeared in the form of ex-cursions sponsored by PAAC. This generatedmuch interest and enthusiasm from everyone,and it served as a focal point for our futureactivities. We went into the community to meetand recruit the kids. According to our commu-nity worker, this went over big, be:;ause itshowed we were interested in associating witheveryone. The trips provided us with the oppor-tunity to talk seriously about health, education,or social concerns. We are hoping that theseopportunities will increase in number duringthe future weeks. Rapport takes time, espe-cially since we were dealing with such a largenumber of people, many (most) of whom "goand come" from day to day. I must mentionthe relationship that we've developed with our"captain," Tom Bradley. He is a great guy whosets an example for his friends.

Much of our time in the passing weeks wasspent in writing to, or contacting, people asso-ciated with recreation or things which wouldinterest the community. We helped to staff theAnnex, and also aided in setting-up "Tot Lot".Tot Lot started nicely, but seems to have

waned. I also became interested in recruitingyouth and helping Jim Washington coach atrack team. Results are OK so far, but theverbal affirmations and support greatly out-weighed the actual number of teens who par-ticipated. However, this is understandable; it'spretty tough to run in 95 degree heat.

Also in the past few weeks I've become afriend with a group of about 10 boys, who are12 and 13 years old. They had been uninter-ested in day camp, and I guess felt young forour PAAC excursions. They are nice guys.docile and willing to learn. We've gone on tripswhich were planned to be both educational andfun. I knew I would encounter difficulty get-ting them to leave their boats at the SchuylkillRiver, but was I amazed when I had to "drag"four boys from the Logan Library. We alsowent to New York, visited science centers, andmedical school labs.

Our efforts during the remainder of the sum-mer will be to continue at the Hawthorne An-nex; to contact local business and perhapsnews media in reference to assistance; to setup a film series.

In answer to the research question of, "Whatis your central problem?" I can make supposi-tions. I must first state that my analysis ismeant to be constructive, and I hope it will beconstrued as such.

A. How important was it to have health sci-ence students since the teens are predominatelyinterested in recreation? There Was a group,however, interested in more than recreationand we are trying new ways to arouse theinterest in the others who are the majority.

B. There are times V'ben I question the nec-essity of three of us as staff on a permanentbasis. Definitely all three were needed at vari-ous occasions for the proper relationships tooccur.

The answer to this dilemma might comeabout if there were much educational interestfrom the teens, but we were there to help in-still this in the first place. In addition theremust be added financial support for equipmentand materials to implement any program weattempt.

Another answer might be a surge of in-creased creativity on my part; heaven know'sI'm trying.

In conclusion, urban development programsare essential, and I hope that our contributionat Hawthorne was meaningful. We would liketo express our gratitude to our preceptors fortheir guidance.

Nate Williams, Community Worker: I wouldlike for the recreation and education programto continue through the fall, because I think itis a wonderful program for the children of theHawthorne community. As for problems, I havehad none except for when we went to AtlanticCity. The PAAC staff were ignorant to the factthat we were dealing with children and notwith adults.

Some of the projects we worked with are nottoo good. And the children are old enough toknow in addition to recreation they must learnother things, like visiting more importantplaces and doing more important work at thecenters. In that way it would be much easierfor the ones that are there to help them. I en-joyed working with the children and maybenext summer it will be better.

Teaching Sex Education Classes atHartranft Community Corporation

Forest Lang: There was no direction at Hart-ranft. The first problem was finding the rightbag. The anatomy and physiology of sexualityis one of our few areas of expertise. Sexualitytranscends racial and ethnic groups. Inadequateand erroneous sex education is the rule. V.D.control is among the four priorities of Hart-ranft health committee. V.D. and prenatal mor-tality are serious medical problems in the area.

Our first problem in planning was to dis-cover the amount of sex information amongarea youth and their interests. A teaching planprogressing along a course envisioned throughthe analytical mind of the medical studentwould fail. We solved the problem by allowinganatomy and physiology to grow naturally outof discussion on V.D., intercourse, birth con-trol, and birth instead of vice versa.

To research and plan a relevant course ranus face to face with institutions entrenched inout-dated mores. Building up a birth controlkit for educational purposes was a real prob-lem. Planned Parenthood decided to loan us,for one day, their birth control kit. They dis-pense thousands of I.U.D. and diaphragms, ye'c

to loan one to a medical student for more thana day became a serious problem. It was onlythrough a personal contact at the health centerthat ve acquired these materials for thesummer.

Also, the films at the Philadelphia PublicHealth Department were often int.iThey were poorly described in theirWe had to personally screen out the moralisticand threatening movies related to sex and V.D.The "Innocent Party" is an example of such amovie. Other movies (Boy to Man) were in-adequate for the white community and inappro-priate for the black. Most characteristic wasthe attitude of the Narcotics Addiction Center.They would not lend us a film on dope addle,.tion for fear of putting ideas in the "littleminds" (our boys have been on grass foryears).

The same problem occurred with films onchildbirth. Jefferson Hospital would not lend usits film because the boys were too young.Hahnemann allowed its birth film out onlywith a physician. Childbirth .Education Asso-ciation has a great film. But the rental is $10because they are a private institution.

Finally Hartranft would not financially backthe necessary expenditures because they didnot approve of our sex education on theirfacilities.

These problems exemplify the need for SHOand all future doctors to push 1.-It* realistic re-sources in youth education.

Yvonne Butterfield: Members of the sex edu-cation classes were recruited from preexistentgroupsclubs, gangs, baseball teams. We feltthat in this way classes would feel more com-fortable if all were already friends, that infor-mation would be more efficiently retained andpassed from one to another, that attendancewould be better if a leader of a group could beinterested in coming himself. This recruit-ment tactic seemed to work well. Attendanceremained a problem as gang fights, baseballgames, and trips conflicted with scheduledclasses. We tried to remain as flexible as pos-sible in scheduling to allow for these occur-rences. If possible, community recruitment isbest. We used this whenever possible.

Classes were kept small (less than six) toencourage questions and discussion. All mate-rial was presented informally, allowing ques-

66

tions at any time. The length of each classvaried depending upon the amount of materialto be covered and class interest.

We found team teaching most effective.Forrest Lang and I felt that we could presenta more honest and accurate picture of the top-ics together than separately. My presence mayhave helped the boys learn to communicatebetter with a woman, Forrest's helped accus-tom the girls to deal with male doctors moreeasily.

We also felt it important that we were youngand not authority figures. We think that theclasses found it easier to ask questions theymight be reluctant to ask their teachers, clergy,parents, etc.

Good vsual aids are of paramount impor-tance. Films should be previewed beforehandsince catalog descriptions can be misleading tosay the least. If material presented in the filmis new it must be discussed before the film isshown. Otherwise the best presented moviemakes little. sense. Many of the films requirediscussion afterwards, especially those dealingwith sexual attitudes.

Clay models of the female reproductive sys-temsimple to makeare invaluable. Concep-tualizing the uterus, vagina, ovaries fromdrawings is practically impossible even forthe medical student. Models were made to scale.A female pelvis was brought in to show howthe organs were situated in the body. A modelpelvis was also useful in describing childbirth.

Whe.i:ever possible examples of tampons,napkins, deodorants, and powders should beused when explaining menstruation to eitherboys or girls. Classes should be directly in-volved by allowing them to open the boxes, usetile powder and sprays, take apart the napkins,place the tampons in water. This same ap-proach is necessary when discussing birth con-trol. We purchased examples of foams, jellies,suppositories and borrowed diaphragms, IUD's,and pills. We inserted IUD's into the clay modelof the uterus to show how it is done by the doc-tor, squirted foams into the clay vagina. Every-one was allowed to handle everything. If pos-sible, material was presented by question andanswer to encourage class participation. Thiswas particularly effective with birth controlsince classes usually had some idea of a meth-od. The idea of "corking" the vagina to sepa-

rate sperm and egg leads easily to the idea offoams and jellies. A rubber for a woman is adiaphragm.

With each subject, particularly venereal dis-ease and birth control, classes must be toldwhere to go for advice and treatment.

In summary, classes were encouraged to par-ticipate themselves as much as possible, by ask-ing questions, handling materials, selectingmovies, and making models.

Preparing a Community Health Booklet atUns "re try, sin i4, Onr-tf tar1 IVIJOlt.il I %J../ iiiiii Ul J,....11%.,1

Zack Pinkney, Mike Rutberg, Lynn Sullivan,and Pat Witherspoon

Our project was the writing of a communityhealth booklet. The booklet contains articles onhealth services available and how to go aboutgetting them. Included topics are: Medical So-cial Service; Community Information and Re-ferral Service ; finanical help through PublicAssistance, Medical Assistance, health insur-anceBlue Cross and Blue Shield, Medicare;Health Center District 2; Chest X-Ray Service;Venereal' Disease; Help for the Alcoholic andDrug Addict; Poison Information Center ; orAmbulance Service, Police Red Car, Cabulance,Wheels for Welfare ; Dental Care; CommunityMental Health Center ; Rehabilitation Center ;Planned Parenthood ; Senior Citizen's Center;and a health director of area hospitals andpracticing physicians, dentists, optometristsand chiropodists in the area.

We decided on writing the booklet on ourown. We wanted to do something tangible sothat people would be able to see that we haddone something. Our work group was twohealth science students and two youth interns.We were responsible to our preceptor, a com-munity organizer at Houston CommunityCenter.

We got information for the booklet by inter-viewing people in the areas previously listed.We started with Public Assistance, MedicalAssistance, Public Health, the Community In-formation and Referral Agency, and MedicalSocial Service. We were further referred bythese people. We then wrote the articles andtyped, stencd and mimeographed the book-let ourselves at Houston Center. The cost of

paper was covered by United Health Services(an agency of United Fund), and the cover'scost was paid by SHO.

We distributed the booklet ourselves goingdoor-to-door to 1,500 households. The people'sresponse was in the main, positive; people wereglad to have a convenient source explainingwhat things are and how to get them. Somepeople accepted them passively. Others saidthey couldn't read.

Southern Philadelphia will hopefully have aCommunity Health Center Service within 5years. Such centers act as a central point forhealth information and referrals as well as forhealth care. Booklets such as ours, written ona community format, can act as a centralsource of information until the centers areformed and active. It is our recommendation,therefore, that booklets be written for all areasof Philadelphia. They can be informative andconvenient based on a community or geo-graphic basis. Booklets could be sponsored bycity agencies interested in healthUnitedHealth Services, Health and Welfare Council.These agencies could be approached to organ-ize and write the booklets themselves, or per-haps health students could be employed on apart-time job basis to write them. Distributioncould be handled by (political) Committeemen,working on a Ward basis.

Working With Pernet Family Health Service

Joan Gomes

I would like to begin this paper by a briefdescription of the Pernet Family Health Serv-ice with which I have been working thissummer.

The Family Health Service is a voluntarynonprofit home health agency, staffed conjoint-ly ')y the Little Sisters of the Assumption andlay personnel. Their work with the families, ineither a crisis intervention situation, or withthe more long-term multi-problem complex,seeks the overall aim of the agency which isthe preservation of the values of family life.

The optimum level of the family's physicaland emotional health is encouraged and fos-tered through the rendering of direct serviceswhich seek to identify and alleviate the healthand social problems that threaten the familystructure. These services are :

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1. Skilled Nursing Care; 2. Maternal andChild Health Care ; 3. Homemaker HomeHealth and Aid Service ; 4. Referral Service;and 5. Health Promotion and Instruction.

Everyone who applies is evaluated for serv-ice. Admission criteria are necessarily limitedto: acuteness of need, geographical area andavailability of staff. Families are referred tothe agency through numerous professional andnonprofessional sources.

The Sisters have recently open a satelliteoffice in Our Mother of Sorrows vial Cen-terwhere 1,100 children from tas.,, neighbor-hood are registered for day camp. The officehas become a first aid station where the chil-dren come for minor injuries or are broughtthere by their counselor for more serk is prob-lems, including infected wounds, ring wormsor suspected battered child syndrome. Theproblem there is that many of these casesshould be closely followed up but the lack ofpersonnel does not permit them to do so atthe present time. The Sisters hope to be ableto penetrate the area where the center is lo-cated, an underprivileged area with a predomi-nantly Negro populatiion. They have pledgedthemselves to combine their individual andgroup efforts with community strengths to re-store families to their rightful place in soci-ety, and to do something about the conditionswhich create poverty.

A problem I have noted in working with theSisters is the geriatric patient. Many times re-ferrals are made for elderly patients who re-quire custodial care in their home. The agingperson is surrounded with loss: loss of spouse,family, health, independence, mental capacity,This sense of loss is a profound human experi-ence. It causes an awareness of isolation, ofnot belonging, oi! uselessness. In trying to re-spond to their needs the Sisters have burdenedthemselves with a heavy case load of geriatricpatients. It seems to me that they should con-centrate their efforts in working with families,especially with multiproblem families, wherethe underlying cause of their problems couldbe explored in an intimate in-depth familycontact.

I have discussed this problem with the Sis-ters who were aware of it and have tried todischarge some geriatric patients in order tobe free to work with families but it is very

68

difficult as the community has no provision forthe patient who requires custodial care. I alsobelieve it is important for the Sisters to limitthe dimension of the am ...J. of service to WestPhiladelphia ; otherwise too much time is spenttravelling.

In my interpersonal relationship with theSisters and other people involved with theagency there was good communication withcoworkers as well as with the patients I havetried to help. The only problem encountered inmy work was my professional limitation. Beingonly a student, my assignment had to be limitedto patients who did not require professionalskilled nursing. But, by penerating the homesof several patients, I feel that I have had aunique experience and an occasion to observemany problems that poverty creates and thatcreate poverty.

Holmesburg Prison Project

Lawrence Kron, Alan Cohler, andN. Joblon, M.D., Preceptor

We have been involved this summer with theState Maximum Security Forensic DiagnosticHospital at Holmesburg Prison. This hospitaldeals primarily with court committed offenders.The hospital serves to give a complete Psychi-atric Evaluation of its inmates, which is subse-quently reported to the court. Our function atthis institution is that of Mental Health Work-ers. In this capacity, we deal with the compil-ing of social history and character evaluationsof the patients. In addition, we have been in-volved in numerous Fact Finding researchprojects concerned with both followup andtherapeutic studies.

Since the hospital deals with an incarceratedpopulation there is little room for flexibility,i.e., the regimented structure is necessary forfunctional utility. It is this high.'y organizedenvironment that we found ourseNes in, andwithin which we must function effectively andeducationally. It is apparent that our primaryproblem was learning to deal with the strict-ness of the environment.

There is no typical character type here, buta general appraisal of the people we work withis in order. The majority of these patients arepoor, deprived, and considerably socially dis-

turbed. They are the products of broken homes,little education, and even less motivation. Themain problem in our dealing with these menhas been the difficulty in establishing interper-sonal communications of a meaningful nature.

We presented ourselves to the patients asboth confidant and therapist. Therefore, to-together with the administrative and psy-chiatric staff, we endeavored to provide thecourts with concrete detailed information, aswell as beginning therapeutic and motivationalprograming.

In summary, the vastness of the problemswhich give rise to the personalities we haveseen is incalculable. Therefore we have strivento work within the structure of this institutionto provide a service to both the prevailing ju-dicial system and, in a limited capacity, the in-mates and their families. Obviously, there aresufficient problems to deal with for a long time.We, therefore, feel this to be a continuing func-tional project for the Student Health Organiza-tion. Both the insight one derives from thisexperience, and the opportunity to he produc-tive, more than justify this project's existence.

Drama as a Means of Changing HealthProfessionals' Attitudes

Lucia Siegel

I came to my experience with the StudentHealth Organization having a fairly well con-ceived idea of the kind of project in whichI wanted to work. Coming from graduateschool of Social Work and having spent sev-eral summers working with rc3idents of theghetto in various capacities, I recently havemade a decision to devote an increasing arronntof my time to understanding and exploringwhat I consider the white economic and politi-cal power structure, responsible for the majordecisionmaking in this country. It is onlythrough influencing this power structure bymany methods"educational" efforts, protestmovements, and mass civil disobedience, etc.that individuals can work for creative change.And the issues that are best suited as rallyingpoints for initiating change are those whichaffect the individuals personally. Nothing ismore personal to an individual than what hap-pens to him as a result of the type of life-

work he chooses. One's daily work experienceis probably the most profound molding influ-ence that is allowed to operate on an individu-al's psyche. Therefo7e, in "The Disaster Drill,"a short, one act play, I wished to not only intro-duce people to and impress them with the grossinadequacies of the existing health-care deliv-ery system, but to confront health profession-als with a situation that they themselves mightbe in someday, and to depict characters thatcould very well be themselves. My primary aimis to make health professionals begin to ques-tion their educational experience, their workenvironment, their attitudes toward those theytreat, and their feelings about the very typeof life they are leading.

Of all the groups to whom I would like topresent the play, medical, dental, and nursingstudents, and beginning students, are first onmy list. These young people must be forced toquestion their most basic assumptions and am-bitions, as well as to see as lucidly as possiblethe huge problems now existing in the healthcare system, In addition, I definitely do seepossibilities for presenting it to any groupwhich is either directly medically oriented orperipherally related.

The best chances for the play being widelycirculated would come from the Student HealthOrganization's sponsorship of it as a packagedprogram, the play being followed by small dis-cussion groups led by people trained in "sensi-tivity" techniques. A permanent cast is yet tobe assembled and the possibilities of obtaininga director have not yet been explored. The playshall have its first rehearsed reading on Au-gust 28, 1968, at the Philadelphia StudentHealth Organization's final conference.

Misericordia Hospital

At the beginning of the summer of 1968, rep-resentatives of the Philadelphia Student HealthOrganizations and Misericordia Hospital Divi-sion of the Mercy Catholic Medical Center dis-cussed the desirability and feasibility of devel-oping and carrying out a 10-week program de-signed to expose health science students to thepatient as a social being. It was proposed that,the health science student who may eventuallyserve lower class patients lacked an under-standing of the problems that beset them. It

69

was also proposed that patients of the lowerclass (ghetto) usually do not receive healthservices commensurate with their needs. Afterweighing the pros and cons and with the con-sent of the hospital administrator and medicaldirector the program was begun.

Purpose of the Program

The purposes of the program were as fol-lows:

1. To make known to the community thehealth service programs offered by the hospital.

2, To reduce the gap of communications andunderstanding between community people andhospital staff.

3, To pin-point problem areas and make rec-ommendations for their resolution.

4. To demonstrate how health services maybe improved and made more available to theentire community.

5. And finally, to give the health science stu-dent the opportunity to develop an awarenessof the problems of those individuals living in alower class area.

Structural Design

The program was composed of the followingcomponents:

1. A cervical cancer detection phase;2. A recruitment phase for the hospital's

Neighborhood Health Center ;3. An emergency room out-patient depart-

ment survey phase ;4. A cultural enrichment phase for neigh-

borhood children (Operation Create).

Personnel

The program was carried out by the follow-ing individuals:

1. Three health science students;2. Three community health aides;3. One art education major (teacher) ; and4. Two Sisters of Mercy of the teaching

vocation.

Preceptorship

In order to develop a smoothly operated pro-gram and to handle problems as they arose,the aides were assigned to preceptors who metwith them periodically.

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The Cervical Cancer Detection Phase

Operating with a grant from the cancer con-trol division of the Department of Health, Edu-cation, and Welfare of the Federal Governmentand under the direction of Dr. J. EdwardLynch, the director of the Department of Ob-stetrics and Gynecology, the hospital estab-lished a cervical cancer detection program forwomen, which is designed to detect cancer ofthe cervix in its earliest stages.

Past efforts to recruit and involve lower classcommunity people in programs designed tomake available and improve the health careservices they receive revealed that this par-ticular segment of the community did not re-spond readily to traditional methods of com-munication, i.e. the news media. Therefore, itwas decided that new methods of recruitmentshould be developed for the Pap smear pro-gram.

Approaches and ResultsThe community health aides decided that the

best way to augment the recruitment effort wasthrough direct and personal contact and estab-lished the following objectives:

1. To recruit women who had not had a Papsmear test within the past 6 months.

2. To inform all women in the area servicedby the hospital of the existence and availabilityof the test.

The program was initiated by conductinginterviews with the mothers of children whowere selected to attend the cultural enrichmentprogram Operation Create (see section below).

Having completed the initial interview, theinterviewer discussed the Pap smear test withthe child's mother ; due to the rapport estab-lished through the interview pertaining to thechild, the reception to the idea of the Pap smeartest was favorable. Moreover, through this con-tact the interviewer was able to get referrals offamilies, friends and neighbors in the area.

The use of a familiar name for introductorypurposes increased the possibility of favorablereception. The interviewers continued usingth.4-,e secondary referrals until they were finallyscheduled for appointments or "disposed of"(i.e. some referrals were outside of the hos-pital's service area and therefore referred tocloser places for treatment).

Extending the concept of direct contact, theinterviewers canvassed door-to-door and con-ducted interviews in the hospital's clinics. Be-cause of the high percentage of working wom-en in the area, contact was made with aboutonly one-fourth of the women in the blockscanvassed.

The door-to-door technique provided veryinteresting insight as to the attitudes of someof the neighborhood residents. The followingstatements were taken from reports submittedby the interviewers:

"A few women, mostly elderly, would notlisten at all. Others listened but were totallydisinterested. Some reacted with a negativeattitude and a fear of cancer. `If I have cancer,I don't want to know it' was one of the com-ments recorded.

"Most of the superstition and misconceptionabout cervical cancer was deeply entrenched.This convinced us of the need and importanceof a program such as this. An attitude held bya woman on the 5300 block of Larchwood Ave-nue, concerned her seeming immunity, becauseshe was white and middle class. This lady saidthat neither she nor the other women on thatstreet would be intereAed, and that what wereally wanted were the 'black streets.' "

The door-to-door contacts were effective butthey consumed a great deal of the interviewers'time; therefore, efforts were concentrated onworking through community organizations andchurches.

Almost immediately the community healthaides discovered that the vast majority of thecommunity organizations in the West Phi la-delphia-Misericordia Hospital area were dis-organized, that they existed only on paper andin name, and had regmters of nonparticipatingmembers. However, those organizations thatwere contacted promised to publicize the cancerdetection program.

Moving on to the area churches, the aideswere able to get several priests and ministersto announce the existence of the program dur-ing church services, in fact, at one RomanCatholic Church the aides, with the assistanceof a church group, solicited registrants for thetest at the end of each Mass on a given Sunday.

While most of the clergymen were coopera-tive the aides recorded the following incidenceswhich are worth relating:

"At (blank) church we were told by the sec-retary that their members were not the typewe were looking for. First she said, that hercongregation was too old, and when this wasanswered by the fact that cervical cancer hasa higher incidence among older women andthat this indeed would be a substantially bene-ficial program for these women, the secretaryabruptly said that most of their women werefrom the suburbs and that she would not see us.

"In another incident Reverend (blank) of(blank) Baptist Church, who is an elderlycleric, said he would be embarrassed to makethe nnnouncement. He did refer us to a womanwho was very active in the parish activitiesand who handled our program as well as couldbe expected."

Avoiding the impulse to hurry the ten-weekperiod of operation to a close, the aides, throughcerebral gymnastics, decided to recruit blockchairmen and to encourage them to solicit theirblock members. They reported the following :

"Astonishing returns resulted. For example,in one block, 95 women responded and havemade appointments for Pap smears. The rea-sons are that these block chairmen know whento contact their neighbors and they do not runinto the obstacle of suspicion. We fully edu-cated these women to our program and an-swered any of their questions so that they, inturn, could act as health educators to the restof the block. It must be emphasized that theseblock chairmen must be fully educated andunderstand their task so that they may notonly carry out their tasks and convince thewomen in their block to take preventive meas-ures against cervical cancer, but to guardagainst any misrepresentation and perpetu-ation of misinformation."

The aides found out as a result of followingup unkept appointments, that people wereoften scheduled for appointments without arealistic assessment of the time factor. Forexample, some were scheduled for appointmentsonly a day or two after they received their an-nouncements and after they had already madeother commitments. In addition, some receivedtheir appointment cards 4 or 5 days after theyhad been scheduled (via Pony Express).Recommendations

1. That appointment be confirmed by tele-phone call before assuming that the woman

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has received information about the appoint-ment.

2. That the postcards be sent out after con-firming the appointment and about a week inadvance of the appointment time.

3. That consideration be taken of the pa-tient, i.e. certain arrangements may have to bemade in order to keep an appointment, i.e.babysitter, transportation, etc.

