world, whether it is an urban setting in North America, or a remote village in southern Africa. RECOMMENDATIONS TO FEDERAL GOVERNMENT BASED ON 1. Work with individuals, families and communities to rebuild a sense of competence in their abilities to solve problems. 2. It is important to get in touch with people at the grassroots level rather than to bring in outside "experts.' 3. In your funding streams, promote collaboration as opposed to independent, isolated action. 4. Build upon what works. 5. Fund programs that can be sustained. SUMMARY One of the great challenges of working in a foundation is to remain connected to society in a broad sense and to be able to be an effective partner in assisting with social change. Any foundation has the capacity to achieve good. On the other hand, the isolated environment and essential removal from the main street arena can foster a hybrid arrogance that is quite resistant to attempts from the wider world to humble it. It is often hard for foundations or government to keep their feet on the ground and to remain humble as our philosophy and approaches would dictate. The federal government likely faces similar challenges. Our suggestion to you would be to develop some internal process that would help you focus on the end beneficiary-those individuals and groups who want to struggle to revitalize their urban environment and need the cooperation and assistance of the public, private and nonprofit sectors as they do so. Only by remaining true to our basic principles, reflecting on our own lessons, and incorporating them into improved practice do foundations remain effective at our work. We would encourage the federal government to do the same. STATEMENT OF STEVEN A. SCHROEDER, M.D. PRESIDENT, THE ROBERT WOOD JOHNSON FOUNDATION I. Mr. Chairman, the Robert Wood Johnson Foundation awards all of its grants to improve the health and health care of Americans. That being the case, it is a very rare thing for us to be invited to participate in a hearing of the Senate's Committee on Banking, Housing, and Urban Affairs. It is also a rare thing for those of us who represent_this_slice of American philanthropy to find ourselves together, and addressing a single subject, especially one as urgently important as long-term federal revitalization strategies for urban America. So let me say here at the outset that I am equally curious and interested in your reaction to what it is you're hearing here today, as I am in what my counterparts are presenting. I know I join them in the hope that this Committee's work will in time yield a set of workable and affordable responses to at least some of the factors that are destroying the quality of life in our cities. Looking at urban American life from the health care vantage point affords an alarming and relentlessly discouraging view in 1992. What we see is not necessarily new. The nation's moral, political and economic shortcomings have always presented themselves-ultimately and in some form-at the hospital door. It's just that today, those social shortcomings-I include ignorance, crime, ill health, poverty and intolerance-are concentrated in our urban centers where they are manifesting themselves, among other ways, as emerging social pathologies-AIDS, homelessness, drug abuse and acute mental illness. At the same time we are witnessing the re-emergence of tuberculosis, hepatitis A, syphilis and other sexually transmitted diseases, mumps, measles, and whooping cough. Arrayed against this tide of disease is an acute care delivery system that is losing its capacity to serve in part because of health personnel shortages in the inner cities and in part because of losses from uncompensated care-a major problem for both public and private urban hospitals. To make a positive difference in such an environment, the Robert Wood Johnson Foundation has begun to look beyond the health provider community, which is where we have and will continue to award most of our grants, and to consider and make awards to organizations thought capable of confronting certain of these illness and injury-producing conditions outside the delivery system. We are now open to organizations operating in the churches, the schools, the shelters, the prisons and in the streets. II. I think you'll see why we're stretching to reach outside the traditional health delivery field when you consider some of the findings or alarms-now surfacing from studies we and others are currently underwriting: URBAN DRUG USE A National Institute of Justice study showed that 70 percent of all arrestees in four of the nation's largest cities tested positive for one or more drugs; in nine additional cities, the rate was 50 percent. • In Washington, D.C., 59 percent of the adult males being booked for arrest are testing positive for one or more drugs; this also applies to 70 percent of the female arrestees and 30 percent of the juvenile males at the time of arrest. At San Bruno Prison in San Francisco County, 88 percent of the inmates have a known alcohol or drug problem. • Thirteen states had fewer liquor stores than did South Central Los Angeles prior to the May riots there! INFANT MORTALITY The national urban infant mortality rate was 8.8 white deaths per 1000 live births in 1988 and 17.0 deaths for blacks that same year. In Washington, D.C. however, the infant mortality rate for whites was 19.9 and for blacks, 26.0. In New York City, it was 11.0 whites and 18.3 blacks. LIFE EXPECTANCY The age adjusted mortality rate in Harlem was the highest in New York City, twice that of U.S. whites and 50 percent higher than for U.S. blacks, "Survival analysis showed that black men in Harlem were less likely to reach the age of 65 than men in Bangladesh... Harlem and probably other inner-city areas with largely black populations have extremely high mortality rates that justify special consideration analogous to that given to natural-disaster areas.' "The pattern of medical care in Harlem is similar to that reported for other poor and black communities. As compared with the per capita averages for New York City, the rate of hospital admissions is 26 percent higher, the use of hospital outpatient departments is 134 percent higher, and the number of primary care physicians per 1000 people is 74 percent lower." 1 • "Death rates standardized for age are almost twice as high in lower and upper North Philadelphia as in the city's wealthiest communities . . . For some causes of death, such as homicide, . tuberculosis, and bronchitis or asthma, the disparity is fourfold to sevenfold." "Reported cases of lead poisoning, tuberculosis, gonorrhea, and syphilis are 2 to 25 times more numerous in lower and upper North Philadelphia than in the city's wealthiest communities." 