Fox, Claude Earl MD, MPH; Morford, Thomas G. MA; Fine, Amy MPH; Gibbons, M Chris MD, MPH
For the better part of the 20th century, and now into the 21st, the United States has rightfully claimed the best medical care system in the world. Looking at the miraculous cures, breath-taking surgical feats, control of infectious disease, and other aspects of U.S. medicine, it is difficult to dispute the claim. But there is another story when one looks at the health of our nation's urban poor. The health care system in the United States seems to hardly touch many of our most vulnerable individuals and communities. In addition, when medical care is delivered, it is often inadequate to meet the complex health, social, economic, educational, and environmental needs of inner-city urban residents.1
The paradox of the modern U.S. medical system is that, although it has an unparalleled capacity to treat and repair (particularly with regard to trauma and infectious disease), it is ill-prepared to prevent illness, especially within the complex context of the urban environment. Although this contradiction has implications for the entire U.S. population, its impact is greatest for those with the fewest resources, including the urban poor. For inner-city residents who often live close to large academic health centers, the paradox is all the more acute. Even though the “best care in the world” may literally be right next door, poor urban residents experience some of the worst health conditions, live in some of the least-healthy environments, and have some of the worst health indices of any population group in the nation—in some instances comparable to those found in developing nations.
This article describes the efforts of one academic health center—Johns Hopkins University—to address the complex health needs of its inner-city neighbors while also strengthening urban health knowledge and practice within the university and the nation.
Urban Health in East Baltimore
East Baltimore is home to major components of Johns Hopkins University, including significant parts of the Johns Hopkins Medical Institutions such as the School of Medicine, the School of Nursing, the Bloomberg School of Public Health, and the Johns Hopkins Hospital. It is also home to about 100,000 residents, over 90% of whom are African American. Many East Baltimore residents suffer from not only poverty, but also poor health. In fact, despite its proximity to Hopkins, the East Baltimore community has experienced startlingly high rates of many preventable diseases and deaths. By the late 1990s, Baltimore's health department statistics indicated that East Baltimore's neighborhoods had the highest age- and sex-adjusted rates of morbidity and mortality from cardiovascular and cerebrovascular disease in the entire city. East Baltimore's residents also suffered disproportionate incidences of diabetes, cancer, some pulmonary diseases, HIV-related illnesses, and substance abuse. The rate of sexually transmitted diseases in East Baltimore was the highest in the country, and, in the case of syphilis, East Baltimore's rates were higher than any city in the developed world. As many as 18% of the babies born in some East Baltimore neighborhoods were likely to experience complications arising from low birth weight, and as many as 12% of the first-graders presented with symptoms of asthma during the school year. East Baltimore had more than 10,000 residents (over one in ten) with alcohol or drug problems requiring treatment, was one of the nation's most violent communities, and ranked near the top in reduced life expectancy.2
During the late 1990s and into the new millennium, the employment statistics for East Baltimore have been equally challenging. In a city with a relatively high unemployment rate (about 7%), the neighborhoods of East Baltimore suffer from higher rates of unemployment than anywhere else in the city. Ranging from about 10% to almost 14%, East Baltimore's unemployment statistics provide another clear indicator of a community in distress.3
Adequately addressing these health challenges has been further complicated by long-standing attitudes of mistrust between the university and the local community. Many in the community believed that the university was only interested in the community as a place to conduct research, and that it continued to build and increase its size at the expense of the community. On the other hand, many at Johns Hopkins were perplexed and resentful because they felt the community did not recognize the institution's commitment to programs and employment or the personal contributions of the university's faculty and staff in providing health care for the community.
