Community Struggles for a New Gouverneur: Tackling the Deeper Roots of the City’s Unequal Hospital Care

Community Struggles for a New Gouverneur: Tackling the Deeper Roots of the City’s Unequal Hospital Care 

By Hongdeng Gao 

The COVID-19 pandemic has exposed deep inequalities in New York City’s hospitals. During the peak of the coronavirus outbreak, patients in public hospitals, which serve largely low-income and uninsured New Yorkers, were relegated to overcrowded and understaffed wards with shortages of equipment, drugs, and supplies. In contrast, at private medical centers in Manhattan, which cater largely to wealthy people with insurance, patients had access to specialized machines, advanced treatments, and more empty beds. The inequalities in hospital care worsened fatality rates among the city’s low-income communities of color — who were already more likely to contract and die from COVID-19 than their wealthier white counterparts due to disparities in housing, employment, and other social determinants of health.[1]

To explain the disparities in the city’s hospital system, studies and newspaper articles have focused on recent policy decisions. According to the reports, New York State’s abandonment of a hospital reimbursement regulation system, elimination of statewide health planning agencies, and allocation of indigent care pool funds to wealthier private hospitals in the past three decades steered money toward private medical centers and health networks, and engendered the closure of hundreds of safety-net public hospitals in low-income communities and in neighborhoods where people of color live.[2]

The decisions made by officials in power to direct money to private hospitals and close safety-net medical institutions in the past thirty years bear many similarities to another large-scale hospital closure effort in the city nearly six decades ago: the hospital affiliation plan authorized by Mayor Robert Wagner. This blog post examines the affiliation plan’s attempt to close Gouverneur Hospital — a public hospital in the Lower East Side neighborhood — without replacing it, and reveals the deeper roots of the inequalities in the city’s hospital care. The Lower East Side community’s successful fight for a new Gouverneur Hospital and implementation of more holistic models of care offers an instructive precedent for advocates hoping to reform the city’s existing hospital system.

Gouverneur — A Safety-Net Hospital Needing Replacement

Gouverneur Hospital, circa 1900. Source: Harvard Art Museums.

Gouverneur first opened in 1885 as a fifty-bed municipal hospital on Gouverneur Slip and Front Street. An increased demand for services and a large fire in 1895 prompted the purchase of the entire block on Cherry Street for a new hospital with construction beginning in 1898.[3] From its founding to the 1950s, Gouverneur provided care to tens of thousands of poor and working-class Lower East Side residents, including European Jews, Italians, Puerto Ricans, and Chinese. Many of its patients worked in factory and service jobs and lived in crowded tenements that made them more vulnerable to injury and illness.[4]

By 1950, Gouverneur had aging structure and facilities that limited care.[5] It also confronted two problems that were common among the city’s public hospitals at the time: shortages of personnel and ballooned expenditures. After the Second World War, increased public faith and government funding in medical research led to an explosion of medical knowledge in the United States. The rapid expansion of medical knowledge made specialization more intellectually necessary and economically rewarding for aspiring physicians. American medical schools responded to medical graduates’ desire for clinical experience and residency positions by forming affiliations with hospitals. In an affiliation, medical schools provided and had administrative control over staffing and other related services at partnered hospitals. [6]

As historian Sandra Opydke argues, New York City’s voluntary hospitals outcompeted public hospitals for personnel and for self-paying and medically insured individuals by offering more advanced facilities, specialized departments, and interesting clinical cases. Private hospitals dealt with the increased expenses from updating their facilities by taking fewer charity patients and shifting these patients and the associated costs to public hospitals — whose mission was to never turn anyone away.[7] By 1960, a New York Times article reported on the conditions in municipal hospitals, which ranged from leaking roofs and long-delayed services to dwindling personnel and shortages of supplies.[8]

Proposals to Close Gouverneur and LENA’s Push Back

In the late 1950s, physician administrators and health planners who set out to reform the municipal hospital system proposed an affiliation plan that put many public hospitals, including Gouverneur, on the chopping block. In 1956, the Hospital Council of Greater New York (an agency responsible for planning hospital construction and allocation of beds in New York State) suggested that the city close Gouverneur Hospital without replacing it. Led by mostly business executives and physicians, the Hospital Council argued that Bellevue Hospital (a public hospital on 26th street and 1st Ave) would have enough general care beds to serve the Lower East Side population. Shifting all the patients from Gouverneur to Bellevue would save the city money and give Lower East Side patients higher quality care. It would also help medical schools, whose inpatient caseloads at Bellevue were “barely sufficient,” to meet their “needs for clinical teaching material.” In 1960, the Hospital Council used this line of reasoning to justify closing all municipal hospitals that had obsolete plants and no medical school affiliations.[9] These recommendations discounted factors such as neighborhood residents’ ties to medical institutions and hospital jobs, and the difficulty of traveling far for care. The suggestions also assumed that inpatient, specialized treatment with the latest technology and elaborate procedures were superior to other approaches to health care.

