Journal of Bioethical Inquiry

, Volume 13, Issue 2, pp 215–221 | Cite as

Medicine for the City: Perspective and Solidarity as Tools for Making Urban Health

Symposium: Structural Competency

Abstract

The United States has pursued policies of urban upheaval that have undermined social organization, dispersed people, particularly African Americans, and increased rates of disease and disorder. Healthcare institutions have been, and can be, a part of this problem or a part of the solution. This essay addresses two tools that healthcare providers can use to repair the urban ecosystem—perspective and solidarity. Perspective addresses both our ability to envision solutions and our ability to see in the space in which we move. Solidarity is our ability to appreciate our fellowship with other people, a mindset that is at the heart of medical practice. These two tools lay the foundation for structurally competent healthcare providers to act in a restorative manner to create a health-giving built environment.

Keywords

Urbanism Urban design Public health Neighbourhoods 

Introduction

In this essay, we will discuss the ways in which healthcare providers in the United States can use the tools of perspective and solidarity to reknit urban ecosystems that have been disrupted by ill-conceived urban policies, beginning with urban renewal in 1949. These policies have been particularly disruptive for African Americans but have caused ripple effects through the whole of U.S. society. Disruption of urban habitat undermines health by numerous pathways. “Urban restoration” can restabilize neighbourhoods and contribute to improvements in health. Healthcare providers can contribute to urban restoration by using tools of perspective and solidarity. This is a form of structural competence that, by making our cities functional, can create the social and physical foundation for health.

David Jenkins and the Harms of Displacement

David Jenkins, a black man who suffered from addiction and AIDS, located the start of his illnesses in the destruction of his boyhood home by urban renewal when he was eleven years old. Over a ten-year period from 1991 to 2001, he collaborated with Mindy Fullilove to articulate the effects of displacement and identify the aspects of his illnesses that displacement had created (Fullilove 2004). His generous public exploration of his life’s woes offered insights into the harms of urban renewal and similar programs.

Mr. Jenkins was part of a fragile family that was supported by a strong neighbourhood, filled with people who worked in nearby factories in southeast Philadelphia. All were forced to move, and their close ties and strong social support were lost. Mr. Jenkins soon found himself on his own, struggling to make a living and advance his singing career. He was infected with HIV early in the epidemic. He was asymptomatic for many years but floundered due to addiction to drugs and alcohol and subsequently became homeless. He was able to achieve sobriety, which helped him manage as AIDS-related problems increased. His recovery helped him to rebuild family and community for the first time since his teenage years. He devoted himself to fighting the AIDS epidemic and to speaking out against displacement, continuing his activism right up to the time of his death in 2008.

The Urbanism of Upheaval

Mr. Jenkins’ story is part of the history of urban upheaval that started in 1949, when the United States government adopted a policy of “slum clearance” that led to 2,532 projects that cleared urban neighbourhoods in 993 cities across the nation (Fullilove 2004). The most famous urbanism book by an American, Jane Jacobs’ 1961 classic, The Death and Life of Great American Cities, was an explicit attack on this program of mass destruction (Jacobs 1991). She described the urban renewal programs as “not the rebuilding of cities. This is the sacking of cities” (Jacobs 1991, 4). She went on in a prescient paragraph to add:

Under the surface, these accomplishments prove even poorer than their poor pretenses. They seldom aid the city areas around them, as in theory they are supposed to. These amputated areas typically develop galloping gangrene. To house people in this planned fashion, price tags are fastened on the population, and each sorted-out chunk of price-tagged populace lives in growing suspicion and tension against the surrounding city (Jacobs 1991, 4).

Upheaval and geographic sorting of the population by race and class have continued under policies of planned shrinkage, deindustrialization, mass incarceration and gentrification (Fullilove 2013). These policies and programs have destroyed large swathes of urban habitat and contributed to disease through several pathways, including:
  • First, destruction of neighbourhoods that destroys social, cultural, political, and economic resources, making it a fundamental cause of disease, in the sense proposed by Bruce Link and Jo Phelan;

  • Second, creation of increasingly distinct geographic separation of the population by social and economic groups which intensifies antagonisms and accelerates inequality; and

  • Third, replacement of dense, complex urban habitat with simpler housing forms like public housing projects or suburban subdivisions that are inadequate to the needs of human populations.

