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Home My WebLink AboutIR 8300 INFORMAL REPORT TO CITY COUNCIL MEMBERS No. 8300 "06A To the Mayor and Members of the City Council February 6, 2001 -,406AT r, "jh'A X _.'Alh J. toil revs SUBJECT: HEALTH DISPARITIES IN THE MINORITY COMMUNITY PURPOSE: The purpose of this Informal Report (IR) is to: a) Provide the Council with a copy of the presentation by Dr. James Dzandu at the Pre-Council Meeting of January 9, 2001. b) Supplement the Tarrant County figures cited by Dr. Dzandu with comparable data for the City of Fort Worth and the State of Texas. c) Respond to the recommendations presented by Dr. Dzandu. BACKGROUND: Health disparities are defined as differences in mortality, burden of disease, and other adverse health conditions that exist among specific population groups. Such variations can be measured by statistics such as infant mortality rates, rates of mortality due to specific causes of death, health care utilization, and health insurance coverage. "In a presentation to the City Council on January 9, Dr. James Dzandu presented numerous health *indicators that identified substantial minority health disparities in the local community. Dr. Dzandu used 1996-1998 data from the Texas Department of Health to demonstrate higher mortality rates among minorities, especially African Americans, in Tarrant County and Texas. The Epidemiology and Assessment Section of the Fort Worth Public Health Department has compiled information regarding health disparities among minorities in Fort Worth to supplement Dr. Dzandu's report. Infant N1 ortality Rates (per 1,000 live births) =White 12.9 NBIack 14 a Hispanic 12 10.4 []0 ther 10 7 2 =Total 8 6 4 5.2 6 4 2 0.0 0 State County City 1998 1998 1998 Sources:State and County Rates:Texas Department of Health.Bureau of Vital Statistics-, City of Fort Worth Rates:Fort Worth Public Health Department,Epidemiology and Assessment Section,Healthy People 2010 Infant Mortality Rate goal is 4.5 per 1,000 live births. MORTALITY RATES: Mortality rates are the most readily available indicators of the health status of a population. Among these, infant mortality rates are the single most indicative measure. The graph above presents infant mortality rates for the city, state and county. Minority infant mortality rates, especially among African Americans, are consistently higher. Mortality rates for cancer, heart disease, stroke and diabetes, as well as the total death rate, were also found to be highest among t African Americans. Details of these rates and illustrative charts are provided I he attachment, ISSUED BY THE CITY MANAGER FORT WORTH, TEXAS INFORMAL REPORT TO CITY COUNCIL MEMBERS No. 8300 - To the Mayor and Members of the City Council February 6, 2001 Page 2 of 4 P't r ft--P� SUBJECT: HEALTH DISPARITIES IN THE MINORITY COMMUNITY ADDITIONAL HEALTH INDICATORS: As noted in Dr. Dzandu's report, a number of other factors contribute to the differences in health status among racial/ethnic groups. These factors include access to health care, socioeconomic factors, occupational exposure, and educational levels. The Community Needs Assessment (CNA) conducted by the Fort Worth Public Health Department in 1998 addressed some of these factors, indicating that 53% of Hispanics have some sort of health insurance compared to 85% for African Americans and 92% for Whites. Further, although the CNA indicated that 92% of Whites and 94% of African Americans had insurance for their children under 5 years old, only 69% of Hispanics reported having such coverage. Minority disparities are also suggested in terms of education, with 58% of Hispanics reporting not having completed high school compared to 29% of African Americans and 15% of Whites. Rates for birth defects, HIV/AIDS cases, and mental health issues are also indicative of overall health. Birth defects have occurred among all races in Fort Worth with similar incidence rates. However, AIDS rates for African Americans in 1.999 were 26.8 per 100,000 compared to 14.5 for Whites and 9.9 for Hispanics, Rates for utilization of adult mental health services for African Americans are almost twice those for Whites and four times those for Hispanics, Additional rates, illustrative charts and sources are presented in the attachment. RECOMMENDATIONS: In his report, Dr. Dzandu listed five recommendations towards impacting minority health disparities. Several of these recommendations validate the current work of the Fort Worth Public Health Department. The following lists Dr. Dzandu's recommendations (italics) followed by a description of ongoing initiatives or areas in need of improvement. 