The state of Health in Baltimore: White Paper, March 2017

It is impossible to discuss the health and well-being of Baltimore City’s residents without applying the lens of health equity and systemic disparities. While the overall mortality rate in Baltimore City has declined over the past decade, the city still has an age-adjusted mortality rate 40 percent higher than the rest of the state and ranks last on key health outcomes compared to other jurisdictions in Maryland.

This reality is compounded by a series of complicated systemic social, political, economic, and environmental obstacles. With more than one in three children living below the federal poverty line and more than 30 percent of households earning less than $25,000 per year, income, poverty, and race have an enormous impact on health outcomes across Baltimore’s neighborhoods.

The state of health is especially urgent when we consider that Baltimore houses some of the best healthcare institutions in the country. We know that healthcare alone cannot drive health: while 97 percent of healthcare costs are spent on medical care delivered in hospitals, only 10 percent of factors that determine life expectancy takes place within the four walls of a clinic. Where we live, work, and play each day drives our health and well-being. 

The mission of the Baltimore City Health Department (BCHD) is to protect the health, eliminate disparities, and ensure the well-being of every resident of Baltimore through education, advocacy, and direct service delivery. We envision an equitable, just, and well Baltimore where everyone has the opportunity to be healthy and thrive.

Current Snapshot of Health in the City:

• The leading causes of death in Baltimore City are heart disease, cancer, stroke, accidents (unintentional injuries), and chronic lower respiratory diseases.1
• Life expectancy differs by up to 20 years between neighborhoods.2
• Although HIV rates in the City have declined over the past decade, Baltimore’s HIV diagnosis rate is more than twice that of the state—57.93 versus 24.64 (per 100,000 population). An estimated 12,400 residents are living with HIV3; while African Americans constitute 63 percent of the City’s population,5 they account for more than 83 percent of those living with HIV in the City.3
• In Baltimore City, one in three high school students is either obese or overweight. One in four high school students drinks one or more regular sodas every day, while less than half eat one or more servings of vegetables a day. Less than half of middle school students eat breakfast on a daily basis.6
• Baltimore City’s asthma-induced emergency department (ED) visit rate is three times the state rate and the highest in Maryland.7
• 12.3 percent8 of babies born in the City are low birth weight, compared to a national average of 8 percent.9
• 30 percent of children in Baltimore have Adverse Childhood Experience (ACE) scores of 2 or more, meaning that they have experienced more than two incidences of events such as domestic violence, living with someone with an alcohol/drug problem, the death of a parent, or being a victim/witness of neighborhood violence.10
• 23 percent of adults living in Baltimore are current smokers, compared to a state average of 15 percent.11
• Baltimore has one of the highest rates of heroin use and overdose in the country—from January to September 2016, there were 342 heroin-related deaths in Baltimore City, an 81 percent increase over the same period in 2015.12 About 11 percent of Baltimore City residents (aged 12 or older) are estimated to abuse and/or be dependent on illicit drugs or alcohol.13

About the Baltimore City Health Department

Founded in 1793, BCHD is the oldest continuously-operating health department in the country, with about 1,000 employees and an annual budget of $130 million. BCHD’s wide-ranging responsibilities include maternal and child health, youth wellness, school health, senior services, animal control, restaurant inspections, violence prevention, emergency preparedness, STI/HIV treatment, and acute and chronic disease prevention.

Over the past two years, under the leadership of Health Commissioner Dr. Leana Wen, BCHD has made major strides in addressing the public health challenges facing Baltimore City. Several programs have moved the needle on health outcomes in the City and are serving as national models for public health innovation. This white paper captures those accomplishments and is intended to serve as an overview of the City’s priority public health issues and BCHD’s responses to them.

Healthy Baltimore 2020

In August 2016, BCHD launched Healthy Baltimore 2020, a strategic blueprint for health in the city. Building upon BCHD’s ongoing work and prior accomplishments, Healthy Baltimore 2020 was designed during an 18-month community listening tour of convenings, town halls, public comment periods, and conversations to solicit feedback from representatives of healthcare institutions, community partners, faith-based institutions, local businesses, universities, youth groups, and others. Specifically, the plan was shaped by input from the Local Health Improvement Council (LHIC), a BCHD-led advisory group consisting of members from each of Baltimore’s hospitals and federally-qualified health centers as well as community-based organizations. The plan articulates a bold vision: to cut health disparities in Baltimore City in half over the next ten years.

This vision is particularly important as rapid shifts take place at the federal level with respect to both public health and healthcare. In this environment, it is even more essential that local health departments lead the way in implementing and expanding programs that serve our most vulnerable residents.  

Healthy Baltimore 2020 tackles this through the lens of three core values:

• Race, Equity, and Inclusion: It is impossible to talk about health in Baltimore without addressing the significant disparities that exist because of structural discrimination, racism, poverty, and historical practices of exclusion. As a result, every aspect of the work we do at BCHD is rooted in combatting health inequity and ensuring that all residents of our city have the right to a healthy, robust life. We commit to applying this lens to our own actions as public health workers and will not shy away from difficult conversations that may arise.
• Focus on Well-Being: As a local health department, we do not merely treat the symptoms of poor health—we also address the barriers to overall well-being. In Baltimore, this specifically means applying a trauma-informed approach to all that we do, recognizing the cyclical, generational nature of trauma and its impact on both physical and mental health. We cannot provide effective services without acknowledging the role that trauma plays across the life course, and we look forward to working with our community partners to promote healing and awareness.
• Health-in-All-Policies: We view health as foundational to every issue—unhealthy children cannot learn in school, and unhealthy adults cannot be a productive part of the workforce. As we examine critical issues across the City—the economy, public safety, education—we believe that health should be addressed as a critical driver of each and should therefore be a key voice at the decision-making table. As a result, our work does not stop at the health department—and we look forward to working together with partners from multiple sectors to realize our vision.

The plan also highlights four priority health topics, based on community feedback, evidence-based practice, and an existing track record of accomplishment. These four areas, described in further detail below, are behavioral health, violence prevention, chronic disease prevention, and life course and core services.

Baltimore’s Public Health Priorities

Priority 1: Behavioral Health

Addressing the Opioid Epidemic

Background: With approximately 20,000 active heroin users in Baltimore and thousands more who misuse prescription opioid medications, our city cannot be healthy without addressing opioid addiction and overdose. In 2015, 393 people died from drug and alcohol overdose, which is more than the number of people who died from homicide. These deaths have continued to increase. From January through September 2016, the most recent date for which official information is available, 481 people died from an overdose in Baltimore City. Drug addiction impacts our entire community and ties into nearly every issue facing our city, including crime, unemployment, poverty, and poor health.

Accomplishments/Progress/Update: BCHD has developed a comprehensive, three-pillar strategy to combat opioid addiction, a strategy that led the way in Maryland and that serves as a national model of innovation:

• Prevent deaths from overdose and save lives. In 2015, Dr. Wen declared opioid overdose a public health emergency. The most critical part of BCHD’s opioid overdose prevention campaign has been expanding access to naloxone, the lifesaving drug that reverses the effect of an opioid drug overdose. In October 2015, a new law went into effect that allowed Dr. Wen to issue a “standing order” and prescribe naloxone to the City’s 620,000 residents. Baltimore City became the first jurisdiction in Maryland to expand access to naloxone using a standing order.
  
