The Boston Foundation - Indicators Project

Boston — home of the first public health department in the US — has a long and illustrious history as a center for innovative public health strategies. From the introduction of smallpox inoculations in the 18th century to NeighborWalk, a community walking program, in the 21st, Boston’s groundbreaking initiatives have become models for public health practices nationally and internationally.

Boston contains an unusually dense and accomplished network of organizations and institutions that work collaboratively to provide high quality care, disease prevention, health education and health promotion.

This network includes the nearly 30 Boston community health centers that provide primary care in neighborhoods throughout the city, traditional fee-for-service and managed-care direct-service providers, three schools of medicine, three schools of public health, and scores of community-based and social service agencies. Boston is also home to 22 hospitals, of which 16 are teaching hospitals — preparing the next generation of physicians, nurses, and technicians from around the nation and around the world.

In the last decade especially, Boston has led the nation in investments in public health directed toward research, screening, and education that prevent minor health problems from becoming major, chronic and costly. The city is an acknowledged leader in building initiatives to address risky behaviors, with measurable outcomes in smoking cessation, youth violence prevention and teen pregnancy prevention. These are considered to be among the most high-impact of all preventive health programs, saving millions of dollars in future public expenditures.

In addition, Boston’s hospital and medical school community contribute significantly to regional economic growth and jobs. Boston’s community health centers alone account for a total of payroll of $300 million — one of the largest industry sectors in the city. Twenty-two inpatient hospitals are located within the city of which 16 are teaching hospitals, including Massachusetts General Hospital, Brigham and Women’s Hospital, Beth Israel/Deaconess Hospital, Children’s Hospital, The New England Medical Center and Boston Medical Center. Drawing from the region and beyond, these hospitals saw a combined total of 217,000 patients, had over 3.8 million outpatient visits, and witnessed over 22,000 births in 2000.

Between 1984 and 1999, the city’s hospital and medical school community invested close to $1.1 billion in new facilities. In 2000, health services accounted for one out of every seven jobs in Boston. Growth in the health services sector in Boston has been stable in varying economic conditions, in part because of Boston’s role as a world-class provider of medical care and research expertise.

Several mergers consolidated health care providers, resulting in the creation of new health systems in Boston. Partners HealthCare system is the outcome of a merger of Massachusetts General Hospital and Brigham and Women’s Hospital. CareGroup Healthcare System is the outcome of a merger of Beth Israel/Deaconess Medical Center, New England Baptist Hospital and Mount Auburn Hospital. Boston Medical Center is the result of a merger of Boston City Hospital and Boston University Hospital. New England Medical Center is the result of a merger of Tufts Medical School and the Floating Hospital. And Caritas Christi Health Care System is the result of a merger of St. Elizabeth Hospital in Brighton and Carney Hospital in Dorchester.

Health care costs are rising again in the state and the nation after a brief hiatus in the mid-1990s — led by increases in prescription drug costs and by increased use of expensive new technologies.

But declining state tax revenues in 2001, 2002 and 2003, coming on the heels of a series of reductions in state tax rates, are now leading to deep cuts in health programs. These cuts are imposing disproportionate burdens on the city’s most vulnerable populations:

the working poor;
families coping with chronic illness;
the uninsured and underinsured;
homeless individuals and families; and
seniors on fixed incomes.

As the economy suffered an initial downturn and then moved into a sluggish recovery, jobs that provided health insurance as well as public health programs serving the community were cut, reducing revenues and the health services funded by them. These same conditions are fueling additional need for public health services, which current and projected budgets cannot meet.

The rapidly changing and challenging public health environment requires innovation and collaboration at every level. If any place on earth can innovate in this critical field, it is Boston, with its history of innovation and committed health care professionals. But finding ways to preserve cost-effective preventive health strategies and services in an environment of shrinking resources will require the cooperation and engagement of all parties.

As a result of the terrorist attacks of 9/11, attention is being paid to community disaster preparedness locally and at the state level. Major initiatives to enhance Boston’s ability to respond to terrorism have been implemented in the wake of these attacks and the continuing threats they represent. This new focus is also redirecting scarce resources away from conventional public health services.