In 1959, a group known as the Heyman Commission drafted an affiliation plan based on the Hospital Council’s suggestions. The Commission consisted mostly of physician administrators from the region’s prominent voluntary hospitals, medical schools and universities — including Ray Trussell of Columbia University and Martin Cherkasky of Montefiore Hospital — who were asked by Mayor Robert Wagner to come up with a reform plan for municipal hospitals. According to the Commission’s affiliation plan, the city would pay its major private medical centers to have control over and provide staffing and related services to public hospitals. Hospitals that were considered unneeded and unlikely to obtain an affiliation would be closed. In March 1961, Dr. Ray Trussell, who had become the Commissioner of Hospitals in New York, ordered the closure of Gouverneur Hospital. He also implemented affiliations for Lincoln, Harlem, Metropolitan, and Elmhurst Hospitals.[10]

Hospitals near the Lower East Side, 1959. From the north to the south are Bellevue Hospital, Beth Israel Hospital, Gouverneur Hospital, and Beekman Downtown Hospital (x represents public hospital, triangle represents private hospital) Source: Manhattan 1960 Census Tract Maps, Box 060283, Folder 9, Robert F. Wagner Documents Collection, LaGuardia and Wagner Archives.

The Hospital Council and the Heyman Commission’s proposals faced organized opposition from the Lower East Side community. The Lower East Side Neighborhood Association (LENA) was founded in 1954 as a coalition of social and civic leaders who were concerned about worsening living conditions and tension among young people in the Lower East Side.[11] LENA challenged the belief that the physician administrators and city officials knew what was best for the community. The organization demanded greater decision-making power for residents of the community in the operations of Gouverneur. Through petition drives, rallies, and testimonies at public hearings, LENA pressured the mayor, borough president, and other city officials to build a new Gouverneur Hospital. Citing a 1955 health survey, Helen Hall of Henry Street Settlement and others from LENA argued that the community had high health needs that could not be adequately addressed if Gouverneur closes. They cited evidence that revealed soaring infant mortality rates and high rates of cancer and heart disease among those over 65 years old in the community. The evidence also suggested that most of the neighborhood’s residents could not pay for the full cost of adequate health care and relied on Gouverneur — the only city hospital in Manhattan below 26th street — for both inpatient and outpatient care.[12]

LENA urged the city to build a new Gouverneur Hospital to be located in a centralized location and to offer a kind of “protective, preventive, positive health care” that integrated social and health services. The hospital could be affiliated with a major medical center, which would provide the professional staffing and services at the hospital and offer back-up services for patients who need specialty care. Such an affiliation plan solved the problem of fragmented care in medicine and encouraged more medical graduates to practice primary care in underserved neighborhoods.[13]

 
The 1961 Compromise and the Opening of the New Gouverneur

In 1961, after a series of negotiations, a compromise between the Heyman Commission’s decision and LENA’s proposal was reached: Mayor Robert Wagner ordered the closing of Gouverneur’s inpatient services but allowed Gouverneur’s outpatient services, including its outpatient clinic, the emergency room, home care services, and the ambulance service to remain open. In order to ensure adequate staffing, Gouverneur’s outpatient services would expand into an experimental ambulatory clinic through an affiliation with a nearby private hospital — Beth Israel. On December 1, 1961, the Gouverneur Hospital became the Gouverneur Ambulatory Care Unit of Beth Israel Hospital.[14]

The compromise gave Beth Israel far-ranging power, allowing for the direct purchase of supplies, the hiring of new staff, and the discretion over how to best serve patient needs. Robb Burlage, head of the Health Policy Advisory Center in New York City, reported in 1967 that the benefits of the city-wide affiliation plan mostly flowed in the direction of the private medical centers. According to Burlage, private hospital affiliates often used city funds to provide padding of payrolls and extravagant offering of salaries. The voluntary hospitals regularly dumped their undesirable patients into municipal affiliates. State Senator Seymour Thaler estimated that by 1966 about 100 million dollars that was budgeted for municipal hospitals had “gone down the drain” because of the affiliation program.[15]

Despite its shortcomings, the 1961 compromise also realized LENA’s innovative vision to some extent. As historian Merlin Chowkwanyun argues, the Gouverneur Ambulatory Care Unit functioned as a “neighborhood health center” for some years before this concept was adopted nationally as part of President Lyndon Johnson’s War on Poverty legislative agenda. The unit emphasized primary adult and pediatric medical care and organized services such that patients were encouraged to maintain a continuing relationship with a personal physician. According to Chowkwanyun, “Gouverneur blurred the boundary separating the clinic from its patient pool, employing community organizers and door-to-door health workers-most from the neighborhood itself — to gauge common problems in the area and encourage more use of its services.”[16]

November 1971 demonstration. The photo was taken by Corky Lee of Chinese seniors at a protest organized by the Health Council to demand the opening of a new Gouverneur Hospital. Source: “Gouverneur History: Community Struggle,” Gouverneur Newsletter 2, no. 4 (May-June 1973): 11.

