Health Care and Urban Revitalization

Introduction

Urban history and the history of health care both in the United States and Europe have always been intimately connected, particularly as urban reformers in the nineteenth century and earlier looked to hospitals and other individual and institutional actors to address the pervasive health problems that accompanied the industrial revolution. However, in recent decades, views of urban health care have increasingly moved beyond this traditional emphasis on individuals and institutions to examine the transformational economic role hospitals, and other health care actors have played in advanced postindustrial urban settings. Indeed, hospitals and the health care industry broadly understood have become central organizing foci for policymakers, lawmakers, urban reformers, and other stakeholders looking to revitalize inner-city economies, neighborhoods in crisis, and regions plagued by pervasive unemployment and social dislocation. ¹

Urban historians have been slow to appreciate the fundamental shifts health care providers (and their wide-ranging interlocutors) have been experiencing since 1960 as well as the critical implications these changes have had for cities, city dwellers, and larger regional economies. Just as critical shifts in manufacturing, waste removal, electrification, transportation, land use, and communication reordered the urban landscape before, so in recent decades has the emergence of the health care industry. Indeed, scholars and policymakers now clearly identify health care as an industry comparable with steel, oil, gas, and the railroads in the nineteenth century. With little fanfare among historians, health care has emerged in the late twentieth and early twenty-first centuries as an economic driver of change and, in the views of many, an essential revitalizing agent for American cities suffering from economic decline accompanied by little public interest in bold initiatives or a longer term commitment to urban problem solving.

The emergence of health care as a greater actor on the urban landscape poses vexing problems for urban historians as well as policymakers and other contemporary stakeholders who laud and even celebrate its growing importance (at least at the rhetorical level). What exactly is the health care industry’s role in reinvigorating American cities? In the past, fundamental urban economic transformations have been accompanied by profound social and political dislocation. For health care, scholars have been slow to take the full measure of the industry’s impact on cities or people of all classes and ethnic groups and on power relations in and outside city hall. In too many ways, the benefits of hospital mergers, high-tech research facilities, and expanded specialty care have been touted or assumed without much critical understanding of how the industry has evolved in cities and what its legacies of economic betterment actually are. The essays in this issue begin to address these important questions.

This historical overview showcases in broad outline on some of the key changes that have occurred in recent decades and goes on to examine how some historians and other scholars have interpreted these changes, to lay out a possible agenda for new scholarship, and to introduce and contextualize the accompanying essays.

An Emerging Health Care Industry: The Example of Pittsburgh

The way in which health services are provided to America’s population has changed dramatically in the last fifty years, and this transformation has impacted the city’s economy, the distribution and types of jobs available, as well as the economic vitality of surrounding regions. As Guenter Risse has noted in his seminal synthesis Mending Bodies, Saving Souls, in recent decades, hospitals have become “houses of technology,” providing mostly intensive patient care aided by a range of powerful and technologically advanced therapeutic and diagnostic tools and machinery. Hospitals still provide the most complex and acute medical interventions, but many routine health care services have been relocated to clinics, specialized facilities, and to patients’ homes. ²

This transition, as Risse notes, has left behind an overabundance of costly beds and underutilized staff and services. In response, most urban centers in the United States have seen hospitals and their network of affiliates engage in intense competition for resources followed by waves of consolidations and closings. For example, in Pittsburgh in the 1970s, most inpatient and nondoctor’s office medical care was provided by a broad range of either unaffiliated or loosely affiliated hospitals that included Allegheny General Hospital, West Penn, Saint Francis, the University Health Center of Pittsburgh (what would become the University of Pittsburgh Medical Center [UPMC]), among others. In the early 1970s, the University Health Center of Pittsburgh was a loose federation of six hospitals with annual revenues of approximately $10 million. The services provided by these institutions were in large part limited to residents of the surrounding neighborhoods and were staffed by attending physicians based in these institutions which, for the most part, respected market boundaries between competing hospitals. ³

By the early twenty-first century, the situation had shifted dramatically. By 2005, most hospitals in the city had affiliated into a network dominated by UPMC. All of these institutions have experienced major restructuring processes with UPMC becoming more like a private for-profit corporation than a not-for-profit charitable institution. UPMC’s affiliated hospitals have been organized into managed service networks designed to compete for customers. By then, thirteen of the region’s twenty-seven hospitals (and most of the largest providers of service) were affiliated with UPMC. ⁴

