UHS: An All - But - Clean Bill of Health
In 1963-64, there were 163,206 visits to the Harvard University Health Services--about 63,000 more than in 1958-59. With 138 medical professionals on its staff and over 25,000 customers (14,000 students and 11,000 faculty and employees), the UHS has become a curious combination of big-city hospital, small-time doctor's office building, business corporation, and Harvard department.
Harvard is regarded as the nation's leader in college health facilities. After three years in operation, Holyoke Center is regarded as about the best central health clinic on American college campuses, and it has been the subject of numerous articles in medical journals. The services available are through and all-inclusive, and now amount to a pioneering program in prepaid medical care (administered through the Blue Cross-Blue Shield system). Last year over 20 members of the staff collaborated in the production of a sort of encylopdeia of college health affairs, College Health Administration, which does everything from reproducing the forms Harvard requires freshmen to fill out to explaining the legal aspects of university medicine.
With all the teaching hospitals in Boston closely affiliated, the Harvard Health Services cannot help but have the finest in medical facilities at its command. But it has even begun to acquire outstanding and unusual equipment of its own. Just this spring a member of the Class of 1915 presented the UHS with a "Pacemaker," the newest and most effective device for diagnosing and treating disorders of the heart. Used to monitor the hearts of people suspected to have heart disease and to provide emergency resuscitation, the Pacemaker will permit the treatment of serious emergencies right in Stillman Infirmary on the fifth floor of Holyoke Center. The Health Center is one of very few institutions in the Boston area that have a Pacemaker.
The dramatic advances and development of facilities are in a sense the climax to a long-range program that began with the appointment of Dr. Dana L. Farnsworth, then of M.I.T., as director (and as Henry K. Oliver Professor of Hygiene) eleven years ago. Farnsworth led the long search for funds for a new building, planned it carefully, and shaped the very-much-expanded facilities in his own image. Dr. Farnsworth himself is an institution. The recipient of about as many honorary degrees as anyone else at Harvard, he is widely regarded as the "dean" of American college health care. He has collaborated in a series of health textbooks for the grade schools and a progressive text for the teaching of hygiene in college, and is the author of countless magazine articles. Dr. Farnsworth's office has him booked for an incredible number of speeches--to audiences of all degrees of sophistication. (Recent ones included an address before the annual meeting of the American Orthopsychiatric Association and a commencement speech at New York's Horace Mann School.) He has been a leader in the aggressive attempt to integrate psychiatric services into college health operations.
But the presence of outstanding facilities and personnel does not save the University Health Services from having manifold problems--some inherent in the operation of a clinical, depersonalized institution, others resulting from the close juxtaposition of the Health Services and the Medical School, and most from the fact that this is, after all, Harvard.
Most student complaints involve dissatisfaction with the open clinic operation; there are complaints of long waits, and diagnoses that vary with the doctor one sees each time--perhaps several different one in the course of a single week. Continual dismay with the clinic arrangement, on the part of both patients and doctors, led to an intensive campaign last year to establish an appointment system. A flyer distributed in Holyoke Center urges students, faculty, and employees to "choose your own doctor" and "whenever possible make an appointment to see him. In other words use these facilities just as you would use your medical facilities at home." This system has, for the most part, been successful; there are now many more hours spent by staff physicans on appointments than in the walk-in clinic. Some doctors, however, sem to prefer the clinic arrangement, and patients have not been thoroughly cooperative; about 20 per cent of the appointments for the special visits of dermatologists are not kept, for example.
When complaints do become specific, they usually refer to a particular experience, when a diagnosis was wrong or a student was in extreme danger. The Health Services is invariably able to discuss the difficulty in presise detail and explain the problem quite reasonably. But as Dr. Farnsworth points out, anyone is likely to blame even his family doctor for an error, and the frame of mind induced by a communal medical setup only tends to exaggerate the anger.
Some areas of the Health Services receive high praise; while the admissions policy often seems to be peculiar strict, Stillman Infirmary gets raves from most people who have spent any time there. The nighttime emergency services, however, are commonly distrusted and characterized as too understaffed and unconcerned. Perhaps the most serious criticism is that the Health Services does not have an ambulance and sometimes appears unequipped to handle emergencies; house calls are made under only the gravest circumstances. 'Cliffies complain of the rather long walk from the quad to Holyoke Center when they are ill during the winter months.
Whatever the extent of the difficulties, one of the most impressive aspects of the Health Services is its perpetual self criticism and its encouragement--even active recruitment--of complaints from patients.
