This essay is reproduced here as it appeared in the print edition of the original Science for the People magazine. These web-formatted archives are preserved complete with typographical errors and available for reference and educational and activist use. Scanned PDFs of the back issues can be browsed by headline at the website for the 2014 SftP conference held at UMass-Amherst. For more information or to support the project, email email@example.com
Community Organizing and Institutional Expansion: Two Views
by Howard Waitzkin & John Grady
I. What to Do When Your Local Medical Center Tries to Tear Down Your Home
Howard Waitzkin acted as coordinator of community support at Harvard Medical Center between 1968 and 1972 and has visited the community frequently since that time. He spent a number of years with the UFW and now teaches and practices medicine in Vermont, where he is active with the Socialist Health Workers.
This article is based in part on materials presented in “Controlling Medical Expansion,” Society (January-February 1977), pp. 30-35; these materials are published by permission of Transaction, Inc. from Society, Voll4 No.2, copyright 1977 by Transaction, Inc.
The U.S. is today served by two health systems, one public and one private, which contradict each other. Currently we are facing cutbacks in urgently needed public hospitals and services in both urban and rural areas.1 On the other hand is a continuing expansion of private hospitals and health facilities, which often results in unnecessary construction, rising costs, and (in many cities) destruction of housing for low-income families.2 Our purpose here is to analyze one side of this duality – private medical expansion – and to describe how a community in Boston has been able to stop it.
In Boston, resistance to medical expansion dates back to student-community coalitions that emerged during the political activism of the late 1960s and is an example where student protest led to sustained community organizing. Successes in controlling the expansion of medical centers or other large urban institutions have been rare. In the future, neighborhood residents and health workers in many U.S. cities will be facing similar conflicts. While some aspects of the situation in Boston are unique, the events there show that community resistance can save housing and improve health planning.
The National Context
In all of the 20 largest U.S. cities, one or more medical centers have expanded during the last 10 years, are currently expanding, or have plans to expand in the future. One hundred and ninety-two expansion projects (including at least one in each city) extend into residential areas; if completed, 125 will lead to the destruction of housing. One hundred and twelve plans for medical expansion have encountered opposition from various sources; for 69 of these, opposition has come from local residents’ organizations.3 Besides Boston, conflicts have occurred between expanding health institutions and local communities in New York, Newark, San Francisco, Oklahoma City, Washington and Chicago.4 In short, medical expansion occurs throughout the country and threatens to eliminate many of our urban residential areas, just as urban renewal (with its emphasis on commercial and other new development), private development (by banks, insurance companies, large corporations), government office buildings and highway construction have destroyed innumerable conmunities.5
The Boston Conflict: Early Stages
Since its construction in 1899, the Mission Hill neighborhood adjoining Harvard Medical School has been composed of white Irish-Catholic, German and a smaller number of black and Spanish-speaking families.6 Most people in the community hold low- to middle-income jobs in manual trades or small businesses. The homes are two and three-family dwellings, in which the owner generally lives on one floor. Many people grew up in the neighborhood and started households near their relatives and friends.
Starting in 1964, Harvard’s real estate agents bought houses in the neighborhood and gave priority in rental policies to transients (students, hippies and young staff members at the hospitals) instead of families. Rents increased; poor maintenance led to the physical deterioration of the properties. Families who had lived in the neighborhood for many years found it difficult to remain. In 1968, Harvard announced its plans to build a new hospital complex -the Affiliated Hospitals Center (AHC) – and sent eviction notices stating that 182 apartments would be vacated and torn down by 1971.
The student strike at Harvard in 1969 publicized the threat to the neighborhood. Students demanded cancellation of the eviction notices and a promise not to destroy housing. During the strike, student organizers met with community residents, who gradually decided to form a tenants’ union, the Roxbury Tenants of Harvard Association (RTH). By the end of 1969, RTH gave Harvard a petition that stated the tenants’ desire to remain in their homes and requested a change of the new hospital’s location. Harvard officials had not clearly explained why the new hospital needed to be built on land occupied by housing, rather than on nearby empty land; nor were there concrete plans for relocation housing.
Responding to the 1969 strike, Harvard decided to build 1100 units of new housing, part of which would accommodate residents displaced by the AHC. Financing remained vague and critics questioned whether appropriate apartments could be constructed for the large families who lived in the neighborhood. Before the announcement about new housing, University officials did not talk with tenants to learn about their perceived housing needs or to obtain their participation in planning.
After the decision was announced, in a move possibly meant to coopt organized resistance, the University set up committees involving tenants, students, and health workers. For at least one year, the committees remained powerless to affect either hospital expansion or housing policies. Actual decision-making power stayed in the hands of the Harvard Corporation and high-level administrators.
The Effects of Community Organizing
Oh well, they could not understand why we had to make such a fuss about it. After all, they were doing a service to the community, I mean they were doing a service to all humanity. And how dare we oppose their ideas? I mean what right did we have? … after all, we didn’t own the houses … So that was their attitude. And you know, they were so much better than everybody else. It was pathetic … It’s just the big institutions like that never think about the little people.
Frustrated by a lack of progress, tenants and their supporters turned to more aggressive tactics. Community residents worked with student organizers in door-to-door canvassing with frequent meetings that took place in people’s homes and at the local church. About 10 leaders emerged, who were of mixed ages with families, and were long-term residents in the neighborhood. They came from different ethnic and racial backgrounds but generally similar economic positions. None had been politically active prior to the expansion conflict. RTH emerged as a durable tenants’ association: membership eventually included most families in the neighborhood, as student organizers gradually took much less initiative.
During late 1969, RTH demanded direct negotiations with the Harvard Corporation and sent delegations to the Corporation and to the Dean of the Medical School. With student and faculty supporters at the University in Cambridge and at the Medical School, tenants organized three demonstrations and a “mill-in” at the Dean’s office involving more than 100 participants. The demonstrators asked the Dean to visit the neighborhood to inspect the deteriorating housing. After a delay of several weeks, the Dean toured the community with a group of tenants. The community also sponsored a city council public hearing at the local church. Newspapers, radio and television stations publicized the demonstrations, the tour and the hearing.
This was the turning point. The University did not change its actual policies until R TH, with supporters among the faculty and student body, showed a willingness to disrupt University business and an ability to attract attention in the public media. The Harvard administration, headed by a new president, became convinced that the tenants’ commitment and power base were so strong that they had to be taken seriously.
Between 1970 and 1975, tenants obtained written agreements that responded to their needs:
Direct negotiations. The Harvard Corporation assigned one of its members and a staff person to take responsibility for negotiations with the tenants. In general, the Corporation has honored agreements reached between RTH and these negotiators.
Rent freeze. The Corporation agreed to roll back and freeze rents at their 1969 level. In addition, the Corporation guaranteed that all future rent increases would be subject to RTH approval.
Maintenance. By 1972, Harvard’s real estate agent made repairs that met most of the safety standards of the Boston Housing Code. At the tenants’ instigation Harvard also began a program of housing rehabilitation, funded by the University.
Tenant-landlord relations. Rental priority was given to families who wanted to remain in the neighborhood. Vacant apartments were rented again as soon as possible. A real estate office was opened in the neighborhood, so that problems could be settled promptly. Because RTH members have participated actively in rental practices the community has overcome pressures that discouraged families from staying in the area. As a result, the composition of the neighborhood again has stabilized.
The events in Boston show that a small community can organize and win a struggle to save housing and to obtain better health care.
