Maria Melendez knew something had to be done. It was the early 1970s, and New Haven’s Fair Haven neighborhood was changing. As Latinos moved into the homes once occupied by Irish and Italian blue-collar families who had moved to the suburbs, health care lagged. The neighborhood had no Spanish-speaking doctors, recalled Melendez, who came to the city from Puerto Rico in the mid-1960s to be with her husband. The few medical services available tended to focus on children.

Determined to meet the larger health needs of her community, Melendez joined with members of the local chapter of the Alliance for Latin American Progress to start a free clinic. The city provided $5,000 for malpractice insurance and offered the nurse’s office at a local elementary school. Volunteers from the Yale School of Nursing staffed the makeshift clinic three nights a week. The New Haven Foundation, a precursor of the Community Foundation for Greater New Haven, provided seed money.

“We were looking to provide something more than immunizations for the community,” Melendez recalled.

Almost 50 years later, that humble operation has grown into the Fair Haven Community Health Center. The clinic now treats about 17,500 patients a year at four locations and operates five school-based health clinics with an annual budget of about $19 million. Funded through a combination of federal and state grants, Medicaid, and private insurance, the clinic accepts all patients. For $25, uninsured patients—sometimes undocumented immigrants—can see a doctor.

“We don’t turn anyone away,” said Suzanne Lagarde, M.D., HS ’77, FW ’80, the center’s chief executive officer, a specialist in gastrointestinal diseases, and a former faculty member at the School of Medicine.

Fair Haven Community Health Center is just one star in a constellation of health organizations created in the last 50 years to serve New Haven’s many underserved residents. They include the even larger Cornell Scott-Hill Health Center in the city’s Hill neighborhood, which serves about 36,000 patients a year. Provision of health care in New Haven has long linked the community with health care providers at Yale. Not only have community health centers benefited from collaborations with the School of Medicine and Yale New Haven Hospital, but Yale clinicians and researchers have worked with and learned much from the city’s residents while seeking to treat and prevent disease. Yale faculty, residents, and students have tackled such issues as asthma, traffic, postnatal care, diabetes, drug addiction, and HIV/AIDS.

“Our ties to Yale and Yale New Haven Hospital are long and deep,” said Michael Taylor, chief executive officer of the Cornell Scott-Hill Health Center. “If Yale were not here, we would need double the health center’s funding.”

Cross-pollination between Yale and the community has led to real progress in such areas as infant mortality, but health problems persist. New Haven remains a city where poverty and chronic diseases are intertwined. The city’s minority residents suffer disproportionately from such serious and often preventable illnesses as diabetes, high blood pressure, obesity, asthma, and heart disease. Rates of chronic disease far exceed those of the state as a whole and those of surrounding communities, according to DataHaven, a local nonprofit. In many cases, the gap is shockingly wide: 11 percent of New Haven’s 130,000 residents have diabetes, compared to 5 percent in the outer-ring suburbs.

More than a fifth of city residents suffer from food insecurity, compared to 7 percent in outer-ring communities.

A closer look at the data reveals that those problems are concentrated in the city’s eight poorest neighborhoods, all of which have largely minority populations: West Rock, Newhallville, Dixwell, Dwight, West River, the Hill, Fair Haven, and Quinnipiac Meadows. About a quarter of the people in those neighborhoods suffer from asthma, double the state rate, according to a 2015 DataHaven study. The incidence of diabetes—13 percent—is nearly twice that of the state as a whole.

The economic gap is equally yawning. As of 2015, the city’s eight poorest neighborhoods had an unemployment rate of 22 percent compared to 5 percent for the rest of the city, according to DataHaven. Connecticut may have the nation’s fourth highest median household income—$65,753—but that figure falls by more than half in neighborhoods like the Hill, where the picture grows even bleaker—one area of central Fair Haven reports a median household income of just $19,485, according to the website City-Data.com. Unemployment there is 24 percent, and almost 46 percent of residents live below the poverty line.

As the saying goes, your ZIP Code reveals more about your health than your genetic code.

Looking at the big picture

In the face of such challenges, health care professionals and researchers in New Haven have in recent years adopted a new approach. They have been incorporating the realities of their patients’ daily lives into treatment plans, said Marjorie S. Rosenthal, M.D. ’95, M.P.H., co-director of the National Clinician Scholars Program at Yale, and director of the program’s Community Research Initiative. The program teaches Yale trainees principles of epidemiology and biostatistics, as well as how to work with community partners to identify critical challenges to the health of individuals and communities.