4. That the backlog of women which wererecruited be scheduled for appointments asearly as possible, even if it would entail anextra day a week for appointments.

5. That a community health aide be hired.This health aide, as a member of the indigenousarea, be assigned certain tasks. Among them :

(1) Continue the program which has al-ready proved successful.

(2) Since the regular secretary cannot makeevening calls to schedule the women for eve-ning clinics, the community health aide wouldassume the task. Considering the fact thatthere are many women in this area that workduring the day (as has been proven by can-vassing and mentioned earlier in this report),the evening service is essei

(3) Consider that this health aide may in-deed be an essential feature of instituting aprogram of preventive medicine in this com-munity with its base at Misericordia Hospital.

Recruitment for the Hospital's NeighborhoodHealth Center

The site of the Neighborhood Clinic (52d andThompson Streets, some 2 miles from the hos-pital) was chosen because no hospital actuallyserves the area and because hospital recordsshowed that a relatively small number of pa-tients from this area had seen a doctor prior toadmission. Since the majority of cases fromthis area wee maternity patients, the pilotprogram, under the department of obstretrics/gynecology, offered prenatal and gynecologicalcare and free cervical cancer detection tests.

Working closely with the West Area Healthand Welfare Council, the Public Relations De-partment discovered that merely establishing aclinic in a giv nn community does not guaranteeits acceptance, no matter what services are of-fered or for how little. Therefore, it was de-cided to invite the chairmen and leaders ofvarious community organizations in the imme-

72

diate area of the clinic to a dinner at the hos-pital for the purpose of seeking their adviceand ideas.

The director of the council, furnished a listof the neighborhood organizations for the invi-tation list. Also, invited were: chairman of theWest Philadelphia Chamber of Commerce, rep-resentatives of the American Cancer Society,head of the local school district, and the arearepresentative of PAAC. Representing Miseri-cordia were: Misericordia Hospital's adminis-trator, director of the clinic, director of thesocial service department and the director ofthe public relations department.

Approaches and Results

In spite of a logical and sequential approachto establishing and publicizing the clinic, re-turns from client appointment files were notfavorable.

As mentioned above, it became obvious tothe Health Aides that the community (forwhich the clinic was established) did not re-spond to traditional methods of communication,i.e., the mass media. Therefore, the followingobpectives were established :

1. To visit meetings of community organiza-tions for the purpose of explaining the func-tion of the clinic.

2. To make door-to-door contacts in order toexplain how community women could use theclinic.

The health aides made numerous visits toCommunity meetings and churches. They no-ticed that those in attendance represented asegment of the community which was articulateand knowledgeable of existing health care serv-ices. Moreover, this particular group of peoplemaintained very little contact with the "grassroots" people and had personal physicians athospitals other than Misericordia (primarilyMercy Douglas Hospital).

During the month of July 1968, the healthaides made door-to-door recruitment contacts.According to Mr. James McGee, director of theout-patient department, the clinic served thegreatest number of patients for any givenmonth since its opening (see July statisticsbelow).

As a result of the door-to-door contacts, thehealth aides discovered that the "community"was not aware of the existence of the clinic

and its purpose. In addition, racial and relig-ious misconceptions were evident. "Most of theblack people that I contacted felt that the clinicwas for Catholics only and they thought thatyou had to be white to receive service. Most ofthe whites living in the area were Italian andthey thought the clinic was for blacks and thatit was degrading for them to go there" wasthe comment of one health aide.

Neighborhood Clinic, July 1968 Statistics

N 211 Ihri. tenonsI. Health services rendered:

Gynecology 14Pap Smear 16Pediatrics 4Prenatal 5

39

II. Information contacts:By telephone 21In person 12

33

Total I and II 72

Recommendations

In an effort to increase the utilization of theclinic, the health aides recommended the fol-lowing:

1. That a black and a white receptionist beon duty on alternate days.

2. That a full-time health aide be hired topromote the clinic and other hospital projects.

Emergency Room-Out PatientDepartment Survey

The Emergency Room Out-Patient Depart-ment represents the point at which most com-munity people have their first contact with thehospital. In instances where there are racialand cultural differences, the community per-son often gets a negative impression of hospi-tal's staff and its policy ; racial prejudice andbigotry are often claimed.

If a hospital is to serve effectively the com-m.inity in which it is located, there must bea reasonable amount of mutual understandingand tolerance of differences by both the patientand hospital staff.

In an effort to pin-point problem areas andto recommend changes directed toward improv-

ing hospital-community relations, a health sci-ence student was assigned to the department.

Approach and ObservationsThe health science student first oriented him-

self (through consultation with staff) to thefunction and operation of the E.R. after whichhe attempted to define existing problems andto relate them to the developing concept ofhospital-community relations. The orientationincluded direct observation of the E.R.'s per-sonnel and procedures as well as interviewingpatients to determine their general background,i.e. economic status and health service orienta-tion.

Of the two hundred (200) respondents inter-viewed, the following percentages were calcu-late :*

(A) 80 percent were employed, 7 percentretired, 8 percent on public assistance, 2 per-cent on social security benefits related to thedeath of husbands, and 3 percent received theirsupport from the divorce courts.

(B) 60 percent had family physicians, 23percent relied on Misericordia Hospital forhealth care, 5 percent relied on PhiladelphiaGeneral Hospital and Hospital of the Univer-sity of Pennsylvania, the remaining 12 percentrepresented Mercy Douglass Hospital, St.Christopher's Hospital, Police Welfare clinicsand union clinics.

(C) 2 percent had periodic physical exami-nation every 6 months, 29 percent every year,12 percent every 2 years, and the remainder(57 percent) only when they were ill.

(D) Less Cnan 5 percent had chronic illnessin their family.

(E) 56 percent of the patients had nev -rusesi the clinics at Misericordia, while the re-maining 44 percent had used the clinics onceor more.

The 'student observed the following situa-tions and occurrences which are submitted aspossible areas of concern as they may affectpatient and hospital staff relationships :

First, situations which usually created con-flict between the patient and hospital staff werethose in which that patient felt that he sufferedfrom a fatal disease or a grave physical in-

NutVe le here given to the fact that this eurvey is skewedand therefore valid only insofar as it helped the Health Sciencestudent to get some very general insight into the background cfthe E. R. patient,.

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jury. As a result of either case the patientwas emotionally upset. To him, his conditionappeared critical and immediate attention wasrequired. To compound the situation he mayhave been accompanied by members of hisfamily or friends who were also emotionallyinvolved.

In addition, this situation in the E.R. is oftencompounded by the fact that the hospital isknown throughout the community as a "whiteCatholic hospital". Consequently, the Negropatient becomes concerned about the possibilityof discrimination against him because hedoesn't trust this alien environment (credi-bility gap).Secondly, as is the case in E.R.'s in general,patients are treated on the basis of the serious-ness of their conditions and often those who areless ill are required to wait several hours. Thepriority of service was often interpreted bythe black patient as being discriminatory. Also,"conflict occurred when patient sought emer-gency treatment for a nonemergency problem.As a result of having to wait while patientswho needed immediate care were served, theblack patient seemingly felt that he was beingdiscriminated against."

Next, "situations which did not produce im-mediate conflict, but which were not conduciveto good rapport between the hospital staff andcommunity people developed when the doctorwas unable to communicate with the patientbecause of a lack of command of the Englishlanguage to say nothing of the vernacular ofthe black patient."

In addition, the problems involved in improv-ing hospital-community relations are greatlyincreased as the result of long waiting periodsbefore the patients received medical attention."In one case a patient was admitted to theaccident ward and 8 hours and 40 minutes laterhe was admitted to the hospital to have a for-eign object removed from his ear."

Finally, several cases which required the at-tention of a resident physician were delayedbecause either "the residents on duty were inconference or because the residents had left thehospital without informing the telephone op-erator or a responsible person in the depart-ment which they were covering, where theywere going, thus making themselves unavail-able." Also, "it was observed that some phy-

sicians either do not hear their page or ignoreit."

Recoinmendatiens1. An extensive effort be made to acquire

more black and white American physicians.2. That patients have priority over confer-

ences which require the presence of on dutyresidents.

3. That a booklet be developed which ex-plains the function of the E.R. and that it ex-plain the need for delays.

Operation Create (Cultural Enrichment forNeighborhood Children)

The short-range objective of the programwas to provide a rewarding and meaningful"cultural enrichment" experience for neighbor-hood children, through stressing the creativeaspects of learning rather than the mechanical.The long-range objectives of the program wereto develop community interest, rapport and theexpertise with the hope of making the hospitala more meaningful institution sensitive to theneeds of the community in which it is located.

"Operation Create" consisted of 7 weeks,divided into two sessions. Forty children par-ticipated. The program was conducted Mondaysthrough Fridays.

The prof?. .am included the following activi-ties : Choral singing, physical education onrecords, reading book corner, finger painting,murals, collages, interpretive painting, sewing,etc. Also, a Red Cross volunteer worker gave5 hours of instruction, complete with films ofinstruction, on safety in the home, child careand personal hygiene. In addition, the childrenwere given practical suggestions on how tohandle fires and burns by the local fire chief.

The children were taken on field trips to thefollowing places : Robin Hood Dell (the chil-dren's concert), Lankenau Hospital to see theHealth Museum Exhibits, St. Joseph's College-Moliere's comedy "The Patient Pretends"adapted for juvenile audiences, the Art Mu-seum, Abbotts Dairy, the Philadelphia EveningBulletin and other sites of interest. Recreationwas provided for them through trips to theWesttown camps and the Sherwood RecreationCenter.

As a result of the varied and interestingactivities provided for the children, tremen-dous community interest was generated by the

program. Many parents visited the centerand requested that their children be includednext year if the program was continued.

"Operation Create" was concluded with corn-

mencement exercises for the group. A programentitled "A Message Through Song" was pre-sented after which certificates of merit weregiven by the hospital administrator.

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Section III

PROJECT WORKER PERSONAL CONTACTS

Jon Snodgrass

Introduction

From the outset the research phase facedtwo major questions : (a) how to evaluate theeffect of student activities on the institutionsand organizations with which they dealt, and(b) how to collect relevant information help-ful to concerned agencies of the Federal gov-ernment who might realistically begin Ao re-form the health system in the future.

The very diversity and complexity of PSHOprevented easy answers to these questions. Forexample, PSHO hae planned to introduce 80health science students, 20 community workersand 20 youth interns to 40 different projectsites. The number of persons at each site wouldvary, the function of each at the sites wouldvary and, of course, the nature of each individ-ual would vary. At first and for a considerableperiod of time, the project appeared to be toodiverse and complex for any evaluative re-search to be conducted. It was impossible, forexample, to develop a standardized reportingprocedure for feedback because the projectswere so diverse that no common questions perti-nent to all participants could be asked. Pre-vious research had asked students to preparea log or diary to be reported periodically fromwhich data could be collected. However, theseresearchers had learned that students soon lostinterest in maintaining a personal account oftheir activities so that by the close of theproject only a minority had made consistentand valuable reports.

An answer to the first question was neverfound by the present research, but one poten-tial answer to the second came to light duringthe presummer research planning. After con-

siderable discussion among the researchers, thestaff and a few health professionals, the ideaof viewing the health delivery system as aprocess within which there were presently vari-ous points of friction came to mind. The ideawas taken to the Washington Conference ofJune 8-9 where it was favorably received byseveral of the social science consultants. Later,their recommendations as to how the projectsmight be evaluated included the notion of peri-odic contact reports which would reflect thepoints at which the health care process waspoor or inoperative.

Basically, the idea was to view the con-sumer at one cnd of a dimension of healthservice and the institutions of delivery at theother. Theoretically, it was thought that at cer-tain points along this dimension, health carewas quite highly developed or at least adequatein comparison to other points in the processat which care is extremely poor or completelyabsent. Student placements in PSHO wouldbe involved with community organizations orofficial institutions which dealt directly or re-latedly with the health status of the consumer.In this capacity we felt that it was possible toconsider students as participant observers ofthe health delivery system, in a position toreport on which aspects seemed adequately de-veloped, inadequately developed or completelyoverlooked. In an effort to systematically un-cover information in this area, the researchersreasoned that if students were able to makebrief reports on the nature and purpose of eachindividual with whom they came into contact,a picture of the points of consumer grievancesand satisfactions would come to light.

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The research, however, did not have the re-sources or the personnel to carry out this planat every site. Consequently it was decided toexperiment with the idea of personal con-tacts revealing the health system deficiencies attwo sites for a 2-week period. If this approachto the investigation of medical services provedsuccessful, then it might be improved and em-ployed in future SHO research.

Appendix 5 is a copy of the PhiladelphiaStudent Health Organization "Personal Con-tact Sheet." It contains a checklist by whichthe respondent can quickly give the biographi-cal characteristics of the person contacted, howthe contact was established, the purpose of thecontact and a means for reporting the conse-quences of the contact. The reporting formwas designed to be brief enough so that stu-dents would not be reluctant to complete itfollowing each personal contact, yet substan-tial enough to indicate whether the outcome ofa contact revealed a complaint or a compli-ment for the health care system.

Two sites for the exploratory use of thepersonal contact sheet were chosen, the St.Christopher's Child and Youth ComprehensiveCare Center and the Spring Garden CommunityCenter, both located in North Philadelphia, St.Christopher's C & Y Center employed all threetypes of PSHO participants, three health sci-ence students, one community worker and oneyouth intern. This site was chosen in the hopethat by multireporting, the three varieties ofproject worker would shed light on the de-livery system at this institution. Unfortunate-ly, the youth intern at this site was not respon-sive to our request and did not file contactreports.

The Spring Garden site also had a varietyof project workers ; one male and one femalehealth science student and two youth interns.Here again, however, we did not receive the co-operation of the youth interns and their con-tacts and perspectives of the health deliverysystem remain unknown.

The project workers at these two sites wereasked to complete a contact sheet for a 2-weekblock of time, (August 12-16 and August 19-23) on each person contacted either by phoneor in person. The results were collected duringthe final conference and subsequently analyzedand collated. The analysis which is presented

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below is a description of the variety, natureand outcome of contact made by these projectworkers. The report is organized according tothe type of contact made by each project work-er, such as city official, community resident,and medical professional.

The reader can judge how valuable thesedescriptions are in the collection of informationhelpful to the Federal Government in improv-ing the health care system. However, in thefinal section the researcher has commented onthe value of the "Personal Contact Sheet" as aresearch instrument in collecting such informa-tion, and its potential as a research device forfuture SHO research.

St. Christopher's Child and YouthComprehensive Care Center

First Health Science Student1. City Officials : During the 2-week period,

there were 15 contacts with Philadelphia cityofficials, a total of eight different Philadelphiagovernmental officials.

The contacts were all associated with casesof lead poisoning in renovated public housingunits. The health science student stated that aspecific accomplishment as a result of these con-tacts was : "The presence of lead poisoning andthe need for immediate relocation of familieswith lead poisoning was brought to the atten-tion of the health department." Also an ap-pointment to meet personally with a responsiblecity official to examine the issue of lead poison-ing was made. There was no indication thatthe student was successful in relocating a spe-cific family which was the victim of the leadpoisoning within the two-week period.

2. Community Leaders : One contact with acommunity leader in person in effort to obtaininformation and advice on how to approach thehealth and housing departments concerningthe cases of lead poisoning.

3. Health Professionals: Three contacts withhealth professionals were established in orderto obtain information on the relocation of thecases of lead poisoning.

4. Community Residents: The health sciencestudent had contact with three communityresidents during the 2-week period. One con-tact was with the woman involved in the leadpoisoning mentioned above. In a second con-tact, the worker collected information for a

woman's public housing application and in thethird, discussed the career opportunities andfurther education of a 14-year-old Negro maleon the verge of quitting school. The healthscience student remarked that he was success-ful in getting the contact interested in investi-gating chances for further education beforedropping out of junior high school. . . ."

5. State Government Officials : A personalcontact was initiated with the Department ofPublic Assistance which was successful in hav-ing the ullotmPnt of a welfftre recipient in-creased to include a dependent child.

6. Community Groups : The health sciencestudent met with one high school drill teamcomposed of both male and female teenagersand one Puerto Rican boy's social organizationto show and discuss a film on venereal diseaseand sex education.

Adult community workers of two differentcommunity organizations were shown the filmwhich was also followed by discussion sessions.

Health Professionals: There were severalcontacts with health professionals for num-erous reasons.

Second Health Science Student1. The director of St. Christopher's Children

and Youth Center was seen personally to discussand revise the informal review clause practicedby the Patient Care Review Board.

2. Later in the week, a personal contact wasmade with a professor at Hahnemann MedicalCollege from whom two films, "Labor and De-livery" and "Natural Childbirth" were bor-rowed.

In a third instance, the health science siu-dent personally contacted a female official ofSt. Christopher's Children and Youth to set upan on-going sex education course in the fall.He offered to her "a resume of our class mate-rials and resources." The student indicated thatthe official was very interested and coopera-tive, but he personally had some reservationsabout the complete success of the contact. Thesame individual was contacted several dayslater and, through her, arrangements weremade to show a film on childbirth to a groupof nurses.

Other. PSHO Project Workers: Over thecourse of the 20-week period, this particularhealth selence student made several contacts

with other PSHO project workers on a numberof issues.

1. He established contact with a health sci-ence student at another site and pursued thepossibility of developing a sex education course.Several films were later reviewed for their pos-sible incorporation into the course.

2. He was in contact with a variety of otherPSHO workers at his site placement, a neigh-boring site, and with PSHO staff in order todiscuss the admission policies of various Phil -adelnhio schools and to discuss whataction and contributions they might collectivelymake toward improving these policies.

3. The health science student called severalmeetings of other members of the child andyouth site to discuss, outline and write theirsite problem paper.

4. The health science student initiated ameeting with three other members of PSHOwho were also enrolled in the same medicalschool to discuss the possibility of creating a"humanitarian program" for their medicalschool in the fall and to investigate this par-ticular school's black admissions policy.

5. He attended a sensitivity training sessionwith other student participants and institu-tic nal residents at Eagleville Hospital.

NonHealth Professionals: A personal contactwith the head of social work department at St.Christopher's Children and Youth Center wasmac and a time arranged for the social work-ers to view the childbirth films.

A going-away party for a nonhealth profes-sional was held one afternoon at which thehealth science student had contact with num-erous doctors, social workers and other person-nel of the St. Christopher's Children and YouthHealth Center.

Medical Technicians: The health science stu-dent met in person with one medical technicianof St. Christopher's Children and Youth Centerafter having shown the childbirth film anddiscussed her attitude toward childbirth andtoward sex in general.

Community Youth: The health science stu-visited the home of a female community resi-dent in an effort to find her son, the leader of ateenage gang. The son was in St. Christopher'sHospital recovering. from a gunshot wound re-ceived from another gang member. The healthscience student visited the gang leader at the

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hospital and had him select the sex educationmovies to be shown to his gang. The followingweek the gang leader was seen in his home todiscuss a date for the films. At this meetingthe health science student reported that theytalked about retribution against another gangthat shot him 2 weeks ago.

Several days later, a group of about 10gang members met at the branch of the PublicLibrary for 3 hours with several health sciencestudents and a physician from HahnemannMedical College in which the "'s on childbirthwere shown, models of the uterus and pelviswere discussed and questions answered.This same forrsat was followed with threeother local gangs during the course of the 2-week period, a total of about 35 gang mem-bers. On the whole, the health science studentreported that the members of the gangs feltthe experience to be interesting and succssful.

At the outset of the 2-week reporting period,the Health Science Student conducted sex edu-cation classes with a local teenage baseballteam. There was more extensive contact withthis particular group than with the others. Thehealth science student had previously estab-lished a relationship with the local baseballteam.

Community Leaders: The health science stu-dent was contacted over the telephone by acommunity leader who was the chairman ofthe St. Christopher's Children and YouthHealth Center Advisory Board. They agreedthat a suggestion box was needed for the griev-ance committee in the health center. Approxi-mately a week later, the health science stu-dent contacted the leader and together theysawed the pieces of wood ncessary to make acomplaint box. Later, the box was actuallybuilt and sanded by the health science student.On several occasions between these two meet-ings, the committee leader was seen twice per-sonally ; once to investigate the bylaws con-cerning the Patient Care Review Board and,secondly, to invite him to attend an eveningmeeting of PSHO's Committee for BlackAdmissions.

The health science student personally con-tacted the pastor of Holy Cross LutheranChurch who "refused to lend his take-up reelfor our films on sex education." The take-upreel was borrowed later that day from a leader

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of the Hartranft Community Corporation afteran in-person contact and request were made.

The health science student telephoned theChildbirth Education Association requesting afilm on childbirth and asking that the centralfee be waived. The contactee responded thatthe film committee would look into the possi-bility of using the film. There is no notationby the student as to whether he was eventuallysuccessful or unsuccessful in this request.

Another community leader, the organizer ofa drill +esm, was contacted in person to srrsngefor a meeting with the team to show films anddiscuss sex education. As described below themeeting of the team was held a few days later.

The health science student had previouslyestablished a relationship with the members ofa local teenage baseball team, so that at theoutset of the 2-week reporting period, sexeducation classes were held with this group.He played a few innings of baseball with theteam after which the players participated insex education classes. Over the 2-week period,four classes were held at which a total of fivefilms were viewed, each of which was followedby a discussion session.

The sex education films and discussion ses-sions were also conducted with other groupsand associations. On one day, the film was seenby three different groups, Negro, and PuertoRican females, and on another day six familyhealth workers from St. Christopher's Chil-dren and Youth Health Center saw and dis-cussed the films. The film was also shown toeight members of a local girl's club. On anotheroccasion, the student took the film to a biologyclass at Gwynedd Mercy College and presentedit to a group of 25 students and faculty.Third Health Science Student

The third health science student was in-volved mainly in the establishment of a cameraclub at St. Christopher's Children and YouthCenter. During the 2-week period, he reportedrepeated contacts with young high school stu-dents interested in learning about photographyand establishing a permanent camera club. Hisactivities were in association with four Negromale and two Negro female teenagers and threePuerto Rican male teenagers. Also involvedwere an 11-year-old Puerto Rican girl and a10-year-old Puerto Rican male. The healthscience student carried out a number of dif-

ferent projects with each of them, all of whichseemed to center around the instruction ofphotography. In addition, they designed a pho-tographic display for the waiting room of thecommunity health center, and worked on apicture story of PSHO. Equipment for thepermanent club was sought and a name for theclub, "Camera & Youth Studio" was decidedupon.

The student was in contact with two adultmembers of the community who he hoped wouldlike to take charge of the club and see that itcontinued after the close of the summer.

Another community resident was contactedin her home in order to take pictures. Thehealth science student reported that, "The pic-tures would be used in an approach to cityagencies to have the house fixed."

Preceptors: The health science student hadseveral personal contacts with his preceptor inan effort to obtain the names of persons whomight be interested in continuing the cameraclub in the fall. One other preceptor was briefedon two occasions about the nature of the finalconference at which his attendance was urged.

Health Professionals: Three different healthprofessionals at St. Christopher's Children andYouth Center were contacted in an effort toprovide for the continuity of the camera club.During the 2-week period no solution to theproblem was obtained.

The health science student also came into awide variety of health science personnel at afarewell party conducted at the institution oneafternoon. Approximately 40 people of all racesand from a wide variety of occupational statuswere present.

City Government Off icials : A group of teach-ers were contacted while on tour of the St.Christopher's Children and Youth Center. Thehealth science student discussed with the prin-cipal of Hartranft School about the furtheldevelopment and continuity of the camera club.In an effort to follow up the possibility, thehealth science student attempted twice by tele-phone to contact the principal of the HartranftSchool ;n order to describe the camera clubactivities and status and to possibly work outa solution of its continuity. In both cases, hewas not able to get beyond the principal's sec-retary, who twice refused to provide a tele-

phone number or address at which the princi-pal could be reached.

The health science student was also in con-tact with the director of educational servicesof the Philadelphia and Montgomery CountyTB and Health Commission who was interestedin obtaining prints of housing and lot condi-tions to be used to display to persons withwhom he officially comes into contact.

Other PSHO Students: The health sciencestudent net with two PSHO workers from an-other site and discussed in general PSHO plansfor the fall of the year. He later talked todifferent area coordinators about the plans forthe final conference. Another telephone contactinvolved one cf the PSHO directors and theplans to show the Children and Youth Centerto out-of-town visitors. This health science stu-dent was also in frequent contact with theyouth intern at the site and numerous conver-sations covering a wide range of subject mat-ter. Finally, on one occasion, the health sciencestudent along with the PSHO committee wentinto the neighborhood to take photographs ofthe housing conditions.

