Manchester,
New Hampshire

Founded along the Merrimack River in the early 19^th century, Manchester, N.H., sprang from a utopian vision: create an industrial center to rival its English namesake, complete with sprawling, red-brick textile mills, workers’ quarters, schools, libraries, theaters and parks for all who lived and worked there. But as manufacturing sagged in the latter half of the 20^th century, the city lagged as well.

Today, in a transformation that has spanned the past several decades, the city’s business core has repositioned itself for the 21^st century. Manchester has evolved into a mid-sized city, and Elm Street—its main thoroughfare—has become a thriving urban hub with trendy restaurants and coffee shops. A few blocks away, long-vacant mill buildings are now home to tech startups, loft condos and two universities.

Now this city of 110,000 people is applying the same resilience and determination that sparked the mill-yard comeback to what may be an even tougher challenge: Revitalizing health and well-being throughout Manchester’s neighborhoods, many of which struggle with common urban afflictions such as poverty, violence, homelessness, and the impacts of the opioid epidemic that has brought national attention to Manchester and other New England cities. Manchester’s health promotion efforts focus on building and bolstering neighborhoods, an approach that harkens back to a time when the city’s earlier immigrants created tight-knit communities and strong support networks. In this context, block parties, schools, community centers, homes and fire stations have become tools for growing trust and delivering services while boosting health and well-being.

“We really focus on where people live and their daily lives,” says deputy public health director Anna Thomas. “We try to respond proactively to residents’ needs, rather than reactively.”

The largest city in a rural and affluent state—and in all of Northern New England—Manchester faces challenges similar to those of larger urban communities. The city is more racially and ethnically diverse than the rest of New Hampshire. And while the state has the nation’s lowest child poverty rate—below 10 percent—one in four children in Manchester lives in poverty. Manchester also has the state’s highest violent crime rate, with the most elevated levels concentrated in its highest poverty neighborhoods. And last year, nearly 1 in 4 drug overdose deaths in New Hampshire happened in Manchester.

A bad month for opioids in Manchester, N.H., meant 30 overdoses when Chris Hickey first started working as a paramedic in the city 15 years ago. These days, the emergency medical services officer says Manchester’s emergency responders see 60 to 70 suspected overdoses each month. More than a half dozen of those are fatal, which represents a nearly 12-fold increase in the city’s overdose deaths between 2003 and 2015.

The spike mirrors a national trend, with opioid prescription drugs, heroin and illegally manufactured fentanyl fueling a 137 percent increase in deaths from drug overdoses between 2000 and 2014, the most recent year for which statistics are available.

“You have people of all backgrounds, of all ages who are all overdosing,” Hickey says. And those are just the emergency cases, he says. “We know that we have a large group of the population who are functioning addicts.”

How does one reach those who are addicted before they overdose? A small piece of the answer appeared to Hickey this spring when another firefighter’s stepbrother—homeless and struggling with heroin addiction—posted suicidal messages on Facebook and his family sent him to the fire department for help. It was the first time Hickey had encountered an addict who really wanted to take the first steps to get better. The two drove in Hickey’s pickup to Hope for New Hampshire Recovery, an organization that helps people overcome addiction. Three days later the man was in an inpatient treatment program, and Hickey was writing a proposal to Manchester’s mayor to turn fire stations into intake centers, where people could come without fear of being arrested.

The Neighborhood Health Improvement Strategy provided just the roadmap the city and philanthropies like the United Way needed. Focused on Manchester’s most impoverished areas and written with input collected from community members via surveys and forums, the strategy put each neighborhood’s needs front and center. Residents had expressed their vision of an ideal city that provided supports for parents, initiatives that address crime and substance use, free fitness programs and affordable public transportation, among other resources.

The Granite United Way’s volunteer leaders listened, and then acted.

The organization took the controversial step of aligning its grant-making with the goals of the Neighborhood Health Improvement Strategy. That meant funding fewer programs and focusing on collaborative, multi-year strategies. One of these was the Manchester Community Schools Project—already established by the city at two elementary schools—which serve as neighborhood hubs providing a wide range of social services and education support to children and families.

In the 19^th and 20^th centuries, French Canadian, Greek, Irish, and Polish immigrants settled in Manchester, N.H., to work in the mills, building neighborhoods around their churches. Today, the same neighborhoods welcome new arrivals from Latin America, Asia, the Middle East and Africa. These new Americans are greeted with new opportunities, as well as the challenges of making a new place home. One of the greatest needs to be addressed in these neighborhoods is child poverty, which affects both new arrivals and lifelong residents.

To ensure better health, education and lives for residents no matter their country of origin, the city is creating a new center of gravity for the neighborhoods: Their schools. With seed money from the Robert Wood Johnson Foundation and matching funds from Granite United Way, the New Hampshire Charitable Foundation, the Endowment for Health and the Cogswell Benevolent Trust, Manchester set up two community schools starting in 2012. The schools are safe havens in neighborhoods facing crime and violence. More than half a dozen partners bring health care, social services, family support and community-building activities such as block parties and health fairs right to the schoolhouses. Work at two more schools began last year.

“By addressing health and social factors, we can free up the teachers to do what they do best, which is to teach,” says Jaime Hoebeke, who leads the Manchester Health Department’s Division of Neighborhood Health. “They were overwhelmed with health needs.”

Many students and families at the community schools face poverty, domestic violence and drug issues, says Wanda Castillo, one of four community health workers employed by the Manchester Community Health Center to assist families at the schools. Castillo, who speaks English and Spanish, might help them apply for Medicaid, get dental treatment, talk to the electric company about a disputed balance or find housing. Two social workers—called family success coordinators—also work in the schools. As an extension of the school staff, they help keep kids in class and engaged in their schooling by calling home when students don’t show up, serving as mentors for students who are struggling, addressing behavior issues and providing brief mental health interventions.

Manchester, N.H., residents have only a 1 in 4 chance of living in a home built after 1950—some of the houses and triple-decker family apartment buildings date back even further, to the 1800s. Homes that haven’t been fixed or updated over the years can harbor health hazards like lead pipes and peeling paint, poor ventilation systems and mold hidden in walls.

The city has long had separate home visiting programs for families whose children have been found to have uncontrolled, unmanaged asthma or high blood-lead levels that could damage their developing brains. In the past, visiting nurses would take the home environment into account only for the particular disease they were focused on. They might tell parents to remove peeling paint on a visit for the lead program. On an asthma visit, they might recommend keeping asthmatic children away from household chemical fumes or show parents how to better manage medications.

In 2010, these disparate services finally came together when Manchester created a comprehensive plan to boost the number of healthy homes in the city. Now, home-visiting nurses are trained to educate people about all the ways they can make their homes healthier.