In Dallas, Texas, people living south of Interstate 30 (I-30) die approximately 20 years before people living north of I-30, on average. The communities are poor and the region has few medical facilities. The opportunity for change emerged when the RedBird Mall — also south of I-30 — underwent a retail space conversion. The repurposed Sears store and surrounding lots now offer low-income communities convenient access to healthcare.
Retail malls, which traditionally serve middle- and high-income predominantly white communities, can flip the script. These spaces, known for spatial segregation and racially discriminatory practices, have an opportunity to become access points for healthcare services. Repurposing shopping malls with a high vacancy rate — so-called dead malls — into medical malls can lead to healthier lives in low-income communities.
For a while now, healthcare systems have been repurposing empty brick-and-mortar businesses, so the retail-to-medical mall migration is not new. We also saw smart use of repurposed spaces during the pandemic when empty malls became COVID testing and vaccination sites. The retrofitted retail spaces may contain services including urgent care, day surgery, optometry, physical therapy, laboratory testing, and diagnostic imaging such as MRIs and mammograms.
However, many medical malls are inaccessible to the people who need healthcare the most. In one study of 28 medical malls, a minority served communities with average household incomes below the federal poverty level.
The White House recently released a playbook to address social determinants of health (SDOH) — features of the places people live, learn, play, work, and worship that affect their access to healthcare, transportation, healthy food, and more. SDOH translate to differing life experiences, such as quality of life, life expectancy, and reliable access to healthcare.
We think dead malls can help marginalized communities lead healthier lives in a few ways.
- Conveniently located medical malls can flip a community’s fragmented and episodic care into consistent and reliable healthcare. Convenience is one of the greatest factors determining where people seek their healthcare.
- Medical malls can make care accessible by providing public transportation options — a known driver of health and equity. In the Philadelphia region, the Main Line Health Center at Exton Square Mall is located along bus lines and regional train routes. Being able to reliably get to a medical appointment means fewer missed and delayed appointments. This reduces the overall cost of accessing care.
- Medical malls can increase a community’s access to healthy food. Major grocery chains and smaller niche food sellers historically abandoned low-income neighborhoods for affluent suburbs. This is changing. One supermarket chain opened a store in a food desert area of southwest Philadelphia and proved that with accessible bus stops, low-income community members can get fresh, healthy, and affordable food. Nonprofit grocery stores are also making affordable and nutritious food available in food deserts. Strategies to mitigate food retail redlining and to attract retailers with higher-quality foods include incentive programs, public-private partnerships, and zoning policy revisions.
- Medical malls can be hubs for public health education and community gatherings (e.g. walking programs and places to socialize over a meal or a cultural activity). A medical mall provides a central location for preventive health and education, such as influenza vaccination drives, diabetes screening, CPR training, and public safety campaigns (e.g. Stop the Bleed).
To be sure, solving the healthcare access epidemic with medical malls may seem financially foolish. Who will pay for this? How will this be incentivized for providers when many people living in lower-income communities have little or no insurance?
Currently, there is no one financial model that applies to repurposing these spaces. The case of one wealthy person financing the mall is not likely sustainable nor feasible. Mixed public-and-private-sector solutions are more tenable (i.e. multiple funding channels through philanthropic organizations, community development corporations, banks, and even state or local governments).
Government incentives for outpatient clinics in these malls could subsidize payments for care. For example, federally qualified health centers in rural areas are eligible for certain reimbursements under Medicare and Medicaid — perhaps some of these centers could qualify. Also, the expansion of Medicaid coming out of the COVID pandemic has grown the role of safety-net providers. They too could provide care in repurposed malls.
Medical malls can also help stimulate local economies: they can be a source for community investment to incentivize job creation and encourage shopping locally, such as for groceries. Community colleges are moving into malls too. Perhaps this provides an opportunity for these malls to train people for the jobs they create, particularly for healthcare sector workers, such as laboratory and imaging technicians, therapists, nurses, and more.
But aren’t hospitals the best places for people to get their care? Well maybe. However, dead malls in rural and low-income urban areas are the same places as where hospitals are closing or medical deserts already exist. That is the point: because hospitals have closed in these communities, we must adapt. Healthcare needs are not going away. In 2020, close to seven out of 10 people obtained healthcare outside of medical office buildings or hospital campuses. As architecture and design critic Alexandra Lange notes, malls are buildings designed to change.
We can do this. Now is the time to think differently about bringing healthcare access and services to communities living in medical deserts. Buildings that historically magnified inequities can serve as a source for equity.
Resa E. Lewiss, MD, is a professor in the Department of Emergency Medicine at The University of Alabama at Birmingham, and a physician healthcare designer. She is the creator and host of The Visible Voices Podcast. Marina Del Rios, MD, MS, is an associate professor in the Department of Emergency Medicine at the University of Iowa in Iowa City. She is a health services researcher with expertise in resuscitation science, social emergency medicine, and population health. Ian Sinnett is a managing principal and health practice leader at the Dallas Studio of Perkins&Will. He has designed multiple retail-to-medical mall conversions and many health facilities across the U.S.
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