Rebuilding Place in the Urban Space

"A community’s physical form, rather than its land uses, is its most intrinsic and enduring characteristic." [Katz, EPA] This blog focuses on place and placemaking and all that makes it work--historic preservation, urban design, transportation, asset-based community development, arts & cultural development, commercial district revitalization, tourism & destination development, and quality of life advocacy--along with doses of civic engagement and good governance watchdogging.

Thursday, April 30, 2020

More communities need to integrate health care and public health programming: Prince George's County, DC, etc.

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Update:  Not only did DC announce ("Bowser strikes deals for new Howard hospital and new Southeast D.C. hospital," Washington Post) that they have inked an agreement with George Washington University Hospital/Universal Health Services to build and manage a new hospital in Southeast DC, they've agreed to pay $300 million toward a new hospital for Howard University, which is becoming integrated into the Washington Adventist health system ("Adventist HealthCare and Howard University Hospital Sign Management Services Agreement," press release).

According to the article the GWU project will include some East of the River clinics beyond the hospital.

One of my "complaints" about DC is that as the nation's only real city-state, not having to kow tow to conservative state legislatures, it has tremendous opportunity to be innovative, but it rarely avails itself of these capability.

Sure, Congress has oversight, but for the most part, the city can do what it wants unfettered (not on debt, and Republicans often pass restrictive legislation as it relates to particular culture war matters).

Health and wellness care is one area where the city could be truly innovative, and really isn't.  This new deal is an example.  It will do a bit more than the current setup, with the outreach clinics, but it could do so much more.

As I wrote in the comment stream, in 2007 I laid out a concept I called "HealthyDC" community clinics to deal with chronic disease management and wellness.  It was inspired by the then new clinics being put in pharmacies.

But the reality is that in A Pattern Language: Towns, Buildings, Construction, Christopher Alexander et al. (List of patterns) id out such a concept in the late 1970s as item #47 (Community) Health Centers, based on the Pioneer Health Centre experiment in Peckham, England.

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Partly because
  • my first DC job was for a public health related organization
  • the closure of DC General Hospital during the Williams Administration around when I started getting more involved in DC issues and when I started blogging
  • a searing article in the no longer published Suburban Maryland Gazette newspapers in 2003 ("Shouldering the burden"), about the impact on Prince George's County with special negative impacts on Prince George's Hospita, from the forced displacement of poor DC residents to that county from the redevelopment of DC's public housing which also when it was rebuilt, was with fewer units than before;
I have written many entries over the years related to what I keyword as "health and wellness planning." Early articles include:

-- "Health planning vs. hospital planning redux," 2006
-- "Piling on the hospital issue," 2006
-- "An opportunity for rethinking health and wellness care in the District of Columbia," 2006
-- "Speaking of rethinking how to offer "public services" and medical care," 2007

In 2018, I wrote a series outlining how a rebuild of United Medical Center in Ward 7/East of the River could be transformational both in terms of health care and public health outcomes as well as an economic development initiative, by marrying it with the simultaneous development of an advanced medical education and research program next door at the St. Elizabeths Campus, which the city has been trying to redevelop for more than a decade, with little to show for it.

-- "Ordinary versus Extraordinary Planning around the rebuilding of the United Medical Center in Southeast Washington DC | Part One: Rearticulating the system of health and wellness care East of the River
-- "Part Two: Creating a graduate health and biotechnology research initiative on the St. Elizabeths campus"
-- "Part three: the potential for donations around an expanded program"
-- "Update on DC's plans to build a new United Medical Center"
-- "Community Health Improvement Planning"
-- "A glaring illustration of the need for comprehensive health and wellness planning in DC: Providence Hospital"

The influences on that program were far and wide, and as I come across other great programs new to me, I enter them in the comments on the various articles.

A few weeks ago, I wrote about how there was something I missed in that series, the need when building that hospital to plan in extra functions and potential capacity in case of epidemic or terrorism, the way that Rush Medical Center in Chicago was constructed, after 9/11.

-- "Rush Medical Center (Chicago) clues us into a gap in state and regional health care planning: planning for disaster and epidemic response"

As I said, the economic and health outcomes problems faced by DC General, Howard University Hospital, and Prince George's Hospitals at the same time made me realize that this issue was regional, not jurisdiction specific.  But I chalked that up mostly to poverty.

-- "When the problem is defects in the structure of "the market", financial incentives won't do much good: Maryland's health enterprise zones," 2013

Health disparities for people of color aren't just about income.  But the issue of health disparity is more than just poverty, it can also be an issue of race, as indicated by the Washington Post article, "Covid-19 is ravaging one of the country’s wealthiest black counties."

Another example was outlined previously in reporting by the New York Times about black women and pregnancy complications, which affect women at all income levels ("Why America's Black Mothers and Babies Are in a Life-or-Death Crisis").

