THE PAST IN THE PRESENT
The Inheritance of the Neighborhoods
Processing migrants by class, race, and religion; four-part cultures
One of the Remarkable Qualities of the American metropolis is the cultural consensus which runs throughout its neighborhoods. For cities so vast, composed as they always have been of migrants from every circumstance of life, the presence of this consensus is an extraordinary historical event well worth understanding for its own sake. Yet the cultural uniformity of the American metropolis, a legacy from the past, has further significance in that it holds the potential of great service to the future. It is the best foundation we have upon which to build powerful and sustained urban plans and policies.
Current social science studies show that our cultural consensus runs far deeper than the common factors of television, automobiles, and the consumerism of the mass media. It is rooted in the behavior and aspirations of millions of American families, rich and poor, black and white. In the everyday behavior of urban families can be seen the commitment to the basic values of an equalitarian private competitive life which is manifested in a common residential style of loyalty to relatives, friendly visiting of neighbors, pressing for the education of children, concern for family health, the use of housing and neighborhoods as the expressions of family status, high tolerance for interfaith marriage, and an openness of membership in churches and other local institutions. The frequent complaints against our urban style of living, the income striving, lack of close communities, the rapid movement of families from place to place,
and the exclusionary tactics of many suburbs are but the concomitants of this same consensus.
Working against this common culture, both its openness and its near-universal private family expectations, are two deeply ingrained attitudes which are endlessly reinforced throughout the metropolis: the tradition of white racism and the differential rewards of capitalism. The former poisons every neighborhood and institution, the latter segregates the city into clusters of families of similar class attainment and delivers the power and destiny of the modes of urban growth into the hands of the well-to-do. By their overwhelming purchasing power and control of most of the political, economic, and social institutions of the city, the upper income groups always have controlled and still do control the allocation of the city's resources and the determination of its patterns of development.
Thus today we do not face an urban crisis brought on by some sudden disaster; we suffer from a heightening of a chronic urban disease. Our situation deserves to be called a disease since most of its symptoms—poverty, slums, self-serving public institutions, violence, epidemics of drugs and diseases, misappropriation of land, and despoiling of the environment—grow upon a healthy body of everyday behavior and aspirations. The cure for these social ills rests upon a public willingness to give the highest priority to the commonplace values of everyday life. Urban crises of the past have been answered by reforms which appealed to the cultural uniformities of the city, and such partial successes show the soundness of such a strategy. But because our political, economic, and social institutions have remained in the hands of the white and the well-to-do, who have chosen to interpret our common culture primarily in terms of rewards for those who succeed and punishments and neglect for those who fall behind, the major causes of our urban maladies have gone unattended. By stressing the value of private competition in the cluster of American aspirations, the well-to-do have legitimized their behavior. At the same time, the losers, in order to understand what was happening to them, have depended upon this same orientation to validate their personal experience. This overwhelming priority for family striving has continually submerged the other behaviors and attitudes of our culture, and therefore the other needs and aspirations have been unable to sustain any enduring efforts to allocate the political, economic, social, and physical resources of the city for the benefit of all its citizens.
Since the existence of a common urban culture is of the utmost importance to any hopes for democratic planning, the history of the process whereby a diversity of migrants became a common people is well worth understanding. This chapter will summarize that history and review some of the recent social science literature on the uniformities and variations now extant in the neighborhoods of the metropolis. The ensuing chapters will show how this culture has fared in respect to two of its universal needs and aspirations: housing and health care. As this story shows, it is the overwhelming of our common culture by the structures of unequal power and wealth which constitutes our chronic urban disease.
The interactions among the economy, the internal structure of cities, and the patterns of migration have produced a common culture whose variations can be interpreted in terms of class and religious identification. Current social science suggests that about 90 percent of the American population can be classified by noting people's class and socioreligious attitudes. Most of our city dwellers have a common American culture but differ according to whether they are upper class, middle class, working class, or lower class. They also differ according to whether they are white Protestant, white Catholic, white Jewish, or black Protestant.
The origins of class attitudes are easy enough to account for. Just as the unfolding economy produced our segregated urban structure, so each day it sifts and grades its members, rewarding some more highly than others. Some men, like Marquand's top executives, inherit or earn large personal fortunes; others push their families forward into power and affluence by means of long years of education and the common striving of a young husband and wife, the sort of steps stressed in Whyte's Organization Man ; still others, like Henry's Bill Greene, can see only a limited future and while teen-agers give up the struggle and spend their lives in routine hard work and domestic comfort. Finally, there are those for whom the economy of the city is essentially closed, men like Liebow's Tally or Harrington's other Americans.
Out of the repetition of thousands of such similar personal experiences come the basic class dimensions of our culture and the common
attitudes and behavior of the upper class, the middle class, the working class, and the lower class.
Yet if one restricted oneself to interpreting the conditions and conflicts of the modern city only in terms of class, the outcome of most elections would be wrongly predicted, and strife over housing, zoning, bussing, schools, police, traffic, and taxes would be unintelligible. The reason that class is an inadequate key to the modern city is that, superimposed on the class-graded cultural variations of Americans, lie the broad bands of their racial and religious identifications: white Protestant, white Catholic, white Jewish, and black Protestant. These religious loyalties derive from our population history. We are a nation of immigrants, and these four socioreligious allegiances have matured out of the process of adaptation of immigrants to the circumstances of American urban life. Over time these loyalties absorbed the immigrant's previous ties to the village, the region, the ethnic group, the religious denomination, or the nation, so that now all but a small fraction of our citizens identify themselves to a greater or lesser degree with the four broad socioreligious orientations.
All American families share a remarkably uniform urban experience, an experience compounded of class, ethnicity, and religion. The pattern is migration, followed by the ghetto or the slum or just hard times in the city, and this is succeeded by the eventual emergence into a stable income position, be it good or bad (and for many it is good), then the church and the suburb. Behind the migrations lay tribes, villages, or family farms, depending on whether the family memory went back to Africa, Europe, or the rural United States. But as each family lives through its experiences in this country, each one passes through the acid of the city which burns off the special qualities of the past. In this corrosive environment Sicilian villagers became Italians, and Italians became neighborhood Catholics; Alabama farm boys, black and white, became slum family men, and family men became builders of Baptist or Methodist churches.
This sequence was, and still is, the sequence of the urbanization of our rural migrants. Put most crudely, one brings to the city an extremely localized culture. After some years in the city the culture becomes broader than the former village or town; it becomes ethnic. The most enduring ethnic cultural institutions in American cities have proved to be the churches, so that over the years or generations ethnic loyalties become merged into religious loyalty. Simultaneously job, income,
housing, and neighborhood teach the class structure of the city, so that in time for some a few years, for others a generation or two—a class and religious culture determines the orientation of all city dwellers. This is a simple model to cover a complex urban and population history, but it seems to order the sequences of the past hundred and fifty years in such a way as to make the contemporary city intelligible.
The population history of the country during the first period of urbanization and industrialization had four notable characteristics. First, the native population prospered and moved westward to fill the continent. At the same time, Americans began sharply to control the size of their families so that population growth after the middle of the nineteenth century no longer depended solely on native reproduction. Second, millions of immigrants from Germany and Great Britain came to join the native population in its westward migration, and they also adopted the new style of the small family. Third, the collapse of the Irish economy expelled millions from that country and added a heavy stream of Irish to the transcontinental flow (Table 3, page 168). They too followed the predilection for family limitation. Fourth, interaction between evangelical Protestantism and Catholicism—especially of the Irish variety reformed two basic elements in American urban culture, the broad Protestant and Catholic allegiances.
At least until 1870, when the standard of living commenced its steady rise in both the United States and Europe, the story of our population and its immigrants was the story of poor farmers, poor peasants, and poor artisans accustomed to subsistence living, who in moving were seeking an opportunity for a decent living for themselves and their families. The sheer abundance of cheap farmland .enabled the
great mass of the nation's white farmers to support large families and for their children to survive. In this era, as always in our history, the rural areas supplied a disproportionate number of the nation's children; even today rural births consistently outrun those in town or city. Moreover, until the twentieth century the death rate among children in American cities was always higher than in the countryside.
Up to 1840 almost all population growth stemmed from natural increase, white and Negro, and although the birth rate fell steadily during the nineteenth century, until 1860 it still continued to exceed European rates. From then on, American birth rates declined in the same general ratios as those of England, France, and Sweden. Scholars do not yet understand the cause of this decline; but it is a long-term historical trend participated in both by natives and immigrants, with only a few very short exceptions and slight reversals. For the moment, all that can be said is that Americans and Europeans limit their families as they become urban industrial peoples.
The native population established the directions for the streams of continental migration which the immigrants followed. Prior to 1870 Americans moved westward in roughly parallel bands: migrants from New England and New York filled the upper Midwest; families from the Southeast settled the lands from Alabama to Texas; and people from Virginia and Pennsylvania settled in Kentucky, Tennessee, and Missouri, and in southern Ohio, Indiana, and Illinois. With the coming of the railroad and the rapid development of the Midwest, settlers from the entire North and Midwest overran the plains, mountain, and Pacific regions.
Slavery was an effective barrier against mass European immigration into the South, but millions of Germans, English, Scots, Welsh, and Irish joined the westward movement in the fifty years after 1820. Farm counties in the Midwest were as rich an ethnic patchwork in those years as the blocks of Manhattan.
Historians of the era have fully documented the special ethnic contributions brought by these immigrants to the first stages of our urbanization and industrialization. In the mill town of Lowell, Massachusetts, there was an "English Row" of houses belonging to calico printers from
Lancashire; English and Scottish workers supplied the skilled labor in the cotton and woolen mills of New England and New York; the woolen weavers and knitters of Philadelphia and Lowell, as well as those of Thompsonville, Connecticut, were Scottish. In the 1820s, English, Scottish, and Welsh miners opened up the anthracite mines of eastern Pennsylvania, Maryland, Ohio, Illinois, and what is now West Virginia. Cornishmen, seeking lead, were the first foreigners to settle in Wisconsin; they also dominated copper mining in the Upper Peninsula of Michigan, and they cut the first railroad tunnels through the Berkshire Hills. The early history of American labor inherited many of its distinguishing features from the British tradition. The great "Ten-Hour" strikes of the big cities, when skilled artisans turned out in vast numbers to demand shorter hours and higher pay, the first fraternal organizations like the Masons or the Odd Fellows, and many of the workers' insurance and benefit funds were in most places initiated by English and Scottish immigrants.
No city or town north of the Ohio River was without a German quarter, and many of the small towns were composed almost entirely of Germans. In the big cities German peasants suffered from poverty and slum housing as severely as did the thousands of Irish peasants and were as cruelly exploited in the cheapest trades. Like the English, however, the skilled among them maintained their tradition of workingmen's associations which flourished in all manner of clubs, benefit associations, and labor organizations.
The new people also brought with them the conflicts of the British Isles. Cornish and Irish mobs—the "pasties" versus the "codfish"—fought pitched battles in the copper country of upper Michigan; the rooms of the New England textile mills were segregated to the disadvantage of the Irish; English and Irish Protestants brawled and rioted in every city; and the murders by the Molly Maguires were an echo of less drastic Irish attacks on their British colliery foremen.
Yet many of the qualities peculiar to the various immigrant cultures were soon lost. Those which could easily be absorbed, like labor unions and lager beer, disappeared into the general cultural scene, and individual manifestations were ground off in the cultural clash between Protestant and Catholic. The 1820-1870 migrations of German and
Irish Catholics met a special kind of Protestantism when they landed—not an established state religion but a collection of thousands of small congregations. But for all its fragmentation, Protestantism flourished during these years and developed into a general Protestant-American consciousness.
A blend of the colonial institutional inheritance with later religious enthusiasms gave the Protestantism of the years between 1820 and 1870 its particular character. Late eighteenth-century colonial Americans had not been churchgoers. Theirs was probably the most secular of all our cultural periods, and scholars estimate that only 10 percent of the population at most belonged to any church at all. Simultaneously the Revolution gave rise to the apprehension that established churches were agents of monarchical tyranny and laid down a tradition that our nation would be one without state-supported churches. All Protestant denominations were in effect compelled to become voluntary, competitive organizations. Except perhaps in the case of the Quakers and some pietists, Protestantism was oriented toward bringing in the unchurched, and most congregations for the sake of their own survival had to adopt not an exclusive but a recruiting mission.
Our colonial history was marked by continual strife along denominational lines—among Anglicans, Quakers, Presbyterians, Congregationalists, Baptists, Methodists, and pietists of various kinds. Some of the confrontations were of course plainly rooted in the home countries, as in the cases of German pietists or Scotch-Irish Presbyterians, but many were not. When Massachusetts Congregationalists persecuted Quakers or Baptists, or when Connecticut Congregationalists expressed their disapproval of Methodists, they were discriminating against their own kind.
The evangelical drives for membership dampened interdenominational conflict and eroded doctrinal lines. Most late eighteenth- and early nineteenth-century American Protestants believed that the individual had to discover God, not vice versa, and that there were rewards and punishments in this world and the next for good Christian behavior. Accordingly waves of evangelism, with ministers welcoming the unchurched into Protestant fellowship, swept the country from 1795 through the next half century or more.
A millennial hope that the spread of Christianity and of liberal
human institutions would bring the Kingdom of God to the United States suffused the era. The means, of course, were individual, "an elevated state of personal holiness." Churchgoing grew more popular. Simultaneously Protestantism became more and more unified both in doctrine and practice, and no deterrent stood in the way of intermarriage between members of different denominations. When conflict arose with Catholic immigrants, a generalized Protestant sentiment defended the voluntarism and individualism of their way of life and warded off Catholic incursions into Protestant control of political organizations and public institutions for education and welfare.
As always in America, the blacks had a separate history. At the time of the Revolution there were no Negro congregations in Northern cities. Blacks attended white Protestant churches, although sometimes, as in Philadelphia, they were segregated to a balcony. In the early nineteenth century the growing emancipation and democratic sentiment in the small black colonies of the Northern cities engendered a move toward self-determination for Negroes in religious matters, so that by the 1840s every city had its black churches and fraternal organizations. The full flowering of this black urban culture nevertheless awaited the substantial migration of blacks to Northern cities, which began in the 1890s.
The massive migration of Germans and Irish from 1830 to 1870 changed the religious composition of the nation. Since the seventeenth century America had been a Protestant country, whether or not devoutly or secularly so; now it became a Protestant-Catholic nation. By 1870 Catholics constituted the largest single religious group, about 40 percent of the churchgoers, and such has been the balance of immigration ever since. A drastic leap in numbers, however, did not immediately imply a unified American Catholicism. Instead, Catholicism during this era was able only to discover and lay down the institutional framework on which later generations would build a Catholic culture for all classes. Until
then, the poverty and fragmentation of the Church and its immigrant membership outweighed every extraneous consideration. Yet in facing poverty, fragmentation, and the contemporary Protestant attack, the foundation of a broad cultural unity was formed.
A nineteenth-century American Catholic, whether immigrant or native-born, inevitably bore an inherited reputation for having advanced the traditions of "popery," which had been the bogy of Great Britain for two hundred and fifty years and had made Catholics the object of deep-seated national prejudice there. Through English colonists and the colonial wars against the French this prejudice was transferred to America, and Catholics of whatever origin were stamped as a negative reference group in the early Republic. Events overseas made matters worse. The campaign in England to remove the last civil penalties from Catholics spawned a deluge of anti-Catholic literature that poured across the Atlantic until the passage of the Catholic Emancipation Act in 1829. At the same time, Protestant ministers and organizations were single-mindedly seizing on anti-Catholicism to inspire popular enthusiasm for affiliating with a Protestant church. The American Bible Society not only published anti-Catholic tracts but even launched a campaign to spread the King James Bible among Catholics. The campaign naturally aroused an angry response among the American bishops. Furthermore the stubborn refusal of poor immigrants to accept the free Bibles gave rise to a widespread belief that Catholics were opposed to the Bible—a conviction that was to play a prominent part in the public-school and nativist controversies of the forties and fifties. Finally, well-known Protestant ministers began to preach anti-Catholic sermons as part of their proselytizing efforts. The Reverend Lyman Beecher of Boston delivered three Sunday sermons in as many churches on August 10, 1834, speaking out violently against Catholicism and its regular clergy and further inflaming an already explosive situation in that city. He and his fellow ministers may be said to have contributed directly to the first burning of a convent in the United States, which took place on the following day. All this fervor, anger, and prejudice preceded (or dated from the very start of) the great wave of German and Irish Catholic immigration. When that tide appeared, the nation's cities, large and small, entered upon three decades of anti-Catholic rioting marked by the burning of churches, orphanages, and convents.
The frequency and virulence of Protestant attacks did not automatically unite the largely impoverished mass of native American, French, German, and Irish Catholics. In 1820 the church was a weak and scattered organization made up of parishes from the old French empire at New Orleans, St. Louis, and Detroit, from the old colonial parishes in Maryland and their more recent offshoots in Kentucky, and of churches in most of the Eastern cities. Because there was but one major facility for training diocesan priests here, St. Mary's Seminary in Baltimore, priests had to be recruited from France, Germany, Italy, England, and Ireland, and they brought with them the diverse national styles endemic to European Catholicism. In addition, no strong hand existed to enforce unity. During the long colonial years of intolerance and penalties against Catholics and of official neglect by the English bishop who had formal charge, priests here evolved an independent collegial style for the management of their common affairs. Perhaps fortunately for Catholicism in America, in view of the variety of backgrounds of the new waves of immigrants, the early nineteenth-century Church depended upon the initiative of scattered bishops who coped with their growing dioceses as best they could. Differences among them had to be reconciled by occasional provincial meetings, most frequently held in Baltimore, where the bishops gathered to legislate for the American Church. In its decentralization and widespread use of democratic and federal forms both within dioceses and among them, the Church of these years reflected the general political thrust of its era.
By 1870 the Catholic Church had four and a half million members. Its parishes were scattered across the land from city slums to Midwestern farm counties, along the banks of every railroad and canal from the Atlantic to the Pacific. Such massive growth forced the Catholic Church into a position not unlike that of its Protestant opposition. The sheer necessity of building churches at a rate rapid enough to bring the Mass within reach of the incoming tides of newcomers necessarily delivered much of the power of the organization into the hands of the parish. Popular church-building priests and successful fund-raising congregations became the models of the day. Although Catholic immigrants
varied a great deal in their use of the Church, some depending upon it solely for its sacraments and others, especially Germans, bringing with them a custom of a village church and related clubs and societies, one can see in this emphasis on fund raising and on the building of churches and parochial schools the beginnings of the transformation of many a European church into the typical American Catholic parish of bingo, basketball, and building funds.
The ethnically fragmented hierarchy and parishes and the pressure for church building were manifested in a particular movement of local-ism—trusteeism—during these years. The trustee movement surfaced in open conflict immediately after the Revolution when local congregations asserted their right to appoint priests and control parish budgets in place of the bishop. In New York, Philadelphia, New Orleans, Norfolk, and Buffalo certain parishes resisted all attempts at discipline for as long as forty years. The difficulties had many dimensions, but the ethnic one proved to be the most obdurate. English priests had been the first to staff the American Church, and trustee clashes took the form of battles between American parishioners and the customs of French priests who fled here from the French Revolution, or between newly formed Irish congregations and native and French styles. Irish-German confrontations fired by English-language conflicts arose in the North and Midwest.
To cope with these conflicts—and they remained bitterly divisive throughout the nineteenth century—the Church was compelled to adopt the rule that special churches for single nationalities might be established within the boundaries of the parishes established for each diocese. Moreover, the bishops endeavored to maintain harmony by calling regular meetings of all the parishes under their supervision. This episcopal compromise, later repeated when Catholics from Southern and Eastern Europe arrived, made it possible for the Church to maintain a troubled unity during the great migrations of the late nineteenth and early twentieth centuries. So successful were these devices in enabling the Church to stay in contact with newly arrived immigrant groups that
when the twentieth-century Church began to speak for all the urban poor in political and philanthropic affairs, the general public found this representation acceptable.
Perhaps even more important for future Catholic culture than the halfway house of the ethnic Church was the establishment of parochial education. The beginning of the parochial system is customarily dated from the opening of a school for poor children in 1810 by Sister Elizabeth Seton at St. Joseph's Parish in Emmitsburg, Maryland. She employed the Sisters of Charity, of whom she was the American founder, to staff the school, and she operated it with free materials and without tuition for the children of the area. The basic formula of an elementary school attached to every church was seized upon by the most ambitious bishops as the best chance for the survival of Catholicism in Protestant America. In 1884 the Council of Baltimore adopted it as the official task of all dioceses. Thus, unlike in Europe, where universal education was yet to be established as a national norm, and where state funds and long-established endowments supported both churches and schools, American Catholic communities faced a double burden of creating a network of schools and churches sufficient to serve the waves of immigrants flooding in from abroad. The sheer poverty of some Catholic communities, like that of Boston, doomed the effort to failure in these first decades. Elsewhere, especially in German-settled cities where the desire for foreign-language teaching lent an additional impetus for local support, and in dioceses of aggressive bishops who successfully solicited funds and teaching orders from Europe, a rough approximation of the goal was attained before the Civil War. Despite the universal emphasis of the parochial-school drive for a free education for every Catholic child, such a massive and relentless fund-raising effort imposed its class mark on Catholic education because it firmly anchored the parochial system to the parents of children of the working class and middle class, the very members of each urban parish who were making their way most successfully.
The building of the parochial system, begun on a large scale to meet the needs of the immigrants' children in the 1840s, had two consequences for American urban culture. First, it began the secularization of the public schools, dominated until that time by Protestants; second, it helped to build a characteristically American style of Catholic culture.
During the forties, Bishop John Hughes of New York and Bishop Francis Kenrick of Philadelphia pressed for the abolition of Protestant teaching in the public schools and for municipal or state aid to parochial schools. An explosion of antiforeign, anti-Catholic prejudice, resentment, and rioting greeted these demands. In every state where Catholics sought funds in the mid-nineteenth century they were refused. Not only did this outcry tend to draw German, Irish, and American Catholics together, but the gigantic effort required to build and to maintain thousands of schools committed each parish to an enduring social task: the education of children. The goal of literacy, both Catholic and secular, for any child who presented himself at the school door meant that the Catholic Church was as securely tied to the task of Americanization through education as were the contemporary public schools. Moreover, because the building and financing of its schools rested with the families of the parish, the values of the Church itself became tied to the hopes and values of child rearing which its neighborhood supporters possessed.
The migrations of native Americans during the second era of urbanization and industrialization reflected some specific changes in the economy. The last years of the nineteenth century and the first two decades of the twentieth have been characterized as the "golden age of American agriculture." It was a time when skillful farmers, using new techniques taught by the agricultural colleges and extension stations, prospered as world prices rose for American staples. The contemporaneous completion of the railway network opened up the high plains, Florida, the Southwest, and the Pacific coast so that every variation in soil and climate was utilized by farmers universally bound to national and international marketing systems.
The completion of the westward movement did not however halt the migratory habits of our restless people. After 1870 systematic information becomes available for the state-by-state migrations of the native-born. There was no settling down. In any given census since 1870,
one-quarter of the population was living outside the state of its birth. Moreover, this documented migration followed the time-honored pattern of the common people: young men, women, and families moved because they were seeking the places where economic opportunity seemed the best. Although in 1920 there were more farms and farmers in the United States than ever before or since, modernization of the economy had already begun to drive many Americans off the land. The young people especially were aware of a choice between farm and city; many of them were sick of farming and began to pour into the cities and towns of the Midwestern manufacturing belt. The Lynds' first Middletown book records the transformation which such shifts from a rural to an industrial society entailed for a small Midwestern city. But the country people also poured into the great cities of the era, helping to build such metropolises as Pittsburgh, Chicago, Cleveland, and Detroit.
During these same years, international immigration reached its flood but did not retrace the patterns of native population flow to the degree that it had in previous years. Only Scandinavians, Bohemians, and some Germans continued to move out onto the farms to swell the westward migration of the natives. Most Europeans were concentrated in the cities and towns of the Northeastern and Midwestern manufacturing belts, thereby settling themselves in the forefront of the urbanization of the era.
Historians refer ,to the migrations of 1870-1920 as the years of the "new immigration," that is, the coming of the Russians, Poles, and Italians as opposed to the "old immigration" of Germans, Irish, and British (Table 3). The shifts in origins and ratios of European migrants reflect the interaction between the modernization of Europe and the industrialization of the United States. For Europe as a whole there were periods of heavy excesses of births over deaths, and these were of course the times of large population gains. When the children represented by these gains reached adulthood, mass migrations took place from rural
TABLE 3 .
Other Central Europe**
Balance of World
* Includes both Northern and South Ireland
** Austria since 1861, except 1938-45, Hungary since 1861, Czechoslovakia and Yugoslavia since 1920. There is no long unbroken time series available for Poland. U.S. Bureau of the Census, Historical Statistics of the United States, Washington, 1960, pp. 56-59; U.S. Department of Justice, Immigration and Naturalization Service, Report of the Commissioner: 1970, Washington, 1971, pp. 63-64.
areas into European cities and beyond to America. The impact of the baby booms of 1825 and 1840-45 in Western Europe had propelled the tides of German, Irish, and British migrants. In later years as railroads and urbanization stimulated the Eastern and Southern European economies, similar population booms swelled rural populations there. The birth surge of 1860-65 appeared in the American immigration peak of 1880-84; the surge of 1885-90 in the peak of 1902-15.
The migrants came to this country in tremendous numbers only when jobs were plentiful here; if hard times prevailed they settled in European cities instead. Such alternative destinations for European rural migrants stemmed from the fact that the nineteenth-century cycles of building activity and capital investment were not the same for Europe and America. Until World War I the United States was a substantial importer of capital from Europe, and accordingly it had to compete with European opportunities for investment in industrial, ventures and urban real estate. Capital sought first one continent and then the other depending upon the expectations for most substantial profits. These capital flows alternately encouraged and impeded employment in the United States. The flow of capital created boom years from 1878 to 1892 and from 1897 to 1913 and opened up many new jobs, and hence there were surges in immigration. Toward the end of the nineteenth century, as cheap steamship passage made the crossing of the ocean easy and safe, skilled workmen often moved between England and the United States, following the crests in wages and employment in their particular crafts. The statistics of net migration, which show departures as well as arrivals from abroad, confirm the employment-opportunity-migration sequence.