1. The City of Fort Worth Health Department to collect, analyze and disseminate baseline data of health indicators to determine the scope and severity of minority health disparities and to measure progress in reducing minority health disparities against those benchmarks. The City of Fort Worth Health Department collects, analyzes and disseminates baseline health indicators on a regular basis. A comprehensive Community Needs Assessment (CNA) was conducted in 1998 and established baseline values for numerous health indicators. These indicators were explored from various perspectives, including race. Further, the Vital Records Section provides ongoing information to the Health Information Systems and Automation Section. This information is routinely assimilated and analyzed by the Epidemiology and Assessment Section to monitor the overall health of the Fort Worth community. This activity maintains surveillance on vital health indicators by race on an ongoing basis and provides the data that drives Health Department interventions. We concur with Dr. Dzandu that broader dissemination of the data needs to occur and that community-wide efforts are necessary to effect positive change. The Health Department will expand its efforts to organize such activities, 2. Expand the Health Department's community outreach programs through effective collaborative partnerships with centers, including UNTHSC, hospitals, clinics, faith and community-based organizations, schools and colleges to educate citizens about nutrition, exercise, alcohol&substance abuse, health maintenance and promotion. The population-based approach of the Outreach Division responds to disparities identified by ongoing assessmell activities. These responses are accomplished by cultivating a myriad of collaborative relationships and partnerships ISSUED BY THE CITY MANAGER FORT WORTH, TEXAS ' INFORMAL REPORT TO CITY COUNCIL MEMBERS No. 8300 To the Mayor and Members of the City Council February 6, 2001 ff Page 3 of 4 SUBJECT: HEALTH DISPARITIES IN THE MINORITY COMMUNITY with local agencies and organizations. The concept of combining resources to effect change is an important part of the Public Health Department's philosophy. Collaborations currently include UNTHSC, TCU, TWU, FWISD, Healthy Tarrant County Coalition, Hugule,y Community Outreach Mobile Unit, Tarrant County Hospital District, All Saints Hospital, Cook Children's Hospital, Ham's Methodist Hospital, Tarrant County Health Department, and the NAACP. Additionally, the Congregational Health Promoter Program, the Care-Partners Program and the Search Your Heart Program specifically link with faith-based organizations. 3. Coordinate comprehensive health fair screening activities through the districts and couple these activities with follow-up programs and referrals to ensure maximum benefit. The Outreach Team participates in and coordinates multiple health fairs and screening events throughout the city. Follow-up is provided to ensure that participants access needed services from area providers. By conducting and participating in such activities, the Outreach Team has demonstrated a proactive posture towards addressing health disparities. In the past 18 months, the Outreach Team was instrumental 'in the following health fair activities: * The annual African-American Wellness Fair to be held February 24, 200 1. * The'annual Hispanic Wellness Fair. * Organization of over 40 health entities for Family Day 2000. * Provision of all prostate and mammogram screening follow up services at select events, + Serve as liaison with JPS to provide prescription services to eligible health fair participants. * Dissemination of minority health pamphlets. * Coordination of congregational health fairs (Our Lady of Guadalupe Church). 