Triage as Urban Policy by Peter Marcuse, Peter Medoff, and Andrea Pereira If the city is to survive with ‘a smaller population, the population must be encouraged to ‘concentrate itself in the sections that remain alive. . . . The natural flow out of the areas tha have be encouraged. ost general attraction must The role of the city planner is to observe and use {the trend of abandonment] so that public investment will be hoarded for those areas where it will sustain life Federal housing subsidies can be used to encourage movement ‘away from deteriorating areas The streiches of empty blocks may then be knocked down, services can be stopped, subway stations closed, and the land left to lie fallow until a change in economic ‘and demographic assumptions makes the land useful once again.—Roger Starr, The New York Times, Nov. 15, 1976 PETER MARCUSE is professor of ur- dan planning at Columbia University PETER MEDOFF is a student in, and ANDREA PEREIRA has recenily com pleted, the graduate program of urban planning, Columbia University. Work ‘on this article was done in part for The Working Group for Community Development Reform, National Citi zens’ Monitoring Project wr J [have] argued for a land management sirategy that would guide centrat-city depopulation toward the complete clearing out of population from the weaker subdivisions and the clustering of the remaining households in the stronger communities. Sizable savings in the cost of producing and delivering public services are most likely 10 be achieved only if whole service ‘areas can be emptied out, so that the service can be completely withdrawn.—Wilbur R. Thompson, in testimony before the Subcommittee on the City fof the Committee on Banking Finance, and Urban Affair. ULS. House of Representatives. 96th Congress, Second session. Sept. 16-17, 1980 There are advantages in clearing first at the edge of the areas we intend to save and ‘moving from there on inward. The worst decay most often is in the center of the area to be eventually cleared... . We [might] choose 10 clear land first very near 10 the most marginal laveas we are trying to save and then work back toward the center (worst) of the blight. We could use this land as an open-space buffer zone.—Wilbur Thompson. Land Management Strat for Central City Depopulation,”” in How Cities Can Grow Old Gracefully, Subcommittee on the City, Committee on Banking, Finance. and Urban Affairs, U.S. House of Representatives, 95th Congress, First session, Dec. 1977‘Triage is a term that came into gen- eral use during the Vietnamese War to describe the policy adopted to es- tablish priorities in treating. wounded soldiers." As they were brought into the medical treatment area, they were classified into one of three groups those whose injuries were slight or for whom no medical emergency existed, those hurt so badly that no available medical treatment would be of real use, and the remainder. [twas the third category. the remainder, that was giv- cn priority, on the theory thatthe first {group would get better even without emergency medical treatment, and the second group would not be served by treatment in any event, Triage is quite at variance with the ‘more conventional approach of first treating those whose condition is the most critica, helping those most who are most in need. It was nevertheless argued that its use was justified in situations where the supply of medical services was grossly overwhelmed by the number of those needing trea tment, whatever medical ethics might say on the matter “Triage has also come to be used to describe a certain policy dealing with neighborhoods in recent times. The concept underlying it was first explic- itly enunciated (although its imple- mentation may well have preceded its enunciation) ina famous article by Roger Starr in The New York Times Magazine in 1976. State, who hac just left his position as administrator of the Housing Development Adminis- tration, New York City’s superagency dealing with issues of housing and community development, argued that cities like New York were declining in population, employment, and re- sources; that such decline was inevi- table, resulting from forces far be- yond the power of the city to control and thatthe most rational response to that decline was a policy of “planned shrinkage."° Rather than attempting to maintain public facilities and services throughout the city, at levels that could no longer be justified. in view of the city's decline, he suggested that the city rationally and consciously select those areas that it would make most sense to abandon. It should then con: centrate its resources in other areas. au ‘The city would be able to strengthen those areas that it could make greater efforts to save by being able to transfer resources to them from the areas it was writing off. Two advantages would thus result. For the city, the net effi ciency of its operation would be in- creased because of the cost-ffective- ness of concentrating services in viable areas and the savings achieved in the written-off areas; for the neighbor- hoods, although those being. written ‘off would decline more rapidly than they might otherwise, only the rate of decline, not its fact, would change, while other neighborhoods would be saved that otherwise might have been lost. ‘The allocation of benefits useful only to areas of growth does not have to entail the writing off of an area of stability or decline, but it may have a similar effect. ee Because of its resemblance