534
INTERRACTION OF HOUSING AND HEALTH CARE INSTITUTIONS* BRUCE C. VLADECK, PH.D. President United Hospital Fund of New York New York, New York
IT WOULD BE PRESUMPTUOUS of me to attempt to summarize the day's discussion of urban decay and deterioration and their impacts on the health of people who live in cities, although I think the Academy is to be commended for this conference, focussing on these issues, and trying to see that they get some of the attention they so fully deserve. Obviously, one could look at the discharge data from any hospital in this city, or talk to the people waiting in emergency rooms, and identify the proportion who are in the health system because of housing-related problems of one sort or another. But while I have been asked to talk about the interaction between housing and health care institutions, I think that the impact of the former on the latter has already been well-explored today by people far more expert than I. Instead, I shall focus on the second part of my assignment, and consider the impact of health care institutions on housing. Health care institutions, especially hospitals, have been in the housing business for quite a long time -for many of them, in fact, as long as they have existed. As many of you know, the customary arrangement among early American hospitals in many parts of the country was to provide the superintendent and his wife with a very limited salary but with room and board on the grounds. Ever since, as we have gotten more sophisticated and as institutions have become more technologically advanced and professionalized, hospitals, to an extent matched by very few other institutions -although certainly universities come to mind-have seen it as part of their fundamental business to provide housing, in one form or another, both for students and trainees associated with the institution and for professionals who work there. If you look around this city, whether you talk about York Avenue or Haven Avenue or Bainbridge Avenue, you can readily see that hospitals, and to a *Presented as part of a Workshop on Housing and Health: Interrelationships and Community Impact held by the Committee on Public Health of the New York Academy of Medicine November 17 and 18, 1989. Address for reprint requests: United Hospital Fund, 55 Fifth Avenue, New York, NY 10003
Bull. N.Y. Acad. Med.
HEALTH CARE CARE INSTITUTIONS INSTITUTIONS-
HEALTH
535
smaller extent other health care institutions, are major landlords and major investors in housing. That role is, if anything, increasing. One could say the same thing, of course, about Boston or Baltimore or Detroit. One of the most interesting developments in this regard during the last several years has been the announcement from the city government of its plans to construct residences for nurses in conjunction with four Health and Hospitals Corporation facilities. The irony, of course, is that prior to the fiscal crisis of the 1970s, the Corporation operated a number of nursing schools, all of which had dormitories or residences available for some employed graduate nurses as well as for students. The point, though, is that the perception is now almost universal that it is impossible to recruit or to retain certain kinds of professionals in New York City, especially in certain parts of the city, unless one provides housing as well. Thus, even when experiencing increasing difficulties in financing the basic services they provide, hospitals and nursing homes and other providers of health services are increasing their commitment to the less than lucrative economics of providing housing. But second, in this city and a few others, there is a reasonably long history of hospital and nursing home and other institutional involvement in housing as a community development issue. The fundamental precept in that regard, which is not universally accepted or always believed but not narrowly held either, is that for an institution of any sort to be healthy it has to be in a healthy community, or at least a community that is getting healthier rather than deteriorating. In this part of the country, the institution most overt and explicit about that set of beliefs is probably Lutheran Medical Center in Brooklyn. Lutheran is the general partner in a housing development corporation that has been very active in housing construction and especially rehabilitation in the neighborhood served by the hospital, not to provide housing to members of its staff, but to promote the economic and social well-being of the neighborhood. Lutheran has also sponsored and operates subsidized housing for the elderly in its service area. There are other examples in this city and elsewhere, including Montefiore Medical Center and Presbyterian Hospital in New York, the Detroit Medical Center, the Greater Southeast Hospital in Washington, D.C., and Johns Hopkins. The most dramatic project currently under way is geographically quite close to the Academy, part of the modernization-really a euphemism for complete replacement of the physical plant -of North General Hospital at 123rd Street and Madison Avenue. The hospital owns roughly three square blocks from 120th to 123rd Street, one of which is occupied by the current Vol. 66, No. 5, September-October 1990
536 536
B.C. VLADECK B.C.
