When Chinese authorities extended high-speed rail lines connecting smaller cities to major urban centres, researchers examining 4 million hospitalisation records discovered patient flows to megacities surged dramatically, while small cities saw no increase. This finding reveals a universal pattern: infrastructure designed to strengthen regional capacity often amplifies concentration instead.
Major cities develop self-reinforcing magnetism for specialised medical care through interconnected mechanisms where each element reinforces others, creating ecosystems progressively more difficult to replicate regionally. This examination progresses from measurable evidence of patient flows through economic and infrastructural dynamics to implications for healthcare equity, maintaining an Australian perspective while examining patterns across Sydney, Nashville, Cleveland, and China.
The Measurable Pull
The Chinese research analysing chronic kidney disease hospitalisations following high-speed rail implementation found an 8.24% overall increase in intercity patient flows, masking dramatic variation by city size. Megacities saw a 23.02% increase, large cities 7.26%, while small cities experienced no significant increase. Infrastructure theoretically capable of strengthening regional capacity instead amplified concentration, with high-speed rail functioning as a conduit toward existing urban centres. Turns out billion-dollar rail lines work better as patient vacuums than capacity distributors.
Three years post-implementation, effects in megacities became negative, suggesting saturation points or evolving patient behaviours. This eventual saturation didn’t redirect flows toward small cities.
These measurable patient flows create powerful incentives for cities to further concentrate healthcare resources rather than support distributed regional capacity. Economic dimensions reveal why concentration is actively cultivated rather than accidental.
Economic Engines of Concentration
In the United States, Middle Tennessee’s healthcare sector has evolved over thirty years into a major economic force, generating an annual economic impact near $72 billion and supporting over 370,000 jobs. Healthcare’s become a primary economic driver comparable to traditional urban engines like finance or technology. Seems we’ve reached the point where cities compete for heart surgeons the way they once fought over steel mills.
The Nashville Health Care Council and Sessions conference exemplify strategic efforts, with Apryl Childs-Potter, President of the Nashville Health Care Council, emphasising the importance of language and branding in positioning Nashville as ‘The Healthcare City.’ This represents active cultivation with unified strategies to attract additional medical investment and talent.
The economic impact approaching mid-sized country GDP creates strong incentives for continued investment in concentrated healthcare infrastructure rather than distributed models. The scale of economic activity means cities view healthcare concentration as a strategic economic advantage.
These economic incentives translate into infrastructure investments – specialised equipment, dedicated facilities, advanced technology platforms. Individual practitioners operating within these urban ecosystems leverage this concentrated infrastructure in ways that perpetuate the very patterns that created it.
Infrastructure Advantage at Practitioner Level
Maintaining subspecialty expertise requires sustained volumes and specialised infrastructure that regional settings often can’t provide. This challenge is particularly pronounced in fields requiring high-volume practice to maintain proficiency and justify the investment in advanced equipment.
A generic solution involves concentrating specialised medical practices in urban centres where patient volumes and infrastructure can support complex procedures. Dr Timothy Steel, an associate professor practising in neurosurgery and minimally invasive spine surgery at St Vincent’s Private Hospital and St Vincent’s Public Hospital in Sydney, provides an example of this approach.
Steel’s consultant appointment commencing in 1998 has accumulated career totals exceeding 2,000 brain surgeries, 8,000 minimally invasive spine procedures, and 2,000 complex spine procedures – volumes reflecting sustained patient flows that major cities provide. The infrastructure supporting this practice includes Brainlab stereotactic navigation, operating microscopes, endoscopic tools, ultrasonic aspiration, and dedicated spine tables.
The NuVasive Pulse digital surgery platform integration at St Vincent’s Private in September 2022, the first hospital in Australasia to offer the platform, combines neuromonitoring, imaging, navigation, planning and rod bending into a single workflow. Look, it’s not just about having fancy equipment – it’s that high volumes justify the investment, which attracts complex cases, which sustain the expertise needed to use it effectively. That equipment-volume-expertise cycle extends beyond technology alone.
Urban infrastructure creates conditions for subspecialty expertise development that lower-volume regional settings cannot replicate – equipment investment enabled by high case volumes attracts complex cases that sustain expertise, which enables training programs that produce additional specialists seeking similar high-volume urban environments. Each element reinforces the others, making replication in regional centres progressively more difficult as the gap in capabilities and volumes widens over time. This clinical infrastructure concentration also generates the data volumes and case complexity that enable research programs to flourish.