to the policy for treating patients in condi- tions of wartime, Starr's policy was soon described by commentators as cone of triage: Starr's arguments have a certain superficial plausibility about them Given limited resources, the cost- effectiveness of this policy may well be enhanced by its concentrated ap- plication in certain neigborhoods, it might seem. If other neighborhoods are inevitably going to decline, given ‘macroeconomic and demographic cir ‘cumstances beyond the control of pub- lie policy, then it could be argued that the continued expenditure of funds 0 preserve those neighborhoods at their ald levels is only an attempt to hold back the tide. Better to accept and plan for the inevitable than to squander resources fighting it to no avail. There should be a net public savings from the strategy, it can be said; part of that savings could then be allocated to alleviating the hardships caused to those in the abandoned neighborhoods and assisting in relocating. retraining. for supporting in other ways their last remaining residents. They. as well as the citizens and taxpayers of the com ‘munity at large, will benefit in the long, run. To help those in the South Bronx hhold out just a few years or even months longer in the face of decay and blight all around them is doing neither them nor anyone else a service. the ‘argument runs, THE FORMS OF TRIAGE [As used in the present context, triage means the exclusion of a particular ‘geographic area from service by gov~ cernmental programs, despite its need for them, on the grounds that the very intensity of those needs make that service in the area inefficient. Such an area is thus “written off” for purposes of those programs. This is the narrow definition of triage. A broader definition might also include (1) public actions favoring cer- tain areas as well as those disfavoring them and (2) public inaction as well as action, The allocation of benefits use: ful only to areas of growth, for it stance. does not have to entail the writing off of an area of stability or decline, but it may have a similar effect. The failure to adopt any pro: gram to deal with certain issues, by the same token, may result in the writing off of certain areas. The failure to deal with arson for profit, forinstance, or provide for programs addressed to sp Cifie problems of new groups of immi- grants may have as much effect in contributing to the decline of a geo- graphic area as any policy formally adopted, even though it constitutes nnonfeasance rather than misfeasance There are four possible forms of triage. Triage I. At the most innocent end is Triage I. which means the distribu: tion of public services or facilities in accordance with nongeographic, non- locational standards, but which bas the unintentional consequence of limi- nating a specific geographical area from the investment or funding pro ‘gram, The distribution of library facili= ties in accordance with existing reader «demand, for instance—as was shown in a recent Los Angeles review—has iF impact of favoring higher- SOCIAL POLICYincome areas and may result in 90 lit- tle investment in certain low-income neighborhoods that (partly as a result of the vicious circle of inadequate supply turning off demand, partly as 4 result of orthodox “cost-etfective- ness” analysis) library facilities may be entirely removed from that neigh- borhood. Triage M1. Triage IL is the use of locational standards for the distribu tion of public goods or services, but without the delineation of specific weo~ ‘graphic areas to be favored or avoided. Under Triage If, for instance, the rule might be formulated that rehabilitation grants will only be given in a block Where there are less than 10 percent abandoned, demolished. or sealed-up buildings. The same results might be produced by providing that rehabilita- tion funds only be granted where after rehabilitation the economic viability of the unit on the private market will sustain its proper maintenance and 0 ‘cupancy. or where a program is cond tional on private participation. which in turn uses locational criteria. Such policies have the effect of eliminat Ing from the program consideration of specific geographic areas where abandonment is widespread. but with- ‘out at the outset outlining the areas to be avoided, Triage Il. In Triage I, either blocks or census tracts may be desig- nated from the beginning to which, because of the high concentration of ‘abandoned buildings or for other eco: nomic or physical reasons, rehabilita tion grants will not be given, or other census tracts or areas may be designat- ed that would have priority claim on rehabilitation funds, Triage IV. Triage IV, finally. is the designation of specific geographic areas for the distribution of public goods and services. Certain areas may be given a high priority for all ser- vices across the board, as in Neigh: borhood Strategy Areas, for instance. but others would be effectively red- lined, Whether Triage IV is done only indirectly, by putting all resources in favored areas and leaving none for triaged areas, or whether itis done as a ‘matter of an explicit policy of planned shrinkage does not seem particularly relevant WINTER 1982 ‘The crucial issue throughout is not one of motivation or intent, but of the clear, known, and foreseeable result of the policy. Only in Triage | could the argument bbe made that the consequence was “accidental."" In each of the others it is a specified and explicit policy that areas be treated