How do Americans medicalize social problems?
Johns Hopkins Hospital's medicalized relationship with its East Baltimore community was typical in postwar America
By definition, the East Baltimore Medical Plan (EBMP) represented a medical approach rather than a comprehensive community development strategy. This meant that often the program could only indirectly address the underlying causes of medical problems that patients brought to the clinic. EBMP doctors and nurses quickly realized that they were treating the symptoms of larger social problems.
a medical approach rather than a comprehensive community development strategy
Robert Heyssel recognized this as early as 1972, when he told a Baltimore Sun reporter that “there are many problems of health in the community that medicine isn’t really equipped to solve because these are commonly social and economic problems. We can sew up the rat bite that comes into the emergency room, but we’ll be sewing it up the next night unless someone does something about the rat, the housing, the job problem, the education problem. Medicine as such isn’t the answer to most of these problems.”
'We can sew up the rat bite that comes into the emergency room, but we’ll be sewing it up the next night unless someone does something about the rat'
In 1977, EBMP medical director Ira Morris put the matter even more directly: “Many of our patients have social problems that override their medical problems.” He cited such examples as asthma attacks induced by poor air quality and a lack of access to air conditioning, chest pains in an elderly woman stressed by frightening encounters with teenagers skipping school, and high rates of obesity and hypertension caused by diet and inadequate access to affordable, healthy food. EBMP and Hopkins attempted to train service providers to address social and economic issues, but the underlying disjuncture remained.
the underlying disjuncture remained
In pursuing this relatively narrow, health care–based strategy for increasing its community engagement, Hopkins had medicalized its engagement with the neighborhood’s social problems. Such medicalization formed part of a much larger pattern in the postwar United States. Health care spending far outstripped funds allocated to poverty interventions or community development, and in neighborhoods such as East Baltimore, few nonmedical options remained for addressing these issues. Moreover, none of those other options had access to the capital or personnel available to academic medical complexes like Johns Hopkins.
Such medicalization formed part of a much larger pattern in the postwar United States
The ultimate effect was that the American state supplied public funding through an associational relationship with a nominally private health care institution, which in turn deployed a portion of those dollars to address, through health services, the highly racialized consequences of the poverty that the state—and society—otherwise chose to ignore. As a further source of tension in these relationships, Hopkins itself contributed to the community’s economic stress through the low wages that it paid to residents (and others) who worked at the hospital.
the highly racialized consequences of the poverty that the state—and society—otherwise chose to ignore
Even so, a critical question remains: why exactly did Hopkins choose to focus on the provision of health care services in East Baltimore rather than adopt a more comprehensive approach as called for by the Feinblatt report? In part, the answer is a simple one: the hospital was a health care institution, not a community development agency, and it was not clear that trying to serve as the latter was within the scope of its mission, its capacity, or even its social obligations. Yet this seemingly simple question about the extent of institutional responsibility lies at the core of any assessment of the role of academic medical centers as urban institutions.
the hospital was a health care institution, not a community development agency
Other considerations shaped the decision as well. Hopkins’s own financial position played a significant part, as the hospital ran annual deficits throughout the period and had to take out a series of loans against endowment to provide working capital. The provision of efficient basic health care services in a more appropriate environment than the hospital’s emergency room offered the promise of substantially improving Hopkins’s finances. In addition, by 1970 Hopkins operated in an aging and outdated facility that badly needed to be replaced or renovated. Such a project would require hundreds of millions of dollars. Much of this would be financed through debt, but doing this required capital reserves that had to be built by increasing the hospital’s revenues. Together, these factors meant that Hopkins’s leadership felt constrained, and even financially threatened, by a combination of costs and capital needs. Positioned in the often unclear nexus of private and public that constitutes the U.S. health care system and the associational state itself, administrators and trustees did not see any likely sources of significant outside aid for a comprehensive program. A focus on the provision of community health care services, in contrast, seemed realistic.
Hopkins’s leadership felt constrained, and even financially threatened, by a combination of costs and capital needs
Robert Heyssel and his team at the Hopkins Office of Health Care Programs, however, had another, much broader ambition: both the East Baltimore and Columbia programs reflected their intense interest in reforming the core system of health care delivery in the United States. They believed that nonprofit, prepaid group practices such as EBMP and Columbia could change the underlying incentives that shaped physician and patient behavior in ways that would make health care simultaneously cheaper and better. The model was part of a movement in the early 1970s to reorganize health care in the United States around such nonprofit organizations.
change the underlying incentives that shaped physician and patient behavior
Although this idea would soon be modified into a for-profit version by the Nixon administration, Heyssel and other liberals during the period saw prepaid, nonprofit group practices as an essentially progressive mechanism for delivering cheaper and superior care while expanding access. In a 1972 speech about EBMP to the Hopkins Department of Pediatrics, Heyssel observed, “I happen to believe that to move in the direction of a system of accessible, quality, efficient, equal as far as possible and economical care for everyone—regardless of former or present status, regardless of socio-economic status, regardless of place of residence, or of color—should be our goal as a medical center as well as the goal of the nation.” In both Columbia and East Baltimore, Heyssel pursued an opportunity to explore these ideas and goals in settings with vastly different populations.
Heyssel and other liberals during the period saw prepaid, nonprofit group practices as an essentially progressive mechanism for delivering cheaper and superior care
Yet the two programs ultimately highlighted the stark racial and economic divisions in the U.S. health care system and, more generally, in the emerging hospital city. EBMP’s financial structure contrasted starkly with that in middle-class Columbia: even with the involvement of Hopkins, significant private financing was simply not available in East Baltimore. The suburban, mostly white new city had access to the nominally private but tax-subsidized system that most Americans thought of as a health insurance market, while the racially and economically marginalized community relied on a jerry-built maze of public programs that struggled to provide new forms of health care to a subset of the racially and economically marginalized poor.
the two programs ultimately highlighted the stark racial and economic divisions in the U.S. health care system
This, in short, was what structural racism in health care financing looked like. Played out on a national scale, these contradictions would generate a renewed national debate over rationalization of the wider system—an effort that would fall prey to the constraints of cost and particularly the costs of hospital care. The racial disparities in health outcomes that resulted have plagued the United States into the twenty-first century.
Excerpted from Hospital City, Health Care Nation, published by University of Pennsylvania Press ©2023