By 2010, there was also much less orientation to the surrounding neighborhoods of these institutions. Instead, they have largely become specialized care centers designed to serve a regional, national, and often an international clientele. For example, the acquisition of and eventual closure of Braddock Hospital by UPMC in October 2009 left the community bereft of readily accessible health services and accentuated the decline of a neighborhood already experiencing long-term economic deterioration. ⁵ Moreover, even as the economically distressed community of Braddock was losing critical services, UPMC was opening facilities in the bedroom community of Monroeville to compete directly with close-by West Penn Forbes Regional Campus. ⁶ By 2005, UPMC had grown into a sprawling twenty-nine-county system with more than 40,000 employees, a for-profit health insurance subsidiary with over half a million members, $5.1 billion in revenue, a network of nineteen hospitals, and seventeen long-term care, retirement or nursing homes, with more than 4,000 affiliated physicians. ⁷ In addition, UPMC began establishing or assuming control of hospitals and medical centers in other countries, including Ireland, Qatar, Cyprus, Japan, Italy, and the United Kingdom. ⁸

At UPMC and other large medical centers, business organization, competition, discriminatory marketing, and financial bottom-line concerns dominate not only the service elements of health care, but increasingly they also shape the activities of research and teaching centers. Thus, the potential efficiencies of more aggressive, systematic, large-scale, organization management have become centered around private institutional gain and survival, rather than community or public accountability, local health needs, and general cost-effectiveness. The failure of urban health care centers to become comprehensive, regionalized systems designed to serve the entire population has happened despite the tremendous growth in federal, state, and local government funding of health services through Medicare, Medicaid, and direct tax levies.

The growing importance of medical centers such as UPMC to America’s urban economy places in sharp relief the normally mundane role of hospital administrators. Much as industrialists such as Andrew Carnegie, Henry Clay Frick, and John D. Rockefeller exercised enormous influence over whole sectors of the U.S. economy in the nineteenth century, so a modest set of health care administrators, chief executive officers (CEOs), and related officials have guided the emerging twenty-first-century urban health care industry. In Beyond the Bounds: A History of UPMC, one cannot read Mary Brignano’s largely favorable portraits of UPMC’s hard-driving and ruthless chief executives, Thomas Detre and Jeffry Romoff, and not hear echoes of these earlier industrial giants. Drawing from private-sector influences, health care administrators have increasingly modeled the provision of health services after the operations of private-sector, for-profit, large-scale business corporations rather than as not-for-profit charitable institutions primarily dedicated to essential public services. ⁹

Given these parallels, it is appropriate to ask the following question: if the actions of Detre and Romoff echo those of industrial titans of the late nineteenth century, does the impact of large health care companies (such as UPMC) on complex urban ecosystems echo the course and impact of large industrial concerns of that earlier age? The essays in this collection began to address this issue, and, as they demonstrate, the answers are predictably multifaceted, often counterintuitive, and highly contingent on local context and the responses of specific groups and individuals. Each story brings forth a different accounting of how power, equity, and economic development resources are distributed (or redistributed) as urban economies and landscapes are transformed. Despite these differences, however, as several of the essays in this issue will show, UPMC’s trajectory in recent decades is far from unique. One can see a similar pattern of closings, consolidations, and corporate restructuring occurring in Boston, Birmingham, San Francisco (the subjects of the studies here) as well as other cities such as New York City, Cleveland, Nashville, Houston, and elsewhere. In addition, the success of large-scale networks of affiliated institutions such as UPMC has put tremendous pressure on those medical centers that have not combined in similar fashion. This pattern of combination, capitalization, intense competition, and its attendant effects on workers, consumers, and communities clearly has resonance from earlier ages of urban development.

In recent years, large health care networks such as UPMC have increasingly become models for policymakers and lawmakers in other cities looking to revitalize inner-city communities or to catalyze economic integration between academic centers and emergent high-tech sectors. In this model, health care becomes a key vector for transforming moribund urban economies. ¹⁰ Pittsburgh has often been touted as a “model city” for health care and “eds and meds” boosters. Once the global center for steel production earlier in the twentieth century, the collapse of the city’s steel industry in the 1980s ushered in decades of social stress, population decline, and broad-based urban decay in the mill towns and valleys surrounding Pittsburgh. At best, it is unclear whether these communities have seen any benefit from the ascendance of the health care industry. The accompanying studies should call into question many of the core assumptions of “eds and meds” promoters, particularly when they relate to the generation of stable and sustainable jobs and communities.