Research Capacity Concentration
Cities concentrate translational research infrastructure due to their ability to support both laboratory facilities and access to diverse patient populations necessary for clinical trials and therapeutic advancements.
A generic solution involves establishing major research institutions within these urban centres to leverage existing clinical infrastructure and patient volumes. Professor Benjamin Kile provides an example of this pattern through his role as Executive Director of the Garvan Institute of Medical Research in Sydney.
Kile’s blood cell molecular biology research focused on programmed cell death mechanisms contributed to the development of BH3 mimetics, a new class of cancer drugs approved by the FDA in 2016. This progression from basic science investigation of cell death pathways to clinically approved therapeutic class demonstrates how major research institutions in established medical centres create environments where laboratory discoveries advance toward clinical applications. Actually, that’s the beauty of concentrated research environments – they’ve got both the lab capacity to investigate molecular mechanisms and the clinical infrastructure to test whether discoveries work in real patients. This enables research capacity that enhances institutional reputation and attracts pharmaceutical partnerships.
Research capacity, once established, enhances institutional reputation and attracts pharmaceutical partnerships and research funding, creating an additional self-reinforcing layer where clinical concentration attracts research activity, which produces innovations enhancing reputation, which attracts additional resources. Research concentration enables another dynamic – knowledge exchange among diverse practitioners that accelerates clinical skill development and further reinforces urban magnetism.
Knowledge Exchange Dynamics
Cities achieving critical mass in specialist concentration attract additional practitioners seeking exposure to diverse cases and colleague expertise. The universal principle: diverse practitioner populations create learning environments accelerating clinical skill development – a dynamic operating across different healthcare systems and geographic contexts.
Cities leveraging international practitioner diversity create knowledge-exchange advantages that reinforce their appeal to subsequent practitioners and patients. The universal principle – exposure to diverse clinical presentations and practitioner approaches accelerates skill development and innovation – operates regardless of specific regional context or healthcare system structure. Dr Hassan Galadari, professor at UAE University, Consulting Dermatologist at Galadari Derma Clinic, and scientific director of Dubai Derma, observes this in Dubai: “When it comes to healthcare, we really need to share know-how, knowledge and experiences from different parts of the world. And Dubai attracts all of these different experts to showcase their knowledge. That’s the beauty of it and that’s where the healthcare industry really thrives.”
This knowledge-exchange dimension explains why cities achieving critical mass in specialist concentration attract additional practitioners seeking collaborative learning environments, perpetuating the self-reinforcing cycle that makes replicating such diverse, high-volume practice environments in smaller centres increasingly difficult. These knowledge-exchange advantages that cities provide become institutional assets that healthcare systems leverage for expansion beyond their original urban base.
Institutional Expansion and Concentrated Cores
Healthcare systems leverage their reputation built in major cities to expand internationally while maintaining their urban core as a concentrated hub of advanced capabilities. This strategy allows them to extend their reach while preserving their foundational strengths.
A generic solution involves leveraging institutional reputation for global expansion while continuing to concentrate advanced capabilities within the original urban core. Tomislav Mihaljevic provides an example through his leadership as CEO and President of Cleveland Clinic since January 2018.
Under Mihaljevic’s leadership, Cleveland Clinic has expanded from its Cleveland base to encompass 23 hospitals and 276 outpatient locations across the United States, Canada, the United Arab Emirates, and the United Kingdom, achieving 15.1 million patient encounters annually and operating revenue reaching $15 billion.
The establishment of Cleveland Clinic London and enhancement of services at Cleveland Clinic Abu Dhabi exemplify reputation-based international expansion. The Cleveland name carries weight built through decades of concentrated expertise in Ohio, enabling the institution to extend its presence globally while the original city remains the recognised centre of the system. But here’s what’s interesting – why does cutting-edge technology like the first quantum computer dedicated to healthcare research still end up in Cleveland despite this global expansion? Because the original urban core remains where the deepest expertise and research partnerships concentrate. This shows how institutions leverage reputation for global expansion while maintaining urban core as concentrated hub.
The deployment of the first quantum computer dedicated to healthcare research in Cleveland in 2023 demonstrates that cutting-edge technology partnerships continue flowing toward the established urban core even as clinical service delivery expands outward. This illustrates how leading institutions in established medical cities continue attracting advanced research technology that further concentrates capabilities in their original urban base.