If there are problems of adjustment to this kind of medical care for students, there are difficulties for the doctors as well. It is difficult to pin-point the reasons a physician might have for choosing college health service over a generally more lucrative practice. Appointments to the staff are made in a similar manner to Faculty appointments; there are physicians, associate physicians, and assistant physicians. Most conduct private practices on the outside, within limits set by the Corporation. It has been suggested that one reason these doctors have chosen this form of practice is that they would be unhappy with the political views of many of their colleagues on the outside; approximately half of the staff members belong to the American Medical Association, but almost all apparently disagree with some AMA political positions. One observer commented that these men had essentially made a commitment to a form of "socialized medicine" which the AMA fears on a national scale.
The variety of activities that go on within Holyoke Center and the other branches of the Health Services is astonishing. There has been an increased preoccupation with research over the past few years, and the Harvard Student Study is now in its seventh year of research under grants from the National Institutes of Health. Novel new projects have begun, and one task force is now studying the extent to which athletes use the psychiatric service--focusing on the kind of sport in which each person engages and the length, type, and treatment of his illness.
According to the 1963-64 annual report of the University Health Services, the activities of the psychiatric service have changed very little over the past few years. The report explains:
The main purposes of the service are to furnish emergency and diagnostic care to those who desire it, to aid in the resolution of crisis situations based on emotional disturbances that may arise anywhere in the University, to furnish brief psycho-therapy to those who may readily aurmount their difficulties with timely help, and to aid those in need of long term treatment to find a suitable therapist. Many students who need extended treatment and cannot obtain it else where are treated in the Department to the extent that available time permits.
Five years ago a CRIMSON feature reported that the old skepticism toward psychiatry frequently noticed in the Harvard Faculty was disappearing; professors just weren't saying "Those damned psychiatrists want to run the University" any more. The ascendancy of psychiatry represents a deeper recognition of Dr. Farnsworth's theory that educational institutions have a responsibility to care about the emotional development of their students. As he once put it, "education and educators should acknowledge that skill in handling emotional conflicts and tensions and the training of character are just as important as traditional subject matter."
In 1963-64, UHS psychiatrists saw a total of 1411 patients in 7251 visits. Many of these were routine interviews for entering students in certain graduate schools, but there has been a sharp increase in the service administered to others over the years. (In 1958-59, only 1013 patients saw psychiatrists in 5528 visits; there were only slightly fewer psychiatrists on the staff at that time). Last year's visits included 408 Harvard undergraduates and 159 at Radcliffe, or 8.6 and 13.7 per cent of those eligible, respectively.
Some perpetually alert Harvard critics have been quick to point to Harvard's propensity to admit neurotics, but the reasons for the increase were apparent solved with some case; "usually live to ten interviews spaced at weekly intervals served to resolve their immediate difficulties or at least to modify them favorably." Techniques used by the psychiatric service are presumably the same as in private practice, despite the attempt to keep the number of visits per person down. "Always with scrupulous regard for privacy and confidentiality," reports the annual summary, "all staff members spend much time consulting with parents, roommates, friends, Faculty members, tutors, deans, and others who are involved in the quandries of any particular person."
Particularly because of the increased attention to mental and emotional health, the University Health Services has come to play a crucial role in all areas of University life. Regular conferences are held between the members of the Administrative Board of deans and the psychiatric service. Dr. Farnsworth sits as a member of the College Admissions Committee, reading the application folders of candidates who seem to have emotional problems, as well as some who do not. If a person appears to have "no chance of succeeding" at Harvard as a result of his health problem, Dr. Farnsworth advises against admitting him. If, on the contrary, "he has handled his problem intelligently, he is generally accepted; very few are rejected on grounds of mental health, according to Dr. Farnsworth.
Even if psychiatry has been accepted as an important part of the college health routine, some of the old complaints recur. Despite persistent rumors to the contrary, Health Services officials insist that information about student visits to a psychiatrist does not become the property of the deans and other officials. Psychiatric records are reportedly kept separate from ordinary medical records, and only the fact that a student has visited the psychiatry section is entered on the medical forms. But if a case becomes serious or if psychiatric information is relevant to deliberations of the Administrative Board, for example, the necessary information will be furnished, and the student will be told. One doctor at the Health Center reports that the senior tutors would like to have considerably more information than they now get from the psychiatric service, but the criticism is usually in the other direction. Faculty members have charged that psychiatrists have broken patient's confidence by revealing illegitmate pregnancies or homosexual experiences to the authorities; Health Service officials absolutely deny all such stories.