Thus the “urbanism of upheaval” has undermined the health of the U.S. population, with the most severe effects on the health of the African American people but with ripples throughout the nation. From the health perspective what is needed is an alternative urbanism that can protect the social and economic assets of neighbourhoods while strengthening their functioning and connections to the larger city. “Urban restoration” tackles this challenge by working from existing strengths to reweave the city, threading the history and culture of the people who live in the area into new developments (Fullilove 2013).

Jacobs was an early proponent of this health-promoting urban restoration. She presented an alternative to mass destruction and sorting-out of the city, which was the careful nurturing of functional urban neighbourhoods. She urged that we should study neighbourhoods carefully, comparing those that flourished with those that failed, while avoiding essentializing conclusions about such factors as poverty, race, and automobiles. She noted: “Cities are fantastically dynamic places, and this is strikingly true of their successful parts, which offer a fertile ground for the plans of thousands of people” (Jacobs 1991, 14).

Based on the knowledge gleaned from diligent observation, she argued that we would be able to transform dull and dysfunctional urban districts into vital, sustaining places for people to live. The interventions we would want to make, she insisted, were absolutely not the quick injection of billions of dollars but rather the slow, steady nurturing of people’s desire to stay in neighbourhoods and be a part of the life that was transpiring there.

This urban restoration is in sharp contrast to the projects of slum clearance that continue to dominate American urban planning. The key feature of urban restoration is the assumption that interventions should address the fundamental injuries to the ecosystem of the city, such as the injuries from mass land clearance, sorting the urban population by race and class, and maldistribution of resources to neighbourhoods according to a hierarchy of privilege.

“Urban restoration” is a domain of “structural competence,” as per the concept advanced by Metzl and Hansen (2014). The work we are describing relates to the second structural competence they propose—developing an extra-clinical language of structure—and the fourth—observing and imagining structural interventions. Metzl and Hansen reference our work specifically and write:

For instance, students might observe how Mindy Fullilove treats cities that have been “fractured and wounded” by racially segregating urban renewal and redlining policies, rather than individual patients. Fullilove works with community based organizations, urban planners, and architects to promote “nine elements of restoration”—including creating healthy spaces for use by all city residents (Fullilove 2013, 130).

Our experience on these matters derives from both our individual practices of urbanism and twenty years of interdisciplinary partnership in the United States and France, described in detail in the book Urban Alchemy: Restoring Joy in America’s Sorted-Out Cities (Fullilove 2013). In this essay we want to highlight the contribution of two tools, perspective and solidarity, to the restoration of the urban ecosystem. Cantal-Dupart has proposed that perspective is the warp and solidarity the woof in the weaving that makes the city. When we work with these powerful tools, we reverse the harms of urban upheaval and create the environmental infrastructure for equity and health.

Perspective: The Warp of the City

According to the Merriam-Webster Dictionary, perspective is the “capacity to see things in their true relations or relative importance.” Cantal-Dupart employs perspective in urban design, framing distant vistas for the eye to see. He also uses the concept of perspective in the philosophical sense, always seeking to “gain perspective” on problems that are disturbing or obtuse.

Individual perspective is critical to action. Physicians are trained in the recognition of pathology. When they observe an obvious wound, they know that it might be symptomatic of important physiological disorders. An open sore on the foot can mean serious, untreated diabetes, for example, and we would not be able to treat the foot without treating the whole body. “The same is true for cities,” Michel Cantal-Dupart told attendees at a 1993 colloquium in France focused on AIDS, homelessness, and substance abuse (Cantal-Dupart 1993).

