wwwelseviercomlocatehealthplace CorrespondingauthorTel6493737599ext8442fax6493737434EmailaddressrkearnsaucklandacnzRAKearns inglyencouragedcorporatephilanthropyandacultu ID: 179104
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``HappyMeals''intheStarshipEnterprise:interpretingamoralgeographyofhealthcareconsumptionRobinA.Kearns*,J.RossBarnettDepartmentofGeography,TheUniversityofAuckland,PrivateBag92019,Auckland,NewZealandDepartmentofGeography,UniversityofCanterbury,PrivateBag4800,Christchurch,NewZealandThispaperextendsearlierexplorationsoftheuseofmetaphorinthemarketingoftheStarshipChildren'sHospitalinAuckland,NewZealand,byexaminingcontroversysurroundingtheopeningofanin-hospitalMcDonaldsfast-foodoutlet.Thegoldenarcheshavebecomeakeyelementofmanychildren'surbangeographiesandapotentsymbolofthecorporatecolonisationoftheNewZealandlandscape.In1997aminormoralpanicensuedwhenaproposalwasunveiledtoopenaMcDonald'srestaurantwithintheStarship.Datacollectedfrommediacoverage,advertisingandinterviewswithhospitalmanagementareanalysedtointerpretcompetingdiscoursesaroundtheissueoffastfoodwithinahealthcaresetting.WecontendthattheintroductionofaMcDonald'sfranchisehasbecomethehospital'sultimateplacialicon,addingambivalencetothemoralgeographyofhealthcareconsumption.WeconcludethatargumentsconcerningtheunhealthynatureofMcDonald'sfoodobscuredeeperdiscoursessurroundingtheunpalatablecharacterofthehealthreforms,andaperceived`Americanisation'ofhealthcareinNewZealand.2000ElsevierScienceLtd.Allrightsreserved.Food;Discourse;Metaphor;Symbol;Consumption;Children'shospitals1.IntroductionThispaperconsidersthelinksbetweenhealthcare,placeandconsumptionthroughthecaseexampleofaMcDonald'srestaurantopeningwithintheStarship,NewZealand'snationalchildren'shospital.Ininter-nationalcontext,thisoccurrenceisneithernewnorunusualgiventhattherearereportedtobe50suchres-taurantsinhospitalselsewhereintheworld(NewZeal-andHerald,1997).However,thisotherwiseminoreventinthere-imagingofAuckland'sbuiltenviron-menttakesongreatersigni®cancegiventhatitisplacedgeographicallywithinachildren'shospitalandtemporallywithinabroadernarrativeofthecommer-cialisationofhealthcareinNewZealand.Theaimofthepaperistoexamineandinterpretnarrativesassoci-atedwiththecollisionoftheglobalandlocalasembo-diedintheopeningofthisin-hospitalfast-foodoutlet.WearguethatMcDonald's`comingonboard'theStarshipwasalogical,ifcontroversial,stepinlightoftwosetsoffactors:®rst,themalleabilityofthesym-bolsandmetaphorsassociatedwithbothMcDonald'sandtheStarship;andsecondthepoliticaleconomyofhealthcare,inNewZealandinthe1990s,thatincreas-Health&Place6(2000)81±931353-8292/00/$-seefrontmatter2000ElsevierScienceLtd.Allrightsreserved.PII:S1353-8292(00)00005-8 www.elsevier.com/locate/healthplace *Correspondingauthor.Tel.:+64-9-373-7599ext.8442;fax:+64-9-373-7434.E-mailaddress:r.kearns@auckland.ac.nz(R.A.Kearns). inglyencouragedcorporatephilanthropyandacultureofconsumption.Inwhatwayshavesymbolsandmetaphorsassoci-atedwiththefastfoodgiantbeenassociatedwithhealthandplacesofhealthcare?GeorgeRitzer(1996,43)discusseshowmodernmedicinebearsunexpectedanalogiestofastfoodpracticesgivenevidenceof``assembly-linemedicine''.Whilesuchrationalisationhasyettobediscernedwithanyfrequencywithinsec-ondaryandtertiarycare(notwithstandingRitzer'sexamplesof`medicalfactories'),thereisapersuasiveanalogyintheproliferationof`walk-in'oraccidentandmedicalclinics(AMCs),astheyareknownintheUSAandNewZealand,respectively.Thesesitesarefrequentlylocatedinconjunctionwithotherconsump-tionservicesando€erpatientsmedicaltreatmentcharacterisedbypredictabilityandhaste.InRitzer'seachcentrehandlesonlyalimitednumberofminorproblemsbutwithgreatdispatch.Althoughthepatientwithalacerationcannotbestitchedasecientlyasacustomerinsearchofahamburgercanbeserved,manyofthesameprinciplesshapethetwooperations(1996,45).Ritzercitestheheightenedeciencyofapatientbeingablewalkinwithoutanappointment,andoftheoverly-personal(andthusinecient)attentionapatientmightotherwisereceivefromatraditionalfamilydoctor.Heidenti®espublicexpectationaspartlyfuellingthesedevelopments.Forincreasingly,consumersare``...accustomedtoecientlyorganised`McDonaldised'systems(anddemand)thattheirtripstoclinicsorHMOso€erone-stopvisitsthatincludelabwork,neededdrugsandconsultationswithphys-icians''(Ritzer,1996,45).RecentevidenceinNewZealandcertainlyemulatessuchtrends,withAMCscommonlyincorporatingone-stop-shoppinginmini-medicalmalls(KearnsandBarnett,1997).Arisingfromboththeircommitmenttoeciencyandtheirsit-inginfast-turnaroundservicehubs,theyhavebeentermedinpopularparlanceÐandsigni®cantlyforthisdiscussionÐ`McDoctors'and`KentuckyFriedMedicine'intheUSandNewZealandrespectively(Ritzer,1996;KearnsandBarnett,1997).Itiswithinthiscontextofsymbolicassociationsthatin1997aminormoralpanicensuedwhenaproposalwasunveiledtoopenaMcDonald'srestaurantwithintheStarshipChildren'sHospitalinAuckland.Thepresentpaperthusfocusesontheinternalge-ographyofasinglehigherorderhealthcarefacility.Thereisprecedentforsuchspeci®cityoffocusinhealthgeographywithChiottiandJoseph's(1995)in-terpretationofanAIDShospiceinToronto,aswellaslocaljusti®cationwiththeStarshipbeingtheonlyter-tiary-levelfacilityforchildreninNewZealand.Pre-viousgeographicalworkonthehospitalsectorinNewZealandhasbeen®rmlyrootedinthewelfaretra-dition,focusingonissuesofdistributionandresourceallocation(e.g.Barnett,1984).InthispaperweextendanearlieranalysisofthedeploymentofmetaphorinthedesignandmarketingoftheStarshiphospital(KearnsandBarnett,1999)toexaminetherecentin-clusionofaMcDonald'sintheStarship.Wearguethatthereisasynergisticrelationbetweenthepowerfulsymbolsandmetaphorsassociatedwiththisfoodout-letandthehospitalitself.Insodoing,thepaperextendsthecontentionthatclinicalsettings,whichhaveprovidedsuchfertilegroundforexploringthepower-dynamicsofprofessionalpractice(e.g.Foucault,1973),arenowbeingmateriallyandsymbolicallytransformedintoarenasofbroaderconsumptionprac-tices.Further,itbuildsonWilbertGesler'sexhortationthatwe``...readordecodehealingenvironmentsfortheirsymbolicmeaning.''(1991,p.182).Whilegeographershavebeenincreasinglyinterestedintherelationsbetweenplaceandconsumption,healthcareisanareaneglectedbyrecentsurveys(e.g.Jack-sonandThrift,1995).Incorporatinghealthcarecon-textsintotheintersectionofurbangeographyandculturalstudiesisoverdueasnewstylesofservicepro-visionhavetakenhighlyvisibleandsymbol-ladenformsinthebuiltenvironment(KearnsandBarnett,1992).Withthisinmind,theremainderofthepaperisorganisedasfollows.First,weprovideapolitical-econ-omiccontextbybrie¯ysurveyingpatternsofhospitalrestructuringinNewZealand.Nextisanoverviewofthebackground,characterandnamingoftheStarshiphospital.Section3surveysdiscoursessurroundingtheannouncementoftheplannedMcDonald'sattheStar-shipandthisisfollowedbyaconsiderationofthecon-ditionsunderwhichthefranchiseopened.The®nalsectionsexplorelinksbetweenfood,healthandmoral-ityanddrawconclusionsfromthecasestudy.2.FrombandagestoburgersInthissectionwesurveythebroaderquestionofwhy,andhow,hospitalsinwesterncountriesareaddressingchanging®nancialcircumstancessuchthatspaceisbeingrentedtofastfoodfranchises.Toalargeextent,changesintheorganisationand®nancialviabilityofhospitalsinwesterncountriescanbeattrib-utedtochangingsourcesofcapital.Historicallycapital®nancingofhospitalscamefromavarietyofsourcesincludingphilanthropy,debt®nancing(loans),govern-mentgrantsorequity®nancing(i.e.saleofstocks)(KearnsandBarnett,1999).Themainfactordetermin-ingaccesstothesedi€erentsourcesof®nancehasbeenthetypeofownership,butincreasinglythisislesstrueR.A.Kearns,J.R.Barnett/Health&Place6(2000)81±93 astheboundarybetweenprivateandpublicsectorshasbecomeblurred(Pinch,1997).AstheearlierStar-shippaperindicated,publichospitalshavefacedincreasingchallengesinreceivinglargeenoughgovern-mentgrants,andproprietaryandnon-pro®thospitalshaveencountereddicultiesingeneratingsucientcash¯owsfrompatientcarerevenuestosupporttheircurrentlevelofoperations(KearnsandBarnett,1999).ThissituationhascomeaboutmainlybecauseofthestructureoftheinternalmarketforhospitalcareinNewZealandandtheinabilityofthecorporatisedpro-viders[i.e.commercialpro®tseekingentities,formerlyknownasCrownHealthEnterprises(CHEs)]secureadequatecontractsfromregionalfunders[Re-gionalHealthAuthorities(RHAs)].GiventhelackofpublicinvolvementinRHAsandclosemonitoringoftheirspendingactivitiesbytheGovernment(Treasury)`watchdog',CCMAU(CrownCompanyMonitoringandAdvisoryUnit),RHAs,notsurprisingly,were®s-callyveryconservative.Theendresulthasbeenadis-tinct`hollowingout'ofthestate(Jessop,1994)wherebyRHAsengagedinacomplexformofcostshiftingwiththeresultthatin1996thecombinedCHE®scalde®citsexceededthoseoftheRHAsby467%.(Attheendofthe1995/96®nancialyearthetotalde®-citofthe23CHEswas$561millionversus$1.2millionforthefourRHAs.)Suchcostshiftingcanbeseenasameansbywhichthenationalstatehasattemptedtodevolveproblemsofeconomicandpoliticallegitimacytolocalgovern-anceorganisations.Inthissensesuchtrendsarecon-sistentwithpost-Fordistnotionsof`increased¯exibility'ofeconomicandwelfarepolicy,buttheyalsore¯ectkeyideasfromagencytheory(e.g.seePetersen,1993).Accordingtothelatterperspective,inhierarchicalsystemsprincipalsandagentswilloftentakeadvantageofoneanothergiventheopportunity.The`hollowingout'processdiscussedaboveindicateshow,intheabsenceofadequateresourceswithwhichtoperformtheirfunction,relativelyweakagentsatonelevel(i.e.RHAs),attempttocopebybehavingasrelativelypowerfulprincipalsatthenextleveldownthehierarchy(i.e.intheircontractswithCHEs).Asaresultofsuchtrends,heavilyindebtedCHEs,inturn,havedevelopedavarietyofcopingstrategies.Thesehavebeenmorefullydiscussedelsewhere(KearnsandBarnett,1999),butincludeclosingordowngradinghospitalservices,exitingfromruralser-vicescompletely,anddevelopingnewsourcesof®nan-cing.Itisthelaststrategywhichisincreasinglybeingfavouredgiventhatdowngradingandclosing,orattemptstoclose