Indeed, one of the common themes that emerges from these studies is the deep instability that expanding medical centers have left in their wake. In Pittsburgh and New York, settings where this process of transformation is well advanced, access to jobs and services remains very problematic and, in many cases, more polarized around issues of race, class, educational training, and geographical location. ¹¹ This is in sharp contrast with the commonly held expectation in the 1960s and 1970s that hospitals would give priority to providing services (and to some extent employment) to a broad population with particular focus on the needs of the local community. ¹² In addition, as large, not-for-profit medical centers and their associated institutions (such as universities) expand, taxable land declines, often further hastening reductions in social, job-training and educational services, and other essential resources. ¹³ Instead, priorities have become oriented toward specialized academic research and teaching as well as applied research and development.

Urban Historians and the Rise of a Health Care Industry

These dramatic transformations have been widely studied and discussed, particularly within health care, public policy, and related arenas. Very little analysis has been done, however, of the historical transformation these fundamental economic shifts have caused in American cities. There are many different dimensions to the growth of the health care industry that dovetail well with long-standing areas of interest to urban historians and scholars. Here we will explore some of the clearest examples and then suggest some additional areas worthy of deeper exploration.

In laying out the general economic contours of the emerging health care industry, perhaps the most prescient study has been Paul Starr’s The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (1982). Starr develops the concept of corporate medicine into a broader description of a “medical-industrial complex” that has arisen since the creation of Medicare in 1965. For Starr, this system included a higher proportion of for-profit hospitals, a concentration of medical facility ownership, and regulatory power that has shifted from community boards to national corporations. Starr also connects the rise of corporate medicine to reduced physician autonomy. ¹⁴ The author squarely repositions health care as a transformative economic activity with clear implications for American cities, especially those already under pressure from urban “blight” and federally sponsored strategies for urban renewal.

Supplementing Starr’s work in the early 1980s is Harry Dowling’s 1982 highly critical multicity comparative study of Boston, Baltimore, Chicago, and Washington, D.C., City Hospitals: The Undercare of the Underprivileged. Dowling examines the challenges faced by urban-based public hospitals and traces the transformation of these institutions from social service facilities to modern medical facilities, a transformation that saw these hospitals become less responsive to political and community pressures with an attendant decline in medical care for the most socially and medically marginal populations. While in many respects still a traditional study of institutions, Dowling’s attempt to place each of his cases within specific urban settings represented an important contribution. ¹⁵

Further developing urban health care’s commercial transition is Rosemary Stevens’s panoramic synthesis, In Sickness and in Wealth: American Hospitals in the Twentieth Century (1989). Echoing Dowling, Stevens argues that the central tension in the development of modern medical centers has been the conflict between the hospital’s traditional role as an institution of community service and its behavior as an income-maximizing commercial entity. Indeed, Stevens views America’s highly segmented system of hospitals and medical centers as a reflection of the values and mores of the larger society and that the stratification of the system’s patients into private, semiprivate, and charity cases reflects the larger stratification of American society generally. As Stevens makes clear, health care (as an industry) has functioned very well in the production of medical care and services—but has distributed it very badly to the populations most in need. ¹⁶

Both case studies and more synthetic analyses have focused on the role of the state in hastening the growth of the health care industry and in shaping inner-city health services and the landscape of urban public health generally. ¹⁷ This state-centered scholarly literature has tended to chronicle a distinct set of urban transformations (particularly for the period beginning in the 1960s): the expansion of lawmakers’ efforts to address the problems of the poor and ethnic and racial minorities, the changing relationship between citizens and the state, evolving notions of individual “rights” including the right to health care and to healthy living spaces, the value of individual lives as a regulatory matter, and the general place of prevention within what James Colgrove has termed the “country’s technocratic and curatively-oriented medical regime.” ¹⁸

Beatrix Hoffman’s recently released Health Care for Some: Rights and Rationing in the United States since 1930 (2012) frames the general role of the state in a way that is quite useful for urban historians, particularly those looking at race, class, and the provision of health services: to explore recent reforms as complex exercises in burden shifting, exercises that showcase another aspect of service distribution and allocation. Burden or cost shifting occurs when one individual, group, or government “underpays” for a service, thus leaving other individuals or entities “overpaying” for the same service. Hoffman argues that the maldistribution and rationing of health care have always been a defining feature of the U.S. system, and that the role of the state and large institutional actors (most notably the insurance industry) has made profound inequality, an almost inescapable element of the U.S. approach to health care. ¹⁹

