This book began with a relatively simple premise: that the organization of health and hospital services was, in a variety of ways, a reflection of historically determined societal values and interests. It was my purpose to investigate these relationships and to understand how certain practices arose and how they changed over time. Of particular interest to me was the history of the relationship between patients, professionals, trustees, workers, and politicians, all of whom had different ideas and distinctly different goals at crucial moments when the modern health system was formed. To address the history of health care in any meaningful way it was necessary to understand the perspectives and interests of the different actors.

My own perspective was shaped by my experience as an administrator in New York's health system as well as by my training in the history of science and American social history at Harvard. It was this background that prompted me to use the tools of urban and social historians to analyze health policy issues of concern to health professionals. This book centers on the historical roots of distinctions in services based upon geography, income, race, and employment status – referred to as “access” and “availability” issues by planners and policy makers; the changing nature of trustee and staff relationships; and the development of new models of hospital and health care – which are often borrowed from business enterprises rather than from other social services.