Minorities in Prince George's County dying from coronavirus aren't "just poor" or people with serious underlying health conditions, they are also healthy people with high incomes who happen to be people of color.

To deal with the problems of PG Hospital, the state facilitated its merger with the University of Maryland Medical System, which because the medical school is in Baltimore, has been less focused on the DC side of Maryland.

Rendering, new hospital in Largo.

The program is now called UMMS Capital Region Health and the linchpin is a new hospital under construction in Largo, which will replace the existing PG Hospital.

-- "Prince George’s health system names permanent chief," Washington Business Journal
-- "New empire in Prince George's: The road ahead for UM Capital Region Health," Washington Business Journal

Probably every new hospital project needs to add capabilities to deal with epidemics and other potential health disasters.  But like with my recommendations for United Medical Center and the recognition that the program should be expanded even further, along the lines of what the Rush Medical Center has done, my sense is that the UMMS program for the new hospital in Largo doesn't link health care and public health programming, and the hospital isn't likely to being outfitted in extranormal ways to deal with epidemics, terrorism events, and other threats.

(And yes, I know many hospitals, at least with catastrophic response to mass casualty events, are already doing some of this.)

PG County needs to do what I recommended DC do.  Looks like Prince George's County, and presumably other communities with high population of people of color need to develop similar programs marrying health care and public health programming more directly.

For example, the Post writes about a similar situation in Milwaukee, "Covid-19 is ravaging black communities. A Milwaukee neighborhood is figuring out how to fight back," and there have been many articles about the hollowing out of the rural health care system ("Closed Hospitals Leave Rural Patients ‘Stranded’ as Coronavirus Spreads," New York Times; "1 In 4 Rural Hospitals Are At Risk Of Closure And The Problem Is Getting Worse," Forbes).  These communities need better care as well as more care.

Like how UMC probably isn't being built the same way that Rush Medical Center was, to be of special use in times of panedemic, the same is probably true of the new UMMS hospital in Largo.

Transformational Projects Action Planning as an approach

This approach, oriented to wringing out every possible benefit from a large project as a way to transform a functional "service" like health and wellness care and public health, is an example of what I call "Transformational Projects Action Planning" applied to health and wellness planning more generally, and specifically to large scale projects, like the planning, development, construction and operation of a new hospital.

-- "Why can't the "Bilbao Effect" be reproduced? | Bilbao as an example of Transformational Projects Action Planning," 2017
-- "Downtown Edmonton cultural facilities development as an example of "Transformational Projects Action Planning"," 2018
-- "A "Transformational Projects Action Plan" for a statewide passenger railroad program in Maryland," 2019
-- "A "Transformational Projects Action Plan" for the Metrorail Blue Line," 2020

The Purple Line series in toto is an example of TPAP. All the relevant articles are linked within this update:

-- "Revisiting the Purple Line (series) and a more complete program of complementary improvements to the transit network," 2019

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16 Comments:

At 4:54 PM, Anonymous charlie said...

excellent post.


I'd say we need to look at Baltimore and BC; for what ever reasons they have been more successful here.

Do I know why? No. But worth asking that question.


There will be federal money for building out hospitals more. Hospitals are actually a huge driver in expenses but yes I'd see a lot of money flowing in there. So both Howard and SE medical center have some chances now.

Here is my question -- how effective has been "networking" within DC. Looks like DC is still constrained and the DC area hospitals may not be working so well together. Again hard to evaluate that claim right now.

You've also got a lot of federal resources here : VA, Bethesda naval, and we could probably use another one.

Can public health outreach to elderly be part of medicaid? Medicare? There are specific programs that do that with children. Likewise there are other program that drive it to special communities (Whitman walker). What is needed is something on that level.

 
At 7:50 AM, Blogger Richard Layman said...

Pharmacy deserts:

https://www.nationalacademies.org/news/2020/04/exploring-the-importance-of-pharmacies-to-public-health

 
At 7:57 AM, Blogger Richard Layman said...

DK if JHU and UMD having great medical schools is an issue.

At the same time the independent, Bon Secours, and to some extent LifeBridge (formerly Sinai, and in the poorer area because it had been Jewish before outmigration) deal with the lower income communities more than the big systems, maybe?

Bon Secours was doing a lot of community work, including building affordable housing. But with the recent merger, they've exited the Baltimore market. Allegedly the community work will continue, and LifeBridge bought the facility, but it will be downgraded to not have hospital beds.

Another thing about Baltimore City, I guess because of ongoing heroin problems and maybe STDs, they have (or at least had) a strong public health unit. Directors have gone on to high profile positions.

But probably, in terms of the difference of what I call health and wellness vs. health care, probably JHU and UMMS are no more forward than anyone else.

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I don't know enough about the medical field to know how important networking is/can be.