4. Mobilize resources from foundations as well as through allocations and grants to fund programs designed to increase access to health services, awareness of minority health disparities and mechanisms for resolution through seminars,presentations, school curriculum development and demonstration projects. The Fort Worth Health Department, in conjunction with the city's Grants Management Department, monitors available grants and funding opportunities on a constant basis. Minority health disparities and other health issues identified by community requests or assessment data are prioritized. The Outreach Team currently conducts activities specifically designed to impact access to health services and other minority health issues. The Health Department will continue to pursue other resources on behalf of both the City of Fort Worth and its community partners. 5. Appoint a taskforce or an advisory committee to include primary care providers and physicians who work with large minority populations to develop and coordinate the above activities within the framework of the city's charge to the Health Department. Although a dialogue and constructive rapport exists between the Health Department and the community, no fbrni�` entity has been organized. It is the intent of the Health Department to pursue this recommendation and orchestrate an advisory committee specifically charged to address minority and other community health disparities. ISSUED BY THE CITY MANAGER FORT WORTH, TEXAS INFORMAL REPORT TO CITY COUNCIL MEMBERS No. 8300 To the Mayor and Members of the City Council February 6, 2001 Page 4 of 4 'Ora f 7 SUBJECT: HEALTH DISPARITIES IN THE MINORITY COMMUNITY CONCLUSION: The Fort Worth Public Health Department concurs with Dr. Dzandu's report. Data indicating disparities have historically driven the interventions fielded by the Public Health Department. Consequently, educational and outreach efforts have primarily targeted "at-risk", often minority populations. However, disparities marked by racial/ethnic groups continue to exist and must remain a priority. The recommendations made by Dr. Dzandu are considered essential components towards ultimate resolution of these disparities. Maintenance of those recommendations that are already in place and development of those that are not yet mobilized will be conscientiously conducted and vehemently pursued by the Fort Worth Public Health Department. Bob Terrell '-'-city Manager ISSUED BY THE CITY MANAGER FORT WORTH, TEXAS Pre-Council Meeting Tuesday, January 9, 2001 Fort Worth City council ✓` Introduction by Ralph McCloud, Mayor Pro-Term Council member, District 8 Topic: Health Disparities in the Minority Community, City of Fort Worth. Presenter: Dr. James Dzandu, My name is Dr. James Dzandu, 2914 East Rosedale, Fort Worth. I am Clinical Laboratory & Program Director, of the Sickle Cell Disease Association Of America, Greater Fort Worth Chapter. Thank you Mayor Pro-Term, Ralph McCloud for your kind introduction. I would also like to thank council members and all those individuals who are working diligently behind the scene to bring awareness of the poor health status of minority populations and to seek viable mechanisms for redress. For purposes of clarity of my presentation, I would like to use the following points as a roadmap to provide guidance and check points in navigating a complex issue within a short time frame. First, it would be helpful to council members to describe what we mean by minority health disparities. Definition of health disparities (transparency 41) Increased pain, suffering and premature death due to differences in health indicators between minority and majority populations in the U.S. Needless to say this applies at State, County, city and district and block levels. These health indicators include: • Disease incidence • Disease prevalence • Morbidity (burden of disease) • Mortality (death) • Other adverse health conditions. Second, council members awareness and sensitivity to the issue of the minority health disparities