Community Worker: The community workercompleted a series of contact sheets; however,some of them were incomplete or else too vagueto give a complete picture of her 2-week con-tacts. She was primarily in contact with com-munity residents and community leaders inreference to a number of issues centered aroundhousing conditions and welfare rights.

Community Residents: On one case she tooka Puerto Rican female to a welfare agencywhere she was successful in having the welfaregrant increased to include a dependent child.In two other instances she obtained permissionfrom two community residents to take photo-graphs of unfit housing conditions. She con-tacted several community residents by tele-phone to give information concerning hearingswhich the residents were unable to attend. Intwo other cases, she went to the homes of com-munity residents to learn the status of theresidents' applications for public housing. Shealso attended several local meetings as re-sources to further her work with housing con-ditions.

Community Leaders: The community workeralso met with several community leaders, par-ticularly ministers, to arrange meetings to or-

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ganize community members to obtain improvedhousing conditions.

Community Organizations: During the 2-week period, the community worker becamean associate member of the Welfare RightsOrganization and worked with them to organizefor the improvement of housing conditions.

Health Professionals: The community workercame into contact with a number of health pro-fessionals in the 2-week period; in some casesmade arrangements via telephone for dentalservices for commtmity residents; in othercases she made contacts in person or by phonewith officials responsible for public health andpublic housing. She also attended a lecture onenvironmental health delivered by a health pro-fessional, and a lecture on housing at theUniversity of Pennsylvania.

Spring Garden Community Center

This female health science student notedthat the contacts which are summarized below"were made at the end of oar project period,when the clinic had closed for the month ofAugust; they are not necessarily typical ofthose contacts with community people we hadbeen making in the beginning."

In reporting the results of this student's con-tacts, the materiel has been organized in termsof the person contacted rather than the type ofperson. Most of the contacts were of a patient-advocate nature.

Mrs. R: Mrs. R. is a 36-year-old PuertoRican living in the neighborhood of the SpringGarden Community Center, who came to thecenter with a letter from the PhiladelphiaHousing Authority. The health science studenttranslated the letter into Spanish, which ap-parently stated that housing was available.From the contact reports it is unclear ; eitherthe housing required a $25 deposit or Mrs. R.felt that she needed this sum in order to makearrangements to inspect the housing and secureit. The health science student telephoned thecity official who had written the letter to Mrs.R. and found that the official was away for aweek. The health science student then spoketo another official and "explained to her thatMrs. R. did not have the $25 to come and seethe house now. The official replied that theycould only hold th.t apartment for a short time

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and then would have to open it to someoneelse.

The next contact with Mrs. R. by the healthscience student was the following day in whichthey had discussion about selling Mrs. R.'sradio-record player. The contact sheet doei notdisclose whether the radio-record player was inconnection with the funds needed to visit thepublic housing or not. The student reportedthat "I have the feeling that Mrs. R. will notfind anyone to buy her record player and willcontinue making the payments on it which shereally does not want to, because of being onwelfare."

Approximately 1 week later, Mr. R. came tothe center and informed the health science stu-dent that she could not attend a clinic at anearby hospital by herself because of the manyother problems she has. "She asked me to goalong I explained the value of going aloneand reporting back to me how she feels itwent." At that time the student did not thinkMrs. R. would attend the clinic.

After Mrs. R. left, the student telephoned anurse at the clinic and informed her of Mrs. R'sreluctance to come to clinic and clarified thatsince she is in the maternal and infant care pro-gram, she need not be there until 12:30, al-though the appointment card reads 11:15. Thestudent also asked that the interpreter be onthe lookout for Mrs. R. The health science stu-dent also noted that the clinic had become morecooperative with her and had followed some ofher suggestions on specific patients since thetime the student had personally aecenipaniedthem to the clinic earlier in the summer. Inspite of this, the student believed that the ob-stetrics clinic process needs a total revision forall patients.

An hour or so later, the student again calledthe nurse at the clinic concerning Mrs. R. andlearned that she had just been seen by the phy-sician. The student noted "this was the firsttime to my knowledge that Mrs. R. was seen soquickly in the clinic."

Mrs. R. stopped by the community center af-ter her visit to the clinic and talked to thehealth science student. The student suggestedthat "Mrs. R. had proved to herself that shecould go to the clinic alone regardless of thelanguage and cultural barriers she might en-counter there and on the way."

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There are no further contacts reports withMrs. R. during the 2-week period. Whether shewas successful in obtaining public housing isunknown.

Officer S.: The health science student calledthe community relations officer of the Philadel-phia Police Department and learned that theyhad no record of a letter written by the studentasking for an officer to speak about the policeand community relations, to a meeting of PSHOstudents.

An officer of the community relations officereturned her call later that day to let it beknown that he could not speak on the day re-quested. A health science student told the officershe would find out what other date might bescheduled for the SHO students.

The following day, Officer S. called the healthscience student to ask whether a definite datehad been arranged. It had not, so the studentpromised to call back as soon as the date wasestablished. After discussing the problem withthe area coordinator, a date was established andOfficer S. was informed.

Several days later the student again tele-phoned Officer S. to confirm the date and thetopic and 2 days following, the officer spoke atthe Hahnemann Medical School Auditorium to agroup of SHO students.

Mr. and Mrs. L.: The health science studenthad been in continuous contact with the L.family during the summer. During the 2-weekreporting period, she was involved in obtainingtreatment for Mr. L., a 30-year-old Negro at amental health clinic and oral surgery for Mrs.L. The first contact during the 2-week period inregard to the L. family was to telephone a pub-lic health nurse to brief her on the L. family inorder to provide continuity of care once thehealth sciene student completed her summerassignme t.

She next went to the L.'s home and informedMr. L. personally of an appointment she had setup with the Community Mental Health Clinic.She also discussed his progress in obtainingpublic housing and informed him that shewculld be leaving soon and that the publichealth nurse would take over his case.

She then called the mental health clinic,thanked the nurse for setting up the appoint-ment for Mr. L.

The following day the health science studentvisited the L.'s home to discuss the results ofthe appointment with the mental health clinic.At that time they also discussed the possibilityof having his wife admitted to the hospital.

The health science student later spoke to amedical secretary to learn how Mrs. L. might beadmitted to the hospital for surgery. The secre-tary offered to contact a doctor who could ex-plain admission procedures. A doctor from thehospital called later and "suggested that Mrs.T..'s other medical problems be handled beforeher oral surgery." The health science studentexplained Dr. R.'s deferral of her oral surgery.Her possible admission was to be discussed withanother doctor. The health science studentstated that she had arranged to page Dr. S. thefollowing day to find out what doctor wouldperform Mrs. L.'s surgery and when she mightbe admitted, but there is no indication whetherthis was done or whether Mrs. L. received thesurgery.

Several days later the health science studentreceived a telephone call from the doctor at themental health clinic with whom she discussedMr. L.'s case.

On the same day Mr. L. came by the SpringGarden Community Center "to thank me forhaving helped him and his family. The fact thatMr. L. sought me out to say goodbye I feel wassignificantapparently he feels our contactwith him this summer has been on a person-to-person basis and that he has made some prog-ress."

Mrs. M.: "Mrs. M. (a 30-year-old PuertoRican) called me over when she was waitingwith her son at the clinic. She asked me to in-quire when her son would be seen, since she hadbeen waiting 2 hours already (she did not speakEnglish). When I explained this to the nurse,she and her son were seen immediately so thatshe cou'd get home to her, other children beforeit got too late. Actually this is not much of anaccomplishment (the intervention of a healthscience student) because it is not remedying thesituation of long waits that almost all patientsat the clinic must endure."

Mrs. C.: A 28-year-old Puerto Rican cameto the Spring Garden Community Center seek-ing health care for her son. The community cen-ter could not provide the care, so the healthscience student called the pediatric clinic at a

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nearby hospital and obtained information onhow Mrs. C.'s son might receive treatment. Thestudent informed Mrs. C. cf the procedure andreferred her to the hospital clinic.

This health science student had numerousother contacts durnig the 2-week period asidefrom those associated with patient advocacy.She worked with a mobile X-ray unit working inthe Spring Garden area, attended a sex educa-tion seminar with other PSHO students whichexplained how one hospital is teaching this topicin the Philadelphia public schools, toured a hoc-pital museum and worked with several oth:a.PSHO members to develop a schedule of meet-ings and speakers for the final convocation.

Second Health Science Student

The contact reports filled in by this health

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science student were done in a perfunctory andcursory fashion so that it is difficult to establishthe purpose and accomplishments of his workactivities. During the first week, he apparentlyworked closely with health professionals of amobile X-ray unit, although the specific tasksremain vague. He also had frequent contactwith a female Puerto Rican over the 2-weekperiod who was a community worker althoughthe reasons for contact are not spelled out. Hewas in continuous contact with two other PSHOstudents of another project to discuss and helpcarry out a project survey. Other than theseissues, the other contact reports filed by thisparticular student are not especially valuable inunderstanding points of grievance in the healthcare delivery system.

Section IV

SHO'S SHOW: AN EVALUATION OF THE 1968PHILADELPHIA STUDENT HEALTH ORGANIZATION

SUMMER PROJECT

Jon Snodgrass

Introduction

The title, "SHO'S Show," may imply that the1968 Philadelphia Student Health OrganizationSummer Project was a ludicrous carnival, or itmay imply that it was a remarkable demonstra-tion in social reform. Possibly it implies both,perhaps neither. In any case, the title is leftsufficiently ambiguous to allow the reader ofthis report to come to his own conclusions bycritically examining the data in this section.

The report can be read on two different levels_The reader can view it as factual, empiricalterial about the 1968 PSHO project. Or thereader can view it as a specific example of largerhistorical trends in society.

On an empirical level PSHO was composed of74 health science students, five area coordina-tors, three directors, 21 community workers and20 youth interns who worked with a total of 34community organizations and health and wel-fare institatiorks within the city of Philadelphia.

On a general level PSHO was composed of agroup cf individuals in an attempt to improvethe social conditions of relatively few victimsof the 20th century.

On an empirical level the evaluation reflectsthat PSHO had mixed resultssuccessful andunsuccessful.

On a general level the actual results appearinsignificant in comparison to 1.he attempt. Theimportance of PSHO lies in the attempt to mi-prove the conditions of less privileged mencaught up in the human race, regardless of

whether the attempt is a grand success or dis-mal failure.

In locating PSHO's relevance to larger socie-tal trends, one of the most outstanding andcurious features of the project was the natureof its financial support and the character of itsparticipants. The administrators and partici-pants were almost entirely youth, while thosefunding the project were primarily adults. It isthis fact, it seems to the researchers, whichcontains PSHO's relevance to the broader so-ciety. It struck the researchers time and timeagain throughout the summer that the relation-ship between the adults and youth in PSHO wassomehow only a reflection of a larger trend insociety. A trend in which it seems that adultsnot only identify strongly with youthful lifestyles, dress and ideology, but place great hopein the present generation to attain a conflict-free society and secure the basic rights of men.This is not the "generation gap." The genera-tion gap is an old phenomenon, widely covered(but never bridged) by the media and generallyacknowledged by the public. Even 170 yearsago de Tocqueville, the French scholar, wasaware of the generation gap when he statedthat in the United States, "The tie that unitesone generation to another is relaxed or broken ;every man there readily loses all trace of theideas of hif., forefathers or takes no account ofthem." But the contemporary relation betweenthe generations as reflected by PSHO seemed

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to indicate that we have moved beyond the gen-eration gap to what we can only describe as the"generational inversion." De Tocqueville sawthat the classical relationship between adultsand youth would be fractured, but not that theymight be totally invertedhe did not foreseethe possibility that the forefathers might imi-tate the traditions and ideas of their offspring.

There presently is much debate over themeaning of active and protective movements ofyouth. On the one hand the vast majority ofpeople overtly claim that this is the undisci-plined response of the permissive generationconstrained to act out of the boredom of itsaffluence. On the other hand, but beneath thisgeneral assessment, there seems to be a mi-nority, but growing number of individuals, whoclaim that this is the generation of hope; thegeneration which can achieve permanent solu-tions to the many and complex problems whichincreasingly plague modern civilization. Thereappears to be a subtle and gradually emergingbelief that youth are prodigies who can ingeni-ously resolve the social pathologies of contem-porary society.

The generation inversion is seen, for example,in a statement by Margaret Mead, the well-known anthropologist, who said, "What's hap-pening now is an immigration in time with thepeople over 40the migrants into the presentage, and the children born in itthe natives."It is also evidenced in the comment by an offi-cial of the U.S. Department of State who re-marked, "These kids are all trying to tell ussomethingand we better damn well figure outwhat it is." Similarly, an eminent fashion de-signer recently quipped that, "It used to be thatthe son who sneaked in to borrow his father'stie, now the father is sneaking in to borrow hisson's turtleneck." And also by a housewife whoreflected, "I believe this whole generation ofyoung people is saying to us, in effect, 'Look,you use beautiful words and do ugly things;we'll take ugly words and make beauty out ofthem.' "

Should the exchange be simply one of clothes,or but old vulgarities seen as new virtues, state-ments of precaution would be improper. How-ever, the inversion permits the older generationto resign its responsibility for building a bettersociety. The reliance and expectation placed onyouth imply a resignation, if not acquiescence

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by adults. This means that the burden of socialreformation rests heavily on the shoulders ofyouth alone. Within the field of medicine itmeans that the passing generation of medicalprofessionals can remain inactive observers astheir youthful successors attempt to improvethe field of medicine.

If PSHO is a representation of a generalsocietal trend in which adults rely on youth,then one has in this report, on the general level,material which would indicate whether the so-cial reforms so urgently needed have been dis-covered by youth. If the generational inversionpermits acquiescence by adults, we fear that thereforms will not be implemented, but held inabeyance awaiting initiative of youth.VVhether all youth will take up the initiative isdoubtful ; whether enough youth alone canmatch the expectations of the adults is at leastuncertain. But efforts by both, either independ-ent or in unison, seem far more promising. With-out broader, transgenerational efforts in socialreform, the generations may not continue toinvert, but both dissolve amidst the crises insociety.

These comments are not restricted to theempirical aspect of the research but apply to thetotal evaluationthe qualitative portion re-ported by Miss Karen Lynch in section II andthe qualitative portion in the present section.

As to the empirical aspect of the research, ithas been directed toward, first, a social-bio-graphical description of student participants,and second, the impact PSHO summer projecthas on student attitudes, student education andstudent future careers. Of these three, thechange in student attitude has received thegreatest study, out of necessity more thanchoice. The impact of PSHO on student futurecareers was beyond the individual ability of theresearchers, beyond the financial resources ofthe project and perhaps beyond the capacity ofsocial science research, at least in its presentstage of development. To learn whether a 10-week work experience altered students' careerdirection would minimally require a longitudinalstudy with a carefully matched control groupa very ambitious undertaking. The most theresearchers have been able to do in this regardis ask students to project the direction of theirfuture careers and to subjectively estimate

what influence PSHO has had in shaping thatdirection.

To know what effect the project has had inincreasing student knowledge and broadeningtheir education assumes that one knows beforehand what will be learned and can devise meth-ods to measure the quantity and quality oflearning. Since PSHO has been organized pre-dominantly by students of medicine, there hasbeen a great interest is discerning what stu-dents have learned with regard to subjectswithin the field of medicine. Unfortunately, pre-vious research has not been able to devisemeans of measuring the quality and quantityof knowledge gained and thus has had to relyprimarily on students' subjective estimate ofthe amount learned ; as, for example, by asking"how much did you learn about health care inan urban setting." "health problems of thepoor," "politics and health care" and so on.While certainly students' judgments are reliableindications of learning, these estimates are notconclusive in themselves. Unfortunately how-ever, the present research has .not been able toavoid this dilemma and students have thereforebeen asked to judge the amount and type oflearning provided by PSHO.

Out of default then, rather than enthusiasticdisposition, the present research has attemptedto evaluate the impact of the PSHO experienceon student attitudes. The measurement of atti-tudes has also been attempted by previous SHOresearch largely without success. T.he 1966 Cali-fornia SHO research, the most highly developedin this regard, attempted to measure the changein student attitude toward a variety of medicaland social issues.'

The two major limitations of that research,(a) the absence of a control group with whichto compare attitude change, and (b) the absenceof a technique by which to control for or at leastaccount for student selection procedures whichtend to choose students already favorably pre-disposed toward the attitude in question, haveboth been partially corrected in this research. Inthe following year, 1967. :le California evalua-tion also concerned itself with attitude change.No conclusions could be drawn in this case be-cause scoring keys were not available. Item an-alysis, however, indicated that a change in atti;

The Student Health Project. IISC-ShIC Stud;n1 Health Project1966, publisher unknown, December 1966.

tude from pre-test to post-test occurred on onlya limited number of questions.'' The present re-search has attempted to rely on this past re-search, using their experience as a guide as towhat pitfalls to avoid and what errors to cor-rect. Both limitations of the California 1966project have been improved upon but not com-pletely resolved.

In the following pages then is the empiricalportion of the evaluation of the 1968 Philadel-phia Student Health Organization SummerProject. It is composed of several parts:

The background characteristics of the 74health science participants and the eight staffmembers.

The influence that PSHO' -as had on studenteducation and careers.

The results of the administration of severalattitudinal tests to the participants, both beforeand after the summer-work experience.

A few of the accomplishments of the studentsover the course of the summer and their reac-tion to PSHO as an organization.

A comparison of the attitudes of 39 medicalstudents in PSHO with 38 medical students notparticipating in PSHO, as they were measuredboth at the beginning and conclusion of theproject.

Background Characteristics of the HealthScience Students

In troduction

Presented here is a description of the back-ground characteristics of PSHO participantsalong with a modest comparison of what isknown about the background characteristics ofmembers in other students' movements. Alsoa few notes of comparison on the compositionof the Philadelphia 168 project with previousSHO projects in other cities.

Methodology

During the initial orientation held June 21-23, 1968, at Eagleville State Hospital and Re-habilitation Center near Norristown, Pa., aquestionnaire consisting of biographical itemsand a battery of five attitudinal tests contain-ing 185 questions were given to the majority ofstudents on the first day immediately after reg-

Evaluation of the California 1967 Student Health Project.n.d., p. 21.

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istration (see app. 1 and 3). For those whoarrived at orientation late, the questionnairewas given to them to answer as soon as pos-sible. By the conclusion of the orientation, 62of the 74 students who were eventually to par-ticipate in the projects had completed the ques-tionnaire. The 12 students who were not sam-pled are those who did not arrive, or were nothired until after orientation, or were either un-willing or neglectful in completing the ques-tionnaire during orientation. A decision wasmade not to follow up the unsampled 12 sincethe orientation period contained a great dealof activity and discussion which might pro-mote attitudinal change. It was felt t.lat any-one not present at orientation would not be ex-posed to the complete range nor the full in-tensity of the simmer project and might con-sequently tend to neutralize attitudinal changesshould their responses be c( mpiled along withthose exposed to the orientation.

On the other hand, data on the backgroundof all 74 student participants is available. Aword of explanation, however, is needed on-cerning the total number of students: of theoriginal 74 students to begin work at projectsites, four dropped out during the course of thesummer for various personal reasons or be-cause of illness. Below are described 73 of theoriginal 74 project fellows, plus one individualwho was employed as a replacement very earlyin the summer. Also described separately arethe background attributes of the five area co-ordinators and three student directors who arejointly reported under the heading of "staff."

The term "health science student" is some-what of a misnomer in describing the field ofstudy of the participants. Roughly 65 percentare osteopathic and medical students, and anadditional 12 percent encompass nursing anddentistry. However, there are also representa-tives of a wide variety of academic disciplinesonly indirectly related to physical health suchas communications, counseling, psychology andanthropology. The term "health science stu-dent" is Le for convenience with the under-standing that it refers in this context to allstudents participating in the project.

The model response of health science partici-pants indicates that they have their origin inthe Philadelphia area from Jewish familieswhich are predominantly middle and upper

88

class and whose father is a medical profes-sional or a businessman earning on the aver-age over $15,000 yearly.

The data which follow describe the charac-teristics cf the students and staff, and theirbackground in greater detail.

Reason for ParticipationStudents were asked both at the opening ori-

entation and at the closing conference to rankthree major reasons for participation in PSHO.In all, there were four dominant interests: (1)to learn about community medicine; (2) tolearn about urban slum conditions; (3) tobring about social change; and (4) to help thepoor. In the beginning, almost one-half selectedeither the opportunity to learn about commu-nity medicine or the opportunity to learn abouturban slum conditions, as their major reasonsfor participation. These were also the first andsecond choices respectively of over one-third ofthe students. This would indicate that studentsperceived the summer project mainly as alearning experience. Approximately one-thirdalso selected two altruistic reasons, creatingsocial change and helping the poor, as amongthe three primary reasons for participation.These two were among the highest first andsecond individual choices. Initially then, stu-dents seemed to have joined primarily for theeducational value, and secondly for humanita-rian interest in community welfare. Personalreward snch as earring $900 and living inPhiladelphia took lower priority originally.

The response to the reason for participationchanged somewhat, however, by the time of theclosing conference. The emphasis on learningand creating social change remained relativelyconstant but the interest in helping the poordropped from the fourth most frequently men,tioned to the ninth position. This shift is notreadily explicable. It may, perhaps, indicate achange in the expectations of what realisticallycan be accomplished in ten weeks. Moreover,twice as many students in the closing sessionindicated an interest in income as being amongthe three major reasons for participation thandid originally. Another curious fact is that con-cern with advancing civil rights was amongthe lowest justifications for participation origi-nally, and while this increased slightly over thesummer, it remained a minor reason for stu-dent participation on the whole.

The data concerning reason for participationboth before and after the summer project areshown in table 1. In general, students initiallygave educational and altruistic reasons for par-ticipation ; for the most part, this remained

constant over the summer with the exceptionof interest in helping the poor which declinedand personal interests which increasedslightly.

Table 1.-Student's Reasons for Participation, Before andAfter.

Reason Priority of reasonFirst Second Third Total

Before After Before After Before After Before After

The opportunity to:Percent Percent Percent Percent Percent Percent Percent Percent

Learn about community medicine 34.4 27.6 21.3 19.0 9.8 17.5 21.9 21.4Learn about urban slum conditions 19.7 19.0 36.1 16.5 13.1 16.8 23.0 16.8Help bring about social change 14.6 20.7 16.4 15.5 18.0 10.5 16.4 15.6Help the poor 11.5 1.7 11.5 8.6 24.6 3.5 16.8 4.6Associate with health science students 3.3 5.2 4.9 6.9 8.2 14.0 5.5 8.7Earn $900 1.6 6.9 6.6 10.3 8.2 15.8 5.5 11.0Help advance Civil Rights movement 3.3 1.7 ... 8.6 8.2 8.6 3.8 6.4Live and work in Philadelphia 3.3 10.3 1.6 5.2 4.9 7.0 3.3 7.5Work with a practicing health science

professional 3.3 1.7 3.3 5.3 2.2 4.6Other 4.9 5.2 1.6 3.4 1.6 1.8 2.7 3.5

Total 99.9 100.0 100.0 99.9 99.9 99.8 100.1 100.1

N Before -61. N After=$8.

Origin of the Students: The majority of thestudent participants considered Pennsylvania,particularly Philadelphia or its surroundingsuburbs, to be their home. Most attended auniversity or medical school in the city ofPhiladelphia. There were, however, some whosehome and school of attendance were quite dis-tant. F07 example, four nursing students camefrom San Jose, Calif., one medical student fromMilwaukee, Wis., and one nursing student fromRochester, N.Y. In a few instances, studentswho considered Philadelphia to be their homestudied at universities outside the State andhad returned to the city for the summer toparticipate in the project.

Ay: The age of the great majority of stu-dents was concentrated in a very narrow rangeof 3 years. Almost 65 percent were betweenthe ages of 21 sild 24 years. The most fre-quently reported age was 22 years and whenthis is broken down categorically into months,the most common age is closer to 23 years. Thestudent project administrators too were ap-proximately the same age as fellow partici..pants. Table 2 following reflects the distribu-tion of ages of the 74 health science studentsand the eight members of the staff.

Table 2.-Students and Administrators.

Age Students StaffN Percent N Percent

Up to 19 years19 to 20 years

46

5.48.1 ....