Guarantees preventing eviction. In 1971, after a long series of negotiations, the Harvard Corporation promised in writing that no tenants could be evicted until suitable relocation housing was available and was approved by RTH. This agreement guaranteed that residents would not be displaced from their homes without concrete relocation plans acceptable to the community. Most of the original structures in the neighborhood will remain intact.
New housing. Early in 1975,. RTH and Harvard finalized agreements concerning new, tenant-controlled, mixed-income housing. R TH is a legal co-developer and has control over architectural plans, rental policies, and maintenance. Ground breaking for the new housing took place in October, 1975. Many of the 774 new units will be located in low-rise townhouses with three to four bedrooms which will provide housing for large families currently living in the community. Smaller units also will be available for elderly persons, students and workers at the medical center. Residents are aware of the potential problems of community-controlled housing,8 but are committed to this goal as one means to stabilize the neighborhood.
Subjective changes. A more general politicization also has occurred. When the struggle against medical expansion began in 1969, most residents wanted to stay in their homes. However, they doubted their ability to win a conflict against such powerful and wealthy institutions. They had seen families like their own displaced by a government center in Boston’s West End, highway construction in various parts of Boston and other urban renewal projects. Initially people were skeptical that they could be successful. Because of their concrete achievements, residents no longer feel powerless.
Gradually many residents have started to link their own troubles to broader political and economic structures. During the 1969 strike at Harvard, student activists focused attention on the University’s role in supporting patterns of social injustice. This analysis dealt with the University’s complicity in the Indochina War (especially ROTC and war-related research), as well as the University’s impact on local communities in Cambridge and Boston.9
At first, most residents did not accept the students’ broader political analysis. Over time, this changed. Through RTH, residents also came into regular contact with the elite members of the Harvard Corporation and the directors and professional staffs of the Harvard-affiliated hospitals. Through this experience, people in the community became sensitive to the political and economic interests of the individuals who control the University and the medical center. Many residents now view their own problems not simply as local and unique issues, but as reflections of broader class structure and power in U.S. society.
The New Hospital: Expansion Controlled
In reading the local hospital bulletins, it always seems that the hospital takes credit for the wonderful work they are doing for the community, and how much they love to work with the community. A lot of hog wash. If it wasn’t for the local health groups demanding good health care, and the use of these Harvard-controlled hospitals, the community would get nothing.
Controlling hospital expansion is no easy task. Until recently, it has been difficult to argue against expansion or new construction. Most people have believed that there is a need for more medical care and that this need justifies new hospitals.
Currently, this belief is meeting criticism from many sources. The most straightforward criticism of unrestricted expansion is that it leads to unnecessary duplication and overlap of facilities in certain geographical areas, while other areas remain underserved.10 This viewpoint argues for comprehensive and regionalized health planning, to correct problems of maldistribution.
A second critique focuses on the problem of costs. Unused hospital beds (“overbedding”) have vastly increased the costs of health care in the U.S. Since it is doubtful that the benefits of more hospital beds justify their costs, a general moratorium on new hospital construction or expansion has been advocated.
A third line of criticism uses an analysis based on political economy.11 Decisions leading to medical expansion often do not reflect the health care needs of the population but rather the concrete political and economic interests of the people who govern medical centers. The governing boards of hospitals, especially university-affiliated teaching hospitals, are heavily slanted
Harvard officials had not clearly explained why the new hospital needed to be built on land occupied by housing rather than on nearby empty land.
toward membership by business executives and other members of the corporate class. The professionals who head the major departments of medical centers control research and clinical “empires.” Expansion of these empires results in increased power, prestige and finances for those in charge. But the effects on health care are dubious or at least difficult to measure.
Fourth, on a more basic level, several critics question the relationship between more health services and better health. Careful epidemiological studies are unable to document improvements in health indices (morbidity, mortality or life expectancy) following most major technical advances of twentieth-century clinical medicine.12 On other other hand, significant iatrogenic13 disease and a dependency on health professionals have occurred, largely because of the ever-increasing scope of health services in modern society. There are calls for a reversal of “medicalization,” especially medical-center expansion, and a renewed emphasis on self-care.14
These general criticisms emerged during the past six years, at the same time as the local community in Boston fought medical expansion. Some community residents were aware of these broader issues. However, most people based their opposition on more concrete problems.
The Political Uses of Legislation: Controlling Hospital Expansion
Community residents perceived that the new hospital complex threatened to destroy their homes and the future of their community. Second, in the AHC’s plans, they saw little commitment to improve health care in ways that would benefit them directly. They especially doubted that the AHC would provide the outpatient services that people in the neighborhood felt they needed. An emerging national critique of hospital expansion plus new legislation gave organized residents tools they could use to make the AHC more responsive to real health needs.
Three areas of legislation pertained to the AHC’s expansion plans.
(a) Certificate of need (CON). The Massachusetts legislature passed laws in 1971 and 1972 requiring that the State Department of Public Health (DPH) issue a certificate of need for any hospital expansion or new construction. As in other states, the laws’ main goal was to help control the costs of health care by avoiding duplication and overlap.15
(b) Comprehensive health planning (CHP). A second area of legislation impinging on the AHC expansion centered on the Federal “Partnership for Health” Act of 1966. This Act helped establish CHP on a regional and local level throughout the country. In Massachusetts, three CHP agencies were involved in reviewing the AHC’s CON application.
The Struggle at Harvard
While the struggle over housing was a consciousness raising experience for the community involved, it also helped to politicize many people who worked or studied at Harvard Medical School. Organizing at Harvard was quite intense; petitions, open meetings, posters, frequent leaflets on bulletin boards, all helped to alert people working there to the issues. We even arranged separate meetings with people working in each department at the Medical School to explain the issues. For many of the 50 or so students, workers and scientists who occupied the Dean’s office during the mill-in, it was their first radical action. For many of them, this experience was the first time they had been involved in a community struggle.
The support group at Harvard recognized the leadership of the community in all of their activities. Petitions and meetings were organized with the approval of members of the Roxbury Tenants’ group and individuals from that group spoke at these meetings. These experiences, the process of the struggle itself, and the recognition of the forces involved (here: corporate leaders of Harvard vs. lower-income groups), all helped to raise consciousness of the class struggle, in general.
The results of this clash between the Roxbury Tenants and Harvard show that people working in academic institutions can play a significant role in preventing those institutions from exploiting the community. While this may have been a limited victory in the sense that Harvard is continuing to attempt expansion into the Mission Hill area, the potential power of alliances between the community and progressive forces in the institution has been demonstrated.
Another victory, also at Harvard Medical School, illustrates the same potential. A coalition of Science for the People people at Harvard Medical School and outside advocacy groups were able to halt the screening and possible stigmatization of XYY infants at a Harvard affiliated hospital.
(c) Environmental impact. Another area of legislation affecting hospital construction was the Massachusetts Environmental Impact Law, which took effect in 1973. According to this law, the evaluation of CON applications had to include a consideration of impact on the environment.
Laws that require comprehensive planning, in health care as in other areas, seldom apply abstract standards of rationality. Since planning is a political process, the effects are often more symbolic than real.16
For instance, expanding institutions can hire staff members who write justifying documents and maintain close contact with regulatory agencies. Communities generally do not have staff people for this work; residents must spend time and energy on the planning process without pay and outside their usual jobs. This imbalance in planning usually favors large institutions over local communities.
