Taking the temperature of DetroitBMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g485 (Published 24 January 2014) Cite this as: BMJ 2014;348:g485
The saying about Detroit goes, “When the nation catches a cold, Detroit gets pneumonia.” Battered by the turbulent US automotive industry, high unemployment, and global recession, Detroit has been critically ill for years, and its residents aren’t faring much better.
When the city declared bankruptcy last summer, it revealed festering problems that have been eroding this once vital American city. Detroit’s ugly financial crisis—including $18bn (11bn; €13bn) in liabilities and debt—unfolded dramatically as city services crumbled, crime rose to nation-leading levels, and residents’ access to jobs, insurance, and healthcare withered. Detroit was left with 23% unemployment—more than triple the national average—and 34.5% of residents living in poverty.
“The biggest health issue in the city is poverty,” notes Marianne Udow-Phillips, former director of the Michigan Department of Human Services, who now heads the University of Michigan’s Center for Healthcare Research and Transformation (CHRT). “There is a very high child poverty rate in Detroit, a very high adult poverty rate and illiteracy rate, and we know these things are more associated with poor health. It’s not that the bankruptcy is the cause, but they are so intertwined. It’s the story of changes in the auto industry leaving this city behind.”
As the auto industry began to flounder in the late 1960s, thousands of middle class jobs were lost causing a domino effect of brutal consequences. Though all of the blame can’t be dumped on the auto industry—Detroit’s leaders get a heaping dose of culpability for financial mismanagement—it certainly started the ball rolling.
Lack of well paid jobs prompted more crime, which led more employers and residents to leave. To make up for its shrinking tax base, the city raised taxes and cut services. Then race riots in the 1960s exacerbated white flight, leaving Detroit’s population comprising more than 90% minority groups. Overall it has shrunk from the country’s fifth biggest city in 1950 with 1.8 million people to just over 700 000 people today.
These troubles trickled down to public and individual health. As residents struggled financially or left for the suburbs, community hospitals could no longer survive. About 15 have closed in the past 10 years, says John Sealey, a cardiothoracic and vascular surgeon at Detroit Medical Center and an associate professor at Michigan State University. Individual providers, lacking enough insured and paying patients, left for practices in the suburbs. Newly qualified doctors joined them instead of signing up to care for a challenging population.
And challenging it is. “Detroit probably has the highest level of renal failure in this country, with high levels of diabetes and hypertension and a significantly obese population,” Sealey says. “And with that comes things like cardiovascular disease and other problems.”
“It hasn’t been easy here for decades,” adds Nancy Schlichting, chief executive of the Henry Ford Health System. “When you have high levels of unemployment, there are a host of behavioral health, mental health, and alcohol and substance abuse problems, and they compound each other. We’re dealing with virtually every aspect you can imagine of physical and mental health challenges that come from very tough economic times.”
A key driver of this poor health—including higher rates of chronic disease and mortality—is residents’ lack of access to primary care. There are three major medical providers in Detroit: Henry Ford, the Detroit Medical Center, and St John Providence Health System, but none are public. All three grapple with patients relying on emergency rooms for all of their medical needs, and they are legally required to treat them.
“One challenge we’ve had in Detroit over time is there has not been public support for primary care,” says Schlichting. “We typically have many patients coming to the ER for care, and those who can pay something go to federally qualified health centers. There are almost no private physicians in the community anymore because their practice can’t be successful with the current payment model.”
The main primary care providers in Detroit are federally qualified health centers, which receive government subsidies, philanthropic grants, and other supports to treat a mix of insured and uninsured patients. There also are many free clinics in the city. But demand outpaces capacity, and it’s not unusual for patients to wait weeks for appointments, says Kimberlydawn Wisdom, former surgeon general of Michigan who practiced emergency medicine for 20 years. She is now senior vice president of community health and equity and chief wellness officer at Henry Ford.
In addition, as many community hospitals closed, there was no longer a broad network of accessible neighborhood providers. Many residents, lacking cars or dependent on Detroit’s inadequate public transport system, just can’t get to physicians in the suburbs. So they delay seeing a doctor for preventive care and when problems emerge turn in crisis to ERs.
“Many of these individuals have non-emergency problems, which lends itself to overcrowding in the ER,” says Wisdom. “When you have people who would be better served in a primary care setting, their care isn’t as efficient and comprehensive because it’s an ER, and they can only address their most pressing issue, not all of their issues.”
In addition, Detroit doesn’t provide medical care like it used to. It slashed its general fund budget for public health from $37m ten years ago to $4.1 million today—a 90% cut—according to the new Institute for Population Health. Detroit outsourced some of its health functions to the institute, a public-private partnership with the state and non-profit organizations that handles services like immunizations, HIV prevention, and food safety.