In the next decade, LENA’s organizing scored several victories despite Beth Israel’s domination and the city’s aggravating financial status. In early 1967, the city agreed to build a new Gouverneur Hospital on 226 Madison Street that would provide both inpatient and outpatient services (albeit through affiliation with Beth Israel Medical Center).[17] LENA helped found a community watchdog group, dubbed the Lower East Side Health Council South, that pressured the city to open the Gouverneur Hospital in 1972 and hire bilingual workers who were representative of the community at the new hospital. The Health Council’s health advocates started street fairs and a mobile van unit that screened and served the health needs of Lower East Side’s Chinese, Black, and Puerto Rican residents. These initiatives developed into the Charles B. Wang and Betances Health Centers that still serve the community today.[18]

Nevertheless, the new Gouverneur’s reliance on Beth Israel for staffing and related services gave the Medical Center wide-reaching power after the hospital had opened. Beth Israel’s administration decided how many doctors it would assign to Gouverneur or terminate and where to use the hospital’s budget. It continued to reject many medically indigent patients who were referred from Gouverneur and offered only second-class treatment to those who were admitted.[19]

The city’s fiscal crisis by 1975 further entranced the affiliation scheme. By 1972, the city relied on Medicaid and Medicare funds to sustain its public hospital system. Federal cuts from health center programs in 1973 exacerbated conditions in municipal hospitals. In March 1975, the city announced that Old Lincoln, Morrisania, and Fordham Hospitals would be closed, and inpatient service would end at Sydenham Hospital and Gouverneur Hospital by June 30.[20]
 

Lessons for Present-Day Reform

The history of Gouverneur Hospital reveals that contemporary inequalities in New York City’s hospital system have much deeper roots. In response to the changes in medicine and the associated financial and personnel crises in municipal hospitals after World War II, physician administrators and health planners implemented reforms that largely redirected money and power away from public medical institutions and to the city’s private medical centers, relegating low-income individuals and people of color to second-class health services.

This case study also suggests that the affiliation plan and the inequalities that resulted from it were avoidable. Through strong and sustained organizing, community groups including LENA and the Health Council successfully made the city rescind its decision to close Gouverneur Hospital without replacement and helped launch innovative health programs that were more sensitive to and conscious of the health needs of the community. The site on 226 Madison Street still serves the Lower East Side community today as a public ambulatory care center. Before the city’s fiscal crisis in the early 1970s, Gouverneur was on its way to becoming a general care hospital with a rigorous community outreach and watchdog program that employed many bilingual personnel who came from the community.

The decades-long struggle over a new Gouverneur Hospital demonstrates the importance of sustaining community representation and decision-making power over the planning and operation of local hospitals and clinics. Such involvement would facilitate the development of programs that are responsive to communities’ needs, improve healthcare infrastructure, and foster leadership building within the local community. Gouverneur’s history also highlights the need for effective mechanisms that hold private medical centers and health networks accountable for their use of public funds. Additional long-term steps to address inequalities in the city’s hospital system include developing incentives to encourage more medical graduates to work at public hospitals in low-income neighborhoods and communities where people of color live. Local and federal governments need to continue to invest in building public health care infrastructures that are accessible to low-income communities of color such that physicians and private patients would be attracted to public medical institutions, rather than to the already well-resourced private hospitals. Another important step toward eradicating New York City’s health disparities involves offering the uninsured health insurance coverage, which would allow them to seek care earlier and bring some of the associated influx of funding and resources to public hospitals and clinics.

Hongdeng Gao is a History PhD candidate at Columbia University. Her dissertation examines how Cold War geopolitics and grassroots activism in New York City improved access to health care for under-served Chinese New Yorkers in the late 20th century.

[1] Brian M. Rosenthal, Joseph Goldestein, Sharon Otterman and Sheri Fink, “Why Surviving the Virus Might Come Down to Which Hospital Admits You,” The New York Times, July 31, 2020; Amanda Dunker and Elisabeth Ryden Benjamin, How Structural Inequalities in New York’s Health Care System Exacerbate Health Disparities During the Covid-19 Pandemic: A Call for Equitable Reform (New York: Community Service Society, June 2020); New York State Nurses Association, “The Crisis Within the Crisis: Covid-19’s Deadly Racial Disparities,” June 2020.