A recent nationwide review showed very little impact of CON laws. While many hospitals’ plans were modified, only a few applications were rejected. The study concluded:
In viewing the certificate-of-need laws across the country, the impression is gathered that a “honeymoon period” still exists in most states between the health planners qua regulators and the health care industry, particularly the voluntary hospitals segment. Control of facilities expansion is currently in accordance with the goals of both the health planners and the dominant, established healthcare institutions in most states and communities.17
Although Boston residents doubted that the Department of Public Health would deny the AHC’s application outright, they realized that the CON procedure provided a political lever by which they could delay and possibly redirect medical expansion. In particular, members of a community organization concerned with health care – the Mission Hill Health Movement (MHHM)- decided to use the AHC’s application as a continuing focus for community organizing. They also hoped that the political process surrounding the application, if not slopping the AHC entirely, at least would postpone and reshape the AHC’s plans so that the community’s needs for housing and adequate medical care would be met. In short, community residents understood the largely political nature of the planning process and decided to use the application procedure as a political strategy.
The CON controversy in Boston consumed over three years and considerable energy from community groups, CHP agencies, and hospital staff. It resulted in several major changes in plans and programs which included concessions from the hospitals and several victories for the community.
(a) Site and design. The AHC moved its site to a parking lot of one of the component hospitals, where housing would not be affected. The original design called for a three-tower structure that would have spread out over about two square blocks of space. The MHHM strongly criticized this design. Current plans proposed a single tower, with reduced research space and parking located away from the site.
(b) Number of beds. The CON law required a detailed analysis of the need for new hospital beds. Eventually, the DPH approved 680 beds for the new facility – eight fewer than the total contained in the original component hospitals and 110 fewer than the AHC initially requested.
(c) Organizational structure and governance. After criticism from the community and CHP agencies, the hospitals agreed to a formal corporate and clinical merger. Mainly through the MHHM, the local community also demanded positions on the governing board. CHP agencies supported this demand. Ultimately the AHC promised direct representation on the board through elections in the local “host community.”
(d) Community health services. The CON struggle led to a firmer commitment to walk-in care. In 1973 the AHC proposed for the first time a unified ambulatory care center serving the local community. The AHC also agreed that a community-controlled board would make policy for the ambulatory care center.
In summary, planning legislation permitted a wider politicization of the expansion issue. Community residents responded aggressively to the political opportunity that the planning laws provided. The MHHM and other local groups actively criticized and redirected the AHC’s proposals. This input delayed expansion. It also made the planning process more consistent with residents’ health-care needs.
What Can We Learn?
I think if we weren’t involved I’m sure that the only thing that would be built around here would be high rise, and the people around there don’t want to live in high rise …. And I would see the community eventually just disappearing as it is now, you know, there wouldn’t be the same type of community as there is now, the same mix of people, the families, and … you’d probably end up with middle-class professionals ….
In Boston, effective organizing and political action have halted medical expansion and stabilized a community. People who live in the community have had a profound impact on their own destinies and on the institutions that affect them. The Mission Hill case illustrates several lessons about community conflict, about the nature of large urban institutions and about strategies for change.
Communities Can Win
It is important to realize that victories are possible. From the history of the last 20 years, optimism about success is difficult. Urban renewal has removed thousands of people from their homes throughout the country. Hospitals, office buildings, highways and parking lots have replaced residential neighborhoods. “Grieving for a lost home” has become a common experience for low-income people living in cities.18
The costs of institutional expansion have been high. Individuals and familes have lost the sense of belonging that comes from the close-knit attachments of a community where people know each other well. American cities suffer as large institutions supersede vital communities where people of different incomes and ethnic traditions live together.19 Expansion and redevelopment benefit small numbers of wealthy and powerful individuals, usually by increasing their profits, power or prestige. Even service institutions like hospitals, find difficulty in justifying expansion plans, especially when one considers the human costs to existing communities.
These costs usually are hard to understand for those who control urban institutions. The attachments of working-class people, both individuals and families, to their neighborhoods generally are much stronger than for the middle class. Fried describes this: “A high degree of residential stability, deep commitment of people to their neighborhoods, and closeknit social organization within the local area are among the most striking features of working-class community life.”20 When working-class people lose their homes because of urban redevelopment, they generally suffer a deep and lasting grief that derives as much from the loss of their social networks as from the destruction of their homes.
The possibility of halting institutional expansion, however, seems remote, particularly when people become accustomed to powerlessness. In the early years of urban renewal, working-class people felt a resignation that they simply were not powerful enough to resist redevelopment. Because of this resignation, the residents of many communities acquiesced to the destruction of their homes.
The events in Boston show that a small community can organize and win a struggle to save housing and to obtain better health care. The Boston victory sets a standard for other communities facing the threat of institutional expansion and similar forms of urban redevelopment.
Political Struggle and Rational Planning
Such struggles are not simply a matter of politics. Community resistance ultimately leads to more rational planning. By taking a strong stand, a community forces planners to adopt a more balanced view of the many different interests affected by a given project. Without input from the community, the main interests considered are those of the people who own or govern urban institutions who can rationalize redevelopment plans by invoking abstract principles- fighting “blight,” building “needed” hospitals, etc. Throughout the country, urban redevelopment has only varied the theme that Gans set forth in his study of Boston’s West End: “In summary, redevelopment proceeded from beginning to end on the assumption that the needs of the site residents were of far less importance than the clearing and rebuilding of the site itself.”21 The history of urban renewal shows decision makers’ consistent unwillingness or inability to consider the desires of the people most profoundly affected – the people who live in areas slated for “renewal.”
Part of the problem has been that people have spoken in whispers. When urban residents speak loudly, and when they back up their words with the cohesiveness shown in the Boston struggle, the whole planning process changes. People get across the message that their homes and neighborhoods are so important that they cannot be sacrificed. The individuals who control urban institutions realize that redevelopment plans can proceed only if they do not interfere with residents’ needs. When people work together collectively old homes get rehabilitated, rents remain stable, new housing is built and the community is revitalized. Through their demands, people also can receive the health care and other human services they desire.
Finally, by forcing the planning process into an open and public arena, the community conflict can change large institutions in positive ways. For example, although proponents of the medical expansion in Boston advocated consolidation of three hospitals, the hospitals’ traditional independence impeded a formal merger. As a result of community pressure, the hospitals reached agreements about consolidation of physical plant, administration, financial structure, and professional staffing that had not been possible previously. The outcome of community pressures has been a more rational planning process that explicitly takes into account the variety of interests affected by institutional expansion.
Struggles concerning expansion lead to heightened consciousness about the nature of large urban institutions. Traditional ideology teaches that the persons who control institutions have an accurate idea about what is best for society. This ideology leads the residents of a community to acquiesce to the community’s destruction to make room for a government center or highway, or to believe that new hospitals must be needed to care for the sick, or doctors and hospital administrators would be satisfied with the buildings they have now.
