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Introduction
Making the Medical Metropolis
In 2008, the University of Pittsburgh Medical Center (UPMC) hoisted its logo atop the U.S. Steel Building, symbolically declaring that the era of big medicine had replaced the era of big steel in Pittsburgh. Since its creation in 1990, UPMC has become the largest private employer in the Commonwealth of Pennsylvania, with more than eighty thousand employees and steadily growing revenue—now well over $15 billion per year. The transition between an industrial economy and a service economy strongly grounded in health care is now central to how Pittsburghers see the identity of their city for the next century.
More than 1,200 miles to the south, in Houston, Texas, health care is also playing a critical role in that city's ability to navigate changes in the global economy and plans for the future. In April 2008, Forbes.com named Houston one of the ten "recession-proof" cities in the United States. While this glowing projection did not come to pass, Houston was able to better weather the most recent economic downturn, actually gaining more jobs by 2010 than it lost in the Great Recession. Oil and natural gas remain important, but the health care and the service sectors also play a critical role in Houston's economy. Since 2007, health care employment has risen by more than 20 percent, and the Texas Medical Center, located only a few miles from downtown, is touted as the "largest medical complex in the world." In 2018, information released by its management organization, TMC Inc., claimed the medical center alone had in excess of 106,000 employees and more than "$3 billion in medical construction projects underway." They also claimed that medical center hospitals had ten million "patient encounters per year, 180,000+ annual surgeries," and three-quarters of a million emergency room visits a year. Like in Pittsburgh, a booming health care sector is critical for how Houstonians see their city's future.
Both Pittsburgh and Houston have emerged as national models for how to build an economy for the postindustrial era. According to pundits and scholars, their "formula" for success is easy and replicable: focus on economic diversification by building strong medical, educational, and applied research sectors through links with hospitals and universities; make older core industries more efficient through automation; attract and retain a young, educated, upwardly mobile workforce by investing in quality-of-life amenities; and draw civic leadership from a new generation of young, hip politicians who can relate to this new "creative class."
Other cities, like Evansville, Indiana, are paying attention. Evansville is located roughly three hundred miles down the Ohio River from Pittsburgh, and over the last several decades, this city of around 120,000 people has lost longtime manufacturing employers like Whirlpool and experienced the boom and bust of the extraction economy (coal). However, it has many of the same features as Pittsburgh and Houston, including multiple universities, an established community college system, and, since 2014, an extension campus of the Indiana UniversitySchool of Medicine. Leaders are promoting these assets by using a civic reinvention narrative that echoes the rallying cry shouted by civic elites in larger cities, claiming that by becoming a regional center for health care delivery and medical education, along with other investments in higher education, finance, and new housing, Evansville will be able to attract and retain a younger population and finally share in the seeming prosperity of the health care-oriented postindustrial city.
This reinvention narrative relies on a flattening of history. In it, hospitals and universities are treated as bit players who suddenly step into a starring role when the lead actors suffer an untimely demise. Its heroes—the elected officials, leaders of not-for-profit health care organizations, and educated in-migrants affiliated with local universities and health care systems—are "visionaries" who make the bold and uncontroversial choice to prioritize the development of advanced research and health care as the new engines of economic development. Reinvention is a foregone conclusion. While this story contains essential elements of truth, it also obscures as much as it illuminates. Almost no attention is given either to the long-term development of not-for-profit hospitals or universities, their changing relationship to American capitalism, or the public policy choices that shaped their development before the moment of economic reshuffling.
This book traces how health care helped to build the postindustrial city into what I call the "medical metropolis," a city where health care plays a dominant role in its economy and identity. From the 1940s to the present, civic elites, including civic development groups, elected officials, not-for-profit health care administrators, and individual physicians, have worked to build a new identity for each city as a site for cutting-edge biomedical and clinical research, medical and health professional education, a home for innovative health care business practices, and centers for quality patient care. The transformation of both Pittsburgh and Houston into medical metropolis is rooted in the changing business environment. Not-for-profit health care emerged as a multi-billion-dollar business at the very moment when the postindustrial turn was reshaping the broader U.S. economy. The medical metropolis is not an accident. At the heart of the process of making it is a set of choices with consequences, both intentional and accidental. Choice matters not only for understanding the actions that built the medical metropolis, but also for understanding how and why these actions often ignored or fell short of creating an economy and city that fully served all residents.
