- The Dutchess County Stabilization Center in Poughkeepsie is a core component of the county’s mental health program
Covid-19. The opioid epidemic. Mental illness. The current state of public health in the Hudson Valley, and in the United States at large, seems to be plagued by one crisis after another. Local public health officials, who have the daunting and sometimes unenviable task of addressing these crises, must also decide which crisis merits the most attention and resources.
Dr. Livia Santiago-Rosado, the Commissioner for the Department of Behavioral and Community Health (DBCH) in Dutchess County, identifies the county's top public health priority as health literacy: the ability to understand, and use, information when making health-related decisions. An estimated 88 percent of Americans lack adequate health literacy skills––and public health officials like Dr. Santiago-Rosado deal with the ramifications.
"Our collective lack of basic knowledge causes the simultaneous overutilization and underutilization of our health care system," she says. "We see long waits at emergency rooms or difficulty contacting a doctor's office. Many folks don't know how to treat a common cold properly, so they go to the emergency room thinking they need antibiotics. Others misunderstand and mismanage acute pain and end up with substance use disorders. Many others don't seek preventative care because they feel fine, until they don't, and end up in the emergency room with a stroke or in a diabetic coma."
The DBCH website is loaded with educational materials like brochures, reports, and instructions to guide readers to the information they need to improve their health literacy––or what Dr. Santiago-Rosado calls "our community's 'health IQ.'" They do it, she says, "because health literacy, or the lack thereof, affects everyone."
Community Health AssessmentPoor health literacy also makes people vulnerable to misinformation that can be harmful to their health and wellbeing, as illustrated by the widespread conspiracy theories about Covid-19 that have been dubbed an epidemic of their own, or an "infodemic." In November 2021, a group called "Do We Need This?" mailed out postcards across Columbia County that urged people not to get Covid-19 vaccines.
At the same time, one county away, Dr. Santiago-Rosado was appointed to her current role as commissioner. When she came onto the scene, the Dutchess County Department of Behavioral and Community Health had been responding to Covid-19 for almost two years. With Covid-19 vaccines and treatments available to the public and relatively high mid-Hudson Valley vaccination rates, Dr. Santiago-Rosado decided to look more broadly at the state of public health in the region by conducting a community health assessment.
- Dr. Livia Santiago-Rosado, Commissioner for the Department of Behavioral and Community Health in Dutchess County.
The DBCH began by gathering data and input from stakeholders to select the public health issues on which they would focus their efforts. They zeroed in on two problems with a unifying theme: chronic disease prevention and the prevention of mental illness and substance-use disorders. "Beyond supporting existing activities and interventions, it's important to remind ourselves that our most vital role is in population health and primary prevention––preventing disease or injury before it occurs," Dr. Santiago-Rosado explains.
Prevention as a public health practice can be thought of as nipping disease in the bud—taking steps to give people the best chance at avoiding illness in the future by doing things like exercising and eating well. Coming up with strategies for prevention requires an understanding of what causes disease in the first place. A key focus for Dr. Santiago-Rosado has been "unearthing root causes for these challenges so we can create interventions and programs to address them at their core, while ensuring we don't lose sight of our most vulnerable populations, such as those who may lack access to care or people with disabilities."
The DBCH focuses on reducing tobacco use rates, particularly among youth, and reducing obesity rates with regard to preventing chronic illness. To mitigate mental illness and substance abuse, the DBCH runs programs such as overdose prevention trainings and suicide support. They provide Narcan training and fentanyl strips, and have begun an initiative to review opioid prescriber patterns to identify those who over-prescribe opiates and educate them on best practices. They offer an Intensive Treatment Alternatives Program, or ITAP—an alternative to inpatient rehabilitation––for those struggling with addiction. A helpline, available to call or text 24/7/365, is available for suicide and crisis intervention, while the Mobile Crisis Intervention and Trauma teams can assist community members in person.
Rural DilemmaThe programs listed above constitute only a small slice of what the DBCH has to offer. It's a pretty comprehensive lineup, but when people seek out support, they often find it in different places: health care providers, community- and faith-based organizations, and governmental agencies. Dr. Santiago-Rosado sees the lack of coordination among these groups as a barrier to successful public health initiatives. She believes that their cooperation during Dutchess County's response to Covid-19 was a great success, and wants to foster further collaboration "so our residents don't fall through proverbial cracks."
These cracks are often wider in rural areas, where health care is usually harder to access than in cities. There are fewer health care providers and medical centers––20 percent of America's population lives rurally, but less than 10 percent of America's physicians practice there, and there are only 13.1 physicians for every 100,000 people compared with 31.2 in urban areas. More than 130 rural hospitals have closed down in the last decade, and an additional 600 rural hospitals, which make up more than 30 percent of all rural hospitals in the country, are at risk of closing in the near future.
Geography poses another barrier to health care access for those in rural areas, who have to travel further distances to get to a doctor's office or the emergency room. For those without cars, public transportation is often piecemeal, if not nonexistent. A poll found that one in four people living in rural areas said they were recently unable to get the health care they needed, and about a quarter of those cited distance and lack of transportation as the reason why. Rural American socioeconomic trends worsen the aforementioned difficulties with health care access. Per capita income in rural areas is nearly $10,000 lower than the average per capita income nationwide, and rural Americans are more likely to live below the poverty level and be without insurance.
Dutchess County contains both urban and rural areas, but the public health priorities that the DBCH and Dr. Santiago-Rosado outlined are particularly acute in the rural community. Inadequate health literacy and chronic disease are more severe in rural America than in urban centers, and while mental illness and substance abuse are widespread across both geographies, rural areas have fewer resources to treat them––for example, mental health providers are more likely to practice in urban regions.
Extra CareImproving health literacy requires improving public access to relevant health information, which is most easily found online––and 53 percent of rural Americans lack access to high-speed internet. Rural residents of the Mid-Hudson Valley experience higher rates of chronic diseases like diabetes and heart disease. Rural youth are twice as likely to commit suicide as their urban counterparts, and mental health clinic visits in Dutchess County have declined by 30 percent since 2001––but the DBCH and the Westchester Medical Center Health Network (WMCHealth) announced a plan in June to better treat mental health in the Hudson Valley.
With Dutchess County providing $3 million in funding, they're establishing the Behavioral Health Center of Excellence, which will be a part of MidHudson Regional Hospital in Poughkeepsie. The funds will also go toward permanently adding 20 inpatient mental health beds, increasing the hospital's total number to 60. The same is happening in Ulster County, where WMCHealth will add 20 inpatient mental health beds to the HealthAlliance Hospital in Kingston.
The DBCH will staff the new Behavioral Health Center, with the goal of connecting future patients with the outpatient services the DBCH offers. "Dutchess County is truly blessed," says Dr. Santiago-Rosado, "to have these devoted public servants working for the improved health of our community."