[2] Ibid. Today, most beds in the city are in hospitals in five private networks: the Montefiore Medical Center; the Mount Sinai Health System; New York-Presbyterian, which has Weill Cornell Medical Center and Columbia University Irving Medical Center; NYU Langone; and Northwell Health.

[3] Background History of the New Gouverneur. The boundaries of what was considered the Lower East Side shifted over time. I follow the Lower East Side Neighborhood Association’s 1968 definition of the neighborhood: the area bounded by 14th St, the Brooklyn Bridge, Broadway, and the East River.

[4] U.S. Census Bureau. Nativity and Occupation, 1930-1950. Prepared by Social Explorer.

[5] George Freedman to Miss Helen Hall, October 25, 1966, Box 82, 1966 Folder, Helen Hall Papers, Social Welfare Archives, University of Minnesota (hereafter cited as Hall Papers).

[6] Kenneth M. Ludmerer, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (Oxford University Press, 1999), 180-181, 343-344. See Merlin Chowkwanyun, “Rethinking Private-Public Partnership in the Health Care Sector: The Case of Municipal Hospital Affiliation,” Bulletin of the History of Medicine 93, no. 4 (Winter 2019), 483-517 for a detailed account of the city’s hospital affiliation history.

[7] Sandra Opdycke, No One Was Turned Away: The Role of Public Hospitals in New York City since 1900 (New York: Oxford University Press, 1999), 51-57, 91.

[8] Emma Harrison, “Low Pay Is Scored in City Hospitals,” The New York Times, April 15, 1960.

[9] March 1956 Report on Hospital Needs of Lower Manhattan, Box 77, 1955-1963 Folder, Henry Street Settlement Records, Social Welfare History Archives, University of Minnesota.

[10] Chowkwanyun, “Rethinking Private-Public Partnership in the Health Care Sector,” 487, 493.

[11] Tamar W. Carroll, Mobilizing New York: AIDS, Antipoverty, and Feminist Activism, (Chapel Hill: University of North Carolina Press, 2015), 26.

[12] Helen Hall and William J. Calise to Mayor Robert Wagner, Box 82, 1955 Folder, Hall Papers.

[13] William J. Calise to Mayor Wagner, June 28, 1956, Box 82, 1955 Folder, Hall Papers.

[14] Howard J. Brown and Raymond S. Alexander, “The Gouverneur Ambulatory Care Unit: A New Approach to Ambulatory Care,” American Journal of Public Health and the Nation’s Health 54, no. 10 (October 1964): 1661.

[15] Anthony Kovner and Milvoy Seacat, “Continuity of Care Maintained in Family-Centered Outpatient Unit,” Hospitals 43, no. 13 (July 1, 1969): 89-94; Merlin Chowkwanyun, “The New Left and Public Health: The Health Policy Advisory Center, Community Organizing, and the Big Business of Health, 1967-1975,” American Journal of Public Health; Washington 101, no. 2 (February 2011): 239-240; Martin Gansberg, “Thaler Says City Hospitals Lost $100-Million Because of Abuses,” The New York Times, December 8, 1966.

[16] Merlin Chowkwanyun, “Biocitizenship on the Ground: Health Activism and the Medical Governance Revolution,” in Biocitizenship: The Politics of Bodies, Governance, and Power, ed. Kelley Happe, Jenell Johnson, and Marina Levina (New York: New York University Press, 2018), 180.

[17] Cecil G. Sheps, Summary of Gouverneur Health Services Program at meeting of the Executive Committee of LENA, January 11, 1967, Box 82, Folder 2, Hall Papers. Beth Israel Hospital became Beth Israel Medical Center in 1965 after purchasing its neighboring Manhattan General Hospital.

[18] Rudy Johnson, “Gouverneur Hospital to Open in ’72, Protesters Told,” The New York Times, November 17, 1971; Roni Ramos, interview with author, November 12, 2019. For more on the Health Council, see Merlin Chowkwanyun, “The War on Poverty’s Health Legacy: What It Was and Why It Matters,” Health Affairs 37, no. 1 (January 1, 2018): 47–53.

[19] Clinton Cox, “Emergency Room (for selected cases only),” Daily News, February 2, 1972.

[20] Martin Tolchin, “Windfall to Help City’s Hospitals,” The New York Times, July 31, 1972; Nancy Hicks, “H.E.W. Office Reducing Health-Center Budgets for 1973,” The New York Times, November 26, 1972; David Bird, “City Decision to Shut 4 Hospitals Approved by State Health Chief,” The New York Times, March 13, 1975.