Almost as a case study of the burden shifting outlined by Hoffman, there is Eileen Boris and Jennifer Klein’s recent Caring for America: Home Health Workers in the Shadow of the Welfare State (2012). This study illuminates the country’s uncoordinated, often chaotic programs for home care for the needy, elderly, and disabled, showing the extraordinary disadvantages home care workers have endured even as their charges rely less on state-run institutions. ²⁰ Boris and Klein’s study underscores a common theme that runs through much of the literature: the extent that both consumers of health care and health care workers bear extraordinary burdens to alleviate both the state and the upper classes from establishing more meaningful, comprehensive responses to the disparate health care crises that haunt urban America since the 1960s and before.

Beyond the issue of burden shifting, recent studies have continued to showcase the importance of public versus private responses to urban health issues. See Jennifer Klein’s For All These Rights: Business, Labor, and the Shaping of America’s Public-Private Welfare State (2003) and Jacob Hacker’s The Divided Welfare State: The Battle Over Public and Private Social Benefits in the United States (2002). ²¹ Urban historians have long known of the complex role of post–World War II federal policy in driving the direction of urban development. These studies suggest that the state has had an equally important role in shaping the public–private workings of the health care industry, particularly in key areas such as labor relations and the provision of health benefits.

State and municipal governments likewise bring public power to bear in establishing boundaries and barriers for the emerging health care industry and its capacity to achieve broad health outcomes in cities. For example, in his study of the New York City Department of Health in the 1960s, James Colgrove ²² has noted the institutional limits of health reform, even in one of the country’s most “liberal” cities, with special focus on the role of professional medical authorities versus community or grassroots activists. This and other studies showcase the significance of government “insider” discourses, program design, and electoral politics often in contrast with the views of “outsider,” grassroots, or other nongovernmental actors in shaping large-scale health care policy making as it relates to cities. ²³

For both urban health care workers and those who receive essential health care services in cities, the historical literature showcases the ongoing importance of class conflict and cooperation. One of the thematic staples of this literature has been unionization among urban health care workers. One of the essential explorations of this subject has been Leon Fink and Brian Greenberg’s groundbreaking and recently updated work, Upheaval in the Quiet Zone: 1199/SEIU and the Politics of Healthcare Unionism. The history of 1199 is especially interesting because of the preponderance of female and minority workers that helped build the union. Relatedly, some scholars have focused on organized labor’s history of health care reform advocacy and activism, a decidedly mixed legacy as Fink and Greenberg note, where urban and regional contexts clearly matter. ²⁴

The urban health care experience for minorities has been understudied, particularly for the post–World War II era. Recent explorations, however, have, showcased key linkages between class and race in magnifying or ameliorating urban health problems for disadvantaged groups and communities. Of note are the studies of Vanessa Northington Gamble, especially her monograph, Making a Place for Ourselves: The Black Hospital Movement, 1920-1945 (1995), which examines the special role of black medical and hospital associations in the creation of separate medical facilities for African Americans in America’s larger cities. Gamble’s examination of Cleveland, Chicago, and Tuskegee demonstrates how the black hospital movement reflected the state of race relations in the country at large as well as the goals, aspirations, and class tensions that existed within black communities. ²⁵ While not focusing on the urban experience explicitly, Colin Gordon’s Dead on Arrival: The Politics of Health Care in Twentieth Century America (2003) provides a useful overview of health care in the African American community, addressing issues of segregation in medical centers and in the medical profession from the 1880s to the late twentieth century. ²⁶

These works, as with much of the literature discussed so far, treat cities largely as a backdrop rather than as an intricate ecosystem that, by its nature, shapes the economic activities, the social actors, and power dynamics that have remade the medical landscape in the last half century. Cities, either specific cases or the urban context broadly understood, are absent or their role assumed. Some recent studies have attempted to pull together these elements. For example, more central to the black urban experience are specific case studies involving health care in well-contextualized urban settings. David McBride’s groundbreaking work, Integrating the City of Medicine: Blacks in Philadelphia Health Care, 1910-1965, illuminates the contradictions of a community that was pacesetting, with its two black hospitals, Mercy and Douglass, and yet lagged behind other cities. The author also powerfully illustrates how one disease (in this case tuberculosis) and the promotion of the message that “germs had no color line” can alter prevailing attitudes toward health care inequality and segregation more generally. ²⁷ Recent works have also showcased the role of community organizations and direct-action protest groups in channeling much-needed health care services and resources to the African American community. In Body and Soul: The Black Panther Party and the Fight against Medical Discrimination, Alondra Nelson argues that the development of health programs by the Black Panther Party was part of a shift in emphasis from self-defense to self-help, and places the creation of the Party’s health care programs in the larger context of health care activism common to cities during the 1960s and 1970s. ²⁸

