The air over Pittsburgh, Pennsylvania, seems different these days. The once smoky skies are brighter, and the signature view of the city is no longer the fiery and smoky mills that once lined its riverbanks. Instead, it is the gleaming downtown skyline of glass and steel office towers best seen from nearby Mt. Washington. Looking up and down the three rivers from this vantage point, you can see the shopping malls that replaced the steel mills and glimpse the hospitals and universities that have been major engines of the city’s economic transformation. The story of this transformation is repeatedly told by elected officials and economic development pundits, and now after several decades of post-industrial change, seems to be hardening into a mythology. While there is much that is true in this telling, the reality has been less linear, less intentional, and far more unequal.

One of the great ironies of how we tell the story of post-industrial change is that the image that so often accompanies it—the downtown skyline—is largely composed of artifacts from the industrial past. For example, sitting near the confluence of the city’s three rivers is the mid-century modern former headquarters of Westinghouse, which towers over Point State Park. Within a few blocks are the Gulf Oil Tower, with its spire that often lights up to celebrate a Pirates home run, the Koppers Building with its signature green roof, and the aluminum-sided former Alcoa Building now converted to high-end apartments. The most prominent part of the downtown skyline is the U.S. Steel Tower, built in the early 1970s to celebrate the relocation of company’s headquarters to the birthplace of the domestic steel industry. Today, it has a new signature tenant (and a new logo on its upper floors) that encapsulates the post-industrial moment—the University of Pittsburgh Medical Center (UPMC), now the largest employer in the region. As I note in my book, The Medical Metropolis: Health Care and Economic Transformation in Pittsburgh and Houston, UPMC’s claiming of the U.S. Steel Tower was a bold statement that health care had replaced steel as the economic engine and new identity of Pittsburgh.

Why the Medical Metropolis

Like many urban historians, my book project started as an attempt to understand the intersection between the city around me and the health care sector, in which my wife and many of our close friends worked. What was particularly striking about Pittsburgh in the late 2000s was the pride residents had in its past and their optimism about the future.

The Medical Metropolis might have remained confined to the Midwest if not for the Urban History Association. In 2008 I attended the biannual conference in Houston, where chance intervened. On a bus tour to Ship Channel to view the miles of refineries and other industrial sites, we made a stop at the Texas Medical Center (TMC). I remember being fascinated at seeing the conglomeration of hospitals and medical schools. I wanted to know how Texas, which also featured universities, hospitals, and high technology firms as agents of economic transformation, compared to the industrial Midwest in which I had grown up.

I expected these stories to be vastly different and to follow the traditional Rustbelt/Sunbelt dichotomy of bust and boom. And, while each city does have its own unique story, I found that there were numerous similarities between Pittsburgh and Houston, largely driven by a national market in health care and a similar set of concerns about what economic competitiveness and social justice should look like. My story was helped by growing urban historiography focusing on the rise of the service economy and the ways that cities and regions used industries like health care to negotiate deindustrialization. Unpacking the “meds” parts of the “eds and meds” economy required that I also understand how the business of health care evolved in the years after World War II. In both Pittsburgh and Houston, the relationship between the two has been mutually beneficial, if not always intentional. For example, in the immediate postwar years, the “civic elites” that often lead growth coalitions largely saw strong health care institutions like hospitals and medical schools as a value-add to existing strategies to attract and retain industrial firms. Hospitals helped to keep an industrial workforce healthy, and medical schools provided prestige—both as an expression of local philanthropic power and through economic status—and the discoveries from their laboratories helped to confer a sense of scientific mastery upon a community. Yet even if these institutions seemed like supporting actors, their value as a significant urban employer was not to be overlooked.

By mid-century, urban development strategies in many American cities began to focus on technology and science. This latter point was especially true in Pittsburgh, where Jonas Salk’s work on the polio vaccine in the 1950s helped the city to make an early claim as a center for cutting edge medical technology. In Houston, cardiovascular surgery helped the Texas Medical Center (TMC), and by extension the city, craft an image as a medical destination. The Medical Metropolis largely focuses on two rival Houston surgeons—Dr. Michael E. DeBakey and Dr. Denton Cooley. From the 1960s until their respective deaths (DeBakey in 2008 and Cooley in 2016), each understood that success on the operating table with new procedures like cardiac transplantation and in the laboratory with new technologies like artificial hearts, artificial heart valves, and ventricular assist devices reshaped both Houston’s future and the future of American medicine. To do this required strong institutions (DeBakey served as Baylor College of Medicine’s first President and Chancellor and chair of their Department of Surgery and Cooley built the Texas Heart Institute) that, in addition to advancing medical knowledge and serving patients at TMC hospitals, also drew students and professionals to the city, thereby helping to bolster its growing postwar professional middle class.

