Strategies Directed at Communities with Greatest Need

Urban communities are typically diverse, characterized by neighborhoods that share social, ethnic and economic characteristics. In the U.S., non-whites are disproportionately low-income and the residential patterns are segregated, resulting in a concentration of the black and latino poor in geographically demarcated communities. The U.S. Census calculates a "dissimilarity index" (DI) to measure racial dispersion (Iceland, et al., 2002). By this index, of 312 metropolitan areas, New York City ranks among the most segregated in the nation. Indeed, nearly 85% of New York City whites would have to move in order to achieve an even black-white distribution. Nearly all U.S. metropolitan areas would be considered at least moderately segregated.

These residential patterns result in the geographic clustering of vulnerable populations. Health disparities, which occur strikingly by race-ethnic group and income level, also occur among neighborhoods (Karpati, et al., 2004). In 2003, in an effort to reduce excess morbidity and mortality in neighborhoods where poor health outcomes aggregate, the DOHMH established three District Public Health Offices (DPHOs) in Harlem, the South Bronx and North-Central Brooklyn. If mortality rates in these targeted areas were the same as in New York's wealthiest neighborhoods, more that 4,000 deaths would be averted each year. Disparities in mortality are complemented by marked differences in individual risk factors reported by residents. New York City is able to document such variation at the neighborhood level with data available from the Community Health Survey. High rates of smoking, HIV infection, sexually transmitted disease, obesity and physical inactivity also cluster in these three communities. This targeting is not perfect. There are geographic communities elsewhere in New York with poor health outcomes. Staten Island, with a population concentration of white, blue-collar workers, has the highest smoking rates. Parts ofJamaica, Queens are poor and have poor health outcomes. Acquisition of HIV infection remains higher in the Manhattan neighborhood of Chelsea than in other New York neighborhoods, reflecting the presence of large numbers of men who have sex with men. The selection ofjust three communities out of the scores of New York City neighborhoods reflects the DOHMH effort to target the neediest communities as its main approach to eliminating health disparities.

The three DPHOs provide community infrastructure for DOHMH activities. In establishing these offices, the DOHMH, for the first time in many years, deployed senior staff (Assistant Commissioners or higher) to communities of need, rather than to lower Manhattan, the seat of city government. This redeployment occurs in the context of a long DOHMH history of district health work. Always conceived as a way to bring services closer to those most in need, earlier efforts were based on the notion of decentralization and direct service provision (Widdemer, 1932). Decades of struggle between the vertically-organized, centrally-managed bureaus and the

District Health Centers ended with the dismantling of district services and the eventual elimination of most clinical services delivered by the DOHMH (Duffy, 1968). The DPHO effort is more limited in scope. Not all communities are in need of a DOHMH presence. Some of New York's wealthiest neighborhoods had, in 2000, already achieved many of the goals laid out in Healthy People 2010, the federal health target-setting document (U.S. Department of Health and Human Services, 2000). High-cost public health interventions, many of which require one-on-one contact with individuals, should be limited to communities that need them most.

DPHO activities fall under three general headings: (1) implementation of health promotion activities, both those launched by DPHO staff and those developed by other agency bureaus but housed in the DPHO; (2) local coordination of agency-wide activities, as well as those of other governmental agencies and community-based organizations; and (3) provision of health information and technical assistance to local community groups.

The DPHO also provides a strategic framework for the entire agency that promotes the targeting of scarce programming resources to communities most in need. Some activities are envisioned as based only in the DPHO. Other activities eventually suitable for citywide implementation can first be piloted in the DPHO. Each DPHO is autonomous and, while all three DPHOs have a similar operational structure, budget and staffing plan, each has a unique public health agenda that reflects specific community needs. The full-time DPHO staff number between 15 and 20. In addition to the District Public Health Officer, there is a program director, epidemiologist and administrator. Other staff are tasked to specific sectors, such as schools, community-based organizations or health services, or smaller geographic areas within the target area.

The catchment area for each DPHO ranges between 225,000 and 500,000. East and Central Harlem comprises about 225,000 residents. Most residents are black (56%) or latino (35%) and poor, with 37% living in poverty (as compared to the citywide average of about 20%) (Karpati, et al., 2003). Its health profile reveals a high rate of obesity, diabetes and childhood asthma. Initial activities identified by the DPHO staff include better management of childhood asthma and the promotion of physical activity. Staff have partnered with the New York City Department of Parks and Recreation to offer Shape Up New York, a free family exercise program. Asthma activities have focused on the development of an asthma registry in schools.

The North-Central Brooklyn DPHO covers a geographic area with a population of about 250,000. With a mostly 19th and early 20th Century housing stock (in contrast to East and Central Harlem, where 25% of the population live in post-World War II government apartment buildings), disproportionate numbers of lead-poisoned children reside here. Thus, the DPHO has focused on housing and health; a home visiting program has been launched to identify peeling paint and pest infestations and make appropriate referrals for remediation. The Brooklyn office, like the Harlem DPHO, has also worked closely with the Parks Department to support the Shape Up New York program.

The Bronx DPHO covers the largest area and population, about 500,000 people. A predominantly latino (62%) and black (33%) community, it is also younger than the Harlem or Brooklyn DPHO areas. Forty percent (40%) of the population is under the age of 20, compared to 28% citywide. Because teen pregnancy rates are 50% higher in this community than in the rest of New York City, the Bronx DPHO has focused on promotion of contraceptive access for teenagers. Much of this work has been done in collaboration with the 11 public high schools located within the target area, which enroll over 10,000 teens. Although contraceptives are not dispensed or prescribed in schools, condoms are available in health resource rooms. The program has aimed to assure that all students know about these resource rooms, and all rooms are stocked with condoms. In addition, the DPHO is working to ensure that community providers are "teen friendly" and community pharmacies stock drugs for emergency contraception. In addition, the Bronx DPHO has promoted physical activity through both Shape Up New York in neighborhood parks and a program to train day care providers to lead physical activity sessions for young children.

In their role as coordinator of public health activities within the community, the DPHOs have housed and provided support to the agency's public health detailing program, a door-to-door direct marketing program for prevention targeting health care settings. In the last year, this effort has promoted flu shots, colon cancer screening and tobacco cessation, providing doctors with brief messages and tools that facilitate best practices for prevention. For a DOHMH rodent control initiative, DPHO staff coordinated the distribution of garbage cans. A billboard public education campaign to promote awareness of emergency contraception and other forms of contraception targeted DPHO neighborhoods, with staff providing assistance in identifying suitable advertisement placement locations. In its role as convener, the Harlem DPHO, for example, brought together organizations involved in improving asthma management in the schools; an activity plan was developed and roles for all involved organizations were delineated, ensuring that efforts were complementary rather than duplicative.

A subcommittee of the DOHMH health advisory council, comprised of many of the Department's key community partners, advises the department on the DPHOs, reviewing plans and providing advice. DPHO efforts to build community relationships have included participating in such events as community health fairs and local planning board meetings and providing testimony at public hearings convened by local political leaders. The DOHMH has a rich repository of city health information, and the DPHOs have tapped into this resource to help build health awareness and provide communities with information that supports advocacy for services.

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