Changing the Way Citizens View Their City

Before Baltimore could help its most at-risk populations, it first had to make them see public services in a positive light.

Baltimore is known for its world-class medical institutions like Johns Hopkins University. But the reputation of the city’s health department is a little less renowned. Hoping to change that, the city is getting serious about tackling the worst health problems affecting its residents -- a battle that begins with changing the way citizens think about its health department.

A major part of this effort centers around the city’s goal of reducing HIV rates, a longtime epidemic that’s made Baltimore home to some of the highest infection rates in the nation. In the past, the Baltimore City Health Department reached about 15,000 residents a year by conducting HIV testing and distributing prevention information at free health clinics and through mobile units. Reaching those with the greatest risks of infection, however, proved even more difficult.

As a result, health officials set out last year to make inroads with gay and transgender residents, and more specifically, with the community of black men who have sex with men (MSM). They are about five times more likely to contract HIV than MSM of other races.

Enter Keith Holt, the department’s youth outreach coordinator, who came to the department thinking he could reach this group through what are called “ballroom” or “house and ball” communities. Ballroom communities are underground subcultures where groups of gay and transgender youth compete in dance and performance competitions for trophies and prizes at events known as “balls.” Often, those involved sought the ballroom community at a young age, looking for a surrogate family.

Before developing his plan of attack, which Holt admits is based on a lot of trial and error, he looked to other large cities, including New York, to find out how health departments were reaching this critical group. He discovered that nonprofits and other community organizations were conducting a majority of work in the ballroom scene, where city health departments were event sponsors. “We saw that this was really something we needed to get involved in,” Holt says.

When Holt began meeting with house and ball leaders, he learned that their opinion of the city’s health department was not always positive. For one, they weren’t even aware of services the city offered beyond HIV testing. Holt realized that changing that opinion would be key in reaching this community. “We want to let people know that we’re not just here to test,” Holt says, “we’re here to help and support.”

In November, Holt partnered with house leaders to throw a free ball with music and dancing alongside HIV screenings and free condoms. The event, which carried a $6,000 price tag (paid for by federal funds for HIV screening) had approximately 500 attendees, all of whom were approached about HIV screening, health care, food stamps, housing and other city services. “The great thing about the ball was our opportunity to really go to the community,” Holt says. People might not always want to come to the clinics, he says, so the ball gave the health department an opportunity to provide HIV prevention and services information to a community that has typically fallen under the radar.

From the November event, Holt and his colleagues have subsequently been invited to sponsor or attend different events where they are given additional opportunities to screen and educate.

Prevention education and enrollment in care has become a hallmark of the department’s outreach and HIV reduction message. Toward that end, the department has taken unique steps to encourage those at high risk of HIV to get educated and tested. If someone in the city needs HIV care, the department not only makes same-day doctor appointments, but also transports that person to his or her first and second appointments. This helps the city ensure that recommended treatments are being sought out and adhered to.

So far, the response from the community has been extremely positive, but evaluating the success of these programs can be difficult. The health department reviews the number of people tested for HIV and the number of those identified as newly infected on an ongoing basis. But in this instance -- because the numbers in the ballroom community are so small -- the sample size is often not large enough to be considered significant for evaluating success. This hindrance, which makes success difficult to measure, shut down a similar ballroom -- community outreach program in Philadelphia in 2004.

What is even more difficult to evaluate is how the health department’s image is changing. One of Baltimore’s goals is to encourage the community to take advantage of the city’s two free health clinics and get tested without fear of rejection or judgment. This data is generally subjective, and can only be collected and evaluated by continuing to meet with community leaders to get a sense of how the department has progressed.

In terms of early success, 115 attendees were screened for HIV at the November ball in Baltimore, and of those, 60 percent were linked to care. That’s an encouraging statistic for a community in which approximately 45 percent of black MSM are HIV positive, according to a Johns Hopkins study. Late last year, the health department’s ball was awarded Ball of the Year -- an accolade that has helped to elevate the department’s profile in the ballroom community.

For health department staff, evaluating success goes beyond the numbers. “Our staff cares about the well-being of the citizens that we do provide the services for,” Holt says. They use this drive to continuously try to identify community stakeholders and make the department ready and available with HIV screening and support information. The department is hoping to begin making similar inroads with the transgender community and reach those beyond the ballroom scene -- with an end goal of decreasing new HIV infections by 25 percent.

Baltimore’s renewed focus on citizen health doesn’t stop at HIV. On May 10, the city unveiled Healthy Baltimore 2015, an ambitious public health plan that focuses on 10 priority areas that have the most potential to improve citizen health. Priority areas include obesity prevention, lowering tobacco use, improving heart health and promoting healthy lifestyles for children. Each priority area is matched with a measurable goal like reducing the rate of early death from cardiovascular disease and decreasing the number of food deserts. “Through an approach that includes policy, promoting access and quality, and maximizing community engagement, we will be able to accelerate and improve health outcomes,” says Baltimore City Health Commissioner Oxiris Barbot.

Baltimore still has a long way to go. Per 100,000 city residents, the number of years of potential life lost before age 75 is 14,887 -- twice the number of years lost in the state as a whole.

Caroline Cournoyer is GOVERNING's senior web editor.