Boston’s EMS responded to more than 100,000 incidents in 2001 — a record for one year. Even before the events of 9/11 and the subsequent feared anthrax attacks, Boston’s EMT Dept was one of the first five in the nation to recognize and respond to incidents involving weapons of mass destruction.

The Boston Public Health Commissioners voted in December 2002 to ban smoking in all places of work, including bars, nightclubs and restaurants beginning May 5, 2003. Boston will then become the largest city outside of California to prohibit smoking in restaurants and bars.

An estimated 8% percent of Boston residents are uninsured, with a higher percentage of non-insured people of color. And increasing costs are driving these numbers up. There is a growing reliance on higher premiums, co-pays, and deductibles in the system with coverage stripped as a result of changes in benefit structure. Experts agree that fewer preventive and primary care resources will result in sicker people and higher costs down the line. Similarly, reductions in insurance coverage are associated with increases in the use of expensive emergency room services for non-acute care. Many in Massachusetts argue for a single-payer health care system — setting an example for the rest of the country to follow. Lawmakers are not convinced.

Declining federal and state revenues and rising health costs threaten to dismantle one of the nation’s most well developed and successful networks of primary, secondary and tertiary care in the nation — with particularly steep reductions in health insurance coverage and public health programs for Boston’s most vulnerable residents.

The number of infants and toddlers suffering from hunger and malnourishment treated at Boston Medical Center increased by 45% between 1999 and 2001, according to a recent Boston University study. This trend is mirrored elsewhere in the country and attributed to decreasing access to benefits and higher rates of unemployment linked to a deteriorating economy.

There are five black infant deaths for every white one in Boston in 2000 — twice the disparity as in the nation as a whole, the greatest disparity in this measure in decades in Boston and a source of great concern. State cuts to home visiting programs, substance abuse and treatment programs, as well as HIV/AIDS prevention and treatment programs are obstacles that will make addressing the infant mortality rate in underserved communities more difficult.

Racial disparities in rates of illness and mortality have not improved despite increased attention to this issue. Rates of some highly preventable cancers continue to be higher among blacks than among other major racial/ethnic groups. Diabetes mortality continues to be higher among blacks and Latinos than among whites. All of these disparities point to much larger social issues and inequities.

Public health service organizations are challenged to respond adequately and competently to Boston’s many newcomer immigrants. Boston is becoming an increasingly diverse community with old roots in Europe and new ones in Asia, Africa, Central and South America and the Caribbean. Meeting the needs of all requires multi-lingual capacity and a range of cultural competencies.

Boston’s hospitals face a nursing shortage, with budget cuts forcing hospitals to reduce staff. Nurses’ contribution to patient heath and recovery is confirmed in a recent study of US hospitals by the Harvard School of Public Health that finds the presence of registered nursing staff has a significant impact on patient outcomes, including reducing the risk of death while in the hospital.

The Boston Public Health Commission — the nations’ first — is itself an innovation, combining leadership grounded in public health research with an understanding of communities as agents of change. It has recently received national recognition for its work, and for groundbreaking initiatives such as:

Entre Familia, a residential substance abuse treatment program for Latina mothers and their children — the only substance abuse program of its kind in the nation, combining substance abuse treatment in a residential setting with English/Spanish literacy classes and skills building for school and employment. This program will soon add daycare for children;
NeighborWalk, a community walking program. In response to survey results showing that only a third of Bostonian’s report participating in a regular exercise program, every Tuesday evening, 46 community groups, supported by mini-grants provided by the BPHC, gather throughout the city’s neighborhoods to walk for better health;
Boston’s nationally recognized pedestrian safety campaign which has contributed to a 10% decrease in traffic incidents involving pedestrians in each of the last two years, making the city’s streets safer for everyone;
Crusade against Cancer, Boston’s comprehensive, multi-faceted campaign focused on prevention and early detection includes easy access mammography vans, time off for cancer screening for all city employees and a transportation program to bring patients to treatment.

Ten hospital emergency rooms in the Boston area participate in an early warning network designed to detect disease outbreaks and bioterrorist attacks by tracking symptoms that might otherwise be dismissed as isolated cases. This network whose cost, beyond computer programming time, was minimal – gave Boston one of the most comprehensive systems in the nation for monitoring bioterrorist attacks and outbreaks of viral and bacterial illness.