facility, which dates back to the earliest part of this century and is completely obsolete. Of the two remaining blocks, one will be the site of the replacement hospital, and the second will be occupied by roughly 200 units of mixed subsidized and unsubsidized housing, along with retail space and community facilities. The hospital will be a partner in the development of this latter site along with both government and private developers, and about a third of the housing units will be reserved for hospital staff. Not so parenthetically, the combined project will be the largest private construction project in the history of Harlem. Again, it is North General's very clear strategic expectation that the fate of the institution as a provider of health services and the fate of the community, at least as defined by the immediately surrounding area, are very much one and the same, and that provision of sound housing in the community is important to the hospital's well-being. On the other hand, it is also true that as participants in local housing markets, hospitals have sometimes been the enemy, rather than a source of assistance. Perhaps the most dramatic example, to the extent that it is really true, is the belief in at least some quarters that the Newark riots in 1967, in which 21 people were killed, were precipitated by the plans to build a medical school and teaching hospital in a residential area, requiring demolition of occupied housing. Certainly to this day there is still considerable bitterness between that medical center and its surrounding community over land use issues. More generally, in many parts of many cities hospitals tend to be both owners of large amounts of real estate and always in need of expansion. What is perhaps most galling to neighbors, of course, are the instances in which hospitals demolish sound housing stock to meet their ever increasing appetites for parking facilities. Communities that will mobilize politically to protect financially endangered hospitals and work actively to expand their services will then turn bitterly on them if they seek to expand their physical facilities in competition with local housing or business uses. The next generation of conflicts, by the way, some of which are already beginning, will have to do with hospital waste disposal. Given the increasingly stringent regulation of hospital waste, the economics of waste disposal, what appears to be the state of the technological art, and the political resistance to regional incinerators, hospitals and nursing homes are increasingly going to be forced to expand substantially and upgrade their existing incineration facilities or to build new ones. In at least one part of Manhattan, that process has already led to conflict at the community board level between the Bull. N.Y. Acad. Med.
HEALTH CARE INSTITUTIONS INSTITJTIONS
HEALTH CARE
537 537
hospital and elements in the community, and I suspect that is just a harbinger of conflicts to come. FUTURE DIRECTIONS
With all of the above as background, the pressing policy question, in the context of this conference, has to do with hospitals as providers of housing of last resort, a role they now often fulfill de facto. Whether they should continue to do so or seek to either plan and to expand such a role or to shrink it is the immediately relevant issue. An increasing proportion of the patient population not only in hospitals, but in public and private nursing homes, mental health facilities, and other health care institutions is comprised of people whose continuing stay in the institution is a result not of their immediate medical status but rather of there not being an adequate residential place for them in which whatever remaining continuing services they need might be provided. No one can give a precise number of the beds now occupied by people who remain in institutions primarily because they have no adequate place to live, but the number is surely substantial-perhaps as high as 3% of all acute hospital beds on any given day and higher proportions in other kinds of facilities. Those percentages equate to somewhere between many hundreds and 1,000 in the hospital sector alone, and hundreds of others in other facilities. This is occurring, of course, in a system already operating in excess of its effective capacity, in which people with acute medical needs are turned away or forced to wait 24 to 36 hours in emergency rooms because of the unavailability of inpatient beds. We are back -in New York City, but I suspect increasingly elsewhere as well -to the old conceptual question of the boundary between the health care system and other socioeconomic systems. That, in essence, is, I guess, the underlying theme of this entire conference. Let me just express my own views on the issue, in terms both of how we should proceed and how we are likely to, which are two entirely different things. First, it seems to me that a primary tenet of public health, particularly appropriate in this instance, is that not all problems defined as health problems have what we might define as health causes; that, in fact, a number of people who are ill need health care services because of problems rooted primarily in the nature of their housing circumstances or the nature of community decay where they live. That implies, in turn, that not all problems that present themselves as health problems to health care institutions are necessarily best solved, or are Vol. 66, No. 5, September-October 1990
538
538
B.C. VLADECK B.C.