,hospitalfacilitieshasledtoconsider-ablepoliticalunrest(Prosseretal.,1996;Kearns,1998).Theemergenceofvariousformsofcollectiveaction,togetherwithawaningofpoliticalsupportfortheneoliberalhealthreformagendainNewZealandhasresultedinanewCentralGovernmenthospitalser-vicesplanwhiche€ectivelyrepresentsamoratoriumonfurtherhospitalclosures(MinistryofHealth,1998).Oneconsequenceofthesedevelopmentsisthathospitalprovidersattemptingtorationalisetheirbudgetshaveincreasinglyresortedtodevelopingnewsourcesof®nancing.ThisisalsothestrategymostevidentintheCCMAU(1996)reporttotheincomingMinisterofHealthwhereinSection3.2.4itisstated;WewishCHEstoaccessprivatesectorcapitalwherepossible.Thisincludesconsideringproposalstoleasefacilitiesorequipmentaswellasborrowingfromtheprivatesector.SuchproposalsshouldbeassessedonacommercialbasisInatleastindirectresponsetothisexhortation,someCHEs,includingA+AucklandHealthcare,haveattemptedtocourtprivatecapitalintheformofencouragingcorporatedonationsfrommajorbanksandcompaniesandhave,inthecaseoftheStarship,o€eredanin-hospitalconcessiontothemajorfastfoodchain,McDonald's.TheStarshipcase,therefore,canbeinterpretedasahospitalmarketingitselftoincreaseincomefromphi-lanthropicdonations.This`packaging'tomaximisesellabilitynotonlybene®tsthehospitalconcernedbutalsopotentiallyenhancestheimageofsponsorsinthecommunityespeciallywhencorporatedonorsareas-sociatedwithhighpro®lecommunityprojects.ThisisevidentattheRoyalAlexandraHospitalforChildreninWestmead,asuburbofSydney,wherethenamesofWoolworthsandShellOilareprominentlydisplayedtoidentifyalandscapedcourtyardandoperatingthea-trerespectively(L.Brown,personalcommunication).Inwhatseemstobeareturntoanineteenthcenturytrend,donationsareagainbecominganimportantsourceofcapitalfor`deservinginstitutions'andinthe1990sarecontributingtonewgeographiesofcorporatephilanthropy(Hurdetal.,1998).Elsewhere(KearnsandBarnett,1999),wehavenotedthatthroughoutthedevelopedworldthereisincreasingpressureonhospitalstomarketthemselvesasdistinctcommoditiesandthattherearestrongpar-allelsbetweenideasof`placemarketing'inthe`sellingcities'literature(eg.KearnsandPhilo,1993)andtrendswithinthehealthcaresector.Inthisdiscoursehospitals,justasotherpartsoftheurbanrealm,havebecomecommodi®edandhavebeenrenderedattrac- In1997CHEswererenamedHealthandHospitalServices(HHSs)andnolongerhaveastatutoryrequirementtobepro®toriented.Inadditionthefourregionalhealthauth-oritieswereabolishedandreplacedbyonecentralfunder,theHealthFundingAuthority(HFA).R.A.Kearns,J.R.Barnett/Health&Place6(2000)81±93 tivetopatientsandinvestorsthroughtheconsciousmanipulationofimages.AsBriavellHolcomb(1993)notes,thesellingofanurbanlifestylehasbecomeanintegralpartofanincreasinglysophisticatedcommodi-®cationofeverydaylife,inwhichimagesandmythsarepackagedand(re)presenteduntiltheybecome`hyperreal'(i.e.elevatedfromthemetaphoricintotheeverydayandtaken-for-granted)(seePerry,1998).Theseobservationsderivedfrominternationallyobservedtrendsandgeographicalliteraturesrelatetothelocalspeci®cityofourcaseexampleofhospitalmarketingandMcDonald'sattheStarship.Exercisingsuch`packaging'viaconsumptionactivi-tieshasbeennotedelsewhereinthehospitalsector.InCanada,forinstance,Johnston(1992)reportsthattheSt.BonifaceHospitalinWinnipeghasopenedanin-housepizzafranchise,andtheRoyalChildren'sHospi-talinMelbourneintroducedaMcDonald'sintoitsfoyer.Childrens'hospitals,inparticular,havebene®tedfromsuchdevelopments.InthecaseoftheStarship,whileNewZealand'ssoleteachingandtertiarycarepaediatrichospitalhasnoneedtocompeteforpatients,itneverthelessneedstocompeteforthedonateddollar.Itisarguablyimportantthatanorgan-isationregardsitspotentialbenefactorsasconsumersofabrandedimage.Thusthestrategicchoicebyahospitaladministrationofacatchylogoandname,andthedevelopmentofabuildingwithhighimage-ability(Lynch,1960),wasseenasawayofencoura-gingpotentialbenefactorstobecomeactualpatronsandconsumersofthecharityinquestion.Inthepre-sentcasestudythereputedcompetitionbetweenMcDonald'sandBurgerKingtobethefranchiseattheentranceoftheStarshipisevidenceoftheimpactofsuchstrategicmovesandthechancetobeassoci-atedwiththechoice`toboldlygo'wherenohealthenterprisehadgonebeforeinNewZealand(KearnsandBarnett,1998).3.TheStarshipEnterpriseAhospitalwithoutsicknessanddeathÐwellnotthatyoutalkabout,anyway...DidIsaydeath?Well,feedmetotheDaleks.The`D'wordmustbebanned.Noonewilldie.They'llbebeameduptotheBigBurgerKingintheskyinstead(Rudman,In1992,therecentlycompletednationalchildren'shospitalwasociallydesignated`Starship'.This185bedhospitalwasopenedthepreviousyearanddescribedbyarchitectsStephensonandTurnerLtdasthemostcomplexbuildinginNewZealand.Atacostof$79million,itwasalsooneofthemostexpensive.Ane€ortwasmadebythedesignerstocreateadis-tinctivepost-modernstructureaswellasaspace-e-cient,yetchild-friendlybuilding(Vernon,1988).Accordingtothearchitect,``thebendingofanotherwiserectangularplanintoacurvesuccessfullyavoidsthetypicallylong,straightcorridorsofaninsti-tutionalbuilding''(Land,1992).Thismoverepresentedabreakfromthecustomaryuseofeciency-drivencalculationsbasedonbednumbers,apracticethathadprevailedatthetimewhentheadjacentbox-likeAuck-landHospitalwasdesignedbythesamearchitectural®rm.TheawardwinningdesignoftheStarshipischaracterisedbypastelcolours,theuseofall-woolcar-petsthroughoutthewardsandwaitingareas,andspaceforchildren'sartworkonthewalls.Thesefea-turesmarkdeparturesfromeciencyandthelaunch-ingofanewdirectioninhospitaldesign:themanufactureofenchantment.Thecynicismofthequo-tationbyanewspapercolumnistopeningthissectioninvolvedaperceptionthattheStarshipwastrivialisingitspurposeand,byallusion,placingitselfintheleagueoffantasyplaygroundsfoundinfastfoodrestaurants.Itisthusironicthat5yearslaterafastfoodfranchisehadindeedbeentakenonboardbyhospitalmanage-Thehospital'snameinvolvesapplicationofameta-phorthatstrategicallyde-emphasisestheinstitution'smedicalpurposesandinvokesnotionsofother-worldli-ness.Thisnamingincorporatesa`norming'(BergandKearns,1996)thatinvolvesacalculatedelisionofimagesordinarilyassociatedwithmedicalenviron-ments(Shore,1984).Thefullname`StarshipChil-dren'sHospitaloftheSouthPaci®c',whichwasociallygiventothehospitalinApril1992,astutelycapturedacombinationofconnotations:familiarityandother-worldliness.Inchoosingthisname,symbolswerebeing(re)placedbothtangiblyandlinguisticallyinanattempttoreorientchildren'shealthcareinaneraofbrandingandmarketing.Elsewherewehaveplacedtheconstructionandnam-ingoftheStarshipChildren'sHospitalinAuckland,withinthecontextofincreasinglyconsumer-orientedhealthcareprovisioninNewZealand(KearnsandBarnett,1998).Thedeploymentofthestarshipmeta-phoralludestothehospital'sdistinctivedesignfeaturesandrepresentsanattempttode-emphasiseconnota-tionsassociatedwithinstitutionalisedmedicine,thusattemptingtonormalisetheplaceforchildren.Tothisextent,theStarshipmightbeinterpretedasanexampleofacontrived`therapeuticlandscape'(Gesler,1992).However,thosenamingthehospitalhadmorethanchildreninmind.Rather,therewasadualintent:tomarketthehospitalasadistinctiveplaceformonetarydonors,aswellaspromotingamorepotentiallyaccep-tablebuiltenvironmentforitsyouthfulusers.HospitalsareconventionallyplacesofmedicalisedR.A.Kearns,J.R.Barnett/Health&Place6(2000)81±93 carethattendtobehighlyfunctionalelementsintheurbanlandscape.Theyhavegenerallyonlyadvertisedthemselvesinadvertentlythroughlocation(e.g.elev-ated,orcentralcitysites),orthroughtheirform(e.g.largesizerelativetosurroundingbuildings).Conso-nantwiththebox-likeformofthemodernistskyscra-perthebuiltformofmanyhospitalsisaustereandangular,theirinteriorspotentiallygeneratingfeelingsofplacelessness(Relph,1987).InNewZealand,manyhospitalswerededicatedaswarmemorialsorinhomagetodistantmembersofBritishroyalty.InthecaseoftheStarship,however,suchanorientationtothepastisreplacedbyanamingthataimstobenovel,marketableandsuggestiveofajourneybeyondtheparticularitiesoftimeandplace.AttheStarship,onecanobserveaproliferationofwhatJe€reyHopkins(1990)hastermed`placialicons':featuresthatpromoteaperceptionof`elsewhere'.Withinthehospital,thegreenastroturf¯ooroftheatrium,togetherwiththepresenceofwoodenparkbenches,issuggestiveoftherelaxingsettingofacitypark.Similarly,thelargeparachutingteddybearsus-pendedwithintheatriumpromptsassociationswithachild'snursery.Butitisplacialiconsassociatedwiththehospitalnameitselfthataremostgermanetothepresentdiscussion.Therocket-likeelevators,forinstancearesaidtohaveinspiredthenamingoftheStarship(B.Harveypersonalcommunication).Further,space-fantasyegiessuchasrobotsspeakofanother-worldlinesscomplementarytothehospital'sname.Theseimageshavebeensedimentedintochil-dren'simaginationsandparadoxicallysuggestaspacethatis®gurativelybeyondknowngeography,yet®rmlylocatedwithinmentalmapsofAuckland.Fromtheoutset,therewasexcitementatthenameintermsofits`sell-ability'andultimatepotentialtobeahighlypopularandvisiblepartofAuckland'sthera-peuticlandscape.Itwasoptimisticallyreportedthat...theStarshipimagecouldputthehospitalonthetouristtrail...overseasvisitorscouldsoonvisitKellyTarlton'sUnderwaterWorld,theAoteaCentreandtheStarship''(NewZealandHerald,1992).Suchmediareportsclearlyaided`inventing'theStarshipasaplace(AndersonandGale,1992),andcementingitsattrac-tivenesstopotentialsponsors.Inavoidingaprosaicthehospitalwasfollowinginthefootstepsofmanyoverseaschildren'shospitalswhichmarketedtheirproducttoattractsponsorship...theStarshipimageandlogowouldgivesponsorssomethingtowhichtheycouldrelatemostimportantly,everychildinthecountrywouldcometoknowtheStar-shipasanexcitingplaceratherthansomethingofwhichtobescared(NewZealandHerald,1992).Thenamingwasthusconcernedwithsettingnormsforthehospital:themetaphorpotentiallyhadeuphe-misticcontentforusers,andalsoconnotedacatchyoptimismforsponsors.Theallusiontoscience-®ctioninvolvedlinksbetweentheStarshipnameandthetele-vision(andlater®lm)series`StarTrek'.SuggestionsoftheStarWarsserieswerealsopresentintheletteringandimageincludedintheoriginalpromotionallogoforthehospital.Inallsuchrepresentations,theemotionsevokedbyyouthfulhospitalusersarelikelytovaryfromexcitementtoanxiety,analmostunavoid-ableambivalencegiventheintrinsicallypolysemicqual-itiesofmetaphoritself(Kearns,1997).Giventhisambivalence,twoeventsareofnote:®rst,thechangetoamorelight-heartedlogo;andsecond,theintroduc-tionofthe`normalising'franchiseMcDonaldsintothehospital'satrium.4.ThepromiseofHappyMeals?TheStarshiphopestofeastonadealstruckwithitsnewtenant,McDonald's,inwhichtherentgoesupasmorehamburgersaresold(Young,1997).ItwasannouncedinlateAugust1997thatadealhadbeenstruckbetweenStarshipmanagementandMcDonald'sthatwouldresultinafranchiseopeningwithintheatriumofthehospital.Theannouncementbroughtimmediatepublicreactioninthecolumnsofthemajordailynewspaper.Cynicismprevailedamongcommentators.DenisWelch,anationalcolumnist,forinstance,identi®edalinkbetweenbenevolentgestureandcommercialfoothold,askingSoyouthoughtthatwhenMcDonald'ssetupRonaldMcDonaldHouseforkidswithcanceratAucklandchildren'shospital,theyweredoingitoutofthegoodnessoftheirhearts?Thinkagain.Correspondentswerequicktolinkhealthandplaceintheirexpectationsregardingchildren'swelfare:NowwehaveourStarshipchildren'shospitalendorsingthesaleofjunkfoodonitspremises,whichsurelymustgivethewrongmessagetoparentsandchildrenthatthistypeoffoodisallrightafterallotherwiseitwouldnotbepromotedthere?(Browning,1997)Inasimilarvein,theexecutiveoceroftheNationalCouncilofWomen(NCW)wroteonbehalfofitsHomeEconomicsandConsumerA€airsStandingCommitteetotheNewZealandHeraldexpressingcon-R.A.Kearns,J.R.Barnett/Health&Place6(2000)81±93 thattheprominentpositionofMcDonald'sres-taurantattheStarshipChildrens'Hospitalwillsendastrongmessageofendorsementbyhealthprofessionalsthattakeawaysareanappropriateeverydayfood(Morris,1997).DianeMorris,thecorrespondent,wentontocitetheMinistryofHealth'sGuidelinesforHealthyChildrenwhichcautionthat``...fastfoodsmustbeeateninmoderation''inlightofthefactthat``avarietyoffoodisessentialforthemaintenanceofgrowthandgoodhealth''.TheNCW'sconcernwas:thathealthpromotionmessageswillnotbee€ec-tivewithavisiblydominantfastfoodoutletwithlimitedfoodvarietyandpossiblyhighinfat,saltandsugar,whichappearstohavetheendorsementoftheStarship...Responsescounteringthismoralhighgroundwererapidlypublished.AweeklycolumnistdismissedtheNCWas`foodpolice'(George,1997)andacorrespon-dent,JoannaRazzell(1977),questioned;HowmanymembersoftheNationalCouncilofWomenhavespentweeksonendlivingattheStar-shipchildren'shospitalatthebedsideofasickchild?HavingbeeninthatsituationmyselfIfeelstronglythataMcDonald'srestaurantwillbewarmlywelcomedbyparentsasasourceofconsist-entqualityfoodatareasonablepricewhenthereisnothingelseconvenientlyavailable.MsRazzellwentontociteinstancesofparentscomingtotheStarshipfromelsewhereinNewZealand,leav-ingbehindtheirsourcesofregularfamilysupport,aswellasfamilieswho,throughthesuddennessofchildhealthemergencies,havebeenunabletobringfoodwiththem.Incounteringtheirobjectionstofastfood,JoannaRazzellproducedatrumpcard,saying:Iamsureagreatpatronagewouldbegiventohomecookedmealsproducedbyarosterofmem-bersfromtheNationalCouncilofWomen.UntilthishappensaMcDonald'srestaurantdownstairswillbeagreatadditiontoawonderfulhospitalAnothercorrespondentsimilarlyrebukestheNCW;blametheweak-willedfatties,particularlytheparents.Asfortheself-appointedguardiansofthenation'shealth,overwhelminglywomen,tellthemtheyhavethecartde®nitelybeforethehorse.Theyshouldbepreachingtothecustomers,notthesup-pliers(Phillips,1997)Withinthesecommentarieswecandiscernindicativeevidenceofatwo-layereddiscourse.Thisinvolvesmostobviouslyaconcernforthehealthe€ectsofexcessivenutritionaltransgressionbyespeciallytheyouthfulusersofthehospital.Thereisalsoadeeper,moreimplicit,concernatthecorporatealliancetheannouncementrepresents,amovedescribedelsewhereas``...anothersliceo€thecarcassoftheailingpublichealthsystem(whichis)increasinglypreytothepreda-tionsofprivateenterprise''(Welch,1997,23).Thecountervailingdiscourseisoneofpragmatism.IndeedtheparentalperspectiveofgratitudeattheprospectofqualityandconvenienceisechoedbyhospitalgeneralmanagerGrantClosewhosawthemoveas``simplyamatterofgettingthebestserviceforthehospital''(Welch,1997,23).5.EnterthegoldenarchesThe(Starship)metaphorisadistractionforkidswhoaretherealtarget.We'rekeentonormalisethehospitalexperience.That'sonereasonwegotMcDonaldsinhere(GrantClose,GeneralMan-ager,personalcommunication1997).I'mnotaspoilsport,but,asapolitician,asamother,asaformerhealthworker,itscreamsouttometobewrong(AnnetteKing,LabourPartyspokespersononhealth,1997)TheMcDonaldsattheStarshipopenedinNovem-ber,1997withthehospitalbeingguaranteedeitheranannualbasereturnof$70,000,oranupwardlygradu-atedpercentagefromsales(from7.5%ofsalesupto$1.29millionto8.5%ofsalesabove$1.69million).Thehospital'sGeneralManagercommentedthatinlieuoftheStarshipbeingashoppingmall,AucklandInternationalAirportwasusedasaguidefortheset-tingoftheserents.HeexpectedthattheStarshipwouldreceiveapproximately$75,000annually,arentalNewZealandHeraldestimatedasbeingclosetothatpaidbystreetfrontshopsonBroadway,oneofAuckland'sbusiestretailingstreets.AmongotherdetailsobtainedbytheNewZealandHeraldundertheOcialInformationAct,itwasreportedthatthisrentwouldgointothehospital'soperatingbudget(ZealandHerald,1997).Thedealalsoinvolvedthreeconditions.First,thefastfoodcorporationhadtoruntwopublicawarenesscampaignseachyearbyprintinghealthmessages(e.g.childsafety)onitspaperplacematsinits138storesnationwide(NewZealandHerald,1997).AccordingtoStarship'sgeneralmanager;Wewerelookingforsomeonewecouldgointoalong-termrelationshipwith,someonewhocouldR.A.Kearns,J.R.Barnett/Health&Place6(2000)81±93 sharesomeofthevaluesweasahospitalhave.McDonaldswastheprovidermostpreparedtogotheextramileandhavethesecampaigns(citedinWelch,1997,23).Asecondconditionwasthatexternalsignagewouldbeminimised.Thusa45cmilluminatedyellow`M'inthewindowofthefrontentranceofthehospital,alongwithwindowdecorationsinvolvingRonaldandfriends,istheextentofstreetfrontadvertising.Thethirdconditionwas`nutritionalextras'.Aboveandbeyondtheirregularmenu,McDonaldsagreedtopro-videcustomerswiththechoiceoflowfatmilk,fruitandfourkindsofbreakfastcereal.Tothislastannouncement,themedicaldirectoroftheNutritionFoundationwrylycommented;Iwouldbeveryinterestedinseeing...statisticssixmonthsafterthey'veopenedtoseehowwellthey'vesold(citedinWelch,1997,23).Aprominentleft-wingpoliticalspokespersononhealth,PhillidaBunkle,addedthatsuchadditionstothemenusurelyamountedtoarecognitionthatregu-larMcDonaldsfoodisnotashealthy,aninterpret-ationMcDonald'scommunicationdirectorGlennCorbettrefutedbystatingthat``wehavethehigheststandardoffoodofanyproviderinNewZealand''(citedinWelch,1997,23)(Figs.1and2).6.Discussion:interpreting`McHospitalisation'Wecaninterpret`McHospitalisation'fromtwoper-spectives;fromthepointofviewofthechangingpol-iticaleconomyofhealthservicesandintermsofthemoralgeographyoffoodconsumption.First,theopeningofaMcDonaldsrestaurantinachildren'shospitalsaysmuchaboutthenatureofthehealthcarereformprocessinNewZealand.Thewithdrawalofthestateandthedecentralisationofresponsibilityforfundinghealthserviceshasresultedincostshiftingbetweenfundersandprovidersandanincreasedin-abilityofthelattertomaintain`normal'levelsofser-vicegivencurrentlevelsofgovernmentfunding.TheincorporationofMcDonaldsintoahospitalenviron-mentmustbeseen,therefore,asacompromisebetweenhealthandeconomicgoals,acompromisethatmayhavebeenavoidedinother®nancialclimates.Thiswasevidentintherelativesilenceofthehospitalmanagementtothepossiblehealthdisadvantageswhichwerelikelytoarisefrom`embracing'McDo-naldsasacorporatesponsor,especiallygiventhehigh Fig.1.`McDonaldsinStarship':viewtowardsmainentrancefromwithinhospital.R.A.Kearns,J.R.Barnett/Health&Place6(2000)81±93 incidenceofhospitaladmissionsfromthepoorerpartsofAuckland(Hoskins,1990).Evenifoneacknowl-edgesthebene®cialnutritionalimpactsofhamburgers(e.g.intermsofironintake),thepresenceofafastfoodrestaurantinahospitalsettingneverthelesscon-veysverymixedmessagestothegeneralpopulationintermsoftherequirementsforhealthyliving.WhiletheMcDonaldsmayhelpcreateacertainnormalcywithintheStarshiponecanonlyspeculateuponitswiderimpactsintermsoflegitimisingnutritionalpracticesdetrimentaltothepopulation'shealth.Secondly,McHospitalisationalsoraisesbroaderquestionsregardingpatternsoffoodconsumptionandtheirlinkstoplaceandculture.AsBellandValentine(1997,p.i)haveindicated,``foodoccupiesaseeminglymundanepositioninallourlives(yet)weallreadfoodconsumptionasapracticewithhighimpactsuponoursenseofplace''.Geographiesoffoodcontinuetobeconstructedpredominantlyfromtheperspectiveofproduction(e.g.,LeHeronandRoche,1995)alegacy,perhaps,ofthediscipline'straditionalfocusonthelandanditsuses.BellandValentine's(1997)recentsurveyofgeographiesoffoodconsumptiono€ersalargesteptowardsredressingthisimbalanceand,insodoing,o€ersaprompttodiscusslinksbetweenfood,healthandmorality.TheyciteArjunAppadurai,forinstance,whowritesofeatingandfoodhavingbecomelargelydominatedbyideasofbodilybeautyandcomportment,ratherthanbyideasofenergyandsuciency''(1993,11).Thus,inwesternso-cietiesinwhichfoodsuciencyisthenorm,adegreeofidentityand`place-in-the-world'isderivedfromwhatandwhereweeat(BellandValentine,1997;Caplan,1997).Forexample,inurbanNewZealand,whichhaswitnessedarecentandrapidriseofconspic-uousconsumption,drinkingcappuccinosratherthanpowderedinstantco€eesaysmuchaboutstatus,incomeandthe`where'ofco€eeconsumption(Liberty,1998).Similarly,Whale's(1993)analysisofthepro-liferationoffoodbankso€ersasalutaryreminderofthespatialityofhungerinAuckland.Thusthereisaclearmoralityoffoodconnectedtoavailabilityandwecanspeculatethatthegeographiesofthis`whogetswhatwhereandwhy'(Smith,1977)aremappedontogeographiesofhealth.However,moresubtlelinksbetweenfood,moralityandhealthcanalsobediscerned.Epidemiologicaladvancesofthelasttwodecadeshavehonedtheabilitiesofexpertstocastjudgementsuponthehealthfulnessoffood.Sig-ni®cantly,itisthemostdemocratisedsitesofeatingoutsuchasfastfoodrestaurantsthathavemostcomeunderscrutinyforthecholesterollevelsoftheirmenus(Welch,1998).Thus,despitevaliantattemptstoaddresstheseconcerns,fastfoodchainsseemwedded