  BCHD and partner organizations have trained over 20,000 people—at street markets, metro stops, jails, and neighborhood meetings—to administer naloxone. Since 2015, naloxone has been used to save more than 800 lives: acts of neighbors saving fellow neighbors. This number does not include the many lives saved by nurses, doctors, EMTs, and police officers. BCHD helped the Baltimore Police Department (BPD) incorporate naloxone training into their programming, and BPD officers have used naloxone to save the lives of over 70 of our citizens. Baltimore City was also one of the first jurisdictions to require naloxone training as part of the court-mandated time in Drug Treatment Court. We have trained federal, state, and city legislators so that they can not only save lives but also serve as ambassadors and champions to their constituents.

We use epidemiological data to target our training to “hotspots,” taking naloxone directly into the most at-risk communities and putting it in the hands of those most in need. This practice began in 2015 when we saw that 39 people died from overdoses involving the opioid fentanyl between January and March. Fentanyl is many times stronger than heroin, and individuals using heroin were not aware that the heroin had been laced with fentanyl. Unfortunately, fentanyl continues to be a key driver of overdose deaths: in Baltimore City, the number of people dying from fentanyl has increased more than 20 times since 2013. 

To address this spike in fentanyl-related deaths, BCHD launched a city-wide Fentanyl Taskforce, which includes representatives from local hospitals, the Baltimore City Police Department, the Baltimore City Fire Department, and more, to discuss ways to identify and prevent fentanyl-related deaths. One of the key recommendations that surfaced was developing and implementing a real-time alert and city-wide rapid response system, a system that would identify unusual spikes in overdoses and deploy street outreach teams to impacted areas of the city to inform residents about the spike and distribute naloxone.

• Increasing access to on-demand treatment and long-term recovery support. Preventing overdose is only the first step in addressing addiction. To adequately treat people with substance use disorders, we must ensure that there is adequate access to on-demand treatment. Nationwide, only 11 percent of patients with addiction get the treatment they need. In collaboration with Behavioral Health System Baltimore (BHSB), the local behavioral health authority, BCHD has already taken several actions to ensure access to treatment, including:
  • Creating a 24/7 Crisis, Information, and Referral phone line for anyone with addiction and mental health concerns that receives nearly 1,000 calls each week for crisis services and referral to appointments.
  • Securing $3.6M in capital funds to build a stabilization center, which will be the first step toward creating a 24/7 emergency department for behavioral health.
  • Hiring community-based peer recovery specialists and piloted universal addiction screening in our hospitals.
  • Implementing the Law Enforcement Assisted Diversion Program (LEAD) with City partners to establish criteria for police officers to identify individuals with behavioral health needs and connect them to services such as drug treatment and housing, rather than taking them to central booking for arrest.
     
• Provide education to reduce stigma and prevent addiction. In addition to treating patients, the dialogue around substance use disorders must also be changed. BCHD has been at the forefront of changing public perception of addiction so that those in need are not ashamed to seek treatment. BCHD is leading a citywide effort to educate the public and providers on the nature of addiction: that it is a disease, that recovery is possible, and that we all must play a role in preventing addiction and saving lives.

Key activities include:

• A public education campaign, “DontDie.org”, teaches citizens about addiction as a chronic disease and encourages individuals to seek treatment.
• Conversations with emergency doctors across the City to increase awareness of the best approaches to prescribing opioid medication.
• Educational programs for doctors and providers of all specialties about the careful prescribing of opioid medications and the need for training in anti-overdose medication naloxone.
• Establishment of the city’s Work Group on Drug Treatment Access and Neighborhood Relations, which has convened public sessions featuring national and local policy experts, including Mayor Catherine E. Pugh, Kana Enomoto, Deputy Assistant Secretary for Mental Health and Substance Use at the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services, and Dr. Wilson Compton, Deputy Director of the National Institute on Drug Abuse. The Work Group was created to expand access to evidence-based treatment in the city while maintaining positive relationships between treatment providers and the communities they serve.

Baltimore City has one of the most ambitious overdose response and addiction treatment programs in the country. The U.S. Senate and House of Representatives, the White House, and the Surgeon General have all highlighted BCHD’s innovative approaches to addressing the opioid epidemic as a national best practice.

Challenges and Aspirations: While we have made important strides in responding to substance use and overdose within the City, there is still an urgent imperative to respond to this crisis by:

• Ensuring naloxone accessibility. This means ensuring that the price of the life-saving antidote, which has more than doubled over the past few years, remains affordable. Rising prices will severely limit the ability of providers and first responders to purchase naloxone, limiting access at a time when an opioid overdose is a national public health emergency. BCHD is also pursuing legislation to remove the existing training requirement for naloxone so that all City residents can attain naloxone and are prepared to prevent overdose death.

• Increasing access to on-demand treatment. We must ensure sufficient high-quality treatment options are available to those suffering from opioid addiction. This includes establishing a stabilization center that diverts patients with substance use issues away from the emergency room and into wraparound care that includes connections to treatment. Ultimately, BCHD intends to implement a 24/7 behavioral health emergency department that would provide on-demand access to addiction support, as well as proven intervention models such as LEAD and expanded case management for individuals being released from jail. Additionally, BCHD is advocating for expanded buprenorphine availability. One of the greatest barriers to treatment access is resources: unless funding is allocated to the areas of greatest need, including Baltimore, we will fail to address the root causes of opioid overdose.  

• Additional funding for upstream prevention and stigma reduction. We know that addressing substance use is key to ensuring that our communities can achieve better physical health and can pursue employment opportunities that will contribute to overall economic development in our city. To stop the cycle of addiction, we must continue to invest in prevention services and anti-stigma education. BCHD will launch a comprehensive anti-stigma campaign in partnership with local community organizations and Behavioral Health System Baltimore to recognize addiction as a disease, rather than a moral failing. 

Addressing Trauma and Access to Mental Health Services

Background: Baltimore City faces significant behavioral health challenges and disparities. City residents, despite making up only 11 percent of Maryland’s total population, have consistently represented 30 percent of all statewide inpatient hospital discharges for individuals with mental illness. In 2013, 28 percent of Baltimore City students reported symptoms of mental illness, compared to 23 percent of Maryland students. Over 60,000 residents are estimated to have a drug or alcohol addiction.

Accomplishments/Progress/Update:

• Addressing trauma in West Baltimore. In September 2016, BCHD was awarded a 5-year, $5 million grant by the Substance Abuse and Mental Health Services Administration (SAMHSA) for the Resiliency in Communities After Stress and Trauma program. The goal of ReCAST is to reduce the impact of trauma and build resilience in Central West Baltimore communities adversely impacted by the April 2015 unrest. The program empowers community organizations from West Baltimore to implement high-quality, trauma-informed services to promote connectedness and resilience in youth.     

• Promoting student resilience. Supplementing ReCAST is Promoting Student Resilience, a $2 million grant awarded by the U.S. Department of Education to the Baltimore City Public School System to fund school-based mental health, counseling, and behavioral programs for students. In partnership with BCHD, City Schools will work to expand access to trauma-informed services and create safe and supportive learning environments.