The ideology of “need” as defined by those in power is related to a second ideologic pattern that rationalizes people’s class positions. As Sennett and Cobb have pointed out, one of the “hidden injuries” of social class in the U.S. is the subtle notion that class position is one’s own responsibility. Working-class people learn, in school and in the occupational system, that success results from hard work and ability. This ideologic pattern often makes working-class people believe that they would have more if they were better individuals, despite the evidence that there is little mobility across major class boundaries in the U.S.22 Rather than seeing the destruction of their neighborhoods as an example of institutional violence, urban residents usually have reacted with passive resignation, as though the loss of a home is part of the buffeting in life that they somehow deserve. These ideologic patterns are weakening at the present time. Struggles like that in Boston heighten people’s skepticism that those who control institutions have greater insight than anyone else into the social good. When the plans of these powerful individuals are scrutinized, the doubtful benefits of much institutional growth become clear. The private interests involved in expansion and redevelopment also grow more evident as communities oppose new projects. In Boston, local residents gradually learned that a series of claims made by hospital officials – the importance of a site that would destroy housing, the need for several towers instead of one structure, the new hospital’s contribution to local health services when there were no plans for an ambulatory care center, etc. -were unfounded.
Gradually many residents have started to link their own troubles to broader political and economic structures.
People also have realized that their personal misfortune is not always their own fault. Mission Hill residents discovered that medical institutions would have destroyed their neighborhood for reasons that could not be justified later, when residents and their supporters took political action to save their homes. Through this process, residents now see that the potential loss of their neighborhood was not their fault and that by organizing together they could affect their destiny.
Demystification has occurred. By struggling against medical expansion, community residents have learned that doctors and other professionals have no special knowledge of the public good and have their own private interests as well. Medical centers, universities, and other large institutions have lost much of their credibility. People who live in cities no longer will accept uncritically these institutions’ claims for land, finances, or popular support. As people organize themselves to protect their communities, they understand more clearly the real services that institutions can provide and the ideology they propound. With understanding comes the confidence to resist and to shape the future.
Tactics That Succeed
When a community wins a victory, it is important to ask what specific actions led to the victory. Large institutions command resources of power and finances that give them an advantage. The institutions can hire specialists to work for goals that communities oppose; residents generally must rely on their own time and energy outside their usual jobs. Perhaps most important, institutions can find innumerable ways to co-opt local opposition. By offering people jobs, or by involving them in committees under the rubric of community participation, institutions can neutralize conflict and antagonism.
Residents in Boston evolved some key tactics that distinguished their work from less successful efforts elsewhere.
Adversary relations. Community members consciously adopted the stance of an adversary relationship. Harvard and its affiliated hospitals were the enemy. Hospital expansion posed a clear, unambiguous threat to the neighborhood. Residents recognized that, until the expansion issue was resolved, relations with the Medical Center and the University would need to be viewed as basically antagonistic.
As Alinsky points out, defining the enemy often is a difficult process. People learn to experience conflict as unpleasant. Large institutions can create fear among families and individuals who have not felt the strength of organizing together. For example, after they received eviction notices, some residents feared that they would lose the chance for any help at all from the University if they actively opposed the new hospital. Institutions also affect public opinion through the media. During the early phases of the Boston struggle, public statements from the Medical Center and the University stressed the importance of the new hospital. Press coverage emphasized the outstanding reputation of the medical facilities and the advantages of consolidation, rather than the community’s housing needs. Some residents were reluctant to oppose medical expansion while the media were placing a high value on the hospital complex.
It was also hard for people in the community to figure out precisely who the enemy was. At first, residents were led to believe that officials at the Medical Center could make decisions about housing and the future of the neighborhood. After many months, however, it became clear that the ultimate power to make decisions about housing was not at the Medical Center at all. Instead, this power rested with the Corporation of the University. Although the process of locating the enemy took time and energy, it was worthwhile. Subsequently, residents refused to deal with lower-level officials who could not make binding decisions. When the Corporation understood the depth of the community’s commitment, University officials began serious negotiations.
One Issue First, Multiple Issues Later. The threat to housing provided a clear-cut issue around which residents could unite. Many other issues presented themselves as areas of concern. For example, medical expansion focused attention on the fact that many residents had no regular source of outpatient health care. Related issues included drug abuse and alcoholism, irregular police services, limited shopping facilities and the need for cooperative food buying, recreational facilities, and local economic problems that resulted from fuel shortages and unemployment.
The leaders of the tenants’ association resisted pressures toward diffusiveness. In general, they directed their primary efforts toward the housing issue and encouraged their neighbors to do the same. During the first two years of the struggle, some residents did specialize in other areas and laid groundwork for later accomplishments. Most people, however, concentrated on the housing issue until the University signed written agreements with the community.
More recently, after the tenants obtained definite commitments, a smaller group has taken responsibility for actions relating to rentals, maintenance, rehabilitation and the construction of new housing. Other residents have pursued different issues. One reason for the community’s success, however, has been the refusal to be sidetracked from the main issue – the neighborhood’s survival.
Power Base and Coalition Building. Throughout the Boston struggle, organizers and community leaders have been careful to cultivate a reliable power base, among both residents and outside supporters. Monthly meetings attract large turnouts. Whenever major policy matters are to be decided, members canvas the neighborhood to assure that residents have a chance to express their opinions. Leaders of the association have developed working relations with other local organizations.
While unity within the community has created the major part of residents’ power base, aid also has come from other sources. Politicians representing the community in the state legislature and city council have responded intermittently to residents’ prodding. Moreover, residents have received assistance from workers, students and faculty members at the Medical Center and University who formed a support group that gathered information and publicized the threat to the neighborhood (see box). During the early phases of the struggle, members of the support group joined with tenants in several demonstrations at the Medical Center. Although residents continued to take primary initiative, support within the Medical Center and University strengthened the community’s power base.
Tactical Flexibility. Another reason for the community’s success has been residents’ flexibility in using a variety of tactics as warranted by different situations. For almost a year after the formation of the tenants’ association, University officials did not respond substantially to residents’ demands. Under these circumstances, tactics involving confrontation and obstruction were necessary. Tenants and their supporters then staged a series of nonviolent demonstrations at the Medical Center to dramatize their commitment. Residents and supporters also picketed at the administrative offices of the AHC, Harvard University and The Boston Globe (the latter because of a misleading article). These actions attracted publicity and showed that the community would have to be reckoned with seriously.
Later, after residents had consolidated their power base and demonstrated their commitment, they turned to negotiations and bargaining. For the past several years, a nucleus of elected leaders of RTH have negotiated with University officials about housing issues. Other residents, usually acting as members of the MHHM, have bargained with AHC officials about plans for the new hospital and other health problems. In these negotiations, residents have made some limited compromises, without sacrificing their overall goals.
Using Local Resources. Residents have increased their effectiveness by creating a division of labor. People who live in the community possess skills and backgrounds that have been useful in different ways. Some professionals who lived in the community before the expansion issue arose have contributed their knowledge and technical abilities to community organizations. For example, a political scientist, a social worker and a physician have worked hard on documents that the MHHM submitted in opposition to the AHC’s proposals and certificate-of-need application. A lawyer and an architect living in the neighborhood have worked with RTH, both to stop expansion and to plan for new housing. In each case, the fact that the professional was part of the community was crucial.
In addition, expertise has not been limited to the local professionals. Many working-class people living in the neighborhood have gained new competencies. Several people have concentrated solely on community organizing skills that will continue to be useful. Individuals with talents in writing, photography, and art have worked on the community newspaper which has helped narrow the distance that otherwise might emerge between leaders and other residents who play a less active role. Other residents have specialized on housing, health problems or other issues. They have realized that knowledge can help improve social conditions, when knowledge is tied to the power base of an organized community.
Allowing Organizations to Die. When an organization is started, pressures arise to maintain and enhance its growth, even if its original purposes are accomplished. In a community struggle, the energies needed to preserve an organization can interfere with new goals that emerge. Letting organizations die requires personal humility and political wisdom to understand what actions are important at what time.