The Johns Hopkins Urban Health Initiative
Confronted with issues of mistrust, a growing contradiction between Johns Hopkins University's role as a world-class academic health center, and the devastating health and social conditions of East Baltimore residents, Johns Hopkins University's president, William Brody, determined the university should take concerted action. In 1997, he appointed a five-person steering committee led by the provost with the top representatives from the Schools of Medicine, Nursing, and Public Health, and the Johns Hopkins Hospital and Health System. Their charge was “...to begin exploring how research, teaching and clinical expertise could be better harnessed for the benefit of East Baltimore's health.”4 The steering committee, in turn, launched the President's Council on Urban Health, which was charged with the goal of “working in concert with the community to significantly enhance the health of East Baltimore through the Hopkins missions of research, teaching, and health care.”4 With this expanded goal, the steering committee added a crucial ingredient to the task at hand: community involvement and collaboration. To accomplish the task in the allotted seven months, the president's council enlisted more than 150 community, business, city government, and Hopkins faculty and staff volunteers to participate on the council itself and/or one of 12 designated working groups. The council's working groups were organized into two broad categories:
* disease-oriented groups (DOGs) focused on substance abuse, violence, sexually transmitted diseases, cardiovascular disease, and pulmonary disease; and
* community-action task (CATs) groups focused on communication, environment, family, maternity and child health, data-information systems, revitalization, governance and promotion, and aging and the elderly.
The Working-Group’s Findings
The two working groups met and worked regularly, producing topic-specific reports. These were then summarized into one final report, which was presented to the university's board of trustees at its annual meeting in May 1999. There were two major findings of the report. First, the president's council identified 13 major obstacles to improved health in East Baltimore, many of which reflected underlying determinants of health and well-being not usually directly addressed by academic health centers. These barriers were poverty; a drug-based economy that promotes crime, saps community resources, creates major health risks, and deters investment in the legitimate economy; a flight to the suburbs by the more economically mobile; a lack of education; a lack of economic and political power; economic and environmental pressures that divert people from healthy lifestyles; a lack of health insurance; issues of racial and economic discrimination; a lack of continuity of care; a lack of community health workers; mistrust of Johns Hopkins, government agencies, and other sectors of the community; a lack of coordination between research projects and clinical care; and concerns about privacy of health information.4
The second major finding focused within the university itself. There, the president's council identified 12 major obstacles, many of them common to academic health centers nationwide: a lack of will and incentives with institutional emphasis on other priorities; economic pressures and a lack of fungible resources; the size and decentralized nature of the institution; a research-driven environment where faculty pursue their own interests; entrepreneurship that hinders communication, sharing of information, and creation of a database; a lack of coordination among experts in health education and between them and clinicians; a lack of coordination with and among city and state departments; the minimal interaction of many faculty and staff with the East Baltimore community; the design of the health care delivery system; the design of the health care reimbursement system; a concern about the privacy of health information; and a lack of adequate numbers of staff to support faculty research and teaching.4
The Council's Recommendations
On the basis of these findings, the president's council developed 18 recommendations for ways in which the university and the community could work collaboratively, calling upon the strengths and resources of each to improve health in East Baltimore.4 The four most critical recommendations were:
* A significant, focused, sustained, collaborative commitment would be required to effectively address these complex health issues. Thus, the council recommended that forming a new institute for urban health should be its top priority. The council noted that any such effort needed to be situated at the highest levels of decision making and affiliated with—but outside existing—Johns Hopkins entities.
* The council also stressed that health is significantly associated with broad, underlying factors; thus, the priorities of the new institute should be firmly rooted in the social and economic contexts of the community. Economic development in East Baltimore was among the top three priorities endorsed by the council.
* The council recognized the importance of building on the university's research and service delivery strengths to address the specific health issues of greatest concern to the community and to better integrate health and other services. Substance-abuse prevention and treatment were specifically stressed as among the top priorities for action.
* Finally, the council also recommended a mission for the institute: “to improve the health and well-being of East Baltimore by merging community strengths with Hopkins expertise and applying these to community-identified health problems.”
Launching The Johns Hopkins Urban Health Institute
In June 2000, acting upon the recommendations of the council, President Brody established the Johns Hopkins Urban Health Institute, and schools across the university committed to an annual core budget to enable the institute to grow and sustain itself without immediate economic pressures.