Mindy Fullilove, who was in the audience at that colloquium, was interested to learn that he saw all three problems as disorders of the modern city caused by fracture between rich and poor neighbourhoods. He explained,

I am convinced that there is a close connection between the signs of exclusion and the shape of the city, whether it is poor neighbourhoods or whole cities that have been shut out. We find neighbourhoods far from everything, without means of transport, where many are unemployed and where there are numerous young people. We find the names of those neighbourhoods in the newspapers. We also know that those neighbourhoods are the neighbourhoods with high rates of illness (Cantal-Dupart 1993, 262).

The organization of the city was what demanded our attention, he averred. This led to a dramatic shift in Fullilove’s perspective. She had been preoccupied with individual neighbourhoods, like Harlem, which had lost many buildings because of disinvestment, rather than examining the ways in which urban policy was creating the problems of the inner-city.

Cantal-Dupart also literally helped her shift her gaze, turning her attention from the emptiness of burned-out neighbourhoods to the signs of reanimation that were all around. While walking together in Harlem in 1996, they passed numerous vacant lots. Cantal-Dupart pointed out a red balloon hanging in a driveway. “Someone had a birthday party,” he commented.

In later meetings with Cantal-Dupart, Fullilove learned that he saw perspective as an essential tool for health-promoting urbanism. For example, he entered a competition to design the grounds for the French national school for prison guards. The call for proposals said they were interested in surrounding the school with a wall, placing a restaurant, to be shared with another school at the entrance, and the school building at the rear. Cantal-Dupart said:

That is a design that replicates the prison, with its visiting facilities near the entrance and the housing for the prisoners near the rear. But our national policy is to help our prisoners return home as productive members of society. How can the guards accomplish that if they’ve been trained to be in prison themselves?

He made a counter proposal.

Let’s place the school in an open park, based on the most elegant example of French landscape design, Vaux-le-Vicomte, the model for Versailles. Place the school building at the entrance and the restaurant across the park. Let the students from the other school enjoy the passage across your grounds. Make your school a part of the city, just as the prison will make its occupants a part of society.

His proposal was accepted and the school built. From within the school grounds, a canal lined with reeds and filled with frogs draws the eye to a church in the distance, an open perspective that embodied the freedom of the place. Shortly after the school was built, a new prison administration wanted to close the school as it was not sufficiently prison-like. The guards protested, saying, “We need perspective in our lives.” In 2011, people from Agen called for this beautiful park to be included on the list of the patrimony of France, a rare honour for landscape design.

Health facilities, like schools, must be sited, and the need for land can catapult healthcare providers into the debate about the use of urban land. In fact, it was the debate about the siting of the University of Medicine and Dentistry of New Jersey that touched off the Newark insurrection in 1967. Newark had been in the throes of urban renewal for nearly two decades when it was proposed that over two hundred additional acres of land be cleared for the school. The African American community, which had borne the brunt of the clearance, protested further displacement at a crucial set of hearings in June, but the city leaders decided to go ahead with the clearance. Although the incident that triggered the riots was police brutality, it was the underlying grievance of massive urban renewal that was the kindling (Fullilove 2004).

After the riots, as the smoke cleared, the newly appointed head of the medical school, Dr. Stanley Bergen, stepped forward to lead negotiations and resolve the problems. He played an important role in setting a course for an institution that would be of service to the neighbourhoods. What he was not able to fix was the deficient design that set the new school apart from its neighbourhood. This contributed to a persistent disruption of the urban fabric, which has left Newark crippled to the present day. Unfortunately, the presence of a strong healthcare institution cannot overcome the health problems that are created by a city that does not work. It is a mistake to put the space demands of the care facility ahead of the urban ecosystem: these elements must work in unison, not opposition.

The problem of healthcare facilities that disconnect and undermine the urban function of neighbourhoods is widespread. Many hospitals are built like castles, with few entrances and exits, and little visual connection to the street. The Columbia University Medical Center built a building with a blank wall to the city. Buildings, Jane Jacobs explained, are the “natural proprietors of the street.” Their “eyes” on the street make for safety and civility. CUMC’s blank wall is a problematic solution, but one that is easily rectified, were alert healthcare providers to think through the issues of urban restoration (Fig. 1).
Fig. 1

The back of a Columbia University Medical Center building, which presents a blank wall to the Dominican neighbourhood on the other side of the street.

