Third world medicine in first world cities: capital accumulation, uneven development and public health.

This paper addresses issues of public health and access to care for the urban poor in the context of current U.S. urban, economic and industrial policy. The pathologies that threaten "inner city" neighborhoods are the result of decades of political neglect, economic exploitation and resource withdrawal, which themselves stem directly from public and corporate sector strategies to facilitate capital accumulation and consolidation. The resulting conditions of uneven development between wealthy and impoverished local sectors mirror similar relationships between First and Third World countries. These same patterns are reflected and reproduced in the health care "industry" itself, where growing corporate dominance has developed alongside a concomitant reduction in support for public sector and community-based care. These trends create and exacerbate conditions that place poor and minority populations at risk. Community development and political empowerment, as well as the overall corporate hegemony that increasingly characterizes the political economy of the U.S.A., are essential public health considerations that must be included in any meaningful health policy or health care reform proposals.

Unhealthy cities: corporate medicine, community economic underdevelopment, and public health.

The growing corporate dominance in U.S. medical care has been a major factor in the increasingly inequitable distribution of health care resources and the declining public health conditions in poor and minority urban communities. Alongside this trend has been a parallel phenomenon of economic disinvestment and political neglect in these same at-risk neighborhoods. This article analyzes these trends as related components of austerity, retrenchment, and capital consolidation policies that have characterized the U.S. political economy for several decades. Emphasized are the relationships among corporatization, capital consolidation, deindustrialization of the workforce, and medical indigence; the resulting economic stress placed upon community hospitals and other caregivers in poor and minority communities; and the marked discrepancy between conditions of development and underdevelopment in American cities. It is argued that the effects of these policies are pathogenic in nature: they place populations at risk for disease and social dysfunction, they reduce access to necessary preventive and curative services, and they weaken coping mechanisms. Community economic development, empowerment, and a direct challenge to the growing concentration of wealth and power in the corporate class are proposed as essential elements of public health policy.

Hospital and community characteristics in closures of urban hospitals, 1980-87.

Characteristics of 190 urban community hospitals that were closed during the period 1980-87 and characteristics of the communities that they served were analyzed and compared to a control group of 380 urban hospitals that remained open. A negative association was found between hospital closure and four hospital characteristics: the presence of a cancer program approved by the American College of Surgeons, the combined characteristics of for-profit status and membership in a multi-institutional chain, the number of admissions, and the number of facilities and services offered. A positive association was found between hospital closure and the percentage of black residents in the community. These findings are discussed in the context of political and economic trends in health care and urban development. Implications for future research are noted, including managerial strategy for hospital administrators and the socioeconomic implications of hospital survival in declining urban communities.

Improving public health care: lessons on governance from five cities.

Policy-oriented investigations into public health care delivery have been limited, especially during the Reagan era of competition and profit-based health care, when the inner city was essentially forgotten. In this study, policymakers toured five urban public health care systems in different parts of the country to promote consideration of a new governance for Chicago and Cook County's complicated and uncoordinated care for the medically indigent. A comparison of patterns of governance revealed strengths and weaknesses of each model. Local leadership and the political will to evolve a system of care, with clear connections between the public and private sectors, account for each city's relative success in addressing mounting needs of inner-city populations.

Public health care delivery in five U.S. municipalities: lessons and implications.

Increasing pressures on private and public hospitals have necessitated a reassessment of urban health care delivery. Patients left unserved by stressed private hospitals have placed a greater burden on public institutions, which themselves are often old, underfunded, and in danger of closure. As policy analysts consider remedies, primary care in community-based settings has reemerged as an important component of planning. We present results of a comparative analysis of five public health care delivery systems (Boston, Dallas, Denver, Milwaukee, and Seattle), reflecting their economic, political, and cultural dynamics. Although significant differences in the relative centralization of care and reliance on community-based clinics are evident, the five cities discussed have incorporated an increased emphasis on preventive and primary care. The diversity among the systems is highlighted; adaptability is apparently a vital component in designing a public health care system appropriate to the needs of particular communities. Implications for Chicago and other cities are discussed.

Rural hospital survival: an analysis of facilities and services correlated with risk of closure.

To test whether the facilities and services offered by rural hospitals can put them at risk of closure or protect against it, this study compares U.S. rural community hospitals that closed during the period 1980-1987, with a matched set of hospitals that remained open. Utilizing epidemiologic matched case-control methods and controlling for type of ownership, we found that (1) physical therapy, respiratory therapy, intensive care unit, computed tomography scanner, hospital auxiliary, and diagnostic radioisotope were negatively correlated with closure (i.e., had a protective effect); (2) the facilities and services correlated with risk of closure differed significantly between the pre-PPS (1980-1983) and post-PPS (1984-1987) periods; and (3) the presence of a skilled nursing or other long-term care unit was a significant risk factor during the period 1984-1987. Implications of these findings for hospital survival strategies and rural health care delivery under PPS are discussed.

Rural community hospitals and factors correlated with their risk of closing.

The issue of rural hospital closings in the United States in recent years has become of increasing concern to health care policy analysts. Rural communities face unique health needs, necessitating access to local health care. Much has been written about the social, economic, legislative, and technological changes that have increased the stress on rural hospitals in the 1980s. However, quantifiable models have been lacking with which to examine in detail factors associated with rural hospitals and to correlate such factors with individual hospitals' risks of closing. In this study, we identify variables correlated with rural community hospital closures in the period 1980-87. Using epidemiologic case-control methods, 161 closed rural hospitals were matched 1 to 3 with a control group of 483 rural hospitals which remained open during the same period. A series of hospital performance indicators and demographic, economic, and social community variables were entered into a multiple logistic regression model. Four variables were found to be positively correlated with risk of closure. They are for-profit ownership; nongovernment, not-for-profit ownership; presence of a skilled nursing or other longterm care unit; and the number of other hospitals in the county. Variables negatively correlated with risk of closure were accreditation by the Joint Commission on the Accreditation of Healthcare Organizations, the number of facilities and services, and membership in a multihospital system. Policy and research implications at the Federal, State, and local levels are discussed.

Hospital closure: management and policy issues.

As hospital closures have increased between the years 1980-1987, it has become essential for hospital administrators to be aware of the effects of an increasingly complex and competitive environment on their institutions. The purpose of this paper is to examine variables correlated with risk of closure, and to use these data in a context to suggest a managerial approach that will minimize risk. The open systems perspective, which emphasizes uncertainty as an essential component of the planning environment, is suggested as the optimal managerial approach.