• Trauma-informed care. There is growing recognition in Baltimore City that generations of exposure to poverty, racism, violent crime, and domestic violence have resulted in extremely high levels of traumatic stress for individuals, families, and communities across the City.  Recognizing that trauma is a major underlying factor of behavioral health issues and violence, BCHD has launched a trauma-informed care training initiative across the city government, which has already reached more than 1,200 City employees, including police officers and other front-line City workers.  The goal of this initiative is to educate all front-line City workers in trauma-informed approaches, including:
  • Understanding trauma
  • Understanding the impact of traumatic stress on brain development
  • Integrating trauma-informed practices into work with City residents

• Establishment of a stabilization center. BCHD has secured $3.6 million in capital funds to build a “stabilization center”—also known as a sobering center—for those in need of temporary service related to intoxication. This is the first step in our efforts to start a 24/7 "Urgent Care" for addiction and mental health disorders—a comprehensive, community-based “emergency department” dedicated to patients presenting with substance abuse and mental health complaints. Just as a patient with a physical complaint can go into an emergency department any time of the day for treatment, a person suffering from addiction must be able to seek treatment on-demand.  This center will enable patients to self-refer or be brought by families, police, or EMS—a “no wrong door” policy ensures that nobody would be turned away. The center would provide full capacity treatment in both intensive inpatient and low-intensity outpatient settings, and connect patients to case management and other necessary services such as housing and job training. 

• Increased focus on treatment and case management. Three hospitals in Baltimore City participate in the Screening, Brief Intervention, and Referral to Treatment (SBIRT) project, an evidence-based public health approach to providing early intervention and treatment services to those at risk of substance use and mental health disorders. BCHD is leading a citywide effort to expand the use of SBIRT to all healthcare institutions in the City to deliver early intervention and treatment services for those with or at risk for behavioral health and substance use disorders.

BCHD seeks to increase case management capability for every individual leaving jails and prisons. These individuals are in a highly vulnerable state, and must be connected to medical treatment, psychiatric and substance use treatments when appropriate, housing and employment support, and more. We know that deploying credible messengers from the community, as community health workers to reach people where they are, works. BCHD aspires to bring jobs and opportunities to vulnerable individuals and neighborhoods that otherwise have limited employment opportunities.

Challenges and Aspirations:

• Citywide trauma strategy. To convene and align trauma-informed care efforts with the ReCAST work and other local collaborations focused on trauma, BCHD has launched a citywide trauma strategy to bring together community-based organizations, academics, foundations, residents, and additional stakeholders to ensure that a shared language and set of practices related to trauma are implemented throughout Baltimore.

• Operational budget for the stabilization center. While we have secured capital funding, the stabilization center requires $2.5M in operating dollars to successfully launch and begin providing services.

• 24/7 Behavioral Health Emergency Department. Building upon the idea of the stabilization center, this facility would be one step closer to on-demand treatment for addiction and mental health services, which are significant unmet needs in Baltimore.  The center will also alleviate pressure from emergency departments and jails, which are ill-equipped to address these patients’ needs.

Priority 2: Violence Prevention

Background: Addressing violence and public safety are key priorities for Baltimore City. BCHD takes a three-pronged public health approach to violence prevention: violence interruption, addressing addiction and mental health needs, and upstream investment.

Accomplishments/Progress/Update: 

• Violence interruption. Safe Streets takes a public health approach to violence and maintains that violence is a learned behavior that can be prevented using disease control methods, as violent events often “cluster” like an infectious disease outbreak. The program has proven successful in significantly reducing incidences of shootings and homicides. In 2016, Safe Streets mediated 888 conflicts, 73 percent of which were deemed very likely or likely to result in violence without an intervention. Safe Streets also had 124 community events with an estimated 12,000 community members in total attendance. In addition to neighborhood-level impact, the program also prevents the intensive trauma and costly citywide ripple effects associated with major acts of violence.
  
  In fall 2016, BCHD was awarded a $500,000 grant by the U.S. Department of Justice’s (DOJ) Office of Juvenile Justice and Delinquency Prevention (OJJDP) to support the planning and implementation of a comprehensive hospital-based community violence intervention program. The program, known as the Baltimore City Thriving Communities Project, will expand Safe Streets into emergency departments utilizing Hospital Responders to reduce violence-related injury re-admissions by resolving conflicts immediately after an altercation occurs to prevent retaliation. The implementation of the Baltimore City Thriving Communities Project has been launched with Johns Hopkins Hospital and is expected to scale throughout the city. 

• Addiction and mental health. Behavioral health and substance use are key factors in violence prevention: eight out of 10 individuals in jail use illegal substances and four out of 10 have a diagnosed mental illness. Every $1 invested in addiction treatment saves society $12. As described above, BCHD has developed a comprehensive, three-pillar strategy to combat opioid addiction and ensure that this root cause of violence is being addressed.

• Violence as a public health issue. We know violence is a generational challenge impacted by the social determinants that shape people’s lives. BCHD’s approach to violence prevention starts as far “upstream” as possible. One such example is ensuring that Baltimore’s youth have access to appropriate eye care and equipment—if a child cannot see, then they are unlikely to be motivated to come to school and may turn to other activities within their neighborhood that increase their likelihood of becoming involved in a violent incident later in life. To that end, BCHD, City Schools, Johns Hopkins University, non-profit provider Vision To Learn, and Warby Parker have launched “Vision for Baltimore,” an innovative citywide strategy to ensure that all students in Baltimore City elementary and middle schools have universal access to glasses, an essential learning tool, in an effort to improve performance, engagement, and opportunity. Vision for Baltimore is also a core component of the BCHD’s Youth Health and Wellness Strategy, a comprehensive 5-year plan to reduce economic, social, and racial disparities among Baltimore City’s children and youth that includes violence prevention. 

Challenges and Aspirations:

• Sustaining the Safe Streets Program. Safe Streets is an effective, evidence-based program. However, ensuring its sustainability remains an ongoing challenge. The program has historically been funded through local philanthropic support as well as federal grants from the U.S. Department of Justice and the Centers for Disease Control and Prevention, which have come to an end. Although the program is directly related to public safety, efforts to secure government funding are ongoing. 
   
• Support to pilot and scale new violence prevention initiatives. Safe Streets, while a best-in-class model, is only one innovative way to tackle youth violence. We must also invest in the upstream interventions described above—including glasses and lead poisoning prevention programs, which address shared risk and protective factors across multiple forms of youth violence and prevention programs.   
   
• Investing upstream to ensure public safety. Addressing violence as a public health issue is a key strategy in ensuring our city’s overall safety. Rather than viewing violence solely through a criminal justice or law enforcement lens, taking a public health approach to violence acknowledges that—like many challenges facing our society—violence is cyclical and tied to systemic barriers. In order to move the needle on crime and homicide, we must deploy our resources toward public health interventions that tackle the root causes of violence.