I know in other areas (higher education, commercial district revitalization, ANCs) it's almost no networking.

At the sub city level of ANCs, community groups, historic preservation, and commercial district revitalization programs, for going on 15 years I keep calling for networking and sharing resources.

But the higher education institutions do have their consortium, which shares resources, allows students to take classes at other institutions, etc. (like the consortium in Amherst, Mass.).

 
At 1:27 PM, Anonymous charlie said...

As I said in other comments, a large part of this reaction is predicated by your familiarity with infection disease. On a national and sub-national - and personal scare.


One reason I've been downplaying it. My mother is a virologist. I've literally had to go in a bio-hazard virus lab as a kid after school. My grandfather died of the bubonic plague. (Long story). On my father's side, the majority of his extended family was wiped out in 1918. My father had to become a doctor because his grandfather -- the only survivor -- saw how important it as to have a doctor around.

For the vast majority of americans, infections disease is something to happens to black/brown people and not a real concept anymore. Strong moral element to it -- if you catch something it is because of morality, not science.

D/K enough about Baltimore and hospital systems to asses. But make everything else equal, it should be ripping through Baltimore more.


From what I can tell, DC is relying on its own pubic health lab, one university lab, and private results 6 labs total. they've been limited with reagents and swaps like everyone else, and DC only doing testing on its own in Ward 7 and 8. (could be mistaken on the last)

And yes that lack of networking is probably an endemic problem.



Going back to the national level on familiarity, you see that with HK, Singapore , south korea. They ran this game 20 years ago. Easy model, no sign that we're duplicating it. Do you think quarantine orders are being followed in DC? Bowser did ban visitors to senior public housing but not to regular PH --- which is also primarily old people.

Manchester UK reports 1/2 of homeless put in hotels left b/c they didn't like the lifestyle. It isn't optional.

What we are really seeing her is how important metabolic health is and those are the easiest interventions.


 
At 4:50 PM, Blogger Richard Layman said...

Like I mentioned in comments, I went through a period where I read a bunch of stories by John O'Hara, and he was a doctor's son and had second hand experience I think with his father's work during the 1918 epidemic. (He wrote about families in mining towns in Pennsylvania being wiped out, among other things, Poles and Welsh, etc.)

Plus Andromeda strain, plus reading about leprosy, TB, AIDs, hantavirus, Legionnaire's disease, vaccine issues, Ebola, cholera, etc. over the years.

I had chicken pox. Not measles. Don't think I knew anyone who had polio. But I just can't remember.

And working for CSPI introduced me to public health. I even considered doing grad work, but then I didn't continue in the field.

So what you're saying is the US was lucky vis a vis first hand experience, for about a century.

So we had structural complacency.

Yes, the Asian countries have to be constantly on watch given the likelihood of new viruses like SARS, now this.

But eventually, luck runs out as it did in this case.
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Yes, reiterates the value of basic health, and wellness.

Not a surprise about Manchester (I'll look it up.)

There was a Reel South documentary a few days ago about removing a homeless tent camp in Nashville. I wanted to watch it because the blurb said it was about "gentrification" etc.

It had nothing to do with gentrification, but did have to do with dealing with homeless policy (which they didn't address) and the use of public space for informal tent communities.

Anyway, from the interviews, no question that every person in the camp had mental and/or substance abuse issues.

That being said, it was a rare example of such a camp where the people had a sense of collective responsibility, maintained the general areas, etc.

But they had wacked ideas that if they did a nice job maintaining it that the city would leave them be...

 
At 10:31 AM, Anonymous charlie said...

Reading the post article on PG county, what strikes me is how many of those cases are just being handled by emergency rooms.

Again may be misreading this, but I'd say the issue is lack of a doctor to talk to.

The public health / metabolic health issue is in another box. I don't think Doctors are the best ones to say how to lose weight and exercise. You need incentives.

In japan if your waist size is over 35" you don't get insurance.

https://www.nytimes.com/2008/06/13/world/asia/13fat.html


 
At 3:11 PM, Blogger Richard Layman said...

Remember I worked at CSPI. In 2007, really intrigued by the introduction of the Minute Clinic concept, I wrote a blog entry suggesting the creation of "HealthyDC" "stores" that would be clinics/wellness centers focused on this and other chronic medical conditions.

http://urbanplacesandspaces.blogspot.com/2008/02/dispuptive-innovation-once-again.html

Putting this together with the other stuff that I have written since, I realize now that my approach about linking planning and mechanisms for change has a lot to do with what I learned while working at CSPI, even though it wasn't a "direct service" group, what I called indirect service, focused on structural change. But it was a self-help oriented group in terms of publishing Nutrition Action Healthletter, while at the same time, working for structural changes in policy and regulation.

(But it's also related to stuff I learned and tried to apply in college, concerning "action research" and organizational development.)