differentially that ‘geographic distinctions be made. In Triage Il, the distinctions arise from program formulations rather than from the designation of geographic areas. as in Triage Ill and IV. The differenc between Triage Il and Triage IV is only in the comprehensiveness of the ‘approach: Triage III may be applied only 10 one oF two programs, while The policy of triage itself is in part responsible for creating the precise conditions that seem to create the need for —the loss of jobs and people from neighborhoods in the inner city. << Triage LV establishes policy more to- tally for a whole variety of investment or funding decisions. Distinetions among the forms of triage are set forth specifically to make it clear that all of the types of public action as noted above can be appro priately classified as triage, regardless of the particular intent of the parties involved or the explicitness of the ‘geographical criteria used, THE CASE AGAINST TRIAGE ‘There are six major arguments against the policy of triage © Many of the problems of neigh- borhoods are by no means inevitable but, in fact, come from prior pub: lic policies that can be altered and reversed © The policy of triage itself is in part responsible for creating the pre- cise conditions that seem to create the need for it—the loss of jobs and people from neighborhoods in the inner city It is by no means clear, even accepting the inevitability of some de- cline in employment and population in @ city, that a policy of writing off specific neighborhoods and concen- trating resources in others is a more effective use of resources than alter ‘nate methods of establishing priorities and distributing resources. © Triage destroys communities just at atime when the values of communi ty preservation are being recognized as ‘central to national urban policy. @ There are adverse distributional clfects in a policy of triage. It is invariably the poor who will suffer— overwhelmingly minority group mem- bers. women, the elderly, and youth; the rich, the business communit well-to-do, and officialdom will not While a policy of triage may be cost- effective for some, it may be devastat- ing for others, generally those least able t0 deal with its consequences. ‘That hardly seems a distribution of costs and benefits that public policy should seek out © Finally, resources are not limited in the sense of the Vietnamese medi cal situation; it is well within the re- sources of the United States of Amer ica to (reat successfully the problems of its neighborhoods The decline of city neighborhoods is not inevitable. The argument that the changes in the character and location of economic activity are not the in- cvitable result of the play of free market forces, but also the result of deliberate and massive public policy, has been spelled out in detail else- where.’ Tax laws, rewarding the writ ing off of existing plant and equipment and providing accelerated depreciation and investment credits for new con struction and equipment; local govern ‘ment bonanzas for businesses moving. into a community, leaving minimum ‘wages low and permitting state action such as right-to-work laws that foster significant wage differentials among ilferent parts of the country; public stimulation of high-technology, capi- taLintensive industries and products rather than labor-intensive, commu- nity-based enterprises; inducements offered to business by state and lo- cal governments to relocate facilities 38within their borders—all these have areatly encouraged the movement of capital and economic activity out of certain areas and into others. The fact that the cost of such moves is borne publicly, while the benefits are reaped privately, worsens the complicity of public policy in the adverse cons quences of shifting locations of eco- nomic activity. Instead of dealing with the symptoms and consequences of these shifts in business activity, their causes can be directly addressed. This ccan be done at least in large part by simply reversing existing public poli- cies. The patient is only terminally ill because of the treatment: a different treatment might effect « miraculous change The policy of triage itself uccenu ates the very conditions itis designed to cure. Even assuming, for the sake of argument, that a city's economic base is declining, that capital, employ~ ment, and consequently the popula- tion are leaving because of forces be- yond the eity’s control, the policy of triage is likely to accentuate these evils rather than cure them. Neigh- borhood conditions are themselves frequently a reason 10 move, even where continued occupancy is other- wise preferred. Given the abandon- ment of half the structures on a block because their residents have moved elsewhere, those wishing to remain will find themselves quickly motivated {© move out as well. The process has been well documented. ‘Once a city policy of triage is adopt- ed, once a given area, still partially ‘occupied, is abandoned by the city, its residents will have no alternative but to move. Given the decision to move, it will more likely be out of the city than within. The same holds true for busi- ness fitms. Once the infrastructure, the access to labor market, the transpor- tation facilities, the public securit the environmental quality of a neigh: bborhood, are written off by the city, firms will move that might otherwise have preferred to stay. Nor is there any reason to believe that their movement will be to another location within the city. Once a move isdecided on, anew and more attractive site out of town— often even out of the region—will generally be found. 