VLADECK
indeed solvable at all, by health care interventions. Again, the long-standing public health principle is that if someone's problem is lead poisoning as a result of the character of the housing unit in which he lives, medical care may have some limited ameliorative effect, but the only cure for the disease is to deal directly with the problem of exposure to lead. On the other hand, whatever the origins of the problems that are presented to health care providers, many of them are still health care problems, and the health care providers must respond to them as such, regardless of their origin. Thus, the real question, from the point of view of policy choice, becomes one of comparative advantage, as it were, in dealing with these problems. To put this point another way, if the world were more rational we might be able to make a rational determination of the point at which we would expect health care institutions to be more involved in solving the underlying problems rather than being the recipients of problems arising in other parts of society. In such a world we would advise health care institutions to avoid involvement in problems other than those narrowly of health care, since it is all many of them can do to maintain adequate services in their principal stock in trade. On the other hand, health care institutions often do possess special resources to a greater extent than many other institutions, especially in our most afflicted communities. To begin with the issue especially critical in New York City -which is why, by the way, the housing problems of persons with AIDS will be addressed to such a large extent by health care institutions they have land. They often own real estate unencumbered by either complicated ownership patterns or in rem status and all that goes with it, and that land is often suitable for as-of-right construction of human service facilities, broadly defined. In addition to land, health care institutions also have access to capital, although that access is now increasingly threatened by financial difficulties in the institutions. While very few of the health care institutions in this city have any money, they still have borrowing capacity, particularly for certain housing-related activities. Once again, that capacity is not widely shared among other kinds of institutions. Health care institutions also have some concentration of managerial resources, institutional resources, and what might be called institutional infrastructures. They tend to be reasonably sophisticated about operating a payroll or maintaining relationships with banks or employing security services and so forth. Yet again, health care institutions in this city and elsewhere have enough Bull. N.Y. Acad. Med.
HEALTH CARE INSTITUTIONS
539
other problems occupying their concentration and their energy, and the financial advantages they may have had in the past are being rapidly depleted. In sum, if we really could develop a systemic and systematic strategy to deal with the problems that have been identified throughout this conference, although health care institutions would in some sense be major beneficiaries of a reduction in housing-related or housing-induced problems, it probably would not make a whole lot of sense to expect them to try to solve them. Other institutions and organizations in society could probably do it a lot better. The first priority ought to be to help health care institutions provide better health care. On the other hand, since we do not live in a rational world making rational systemic strategies, whether it is a good idea or not I can predict that the combination of the continuing decay of housing, the continuing spiral of neighborhood disintegration, and the continuing growth of associated health problems will not only keep health care institutions implicated in the provision of housing services, but, in fact, will generate still more activity on their part in the years to come. Whether or not one thinks that is a good idea depends primarily on whether one thinks there is a plausible alternative. In the absence of seeing such an alternative on the immediate horizon, I have a strong suspicion that second best in this regard is probably better than none at all.
Vol. 66, No. 5, September-October 1990
INTERRACTION OF HOUSING AND HEALTH CARE INSTITUTIONS* BRUCE C. VLADECK, PH.D. President United Hospital Fund of New York New York, New York
IT WOULD BE PRESUMPTUOUS of me to attempt to summarize the day's discussion of urban decay and deterioration and their impacts on the health of people who live in cities, although I think the Academy is to be commended for this conference, focussing on these issues, and trying to see that they get some of the attention they so fully deserve. Obviously, one could look at the discharge data from any hospital in this city, or talk to the people waiting in emergency rooms, and identify the proportion who are in the health system because of housing-related problems of one sort or another. But while I have been asked to talk about the interaction between housing and health care institutions, I think that the impact of the former on the latter has already been well-explored today by people far more expert than I. Instead, I shall focus on the second part of my assignment, and consider the impact of health care institutions on housing. Health care institutions, especially hospitals, have been in the housing business for quite a long time -for many of them, in fact, as long as they have existed. As many of you know, the customary arrangement among early American hospitals in many parts of the country was to provide the superintendent and his wife with a very limited salary but with room and board on the grounds. Ever since, as we have gotten more sophisticated and as institutions have become more technologically advanced and professionalized, hospitals, to an extent matched by very few other institutions -although certainly universities come to mind-have seen it as part of their fundamental business to provide housing, in one form or another, both for students and trainees associated with the institution and for professionals who work there. If you look around this city, whether you talk about York Avenue or Haven Avenue or Bainbridge Avenue, you can readily see that hospitals, and to a *Presented as part of a Workshop on Housing and Health: Interrelationships and Community Impact held by the Committee on Public Health of the New York Academy of Medicine November 17 and 18, 1989. Address for reprint requests: United Hospital Fund, 55 Fifth Avenue, New York, NY 10003
Bull. N.Y. Acad. Med.