20 to 21 years 2 2.7 1 12.521 to 22 years 15 20.3 ....22 to 2:1 years 17 23.0 2 25.023 to 24 years 16 21.6 3 37.524 to 25 years 1 9.4 ....25 to 26 years 4 5.4 1 12.526 to 27 years 2 2.7 ...27 years snd older 1 1.4 1 12.5

Sex and Race: The student participants werepredominantly white males. The sex and raceof the staff and students are shown in the tablebelow.

Table 3.-Sex and Race of Students and Staff.

Sex Students StaffN Percent N Percent

Male 51 68.9 6 75.0Female 23 31.1 2 25.0

Total 74 100.0 8 100.0

P.r.st Stutirnts StaffN Percent N Percent

White 70 94.6 7 87.5Negro 4 5.4 1 12.5

Total 74 100.0 8 100.0

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Religion: Students were asked to provide in-formation on their family religion. Table 4 de-picts the religion of their family, that is, thetype of religious background in which theywere reared rather than their own personalbelief.

Table 4.-Family Religion of Students and Staff.

Religion Students StaffN Percent N Percent

Protestant 19 25.6 5 62.5Catholic 18 24.4Jewish 31 41.8 3 37.5Mormon 1 1.4Quaker 1 1.4Russian Orthodox 1 1.4Eastern Orthodox 1 1.4Atheist 1 1.4Unknown 1 1.4

Total 74 100.2 8 100.0

Educational Experiences: Eighty-one percentof the students were enrolled in professionalschools, either medicine, osteopathic, dental,law or nursing. Approximately 10 percent werein various graduate schools and 10 percentwere undergraduates. Table 5 below reflects thevariety of professional and graduate schoolswhich the students attended.

Table 5.--Fie ld of Study of Students and Staff.

Field of study Students StaffN Percent N Percent

MedicineNursingOsteopathyDentistryLawSocial workAnthropologyCommunicationsCounselingEducationPsychologyUndergraduate

Total

3979222111

117

52.79.5

12.22.72.72.71.41.41.41.41.49.5

8 100.0

74 99.0 8 100.0

Over 75 percent of the students were en-rolled in disciplines directly related to healthcare-medicine, osteopathy, nursing and den-tistry.

The undergraduate majors, however, showa maL,h wider variety of scholarship. Here,there is a greater representation of the socialsciences and humanities indicating that almost

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30 percent have a background in studies otherthan the physical and natural sciences. Table 6displays the major area of study as under -graduaes.

Table 6.-Undergraduate Major of Students and Staff.

Major Students StaffN Percent N Percent

Natural sciences:Biology 28 37.8 3 47.5Pre-med 3 4.0 1 12.5Other (chemistry,

zoology) 8 10.8 2 25.0Total 39 52.6 6 75.0

Physical sciences:Engineering 1 1.4

Total 1 1.4

Social sciences:Psychology 5 6.8 ....Philosophy 3 4.0 1 12.5Sociology 4 5.4 ....History 1 1.4 1 12.5Political science 2 2.7 ....

Total 15 20.3 2 25.0

Humanities:German 1 1.4English 3 4.0French 1 1.4Art 1 1.4

Total 6 8.2

Other:Nursing 7 9.5Pharmacy 3 4.0Physical therapy 3 4.0

Total 13 17.5Total 74 100.0 8 100.0

Family Background: A well-known techniquefor determining social class 3 reveals that mostof the PSHO participants are from either theupper or middle class. This technique estimatesan individual's social class position based onthe amount of esteem accorded by the generalpublic to the father's occupation. Table 7 re-flects the distributions of students accordingto social class.

s The North-Hatt Occupational Prestige Scale ranks the prestigeaccorded by the general public to some 90 occupations. The North-Hatt 5,ale was divided into four equal parts each representing theupper, middle, working and low classes. A student was placed intoa particular class based on his father's occupation. Where no oh-vious equivalent occupation is provided on the North-Hatt Scale,an estimate was made on the basis of the amount of skill andeducation required. See Delbert C. Miller, Handbook of ResearchDesign and Social Measurement (David McKay Co.: New York, 1964pp. 106-110.)

Table 7.-Social Class of Students and Staff.

Social class Students StaffN Percent N Percent

Upper 23 31.1 2 25.0Middle 30 40.5 4 50.0Working 17 23.0 2 25.0Lower 2 2.7Unknown 2 2.7

Total 74 100.0 8 100.0

Family Income: Combined parental incomeof students averaged $15,195, while that ofstaff was $9,312. These figures indicate thatthe students for the most part come from themore affluent sectors of the economy.

Table 8.-Family Income of Students and Staff.

Family income Students StaffN Percent N ?ercent

Up to 2,999 3 4.1 1 12.53,000 to 5,999 3 4.1 1 12.56,000 to 8,999 15 20.3 2 25.09,000 to 14.999 17 23.0 3 37.515,000 to 19,999 8 10.8 1 12.520,0,00 to 24,999 13 17.5 ....25,500 and over 13 17.5 ....Unknown 2 2.7

Total 74 100.0 8 100.0

Father's Occupation: Classifying father's oc-cupation into several broad categories shows awide range of occupational types as indicatedin table 9 below.:

Table 9.-Occupation of Fathers of Students and Staff.

Occupation Students StaffN Percent N Percent

Professional medical 17 23.0 1 12.6Professional nonmedical 9 12.2 1 12.5Proprietors and managers 2 2.7 ....Businessmen 15 20.3 1 12.5Clerks and kindred 11 14.7 2 25.0Manual 12 16.2 1 12.5Protective and service 3 4.1 ....Deceased 4 5.4 2 25.0Unknown 1 1.4 ....

Total 74 100.2 8 100.0

Mother's Occupation: Most of the students'mothers were occupied as housewives, very fewwere professionals in the health science field,and only about 40 percent worked outside thehome.

Table 1.0.- Occupation of Mothers of Students and Staff.

Occupation Students StaffN Percent N Percent

Professional medical 3 4.1 2 25.0Professional nonmedical 11 14.9 1 12.5Proprietors and managers 1 1.4 ....Businesswomen 1 1.4 ....Clerks and kindred 9 12.2 3 37.5Manual 1 1.4 ....Protective and service 4 5.4Housewife 44 59.5 2 25.0

Total 74 100.3 8 100.0

Previous Experience: Students were askedwhether they previously had any experiencewith social action programs. Only 39 percentof the students, but 75 percent of the staff, hadpreviously participated in at least some :":brmof community work.

Students were also questioned as to whetherthey had taken coursework in comprehensivemedical care or community medicine. Here ap-proximately 15 percent of the students and 25percent of the staff had had this sort of aca-demic preparation.

Combining these two as indicators of aninterest in social activism reveals that, alto-gether, approximately 50 percent of the stu-dents had either practical experience or aca-demic coursework that might prepare them tocarry out their summer work projects.

Previous SHO Comparison: It is difficult tocompare the members of PSHO with previousSHO projects since the past method of report-ing is considerably different or in many cases,severely limited. This is possible in a few in-stances ; however, the composition of Philadel-phia 1968 in terms of percentage of medicalstudents is identical to that of Bronx 1967 andChicago 1967 ; all three had 65 percent medicalstudent participation. The students of Phila-delphia 1968 also reported fewer Protestantsand Atheists and more Catholics and Jews thanprevious projects. However, this may be ac-counted for by the fact that Philadelphia 1968students noted their family religious back-ground rather than their personal faith. Addi-tionally, Philadelphia 1968 Ind fewer blackhealth science students than any previous proj-ect (5.4 percent) except possibly Chicago 1967,which made no report on its racial composition.

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Discussion of Background Characteristics:Using the most frequently reported character-istics as an indication of the typical health sci-ence student, one finds a 22-year-old, white,Jewish, male, student of medicine, who minoredin biology as an undergraduate. He has hisorigin in the upper middle class and his fatheris a medical professional. On the .average hehas had no previous experience in social actionprograms nor substantial academic preparationfor medical work in the community.

There is a growing body of research beingconducted concerning student social activismand the student protest movement. One of themost frequently reported observations is thatthe vast majority of college students are notactivists. Most students across the countryseem to uncritically accept society as it is pres-ently established, see college as an extension ofhigh school and as a vehicle to a comfortablecareer. Rarely are they apparently deeply con-cerned with political and social issues or per-ceptive of disturbing social conditions in thiscountry or abroad. Student disSent seems tooccur predominantly among a minority of stu-dents in large, urban universities either in theNorth or Far West which are well-known fortheir academic standing.; Two recent studies byone social scientist investigated the backgroundof 50 activists in Chicago area colleges and 65students who sat-in at the AdministrationBuilding of one university in protest againstthe administration's cooperation with the Selec-tive Service System. The findings disclosed thatstudents involved in protest activity generallyare from upper status families which are Jew-ish or irreligious and whose head of the house-hold is an affluent professional.a

One would like to be able to compare theattributes of PSHO students with the membersof activist groups to discover whether thereare similarities and dissimilarities. Unfortu-nately, no tabulation of the biographical fea-tures of student activists is available. Impres-sionistically it seems that PSHO and membersof student movements generally may have com-parable traits in some cases and remarkablydifferent traits in others. PSHO students were

J. W. Trene and J. L. Craise, "Commitment and Conformityin the Americas: College," Journal of Social Issues 23 (July 1967)p. 36.

5 Riebard Flacks, "The Liberated Generation: An Exploration ofthe Roots of Student Protest", Ibid., p. 66.

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a heterogeneous group whose level of socialawareness, previous experience in social recon-struction and background vary widely. Certain-ly same members of PSHO were deeply com-mitted to the improvement of social conditions,others were as unseeing and indifferent as thecareer-bound normal student, and others yetbegan to emerge as among the concerned. Itseems reasonable to state that students inPSHO had many characteristics in commonwith students in dissent groups with one not-able exception. The major fields of study ofmost activists are the humanities or morecommonly the social sciences.° PSHO partici-pants are mainly medical students and even intheir undergraduate careers majored in thenatural sciences. Also, student activists tend tobe more intellectually or esthetically orientedand not concerned with specialization in a tech-nical field which more or less guarantees asecure and durable position in society. PSHOstudents are overwhelmingly oriented towarda professional career, particularly in medicine.As mentioned, over 80 percent of PSHO healthscience students were enrolled in schools ofprofessionalization, either law, dentistry, nurs-ing, medicine or osteopathy. The moderatenessof the students of professions, including thoseof medicine in the United States, is not typicalin other parts of the world. Lipset reports thatmedical students in Latin America and south-ern Europe are historically more. leftist in ori-entation, while in northern Europe and the"Anglophonic" world they have a traditionallyconservative orientation., In Holland and Ger-many, for example, medical students' participa-tion in reformative groups is a rarity.8 Thecomparison of PSHO students with protestgroups is basically a comparison between twostudent groups and not a comparison betweentwo protest groups. The activities of PSHO stu-dents over the summer were more in the tradi-tion of moderate casework-like improvement ofsocial conditions rather than strong dissent anddemand for radical change in the existing socialstructure.

6 Trent, op. cit., p. 42. And Seymour Martin Lipset, "Student andPolitics in Comparative Perspective", Daedalus (Winter 1968)pp. 1-20.

Lipset, op. cit.. p. 17.Frank E. Pinner, "Tradition and Transgression. Western Euro-

pean Students in the Postwar Period", Daedalus, op. eit. p. 144.

Student Education

The Goats of PSHO

The Student Health Project Proposal forPhiladelphia Summer 1968 emphasized the edu-cational importance of the project. The pro-posal stated that the Summer Health Prf.dect"will provide 80 health students from varioussectors of the country with a new and vitaleducational experience. "' Students would hope-fully learn about problems of health care inindigent areas, preventive solutions to healthproblems, a multidisciplinary approach tohealth care, the economics of health deliverysystems and community medicine among otherissues.

Aside from education, the goals of the Stu-dent Health Organization summer projects area complicated mattter. Primarily, the philoso-phy of the staff was to allow students to expe-rience the multifaceted problems of health andthe urban poor on an individualistic level,through a decentralized organizational struc-ture with nondirective leadership. There were,then, no ubiquitous, definitive goals. The or-ganization did not establish goals for studentparticipants to achieve other than self-edifica-tion through firsthand experience. PSHO wasdesigned to allow students to witness alone orin small teams the social conditions of the poor,particularly health conditions in industrial so-ciety, and from this experience create and ini-tiate new and hopefully practical reforms. Thestaff itself and the office materials were avail-able as resources to the students. The directorscould be contacted for advice and recommenda-tions on how students might approach the re-form of particular problems, but the directorsdid not feel it their task to select specific goals,make strategy decisions and outline the aim ofall project members for the total summer. Theleadership did not conceive of itself as leadersbut as coordinators. The organization did nothave formal organization, but was flexibly or-ganized so that students could follow their ownindividually conceived courses of action and itdid not designate major purposes for the totalproject.

o Student Hearth Project Proposal for Philadelphia, Summer 1968,n.d., mimeo, p. 2.

There were of course vague goals that vari-ous staff members held such ss reforming thehealth care system, improvi3tg conditions ofthe poor, effecting social change. But thesewere abstract, almost bordering on the trans-cendental, and not intended for actual imple-mentation unless a united movement in thisdirection naturally developed out of the sum-mer's experiences. Staff and students did notfully agree on the major goals of PSHO, asidefrom the goal of education, and on particularissues, opinion was fragmented.

If one had to define the goals of the PSHOsummer project, its goals were what each indi-vidual participant defined as his goal on a per-sonal basis. If individual goals coincided andthey desired to join together, initiate a reform-ative movement within the organization anddraw in other members, then the structure wasflexible enough to permit this to occur.

Education, then, was the primary empha-sisbetterment of the poor and social reformwere incidental, if not serendipitous. In regardto education, it was believed that should therebe no reformative movement as an outcome, atleast students had personally witnessed the im-poverished conditions of the urban lower class ;and students could learn how the educationalinstitutions might be altered in order to ad-dress themselves to the medically indigent andhow students themselves, once they hadachieved positions of influence in the medicalor professional field, might from that staturebe successful in bringing about constructivechange.

The research collected some data on the heur-istic effects of PSHO which are presented indetail in the following paragraphs.

PSHO as an Educational Experience

As mentioned in the section concerning stu-dent characteristics, roughly 50 percent of thestudents joined the summer projects in antici-pation of a learning experience. When askedspecifically during the introductory orientation"how much do you think your summer workexperience will -idd to your professional educa-tion," over 40 percent thought it would con-tribute a "great deal" and an additional 42percent thought it would make a "considerable"contribution. However, by the close of tiro sum-mer, 10 percent fewer students in each of these

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categories felt that the summer had matchedtheir expectations. Moreover, almost twice asmany (30.5 percent vs. 17.7 percent) thoughtthe summer provided only a moderate learningexperience in the end as they expected in thebeginning. Also, while no one thought the proj-ect would have "little or no" educational valueprior to the actual work experience, 10 percentfelt this way at the closing conference.

As for the staff, all but one member expectedthe summer to have a great deal of educationalvalue before the project began, but only fivefelt this way after the project closed. Table 11reveals students' and staff's before and afterresponses to the question, "How much do youthink your summer work experience will add(has added) to your professional education?"

Table H.-udgment of Students and Staff on PSHO'sEducational Value.

Students StaffEducational value Before After Before After

percent percent percent percentA great deaf. 40.3 28.8 87.5 62.5Considerably 41.9 30.5 12.5 12.5Moderately 17.7 30.5 25.0Very little 10.2Nothing

Total 99.9 100.0 100.0 100.0

N Students before=62.N Students after=59.N Staff before and after=8.

Students X2=10.6, df=--4,

In general, both staff and students reporteda decline in education enrichment in compari-son to their original expectations. Chi Squarecalculated for students indicates that this de-crease is probably not a chance occurrence, butrather a significant decrease in judged educa-tional value. The only source of comparison isthe Bronx 1968 project wzich asked the samequestion. In that project, 53 percent thoughtthat the work experience contributed a greatdeal to their professional education as con-trasted with 29 percent for Philadelphia 1968."One should bear in mind, however, that follow-ing the summer experience, 90 percent of thestudents and all of the staff believed it to be ofsome educational enhancement.

As to what was learned, students and staffboth were asked to what extent the summerexperience contributed knowledge and specificskills helpful to their future careers. Over 93percent of the students and 100 percent of the

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staff thought general knowledge was acquired.A lesser percentage of both groups (80 percentand 87.5 percent) felt that specific skills helpfulto their career were gained. In both the cases,the experience was judged to be more valuablein the acquisition of knowledge than in theacquisition of skills. In fact, 20 percent of thestudents thought the summer was not helpfulat all in terms of skills as contrasted with only5 percent who felt this way in terms of knowl-edge. The distribution of student responses arepresented below in table 12.

Table 12.- Judgment by Students and Staff of Knowledgeand Specific Skills Acquired.

'Students StaffKnewlerge Skills Knowlerge Skills

percent percent percent percentVery helpful 35.6 18.6 '75.0 25.0Moderately helpful 44.1 32.2 12.5 50.0Slightly helpful ...... 13.6 28.8 12.5 12.5Not helpful at all 5.1 18.6 .... 12.5Detrimental 1.7 1.7 .... ....

Total 100.1 99.9 100.0 100.0N Students=69.N Sta2=8.

" Rcnald Miller, "The Project Evaluated:, The Student HealthProject of the South Bronx Summer 1967. ed. S. Fisch & J. Wil-liams, publisher unk., n.d. p. 188.

Estimating the value of the PSHO in termsof student education is a difficult matter, andthe above figures should be used only as roughindicators. It may be that the projects hadmore educational impact than students recog-nize or were willing to report during the imme-diacy of the closing conference. It is also pos-sible that educational value may only material-ize over a more extended period of time. In anycase, it can be fairly stated that on the wholea great majority of students and staff did sub-jectively estimate that the summer programwas helpful to a varying extent in acquiringknowledge relevant to their future careers.

Students were also questioned as to whatthey saw as the "major benefits" of participa-tion in PSHO. The major benefit agreed uponby 20 percent of the students was the oppor-tunity to learn about urban slum conditionsfirsthand. Here again, self-education is thepoint most heavily emphasized by students.Approximately the same percentage, one mayrecall, stated that they joined the program forthis specific learning opportunity (see p. 88).

However, several curious facts stand out-over20 percent of the students joined for the oppor-tunity to learn about community medicine, butless than 4 percent listed this among the topthree benefits of participation. Likewise, some16 percent joined for the opportunity to helpthe poor, but only 5 percent considered this anadvantage to participation. On the other hand,20 percent joined to learn. about urban slumconditions and approximately the same num-ber agreed that this was a major advantage.Similarly, creating social change was equallyconsidered to be a major reason for participa-tion and a major benefit. Other advantagesmost frequently mentioned were : earning $900,working with a practicing health professional,and associating with fellow health science stu-dents. Data concerning the major advantagesof participation are shown in table 13 below.

Table 13.-Rank Judgments of Students on Major BenefitsResulting From PSHO Participation.

Benefits Priority of benefits (percent)1st 2d 3d Total

The opportunity to:Learn about urban

slum conditions 30.9 14.8 13.0 19.0Help bring about

social change 16.4 10.7 14.8 16.0Earn $900 9.1 1.11 22.2 14.1Work with a practicing

health professional 12.7 11.1 13.0 12.3Associate with health

science students 5.5 14.8 14.8 11.7Live and work in

Philadelphia 3.6 13.0 5.6 7.4Help the poor 1.8 7.4 5.6 4.9Help advance civil

rights 3.6 3.7 5.6 4.3Learn about commu-

nity medicine 1.8 5.6 3.7 3.7Other 14.5 1.9 1.9 6.1

Total 99.9 100.1 100.2 100.1

Any conclusions concerning the total heuris-tic effect of PSHO must remain tentative. Stu-dents joined mainly for the educational advan-tages offered. The outcome, however, did notfulfill their complete expectations and studentsin Philadelphia SHO felt they learned less thanstudents in the Bronx 1967 project. In spite ofthis it bears reiterating that over 90 percentfelt the project was moderately to greatly help-ful in educating them for their future careers.

Students' Ideology

A major question in previous SHO evalua-tive research reports has been the degree towhich the selection of students has a bias builtin which naturally selects students with viewsalready favoring particular attitudes. Studentsare selected on the basis of their interest ingaining insights into community health prob-lems and their previous participation in com-munity involvement projects. As a result, pre-vious research has been unable to discernwhether students are converted to liberal viewsas a result of project participation or whetherthe summer simpy reinforces liberal attitudespreviously established.

Consequently before measuring student at-titudes on more specific issues such as compre-hensive medical care and socialized medicine,a technique for learning an individual's degreeof liberalism and conservatism was employed.Milton Rokeach has devoted a considerableamount of his career to the measurement ofbelief systems. This research utilized Rokeach'sOpinionation Scale, 40 item test, designed touncover an individual's degree of left opiniona-tion, right opinionation, total opinionation andconservatism, "liberalism_'' Rokeach claims thatthe Opinionation Scale is meant to measure"general intolerance". It consists of a series of20 statements prejudged to be leftist in orien-tation politically and 20 statements indicatinga rightist political position. Within each ofthese two positions are 10 questions indicatingeither an acceptance or a rejection of the par-ticular political stance. The Rokeach Opiniona-tion Scale appears in appendix 2.

Total opinionation indicates how strongly anindividual responds to both political positionscombined. Left opinionation is the degree towhich an individual accepts those statementsindicating a left orientation. Right opiniona-tion is the strength of agreement with state-ments associated with rightist political views.Liberalism/Conservatism is the difference be-tween right opinionation and left opinionation ;a positive score indicating conservatism, anegative score indicating liberalism.

Although Rokeach's scale is undoubtedlyfilled with flaws, and dated, if not questionable,

Rokeach, Milton, The Open and The Closed Mind. (New York,Basic Socks, Inc., 1960.) Pp. 80-97.

95

coatent, it is the most highly researched atti-tudinal scale of this nature available, and byall indications the most accurate. There hasbeen a great body of research to test its valid-ity and reliability. For these reasons it wasselected in this research. (For a further dis-cussion of this scale see pp. 105-106 of thisreport.) -

In the experimental study (pp. 106-108) onecan compare the political stance of PSHO medi-cal students with Penn medical students whoattended school during the summer. As notedthere, PSHO medical students are significantlymore left in orientation than are medical stu-dents who attended school.

The mean score for the subsample of PSHOmedical students is almost identical to the mean

score for all student participants. The sub-sample had an average left opinionation scoreof 84.2, while all students scored 84.7. ThePenn medical students were not as far left inopinionation, scoring 72.81. Rokeach has alsoadministered this scale to groups of students:in 1955, 186 Michigan State University under-graduates had an average left opinionationscore of 61.2.12 The comparison of PSHO par-ticipants with the Michigan sample revealsthat PSHO was considerably more left in ori-entation. Also, however, the Penn medical stu-dents had a more leftist opinionation than theMichigan students. Table 14 below, shows thevarious sample scores on left opinionation. Thehigher the score, the more left opinionation.

Table 14.Left and Right Opinionation of Students.

N X SD t p X SD t p

PSHO students 60 84.7 20.03 S 63.8 10.0 lMichigan State 186 61.2 11.9 S 8.4 0.0005 1 80.8 1.1.9 1

Difference 23.5 3.5 0.0005 17.0 10.8 0.0005

PSHO medical students 39 84.2 16.9 j 5 62.8 12.5 l 1.82 0.05Penn Medical students 36 72.8 10.1 l 68.8 12.0 S

Difference 11.4 6.0

In terms of right opinionation, PSHO stu-dents in general during the initial orientationwere less right oriented than Rokeach's sample,and the subsample of SHO medical studentsless right than Penn medical students. Table14 above shows the sample scores on rightopinionation. The higher the score the moreright the opinionation.

In general, the PSHO students have a sig-nificantly greater left orientation than studentssampled by Rokeach and a sample of medicalstudents attending school.

The difference between the right and leftopinionation results is a measure of liberal-ism-conservatism. PSHO students averagescore on this index placed them in a liberalposition. There are no Rokeach scores withwhich to compare PSHO students on this di-mension. However, the reader is again referredto the section concerning a comparison ofPSHO medical students with Penn medical stu-dents. There it is shown that PSHO medical

12 Rokeach, op. cit.. P. 95.

96

students are significantly more liberal than thePenn medical students who were sampled.Since PSHO students average liberalism scoresare very similar to that of the PSHO medicalstudent subsample, one would be led to believethat PSHO students on the whole came to theproject with a tendency toward liberalismgreater than that of students in general. There-fore, it would seem likely that PSHO healthscience students would tend to come to the proj-ects predisposed to favor certain liberal atti-tudes.

