THE HOUSES OF HEALTH

...This was the period when the availability of hospitals became increasingly important in the treatment of patients...

...On the other hand, the hospital values this subvention very much because it represents useful seed money for the development and support of new and experimental programs...

...Thus, for example: The Sinai Hospital of Detroit has an operating budget this year of approximately $50 million...

...And, so long as Federation dollars are used — as they typically are — to help meet the general operating deficit of the hospital, the critics have a point...

...When the Beth Israel Hospital in Boston organized a social service department, it was very quickly recognized (in the 1930's) as one of the leading departments in the nation, and it made crucial methodological contributions in the teaching of medical students...

...And, if they do, should Federations insist that research programs in such areas be given priority by Jewish hospitals...

...if so, to what extent they do...

...a number of important arguments that can be mustered in defense of Jewish hospitals...

...The fraction ranges from a low of .3 percent (Detroit's Sinai) to a high of 2.4 percent (Baltimore's Sinai...

...Is this the case with Jewish hospitals, or is there a more convincing defense of their status, of the continuing propriety of investing large sums of Jewish money in them...

...Or are there no particular Jewish needs in the field of health...

...Jewish hospitals were dependent upon contributions from the Jewish community for a large and significant portion of their operating budget...

...This has changed quite dramatically over the past decade or so...

...Jewish life and Jewish law have much to say about medical ethics...

...How can it be, the critics ask, that the Jewish community will pay so large a portion of its budget to meet so small a portion of the hospital budget...

...How many do...

...There is no question at all that Jewish hospitals today have a meaningful mission...

...The real answer is that Jewish dollars could, and should, be used for the subvention of specific services which are quite important, as important in our own day as earlier justifications were decades ago...

...Yet, of course, these are critical dollars for the Federation...

...At the same time, not all Jewish physicians seek — or ever sought — affiliation with the Jewish hospitals of their communities...

...At the present time, the debate is about other things...

...So say the critics...

...In this effort, the general understanding and support provided by the medical staff and the Board of Trustees to the professional leadership of the Social Service Department have been central...

...More commonly, two kitchens are maintained, the kosher kitchen serving only those who request kosher food...

...There nave been, typically, three kinds of answers: 1. Jewish immigrants and the Jewish poor needed medical care, and the Jewish community felt an obligation to "look after its own...

...In these efforts — the need for which has now increased, as we have come to appreciate the importance of integrated services — Jewish hospitals have frequently done pioneering work...

...It is true, of course, that discrimination against Jewish physicians by hospitals was a very prominent feature of American and Canadian medicine in the first half of the 20th century...

...It is generally recognized in the health professions that Jewish hospitals are among the best in the nation...

...Jewish efforts in the health field in the United States began in the 19th century, during the first period of mass Jewish immigration (1848...

...And if those dollars are designated to support specific activities, then we will, a generation from now, have a new way of understanding the Jewishness of Jewish hospitals...

...Jewish hospitals have made outstanding contributions to the development of new, more efficient and more comprehensive health services...

...The aggregate budget of the general hospitals sponsored by Jewish communities across the land is almost surely more than $1 billion...

...But the good will that is the offshoot of our endeavor should not be ignored...

...In the 1940's and early 1950's there were instances, not uncommon, where the Federation contribution constituted as much as 20 percent or more of the total resources available for operating expenditures...

...Thus, for example, only about half of Detroit's (estimated) 600 Jewish physicians are affiliated with that community's Sinai...

...It has now emerged as a subject of more active discussion, this for a variety of reasons...

...Tts new site was then remote from most of the Jewish population, but it was very close to, and was selected to facilitate an affiliation with, the Harvard Medical School...

...There are now more than 4.000 graduates of the Harvard Medical School, many in key positions in American life, who have, as part of their background, a positive experience with Jewish philanthropy, with Jewish concern for the poor, for excellence, for humanity...

...2. The distinctive religious and ethnic background of the Jews created distinctive needs, such as kashrut or language, which could only be met in Jewish institutions...

...Not only was there a discriminatory quota for the admission of Jewish students to medical, schools, but opportunities for specialized post-graduate education in leading hospitals were also sharply limited and discriminatory...

