Barbra Mann Wall, Unlikely Entrepreneurs: Catholic Sisters and the Hospital Marketplace, 1865-1925, Columbus: The Ohio State University Press, 2005.

Barbra Mann Wall, Unlikely Entrepreneurs: Catholic Sisters and the Hospital Marketplace, 1865-1925, Columbus: The Ohio State University Press, 2005. $79.95, ISBN 978-0-8142-0993-6 (hardback), xviii, 267 pp.


Barbra Mann Wall, American Catholic Hospitals: A Century of Changing Markets and Missions, New Brunswick, NJ: Rutgers University Press, 2011. $45.95, ISBN 978-0-8135-4940-8 (hardback), xv, 238 pp.


Reviewed by: Thomas F. Rzeznik, Seton Hall University (South Orange, New Jersey, USA), October 2013.



Recent political debates in the United States over the implementation of the Affordable Care Act and federal mandates on contraception coverage have brought new attention to the role that Catholic institutions—and their moral witness—play in the nation’s health care sector. At present, the Catholic Church sponsors the largest network of not-for-profit health care institutions in the United States, including more than 600 hospitals and 1,400 other facilities across the country. Not only do these institutions play a vital role in the delivery of health care services to millions, especially to the poor and vulnerable, they also serve as a testimony to the ardent faith, dedicated charity, and entrepreneurial zeal of the religious communities who established, operated, and staffed them. Women religious, in particular, provided the vision, labour, and moral leadership that were instrumental to the development of Catholic health care ministries in the United States.

In these two finely-crafted books, Barbra Mann Wall traces the history of the Catholic hospital system in the United States in two distinct periods of growth. The first, Unlikely Entreprenuers, recounts the early trajectory of Catholic hospital growth from the mid-nineteenth century to the hospital standardization movement of the early twentieth century. The second, American Catholic Hospitals, continues the story from the mid-twentieth century to dawn of the twenty-first, a time in which hospitals gave rise to modern medical centres characterized by ever-increasing scientific sophistication, administrative complexity and regulatory structures.  Both are focused on how hospitals developed and operated; they do not delve deeply into how patients experienced care within Catholic hospitals or the daily routines of doctors, nurses and other staff members.

Central to both books is a focus on how Catholic hospitals and their sponsoring religious orders have sought to promote and preserve their religious mission amid changing medical, social and political realities within the competitive health care marketplace. In addition to their focus on institutional and economic dynamics, the two works also pay close attention to the gendered nature of authority within Catholic hospitals and highlight the distinct ways that women religious shaped the character of their institutions and exercised influence within the American health care system. As a professional historian and trained nurse, Wall is attuned to both the internal and external factors that shaped how these hospitals operated and the challenges they faced.

In describing the early period of Catholic hospital development in the United States, Wall’s first book, Unlikely Entrepreneurs: Catholic Sisters and the Hospital Marketplace, 1865-1925, highlights the remarkable degree of market engagement that characterized the work of the women religious as they sought to develop health care institutions that would embody their religious values. By examining hospital growth through the interpretive lens of entrepreneurship, Wall demonstrates how sisters combined religious and economic activity to create ‘viable health care institutions’ (p. xii). The strategies they employed not only enabled their institutions to flourish, but also revealed sisters to be engaged actors in the economic sphere at a time when women were not considered capable of operating businesses or managing complex financial affairs.

The book thus provides a helpful corrective not only to those accounts of American health care that have overlooked the contributions of women religious, but also to Catholic institutional narratives—including many written by members of religious orders themselves—that downplay or deny sisters’ own agency. Although Catholic hospitals faced persistent economic hardship and sisters did at times find themselves victims of the competitive hospital marketplace, they more often than not proved themselves adept at seizing opportunity and developing innovative strategies to support their institutions. Recognized for their nursing skill, especially in light of their service during the Civil War, women religious were encouraged by bishops and doctors alike to establish hospitals, and theirs were often the first to serve many communities. In the American West, they contracted with mining firms and railroad companies to provide care for sick and injured workers, and some sold contracts for hospital services that served as early health insurance policies. Yet even though sisters were enmeshed in market relations, Wall posits that ‘their entrepreneurship was not to expand earnings but rather to advance Catholic spirituality’ (p. xii). She later argues that there was ‘no clear dichotomy between charity and marketplace roles’ (p. 189), a slightly more tenuous claim given Catholic unwillingness to accept stern market logic and the commodification of health care.