Attitude Change

The data above tends to indicate that PSHOparticipants in general have liberal attitudes.Thus, the PSHO project, rather than an agentto convert conservative students to liberals,would appear to be geared toward carryingliberal attitudes to more liberal positions, orat least reaffirming liberal positions alreadyheld. At the beginning of the summer only 11students (18 percent) held a conservative view

and the majority of these were very mildlyconservative. At the close of the summer, severor 11.6 percent still held conservative views sothat, at most, only four students moved froma conservative to a liberal position.

Tables 15, 16, 17, and 18 compare students'and staff's scores both before and after thesummer experience on left opinionation, rightopinionation, total opinionation and liberal-ism/conservatism. In each case, a higher scoremeans a greater acceptance of the attitude inquestion. On the left and right opinionationscales scores can range from 20 to 140; on totalopinionation, _from 40-200; and on liberal-ism/conservatism, from ±1 to ±140. As canbe seen from a glance at all tables, there wasapparently a change only in right opinionamong the students. That is, students did notbecome more left in opinionation (table 15),but less right (table 16). This, however, didnot significantly affect their general scores onliberalism. The staff as well became less right

and this change was sufficiently large to affectliberalism scores; therefore, staff members ap-parently became less right in opinionation andalso moderately more liberal. Total opiniona-tion, that is, how emphatically students rejectone political stand and accept the other, or inthis case the degree of leftism, remained con-stant from pre-test to post-test.

In terms of liberalism there was no signifi-cant change in attitude; students maintainedapproximately the same degree of liberalismfrom pre-test to post-test. The staff on thewhole moved considerably more to the left;in fact, their average liberalism score morethan doubled over the course of the summer.

On the whole, however, there was littlechange in the ideological position among thestudent participants in PSHO. This findingwould tend to support the assertion that theexperiences operate to reinforce opinions andbeliefs already held and does not result in sig-nificant attitudinal shifts.

Table 15.-Left Opinionation of Students and Staff.

StudentsSD

Stafft p X SD t p

BeforeAfterDifference

84.678'7.00

20.03 /18.34 0.66 N.S.

5 86.38 16.53 /18.04 1 0.59 N.S.

2.33 -1.69 5.50 1.51

Table 16.-Right Opinionation of Students and Staff.

StudentsX SD t p

StaffX SD t p

Before 63.83 10.02After 57.83 10.44 5 3.19 0.005

5 70.1354.12

0.025 Z9.20 5 2.25 0.025

Difference -6.00 .42 -16.01 -7.27

Table 17.-Total Opinionation of Students and Staff.

Students StaffX SD t p X SD t p

Before 143.83 17.76 IAfter 144.08 17.67 5Difference .25 -.09

( 155.250.08 N.S. Z 146.00

23.58 Z17.46 5

0.84 N.S.

-9.25 -6.12

Table 18.-Liberalism of Students and Staff.

StudentsSo t p

StaffX SD t p

Before 23.33 24.84 IAfter 24.51 24.51 5Difference 1.18 -.33

0.26 N.S.16.38 16.92

22.12 5 2.03 0.025

21.67 5.20

97

Medical Attitudes: Since the majority of thestudents were pursuing careers in the field ofhealth science, the research was interested inlearning whether there were changes in medi-cal attitudes over the court e of the summer.Considerable research was conducted by theUniversity of Colorado School of Medicine inthe 1950's when they introduced a physician'seducational program which emphasized com-prehensive medical care. That research com-pared two groups, one exposed to a traditionaleducational program and the other exposed tothe innovative comprehensive care program."In an attempt to evaluate the newer andbroader program's effect on medical students'training, the researchers used Boswell andNewman's "Medical Attitudes Test. Since thepurpose of the comprehensive coursework atColorado was much like the purpose of PSHO,that is, cultivating a broader approach to treat-ment rather than concern with the narrow or-ganic disorder, interest in the prevention ofdisease rather than the curative process only,and the development of a multidisciplinary ap-

proach in medical treatment, it was an excel-lent model for the present research. Three ofthe five scales in Boswell and Newman instru-ment were used : (a) Attitude toward compre-hensive medical care; (b) attitude toward theteam approach in medicine ; and (c) attitudetoward prevent 7e medicine. The three scalesin combination are compiled as a total medi-cal attitude scale. A brief description of eachof the scales is given below along with the re-sults of the pre- and post-test administrationto the PSHO students.

Comprehensive Care: This scale measures asubject's attitude as a physician toward takingresponsibility for the patient's total health, thegeneral health of other family members, andthe environmental and social factors whichenter into an individual's health status. Thebefore and after results on this scale for boththe staff and student workers is presented intable 19 below. Scores can range from 1 to 50;the higher the score, the more favorable theattitude toward comprehensive care.

Table 19.-Attitude of Students and Staff TowardComprehensive Medical Care.

Students StaffX SD t p X at1) t p

Before 36.97 3.62After 37.03 3.56 S

Difference .06 -.060.09 N.S.

j 40.3841.75

2.742.16 S 1.00 N.S.

1.37 -.58

The table shows that students' and Staff's at-titudes did not become more favorably disposedtoward comprehensive medical care but re-mained remarkably constant from pre-test topost-test.

Team Approach: This scale measures thesubject's opinion concerning the value of con-

suiting and working with other nonmedicalprofessionals and such as social worker, psy-chologists, and the benefit of a team consulta-tion among all treatment personnel such astechnician, therapist and nurse. Table 20 re-flects the test results on this attitude scale.

Table 20.-Attitude of Students and Staff Toward theTeam Approach in Medicine.

StudentsX SD t p

SteilX SD t p

BeforeAfterDifference

37.3036.50

4.29 13.56 5 1.10 N.S.

140.1336.25

2.93 14.18 2.01 0.025

-.80 -.73 -3.88 1.25

13 Kenneth R. Hammond and Fred Kern, Teaching Comprchcnave Medical Care (Cambridge, Mass.: Harvard Univ. Press 1959.)

98

Table 21.-Attitude of Students and Staff TowardPreventive Medicine.

StudentsX SD

Before 39.13 4.82After 39.23 4.32

t pStaff

X SD t p

0.11 N.S. 39.6041.38 2.12

6.22 50.72 N.S.

Difference .10 .00 -1.78 4.10

This table shows that the staff became sig-nificantly less in favor of a multidisciplinaryapproach to medical treatment over the courseof the summer. If this finding is not spurious,one would be led to interpret that the inter-action of staff with persons of other disciplinesand in many different roles, resulted in a de-cline in proteam approach in medicine. As forstudents in general, there was no attitudechange on this scale whatsoever.

Preventive Medicine: This scale measuresopinion concerning the need for and impor-tance of preventive medicine as opposed to aconcentration on curative medicine alone.

Table 21 contains the results on this scale.There was no attitude change for the stu-

dents on this measure ; however, the averagestaff score was less in the post-test than in thepre-test. The difference between the two is notsufficiently large to indicate anything morethan random variation, however.

Total Medical Attitude: This is a combinationof all three scales and is an indication of anindividual's overall opinion on these threemedical issues in general. There is no signifi-cant change either for students or for staffas the following table summarizes.

Table 22.-Total Medical Attitude of Students and Staff.

StudentsX SD t p

StaffX SD t p

BeforeAfterDifference

114.17113.42

8.6019.64 5 0.45 N.S.

5 121.88117.13

4.31 110.46 5 1.13 N.S.

-.75 1.04 -4.75 6.15

In summary, the findings in regard to atti-tude toward various medical issues for studentsindicate that there was no change over thelength of the summer. As for staff, the onechange was a shift from a more favorable toa less favorable view of the team approach inmedicine. To be noted too was the downwardshift, although not statistically significant, theattitude toward preventive medicine and intotal medical attitude for the staff.

Socialized Medicine: Another attitudinalscale administered to students concerned theiropinion on the issue of socialized medicine.The scale was developed by R. A. Mahler in1953 and is reproduced in Shaw and Wright's

"Marvin E. Shaw and Jack M. Wright, Scales for the Measure-ment of Attitudes. ( New York : McGraw-Hill Book Co., 1967) PP152-154.

Scales for the Measurement of Attitudes.'4 Inthe original scale Mahler used the terms "com-pulsory health program" and "compulsoryhealth insurance" to refer to a medical sys-tem supervised by the Federal government. Inthis research these terms were replaced by thephrase "socialized medicine" to avoid confusionand ambiguity.

Both among the staff members and thePSHO students there was a more favorableview of socialized medicine after the summerwork experience, although the significancelevel in both cases leaves open to doubt thepossibility that this change occurred by chance.The findings for socialized medicine are re-flected in the Table below. Here the higherthe score the more favorable the attitude to-ward socialized medicine.

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Table 23.-Attitude of Students and Staff TowardSocialized Medicine.

Students StaffX SD t p X SD t p

BeforeAfter

50.1754.83

17.93 114.53 1.55 0.10

S 49.25155.38

8.507.97 1.39 0.10

Difference 4,66 -3.39 6.13 -.53

Attitude Toward the Poor: A great numberof the site assignments were to indigenous com-munity organizations or to health and welfareinstitutions which serve the citizens of impov-erished neighborhoods. Consequently, it wasfelt appropriate to discover whether studentopinions about the poor were altered signifi-cantly as a result of their contact with theurban poor. The researchers were dissatisfiedwith the types of tests already available tomeasure individual's opinions about the poor.As a result a Likert scale, the "PhiladelphiaStudent Health Organization Opinions Aboutthe Poor" tes'., was constructed. There are 70questions derived primarily from the works ofMiller and Riessman 15 and Lewis.16 Miller andRiessman in their article describe the life styleof the working class in the United States. Itincludes working class attitudes toward thefamily, children, employment, politics, educa-tion and numerous other issues. Lewis, on theother hand, describes the lower class subcul-ture of Puerto Ricans both in San Juan and inNew York City. Both of these sources wereused to obtain statements that might be trueor not true of the urban poor in the UnitedStates. The research here is not concernedwith whether Riessman and Lewis' statementsabout the social classes are accurate or not, butonly whether students agree or disagree with

the assertions made by the two authors afterhaving been exposed to the poor. It was as-sumed that students would become more famil-iar with this group's qualities and, therebygain sufficient firsthand knowledge to reject oraccept the statements more decidedly. Anychange in attitude assumedly would be basedon actual field experience. Thirty-eight of thequestions are drawn from the Riessman refer-ence, 28 from Lewis and the remaining fourfrom other sources. They primarily deal withfactual matters which could be empirically ver-ified su31 as the amount of illegitimacy andfamily conflict, nature of political opinion andthe economic outlook of indigent persons gen-erally.

This instrument must be viewed as com-pletely exploratory at this point. No work hasbeen done here to test its reliability and valid-ity although this may be forthcoming.

Student attitudes toward the poor did changesignificantly over the course of the summer astable 24 indicates. Staff attitudes were not sig-nificantly different. However, this would beexpected since the staff was manly concernedwith administrative matters which providedlittle contact with the urban poor. In this table,the higher the value the more agreement thestudents have with the Riessman & Miller de-scriptions.

Table 24.-Opinion of Student and Staff About the Poor.

Students StaffX SD t p X SD t p

BeforeAfter

327.83338.00

21.76124.24 5 2.40 0.01

5 331.25339.13

22.33 133.00 5 0.52 N.S.

Difference 10.17 2.38 7.88 10.67

Segregation: Since many of the studentswould be working in black ghettos and gen-erally coming into closer contact with black

" S. M. Miller and Frank Rieseman, "The Working Class Subul-ture: A New View," Social Problems. 9 (Summer 61). pp. 86-97.

us Oscar Lewis, La Vida (New York : Random House, 1964).

100

citizens than had been their custom in the past,a test in attitude change in terms of racialprejudice was deemed appropriate. Quite anextensive search of the literature for attitudestoward Negroes was made. Most of the scalesencountered were far too simplistic to measure

subtle, unacknowledged prejudice that mightbe held among educated white students. Nocompletely satisfactory measure was located,but among the most sophisticated appeared tobe Rosenbaum and Zimmerman's "AttitudeToward Segregation Scale." " This is a 25-

item scale which asks respondents for theirfeelings about racial integration of schools.Table 25 below reflects the before and afterresponses to the issue. The higher the score,the more prointegration the response.

Table 25.Attitude of StudentsSegregation.

and Staff Toward

StudentsX SD t p

StaffX SD t p

Before 122.08 11.47 1After 120,33 12.69 5Difference 1.75 1.22

0.79 N.S.$ 118.881 118.88

6.77 19.03 5

0.00. 2.26

0 N.S.

There was no significant change in attitudetoward segregation either by the staff or bythe students.

Involvement and Attitude Change: One pos-sible reason for the absence of attitude changemight be the assertion that attitude change oc-curred only among students who became deeplyinvolved in the summer project and attitudesremained relatively constant for those whowere uninvolved. In order to test this hypothe-sis, that attitude change depends upon degreeof involvement, the research has correlatedthese two factors.

On the whole, attitude change is not relatedto involvement, except for two instances. Inthese two cases, however, the attitude becomesless favorable among the involved and morefavorable among the uninvolved. The follow-ing paragraphs explain these findings.

In the questionnaire of the closing confer-ence, students were given a list of PSHO ac-tivities, such as lectures, work-groups, confer-ences, social outings and weekly meetings (seeapp. 2). They were asked to check which ofthese they participated in or attended. Fromthis list was constructed an index of involve-ment, the greater the number of activities inwhich one participated, the greater the involve-ment. The possible range extends from par-ticipation in no activities to 19 activities. Theactual range was participation in one, to par-ticipation in 19 activities. In the date presentedbelow, involvement has been defined as par-ticipation in five activities, or more, and unin-volvement in four or fewer activities. While

17 Marvin E. Shaw and Jack M. Weight, Scalea jar the Measure-ment of Attitudes, op. cit., pp. 168-177.

for the most part this decision is arbitrary, areview of the students and their involvementscores indicates from personal experience, thatthis is not an unreasonable point at which todraw the demarcation line between involve-ment and uninvolvement. .

The contingency tables in which a significantrelationship exists between involvement andattitude change are presented below.

Table 26.Student Involvement and Opinionation.

Opinionation Involved Uninvolved

Increased right opinionation 23 16Increased left opinionation 6 14

Total 29 30X=4.44, 0=0.27, p=0.05.

Table 27.Studerit Involvement and Opinions About thePoor.

Uninvolve-Opiniono about Poor Involvement mane

More empathic 14 25Less empathic 15 5

Total 29 30X=11.9, 0=0.45, p= 0.001.

In these Lwo cases, there is an associai ionbetween il. 7ement and attitude change, butin both cases those involved reflected attitudechanges in a direction opposite that expectedby the project. That is, the involved movedmore to a rightist and the uninvolved to a left-ist orientation politically and the involved to aless emphatic and the uninvolved to a moreemphatic orientation toward the poor.

There is no significant association betweeninvolvement and attitude toward comprehen-sive medical care, total medical attitudes, lib-

101

eralism, socialized medicine and attitude to-ward integration.

The surprising finding then is that, "whilefor the most part there is no contingency be-tween attitude change and project involve-ment, where such a contingency exists, it isantithetical to the project's intentions.

A note of caution should be interjected, how-ever, concerning the relationship between opin-ions about the poor and involvement. It is quitepossible that those who came into intimatecontact with the poor learned that one cannotmake sweeping generalizations about the poorand consequently lowered their score on thisscale of indicating uncertainty or makingagreement or disagreement with less definitive-ness than initially. As mentioned previously,this is the first usage of this scale, and untilit has been validated, the test results remainopen to question.

Conclusion: The results of the administrationof a total of eleven attitudinal scales givesevidence of change only on two of these forstudents (right opinionation and opinionsabout the poor) and on four for the staff(team approach in medical treatment, rightopinionation, liberalism and possible socializedmedicine). Testing whether the lack of changeis a result of noninvolvement in the projectreveals that involvement and attitudinal changeare not generally related, except in two caseswhere the noninvolved had significantly morepositive changes in attitude than the involved.

Student Accomplishments and StudentPerceptions of PSHO

Student Accomplishment: Very little of theresearch effort has been devoted to evaluatingthe impact of PSHO on the community or oninstitutions in which students were placed.While highly desirous of obtaining informationabout specific accomplishments, it is practicallyimpossible to measure the collective influenceof 80 health science students dispersedthroughout a city of 2 million people. Informa-tion in other sections of the report reveals indescriptive fashion the efforts and attainmentsof specific projects. Here mention can only bemade to several minor indices of accomplish-ment.

Continuity of Projects: Twenty-seven per-cent of the students indicated they planned to

102

continue to work in the ensuing year with thecommunity organization or the institution withwhich they were placed, 56 percent had no suchplans, and 16 percent were uncertain.

Curricula Reform: Thirty-nine percent indi-cated that they had specific plans for attempt-ing curricula reform or facalty education intheir professional school in the following aca-demic year, 27 percent were uncertain, and 30percent had no definite plans.

Poverty Practice: At the close of the sum-mer, 22 percent had plans to eventually prac-tice their profession in a poverty area, 61 per-cent were undecided and 17 percent did nothave such plans.

Council in Medicine: During the course of thesummer, 26' Atudents counseled 87 individualsabout a career in medicine. No effort was madein the research to elicit in what depth thiscounseling took place, nor whether some indi-viduals, particularly the youth interns, werethe recipients of multicounseling.

Active Reform: Students were asked if as aresult of their participation in PSHO, they hadbecome active and 59 percent were not.

The section on problem papers by MissLynch reflects a great deal of informationrelevant to the perceptions of PSHO. Only a.few items on this topic were covered by thequestionnaire method. In general, however, itappears that there is a considerable discrep-ancy between what students expected to ac-complish and what they felt actually was ac-complished. This discrepancy holds true bothat the individual level and for PSHO as anorganization. Students were asked at the open-ing orientation "how effective do you thinkyour summer activities will be in improving theconditions of the poor. : At the closing confer-ence the same question was repeated with onlya change in wording, that is, "How effectivedo you think your activities were . . . " Resultson the pre-and post-question show a sharp de-cline in estimated effectiveness. Originally, al-most all students felt that they as individualswould be to varying degrees effective, and only5 percent thought they would have no effect.However, by the closing conference, over 50percent thought they personally had no effectand only 33 percent thought they had been tosome extent effective. Moreover, only one in-dividual originally thought he personally might

be ineffective ; nine individuals felt this way atthe close of the summer. In general termsthen, there was a considerable downward shiftin effeeiveness judged by students from thebeginning to the end of the summer. Table 28reflects these facts.Table 28.-Judgment of Students and Staff as to Indi-

vidual Effectiveness in Improving Conditions of Poor,Before and After.

Degree of effectiveness Students(percent)

Staff(percent)

Before After Before After

Exertmely effectiveVery effective

1.61.6 .... ....

Moderately effective 30.6 8.3 .... 12.5Slightly effective 59.7 25.4 25.0 ....No effect 4.8 50.8 50.0 62.5Slightly ineffective 1.7 .... ....Moderately ineffective 1.6 3.4 ....Very effective 5.1 .... ....Extremely ineffective 5.1 25.0 12.5

Total 99.9 99.8 100.0 100.0N Students before =62.N Students after=59.N Staff=8.X2=48.9; df=8; p=0.001.

Students and staff were also asked both atthe orientation and final conference "how effec-tive do you think the PSHO project as a wholewill be (was) in improving conditions of thepoor." There was here also a significant de-crease in students judgment of organizationaleffectiveness. At the outset, over 90 percentfelt the organization would be effective to someextent, whereas in the end this had decreasedto about 53 percent. Only one individual judgedthe project would be ineffective during orienta-tion, but 13 held this judgment at the finalconvocation. Data on this questi ,L.1 are shownin table 29.

Table 29.-Judgment of Students and Staff as to Effective-tiveness of PSHO in Improving the Conditions of thePoor, Before and After.

Degree of effectiveness Students(percent)

Staff(percent)

Before After Before After

Extremely effectiveVery effective

1.61.6

Moderately effective 38.7 3.4 12.5Slightly effective 50.0 49.2 50.0 25.0No effect 6.5 25.4 25.0 75.0Slightly ineffective 1.6 6.8Moderately ineffective 1.6 5.1Very ineffective 6.8Extremely ineffective 3.4 12.5 .

Total 100.0 100.1 100.0Students X2=33.9; df ; p=0.001 (N'a =Same as table 28).

In an effort to determine what might be thesource of dissatisfaction, an open-ended ques-tion at the close of the projects asked "whatmajor problem if any, do you see with theinternal organization of PSHO." Below arethe classified results.

Table 30.-Judgment of Students on Major InternalProblems of PSHO

Percent

Lack of formal organization 25.4Lack of clear-cut goals 15.3Lack of leadership 13.6Lack of communication 5.1Overly theoretical 5.1Inadequate site development 5.1Inadequate area coordination 3.4Absence of community personnel on staff 3.4Inadequate preceptors 1.7Inadequate representation of nonmedical

students 1.7Inadequate office management 1.7No answer-none 18.6

Total 100.1N=59.

Students were asked at the final session toindicate- how satisfied they felt in general abouttheir role in PSHO. In table 31 below, one cansee that 58 percent indicated that they werevery or somewhat satisfied and 32 percent werevery or somewhat dissatisfied.

Table 31.-Satisfaction of Staff and Students With Rolein PSHO.

Students(percent)

Staff(percent)

Very satisfied 15.3 12.5Somewhat satisfied 42.4 50.0Uncertain 10.2 ....Somewhat dissatisfied 25.4 37.5Very dissatisfied 6.8 --

Total 100.1 100.0Student N=59. Staff N=8.

While 'it seems probable that there wouldalways be a percentage of student discontentwith their position no matter what its nature,the fact that one-third of the students indi-cate dissatisfaction and another 10 percent un-certainty may be disproportionate. Also, only15 percent responded as being "very satisfied."

From this tabulation it would seem that theadministration of the project in the eyes of thestudents was lacking. The lack of formal or-ganization, goals and leadership all involve thebasic structure of the organization. .is men-tioned earlier, however, the project was inten-

103

tionally designed to be decentralized in orderthat students themselves might establish theirown goals on an individual basis ratherthan be handed guidelines and directions froma central authority. These findings might showthat students were displeased with an unstruc-tured program and would be desirous of moredirection and formal organization. In any case,it should be made explicit that student dissat-isfaction may result from other sources in ad-dition to the internal organization, and in fact,this conceivably may not be the primary sourceof dissatisfaction.

Finally, students were asked if they wouldparticipate in PSHO if it were repeated in thefuture : 32 percent stated that they would, 22percent that they would not, and 46 percentwere uncertain.

It is impossible to make any definitive state-ments about student perceptions of PSHO ;however, it would seem reasonable that stu-dents were somewhat less than enthusiasticabout the summer project. There appears tohave been a decided change in their anticipatedeffectiveness both individually and organiza-tionally, two out of five were uncertain aboutor dissatisfied with their role, and only threeout of ten were readily willing to reparticipatein a future project.

Penn Medical Student and PSHO MedicalStudent Comparison

IntroductionThis report compares the attitudes of medi-

cal students who attended school during thesummer with those of medical students partici-pating in PSHO. Within PSHO there were in-itially 3 individuals, both male and female, at-tending medical schools. The remaining 35PSHO participants were students of numerousother disciplines ranging from nursing anddentistry to social work and law. This reportcompares the 39 PSHO medical students witha group of nonparticipating medical studentswho were actually attending medical schoolduring the summer.

The Problem:

PSHO research in the past has been interestedin learning what effect actual participation incommunity work projects has on both the medi-

104

cal and social attitudes of the project workers.It attempted to learn whether this experienceis successful in provoking attitude change. Thisprevious PSHO research, however, has been be-set by two major limitations: (a) the absenceof a control group by which comparison in at-titude change might be made, and (b) the in-ability to determine how strongly student par-ticipants identified with the attitudes in ques-tion prior to their participation. The small ex-perimental comparison reported here has at-tempted to correct these limitations. Hereinis presented a comparison of second year medi-cal students both before and after the summerwith the medical student participants of PSHOat the same time periods.

