Transforming Industrial Hubs — A Review of The Medical Metropolis

Simpson, Andrew T. The Medical Metropolis: Health Care and Economic Transformation in Pittsburgh and Houston. Philadelphia: University of Pennsylvania Press, 2019.

Reviewed by Kenneth Alyass

The COVID-19 pandemic has made the geographies of health care systems visible in new ways, as cameras have focused on the harrowing scenes of filled-to-capacity ICUs, health care workers draped in homemade protective equipment, and rented refrigerated trucks awaiting the causalities of the virus. The legacies of a health care system built on market-oriented practices and policies have come to haunt us, as the combination of the disease and medical inequality have culminated in mass death for Black and Brown communities and frontline workers. Part of the answer of how the United States’ health care system has failed to adequately respond to the pandemic is rooted in the historical transformation of large, urban medical centers that have embraced a business-oriented model of health care, as opposed to a civic and community service model. Historian Andrew T. Simpson examines exactly that in his comparative urban history The Medical Metropolis: Health Care and Economic Transformation in Pittsburgh and Houston.

Simpson demonstrates how, from the 1940s to the present, a myriad set of urban, civic, business, and medical actors reconfigured what he calls the “hospital-civic relationship” from one focused on supporting the urban industrial economy of the postwar period to a market-oriented relationship which prioritized specialty medicine, revenue generation, and biotechnology at the expense of community health services and social justice. These individuals and groups struggled with activists and organizers to redefine the role of health care in cities like Pittsburgh and Houston and in the process birthed new urban identities based on economic revitalization through research, education, and health care. This struggle mattered because, as historian Gabriel Winant has noted in his latest book, the transition from industry to health care and services in rust-belt America constituted the “next shift,” which restructured American politics, capitalism, and society in the post-1970 period.

The transformations in the health care system of the postwar United States were rooted in the changing business environment of the late twentieth century, notably the forces of deindustrialization and neoliberalism. Not-for-profit health care emerged as an enormously profitable business at the same time resource based, industrial hubs, such as Houston and Pittsburgh, underwent economic restructuring and social dislocation. These transformations opened physical space and ideological room for the expansion and growth of medical centers to become a cornerstone of urban economic development. Medical discoveries and technological development, research monies and top-notch medical education, and the commercialization of specialty medicine made these two cities hubs of the newly globalized health care industry, as people from around the world traveled to receive treatment and consultations from the newest innovations in medical treatment, from biotech to organ transplantation. 

While Simpson focuses on Houston and Pittsburgh, his model of the “medical metropolis” could be applied to many large cities across the United States. Take Detroit, for example, another industrial titian of the postwar period which has undergone dramatic dislocations in the post-1970s. The sprawling Detroit Medical Center (DMC), which is connected to a web of health care providers across the metropolis, emerged as the predominate business in the city which employs more people than any other industry—nearly 30,000 workers, more than manufacturing and construction combined. The influence of this industry has also made headways into politics as the current mayor of the city, Mike Duggan, worked as the former president of the DMC.

While the book periodically examines health care labor throughout its chapters, it could have used a standalone section on unions and labor conflicts in the industry. The book stands at 187 pages, and with the stunning and clearly thought-out argument I was left wanting more—not because Simpson fails to persuasively argue his case but because his framework provided much more space to do a deep dive into other aspects of health care during this period. Nonetheless, this book will serve those who are curious about the linkages between American capitalism, health care, and urban development well. It also will be useful to all of us living through a lifechanging pandemic that has made the importance of accessible and affordable health care all too obvious.


Kenneth Alyass is a Ph.D. student in history at Harvard University. He studies race, class, and crime in the late twentieth century United States with an emphasis on political and social histories of the state, social movements, and capitalism in urban and suburban spaces.

Featured image (at top): The “Steel Tower” in Pittsburgh, whose former largest tenant, U.S. Steel, was replaced by University of Pittsburgh Medical Center. “Mercy Hospital viewed from across the Monongahela River,” Cbaile19, 2020, Wikimedia Commons.

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