Fig.2.MuraladjacenttotheMcDonaldsoutlet:hospitalmascot`StarTed'withfries.R.A.Kearns,J.R.Barnett/Health&Place6(2000)81±93 tothe`junkfood'labelsuchthat,despitetheobviousbene®tsofmoderatelevelsofconsumption,tosome,partakinginaburgerandfriesamountstoatransgres-sionoffoodmorality.However,despitesuchconcerns,onlyrecentlyhavedietaryissuesbecomeanintegralpartofchildhealthpolicy(Welch,1998).But,inNewZealand,muchremainstobedoneintermsofdisen-tanglingthesubtlelinksbetweenpatternsoffoodcon-sumptionandhealthandhowtheseareshapedbythecombinedin¯uencesofclass,ethnicityandplace.Akeylandmarkinthe(atleastperceived)linksbetweenfood,healthandplacecanbetracedtothe1976launchofNewZealand's®rstMcDonald'sres-taurantinAuckland.Thedevelopmentopenedthedoortoeatingtakeawayswithouttakingthemaway.Therehavebeenatleasttwosymbolicimplicationsofthisopportunity.First,thelowcostandno-dresscodeapproachmeantthatforthe®rsttimeoutsidepubsinNewZealand,arestaurantwasopentoall.Secondly,theAmericanoriginsofMcDonald'shavealsobeenimportant.TherehaslongbeenatleastanimplicitlinkbetweenEuropeand`highculture'andtheUnitedStatesand`popularculture'(Lealand,1988).Thepro-liferationofgrati`tags'inAuckland,forinstance,hasbeenregardedasanAmericanscourgeandlinkedtotheemulationofAfro-Americanculturebydisen-franchisedPaci®cislandyouths(LindseyandKearns,1994).Thusinthiscontext,the`goldenarches'haveanambivalentplaceintheNewZealandlandscape:theyhaveatoncebecomeakeyelementofchildren'smen-talmapsandapotentsymbolofthemultinationalcolonisationoftheNewZealandlandscape. Fig.3.CosMc:theresidentalienatMcDonaldsintheStarship.R.A.Kearns,J.R.Barnett/Health&Place6(2000)81±93 Beyondthespeci®callyNewZealand'scultural-geo-graphicalcontext,McDonald'sanditsnear-synon-ymousgastronomiccreation,the`BigMac',isprobablyunrivalledasatargetofmoralandculturalcomment.AsBellandValentine's(1997)surveyattests,thesenameshavebecomemetaphoricandsym-bolicstand-insforcommentaryonaspectsof1990swesternsocietyandculture.CoinedneologismshaverangedfromMcJobs(Coupland,1991)totheMcUni-versity(ParkerandJarry,1995)andMcIdentity(Pro-byn,1998),ineachcaseimplyingadiminutionofstatusandpopularisationtothepointofblandness.Indeed,inhisseminalwork,GeorgeRitzer(1996)describesthe`McDonaldizationofsociety'.Inthiscoinage,Ritzergoesbeyondpopularvernacularassoci-ationsandascribestheproductionandconsumptionoftheBigMacasiconicinitsrepresentationofthedriveforeciencywithintheWesternworldingeneral,andAmericainparticular.BuildingontheideasofGeorgeRitzer(1998),wecaninterprettheStarshipasanewcathedralof(healthcare)consumptioninwhichthedisenchantmentsofmodernmedicinehavebeendiagnosedandtreatedwiththecreationofanillusoryenvironmentofpara-chutingteddybears,mockcityparksand¯ashingrobots.TheentryofaMcDonald'sfranchiseextendsthesimulationofhospital-as-mall,addingopportu-nitiestoconsumefood(ratherthansimplymedicaltreatment)inthisother-worldlyspace.Theinstallationof`CosMc',asite-speci®cMcDonald'sfantasy®gureattheStarshipoutletrepresentsthemalleabilityoftheboththeMcDonald'srepertoireofsymbolsandtheStarshipmetaphor.Itlocalisesintothespeci®ctimeless(outer)spaceoftheStarshipwhatmightotherwisebeanacutelyordinaryexperienceofconsumption.Inthissense,timebecomespartofthespectaclethatisStar-ship:thefastfoodrestaurantproducesmealsataspeedthatis(metaphorically)lightyearsaheadofcon-ventionalhospitalkitchens,thusparadoxicallyintrodu-cingasenseofwonderthroughtheintroductionoffamiliarity.AMcDonaldsheightenstheinvitationtobeaconsumerat(andof)thehospital,illustratinghowthemastermetaphor(Starship)e€ectivelyworkstolinkhealthandplace(Figs.3and4).Whilesmellandsoundcontributetoplace(Rod-away,1994),themaincuesfortransmissionofidentityarevisualandaretobefoundbothtangiblyinthebuiltenvironmentandreproducedinprintedrepresen-tationsofproductsandservices.Thus,whiletheseduc-tivesmellofBigMacspotentiallyneutralisesthemoresterilesmellscapesassociatedwithhospitals(Porteous,1985),itisthevisualimpactofthegoldenarchesandjollyegiesofRonaldMcDonaldandfriendsatthemainentrancetothehospitalthatcompellinglycomp-lementtheimpactoftheStarshipexperience.TheMcDonald'sfranchiseisparadoxicallybothextendingtherationality/eciencyofthehospital-as-service-hubaswellasaddingtotheenchantmentoftheplaceforitsyouthfulconsumersbyo€eringafantasy-ladeneat-ingexperience.InthewordsofBellandValentine(1997)`wearewhereweeat'.Inthiscase,attheStar-shipMcDonald's,weareplacedinatwo-foldposition:bothasaco-participantinaspatio-temporalfantasy;andattheoutputendofahighlyrationalisedfoodassemblyline.Theresultisan`all-consuming'experi-encewithintheinternalgeographyofahighlymedica-lisedenvironment.7.ConclusionThispaperhasarguedfortheneedtomovebeyondviewinghospitalsasserviceentities,andequatinghealthcareconsumptionwithutilisationbehaviour.Rather,amergingofinsightsfromthepoliticalecon-omyofhealthcareandnewculturalgeographylitera-turescanaidthedevelopmentofmore®nelytexturedunderstandingsofthemeaningofcontemporaryhealthcare,andtheroleofmetaphorandmarketinginselling