The Decline 

Opened in 1929 on the eve of the Great Depression, Met State, as it was popularly known, had been in operation for sixty-three years. During this extended period it had provided both acute and long-term care for patients suffering from various mental and personality disorders. Over the years thousands upon thousands of patients had been treated there on their road to recovery or stability. Most referrals originated with families who found themselves unable to cope with the bizarre and erratic behavior of a troubled member. The hospital admitted people from three of  DMH's nine catchment areas. These included the Cambridge-Somerville area; the Beaverbrook-Concord -Mystic Valley area; and the Tri-City area, which encompassed the cities of Everett, Malden, and Medford.

Metropolitan State Hospital was supposed to be closed in 1978, but that did not happen. The plan was for McLean Hospital to replace Met State in terms of acute and long-term care, but the Public Health Council turned down the plan. Meanwhile, the eight remaining state hospitals continued to decline and decay, becoming little more than holding cages for the acutely and chronically insane. All eight were guilty of flagrant neglect and harm to nearly helpless people. The back wards were filthy and appallingly inhumane. Patients were not only stripped of their self-esteem and human dignity, but the restive and unruly ones were forcibly placed in seclusion and mechanical restraints, some forced to take medication against their will. Grim stories about physical and sexual abuse abounded. Hospital attendants often played mind games with patients by threatening to send them to Bridgewater with the criminally insane if they acted up or otherwise caused trouble. Since the law called for strict security, this kind of intimidation and cruelty was no idle threat.

 

The quality of care at Met State in the late 1980s left much to be desired. Most of its patients suffered severe mental illnesses ranging from paranoid schizophrenia to bipolar disorder. Some of these illnesses are associated with chemical changes in the brain, which caused their victims to lose touch with reality. Theirs was a world haunted by failed treatments and fearful delusions and hallucinations. Those who suffered psychotic relapses returned to the hospital for repeated commitments. The recidivism rate was fairly high. The most costly aspect of mental health is hospitalization the average cost per patient per year at Met State in 1991 was $98,500. By marked contrast, a similar stay at a community setting cost, on average, $55,000 per client, which included residential, day, and support services.

 

In carrying out its responsibilities, Met State was plagued by numerous problems. Client concerns that had been so troubling to so many were legendary, serious care deficiencies and staffing shortages being among the most prevalent. This led to many reports of abuses, for example, individuals being misdiagnosed or over drugged and neglected in the back wards. Before long it encountered financial problems and found itself continually underfunded and understaffed. Year after year it experienced successive expansions and contractions of public and political support. This pattern of unstable funding explains in large measure why the hospital declined

 

Throughout its sixty-three-year history, Metropolitan State Hospital had operated as a site-specific organization where bureaucrats and clients coexisted with one another. In 1990 by a chief operating officer and a staff of physicians, nurses, hospital attendants, social workers, security guards, and building managers. As one participant recalls, "Met State was a fiefdom in and of itself; it had its own rules and its own code of conduct."23 Most of its employees worked in rotating shifts around the clock. The hospital was a highly labor-intensive enterprise that typically allocated about 85 percent of its budget to personnel.

 

Met State lost its JCAHO (Joint Commission on Accreditation of Healthcare Organizations) accreditation in 1980, and from then on it was all downhill. By this time the physical plant was in bad shape, incrementalism had taken its toll, and patients com­plained about poor heating, poor ventilation, lack of air conditioning, foul odors, and filthy conditions. Only three of the seventeen original structures still housed patients. The aging buildings were falling apart: crumbling bricks, leaking roofs, and a wasteful heating system characterized their physical deterioration. In August 1983 the hospital was forced to operate without running water for two days, a debacle that occurred when a fifty-five-year-old water pump broke and caused the water tower to run dry.73 Water had to be trucked in by mobile units of the National Guard.

Since the old steam lines had few operable control valves, much vacant space in the abandoned buildings remained heated, resulting in huge energy losses. Other mechanical, electrical, and emergency systems were outdated and inefficient. It was estimated that the hospital wasted about three-quarters of its annual $1.7-million heating budget.

 

By 1991 it had become a remnant of a bygone era when bigger and better hospitals were seen as the only viable option for the mentally sick. The decision to close Metropolitan State was based largely on the worn-out condition of its buildings, their replacement value, maintenance, and capital funding, and their physical and functional obsolescence. In short, this sprawling hospital complex was underutilized and too expensive to operate.

New England Journal of Public Policy 1999 edited for length