In Boston several organizations have died simple deaths when they no longer were needed. One of the early organizations that concerned itself with area-wide planning was the Housing and Land Use Committee, composed of residents, local merchants and representatives of the medical institutions. Residents allowed it to die when it later became clear that an elected organization with certain legal powers was needed. The Mission Hill Planning Commission superseded the Housing and Land Use Committee: some but not all members of the Committee gained election to the Commission.
Another example of a peacefully dying organization was the Medical Center Tenants Support Group. The Support Group was very active in the first two years of the Boston struggle, when periodic confrontations were necessary to obtain serious negotiations. Later, after residents’ commitment was clear, demonstrations no longer were a major tactic. The Support Group disbanded, with the understanding that it could be reactivated if needed.
The community newspaper (The Good News) also entered a period of dormancy, though for somewhat different reasons. Most residents believed that the newspaper played a vital role in community organizing. However, between 1974 and 1975, the individuals who worked on the newspaper decided that they could use their energies more effectively in relation to other issues – especially opposing the AHC’s certificate-of-need application. After one year of inactivity, the newspaper resumed publication.
Avoiding Factionalism. Factionalism can be a great impediment to progressive social change. Recently, the problem of factionalism has slowed or halted political work in many communities and workplaces.
A coherent ideology, linking progressive theory with concrete practice, is necessary to build an effective mass movement. For example, the issue of a unifying ideology is a crucial concern for people working to form a party committed to a basic reconstruction of U.S. society. Disagreements in the party-building movement focus largely on the distinction between vanguard party and mass party. Advocates of a vanguard party believe that historically all successful revolutions have resulted from the efforts of a small vanguard. Members of the vanguard hold a consistent ideology and attract mass support during periods of political and economic upheaval. Supporters of a mass party argue that, given the historical conditions of the U.S., mass organizing must precede rather than follow the development of a coherent ideology: therefore, political energies should go toward building broad-based alliances within the working class that embrace a spectrum of ideologic views.
This debate is crucial. On the other hand, many factions have emerged from slight differences in ideologic line. Factionalism has weakened the movement toward a progressive party. Moreover, the divisiveness of factionalism has hampered people’s ability to work together in local struggles. In many areas of the country, community and workplace organizing has proceeded very slowly, as people have debated small points of ideology. Irrevocable splits have occurred among groups working toward similar goals; these splits have strengthened the positions of those in power.
In Boston, residents have held a variety of political orientations. People who lived in the community for many years were mostly members of the Democratic Party. Though increasingly skeptical about the responsiveness of elected representatives, these individuals have not previously seen the movement toward socialism as a desirable alternative. More radical residents, especially younger people who were drafted during the Indochina War or who face unemployment during the current economic crisis, are bitter about exploitation b-y the capitalist system. Some of these individuals have allied themselves with groups advocating revolutionary political action.
Despite these different views, residents have worked together effectively. Between 1969 and 1976, the only major disagreement that occurred within the community concerned a new power plant for, the medical center and for the new housing. Even in this disagreement, residents tried not to interfere with mutual goals. Whenever possible, people have expressed their political analysis in ways that would not alienate others who were committed to the same local purposes. Residents have been frank with each other about their views. When local events have reflected broader contradictions in the capitalist system -especially power relationships and economic problems – people have discussed these issues openly. However, individuals committed to specific political ideas have respected the different pace at which their neighbors’ attitudes would change. Through mutual tolerance, the community has developed a strong power base. At the same time, residents have learned and developed a more sophisticated analysis about the realities of our society.
Community Organizing and Broad Political Strategy
While work on many fronts is essential, local community organizing should continue to be a central part of broad political strategy. There are many possible pitfalls of community struggles. Partial successes can coopt people’s energies through the impression that, since some improvements are possible, the present system can be preserved. Demoralizing failures can discourage people from sustained efforts. Nevertheless, successful struggles like that in Boston reveal several ways in which community organizing can contribute to broader strategy.
First, community organizing clarifies the nature of class conflict and heightens class consciousness. Struggles against expansion or other urban redevelopment put people in direct confrontation with the individuals who control major social institutions. Through this exposure, working-class people reach a clearer understanding of the personal and corporate interests that affect their lives. They also learn to distinguish these interests from the ideologic statements about public “need” that are used to justify expansion and redevelopment. It becomes clear that disputes between communities and urban institutions are manifestations of more basic conflict between social classes.
It is important to realize that victories are possible.
In Boston, people from diverse backgrounds came to recognize that they all must fight the same enemies. Unity within the community becomes more important than barriers of race or ethnicity. They also realized that coalitions with other working-class communities with overlapping problems and goals can be worthwhile. Community struggles then can form the basis of further political action that extends beyond the local community itself.
Second, community struggles expose the contradictions and demystify the dominant ideologies of capitalist society. In addition to class structure, community organizing clarifies the contradiction of hierarchies based on expertise. Institutional expansion and redevelopment often are justified by the opinions of “experts,” just as notions of the need for health services have traditionally come from doctors and other professionals associated with hospitals. These justifications mask the private interests that are involved. Expertise is closely linked to class power and often is used to reinforce patterns of domination in society. In Boston and elsewhere, people participating in community struggles have realized that professionals can use expert knowledge to legitimate their own interests, and the interests of other powerful persons with whom they are allied.
Third, community organizing can lead to progressive reforms that encourage subsequent political action. One danger in limited political efforts of this type is that small incremental improvements can lull people into a sense of satisfaction with the present. political and economic system. Reformism in the U.S. and other capitalist countries has often been the response to popular protest. More often than not (especially in health . and welfare services), reforms have improved people’s material situation slightly, without changing overall relations of power and finances in the society; they leave the political and economic system intact while reducing opposition. Therefore reformism tends to inhibit more fundamental change.23
On the other hand, certain reforms can be an important part of long-term revolutionary strategy. Progressive reforms involve concrete changes in people’s control over their living or working conditions. Such changes may include material improvements (stable rents, better health care, etc.). The progressive element depends on the realization that organizing gives people power and highlights the inequities of the present system. These reforms raise people’s consciousness that fundamental change in the system is necessary.
Successful community struggles, as in Boston, can result in reforms that are progressive. In the first place, people learn to draw a link between material improvements and political organizing. People working in a unified way can stop institutional expansion into their neighborhood. Moreover, they can obtain many needed benefits, including rehabilitated and newly constructed housing, subsidized rent levels, and more accessible medical services. Because these reforms directly follow from the community’s political action, people realize the power that comes from their own organization.
These reforms also permit the emergence of popular control. For example, the tenants’ association in Boston has won control over rental and maintenance policies that previously jeopardized the neighborhood’s stability. In the role of co-developer of new housing, the association also will decide broad questions of design, financial responsibility, and tenant relations. Residents have gained access to the governance structure of the major medical institutions in the area. People living in the community therefore can exert an influence over the nature of the health services that are available.
It is doubtful that these reforms will lead to complacence about the present system. Residents will continue to come into contact with wealthy and powerful individuals who control major institutions. As conflicts arise, residents will see again how the interests of these individuals differ from their own. A community cannot act as co-developers of new housing without confronting, on a day-to-day basis, inequities of finance and power. Similarly, people who serve on the governing board and committees of the new hospital will see the power structure of medical institutions more clearly. The frustrations that occur will highlight the inherent difficulties of working toward improved health care or other services, while basic patterns of political, economic, and professional dominance persist.