Methodology:

The Dean of the medical school of the Uni-versity of Pennsylvania permitted the re-searchers to record the names and addressesof 61 second -year medical students attendingclasses and working in hospitals during thesummer. The same questionnaire given toPSHO medical students during orientation wasmailed to Penn students during the first weekof the project. The questionnaire was coded foranonymous replies and contained backgrounddata questions and four attitudinal tests : atti-tudes towards the poor, socialized medicine,general medical attitudes, and the Rokeachopinionation scale. The entire instrument re-quired approximately one hour to complete.Most of these students were telephoned in ad-vance and informed that they had been selectedas a member of the control group and that aquestionnaire addressed to them was beingplaced in the mail. No student objected to re-ceiving the questic

Originally, the researchers wanted to com-pensate the Penn students for their effort andfunds that could be devoted to this purposewere available. It was known that medical stu-dents were exceptionally busy, both attendingcourses and working long hours, often at night,and consequently seldom had free time. Somemonetary compensation for the time requiredto fill out the questionnaire, it was felt, mightinsure a larger and more adequate return, par-ticularly since the researchers were asking fora return at two different times of which theabsence of either would make the participants'

results unusable. Members of the medical pro-fession, however, counseleed that paymentwould be "unethical." They suggested that mostmedical students would be willing to contributeto a research project voluntarily since it con-cerned their professionstudents would bewilling to participate freely as fellows in themedical community. This was not completelythe case.

Of the 61 questionnaires mailed to the stu-dents, three were undeliverable by the postoffice and 38 were completed and returned atthe start of the summer. This is a return rateof 67 percent. As for the post-test mailingwhich began when the projects closed in lateAugust 1968, only 32 or 54 percent of the totalstudents fully cooperated with the researcheffort by returning completed questionnaires.When contacted by telephone, most of thosewho did not cooperate explained that they weresimply far too busy to devote time to the re-search. A few other students reacted vehe-mently to the content of the questionnaire, how-ever, claiming that it was highly biased.

The content of the questionnaire, actually,was determined by the nature of the PSHOproject, that is, the attitude scales were thoserelevant to the attitudes PSHO was interestedin changing. They were selected on the basisof the goals PSHO was attempting to attain.There was no implicit interest by the research-ers in demonstrating that PSHO students werein any way superior to medical students at-tending school. While no social science researchis ever successful in being completely valuefree, the research was not out to prove thatPSHO participants were the socially concernedreformers and the medical students attendingschool, the unconcerned conservatives. The re-search simply required a base group by whichcomparisons in attitule shifts could be made,and the Penn medical students were a con-venient and available group.

A major criticism by the Penn students cen-tered around the Rokeach Opinionation Scale(see app. 3 and pp. 95-96) . This scale at-tempts to measure an individual's political posi-tion by asking for agreement or disagreementwith brief, opinioned statements. The state-ments admittedly are dated, concerning politi-cal issues and personalities no longer contem-porary, and the items are so blunt and naive

as to be an insult when answered by intelligent,sensitive individuals.

This test, although certainly filled with flaws,is designed to uncover how intolerant an in-dividual is of opposing points of view andhow dogmatically he accepts his own view.Failing to agree strongly with one's own pOsi-tion and failing to reject strongly alternativepositions theoretically gives evidence of one'stolerance level. At the same time the mildacceptance reveals one's political stance. TheRokeach instrument unquestionably requiresrefinement and greater .sophistication. In theinterest of overcoming the limitations of pre-vious studies, namely the inability to know theideological position of PSHO students priorto the entry in the project, the Rokeach scalewas used. Its validity and reliability have beenheavily researched both in this country andabroad. Until an improved scale is developed,the Rokeach scale will probably continue to beused with apologies.

Had the researchers been able to plan suf-ficiently in advance, a matched control groupwould have been selected. Not only a lack oftime, but other difficulties as well, preventedthis possibility. For example, we did not knowsome of the characteristics of PSHO partici-pants until after orientation in June 1968. Ap-plication forms do not ask for characteristicssuch as race and religion, two attitudes whichshould be controlled in an experiment of thisnature. Secondly, a delay by the medical schoolin granting permission to review student char-acteristics to choose matched pairs, even onattributes such as sex and age, precluded amatched control group. In fact, the use of theterm "control group" is dubious. Actually, thisreport simply draws a comparison betweenmedical students in school and medical stu-dents in PSHO. A full report is provided be-low as to what changes in attitude occurredamong PSHO medical students compared withthe Penn medical students, the difference inattitudes between the two groups and, finally,a comparison of the social background fea-tures of both groups.

The samples are small and the returns byPenn medical students limited, so that the re-search should be viewed as an exploratory at-tempt to extend PSHO research with the hopethat future projects of this nature might come

105

to more decisive findings.

Findings:

The findings are generally that little attitu-dinal change occurred, among PSHO studentsfrom pre-test to post -test, but that there werestrong distinctions between the two groups atboth time periods.

Ideology:

The results indicate that the PSHO medicalstudents did not alter their political attitudes

as a result of the summer experience. On theleft opinionation portion of the Rokeach scale,the PSHO medical students maintained almostidentical average scores from pre-test to ppst-test Penn medical students' attitudes also re-mained constant over the summer. There was,however, a significant difference between thetwo groups at both time periods, PSHO tend-ing to be more leftist in outlook. Table 32 belowdescribes the before and after results on thisscale. The higher the score, the more left theopinionation.

Table 32.-Mean Left Opinionation Scores, PSHO andPenn Medical Students.

PSHO medical PSHO medicalDifference tX X

BeforeAfter

Differencetp

84.284.6

3936

72.872.5

3630

11.412.1

3.53.8

0.00050.0005

.4

.11N.S.

-.3.14

N.S.One tail test.

On the right opinionation scale PSHO medi-cal students tended to become less and Pennmedical students more, rightist in orientation 4over the summer. In the pre-test the differencein scores between PSHO and Penn medicalstudents was 5.4 (p=0.05) while at the closeof the summer the difference had increased to13.8 (p=0.0005). It is then open to question

as to whether the PSHO project is necessarilyeffecting attitude change. Quite possibly, na-tional and international events, particularly inan election year, could be influencing studentscores. Whatever the source, however, bothgroups appear to have changed position duringthe summer months. Table 33, below, reflectsthese findings.

Table 33.-Mean Right Opinionation Scores, PSHO andPenn Medical Students.

PSHO medical Penn medicalX X Difference t P

BeforeAfter

Differencet

p

62.859.1

3938

68.272.8

3630

5.413.8

1.84.7

0.05.00U5

-3.71.4.10

4.61.4.10

One tail test.

Neither group reflected a change in TotalOpinionation, that is, the combination of rightand left opinionation, over the course of thesummer. However, in the pre-test, PSHO stu-dents were significantly more opinionated thanthe Penn students although this difference de-creased in the post-test in which both scored atapproximately the same level.

106

The right and left opinionation scores canbe used to measure liberalism and conserva-tism, by subtracting right from left opiniona-tion. Scoring high on right and low on leftmeasures a conservative political orientation,while scoring high on left and low on rightindicates liberalism.

PSHO students did not become more liberalas a result of participation. Although the scoresmove in this direction, they are not sufficientlylarge to indicate more than chance variation.

The Penn medical students in the pre-testscored slightly liberal a- .d in the post-test lessliberal, although here too the difference maybe due to chance variation in scoring. The com-bination of these slight movements, however,adds up to large differences between the twogroups. While the difference between the twoat the beginning of the summer was 14.5(p=0.01), it increased greatly by the end to26.4 (p=41.0005). This is similar to the findingson the right opinionation: the two groups

moved in contrary directions which leads thepost-test results to show far greater differ-ences than the pre-test. Here also it would bedifficult to assume that PSHO is the agentresponsible for the attitude change. Had thePenn students score remained approximatelythe same, while only PSHO students scoreschanged, then there would be reason to con-tend that the PSHO experience induced thechange. The trend of Penn medical students"downward" and PSHO students "upward"may reflect the trend in the United Statesgenerally toward a "polarization" of liberaland conservative attitudes. Table 34 summar-izes the findings on liberalism; the higher thescore the more liberal the attitude.

Table 34.Mean Liberalism Scores, PSHO and PennMedical Students.

PSHO Penn medicalDifference t pN X N

BeforeAfterDifference

tp

21.728.4

6.71.2

N.S.

3938

7.22.0

5.21.0

N.S.

3630

14.526.4

2.64.8

0.01.0005

One tail test.

Medical Attitudes:Both groups completed two sets of questions

concerned with attitudes within the field ofmedicine. A more elaborat? explanation of thecontent of these atttiude scales can be foundon pp 287. One was Boswell & Newman's"Medical Attitudes Test" consisting of threesubscales : attitude toward comprehensive med-ical care, attitude toward the team approachin medicine, and attitude toward preventivemedicine. The second was Mahler's "Social-ized Medicine Attitude Scale" (see app. 3, pts.II and V).

Comprehensive Care:

This scale concerns attitudes toward regard-ing a patient's total health as within the physi-cian's purview, the willingness to assume re-sponsibility for additional family membershealth care needs, and concern with social andenvironmental conditions which might influ-ence health status.

PSHO students did not alter their attitudeon this dimension. In regard to the differences

between the two groups, initially PSHO had asignificantly higher average score in favor ofcomprehensive care than Penn students ; how-ever, by August both groups average scoresmoved closer together, PSHO's slightly de-creasing and Penn's slightly increasing so thatno significant difference remained.

Team, Approach:

Neither group's attitude toward the team ap-proach in medicine, that is favoring the use ofnon-medical professionals such as psychologistsand social workers and favoring conference-like discussions with medical specialists suchas nurses and technicians in the treatment ofa case, reflected a change over the summer.

However, PSHO students demonstrate a.nore favorable attitude on this measure thando the Penn medical students in the beginningof the summer, but not necessarily at its con-clusion. The difference between the two groupsinitially was 2.8 (p=0.01) but only 1/5(p=0.10) after. The average score for Pennslightly increased and the PSHO average

107

slightly decreased thereby eliminating a signifi-cant difference in the post-test.

Preventive Medicine:PSHO students' attitude toward the impor-

tance of preventive medicine as opposed tocurative medicine did reflect a significant posi-tion change. Table 35 below indicates thatPenn medical students average scare remainedrelatively constant while that of PSHO stu-dents increased. In this table, the higher the

score, the more favorable the attitude towardpreventive medicine.

There was also a considerable difference be-tween the two groups in both the pre- and post-test; PSHO in both cases evincing a higherpreventive medicine score than Penn students.

Total Medical Attitude:

PSHO students' and Penn students' averageson a combination of all three measures reflects

Table 35.-Mean Preventive Medicine Scores, PSHO andPenn Medical Students.

PSHO medical Penn medicalDifferenceX X

BeforeAfter

Differencetp

36.338.4

2.12.1

.025

3938

32.433.6

1.21.0

N.S.

3832

3.94.8

3.63.9

0.0005.0005

On, tail test.

no changes from pre- to post-test. There is,however, a significant difference between thetwo groups at both stages of measurement.PSHO students score higher than Penn stu-dents both at the beginning (t=9.7, p=0.0005)and conclusion (t=6.8, ).005).

Socialized Medicine:This test measures to what degree an indi-

vidual favors a health care system in theUnited States which is supervised by the Fled-

eral Government. The PSHO students' attitudein this area was more in favor of a federallyregulated medical system at the end of thesummer than at the beginning although thestatistics indicate that possibly this changeis due to random variation in responding tothe questions rather than an actual change inattitude. Table 36 below shows the pre- andpost-test results for PSHO students on thisindex.

Table 36. -Mean Socialized Medicine Scores, PSHO andPenn Medical Students.

PSHO students Penn studentsDifference t PX X

BeforeAfter

Differencet

p

49.655.0

3938

35.635.3

.3

.05N.S.

3631

14.019.7

3.45.4

0.00060.0005

5.41.4.10

One tail test.

This table also shows that PSHO studentsare far more inclined to favor socialized medi-cine than are Penn students.

108

Attitude Toward the Poor:About two-thirds of the PSHO project sites

were with community organizations in urban

Table 37.Mean Opinions About the !kw Score, PSHOand Penn Medical Students.

P5110 students Penn studentsDifference t pX X

BeforeAfter

Differencet

p

323.7333.4

9.71.9.025

3938

341.1327.3

3631

17.46.1

4.21.2

0.00050.10

13.83.3

.005One tail teat.

slum areas and most of the remaining one-third were with official institutions servingsuch areas. Intimate exposure to the living con-ditions and problems of the poor were expectedas a part of the summer activities. In order tofind whether personal contact lead to changesin attitudes toward the poor, the research teamdeveloped a 70-item test (see pp. 100-101 andapp. 3). It consists of statements to be ac-cepted or rejected by the respondent concern-ing the political philosophy, family structure,economic views and other social matters, of thepoor. The test was constructed hurriedlyshortly before the summer project waslaunched in June 1968 and consequently notime was available to perform extensive pre-testing, nor to establish its validity and reli-ability. The results show a great deal of atti-tudinal shifting both by Penn medical andPSHO medical students, so that its contentneeds to be very carefully investigated beforeit is used in the future. The basic problem isdetermining the scoring of the questions. Forthe present research they were scored when asubject indicated agreement with the twomajor scholars' monographs from which thequestions are drawn (see p. 100), However,one scholar describes the working class, notthe lower class, so that agreement with theitems taken from his reference may not be ac-curate in regard to the lower class. If, forexample some of these items apply exclusivelyto the working class, then answering in agree-ment with his assertions is inaccurate in re-gard to the lower class and the scoring would,therefore, need to be reversed. A second prob-lem concerns the wisdom of generalizing aboutthe poor. Although the test is designed for at-titudes about the urban poor specifically, thispopulation's characteristics undoubtedly variesaccording to rate and geographical region as

well as other factors. It may be that intimatecontact results in a lowering of overall score,since the respondent may come to feel that itis inappropriate to generalize widely about thepoor after having personally observed their lifeconditions.

The researchers feel that t,..3 attitude towardthe poor test developed by PSHO is an im-provement over existing tests, but requiresitem analysis and additional study before itis adopted by future research projects.

The findings indicate that both groupschanged attitudes toward the poor. These factsare illustrated in table 37 below. The higher thescore, the more familiar with the circumstancesof the poor.

The table reveals that PSHO students sig-nificantly increased scores while Penn studentsdecreased in regard to the poor. While onemight expect PSHO student scores to changeas a result of exposure to indigent communitylife, the change by Penn students is not readilyexplicable.

Background Comparison:

As mentioned earlier in the research, a morestructured research design would have requireda matched control group or the experimentalcomparison. Time limitations prevented thispossibility and, as a consequence, the research-ers opted for what they hoped would be anacceptable matched group control. Thus, ratherthan matching pairs, it was hoped that theaverage background characteristics of the twogroups would be sufficiently similar to allowgroup comparisons. What follows then is a de-scription of the background differences of thetwo groups. The group.; were, of course, sim-ilar in some traits on the average and consider-ably different in others.

109

Both groups consisted of 89 percent males,end approximately 95 percent of each groupwas white. However, the Penn medical stu-dents were on the average significantly olderand had significantly different religious back-grounds. The average age of PSHO medicalstudents was 22.9 years, whereas the ''enn stu-dents were slightly over 24 years of age. (Thisdifference is statistically significant-X2=28.4 ;df=7, p=0.001.)

The two groups also differed significantly interms of family religious background. Almosthalf of the PSHO medical students come fromJewish families, whereas more than half of thePenn students have a Protestant family reli-gion. This data is shown in table 38 below.

Table 38.-Family Religion of PSHO and Penn MedicalStudents.

PSHO students Penn studentsPercent Percent

Protestant 20.5 8 56.8 21Catholic 17.9 7 21.6 8Jewish 48.7 19 18.9 7Other 12.7 5 0

Total 99.8 39 100.0 36X2=15.8. df=3. P=0.01.

In terms of social class, PSHO students andPenn students differ, but not significantly.Most students in both groups come mainly fromthe middle and upper classes (see p. XX for themethod of determining social class) . Table 39gives the data on social class.

Table 39.-Social Class of PSHO and Penn MedicalStudents.

Social class PSHO students Penn studentsPercent N Percent N

Upper 38.5 15 35.1 13Middle 38.5 15 56.8 21Working 20.6 8 8.7 3Lower 2.5 1 --- b

Total 100.0 3i 100.0 37X2=4.4; df=3 ; p=0.30.

Family income of the parents of the twogroups does not vary significantly althoughPenn students come from families that earnmore money on the average. The mean incomeof Penn students' parents was $18,776 whereasPSHO was $16,664, a difference of over $2.000annually. This does not amount to a statis-tically significant difference, however (X2=5,6,df=6, p=0.50).

In regard to educational experience whichmight have influenced the manner in which thetwo groups answered the questionnaire, Pennstudents in general had significantly more aca-demic preparation by enrollment in coursesconcerning community medicine. Twenty-sevenpercent of the Penn, but only 8 percent of thePSHO students had coursework in this area.On the other hand, however, PSHO studentshad significantly more actual experience incommunity work. Over 38 percent of the PSHOstudents had previous participation in socialaction projects, whereas less than 11 percentof Penn medical students had this experience.Table 40 below reflects these differences be-tween the two groups.

Table 40.-Community Medicine Coursework and PracticalExperience of PSHO and Penn Students.

CourseworkPSHO studentsPercent

ExperiencePenn studentsl'ercent N

PSHO students Penn studentsPercent Percent

Yes 7.7 3 27.0 10 38.5 15 10.8 4No 92.3 36 73.0 27 61.5 24 89.2 33

Total 100.0 39 100.0 37 100.0 39 100.0 37

X2=5.00; df=1; p=0.05. Xg=7.74; df=1; p=0.01.

In summary, a comparison of the two groupsshows that Penn medical students are signifi-cantly older, have had significantly morecourse work in community medicine and lesspractical experience in social action programsthan PSHO medical students. In terms of other

110

characteristics ; sex, race, social class andfamily income, the two groups are essentiallysimilar.

How much these background differences con-tribute to the differences in responses to theattitude scales is purely a matter for specula-

tion. It is possible that age alone could accountfor the difference in answering. Therefore, wecan only note the possibility that the summerexperience is only one contributing factor tothe differences in response to the questionnaire.

Conclusion:

There was no change in PSHO medical stu-dents atti',udes from pre-test to post-test interms of left opinionation, total opinionation,liberalism, comprehensive medical care, teamapproach in medicine, and medical attitudes ingeneral. There is a possibility that PSHO stu-dents became less rightist in political ideologyand more in favor of socialized medicine, butthese changes may be due to random variation.The two measures on which there are definite,significant changes are : more favorable atti-tudes toward the poor and more favorable at-titudes toward preventive medicine.

As for the Penn medical students, therewas no change in left opinionation, total opin-ionation, liberalism, comprehensive care, teamapproach, preventive medicine, medical atti-tudes in general, and socialized medicine. Therewas possibly a more right-leaning politicalstance at the end of the summer, but here toothe resulting difference may be simply scoringfluctuation. Penn medical students became sig-nificantly less favorably inclined toward thepoor in the post-test.

As to the difference between the two groups,however, they are significant on all ten indexes

USC-SMIC Student Health Project, op. cit.. p. 17.

in the pre-test and on six in the post-test. Incases where the difference dissipated over thesummer, it is generally movement by bothgroups in the other group's direection. Thereis no way to determine why there was no-dis-tinction between PSHO and Penn students oncomprehensive care, team approach, total opin-ionation, and attitudes toward the poor in thepost-test as there was in the pre-test. Quitepossibly events external to both groups werecreating a stimulus for opinion change.

Since the ten attitude scales have differenti-ated between the two groups, particularly inthe initial testing, one is tempted to think thatthe tests are relatively accurate and there existother factors to account for the absence of morewidespread attitudinal change within thePSHO student group. The most apparent rea-son would be the assertion that PSHO projecton the whole is not a source of pervasive atti-tude change. This would be corroborated bythe fact that there was little manifest atti-tudinal change among the total SHO partici-pants (see pp. 95-101). Whether this is thecase or not, remains open to question and de-bate. It should also be mentioned that theCalifornia 1966 research project, using a com-pletely different set of attitude scales found achange only in attitudes toward the poor."

It should be stipulated very clearly, however,that the absence of profound attitude changeis possibly not a just reason to question thevalue of the total PSHO experience.

111

Section V

APPENDIXES

APPENDIX 1

Pre-Test Background QuestionnairePhiladelphia Student Health Organization

The following questionnaire consists of six parts. Please read the instructions to each partand answer each one carefully.

PART I: BIOGRAPHICAL DATA

1. Name2. Home address3. School address4. Age

(years) (months)5. Field of Study6. Undergraduate major7. Race8. Family religion9. Family's annual income :

up to $2,999$3,000 to $5,999$6,000 to $8,999$9,000 to $14,999

10. Father's occupation(be specific: if deceased or retired list former occupation)

$15,000 to $19,999$20,000 to $24,999over $25,000

11. Mother's occupation12. Have you previously had any actual experience with social action programs in poverty

areas such as SHO. If so please list locations and dates :13. Have you ever had a course in comprehensive medical care or community medicine :

yes no14. Please rank in decreasing order of importance (from 1 to 5) your major reasons for par-

ticipatior. in the Philadelphia SHO project for the summer :the opportunity to learn about urban slum conditions firsthand.the opportunity to live and work in Philadelphia.the opportunity to help advance the civil rights movement.the opportunity to earn $900.00.

the opportunity to associate with health science students.the opportunity to learn about community medicine firsthand.

the opportunity to help the poor.the opportunity to work with a practicing health professional.

113

the opportunity to help bring about social change.others (please list).

15. Describe what you presently feel will be the biggest problem you face in carrying out yourwork activities this summer :

16. How effective do you think your summer activities will be in improving the conditions ofthe poor :

Extremely effectiveVery effectiveModerately effectiveSlightly effectiveNo effect

17. How effective do you thinktions of the poor:

Extremely effectiveVery effectiveModerately effectiveSlightly effectiveNo effect

18. How much do you think yourcation :

A great dealConsiderablyModerately

Slightly ineffectiveModerately ineffectiveVery ineffectiveExtremely ineffective

the SHO project will be as a whole in improving the condi -.

Slightly ineffectiveModerately ineffectiveVery ineffectiveExtremely ineffective

summer work experience will add to your professional edu-

APPENDIX 2

Very littleNothing

Post-Test Background QuestionnairePhiladelphia Student Health Organization

The following questionnaire consists of six parts. Please read the instructions to each partand answer each carefully.

PART I: EVALUATIONAL DATA

1. Name2. How much do you think your work experience this summer has added to your profes-

sional education :._a great deal_considerably_moderately

3. To what extent, if any, was thefuture career : _not helpful at all

_very helpful_moderately helpful _detrimental_slightly helpful

4. To what extent, if any, was theyour future career.

_very helpful ._not helpful at all_moderately helpful _detrimental_slightly helpful

_very little_nothing

summer experience helpful in acquiring knowledge for your

114

summer experience helpful in acquiring specific skills for

5. Which of the following type of school do you attend:_professional _technical_graduate _other (specify)_undergraduate

6. What was your grade point average (4 pt. system) for the last semester of school attended :

7. In terms of academic standing where do you rank :_top 10 percent of class _top 50 percent of class_top 25 percent of class _below the top 50 percent of class

8. Please rank in decreasing order of importance (from 1 to 5) your major reasons for par-ticipation in the PSHO project for the summer :

the opportunity to learn about urban slum conditions firsthandthe opportunity to live and work in Philadelphiathe opportunity to help advance the civil rights movement.The opportunity to earn $900.00

the opportunity to associate with health science students.the opportunity to learn about community medicine firsthand.the opportunity to help the poor.

the opportunity to work with a practicing health professional.t"ie opportunity to help bring about social change.

other (please specify)9. Please rank in decreasing order of importance (from 1 to 3) the major benefits as a

result of participation in the PSHO project, if any :the opportunity to learn about urban slum conditions firsthand.

the opportunity to live and work in Philadelphia.the opportunity to help advance the civil rights movement.the opportunity to earn $900.00

the opportunity to associate with health science students.the opportunity to help the poor.the opportuni- to work with a practicing health professional.the opportunity to help bring about social change.the opportunity to learn about community medicine fiirsthand.

other (please specify)10. Describe what you presently feel was the biggest problem you faced in carrying out

your work activities this suini-ner :11. Did you live in the area in which you worked :

_yes, if yes was it a poverty area: _yesno _no

12. Did you attend the initial PSHO orientation session at Eagleville :__yes_no

13. Did you attend the PSHO picnic at Pary in State Park :_.yes_no

14. Did you attend the PSHO midsummer conference r_..t Eagleville :_yes_no

15. Please indicate how frequently, if at all, you attended the "Tuesday night groupmeetings:"

__regularly _irregularly_somewhat regularly not at all

115

16. Please indicate which of the following PSHO activities you attended or participated in,if any :

Cherry's "The Jungle."Woodruff's "A Black Analysis of Our Society."