American urbanists, Ken Doyno and Dan Rothschild, principals of Rothschild Doyno Collaborative (RDCollab), have demonstrated a creative solution for a blank wall in the small American city of Braddoce, once a centre of the U.S. steel industry. When RDCollab started its work, Braddock Avenue, the city’s Main Street, was nearly depleted. Commissioned to build affordable senior housing on that main street, Rotchschild and Doyno thought their building had a heavy responsibility to the city, a duty it could meet by reinvigorating the whole street. RDCollab used many tools of connection to solve this problem, putting social rooms on the street with floor-to-ceiling windows so that the building’s lounges were also the city’s lounges. A set of outdoor benches echoed that welcome. They hung a light high in a building well, burning day and night to call to the side street that connected with Braddock Avenue at that point.

But they faced a difficult challenge in solving the problem of parking. They could not put the parking completely underground but they knew the half-buried parking would present a blank wall to the street, similar to the CUMC wall. They decided to use public art to enliven that part of the building. Rothschild met with a citizens’ art committee. Five people who had always lived in Braddock were assembled to discuss the content for the artwork. In the first meeting, they passed the time telling stories about their lives in Braddock. In the second meeting they told more stories, and in the third meeting yet more stories. Rothschild, who had been wondering how to get the committee focused on the content of the project, realized that their stories were the project. What needed to be displayed on Braddock Avenue was a celebration of the people’s stories (Fig. 2).
Fig. 2

The Avenue, on Braddock Avenue, showing the murals that enliven that blank section of the wall and the open windows along the lounge area, which link the inside of the building with the street outside

Artist Robert Qualters, who mixed storytelling with painting, created a set of murals that depicted significant places, people, and events and quoted generously from what residents had to say. Each panel faces a bench, creating the classic memorial triptych of seats for the guardians, sidewalk space for the passers-by and casual observers, and space for those who needed to move in closely to honour their losses. Dan Rothschild concluded, “There isn’t a neighbourhood in this country where people are relocating back to Main Street that couldn’t use this display of securing a community’s memories as a ​model” (Fig. 3).
Fig 3

Mural depicting local stories, placed on a blank wall to provide perspective

Solidarity: The Woof of the City

Solidarity, Merriam-Webster says, is a “union or fellowship arising from common responsibilities and interests, as between members of a group or between classes, peoples.” All of medical care may be understood as an act of solidarity, because it involves, to one degree or another, putting oneself at risk in order to heal another. In fact, in the student lounge at Columbia University College of Physicians and Surgeons there is plaque honouring doctors who died in an outbreak of infectious disease. The plaque urges the reader to go forth and do likewise.

A story from Columbia University College of Physicians and Surgeons (P&S) is an excellent illustration of solidarity. Prior to the Civil Rights Movement of the 1960s, the medical school was ruled by restrictive quotas that limited the number of religious and racial minorities and women. When P&S was desegregated in the 1970s, the new cohorts of minority students, and the increasing number of women, entered into a traditionally competitive place, in which students studied largely in isolation. For years the failure rate among minority students was much higher than among white students. Despite continual protests, there were few academic supports until 1991, when four women of colour were asked to repeat the first year of medical school. In a show of solidarity, the whole student body protested the lack of support, and the dean of students, Dr. Linda Lewis, decided to implement a new programme, the Student Success Network (SSN), modelled on the highly successful UC Berkeley Professional Development Program, a programme for ensuring minority success in first-year calculus.

The Student Success Network, though founded to prevent minority failure, was directed at the entire first-year class. The programme was developed and implemented by second-year students and focused largely around workshops and practice practical exams that ran parallel to the core curriculum and helped students master the material and perform well on exams. Within its first three years of operation, SSN was able to eliminate “preventable” failure of the first year coursework and Part I of the National Board of Medical Examiners.