A physician can tell a diabetic to take a daily walk, she said, but what if gunfire on the street keeps people indoors? And what good is it to recommend a diet that includes fresh fruits and vegetables in food deserts where produce is unavailable? “If we are not looking at the bigger issues, we won’t be able to do our jobs as doctors,” Rosenthal said. “This is not just frosting on the cake. This is the cake.

”The approach doesn’t focus only on such negatives as violence, lack of fresh food, and a poor understanding of nutrition, Rosenthal added. Medical professionals also need to know what works—community gardens that provide good inexpensive food, and walking trails for exercise—and leverage those positives, she said.

Cooking, gardens, and exercise

Desiree Williams couldn’t get her diabetes under control. Her A1C glucose level was a sky-high 16, nearly three times that of a nondiabetic. She didn’t understand it. She didn’t eat a lot of sweets, so why were her numbers so bad?

At the Cornell Scott-Hill Health Center, Williams enrolled in a new nutrition and cooking class for people with the same problem. It was a revelation. Carbohydrates, she learned, were the culprit. A Southerner, Williams was eating way too much of the rice that she’d grown up eating. “I wasn’t a junk food junkie,” Williams, 56, said. “I was a carb junkie.”

Williams not only learned what to avoid, but how to read labels and cook healthier food. She no longer put sugar and other unhealthful ingredients in her beloved collard greens. The result: Williams cut her A1C glucose level by more than half and lost 10 pounds. She’s eager to learn even more and wants Cornell Scott-Hill Health Center to start similar classes for pre-diabetic kids.

“I think I’m going to take every last cooking class they have,” Williams said. “It wasn’t like going to school. These people were my friends, and they were looking out for me.”

The health center’s six-week cooking and nutrition classes, introduced last year, are part of a growing trend in tackling chronic diseases prevalent in New Haven’s poorer neighborhoods. The course teaches patients which foods to eat, which ones to avoid, how to read labels, and how to cook healthier meals, said Natalie Lourenco, P.A.-C., director of wellness education and outreach at the center.

“I think we all have the goal of treating things holistically, but practically speaking, it’s always a challenge,” Lourenco said. “People have 15 minutes with their doctor, and they’re given a prescription. The cooking and nutrition course is an opportunity for us to take more time and reinforce the other things that need to happen.”

On the other side of the city, Fair Haven Community Health Center has a similar program, Lagarde said. The center teaches people with diabetes about nutrition and cooking, holds exercise classes at an elementary school, and encourages people to grow their own vegetables at one of the neighborhood’s urban farms, even providing a farmer to teach them. “In the fall, we have a dinner from the farms,” Lagarde said. “It’s worthy of a four-star restaurant.”

Others are expanding the concept. Lee Cruz, a director of community outreach at the Community Foundation for Greater New Haven and a member of the Chatham Square Neighborhood Association in Fair Haven, wants doctors to understand the realities of life in a poorer community. Physicians need to know the difficulties people face in obtaining fresh food, exercising, and getting to an appointment, he said. But they also must understand such community assets as Fair Haven’s network of community gardens. That gets them “out of their bubbles” and better informs their care, he said. That requires more than handing out pamphlets and engaging people at a table for 30 seconds. “In my experience,” Cruz said, “what has to happen is you have to build the relationships first.”

To that end, Cruz has worked with Yale to sponsor walking tours of Fair Haven for medical students and residents so they can get to know the neighborhood and its people. The tours have proven a big hit, he said.

Cary Gross, M.D., director of the National Clinician Scholars Program at Yale, heartily endorses Cruz’s approach and the Fair Haven walking tours program. It’s just one of many innovative efforts that Gross and his colleagues in the scholars program are pursuing to better understand and attack the root causes of chronic disease and inequity in health and health care in New Haven. The approach of focusing on specific diseases and identifying the best pharmacologic therapy—the biomedical model—has reached its limits, Gross said. Medical professionals must understand the lives of their patients if they are going to make a lasting impact on improving their health and well-being, he said.

“This is one of the things that makes the scholars program special—we are training nurses and physicians to conduct research that will drive change. Often, we work at these large institutions, but we’re not familiar with the surrounding neighborhoods,” Gross said. “This is getting us out of the ivory tower and into the real world.”