36 The triage of entire neighborhoods is less economical shan a planned reduction in density more broadly dis tributed throughout the city. Again, assuming for the sake of argument that loss of population and economic activity will take place, there are ad- vantages as well as disadvantages that can be obtained by a community from the process. Most older cities have areas of extraordinarily high density ‘They have buildings constructed for uses that are outdated, technologically and. socially obsolete, They have a need for more open space, for recrea- tion facilities, for more light and air. They have overcrowded transit facili- ties, congested sidewalks and streets, noise and pollution resulting from heavy use. They lack playgrounds, trees, benches, altractive green spaces for outside activities A policy of planned reduction in density might, in fact, make a great deal of sense in many older cities. It would involve looking at the quality of individual structures, their age, their suitability for their current uses. It would involve looking at the quantity and quality of community facilities available and calculating the densi- ties most appropriate for optimum use of those facilities. It would involve looking at existing fixed-route transit facilities and planning the best use of their layout. It may then invoive a policy of very strict code enforce- ment in areas where reductions in den sity are desirable, labeling obsolete arrangements as nonconforming, and condemning other steuetures where al temative public uses are desirable. Planning thus becomes planning for reduction in size and planning for re- duced densities and improved quali- ty of life, rather than planning for the amputation and death of entire neighborhoods, New York City figures suggest the problem. A majority of all apartments Im the city are in either “Old Law Tenements”” or “New Law Tene ments."’ Old Law Tenements are those built before 1901, generally to much lower building standards—with much greater lot coverage, less light and air, et cetera—than exist in those buildings built after the new Tenement House Act became effective in 1901. A total of 135,000 units were removed from the housing inventory between 1975 and 1978: 33,000 of these, from the available figures,* were Old Law Ten- cements, but 75,000 were New Law Tenements. This is not the market removing the oldest and worst of the housing stock as the overall quality of housing improves; rather, this is a process, whether deliberate triage or hot, that removes more newer units than old from current use and leaves behind a vacancy rate of 2.9 percent, the present figure in the city. well below what a balanced market would show. Even the increased vacancies and loosened market for housing that could be the silver lining in the cloud of population loss does not take place in New York today. Surely these re sults cannot be defended as part of a desirable public policy ‘What an alternative approach would look like is, in fact, not so hard to imagine; by something less than coin- idence, New York City has a classic example right at hand. The very first public housing in the country, spon- sored by the Public Housing Adminis- tration in the early years of the New Deal, was in New York, First Houses, ‘on the Lower East Side, was in fact not new construction but the rehabilitation of Old Law Tenements. One of the ingredients that made it a universally acknowledged success was that every third building on the block was demol- ished to make light and air for the remaining two, and back portions of buildings were taken down to create pedestrian ways and play spaces for residents. In a city with a declining population and an older housing stock, such an approach makes super com- mon sense, As selected units are taken off the market and demolished, the r maining units are improved, the neigh- bborhood changes for the better. and the community is preserved and strength- ened. These results are just the oppo- site of those produced by a policy of triage. Triage desiroys communities. The loss of the spirit of a community that accompanies a policy of planned shrinkage is one of its serious draw backs. It is the relationship to the community in which one lives, after all, that creates @ great deal of the SOCIAL POLICYsatisfaction one obtains from one’s residential environment. Neighbors, ‘one has known a long time, stores offering known goods, patterns, net- works of support, habits, traditions of community, all mean a great deal to people—and their disruption and de- struction can take away much of the attraction of life in a city. The strength ‘of the opposition to policies of neglect and abandonment shown by residents ‘and community groups in the South Bronx attests to the strength of the spirit of community even in such & devastated area. Yet triage deliberate~ ly sets out precisely to destroy such communities. In a period in which the forces of community, neighborliness, and belonging are increasingly looked to as a bulwark against anomie, de- inquency, vandalism, hopelessness, and where the preservation of existing ‘communities in other areas of the city are major objectives of public policy the deliberate destruction of these very values in areas of triage seems a dubi- ous policy. Beyond this, of course, the destruc tion of communities accelerates the very losses of population