Energies of MantuaCommunities Relations and the Police.Rat Control and Health Problems in the Ghetto.

First Aid Course.Friends Peace Committee Non-violent, Direct Action Course.Workgroup on Curricula Reform.Workgroup on Black Admissions.Workgroup on Education (Elaine Hagen's planning group).--Workgroup on Communication & Publicity (Chip Smith & Joan Horan).--Workgroup on Project Continuity (Ron Blum)Workgroup on the Newsletter (Dick Devereaux).Workgroup on Lucia's Play.Other (please specify).

17. Do you presently plan to practice your profession in a poverty area:_yesno_uncertain

18. Do you presently have any specific plans for attempting curricula reform or faculty educationat your college in the fall:

_yes_no_uncertain

19. Do you presently have plans to continue to work in the fall with the community organizationor institution with which you were placed this summer :

_yesno_uncertain

20. Are you presently active in any group seeking social change as a result of your participa-tion in the PSHO summer project.

yesno21. During your summer activities did you counsel anyone about a career in medicine:

_yes, if yes how many_no

22. How effective do you think your summer activities were in improving the conditions of thepoor :

_extremely effectivevery effective_moderately effective._slightly effective_no effect

23. How effective do you think the PSHOof the poor:

_extremely effective_very effective_moderately effective_slightly effective_no effect

116

_slightly ineffective__moderately ineffective_very ineffective_extremely ineffective

project was as a whole in improving the conditions

_slightly ineffective__moderately ineffective_very ineffective_extremely ineffective

24. Indicate how you feel in general terms about your role in the Summer project :_very satisfied _somewhat dissatisfied_somewhat satisfied _very dissatisfied_uncertain

25. Assuming that PSHO repeated its summer project in the future, would you participate :_yesno_uncertain

26. What major problem, if any, do you see with the internal organization of PSHO: (explain).Use the back of this page for other comments, criticism, observations, suggestions, etc.

APPENDIX 3

Attitude Scales

PART II : BOSWELL AND NEWMAN MAT

Instructions: This is a study of what medical students and people in general think about anumber of social and medical questions. The best answer to each question below is your personalopinion. We have tried to cover many different points of view. You will find yourself stronglyin favor of some and disagree strongly with others. For some statements your opinions will notbe as clear cut. Whatever way you feel about any of the statements you can be certain that a goodmany people feel the way you do. Be sure to answer every item. After all, no knowledge, butonly your opinion is involved. Think quickly : your immediate reaction to the statement is prob-ably the best one.

Read each statement carefully. Below it are five possible answers numbered 1, 2, 3, 4, and 5.Circle the answer you think best represents the way you feel.

1. How important do you think it is for the doctor to know the effect of the patient's illnesson his family in order to provide adequate treatment?

1. Not important at all 4. Pretty important2. Pretty unimportant 5. Very important3. Not so important

2. The greatest service a physician can provide is in following longterm health and adjust-ment of patients and families rather than in concentrating only on the treatment of immediateillness complaints of his patients.

1. Strongly disagree 4. Agree2. Disagree 5. Strongly agree3. Undecided

3. In medical practice today there are sufficient specialists so that a physician in generalpractice should not assume long-term responsibility for his patients.

1. Completely disagree 4. Agree for the most part2. Disagree 5. Agree completely3. undecided

4. The medical school should train students for specialties rather than general practice.1. Disagree completely 4. Agree2. Disagree 5. Agree completely3. Undecided

117

5. Do you think that as a physician you would prefer to have for your patients all membersof a family rather than patients as individuals?

1. Definitely not 4. Yes2. No 5. Definitely yes3. Undecided

6. The most important function of the physician is to immediately relieve the suffering ofthe patient.

1. Strongly disagree 4. Agree2. Disagree 5. Strongly agree3. Undecided

7. In a general practice there is no reason to stress good health and promote disease pre-vention since the average patient only wants to pay for the alleviation of his disease.

1. For practically no cases at all 4. For most cases2. For very few cases 5. For practically all cases3. For some cases

8. How practical do you think it is for a doctor in clinical practice to take time to follow upprovocative clues other than the presenting symptoms?

1. It is always impractical 4. It is usually practical2. It is usually impractical 5. It is always practical3. Undecided

9. Do you think medical training in the clinical years should concentrate most of the stu-dent's time on evaluation and treatment of specific disease processes?

1. Definitely not 4. Yes2. No 5. Definitely yes3. Undecided

10. A specialist such as an otologist, gynecologist, psychiatrist, etc., generally would be lesseffective on a. routine home call than a general practioner.

1. Strongly disagree 4. Agree2. Disagree 5. Strongly agree3. Undecided

11. Do you think that in a medical setting, the doctor should have all personnel involved inthe treatment of patients participate in case discussions regardless of their profession?

1. Almost never 4. Usually2. Not very often 5. Almost always3. Quite often

12. To what extent do you think a medical doctor in a clinical team should consult withthe team members, such as social worker, psychologist, etc., before making basic decisions in themanagement of the patient, such as discharge, referrals, or pronounced changes in therapy?

1. In none of his cases 4. In most of his cases2. In some of his cases 5. In nearly all of his cases3. In about half of his cases

13. How important do you think it is to have nonmedical specialists included on a treat-ment team in a medical setting?

1. Not important at all 4. Pretty important2. Pretty unimportant 5. Very important3. Not so important

14. The medical doctor in a clinical team consisting of psychologist, social worker, nurse,therapists, and technicians should take a decidedly directive rather than coordinating positionif treatment is to be effective.

1. Strongly disagree 4. Agree2. Disagree 5. Strongly agree3. Undecided

118

15. How important do you think it is for astate public health programs?

1. Not important at all2. Pretty unimportant3. Not so important

physician to actively participate

4. Pretty important5. Very important

in organized

16. A medical doctor is free to decide whether or not he wants to accept the opinion of aconsultant.

1. Almost never2. Seldom3. Undecided

17. In general clinical practiceenced nurse is available.

1. Disagree completely2. Disagree3. Undecided

4. Qnite often5. Almost always

a medical social worker is unnecessary provided an experi-

4. Agree for the most part5. Agree completely

18. A medical doctor should accept the opinion of a consultant without reservation.1. Never 4. Most of the time2. Seldom 5. Always3. Undecided

19. After a physician has explained the medical diagnosis and prognosis of a patient to hisrelatives he refers the family to the social worker for further discussion of their reactions to thepatient's diagnosis and illness. How good a practice do you think this is?

1. A very poor practice 4. A fairly good practice2. A somewhat poor practice 5. A very good practice3. Undecided

20. A patient's ability to pay for medical services should not influence treatment given bythe doctor.

1. Strongly agree 4. Agree2. Disagree 5. Strongly agree3. Undecided

21. Health supervision as compared with curative medicine is uninteresting and unprofit-able to the physician.

1. Definitely not 4. Yes2. No 5. Definitely yes3. Undecided

22. Hygiene, often defined as the science of health, is as much a science as internal medicineand pediatrics.

1. Disagree completely 4. Agree2. Disagree 5. Agree completely3. Undecided

23. Specific knowledge necessary for prevention of disease is so limited at this state of de-velopment that the time of a practicing physician is much better spent in curative medicine.

1. Completely disagree 4. Agree for the most part2. Disagree 5. Completely agree3. Undecided

24. For a well-rounded medical education, work in pediatrics and surgery is decidedly moreimportant than work in preventive medicine.

1. Strongly disagree 4. Agree2. Disagree 5. Strongly agree3. Undecided

119

25. Preventive medicine necessitates a degree of understanding of patient's attitude towardhealth and disease that is unusual in the current practice of medicine.

1. Completely disagree 4. Agree for the most part2. Disagree 5. Completely agree3. Undecided

26. In present day practice the demand for treatment of disease is so great that hardly anytime can be spared to concern oneself with prevention of illness.

1. Completely disagree 4. Agree for the most part2. Disagree 5. Completely agree3. Undecided

27. How important do you think it is for a physician to participate in programs of accidentprevention?

1. Not important at all 4. Pretty important2. Pretty unimportant 5. Very important3. Undecided

28. Since prevention of disease is directly related to the properties of disease itself, thereis no special reason to teach the preventive aspects in separate courses.

1. Disagree completely 4. Agree2. Disagree 5. Agree completely3. Undecided

29. There is little value in stressing principles of disease prevention as personal habits ofmost adult patients are so firmly established that the possibility of effecting more lasting change israther unlikely.

1. Disagree completely 4. Agree2. Disagree 5. Agree completely3. Undecided

30. Prevention of disease as a medical activity is primarily the responsibility of health de-partments rather than the responsibility of bedside physicians.

1. Disagree completely 4. Agree2. Disagree 5. Agree completely3. Undecided

PART III: THE R-0 SCALE

Instructions: The following are questions concerning what students think and feel about anumber of important social and personal questions. The best answer to each statement below isyour personal opinion. We have tried to cover many different and opposing points of view; youmay find yourself agreeing strongly with some of the statements, disagreeing just as stronglywith others, and perhaps uncertain about others; whether you agree or disagree with any state-ment, you ,:an be sure that many people feel the the same as you do.

Mark each statement in the left margin according to how much you agree or disagree withit. Please mark every one. Write +1, +2, +3, -2, -3 depending on how you feel in eachcase.

+1; I agree a little+2: I agree on the whole+3: I agree very much

-1: I disagree a little-2: I disagree on the whole-3: I disagree very much

+3 +2 +1 -1 -2-3 (1) It's all too true that the rich are getting richer and the poor aregetting poorer.

3 +2 +1 -1 -2 -3 (2) It is very foolish to advocate government support of religion.+3 +2 +1 -1 -2 -3 (3) This much is certain : The only way to defeat tyranny in China is

to support Chiang Kai-Shek.

120

+3 +2+1-1-2--3 (4)

+3 +2 +1 -1 -2-3 (5)

+3+2+1-1-2-3 (6)

+3+2+1-1-2-3 (7)

+3+2+1-1-2-3 (8)

+3 +2 +1-1-2-3 (9)

+3+2+1-1-2-3 (10)

+3+2+1-1-2-3 (11)

+3+2+1-1-2-3 (12)

+3 +2 +1 -1 -2-3 (13)+3 +2 +1 -1 -2 -3 (14)

+3 +2 +1 -1 -2 -3 (15)

+3 +2 +1 -1 -2 -3 (16)

+3 +2 +1 -1 -2 -3 (17)

__+.3.+2 +1-1-2-3 (18)

+3 +2 +1 -1 -2 -3 (19)

+3 +2 +1 -1 -2 -3 (20)

+3 +2 +1 -1 -2 -3 (21)

9-3 +2+1-1-2-3 (22)

+3+2+1-1-2-3 (23)

+3 +2+1-1-2-3 (24)

+3 +2 +1 -1 -2 -3 (25)

+3 +2 +1 -1 -2 -3 (26)

+3 +2 +1 -1 -2 -3 (27)

+3 +2 +1-1-2-3 (28)

+3 +2 +1-1-2-3 (29)

It's perfectly clear that the decision to execute the Rosenberg's hasdone us more harm than good.A person must be pretty short-sighted if he believes that collegeprofessors should be forced to take special loyalty oaths.It's mainly those who believe the propaganda put out by the realestate interests who are against a federal slum clearance program.Anyone who's old enough to remember the Hoover days will tellyou that it's lucky thing Hoover was never reelected.The American rearmament program is clear and positive proof thatwe are willing to sacrifice to preserve our freedom.It's mostly the noisy liberals who try to tell us that we will be betteroff under socialism.It's usually the troublemakers who talk about government owner-ship of public utilities.History clearly shows that it is the private enterprise system whichis at the root of depressions and wars.It's perfectly clear to all thinking persons that the way to solve ourfinancial problem is by soak-the-rich tax program.It's already crystal clear that the United Nations is a failure.Anyone who is really for democracy knows very well that the onlyway for America to head off revolution and civil war in backwardcountries is to send military aid.There are two kinds of people who fought Truman's fair Deal pro-gram: the selfish and the stupid.It's the radicals and the labor racketeers who yell the loudest aboutlabor's right to strike.A person must be pretty gullible if he really believes that the Com-munists have actually infiltrated into government and education.Only a misguided idealist would believe that the United States isan imperialist warmonger.Plain common sense tells you that prejudice can be removed byeducation, not legislation.It's the fellow travellers or reds who keep yelling all the time aboutCivil Rights.A person must be pretty stupid if he still believes in differencesbetween the races.A person must be very ignorant if he things that Rockefeller is goingto let the "big boys" run this country.Anyone who knows what is going on will tell you that Alger Hisswas a traitor who betrayed his country.Any person with even a brain in his head knows that it would bedangerous to let our country be run by men like General MacArthur.Thoughtful persons know that the American Legion is not reallyinterested in democracy.Only a simple-minded fool would think that Senator Joseph Mc-Carthy is a defender of American democracy.You can't help but feel sorry for those who believe that the worldcouldn't exist without the Creator.Any intelligent person can plainly see that the real reason Americais rearming is to stop aggression.The truth of the matter is this: it is big business that wants tocontinue the cold war.

121

+3+2+1-1-2-3

+3+2+1-1- -2-3

+3+2+1-1-2-3

+3+2+1-1-2-3

+3 +2+1-1-2-3

+3 +2+1-1-2-3

+3 +2+1-1-2-3

+3 +2 +1 -1 -2-3

+3+2+1-1-2-3

+3 +2 +1 -1 -2 -3

+3 +2 +1 -1 -2 -3

(30)

(31)

(32)

(33)

(34)

(35)

(36)

(37)

(38)

(39)

(40)

History will clearly show that Churchill's victory over the LabourParty in 1951 was a step forward for the British people.Even a person of average intelligence knows that to defend our-selves against aggression we should wc._:.:ome helpincluding FrancoSpain.It's the agitators and left-wingers who are trying to get Red Chinainto the United Nations.It's simply incredible that anyone should believe that socializedmedicine will actually help solve our health problems.It's the people who believe everything they read in the papers whoare convinced that Russia is pursuing a ruthless policy of aggression.It's mostly those who are itching for a fight who want a universalmilitary training law.It's perfectly clear to all decent Americans that congressional com-mittees which investigate communism do more good than harm.It's just plain stupid to say that it was Franklin Roosevelt who gotus in the war.A study of American history clearly shows that it is the Americanbusinessman who hay contributed most to our society.It is foolish to think that the Democratic Party is really the partyof the common man.Make no mistake about it! The best way to achieve security is forthe government to guarantee jobs for all.

PART IV: THE PSHO-OAP SCALE

Instructions: In the following series of questions we are interested in your opinion aboutpoor people in general. We are interested in your own personal opinion therefore there areno "right" or "wrong" answers. Please indicate how you feel about each statement by decidingif you agree or disagree, and the strength of your opinion. Then circle the appropriate numberin front of the statement in the following fashion:

+3: Strongly agree 1: Slightly disagree+2: Moderately agree 2: Moderately disagree+1: Slightly agree 3: Strongly disagree0: Uncertain

Many of the statements may seem absurd and impossible to answer by simply noting howstrongly you agree or disagree. Nevertheless, answer every item even if you must guess atsome. Keep in mind that the questions concern the URBAN POOR in general and not any spe-cific minority group.

+3+2+1 0 1-2-3+3+2+1 0 1-2-3

+3+2+1 0 1-2-3

+3+2+1 0 1-2-3

+3+2+1 0 1-2-3+3+2+1 0 1-2-3

+3+2+1 0 1-2-3

122

(1) Most poor people are poor because they are lazy.(2) There is little antagonism or conflict between poor parents and

their children.(3) The poor are greatly concerned with gaining social status and

prestige.(4) Children in poor families are expected to obey parental authority

immediately.Wives of the poor frequently face the threat of desertion.The poor generally resist innovation in preference for traditionalways of doing things.The poor would rather learn things from books than from otherpeople.

(5)(6)

(7)

+3+2+1 0 1-2-3 (8)

+3+2+1 0 1-2-3 (9)

+3+2+1 0 1-2-3 (10)

+3+2+1 0 1-2-3 (11)

+3+2+1 0 1-2-3 (12)+3+2+1 0 1-2-3 (13)

+3+2+1 0 1-2-3 (14)+3+2+1 0 1-2-3 (15)

+3+2+1 0 1-2-3 (16)+3+2+1 0 1-2-3 (17)

+3+2+1 0 1-2-3 (18)

+3+2+1 0 1 -2 -3 (19)

+3+2+1 0 1-2-3 (20)

+3+2+1 0 1-2-3 (21)

+3+2+1 0 1-2-3 (22)

+3+2+1 0 1-2-3 (23)+3+2+1 0 1-2-3 (24)+3+2+1 0 1-2-3 (25)

+3+2+1 0 1-2-3 (26)

+3+2+1 0 1-2-3 (27)+3+2+1 0 1-2-3 (28)

+3+2+1 0 1-2-3 (29)

+3+2+1 0 1-2-3 (30)

+3+2+1 0 1-2-3 (31)

+3+2+1 0 1-2-3 (32)

+3+2+1 0 1-2-3 (33)

+3+2+1 0 1 -2-3 (34)

+3+2+1 0 1-2-3 (35)

While desiring a good standard of living, the poor are not at-tracted to a middle class style of life.Most poor families are dominantly concerned with "getting by"rather than "getting ahead."The poor are compensated for their poverty by enjoying a moresensual life.The poor usually find it difficult to have informal, comfortablerelationships with other persons.The poor are not readily open to reason.The poor are not class conscious, although aware of class differ-ences.The poor usually read very little and ineffectively.In poor families there is a great deal of family discord and inter-personal conflict.The poor generally think of intellectuals as "egg-heads."Generally the poor have a considerable interest in encouraging acollege education for their children.The poor prefer passive entertainment such as movies to activeentertainment such as parties and dances.The poor are able to build abstractions, but it is done in a slow,physical fashion.The poor are usually not interested in planning for long-termgoals, but rather prefer immediate gratification of needs.One of the major problems of the poor is unemployment and thethreat of layoff.The poor generally judge a political candidate on the basis of per-sonality rather than on qualifications or platform.The poor family is frequently "child-centered."The poor are largely uninterested in politics.The poor prefer abstract planning to direct, concrete action inattaining goals.The grandparents, uncles, aunts and cousins of the poor usuallymaintain close family ties.The poor view most political leaders as compt "bigshots."The poor prefer voluntary associations to be loosely organized tothose with more structure.In poor families the husband is generally not the dominant author-ity figure.The poor are quite well informed about most social and politicalissues.The poor prefer strong, directive leadership to that of nondirec-tive leadership.The poor generally have sufficient contact with most social insti-tutions such as the school.Humor among the poor often takes the form of physical acts suchas "horseplay."The duties of husbands and wives are not sharply differentiatedin poor families.Usually the poor will accept jobs that provide moderate economicsecurity as opposed to those involving risk but the possibility ofhigh monetary return.

123

+3+2+1 0 1-2,3 (36) Most poor people believe that the "insanity plea" is not a legiti-mate defense in a criminal trial.

+3+2+1 0 1-2-3 (37) The poor usually hold flexible opinions.+3+2+1 0 1-2-3 (38) The outstanding weakness of the poor is a lack of education.+3+2+1 0 1-2-3 (39) The poor rarely have firm convictions about such issues as re-

ligion, morality and custom.+34-2+1 0 1-2-3 (40) Physical punishment is the basic disciplinary technique for the

children of the poor.+3+2+1 0 1-2-3 (41) Most poor people are not willing to work even if given the oppor-

tunity.+3+2+1 0 1-2-3 (42) The poor are an outgoing, friendly and amiable people.+3+244 0 1-2-3 (43) The poor rarely rely on such facilities as bank?, hospitals and

department stores.+3+2+1 0 1-2-3 (44) There is a considerable amount of preoccupation with sex among

the poor.+3+2+1 0 1-2--3 (45) The wives of the poor generally accept a tradtionally submissive

role in relation to their husband.+3+2+1 0 1-2-3 (46) Mothers in poor families tend to deprive their children of ma-

tternal affection.+3+2+1 0 1-2-3 (47) Even the poor who show initiative and industry are prevented

from improving their lot by overwhelming circumstances.+3 +2 +1 0 1-2-3 (48) Most poor people are concerned with the future rather than the

present "here and now."+3+24 1 0 1-2-3 (49) There is a high incidence of common-law marriages among the

poor.+3+2 , 1 0 1-2-3 (50) The poor tend to be narrow-minded and self centered.+3+2+1 0 1-2-3 (51) The poor are generally isolated and withdrawn from their own

community.+3+2+1 0 1-2-3 (52) The poor have a low level of literacy.+3+2+1 0 1-2-3 (53) Children of the poor generally do not have long protected child-

hoods.+3+2+1 0 1-2-3 (54) In most poor areas there is an absence of local community spirit.+3+2+1 0 1-2-3 (55) There is a good deal of metaphor and analogy used in the language

of the poor.+3+2+1 0 1--2-3 (56) The poor are not easily capable of kindness, generosity and com-

passion.4 3+2+1 0 3 (57) The poor are tough people who cope with problems that would

overwhelm many middle class individuals.+3+2+1 0 1-2-3 (58) The poor tend to be provincial and ethnocentric.+3+2+1 0 1-2-3 (59) Children of the poor are initiated into sex late in life.+3+2+1 0 1-2-3 (60) The poor are members of few social organizations beyond that

of the family.+3+2+1 0 1-2-3 (61) The poor live in areas in which there are numerous murderers,

drug addicts, thieves and prostitues.+3+2+1 0 1-2-3 (62) The poor are quite impulsive in their behavior.+3+2+1 0 1-2-3 (63) The poor usually belong to numerous voluntary associations.+3+2+1 0 1-2-3 (64) Most poor persons consider poverty to be their fate.

(65) Most poor persons have a feeling of helplessness, dependency and+3+2+1 0 1-2-3 inferiority.+3+2+1 0 1-2-3 (66) The poor have a basic distrust of the police.+3+2+1 0 1-2-3 (67) The language used by the poor is simple, direct and earthy.

124

+3+2+10 1-2-3 (68) The poor are aware of middle class values and try to live by them.+3+2+1 0 1-2-3 (69) There is a high incidence of illegitimate children among the poor.+3+2+1 0 1-2--3 (70) The poor show a need for excitement, new experence and adven-

ture.

PART V: THE SMA SCALE

Instructions: This is a study of what medical students and people in general think about anumber of social and medical questions. The best answer to each statement below is your per-sonal opinion.

Please indicate your response to the following statements using these alternatives:+2: Strongly agree 1: Disagree+1: Agree 2: Strongly disagree

0: UndecidedThe quality of medical care under the system of private practice issuperior to that under a system of socialized medicine.Socialized medicine will produce a healthier and more productive popu-lation.Under the socialized medicine there would be less incentive for youngmen to become doctors.Socialized medicine is necessary because it brings the greatest good tothe greatest number of people.Treatment under socialized medicine would be meclmnical and super-ficial.Socialized medicine would be realization of one of the true aims of ademocracy.Socialized medicine would upset the traditional relationship between thefamily doctor and the patient.I feel that I would get better care from a doctor whom I am paying thanfrom a doctor who is being paid by the government.Despite many practical objections, I feel that socialized medicine is areal need of the American people.Socialized medicine could be administered quite efficiently if the doctorswould cooperate.There is no reason why the traditional relationship between doctors andpatient cannot be continued under socialized medicine.If socialized medicine were enacted, politicians would have control overdoctors.The present system of private medical practice is the one best adaptedto the liberal philosophy of democracy.There is no reason why doctors should not be able to work just as wellunder socialized medicine as they do now.More and better care will be obtained under socialized medicine.The atmosphere of socialized medicine would destroy the initiative andthe ambition of young doctors.Politicians are trying to force socialized medicine upon the people with-out giving them the true facts.Administrative costs under socialized medicine would be exorbitant.Red tape and bureaucratic problems would make socialized medicinegrossly inefficient.Any system of socialized medicine would invade the privacy of the indi-vidual.

