A survey conducted several years ago estimated that roughly 10,000 residents of East Baltimore are in need of alcohol or drug treatment at any given time--a particularly alarming figure when one considers the total population of the area is an estimated 99,000.

However, that statistic still doesn't paint the whole picture, according to Mary Elizabeth McCaul, associate professor of psychiatry at the School of Medicine and director of the Johns Hopkins Broadway Center, an East Baltimore outpatient clinic for those with substance abuse problems.

Substance abuse is a significant contributor to and acutely entwined with, McCaul said, the array of health, environmental and social problems that face this particular community, from heart disease and sexually transmitted diseases to high crime and unemployment rates. This pervasive problem affects--directly or indirectly--nearly everyone in the community.

"Probably, it's more accurate to say who is not affected by [substance abuse]," said McCaul. "Until something has been done to address the enormity of the substance abuse problem and the personal harm it causes, moving this community in a positive direction is not a realistic goal that can be maintained."

And that "something," McCaul said, is currently front and center in the eyes of the Urban Health Council, of which she is a member.

The Urban Health Council is a Hopkins-led consortium of faculty and staff, community residents, local leaders and city officials convened in 1998 by President William R. Brody to address the needs of East Baltimore and suggest ways to marshal efforts to effectively combat the community's unyielding health crisis. The group was originally known as the President's Council on Urban Health.

Health status indicators for the area surrounding the Johns Hopkins Medical Institutions are among the worst in the city and the entire state. The City Health Department's 1998 statistics show that these neighborhoods have Baltimore's highest age- and sex-adjusted rates of morbidity and mortality from cardiovascular and cerebrovascular disease. Their residents suffer unduly high incidence of diabetes and cancer as well as from some pulmonary diseases, violence, HIV-related illnesses and an epidemic level of substance abuse. The rate of sexually transmitted diseases in East Baltimore is the highest in the country and, in the case of syphilis, the highest of any city in the developed world.

In January, UHC identified substance abuse, specifically as it pertains to women with children between the ages of 0 and 6, as one of its initial target areas, and since that time has been inventorying and examining the resources currently available to deal with this issue.

This focus joins other ongoing efforts of the council, including the encouragement and facilitation of the economic growth of East Baltimore and the proposed establishment of an Urban Health Institute. The envisioned institute would be a multidisciplinary entity for research, education and community outreach on issues related to urban health. It would have jointly appointed faculty, a core staff and connections to relevant community organizations, government and health agencies, and other academic institions.

By the end of the current academic year, the Urban Health Council aims to be far along in the development of its comprehensive strategy to deal with the substance abuse problem in East Baltimore.

Martha Hill, co-chair of the Urban Health Council and director of the Center for Nursing Research and a professor at the School of Nursing, said a recent meeting of the council provided a good snapshot of ongoing projects focused on substance abuse. Presentations were made by representatives of organizations including Johns Hopkins Health Care, the Bayview Center for Addiction and Pregnancy, the Historic East Baltimore Community Action Coalition, the South East Community Organization and the Baltimore City Department of Health, who discussed their organization's various strengths, achievements, methodology and the challenges they face.

Two major concerns that came up at the meeting were the lack of current capacity in community clinics and the need for better information management to help those in need, and their caregivers, to identify all available community resources--including support services like child care, transportation, remedial education and job training for community residents. On the issue of capacity, McCaul pointed out that existing clinics have about 750 treatment slots for the 10,000 people who are in need of assistance.

"We are woefully prepared to deal with the volume," McCaul said. "We have people walk into our clinic every day, and we just can't take them in. Some can hang in there and wait for a space to open up, and some can't."

Hill said the Urban Health Council, which she defines as a partnership vehicle with the community, needs to be fully aware of all these types of shortcomings as it readies a comprehensive strategic plan. For example, detoxification, though necessary, is insufficient for sustained behavior change; job training, social support and instruction in parenting skills must be provided.

The council envisions a multidisciplinary, multifaceted initiative that reaches into areas of economic development, housing improvement, violence prevention and school retention, among others.

"We need to have a better understanding so we can begin to identify ways we can leverage activities in the community, and at Hopkins, for a more coordinated attack on substance abuse," Hill said. "We think we can learn a lot from initially focusing on substance-abusing women with young children. It's a group we could identify and whose needs are great."

Among the next steps for the council will be the examination of four areas: increasing the capacity for medical services, the development of a database and evaluation tool, financing policies and what is being referred to as a "one-stop shopping" resource program for community caregivers and residents. The resource program might involve the creation of a type of clearing house that could categorize all clinics, services and resources available to the community. The database and evaluation tool would be a mechanism to help determine the effectiveness of current programs.

Paula Burger, vice provost for academic affairs and international programs and a member of UHC's executive committee, said that currently the council also is working on putting together a plan for creating a structure that brings together senior city, state, civic, academic and community leaders in an effort "to mobilize resources and foster enduring, comprehensive solutions to community problems."

Hill said she understands some of the frustration on the part of people who feel the council hasn't produced enough concrete results to date. To these concerns, Hill said that people must understand that the council is dealing with an inordinately complex problem that takes an incredible amount of time to evaluate, and the council is fully dedicated to understanding the problem and sharing information with community members before it acts.

"I think the council members have commitment and talent, and we certainly have passion for these issues," Hill said. "But what we really need is people with dedicated time and understanding so that as we go forward we can help fill in these gaps of community services. Part of the challenge of the [proposed] Urban Health Institute will be to retain a role as facilitator of increasing our knowledge on urban health issues."

For more information concerning the Johns Hopkins Urban Health initiative, go to http://www.med.jhu.edu/urbanhealth.