will be increased if we can show concrete examples of these disparities in terms of scope, magnitude and severity. (transparency 42) Disease categories (morbidity and mortality) • Short overall life expectancy • Disease and death due to major types of cancer • Infant mortality Fort Worth City Council Briefing/Dr. Dzandu/01/09/01 1 41 • Birth defects • Asthma • Diabetes • Stroke • STDS/1-UV • Oral disease • Mental disorders Evidence based on observing, citizens in Texas makes a compelling case for minority health disparities. (transparency 93): Total death rate /100,000 (Black, Hispanic, White , 1996 Data TDH) (transparency 94): Female breast cancer mortality rate/100,000 ( Black, Hispanic, White , 1996 Data TDH) (transparency f15): Heart Disease mortality rate/100,000 ( Black, Hispanic, White , 1996 Data TDH) (transparency 146): Texas Stroke mortality rate /100,000 ( Black, Hispanic, White , 1996 Data TDH) , (transparency 97): Tar-rant County mortality rate /100,000 Black, Hispanic, White , 1996-1998 Averaged Data TDH) • Total death rate • Heart disease • Stroke • Cancer • Cardio-pulmonary disease Diabetes • Accidents • Infant mortality Third, any strategic planning and rational development of*intervention program council members contemplate for their lead Health agency must be formulated within the frame work of the forces and processes that are driving these Health disparities. transparency 148): Factors contributing to Health Disparities • Reduced access and utilization of healthcare services • Socioeconomic factors • Increased risk of disease and disability due to occupation or exposure in different settings (home, school, work, playground, etc) • Racism • Biological factors (genetic variation) : systemic under-representation of minorities in phased clinical trials that establish thresholds for side-effects, efficacy, etc • Education Fourth, what do we want the city council to do? Fort Worth City Council Briefing/Dr. Dzandu/01/09/01 2 A clear rationale establishing a need for minority health initiatives in the city of Fort Worth has been presented with the following recommendations: 1 1. The city of Fort Worth Health Department to collect, analyze and disseminate baseline data of health indicators to determine the scope and severity of minority health disparities and to measure progress in reducing minority health disparities against those benchmarks. 2. Expand the Health Department's community outreach programs through effective collaborative partnerships with centers, including UNTHSC, hospitals, clinics, faith and community-based organizations, schools and colleges to educate citizens about nutrition, exercise, alcohol & substance abuse, health maintenance and promotion. 3. Coordinate comprehensive health fair screening activities through the districts and couple these activities with follow-up programs and referrals to ensure maximum benefit. 4. Mobilize resources from foundations as well through allocations and grants to fund programs designed to increase access to health services, awareness of minority health disparities and mechanisms for resolution through seminars, presentations, school .curriculum development and demonstration projects. 5. Appoint a taskforce or an advisory committee to include primary care providers and physicians who work with large minority populations to develop and coordinate the above activities within the frame work of the city's charge to the Health Department. �i Fort Worth City Council Briefing/Dr. Dzandu/O1/09/01 3 i HEALTH DISPARITIES DEFINITION • INCREASED PAIN, SUFFERING AND DEATH DUE TO DIFFERENCES IN HEALTH INDICATORS BETWEEN MINORITY AND MAJORITY POPULATIONS IN THE US. y o DISEASE INCIDENCE o DISEASE PREVALENCE • MORBIDITY (BURDEN OF DISEASE) e MORTALITY (DEATH) o OTHER ADVERSE HEALTH CONDITIONS HEALTH DISPARITIES • SHORTER OVERALL LIFE EXPECTANCE' • HIGHER. RATES OF CARDIOVASCULAR DISEASE • CANCER .INFANT MORTALITY • BIRTH DEFEC'T'S e ASTHNT IA • DIABETES • STR.O� STDSTEIIV ORA.L.., DISEASES AND DISORDERS �� MENTAL DISORDERS AON < � � roar°+ LLJ ry >s� 1 \ LU oz � c� 000c� o � J p Q O O O Q W CD Q HW (.C) a= � n WWQG) O w Lli FF LIJ U) oQ � � o �%/i Qcr) J� IIII �b 000000000 � 00000000 001`tO��t-c�Nr- F-- ry X2WZ � -� IW- �i.WmU U 0 � U � � 0 �j � U mho ' _ o� Q J� -w � ° LL. co CD w OZOO o' oLOoLnoLno c'7NNr— T— O '"wwr/ CD /� Y /Lli ry w LLJU) ry1 0 7 r ) I V / w C"' CD ui C) ui W / CO 4s w ► i i i • �- C) C) C ) C) C► LO (DLO C ) LO CN (N Tarrant County Public Health Measures 1996-1-998 Average Values (MORTALITY RATE /100,000 POPULATION) MORTALITY VALUE C&IVIPARISON1 TEXAS RATE WITH TEXAS VAI J a 1 TOTAL 52 .4 NIGH 1 . DEATH RATE - f .HEART 149 . 