There were two immediate results of this pulsating flow of peoples from Europe. The continued flood of unskilled workers directly influenced the development of mechanization in American industry, while the interaction between the origins of immigrants and the increasing urbanization of the United States determined which groups were to advance with certain elements of the economy. With immigration bringing in tides of unskilled labor to the nation, industry before the Great Depression had always to adjust to a plentiful supply of cheap unskilled labor and to a concurrent shortage of skilled workmen. The result was
to give our technology a particular cast: the most complicated processes were mechanized first, in contrast to European practice, in order to conserve highly skilled and paid craft workers, and were mechanized in such a way that they could be carried out by men with very little training. Gradually an industrial style of high mechanization developed. It did not always present the cheapest solution, as twentieth-century competition with German manufacture made plain, for Germany used highly skilled techniques coupled with less mechanization, but it became an enduring part of American industrial culture.
The second consequence of the shifting origins of European migration was that it aroused considerable alarm among both native Americans and children of the older immigration. To be sure, those native-born who moved to the cities, factories, and offices of the nation had a strong competitive advantage over most foreigners. They often possessed more formal education, some savings, and connections with well-placed relatives. Above all, they were members of the dominant culture. Studies of social mobility show that the native-born and their children moved more easily into white-collar jobs than did the immigrants or their children. Yet during the 1870-1920 years native Americans were disproportionately concentrated in the farms and small towns of the United States, and their apprehensions that they were being left behind contained some measure of truth.
For example, national statistics show that the children of English and Irish immigrants achieved high-status positions more rapidly than the native population did simply because their parents had settled in greater concentrations in the cities; and since in the half century after 1870 these were the locations of widest opportunity, the immigrant child had a better chance for education and for an eventual high-status position. In 1900, 5.7 percent of all white Americans were illiterate as opposed to only 1.6 percent of the children of immigrants. In that census year the ratios of whites in professional and clerical positions and in government employment summarize the differential effects of migration, urbanization, and social mobility: 14 percent of all Americans appeared in these categories but 22.6 percent of the children of both British and Irish immigrants. Because of their traditional rural position
in the economy, native Americans as a whole were indeed being left behind.
Conditions prevailing in the new mill towns and metropolises of the late nineteenth and early twentieth centuries also conspired to shake the confidence of both native and "old immigrant" stock. The men there had acquired the urban industrial skills of their day and counted on the continuation of the nineteenth-century world, where the continual arrival of fresh unskilled immigrants signaled not only expansion of the job market but also promotion and advancement for earlier comers. Under this mode of growth in the economy, natives and old immigrant groups had become the skilled hands, the foremen, the bosses of the new incursions of rural migrants. The repetition of this sequence of events had meant that for at least the previous century immigration and social mobility had had no grounds for conflict.
In the 1890s the scale of the city and of industry reached swollen proportions, and the scope and possibility for the social and economic mobility of the ordinary citizen seemed to narrow. Although studies by historians seem to show that the chances for individual advancement did not in fact decline during the years after 1890, nevertheless a feeling was prevalent that a man's chances to get ahead had dwindled with the coming of the giant metropolis and the factory. For the first time, the waves of European immigrants appeared as a threat: perhaps to the workers of the time, certainly to their children. As unions became fearful for the jobs of their members, the men lost confidence in the future for themselves and their children.
Concomitantly an ugly rise in ethnic stereotyping swept the nation. Racial prejudice, anti-Semitism, anti-immigration sentiment, and the inflated patriotism of World War I with its phobia against Communism combined to pass in 1921 an immigration law that set limited quotas based on the ethnic mixture of the population as it was found to exist in 1910. So it was that fear of the industrial structure and of the metropolis that housed it, augmented by jealousy between rural and urban dwellers, ended the century-old pattern of migration, industrialization, and urban-
ization. The atmosphere since the twenties has been a miasma of anti-foreign sentiment. The paradoxical result of the 1921 law and its subsequent revisions was to close immigration from peasant countries and to encourage the entrance of skilled workers and professional men from the more advanced countries, thereby exacerbating competition for the most prized jobs. Our nation with its high levels of skill and education thus continued to draw the trained sectors of population away from those nations that had the most crying need for modern skills.
During the last years of the nineteenth century, the black population of the United States began to move from its historic place in the rural Southeast. The special qualities of Negro migration in America have been twofold: it has been small compared to both native-white and European migrations, and it is a migration that has taken place under severe handicaps, because for many years it proved difficult for blacks to escape from their home territory.
Like earlier migrants, the blacks followed existing transportation routes, pursuing the cheapest paths. Negroes from Maryland to Florida came by coastal steamer and railroad to the cities of the Northeast. Negroes west of the Alleghenies moved up the Mississippi by rail on the Illinois Central, Gulf Mobile and Ohio, and the Wabash to St. Louis, Chicago, Cleveland, and Detroit. The pioneering settlers were young people who ventured north to seek a place in the small ghettos that had existed in every city since before the Civil War. The availability of jobs in Washington, D.C., fostered a large colony there of blacks from Virginia and the upper South, while industrial and service jobs in Philadelphia and New York attracted blacks along the Atlantic. As in other migrations the pioneers sent back letters of encouragement, sometimes money and tickets, and the channels of migration opened and began to flow, pulsating with the rhythms of urbanization and economic growth. During both World Wars this normal migration was spurred by the active labor-recruiting policies of the steel mills and other large firms in need of quantities of cheap labor. Indeed, the precedent for the recruitment of black Southern labor lay in the nineteenth-century practices of those companies who had imported gangs of laborers from Italy and Eastern Europe.
Although the total volume of black migration remained small until World War II, it was enough in the early years to create in New York, Chicago, and St. Louis black ghettos that would nurture the beginnings of a modern urban American Negro culture. The Harlem Renaissance in New York began with the first waves of late nineteenth-century northward migration. The timing of the start of black migration, however, proved to be disastrous. Negroes began arriving in large numbers in Northern cities exactly at the time when the great swells of fear and prejudice had begun to break over America, indeed over all the European world as well. The bitter race riots of East St. Louis in 1917 and of Chicago in 1919 testify to the anger and brutality of the climate into which the native blacks were moving in their search for opportunities in the cities of the North.
The cultural effects of these new sources and differential patterns of migration immediately manifested themselves. The coming of the Jews from Eastern Europe and of the black Protestants from the South completed the roster of elements that compose our modern urban culture: white Protestant, white Catholic, white Jewish, and black Protestant. Yet since each of these socioreligious clusters consisted largely of recent rural migrants, American and European, the cultural life of each group evolved around its adjustments to new urban conditions. Each group accordingly developed pronounced old-value and new-value wings.
For the white Protestants the important cultural event of the years from 1870 to 1900 was the formation of a liberal, urban middle-class movement—the social gospel—extending laterally across all denominations. The movement reflected a self-conscious attempt on the part of Protestant ministers and laymen to comprehend and make some adjustment to the realities of their day. It drew upon the millennial enthusiasm of the earlier evangelical era but transformed it into a secular optimism based on the efficacy of social reform. It drew also upon the past emphasis on individual religious responsibility but transformed it into a
call for an active citizenship informed by Christian ethics. The modern American Christian, according to the social gospel, was to address himself to the affairs of the world, to work as an individual and to join others in his congregation in combating such evils as child labor, exploitation of women, Negroes, and workingmen, and the social pathology of slum housing, alcoholism, and unregulated immigration.
Institutionally the movement became apparent in interdenominational organizations like the Federal (later National) Council of Churches of Christ in America (1908), in the founding of settlement houses and the development of social work as a profession, in church-sponsored investigations of major strikes, and in a vast amount of debating and pamphleteering. Conceptually the social gospel enlarged the old reformist wing of American Protestantism and brought this branch of the culture up to date by leading it into sympathetic contact with the realities of Protestant, Catholic, and Jewish working-class and lower-class life. Of course the old axes of conflict still existed within Protestantism. A strong draft of nativism blew through many of the Americanization programs of progressive settlements, churches, and public schools of the day. The temperance and antiprostitution campaigns, so important in these years, were at once real issues of social liberation and continuations of early nineteenth-century Protestant-Catholic warfare over alcohol, dancing, and Sabbath observance. Yet for all this persistence of old habits of thought the social-gospel wing of Protestantism initiated the very important task of establishing a modern liberal middle-class sentiment that could build bridges to the three other contemporary urbanizing cultures.
The great majority of both rural and urban Protestants were not in any case followers of the social gospel. In these years urban Protestantism lost much of its older working-class base and became very much a middle-class suburban phenomenon. Moreover, the new rich of the city dominated many congregations with their conservative blend of self-righteous capitalism and old-fashioned insistence that poverty was a manifestation of unworthiness and sin.
For Catholicism the years from 1870 to 1920 were also ones of liberalization. In Europe the liberal-national revolutions and the rise of Catholic unionism and Christian socialism drove the hierarchy into a degree of accommodation with the modern world. The deep suspicion of and hostility to humanitarian reform that had marked many Papal and American Catholic attitudes in the earlier era now gave way to a sense that the Church ought to interest itself in the problems posed by industrialization and the urban masses. Pope Leo XIII's 1891 encyclical Rerum novarum on the relations of capital and labor and the work of James Cardinal Gibbons on behalf of the Knights of Labor marked the new trend.
As Irish and German Catholics rose in large numbers from immigrant poverty to positions of success and affluence, the Catholic Church became an all-class, fully organized institution in the United States. These were the years of cathedral building in every major urban diocese, the years of the widespread establishment of the parish elementary-school system and, following the trends in public education, the opening of parochial high schools. The Church began to train its own priests, and although a continuing shortage required European recruits, the Catholic Church in America became a highly integrated organization dominated by native-born descendants of Irishmen and Germans.
Much of the liberalization of Catholicism derived from the personal experience of its membership. As millions of Catholics moved out from the poverty of the central city to the new working-class settlements and middle-class suburbs, they settled in mixed Protestant-Catholic communities. The needs of the parish for church and school building and the associational style of middle-class Americans caused Catholic clubs and societies to multiply as they did at neighboring Protestant churches. The charitable work of the Society of St. Vincent de Paul and the fraternal organization of the Knights of Columbus proved immensely popular.
Catholicism did not, on the other hand, become absorbed in the social gospel in the same way that contemporary Protestantism had done. The social gospel was after all a movement of middle-class people, often with small-town backgrounds, who were trying to come to grips with the strangeness of the industrial metropolis. Catholic liberalism in these years most commonly took the form of speeches made by Irish and German politicians and priests in behalf of the working classes and
lower classes of the city. They spoke not as social investigators but as representatives. Theirs was not a movement of discovery and accommodation but a call for recognition and a demand for a more just share of the fruits of the society. Many Irish and German politicians prospered and in their success were as callous, corrupt, and conservative as the Presbyterian steel barons of Pittsburgh. But there were others who used their success to represent their constituents, men like Martin Lomasney of Boston or Charles F. Murphy of New York. These politicians joined with settlement-house workers, Protestant ministers, Jewish philanthropists, and union leaders to carry the important social legislation of the day through city councils, state legislatures, and Congress. By 1920, though the Church was full of conflicts between new Slavic and Italian ethnic groups and the established Irish and Germans and though many Catholics and priests were as doubtful as ever of the efficacy of reform and as fearful of liberalism and socialism, the success of millions of urban Catholics in moving into positions of comfort and power produced a sense of widespread personal optimism to reinforce the liberal tendencies of some political and religious leaders.
For the Jewish immigrants, whose massive migration during the late nineteenth and early twentieth centuries made Jewish culture a permanent element in American life, the polarization between old-fashioned ghetto and village ways and modern urban life had commenced in Europe. German liberal Judaism and German and Russian anarchism and socialism traveled across the Atlantic to foster progressive movements among Jewish immigrants and the small Jewish communities that already existed in Eastern and Midwestern cities. There was probably not a reform effort in any big city in the United States after about 1880 that did not include at least one Jewish member. Indeed, the American version of the charitable tradition of the Jewish ghetto soon proved to be a major urban cultural bridge. Even in the face of rising anti-Semitism during these same years, Jewish philanthropists served on most metropolitan committees for child care, unemployment relief, and hospital and community fund drives, as well as on those directed to race relations and social legislation. Thus the Jewish philanthropist became a permanent element in metropolitan elite life.
But for most Jews, the 1870-1920 decades were years of struggle with immigration and poverty. Just as the Irish and German slums had been symbols of poverty and exploitation in the earlier mixed commercial and industrial city, so the Jewish slum of the metropolis epitomized urban life of the "new immigration." The tenements of New York's lower East Side, housing thousands of little sweatshops where Jewish immigrants labored on suits, overcoats, trimmings, dresses, and shirts, have become, thanks to liberal Jewish and Protestant writing, classic statements of the American immigrant experience. The raw exploitation of these industries was finally brought under control only by means of the organization and repeated strikes of the workers in these crafts and by the passage of restraining legislation.
Because Jews located in the largest cities, where economic opportunities were then the most abundant, because they had a strong cultural imperative toward education at a time when the economy demanded the skills of formal education, and because their culture seemed so compatible with individualistic capitalism, Jewish immigrants rapidly took their places in the middle and upper levels of the class structure. Indeed, the story of the continuous struggles of these immigrant parents to provide their children with education, better jobs, and a better future has become today the controversial model of social and economic mobility. It is against this model that current arguments for cultural pluralism for Negroes, Chicanos, Indians, and old ethnic groups are being debated.
Finally, the small black ghettos of Northern cities in these years laid the foundations for what would later become a revolution in black and white culture. Since job discrimination held so many Negroes in permanent poverty and race prejudice crowded blacks into expensive all-Negro communities, their liberalization and urbanization could not be borne on a wave of rising affluence and integration of the members of the culture,
as had been the case for Catholics and Jews. Rather black culture had to accommodate itself to the fact of ghetto poverty and the capabilities of a small elite whose actions were narrowly circumscribed by the discrimination of the outside white society. Despite this confinement, the ghetto years of the first waves of migration from the South between 1890 and 1920 were a time of extraordinary cultural growth: the Negro churches adapted to the rush of migrants and participated in the general liberalization of Protestantism, while a parallel secular flowering established a modern definition of black Americans as a people with a unique art, history, literature, and music.
Before these migrations, when Negro clusters in Northern cities were small, the churches had served as community centers. They were the principal sources of black news, the cement that held clubs and lodges together, the bases for political action, and the links between the tiny black elite and the generality of low-paid black workers and servants. Rapid growth of black blocks to entire urban ghettos after 1890 inevitably destroyed such small-scale social unities. Though the web of discrimination hampered Negroes in a thousand ways, a small business and professional elite grew with the ghetto, thereby fragmenting the community's secular and religious leadership. Ministers had to share their role with doctors, teachers, newspapermen, government workers, politicians, and liquor and gambling operators, while at the same time large and successful congregations set themselves apart from the proliferation of store-front churches which sprang up to meet the needs of the new migrants. The extreme poverty of urban Negroes has forced black Protestantism to cope with far more extreme institutional divisions than its white counterpart, and it maintains to this day its character of a few large well-established churches surrounded by a sea of informal evanescent one-room congregations. Nevertheless all the features of white Protestantism prevail: a core belief and practice which allows blacks to move easily from one church to the next, the insistence among respectable families of every income that Sunday school is essential for children's education, the mixture of classes in each denomination, and the widespread participation in ancillary clubs, entertainments, and lectures.
Thus the twentieth-century liberalization of black Protestantism
went forward in the general climate of American religious practice, constrained only by the facts of ghetto poverty and the inescapable demand that ghetto Protestantism, like all ghetto institutions, serve the race. In the three decades after the Civil War, Negro ministers had participated in the fight to obtain the vote for Northern Negroes, to desegregate Northern city schools, and to seek full citizenship for the race. With the rise in the late nineteenth century of a new urban humanitarianism among Protestant and Jewish churchmen and philanthropists, the black elite absorbed and adapted the social gospel to its own race purposes. On the white side, slum missions gave way to settlement houses, social surveys, and reform politics, thereby building a new bridge toward the black leaders. The result was the formation of two new permanent organizations, the National Association for the Advancement of Colored People (1909) and the Urban League (1911), which embodied the spirit and technique of the new social consciousness. Although for a time in Southern cities white and black governing boards had to sit separately, with the spread of their chapters into every large city these new organizations formed a liberal interracial core which led the civil-rights campaigns throughout the nation until the 1960s.
A unique cultural flowering also accompanied the 1890-1920 migrations and the growth of urban ghettos. In view of the poverty of Negro city dwellers and the small base of support which the elite could offer to black theater and arts, the Harlem Renaissance was a remarkable achievement of black liberation. A handful of poets, actors, dancers, painters, writers, and musicians fashioned a coherent heritage and modern image of a black American: a free man in the midst of oppression whose culture stretched back to Africa and Jerusalem. The discrimination against blacks in the entertainment, commercial-art, and publishing industries and their virtual exclusion from universities forced most Negro artists to depend upon the inadequate resources of the impoverished ghetto or to leave the black world altogether. As a result the cultural stream which the Harlem Renaissance opened early in this century was choked to a mere trickle. Only jazz, which could be nourished in the ghetto while meeting universal outside demand, flourished.
When the boom in the world market for agricultural products collapsed in 1921, the historic drive of Americans to cultivate their land on independent family farms collapsed with it. Troubles for the small farmer had been accumulating for years. Failure to secure credit for new machinery and new methods had driven many into mortgage foreclosure and tenancy, and competition from large-scale operators harried others. The discrepancy between what the ordinary farmer could earn by his labor and what his son or daughter could make in a city office or factory drew young people increasingly away from the land. Now as twenty years of depressed farm prices began, a term longer than anyone's savings or mortgage could sustain, farmers, white and black, gave up in droves and sought a new chance in the mill towns and cities. New Deal and subsequent agricultural legislation, far from helping the small farmer, brought new and highly productive irrigated land into competition and put capital into the hands of those who were already the most successful; the strong waxed rich and the weak were driven off the land.
From Texas to Minnesota, thousands of Midwesterners gave up and moved to the Pacific; it was said that Los Angeles was Iowa transplanted. The textile, lumber, chemical, and petroleum industries gave employment to Southern farmers, while the continued expansion of the automobile industry in the Midwest absorbed many thousands from there and other regions. In this great exodus the rural American suffered all the exploitation and punishment of slum living that migrants from abroad suffered earlier. The shanty and trailer camps of Willow Run, thrown together for war workers, or the Appalachian North Side of Chicago today bear the marks of conflict between the rural style of life and that of the modern industrial city with its low pay, uncertain income, and harsh discipline.
Beginning with World War II the blacks of the Southeast were finally able to participate fully in this national pattern, and they poured
out of the old Confederacy into Northern and Pacific cities. There they have faced in our own time, as in previous periods, two special obstacles that have never confronted their white counterparts. Job prejudice consistently held down newcomers and older residents alike and excluded even the skilled and qualified from jobs commensurate with their abilities. Moreover, prejudice blocked Negroes from the traditional practice of one man's using his established position to make room for his friends, relatives, townsmen, and fellow ethnics. Employment restrictions closed down the historical process of urbanization whereby newcomers advanced either through job improvement or accumulation of property. Housing prejudice, far in excess of any that existed in respect to Jews or poor families of any sort, closed vast areas of the city to Negroes, and the black ghettos could often only expand by violence or by the purchase of housing at exorbitant prices. There had been ghettos and prejudice before in American cities, but the rapid growth of communities of Negro migrants in the North and the relentless job discrimination heightened the segregation. The outcome has been the emergence of an unprecedented situation in American cities: vast quarters are occupied exclusively by the members of a single race or origin.
These special barriers against blacks made the Negro ghettos of the Northern cities a distinct departure from the slums where foreign immigrants or rural white natives lived. With housing choices and job access both severely curtailed, black ghettos became huge basins of poverty and low-income housing. They were very far from being "ports of entry," stopping places for the first years or the first generation, as twentieth-century Italian slums had been. There the population repeatedly shifted as the more successful members followed jobs into industrial sectors or managed to purchase a house in a decent working-
class district. But newcomers kept pouring into the black ghettos and were kept there by the whites. Consequently our modern ghetto resembles the classic European one. Spatially and socially it is a microcosm of the metropolis, where the poor crowd into the oldest housing of the quarter and the skilled and more prosperous huddle together at the newer periphery. All classes of blacks form an exploited community, as did the Jews in the ghettos of Europe, and they make up an isolated colony in the host society.
Furthermore, sizable black migration is a recent phenomenon, coinciding with the economic faltering of the old core cities in which blacks had to settle. Bad economic surroundings served as the unfortunate reinforcement to job prejudice, and both exacerbated the problem of the impoverishment of black migrants, of whom there were already a disproportionately large number as compared to white migrants. The American Jewish ghetto had stemmed from specialization in the garment industry; the Irish, Italians, and Poles prospered in the construction trades attendant on the industrialization of booming cities. But blacks arrived to find both prejudice and an environment of low-paying, sluggish industries. This economic geography of the decentralizing metropolis creates for Negro migrants yet another hardship: the black ghetto is a residential place, not a mixed settlement of industry, commerce, and homes. Lacking skilled migrants or much employment of its own and blocked by the prejudice of bankers, insurance companies, wholesale outlets, and retailers, black capitalism can hope at most to serve the ghetto itself. Until the metropolis is opened, the skills, leadership, and capital of the black community are in the wrong place, at the wrong time, to participate in the profits of the growing metropolis.
Concurrently with urbanization, a number of events conspired to diminish the importance of overseas migration. Successive restrictions in this country and abroad prevented people from coming to the United States or leaving their own country. The United States excluded the Chinese in 1882, the Japanese in 1900, and then in a succession of laws in 1921, 1924, and 1929 set restrictive quotas that choked down the flow of population from Asia and Southern and Eastern Europe. The unemployment of the Great Depression followed and closed the United
States to those who were seeking improvement over the economic conditions in advanced European countries. American immigration restrictions and those of Germany, Italy, the Soviet Union, and Great Britain trapped thousands of political prisoners, especially Jews, who by nineteenth-century practices would have sought asylum in the United States. Rejected by their own country and refused by ours, millions met their death in prisons and concentration camps.
Since World War II, German and Italian migration has revived to a great extent (Table 2, page 93), and it is expected that the 1968 relaxation of quota restrictions will bring in Eastern Europeans and Asians once more. Under the restrictive policies of the 1920s the major foreign influx up to now has been from Canada, Mexico, and the Caribbean. Except for the French Canadians in New England, the Canadians have melted into the native population like the British before them. The Mexican, however, is the prototype of the immigrant of today. Although a few special characteristics, especially a propensity to large families, the proximity of the parent country, and the historically unique practice of many southwestern agricultural laborers dwelling in cities instead of out on farms, differentiate Mexican immigrant life from nineteenth-century precedents, much repeats the past. Like the Irish peasants before them, Mexicans work in the lowest-paid, nonunion, marginal small firms; like the Irish they are employed in seasonal gangs as railroad, construction, and farm laborers; like the Irish they do the heavy, unrewarding labor on the streets and in the homes, hotels, restaurants, and food-processing plants of the American city. Again like the Irish peasants before them, the Mexicans have been the object of prejudice and persecution, facing additionally the racial antipathies directed in the United States against any nonwhite. But the Mexican experience in the West and the Puerto Rican experience in the East have taken on a special quality ascribable to the nature of the giant cities they entered. More than for any previous groups, theirs is the unseen migration because theirs is the era of the megalopolis, made up of rigidly segregated cities and metropolises. As a result the browns may live by the thousands in a city and yet go unnoticed by their fellow citizens. In the mid-nineteenth century the Irish could not have been thus ignored; they lived in every-
one's alley, attic, and cellar, and mixed in among the families of middle-class native Americans. Again the structure of the present economy is such that the Mexican's manual labor and service exist at the margins of our advanced technology in industry and commerce: he can be replaced by a machine; he can be kept on at less than a living wage because often he has no other job choices. When Chicano families do break through the barriers of poverty they settle, like the blacks, in class-graded ghettos and replicate on a small scale the divisions of the larger society, yet like the blacks they are denied the opportunities for dispersion that are open to whites. So it was that Los Angeles, the twentieth-century metropolis, expanded with new slums and a new people of slum dwellers, and New York, the oldest metropolis, found its slums filled with yet another new people, the Puerto Ricans.
The cultural consequences of the low level of foreign migration for the past half century have been to permit the unification of domestic cultures along the lines of their class and religious attributes, undisturbed by major incursions of new ethnic cultures. At the same time, the high rates of migration within the country have subjected these cultural components to the pressures of a metropolis continually being restructured into diffuse suburban patterns. In general these two demographic trends of urbanization and suburbanization have brought the leveling out of the white socioreligious groups—Protestant, Catholic, and Jewish—into a bourgeois culture consensus and the fostering of a nationalist component in black Protestantism.
Looking back from today's perspective on the fate of the liberal social gospel, one can see that it contributed to the general secularization of Protestantism and to the continued trend toward the transformation of Protestant churches into middle-class social institutions. The strong call for ministerial and lay action issued by the early social gospel was accepted, but through widespread acceptance it lost its millennial imperative to build a better kingdom here and now in the United States. Instead it turned into a benign tincture for the social education of the ministry and for the encouragement of civic committees in every congregation. In time the social gospel became absorbed in the progressive domestic morality and politics of many Protestants. It became a part of
their concern for the decent treatment of women and children, a clean, healthy environment, good schools, effective charity, a humane settlement of the conflicts between capital and labor, even for a sympathetic attitude toward pacifism.
The weakness of these trends lay in the marginal position of working-class and lower-class participation. Protestantism, the congregation of the faithful gathered to hear the Word, has always been the prisoner of its adherents. The well-to-do in each congregation have always specified the location of the church, decisively influenced the selection and tenure of ministers, upheld the missions, and controlled the addition of new programs, whether for Sunday schools or the introduction of a basketball team. The almost complete suburbanization of the white middle class and upper middle class after 1920 quickened the momentum of these trends, which had been in motion since 1870. Protestantism has been carried on to the suburbs; even the wealthy fashionable downtown churches, which for years had attracted a metropolitan following, have been faltering.