Persistent racial and ethnic inequities

When Cruz takes residents and students in the health professions on walking tours of Fair Haven, he starts along the banks of the Quinnipiac River at a memorial to the 29th Connecticut Colored Regiment, whose members served in the Civil War. He wants to remind the future doctors of the injustices that black men and others have faced in this country. He wants them to keep that in mind when they face disproportionate rates of chronic illnesses among the city’s minorities.

Addressing those persistent racial and ethnic inequities is a focus of the Community Foundation for Greater New Haven, the region’s largest grantor and a longtime supporter of a wide variety of public health programs and organizations in the city.

“The community overall is getting healthier,” said Christina Ciociola, M.S.W., M.P.H., the community foundation’s senior vice president for grant making and strategy. “Everyone is getting healthier, but these disparities still exist. We’re trying to understand what that’s about.”

One way that the foundation is tackling the problem is the Healthy Start Program that seeks to reduce the black infant mortality rate in New Haven. At one point in the mid-1980s, the city’s infant mortality rivaled that of a Third World country, Ciociola said. Healthy Start works with mothers to teach them skills and connect them with services to assure that their babies are healthy and thriving, said Kenn Harris, the community foundation’s vice president for community engagement and director of New Haven Healthy Start.

The program, which recently celebrated its 20th anniversary, has cut the infant mortality rate for black babies about in half, Harris said. Mothers who participate in the program have infant mortality rates lower than those in the state’s outer-ring suburbs, he added.

But the program, which accepts mothers of all races and ethnicities, has 38 percent black participation, below its goal of 50 percent. The reason: blacks are less likely to engage with health care professionals. Harris attributes that to a long history of medical professionals judging blacks. The dearth of black health care professionals—Latinos are more likely to encounter Latino doctors and nurses—is another factor, he said. He attributes the stubborn inequity in outcomes at least in part to the legacy of racism.

“The impact of racism, not just being called a name, is still there,” Harris said. “The trauma gets passed on.”

Opioids and immigration

For 53-year-old Candida Saunders, the trouble began after her mother’s death. She became depressed and anxious, and her physician prescribed Xanax. She graduated to heroin and soon found herself a full-blown addict. The drug, she said, is everywhere. “You can get it on any street corner,” Saunders said.

Luckily, Saunders got help. She learned of the Cornell Scott-Hill Health Center’s drug rehabilitation program and decided it was worth the trek from her home in Waterbury. The center put her in treatment and on methadone, and she has been off heroin for two and a half years. “I came here and got a lot of help that I needed,” Saunders said.

Ask Taylor, CEO of the Cornell Scott-Hill Health Center, about his biggest concern for the future, and he answers without hesitation: the crisis of opioid abuse. The clinic’s treatment facilities are at capacity and would need to triple in size to meet the exploding demand.

“I will say it’s on everyone’s lips these days,” Taylor said. “As a substance use treatment provider, we’ve been very aware of increased use for years, but the growth we’ve seen in the last year or two is off the charts.”

Driving the problem is fentanyl, a highly potent cheap synthetic heroin, much of it from Mexico, that has flooded the region, Taylor said. It’s also a big concern of the city, especially after 17 overdoses—including three fatalities—in one 24-hour period last year, said New Haven Director of Health Byron Kennedy, M.P.H. ’01, M.D. ’04, Ph.D. ’04. “Something as small as a grain of sand could be sufficient to kill a person,” Kennedy said.

In Fair Haven, Lagarde said her biggest concern is treating undocumented immigrants. The neighborhood has the largest concentration of undocumented immigrants in the city, and they make up a significant percentage of her clients. President Donald J. Trump’s immigration crackdown is pushing those patients into the shadows and threatens to make treating them even more difficult, she said.

Amid the never-ending challenges, it’s easy to forget just how much has been accomplished in the last five decades. Maria Melendez hasn’t. She never dreamt the small clinic she helped found in an elementary school nurse’s office would grow to provide health care to thousands of neighborhood residents.

“To keep growing and growing to what we have become is beyond my imagination,” said Melendez, who has worked at the clinic since its inception. “We’ve served the community with pride.”

Whatever obstacles may lie ahead, Melendez is confident that Fair Haven will meet and overcome them. “Our goal when we started was to provide services that people need and really appreciate,” she said. “We are there to serve the community.”