Priority 3: Chronic Disease Prevention

Background: BCHD is committed to fighting chronic disease, one of the leading causes of death and poor health in Baltimore City. We take a multi-pronged approach to addressing chronic disease that encompasses direct services, education, and policy actions. Our chronic disease efforts include:

• Tobacco Use Prevention and Cessation. Smoking is the leading cause of preventable death from heart disease, stroke, and cancer. BCHD’s Tobacco-Free Baltimore program envisions a smoke-free City that is free of addiction to tobacco products and the diseases that tobacco use causes, like heart disease, lung disease, lung cancer, and asthma. Tobacco-Free Baltimore provides outreach and education including smoking cessation, community and school-based projects, and enforcement of local tobacco control ordinances. 

• Hypertension and Diabetes. BCHD is working with community clinics to implement screening and treatment best practices for hypertension, prediabetes, and diabetes.  Enabling clinics to catch diabetes before it starts means that patients have the opportunity to make lifestyle changes like eating healthy foods, becoming physically active, and maintaining a healthy weight. BCHD is supporting evidence-based programming to support such lifestyle changes by providing funding for and establishing a National Diabetes Prevention Program (NDPP) network to provide technical assistance and tools to local NDPP programs. BCHD also targets disparities in hypertension by funding the Healthy Men Project, run by the University of Maryland Medical Center. The program offers free screenings, cooking classes, gym memberships, and grocery store tours to African American men with high blood pressure.
• Food Access. Baltimarket is a suite of community-based food access and food justice programs hosted through BCHD. The program envisions a Baltimore with communities that have equitable access to healthy, affordable, and culturally-specific foods every day. The mission of the program is to improve the health and wellness of Baltimore City residents by using food access and food justice as strategies for community transformation. The three programs that makeup Baltimarket are:
  • Virtual Supermarket: A grocery delivery service that serves over 900 customers at 9 sites and manages over $300,000 in orders, which are handled by 35 trained community-based advocates.  In early 2017, Virtual Supermarket will serve its 1,000th customer, with approximately 400 unique clients served annually.
  • Healthy Corner Stores: The program currently works with 15 stores—located in the Upton/Druid Heights, Harlem Park, Franklin Square, Washington Village/Pigtown, Park Heights, and Patterson Park communities—that engage in the promotion of healthy eating via community nutrition education, PSAs about healthy snacking, and more.
  • Neighborhood Health Advocates and Food Justice Forum: In the summer of 2017, the Food Justice Community Conversation Guide will launch with the goal of 25 community-run conversations about food justice in the next year. These conversations are facilitated by BCHD-trained Neighborhood Health Advocates—members of the community who work to help others to get access to healthy, affordable, and fresh food through BCHD.

• Lead Prevention. BCHD seeks to reduce lead poisoning in the City through primary prevention and aggressive enforcement of the City's lead laws. More than 56,000 children under age 6 are at risk for lead poisoning in Baltimore. Lead poisoning can cause permanent brain damage; no amount of lead in children is safe. BCHD educates and strongly encourages families and providers to test children ages 1 and 2 for lead levels, performs outreach to pregnant women to evaluate potential lead hazards, and, with numerous partners, including Baltimore City Housing, conducts home visits and develops strategies to reduce lead paint hazards in homes.

• Asthma. According to the 2015 Youth Risk Behavior Survey, more than a third of Baltimore City high school students self-report a diagnosis of asthma, compared to 26.3 percent statewide and 22.8 percent nationally. The pediatric ED visit rate for asthma in the City was 2.6 times higher than the state rate (360.2 vs 136.1 per 10,000 people). BCHD’s Community Asthma Program focuses on reducing the burden of asthma for Baltimore City residents through:
  • Home visits for children with asthma to educate families about the medical management of asthma and about preventing environmental asthma triggers, thereby reducing ED visits for children.
  • Community education and outreach to increase community capacity to understand and address barriers to asthma management.
  • Convening the Greater Baltimore Asthma Alliance, which brings together individuals and organizations invested in improving asthma outcomes.

Accomplishments/Progress/Update: We have made significant progress in tackling chronic disease through public health campaigns and advocating for policy changes at all levels of government:

• Lead prevention reforms. Childhood lead poisoning has decreased significantly and is currently at the lowest level since Maryland’s lead law was implemented in 1994 and enhanced enforcement began at the City level in 2000. Since then, the number of lead poisoning cases has decreased by 98 percent. Additionally, a BCHD-led pilot to test children’s jewelry revealed extreme levels of lead in many readily available products at local stores. Based on the results of this testing, BCHD implemented regulatory action against lead in children’s jewelry that prohibits the sale of such jewelry if measuring over 100ppm of lead. If a violation is issued a fine of up to $1000 may be levied.
   
• Alcohol and tobacco regulation. BCHD has advocated for several policy initiatives to address the harmful effects of tobacco and alcohol. These include regulation of hookah establishments, a state-wide tobacco tax to be used for medical care, a ban on indoor smoking, including e-cigarettes, buffer zones around schools, and increased enforcement funding and capacity. In the last year, BCHD’s advocacy has resulted in a statewide ban on powdered alcohol and a citywide ban on the sale of the dangerous compounds known as synthetic drugs. BCHD has also successfully implemented its strategy to reduce the sales of tobacco to youth under the age of 18. By providing store education, increasing enforcement, and engaging stakeholders, BCHD decreased the rate of non-compliance by 56 percent from 2015 to 2016.

Challenges and Aspirations:

• Lead prevention. Despite significant progress, our work is far from done: over 5.2 percent of children test positive for lead. Building upon current lead prevention efforts, additional funding is necessary at the local, state, and federal levels in order to increase testing and provide primary prevention services. Most importantly, additional efforts are needed to support lead abatement in homes, as lead paint hazards are the leading cause of childhood lead poisoning.

• Sugar-sweetened beverage labels. Legislation was previously proposed to the City Council that would require retailers to post warning labels noting the connection between sugar-sweetened beverages and health conditions such as obesity. BCHD hopes to work with City Council to ensure residents are aware of the link between such beverages and poor health. We are continuing to work with community partners on this and other efforts to reduce the scourge of childhood obesity and reduce disparities in Baltimore.

• Local tobacco authority. Due to a previous ruling, Baltimore City is unable to successfully enforce certain tobacco violations locally. We are working with our representatives in the Maryland General Assembly on legislation that would permit local jurisdictions to enact and enforce measures regulating the sale and distribution of tobacco products, with measures at least as stringent as those enacted in state law.  Preventing youth from smoking in the first place is critical to reducing tobacco use in Baltimore. 90 percent of smokers start before the age of 18. However, telling kids about the dangers of smoking is not enough when they are exposed to those same dangers at home every day. Inspiring families to create smoke-free homes can be an effective way to limit exposure to both secondhand smoke and tobacco use for kids.

• Decreased funding for public health prevention. Funding to conduct public health education about asthma, lead poisoning prevention, and tobacco comes from federal agencies like the Centers for Disease Control and the National Institutes of Health. Those agencies are now facing the threat of severe funding cuts, which will cause Baltimore City to lose essential prevention dollars. We must advocate for the preservation of these prevention dollars and work collectively to identify strategies for filling the funding gaps that may be caused by shifts at the federal level.

