free services was a major contributing factor to
the City's virtual bankruptcy.
This philosophical position was reinforced by
the belief that District Health Services contained
a great deal of "fat." According to Deputy Com-
missioner Mustalish, there was a lot of "excess
personnel, second rate people, inappropriate
activity and ineffectual programs. Many of the
cuts were long overdue." He felt that the budget
cuts were good overall decisions, giving the De-
partment an opportunity to clean house and to
bring the District Services system up to date.
This point of view breaks sharply with the
traditional model of public health services deliv-
ery. Since 1974, instead of delivery based on
need, the DOH has moved toward delivery based
on demand. The shift is from a service to a mar-
ket model. The criteria for reducing services was
not declining community need, but utilization
statistics and short-run measures of efficiency.
No doubt, this change of focus from what Dean
Wegman remembers as "everything that might
affect a citizen's health," to what Drs. Bellin and
Imperato call a "lifeboat mentality," was partly
a consequence of the fiscal crisis. Some cuts were
laudable efforts to weed out actual fat from Dis-
trict Services programs. Health officers who were
second rate and ineffectual, according to Dr. Mus-
talish, were dropped or forced into retirement.
Physicians who were being paid salaries without
ever working, including one earning $25,000 an-
nually as director of a tropical disease clinic who
had not had a case in years, were dropped as well.
DOH planners also considered the master plan
for District Health Services, drawn up in the
1930s, as hopelessly dated. Demographic shifts
had left Health Centers in areas that did not
need them, because other providers were avail-
able. The Lower East Side Health Center's lo-
cation on "hospital row," distant from the slums,
was cited as one reason for closing it. (Some
agencies that formerly occupied the DOH build-
ings as part of their "in kind contributions to
federal and state programs were able to take over
the facilities following the removal of DOH
programs and personnel.)
Scattered categorical programs often competed
with programs offering more comprehensive
medical care. In the case of well-baby clinics,
for example, their declining registration (without
a comparable reduction in services) was used to
justify upgrading a few into comprehensive, full-
time Pediatric Treatment Centers, while closing
many others. Isolated Chest Clinics were closed
and chest-tuberculosis clinics, which primarily
Decisions to cut services and/or
spending were, at times, 'very pain-
ful' for those involved. However, it
would be a mistake to assume that
those who played key policy-
making roles during the fiscal crisis
were simply following orders. Some
brought an ideology opposed to
public sector services into office
with them
served drug addicts, alcoholics and the aged,
were transferred into hospital settings. Two part-
time VD clinics were closed and the rest upgraded
to full-time operations.
The DOH officials used several rationales to
justify reductions. Eye Clinics, sickle cell screen-
ing, lead poisoning case finding and school health
examinations were cut back because they lacked
follow-up; Immunization Clinics (for adults and
travelers), CHAP (Child Health Assurance Pro-
gram) in day care centers, and school health
because they duplicated services; and dental care
because, in Dr. Bellip's words, "Nobody ever died
of bad teeth and bad gums. I had to weigh that
against diphtheria innoculations. I didn't have
money for both."
The Commissioners' choices were not easy.
In a recent interview, Dr. Bellin noted, "It was a
very painful time to be Commissioner. These cuts
had to be made. None of us enjoyed it."
While City officials continued to cut back the
personal health services of DOH, the Department's
regulatory and monitoring functions were coming
under attack from another quarter. Beginning
in the late 1960s the New York State Health De-
partment began usurping many City DOH func-
tions and asserting increasing control over the ci-
ty's health activities. The regulation of the Medic-
aid and Ghetto Medicine programs; inspection of
hospitals, nursing homes and supermarkets; and
certain environmental activities eventually passed
into State hands.