HEALTH CARE CARE INSTITUTIONS INSTITUTIONS-
HEALTH
535
smaller extent other health care institutions, are major landlords and major investors in housing. That role is, if anything, increasing. One could say the same thing, of course, about Boston or Baltimore or Detroit. One of the most interesting developments in this regard during the last several years has been the announcement from the city government of its plans to construct residences for nurses in conjunction with four Health and Hospitals Corporation facilities. The irony, of course, is that prior to the fiscal crisis of the 1970s, the Corporation operated a number of nursing schools, all of which had dormitories or residences available for some employed graduate nurses as well as for students. The point, though, is that the perception is now almost universal that it is impossible to recruit or to retain certain kinds of professionals in New York City, especially in certain parts of the city, unless one provides housing as well. Thus, even when experiencing increasing difficulties in financing the basic services they provide, hospitals and nursing homes and other providers of health services are increasing their commitment to the less than lucrative economics of providing housing. But second, in this city and a few others, there is a reasonably long history of hospital and nursing home and other institutional involvement in housing as a community development issue. The fundamental precept in that regard, which is not universally accepted or always believed but not narrowly held either, is that for an institution of any sort to be healthy it has to be in a healthy community, or at least a community that is getting healthier rather than deteriorating. In this part of the country, the institution most overt and explicit about that set of beliefs is probably Lutheran Medical Center in Brooklyn. Lutheran is the general partner in a housing development corporation that has been very active in housing construction and especially rehabilitation in the neighborhood served by the hospital, not to provide housing to members of its staff, but to promote the economic and social well-being of the neighborhood. Lutheran has also sponsored and operates subsidized housing for the elderly in its service area. There are other examples in this city and elsewhere, including Montefiore Medical Center and Presbyterian Hospital in New York, the Detroit Medical Center, the Greater Southeast Hospital in Washington, D.C., and Johns Hopkins. The most dramatic project currently under way is geographically quite close to the Academy, part of the modernization-really a euphemism for complete replacement of the physical plant -of North General Hospital at 123rd Street and Madison Avenue. The hospital owns roughly three square blocks from 120th to 123rd Street, one of which is occupied by the current Vol. 66, No. 5, September-October 1990
536 536
B.C. VLADECK B.C.
facility, which dates back to the earliest part of this century and is completely obsolete. Of the two remaining blocks, one will be the site of the replacement hospital, and the second will be occupied by roughly 200 units of mixed subsidized and unsubsidized housing, along with retail space and community facilities. The hospital will be a partner in the development of this latter site along with both government and private developers, and about a third of the housing units will be reserved for hospital staff. Not so parenthetically, the combined project will be the largest private construction project in the history of Harlem. Again, it is North General's very clear strategic expectation that the fate of the institution as a provider of health services and the fate of the community, at least as defined by the immediately surrounding area, are very much one and the same, and that provision of sound housing in the community is important to the hospital's well-being. On the other hand, it is also true that as participants in local housing markets, hospitals have sometimes been the enemy, rather than a source of assistance. Perhaps the most dramatic example, to the extent that it is really true, is the belief in at least some quarters that the Newark riots in 1967, in which 21 people were killed, were precipitated by the plans to build a medical school and teaching hospital in a residential area, requiring demolition of occupied housing. Certainly to this day there is still considerable bitterness between that medical center and its surrounding community over land use issues. More generally, in many parts of many cities hospitals tend to be both owners of large amounts of real estate and always in need of expansion. What is perhaps most galling to neighbors, of course, are the instances in which hospitals demolish sound housing stock to meet their ever increasing appetites for parking facilities. Communities that will mobilize politically to protect financially endangered hospitals and work actively to expand their services will then turn bitterly on them if they seek to expand their physical facilities in competition with local housing or business uses. The next generation of conflicts, by the way, some of which are already beginning, will have to do with hospital waste disposal. Given the increasingly stringent regulation of hospital waste, the economics of waste disposal, what appears to be the state of the technological art, and the political resistance to regional incinerators, hospitals and nursing homes are increasingly going to be forced to expand substantially and upgrade their existing incineration facilities or to build new ones. In at least one part of Manhattan, that process has already led to conflict at the community board level between the Bull. N.Y. Acad. Med.