It has been estimated that for the past century the churches of every major Protestant denomination have moved once a generation to follow their congregations. Now situated as they are in all-residential suburbs without the stress of offices and factories, without blacks, browns, or the poor, is it any wonder that the concerns of modern Protestant churches have become the concerns of the middle class, the upper class, and the working class which aspires to middle-class ways? The lower class and the working class have been left to fall back on their own devices. Their patterns are more secular and familial, less preoccupied with middle-class voluntary organizations, but in the past fifty years an old style of evangelical Protestantism has flourished among them. The Bible store front and the organized churches of Jehovah's Witnesses, Nazarenes, and the Holiness groups have multiplied, but neither by membership nor by influence can these class variants yet be called alternatives to the dominant suburban trend of middle-class modern Protestantism. Dwelling in the suburbs, the place of homes and domestic issues, Protestantism has become the medium for the concerns of the family as a residential unit. The settlement house of the social-gospel era, which had been so essential to an earlier generation's discovery of the city, died out
or became an anachronism in both the aging core city and in the suburbs. Now, as continued black migration threatened the all-white suburb and its schools, civil-rights issues polarized Protestant congregations. As repeated wars threatened the children of the suburbs with military service peace movements sprang up, and the isolated domesticity of the suburban wife gave rise to a new set of moral imperatives in the women's liberation movement. Thus modem moral polarities overlay the basic middle-class preoccupation with home, children, safety, and order.
Catholicism had reached a similar destination by the 1950s though it had traveled a different path. Conflicts with recent immigrants continued to divide the Church until the emergence of a large second and third generation of Poles and Italians after World War II indicated that the largest immigrant groups had grown used to the ways of American Catholicism. The first-generation Poles, dependent on their parish church as the center of community life, fought for independence from territorial parishes dominated by the Irish, and indeed many Poles left the Church to found a separate national church. The southern Italians, whose males were quite unaccustomed to support the established Catholic Church in their home country, and the Italian immigrants from the former Papal States, who were strongly anticlerical, failed to follow the Irish and Poles in active parish building. Rather they remained hostile to and ill-served by the Irish-dominated Church. Only the passing of time and the Americanization of Italian Catholicism in the second and third generations brought ultimate accommodation and harmony.
With ethnic conflicts quieting with each year after 1920, an international reaction within the Catholic Church itself hastened the diversion of the American branch from its working-class connections. The liberal Irish bishops of the late nineteenth century were men who spoke in behalf of the working class or who protected outspoken priests who did, but they were also interested in centralizing U.S. Church politics and were proponents of a vigorous national Church with definite self-determination vis-à-vis Rome. These same men had been frequently in conflict with new immigrants because of their insistence on episcopal power, their questioning of the credentials of immigrant priests, their
hostility to new national parishes, and their lack of sympathy for variant styles and practices of Catholicism. Yet as vigorous Americanizers and as representatives of a large urban working class—as well as of a growing middle class—they participated enthusiastically in American nationalism. They energetically supported World War I with public appearances, ministry to the troops, and charity campaigns. At the end of the war the National Catholic War Council issued a platform for the future that endorsed all the progressive notions of the day, and indeed the statement would have done credit to the American Federation of Labor. Unions, cooperatives, public housing, everything short of socialism was recommended.
Yet this working-class nationalism was the legacy of a dying generation, and its leaders passed away in the teens and twenties. They had been socially too liberal for the Papacy and too demanding of autonomy for the American Church. So fearful of this liberal nationalism had the Papacy become that only in 1908 did America cease to be directed by the Curia's Congregation of Propaganda as a missionary land. In 1921 the National Catholic Welfare Council was all but abolished because it seemed a dangerous structure and, as a national body of mixed lay and clerical affiliates, posed a potential threat to the strict hierarchical organization of the Church.
The wave of conservatism that swept over the world after World War I swept with it the Catholic Church and its American clergy. Within the Church, reaction took the form of increasing repression of "modernism," by which was meant the irregular views and practices spontaneously springing up throughout the modern Catholic world. The conservative hoped to suppress cultural variations in the regulation of marriage, customs among the religious orders, governance of the Church, and in theological writing and speculation. Bishops were encouraged to master and enforce the Canon Law of 1917, which itself fostered a narrow clerical legalism. It provided for the strict seminary training of priests and active censorship of books and magazines, and required clergy who wished to speak in public or write for general audiences to do so only with episcopal permission. Furthermore, it demanded that the laity send their children to parochial schools and that noncomplying parents be disciplined by their bishops. Finally, both clergy and laymen were making popular a new style of worship—fre-
quent attendance at church accompanied by a regular reception of the sacraments—and a campaign was launched for the daily receiving of Communion.
The long-term consequence of this insistence on orthodoxy and devotionalism was to hasten the removal of American Catholicism from working-class and lower-class contact and sympathy. The new imperative for parochial education implied that it would join the prevailing trend toward the establishment of separate high schools, so that the expansion of the parochial system meant not only additional elementary schools but a large secondary network also. During the twenties an enormous program of school building was launched and attendance increased dramatically, but the new parish schools could never handle more than a fraction of the poor of the mill town and metropolis. The new schools, like the old, were vehicles for the middle class and for working-class aspirants to the middle class just as much as the public educational system was, and indeed when prosperous Catholics went to the suburbs so too did the new schools.
Recent studies say that the assimilation of Catholic immigrants is complete as a major social event and that Catholics are now as fully dispersed among the class positions of the nation as the members of any other group. In the cities this distribution among the units of the national class structure has resulted in vitality in the suburbs but decay in the central city, where the inner-city territorial and national parishes and schools have lost attendance and support. Currently lay opinion is exerting pressure for the closing of inner-city churches and parochial schools, which serve few whites and many blacks and are costly to maintain. The working-class Catholic family is having difficulty in supporting the more expensive and ambitious parochial schools in its neighborhood, while the middle class and upper middle class urge the creation of country day schools and a network of elite Catholic schools and colleges to match the private educational system of the well-to-do
Protestants. At the same time, the management of colleges, schools, and hospitals has made the administration of the dioceses themselves so elaborate that many more clergy are working in administration today than fifty years ago. Here again it is the wealthy or middle-class layman who assists on episcopal boards and committees and dominates the post-Vatican Council II parish councils. For these reasons, an international movement for strict orthodoxy found its American expression in the context of suburbanization and middle-class dominance. The Catholic Church has always thought of itself as an institution of families and a supporter of family life, but the economic and social progress of its constituency has made it, like the Protestant churches, an institution of middle-class families.
The signal success of Jewish immigrants and their children meant the rapid embourgeoisment of this denominational group. No longer can the American Jew be characterized as a socialist, a union organizer, and an activist in working-class politics; the liberal charitable trend of German-based Reform Judaism has become the model. Urban and industrial conditions have eroded or destroyed Orthodox practices for most Jews, and a range of adaptations from Conservatism to Reform now obtain. There is some evidence that both modes are receiving an increasingly associational, as opposed to the older kinship, emphasis and that the structure of suburban Judaism is becoming more and more similar to the Protestant style, with the congregational services as the core social institution. It has long been the custom of Jewish families to cluster in the metropolitan region more than other denominational groups, and their related tendency to turn to their fellow Jews for most of their friendships has fostered the expansion of Jewish community institutions. No other group in the American city sponsors so wide a range of charitable institutions. No group is more domesticated, more centered on the care and nurture of family life. What effect the continuing demands of Israel will have upon American Judaism is still
unclear. What is clear, however, is that in two or three generations a diverse and fragmented conglomeration of German and Eastern European Jewish peasants, artisans, and city dwellers has been transformed into a unified, predominantly middle-class cultural group.
The persecution of Negroes and the impoverishment of the black community make it impossible for black Protestantism to follow the orientations of the white middle class. The continued hostility of the white world has meant that black Protestantism has always spoken for a people as well as for congregations of the faithful. The periodic surges of black nationalism during the twenties and the sixties served to exalt the racial component in black religion. Church leadership of and participation in the civil-rights movement was an unprecedented development for modern Christianity. Denied participation in the general social rewards of the modern city, the culture of black Protestantism has never been suburbanized, and its contemporary attitudes differ more widely from white religious cultures than the white ones differ among themselves.
Thus during the past fifty years the slackening of foreign migration and the changes in urban religions have turned our ethnic history into the history of classes and religions. Recent sociological studies have demonstrated that these broad allegiances function both as a common national culture and as a set of variations on the theme of family life. The statistics of each study show two tendencies. The fact that the tables report heavy percentages of white Protestants, white Catholics, white Jews, and black Protestants following similar patterns and sharing common beliefs gives the historian evidence of the emergence of a national culture. The fact that the same tables also show differences in the percentages, differences of a range from 46 to 75 percent, also tells the historian of the presence of important socioreligious habits.
The common denominators in the habits and points of view of Americans of all religious loyalties are impressive. The basic custom is commitment to familialism. Although the commitment to and interaction with kin varies somewhat by class and religious identification, the family invariably remains the first object of loyalty. The common national manifestation of this loyalty is the visiting of relatives; many see at least one relative once a week, many more at least stay in touch
with kin. Such familial orientation, even in the face of a high degree of intracity and intercity mobility, must be recognized as a crucial dimension in the analysis of the modern city and in designs for its future. Here in familialism lie the roots of some of the urban dichotomies—well-ordered neighborhoods and acres of neglect, the weakness of organizational power in working-class and lower-class neighborhoods and the difficulties of bringing tenants together for purposes of defense. Perhaps too the failure of police protection and the confused state of public education can be ascribed to familialism and the lack of meaningful local community life. The modern city family has become a tiny island of escape in a sea of fragmented and bureaucratized individuals.
Next in importance after relations with kin, but on a lower scale of frequency and intensity, comes the universal predilection to visit with neighbors. Again there are variations according to class and denominational identifications, but "neighboring" is a basic urban American style among all classes. (It is severely constrained, however, when families must live in apartment houses.) In the past as at the present moment, it has strengthened localism and local institutions, but it has also proved to be a weak and uncertain reed for any decentralized management of the city, whether at the hands of early twentieth-century Midwestern Progressives or today's New York City reformers.
Relics of historical cultural conflicts still persist. Whites, solidly racist, are more interested in avoiding the integration of their residential blocks than in keeping Negroes out of their children's schools. Of the four large socioreligious groups, white Protestants tend to be most critical of the others. These habits of thought are pallid remnants of the old nativist tenet that the United States was and ought to be a Protestant country and that Protestantism was the American culture. A number of events have stopped the historic mills of Catholic-Protestant conflict and difference. The white Protestant group's attempt to force its own liquor laws upon the nation failed with Prohibition, and much of the aggressiveness of Protestantism lost its legitimacy in that failure. Longstanding conflicts over the status of women, issues that reached back
even to the Abolitionist era, have died down with the suburbanization of the Catholic housewife and her participation in the peculiar freedoms and constraints of this modern environment. Finally, Catholics and white Protestants have been intermarrying at a steady and substantial rate.
There is an emphasis on churchgoing among all denominational groups. Church attendance rises with class status and according to the length of time the individual has lived in America, and the third generation goes to church or temple more often than the first or second. Moreover, there is a core of belief that all Christians share. Modern surveys show that American churchgoers accept most of the propositions of a Christianity which says that God watches over us like a Heavenly Father; He answers prayers; He expects weekly worship. Most of them also believe that Jesus was God's only son and have faith in the rewards and punishments of a life after death. Such a consensus has preserved Protestant congregationalism in the midst of competition and change, and it has enabled the Catholic Church to bury ethnic differences. Such a consensus has gained strength from the urban churches' decades of stressing the familial and orthodox aspects of Christianity in preference to encouraging devotional enthusiasms and religious particularism.
Beyond this evidence of an unfolding national cultural consensus, the studies show the presence of important differences by class and differences by religious identification. The class segregation of the modern city is mirrored in the surveys' reports of variations in the class attitudes within religious groups. They testify to the correspondence of the structure of the city and its culture. At the same time, religious identification is shown to be an important and continuing quality of urban life.
Few members of any of the four socioreligious groups were heedless of kin or neighbor, but their loyalties did tend to make some difference. For example, along the axis of cultural issues that runs from participation in associational life as against communal life, most Protestants were more interested in voluntary organizations and neighborhood—that is, they were more associational than Catholics, who were more concerned with kin. Jews did even more visiting with relatives, but were less aware of their neighbors than Catholics. This is not to say that urban
Protestants are nonfamilial and that Catholics and Jews are familial; the reports indicate only variations in central tendencies. The surveys also reveal differences by class, and participation in associational life rises in all denominations as class position rises. The well-to-do are the organization men in America. Perhaps this report reflects the fact that the urban working class has lost its early nineteenth-century fondness for clubs and associations as work has become bureaucratized and neighborhood life has been broken up.
To the extent that these variations by denomination and class have been tabulated, they throw considerable light on the everyday problems that dominate our segregated metropolises. In local elections, in black-white confrontations, in planning-board and zoning hearings, in P.T.A. meetings and school elections, the differences among the religious groups are tremendously important. The spectrum of views that they bring to commonplace problems and the variations in popular attitudes common to certain neighborhood or suburban populations are the elements that carry elections and determine administrative decisions. For example, white Protestants are more concerned with controlling "sin" than are Catholics or Jews or black Protestants. As for divorce, Negro Protestants are largely unconcerned, having fewer among them who oppose it than the white Protestants do, but Catholic communicants are opposed to it. All Christian denominational groups tend to oppose keeping stores open on Sundays. The patchwork of such variations affects many areas: sex education in the schools, licensing of bars and package stores, and the night and Sunday hours of great suburban shopping centers. Yet still another cultural position has its surprises: non-churchgoers of whatever religious orientation are quite uninterested in any of these issues! Such surveys suggest that our urban culture is a consensus closely woven from class and religious threads.
A fascinating section of the studies is given over to information about attitudes in respect to personal autonomy as opposed to discipline. Even simple questions about home and children uncover issues that can vex local politics and education and that are symptomatic of the current state of the classes.
First, all classes and religious groups restrict the size of their families, and the variations from large to small numbers of children follow the cultural groups from black Protestant to white Catholic, then
white Protestant, and finally Jewish. The differences, even in the metropolises, among the groups are not significant. Second, as to women's role in raising children, families did not vary widely in their attitudes by class, but when Catholic and Protestant mothers were asked if child rearing was "burdensome," 60 percent of the Protestant mothers but only 47 percent of the Catholic mothers replied affirmatively. Perhaps here we can find in today's city a reflection of the Protestant women's liberation movement, which has been active in America since the early nineteenth century. Perhaps too this greater dissatisfaction of Protestant families with the child-rearing role encourages club and associational activity.
Such basic behavioral attitudes expand into local issues such as police protection and education. When city dwellers were asked whether intellectual autonomy or obedience was more to be desired in schoolchildren, religious loyalties were identifiable. Jews and the Protestants, white and black, tended to put a higher value on intellectual autonomy than did Catholics. But the families' class status had even stronger repercussions. The upper class and the middle-class Jews, Protestants, and Catholics were all decidedly in favor of intellectual autonomy for their children, but the working class and lower class attached far greater importance to obedience. In the related issue of the enforcement of discipline, few white Protestants favored physical punishment, preferring the use of guilt or shame. Among the working classes—both white Catholic and black Protestant—there was division on the issue, although many of them favored the use of physical punishment as a means of controlling ten-year-olds in school. Here one can detect echoes of both religious and demographic history. The Catholic repression of the years from World War I to the 1950s stressed authority, discipline, and orthodoxy. At the same time such an approach to the world was reinforced by the fact that there were a disproportionate number of working-class families in urban Catholic schools. The similarity of black Protestant and white Catholic attitudes here seems to reflect the Negro's disadvantaged position in the general society.
The exploration of American attitudes toward such issues as child rearing and education holds some promise of linking our past history to the everyday cultural and political confrontations that trouble our neighborhoods and suburbs. Even this pilot report, from a Detroit survey,
shows that the family, school, and neighborhood betray the effects of a sense of powerlessness on the part of the working class and lower class. Should we wonder that class lines are followed more often than those of the religions? After all, the working class and lower class are the ones whose members have the least freedom in today's city. They are subject to bureaucratic control by unions, factories, and offices; their hours are the most strictly regulated and their tasks the most standardized; they are the ones who bring home the smallest or most variable paycheck with which to exercise the personal freedoms of leisure. Finally, they are the ones who live in the most crowded districts, walk the most dangerous streets, deal with a mass of the most unsupervised children who attend the worst schools. It is not surprising that after fifty or a hundred years of such conditions so many working-class and lower-class Americans distrust intellectual autonomy in their children, demand obedience, and use physical punishment. Orderly behavior, not flexible self-discipline, is what has constantly been demanded of these families. Lacking personal autonomy or participation as equals in institutions which do have power, many city dwellers share a dependence on discipline and authority. They may call for more police, but they will not turn out for a P.T.A. meeting on the free classroom.
Out of such class and socioreligious differences—small variations for the most part, but representative of convictions deeply held and often the product of long history and overbearing social pressures—the American city must find strength and support. And the preconditions for abundant support for strong democratic planning are there. The history and present state of American urban culture meet three basic requirements for democratic planning: common cultural goals, a tolerable range of variation within the culture, and a process of change which could be activated to let more of those outside the culture join the mainstream.
In order for a democratic nation of giant cities to plan for the allocation of its wealth, for the control of the growth of its cities, and for the distribution of its jobs and services, its politics must be undergirded by a broad consensus on the goals to be sought. To plan means at the very least to set goals toward which sustained public projects and
private enterprise can work. If regional divisions, class differences, and racial and national conflicts tear at the political fabric, then long-term agreed-upon goals cannot be set and planning must be the activity of a powerful, even dictatorial minority. In the United States such divisions do not obtain, and a social underpinning of sufficient unanimity exists so that an open democratic politics could be expected to manage the setting of goals and resolution of conflict inherent in large-scale national economic and regional planning. Broad agreement has been our cultural circumstance at least since the twenties, if not for much longer. What has been missing in the past, and is still absent, is a popular willingness to raise the demands of our cultural aspirations of everyday life to a status equal to our traditional capitalist drives for wealth and power. Until as a nation we are willing to subject our political, social, and economic institutions to these demands, the potential for democratic planning of our cultural consensus will remain untapped, and common life in the city will remain the creature of the higher priorities of capitalist competition, and now of imperialism as well.
The narrow range of diversity within our class and socioreligious cultures also holds out the promise that national planning may be teamed up with decentralized decision making, and suggests that local interpretations of goals for national well-being will not be extreme. A Washington or state-capital policy when filtered through the myriad metropolitan governments and administrative agencies will not meet such a range of conflicting local demands as to lose its coherence. We are therefore in the fortunate position of being able to contemplate democratic planning structures that will combine broad national objectives with state and local decisions so that the variety within the culture may find expression in the politics of the ward, the neighborhood, and the town.
Only in the relationships between whites and blacks does our common culture need to be challenged. As both history and today's television demonstrate, white Americans if left to themselves will oppress their black fellow citizens. The recent civil-rights movement shows that local actions supported by national political coalitions can overcome such oppression. The country will have to continue to spend its political energy and capital to discipline both public and private institutions and even to take affirmative federal action if white racism is finally to be conquered. One important reward for such an effort will be the
increasing possibilities for local autonomy as the need for central bureaucratic control over racial affairs relaxes.
Finally, the very historical process by which our cultural consensus was reached reveals the mechanism for gaining a more inclusive democratic society. In years past, poor migrants from the rural .United States and overseas came to the cities; and in time, either through the institutions of the inner city itself or by further migration to the suburbs, they became absorbed in the general class and socioreligious culture. For the millions who survived this process, the new culture provided a way for coping with the realities of American urban life. Yet the social pathologies of the city were never less than they are today, probably much worse, and millions of persons were disabled or destroyed by alcoholism, crime, disease, despair, desertion, and insanity. The single most important difference between the lower incidence of pathology among those who made it into membership in the city and those who did not was the difference between those families who could earn a living wage and those who could not. If every American who wanted a job could get one, and if every employed person received wages sufficient to support himself and his family or herself and her dependents, the disproportionate social pathologies of our ghettos and slums would disappear. Such a full-employment, living-wage policy would not solve all our urban problems by any means, but our history tells us that it would enable all Americans to participate in our culture as full-fledged members of the society and thereby it would build a firm foundation for both national and local democratic planning.
Coping with the Urban Environment
Public crises and private benefit; the response of charity, reform, and science
The Problems of Health and housing in today's American cities are often perceived as belonging to two quite different domains. One cluster of problems relates to the fundamental inequality of our citizens and is manifested in the inability of inner-city poor whites and blacks to obtain the levels of health care and of a safe sanitary environment that were achieved by the majority of their fellow urban dwellers half a century ago. A second cluster of problems concerns the inability of more prosperous white Americans to obtain the kind of preventive care, day-to-day medical service, and supportive physical and social environments to which they should be entitled by modern medicine and modern physical planning. Because of the segregated structure of the metropolis and the class and racial politics of health and housing, the two problems are now dealt with as isolated issues. We debate welfare, clinics, public housing, and urban renewal for the inner city; we also debate voluntary insurance, aid to the medically indigent, community hospital service, group practice, the housing shortage, and improved planning and subdivision control for the suburbs. Yet because the entire metropolis or megalopolis is part of one national urban system and is dependent in most of its parts upon the workings of that system, the two clusters of problems are in fact inseparable: the failure of the health-delivery institutions to meet the acute needs of the inner-city poor is tied to the failure of the preventive services to meet the needs of the outer-city
majority; today's housing crisis of the slum is a product of yesterday's planning failure of the suburbs.
Although the death rate in American cities varies systematically by race and class, with the poor and the black having the shortest lives, the gap is small and would disappear as a by-product of the modernization of health and housing services as a whole. Today's problems rest in the context of a stable incidence of mortality and a widespread expectation of a long life. The difficult issues of our own tune turn around the universal experiences of city dwellers as they live out a more or less common life span. The urgent agenda of both inner city and suburbs speaks to the quality of life as we all undergo generally inevitable traumas, accidents, communicable diseases, confusions, criminal assaults, and physical disabilities from birth to death. The quantity and quality of available housing is inextricably tied to well-baby, pediatric, communicable-disease, drug, and accident services for young people and their families; community planning is linked to mental-health, accident, and chronic-disease care for middle age; and the placement, design, and supply of housing are crucial ingredients of geriatric care and social services to the old. The failure of the modern city to realize its potential in these fields is as much a product of the workings of the urban system as is its failure to distribute its wealth equitably in respect to family income and full employment.
The gap in health and housing between potential and realization can be understood in two ways: in terms of class and in terms of institutions. First, the construction of housing (and therefore the available urban stock of housing) has always depended on the capital resources and rent-paying abilities of city dwellers. It has always reflected the differential distribution of income in the city, and it has been dependent upon the fashions and abilities of the upper one-third to one-half of the population. Similarly, medical services have been closely bound to patients' ability to pay, to the class ambitions of doctors, and to the philanthropic styles of the rich, so that the health of the urban population as a whole has always mirrored the class structure of the city. Second, in institutional terms our provisions for both housing and health take their basic configuration from the pre-1920 era of the industrial metropolis. The real-estate and housing industries and their regulatory monitors assumed most of their current form in response to the problems and capabilities of the old crowded metropolis. Similarly, the modes of American medicine—public-health institutions, acute-care
hospitals, private doctors—arose in the late nineteenth and early twentieth centuries when such a structure suited the financial resources, scientific progress, and personnel capabilities of that era. Considering the advances in social science and medical science since 1920, one might reasonably expect that American society would have moved more rapidly away from these inherited constraints, but the painfully slow advance in these key elements of a humane environment can be attributed to the interactions between class-based financing and the power relationships of the accompanying institutions.
During America's first century of rapid urbanization, the years from 1820 to 1920, our urban environments polarized about two extremes. In the early nineteenth century the health of city dwellers depended upon the amplitude and adequacy of the traditional design of individual houses, upon the purity of family and neighborhood wells, the happenstance of open lots, and the variations in care of backyard and basement privies. Booming growth and mass migrations relentlessly pressed against this almost universal big-city environment, placing all citizens in continuous jeopardy from fire and disease. Innovations in transportation, municipal sanitary services, plumbing, heating, lighting, and to a lesser extent in the design of housing created a new environment for one-half to two-thirds of the urban population. By the 1890s the disparate trends of urban growth had become apparent. At one extreme stood the new urban world of single-family houses, row houses, two-families, and apartments, where an unprecedented part of the population enjoyed equally unprecedented security and a rapidly rising standard of living; at the other extreme stood the old big-city world of overcrowding in rooms and obsolete structures, faulty or nonexistent plumbing and heating, firetraps, fever nests, and malfunctioning integration of public and private sanitary systems. The potentials of the new environment and their unavoidable tensions with the old combined to call forth the housing practices and health programs of the industrial metropolis. The same potentials and tensions also set for our own era the basic institutional structures that still determine our housing supply, public health, and private care systems.
The safer and more wholesome urban environment sprang from a series of complementary events in transportation, public services, site planning, mechanical inventions, and home design. The succession of transportation innovations, from the introduction of horse-drawn streetcars in the 1830s to the electrification of street railways in the 1890s
and the supplementing of public transit by the automobile after 1910, had a contradictory environmental effect. As possible commuting distances lengthened with each transportation advance, the supply of land expanded exponentially, thereby relieving what would otherwise have been an intolerable pressure upon land within the reach of pedestrian journeys to work. The fact that fringe land around each booming city grew at a rate even more rapid than the city's population made possible a lowered density of many new residential environments in the industrial metropolis.
For housing built after about 1880 a new minimum standard prevailed. In most cities the standard manifested itself in miles upon miles of small wooden freestanding houses set back by a tiny lawn from the dirt and dust of the street, each separated from its neighbor by a narrow side yard and boasting a rear yard often as deep again as the house itself. The cumulative effect of forty years of such construction was to free the middle-class and typical working-class Americans from the dangers of alley housing, boardinghouses, and jerry-built conversions typical of the high land values of the big city of the early nineteenth century. Even in the nation's largest cities, where land costs were high and multistory housing prevailed, the opening of new land brought salutary effects. The universal two-family structures, the three-deckers of New England, and the flats of Chicago, though they crowded the land by today's standards, at least guaranteed no windowless rooms, and two exits—front and back stairs—in case of fire. Philadelphia's and Baltimore's row houses gained in amenity when builders stopped squeezing them into courts and rear alleys and began to lay them out instead in strips fronting only the main streets. The perspective of mile upon mile of houses of the industrial metropolis presents a dreary aspect to today's viewer, but in the essential ingredients of light, air, and fire safety the structures represent an important advance over the earlier practices of urban land crowding. Only in the inner-city tenements of every city, and especially in the crowded centers of New York and Boston, did the industrial metropolis's new transportation fail to improve the environment of large numbers of its citizens.