The institute was established as focal point for Johns Hopkins on urban health. The institute was to coordinate and strengthen efforts to more efficiently and effectively respond to the serious health needs of East Baltimore. In order to freely draw on the breadth of expertise at the university, the institute was not affiliated with any one school or division, but rather was launched as a freestanding entity reporting to the Johns Hopkins University's president. The institute's board of directors was composed of the deans of the major schools, the president of the Johns Hopkins Health System, and community representatives, and Johns Hopkins University's provost served as the board's chair. This structure, which continues to the present, gives the institute a voice at the highest levels of decision making within the Johns Hopkins University, the ability to coordinate efforts across the institution, and the opportunity to hear and reflect the voice of the community. The institute operated under an interim director for the first year. In June 2001, one of the authors (CEF) was appointed the first permanent director.
Mission and Goals
In June 2001, with its board and key staff in place, the institute began to refine and further develop the president's council's recommendations, establishing a revised mission statement and three strategic goals.
The institute's current mission is to marshal the resources of the university and external groups to improve the health and well-being of the residents of East Baltimore and to promote evidence-based interventions to solve urban health problems nationwide.
The institute's current strategic goals are to:
* strengthen and enhance urban-health research and learning both locally and nationwide,
* reduce disparities in health and health care for East Baltimore residents, and
* promote economic growth in East Baltimore.
The Johns Hopkins Urban Health Institute in Operation
To achieve its goals, the institute needed to employ multiple strategies, promoting research and learning in parallel with efforts to enhance health services and economic opportunities for East Baltimore residents. Each of its strategies has required building partnerships both within the university and between the university and the community. Within Hopkins, the institute has tapped faculty and others to utilize the intellectual capital. At the same time, it has also worked to strengthen the university's ties to the community and enhance learning, scholarship, and experience for faculty and students. Within the community, the institute has worked with “anchor” institutions and community leaders, supporting their efforts to stabilize the neighborhood and building trust one block and one project at a time.
Thus, in its initial three years of operation, the institute has spent considerable effort on both outreach to the community and “in reach” to Hopkins faculty, staff, students, and administration. Collaboration on both fronts is essential to the institute's success and is, therefore, integral to the strategies it has implemented. Below, we describe how collaboration is integral for each of the institute's goals.
Goal 1: Strengthen and Enhance Urban Health Research and Learning
The major priorities with respect to research and learning are to build an evidence base of practices and programs that improve the health and well being of inner-city residents, integrate urban health issues into the Hopkins research and training activities, and establish Johns Hopkins University as a national leader in urban health research and scholarship. As with all other aspects of the institute's work, activities related to research and learning are undertaken with a good deal of collaboration, both within the university and between the university and the community. Work to date falls into two broad categories: (1) support for community-based participatory research (CBPR), with a particular focus on issues of concern within the East Baltimore community, and (2) efforts to integrate urban health issues and practice into the broader university agenda. The major activities in these two categories are described below.
Community-based participatory research.
The institute supports a range of CBPR activities, including monthly seminars; an electronic newsletter; and the work of three junior faculty from the Schools of Medicine, Nursing, and Public Health, who are developing CBPR projects suitable for external funding. In selecting CBPR projects, the institute focuses on efforts that involve strong partnerships between researchers and the community and that potentially can have a significant impact on one or more of the major health and/or socioeconomic problems facing East Baltimore. For example, one of the institute's first CBPR initiatives –“Breaking the Grip of Drugs in East Baltimore” – piloted four community-based interventions focused on substance abuse, the top priority health issue identified by East Baltimore residents. This initiative provided grants to partnerships between Hopkins researchers and community-based organizations to pilot innovative approaches for combating the effects of drugs in East Baltimore. Applications were evaluated by a committee consisting mostly of community representatives. Funded projects included:
* The Amazing Grandmothers—This project provided support services to grandmothers of children whose parents are absent or incapacitated by substance abuse.