In Pittsburgh, Dr. Thomas Detre helped to build the University of Pittsburgh Medical Center into a global institution by the 2000s, and along with the contributions of numerous administrators and medical professionals like Dr. Thomas Starzl, helped the city become a global leader in transplantation medicine and laid the groundwork for Pittsburgh’s embrace of the health care economy.

One of the most interesting parts of The Medical Metropolis for urban historians may be the way that not-for-profit medical centers globalized alongside the service-oriented American city. Today it is common for these institutions to brag that they have a major national and international footprint, but for many years this expansion into new markets was not a major institutional priority. After all, if health care was supposed to support industrial development, then staying close to these industrial sites was a priority. However, as the global economy grew in the 1970s and 1980s, not-for-profit hospitals and medical schools increasingly became health systems. The arrival of new payment systems threatened their traditional revenue sources, and new markets became the key to their survival. Institutions built relationships overseas, often in places that had longstanding business ties to firms in their respective cities, by partnering with foreign governments or for-profit health care firms. Tracing these partnerships reveals how globalization shaped the medical metropolis. My future work will explore the increasingly complex network of relationships that emerged in the late-twentieth-century health care market.

The Sources

The Medical Metropolis draws from a diverse range of sources. Institutional records, including hospital and medical school records, formed an important base for my story. By looking at these files, mostly administrative records and marketing materials, I developed an understanding of how health care leaders planned for the growth of their institutions and managed changes to the health care industry, like AIDS in the 1980s and proposed health care reform efforts in the 1990s, as well as how they envisioned fitting their institutions into the civic fabric of the communities they served. Archives like the John P. McGovern Center at the Texas Medical Center, Baylor College of Medicine Archives, the M.D. Anderson Cancer Center’s Historical Resources Center, the  University of Pittsburgh Archives Service Center, and the newspaper collections at the Houston Public Library and the Carnegie Library of Pittsburgh were some of the places where I conducted research for this project. This work would not have been possible without the help of dedicated archivists who not only located materials I thought would be important but who also made helpful suggestions about new collections and new archives to explore.

Another significant set of sources were Dr. DeBakey’s papers, held at the National Library of Medicine (NLM). Through the generous support of the Michael E. DeBakey Fellowship in the History of Medicine, supported by the DeBakey Medical Foundation, I was able to make several trips to NLM.  These records were essential for understanding the history of international and domestic expansion and the history of medical technology

I was also very fortunate to speak with a range of participants in the story that I tell. One of the most influential conversations was with Dr. Starzl. Our conversation not only helped me to get a better understanding of the scientific and technical challenges associated with liver transplantation but also helped me better understand the frustrations he and others faced when trying to get the procedure covered by private insurance companies. After this conversation, Dr. Starzl graciously allowed me to review his papers while they were being processed at the University of Pittsburgh. Today the papers are open to all researchers and provide an unparalleled resource to learn about the early history of transplantation medicine. I was also privileged to speak with Dr. William T. Butler, the Chancellor Emeritus of Baylor College of Medicine, and the author of a very detailed multi-volume history of the school. His insights, connections with other individuals, and knowledge of the archives at Baylor (along with their archivists) helped to improve the final product.

The Consequences of Eds and Meds

I hope that the personal journey that inspired The Medical Metropolis will help historians and policymakers to understand how the past can shape the future of the post-industrial city. As both Pittsburgh and Houston attempt to reinvent themselves for an uncertain future, inequality remains a persistent feature of the medical metropolis. This inequality takes several forms beyond just access to health care, which is especially problematic in Pittsburgh, depending on race and gender. But another important area of inequality has to do with the future of health care employment in both cities. While hospitals and health systems do create a range of jobs, the pay and the level of required training and professional education vary. Moreover, the migrants that they attract to staff hospitals often fill the higher-waged and more specialized jobs. This can help to drive up the cost of living and, at least in Pittsburgh, is helping to make a once-livable city a bit less livable. Houston has also seen its own gentrification, driven, at least partially, by the medical and technology economy.

Finally, COVID-19 has thrown the growing inequalities of the post-industrial city into sharp relief. As many service economy workers are able to stay home and limit their exposure to the virus, others, especially health care workers across the pay spectrum, have been required to report to work, to treat the region’s sick, to clean and sterilize health care faculties, and to provide the other essential services that keep hospitals running and health systems operating. While reliance on essential workers has somewhat offset the economic damage from the virus, and also seems validate the long-time push for an economy that is diverse and not overly reliant on legacy industries like steel or oil, it does leave open the question: what is the long term cost, for all citizens, of this version of the post-industrial future?

Andrew Simpson is an Assistant Professor of History at Duquesne University, where he teaches courses on health care history, urban history, and environmental history. He is a founding member of the Terra Learning Community and is currently the History Department Internship Coordinator. Prior to attending graduate school, Simpson worked in community development and on political campaigns.

Featured Image: Carol Highsmith, Pittsburgh, Pennsylvania skyline, 2006. Library of Congress, Prints and Photographs Division.