The Medical Metropolis is the first comparative historical study of the evolution of academic medical centers, the business of not-for-profit health care, and the effect of using hospitals as a cornerstone of urban economic development across multiple cities from 1945 to the present. Urban historians have been more attentive to the ways that health care shapes the city than historians of medicine, but within both fields, there is more work to be done. One important new direction is to examine the synergistic relationship between the business of not-for-profit health care and urban development. Doing so reminds us that both private markets and public policy matter for understanding why change over time occurs.
Examining the intersection between private markets and public policy also requires exploring the dynamic relationship between health care payment and health care policy—a nexus which has been a particularly fruitful area of study for several generations of historians of medicine, but that only recently has been examined the 1980s and beyond in sufficient detail. By detailing the growth of specialty medical services such as cardiovascular surgery and transplantation medicine, this book shows how these not only contributed to the civic identity of Pittsburgh and Houston but also how specialty medicine became a lucrative business that imported patients into each city and exported the clinical knowledge and business acumen of not-for-profit health care institutions and their famous physicians.
It also examines the relationship between not-for-profit health care and efforts to use biomedical research to help reinvent the postindustrial city. Biotechnology became a way to bring together civic elites, elected officials, and not-for-profit health care into a conversation about what the future of the medical metropolis should look like and how to share the responsibility to achieve this vision. While biotechnology has failed to meet its lofty expectations in both communities, nevertheless it has played an essential role in rebranding each city as a global center of innovation, which has attracted a wide range of other technologically focused investments.
The Medical Metropolis contributes to an emerging debate about the growing role of not-for-profit institutions in modern American communities, though less attention has been paid to their history in the post-World War II era. This book examines these institutions in two critical ways. The first is by showing why large not-for-profit health systems are created and how they grew in the 1980s and beyond, including building affiliation networks, showing why large health systems sought merger partners, and illustrating how some grew through acquisition. This provides context for the book's second contribution to the debate about not-for-profit community responsibility—examining demands by elected officials on not-for-profit health systems to provide more reduced cost patient care, as was the case in Houston, or make payments in lieu of taxes to cash-strapped cities, as was the case in Pittsburgh. Each of these stories shows the tension that occurs when health care institutions, seen as "a once charitable enterprise," grow to become a foundational part of the modern urban economy.
At the heart of this story is what I term the hospital-civic relationship. This idea is shorthand for the theoretical and practical relationship between civic elites, not-for-profit health care administrators, physicians, elected officials, and ordinary citizens with not-for-profit health care institutions. This is a dynamic relationship that evolves from a model where hospitals and health care supported the growth of the industrial city in the early postwar years to a more market-oriented vision by the end of the century. It is also a relationship that is deeply contested and reflects the goals, priorities, and values of each party.
I use "hospital" in this formulation because not-for-profit hospitals are the most visible way that most residents of the medical metropolis relate to health care. Academic medical centers have emerged as a triumph of modernity and a symbol of what the American health care system can accomplish. They are often a focal point of community identity and a potent symbol of modernity. At the same time, to urban residents displaced by their expansion, used willingly or unwillingly as clinical material, or denied their services because of an inability to pay, they are symbols of the excesses of capitalism and the persistent racism and injustice that still scar the face of the American city. Not-for-profit health care also includes medical schools, insurance companies, and physician practices. Not all of these have received sufficient attention from historians, and this book touches on the contributions of each. Making the Medical Metropolis draws from existing literature in the history of medicine and business history, as well as a robust and growing literature about the history of community medicine, to examine how business decisions and social justice concerns intersected around issues of health.
Why Pittsburgh and Houston?