...Do Jewish hospitals have a special responsibility in such areas...

...The answer to that point is not institutional inertia, nor is it even that the hospitals sustain a positive image of the Jewish community...

...medically relevant scientific knowledge expanded enormously, thereby creating still greater need for skilled personnel...

...Indeed, there is every reason to suppose that the need to provide for charity patients will continue to decline...

...If we are to know how many dollars Federations should give to hospitals, we must first know what hospitals can do for us, whether the doing is defined in strictly medical terms, or in terms of the good name of the Jews, or in terms of ethics...

...So, too, within the Jewish community, there has emerged a fairly conventional demand for reallocation, and its common version is that less money should be granted to Jewish hospitals, more to Jewish education...

...it does not have to be invented, it does not have to be pasted together...

...In fact, the reputation of the Beth Israel as one of the nation's outstanding hospitals owes significantly to the way in which it has combined the latest scientific information and research with a very warm, sympathetic and effective understanding of the personal, emotional and social needs of its patients...

...The issue before Federations — and hospitals — is to relate our understanding of Jewish purpose to the allocations process...

...From the point of view of the Jewish community, this amount of money, though it represents a very tiny fraction of the operating budget of the hospital, could be used to prod and assist the hospital into developing community programs...

...Or would the acknowledgment of such a responsibility "ghettoize" medicine...

...Sec-Cecil Sheps is Vice Chancellor for Health Sciences and Professor of Social Medicine at the University of North Carolina at Chapel Hill...

...These would represent a modern, progressive and needed new service provided by the Jewish community to the community as a whole or for one of the other Jewish agencies in the city...

...The leader here again was the Beth Israel in Boston, which established its Harvard affiliation in 1924...

...Why Jewish hospitals...

...We all understand institutional inertia, we know how difficult it is to alter institutional trajectories, we know how common it is for an institution whose original purpose has long since waned to persist, either pretending that the old needs continue or frantically searching for some new self-justification...

...Clearly, from the financial point of view, though every dollar is valuable, the hospital would not be seriously inconvenienced if this contribution was not made...

...So, too, we have now learned that non-Jewish hospitals can readily provide religious counseling and services for their Jewish patients...

...Traditional Bikur Cholim societies (to perform the milzvah of visiting and aiding the sick) were no longer adequate, so hospitals were organized to provide systematic quality care...

...But perhaps even more important than its general reputation is the fact that since 1928 every Harvard medical student has received some of his or her medical education at this hospital...

...But we have a long way to go here, and any number of issues that could properly be debated have yet to be joined...

...In brief...

...And within a very few years after the opening of the Beth Israel, it became known as one of the best hospitals in the country...

...New York City alone has 10 Jewish hospitals...

...the wisest defense here, as in medicine itself, is to prevent the disease...

...First, there has never been a time in the history of this country when health and health policy have been more prominent as political issues...

...Thus the original staff of Mount Sinai Hospital of New York was led by non-Jews such as Valentine Mott, the dean of American surgery, and Willard Parker, a brilliant teacher and leader in public health...

...My purpose in criticizing the traditional defense has not been to leave the hospitals without defense, but to suggest that a new defense is not only required, but is actually available...

...Previously, he served as the General Director of Beth Israel Hospital in Boston and of Beth Israel Medical Center in New York...

...American attitudes towards the meaning of citizenship changed, and American culture was no longer prepared to endorse blatant discriminatory behavior...

...it seems to me...

...Should Federations insist on some application of Jewish ethics...

...The Jewish Federation of Detroit provides a subvention to this hospital of $150,000...

...It clearly cannot make much difference to the hospital — how big a difference can 2.4 percent be...

...Accordingly, the second classic defense of the Jewish hospital is also no longer compelling...

...As to the special needs of Jews, such as kashrut, we find that only a very few hospitals have wholly kosher facilities...

...Indeed, no small part of the reputation for excellence which Jewish hospitals enjoy derives from their early and effective concern with comprehensive social service...

...Of this sum, about 40 percent comes from government agencies, and another one-third from voluntary insurance plans...

...This relatively recent development means that private philanthropy is no longer the primary subsidizer of medical care for the poor and those of modest means...

...it is about "more dollars" or "less dollars...