Priority 4: Life Course and Core Services

Youth Health and Wellness

Background: A decade ago, Baltimore City’s infant health outcomes ranked as one of the worst in the country, with an infant mortality rate nearly twice the national average and with very large disparities between black and white birth outcomes. In response, B’More for Healthy Babies (BHB) was born as a city-wide public-private coalition of more than 150 nonprofits, public agencies, and foundations. The goal of the initiative is to ensure that all of Baltimore’s babies are born at a healthy weight, full-term, and ready to thrive in healthy families. It is a comprehensive, evidence-based solution that builds cross-sector partnerships for strategic planning and implementation; strengthens systems and streamlines interventions to assure maximum effectiveness; ensures community and client participation in planning, and emphasizes proactive monitoring and data-driven decision-making.

Accomplishments/Progress/Update:

• B’More for Healthy Babies. Since its inception, BHB has experienced extraordinary success. It has:
  • Reduced infant mortality by an astonishing 38 percent, bringing it to its lowest point in Baltimore’s history.
  • Closed the disparity between black and white infant deaths by almost 50 percent between 2009 and 2016.
  • Decreased the teen birth rate in the City by an unprecedented 36 percent.
  • Reduced sleep-related infant deaths by 50 percent.

The program’s success has been widely recognized; it was awarded the 2014 Family League Award, the 2015 Academy

Building upon the success of B’More for Healthy Babies, BCHD seeks to take a comprehensive approach to youth health and wellness

• Youth Health and Wellness Plan. BCHD has developed a comprehensive youth health and wellness plan that applies the same principles that have made the B’More for Healthy Babies program so successful to the full youth life course of 0-19 years old. This plan will focus on three categories of long-term outcomes:

• Healthy Minds: including improved social and emotional development as well as improved behavioral health.
• Healthy Bodies: including the continuation of reduced teen births and improved physical health outcomes, including immunizations and oral health.
• Healthy Communities: including improved peer relationships, community connectedness, and connections with trusted adults.

​School Health. The Bureau of School Health at BCHD provides health services in all Baltimore City Public Schools. We have helped children better achieve their potential by supporting mental health services in 119 schools and by providing students with access to health suite services, with nearly 300,000 annual visits in 180 schools. However, capacity is severely limited: several school-based health centers must share one nurse practitioner or provide care via the school health suites, which do not have nurse practitioners or physicians readily available to provide diagnosis, treatment, and preventative services.

Telemedicine is an innovative and effective way to address the gap in capacity and expand the level of care offered across schools without having to staff each with a full-time primary care provider. BCHD is launching a telemedicine pilot to improve care coordination by virtually connecting community physician providers to Baltimore City Public School students, allowing them to stay in class and their parents to stay at work. This will enable regular evaluation and treatment of both acute and chronic illnesses, and it will increase the availability of key behavioral and mental health services.

• Reproductive health in 2017. BCHD and a broad coalition of partners in the City, including Baltimore City Public Schools, were awarded an $8.5 million grant from the U.S. Department of Health and Human Services that will be used to ensure that there is comprehensive sex education in middle schools and high schools, with the aim of reducing the teen birth rate and providing accurate, evidence-based reproductive health education. 

Challenges and Aspirations:

• Sustainability challenges tied to federal policy. With state and federal budgets steadily decreasing, these critical programs face potential funding cuts. In addition to general funding cuts, several components of BHB and the Youth Health and Wellness Plan are under threat as federal priorities shift. For example, reproductive health programs and services for pregnant women are at risk, as the federal government is currently proposing cuts to several key offices, including the Office of Adolescent Health. Given this landscape, implementing and expanding both the initiatives described above will require multiple funding streams, including philanthropic, government, and billable services.

Senior Health and Wellness

Background: BCHD is committed to enhancing the quality of life of older adults in our city.  BCHD works to help these residents age in place and remain connected to their communities, by delaying premature institutionalization and providing protection from abuse and neglect. The Division of Aging and CARE Services serves as Baltimore City’s local Area Agency on Aging (AAA) and guarantees essential core programs for older adults that include the operation of 14 senior centers, advocacy, guardianship, in-home care services, health evaluation, transportation, training, and volunteer opportunities.

Accomplishments/Progress/Updates: BCHD has piloted several innovative approaches to improve health outcomes among older adults, including:

• Preventing Falls. The Robert Wood Johnson Foundation awarded a $200,000 grant to a BCHD-led initiative with community partners to reduce falls among older adults by one-third over 3 years. This project involves the use of data from the Maryland Health Services Cost Review Commission. BCHD is currently developing protocols to identify falls “hot spots” across the City. Findings will inform a wide variety of fall prevention interventions for older adults, including in senior housing buildings and in services provided by community partners.
   
• Senior Centers as Neighborhood Hubs. Senior centers serve as focal points or one-stop shops for older adults to access services directly from within their community. This includes access to healthcare, educational opportunities, and a variety of social and recreational activities. Despite a decrease in funding for senior center operations, the City’s 14 senior centers served over 55,000 individuals last year by focusing on strategies that expand partnerships and innovation. One such effort is the Waxter Wisdom program, which uses theatrical presentations to promote educational awareness of the historic contributions of African American men and women.  Participation in fitness programs continues to rise. Fitness classes provided at senior centers ensure that older adults have the resources to address chronic conditions that may otherwise exacerbate and rob them of their physical independence and ability to live a long and healthy life.

• City-wide strategy. BCHD was awarded an $85,000 grant from the Stulman Foundation to develop a city-wide strategy to care for older adults in Baltimore. Like the Youth Health and Wellness Plan, this strategy will tie together efforts across the city and present a blueprint for ensuring that our most vulnerable seniors have access to the comprehensive care and community that they need.

Challenges and Aspirations:

• Older Americans Act. The Older Americans Act was created to ensure that preference is given to providing services to older persons with the greatest economic and social needs, particularly low-income minority persons. Baltimore City’s seniors tend to be older, more disabled, and lower-income than seniors in other Maryland jurisdictions. The City is home to 38 percent of the state’s low-income minority population 60 years and over. The Division serves a population that has much greater needs than its counterparts, and funding has not kept up with the aging impoverished population. It is essential that those dollars are aligned with those who have the greatest economic need and that the right balance is struck between need and costs. The current intrastate funding formula does not adequately target this vulnerable population, and we have proposed revisions so that it is more responsive to the need of Baltimore City seniors.
   
• A connected ecosystem. To address the rapidly growing population of older adults in the City, BCHD is committed to creating a “no wrong door” service delivery model. The Division will seek to invest in its technological infrastructure for the Maryland Access Point (MAP) call center. Through a partnership with United Way’s 211 Call Center, BCHD will look to expand its information and assistance services by creating a connected ecosystem that will enhance care coordination for older adults, better allowing them to remain independent and age in their communities. This system of service delivery will allow the tracking of services to individuals, stem duplication of efforts, support efficient referrals and follow-up, and foster interconnections among partnering agencies. 

Core Public Health Services

Background: BCHD provides essential public health services for the City, including communicable disease tracking, education and prevention, emergency preparedness and response, restaurant inspections, and animal control. Our field staff, from our animal control officers to our sanitarians, and outbreak investigators, have tackled emergencies ranging from Legionnaire’s, measles, and Ebola investigations to transporting patients to life-saving treatment during severe weather. These activities are core to Baltimore City’s safety and preparedness response.