A contrary tendency of transportation innovation controlled the inner city. The ability of electric-powered surface transportation to deliver ever more thousands of commuters to the downtown sent the price of centrally situated parcels of land skyrocketing, thereby raising the rents for close-in housing to higher and higher levels. For the poor, confined by their job-access needs to the center of the city, this effect of transportation improvement on rents proved an insurmountable barrier to their realization of the benefits of modernization. For the well-to-do a modest move uptown and the purchase of new building designs and mechanical services in the form of firewalls, fire barriers, central heating and lighting, and a full complement of sanitary equipment secured the safety of their town houses. In addition, the invention of a wholly new structure, the fire-resistant steel-frame multistory apartment house with elevators and generous light and air shafts, allowed the inner-city middle class to attain the minimum benefits of suburban environmental safety in the face of high-density urban living.
Not more orderly land use alone, but light and air in conjunction with a more dependable water supply and waste disposal, made the early twentieth-century urban environment the safest form of mass habitation yet built. The mode of construction of water-supply and sewerage systems divided the responsibility between municipal capital on the one side and the individual installations of middle-class homeowners and home builders for the middle-class market on the other. For the majority of city dwellers this division of responsibility proved to be a workable partnership for the raising of living standards. Yet the unnecessary exclusion of perhaps a third of urban Americans in the 1920s from these standards may be laid to a lack of public attention to the inevitable class shortcomings that would spring from such a division.
The mode of construction of waterworks and sewerage in the United States arose out of the traditions and exigencies of the mid-nineteenth-century city. Sheer numbers, onrushing growth, and the crowding of land broke down the earlier small-town checks against fire and communicable disease. In every American city devastating fires swept whole blocks of valuable downtown districts. The Chicago Fire of 1871 was
but the most celebrated of a half century of conflagrations. Contaminated wells, overused and ill-tended privies, overcrowded buildings and rooms, and shiploads of undernourished and sick immigrants simultaneously brought epidemic waves of cholera, typhus, and yellow fever which swept the downtown districts of the poor, seeped into hotels and public places, and frightened all classes of city dwellers. Those who could afford to commute or leave their jobs fled the city during periodic epidemics, and the well-to-do adopted the habit of spending summers in distant suburbs in order to escape the season of greatest danger. Although public toleration for fire and disease stood at a much higher threshold in 1840 than in 1920, the desire to mitigate these trials found daily reinforcement in the sheer lack of reasonably clear water in many parts of the city. Water peddlers' wagons moved through the streets of New York selling spring water to housewives so they could brew a palatable pot of tea or coffee. A clouded and murky pail was often the best that a backyard well or neighborhood pump could offer for the family washing. By the 1840s the merchants' fear of fires and the desire for household convenience reached a pitch that overcame the universal distaste for taxes and heavy public expense.
During the 1840s and 1850s the major cities of the nation built reservoirs, aqueducts, and pumping stations, and laid water mains through almost every street. Yet no sooner had these giant municipal undertakings been completed than the abundance of water clogged the haphazard neighborhood sewers and flooded the streets, alleys, and back-yards of the city. And the threat of epidemics did not disappear. According to contemporary theory, stagnant water, putrefaction, and bad odors were the breeders and carriers of disease. Repeated statistical investigations by doctors and laymen established an incontrovertible correlation between the incidence of infection and inadequate sanitation. Thus from the 1850s to the 1870s cities shouldered the heavy burden of constructing their initial unified sewer systems to match the waterworks of the previous decades.
Both halves of the sanitary system again rested upon the divided responsibility of public and private effort. The division of labor seemed perfectly natural to the age. It minimized public costs, especially when complete systems had to be constructed from scratch, and at the same time it continued the long-standing tradition by which each property owner shouldered the responsibility for the improvement of his own buildings. The public water effort stopped with the laying of water mains in the streets and placing of hydrants from which householders could draw water and to which fire pumps could be attached. Any abutter who wished to tap the main in the street for service to his house, store, or factory could do so, but he had to bear the expense of the connection as well as to pay for his own plumbing and fixtures. Similarly, the sewer ran underground through the street, available to those who chose to make a direct connection to it.
The immediate consequence of this division of labor and responsibility was to hobble the effectiveness of the sanitary system. Homeowners and landlords whose tenants could afford a moderate increase in rents rapidly installed the water tap at the kitchen sink and the flush toilet, the essentials of the new environmental safety. Bathtubs, long considered a luxury, gained popularity more slowly. At the growing fringe of the city the financial partnership of public and private effort placed even more expense on the individual household. Here costs were allocated according to the traditions of beneficial assessment—that is, owners of land abutting a street were charged for a share of any public improvement that raised the value of their land. In opening up new land, the purchaser of each lot had to pay for all or some very substantial fraction of the costs of laying of the water mains and sewers, as well as for the house connections and equipment. The effect was to both raise the amenity level and the costs of new construction beyond pre-plumbing levels. For its part the city waterworks and later metropolitan water and sewer boards endeavored to keep up with suburban demand by building new (and rebuilding old) water mains, pumping stations, and trunk-line sewers. It was a costly race in pursuit of new development, and some
modern authors who have reviewed the pricing of water contend that the total effect was to encourage not only suburbanization but also the commercial and industrial waste of water.
Whatever the merits of alternative pricing schedules might be, there can be no doubt about the long-term environmental effects of the municipal-private partnership. By 1920 the middle class both within the city and in the suburbs had attained a newly safe and salubrious environment, while the working-class families who inherited old middle-class neighborhoods, or rented newly constructed multifamily housing of their own, reaped the same benefit. The poorest third of the population, however, was left out or lagged badly behind, suffering either from the complete absence of the new facilities in their homes or from limited plumbing facilities used by too many people. The water rates could easily have been used to install and maintain the necessary faucets and toilets, thereby overcoming some of the worst effects of the unequal distribution of personal income in the society. The public costs would have been relatively slight and the gains in health substantial. All that was lacking was the popular willingness to make available to all the minimum standards of decent middle-class and working-class life.
Because the lower-income half of American urban families had to find their housing in the structures vacated by the upper half, the new environment of the 1880-1920 years is the old environment of today's cities. These former growth rings are now the gray areas of today's metropolis the Brooklyns and Bronxes of New York, the West and South Sides of Chicago, the East Sides and Hamtramcks of Detroit. The weaknesses of a previous style of environmental progress have ripened into contemporary problems. It therefore repays us to identify the inadequacies of the past so that we will not repeat the same behavior.
The most serious failures of the 1880-1920 environment stemmed from faulty land practices. The structures themselves now suffer from inevitable obsolescence and aging, but many could be brought up to
current acceptance by sustained national prosperity and a steady attention by homeowners and municipalities. In the boom after World War II an extraordinary modernization of American housing went forward, and so it could again. The social and economic consequences of bad land planning, however, confront today's householder and public official with extremely costly and painful choices.
The ugliness of these old areas stems directly from the habitual land crowding of the past and from its use of uniform grid streets and narrow rectangular lots. Yesterday's developer, like today's, sought his profit by putting together a land-house package in which modish ornament and late-model fixtures were combined with a generous house size. The structure conforming so nicely to fashion was the sales item, and the land beneath it was skimped so that the total price could be held down and the lot-house package marketed to as wide a custom as possible. Actually there was much good sense in this strategy. Buyers could easily compare one standardized house with another, and the developer could save little on his houses by alternative designs or by cutting comers in construction. On the other hand, much could be gained by the developer who shopped in the metropolitan market for land. Land always ranged widely in price, in accordance with numerous variables, so that the developer who took his profit by marking up the land in the lot-house package rather than by alienating the buyer by radical alterations in the structure enriched himself, while he simultaneously catered to a mass middle-income market.
The consequences of this strategy in private development have been an array of relatively generous structures and pinched and inflexible land divisions. From such practices came the handkerchief front lawns, dark and narrow side yards, garage-lined alleys, solid blocks without parks or playgrounds, and the apartment-walled streets that are common to all our cities. In their day such areas were to achieve aesthetic success through the softening of awkward structures by means of trees planted between sidewalk and street and the visual merging of one tiny lawn with its neighbor. Although each lot might be small, the overall effect of the
block would be the relief of repeated buildings by continuous bands of green. Moreover, land covenants and later zoning ordinances against particular uses were designed to protect the residential grids from the encroachment of commerce and industry by confining these activities to a corner store, strips along the main thoroughfare, or bands on each side of railroad tracks.
Over time such expectations and achievements have been severely eroded by the coming of the automobile and also by the inherent rigidity of the social and economic requirements of the land plan. These grids were not designs for future growth and inevitable change; they were static layouts, and this in a country with a long history of racing urban transformation. Sheer crowding of the streets and yards by automobiles since World War II has destroyed the trees, hedges, and lawns, and since side and rear yards were small (or nonexistent on apartment blocks) cluster parking could not be introduced except by tearing down some houses and apartments. With the coming of the automobile the old residential areas of American cities have irrevocably lost their earlier pleasant qualities.
Such crowded and unwalled land presupposed adequate incomes and a neighborhood consensus for the private maintenance of what were in function the public amenities of the block. Children had continually to be restrained; lawns, hedges, and trees tended and replanted; janitors, tenants, and homeowners had to be fussy about trash; home businesses and car repairs had to be excluded; and the city had to be vigilant in its cleaning, policing, and planting if the fragile green strips were to be preserved. Declining incomes of old people, lowered wealth of successors to the first settlers, crowding by the poor, small businesses, multiple occupancy, multiplication of automobiles, loss of political status at City Hall, and impoverishment of municipal governments made such a demanding neighborhood performance impossible of perpetuation. High walls and enclosed gardens and courtyards in the European manner would have enabled American residential neighborhoods to be used more comfortably by people of varying incomes and ways of life, but to modernize our inherited gray areas in such patterns and also to make room for automobiles would require a heavy investment, to say nothing of tearing down structures to make parking places. All in all, such modernization will demand an investment in landscape construction which far exceeds that allotted to our common open urban and suburban styles.
Residential areas are not alone in suffering from the real-estate practices of the past. The developer's goal of selling every last lot meant that commercial and industrial strips were cut up and filled without regard for a reserve of space needed for the future. Today narrow strips of stores laid out to serve pedestrian and streetcar traffic cannot be readily adapted to automobile traffic. No land was set aside for commercial and industrial expansion, so that firms that prosper in old sections of the metropolis must move, much to the detriment of the local economy, to find adequate space. The inner city and gray areas thus become, by a kind of anti-Darwinian selection, the sites of the old-fashioned and least successful enterprises.
Finally, the new environment of 1880-1920 was more a machine for social mobility than a model for urban communities. The sociability of Americans, especially housewives and their children, did create friendly neighborhoods within the ever-expanding grids of streets and houses, but these important interactions took place despite, not because of, the land plans. The shopping strips, scattered churches and schools, and grid streets did not focus the paths of neighboring and daily errands in a way that made it possible for groups of people living within the same few blocks to know or recognize each other. This absence of widespread acquaintanceship caused by disparate daily paths has hindered the informal policing of old urban and suburban neighborhoods. Such sociability networks as did establish themselves were hardly a match for the contrary impulsion toward anonymity which American mobility patterns foster. We use housing as an expression of family status and affluence, to move out when we move up, or to shift houses in a restless search for better jobs. The inevitable consequence of these habits has been very high levels of neighborhood turnover, with all the social stresses and threats to stable property maintenance and values that such behavior entails.
The instability of residential property, the customary failure of builders to lay out or maintain a gardenlike neighborhood, and the universal lack of community solidarity led some wealthy nineteenth- and twentieth-century Americans to experiment with communities planned to overcome these failings and to protect suburbs from the usual processes of urban growth. The earliest experiment, Llewellyn Park, New Jersey (1853-69), had a single-gated entrance which opened to a sinuous ribbon of streets laid out along the contours of a hilly site. Four hundred acres were subdivided into one-acre sites abutting an interior fifty-acre park. The park was to be controlled and maintained by the homeowners as common land. Thus the enjoyment of a country gentleman's park in the then-popular romantic style became possible for several hundred families, each of whom was responsible individually for the upkeep of only one acre. A similar design for sixteen hundred acres in suburban Chicago was laid out by New York City's Central Park designers, Frederick L. Olmsted and Calvert Vaux, in 1868-69. Here an entire residential community was contemplated. The commuters' railroad station and the town stores served as the community center, while curved streets sunk below the grade of the house lots, reserved parkland, and subtle alterations in the Des Plaines River created the garden effect. In this case the subdivision—Riverside, Illinois—constituted a single political unit, so that the regular political machinery of local government could be employed for the maintenance of public spaces and for the policing of the subsequent development of the town.
The enthusiasm for golf, which seized the rich in the late 1880s, offered new devices for community planning of wealthy subdivisions. The golf club with its expensive lawns and plantings could serve as a park in its own right and also as a barrier to later encroachment by smaller houses and apartments. It could in addition serve as a powerful mechanism for controlling the social unity of the area, and with such merits the golf club became the most widespread tool of suburban community design in the American metropolis. Its failings of course lay in the substitution of private club for public community and in the extreme class, race, and ethnic segregation it inevitably imposed.
The largest and most successful of all these upper-income residential communities has been the Country Club District of Kansas City, begun in 1905. One firm has since continued to develop a succession of subdivisions that fan out from the axes of two main streets that join at a shopping center. An extensive list of covenants between the developer and the purchaser including for many years covenants against black purchase—and active homeowners' associations have been used to control the siting of the houses and the type of structure built and to maintain the public services of the streets and district.
In 1911 the Russell Sage Foundation attempted to demonstrate in its Forest Hills, Long Island, project that these examples of design of suburban communities for the wealthy could be adapted for middle-income housing. The experiment, taking place within the municipal boundaries of New York City, attracted a great deal of attention and was a considerable success in the field of design, but it also conclusively proved that the conventional subdivision was more profitable. The lesson Forest Hills taught the infant city-planning profession was that the community planning features of curvilinear streets, cul-de-sacs, playgrounds, parks, and unified shopping centers would be adopted by subdividers only if local government regulations required them. This lesson has been well learned, and much of the superiority of post-1920 suburban subdivisions over their predecessors comes from the imposition of such rules for land platting by professional planners employed by the local governments of the American metropolis.
In particular the neighborhood unit scheme, derived from nineteenth-century planned community experiments and advocated by Russell Sage Foundation executive Clarence Perry, proved a flexible device. The neighborhood unit idea, modeled in part at Forest Hills, was an institutional and traffic design program for promoting the social organization of new suburbs. Each neighborhood was to be defined by one primary school, situated in a central park. The borders of the neighborhood were to be set off by main traffic arteries. In this way only neighborhood-serving and local residents' traffic would move through the area, while
the schoolchildren and their after-school play would bring resident families into contact with one another. Service stores were to be so placed as to make for social unification, and the daily round of errands would also promote acquaintanceship. In varying modifications the neighborhood-unit idea for suburban planning has been promoted by professional planners and widely adopted in middle-class subdivisions across the nation.
Gans's study of Levittown, New Jersey, demonstrates that school, street, and errand planning do not make communitarians out of America's nuclear and highly mobile families, but such designs do reduce traffic accidents and provide an informal atmosphere in which to raise children. Only in cases where subdivisions of limited class range have coincided with local political boundaries do strong suburban communities seem to develop in the metropolis. In such cases the positive effects of the promotion of public facilities, high levels of maintenance, and innovative municipal services manifest themselves, but so also do the negative effects of racial and class exclusiveness. For the preponderance of Americans, neither the old grids nor the community-planning experiments of the nineteenth century seem to create an adequate urban environment—an environment able to roll with the social impacts of a rapid rate of urban development and at the same time to fill the gap between family isolation and the goal of an open democratic community life.
If the environment of 1880-1920 is the physical inheritance of our cities, it was the medical responses of that same era that fashioned the basic set of institutions established to protect the health of our urban populations. The staying power and rigidity of this legacy derives from its extraordinary successes in its own time. Armed with new scientific discoveries and techniques, these medical institutions scored an undreamed-of victory over the epidemic and mortality crises of the nineteenth-century city. Simultaneously doctors, hospitals, dispensaries, and public-health units offered a broad range of acute-care services which met many of the day-to-day needs of the upper two-thirds of the population. Such remarkable accomplishments so raised the status and popularity of doctors and their institutions that not until our own time have the shortcomings of these arrangements from the past come under scrutiny. Yet today's problems were also those of the years of first
triumph: a badly skewed delivery of health-care services that favored city dwellers, whites, men, and the well-to-do; an arrested environmentalism that neglected nutrition, housing, community, family life, and preventive care; narrow specialization and bureaucratization which de-humanized the patient; an overemphasis on drugs, surgery, and advanced instrumentation which drew scarce resources from the essential, if less heroic, long-term physical and mental therapies; a general self-satisfaction on the part of the medical fraternity which isolated it from a range of overlapping professions in education, engineering, planning, and social science.
The sustained contagious-disease and mortality crises of giant nineteenth-century cities manifested themselves most ominously in the old environment, the quarters of the poor untouched by or only partially improved by the new patterns of city building or the new sanitary services of the 1880-1920 metropolis. Here society had proved unwilling or unable to extend its environmental remedies, but fortunately the nation was spared the endless recurrence of the ancient disabilities of great cities because the discoveries of medical science were able to deal with a select list of disease and thereby reach out to protect almost the entire urban population. In addition, such was the new wealth of these cities that the adequate-income majority was able to purchase a greatly enlarged range of services for its routine health care.
In the 1820s, at the onset of rapid urbanization, American cities were virtually defenseless against both epidemics and the normal incidence of disease. The art of medicine could do little but set bones, amputate limbs, pull teeth, vaccinate against smallpox, and assist births. The few drugs doctors prescribed were unspecific and often given in debilitating dosages. Worse still, the contemporary custom of drawing blood and purging bowels was actually injurious to the ill. In these early nineteenth-century years the best medical care consisted of commonsensical home nursing by relatives and the family physician so that nature's own cures could most effectively take place. For the ordinary citizen the comfort of one's own family and the attendance of the solo practitioner were the normal recourse in times of accident or sickness.
For those outside the ministrations of family comfort, the largest
cities like Philadelphia, New York, and Boston had established hospitals open to migrants, sailors, the old, mentally ill, and the sick poor. Despite good intentions, extreme class segregation inevitably undermined these institutions. As custodians of outsiders and castoffs, these early hospitals fell far short of contemporary home standards. Except in the few hospitals staffed by Catholic orders, nurses were those with the lowest status and little opportunity for other employment and were sometimes even superannuated prostitutes and former felons. Only when the middle class itself experienced hospital conditions, as thousands did as soldiers and volunteer nurses during the Civil War, did the importance of hospital nursing impress itself on the consciousness of the mainstream of the society. Hospital funds were always short, rooms overcrowded, bedding dirty; in the absence of special operating rooms and anesthesia, the screams of the patients echoed through the wards. Under such conditions, alcohol, then a major hospital remedy, was perhaps the most humane prescription. In the early nineteenth century, hospitals deserved their popular reputation as places where shiploads of sick immigrants were dumped, and where the poor and the unfortunate went to die.
A more successful institution of these early years was the dispensary, a neighborhood clinic where medicines and advice were given to poor patients. Since dispensaries held no resident patients, they escaped some of the effects of ward contagion. They were cheap to run, and they also enjoyed a measure of public support as the one medical institution that could help the city in its continuing struggle against smallpox. The common council of New York, for instance, frequently voted funds to the dispensaries for immunization, but popular distrust of vaccination limited their effectiveness. Though charities, the dispensaries rose above some of the worst degradation of philanthropy because the needs of the medical profession elevated the quality of their services. There were few medical schools in those days and even less clinical supervision, so that ambitious young doctors who wanted to extend their apprenticeship sought dispensary positions much as today they seek hospital residencies. With such diverse roots of support, city dispensaries multiplied during the years before the Civil War; New York's first dispensary opened in 1791, and by 1866 there were ten.
Altogether, family nursing, the private practitioner, the hospital
and the dispensary were but a tenuous defense against accident and disease. Today the national death rate stands at about 9.5 per thousand inhabitants; in 1900 it was 17.2; in New York prior to the Civil War, so far as records tell, it fluctuated between 26.1 and 40.7. Infants and children dwelt in greatest jeopardy, suffering about two-thirds of each year's deaths. Yet public concern did not then, nor did it earlier, focus on childbirth and child care, or even on the major day-to-day causes of adult death and morbidity:' tuberculosis, typhoid, and dysentery. The public accepted these diseases as the hazards of life itself, though statistics seem to show that in the nineteenth-century urban environment such dangers to life increased with city size. Rather it was the dramatic summer incursions of epidemics of yellow fever, Asiatic cholera, and to a lesser extent typhus (a disease the well-to-do could ignore as the special providence of poverty-stricken immigrants) that mobilized public opinion. These epidemics called forth the nation's earliest environmental public-health programs: quarantines, emergency and immigrant pesthouses, disinfection of the rooms and houses of the stricken, and attacks on nuisances and filth.
Although the causes of the epidemics were unknown at the time, European sanitarians had conclusively shown (and American investigators confirmed) that overcrowding and bad sanitary conditions were correlated with a high incidence of such cases. Landmark studies were Lemuel Shattuck's Census of Boston (1845) and his Report of a General Plan for the Promotion of Public and Personal Health (1850), John H. Griscom's The Sanitary Conditions of the Laboring Population of New York (1845), and the American Medical Association's multi-city investigations of 1849. The net effect of these measures and of the water and sanitary constructions which accompanied them seems to have been to stem the potential for an ever-rising death rate, which unattended urban growth would have unleashed. Until the new medical science arrived high mortality could not be turned back, but the early environmentalists did at least succeed in holding the half-dozen largest cities of 250,000 to 2,000,000 inhabitants to levels of safety commensurate with those of less than 100,000.
The rapid succession of medical discoveries which began to accelerate after 1870 led to a proliferation of medical institutions whose innovative services were as important to urban living as the sanitary engineering of the former big-city era had been. The discoveries of bacteriology made possible the specific identification of an impressive list of common diseases like pneumonia, typhoid, tetanus, dysentery, whooping cough, tuberculosis, and numerous wound infections. Parallel discoveries in chemistry, pathology, and endocrinology allowed the effective intervention by doctors in a considerable number of both children's and adults' illnesses. Thanks to the new science, by 1900 the profession of medicine was rushing forward from its previous statistical observations and commonsensical nursing toward active intervention both in individual cases and in the urban environment. The new capabilities manifested themselves in traditional and novel forms alike: in the private practice of the single physician, in the totally refashioned institution of the voluntary hospital, in the expanded private and municipal public-health clinics and dispensaries, and in new regulatory programs.
For the majority of urban dwellers, the most obvious gift of the new science appeared in the augmented effectiveness of the neighborhood physician. In 1900, solo practitioners' training and equipment were still quite primitive. Nevertheless those who kept abreast of recent discoveries could carry a few efficacious drugs and vaccines in their black bags, by now knew enough pharmacology to avoid the destructive dosages of unspecific drugs, owned a small table-top laboratory where they could perform a few simple urine and blood tests, had a systematic method for examining patients to detect their symptoms, and possessed sufficient knowledge and technique of asepsis to treat minor injuries, deliver babies, and handle contagious disease without endangering their patients.
Furthermore, now that the scientific foundations of medicine had been established beyond cavil, it became possible to standardize the norms of competence and to extinguish the professional conflicts that had raged among believers in various causes of disease and different methods of therapy. The nineteenth-century hodgepodge of quacks and of physicians trained in commercial medical schools as well as in universities was soon placed under strict licensing and educational standards. By 1920, city dwellers who could pay a private doctor's fee could expect
a fair level of competence in the treatment of a considerable list of common diseases and injuries. This new effectiveness, achieved in the lifetime of one generation, raised the status of the family physician to a position of extraordinary popularity. The private practitioner became that legendary figure of healer, father, and family guardian which enabled the medical profession to defend itself against major reform in our own time.
In the late nineteenth and early twentieth centuries a wholly new kind of institution, the voluntary general hospital, served as the social agent of medical progress and the adjuvant, teacher, and disciplinarian of the private city physician. By ceasing to be merely the repository for the unfortunate and becoming instead the home of the new advanced practice and the servant of the middle class, it moved from the periphery to the center of medical care. In the years after the Civil War, everything about the hospital changed. The discovery and perfection of techniques of asepsis made it a reasonably safe place to go for treatment of serious illness or severe accidents. Surgery became reliable and effective. With the growth of science and the shift in hospital clientele, nursing ceased to be the resort of undesirables or a province of religious orders. It matured instead into a suitable lay occupation for those educated middle-class and working-class girls who were seeking independent roles in a society that had formerly offered little outside the factory, shop, school, or home. Finally, the hospital became the center of scientific progress. Only the large hospital could afford the expensive equipment and laboratories required for complicated techniques; only the large hospital could provide the variety of cases essential to research and medical education. These science-based changes in the hospital engendered a new fusion—the union of university medical schools, voluntary general hospitals, medical researchers and specialists, private practitioners, and their middle-class clients.
Such a fusion was a reflection of the social structure and economic power of the industrial metropolis. The fabulous fortunes of the late nineteenth and early twentieth centuries were represented on the governing boards of general hospitals and universities. The urban rich, as yet but minimally taxed for public programs, expressed their enthusiasm for
the new science, and often their gratitude for medical care, by endowing chairs of medicine and furnishing the capital for new universities, new hospitals, and numerous additions to existing facilities. On these boards representatives of wealthy families met with fashionable practitioners and distinguished specialists to determine the broad policies of medical schools, hospitals, and research. Here lay the source and direction of pre-World War I medical capital. The middle-class patient, too, made his contribution. Hospital fees began to be levied for service, and these fees provided a major fraction, or even the entire funding, of the day-to-day operation of the hospital. The working class and the poor, here as in the city at large, were subject to means tests to set the degrees of remission of their charges. Moreover, as charity cases they were subject to crowding, segregation in the wards and outpatient clinics, and a cheapening of service that paralleled their outside lives as residents of the city and as low-income consumers. Nevertheless, analogous to the rising living standards of the industrial metropolis itself, the new general hospital did give the poor access to an unprecedented level of medical care.