+2+1 0 1-2 (1)

+2+1 U 1-2 (2)

+2,-1 0 1-2 (3)

+2+1 0 1-2 (4)

+2+1 0 1-2 (5)

+2+1 0 1-2 (6)

+2+1 0 1-2 (7)

+2+1 0 1-2 (8)

+2+1 0 1-2 (9)

+2+1 0 1-2 (10)

+2+1 0 1 -2 (11)

+2+1 0 1-2 (12)

+2+1 0 1-2 (13)

+2+1 0 1-2 (14)

+2+1 0 1-2 (15)+2+1 0 1-2 (16)

+2+1 0 1-2 (17)

+2+1 0 1-2 (18)+2+1 0 1-2 (19)

+2+1 0 1-2 (20)

125

t le". Iry , V 1, MCI CI Clr pin I.litstructions: This last series of questions survey students opinion on the issue of segrega-

tion. Please indicate your response to the statements using these alternatives:+3: Strongly agree 1: Slightly disagree+2: Moderately agree 2: Moderately disagree+ 1: Slightly agree 3: Strongly disagree

+3+2+1-1-2-3 ,(1) Racial segregation is an effective and practical social arrangementwhich has no serious effect on the vitality of democratic ideals.

+3-4-9+1-1-2-3 (2) The Negroes' main concern is with equal educational opportunities.They have no intention of interferring with the social patterns of thewhite community.The best safeguard of a democracy is the solid stability of social tradi-tion such as is involved in the maintenance of segregation.Integration threatens one of the principles of democracy, the right ofeach citizen to choose his own associates.The end of segregation would bring a continuing increase in social con-flict and violence.Although the IQ of Negroes in the South is on the whole lower thanthe IQ of whites, this difference in intelligence is mainly due to lackof opportunity for the Negro and will eventually disappear under anintegrated school system.Since integration will require some painful adjustments to be madein changing from segregated schools, the best solution will be to leavethe races segregated.Equal educational exposures in integrated schools will help both theNegro and white students to profit from the best of two cultures.Desegregation can in most cases be accomplished without being fol-lowed by social conflict and violence.Improving Negro education via integregation will lead to a higherstandard of living in the South accompanied by more and better jobsfor everybody.The Supreme Court's decision on segregation was a politically inspiredinvasion of states' rights and represents a miscarriage of justice.The Negro race is physically and mentally inferior to the white raceand integregation would not help to erase the innate differences betweenthe two races.Integregated and therefore better education for the Negro via integra-tion is certain to result in increased feelings of responsibility and co-operation in his part.The successes of already completed integration attempts are clear evi-dence that the fears of extreme pro-segregationists are unfounded.Negroes who are given the opportunity to go to integrated schools areapt to become demanding, officious and overbearing.Although certain radical Negro leaders try to make people think other-wise, the majority of Negroes do not want integration and would besatisfied with "equal but separate" school facilities.Desegmtion will develop a false sense of power among Negroes and willmove us closer to having a "Negro party" in America.The South has failed to adequately draw upon the resources of theNegro race and integrated schools will enable the Negro to make agreater contribution to the South economically and socially than theyhave been able to make with segregated schools.

+3+2+1-1-2--3

+3+2+1-1-2-3

+3+2+1.-1-2-3

+ 3 +2 +1-1 2-3

4 3+2 4. 1_1_2_3

+3+2 4-1-1-2-3

+3 +2 +1 -1 -2 -3

+3+2+1-1-2-3

+3+2+1-1-2-3

4 3 4 2 + 1-1-2-3

+3 +2+1 -1 -2-3

+3 +2 +1 -1 -2-3

+3+2+1-1-2-3

+3+2+-1 I 2-3_

+3 +2 +1 -1 -2-3

+3+2+1-1-2-3

126

+3+2+1-1-2-3

+3+2+1-1-2-3

+3+2+1-1-2-3

+3+2+1-1-2 3

+3+2+1-1-2--3

+3+2+1-1-2-3

+3+2+1-1-2-3

(19) Once you start letting Negroes attend the schools of whites they willdemand complete social equality in all respects including dating andclub privileges.

(20) The desegregation law is basically unfair to the Negroes who will nowhave to compete on equal terms with the whites.

(21) Negroes and whites will find it i.asier to get along together in the sameschool than most people think.

(22) In dealing with the problems of desegr.gation we should always act interms of the Christian rule of brotherhood and justice for all and notin terms of social attitudes based on tradition.

(23) The practice of segregation cannot help but reduce our political influ-ence in international affairs.

(24) Desegregation will lead to a permanent lowering of standards in thepublic schools.

(25) Desegregation is economically wise since the South's poor economicstate may in part be due to the double expense of segregation.

APPENDIX 4

Guidelines for Problem and Community Papers

MEMO TO: PRECEPTORS AND PROJECT WORKERS INVOLVED IN GROUP WORK,TEACHING CLASSES, LEADING RECREATION, AND OTHER KINDS OFACTIVITIES WITH COMMUNITIES AND ORGANIZATIONS.

FROM: KAREN LYNCH

SUBJECT: PROBLEM PAPERS (YELLOW GUIDELINES 1)You should present your activities of the summer from several points of view. I would like

you to focus on the problems and conflicts yov have encountered in working with your groupor community.

You'll probably make the greatest impact by describing specific problems as,,c1 specific ex-amples of the things which have happened this summer. Focusing on problems and conflictswill highlight the critical issues you've encountered. These may appear to be "personality prob-lems," or misunderstandings between you and community people or you and health producers.Examine these problems from the point of view of the process of getting services to people.

These guidelines may help in thinking about your activities:1. Groups. If you've been in contact with groups of peoplethrough recreation programs,

se,, education classes, group therapy, day camp, psychiatric followup, or other similar ac-tivitydescribe your activities with these groups, your intentions or plans for the groupsand the development of these activities. Speak in examples including time, names, andidentifying information.

2. Health problems. If you have come across health problems, become involved with at-tempts to meet health needs, discovered gaps in information about health services, or mis-informed attitudes, describe these problems in detail and your attempts to deal with them.

3. Resources. If you have become aware of resources at your sitepeople, experience, orga-nizations, placeswhich can be effectively utilized in the delivery of health services,describe these, how you found them, and what potential they offer.

The most vivid and striking approach to this is by presenting one incident or project activ-ity. This incident should point out a problem in the health care system or in community's re-sponse to health issues. It should show how you decided to deal with it, what help, difficulty, or

127

indifference you received from the medical "establishment," and what help, difficulty, or indiffer-ence you encountered from communities. Be as specific as possible in your descriptions andanalysis.

RETURN THE PROBLEM PAPER TO KAREN LYNCH. SHO OFFICE, BY AUGUST 14,1968

MEMO TO: PRECEPTORS AND PROJECT WORKERS INVOLVED IN THE DEVELOP-MENT OF SERVICES, COMMUNITY ORGANIZING, PLANNING WITH COM-MUNITIES, ACTING ON SURVEY FINDINGS.

FROM: KAREN LYNCH

SUBJECT: PROBLEM PAPERS (YELLOW GUIDELINE 2)

1. What is the central issue you've worked on this summer?2. Why is this an issue, who identified it, and who wanted action on it?3. Describe what you've been doing this summer, focusing on the problems and conflicts

you have encountered. You may want to include a chronology of activities, includingnames, titles, and ways of contacting people of the community and of the "establishment."

Include a description of how the medical establishment (or nonhealth establishment)related to your summer's activitiesthe cooperation, conflicts, and problems you encoun-tered with them and how you dealt with them. Describe specific incidents.Include a descr;ption of the way health consumers, community, patients, clients re-

lated to your activities. Were they resposive, hostile, cooperative? How did you deal withtheir reactions. Describe specific incidents.

RETURN THE PROBLEM PAPER TO KAREN LYNCH, SHO OFFICE, BY AUGUST 14,1968

MEMO TO: PROJECT WORKERS INVOLVED IN SURVEY WORK AND STUDIES PRE-CEPTORS.

FROM: KAREN LYNCH

SUBJECT: PROBLEM PAPERS (YELLOW GUIDELINE 3)

1. Why did you undertake the survey or study? What, in other words, is the rationale, justi-fication, or purpose of the survey or study?

2. What is the intended use of your survey or study? Who, what group, is involved?3. Who asked that it be done? Who supervises or has overall responsibility for it?4. How did you go about setting up your survey or study? Describe the planning and who

was involved, the design of the study, sampling procedures, development of survey, andso on. Tell as much as you can about the problems of developing the study and working upthe findings.

5. Did you follow through and use the instrumentsurvey? Did you present (or are youpresenting) a report? To whom?

6. Did you encounter hostile or cooperative responses by those interviewed or studied? Doesthis tell you anything about the attitudes of your population?

7. What are the descriptive findings of the survey or study?8. What were your results in terms of problems to deal with and action on findings?If you have presented a report to your site or anyone else, please enclose a copy of that

with your problem paper.If you acted on survey findings or undertook the development cf services, use one of the yel-

low guidelines for presenting those activities. If those guidelines are inappropriate, go aheadand explain in your own terms what happened after the survey or study was completed.

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RETURN THE PROBLEM PAPER TO KAREN LYNCH, SHO OFFICE, BY AUGUST 14,1968

MEMO TO: PROJECT WORKERS IN COMMUNITIES

FROM: KAREN LYNCH

COMMUNITY PAPERS (GREEN GUIDELINE)

You know the local community where you are working this summer. Others concerned withthe delivery of health services don't know your community. I would like you to use the questionson this green page as a guideline for writing a description of the local community you are work-ing in.

This description of the local community should be written with the cooperation and ap-proval of your preceptor and organization. Nothing should be included which you or your com-munity would find objectionable. The purpose of these questions is to provide Philadelphia SHOand others interested in getting health care to local communities with information about yourcommunity so that they will be a better informed position in planning their programs with localcommunities.

1. How is your community defined? Indicate geographical boundaries and characteristics ofthe people and the area which are important. (Keep this description relevant, but brief.)

2. What services are provided your community and how adequate are these services? Someof the services you may wish to comment on are transportation system, shopping, schools,rubbish and trash collection, police protection, and recreation.

3. More specifically, what is the condition of the health care system in your community?What services are known and not known? What is the response of the community topresent services.

4. What major community health problems have you encountered this summer?5. Has the community been involved with health planning? Describe experiences you have

been involved with and experiences you have heard about.6. From your experience in the community, if you want to get things done, how do you go

about it? If you have a plan or a grievance, for example, how do you go about acting onit in your community?

As I mentioned above, these are only guidelines for presenting your community in such away that those who haven't had the experience of working with it will have some idea of yourcommunity and health services. I suggest that you keep the paper brief but accurate.

RETURN THE PROBLEM PAPER TO KAREN LYNCH, SHO OFFICE, BY AUGUST 14,1968

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APPENDIX 5

Personal Contacts

PHILADELPHIA STUDENT HEALTH ORGANIZATIONPERSONAL CONTACTS SHEET Contactor

State DateTime : Begin_ End

1. NAME OF CONTACT

RMaleFemalePuerto Rican

O Negro0 White

AgeLast year of school completedATUS OF PERSON CONTACTED

O Community workerO Community leaderO Health professional

Nonhealth professional0 Medical technician0 City government officialO Other SHO workerO Other

3. CONTACT SITUATIONO Person contacted by phone

Person contacted in personO Person contacted individuallyO Size of group

Names of others contacted in group

0 First contact with personO Contactor initiated meeting

Contact initiated meetingO Other initiated meeting

4. CIRCUMSTANCES OF CONTACTPlace of Contact

O Home of contactO Community health centerO Welfare AgencyO On the street

HospitalO Other

0 Contact was intentionally plannedContact was part of some other activity

n There will be follow-up contact with thisperson

O There will not be follow-up contact withthis person

5. PURPOSE OF CONTACTO Investigate housing conditionsO Self education

Self educationO Resource for further workn Patient advocacy

ReferralsO Providing medical servicesO Other

6. DESCRIBE BRIEFLY WHAT ACTIONWAS TAKEN

7. EVALUATION OF CONTACTThe person contacted seemed to be satisfied 5 4 3 2 1 unsatisfied with the contact.The person contacted seemed to be interested 5 4 3 2 1 disinterested in the contact.The person contacted seemed to be cooperative 5 4 3 2 1 uncooperative in the contact.The person contacted seemed to feel that the contact was a success 5 4 3 2 1 a failure.I think that the contact was a success 5 4 3 2 1 a failure.

8. If possible, please state the results of the contact in terms of special accomplishments

9. Additional comments :

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Contact Sheets as a Research Technique

The purpose of asking project workers atSpring Garden Community center and St.Christcpher's Child and Comprehensive CareCenter to report on their personal contactswas to experiment with a reporting methodwhich might provide unique and previouslyuntapped data regarding the deficiencies ofthe health care system and to help develop anevaluational technique for future SHO researchprojects. The "personal contact sheet" has vari-ous merits and demerits in this regard.

Probably the most suitable usage of thechecklist would be for students to complete iton an individual basis, over the course of thesummer, and use it as a reference to write. anend-of-summer report. In this sense the con-tact report sheets are an adequate, quickly com-pleted format by which students can makedaily logs of their activities and use them as apersonal record for a final report. The contactsheets do not seem suitable for the method usedin this researchthat is, as a report to a cen-tral research unit. The central unit is too dis-tant from the daily activities to make a valu-able report on health system deficiencies. Ifin the case of the present research, each proj-ect worker had utilized his own contact sheetsas a reference to write a report on the healthsystem, it would have been for more factual,informative, specific, detailed and readable than

the attempt by a removed person to integrateand summarize a second party's summer workactivities. For example, had the health sciencestudent at St. Christopher's used his own con-tact sheets in regard to attracting teenagegangs to sex education classes, he would be ableto present a more expressive and sensitive ac-count than can a researcher who is uninvolvedwith the activity first hand.

The "contact report sheet" then seems to bemost applicable as a personal accounting formfor use by the individual project workers.Should this form be used in future research,it should be modified to a certain extent andstudents should be thoroughly briefed on itspurpose. The modifications should expand thesections on purpose of contact, action takenand accomplishments of contact. An effortshould be made to encourage a more elaboratereporting on these items ; otherwise, the re-maining data have no relevance. This mightbe accomplished by encouraging students tomake more detailed notes rather than attempt-ing to develop additional questions.

Also, any future use of this form should askfor the occupation of the person contacted andhis title, and the specific name of the agencyor organization for which the person contactedworks. As a reporting technique to a centralresearcher, however, its usage is not recommended.

APPENDIX 6

Project List: Project Sites and Participants

Black SummerPreceptor: Lee Montgomery, Office of Urban Affairs,

Temple University.Project workers: Mike Roth (HSS), Bob Sussman

(HSS).Area coordinator: Paul Fernhoff.

CEPAConsumer's Education and ProtectiveAssociation

Preceptor: Max Weiner, 6048 OgontzProject workers: Clarissa Cain (CW);

sey (CW), Jane Friedman (HSS),(HSS).

Area coordinator: Paul. Fernhoff.Citizen Concerned for Welfare

Preceptor: Leona Thomas, 741 North

Avenue.Garland Demp-Steve Marder

RightsPreston Street.

Project workers: Kathryne Dunbar (CW), DorothyFederman (HSS), Ida Floyd (CW).

Area coordinator: Jay Federman.Delaware County Health and Welfare (Citizens for

Better Public Health)Preceptor: Peter Brigham.Project workers: Jan Baxt (HSS), Sheldon Halpern

(HSS).Area coordinator: Dick Devereux.

Eagleville HospitalPreceptor: Donald Ottenberg, M.D., Eagleville Hospital

and Rehabilitation Center, Eagleville, Pa.Project workers: Debbie Finkelstein (HSS), Darryl

Robbins (HSS).Area coordinator: Paul Fernhoff.

131

Eastwicic Community OrganizationPreceptors: Regina Eichinger, 8508 Harley Avenue;

Joan Baker, 2816 South 81st Street.Project workers: Andrea Benn (YI), Clark Bird (YI),

Renee Edwards (YI), Eileen Fair (HSS), PaulFrame (HSS), Bill Woods (HSS).

Area coordinator: Dick Devereux.

Experiment in Community ActionProject worker: Lucia Siegel (HSS).

Fairmont Community CouncilPreceptor: Marion Hilliard, 3956 Pennsgrove Street.Project workers: Frank Ferri (HSS), Steve Fox

(HSS), Nathan Smith (YI).Area coordinator: Jay Federman.

Fishtown Civic AssociationProject worker: Bill Halperin (HSS).Area coordinator: Cleve Dawson.

Gray's FerryPreceptor: Velva Taylor, 1337 South 28th Street.Project workers: Rich &mann° (HSS), Rhoda Hal-

perin (HSS), Francine Lewis (CW).Area coordinator: Paul Fernhoff.

Haddington HomesPreceptor: Mary Voughn, 5448 Aspen Place.Project workers: Keith Hansen (HSS), Mary Rich

(CW).Area coordinator: Jay Federman.

H artran f t Community CorporationPreceptor: Hector Rodrigues, 3257 Germantown Ave-

nue.Project workers: Yvonne Butterfield (HSS), Charles

Cook (YI), David Eisenberg (HSS), Natline Thorn-ton (CW), Van Williams (CW), Heidi Wolf (HSS).

Area coordinator: Cleve Dawson.

Hawthorne Community CenterPreceptors: Charles Floyd, 5215 Spruce Street; Caryl

Heimer, M.D., 235 South Third Street; JeffersonC & Y, 1332 Fitzwater Street; Hawthorne Commu-nity Center.

Project workers: Susan Oster (HSS), Don Sesso(HSS), Nate Williams (CW).

Area coordinator: Mary Lou Evitts.

Holmesburg PrisonPreceptor: Norman Jablon, M.D., Holmesburg Prison,

Torresdale Avenue.Project workers: Alan Cohler (HSS), Lawrence Kron

(HSS).Area coordinator: Paul Fernhoff.

Horizon HousePreceptors: Armin Loeb, M.D., Research Director, 1825

Pine Street; Audrie Russell, Director of Case Work-ers, 1823 Pine Street; Lee Booth, Director of Resi-dence, 504-6 South 42d Street.

Project workers: Steve Ager (HSS), Jim Padget(HSS).

Area coordinator: Mary Lou Evitts.

132

Jefferson Community Mental HealthPrecepi,or: Jerry

Walnut Street;eral Hospital.

Project workers:(HSS).

Area coordinator: Mary Lou Evitts.

Ludlow Community Association

Preceptor: Marvin Lewis, 1233 North Franklin Street.Project workers: Darlene Bredell (YI), Gustine Bre-

dell (CW), Jerry Braverman (HSS), Carol Dinker-lacker (HSS), Peter Eisenberg (HSS), RichardLockett (HSS), Denise Smith tYI), Brenda Wil-liams (CW).

Area coordinator: Cleve Dawson.

Mantua Community PlannersPreceptors: Forrest Adams; John Ciccone; MCP Work-

shop, 3625 Wallace Street.Project workers: Phil Graitcer (HSS), Frank Hart

(YI), Ken Logan (HSS), William Roundtree (CW).Areea coordinator: Jay Federman.

Mill CreekPreceptor: Onna Parker, 709 June Court.Project Worker: Claudia Mills (YI), David Stewart

(HSS).Area coordinator: Jay Federman.

Misericordia HospitalPreceptors: Henry Hunter, Department of Public Re-

lations, 54th and Cedar Avenue; Dr. Lynch, Depart-ment of OB GYN, 54th & Cedar Avenue; Dr. Hesch,Outpatient Department, 54th & Cedar Avenue.

Project workers: Gwendolyn Anthony (CW), RichardBremer (HSS), Dan Brzusek (Has), Willie MaeHarris (CW), Leonore Lee (CW), Susan Skulnick(HSS), Bettina Stronach (HSS).

Area coordinator: Dick Devereux.

North City CongressPreceptors: Alvin E. Nichols, Director; Steve Turner,

Mr. Cameron, Tony Lewis, 1428 North Broad Street.Project workers: Meredith Hand (HSS), Stanley Rey-

nolds (HSS).Area coordinator: Cleve Dawson.

Jacobs, Junto Building, 12th andJohn Mock, M.D., Philadelphia Gen-

Mike Geha (HSS), Payle Jones

Ogden Civic AssociationPreceptor: Mamie Weaver, 4117 Ogden Street.Project workers: Martha Arey (HSS), Alma McEl-

roy (YI).Area coordinator: Jay Federman.Preceptors: Mike Simmons, 3702 Spring Garden

Street; Lou Ellen Williams, 7235 Paschall Avenue;Rhoda Houston, 7225 Greenway Avenue.

Project workers: Lawrence Budner (HSS), Renel Bur-den (YI), Dudley Goetz' (HSS), Chris White (YI).

Area coordinator: Dick Devereux.Pernet Family Health Service (Little Sisters of the

Assumption)Preceptors: Sister Rita, Sister Marguerite, 1001 South

47th Street.

Project worker: Joan Gomes (HSS).Area coordinator: Dick Devereux.

Presbyterian HospitalPreceptor: Neville R. Vines, 51 North 39th Street.Project workers: Frank Greer (HSS), Ghrnette Hicks

(CW), Jerry Lozner (iISS), Wilbelmina Searnon(CW).

Area coordinator: Jay Federman.Southwest Center City Community Council (SWCC)Preceptor: Joseph Cooper, 1132 Catherine Street.Project workers: Isma Jackson (CW), Carla Oswald

(HSS), Ed Pisko (HSS).Area coordinator: Mary Lou Evitts.

Spring GardenPreceptor: Pat Story, M.D., 1,812 Green Street.Project workers: Anita Costa (HSS), Tom Fiss

(HSS), Walley Pillich (YI), William Smith (YI).Areea coordinator: Paul Fernhoff.

Spruce Hill Community AssociationPreceptor: David E. Boyce, Department of City and

Regional Planning, University of Pennsylvania, 4428Pine Street.

Project workers: Stephen Terzian (HSS).Area coordinator: Dick Devereux.

St. Christopher's Child and Youth ComprehensiveCare Center

Preceptor: Evelyn B. Wilson, Director; Nina Perry,Mrs. Kennedy.

Project workers: Dick Bagge (HSS), Forrest Lange(HSS), Richard Morrison (YI), Hetherwich Ntaba(HSS).

Area coordinator: Cleve Dawson.Temple Community Mental Health Center

Preceptors: Stanton B. Fetzer, Ph.D., Assistant Di-rector; Alvin Thomas, Director, Community Organiza-

tion, 1531 West Tioga Street.Project workers: Bess Aronian (HSS), Philip Herber(HSS), Anne Sheehan (HSS).Area coordinator: Cleve Dawson.

University SettlementsPreceptors: Jerry Gardner, Mike Norris, 2601 Lombard

Street.

Project workers: Art Pressman (HSS), Bill Robinson(HSS).

Area coordinator: Mary Lou Evitts.

Welfare Rights OrganizationPreceptor: Roxanne Jones, 1520 Green Street; 1021

South Fourth Street.Project workers: Marpha Crafton (Y1), Shirley

Fischer (HSS), Gene Shatz (HSS), John Zonano(HSS), Jean Wilkerson (YI).

Area coordinator: Dick Devereux.West P delphia Community Mental Health

Consortium1. Trouble Clinic.Preceptors: Jacob Schuts, M.D.; Gordon Podenaky,

5001 Woodlr.iad Avenue.Project workers: Bart Butte (HSS), Robert Lewy

(HSS).Area coordinator: Dick Devereux.11. Recreation Project.Preceptor: Christine Westfall, PGH.Project workers: Richard Bernstein (HSS), Harry

Hirsh (HHS), Lucia Sosnowaki (11SS).Area coordinator: Dick Devereux.

Young Great SocietyPreceptors: Lillian Johnson; William Spotwood, 603

North 33d Street.Project workers: Ivan Cohen (HSS), Thomas Devlin(HSS), Freida Far low (CW), Patricia Ford (YI).Area coordinator: Jay Federman.

Project StaffDirector: Robert L. Leopold, M.D.Student directors: Chip Smith, Ron Blum, Elaine

Haagen.Research directors: Karen Lynch, Jon Snodgrass.Area coordinators: Cleve Dawson, Dick Devereux,

Mary Lou Evitts, Jay Federman, Paul Fernhoff.Secretaries: Carrolyn Morgan, Rita Bo ler, Edith Barn-

hill.Advisory council: Walter J. Lear, M.D., Sue Leslie;

Jim Shelton; William A. Steiger, M.D.

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Public Health Service

Philadelphia Student Health ProjectSummer 1968

GOVERNMENT PRINTING OFFICE: 1989 0-355-229

133