Overview of the State

The District of Columbia is located in the urban center of the Washington Metropolitan Statistical Area. This geographic area is bordered by the county of Arlington and the city of Alexandria in Virginia; Prince George’s and Montgomery counties in Maryland, and the Potomac River. At only 61 square miles, it ranks as the 20th most populated city in the United States.[1]

The District is divided into approximately 100 ZIP codes, four quadrants (northeast, northwest, southeast and southwest) and eight principal Wards which are subdivisions founded for the purposes of voting and political representation. The divisions of the Wards allow for the comparison of subpopulations and the analysis of data that can offer insight about the health status and equity of the District’s residents. From 2012 to 2018, the District’s population has grown approximately 10.5% from 635,630 to 702,455.[2]

Often referred to as “Chocolate City,” DC's Black population became the majority in the 1950s, and the city had been majority African American until recent years. That majority began steadily shrinking in the 1980s. In 1980, 70% of DC's population was Black; that share fell to 61% in 2000 and 51% by 2010. By 2018, the Black population represented only 47.7% of all residents.2

DC’s population skews to a younger age group, with a median age of 33.9 years.2 Children under the age of 18 comprise about 18% of the total population, with seniors (over age 65) representing the age minority at 11.9%.2 There are over 280,000 households in DC, averaging 2.3 persons per household.2 Nearly 90% of residents are high school graduates or higher, with more than half (56.6% of residents) holding a bachelor’s degree or higher.2 While the District’s median household income is $77,649, about 17% of the population live below the poverty line.2 About 18% of residents speak more than one language at home, with Spanish being spoken in about 9% of all households.2

2017 D.C. Demographics by Ward

Age and Gender

Like most urban areas, the median age of District residents is younger than the US average (34 vs. 37.8, respectively).[11]  Females comprise 53% of the population.11  Ward 2 has the lowest proportion of children under 10 (4%), compared with Wards 7 and 8, where children under 10 are 15-19% of the population.11  Furthermore, children under 18 account for almost 18% of the population, about 80% of the rate in the United States (23%).11

Race and Ethnicity

In 2017, the racial makeup of DC was majority non-White; 45% of the population was Black and 11% was Hispanic.11 Whites account for over one-third (37%) of District residents.11 Wards in the Northwest quadrant of the District, Wards 1, 2, and 3, have disproportionately higher White population, at approximately 45%, 66% and 72%, respectively.11 Wards 7 and 8 are disproportionately Black, comprising 93% and 90% of the population, respectively.11 Hispanics represent about 20% of the population in Ward 1 and Ward 4.11

Poverty, Income, Employment and Education

Socioeconomic status, as measured by income, employment status, occupation and education, widely varies among DC based on geography. In 2018, 17.4% of DC residents lived in poverty,2 rising to 26% when examining poverty for those under 18 years old.1 Child poverty rates have declined District-wide since 2010 by 3.8%, decreasing most significantly in Ward 6.4 More than one-quarter of people in Wards 7 and 8 live in poverty (26.6% and 35.7%, respectively).2 In 2017, the median household income for DC’s White population ($160,100) was 109.8% higher than the median household income for the Hispanic ($76,308) population, and 229% higher than the Black population ($48,572).5 Notably, the Wards that are home to the largest number of young children, Wards 7 and 8, also have the lowest median family incomes in the District.

The District’s total unemployment rate has been falling since a peak of 9.3% in 2010.[12] In 2019, the overall unemployment rate was 5.7%.12 Despite the overall economic progress for the city, Black residents, and residents without a college degree have not benefitted as much. Looking over the last decade, the Black-White unemployment gap has grown. In December 2017, Wards 7 and 8 are disproportionately Black and has the highest unemployment rates (9.9% and 12.8%, respectively) in the District.11,[13] In contrast, Wards 2and 3 are primarily white and have the lowest unemployment rates (3.2% and 3.3%, respectively), indicating a racial disparity.11,13

D.C. Socioeconomic Indicators by Ward

Though the vast majority (90.2%) of District residents are high school graduates, and more than half (57.3%) have bachelor’s degree or higher, as with other socioeconomic indicators, significant disparities are found among races and Wards.2  Ward 3 is home to the most educated residents, with 87.0% of those residents holding bachelor’s degrees or higher.2 In Ward 8, only 15.6% of the population achieved a bachelor’s degree.2 When considering the total population in the District from 2010 to 2017, the city’s total percentage of individuals with high school diploma or higher increased slightly during the six year period by 4.3% (from 86.5% to 90.2%).2 During the same time period, the District’s total percentage of individuals with a bachelor’s degree or higher increased by 16.5% (49.2% to 57.3%).2 In DC, the average public high school graduation rate for all students was 72.4% for the 2016–17 school year, which was lower than the national average of 84%.[16] That year, the highest high school graduation rate for White students was 86%, compared to 73% for Black students.16  