HEALTH CARE INSTITUTIONS INSTITJTIONS
HEALTH CARE
537 537
hospital and elements in the community, and I suspect that is just a harbinger of conflicts to come. FUTURE DIRECTIONS
With all of the above as background, the pressing policy question, in the context of this conference, has to do with hospitals as providers of housing of last resort, a role they now often fulfill de facto. Whether they should continue to do so or seek to either plan and to expand such a role or to shrink it is the immediately relevant issue. An increasing proportion of the patient population not only in hospitals, but in public and private nursing homes, mental health facilities, and other health care institutions is comprised of people whose continuing stay in the institution is a result not of their immediate medical status but rather of there not being an adequate residential place for them in which whatever remaining continuing services they need might be provided. No one can give a precise number of the beds now occupied by people who remain in institutions primarily because they have no adequate place to live, but the number is surely substantial-perhaps as high as 3% of all acute hospital beds on any given day and higher proportions in other kinds of facilities. Those percentages equate to somewhere between many hundreds and 1,000 in the hospital sector alone, and hundreds of others in other facilities. This is occurring, of course, in a system already operating in excess of its effective capacity, in which people with acute medical needs are turned away or forced to wait 24 to 36 hours in emergency rooms because of the unavailability of inpatient beds. We are back -in New York City, but I suspect increasingly elsewhere as well -to the old conceptual question of the boundary between the health care system and other socioeconomic systems. That, in essence, is, I guess, the underlying theme of this entire conference. Let me just express my own views on the issue, in terms both of how we should proceed and how we are likely to, which are two entirely different things. First, it seems to me that a primary tenet of public health, particularly appropriate in this instance, is that not all problems defined as health problems have what we might define as health causes; that, in fact, a number of people who are ill need health care services because of problems rooted primarily in the nature of their housing circumstances or the nature of community decay where they live. That implies, in turn, that not all problems that present themselves as health problems to health care institutions are necessarily best solved, or are Vol. 66, No. 5, September-October 1990
538
538
B.C. VLADECK B.C.
VLADECK
indeed solvable at all, by health care interventions. Again, the long-standing public health principle is that if someone's problem is lead poisoning as a result of the character of the housing unit in which he lives, medical care may have some limited ameliorative effect, but the only cure for the disease is to deal directly with the problem of exposure to lead. On the other hand, whatever the origins of the problems that are presented to health care providers, many of them are still health care problems, and the health care providers must respond to them as such, regardless of their origin. Thus, the real question, from the point of view of policy choice, becomes one of comparative advantage, as it were, in dealing with these problems. To put this point another way, if the world were more rational we might be able to make a rational determination of the point at which we would expect health care institutions to be more involved in solving the underlying problems rather than being the recipients of problems arising in other parts of society. In such a world we would advise health care institutions to avoid involvement in problems other than those narrowly of health care, since it is all many of them can do to maintain adequate services in their principal stock in trade. On the other hand, health care institutions often do possess special resources to a greater extent than many other institutions, especially in our most afflicted communities. To begin with the issue especially critical in New York City -which is why, by the way, the housing problems of persons with AIDS will be addressed to such a large extent by health care institutions they have land. They often own real estate unencumbered by either complicated ownership patterns or in rem status and all that goes with it, and that land is often suitable for as-of-right construction of human service facilities, broadly defined. In addition to land, health care institutions also have access to capital, although that access is now increasingly threatened by financial difficulties in the institutions. While very few of the health care institutions in this city have any money, they still have borrowing capacity, particularly for certain housing-related activities. Once again, that capacity is not widely shared among other kinds of institutions. Health care institutions also have some concentration of managerial resources, institutional resources, and what might be called institutional infrastructures. They tend to be reasonably sophisticated about operating a payroll or maintaining relationships with banks or employing security services and so forth. Yet again, health care institutions in this city and elsewhere have enough Bull. N.Y. Acad. Med.
HEALTH CARE INSTITUTIONS
539
other problems occupying their concentration and their energy, and the financial advantages they may have had in the past are being rapidly depleted. In sum, if we really could develop a systemic and systematic strategy to deal with the problems that have been identified throughout this conference, although health care institutions would in some sense be major beneficiaries of a reduction in housing-related or housing-induced problems, it probably would not make a whole lot of sense to expect them to try to solve them. Other institutions and organizations in society could probably do it a lot better. The first priority ought to be to help health care institutions provide better health care. On the other hand, since we do not live in a rational world making rational systemic strategies, whether it is a good idea or not I can predict that the combination of the continuing decay of housing, the continuing spiral of neighborhood disintegration, and the continuing growth of associated health problems will not only keep health care institutions implicated in the provision of housing services, but, in fact, will generate still more activity on their part in the years to come. Whether or not one thinks that is a good idea depends primarily on whether one thinks there is a plausible alternative. In the absence of seeing such an alternative on the immediate horizon, I have a strong suspicion that second best in this regard is probably better than none at all.
Vol. 66, No. 5, September-October 1990