One issue during the past year which involved the psychiatric services, as well as the medical section of the Health Services, was the running controversy over drugs and their use at Harvard. While estimates of the percentage of Harvard students who take drugs--and specifically who smoke marijuana--ran as high as 50 per cent and as low as one or two in the newspapers, most members of the Administration belittled the extent of the problem.
In an interview with the CRIMSON, Dr. Graham B. Blaine Jr. '40, newly appointed Chief of Psychiatry (whose article on collegiate mores had touched off the 1963 "Harvard sex scandal" in the press), said that "we at the Health Services take a fairly casual attitude toward pot. We know that some Harvard students are using marijuana. We know they get it from townies. But it isn't harmful, and there's no evidence to show it's even as addictive as cigarettes." While he warned of the possibility that smoking marijuana could lead to involvement with more serious drugs, such as heroin, Dr. Blaine asserted that there is no evidence that marijuana itself is addictive. He indicated that the Administration took a more disapproving view than the medical officials, because of a responsibility to law enforcement officials, and that the doctors were often urged to provide information.
But within a week, Dr. Blaine had apparently changed his mind. In a letter to the CRIMSON, he said that he "did not mean to imply . . . that there is a difference in attitude toward drug taking on the part of the University Health Services, the Administration and the law enforcing agencies. . . . I feel that the fact that we do not have a drug problem here at Harvard now is largely due to the fact that there has been excellent co-operation within the limits of confidentiality between individuals from these quarters. Everything that can be done to discourage the use of drugs is being carried out and in my opinion effectively."
The sharpest reply to Dr. Blaine's earlier assertion of "a fairly casual view toward pot" came from Dr.
There are Complaints About its Clinic and Confusion About its Position on Drugs, but Harvard's Health Service is Considered One of the Best.... Farnsworth two months later. After sentencing a local 19-year-old for selling drugs in Harvard Square, Midlesex Superior Court Judge Frank W. Tomasello charged that there was a serious drug problem here and urged an investigation to "clean out Harvard Square;" the Cambridge City Council responded in kind, citing evidence of narcotics transactions in Square cafeterias.
While Dr. Farnsworth charged that "the crisis in drug traffic has been greatly exaggerated by people without accurate information," he strongly discouraged the use of any sort of drugs by students and pointed to a continual concern at the Health Center about their effects. He characterized marijuana as a harmful drug, which should be avoided for its own effects as well as the more serious drugs may exaggerate and complicate he said, is "a way-station on the road to a life different from that for which students come to a university. He warned of the serious danger that drugs may exaggerate and complicate the problems one has when he begins to take them. Dr. Farnsworth intends a thorough discussion of the drug problem in colleges in a forth-coming book.
A persistently interesting issue is the matter of communications between the Administration and Health Services in drug cases. Dr. Farnsworth urged an attempt to help students find "medical solutions" before they are implicated in legal or disciplinary action; no "spy system" would be set up to inform the authorities, he promised. Later in the spring, when the Administrative Board ousted a freshman for giving and selling marijuana to his friends, the Health Services were involved only after the case went to the Police--and then only in an attempt to assist the victims medically.
One of the more volatile subjects for the Health Services' attention has been the question of just how concerned the college should be about its students' sex lives. In a New York speech in March Dr. Farnsworth said that colleges should think about this matter, but that they should not attempt to force a particular point of view upon their students. The basic solution for the dilemma, he suggested, is honest, uncommitted education "full and frank discussion in families, in groups, between couples, and between older and younger collegeagues in the college." But he cautioned his audience of physicians that "until we resolve our own confusions we will not be in a favorable position to help our younger colleagues thread their way through the devious paths of development to sexual maturity."
The ubiquitous Dr. Blaine, writing in Mosaic, the magazine of the Harvard-Radcliffe Hillel Society, urged in March that information on birth control be made part of the curricula of high schools and colleges, suggesting that such a move would reduce the number of illegitimate births in this country.
Dr. Farnsworth is more cautious, however, and points to the difficulties involved in any active role in the matter of contraception. The official policy of the UHS is straightforward:Members of a college health services staff may discuss with students any aspect of their private lives about which there is any concern. However, supervision of contraceptive practices of unmarried students is not an appropriate function for a college health service. To do so would suggest approval to many, implies that the college assumes responsibility which does not properly belong to it, and runs counter to the sincere wishes of the great majority of parents (and the law as well as in Massachusetts).
The nature of doctors' decisions on these matters is almost impossible to determine