Emergency rooms also get bogged down because Detroiters are accustomed to calling for ambulances. Seventy five per cent of all ambulance calls are for primary care problems, says Kate Kohn-Parrott, president and chief executive of the Greater Detroit Area Health Council. “The city has been working with non-profit groups like the Voices of Detroit Initiative and ours to find ways to provide access to healthcare and get people to not use the ER for primary care,” she says. “We want to make sure we’re not spending dollars to transport people with primary care conditions.”
It’s especially a concern because ambulance response times in Detroit hover around 58 minutes compared with a national average of 11 minutes. Ambulances responding to non-emergencies is a factor. The city’s finances also prevented Detroit from maintaining its fleet of ambulances, so only a fraction are in service at one time, says Eric Lupher, director of local affairs for the Citizens Research Council. “It became very noticeable that services weren’t what they were supposed to be, and people reacted to that by voting with their feet and leaving the city,” he adds. “That leads to a downward spiral of less tax base and less revenue, then more cuts, and on and on.”
It gets personal
When it comes to individual health, grinding poverty, higher rates of obesity, tobacco use, alcohol or substance misuse, and a lack of preventive care have taken a toll. Rates of heart disease, cancer, and stroke in Detroit residents are well above the state and national average, reports Henry Ford’s 2013 Community Health Needs Assessment.1 As one example, 318.4/ 100 000 population die from heart disease in Detroit compared with 193.6/100 000 nationwide, according to the federal Centers for Disease Control.
Another troubling problem is Detroit’s high infant mortality rate—14.4/1000 live births compared with a 6.1/1000 nationally, according to the assessment. In some neighborhoods, the rate reaches as high as 22 or 23/1000, Wisdom says. “It’s a concern because infant mortality is seen as a sentinel event that’s indicative of other more profound issues occurring in the community. It’s the tip of the iceberg,” she adds. “And then there are other children who don’t die, but they don’t have all the supports in place to live to their highest potential. They are close to the edge of the cliff.”
Richard Bryce, a family physician at Detroit’s Community Health and Social Services federally qualified health center, sees the difficulty of Detroit life affecting his patients. Many are retired city workers worried about their pensions being slashed because of the bankruptcy; others currently work for the city and face reduced healthcare benefits.
“If they are from Detroit they feel the bankruptcy issue,” says Bryce. “I don’t think the day the bankruptcy became known that it made much difference. The challenges they have been dealing with have been going on for at least five years. With the patients who work or have worked for the city, you can definitely feel some of the stress they have to deal with and some anxiety about what it means for them.”
Residents also lack access to mental health services. According to the Center for Healthcare Research and Transformation’s research, 68% of physicians think that access to mental health services for children in Michigan is inadequate and 57% say the same for adults, Udow-Phillips says. Additionally, 64% of doctors believe there is a dearth of substance abuse treatment for adults.2 “There is no question that mental health is a huge problem,” she adds, one that often is a barrier to employment.
Even if Detroiters want to be healthy they face constant barriers, Bryce says. Just take the city’s lack of street lights. Detroit’s budget cuts affected its ability to maintain them, and currently only 40% of the lights work. Add on shoddy roads, more than 75 000 abandoned homes and building, and the highest violent crime rate of US cities bigger than 200 000 people,3 and it’s not exactly a comfortable place to exercise outside.
Then there’s access to fresh fruits and vegetables. Detroit is a food desert, where residents don’t have many options for nearby grocery shops. Instead, they must buy their food at convenience stores and corner markets. Detroit also has more fast food restaurants per capita than other US cities, notes Kohn-Parrott. Her organization and many others are working to change that, bringing farmers’ markets to Detroit and encouraging grocery stores to open throughout the city.
Yet it’s not all doom and gloom. Kohn-Parrott, Bryce, and others are hopeful that bankruptcy is the city’s rock bottom, and they already see positive changes. Some neighborhoods like downtown and midtown have begun to attract new residents, businesses, and real estate development.
Sealey believes that a new joint residency program he leads for Michigan State University and the Detroit Wayne County Health Authority will get primary care residents familiar with—and fond of—treating patients in the city. After they complete their residencies at community clinics, they might be more likely to practice in underserved neighborhoods.
“We hope it will be a way residents and young physicians see that you can come into the inner city and get paid to provide preventive care in the community,” Sealey says. “We have to stop the episodic care, put more physicians in the city, and spread them out.”
That would be an excellent start to improving the health of all Detroiters.
Cite this as: BMJ 2014;348:g485
Competing interests: I have read and understood the BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.