Healthcare systems achieving prominence in major cities leverage reputation to build international networks while maintaining urban core as concentrated hub of advanced capabilities – magnetism operates at institutional scales, with successful urban centres expanding globally while continuing to concentrate research and cutting-edge technology in their original city. Yet this very success in concentrating advanced capabilities raises questions about whether these self-reinforcing forces can be counteracted.
Counterforces and Distribution Challenges
The Chinese high-speed rail finding that small cities saw no increase in patient flows despite improved connectivity demonstrates infrastructure investments that theoretically could strengthen regional capacity instead created more efficient pipelines toward existing urban centres.
Telehealth presents a potential counterbalancing force. John Williams, assistant vice president of telehealth services at Intermountain Health in the United States articulates this possibility: “Through telehealth, we can bring specialty care to the patients, instead of bringing the patient to specialty care.” While telehealth can extend consultation access to regional patients, it may simultaneously make urban centres more accessible to those considering complex procedures, potentially increasing rather than decreasing patient flows toward cities by reducing one barrier – travel difficulty – without addressing the underlying pull of concentrated infrastructure and expertise. Funny how technology designed to keep patients home might actually make it easier for them to travel to the big city. This suggests urban expertise might extend outward through digital channels while paradoxically reinforcing the mechanisms that concentrate advanced care in major cities.
However, proximity alone doesn’t automatically translate to distributed care. Devon Noonan, Associate Professor and project lead for the Interdisciplinary Hub for Rural Health Equity at Duke University in the United States observes: “Duke resides in North Carolina… Our hub grew from the idea that we need to be doing more with and for rural communities… we currently lack a unified approach… despite our proximity.” This suggests intentional efforts are required to counteract centralising forces.
The tension between telehealth’s potential to extend expertise and the reality that proximity doesn’t guarantee distributed models raises fundamental questions about whether the self-reinforcing elements can be interrupted.
Equity Implications and the Replication Challenge
The self-reinforcing mechanisms that concentrate healthcare capacity in major cities create mirror-image challenges for regional centres attempting to build comparable capability. Regional centres face a compounding problem: lower patient volumes make advanced equipment investments harder to justify economically, which limits the complexity of cases they can handle, which further reduces volumes as complex cases migrate to urban centres that can accommodate them.
Where urban centres experience positive feedback loops – volumes enabling infrastructure, infrastructure attracting complex cases, complex cases sustaining expertise, expertise enabling training programs that produce additional specialists – regional centres experience the inverse, with each disadvantage reinforcing the others. Concentration delivers genuine clinical benefits through economies of scale – high volumes maintain expertise, shared infrastructure enables innovation – but self-reinforcing nature means gaps between what major cities offer and what regional centres can sustain progressively widen.
Technology-enabled solutions like telehealth might extend urban expertise outward but could also facilitate patient flows inward by making urban centres more accessible. The core question is whether self-reinforcing elements can be interrupted or whether dynamics are too powerful to reverse without fundamentally restructuring how specialised healthcare is organised and financed.
The Chinese high-speed rail case suggests that even infrastructure investments explicitly intended to strengthen regional capacity can instead amplify concentration when the underlying economic and professional incentives remain unchanged, illustrating why interrupting self-reinforcing dynamics may require more fundamental restructuring than incremental improvements in connectivity. The progressive difficulty of replicating urban healthcare ecosystems in regional settings may be enduring, creating lasting implications for healthcare equity that require recognition of the concentrated responsibility major cities bear when they become dominant hubs for specialised medical care.
Reflecting on Urban Healthcare Magnetism
The pattern’s clear across continents: major cities develop magnetic pull through dynamics that intensify over time. Patient volumes enable infrastructure investments that attract complex cases sustaining expertise that enables training programs producing additional specialists seeking similar environments – each element reinforcing others.
While clinical benefits of concentration are genuine – high volumes maintain expertise, shared infrastructure enables innovation – the gap between what major cities offer and what regional centres sustain widens progressively. The Chinese high-speed rail lesson applies broadly: forces concentrating healthcare in major cities are so powerful that even well-intentioned interventions can amplify rather than counteract them.
The question isn’t whether to reverse concentration but whether cities achieving healthcare magnetism recognise the broader responsibility that comes with it. After all, when billion-dollar infrastructure investments can’t break the pull, the magnetism might be here to stay.