The economic formula of the new voluntary hospital, altered by the omission of expensive charity, research, and training by proprietary hospitals but emulated in the best municipal hospitals by the substitution of the city's funds for the wealthy donor, proved so successful that hospitals multiplied at exceptional rates in the late nineteenth and early twentieth centuries. In 1873 there were only 178 hospitals in the United States; by 1909 there were 4,400; by 1918, when the number of non-federal institutions peaked, there were 7,000. A totally unplanned growth, which was the outcome of the potentials of new science and the wealth of industrialization, had produced the social structure of the hospital-based medical profession that has proved to have serious consequences for our own time. In the early years, when research was first lifting the veil of ignorance and when new techniques and new hospital practices constituted such tremendous advances over what had prevailed, the gifts of the rich and the making of decisions by the wealthy and the professional elite seemed natural and beneficent. Yet the failure of the American medical structure to represent either the middle-class or low-income patient in what were in fact public policy decisions has badly distorted our medical undertakings.
Ever more expensive research, ever more elaborate techniques, and
the concentration on surgery at the expense of long-term care for the old were some of the most obvious results of the exclusive representation of wealthy donors and the medical elite. Environmental and preventive measures, chronic diseases, dentistry, the day-to-day rendering of service, and what might be termed throat-stick medicine have been relatively neglected. Moreover, with the rapid advance of science the solo practitioner became more and more closely allied to the hospital because it was the source of personal prestige and advanced knowledge and technique. As a result, neighborhood practice almost disappeared from poor districts, and the working class has come to be dependent upon the accident of location of hospital outpatient facilities. In 1920 the future of increasing medical specialization and the class, racial, and neighborhood consequences of the hospital structure of American medicine were only beginning to be perceived, but the seeds of our current difficulties had been sown.
Not that the industrial metropolis ignored the public-health possibilities of the new science; it pursued them vigorously, constructing the institutional framework and practices that still supplement our practitioners and hospitals. Indeed, the totality of environmental services and health-care institutions succeeded at last in bringing an end to the historic linkage of large cities and death. In New York, despite its gigantic size, and despite some of the most densely crowded wards in the world, the death rate had already by 1900 been brought below its lowest nineteenth-century levels, and it continued to fall in the big cities almost every year thereafter so that in our own time urban and rural death rates have at last converged. But at such a moment we face a familiar historical crisis—the institutions of the past fail to adapt to the needs of the present. As our health concerns have shifted from mortality to morbidity, we begin to experience all the failings of our old health-delivery structure.
The discoveries of bacteriology reinforced the nineteenth-century campaign of urban sanitarians. Water departments introduced filtration and chemical purification in the early years of the twentieth century. The identification of both human and animal tuberculosis bacilli led to the testing of herds and the certification and pasteurization of milk, which
had been a major source of child-killing infections. The precision of modern chemistry, coupled with the new large-scale marketing of meat, food products, and drugs, made it possible for the federal government to augment ineffective municipal market inspections by nationally enforced standards for purity in foods and drugs that moved in interstate commerce. The ability of the new science to explain how vaccination gave immunity even made it possible for cities and states to overcome hoary public prejudice and to institute safe, effective, compulsory smallpox vaccination for schoolchildren. Finally, by shifting the focus of attention in the campaigns to remedy the ills of slum housing, the new science brought the regulatory effort to its peak and logical stopping place.
The "fever nest" slum blocks, with their high incidence of cholera and typhus mapped by the early sanitarians, had spurred the public to establish municipal boards of health and to support their pioneering programs for the removal of nuisances and for cleanup and disinfection. In New York such expert reforms had been given impetus by the frightening experience of the Draft Riots of 1863, and the city enacted the nation's first tenement-house regulation. But when quarantine measures ended the plagues, the working-class and middle-class voters lost their fright and with it their enthusiasm for aggressive public-health measures. Housing reformers were forced to fall back more and more on appeals for public support on the grounds that overcrowding led to drink, crime, and prostitution, rather than urging a community of interest in safety from disease. The threads of moral horror and the community of health have always been intertwined in American housing proposals, and the early twentieth-century tuberculosis and well-baby campaigns did aid housing reform by contributing a set of causes for which there was broad popular experience and sympathy.
As a result of the intensification of the sanitary attack on slum housing, by World War I all of the nation's large cities had modern housing codes specifying permissible room density, ventilation, and sanitation. These laws were an important achievement in ensuring that all future construction would conform to decent minimum standards. But regulation of housing cannot by definition expand the supply of housing, and indeed it tends to raise rents when it is enforced. Also, it offers no
remedy for the common situation where poor tenants and poor landlords meet. Much slum property is owned by slum dwellers, not by rich corporations. Many slum owners scrape their way into a heavily mortgaged landlord status. Neither they nor their tenants welcome the news that costly repairs must be undertaken to bring their old buildings up to modem standards. The nineteenth- and early twentieth-century housing-regulation movement was after all the achievement of sanitary specialists and wealthy philanthropists, both of whom were unwilling to disturb the basic property and income relationships of the society. Therefore however well-meaning, and despite its long-term contributions, the regulatory movement often appeared in poor neighborhoods as an exercise in harassment of the poor, against which petty bribes and aid from the ward boss in inducing inspectors to wink at violations were the best defense. Housing reform shed some of its early philanthropic incubus thereafter, and in the thirties it picked up labor support when it was recast in the form of public construction and appeared as an aid to full employment for building-trades workers.
The wealth of the industrial metropolis and the efficacy of the new science also enabled the cities of the nation to establish a series of institutions that would offer specialized medical services to supplement the basic system of private practitioners and hospitals. Unfortunately for the public welfare, the urban health-delivery system was weakest in low-income areas, as housing regulations also had been, and it was in these areas that the incidence of disease and accidents rose most sharply.
Infants and children of the poor lived in the greatest danger. In the summer of 1893, Dr. Abraham Jacobi and the philanthropist Nathan Straus opened a milk station, where boiled milk and advice on infant care were offered free to mothers of slum children. The immediate success of the project in preventing deadly summer fevers led to imitation and the rapid maturing of municipally managed well-baby clinics. Soon clinics for tuberculosis and venereal disease were added to the public list. The new medicine encouraged the multiplication of dispensaries, both in the old form of the freestanding clinic located in a poor neighborhood and in the new form of the outpatient departments of public and voluntary general hospitals.
By 1920 New York City possessed 228 dispensaries and clinics. There were 60 baby-health stations; 21 tuberculosis clinics; 12 venereal-disease clinics, only two of which offered treatment; 26 municipal single-purpose clinics for treatment of eyes, teeth, rabies infection, and occupational hazards; 34 independent dispensaries; 65 outpatient departments of hospitals; four children's dental clinics in schools; and even six dispensaries for college students. A fourth of New York's eight thousand physicians put in some of their time staffing these institutions, at which approximately 1,250,000 patients were treated annually. Although these statistics of institutional growth, doctor participation, and patient use were impressive when held against the light of the preceding half century, the deficiencies of these supplements to private fee-paying doctor and hospital care had already revealed themselves. They were second-rate charitable supplements and as such were bound to atrophy in a society that honored self-help and responded most positively to fee-paying patients.
The entire list of clinics and dispensaries was not regarded by doctors as a group of institutions on their way to the provision of complete neighborhood care. Instead they were viewed as charities for the improvident and the unfortunate or as a restricted concourse of specialists who would not compete with the private doctor's general practice. The New York dispensary law required that all patients be subjected to a means test to determine medical indigency before treatment, granting exceptions only for a few contagious diseases, notably tuberculosis and venereal disease. Numerous studies were conducted, as in welfare today, to detect cheating by patients who could afford to pay the normal rates. The baby-health stations could administer only to well babies, while sick babies had to be taken to a general practitioner, dispensary, or outpatient department of a hospital. The public acquiesced in these constraints, and the network of supplementary institutions was used by the working class and the poor as their means of access to specialists and to doctors essential in cases of serious accidents or of sicknesses they could not neglect.
The whole charitable nature of these institutions prevented their maturing into adequate general-care centers. The doctors who staffed them were either ill-paid or, in the majority of cases, contributed their services. Dispensary and clinic work carried no prestige; such jobs were
either the doctor's tithe or were sought by young men hoping for an entrée to a regular hospital appointment by way of clinic duty. Although dealing with a public which suffered special hardships from the loss of working hours or days, only 2.5 percent of the total New York clinics' time was scheduled outside the normal business day. Patients had to wait in long lines. There was a shortage of supplementary personnel for the routing of patients, follow-up of cases, handling of records, and the offering of social services. Diagnosis was weak, records fragmentary and often illegible; tests were neglected and treatment haphazard. "Among cases of syphilis studied in only 50 percent was an indication found that the patient had been given the proper treatment," one study reported. Even the outpatient departments of general hospitals, where the latest equipment and laboratories at least existed within the same building, suffered because such facilities were planned and scheduled for resident patients. The outpatient service was the stepchild of the hospital, its trustees, its administrators, and its doctors. All in all, despite its lusty growth from 1870 to 1920, the system of clinic and dispensary was poor man's medicine.
The important public consequences of this charitable incubus lay in the withdrawal of popular support for all kinds of group and socialized medicine. As in the case of public housing, promising reforms directed to the social consequences of the unequal distribution of personal income went unsupported by working-class organizations because of their experience with services which departed from the normal private market form. In medicine the urban dispensary and clinic did not grow into a successful neighborhood or district institution, and the campaigns for health insurance faced opposition or apathy from organized labor. Similarly, the federal government's promising demonstration of non-charity public housing during World War I died as suddenly as it appeared. In both cases small groups of professionals and intellectuals had demonstrated that they had fully mastered the logic of the industrial metropolis's housing and health structures, but many more years of investigations, reports, and social failures would be required before major segments of the public would mobilize for change.
The extreme shortage of housing near war plants and navy yards forced a reluctant federal government into its first venture in civilian public housing. Prior to the war the housing-reform movement had been
102. Row House Yards, South and Iranistan Avenues, Bridgeport, Connecticut, 1919. The U.S. Housing Corporation employed the most advanced land-planning practices of its day. On an expensive 25-acre site, using the smallest two-bedroom units of any project, designers mixed a colonial American building style with contemporary English Garden City site planning to provide these generous garden spaces. National Archives
103. War Workers' Housing, Madison Street, Waterbury, Connecticut, 1919. English cottage version of contemporary suburban styles employed by the federal government in its first public housing venture. These duplexes, pairing five- and six-room units, were erected for skilled brass workers. National Archives
104. War Housing Twenty Years Later, off Lincoln Street, Bath, Maine, 1940. Because the sites were well planned and the architecture met the local consensus about what constituted decent housing, the U.S. Housing Corporation's work remained popular and aged well. Library of Congress
105. Country Club Plaza, Kansas City, ca. 1930. Since 1905 the J. C. Nichols Company has been managing the nation's only continuously planned residential development. The basic strategy has been to follow the city's growth by subdividing land in an ever-widening triangle. Houses and lots are sold, but the company keeps the shopping centers it builds. This is the first (1923), at the intown apex of the development triangle. Nearby apartments helped to get the shopping center started. J. C. Nichols Company
106. Grand Drive from 53rd Terrace, Country Club District, Kansas City, ca. 1914. Following contemporary examples of other upper-middle-class suburbs, especially Roland Park, Baltimore, the company gave special attention to site preparation and landscaping. Small parks, winding streets, and generous plantings are its hallmarks. With each subdivision Homes Associations are formed to maintain the local common grounds. J. C. Nichols Company
107. Belinder Avenue, Country Club District, Kansas City, 1963. Uniform setbacks of the houses, careful plantings and maintenance produce the epitome of the American residential street. Photograph taken twenty-five years after first development. J. C Nichols Company
108. Parking Garage, 47th Street, Country Club Plaza, Kansas City, ca. 1948. By keeping title to the shopping centers the developers can control and
finance continuous modernization. Here a former parking lot was converted into a free parking structure for 400 cars. In contrast to the pains of urban renewal, the Country Club Plaza stands as a convincing argument for municipal ownership and management of the commercial and industrial land of the metropolis. J. C. Nichols Company
109. Homestead Country Club, Country Club District, Kansas City, 1954. Since full-amenity development to high standards can only be profitable for middle-to-upper-income families, the entire Country Club District is a city planning triumph but a social disaster for Kansas City. Only public financing and control of land and housing development could have prevented the inevitable side effects of class and racial segregation. J. C. Nichols Company
110. Public Housing, Holyoke, Massachusetts, 1941. Controls against giving too much to the poor reduced New Deal housing to levels below that of the World War I projects, thereby ensuring that the gap between the rewarded poor and the middle class would widen disastrously once the Depression ended. Nevertheless, in small cities across the nation where land costs were low and projects not too large, substantial gains were made over local slum conditions. Compare these new two-story row-house apartments to the four-story wooden tenements in the background. Library of Congress
111. Subsistence Homesteads, El Monte, Los Angeles, 1936. A Resettlement Administration demonstration project of farm homes for clerks and industrial workers employed in the city. The three-quarter-acre lots and locally designed five-room houses successfully captured a broad popular demand. Two thousand families applied initially for the planned 140 units. Houses were ultimately sold to their occupants without loss to the government because the project was sensibly located along one axis of metropolitan growth. Library of Congress
112. Ida B. Wells Housing Project, Pershing Road and Martin Luther King Drive, Chicago, 1942. Typical New Deal big-city federal housing project—barracks for 1,655 black families. White antipathy to public housing outside the established ghetto forced enlargement of the project in 1955 and 1961 so that it is now an all-black philanthropic city of 12,000 inhabitants. Library of Congress
113. Lakeview Terrace, Whiskey Island, Cleveland, ca. 1936. Local housing authorities, unwilling and unable to see housing as an opportunity to let the poor move to modern neighborhoods and closer to the growing sectors of the metropolitan economy, frequently repackaged the poor in old slum sites. Here, 620 families were settled in an industrially impacted neighborhood. Subsequently an interstate highway has further blighted one edge of the project. Urban Archives, Temple University
114. Lafayette Park, Detroit, ca. 1962. A 164-acre urban-renewal project one mile east of the downtown. Conceived first in 1949 as a public housing program, it was redesigned when urban-renewal legislation offered a tax-hungry city the opportunity to clear land and build for the wealthy. Low-income property on the site was leveled without adequate relocation measures and luxury row houses and apartment towers were built. Completed 1971. U.S. Department of Housing and Urban Development
115. Prefabricated Housing Experiment, Akron, Ohio, 1971. Mistaking a social and economic problem for a technological one, the U.S. Department of Housing and Urban Development recently launched a high-publicity program for factory-made homes. Scarcity and costs of well-prepared land, class and racial segregation, and the financing of adequate social and educational services to housing, not the structures themselves, have been the real problem. U.S. Department of Housing and Urban Development
116. Scattered-Site Public Housing, Mount Clemens, Michigan, ca. 1964. Occasionally public housing meets the popular norms for decent living. Here 160 units for blacks, whites, and the elderly were mixed within a small metropolitan satellite city's urban-renewal program. Eight sites were scattered over 485 acres so as not to disturb the existing neighborhood fabric. Tenants paint their own apartments and keep up their own lawns and gardens. Problems so far: kitchens too small, not enough closet space! U.S. Department of Housing and Urban Development
fully occupied with building regulations, the brand-new controls of zoning, and experiments with philanthropic and limited-dividend model-tenement housing. Continental and British examples had begun to attract attention in advanced professional circles, and Massachusetts had tried a small experiment, but to most Americans governmental construction of houses seemed to represent a dangerous step toward socialism and a direct threat to the genius of the Republic. Despite successive reports of an inability to attract and hold skilled workers without the provision of some decent accommodation for their families, Congress delayed authorization of public war housing. The fact that such an undertaking resembled German socialism more than anything else made it doubly unpalatable to Congress. Yet skilled workers would not tolerate for long the boardinghouses, barracks, and made-over garages that unskilled men and women accepted. Therefore, five months before the Armistice, a public-housing program for skilled workers was at last authorized, subject to the strict condition that all housing so built be sold to private persons at the war's end. Two federal agencies, the Emergency Fleet Corporation and the U.S. Housing Corporation, undertook the rush task and together they built or subsidized the construction of more than fifteen thousand dwelling units at seventy-nine project sites across the country.
The final report of Frederick Law Olmsted, Jr., planner of Forest Hills and manager of the Town Planning Division of the U.S. Housing Corporation, is of exceptional interest because it demonstrates that professionals had early thoroughly understood the mechanisms and limitations of the private housing market and the remedies needed to maximize the social benefits of private construction. The report also shows that the U.S. Housing Corporation had demonstrated how a model public-housing program should be managed if the government should ever have wished to move beyond the limitations of the private market.
First, the summary report recognized the basic trickle-down nature of American housing. New housing is built for the middle class and the upper levels of the working class, and all others inherit what is vacated by these. Thus the quality of housing in a given city depends directly upon its quantity. If there is a shortage of housing, Olmsted stated, then those least able to pay rents must double up and occupy unfit structures,
and the immediate result is "slum conditions unfavorable to that self-respecting family life upon which the security of our democracy rests."
Second, he recognized local housing conditions to be a national and not a local problem, because of the crucial role played by the national flows of mortgage capital. Thus during the years from 1914 to 1918 rising building costs and more lucrative opportunities for investment elsewhere had driven capital away from new construction, so that a housing shortage existed even prior to our entry into the war in 1917. As a permanent remedy for the inevitable periodic shortage of money for home construction, Olmsted recommended federal intervention in the capital-supply market along the lines that had recently been followed by the 1916 Farm Loan Act. Under this program the government lent money to local cooperative banks, and they in turn extended cheap long-term mortgages to farmers. In 1933, with the crisis of the Great Depression, the Home Owners Loan Corporation was created exactly along such lines. This act, plus subsequent New Deal additions, established the basic American housing strategy: to encourage the private trickle-down housing market through government intervention and government support for the supply of mortgage funds.
Olmsted noted that the U.S. Housing Corporation had "dealt but little with the more difficult problem of satisfactory and economical housing for the families of unskilled and relatively low paid workers." Yet looking back on the pioneering work of this agency and assessing its accomplishment in the light of America's subsequent public-housing disasters, one can appreciate these World War I construction projects as model programs that defined the basic conditions under which any successful public-housing policy must proceed. The essence of the corporation's work lay in its adoption of a contemporary consensus for standard new housing. In designing for skilled workers who were engaged in a common patriotic enterprise, the corporation's program was not obliged to lower its standards to a level below that of private housing. It did not have to avoid offending the sensibilities of private tenants and homeowners by offering less than the equivalent housing to its recipients of public welfare. On the contrary, the central office in Washington set normal prevailing standards, called together mixed planning and archi-
tectural teams, and turned them loose to do as good a job as they could. The result varied from the ordinary to the excellent. Many projects used the latest traffic, curvilinear-street, park-reservation, and community-center devices of the best English Garden City and wealthy American garden-suburb practice. Taste was not regimented. There were Colonial and Tudor houses in the East, stone houses in Ohio, Spanish stucco in California, and neat wooden bungalows in the state of Washington. Moreover by a strong emphasis on site planning these projects enjoyed the lasting advantage of having their utilities, streets, and services finished and located in a way that would enhance the long-term use and maintenance of the homes, instead of leaving newcomers stranded and struggling for city services, as had so often happened in low-cost outlying private developments and would occur later in public housing.
When the federal government did finally enter on public housing during the New Deal, it violated (except in its three controversial Greenbelt towns) the basic World War I conditions of success. Instead of building to the standard of middle-class private consensus it built second-class philanthropic housing. By so doing it drove off local architectural and planning talent, erected obsolete structures that would have to be lived in for fifty years, and stigmatized the beneficiaries as second-class citizens.
The health-insurance reformers of the pre-World War I era also displayed a competent perception of the shortcomings of the existing medical structure. The remedies they proposed, like those of the U.S. Housing Corporation group, were essentially conservative—designed to use government to make the private system more effective, not to institute a novel public organization. The health-insurance movement began in Europe and was carried to America by intellectuals, and accordingly it was never a campaign of the medical practitioners. It commenced with a concern for the maintenance of income for injured workers' families, and then as it gained momentum it moved on to proposals for insurance against everyday medical expenses. As the campaign progressed from legal and industrial reform to contact with medical practitioners and conflict with private insurance companies, it encountered a paranoid counterattack which defended the recently developed institutional struc-
ture of medicine as if it were the last bastion of American free enterprise and the most sacred of the nation's ancient traditions.
The first phase of reform, employers' liability laws and workmen's compensation insurance, advanced smoothly because it proved itself able to gather adherents from all the concerned parties successively—reformers, labor unions, industrialists, and insurance carriers. Under the old common law, each individual worker had been held to have assumed the risks of accident and disease inherent in his occupation. If he suffered injury or disability in the course of his employment, he had to pay his own expenses or else initiate a lawsuit to prove not only that he was without fault but that his employer had in fact been negligent in the operation of his business. The expense of these suits, the callousness of the age, and the imbalance of power between worker-plaintiff and boss-defendant made such a recourse uncertain and the awards niggardly.
Yet the accident and disease rates in such large industries as textiles, steel, glass, mining, chemicals, and railroads added scandalously to the local relief rolls. In 1885 Alabama enacted an employer liability law making manufacturers responsible for their employees' injuries. Other states followed, and they simultaneously established numerous commissions to investigate European schemes for insuring workers' wages against days lost because of occupation-related disease and injury. These studies uncovered a mutuality of private interest. Manufacturers, by devoting increased attention to guards on machinery, the handling of materials, dust control, and prevailing shop conditions, could increase the productivity of their crews. The incidence of accidents and disease proved calculable, and it was found that insurance companies could write policies at reasonable rates and workers could benefit by an administered schedule of payments for lost wages, injuries, dismemberment, and even death. Maryland passed the first workmen's compensation law in 1902, and by 1920 forty-two states had followed. Though a highly successful advance, workmen's compensation always suffered from the weaknesses of its original consensus. As an insurance program it never covered all workers and, since employer and carriers both had an interest in low and stable payments, compensation schedules in America have recompensed workers for only a small fraction of their real costs. Although provisions for medical charges were added to the original wage-based cash benefits, the restriction of the program to work-related health problems seems to have prevented practitioners from
perceiving this insurance scheme as a threat to private doctor-patient relationships. Hospitals did, however, receive direct payments from insurance companies for treatment of accident cases, and this innovation seems to have softened hospital administrators toward insurance schemes in general.
Again it was Europe that pioneered in payments for sickness and accidents not related to the job. Here the issue concerned income maintenance for workers' families when the wage earner could not work, payments for medical care, and funeral expenses. As early as 1883 Germany had begun contributory employer-employee local insurance funds, and in subsequent years the number of industries to undertake such coverage was steadily expanded. Great Britain followed a parallel course in enacting in 1911 a National Insurance Act, which established compulsory unemployment and health insurance. Workers were to receive some measure of protection against the inevitable occurrence of periodic unemployment as well as some assistance to defray the costs of health maintenance. A special feature of the British scheme was its accommodation of existing benefit associations and insurance companies. The government promulgated a list of approved insurance societies, and these were to receive the joint payments of workers, employers, and the government. Local boards of doctors, insurance representatives, and government officials were to oversee the payments.
Reformers in the United States were primarily academicians organized in the American Association for Labor Legislation. In 1914 the Association reported on its studies of European precedents and opened a campaign for medical insurance at the federal and state levels. The Association did not contemplate total unemployment compensation. The reformers hoped to insure industrial workers against the expenses of childbirth, accidents, sickness, and funerals so that the working class could become full-paying patients of the private medical-care system. As in Great Britain, government, employer, and employee would all contribute to funding the compulsory insurance pools. The AALL report also allowed self-employed persons not covered by the legislation to join such programs on a voluntary basis. Either state or private insurance carriers were envisaged as insurers, and the schedule of payments was to
be administered by employer-employee boards supervised by the government. The report also expressed the hope that such an insurance scheme would encourage physical examinations, early diagnosis, and such general preventive health practices as well as finance the care of acute illness.
From 1916 to 1920, bills for federal investigation of health insurance and bills for state programs were put forward. The American Hospital Association and the three nursing associations reviewed the question and issued reports calling such a step inevitable and urging hospital administrators to be sure that the scheduled fees were adequate even as they prepared for increased case loads. The National Association of Manufacturers, pleased with its workmen's compensation experience and safety-first campaigns and impressed by German business practice, expressed itself at first as favorable and then moved to a position of supporting private insurance only. Organized labor offered weak support at best along with some opposition, with the A F of L executive committee unable to agree on a position. President Samuel Gompers testified before Congress that such schemes would lead to federal spying on the homes of workingmen. The treasurer and a vice-president of the same union testified in favor, as did the railroad conductors. The poor quality of medical service offered by practitioners working for British insurance funds there created unfavorable publicity, but the medical insurance campaign here did not in any case call for group practice or any other alteration in the delivery of medical care. The low quality of American clinic practice may also have entered the minds of union leaders, since one of their major goals at the time was to achieve full equality of status for the American workingman.
But the violent opposition came from a coalition of private insurance companies and doctors. One insurance executive campaigned full-time against the legislation. Once again the war inflated the specter of German socialism. "When compulsory health insurance enters the United States, Socialism will have its feet upon the throat of the Nation," he said. In 1917, private insurance companies had written industrial policies covering in some way 37,500,000 workers. Conservative doctors in the American Medical Association repudiated the early stand of its leadership in favor of insurance and in a fit of wartime xenophobia voted the "do-gooders" out of office. Everywhere the state
bills were defeated and the isolated reform intellectuals faced heated doctor, insurance and even Christian Science opposition.
