Book Review: Medicine moves to the mall

The American healthcare system is at a crossroads. With 41 million persons lacking comprehensive health insurance, and with hundreds of small rural, mid-size, and large urban hospitals teetering on the brink of insolvency, it is indeed an opportune moment to examine the function of architecture for health within its broader cultural contexts. This book, co-authored by David Charles Sloane and Beverlie Conant Sloane, writers based in Los Angeles, centres on the historical evolution and functions of healthcare institutions in the everyday American landscape. Their core thesis centres on the shopping mall's emergence as an economically and socially viable precursor, as well as alternative. The mall is examined as a precursor within the post Second World War automobile culture that enveloped America and that continues unchecked to this day. Mall settings provide an alternative, serving stringent economic and access to care requirements of the provider in ways that no longer can be fully met by traditional, highly centralized medical centre-based hospitals. Hospitals which have reinvented themselves in this manner are discussed at some length, notably the Dartmouth-Hitchcock Medical Center in New Hampshire. It is argued that due to its success as a type, it was natural to relocate services from what the late Roselyn Lindheim termed inflexible “pill hill” medical centre aggregations to smaller, far more flexible outpatient care settings. The focus on place—the relationship between the care recipient and the places where care is dispensed—is the book's key original contribution. This alone sets it apart from other recent books on the subject of twentieth-century transformations in the American healthcare landscape. This focus on geographic proximity between home, workplace, and care setting is admirably amplified throughout the book's prologue, titled ‘The evolving architecture of healthcare’, and its three major chapters: ‘The medical workshop’, ‘Humanizing the hospital’, and ‘Shopping for healthcare’. Three photo “galleries” are sandwiched between these chapters: ‘Machine medicine’, ‘Mall medicine’, and ‘Mini-mall medicine’. The book begins with an informative historical account of the rise of the American hospital as an institution and as a building type, from its nineteenth-century inauspicious origins. These institutions were often housed in large manor residences in cities, in stark contrast to the sprawling, monotonous, technology-obsessed contemporary medical centres of today. Many of the accompanying photographs will be of particular interest both to the architectural historian and to the general reader. The authors come out on the side of the mini mall, extolling its supposed “virtues”. These include their convenience, not unlike a short jaunt to one's neighborhood convenience store, closeness to home, and their clear, concise internal wayfinding attributes. These latter qualities contrast with the labyrinth of corridors encountered on the typical medical centre campus and are viewed as essential to the mini mall clinic's success; otherwise people will not come back to “shop” for healthcare, regardless of whether desirable non-health care amenities are close by. A question arises. Does not the quality of services diminish when the strip mall clinic comes to be perceived as little different from the payless shoe store next door? This is acknowledged by the authors as the Achilles heel of the strip mall clinic. In the second half, the significant share of the discussion is devoted to the ongoing tug of war between advocates of New Urbanism smart growth policies, and advocates (many of which are healthcare institutions, for better or worse) of unbridled suburban roadside sprawl. These opposing positions are not-so-subliminally underscored in the illustrations contained in the third photo gallery. Unfortunately, these are mostly of banal, formless buildings, bearing very little intrinsic architectural merit. This is precisely where the authors' de-emphasis on architectural design per se comes back to haunt them, for the buildings shown are architecturally uninspiring, and, ultimately, somewhat undermine the core thesis. This facet of their argument would have been greatly fortified had genuinely clever, architecturally innovative clinics been included. They are not impossible to find (particularly outside the US) if one looks hard enough. Regardless, in sum, this book fills an important void with respect to our understanding of recent developments in the milieu of the American everyday suburban healthcare landscape, and helps the reader understand how the current hub (mothership hospital) and spoke (spatially dispersed network of outpatient clinics) system became ubiquitous. Above all else, this book holds the potential to fuel much-needed further research and debate.