2 ACCESS TO CARE • Nearly 35 million people-one of every nine working familieshave no health insurance, and another 40 million are seriously underinsured. The result? Medical care becomes a luxury, and 8 million children grow up without adequate medical and dental care, and nearly one of every five Americans with diabetes and hypertension receives no treatment. Many parts of the country suffer a serious shortage of generalist physicians, and specialty choices among medical students indicate that the situation will worsen. And, again, many inner-city hospitals are struggling for their very existence, besieged by problems of inadequate staff, uncompensated care and the scourges of drugs, HIV infection and alcoholism. • Lack of access to care, real or perceived, is a major contributor to the category of unnecessary morbidity and death that place this nation a dismal 24th in the world in infant mortality and 19th in life expectancy from birth. Into that category falls every case of untreated angina pectoris, hypertension, diabetes mellitus and breast cancer. According to estimates from a recent study at the emergency department at Harbor-UCLA Medical Center, Torrance, California, "more than 500 patients leave the Harbor-UCLA Medical Center 1McCord D. Freeman HP. "Excess Mortality in Harlem" NEJM 322(3): 173:177. emergency department without being seen (each year) and are subsequently hospitalized." Of those who left, 46 percent were "judged to need immediate medical attention, and 29 percent needed care within 24 to 48 hours." This situation reflects the longer and longer waiting periods, which are now a standard feature of emergency departments in big urban hospitals serving the poor. • In a study of hospital admission rates for preventable conditions in New York City, it was found that people in low income neighborhoods (the "urban core") were six times more likely than those in high income areas to be admitted for ketoacidosis, five times more likely to be admitted for congestive heart failure, nearly seven times more likely for asthma, five times more likely for bacterial pneumonia, and four times more likely for severe ear, nose, and throat infections. • According to a Los Angeles County Health Department official, there are 1.2 million Medicaid recipients and 2.7 million uninsured in Los Angeles County alone, many of whom are working as "illegals." SOURCE OF CARE Nearly one in five urban residents does not have a regular source of ambulatory care. • It takes "several months" to schedule a pediatric appointment at an inner New York City clinic. • In a recent study of emergency department overcrowding, approximately 10-15 percent of patients reported that they were unable to read a simple health status questionnaire in either English or Spanish. HOMELESSNESS • It is generally agreed that 3 of the homeless have serious mental illnesses, and even more have affective disorders. Between 30 percent to 50 percent have serious problems with substance abuse, including alcohol, illegal drugs and tobacco. According to the National Coalition on the Homeless, the rates of alcohol and drug abuse are disproportionately high among homeless adults— perhaps as high as 50 percent. But this figure tells us little about the role factors other than substance abuse play in causing an individual to become homeless, or whether abuse is actually a symptom of the homeless existence. Many turn to drugs and alcohol once they hit the streets in order to cope with the degradation of homelessness. LEAD POISONING • The New York Times has reported that "living in decaying housing, 68 percent of very poor black children and 36 percent of very poor white children in central cities have blood lead levels greater than 15 micrograms per deciliter. The centers for disease control currently defines toxic levels at above 25, but the agency said last week it will advise local health officials to take action when children have lead levels higher than 10. III. In your invitation for me to testify here today, I was asked to cite successful Foundation projects in urban areas that might lend themselves to national replication or expansion. Before I discuss several such initiatives, you ought to know that we used to count on the federal government to replicate our successes, although we can no longer do so, given budget constraints. But there are exceptions to prove the rule. When federal replication of our model projects does occur the effect can be far-reaching, especially in urban settings. In 1987, Congress passed the Stuart B. McKinney Homeless Assistance Act, the health care portion of which replicated our 19 city, $25 million collaboration with the Pew Charitable Trusts-the Health Care for the Homeless Program. New York, Chicago, Los Angeles, San Francisco and Detroit were all original and successful sites. At last count, there were similar programs in nearly 150 cities across the country. Our investment in urban homelessness, led, in turn, to two additional national programs that are significant in several ways. The Program on Chronic Mental Illness and the Homeless Families Program grew out of a recognition that large subsets of the homeless with complex problems need more comprehensive help than they can get in health care clinics. The de-institutionalized mentally ill, for example, need more than mental health services or housing alone. They need the kind of integration of services that can be provided in supportive housing. Of particular note to this Committee may be that in both cases, we formed very successful partnerships with the cabinet agency reporting directly to you-the U.S. Department of Housing and Urban Development (HUD). Our joint program on chronic mental illness has produced more new units of supportive housing for people with mental illness than any other national initiative to our knowledge. To date, 2,000 new units have been secured in our 9 demonstration cities. This has been accomplished through a combination of $20 million in grants from the Robert Wood Johnson Foundation for service development, $9 million in foundation low-interest housing loans, and HUD's commitment of 1,200 section 8 certificates worth some $75 million over 10 years. Similarly, under the homeless families program, Secretary Kemp provided 1,200 section 8 certificates to nine demonstration cities to provide housing for homeless women and children with mental illnesses, substance abuse and other complex problems. Another of our housing programs was done without the involvement of HUD. The Supportive Services Program in Senior Housing has made social services available to more than 45,000 elderly residents of publicly subsidized, private housing projects. So far, we have worked with ten state housing finance agencies and are planning to expand our efforts to other agencies. We believe that these programs have contributed to the development of the federal government's new emphasis on supportive housing for older Americans and persons with disabilities. |