The American Heart Association says it wants to recoup expenses. Critics question whether the group is serving itself or the public.
When it comes to CPR training, the American Heart Association sets the standard.
The tax-exempt public charity, whose mission is to reduce heart disease and stroke, is named in many state laws and regulations as the ultimate authority on emergency cardiac care. Florida law, for example, requires paramedics to "hold a certificate of successful course completion in advanced cardiac life support from the American Heart Association or its equivalent."
When it comes to training lay people in CPR, many organizations _ from private companies to school districts to day care programs _ follow the lead of their state's medical authorities and accept only heart association or equivalent programs.
For that reason, recent moves by the charity to copyright its CPR training guidelines and to begin charging fees to organizations that model their courses after them are stirring enormous controversy in the world of emergency medical training and research.
The charity says it simply wants to recoup $1-million in expenses for hosting meetings of scientists and other experts to develop the guidelines. But critics accuse the heart association of plotting to use its unique legal and moral position as a non-profit charity to clobber the competition in CPR instruction.
Small businesses involved in CPR instruction are especially wary.
"The reason it's raising so many eyebrows is there's a fear that you will have to pay to play," said Lou Jordan, president of Emergency Training Associates, a textbook company in Maryland.
Medical researchers, meanwhile, express concern that lives might be lost if the heart association's financial demands cause training organizations to raise prices or lose clients, with the result that fewer people learn CPR. Some question why a tax-exempt charity would not consider the unfettered dissemination of the information to be part of its public mission.
"A non-governmental organization which is supposed to be doing good for the public suddenly claims they are owning what researchers have developed over decades with their own sweat? That would be wrong," said Dr. Peter Safar, distinguished professor of resuscitation medicine at the University of Pittsburgh.
"It would reduce the spread of the gospel of lifesaving, because these skills should be acquired by as many people as possible. And the heart association can't reach all these millions and billions of people around the world," said Safar, who played a leading role in developing the technique in the 1960s.
"That is unequivocably not our goal in doing this," said Ted Borek, vice president of the heart association's emergency cardiovascular care program. "Our goal is to increase the science and knowledge of lifesaving techniques to all organizations. But obviously in saying that, we have an obligation to the organization to protect its intellectual property. And that's what we're doing."
The heart association took in $451-million from charitable donations, foundations and corporate sponsors last year. Charitable gifts go to medical research and community programs; they do not fund the cardiovascular care program, which is self-supporting through money the heart association earns from selling its training materials.
That's why there is no conflict between the association's charitable mission and its effort to recoup $1-million for the guidelines conferences, Borek said. The association does not want to siphon money from research for education.
The association helped pay for air fare, food and lodging for medical experts who attended six conferences over three years in Dallas, where its headquarters are located. A spokeswoman said corporations helped defray costs, but she could not say how much they contributed.
"We have gone to great expense in trying to develop the best science standards known to man," Borek said. "And I guess if we're going to get criticized for that, so be it. But somebody's got to put this science together."
Countered Safar: "They haven't made any science. They have held meetings."
Turning into a business?
The heart association last published basic and advanced CPR guidelines in the Journal of the American Medical Association in 1992. But in August, it will publish updated guidelines in its own journal, Circulation, where it will own the copyright.
Borek declined to specify how the new guidelines will differ from the 1992 version. And others can't say; the heart association has asked experts who have reviewed the guidelines to sign confidentiality agreements pledging not to discuss them, citing the need to complete a peer review process.
To many observers, the copyright plan fits in with a push that began several years ago to increase the quality of heart association educational materials, with the apparent goal of bringing in more revenue.
It is unclear how much the association earns on emergency cardiovascular care programs that train about 6-million people annually. A spokeswoman initially said the organization posted a surplus of nearly $900,000 on the CPR education programs in fiscal year 1999 on revenues of $27.2-million. Then she called back to say those numbers might not be accurate. The association's most recently available public tax return, meanwhile, gives no detail on CPR training.
In 1997, the association effectively raised prices for its materials in much of the country. Basic CPR books that volunteer instructors say once cost 50 cents to a dollar in the Tampa Bay area leapt to $3.50 each _ costs that instructors then passed on to their students in the form of higher course prices.
While the new materials were of better quality, heart association volunteers found that even a modest price increase sometimes discouraged lay people from taking courses or put them out of reach of organizations with tight budgets.
"If we don't get people out there knowing CPR, we've got a hole in the system," said Rick Walker, a heart association volunteer since 1979, an Indian Rocks Fire District shift commander and a part-time CPR instructor in the Pinellas County school district's adult education program.