The turning back of medical insurance proved more than a temporary setback for an idea whose time had not yet come. The campaign took place during the wave of reaction that swept the country during and immediately after World War I. In this climate the American Medical Association, an institution that had begun its organized life with an advanced survey of urban slum conditions, confused the conservative reform of insurance with public medicine and nailed itself to an intransigent defense of the institutional system of American medicine as it obtained in 1920. The Association's permanent resolution on state medicine, one just recently modified, forbade support of government programs of any kind except those already in existence for charity, mental health, communicable diseases, and military care. This legacy from the years of the first half century of rapid progress has cost the nation dear, the rural areas even more than the cities. It has cost the public and doctors alike. For years large numbers of American citizens have been denied access to decent medical services, and the medical profession itself has been denied the adjustments and steady evolution that would have attended the public insurance reforms. Instead of medical problems, our cities now face a medical crisis.
The Neglect of Everyday Life
Pouring new money into old institutions; housing and health care
The History of Urban Housing and health since 1920 is a history of both arrested development and rapid growth. Our twentieth-century campaigns for social justice have failed to redress the inequalities characteristic of the industrial metropolis. Yet despite this social and political lag the city itself has continued to grow and to change with the unfolding of the national economy so that in our own time it confronts a twofold crisis. On the one hand we continue to struggle with the old issues of sufficient diet, decent housing, adequate medical care, and a safe environment for the lowest third of our citizenry, while at the same time new demands, called forth by the conflicts and expectations of a high standard of living, bureaucratic work, government services, and suburban living, pour in upon the city. The new metropolises and megalopolises of the post-1920 era are both the weary settlements of unanswered poverty and the conflict-ridden arenas of mass luxury and privilege.
The full reasons for the arrested development of housing, health, and other American social programs demand sustained political analysis for explication, but two obvious trends suffice to frame the past half century. First, the late development of the labor movement, legitimized only in the mid-thirties, and the consequent failure of the labor and urban reform movements to coalesce have contributed to the heavy middle-class bias of our urban programs and weakened all attempts to
serve the lowest third of the population. Second, the preoccupation of the nation and its leaders with great national crises, first the Great Depression and then a continuing series of hot and cold wars since 1941, has distracted the nation's talent, energy, and wealth from the tasks of building a humane and just urban society at home. In the last three decades we have systematically neglected the needs of everyday life for a national career of war and imperialism.
Although we had wealth enough for full employment and a living wage for all able-bodied citizens, although we had plentiful resources for the world's most ambitious public-housing program, although we had educational and research institutions aplenty to seek new drugs and therapies while also manning a full complement of institutions for acute, chronic, and preventive care, we did not do any of these things. All our social programs that touch urban life have been tentative, held to experimental levels for long periods, and when finally adopted as permanent national programs they have been underfunded and extended only to a small fraction of the population they ought to serve.
A brief list of the angry groups in today's television news recalls the dual nature of the urban crisis: blacks, working-class whites, middle-class women, soldiers, students, and suburban homeowners. If there were but a single environment with a single set of problems, the energy behind the grievances of these groups would long ago have transformed the politics and programs of the nation. But blacks and many working-class white families suffer the old failure of the city to deal with racism, full employment, adequate wages, and decent housing and health care, while the women, soldiers, students, and homeowners suffer from the new failure of the society to deliver on the promises of its wealth and freedom.
The present generation of Americans thus confronts a double burden—it must solve the old job, food, health, and shelter problems while simultaneously addressing itself to the conflicts and potentials of an extremely wealthy, bureaucratic, mechanized society. This arduous task compounds so many ingredients. White racism, mass middle-class privilege, and elite class power are milled together with the interdependencies of a high-energy, high-technology, thoroughly urbanized society. If the task is vigorously undertaken, the society should be able to catch up with itself by ending the old injustices and should also be able to keep pace with the ever-unfolding sets of problems and possibilities that urban and economic growth will bring. At the very least our present
situation is much improved over that of 1920: the nation is now much wealthier, and we have the benefit of knowing what remedies to take because we can learn from the experience of the partial programs undertaken during the past half-century. The most severe test now, as always, is the question whether the public and its leaders are willing to shoulder the burden of ending the failings and injustices of the system.
In terms of housing the United States already operates a sufficient range of public programs to redress the grievances of the bottom third of the urban population while simultaneously adapting to the new possibilities and demands of the more prosperous two-thirds. Together, the major housing and planning devices of insured mortgages, subsidized public housing, and urban renewal could transform our cities. For the past thirty-five years, however, underfunding, narrowly circumscribed and antisocial goals, and plain bad administration have prevented this set of tools from relieving our metropolitan-wide housing crises. Indeed, rather than aiding the modernization of our cities and enlarging the inclusiveness of our society, these programs directly interfere with wholesome metropolitan growth and pile governmental injustices upon the heap of private prejudice and exploitation.
The most successful and largest of all the public measures has been the national mortgage-insurance program. Born of the banking crisis of the Great Depression, the Federal Housing Administration's mortgage insurance quickly assumed a major role in helping marginal buyers to homeownership because it fitted in so neatly with the existing organizations of private moneylending, construction, and sales. Since its first full elaboration in the late thirties, FHA mortgages have covered about a fifth of all the privately owned nonfarm housing units of the nation. During World War II and the recent money shortage the federally insured fraction rose to 45 percent and 35 percent respectively.
The circumstances surrounding these programs' origins determined their subsequent history. In 1925 the post—World War I housing boom began to slacken as private capital took flight from mortgages to seek higher returns elsewhere. As a result the costs of housing rose and the number of building starts declined steadily as more and more thousands of American families on the margin of home purchase were squeezed out of the market. The financial collapse of 1929 then delivered a final blow to an already weakened building industry. National banks and trust companies emptied their mortgage portfolios to cover depositors' runs on cash accounts. Savings banks and building and loan associa-
tions, institutions which specialized in home mortgages and which lent money for long terms, typically for fifteen years, found themselves in deep trouble. The savings and loans, however, possessed important political assets. They could and did pose in Washington as innocent local small businessmen, the friends, neighbors, and servants of hard-pressed homeowners, and thereby received prompt and sympathetic action from the national government. In 1932 the Home Loan Bank Act stemmed part of the banking crisis by establishing twelve regional banks for the purpose of lending money to the 12,000 savings and loan associations across the country, thereby preserving the assets of their twelve million depositors and saving the 7,700,000 mortgages on which they had made loans.
Yet the financial collapse was so deep that during 1932 and 1933 mortgage foreclosures continued unabated, reaching a peak of a thousand a day. This prolonged crisis made irresistible the pleas for an extension of aid to all banks rather than to just savings and loan companies. At the same time the extreme pressures of unrelenting unemployment (half to two-thirds of the unemployed males were workers in construction and related building-materials industries) fused in official government thinking the plight of homeowners, bankers, and the unemployed. This fusion brought forth the New Deal housing program—mortgage insurance to aid the banker and the homeowner and federally subsidized construction of public housing to increase building trades' employment. A set of remedies addressed to national economic problems, these measures have powerfully affected the growth of American cities ever since.
First as a bankers' program, the giant FHA loan system had a decidedly conservative charge: it was to concern itself with investments which were economically sound by the current tests of the private market. It was thereby to limit its social reform to aiding the lower middle class and upper working classes in their attempts to borrow money for homeownership or to aid that large segment of the population by guaranteeing the mortgages of builders of apartments and rental units in an appropriate range of rents. Though the total volume of FHA activity had tremendous and enduring impact upon the American city, most particularly by hastening the flight of the white middle class from the central city, open and formal concern for social reform was shunted
to other departments of government. The New Deal generally, and the FHA in particular, fully accepted the racial practices of the private society. The FHA always stayed away from the inner city and gray areas and it even connived with fire insurance companies in their refusal to insure housing in black slums. Far from leading, it tagged behind in racial change. Thus it was not until a year after the Supreme Court decree of 1948 declaring racial covenants on land unenforceable that regulations were promulgated forbidding the issuance of new insured mortgages on such property. Only on November 20, 1962, did a reluctant Kennedy administration issue Executive Order 11063 directing all departments of government to take affirmative action against racial discrimination. For the mortgage market this order meant a timid enforcement of a FHA prohibition against new mortgage money for segregated housing developments.
Extreme caution has also marked the standard-setting functions of the agency. As a partner of private bankers, the FHA has not conceived its role to be that of the protector of the mass of mortgage borrowers, and it has therefore never pressed the consumer's interest in lowering fees for title searches, extra bank charges, and lawyers' services. A similar tendency has characterized the agency's construction and land-planning policies. Quite naturally the first concerns of the FHA were to see that mortgages it insured rested on houses that conformed to the current consensus for adequate construction, and periodically these specifications have been reviewed to keep pace with changing fashions in housing. Yet the structure itself, as miles of decayed inner-city neighborhoods and half-finished and ill-equipped new suburbs witness, is at most half the cost of a decent home. The landscaping, drainage, streets, utilities, shopping centers, schools, hospitals, clinics, playgrounds, parks, public transportation, and highways require an investment at least equal to, if not far in excess of, that in the dwelling unit itself. Moreover, in the long term, say the thirty-five-year term of a FHA mortgage, the quality of these public services has more to do with the sustained value and utility of a house than do minor variations in its quality. Yet the FHA has not moved far toward using its power of awarding or withholding credit to
influence the coordination of public services with land development at the expanding edges of our metropolitan regions. Overcrowded schools, inadequate drainage, poor street and highway layout, and bad siting of structures are the hallmarks of the lower middle-class and working-class suburbs financed by the agency. The "tickey-tackey" of our new metropolitan regions, to use the current snobbish phrase, is more the product of inadequate public services and bad land planning than poor building practice.
The local-bank focus, especially the local savings and loan association focus, of the federal insurance program also hampers its promotion of good vacant-land development. The local savings bank is the principal supplier of credit to the small underfinanced builder who assembles a parcel and runs up a few houses for quick turnover. The added efforts of such builders (those building less than twenty-five houses a year) contributes approximately two-thirds of each year's new suburban construction. Yet such men have neither the capital, interest, nor political power to plan large-scale coordination of public and private facilities. As a result, federal insurance underwrites a series of small ventures whose combined effect is rapid urban growth, but rapid urban growth at a standard far below the capability of the total capital invested in land, mortgages, and public facilities which this work requires.
In sum, the FHA mortgage-insurance system and parallel Veterans Administration programs have proved tremendously helpful to the emerging middle-class families of America, although they have not served this class nearly as well as they might. The very fact that 60 percent of metropolitan dwellers occupy homes that they own testifies to the popularity and success of the strategy. The plentiful financial resources and high volume of construction which the American housing industry periodically attains have inspired much envy in European countries where chronic housing shortages persist. With our federal
mortgage insurance and concurrent interest and property-tax deduction, which subsidize the middle- and upper-income home buyers and co-operative-apartment owners, we have pushed the limits of massive government assistance to private housing. As a nation we have reaped the full benefits of a trickle-down housing market: no severe housing shortages for the upper two-thirds of the urban population and rapid new construction for the upper half.
Not only has the great mass of working-class successors to secondhand housing benefited; even the poor can count some gains. The decline in density of most areas of the inner city brought about by the rapid distention of the metropolis has meant that the greatest part of our city dwellers can now afford private housing without doubling up. Thus, except for the worst black inner-city ghettos, city apartments meet the occupancy rules that were first laid down about 1900, and single-family and two-family homes in run-down neighborhoods can be used as such by low-income families without the need to take in boarders or share with other families. This drop in crude density also ramifies through many aspects of public health: it reduces the dangers of contagious diseases; it gives the poor some of the personal privacy that hitherto had been a luxury of middle-class life; it makes housekeeping easier and neighborly neglect or sloppiness of less consequence. Finally, with the decline in density the buildings themselves last longer, even though repairs may be neglected. The poor can now use up their structures with a lower rate of decay than in earlier times of overuse.
The social costs to the city and the nation, however, have outweighed such benefits. FHA conservatism in land planning has meant the laying down of thousands of neighborhoods which now must be used for a century whether we like them or not, and they are neighborhoods which failed to meet the best commonplace standards of our own time. There is even evidence today that by taking the indirect approach of increasing mortgage credit rather than by building itself, the federal government may unwittingly have inflated building costs to such a
degree that many marginal families it hoped to aid are now priced out of the market. More serious still, government mortgage insurance and tax subsidies have vigorously promoted the racial segregation of the metropolis. The government now faces the herculean task of undoing its own work, of having American city dwellers unlearn the habits and attitudes of class and racial segregation which government policies have been consciously and unconsciously teaching them since 1935. It is a task at which the nation may well falter because of the weight of political habit and precedent which these policies have saddled upon homeowners, tenants, builders, bankers, government officials, and Congressmen. Over the past thirty-five years the nation has grown comfortable, even proud, of its commitment of billions of dollars in tax exemptions and government insurance for the benefit of the upper two-thirds of the population. We have grown accustomed in the housing field, as in so many others, to using government to give the most aid and service to those among us who need it least. Such a habit of government, the very essence of promoting a trickle-down housing policy, flies in the face of a goal of building a more inclusive society. Although aid to marginal home buyers is a useful policy when used in combination with a massive public-housing program, the latter has failed in its purpose because of habits of class greed, racial animosity, and majoritarian self-satisfaction which mortgage insurance and tax exemptions have long nourished. With the upper two-thirds of the population attended to, how was the lowest third to be heeded?
Since 1934 the federal government has administered a small program of housing aid to the low-income families of the nation. Much has been learned from these experiments and past errors have been eliminated by corrective legislation, especially in the basic acts of 1949 and 1968. The requirements for a decent housing program for the ill-housed third of our urban fellow citizens are now known. All the legislative shortcomings, except the correction of the disorders of the local property tax, have been rectified. It only remains for the general public to vote the necessary funds and for the public and its administrators to pursue the task with good will and energy.
Inexcusable class, racial, and commercial antagonisms have dogged American public housing from its inception, and to these antagonisms must be ascribed the most serious and enduring failings of the programs.
Initially prejudice against such work was overcome by the sheer collapse of the construction industry, which served to bring labor unions and urban reformers together. Labor wanted construction jobs, while the reformers wanted to clear some of the slums which they had without avail been trying to exorcise by regulations. From 1934 through 1937 the Public Works Administration of the federal government built 22,000 low-rent units in fifty projects about the country on the make-work justification. Court opposition, a diffuse but nonetheless widespread sentiment that direct federal construction somehow impinged too closely on local government and the sanctity of the home, and fears of real-estate dealers and bankers of price-cutting competition forced changes in the federal participation. Alarm over a monstrous federal bureaucracy was overcome by a grants-in-aid system for the benefit of locally managed housing authorities. Local landlords and real-estate interests were placated by a formula which required that public-housing families must be sufficiently poor so that they could afford rents no higher than 20 percent below those prevailing locally for safe, sanitary shelter. Reformers were given their goal by a provision that for every new low-income unit built, a dilapidated one must be rehabilitated or demolished. Beyond these political bargains the essence of the new program lay in the degree of federal support: the government would contribute the capital sufficient to build the project, the tenants must through their rents pay enough to carry the interest, depreciation, maintenance, and operating costs.
Such a compromise system set some of the long-lasting failings of federal low-rent housing. The support formulas meant that the very poor could not afford to live in public housing because the rents to cover maintenance and management were too high for them. Families whose income rose above the maximum had to leave the projects for private slum housing because of the 20 percent differential which had to be maintained between the top of public housing rents and the bottom of the private market. The rules tying subsidized rent to the personal income of families were so written that if a family's fortune rose its rents could not also float up to fair market values while they continued to occupy their apartment. Instead the most economically successful families were forced out of the projects regardless of their personal prefer-
ences. In Europe the common practice is to allow families settled in public housing to remain and pay market-equivalent rents if they so choose. The 1968 revisions of the federal laws have finally begun tentative steps to end these antisocial income policies.
There have been other unfortunate aspects of our housing program revolving around such issues as lack of tenant participation in project management, harassment of tenants to enforce income and conduct rules, lack of social services and community facilities, neglect of space for large families, poor siting, and so forth. But most crippling of all, because these shortcomings permeate all aspects of public housing from the corridors of the apartment houses to the Housing and Urban Development Department offices in Washington, have been the interacting failures of low-volume construction, segregation, and bad design. Since the goal of the 1949 act of "a decent home and a suitable living environment for every American family" has never been popularly accepted as a right of citizenship either by the victimized poor or the fearful affluent, a terrible incubus of philanthropy has plagued public housing and steadily brings on it cycles of sickness. With public housing perceived as a burden and an expression of charity rather than a right of all and an investment in the human capital of the city, both local and federal governments have consistently scrimped, saved, and limited the program. Underfunding has meant cut-down design programs, high-rise jungles, and low-rise projects which do not even match the standards of World War I workers' housing. When an occasional good design comes forward, it must be built against the weight of bureaucratic regulations and popular prejudices and is rarely imitated. Good architects and aggressive administrators have been driven off by red tape and low morale. As residents of ill-designed and ill-managed facilities, tenants have often felt little responsibility for their quarters and resented the public stigma of institutionalized charity. Underdesign meant that children soon overran such amenities as were provided, with shattered trees, worn-out grass, broken windows, and a periphery of derelict cars confirming the passing citizen's view that "those people" didn't deserve decent housing. As undeserving poor and black citizens, project dwellers must be restricted to the old slum neighborhoods, or as in Boston, be put out next to the city
dump, and not allowed to settle in the suburbs. Thus even after the federal policy of deliberate racial segregation was rescinded in 1949, segregation of public housing has continued because the housing projects we have built in our large cities stereotype the poor and the black in a way that reinforces all the fears and prejudices of working-class and middle-class Americans. Thus underfunding brought poor design, poor design fed segregation, segregation fostered the social and economic failure of projects, and failure justified underfunding. Round and round the cycle went, constantly eroding what was potentially one of the most useful tools of American urban policy.
With the post—World War II FHA-funded housing boom, organized labor lost interest in public housing; those construction jobs weren't needed any longer. Underfunding, bad design, and repeated reports and observations of the social pathology of projects drove off the urban reformers' support. In 1957 one of the most perceptive supporters of public housing, Catherine Bauer, summarized the reformers' dismay.
Public-housing projects tend to be very large and highly standardized in their design. Visually they may be no more monotonous than a typical suburban tract, but their density makes them seem much more institutional, like veterans' hospitals or old-fashioned orphan asylums. The fact they are usually designed as Islands—"community units" turning their back to the surrounding neighborhood which looks entirely different—only adds to this institutional quality. Any charity stigma that attaches to subsidized housing is thus reinforced. Each project proclaims, visually, that it serves the "lowest income group."
Though Congressional support has continued on the momentum of the past, within most large cities opposition to public housing has mounted. Detroit has only 8,200 units and has not undertaken a new project for some years; Philadelphia, Boston, Houston, Los Angeles, and Washington all have under 16,000 units for metropolitan populations well in excess of a million inhabitants. Only New York has pursued public housing vigorously, and the pathologies of that city's projects are accordingly the most visible to the nation. The central city's courtship of the middle-income and wealthy taxpayer puts the final stigma on public housing. After a generation of construction, from 1934 to 1970, only 893,500 units were completed and in operation around the
country. Of this total 143,400 were for the benefit of the elderly. Less than 2 percent of our metropolitan population occupies such structures. Bad as it is, the popularity of public housing tells of the hard choices the poor must make. For most spaces there are long waiting lists. The projects are not catchbasins of abject and defeated poor, but are used by low-income families much as Americans use their private housing. The annual turnover rate, the coming and going of families, is only somewhat less than the general national norm. Finally, because of the relatively small number of units the poor have had to bear the brunt of the social and economic dislocations attendant upon giant highway and urban-renewal land clearances since World War II. In no city did public housing even approach the volume of destruction of the stock of housing from which the poor had to choose.
The 1968 act has ended most of the formal barriers to a decent American public-housing program. If new court decisions in the states reduce municipal dependence upon the local property tax, the last institutional justification for excluding the poor from any neighborhood will be removed. What remains is clear enough. To end the sick self-defeating cycle of low volume of construction, segregation of sites, and institutional design, the public, both the victimized third and the fearful upper two-thirds, must come to think of all Americans as members of one society. They must come to believe that every one of us has a right to "a decent home and a suitable living environment." Surely such a principle is one of the essential elements in a minimum definition of the meaning of an affluent democracy. Once that spirit is accepted, public housing can easily be attached to urban-renewal reconstruction and the building of new towns. Most importantly of all, it can be located on vacant sites in the suburbs and the new centers of our ever-enlarging metropolitan regions. When public housing ceases to be a grudging philanthropy and becomes a goal of granting our fellow citizens their just rights, then projects can be designed to meet the standards of
commonplace American aspirations and to be related to their neighborhoods instead of being isolated from them. Such a program would take time, but steadily pursued for a generation it could close the gap of isolation and punishment of the lower third of the population and enable the poor and the black of America to participate as equals in the new freedoms of our metropolitan society.
Had the United States been pursuing an active and humane public-housing program in the years since 1949, and had urban-renewal allocations been consciously tied to a national urban policy, then urban renewal could have assumed its proper role as the program for the upper two-thirds of the population. Properly understood, the many interrelated programs which go under the rubric "urban renewal" have as their legitimate function the modernizing of our metropolitan regions in a way which will bring them in closer accord to the possibilities of a wealthy and expanding economy. Urban renewal could and should be the tool whereby the prospering elements in the society get a chance to remake the old sections of the metropolis in conformity to national goals for full employment and planned urban and regional growth. Unlike public housing, which now authorizes a very wide range of programs and is sufficient to allow vigorous administration, urban renewal still contains a fatal flaw: it lacks adequate political and policy structure. This flaw, which derives from its historical development, has in large measure accounted for its extremely wasteful and scandalously inhumane practices.
After World War II, an enlarged understanding of the mechanisms of urban growth gained from research and experiments of the thirties and early forties, along with dissatisfaction over the small public housing program, led urban reformers to propose a grand attack on the slums. By 1945 it had become generally understood that the land itself and its supporting public facilities were the key to housing, and experts testifying in extended hearings before Congress urged that the attack upon the slums be redirected toward the land under the structures. The federal government should finance the clearance of slum districts and the assembling of the hundreds of small parcels of land into which such property was divided. For their part, municipalities should administer the program, make use of their powers of eminent domain for parcel assembly, and build new streets, install new lighting, erect schools, and the like. After these steps the public low-rent housing and privately constructed middle-income housing could be erected on the prepared
sites, thereby modernizing great tracts of decayed slums. The essential soundness of the suggestion lay in its focus on urban land reclamation and the division of governmental effort according to the relative resources of the federal government and municipalities. The federal government would be harnessed to the most expensive task, clearance and parcel assembly, while the city would contribute by using its planning offices and its powers of eminent domain, and by constructing supporting services and organizing local support.
Despite its insights and clear intentions, the 1949 urban-renewal legislation ignored the power relationships within the cities which were to carry out the Congressional intent. Rather than initiate a new method for aiding the poor, municipal officials and commercial interests turned the ten-billion-dollar program into an irresponsible social monster. The post-World War II economic boom, combining as it did new metropolitan highway systems, rapid suburban construction of houses, shopping centers, and offices and plants, left the old central cities stranded with billions of dollars tied up in investments in a downtown pattern suited to the streetcar era. Poor whites and blacks streamed into the old cores as the working-class and middle-class whites sought the new suburbs., The poor newcomers, without organized political representation at City Hall, often deliberately excluded from power and political expression, tilted the balance of postwar urban politics. With working-class machines weakened by outmigration of their former constituents, a coalition of inner-city business interests and reform-minded moderates who were unaware of the future consequences of urban renewal, or who wanted to protect their own neighborhoods against the poor and the black, swept into office on urban renewal platforms. Again, as in the current animosity against low-income public housing and even working-class and lower middle-class FHA housing, the metropolitan dysfunction of the property tax played an important role in subverting urban renewal. Mayors, hard pressed for funds because the middle-class exodus cut property values in the central city, sought to use the new federal program to woo back the deserters. They hoped that by rebuilding the downtown core of the cities in the new styles of the day they could lure back wealthy taxpayers and shore up downtown retail sales and office rentals, thereby enlarging the municipality's tax resources. Thus, the low-
rent and public-housing goals of the 1949 legislation were subverted or ignored, and in time conservative Congresses consented to this alteration in favor of the well-to-do. The downtown horse was to be fed to aid the starving municipal pigeons.
Although all past and currently authorized projects will demolish more than a million housing units, almost entirely the former homes of the bottom third of the population who cannot afford any kind of new housing, only 5 percent of the housing in the Community Renewal Projects approved through 1967 will be for low-rent public housing. In the first rushes of clearance, thousands of poor families were displaced without adequate compensation or decent attention to their alternatives. "Negro removal" justifiably became the tag for these programs, and some cities even used urban renewal to force blacks into a single ghetto where previously they had been scattered at several locations about town. The refurbished downtowns, sports stadia, new government and corporate office towers, and slabs of high-rise luxury apartments which typically characterize big-city urban renewal stand in shameless witness to the callousness of American class and race relations. The well-to-do have spent ten billion dollars to redecorate their central cities for their own use and benefit while pushing perhaps a comparable social and economic cost off upon the low-income third of the population. Urban renewal is now a social and political scandal. Its only likely benefit to the poor seems to be its delivery of new capital into the hands of black political groups who are now inheriting the centers of our metropolitan regions. Perhaps they can use these cores as hostages for an increase of their state and federal bargaining power.
In spite of everything, the redevelopment of the old parts of our cities is surely a worthwhile public function; and were the planning and political shortcomings of urban renewal rectified, it could be a useful part of American urban policy. Unfortunately, four key elements were missing from the original legislation and its subsequent administration.
First and most apparent was its callous disregard of the effects of urban renewal upon the living conditions of low-income groups. Rapid construction of public housing in the suburbs could have easily overcome this fault, and since 1967 HUD regulations and subsequent legislation
have been moving in this direction. To date, all the old shortcomings of public housing and virulent class and racial antipathy prevent any substantial increase in the access of the inner-city poor to vacant suburban land.
Second, the long-standing tie between city services and the strength of the local property tax encouraged a socially lethal game of municipal competition for new middle-class and wealthy residents to the exclusion of poor and even working-class families. Successful urban renewal and many other improvements in the American city await the reorganization of metropolitan finances upon some more socially beneficial base. Recent state cases in California and elsewhere, ruling the local property tax an unconstitutional basis for educational taxation, are at last opening up this set of issues.