0 HIGH 14 -) DISEASE { STROKE ) � .�� HIGH � (� . 4� 4 1 CANCER. 125 . 8 j 126 j COPD 26 .3 HIGH i DIABETES 16 .4 17 . 7 ACCIDENT 2 . 1 LOW 34 � INFANT 7 .0 6 .4 MORTALITY* *PER 1 ,000 LIVE BIRTHS REF: OFFICE OF POLICY &PLANNING (TDH) FACTORS CONTRIBUTING 'T O HEALTH T' DISPARITIES REDUCED ACCESS TO HEALTH CARE • SOCIOECONOMIC FACTORS INCREASED RISK OF DISEASE AND D18ABILITY DUE TO OCCUPATION OR EXPOSURE ® RACISM BIOLOGICAL FACTORS (GENETIC VARIATION) EDUCATION 0 THE CI'T'Y OF FORT WORTH PUBLIC HEALTH DEPARTMENT ATTACHi4ENT PACKET FOR REPORT ON: HEALTH DISPARITIES IN THE MINORITY COMMUNITY Attachments include: Select Age-Adjusted Mortality Rates by Race/Ethnicity Comparison Illustrations of Health Indicators for Texas, Tarrant County and Fort Worth February 2001 l; THE CITY OF FORT WORTH PUBLIC HEALTH DEPARTMENT' . Epidemiology and Assessment Section Select Ate-Adiusted Mortality Rates by Race/ Ethnicity Rates per 100,000 Population MORTALITY COMPARISON�(RSTES) Cause of Death Total Race State(1998) I County(1998) City (1998) 201 1 0 Goal 504.1 508.2 561.8 White 488.1 483.6 491.5 Total Death Rate-All Causes Black 747,1 798.6 758.1 Hispanic 442.9 404.6 456.9 Other 262.6 260,4 284.8 Total 124.0 120.5 131.37 White 124.9 118.9 122.9 Cancer(Total) Black 182.5 176.9 160.5 159.9 Hispanic 95.2 81.1 105.0 Other 67,7 64.4 62.5 Total 18.7 16.2 20.5 White 18.3 17.1 20.9 Breast Cancer Black 27.8 17.0 17.6 22.3 Hispanic 15.5 6.9* 14.6* Other 8.9 4.2* 0 Total 139.3 143.6 127.3 White 136.9 138.8 117.2 Heart Disease Black 215.7 232.3 185.3 166.0 Hispanic 113.2 92.5 69.9 Other 66.8 95.1 71.3 Total 29.5 33.1 35.4 White 27,1 30.1 29.7 rrl , Stroke Black 49.9 58.7 48.7 48.0 Hispanic 27.5 31.6 31.I Other 20.3 223 60.8* Total 21.9 25.5 25.6 White 25.4 273 29.3 Chronic Obstructive Black 19.5 25.8 204 60.0 Pulmonary Disorders Hispanic 8.6 5.8 *6.4 Other 8.1 7.0* 0 Total 67.9 65.1 64.1 White 69. 67.2 47.0 Diabetes' Black 96.8 93.4 107.2 45.0 Hispanic 58.4 42.9 84.8 Other 20.4 17,4 17.5 Total 34.0 28.3 28.7 White 33.2 25.3 21.2 Accidents Black 38.4 37.4 33.9 17.5 Hispanic 34.5 40.0 36.2 Other 22.0 7.8* 7.7* Total 6.4 7.0 7.2 White 5.6 5.6 5.2 Infant Mortality Rate" Black I1.6 12.9 10.4 4.5 Hispanic 5.9 7.2 7.6 Other 19 3.7* 0 *Caution:Rates based on less than 5 observations. Figures presented in red indicate rates for the city of Fort Worth Goal rates based "Rates are calculated per 1000 live births. that exceed the rates of both Texas and Tarrant County, on Healthy ***Diabetes included as multiple cause of death. People 2010 Sources: State and County data from TDH Epigram Vital Statistics Database(Age adjusted). City data calculated directly Crom Fort Worth Vital Records Database(Age-Adjusted). I THE CITY OF FORT WORTH PUBLIC HEALTH DEPARTMENT Epidemiology and Assessment Section Comparison Illustrations of Heahh Indicators for Texas, Tarrant County and Fort Worth Total Death Rate(per 100,000 population) ,White 747.1 798.6 758,1 w Black 800 ■Hispanic 700 488.1 508.2 491.5 ❑Other 600 4. wT otal 500 400 4` 300 200 100 state County City 1998 1998 1998 Sewer State and County data from TDH Epigram Vital Statistics Database(Age-adjusted).City data calculated&nm Font Worth Vital Records Database(Age-adjusted). Cancer Mortality Rate(per 100,000 population) White ■Black 200.0 182.5 175.9 174.0 Hispanic 150.0 124.9 124.0 118, 120.5 122.9 19.4 119.4 Cl Other ■Total 100.0 i, 4, 2 50.0 0.0 - State County City tag 1998 1998 1998 Soarer:State and County data from TDH Epigram Vital Statistics Database(Age-adjusted).City data calculated from Fort Worth Vital Records Database(Age-adjusted). Breast Cancer Mortality Rate (per 100,000 female population) white 27 8 ■Black 30. wHispanic 25 20.9 20.46 00t.her 20 15.5 17.1 17 16.2 ...77.6 MTotal 15 10 C.9 5 0 0 State County City 1998 1998 1998 Source:State and County data from TDH Epigram Vital Statistics Database(Age-adjusted).City data calculated from Fort Worth Vigil Recortit Database(Age-adjusted). Heart Disease Mortality Rate(per 100,000 population) Mwhite 232.3 1n Slack Z50 213.7 195.4 ®Hispanic 200 143.6 - CiOther 139.3 i5 150 ll3 2 95. 