My 2006 piece on Arlington's commuter stores, the Idea Store library-workforce centers in Tower Hamlets, and one other program I don't remember, makes similar kinds of points.

... how I have advocated for a teaching kitchen at Eastern Market for more than one decade.

... how I argue for providing programs for assisting people in making the switch to biking and other forms of active transportation.

Of course, the PL series or the hospital series originally.

It's a form of the "nudge" thesis. (Another complaint, about kids being not allowed to go to school without shots. I said, "set up a time before the start of the school year with a doctor and nurse and do it production line style.)

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CSPI did some educational films. A couple years I exhibited at the Am. Home Economics Assn., and a teacher from Eastern High School asked me to show the film to her classes. I did. In our talking about it, she said that for many of her students, having a group meal in class was one of their only experiences eating a meal together. Etc.

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But as great as my HealthyDC idea was, it turns out that Christopher Alexander has a similar concept in _Pattern Language_. Then again, it's not rocket science.

But the HealthyDC clinic/"stores" are basically creating the kind of GP practice that marks the NHS set up, at least as it is portrayed on "Doc Martin."

Moving it away from the emergency room.

It wasn't just not having insurance that sent people to ERs before ACA, it was not having doctors. And obviously that is still mostly the case in these kinds of communities.

 
At 3:30 PM, Blogger Richard Layman said...

https://hbr.org/2006/12/disruptive-innovation-for-social-change

 
At 9:00 AM, Anonymous charlie said...

https://www.washingtonpost.com/local/dc-politics/bowser-strikes-deals-for-new-howard-hospital-new-southeast-dc-hospital/2020/04/29/8483ffea-8a69-11ea-9dfd-990f9dcc71fc_story.html

 
At 9:47 AM, Anonymous charlie said...

https://on.ft.com/2SlG7FE

 
At 11:08 AM, Anonymous charlie said...

https://www.statnews.com/2020/04/29/we-need-the-real-cdc-back-and-we-need-it-now/

 
At 12:02 PM, Blogger Richard Layman said...

he FT story is great.

“When we look back, we will see this as a moment that laid bare some of the dysfunctions and inequalities in the American healthcare system,” says Adam Gaffney, an instructor of medicine at Harvard Medical School, and a pulmonary and critical care doctor. “We have a completely fragmented, privatised health system that continues to fail us.”

But yes, I started learning that at the Academy of Health Services Marketing conference I exhibited at in something like 1990 or 1989...

One of the things that I thought was really wrong about Obama's approach to health care, was a failure to lay out some parameters of the ideal.

It's easy for me to say that though, me not being focused on what was possible politically.

Especially with the tea party counterattack which moved Congress to Republican control.

While so many criticize "Medicare for All" the issue really is do we want a catastrophic care system or a health and wellness system.

... and a care system vs. a set of disconnected markets.

Except Medicare for all is still insurance focused. Maybe with such a system, we'd start getting community based physician practices again. Maybe not.

(I presume you saw the Post article about doctor practices being seriously economically impacted by the pandemic. Like hospitals postponing elective procedures, not seeing patients means no income.)

BUT without people laying out the alternative/an alternative ultimately things won't change much.

... and when I was processing this a.m., speaking of your point about metabolic health,

https://www.nytimes.com/2020/04/20/well/eat/coronavirus-diet-metabolic-health.html

 
At 12:07 PM, Blogger Richard Layman said...

wrt the CDC piece. Yep. Wow. They were thought of as the consummate professionals. Everyone looked up to them.

Again, this idea I laid out of reshaping the Public Health Service, CDC, schools of public health, and state and local departments of public health as an integrated system on the extension model is key.

It's somewhat on those lines already. But with a huge gap in funding.

And obviously, there needs to be some independence, given how f* up our politics are.

In the old days, it wasn't like that so much.

 
At 11:34 AM, Blogger Richard Layman said...

https://www.bizjournals.com/washington/news/2020/05/01/d-c-is-getting-a-pair-of-new-hospitals-here-are-5.html

Article about what the funding for the new hospitals means.

 
At 11:52 AM, Blogger Richard Layman said...

Poor state of metabolic health demonstrated as a result of coronavirus hospital admissions:

https://www.bostonglobe.com/2020/05/07/opinion/link-between-coronavirus-deaths-those-french-fries/

 
At 9:40 AM, Blogger Richard Layman said...

Michael Marmot, director of the UCL Institute of Health Equity

https://www.ft.com/content/5e6330de-1e95-4343-8424-184d19dc34b9


2. Another area for a program like the one outlined here appears to be the area served by the University Hospital in Brooklyn (SUNY Downstate Medical Center).

https://www.nytimes.com/2020/04/26/nyregion/coronavirus-new-york-university-hospital.html

 

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