and housing that are supposed to have produced the need for their destruction to begin with; the circle is tight and vicious indeed The damage done by triage hurts those most who can afford it least. The areas of the wealthy are not likely to be subject to triage: central business dis- twicts are not likely to be neglected; luxury apartments are not likely to be abandoned; solid single-family home- owners will protect their own neigh- borhoods and schools—often to the exclusion of others. Those excluded from both the residential and economic benefits of this society are precisely the ones who will be most negatively affected by triage. Those are inevita- bly Blacks, Hispanics, recent immi- grants, women and households headed by women, teen-agers who are out of work, the elderly. It is their schools that will be abandoned, their streets that will be neglected, their sidewalks filled with broken glass, their trans: portation cut off, their employment moved away, their buildings neglect- ed, their safety ignored. The vague promises to make up to them else~ WINTER 1982 where for the losses occasioned by their geographical location are lip ser vice indeed, If economic and/or demo- ‘graphic decline dictate that some in a community must bear unusual if temporary costs, surely public policy should seek (0 distribute those costs ‘mote equitably than by a policy of triage of the poorest neighborhoods Resources for the preservation of neighborhoods are not inadequate This is perhaps the most important and simplest point, although the one most often lost sight of. Ibis, at the very least, startling to assume that the na- tional resources of the United States are inadequate to cope with the prob- lems of our most depressed neighbor- hoods. In absolute wealth. this country is the richest nation on earth; in Gross. National Product per capita, it is in the top five: its technology is unri- valed, its government stable, its com: mitment (© democratic values long- standing and widely heralded. To give but one example, in a comparison between the United States, the United Kingdom, and West Germany in the extent of public support for new hous ing construction, the United States shows up as a very poor third over the years The concept that this nation is mate rially unable to deal with the problems of the South Bronx because of some inherent limitation on its national re- sources would, one might think, be accepted only with the greatest reluc- tance, intellectual as well as moral. It ccortainly should not be made the start- ing point of public policy Dispute about the pros and cons of triage is by no means academic. It is a policy that, in the form of Triage | or I, has been with us for some time; Triage I and IV are more newly arrived, the advent ofthe latest “urban fiscal crisis” ushering in their whole- sale use. The closing of schools, the elimination of transportation services, cessation of upkeep of parks, elimina tion of building inspections, denial of rehabilitation funds, have ail been ac celerated in arcas where blight is “too severe."” The National Citizens’ Mon- itoring Project of the Working Group for Community Development Reform’ of the Center for Community Change hhas documented the way in which community development block grant fands have been used to effectuate triage, despite the (weak) federal regu- lations against certain forms ofit. Now, with the further weakening of federal guidelines for a variety of programs, land the increased discretion given mu nicipalities and states, the threat of triage is dramatically increased In this context, community groups, all faced with reduced funding, may easily find themselves fighting among themselves forthe erumbs that remain, and it will be harder to keep a focus on the big picture. Yet that is where the focus must be, if triage is not to be allowed to be part of a divide-and- conquer strategy. Community groups must fight to have adopted local guide- lines at least as strong as those that have existed (or have been advocated) atthe federal level. They must join together in insisting that severity of need and human benefits, including the protection of communities, be the priority for the allocation of funds, not some abstract economic cost-bene- fit measure that ignores distributional effects entirely Al NOTES ihe word “triago” isan old one, dating back fo atleast 1927, and comes from the Same root as the word “Wy.” Ns. onginal meaning was simply tosor to sleet nthe mineteorin century, -viaged cofes® came to mean coflee tna has Been rejected fn tho Tormal sonng-out process when the beans wore inspects, and was sald at aout pce ‘The applealon to seting ports for mea ca treatment apparently dates Back tothe French amy eng he ist Word War, but the" enotaion wing a -npelss Eases ony came ino vogue withthe Veta War,” eter Marcuse, “Pubic Cris for Private profs: Onine Usetuness ofthe ban Fiscal Gras, Working Paper 20, sen of Uban Frgpning, Coumbia Universtiy 1981 ‘Peis Mareuso, Renta Rousing n the iy. of New York: Supply ‘and Condon, {ars1076, New York Department of Hox ing Preservation ‘and. Development, Rent (CBarot Dvsion, January 1973. “Gee tne excsonteatlogue ofthe exh bition on the South Gronx prepared atthe Bronx Whiseum, Devastabon Resurrection ‘he South Bronk, 1979. “ine project nay Be reached at 1000 Wisconsin Avenue, KLW., Washington, D.C. So0ar, Paul Boyd i projet recor MOVING? Don't forget to send us your New address. Enclose address label from your last issue. 37