Beyond the African American experience, the study of other ethnic or racial groups is largely absent from the literature. Asian and Hispanic city dwellers have received little or no attention. ²⁹ Guian McKee’s study of Boston’s Chinese community in the current volume suggests that the urban health care experience of Asian Americans can follow very different historical trajectories than other ethnic groups, particularly as these communities shift from a struggling dependency to genuine political power.

Since the late 1990s, there has been a wave of new scholarship (much of as yet unpublished) exploring health care through the lens of race and class in specific urban contexts. Of special note to urban historians are studies showcasing the complex (and often counterintuitive) role played by public and private hospitals and for-profit and not-for-profit institutions—and the urban communities they serve. In 1999, for example, Sandra Opdycke’s work, No One Was Turned Away: The Role of Public Hospitals in New York City since 1900, went beyond traditional institutional studies to conduct a richly contextualized comparative look at New York City’s Bellevue Hospital and New York Hospital. She explores the tensions faced by public and private hospitals as they felt the economic effects of the transformations charted by Starr. While patient care is at the center of each discussion, Opdycke also covers relations with medical schools, the impact on the community, gender and race issues, working conditions, and responses to developments in health insurance. As we will see in the accompanying essays, one of the central health care stories of the last half century has been the transformation of hospital missions, the communities being served, and their roles as charities, political actors, and job creators. ³⁰

As urban economic actors, the health care industry impacts workers and families in distinct ways. For this and other reasons, gender has special relevance for urban historians looking at the transformations that have occurred in urban health care. As a workplace, the health care industry presents a very class- and gender-polarized setting, one where the highest paid workers (doctors, administrators, professors, and specialized staff) have historically been dominated by highly educated, well-paid white men. While these higher echelon workers now show more ethnic and gender diversity than in the past, the lingering effects of historical, social, and economic discrimination are still quite evident. Relatedly, the gender and class profile of unskilled or semiskilled health care workers (nurses, aids, office, food service, and custodial workers) contrasts markedly with that of managerial and higher skilled and higher educated workers. The history of nursing and health care work showcases these differences, particularly in studies by Deborah Judd, Kathleen Sitzman, and G. Megan Davis, along with the studies already mentioned by Eileen Boris and Jennifer Klein, among many others. ³¹ For urban historians, one of the most interesting (and yet largely underutilized) studies involving hospitals and women in urban settings is Barbra Mann Wall’s American Catholic Hospitals: A Century of Changing Markets and Missions. While in most respects still a traditional study of institutions, Wall’s approach to gender, religion, and the impact of the state on religious hospitals in post-1950 America does bring in the transformation of the health care industry itself. Her study examines the ongoing tension between religious hospitals and their mission to minister to the needy and the demands of market competition and intensifying secularization. ³²

These studies and others substantively advance our understanding of the critical role hospitals and medical centers can play in transforming communities and asserting themselves into larger discourses on urban development. However, like much of the existing literature, the role of the emerging health care industry as an industry is either missing or only vaguely presented. Large-scale economic actors matter in cities, and in the last fifty years, hospitals and medical centers with their attendant high-tech and higher ed partners have recast many inner-city economies and reimagined whole communities. They have also asserted themselves into racial, ethnic, and gender relations in both new and traditional ways. Many of the essays in this special issue place these dynamics at center stage.

Looking Ahead

The existing literature poses distinct questions for historians looking at the evolution of an urban health care industry and its impact on cities. As municipal hospitals, medical centers, and their ancillary services have overtaken whole neighborhoods in some cities, the themes of physical change and landscape transformation should receive more attention. Urban historians have long studied cities as arenas of extraordinary visual and structural creativity and destruction both for planners and policymakers, on one hand, and average city dwellers of all classes and races on the other. Four of the contributions in this issue explore important dimensions of these processes. In “The Hospital City in an Ethnic Enclave,” contributor Guian McKee presents a thought-provoking example of largely state-supported urban change in his study of the Tufts-New England Medical Center’s expansion into Boston’s Chinatown neighborhood. Indeed, McKee’s central argument should shake many a historian’s proclivity to view state actions as somehow one-directional. In Boston, federal officials did not simply impose policy from above but instead, the hospital construction programs emerged as part of local redevelopment strategies conceived with the explicit goal of building a new political economic order in the city. Yet McKee also shows that community members contested aspects of these local policy strategies and, at least in some cases, shaped their trajectories.