The Codman Square Health Center and Dorchester House Multi-Service Center have formed a new corporation called Health Services Partnership, merging departments of medical and behavioral health, information technology, managed care services, quality improvement, some financial services, public health, education, and youth and family support. Saving hundreds of thousands of dollars, the merger creates efficiencies while preserving the identity and culture of each health center.

The Dimock Community Health Center and the Urban Edge Housing Corporation have entered into five-year strategic alliance, to improve health outcomes by improving housing conditions for Dimock’s clients. The “healthy homes” initiative also includes economic development and education. The joint venture is based on six “process measures”: shared goals; mutual trust; constant communication; building consensus; leadership structures; and availability of adequate resources.

Fenway Community Health Center is internationally known for its work on HIV prevention, treatment and research. And its innovative acupuncture detoxification program has been widely studied and much imitated.

The Boston Public Health Commission EMS has broadened its mission to include innovative treatment programs such as the Assisted Albuterol Program that provides a greater level of service to residents with asthma and the Boston EMS First Responder Defibrillation Program that has trained 7,000 people in the use of cardiac defibrillators. These life-saving machines, and the people trained to use them, have helped push Boston’s cardiac arrest survival rate to 34% -- one of the best survival rates for sudden cardiac death in the country.

DeNovis Inc, a Boston-based start-up, is overhauling the federal government’s medical claims system in partnership with IBM. Its information technology and data-sharing advances are also being applied to reduce the proportion of health care dollars spent on administration in the state. A client-centered approach to information management is being developed by the state’s Executive Office of Health and Human Services. This will help to update old data systems.

Religious leaders in Boston’s black community put their names on HIV/AIDS prevention billboards in Boston neighborhoods with high rates of infection — broadening the base of community action against HIV/AIDS. Faith communities are increasingly introducing AIDS outreach that provides everything from transportation to food to prayer partners. The billboards represent the most visible manifestation of a growing commitment to address the epidemic by black congregations.

The United States is the only industrialized nation that does not provide full health care coverage to all of its residents. Given the dismal outcomes and staggering costs of health care among low-income residents in Boston, perhaps it is time to admit that health care in Boston — and in the United States as a whole — is not producing a desirable level of health. And yet costs are rising. Just a few hundred miles to the north is a health care system that has been in place for decades. It covers everyone and, according to data from the World Health Organization, outperforms the United States on the important measures of health, as do most of the European nations and Japan. Americans tend to hear only about the “long lines” for care in Canada, but most people who have experienced the system firsthand are surprised to hear that, and at least some of the lines today are made up of US seniors purchasing prescription drugs at Canada’s much more affordable prices. And with full coverage of all of its residents and excellent health outcomes, New England Journal of Medicine reports that Canada’s per capita costs in 1998 were only 53% of those for health care in the US.

Massachusetts Department of Public Health
The Commonwealth’s public health department. Website provides statistics and publications in pdf format on Massachusetts public health issues, press releases, links and information on programs.

Boston Public Health Commission
The public health department for the City of Boston. Website provides information on programs, press releases, reports in pdf format, a directory of Boston-area community health centers and links.

Massachusetts Community Information Profile --MassCHIP
An information service that provides free, online access to many health and social indicators. Provides community-level data to assess health needs, monitor health status indicators, and evaluate health programs.

Massachusetts Office of Health and Human Services
Website provides information on a wide variety of Massachusetts health policy issues, a searchable state provider database, as well as program and initiative information and press releases.

US Department of Health and Human Services
Website provides information, publications, research, and statistics on a wide variety of health and national health policy issues, as well as program information and press releases.

Henry J. Kaiser Family Foundation
Focuses on health care issues, particularly policy, public education, and health and development. Website provides a state-by-state searchable database of relevant statistics, pdf publications and news releases, and information on events, programs, and initiatives.

Kids Count
A national and state-by-state effort to track the status of children in the United States.

Population Reference Bureau
A non-profit organization that provides objective information on US and international population trends. Website provides searchable population and health data, educator and journalist resource guides, ordering information on PRB publications, and information on events and programs. Some information in French and Spanish.

World Health Organization
The United Nations specialized agency for health. Website provides a WHO publications library database and health-related epidemiological and statistical information throughout the world.


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