* Linking Individuals to New and Continuing Support—This partnership between the Johns Hopkins Wald Community Nursing Center and seven community entities used the health care episode to help addicted men and women get treatment. It also increased community capacity for substance abuse treatment and support services.
* Spirituality, Substance Abuse, and Mental Illness—Aiming to improve services for a high-risk group with co-occurring substance disorders and mental illness, this partnership elicited opinions from professionals and patients of different racial, social, and economic groups and then used a pilot program to evaluate spiritual intervention among a sample of predominately African-American patients with the dual problem.
* Intensive Treatment—A partnership between a community-outreach center and the Johns Hopkins Hospital Intensive Treatment Unit, this project helped link drug-addicted individuals to intensive care, as well as to referral and follow-up services in the community.
Most recently, the institute has laid the groundwork for establishing the Journal of Community-Based Participatory Research. Although CBPR is a growing field, it lacks a professional vehicle for communicating research findings among academics, communities, and practitioners. The journal will fill this void, while promoting further collaboration and elevating the visibility and stature of CBPR as a means toward eliminating health disparities and improving health outcomes.
Integrating urban health into Johns Hopkins research and training activities.
If Johns Hopkins is to fully embrace the challenge of improving health in East Baltimore and other urban communities, it is critical that urban health be further integrated into the curricula of the appropriate schools across Johns Hopkins University. It is equally important to stimulate interest among senior faculty and, especially, junior faculty who will carry forward urban health research and scholarship into the future. To better integrate urban health into the university's agenda, the institute recruited professors from the Bloomberg School of Public Health, the School of Nursing, the School of Medicine, and the institute for Policy Studies to constitute an Academic Advisory Council (AAC) that provides guidance on the institute's research program. The AAC developed a vigorous agenda, which the institute has already used to initiate several key programs to promote urban health scholarship within the university. Several examples are:
* The Urban Health Post-Doctoral Fellowship Program—This program couples promising postdoctoral fellows with senior faculty mentors from the Schools of Medicine, Nursing, and Public Health to advance urban health research and publication across the university. It has also developed partnerships with Morgan State University and the Johns Hopkins Adolescent Center to recruit additional postdoctoral fellows who will work with senior faculty at both universities on urban health and community-based participatory research. To date, the institute has appointed three fellows, and at least four additional fellows will join the program in the near future.
* Senior Faculty Research Fellowship Program—Recently launched, this program pairs senior faculty with research interests in urban health, with the institute's postdoctoral research fellows. Senior faculty serve as mentors to the fellows, assisting the new investigators as they carry out work in the community, develop funded-research projects, engage in efforts to strengthen the university's links to the residents of East Baltimore, and participate in seminars, workshops, conferences, and courses related to urban health.
* Needs Assessment and Database Development Projects—Two efforts currently underway will provide much-needed baseline data and will make already-completed needs assessments more accessible to researchers and others with an interest in improving health in East Baltimore. Under a Faculty Research Initiative Grant received this year, the institute will support primary data collection of baseline information on the health of East Baltimore residents. In a related effort, the institute is nearing completion of a project that compiles needs assessments already completed by researchers into an easily accessible database that will be posted on the institute's Web site. New assessments will be added as available.
Goal 2: Reduce Disparities in Health and Health Care for East Baltimore Residents
As demonstrated in its morbidity and mortality statistics, the health problems in East Baltimore are incredibly pervasive. Realizing that it cannot address every problem simultaneously, the institute's strategy is to initiate projects that maximize impact, utilize the clinical expertise of the Johns Hopkins Medical Institutions, and maintain the impeccable clinical standards that make Hopkins a world-renowned organization. After consulting with community leaders as well as Hopkins faculty and staff and analyzing available data on disease and treatment patterns in the community, the institute focused its first efforts on HIV/AIDS and primary care.