117.2 115.7 IaTota! 100 6. 3 50 0 State County City.) 1998 1993 1998 Sevres:State and County dam from TDH Epigram Vital Statistics Database(Age-adjusted).City dam calculated from Fort Worth Vital Records Dalabtase(Age-adjusW4 2 Stroke Mortality Rate(per 100,000 population) NWhite NBlack 70 58 7 60.8 WHispanic 60-1-1, 0 49.9 54.4 ta 50 0ther 40 30.1 1.6 33.1 29.7 344 32.2 mTotal 30 2. 20 10 0 State County City 1998 1998 1998 Sauce:State and Contrary dam from TDH Epigram Vital Statistics Database(Age-adjusted).City data calculated fr6m Fort Worth Vital Records Database(Age-adjusted). Chronic Obstructive Pulmonary Disorder Mortality Rate(per 100,000 population) m W kite 29.4 NBlaek 30 273 5.8 25.5 •Hispanic 25 21.9 ❑Other 20 NT otal t5 t 0 I 5.8 7 7.7 5 .0 0 State County City 1998 1998 1998 Saeee:State and County data from MR Epigrarn Vital Statistics Database(Age-adjusted).City data calculated from Fort Worth Vital Records Database(Age-adjusted). Diabetes Mortality Rate (per 100,000 population) White 1 1 4.8 N B tack 120- E Hispanic 93.4 100 ❑Other 80 69.6 67.9 67. 65A MTotal 60 42.9 47. 40 20 0 State County City 1998 1998 1998 Siaum7 State and County data from MH Bureau of V 3l Statistics.City data calculated from Fort Worth Vita]Records Database(Age-adjusted). Mortality Due to Accidents (rate per 100,000 population) OW hite 38,4 J7. 40.0 37.8 MBlack 40.0 4.6 OHiap an ie 35.0 pother 30.0 s 26.0 25.0 2" 2 1.2 mT o tal 20.0 1 5.0 7. 10.0 5.0 State County City 1998 1998 1998 Sow":State and County data from TDH Epigram Vital Statistics Database(Age-adjusted).City data calculated from Fort Worth Vita!Records Database(Age-adjusted). 3 Birth Detects by Race, City of Fort Worth �W hire 10 8.51 =Black MHiapanic .rte 8 E30ther 6 4.9 3.94 5.49 4 2 r' D 1998 1999 Sato:Fort Worth VrW Records Database,City of Fort Worth Public Health Department AIDS Prevalence Rate (per 100,000 population) ■White (" ■Black 100 I 84.67 —J MH isp snit ❑cJther 60 40 24.8 20 9.95 54 1k- 47 3.75 a Fort Worth Fort Worth Tarrant County Tarrant County 1999 2000 1999 2000 nr 1„ Source:Tarrant Caanty H .. ealth Department,Office of Epidemiology. — r Percent Reporting Someone with Asthma in the Home,1998 CNA 28,l 30 25 18.1 20 i 16 17.5„s 15 41,-5 0 --— White Black Hispanic Other Total Soturce:1998 Community Needs Assessment,City of Fort Worth Public Health Department — Percent Reporting Someone with Diabetes In the Home,1998 CNA 20 17.4 14.5 13.1 15 i 10 S d 0 White Black Hispanic Other Total Saud:1998 Community Needs Assessment,City of Fort Worth Public Health Depament 4 Percent Reporting Someone with Heart Problems In the Home,1999 CNA 20 14 4 16,2 14.2 13.5= IS 0 6.8 5- 0 White Black Hispanic 0 ther Total Source:1998 Comnanty Needs AssesameM City of Fort Worth Public Health Depivanem. Percent Reporting S om a Kind of Health Insurance C overage,1998 CNA 100 87.1 84 83 2 84 80 54 1 60- 40-1-1 20 0 -1 W hite B lack H is p a n ic 0 ther T otal Source:1998 Counnunity Needs MsesmneM City of Fort Worth Public Health Departrom Percent Reporting Some Kind of Health Insurance Coverage for Children < 5 years old, 1998 CNA too. $4.5 89.5 80 6319 60 40- L 20- 0 White Black i Hispanic Other Total Source:1998 Cottunmuty Needs Assmruertt,City of Fort Worth Public Health department. Where do you go when you get sick? (Self-reported responses from the 1998 Fort Worth Communi ty Needs Assessment Race Doctor's Ofjice ER Chide Alternative practice Nowhere Other White 75.1 4.6 8.1 1.3 2.4 8.5 Black 51.8 15.6 13.7 0.6 2.3 15.9 Hispanic 43.5 10.4 29.8 0.9 4.3 11.1 Other 58.7 9.9 10.7 0.2 2.5 17.8 TOTAL 63.0 8.4 1 110 0.9 2.7 110 Swm=:1998 Community Needs Assessmaik Pity ofFort Worth Public H=Dep, ME. 5