Today, not-for-profit health care is a major employer in several major American cities besides Pittsburgh and Houston, including Cleveland, Baltimore, Atlanta, and Chicago. Health care has also helped to provide these cities with a new way to market their postindustrial identity. Simply fly into their airports and the traveler is confronted with an eye-popping number of advertisements linking health care, innovation, and future urban growth. So, if the health care economy is now touted as part of the solution for postindustrial inequality, then the lack of attention paid by historians to its development is an oversight which should be corrected if we want to plan for a just and sustainable economic future. By using a case study approach that focuses more deeply on two cities, I hope to provide insight that historians, policymakers, and citizens can apply to conversations about their own city's past and present.
Even as the medical metropolis is marketed as the future of these cities, their deep roots in the older industrial economy are still strong. Pittsburgh's nickname remains the "Steel City"—branding which still appears frequently on everything from T-shirts to the names of numerous businesses. Even the three "diamonds" in the logo of the city's professional football team, the Steelers, represents the three critical elements of steel making (coal, iron, and scrap steel), and helps to tie that team to the region's past. In Houston, while the Oilers may have given way to the Texans, the extraction economy and the city are still synonymous.
There are, however, a number of reasons why these cities work as units of analysis. Perhaps the most important is that they are broadly representative of the historical and geographical trends that converged in other cities to help make the medical metropolis. I didn't always assume this was the case. In fact, when I began this project, I assumed that city had a widely different story. Pittsburgh, after all, is a fading industrial city located in the heart of the Rust Belt, whose recent history is marked by decline, population loss, and much-touted, but still uneven and incomplete, reinvention. Houston is a growing Sun Belt city that, since World War II, has struggled more often with managing the problems of growth than those of decline. Instead, what I found was that while local differences do matter, broad national forces such as medical reimbursement streams, federal biomedical research monies, and individual decisions made in the private medical market by physicians, hospitals, and consumers played a homogenizing role in making the medical metropolis. A focus on health care also helps to enrich a growing literature on the rise of service sector jobs over manufacturing ones and high technology over heavy industry as part of the development of a broader neoliberal project.
Access to archival and other primary sources also played a central role in determining my choice of cases. In both cities, there is a rich array of archival sources that help to tell the story of making the medical metropolis. With a bit of searching, it is possible to access at least some records of large not-for-profit health care organizations, as well as the papers of the individual physicians and administrators who provided these organizations with leadership. Access is, of course, easier for the more distant past than the present. However, as new collections of personal and institutional papers are being added to area archives at a rapid pace, the documentary record continues to grow and will enable future generations of historians with more evidence to continue to tell the story of the medical metropolis as it evolves in the twenty-first century and beyond. Finally, I was the beneficiary of the generosity of numerous individuals and organizations, many of whom are named in the acknowledgments, who shared their time and their personal and organizational records.
An examination of both Pittsburgh and Houston also helps the reader to understand how national definitions of urban health and civic identity have changed over the course of the last seventy-odd years. Even though the way that an individual city's leaders and citizens choose to present it to the world is a deeply local choice, the decision to highlight certain sectors, like health care, as part of Pittsburgh's and Houston's national and international images reflects broader national values about social justice, economic competition, and the distribution of power. As more historians embrace the comparative case study approach, this question of the construction of civic identity in the post-World War II era is being engaged in more detail, which can help civic leaders and individuals committed to urban development to go beyond the platitudes of health care's civic contribution and think critically about how the business model for this sector can be reformed to build vibrant, just, and sustainable communities for the future.
The medical metropolis is not a product of chance or luck, nor did it suddenly emerge with the collapse of the industrial economy. For more than half a century, efforts to think critically about the role of health care and its relationship to the economic and physical health of the American city have played an important role in how civic elites, leaders of not-for-profit health care institutions and universities, and ordinary citizens have planned for the future. While these plans have often focused on the narrowly defined interest of each group, the consequences of their shared efforts, both intentional and unintentional, built the medical metropolis.