In apparent response to such concerns, the heart association is replacing its old "Heart Saver" basic CPR program for lay people with a new course. Dubbed "CPR for Family and Friends," the instruction book will cost $1. Participants will not receive a card certifying they have completed the course. Medical professionals will continue to pay higher prices for their advanced technical books and certification.
Owners of small training businesses say it is difficult enough to compete with deep-pocketed charities such as the heart association or the American Red Cross, which neither pay taxes nor, because of their established names, struggle with credibility questions.
But what really chafes about the copyright plan, the businesses say, is that the charity has them over a barrel, thanks to state laws that require companies to model their programs after the heart association's.
"We are more than interested in giving a percentage of what we receive on sale of publications to American Heart," said Gregg Rich, co-founder of the American Safety and Health Institute in New Port Richey, one of the larger for-profit CPR and first aid educational companies.
"But when a non-profit organization aggressively competes with you for business, their objectivity comes into question," Rich said. "I think unfair competition results whenever a tax-exempt entity competes with for-profits."
Last year, for instance, an executive of a Massachusetts training company wrote ASHI that a local heart association representative pressured him to drop an ASHI course on use of automated external defibrillators, devices that can jump-start a stopped heart with electrical shock.
"Although he told me, "I am not going to discipline you' for teaching (a non-heart association course), I was told that "it is not right to do it,' " wrote John J. Muglia, senior vice president of Community Health Training Solutions, in an Oct. 27, 1999, letter.
"He went on to add that he was going to contact my customer . . . and recommend to them that they take" such a course from a certified heart association training center, Muglia wrote.
Muglia did not return a phone call seeking comment about the letter. But Michael C. Bell, director of training and field operations for the heart association, said the incident was a "misunderstanding" that was "resolved."
"We believe that the opportunities for CPR vastly exceed the ability of all of us to deliver training. We don't malign anybody else's courses," Bell said.
The heart association has proposed a financial arrangement with ASHI to allow the business to continue to market its courses as "equivalent" to the charity's, but neither side would discuss the details.
Red Cross is a rival
Rumors that the heart association plans to demand royalties or fees from all companies that publish or write training materials are misguided, Borek said. He said the charity has approached four organizations that "make money" off the association's guidelines: the American Red Cross; the non-profit National Safety Council in Chicago; and two private businesses, Oregon-based EMP International and ASHI.
"These are the four organizations I am aware of that generate revenue by selling courses or materials for medical professionals that utilize" heart association guidelines, Borek said. "I'm asking them to help us participate in making sure we have the best science possible in all our training materials."
Although he refused to discuss details of his talks with the organizations, he insisted the heart association was making no demands.
"This is a request," Borek said.
Many of the heart association's efforts to protect its "intellectual property" on CPR guidelines appear aimed at the Red Cross. One of the nation's largest charities with $2-billion in revenues in 1997, the Red Cross is the 800-pound gorilla in the area of health and safety education.
Like the heart association, the Red Cross is designated in many state rules as the sole or a preferred provider of emergency medical training, usually first aid but often CPR as well.
Behind the scenes, the two non-profits jockey fiercely for dominance in health and safety training, observers say.
"The battles are very quiet, private battles. They would never attack each other publicly because of their names," said Frank Poliafico, president of Emergency and Safety Programs, a training company in Pennsylvania.
Last year, the Red Cross spent $170-million on public education courses, from water safety to first aid to CPR, said Don Vardell, operations officer of the Red Cross's health safety and community services department. Its revenues on those programs amounted to only $108-million, Vardell said. The Red Cross estimates it trained 4.7-million people in CPR last year.
Vardell declined to comment on the Red Cross's talks with the heart association about the CPR guidelines issue.
Meanwhile, some state regulators say the problem is outdated laws that give the heart association and Red Cross an advantage over competitors.
In Alabama, for example, the Red Cross and the American Heart Association are named in training regulations written in 1973 because at the time, "they were the only programs available," said Russell Crowley, EMS education director for the Alabama Department of Public Health.
But Alabama is considering changing its rule to allow training programs offered by the Red Cross, the heart association or their "equivalent."
"We've been seeing a lot of other organizations trying to compete. And from what I've seen, they meet the exact same standards" as the Red Cross and the heart association, Crowley said. "It's a new day. I'm not sure there's a reason to exclude them."
_ Researcher Caryn Baird contributed to this report.