...In many cases, this may represent their only direct experience with Jews...

...And there is no reason to believe that those who are affiliated elsewhere are not entirely satisfied with the quality of care they can obtain for their patients or with their own opportunities for professional growth...

...There are...

...But I believe that in a pluralistic society there is much to be said for the distinctive contributions which specific groups can make to the general welfare, as also to their own welfare...

...Lately, Jewish hospitals, sensitive to the criticism, have begun to move into "Jewish" programs that can serve as an answer to the critics...

...What of the particular needs of Holocaust survivors, or of other groups within the Jewish population...

...Or does the Jewish community not have an abiding concern with human welfare...

...This represents only .3 percent of the total operating budget of this institution...

...Three of these were founded as late as the 1950's...

...3. Jewish doctors were not able to find employment in non-Jewish hospitals...

...Unhappily, most Federation debate centers around the amount of money which ought to go to hospitals, and relatively little debate around the purposes to which Federation allocations should be devoted...

...In Boston's Beth Israel, there are today three Chiefs of Service who are not Jewish...

...Surely an argument from inertia is inadequate...

...Those who could defend Jewish communal investment in hospitals should — and can — muster more persuasive reasons...

...They represent a significant proportion of the local budgets of Federations in every city where such allocations are made, and that is why they are such ready targets for those who would reshape Federation policy...

...Or is there no particular Jewish understanding of medical ethics...

...Yet the needs for innovation, for difference, have not diminished...

...There was much disagreement about this in the Jewish community, and among Jewish physicians, but the community leadership insisted, and prevailed...

...And what of outreach programs for the Jewish elderly and the Jewish poor...

...But after World War II, several factors combined to bring discrimination against Jewish doctors to a virtual halt...

...Regarding Jewish doctors, it has been the clear tradition of Jewish hospitals, intent on providing high quality service, to employ able physicians, Jewish or not...

...The first of these was Mount Sinai Hospital in New York, founded as Jews' Hospital in 1852...

...They constitute a very strong expression of Jewish philanthropy in this country, an expression easily understood and appreciated by the general community...

...There are, in short, any number of substantive areas, ranging from the nature of the services the hospital provides to the manner in which the hospital is managed, in which Federation has a stake, and around which the debate on the role of the Jewish hospital might fruitfully be organized...

...The meaning of "looking after our own," therefore, has changed quite radically...

...The issue here is not image-building or public relations...

...Do these arguments still convince...

...What is Jewish about Jewish hospitals...

...At the present time, Federation allocations to Jewish hospitals provide only a very small fraction of their operating expense...

...There is a new consciousness of health as an industry, and of the hospital as the key component of that industry...

...The organized Jewish community does not have to provide hospital services for all Jewish doctors in a community, nor for all Jewish patients...

...All this has meant that anti-Semitic discrimination as a factor in physician-hospital relationships has virtually disappeared...

...And what of the observant physician, and the sometime conflict between his requirements and those of the hospital...

...Hence we now know that the demand for particular Jewish services has declined, at the same time that the capacity of non-Jewish hospitals to meet such demand has increased...

...They vary greatly in size, with the largest having more than 1.000 beds, and, in some cases, it is clear that the size of the hospital is in excess of any plausible need of its sponsoring Jewish community...

...2. Originally...

...The argument I propose proceeds as follows: 1. Jewish hospitals have worked closely with their sister Jewish agencies to supply health services...

...What, then, can be said in the defense of Jewish hospitals today...

...Cincinnati, New Orleans, San Francisco and Chicago, and more were founded in other communities as the great immigration of 1882-1924 continued...

...In short, it is high time that we move from the sterile debate over allocation into a meaningful debate over policy...

...even though incidental to the enterprise, it should be counted a major contribution...

...Surely the best course in dealing with discrimination, should it ever arise again, is not to compensate for it by providing substitute opportunities for its victims...

...By the end of the century, additional hospitals were founded by the Jewish communities of New York, Philadelphia...

...And I think the case for such contributions becomes the more compelling in a time such as our own, when the very meaning of hospital ownership is changing dramatically...

...It is not that we engage in a massive endeavor in order to breed good will...

