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public of or involve it in the work of the agency. The area has a sizable black population, but there are no blacks on the staff, and the black board members (20%) do not adequately reflect the number of blacks in the area served. Two black providers in Macon were included on the board only after members of the black community expressed dissatisfaction with the board's composition. Second, the agency has had no organized training session for its members.

The agency evolved from the Regional Medical Program, and the director and staff appear to be satisfied with using the same basic approach to health planning that they used in the previous program. That approach is characterized by a minimum of consumer involvement in planning and a close working relationship between the staff and the provider members of the governing board.`

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EAST TENNESSEE HEALTH IMPROVEMENT COUNCIL

The East Tennessee Health Improvement Council (ETHIC), located in Knoxville, has many of the consumer-related problems common to HSAS in the South. The former executive director, Spencer Ralston, had an interest in consumer involvement in the agency, but was largely unsuccessful in creating much interest among consumer members or the public at large. At the first full membership meeting of the agency, after it was conditionally designated, only eleven consumer members attended. At the first executive board meeting only four consumers were present.

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The political history of this region does not contribute to active consumer involvement in decision making. Much influence is still wielded by courthouse politicians and the people tend to be highly suspicious of agencies that purport to serve them. For example, the Appalachia Regional Commission, long active in the area, held no local public hearings during the first ten years of its operation. Land developers, lobbyists, and officials on expense accounts could attend the hearings held at the bureaucracy's headquarters in Washington (or Hawaii, where one Appalachian meeting was held) but not the people. ARC is now more attuned to the views

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of people at the local level. However, the people of the region are still reluctant to entrust much power or faith in institutions, agencies, or commissions. They are more familiar with outside exploitation, such as stripmining, than with community based activity. Thus, the East Tennessee Health Improvement Council has the difficult task of gaining public support from a populace that is cynical and apathetic.

The unreceptive mood of the people of the area has not been helped by the inadequate publicity about the HSA and its work. Some committee members complained that they were not informed about

scheduled meetings.

The local papers sometimes print, as news

articles, notices of meetings; but they do not have a column of public meeting announcements. The director and staff hope to increase public interest and awareness through the county health councils and through public hearings. The agency publishes an informative periodical that, if more widely disseminated, could help fill the publicity gap and perhaps increase consumer participation.

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PRESSURES BY PHYSICIAN BOARD MEMBERS

Providers protect their interests by influencing the choice of consumer members and by dominating policy making of the HSAs. The medical doctors and hospital administrators combined make up the most influential groups of providers. They enhance their power by working with sympathetic HSA directors and staff to minimize not only the role of consumers but of other providers as well. Optometrists, mental health officials, and nurses throughout the region have been excluded from HSA boards or given only minimal representation.

In South Carolina, for example, the Optometric Association encouraged its members to participate in HSA formation and seek nominations to HSA boards. Optometrists attended organizational meetings and applied for board membership. But no optometrists were among those initially appointed to HSA boards in South Carolina. J. W. Jenkins, Director of the Optometric Association, pointed out that the statistical probability of this occurring is highly unlikely. He suspects it was an intentional omission.

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An incident in Orangeburg County lends credence to Jenkins' suspicion. There forty local doctors wrote protest letters and telephoned the conveners when they learned that an optometrist had asked to be considered for the board of the Palmetto Low Country HSA. Because of the obstacles they have encountered, optometrists are now concentrating on getting appointments to the Statewide Health Coordinating Council, where they hope to help shape planning policies.

As previously mentioned, nurses in South Carolina were able to get only one representative on the Three Rivers HSA, although seventeen nurses were nominated. A number of other HSAs in the South have excluded nurses from boards entirely. Among nurses, expectations for board membership are often low, but they have usually requested that at least one nurse be included on the various boards. This was done at the Piedmont Health Systems Agency in Greensboro, North Carolina, where nurses had been excluded from the board. After

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considerable protest HSA officials promised that a nurse would be placed on the board at the first opportunity. But when elections for the Piedmont Health Systems Agency board were held in January, 1977, no nurse was elected. However, after the resignation of the County Public Health Director in February, a Public Health nurse was chosen to fill her position on the board.

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STAFF INFLUENCE

The extent to which consumers shape policy decisions varies from agency to agency. But providers and HSA staff members are too often reluctant to permit consumers to assume their full responsibilities. Many providers and HSA staff members worked together either in the RMP or CHP programs, and it is not uncommon to find that they share common attitudes and biases towards consumers in health planning. In some instances, the result is tension between consumer board members and the staff. In other cases, staff members sympathetic to the consumers find themselves in conflict with providers.

As consumer oriented staffs attempt to act as a counter force to the providers, they sometimes displace the providers as the key group of decision makers. In some cases, they extend their influence to the point where they dominate the agency and its programs. The result is an agency where the staff does all the preparatory work and makes decisions concerning agency functions and programs. board becomes a "rubber stamp" for staff decisions.

SOUTH FLORIDA HEALTH SYSTEMS AGENCY

The

The Health Systems Agency of South Florida, located in Miami, evolved from an established regional planning body and has a relatively large staff and budget. The ratio of consumer board members to providers is approximately 60% to 40%. The agency attempts to insure that the consumer members are indeed consumers within the official definition, with no connections to the professional medical organizations. This policy has aroused the ire of many of the providers on the board, but it has helped create a relatively innovative planning body.

One provider member expressed the view that there is not enough physician representation on the board. He maintains that the pre

dominance of consumers has resulted in an HSA which consists of an "uninformed majority." Wood McCue, former executive director of the HSA, feels that this viewpoint is "nonsense." He added, "the board

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