Catherine Conner’s essay explores the meanings of race, citizenship, and democracy in relation to a similar economic restructuring in postwar metropolitan Birmingham, Alabama. In “The University that Ate Birmingham,” Conner explores the development of the local professional service economy, anchored by the University of Alabama at Birmingham and its medical center and certain private-sector actors. Conner shows that the expansion of health facilities was central to the “progressive” vision for the city articulated by an evolving biracial coalition, and that the politics of progress enhanced political self-determination for black residents of urban neighborhoods. At the same time, however, it also narrowed longer term economic opportunities to favor an educated suburban middle class.

Another critical area urban historians need to examine is the long-term decline of the urban tax base as reflected in the extraordinary expansion of health care facilities and the attendant withdrawal of large parcels of land from the tax rolls. Andrew Simpson brings clarity and insight to this topic in his essay, “We Will Gladly Join You in Partnership or See You in Court,” an examination of the growing imbalance of power that has emerged in Pittsburgh between large not-for-profit health care employers and local government, as elected officials struggled in the late 1980s to react to the precipitous decline in the city’s traditional manufacturing economy and the attendant decline in tax revenues to fund critical infrastructure, education, and antipoverty programs.

Supplementing this series of case studies is Guenter Risse’s firsthand account of his experience as an administrator and department head at the University of California–San Francisco’s medical center during a time of tremendous expansion into other urban neighborhoods, a shift accompanied by institutional upheaval, social dislocation, and protest. Risse’s unique perspective showcases how large institutions and powerful political actors can “accommodate” both internal and external forms of protest and resistance and still achieve their goals.

The state’s role in shaping health care in the city requires more attention, especially as the country goes through the largest transformation in the federalization of health care services with the gradual implementation of President Barack Obama’s Patient Protection and Affordable Care Act of 2010. The need is great here for urban historians to have a clearer understanding of how state and federal programs have functioned and how remote administrators, constituencies, and other political actors have transformed and adapted over time. Two of our contributors, David Rosner and Gerald Markowitz, are among a small set of scholars who have developed this area of historical inquiry as it relates to the history of urban health care policy. ³³ While several of the studies in this issue examine the role of the state, Rosner and Markowitz bring special focus to it in their study of the programmatic conflicts that developed on the federal level between the Department of Housing and Urban Development (HUD) and the U.S. Department of Health in their divergent views of housing pollution and remediation.

In the issue’s concluding commentary, eminent health care scholar Guenter Risse develops further the importance of these essays and their implications looking forward.

The growth of the health care industry and its impact on American cities has been one of the most fundamental economic shifts in recent urban history; and urban historians must begin to integrate this development into larger syntheses and into our understanding of urban social change, particularly since the advent of Medicare in the 1960s. The evolving role of the state here is critical, complex, and often counterintuitive. Its importance is further heightened as policymakers, legislators, and other stakeholders look increasingly (and often uncritically) to the health care industry for long-term and sustainable job growth in the twenty-first century.

Given the recent history of health care, are these expectations warranted? In her classic 1961 study, The Death and Life of Great American Cities, Jane Jacobs outlined many key elements of what made cities livable, vibrant, and welcomingly diverse places for average people and families. In her time, Jacobs attacked the distorting and dehumanizing impact of federally promoted high-rise public housing developments and their dehumanizing and dislocative capacities. ³⁴ As sprawling medical and university centers claim more urban space, how will they affect these and other ecosystemic issues? Relatedly, in what ways does the emerging health care industry impact and interact with other urban trends such as gentrification, the decline of infrastructure, privatization, disinvestment, and key policy areas such as public transportation, taxation, and housing? If indeed the health care industry is going to revitalize or “renew” inner cities, in what ways can underserved communities capture more of the benefits of this change and minimize the destabilizing impacts? As medical centers and health care services become more internationalized, what are the implications for original host cities, their communities, workers, and families? To the extent possible, urban historians must bring forward the lessons from the past to address these and other questions while those lessons can be most fruitfully applied.