We can take pride in our victories. This is especially true when victories lay the groundwork for continuing struggle toward the reconstruction of our society.
II. Who’s Controlling Whom? A Reply to Waitzkin
John Grady has lived on Mission Hill for 8 years. During much of this time he has been part of a number of community organizations, including the Back of the Hill Organization, the Mission Hill Planning Comission and Residents United to Stop Harvard (RUSH). He teaches sociology at Framingham State College.
Howard Waitzkin has written the story of a neighborhood that took on a corporate giant and won. The article is intended as an object lesson for the at least 68 other local neighborhood organizations across the country who are facing institutional expansion by large medical empires: “Be of good heart, you too can fight city hall; what’s more, you can win, and preserve your neighborhood.” The article has another message, directed at self-conscious radicals: Single-issue reformism can develop into a multi-issue movement for more embracing social change.
Like Waitzkin we live and are active in the Mission Hill section of Roxbury, but we have a different story to tell: Mission Hill is losing its fight for survival against Harvard University and the other powers that be, and is losing badly!
Waitzkin argues that the Mission Hill community has won some significant victories. This is a complicated question, but for the most part we tend to disagree. 1) He fundamentally misperceives. 2) He doesn’t cover events after 1974-75 during which the situation changed. It is clear that during the period from 1969-73, what Roxbury Tenants of Harvard (RTH) had done was of inestimable value for Mission Hill as a whole. Housing was not torn down; rents were frozen at 1969 levels; and close to half of the old housing stock in the RTH area was rehabilitated.
It is unclear, however, if the new housing and the energy that is going into it is worth it for the people in RTH. The rent of the new housing, even when subsidized, will only be affordable by a small minority of Mission Hill residents. Secondly, Harvard University has de facto ownership of the project, and one can expect that they will use the properties increasingly for their own benefit. For example, the commercial space built into the new development (originally touted as providing a place for neighborhood shops) has already been appropriated by a Harvard-related agency, the Brigham Surgical Group. Thirdly, because the new housing is considered replacement housing, RTH residents will lose their rights to use existing housing under the earlier terms of the agreement negotiated with Harvard. In other words, RTH has given up hard-won realities (which they would, of course, have had to defend) for an as yet unfinished fantasy.
Waitzkin implies that most of the community victories involve the Affiliated Hospital Complex (AHC) itself. However, the actual victories are meager: The AHC has been moved one city block from its originally planned location: it has a formal although low priority commitment to ambulatory care; it is 110 beds smaller than it was originally planned; and the AHC has added two community slots on the board of trustees. The most that can be said is that community pressure has to a small degree rationalized the planning and construction of the hospital. But the AHC planning process has not been seriously constrained by the health needs of Mission Hill residents and other working-class people, and the physical construction on its new site still constitutes a massive threat to the continued survival of the existing RTH neighborhood.
The tenant’s union has given up hard-won realities for an as yet unfinished fantasy.
RTH has in fact given up any claim to two city blocks of low-income housing, and has agreed to the construction of a massive wall of institutional development. Residents who used to face out on the low-lying Peter Bent Brigham Hospital, a large parking lot and a block of aesthetically pleasing red-brick townhouses will now face: the new AHC (l6 stories high and consisting of four towers) built at a cost of $130 million; a massive total-energy industrial power plant with a smokestack at least 315 feet high and constructed at a cost exceeding $66 million; and, finally, the construction of something referred to as the Medical Area Service Corporation (MASCO) service center. As yet it is unclear how big this last giant warehouse will be or how much it will cost. But one thing is clear: close to a city block of housing now occupied by RTH residents who are reluctant to move will be demolished. This all adds up to institutional expansion of the grossest sort.
There have been other community victories. Mission Hill residents played a small role in preventing the New England Baptist Hospital from expanding onto the top of Mission Hill. In addition, residents of the Back of the Hill section of Mission Hill, through a rather dramatic building seizure, forced the Ruggles Baptist Church to turn over 21 units of housing which were slated for demolition to predominantly Spanish and Black tenants at a nominal cost. But all of these are holding actions and even these victories, when added to the genuine accomplishments of RTH, still don’t justify the assertion that Mission Hill residents have any significant leverage at present with the powers that be, whether institutions or otherwise.
People counselled, “Listen, I hope you win, but you can’t beat Harvard. They’ve got the money, and whatever they want, they get.”
Waitzkin points to the subjective state of Mission Hill residents as the most important of all the accomplishments of community action. He argues that the system of power has been demystified for the ordinary people of Mission Hill, and whereas people once felt that “you can’t fight City Hall,” they now have had a taste of their own power. Our impression of the subjectivity of Mission Hill residents is quite different. When members of Residents United to Stop Harvard RUSH, an organization set up to fight the power plant’s construction, took around a petition demanding that the MASCO Total Energy Plant not be built, and got over 500 signatures (well over 80 per cent of those asked signed the petition), they were wished luck, but counselled, “Listen, you guys, I hope you win, but you can’t beat Harvard. They’ve got the money, and whatever they want, they get.”
While the reader might think that attitudes like the above are merely an instance of unfinished business in the process of organizing the community, the same kind of cynicism is expressed about community organizing in general and the history of Mission Hill organizations in particular. A rather widespread sentiment is that the major motivation behind most activists and organizations on Mission Hill is a barely disguised “hustle” orientation. RUSH activists often found themselves in the curious position of having to defend the personal integrity of many of their opponents in the community against accusations that invariably took the form: “All that community stuff is a hustle. It’s all fixed. Our leaders will and have sold us out. They’re on the take. Anybody who does anything has got an angle.” Boston is a very political city. The class struggle has been waged to a great extent through the electoral process, and anybody with common sense knows that you don’t trust anybody unless you are tied to him or her by the strongest ties of reciprocity, and even then you’ve got to watch out that you don’t get stabbed in the back. Nevertheless, on Mission Hill from 1969-73, many active people were convinced that this was changing, wanted it to change, and acted accordingly. Although a more thorough retelling of the history of this period would reveal different emphases than the Waitzkin article, his account does give a generally accurate picture of what people were doing and what some people in particular thought it meant. But what Waitzkin has not told us is how this changed from 1973 on.
Mission Hill activists made two major errors. The first was a decision to negotiate with the AHC. Initially Mission Hill residents had insisted that not only was the AHC badly planned for health reasons, but also that it should never be built on Mission Hill because the area was already overbuilt with hospitals and would destroy the residential quality of the neighborhood. Mission Hill activists successfully built mass support on Mission Hill for this position. They had influenced the Public Health Council of the Commonwealth of Massachusetts as well. This was important because the Public Health Council had the power to grant the AHC the Certificate of Need determination necessary to build the hospital. The Public Health Council was impressed with the Mission Hill Health Movement’s ability to mobilize over 600 residents for a public hearing; they were shocked by the MHHM’s scientifically convincing critique of the proposed hospital; and, finally, they knew that the Mission Hill Health Movement knew that the Public Health Council had violated the legal process by not having initiated a study on the environmental impact of the project. Thus, even if the Public Health Council should grant the certificate of need, an environmental suit by the community could tie up the whole process for years, if not win outright.
If Harvard provided free steam heat for the proposed new housing, then costs could be brought to manageable levels. But, of course, that meant that the power plant had to be built.
