Homes or hospitals? Contradictions of the urban crisis

Medical expansion is threatening to eliminate many urban residential areas, despite criticisim that argues for comprehensive planning, reduced costs, less concentrated power in the health sector, and a reversal of "medicalization." Our research on expansion, which grew partly from personal participation in a local struggle against expanding institutions in Boston, revealed certain tensions in combining sociomedical research with concrete political practice. From events in Boston and from an exploratory review of periodicals, we recognized that medical expansion and community conflict occur frequently in cities throughtout the United States. Based on general theoretical perspectives from organizational analysis and political economy, we made several hypotheses that we tested through a questionnaire sent to all hospitals in the 20 largest cities of the United States and through other data available on the same hospitals. In large part, this empirical study confirmed our theoretical expectations that (a) larger medical centers show a greater tendency toward territorial growth than smaller hospitals; (b) bureaucratic and administrative dynamics lead to facilities that do not necessarily enhance patient care; (c) despite short-term cycles of expansion and contraction in public hospital growth, expansion projects are widespread and generate considerable political conflict; (d) because of the state's contradictory roles in regulation and social capital expenditures, opposition to medical expansion comes more from community organizations than from governmental monitoring or planning bodies; and (e) the needs of capital determine that medical expansion has a more detrimental impact on housing than on commercial or industrial facilities. Future expansion of private medical facilities is more likely than that of public facilities, although much private expansion may receive public subsidization. As ideologic patterns are demystified, the contradictions between medical expansion and housing needs can provide a focus for successful community organizing.