* HIV/AIDS—In 2003, the institute opened a community-based HIV/AIDS counseling and testing center in East Baltimore. Staffed by medical student volunteers who had been trained and certified by the State of Maryland, this state-approved center has increased the number of at-risk individuals who have been tested and, if positive, placed into appropriate care. In 2004, the institute expanded its HIV/AIDS program to four sites. Not only has this effort helped increase the number of individuals in East Baltimore who are aware of their HIV/AIDS status, but it has also been a step forward in educating medical students in urban health. Working directly with community-based organizations and East Baltimore residents, the students have received a real-life practicum on a range of urban health issues and community concerns, and they are learning to meet the health needs of individuals in an intense urban setting.
* Primary Care—A very fundamental problem for residents of East Baltimore is lack of access to primary health care, a problem related to the lack of health insurance among a large portion of the population. To address the need for accessible services, the institute has opened a primary care clinic for the uninsured that provides screening and diagnostic services, disease management, health literacy and education services, and assists individuals in adhering to health guidelines and drug regimens. This cluster of care helps residents stay healthy and assists those with disease, especially chronic conditions, to manage their illnesses more effectively. The institute's primary care clinic is expected to provide five principal benefits: (1) have a measurable impact on the health of East Baltimore residents, (2) provide another mechanism to promote community involvement, (3) educate the next generation of Hopkins physicians and nurses in urban health (since a major part of the clinic staff will be Hopkins residents and medical and nursing students), (4) have a positive impact on the Johns Hopkins Hospital and Health System by reducing the amount of emergency and other secondary and tertiary care provided to the uninsured, and (5) contribute to the evidence base on the efficacy of primary care in improving the health of inner-city residents.
Goal 3: Promote Economic Growth in East Baltimore
Economic well-being and health go hand-in-hand. To be economically viable, community residents must be employed in jobs that at least pay a living wage; to be employed, residents must be trained to meet the needs of the job market. To address its third goal, the institute assessed job-training opportunities for the East Baltimore community and discovered that although there were a variety of training programs in Baltimore and across Maryland, none provided computer literacy and related technical training in a setting easily accessible to East Baltimore residents.
To fill this need, the institute recently launched the East Baltimore Technology Resource Center. Located in the heart of East Baltimore, the center provides a number of learning paths from informal, self-directed activities to structured curricula. By offering information-technology training that ranges from the general to the highly technical, creating “real-world” work experiences, and facilitating employment opportunities through relationships with employers, the technology center aims to significantly improve the employability of East Baltimore residents. It will also play a critical role in improving computer literacy by providing computer access, computer-use instruction, and technical support.
In June 2004, the institute completed its first three years of program activities. During this period, core funding from across the university enabled the institute to maintain its mission-based focus. The judicious use of core funding has enabled it to launch major programs in a careful strategy to accomplish its goals; success in attaining outside funding has enabled it to strengthen these programs; and support from the community and from Hopkins faculty and students has enabled it to establish a credible presence both in East Baltimore and also within the university.
The institute's third-year anniversary also marks a transition from a “start up” mode of laying organizational, relationship, and program foundations, to a “Phase II” mode during which it will build on the established foundations to enhance and fine-tune existing efforts; identify and launch new, complementary activities; ensure that key programs are sustained for the long-term; and evaluate the initial impact and outcomes of its programs.
The most immediate priorities for Phase II are to expand the primary care clinic's hours and operations to provide services five nights per week and to assure steady growth of the East Baltimore Technology Resource Center. At the same time, the institute will begin to formally assess its impact to date, drawing on lessons learned to chart the course for future efforts.
The challenges of fulfilling the institute's mission and achieving its goals are substantial: To increase urban health research and learning and improve the health and well-being of the residents of East Baltimore will require persistence, skill in advocacy and human relations, good management, sound evaluation, and increasing resources. The institute is committed to meeting these challenges by strengthening collaboration—both within the university and between the university and the community—and by marshalling the knowledge, resources, and political will needed to address significant urban health problems in East Baltimore and beyond.