Accomplishments/Progress/Update:

• HIV Prevention and Education. In the fall of 2015, BCHD secured two grants totaling $22 million to bring HIV prevention, prophylaxis, and treatment to underserved populations while creating 70 new jobs in the City. The White House has acknowledged Baltimore's leadership in this area, and Baltimore was one of a handful of cities to join the Fast Track Cities coalition to end AIDS by 2030. Our HIV team will continue to partner directly with community and provider groups to provide education and treatment in one of the largest collaborations to combat HIV.

BCHD has a long history of providing innovative services to prevent and treat HIV/AIDS. As one of the first jurisdictions in the country to implement a Needle Exchange Program (NEP), the program has exchanged over one million syringes annually with a 75 percent return rate. The NEP program is credited with significantly moving the needle on HIV transmission with injecting drug users in Baltimore since its inception. The NEP is also the testbed for the Staying Alive Program, naloxone training, and directly observed therapy for non-compliant patients on HIV medications. In 2015, almost 3,000 individuals received naloxone training conducted by NEP staff. A service expansion is currently underway—with implementation scheduled for late 2017—which will include wound care and buprenorphine induction services. 

The transmission rate of HIV attributed to injection drug use has significantly declined because of this program. In 1992, the rate of new HIV infections attributed to injection drug use was greater than 64 percent but has now declined to less than 8 percent (2015); the rate continues to drop within the City of Baltimore.

Due to the program’s success, BCHD is coordinating with the State and several surrounding counties to expand needle exchange services using the mobile clinic model. 

While the Affordable Care Act (ACA) has improved access to health insurance and Medicaid, many of our residents with HIV/AIDS need additional support.  BCHD provides clinical and support services for people living with HIV/AIDS and their contacts through programs like Linkage to Care and the Ryan White Program. Linkage to Care staff members identify patients who test HIV positive and take them directly to a participating physician to provide education and initiate the appropriate therapy.  This program has linked over 1200 patients to primary care, an important step in stopping the transmission of HIV. In 2015, the Maryland Department of Health and Mental Hygiene recognized this program by awarding the staff two state-wide awards, “Most Encounters with HIV Positive Clients” and “Most Referrals to HIV Primary Care.” The Ryan White Program receives approximately $17 million annually to provide HIV-related medical and support services to over 10,000 individuals living in Baltimore City and the five surrounding counties.

BCHD has hosted the "Know Your Status" Ball annually for the last six years. This event is aimed at the House and Ball community, which is made up of gay and transgender individuals. Each year, approximately 600 individuals attend the event, with hundreds of people volunteering for HIV testing. The individuals who attend this event are statistically at the highest risk for contracting HIV and are often stigmatized in other health settings. There is a higher HIV detection rate at the event than with typical outreach methods. Those who test positive are contacted by our Linkage to Care Program and are linked with primary care. Baltimore City Health Department is one of the only health departments in the country to host this type of event.

BCHD’s IMPACT Campaign (Initiative to Maximize Prevention, Access, Care, and Treatment) is a social marketing and community outreach campaign led by BCHD with the goal of reducing social stigma and medical mistrust in the community. Project Impact is composed of three initiatives: Baltimore in Conversation, Project Presence, and Baltimore in Action. Baltimore in Conversation focuses on fostering more holistic sexual health for queer people of color in Baltimore through shared stories and lived experiences. Project Presence uses photography as a medium to address social stigma. The photo exhibition has rotated through buildings and galleries across Baltimore, narrating the stories of queer individuals of color in Baltimore. Finally, Baltimore in Action is the culminating event of Project IMPACT. Baltimore in Action convened Baltimore’s healthcare providers, members and allies of the LGBTQ community, social service providers, businesses, and community-based organizations to co-create and create a citywide HIV prevention and care plan. Using the triumphs, challenges, and barriers identified from Baltimore in Conversation, the plan aims to improve access to and delivery of prevention and care services in an approach that is community-driven and socially conscious.

• Vaccines. BCHD has led partners in coordinating the Baltimore Statement on Childhood Vaccinations through a coalition of pediatric chiefs and chairs in the City, as well as the Maryland Chapter of the American Academy of Pediatrics. The statement highlighted BCHD’s unequivocal message regarding the safety and effectiveness of childhood vaccines and has contributed to one of the highest vaccine compliance rates in the country.
   
• Public Health Preparedness. BCHD’s Office of Public Health Preparedness and Response (OPHPR) is equipped to steward the City through any major public health emergency. This program trains staff and, during times of emergency, convenes and communicates with the City’s healthcare infrastructure. In the aftermath of the unrest following Freddie Gray’s death, BCHD lead the public health response, setting up a prescription access line to assist seniors whose pharmacies were closed and arranging shuttles to and from senior buildings for food and banking needs.

In response to the record-breaking blizzard that hit Baltimore City in January 2016, BCHD led a citywide response to ensure that patients were able to access life-saving medical treatments, including dialysis and chemotherapy. Working in tandem with the Baltimore City Fire Department, the Office of Emergency Management, and the National Guard, BCHD was able to deploy resources to safely and successfully transport more than 300 patients in the midst of snow-covered roads and hazardous driving conditions. Baltimore City was recognized as the only jurisdiction in the state that provided medical transport immediately after the blizzard.

Other ongoing efforts include BCHD’s response to emerging diseases like the Zika virus; the essential core public health activities that include investigation and surveillance of foodborne illness, animal bites/rabies, and other infectious diseases such as Legionnaire’s disease; and the tracking of HIV, syphilis, gonorrhea, chlamydia, and other sexually-transmitted diseases. In 2016, the Acute Communicable Disease Program (ACD) investigated more than 500 reportable disease cases, over 30 outbreaks, and approximately 1200 potential rabies exposures. Outbreaks occur in many settings, including restaurants, hospitals, schools, and daycares, and the health impact of a reportable disease is often significant. In 2016, ACD triaged nearly 500 calls for Zika testing from physicians and investigated multiple cases.

In March 2016, BCHD worked with city, state, and federal agencies to develop a comprehensive, citywide plan in response to the Zika virus. The citywide plan was based on a three-pronged approach, including mosquito surveillance and response to standing water complaints; case investigation; and comprehensive public education through training throughout the City. In collaboration with partner agencies, BCHD responded to multiple confirmed cases of Zika during 2016. 

Activation of the response plan was labor-intensive and reached many neighborhoods and thousands of citizens with Zika prevention education. BCHD’s Zika Plan was presented at the Annual MACO Conference in Ocean City where it was highlighted for its innovative, multi-disciplinary approach.

• Environmental Inspection Services. BCHD staff works tirelessly to ensure that the City’s restaurants and other service establishments serve food in a hygienic and safe way, and we believe that providing information directly to residents allows them to make the best choices possible. The Office of Environmental Inspection responds to over 1,600 food-borne outbreaks, fires, and other environmental complaints annually. Services include plan review, routine inspections of food service facilities, and routine inspection of nuisance complaints such as odors, mosquitoes, noise, etc. This process aims to support businesses so that they can provide the best possible service to Baltimore’s residents and help create a healthier city.