At the last minute in June of 1973, however, the predominantly professional leadership of the Mission Hill Health Movement lost their nerve. They reasoned that if the Public Health Council found in favor of the AHC, Mission Hill residents might not be able to raise the necessary funds for the suit, and the community would lose everything. The MHHM decided to seek a compromise and the Public Health Council was only too willing to put pressure on the AHC to negotiate with the community. It is now generally agreed by almost all activists in the community that the final document (which, incidentally, has still not been signed) is far weaker than the original demands taken by the community residents to the negotiating table. With the exception of $100,000 given to the MHHM for a family practice clinic, and $50,000 for the Mission Hill Planning Commission for a staff position during the construction phase of the hospital, Mission Hill has gained nothing from the agreement. It has lost the effective right to sue on the environmental issue, and, most importantly, its mass base has been demolished.
The second major mistake made by Mission Hill residents concerned the MASCO Total Energy Plant. Although for years there had been rumors that Harvard wanted to build a large power plant somewhere in the area of the proposed AHC, Harvard publically denied that this was necessary for the construction of the new hospital. During the winter of 1973-74 it became clear to RTH that Harvard was serious about the power plant. RTH gathered together a handful of activists from other organizations on Mission Hill to do some initial research on the power plant and plan a course of action against it. RTH was very worried that they would have to fight the power plant alone. Initial research, done in conjunction with Urban Planning Aid, showed that the power plant lived up to everybody’s worst fears. Nevertheless, those people involved in preparing for the power plant fight decided to wait until Harvard actually began to go public on it to mobilize Mission Hill residents for the fight. In January of 1975, however, RTH
The testimony of the power plant opponents was overwhelmed by the appearance of scores of construction workers and RTH residents bearing such signs as “The Power Plant is Power to the People!”
signed an agreement with Harvard that stated in part “RTH agrees to support publically the construction of the total energy plant by, among other things, using its best efforts to inform residents of the community and other interested civic and governmental groups of the financial interdependence of the project and the total energy plant.” It must be stressed that R TH signed this memorandum of understanding that committed them to supporting the construction of the power plant without consulting any other groups in the community.
The reasons for RTH’s support of the power plant were classic. Harvard made it clear to them that without the power plant, the new housing that RTH was planning, and which Harvard was supposed to make a financial reality, would not be built. Harvard informed RTH in the latter stages of planning the housing that the whole project was unfortunately no longer financially feasible. The only way that a loan could be guaranteed by the MHFA (Massachusetts Housing Finance Authority) would be if Harvard would stand behind any possible fluctuation in interest costs. Harvard said they would only do this if the costs of the project could be lowered significantly. Fortunately, Harvard just happened to have a solution for the frightened RTH residents who saw their long-hoped-for dream going down the tubes: If Harvard provided free steam heat from the proposed MASCO power plant then costs could be brought within manageable levels. But, of course, that meant that the power plant had to be built.
A major consequence of this decision was to create a visible split within the community, which became increasingly exacerbated when other Mission Hill residents created an organization, Residents United to Stop Harvard (RUSH}, to fight the power plant. Needless to say, this split has been used quite effectively by Harvard and related institutions as a way of avoiding dealing with those community activists and issues they find unpleasant or embarrassing. Possibly the most striking example of this took place at a public hearing called by Boston’s urban renewal agency, the Boston Redevelopment Authority (BRA) to determine whether the MASCO power plant could be granted a maior tax break under Chapter l21A of the Laws of the Commonwealth of Massachusetts. The testimony of the 80 or so MASCO opponents was overwhelmed by the very vocal appearance of 80 or so construction workers brought out by the building trades and close to 100 RTH residents bearing such signs as “The Power Plant is Power to the People!”
The major effect of these two mistakes – the Mission Hill Health Movement’s decision to negotiate with the AHC and RTH’s buying of the MASCO power plant – has been to first politically demobilize the community and then create a major obstacle to remobilizing it. But, for Mission Hill residents, the most important consequence has been subjective. The behavior of activists has confirmed community resident’s deepest fears that after all, everybody’s got an angle, everybody’s got a price. As such the brief interlude from 1969-7 3 appears as just another part of the melody in a song of betrayal that extends back to the days of the first ward bosses in Boston.
Part of the reason all this happened is that the community organizations had no strategy. What Waitzkin has described as a coherent strategy is merely the protocol of power that anybody with any sense uses to make friends and influence people and it has been described better by Machiavelli and George Washington Plunkitt of Tammany Hall. As a political strategy, it is sadly lacking. For one thing, it doesn’t acknowledge the strategic significance of the fact that it was a highly ideological multi-issue student strike that catalyzed R TH in the first place, and provided the community activists with the clout they needed to extract any concessions from Harvard. Secondly, it doesn’t clearly acknowledge that Harvard is a capitalist institution and is part of a network of relationships, events and processes that effectively insulate any community activity unless it fosters more encompassing, broader class-wide mobilization.
Organizations and activists who were formerly in the forefront of the struggle against a specific capitalist development, now serve to broker and cushion that process.
Waitzkin has just as accurately described the process by which new institutions of social control are built. While extra-community support (paralleling the decline of the student movement) withered away and activists made a series of mistakes, a major class-wide capitalist offensive to roll back the standard of living was being made because of the declining rate of profitability on investment (most dramatically experienced by all of us during the so-called energy crisis). Prestochango, organizations and activists who were formerly in the forefront of the struggle against a specific capitalist development, now serve to broker and cushion that process.
All of this is a fairly common historical process. Reform movements, which some had hoped would provide an opening for wide political action, end up accomplishing a minor reform. One of the functions of this is not only the creation of a change that helps the system work more smoothly, but more importantly, it creates a constituency supporting that reform, even though the direct material benefits to that constituency might be marginal. If Harvard had had to carry the MASCO Total Energy Plant through the political process on their own, they would have risked a repeat of earlier experiences where upwards of 600 Mission Hill residents vociferously supported their own spokespeople. And if the past is a reliable indicator, those spokespeople would have made mincemeat of Harvard’s arguments. But, when RTH agreed to support the power plant, all Harvard had to do was to quietly step aside and let community groups fight it out among themselves.
When you get down to it, I guess it’s all a matter of what’s written on the bottom line. And the bottom line for the process that Waitzkin describes is that community organizing has created a political front for Harvard University and its allies within the Mission Hill community. That they argue to the contrary needs explaining. Part of the story is that while it is hard for anybody to acknowledge when they’ve been beaten, it is especially hard for professionally-oriented workers who have sought to resolve the ambiguities in their work by fully integrating that work with the desires of the people. Acknowledging that one’s plans and hopes have been dashed poses a serious threat to the way that professionals (be they architects, doctors, sociologists, or whatever) construct their identity by implicitly questioning the delicate and fragile way they have blended their personal and professional competencies.
Nevertheless, while these considerations may explain why Waitzkin does not acknowledge that Harvard University’s hegemony over the development of the Mission Hill community has been restored, it does not justify the analysis. The future for Mission Hill is ominous. Not only is Harvard on the move again, but it is only a matter of time before $600 million worth of construction will begin on the Southwest Corridor Development – a massive public works project. This development, to build a highway and public transportation line that will provide the infrastructure for the corporate development of lower Roxbury, of which part borders Mission Hill’s southern boundary, will aggravate the economic and ecological pressures that are making the central city unliveable for working class families. Add to this the fact that homeowners and tenants are being forced to pay the burden of Boston’s fiscal crisis and you have a situation where the residents of the Mission Hill community are under the most serious political and economic assault since the Depression, and yet where, relatively speaking, community institutions have never been so weak.