Third, adequate mechanisms for citizen participation and defense against local projects has not yet been devised. Although successive Congressional enactments called for metropolitan and city-wide planning and for neighborhood consultation, the standards of performance for an adequate project have not yet been made sufficiently definite. HUD's urban-renewal standards should closely reflect the common housing and environmental standards of the nation, and should be stated clearly enough so that local citizens and officials could test their proposals against such goals. The citizen should be able to tell in advance if a given proposal will in fact raise his neighborhood to compliance with the standards of the new suburbs. As in the case of the conflicts between highways and their abutters, should a project fail to meet those standards the affected property owner ought to have standing in court to stop the project until he is guaranteed that it will truly renew his surroundings. As now practiced, urban renewal confronts both the citizen and the planner with mountains of red tape and all the vagueness, delays, powerlessness, manipulation, and profiteering that such procedures inevitably create.
Fourth, urban renewal goes forward in a national policy vacuum. Rather than being integrated with national income and employment
plans and with set goals for regional growth and modernization, it is but another large chunk in the Congressional pork barrel. The Tennessee Valley Authority and the long-continued water, electric, war, and space investments in the Los Angeles region have shown that federal policy can be used to influence the jobs, personal income, private investment, and physical growth of our urban regions. Overseas, European national economic policy has been successfully harnessed to plans for urban and regional growth so that depressed areas, low-income populations, and obsolete cities are benefited through consciously articulated programs for industrial location, transportation improvement, and housing, education, health, and welfare services. As these European undertakings have become effective a new kind of urban and regional politics has developed, commencing an open and wholesome conflict among the affected cities and regions. To neglect such interrelationships between federal programs is to irresponsibly squander the nation's scarce resources. It is our political disgrace that as a nation we could not, and did not, debate a ten-billion-dollar program for the subsidized rebuilding of central-city office and apartment cores in the context of our needs for low- and moderate-income housing, racial desegregation, full employment, medical care, education, highways, farm subsidies, armaments, and a standing army. These are all major undertakings and major concerns of the nation. A decision on one affects all the others, and together they have influenced the growth and present condition of our cities. For urban renewal to become a legitimate undertaking, it must be debated and administered in such a context.
The parallels between American housing and health programs since 1920 are naturally close, since both are integral parts of the same national culture and urban system. Innovations in both have strongly favored the upper two-thirds of the population; both have relied heavily on insurance and tax concessions; both have depended upon local private and public agencies to do their work; both have ignored the poor or served them ill; and both have used large-scale organizations of the central government, banking, and insurance to manipulate the pace and direction of change so that in the name of maintaining the status quo a conservative revolution has been wrought: in housing the dispersal of the old industrial metropolis, in health the near abolition of the solo general practitioner. Finally, after years of divergence, during which
time American medicine concentrated its attention on communicable disease and acute care to the neglect of the larger social issues of class, race, and environment, housing and health are now once more converging as an interlinking set of concerns for the maintenance of a healthy population.
For the vast majority of Americans, altering the death rate is no longer the central health issue. Though there are still highly significant mortality differences caused by race and class position, any truly universal health program whose major foci were preventive care, chronic-ailment care, and the public environment could end such differentials. A 1968 survey of existing Chicago health services defined our modern situation:
Certainly it is a reasonable assumption that timely and proper health care can postpone death from some causes, and prevent, cure, or palliate some diseases. At the same time, however, it is also reasonable to assume that a salubrious environment, only moderately stressful life styles, balanced diet, exercise, good housing, and so on probably have a greater indirect and direct effect on the disease patterns and age at death than do health services as such.
It is the failure of the American health system to adapt to these new conditions, both in its unsatisfactory service to the prosperous and its near-criminal neglect and treatment of the blacks and the poor, that constitutes today's medical crisis.
For the prosperous two-thirds of American society, the history of urban health since 1920 is the history of private medical insurance and the effects that this new mode of payment has had upon the inherited structure of medical practice. In the first years of the era, systematic social and economic research established with certainty that the expense of illness could be insured. The U.S. Public Health Service did a study of the incidence of illness in a small Maryland city during the years 1921-24. Three years later this pilot study was followed by a giant assessment, funded by a number of foundations, of the national incidence of illness, family medical expenses, the incomes of health-service personnel, the nature and distribution of health facilities, and related subjects. The final twenty-eight-volume report of the Committee on the Costs of Medical Care, issued in 1932, showed that insurance was
definitely feasible. The burden of the costs of care fell heavily on a very small fraction of the nation's families in any given year. The reporting committee was divided on the issues of how this insurance should be funded and how it should be related to the provision of medical service. The majority favored government insurance to protect all Americans and proposed that health care be centered in groups of doctors working as teams through hospitals. They saw the hospital as the institution best adapted to the benign management of the increasing specialization and complexity of technique. They objected to privately funded insurance on the grounds that it would offer an insufficient check on doctors and hospitals and therefore would encourage the inflation of medical costs. An accurate prediction!
On the other hand, the minority report better captured the mood and traditions of American patients and physicians, and for its part foresaw the basic flaw in the hospital strategy. Solo general practitioners were already a declining, though still preponderant, fraction of the profession, and the minority felt they should be encouraged as the best hope for ordinary family needs. They estimated that 82 percent of all illness could be competently treated by a well-trained solo practitioner who possessed simple equipment. The dissenters stressed the desirability of individuals' being able to select their personal physician and stressed the efficacy of sustained personal relationships. Group practice and hospitals, as advocated by the majority report, seemed to be applying inhumane big-business and mass-production techniques to human needs. So they proved to be. In keeping with its focus, the minority called for private nonprofit insurance to be managed by the professionals themselves. In short, they endorsed what was to be the wave of the future—the Blue Cross and Blue Shield approach to payment for medical service.
Unfortunately for us all, however, history gave neither side the arrangement it wished; we got instead the worst mix of both. The majority never saw the rise of adequate government insurance or widespread group practice, while the minority lived to see the hospital and specialist trend they deplored accelerated by private insurance. Like the
U.S. government's FHA mortgage program, a creature of depression and threatened bankruptcy, the nonprofit hospital-insurance system worked a conservative revolution upon established patterns by pouring money into the established acute-care hospitals of the nation.
Historians trace the lineage of Blue Cross, the parent hospital-insurance organizations, to 1929 and Dallas, Texas, where Baylor University Hospital took over a local schoolteachers' sick-benefit plan and began to enroll other groups in the city for insured service at the hospital. The example might not have spread far had not the Great Depression undermined the finances of big-city voluntary hospitals everywhere: wealthy donors cut back their giving and patients simply stopped paying their bills. It has been estimated that during one depression year 60 percent of the hospital services in Philadelphia were rendered without any reimbursement. Desperate hospital administrators seized upon the Baylor example and other early experiments, so that by 1932 clusters of city hospitals were banding together to form community-wide insured hospital-service plans. These groups in turn secured appropriate state insurance legislation, developed standard administrative practices, and emerged prior to World War II ás the regional and state-wide Blue Cross insurance companies in the form we now know them.
A few particular arrangements give Blue Cross private-insurance programs their distinctive quality. The companies are nonprofit and are managed by boards of directors who represent the participating hospitals, the medical profession, and community leaders. Their salesmen are salaried, not paid on a commission basis. The companies endeavor by seeking wide participation so as to pool all the medical risks of the state and its cities in order that rates for members who join as individuals do not exceed by too far the rates of those who enroll all together as a group of employees. Finally, Blue Cross plans are not primarily cash-indemnity plans but service plans. The participating hospitals agree to render a specific list of services to members for a fixed fee. The hospital is reimbursed by the insurance company, not the patient. These modes of governance and payment, originally conceived to avoid doctors' reactionary laws against the corporate practice of medicine, proved to have important consequences as the insurance system spread, principally
by making Blue Cross the prisoner of its hospital beneficiaries, not the representative of its patient-members. Well established by 1938, the subsequent wartime boom and the influence of wartime wage controls, which favored rewarding employees with noncash benefits, transformed this Depression defense into a mass institution. By the middle of the fifties, hospital insurance—Blue Cross and its commercial competition had become a fact of life for regularly employed urban Americans.
Blue Shield insurance, a similar set of arrangements for reimbursing participating doctors for a specific list of surgical procedures, had a different origin from Blue Cross, and quite different rationale. Its secondary goal was to rescue doctors from unpaid bills, while its primary goal has been to defend private practice against public demands for government insurance. The ancestors of Blue Shield first appeared on the Pacific coast around 1917, when county medical societies in the states of Washington and Oregon organized prepayment service as an alternative to the current unscrupulous contract practice then prevalent in lumbering, mining, and railroad communities. At that time employers in these isolated settlements were paying for medical services to their hands, but often the patients received scandalously low-quality treatment.
The Great Depression and a threat by the governor of California to press for compulsory insurance carried such plans down the Pacific coast and across the nation. Originally such plans offered a broad range of services, but as they were introduced on a larger scale heavy usage threatened them with bankruptcy and the coverage had to be pruned. The American Medical Association always viewed these programs with suspicion, favoring cash-indemnity insurance for the patient rather than insured services, since the former seemed to sharply differentiate financial matters from practice and hence seemed to threaten less of an opening toward the group medical practice the Association feared. In the immediate post-World War II years, when every Congress debated bills for government medical insurance and President Truman pressed for such measures, the medical profession actively promoted surgical and hospital insurance as its answer to socialized medicine. With a structure similar to that of Blue Cross, often even sharing combined offices, Blue Shield rode the coattails of its more established hospital patron until by the mid-fifties it was almost as widespread, and the two
programs came to be fused in the popular mind as "medical insurance."
Fraught with major limitations as the Blues are—limitations of both governance and coverage—the post-World War II rush of commercial insurance companies into competition with them has exacerbated all the shortcomings of the nonprofit system's effects upon private medical institutions. Although private insurance companies had sold cash disability benefits as extras on their basic workmen's compensation policies for years, the Depression wiped out many company-sponsored employee benefit plans, and commercial insurers were reluctant to return to the health field until the Blues had shown a safe path. In the postwar years a coalition of insurance companies and medical societies defeated the labor-supported government insurance bills before Congress. Rebuffed, the unions returned to the industrial bargaining tables to demand more health benefits for their members. Pressed by such demands and reassured by the booming growth of the Blues, commercial carriers took up group hospital and surgical insurance. Because giant national corporations needed uniform policies for industry-wide bargaining, the largest insurance companies were the best equipped to meet the demand, and soon the top twelve had cornered 90 percent of the business.
Associated differences in mode of payment, rates, and risk pools distinguish commercial policies from the Blues. The standard private carrier's group policy is written for an employer who collects his workers' monthly contributions, if the workers contribute at all, while the insurance company reimburses the employee when he submits his hospital and medical bills. Since most policies today are written with a rate-adjustment clause calling for an increase or decrease in charges based upon a yearly audit of claims, neither the carrier nor the employer has any role in or much incentive to control the quality, quantity, or price of medical services purchased by their beneficiaries. Second, even more than the Blues, commercial policies pool the safest risks and so do not reach out to the most health-endangered populations. As cheap policies, tailored for competitive bidding, commercial insurance skips the old, the irregularly employed, the chronically ill. Moreover, the extent of its coverage depends upon the wit and aggressiveness of union bargaining and does not rest upon a planned assessment of the best deployment of limited health services. At least the Blues seek to build community-wide pools of risks so that individuals may purchase insur-
ance at rates not too far in advance of group charges. The sales and administrative costs of commercial individual policies forbid commercial carriers from following even the Blues' modest lead.
Thus to a remarkable degree the success of the private insurance movement has had much the same effect on the structure of medical services that the FHA did upon the housing market. By establishing insurance pools of safe economic risks, like the safe mortgages, health insurers have extended the purchasing power of working-class and middle-class Americans in such a way as increasingly to neglect the poor, the black, and the old. Moreover, the concentration of policies upon hospitalization, surgery, and catastrophe instead of everyday family needs like dentistry, pediatric care, mental health, and long term paramedical services for both the old and the chronically ill accelerated the pre-existing trends of American medicine toward hospitals, high technology, and bureaucratic doctor-patient relationships.
Complementary policies of the medical profession and the federal government exacerbated these tendencies of mass private insurance. For its part, the medical profession systematically limited the supply of doctors by restricting the output of medical education, thus stifling supply at a time of accelerating demand. Such a monopolistic professional policy inevitably caused a steep rise in medical charges as patients outbid each other for medical attention. At the same time doctors, like all good Americans, competed among themselves for the most lucrative practices and the highest-status positions, thereby rushing headlong toward the most prestigious hospitals, the wealthiest populations, and the most refined specialties.
The government contributed to this flight toward specialized bureaucratic medicine and hospital-based practice in two ways. First, urged on by the successes of national health foundations in tuberculosis and polio research, and beguiled by the seeming political neutrality of research, it poured millions of dollars into research programs, thereby removing doctors from full-time practice and adding prestige to research physicians who contributed little or nothing to meeting the day-to-day needs of the mass of patients. Second, the government invested several billion dollars, starting in 1946 with its Hill-Burton program, in modernizing old acute-care hospitals and building new ones. These federal policies were calculated not to agitate the politically explosive issues of estab-
lished medical practice, but the diversion of billions into research and hospitals had the effect of accelerating the bureaucratization of medical care and the neglect of commonplace needs, central-city services, and low-income groups which the private insurance boom initiated.
Thus, for the upper two-thirds of American city dwellers the trends of private insurance and public policy since 1920 have brought mixed blessings. There is too much emphasis on hospitals and surgery, since these are subsidized institutions and practices; there is too much emphasis on advanced science, technology, and drugs, since these are the traditional successes of American medicine; and there is too much emphasis on the physicians' and other professionals' needs, and too little on the needs of patients. Both insurance funding and the ever-expanding reach of medical science have raised the expectations of Americans as to what constitutes an adequate medical relationship. Yet the screening of physicians from patients by standard commercial hours, overcrowded waiting rooms, secretaries, technicians, nurses, medical centers, hospitals, and insurance forms has poisoned doctor-patient interactions. Middle-class Americans, the former heart of traditional solo practice, have been forced increasingly to use the emergency and outpatient services of urban hospitals, where they encounter the long lines, unkept schedules, lost records, and impersonal and even hostile treatment that the working class has suffered for years. The result has been a partial breakdown of confidence between doctors and private patients, a rapid rise in malpractice suits, a weakening of middle-class opposition to all forms of socialized medicine, and a pervasive feeling of exploitation. Like so many institutions in the modern city, whether nonprofit like universities, schools, and housing authorities, or profit-making like manufacturing corporations, retail stores, and insurance companies, our medical institutions, by expanding into giant permanent organizations without any satisfactory mechanisms for their democratic control by those whom they are supposed to serve, have become mired in bureaucratic self-serving and public malfunction.
Our medical institutions, like so many institutions in America, have a
predominant form, but are not all cast in the same mold. At present a variety of group-practice and insurance systems offer a broad range of alternatives to the regularly employed. None have yet evolved any adequate mode of patient representation, so that should they expand they will do so with all the limitations inherent in professionally managed bureaucracies. California, with its early experience with railroad and mining-camp group practice and its long-sustained population boom and doctor shortages, offers the widest range of alternatives. In addition to a few survivors of the early general-practitioner era and the standard solo doctors with hospital affiliations, the state has nurtured all manner of medical modes, from the informal referrals of a cluster of specialists sharing a suburban medical building to large-scale, prepaid group practice and hospital service.
Two examples can serve to express the range of California medical forms and the potentials and shortcomings which these variations now present: the San Joaquin County Foundation for Medical Care and the Kaiser Foundation Health Plan. The first is an organization which attempts to solve the problems of lack of quality and cost supervision inherent in the Blues and commercial insurance, while simultaneously giving its members the traditional minor consumer protection of free choice of a private physician. The second seeks to maximize the savings inherent in large-scale, well-organized clinic and hospital practice, and to pass these savings on in terms of the widest possible coverage against needs for medical attention.
The San Joaquin plan sprang up in response to competition from the Kaiser Plan. The county medical society formed its own foundation in 1954 to mediate among the private insurance carriers and the doctors and patients in its area. The physicians agreed to a fixed schedule of fees for service, while on its side the foundation offered to certify privately marketed insurance policies if such policies offered the range of benefits it thought appropriate to good family medical care. Families who purchased policies could choose their own physician from the society's list and gain the benefit of regular insurance payments against most medical expenses. The unique feature of the plan, a benefit both to carriers and patients, lay in the foundation's processing of claims for the certified policies. Bills are audited in two ways. Trained accountants review them to determine their validity, and county doctors volunteer their time on rotation to determine the appropriateness of the treatment. In cases of
abuse on either count, the foundation undertakes to negotiate the charges between the physician and the patient.
Although such supervision of costs and quality far exceeds that undertaken by large private carriers, the San Joaquin methods of shoring up the existing system cannot offset the expensive habits of overhospitalization and inefficient allocation of medical personnel's time which is inherent in American solo or informal referral practice. Its conservatism, harking back to the criticisms of the minority in the Committee on the Cost of Medical Care of 1932, does meet a persistent and important charge against group practice. Although crowded waiting rooms, overscheduling, an authoritarian manner, and a bureaucratic style bring many solo practitioners' habits dangerously close to the classic outpatient hospital style, some residual consumer benefits remain in the patient's free choice of his physician. The San Joaquin plan preserves this traditional margin of benefit. Yet since it does not attack either the problems of costs or depersonalization directly it leaves its working-class and middle-class members far from their legitimate goals of cheap, humane medical service.
The Kaiser Plan is a much more ambitious insurance and service scheme. It began in the late thirties with a prepaid plan for workers and their families at the Grand Coulee Dam site in Washington, where Edgar Kaiser was the prime contractor. Dr. Sidney Garfield, who ran the service, noticed that the method of payment had a good effect on the quality of service he and his colleagues gave. Prepayment weakened the habit of thinking in terms of repeated visits and expensive hospital procedures; and with this traditional economic pressure relaxed, both service improved and costs declined. During World War II, Dr. Garfield operated a large medical and hospital service for Kaiser's shipyards in the San Francisco area, and the program was so popular that workers kept up their memberships after the war. In 1952 the Kaiser Foundation Health Plan was established as a nonprofit corporation and burgeoned to serve about one and a half million people in California, Oregon, and Hawaii.
The heart of the plan lies in its fixed insurance charges to members,
which guarantee the widest range of services offered anywhere, the most notable exclusions from the contract being dentistry, psychiatry, and drugs. Patients are encouraged to seek regular relationships with one physician, but there are also walk-in clinic hours when members can be attended to on a first come, first served basis. The foundation also operates its own hospitals and emergency services. In addition to its economies of carefully managed group practice, the Kaiser Plan undertakes systematic review and supervision of its doctors' performance. A special bonus system acts as an incentive against hospitalization, and the foundation has organized home-care teams of physicians, public health nurses, and physical therapists to match its campaign to reduce the incidence of hospital treatment.
Because of its reasonable charges and extensive services, the Kaiser Plan has been extremely popular in the Pacific states. Indeed, shortages of doctors and capital for hospitals and clinics have restricted its growth and forced it to close its membership lists from time to time. Its immediate shortcomings of delays for appointments and inaccessibility of some clinics stem principally from its inability to keep pace with popular demand. Its success and those of similar insured group-practice schemes have led to numerous imitators, most notably by the Hospital Insurance Plan in New York City and labor-union plans in other cities. Although it suffers the general shortcomings of all privately funded programs—it cannot reach its proportionate share of the poor and the old—the Kaiser Plan is often hailed as the ideal model for the restructuring of American medical practice, and for universalization by way of federal subsidies for low-income groups.
If such a policy were to be undertaken either by a state or the federal government (and such a policy seems to be a logical next step), then two basic limitations of the Kaiser Plan must be dealt with. First, the traditional isolation of the medical profession from social and environmental issues must be overcome. In the narrowest sense, new clinics and hospitals must be consciously located in respect to patterns of urban growth and population need. New York State alone uses its licensing powers to plan in this way, but the federal government has
begun since 1966 to move in the same direction, and public supervision of medical-facility location seems an easy step to take. More difficult, yet perhaps more important to the long-run health of ordinary American families, is the need to use the records and experience of physicians as information in the planning of school nutrition, industrial health, and water, air, housing, and recreation planning for metropolitan regions. For the development of subdivisions, where typically homes are built without coordination with the public facilities which make them viable, the day-to-day records of urban families' health experience should be an important determinant of our social and environmental investments. In view of the current high medical and living standards of the upper two-thirds of our population the social and environmental aspects of modern living are the most significant tools for improving the majority's health.
Second, some methods for patient participation in the management or supervision of large-scale health institutions are absolutely essential. The long history of hospitals, especially of hospital outpatient services, and our abundant experience with all manner of bureaucracies show that management left to professionals, no matter how well-intentioned, soon degenerates into a bad mix of self-serving and philanthropy. Although the Office of Economic Opportunity and Model Cities programs for the poor involve neighborhood participation, the working class and middle class have not yet demanded representation in their medical institutions. Until then, and until appropriate forms of public participation are devised, regional hospitals, Kaiser Plans, county medical society programs, and union-sponsored clinics will suffer all the shortcomings of bureaucratic service. Since such organized prepayment programs do seem able to meet the twin needs of moderate cost and high levels of competence so much better than the solo practitioner funded by private insurance, it seems imperative that this form of consumer representation be built into such institutions before they expand further.
For the bottom third of America's urban population, the years since 1920 have been a medical disaster. Put in simplest terms, those with the greatest needs have been getting the least and the worst. All the problems which beset services to the upper two-thirds also bore on this group, and much more besides. The sheer growth of our cities has left them stranded, while the inflationary pressures of the monopolistic
practices of physicians acting in tandem with federal programs have priced millions out of the medical market and left entire core-city populations without access to decent health services. As in the trickle-down housing market, where the ability to obtain adequate housing and to benefit from federal subsidies depended upon a family's having attained an income threshold at least a third above the bottom level, so too access to good medical service and hospital insurance had to be purchased by regular employment and residence in a decent neighborhood. Although since the twenties rapid urbanization, rising living standards, and additions to medical science have markedly improved the health of a giant marginal group of city dwellers, say those in the range from the bottom third upward to the midpoint of the total income distribution, everything conspired against the lowest third's getting its fair share of the benefits of the last fifty years' advances.
Perhaps first and foremost, the growth pattern of the city, intensifying the segregation of white and black poor at the center of the metropolis, had the most damaging effects. The rising geographical concentration of what is now termed the medically indigent exacerbated the division between ordinary private medicine and philanthropic practice which was the legacy of the previous era's establishment. The entrapment of poor whites and blacks in old central cities weakened the tax base of their communities at the very moment when municipal hospitals, dispensaries, and social services required heavy additional funding to meet the legitimate needs of their neighborhood populations. Once again the dependence of American municipal government on the local property tax played its antisocial role. The rich, increasingly dwelling in the suburbs, failed to contribute the necessary capital to inner-city voluntary hospitals; indeed, many shifted their attention to new institutions closer to their homes. The relatively declining core-city tax base meant the progressive neglect of already established city hospitals and clinics. The Hill-Burton hospital building program of the federal government, begun in 1946, accelerated these trends by subsidizing the construction of new suburban hospitals while its contributions to remodeling old central-city institutions at best enabled them to catch up with their own obsolescence but did not in any way direct inner-city medical service to the neighborhoods where the severest crises were occurring. Neither did the Hill-Burton money attack the racism of the established
mixed private and public hospital network. The suburbanization of the upper working class and middle class, the spread of private insurance among them, and the new suburban hospitals all conspired to draw private physicians out of the old neighborhoods to follow the paying patients. Finally, the restriction of output by American medical schools and their deep-seated prejudice against training black physicians completed the tragedy.
Recent Chicago surveys taken even after the Great Society reforms of the sixties tell of the depth and magnitude of our urban health failure. The metropolitan region is characterized by "spatial epidemics" where the core districts of white poverty and black segregation suffer disproportionate infant mortality, tuberculosis, hepatitis, pneumonia, rheumatic fever, venereal diseases, measles, and other illnesses. The morbidity and mortality maps of the city give bitter confirmation to the additive effects of our urban traditions: poverty, social pathology, high-density living, low-level sanitary services, and inadequate or nonexistent medical care combine to make what one student of Chicago's public health has called an apartheid health system. Public neglect of the critical need for full employment at living wages, callous disregard for the maintenance of the physical environment, the punitive practice of welfare and charity medicine, and institutional racism in both public and private health facilities have cumulated in a social disaster for the inner city. Stranded all-white hospitals do not serve their black neighbors for fear of losing their regular physicians' and patients' support, many black families have only mass-production welfare practitioners to serve their neighborhood, white physicians cannot venture into black neighborhoods at night, both the white poor and the black of Chicago travel miles to wait in long lines at the monster Cook County Hospital complex, and they wait there to be seen by a physician who likely as not hardly speaks English. These are some of the commonplace Chicago anomalies, and similar ones exist in every large American city.
The mounting day-to-day count of preventable disease and death accuses the majority of Americans, their physicians, and their insurance companies. Because of their past actions in defeating government medical insurance on the eve of the two suburban booms after the two World Wars, we now face a breakdown of our medical system. American cities should be coping with the task of adapting well-established institutions to new needs. Instead they face a situation where inner-city health facilities cannot carry their load and the private insurance and suburban medical network is insufficiently organized to come to the aid of the inner city poor and black.
Just as in the housing field, where the federal government attempted to get the private market to attend to the needs of the poor and inevitably failed, so in the health field where Great Society programs have attempted to cajole the established health-care system into care of the old, the black, and the poor, it inevitably failed. In both fields excellent small-scale experiments in the United States abounded, but they could not flourish and multiply here without genuine popular support. Until the majority of Americans are willing to accept the standard of a decent home, a suitable living environment, and adequate health care as a right of all citizens, an urgent right that takes precedence over armaments, imperialism, private property, and private profit, public programs will do little more than reveal the basic injustice and social disorders of our unequal distribution of income and services.
The lifeless continuation of charity services and public-welfare medicine, so well demonstrated in the Chicago studies, when contrasted to the robust growth of Veterans Administration medicine after 1945 testifies to the difference between programs of philanthropy and a program of popular rights. The former are chronically underfunded by a wide margin, grudgingly expanded, shot through with incompetence, abuse, and fraud, and periodically reformed by novelties tailored to political crises; the latter is generously supported, rapidly expanded to match the veteran population, as competent as the general run of American medicine, and has been evolving as a set of institutions since World War I until now they offer full health services to all veterans regardless of the origins of their medical needs. The former consist of
a reluctant philanthropy for second-class citizens, while the latter is a patriotic practice of socialism for first-class citizens, a service which treats its clients as well and as badly as American medicine treats the upper two-thirds of our civilian society.
