Citing race as the difference maker for many of the city's health problems, the Baltimore City Health Department has developed a plan to assess and address those disparities.
In a report released Tuesday, the department outlined plans to cut health disparities in half in the next decade by focusing on four areas: behavioral health such as drug overdoses; violence; chronic disease; and "life course," which includes the often-cited 20-year gap in life expectancy between Baltimore's richest, white neighborhoods and poorest, black ones.
Officials dubbed the report Healthy Baltimore 2020 because they plan to assess progress incrementally and not wait 10 years to say if they've reached their goal.
The report speaks to much that has gone wrong in the city with residents' health because of historic racial inequality and economic and geographic disparity, said Dr. Leana S. Wen, the city's health commissioner. It looks beyond traditional indicators of good health such as education, public safety and the economy.
"It's taken 18 months to get this process to where it is now because we wanted to make sure we had a cohesive framework to look at health issues in the city," Wen said. "You can name all the health issues in the city, but that would just be a list of problems and not a strategy. We needed something to tackle and to communicate our priorities to our residents."
Many cities have such blueprints for addressing vexing socio-economic problems as a means to address health. The U.S. Centers for Disease Control and Prevention's last accounting of the nation's overall health in 2015 looked at such racial disparities.
Baltimore's health department outlined what was billed as the city's first comprehensive plan to address intractable health problems in 2011. It targeted the top 10 serious ailments, including HIV infection and heart disease, adopting a model developed in New York City in 2004 called Take Care New York.
Other cities have used different outlines. Washington, for example, has a plan called DC Healthy People 2020 Framework that monitors 150 objectives and recommends 85 strategies for improving health in 29 areas, including substance abuse, oral and mental health, and food safety.
The New Orleans Community Health Improvement Plan for 2015 outlines a "shared vision" for health that targets five areas, including access to physical and behavioral health, social determinants of health, violence prevention, healthy lifestyles and family health.
Baltimore's focus on disparities "makes good sense," said Dr. Peter Beilenson, a former Baltimore health commissioner who is now CEO of the health insurance co-op Evergreen Health.
"The overarching goal is hugely important," he said. "Race and class disparities in this city are dramatic, probably more so than in other urban jurisdictions."
Jan Desper Peters, CEO of the Black Mental Health Alliance, said that community input will be crucial in making any plan work.
She said the report's approach to reducing disparities by tackling social determinants of health is in sync with the alliance's mission. But she still wants to ensure that those outside government have a say going forward.
"Anyone attempting a plan to attack disparities has to be concerned with the whole person," Desper Peters said. "And the community needs to play a significant role in what that plan looks like, not the health department telling the community what's best for them."
Raimee Eck, president-elect of the Maryland Public Health Association, an organization of public health professionals, said the city appears to have gotten off to a good start by considering historic barriers to health across neighborhoods.
"Dr. Wen's team has promoted a plan to address the environmental factors, or social determinants of health, in a way that will hopefully reshape our communities and not just try to 'treat' them," she said. "Structural racism is certainly an important factor in how our city has been shaped over time, and not for the better; understanding that history and approaching health-related issues with this concept in mind is a necessity, not an option."
The report outlines up to five objectives under each focus area and lists how progress will be tracked, though there are specific goals for individual disparities.
Examples of objectives include reducing disparities in overdose deaths, youth homicides and school absenteeism, in the number of children with unmet medical needs and who are obese, and in the infant mortality rate and fatal falls among seniors.
Wen said such disparities have long been evident in health outcomes, but they gained a particular urgency after the riots that followed the death last year of Freddie Gray, a 25-year-old black man who suffered a spinal injury in police custody. Residents in the poor community where Gray lived, in addition to many others, expressed frustration about the lack of jobs and opportunities, which Wen said contributed to poor health conditions.
Residents who are black or live in certain ZIP codes were more likely than people in better-off areas of the city or the state to be addicted to drugs or alcohol, die violently, be obese, have asthma, or be born underweight, for example.
Baltimore now has one of the five highest rates of drug overdoses in the country, with 393 fatalities last year, more than the number of homicides. African-Americans make up about 63 percent of the city's population, but more than 90 percent of homicide victims are black.
One city child in four drinks a soda daily, and fewer than one in five eats the recommended servings of fruits and vegetables.
"We see how health ties into everything," Wen said.
Wen cited programs that are working and can be bolstered going forward. They include Safe Streets, a program which officials said mediated 692 conflicts to avoid violence in the last year. They also include other programs that have trained 1,200 residents to use the opioid overdose antidote naloxone, contributed to a 36 percent decrease in teen births, and supported 298,870 trips to school health providers.
Beilenson said the health department should seek community input in picking three or four priorities, perhaps one under each of the four focus areas, to address, so resources aren't spread too thin.
City officials said programs will be improved or developed in consultation with community members. Neighborhood meetings are planned, including one at the Y in Druid Hill in West Baltimore on Tuesday.
"Growing a healthier Baltimore is foundational to our sustained success as a city," Mayor Stephanie Rawlings-Blake said in a statement. "My administration — along with support from numerous city and state agencies — has maintained a commitment to improving health and equity within our communities. We must recommit ourselves to the challenges we continue to face."