At times like these, ruthless honesty and clarity are essential preconditions for survival. Waitzkin’s analysis is of value insofar as it contributes to sparking such a debate. Unfortunately, as it stands, his story only adds to the mystification, which he quite correctly points out should be the major target of community activity .
- E. Blake and T. Bodenheimer, Closing the Doors on the Poor (San Francisco: Health Policy Advisory Center, 1975).
- M.I. Roemer and M. Shain, Hospitalization Under Insurance (Chicago: American Hospital Association, 1959). D. Feshbach, “The Dynamics of Hospital Expansion,” Health-PAC Bulletin. May-June 1975, pp. 1-6, 15-21. B. Ensminger, The $8 Billion Hospital Bed Overrun (Washington: Public Citizen’s Health Research Group, 1975). V. Fuchs, Who Shall Live? Health. Economics and Social Choice (New York: Basic Books, 1974),pp. 79-104, 151.
- In July, 1975, a questionnaire was sent to the public relations officers of the universe of 662 hospitals- as determined from American Hospital Association, List of Health Care Institutions (Chicago: The Association, 1975)- in the 20 largest U.S. cities according to the 1970 census (New York Chicago, Los Angeles, Philadelphia, Detroit, Houston, Baltimore, Dallas, Washington, Cleveland, Indianapolis, Milwaukee, San Diego, San Francisco, San Antonio, Boston, Memphis, St. Louis, New Orleans, and Phoenix). Responses were received from 411 institutions for a response rate of 62 percent. For a second mailing in November, 1975, responses were received from an additional 138 institutions, yielding 549 total respondents and a response rate of 83 percent.
- Based on newspaper clippings from these cities, available on request.
- H.J. Gans, The Urban Villagers (New York: Free Press, 1962); C. Hartman, Yerba Buena: Land Grab and Community Resistance in San Francisco (San Francisco: Glide Publications, 1974). R.J. Barnet and R.E. Muller, Global Reach (New York Simon & Schuster, 1974),pp. 359-362. A. Lupo, F. Colcord, and E.P. Fowler, Rites of Way (Boston: Little, Brown, 1971). G. Fellman and B. Brandt, The Deceived Majority (New Branswick, N.J.: Trans-Action Books, 1973). H. Brill, Why Organizers Fail (Berkeley: University of California Press, 1971). D.M. Gordon, Problems of Political Economy: An Urban Perspective (Lexington, Mass.: Lexington Books, 1971). F. Wirt, Power in the City (Berkeley: University of California Press, 1974).
- H. Waitzkin, “Expansion of Medical Institutions into Urban Residential Areas,” New England Journal of Medicine 282 (1970), pp. 1003-1007. R.J. Bazell, “Boston Hospital Dispute,” Science 171 (1971 ), pp. 358-361.
- This and later quotes are from informal interviews-discussions with Roxbury Tenants of Harvard (qTH) members
- D. Morris and K. Hess, Neighborhood Power: The New Localism (Boston: Beacon, 1975). L. Shipnuck, D. Keating, and M. Morgan, The People’s Guide to Urban Renewal and Community Development Programs (Oakland: Maud Gonne Press, 1974). C. Hampden-Turner, From Poverty to Dignity: A Strategy for Poor Americans (New York: Doubleday, 1975).
- Africa Research Group, Who Rules Harvard? (Boston: New England Free Press, 1969). D.N. Smith, Who Rules the Universities? (New York: Monthly Review Press, 1975). R. Sobel, Community University Housing and Relations (New York: Educational Facilities Laboratories, 1975).
- A.L Komaroff, “Regional Medical Programs in Search of a Mission,” New England Journal of Medicine 284 (1971), pp. 758-764. T.S. Bodenheimer, “Regional Medical Programs: No Road to Regionalization,” Medical Care Review 26 (1969), pp. 1125-1166. E. Ginzberg, “Dilemmas and Directions,” in The University Medical Center and the Metropolis. E. Ginzberg and A.H. Yohalem, eds. (New York: Macy, 1974), p. 158.
- J. Pfeffer, “Size, Composition and Function of Hospital Boards of Directors: A Study of Organization-Environment Linkage,” Administrative Science Quarterly 18 (1973), pp. 349-364. V. Navarro, “Social Policy Issues: An Exploration of the Composition, Nature and Functions of the Present Health Sector of the United States,” Bulletin of the New York Academy of Medicine 51 (1975), pp. 199-234. R.R. Alford, “The Political Economy of Health Care: Dynamics Without Change,” Politics and Society 2 (1972), pp. 127-164. R.R. Alford, Health Care Politics (Chicago: University of Chicago Press, 1975). S. Kelman, “Toward the Political Economy of Medical Care,” Inquiry 8 (1971 ), pp. 30-38.
- R. Dubos, The Mirage of Health (New York: Anchor, 1959). Medical History and Medical Care, T. McKeown and G. McLachlan, eds. (London: Oxford University Press, 1971). E.H. Kass, “Infectious Disease and Social Change,” Journal of Infectious Diseases 123 (1971), pp. 110-114. A.L. Cochrane, Efficiency and Effectiveness: Random Reflections on Health Services (London: Nuffield Hospitals Trust, 1972). J. Powles, “On the Limitations of Modern Medicine,” Science, Medicine & Man I (1973), pp. 1-30.
- I. Illich, Medical Nemesis (New York: Pantheon, 1976). R. Carlson, The End of Medicine (New York: Wiley, 1975). R. Lindheim, The Hospitalization of Space (London: Calder & Boyars, in press). H. Waitzkin, “The New Reductionism in Health Care Research,” Contemporary Sociology 5 (1976), pp. 401-405.
- W.J. Bicknell and D.C. Walsh, “Certificate-of-need: The Massachusetts Experience,” New England Journal of Medicine 292 (1975), pp. 1054-1061. W.J. Curran, “A Severe Blow to Hospital Planning: ‘Certificate-of-Need’ Declared Unconstitutional,” New England Journal of Medicine 288 (1973), pp. 723-724. C. C. Havighurst, “Regulation of Health Facilities and Services by ‘Certificate-of-Need,” Virginia Law Review 59 (1973), pp. 1143-1232. E. Rothenberg, Regulation and Expansion of Health Facilities: The Certificate of Need Experience in New York State (New York: Praeger, 1976).
- S.M. Miller, “Planning: Can It Make a Difference in Capitalist America?” Social Policy 6 (September-October 1975), pp. 12-22. R.L. Warren, “Comprehensive Planning and Coordination: Some Functional Aspects,” Social Problems 20 (1973), pp. 355-364.
- W.J. Curran et al., “Government Intervention on Increase” Medical History and Medical Care, T. McKeown and G. McLachlan, Hospitals 49 (May 16, 1975), pp. 57-61.
- M. Fried, “Grieving for a Lost Home,” in The Urban Condition, L.J. Duhl, ed. (New York: Basic Books, 1963).
- J.Jacobs, The Death and Life of Great American Cities (New York: Vintage, 1961), pp. 143-177,270-290.
- M. Fried, The World of the Urban Working Class (Cambridge: Harvard University Press, 1973), pp. 94, 120.
- H.J. Gans, The Urban Villagers (New York: Free Press, 1962)
- R. Sennett and J. Cobb, The Hidden Injuries of Class (New York: Vintage, 1973), pp. 97-98, 153-159.
- A. Gorz, Socialism and Revolution (Garden City, N.Y.: Anchor, 1973).