Organized both chronologically and thematically, the book is divided into three main sections. The first section provides a brief overview of the origins of Catholic hospital care in the United States and offers background on the sisters and their religious communities. While some religious institutes, like the Daughters of Charity, had a long-established commitment to the care of the sick as part of their charism, others became involved in nursing and hospital care in response to local needs. The second section traces trends within the development of Catholic hospitals through case studies of institutions established in the Midwest, Utah, and Texas by three distinct religious communities: the Sisters of St. Joseph of Carondelet, the Sisters of the Holy Cross and the Sisters of Charity of the Incarnate Word. The chapters in the final section move beyond institutional development and financial concerns to explore the spiritual beliefs that guided the sisters’ ministry, the gendered power dynamics of hospital management and the tensions created by medical professionalization and hospital standardization. The book concludes with a discussion of the formation of the Catholic Hospital Association and its efforts to promote hospital modernization consistent with both scientific standards and religious values.

Unlikely Entrepreneurs does not attempt to provide an exhaustive chronicle of Catholic hospital foundations. Rather, it offers an overview of hospital development through a collective portrait of select institutions. The case studies serve as a particularly effective means of illustrating institutional dynamics. Wall’s focus on hospitals in the American South, West and Upper Midwest also draw attention to regions farther removed from the nation’s main population centres. This allows her to chart Catholic influence where it might not generally have been expected to the degree that it was. One might wonder, however, how the story might differ if she had included hospitals in major East Coast cities, where Catholic hospitals faced more vigorous market competition not only from public and other voluntary hospitals, but also in relation to each other.

Wall’s second book, American Catholic Hospitals, serves as a sequel to Unlikely Entrepreneurs, tracing the history of Catholic hospitals and health care ministry from the middle decades of the twentieth century to the passage of the Affordable Care Act under the Obama administration. During this period, Catholic hospitals attained institutional maturity and emerged as major players in the U.S. health care sector. Federal funding for hospital construction under the Hill-Burton Act fuelled post-war hospital growth and expansion, while the passage of Medicare and Medicaid in 1965 helped to improve the financial health of Catholic and other not-for-profit hospitals by offering reimbursements for much of the charity care they had traditionally provided at their own expense. Yet as welcome as these programmes were, they also brought with them greater administrative complexity and new government regulatory entanglements. The rise of HMOs (health maintenance organizations) and the consolidation of the hospital industry in the closing decades of the twentieth century further altered the environment in which Catholic institutions operated. In describing how they negotiated these changes, Wall highlights how Catholic hospitals ‘attempted to fulfil religious missions to care for the sick within a commodified health delivery system’ (p. 3).

To chart these changes within the Catholic health care sector, Wall again turns to case studies in her opening chapters to reveal how particular institutions and their sponsoring religious communities responded to both internal and external pressures. In particular, she examines hospitals operated by the Sisters of Providence in Seattle, the Daughters of Charity in Austin, the Sisters of Charity in Pittsburgh and Chicago and the Alexian Brothers in Chicago, the latter being one of the few male religious orders involved in nursing and hospital sponsorship. Later in the book, she broadens her discussion to include other communities as she takes up particular thematic issues, including challenges posed by race relations and desegregation, unionization and labour strikes, and hospital consolidation, including the tricky ecclesiastical politics that have arisen when Catholic and non-Catholic institutions have merged.

Wall notes that the struggle to maintain Catholic distinctiveness became more pronounced during this period, as Catholic hospitals became more like their secular counterparts in structure and function. In more recent decades, religious mission, she argues, has become a marketing tool rather than an animating feature of the life of the hospital. Even though the work of the sisters (and brothers) remains a central component to the story—especially their contributions to the fields of nursing, hospital administration and public advocacy—their presence within the institutions they founded steadily diminishes over the course of the narrative. As a result, Wall’s account in this book tends to focus on Catholic hospitals as corporate entities and institutional actors rather than ministries.

In thinking about the fate of Catholic mission and identity, Wall explores national debates among Catholic health care leaders more than local debates within particular religious congregations or their hospitals. It would have been helpful, though, to learn more about how religious orders worked to safeguard the religious character of their institutions as the number of sisters declined (both as a percentage of total staff and in absolute numbers) and as religious communities relinquished control over hospital governance. The establishment of offices for mission integration, for instance, is a trend Wall does not discuss. More attention might also have been given to hospital sponsorship of neighbourhood clinics as a form of renewed ministry to the poor and marginalized, as well as the expansion of hospital-based social services and the interactions that sisters had with Catholic Charities and other social welfare agencies.

Taken together, Unlikely Entrepreneurs  and American Catholic Hospitals provide a clear and accessible introduction to the history of Catholic hospitals in the United States.  Broad in scope, but enlivened by choice case studies, these two works capture the vitality of Catholic hospitals without whitewashing the challenges they faced. The books should encourage further, more detailed studies of Catholic hospitals and the role of women religious in the American health care sector.