Ghost Hospitals: A History of Rural Hospitals and Efforts to Keep Them Alive in the 20th Century United States

Abstract

In the early 2000s, American journalists reported an emerging crisis of rural hospital closures in the United States. Rural people despaired that a hospital closure heralded the death of their community—not only in terms of their own mortality, but also in terms of their economic and cultural vitality. When shuttered, these “ghost hospitals,” as some have described them, are sites of lingering memory and unfinished business for rural communities across the American landscape. In my dissertation, I trace, and at times complicate, this tale of the rural hospital’s supposed demise. The decline narratives that pervade the contemporary news media shroud a deeper truth: rural hospitals and their communities endured a continuous state of precarity throughout the 20th century. My dissertation investigates how rural hospitals have survived and changed over these decades—and what these hospitals’ challenges reveal about fundamental inequities in disease burden and resource allocation in the United States.

The history of American medicine is usually told as a history of urbanization, with the emergence of the hospital as the main act. A history of rural hospitals, however, can illuminate legacies of neglect and disenfranchisement that traditional histories do not. This dissertation offers three main arguments. First, the challenges that rural Americans face in building and sustaining healthcare systems in their communities today are largely the same as the hurdles their predecessors faced a century ago. Examining these throughlines offers not only a deeper understanding of disparities in rural healthcare, but also a lens to examine the biases, contradictions, and blind spots of the urban-centric American medical system and political economy more broadly. Second, the American rural is not a monolith: while rural people across time and place shared a desire for hospitals of their own, their experiences in sustaining these institutions varied significantly across lines of race, Indigeneity, gender, and class. Rural geography layers on other legacies of disenfranchisement to create the worst health conditions in the most marginalized rural communities. Third, even more than their urban counterparts, rural hospitals perform crucial economic, cultural, and symbolic work in their communities. These institutions are integral to local identity formation, anchoring down and knitting together isolated communities in ways that transcend their medical functions. However, these forms of work are not captured in market-oriented analyses of rural hospitals. Only by paying attention to how rural people ascribe meaning to their hospitals can we understand why financial analyses fall short in capturing these institutions’ value, and the impact they have when they are gone.

This project begins with an exploration of Progressive reformers’ forays into rural public health work in the early 1900s, and their discovery of high morbidity and mortality in the countryside (Chapter 1). The following chapters trace the development of American rural hospitals through historical case studies of four hospitals across some of the nation’s most rural lands—from the American South and Appalachia, to the Midwest, to the Pacific Northwest and Alaska. Each chapter addresses a distinct theme: the birth of the national rural hospital movement during the Progressive Era (Chapter 2); the racial politics of rural hospital construction in the Jim Crow South after World War II (Chapter 3); the rural hospital as a site of Indigenous self-determination during the Red Power movement in the 1960s (Chapter 4); and finally, the economic precarity of rural hospitals during the 1980s, as the American healthcare system rode the tumultuous tides of global neoliberalization (Chapter 5).