An unexpected outcome was that students developed a spirit of collaboration that broke down old barriers of race and gender. Student Success Network recognized that medical care would be delivered by teams and that teamwork was a critical skill missing from the school’s curriculum. By teaching team skills and providing the conceptual underpinnings for this approach, SSN accelerated the school’s evolution from competition to collaboration.

In preparation for the organization’s twenty-fifth anniversary in 2016, its leaders prepared a poster for American Association of Medical Colleges’ annual meeting (Stein et al. 2015). They reported that the overwhelming majority of first-year students participated in SSN. For example, 98 per cent had attended a practice practical examination in Anatomy (Fig. 4). Among second-year students, 45 per cent reported they had taught the first-year class in some capacity. Sixty-seven per cent of students rated SSN teachers as “slightly” or “significantly” better than the professors teaching the basic sciences. Decades of student devotion to inclusion have not solved all the problems of aversive racism at the medical school but they have ensured that all students can master the academic work. In 2015, when Mindy Fullilove mentioned to a meeting of the Black and Latin Student Association that she had founded SSN, the packed room burst into applause.
Fig 4

First-year students at the College of Physicians and Surgeons, (from left) Tegan Donnelley, Emery Jamerson, Caroline Park, and David Edelman, work as a team to answer a question on a student-run practice practical exam prior to their first anatomy test. Approximately 90 per cent of students from the medical and dental schools at Columbia University participate in the practice exams that are coordinated and prepared by second year medical students as part of the Student Success Network.

Solidarity among medical students of diverse backgrounds is one level of this action. Healthcare institutions can organize in solidarity with the neighbourhoods surrounding them. The University Circle neighbourhood in Cleveland is a centre of universities and hospitals, surrounded by neighbourhoods that have suffered from severe disinvestment following deindustrialization. Foundation leaders pondered how the resource-rich institutions might be of service to the resource-deprived neighbourhood. They proposed that the institutions act as “neighbourhood anchors,” making connections with their neighbours through a series of projects, such as developing worker-owned cooperatives that could supply needed services like laundry.

Another example of solidarity is demonstrated in the work of the medical student organization “White Coats for Black Lives” (Charles et al. 2015). The 2014 police murders of Michael Brown and Eric Garner shocked the United States and a national movement, Black Lives Matter, arose. So that they might contribute to that movement and make connections to medical care, medical students created a national “die-in,” and on the heels of that successful demonstration, created the organization “White Coats for Black Lives” (WC4BL). In an essay describing the evolution of this demonstration, they wrote:

In founding WC4BL, we identified three key levels on which medical students could promote racial justice. First, we must fight to eliminate racism in housing, criminal justice, education, and other areas as a threat to the lives and well-being of people of colour. Second, we must end racial discrimination in the distribution and provision of medical care. Finally, we must demand that our medical schools create a physician workforce that reflects our nation’s diversity and is prepared to fight for racial justice (Charles et al. 2015, 1008).

This organization is a remarkable manifestation of solidarity across noxious societal divides. As healthcare providers gain perspective that medical care depends on solidarity among providers and with all neighbourhoods, the quality of care will improve, as will the health of the populace. This is the heart of the contribution structural competence can make toward creating population health.

Conclusion

The United States has practiced a vicious and unrelenting “urbanism of upheaval” that has undermined the social bonds, equity, and integrity of the population. We need, instead, to implement an urbanism of restoration. Healthcare providers, situated as they are in major buildings, are important actors in the built environment but heretofore have largely been part of the urbanism of upheaval. By developing structural competence, and in particular mastering the tools of perspective and solidarity, healthcare providers will be able to make major contributions to urban integrity and functionality, thereby raising population health and morale. David Jenkins, Michael Brown, Eric Garner and many others are cheering us on.

References

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Copyright information

© Journal of Bioethical Inquiry Pty Ltd. 2016

Authors and Affiliations

  • Mindy Thompson Fullilove
    • 1
  • Michel Cantal-Dupart
    • 2
  1. 1.Columbia University Mailman School of Public HealthNew YorkUSA
  2. 2.Atelier Cantal-DupartParisFrance

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