The health-care reforms of the urban crisis of the sixties are therefore, like the postwar housing policies, attempts to deal with the historical unfolding of long-standing urban problems without a popular commitment to the rights of full citizenship, and without a sense of urgency for the demands of everyday life. Instead the impulse for reform was instigated by the national confrontation with white racism, the explosion of inner cities in the riots of the mid-sixties, and the need of Democratic Presidents to seek old people's and black people's votes. Such expediencies brought forward the federally sponsored package of Great Society health-care measures—neighborhood clinics, Model Cities coordinated planning, and Medicare and Medicaid.
The neighborhood clinics sponsored by the Office of Economic Opportunity and other agencies were designed to meet the immediate shortage of doctors in poor areas of the city and also to overcome some of the historic limitations of the old-fashioned hospital and dispensary network. In a typical case, the Mile Square Clinic in Chicago, OEO contracted with a voluntary teaching hospital to serve an impoverished population of 25,000 on the West Side. The hope of the contract device was to draw upon an established pool of high-quality personnel rather than funding a new municipal or state clinic. Since all the clinic employees remain employees of the Presbyterian—St. Luke's Hospital, they can still keep their ties and advancement orientation to that prestigious medical hierarchy. Such contracts seem a reasonable emergency strategy, but the historical record of hospital management of outpatient services demonstrates that it is an unstable form. In time either the hospital will neglect its clinic staff or the staff will neglect its patients. To circumvent the old abuses of dispensary service, the clinic employs local residents and has created a neighborhood advisory council to participate in its management. But neighborhood control will come to naught unless the clinic receives ample and continuing public funding to enable it to attract and retain a good staff. The clinic itself functions by group practice much in the Kaiser Fund manner, and like the California model it
employs public-health nurse teams to give home follow-up care and service.
At present such neighborhood clinics are regarded as the best hope for the inner city. A Chicago study calls for the creation of twenty-four there, and public-health surveys in other cities suggest similar strategies. Thanks to the crisis of the sixties, plentiful examples exist for adaptation to particular city needs. The unresolved issue, however, remains the same as before. Today's clinics are temporary and under-funded, and they are just a tiny fraction of the total required. In parts of the city where doctors are more plentiful but where commonplace services are still in short supply, as in many white working-class areas, such clinics will inevitably face the bitter opposition of a coalition of private practitioners, insurance companies, and medical societies. As in the sick cycle of public housing, the stigma of low-quality clinic service inherited from the past will make it difficult for health reformers to form a coalition among poor, working-class, and middle-class citizens to press for the creation of all-class clinics which would benefit everyone. As in so many fields, the current political equilibrium sustained by partial service to the majority blocks the realization of our potential for building good universal programs.
The Model Cities innovation, launched in 1967, was designed to offset the overly physical City Hall and business orientation of extant urban programs. The federal government held out the tempting carrot of extra subsidies for cities which would establish Model Cities districts where locally elected boards would attempt to carry out a coordinated development plan for housing, employment, health, education, welfare, and public amenity improvement. Nothing less than a simultaneous demonstration of comprehensive, multi-institutional, local planning coupled with local decision-making was to be attempted. Model Cities boldly took on all the lack of coordination of the suburbs in a setting which added all the problems of inner-city poverty. It is still too early to predict what the ultimate outcome of this heroic leap will be if it becomes a permanent institution of municipal government in America. So far it has at least given an effective veto power to some formerly
unrepresented groups of poor people in the inner city. It seems doubtful, however, that without decent federally maintained full-employment, public-housing, and medical programs, and without state reform of the municipal tax base, that local groups, no matter how intelligent, aggressive, and well subsidized, can make much headway against the heavy historical forces which press upon their neighborhoods. Properly considered, Model Cities planning should have followed major federal and state programs in order to guide and check on their local impacts; by itself it cannot be a substitute for national and regional planning.
In 1965, after years of controversy, Congress finally passed a broad health-insurance law (Medicare). It was not a compulsory insurance program for all employed Americans as contemplated in 1916, but a compulsory hospital-insurance fund and a voluntary medical-insurance scheme for those over sixty-five. At the same time Congress voted to liberalize and rationalize its grants-in-aid support for state welfare recipients (Medicaid) in order to guarantee payments for hospitalization and medical service to the poor. Neither Medicare nor Medicaid looked toward any alteration in the provision of services, except for the promotion of nursing homes, and neither demanded any restructuring of the established institutions of medicine. Under Medicare an increment was added to the general Social Security payroll taxes to finance a government hospital-insurance fund which would enable the aged to receive upon retirement the benefits which existing private insurance often denied them. Old people could further elect to make a small monthly payment (now about five dollars) which the federal government would match to entitle them to a broad range of medical service. The principal uninsured items were dentistry, hearing aids, self-administered drugs, immunizations, and physical checkups. Under Medicaid, Congress offered to match states' payments for hospital and physicians' services to welfare recipients if the states passed appropriate enabling legislation. All the states except Alaska and Arizona have now done so. In keeping with the open-ended intent of the statute, the range of benefits and eligibility vary widely from state to state.
Although the passage of Medicare and Medicaid is undoubtedly an important event in the political history of public health in that it allowed
the federal government to break half a century's barriers against national insurance, and although many old people's medical bills have been reduced, and many poor people's chances for attention have increased, the most significant effect of the 1965 legislation may well prove to be its subsequent public exposure of the weaknesses in the structure of the American health-care system. With federal taxes and subsidies increasing the demand against the limited supply, the first effects were to inflate the costs of service. Under Medicare, hospital costs soared to double the first estimates, and the annual rate of increase in charges for physicians' services almost doubled. Since nothing in the statutes increased the numbers of doctors attending the old and the poor or altered the mode of practice by professionals, the long lines at hospitals, mass-production methods of welfare specialists, and the sheer lack of practitioners in central city neighborhoods went unchanged or got worse. Young inner-city mothers and their children continued to suffer all the neglects of charity medicine. Indeed Medicaid engendered a kind of health-care backlash. The inflation of medical charges in state welfare budgets which immediately followed the passage of state enabling acts forced several states to cut back their eligibility and coverage so that the general public was left with the sour impression that the majority could not afford decent medical aid to the bottom third.
Predictably, the attempt of Medicare to find an adequate low-cost alternative to hospitalization of the aged by stimulating the profit appetite of doctors failed. Lured by the promise of Medicare payment for nursing-home service, syndicates of doctors and real-estate investors in every city teamed up to build and to operate such facilities. The gentlest criticism that can be directed toward this policy and its outcome is to observe that the scattering of nursing homes isolates old people and wrongly focuses attention on medical problems, to the neglect of the patients' needs for self-respect, self-care, social life, and participation in the world around them. Comprehensive Jewish charities in many U.S. cities and integrated programs in countries like Sweden have abundantly demonstrated that helping old people to deal with their declining health requires a cluster of institutions ranging from sheltered workshops and recreation centers to home care and hospitalization. It is a measure of
our general society's callousness toward old people, and of the medical profession's isolation from serious concern for the social issues affecting the health of its patients, that together we all consented to a crash program of profit-making nursing homes.
Medicare and Medicaid also had their corrupt side. Doctors bought and sold nursing homes for speculative profit, unscrupulous practitioners took up "gang visiting," rushing through nursing homes collecting Medicare and Medicaid fees as they passed each bed, and drugs and procedures were prescribed and hospital bills padded in the happy expectation that the state and federal treasuries would pay while patients suffered disgraceful neglect.
The spiraling costs, sloppy service, and outright malpractice exposed the social disorders that throve as a result of pouring insurance money and a patchwork of public funds into an unreconstructed medical establishment. In most cases insurance companies, especially the Blues, became the Medicare and Medicaid intermediaries who processed the hospitals' and doctors' bills to pass on for government payment. The mountain of padded bills submitted told more clearly than years of investigations that private insurance companies in no way represented the consumer. They also testified to the fact that despite plentiful hospital and medical representation on their governing boards, the carriers did not see fit to police the profession even to the extent of guaranteeing performance at the levels of the current consensus of standard good practice. The insurance companies functioned solely as collection agencies for their hospital and doctor clients. When the Department of Health, Education and Welfare requested the names of physicians receiving Medicare and Medicaid payments in excess of $25,000 a year, many companies refused to comply.
Thanks to the Great Society attempts to aid the poor and the aged, the long-neglected urban health agenda is now a public political issue. Public-health follow-up studies and OEO neighborhood clinics tell of the tremendous need for commonplace service to inner-city dwellers, the severe inflation of medical costs dramatizes the monopolistic practices of medical schools, the nursing-home failures and scandals speak to the social issues of adequate health care, while the abnegation of supervision by insurance carriers and the long lines and bureaucratic abuses
of big-city hospitals tell of the necessity to reorganize the power balances of medical practice. Once again epidemics, slums, and the suffering of the urban poor have demonstrated to the larger society the weaknesses of its institutions.
Yet in health care, as in housing, a crisis response which is the traditional reflex of our society will miss the essence of the situation and inevitably fall far short of the goal of a humane urban community. The poor are indeed treated far worse than the majority, yet such are the linkages and interconnections of a highly urbanized nation, they are treated worse in the same ways as are those who are comfortably off. The consequences of class and racial segregation which now press so cruelly upon the inner city are part and parcel of the disrespect for commonplace human life, and the denial of full citizenship to blacks, minorities, children, women, and old people throughout the metropolis. The fallen-down buildings, uncollected trash, conflict-ridden schools, grimy hospitals, and bottle-strewn parks are but the frightening evidence of a pervasive neglect of the supporting public services to homes and families which prevails in all but the wealthiest suburbs. The traditional American response is to seek to obliterate the dramatic symptoms while leaving the basic malady untouched. To do so is to repeat once again our long history of failure to build truly humane and inclusive cities. The hope of the American city lies in a public recognition of the interconnections of everyday urban life, and from that recognition to commit the nation to a deep and long-sustained effort to rework its physical and institutional structure.
Choice and Continuity
American Urban Life confuses us in its intermingling of endless repetition with ceaseless change. Consider our habitual responses. We do not see in the brand-new downtown apartment towers or the freshly carpeted suburban model home the inevitable repetition of failure which surely awaits them. Nor do we see in the aging suburbs and dreary slums the economic vitality of the offices, stores, and factories in which their residents work. The newness is a goal for family achievement, the reality of aging is either to be obliterated or escaped. The past is not seen in the present, or the jobs in the houses. These are deep habits of mind. Since at least the founding of the Republic we have been concealing failure from ourselves with newness, and ever since we proved unable to protect our farmer and artisan forefathers from the oppressions of the workplace we have desperately sought to isolate home from work. Thus for generations we have dwelt in a self-created urban wilderness of time and space, confounding ourselves with its lusty growth and rising to periodic alarms in the night. It is no accident that we have no urban history.
Perhaps the frightening specter of black cities of needless suffering at home and the prevalence of poverty across the world will force us finally to look more steadily at what we are and do. As a nation we will not thereby be free, but we will confront both the weight of the past and the freedoms of the present. Should we venture out beyond the narrow confines of habitual behavior, we will carry with us our traditional
values—for what else will guide us? Thus, if we are to have new cities they must be compounded of the aims and contradictions of our long quest for open competition, inclusive community, and rapid innovation. No matter what confronts us, we will make our choices within the boundaries of these traditional ideals.
Our cities, burdened as they are by the constructions and habits of the past and yet filled with the bustle of ever-present change, tell us much about the weight of continuity and the dimensions of choice. Although the social geography of the dispersed metropolis differs substantially from its predecessors, still its class and racial segregation, and its class, racial, and sexual discrimination testify to the terrible endurance of past habits. Flourishing amid unprecedented wealth and extraordinary mass freedoms of movement and communication, they bring to a climax the long trends of American city building. Such segregation and discrimination violate every ideal we hold: they foster unequal care and education of children, shut out adults from jobs and homes, foster unemployment and underemployment, maintain wages below decent living standards, create slums, stifle personal freedom, creativity and expression, deliver the wealth of the city to the rich and the powerful, divide the city against itself, and nourish an exploitative politics.
Class and racial segregation and class, racial, and sexual discrimination lie at the root of almost all the pathologies of the current city. As manifestations of our nation's deepest feelings, of our long racist, capitalist, and sexist traditions, such behavior is both the most grievous, and the most difficult of all the burdens which the past has fastened upon the present. The essence of our urban history has been rapid growth and pervasive change working within the confines of ceaseless exploitation of white over black, rich over poor, men over women. The contradictions of slums and suburbs, freeways and sidewalks, research hospitals and welfare clinics, new towns and public housing projects, are but the latest manifestations of the American way.
Since segregation and discrimination are the most pervasive failings of the modern city and thus the social issues which we must attack if we are to realize more of the potentials of our ideals, let us review our urban history in these terms. Where we now stand, some aspects of the metropolis offer us a great deal of latitude in choosing a fresh path, while others do not lend themselves easily to an attack on this negative inheritance.
With the rise of cities, the social value and interconnections among
parcels of land soon outstripped any benefits from treating real property as a civil liberty. In the face of urban interdependencies, the attempt to maintain a property law oriented in this tradition fostered a continuous stream of needless anomalies, from inadequate sanitation in the early nineteenth century to the injustices of today's urban-renewal and highway projects. True, legal reform could overcome some of the past handicaps. Especially it could redress the balance of power between landlord and tenant, public projects and private abutters, metropolitan plans and neighborhood improvement, and inner-city residents and suburban landholders. Yet no amount of legal reform and no amount of regulation can provide every city dweller with a decent home and a suitable living environment. Despite 150 years of urban growth and ever-shifting patterns of housing style and location, the trickle-down private housing market has never been able to meet these standards for the bottom third of our population. The changing measure set by the middle-class consensus as to what constituted adequate housing in 1870, or 1920, or 1970 has never been matched despite generations of reform. It can be met only by long-sustained government action.
Since the sheer supply of housing has the greatest impact upon the quality of housing for the third of our population with the lowest income, the government must become a major builder so that there is an abundant urban housing stock. As the repeated failures of philanthropic projects never fail to demonstrate, such a government program must start with a conviction of the right of all Americans to decent housing. From this platform the government should enter the housing field as a builder of model subdivisions, apartments, and new towns that conform to the consensus of our day. The advantages of such an approach are many. By building on a large scale according to accepted norms, state and federal agencies can influence the private market to conform to such standards, just as the TVA example stood as the yardstick for private utility operation elsewhere. The building of large quantities of housing is also the most promising way to break the barriers of class and racial segregation. The barriers will fall in two ways. First by offering the poor, the old, and the black a multiplicity of locations, many now pinned down in one part of the city will be able to relocate. Second, the plentiful housing stock will benefit the mass of white working-class and lower middle-class citizens who must now find homes within the narrowest of choices. Today's pockets of public housing projects heighten class and racial animosities because they benefit so few at an obvious cost to local
taxpayers who themselves are struggling to maintain a grip on home-ownership.
Finally, since land and public services are the essence of housing costs and the key to successful development, the government should become a buyer and seller of metropolitan land in its own right so that it may harvest the speculative profits of urban growth and coordinate the timing and placement of public investments and services. The state housing authorities appear to be agencies of sufficient scale and expertise to take metropolitan-wide action for major home building and for major class and racial integration programs. In view of the importance of land and services to the ultimate land and housing package, they need not be the builders of homes themselves but could leave construction to the private market, regulating its quality and subsidizing low-income occupants. Whatever the administrative mode, the public capture of the public value of urban land could go a long way toward financing decent housing and achieving a desegregated, free-choice metropolis.
With the U.S. Routes completed in the late twenties, the airline schedules established in the fifties, and the interstate highways almost completed today, the latest transportation revolution is complete. The national network of cities is now functioning on the basis of these systems, and the internal structure of the metropolis and megalopolis is rapidly assuming an appropriate configuration. On the national level, further allocation of the Highway Trust Funds should be coordinated with a federal urban growth policy that would seek to bring all Americans into their share of the wealth of the nation. In such a context, further elaboration of transportation becomes part of a series of planned urban and regional programs that would combine investments in research, education, health, housing, public utility, and environmental quality. As the Los Angeles case and European examples show, such coordinated programs can effectively aid low-income populations and depressed areas.
In underdeveloped countries lack of capital resources forces the harshest of choices in selecting the priorities and placement of such investments, but the wealth of the United States allows a broader approach. We need not apply the strictest tests to urban planning to determine whether one cluster of investments or another will promote the most rapid national economic growth, but may instead only require that our national planning show reasonable progress toward redistributing jobs, income, and living standards to the benefit of depressed areas
or depressed populations. We can leave to the open conflicts of inter-regional federal politics the decision whether such aid take the form of modernizing Appalachia, or whether instead it makes it possible for the poor of these areas to move to new high-standard urban areas.
A serious transportation problem, however, remains neglected within the metropolises of the nation. Women, blacks, and some of the poor in general lack decent access to jobs which pay a living wage in their regions. In such cases transportation planning must be combined with a full-employment, living-wage policy. If we can do nothing else for the cities of the nation, we could see to it that no American goes unemployed or underemployed, and that no American need work for wages which will not support a decent standard of living. A number of European countries have achieved this minimum. Such a commitment carries as its immediate and far-reaching consequences the funding of consumer demand to stimulate the economy, and the support of family budgets which grant immediately a large measure of freedom and equality to our low-income fellow citizens. Progressive taxation and national fiscal planning are the prerequisites of such a crucial urban policy, but a residual urban transportation issue remains.
With the interstates in place and job locations scattering in response to their efficiency, most Americans go to work by automobile. The automobile mode is more convenient than public transportation, multiplies the effective range of job choice, and increases social freedoms after working hours. The Los Angeles demonstration shows what we might expect if a metropolitan transportation program were tied to a national full-employment and living-wage policy. There a public agency was specifically charged with serving as the transportation advocate of the poor, for arranging new bus routes where existing companies could adapt their schedules, and of operating its own multiple-destination bus service. By such subsidizing of public transportation for the poor, many of them, especially women, were able to find jobs outside their immediate neighborhoods. Had such a program been continued and the women able to earn a living wage, in time they could have purchased cars of their own, thereby decreasing the need for subsidized bussing. Over the long run, say a decade, these paired policies could be expected to provide the poor with a way to purchase entrance into the freedoms of the metropolis and reduce the need for public transportation to a kind of taxi service for the old and the disabled.
At present, however, an active middle-class coalition is lobbying in
Washington and in state legislatures to introduce costly traffic reforms which will perpetuate the injustices of our present transportation system at a new higher level of costs. The coalition for rail transportation consists of middle-class commuters, suburban environmentalists who are concerned with urban aesthetics and air pollution, rail-equipment suppliers, tax-hungry mayors, and downtown real-estate men who hope to find yet another subsidy to shore up inner-city land values. To this group is added professional planners and architects whose nostalgia for the highly concentrated city of America before World War I has led them to argue that urban civilization cannot endure in a multicentered metropolis. The coalition powerfully resembles the same union that sponsored the City Beautiful and urban-renewal projects which cost our cities so much and did nothing to help low-income Americans achieve equal membership in our society. In this case, however, rail proponents argue that the construction of rail lines will let the central-city poor reach jobs on the fringe. So it would—a few in a limited way. There was a time in the thirties when rails, busses, and highways could have been planned as a coordinated metropolitan system and such plans would have caused the city to conform to its patterns, but now with the superhighways in place it is too late. To be a full-fledged member of the American city means to own a car, and everyone knows it.
Even if the rail lines duplicated every intrametropolitan superhighway, and no one has yet dared to suggest such a costly duplication of investment and horrendous operating subsidy, the poor would still have less job access than if they had cars because they would still need to get from their homes to the stations, and from the stations to the scattered workplaces. The subsidies, for their part, would tie up billions of dollars which could better be used for incremental addition to existing road networks, new schools, parks, health facilities, and minibus subsidies. A nonpolluting automobile and reform of the local property tax are all that is required to save our cities and their disadvantaged populations from yet another massive raid by the rich and the midle class on the public treasury.
The transportation and technological climate that caused the national network of cities to grow and conform to its configuration also nourished the bureaucratization of modern urban life. Today's corporate cities offer immediate possibilities for ending segregation and discrimination, and in the long run the potential for a more humane and democratic way of life. Throughout our history, conditions in the work-
places of the city have been the most important determinants of the quality of urban life. The discipline, machinery, hours, and social amenities of work have set the boundaries of families' everyday experience. Although a new middle class of professionals and proprietors has burgeoned with the expansion of suburban retailing and services, a much larger segment of urban society labors in private and public bureaucracies. Factory workers, salesmen, clerks, engineers, schoolteachers, municipal employees, medical personnel, altogether a giant fraction of the modern city's population at every skill level, now participate in and endure bureaucratic labor. In this labor rests the fate of our cities.
The ability of large organizations to manage complex tasks and to coordinate diverse personnel makes them ideal instruments for assistance in managing urban growth and helping with the task of full employment and living wages. In Europe, subsidies and licenses are used to get businesses to locate in accordance with national and regional employment plans, and there is no reason why both private and public corporations in this country cannot be asked to meet similar demands. At the same time, the underserving of the urban physical and social environment makes the large public corporations of our cities ideal candidates for full-employment hiring. Nothing is more absurd in the contemporary American city than its neglect of public services while thousands of young people and older men and women go unemployed or underemployed.
In the long run, the bureaucratized workplace offers the chance for a major improvement in the quality of urban life. At present the corporate society, both in our capitalism and in other nations' socialism, delivers altogether too much power to the elites at the top of the bureaucracies. At the same time, the mass of employees are organized into authoritarian hierarchical relationships in the plant, office, store, or public institution. From this pervasive structure comes the management which makes the cars that pollute and rust away, the office that won't promote women or hire blacks, the communications media which lie to the public, the chain stores which cheat their customers, the hospital which serves the doctors, the school which cannot teach the children. In short, bureaucracy institutionalizes all the bad habits of the general culture and by its institutional size and many levels of responsibility erects a deep defense which makes any of these evils hard to dislodge.
The student strikes, workers' wildcat walkouts, the sudden spread of
unions among professionals, women's protests, and consumer movements in the developed countries of the world express the pent-up frustrations of people who sense some of the possibilities of our new social situation and who face instead the senseless oppression of bureaucratic control over their lives. Although unionization has protected many workers from the worst kinds of exploitation and the rise of productivity has benefited many more, as things now stand neither the consumer nor the employee has any real control over the work of the city and hence no control over the essence of his culture and his daily environment. No country has yet devised methods for the democratic control of production and services by consumers or democratic control of the mode of work by the employees; yet if our cities are to approach our goals of open competition, community, and innovation and not become managed societies run for the benefit of the elite, we must face the fact of the bureaucratized metropolis.
Consider how far we now are from respecting the rights of consumer and employee as commanding the same respect as one's rights as a voter in the political city. Recall the expression on the school superintendent's face when the students demanded control of their schools, or the office manager's incredulous expression when challenged for discrimination against blacks or women, or the shock and disbelief among the executives at the General Motors stockholders' meeting when a minority suggested that consumers should be represented. Our executives no more believe that the consumer and the employee are capable of intelligently representing their own interests than the British colonial governors of the eighteenth century believed Americans could govern themselves. Unfortunately for us all, most Americans also don't. We accept responsibility without autonomy, routine without meaning, demands for loyalty in the face of the most obvious fraud and injustice, consider power legitimate when exercised in the name of property or title, and make our separate peace within the interstices of routine bureaucracy. For our discomfort and the malaise of the city we prescribe more of the same—pills, police, education, more enlightened bureaucratic management, more consumerism. The highly organized structure of the modern city and the heightened consciousness of the sixties do, however, offer a place to begin. The group structure of the most urban workplaces is already a form which can be subject to the same sort of politicization as government institutions. In the public corporations where there is now the greatest conflict, in public housing, welfare, recreation, health, edu-
cation, and police, groups of embattled consumers and harassed employees are demanding representation in management decisions. Examples of participatory management and cooperative enterprise exist in scattered private firms. We have the precedent of the New Deal encouragement of rural cooperatives and the recent Great Society programs to tell of the possibilities for public aid to such experiments. In the long run the continued health of American urban society will depend upon the extension of democracy into the bureaucratic workplaces which now control the fate of the city and its inhabitants.
It is customary to conclude books on urban reform with a lament over the decay of the neighborhoods and the decline of small-scale community life. Although some neighborhoods are ravaged by heroin, many are afflicted by poverty, and all suffer the disease of white racism, there is no reliable historical evidence which suggests that local government, local institutions, or local life are decaying. The behavior of local government and the studies of social science show that a broad consensus on what constitutes a decent American life runs throughout the city. A decent job, a good education for one's children, a comfortable home, and adequate health care are on everyone's list of priorities, and the cultural variations by class, race and religion which give specific meaning to these priorities are not very wide. Wide enough to tip the balance in a local election, to be sure, but narrow enough to support a common set of public and private institutions in all but the impoverished sections of the city.
When the Presidents of the United States decide to finance their wars with inflation and unemployment, it is the local community which must cope with the impacts. When tax lawyers and Congressmen connive to destroy an equitable progressive tax structure, it is the neighborhoods which must suffer the housing shortages, overcrowded schools, and hospitals. When the young people begin to march for civil rights and peace, it is the churches that organize for support. When the state police beat and shoot the prisoners, it is volunteers from the city who drive out to the prison to see if they can help the convicts. When legislatures and Congress fear to regulate the smokestacks and automobiles of the nation, it is the Boy Scouts and housewives who gather up the newspapers and collect the bottles. For every race-torn town in the metropolis, there are others that are coping patiently with the transition to an integrated society.
American urban neighborhoods are not nor have they ever been
peasant villages; nor are they nor have they ever been model republics. Yet to an extraordinary degree, considering the rapid movement of millions of American families, they have been able to muster men and women who pass petitions, sit patiently for hours on local boards, and help out their friends and neighbors in emergencies. To the extent that the American city is now rotten, it is rotten at the top, not the bottom. What the neighborhoods need at the present moment, and what they have been needing ever since our cities became the creatures of large interconnecting economic forces and institutions, is the assistance of democratic national and regional planning.