• Animal Control and Shelter. At BCHD, our responsibility is to protect the health not only of Baltimore’s human residents but also of our animal residents. The Office of Animal Control enforces city and state codes, rules, and regulations and investigates animal neglect and cruelty cases for the purpose of protecting Baltimore’s human and animal residents.

Receiving an average of 23,000 complaints annually, the Office of Animal Control investigates approximately 5,000 animal endangerment cases and nearly 1,200 animal bite or exposure cases every year.

Baltimore Animal Rescue and Care Shelter (BARCS) is a 501(c)(3) non-profit organization contracted to provide sheltering and care services for the City. BARCS provides care for over 12,000 animals every year. 

• Acute Communicable Diseases. The Office of Acute Communicable Diseases is responsible for the surveillance of over 60 types of reportable communicable diseases and outbreaks in Baltimore City. The program investigates cases and outbreaks of communicable diseases and recommends control measures for the affected facility or population, reducing morbidity and mortality. The program provides technical assistance and education to many business sectors including hospitals, long-term care facilities, and daycare providers.

• Clinical Services. The Bureau of Clinical Services manages several clinics that serve the population of Baltimore City. These include a Sexually Transmitted Disease (STD) clinic, HIV and Hepatitis C clinic, Tuberculosis (TB) clinic, and Dental clinic. The Bureau also has a clinical lab that supports the clinics and other programs in the Health Department by providing STD testing services. More than 15,000 patients receive care through BCHD communicable disease clinics each year. 
   
• Field Health Services. To provide safe and reliable medical transport for residents—many of whom are elderly or handicapped—Baltimore City’s Field Health Services coordinates transportation to non-emergency medically necessary medical appointments for eligible Medicaid patients. Through the management of a call center that schedules these rides for Medicare patients, Field Health provides almost 13,000 medically fragile patients with more than 130,000 riders annually.

Challenges and Aspirations:

• Funding for emergency preparedness. We can and should be prepared for all emergencies, particularly unanticipated ones. We advocate for continued funding to prepare for emergencies and outbreaks, particularly in anticipation of an upcoming Zika virus outbreak. Potential cuts to the Prevention and Public Health Fund, created by the ACA, and to other preparedness programs are a major threat to national security. After the September 11th attacks and the 2001 anthrax attacks, the federal government made available significant grant funding to build public health capacity to train staff, plan for emergencies, and respond to them. In 2012, BCHD’s OPHPR had a staff of 12. By 2016, its staff has declined to 4, which severely limits the department’s capacity to respond to any sustained emergency. As federal funding decreases, the program’s capacity will decrease, leaving the City vulnerable. Without a sustained increase in funding, the agency’s capacity to effectively respond in a frontline manner to public health threats like Zika and other emerging infections is limited.
   
• Funding for the clinic safety net. The decrease in state and federal funding is not limited to the emergency preparedness program, extending to many of the safety net programs our vulnerable citizens depend on. As mentioned previously, the ACA was intended to provide all citizens access to health insurance and healthcare. While there have been some successes, many of our very low income, vulnerable citizens rely on our grant-funded safety net programs, such as tuberculosis control, syphilis and gonorrhea testing, and family planning clinics. Failure to support essential public health services will dramatically impact very visible public health measures and the lives of all our citizens.   

Population Health and Health in All Policies

Background: Where we live, work, and play is the major driver of health outcomes, and, as the public health authority for the City, BCHD is leading the way on initiatives that address the “upstream” factors of health—the social determinants—from housing to food to transportation to education.

We view health as foundational to every issue—unhealthy children cannot learn in school, and unhealthy adults cannot be a productive part of the workforce. As we examine critical issues across the City—the economy, public safety, education— health is an essential driver that cuts across all of them. 

This is particularly significant in Maryland, where we are already leading the way in public health due to the establishment of global budgeting. Global budgeting shifts virtually all the hospital revenue from a “fee-for-service” model to a global payment model, incentivizing hospitals to work in partnership with other providers and the community to prevent unnecessary hospitalizations and readmissions. The goal of the model is to promote quality healthcare, improve patient health, and lower costs. As a result, it creates incentives for treating the whole person and focusing on the intersection of health with other policy priorities.

BCHD works closely with local healthcare providers, including hospitals and federally qualified health centers, to identify shared priorities, like behavioral health. From creating a stabilization center to tracking patients who are the highest utilizers of care, coordination with our healthcare partners is key to ensuring that patients are receiving essential public health services. As the neutral convener, BCHD is positioned to coordinate citywide initiatives and collaborations that involve competing hospital systems and other health organizations.

Accomplishments/Progress/Update:

Our current initiatives include:

• Local Health Improvement Council. As discussed above, the LHIC, led by BCHD, is a coalition of representatives from Baltimore City healthcare systems, community-based organizations, faith-based institutions, businesses, foundations, and other sectors across the City who convene to align population health agendas and resources, establish strategic health priorities for the city, and drive improved health outcomes at the population level. LHIC members serve as key advisors and implementation partners with respect to the design and execution of Healthy Baltimore 2020.

• High Utilizer Taskforce. In September 2015, BCHD convened over 100 hospital and healthcare leaders to discuss behavioral health priorities and coordination of case management services for high utilizers. This work has evolved into a High Utilizer Taskforce that addresses a significant issue facing hospitals and service providers: post-discharge placement for patients with multiple illnesses who are often also homeless and/or suffering from behavioral health issues. The Taskforce is finalizing a guide for hospital staff to understand discharge options and is also piloting a framework for care management with CRISP, to be launched with Mercy Hospital, Health Care for the Homeless, and Weinberg Housing Resource Center.

• Emergency department convenings. BCHD also regularly convenes EDs to discuss best practices ranging from buprenorphine induction to appropriate care coordination. This convening success was recognized at the federal level by visits from Surgeon General Vivek Murthy, former Federal Drug Administration Commissioner Dr. Robert Califf, and Michael Botticelli, the former head of the White House Office of National Drug Control Policy, each of whom pointed out Baltimore’s track record of multi-stakeholder convening as a national model for addressing public health challenges.

• Business Advisory Group. BCHD’s Business Advisory Group is comprised of nearly 30 representatives from Baltimore’s leading companies, including T. Rowe Price, UnderArmour, and Legg Mason. BCHD formed the Business Advisory Group to collaborate with partners from the business community to promote health and well-being for all residents and employees of Baltimore. Members provide advice, insight, and support for BCHD initiatives that aim to improve health throughout the City.

• Social determinants of health. All of BCHD’s programs, from B’More for Healthy Babies to Safe Streets, to HIV prevention and treatment programs, adopt an approach of comprehensive attention to social needs and services—and as a result, have experienced significant success. Last May, in partnership with all of the Baltimore City hospitals and federally qualified health centers, BCHD led a citywide proposal to the Centers for Medicaid and Medicare Services, the federal agency responsible for overseeing services, payments, and innovations for Medicaid and Medicare patients, to develop an “Accountable Health Community.” This model will enable more than 75,000 patients in Baltimore City to access screening, referral, and navigation to essential community resources—as well as enable BCHD to collect population-level data regarding the necessity of addressing patients’ social needs.
   