...There is, for example, the issue of Jewish-related medical phenomena — Tay-Sachs and Neiman-Picks, hymolytic anemia, Dublin-Johnson disease, a generally higher mortality rate among Jews over the age of 55...

...I believe that such a debate would show a continuing purpose, even a continuing need, for Jewish hospitals...

...Tn the same way, Jewish hospitals pioneered in the development of intimate and pervasive relationships between community hospitals and universities and medical schools...

...In what follows, I propose that they do not — that, in fact, their character and cogency have changed radically...

...There are those who argue that support for Jewish hospitals should be continued "just in case" — in case, that is, discrimination against Jews and Jewish doctors happens again...

...Is such movement adequate, or should there — as I believe — actually be a contractual relationship between Federation and hospital, in which specific dollars are provided to purchase specific programs of concern to the Federation, be they programs oriented towards Jewish needs alone or towards general community needs...

...CECIL SHEPS ond, the introduction of government as a major factor in health care has created a revolution in the financing of hospitals...

...But, for the most part, the largest hospitals are found in cities with the largest Jewish populations...

...These have been developed with, and for, homes for the aged, family and child service agencies, vocational services, fresh air camps and community centers...

...As Jewish as, in our wisdom, we choose to have them become...

...This, in my opinion, is an unsound, even a retrogressive view...

...How Jewish can Jewish hospitals be...

...It was in this period also that the use of the hospital in the education of physicians, particularly for postgraduate education as specialists, became crucial...

...Hospitals When a reallocation of the nation's priorities is called for, its typical expression is the demand that less be spent on defense, more on domestic needs...

...yet it makes an enormous difference to the Federation...

...And, third, a new generation of Jewish communal leaders has begun to assume responsibility for communal affairs, and many of these are quite removed, personally and ideologically, from the experiences which first gave rise to a specific Jewish concern for health and hospitals...

...Further, ought Federation to be concerned with ethical practice within Jewish hospitals...

...Yet the real question is whether Jewish hospitals are, or can be, or should be, meaningful Jewish institutions, and that question has not yet been adequately discussed...

...The continuing investment of the Jewish community in hospitals should not be permitted to proceed simply out of inertia...

...Federation dollars help to provide Jewish hospitals some leeway, some measure of freedom to stake out new paths in medical care, as they have done so brilliantly in the past...

...This contribution from the Federations made possible the substantial volume of care that these institutions were providing to indigent patients...

...There have lately been some steps in this direction, most notably in Philadelphia, where a policy of special grants for mutually agreed upon programs has been instituted...

...If the current debate is to be reasoned, we need first to ask whether the arguments that led to the creation of Jewish hospitals still make sense, and...

...The freedom of a voluntary hospital to make its own policy, to determine the scope, quality and priorities of its program has been considerably reduced...

...Here, as in the area of research, we have an example of an important substantive contribution which Jewish hospitals have made, and can continue to make, as well as of an enterprise which has earned both appreciation and respect for the Jewish community...

...Today, there are 54 Jewish hospitals, of which 36 are general institutions...

...Hospitals grew very rapidly, creating urgent needs for new personnel...

...That depends on what, in the course of the needed debate, we come to decide about our present needs and interests...

...The Federation contribution was crucial in meeting their operating deficits...

...In the climate of the times, government could not be depended upon, and much of the argument around America's immigration policy hinged on the promise of the Jewish community that its needy would not become a public burden...

...The debate over the wisdom of Jewish communal support for hospitals has simmered for a long time...

...In Detroit's Sinai Hospital, which has a "two kitchen" policy, only 20 percent of the Jewish patients request kosher food...

...The New York Federation does have a Medical Ethics Committee, with six physicians and six rabbis, which tries to wrestle with this problem...

...Some Jewish hospitals do not operate a kosher kitchen, but do arrange to have kosher food brought in on request — as, in fact, do many non-Jewish hospitals...

...Highly developed Jewish hospitals, such as the Mount Sinai of New York, the Beth Israel of Boston, and Michael Reese of Chicago, played a crucial role in providing young Jewish physicians opportunities for specialized training that were otherwise unavailable...

...Indeed, one might even argue that discrimination is encouraged by anticipating it: after all, the would-be discriminator can then argue that his actions will not hurt too much...