Fig.4.CosMc'smessage.R.A.Kearns,J.R.Barnett/Health&Place6(2000)81±93 placesofhealthcareconsumption(KearnsandBar-nett,1999).Thelabellingoftheboldnewhospitalas`Starship'worksasamoregeneralmetaphorforthechangesinNewZealand'shealthcaresystem.AsKearnsandBar-nett(1998)remark,withinthenarrative(s)oftheplanning,namingthenlaunchingoftheStarship,wecandiscerninmicrocosmthebroadershiftfromastate-ownedandrunhealthcaresystemfocusedonsickpeopletoacommercially-in¯uencedsystemcon-sciousofitscorporateidentityandservingpeoplewhoarenotonlypatientsbutalso`con-Tothisextent,theStarshiprepresentsaniconicmeta-phorforwhatJaneKelsey(1995)hasdescribedasthe`NewZealandExperiment'inawaythathealthcampssimilarlyepitomisedanearlierexperimentÐthequestforaboldnewworldwithinthewelfarestateinNewZealandhalfacenturyago(Bryder,1991;KearnsandCollins,2000).Gesler'stherapeuticlandscapeidearemindsusthattheurbanenvironmentcomprisesmorethancompositeelementsoftangiblebuiltform.Ratheritisaninter-pretabletextwhichcontributestomeaningandwell-beinginthebroadercanvasofurbanlife.In1989,JohnRennieShortclaimedthatourcitiesaregenerallyunresponsivetotheneedsofchildren.TheStarshipcasestudyhaspresentedanopportunitytoassesstheextenttowhichthehospitalhasrespondedtochil-dren'sneedsinatight®scalenvironment.Inthepre-sentpaper,weextendedthatassessmentbyconsideringthecaseoftheincursionofcorporatecapitalandsym-bolismintothebuiltenvironmentoftheStarship.Thus,inconsideringtheevolutionofahealthcareset-tingforchildren,thepapercontributestoredressingthelimitedplaceforchildreningeography(James,1990),agapthathasonlyrecentlybeenaddressedinasustainedmanner(e.g.Valentine,1996,1997).OverthecourseofthehealthreformsinNewZeal-and,usershavebeensystematicallytransformedintoconsumers.AccordingtoRitzer(1998),consumersthroughoutthecapitalistworldaredemandingincreas-inglyenchantedsettings.InNewZealand,previousworkonprimaryhealthcarehasindicatedthatitistheenchantingelementsofnewclinicsthatareofgreatestappealtoespeciallylow-incomeusers(BarnettandKearns,1996).ThispaperhasdemonstratedthesymbioticrelationshipbetweenafastfoodcorporationandthenewStarshiphospital.Thissymbiosishasbeenfacilitatedbythemalleabilityofthesymbolismandmetaphoricalcontentofeachpartner.Intermsofben-e®ts,theStarshiphasgainedrevenuefromsiterentalandpercentagereturnsthatisneededintimesof®scalausterityinthehealthsystem,andisresponsivetotheexhortationsofthestatehealthfundingwatchdog,theCCMAU.Starshiphasalsogainedaraisedpro®leasaplacemorefullyintegratedintoAuckland'surbanfab-ricthanitsmedicalfunctionmightotherwisesuggest.Tothisextent,Starshipisedgingclosertoaninter-nationalairportinitsabilitytoaddressaspectrumofserviceandconsumptionneedswithinaquasi-publicplace.Foritspart,McDonaldshasgainedaprominentifmodestly-sizedoutletinwhichpatronageatvariedhoursbypatients,parents,sta€andvisitorsisassured.Perhaps,moresigni®cantly,ithasalsogainedapos-itionfromwhichtospeakmoreforcefullyofitsphilan-thropicacts.Whatoftheactualandpotentialusers?WehavearguedthattheintroductionofaMcDonald'sfran-chisewasapredictableoutcomeofaconsciousprocessofmystifyingillnessandmedicine,andhasbecomethehospital'sultimateplacialicon.Theconcernsaboutnutritionalqualityandthemysti®cationofmedicalpurposesexpressedthroughnewspapercolumnshigh-lightanambivalenceinthemoralgeographyoffastfoodconsumption.WeconcludethatargumentsraisedbyadultsconcerningtheunhealthynatureofMcDo-nald'sfoodessentiallyobscuredeeperdiscoursessur-roundingtheunpalatablecharacterofthehealthreforms,particularlythecommericialisationofhealthcareinNewZealand.Forchildren,however,McDo-nald'spotentiallyo€ersadditionalfamiliarityinamed-icalisedsiteofconsiderableuncertainty.Asthewordsononepieceofchildren'sartproclaimedfromahospi-taldisplayboard``Ilovehappymeals.Theymakemehappyinhospital''.Farfromtheevilincursionofpoornutritionasportrayedbysomecommentators,McDonald'sseemstohavefastbecomeacomfortablepassengerontheStarship,literallyaddingtothe`McDonaldisationofSociety'inNewZealand.ThisresearchwasconductedwiththesupportofagrantprovidedbytheUniversityofAucklandResearchCommittee.DamianCollinsandWilbertGeslerkindlymadeusefulsuggestions.FinallywearegratefulforthecooperationofMrGrantClose,gen-eralmanagerattheStarship.Anderson,K.,Gale,F.,1992.InventingPlaces:StudiesinCulturalGeography.Longmans,Melbourne.Appadurai,A.,1993.Consumption,durationandhistory.StanfordLiteratureReview10,11±33.Barnett,J.R.,1984.Equity,accessandresourceallocation:R.A.Kearns,J.R.Barnett/Health&Place6(2000)81±93 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