Friday, December 26, 2014

Care for all: A look back at Philadelphia General Hospital

Closure of the municipal hospital that had served the city's poor since 1732 impacted all of Philadelphia, and still does.

Care for all: A look back at Philadelphia General Hospital

Student nurse with patient at Philadelphia General Hospital, circa 1970.
Student nurse with patient at Philadelphia General Hospital, circa 1970. © University of Pennsylvania / Barbara Bates Center for the Study of the History of Nursing

I moved to Philadelphia in 1976, and the first thing on my agenda was to get a job. After making the rounds of several hospitals, I made my way to Philadelphia General Hospital (PGH) and applied for a faculty position in its school of nursing.

Philadelphia General Hospital, a tax supported municipal hospital—the oldest in the United States—was located at 34th Street and Civic Center Boulevard and delivered healthcare mainly to a mainly medically indigent population. The interview went quite well and I decided that PGH would be a good place in which to work. Advised that I must take the required civil service exam, I set out the next day to take the test. As I was walking down Market Street towards City Hall, there appeared some unusual activity around a newsstand. I stopped to take a look at the papers whose headlines screamed, “RIZZO TO CLOSE PGH.” With that breaking news, my career as a PGH nurse came to an abrupt end!

Mayor Frank Rizzo’s decision to close an institution that had served Philadelphians since 1732 held ramifications not just for my immediate career prospects but also for the legions of Philadelphians who depended on PGH for their health care. Originally established as an almshouse in the English poor law tradition, the institution reflected the idea that communities assume some responsibility for those unable to do so themselves. In its early years, the almshouse, located at 10th and Spruce Streets (this link, like others in italics in this post, takes you historical images, in this case a sketch of the almshouse circa 1921), carried out a number of functions including housing for the elderly and poor, maintenance of a house of correction, psychiatric care, the housing of foundlings, a workhouse, accommodations for indigent women about to give birth and the operation of a hospital. In 1835, the almshouse moved to the west side of the Schuylkill, renamed its hospital section the Philadelphia Hospital and delivered services typical of hospitals of the time. Nicknamed “Blockley,” after the township in which it was located, the hospital thrived as a center of medical education, distinguished by its rich source of “clinical materials,” also known as patients or inmates in the parlance of the time. In the early 1880s, reform minded members of the hospital’s governing Board of Guardians, determined to improve the nursing care (which had never been very good) by establishing a school of nursing. The Guardians arranged for an English nurse, Alice Fisher, a colleague of Florence Nightingale, to take on the task of setting up a professional school of nursing. An accomplished and competent administrator, Fisher used a combination of brains, political savvy and her charismatic personality to establish a school that operated for 92 years and became known as one of the best in the country.

By the early 20th century, the institution shed its almshouse functions, was renamed Philadelphia General Hospital, and became a full-fledged general hospital offering modern medical and nursing care. Its reputation depended not just on the excellence of the medical and nursing staff but also on its role as provider of health care to those unable to access other hospitals due to their race or ethnicity, low income, or lack of health insurance. Its doors were always open to all Philadelphians. In a pre-Medicare, pre-Medicaid, pre-Affordable Care Act era, PGH guaranteed that no Philadelphian would go without needed hospital care in a city that took as a given the community’s responsibility to citizens less fortunate.

To be sure, care delivered at PGH was not perfect. Tax-supported hospitals suffered from a number of deficits such as insufficient staff, supplies, and funding, all of which characterized PGH. Too often in its 245 years of existence it served as a source of political graft and was mired in scandal. With a patient population made up disproportionately of members of ethnic and racial minorities, issues of class, race, and unjust treatment constantly bubbled to the surface. An aging physical plant, unable to meet the needs of late 20th century medical care, stymied PGH’s ability to survive as a modern hospital. Even its renowned school of nursing failed to keep pace as nursing education moved into institutions of higher education.

Mayor Rizzo’s controversial decision to close PGH was bolstered by passage of the 1965 Medicare and Medicaid legislation. Many thought that Medicare and Medicaid would substantially decrease the need for public hospitals by providing health insurance coverage for the elderly and very poor. Yet Medicare and Medicaid were not intended to reach the entire population and left too many Americans out of the health insurance safety net—one of the many reasons for passing the Affordable Care Act.

PGH’s closure left a gap in services for the West Philadelphia community, which depended on PGH as its hospital of first resort. Even today, despite the good news that between 8 and 11 million Americans have gained health insurance under various provisions of the ACA, millions of remain uncovered. In Pennsylvania, Gov. Corbett declined to accept the Medicaid expansion offered by the federal government, leaving substantial numbers of Pennsylvanians without health insurance. Instead, Corbett offered an alternative plan “Healthy PA” which has received significant criticism and is presently being considered by the federal government. Pennsylvania Democrats—and quite a few Republicans— have taken action to move on state Medicaid expansion but, while we wait to see what happens, no PGH exists to take up the slack for those uninsured.

I never did get to work at Philadelphia General Hospital, but my interest in the institution continued. Years later, I led a project that digitized the photo collection of the Alumnae Association of the PGH School of Nursing. The photo collection, which covers the years 1870-1977, and includes over 1,300 images, is a remarkable lens through which to view hospital care of another era. It provides a pictorial lesson on how hospitals operated and highlights both the successes and deficiencies of tax supported care facilities. It serves as a visual reminder that there is a strong historical argument in favor of Obamacare.

Today, the site on which PGH stood houses a number of health-care facilities, including Children’s Hospital of Philadelphia, University of Pennsylvania medical buildings, the Philadelphia VA Hospital and the University of Pennsylvania’s School of Nursing's Claire M. Fagin Hall, continuing a legacy of care. (I am writing this post in the building in which I interviewed for the PGH position 38 years ago!) An historical marker stands in place on the grounds commemorating the site.

 


Jean C. Whelan, PhD, RN assistant director, Barbara Bates Center for the Study of the History of Nursing, adjunct associate professor of nursing, University of Pennsylvania, and president of the American Association for the History of Nursing.

 


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