• Health in all policies. Health touches every issue. As a result, BCHD’s health perspective must be a consideration in all policies in the City. For example, if the City is considering implementing bike paths, or placing an incinerator in the community, the health impact should be considered. In the spring of 2017, BCHD brought a public health perspective to technology and innovation through the launch of TECHealth (Transforming Engineering for Civic Health), an initiative that deploys coders, designers, and innovators across the City to develop solutions to scoped public health challenges. Reflecting BCHD’s philosophy that a leading 21st-century health department must intersect with multiple industries, TECHealth leverages Baltimore’s rich technology community to modernize public health interventions and deliver effective services on behalf of residents.

Challenges and Aspirations:

• A unified approach to care coordination and alignment. While BCHD has continued to convene stakeholders around care coordination, social needs integration, and several other key population health issues, the true integration of public health and healthcare is still evolving. To that end, we look to deeper partnerships with our hospital partners—including the potential alignment of their community benefits strategies with citywide health priorities—to ensure that all residents are able to benefit from a comprehensive approach to health.
   
• Moving the needle on health outcomes. In launching Healthy Baltimore 2020, BCHD is also developing a dashboard to track each of the equity objectives and targets laid out in the plan. These targets build upon ongoing epidemiology work—including our Neighborhood Health Profiles, which provide snapshots of key health outcomes in each city neighborhood—as well as input from key community stakeholders. The dashboard will be publicly available and enable ongoing feedback on the progress of Healthy Baltimore 2020. 
   
• Citywide wellness initiative. BCHD will launch Baltimore Billion, a citywide fitness initiative focused on physical activity and nutrition. In partnership with corporate sponsors and community organizations, the initiative will provide incentives and host ongoing community events to encourage Baltimore residents to move and play with their friends, colleagues, and communities.
   
• Engaging the private sector. Building upon the success of BCHD’s Business Advisory Group as well as TECHealth, we will continue to engage private sector partners in ongoing program expansion and innovation. We firmly believe that public health should be at the table not only as a public service but also as an engine of workforce development and business efficiency, and we look forward to engaging our many partners in enabling that vision.

Conclusion

While Baltimore City faces several public health challenges, we also have invaluable assets: one of the strongest healthcare infrastructures in the country, invested community members and partners, and a willingness—born of necessity—to test and implement new, innovative approaches to keep our citizens healthy. As the City’s health authority, BCHD is fortunate to work directly with excellent partners and leaders in every sector—government, business, community advocacy, healthcare, faith-based, and more—all of whom share a deep commitment to ensuring health of our citizens.

We hope that this briefing serves as a valuable tool and look forward to answering any questions you may have.

Thank you for your partnership in ensuring that all of Baltimore’s citizens are healthy and well.

References

1 Table 49. Crude Death Rates For Ten Leading Causes by Region and Political Subdivision, Maryland, 2015, 2015 Vital Statistics Administration Annual Report, Maryland Department of Health and Mental Hygiene.

2 Baltimore City Health Department analysis of 2011-2015 Maryland Department of Health and Mental Hygiene Vital Statistics Administration data.

3 2014 Baltimore City HIV Annual Epidemiological Profile, Data reported through December 31, 2015, Table 1 – Adult/Adolescent HIV Diagnoses during 2014, First CD4 Test Result, Percent Linked to Care, and Percent Late Diagnosis, by Jurisdiction, Reported through 12/31/2015; Figure 2 – Trends in Living HIV Cases, 1985-2014, Reported through 12/31/2015; Table 13 – Adult/Adolescent Living HIV Cases with and without AIDS by Sex at Birth, Race/Ethnicity, and Country of Birth, Alive on 12/31/2014 and Reported through 12/31/2015. Baltimore, MD: Center for HIV Surveillance, Epidemiology, and Evaluation, Maryland Department of Health and Mental Hygiene.

4 2014 Maryland HIV Annual Epidemiological Profile, Data reported through December 31, 2015, Table 1 – Adult/Adolescent HIV Diagnoses during 2014, First CD4 Test Result, Percent Linked to Care, and Percent Late Diagnosis, by Jurisdiction, Reported through 12/31/2015. Baltimore, MD: Center for HIV Surveillance, Epidemiology, and Evaluation, Maryland Department of Health and Mental Hygiene.

5 American Community Survey. Table DP05: ACS Demographic and Housing Estimates, 2010-2014 American Community Survey 5-Year Estimates. Baltimore, MD: American FactFinder, accessed 11/18/16.

6 Maryland Youth Risk Behavior Survey, Baltimore City, 2014, Tables QNOBESE: Percentage of students who were obese (>= 95th percentile for body mass index, based on sex- and age-specific reference data from the 2000 CDC growth charts); QNOWT: Percentage of students who were overweight (>= 85th percentile but <95th percentile for body mass index, based on sex- and age-specific reference data from the 2000 CDC growth charts);  QNSODA1: Percentage of students who drank a can, bottle, or glass of soda or pop one or more times per day (not including diet soda or diet pop, during the 7 days before the survey); QNVEG1: Percentage of students who ate vegetables one or more times per day (green salad, potatoes [excluding French fries, fried potatoes, or potato chips], carrots, or other vegetables, during the 7 days before the survey); QNBK7DAY: Percentage of students who ate breakfast on all 7 days (during the 7 days before the survey).

7 Maryland State Health Improvement Process, Emergency Department Visit Rate due to Asthma, 2014, Data Trend, accessed 11/21/16.

8 Maryland Vital Statistics 2015 Preliminary Report, Table 2: Number and Percentage of Births of Low Birth Weight by Maternal Race, Hispanic Origin, Region and Political Subdivision, Maryland, 2015. Baltimore, MD: Vital Statistics Administration, Maryland Department of Health and Mental Hygiene.

9 National Vital Statistics Reports, Volume 65, Number 3, Births: Preliminary Data for 2015, Table 5. Selected health characteristics of births, by race and Hispanic origin of mother: the United States, final 2014 and preliminary 2015. Atlanta, GA: Centers for Disease Control and Prevention.

10 Adverse Childhood Experiences among Baltimore & Maryland’s Children. Baltimore, MD: Child and Adolescent Health Measurement Initiative, Data Resource Center; 2014.

11 Maryland Behavior Risk Factor Surveillance System, Query: Column = Tobacco: Current smoker (smoked at least 100 cigarettes in their lifetime and currently smoke), Row = Demographics: County, Years Requested: 2014, accessed 11/17/16.

12 Maryland Department of Health and Mental Hygiene, Drug- and Alcohol-Related Intoxication Deaths in Maryland, 2016 Quarterly Report – 3rd Quarter. Table 1: Total Number of Drug and Alcohol-related Intoxication Deaths by Place of Occurrence, 2007-2015 and YTD 2016 Through September.

13 2012, 2013, and 2014 National Surveys on Drug Use and Health: Substate Estimates, Percentages, Table 21: Dependence or Abuse of Illicit Drugs or Alcohol in the Past Year among Individuals Aged 12 or Older, by State and Substate Region: Percentages, Annual Averages Based on 2012, 2013, and 2014 NSDUHs. Rockville, MD: Substance Abuse and Mental Health Services Administration.