Housing

Over the last decade, DC has seen rapidly rising housing costs, leading to a significant loss of affordable housing. The median value of owner occupied housing units price of a single family home was $157,200 in 2000.[17] That more than tripled by 2018, with a median price of $607,200.2 The median rent price in DC is $500 higher than that of the Washington Metropolitan area.[18] About 40% of all DC residents spend more than a third of their monthly income on costs related to rent, mortgages, taxes and other related expenses.[19] DC’s delinquent mortgage value is 1.8%, which is 0.7% higher than the national value.18 As home prices rise, so do the rates of homelessness. DC had a 24% increase homeless individuals between 2008 and 2017.[20]

Food Access

Food deserts are geographic areas where people have limited access to healthy food, and tend to be located in places where residents are predominately low income and minority. A 2017 report by the D.C. Policy Center states that approximately 11% of areas in the District are food deserts, with more than three-quarters located in Wards 7 and 8.[21] Of the 49 full-service grocery stores in the District of Columbia, only two are located in Ward 7 and just one is in Ward 8.[22] The three full-service grocery stores east of the Anacostia River serve 149,750 residents, while the 82,000 residents of Ward 6 are served by ten full-service grocery stores.22 Nearly half of the District’s SNAP and WIC recipients live in Wards 7 and 8.

Changes in the Number of Confirmed and Planned Full-Service Grocery Stores in DC[23]

Health Insurance

The 2017 American Community reported that the District had the second lowest uninsured rate in the nation, with only 4.1% uninsured residents.[24] Of those insured, approximately 37% of residents receive public coverage (includes Medicare, Medicaid, and other public coverage), while 59% are privately insured.[25] In 2017, about 44% of all District children had public insurance.[26] Of the entire child population, 94% are insured.26 The District has had historically higher rates of insured residents, in much part due to publically financed insurance. In 2001, DC established the DC Healthcare Alliance (Alliance) program. The Alliance program provides healthcare to low-income (200% below federal poverty level) District residents who are ineligible for either Medicaid or Medicare regardless of citizenship. DC joined Medicaid expansion offered through the Affordable Care Act (ACA), enabling over 30,000 newly-Medicaid eligible DC HealthCare Alliance members to move to Medicaid. In 2009, prior to the Affordable Care Act, approximately 12.4% of residents were uninsured.[27]

Health Services for Children with Special Needs (HSCSN) is a Medicaid managed care organization that serves District children and young adults up to age 26 who receive Supplemental Security Income (SSI). HSCSN is a key component of the HSC Health Care System's unique structure, which offers an integrated approach to stabilize families and encourage independence by combining the resources of a care coordination plan, pediatric specialty hospital, home health agency and parent foundation. HSCSN's care management network provides traditional Medicaid benefits plus an array of expanded health care and wraparound services, such as individualized care management, 24-hour access to care coordination, outreach services, respite care and medically necessary home modifications. Each member has a care manager responsible for coordinating access to primary and specialty care, developing an individualized care plan, and educating the family on how to best prepare for care transitions. HSCSN started as a demonstration pilot to serve Supplemental Security Income (SSI) beneficiaries and was incorporated in 1994 to develop a national model of managed care services for children with complex health care needs.

Health Systems

The District is home to seven hospitals and hospital systems, of which five are birthing facilities. In 2017, two hospitals ceased obstetrical services. Providence Hospital, in Ward 5, announced the closure as part of a revised strategic plan. United Medical Center’s (Ward 8) board decided to permanently close the labor and delivery unity after a temporary closure by the Department of Health due to concerns with quality of care. Hospitals, are concentrated in the Northwest and Northeast quadrants of the District, leaving many residents to reside in areas with few hospital options. Despite this high ratio, providers, particularly specialty providers, are also concentrated in neighborhoods that are difficult to reach for many residents.

As is the case with most components of DC’s health system, there is a diverse and geographically well-distributed network of primary care practice sites that provide a comprehensive array of high quality, well-integrated, and coordinated services to residents of DC and beyond. In 2006, the District Government enacted legislation to invest proceeds from the sale of bonds backed by the District’s share of the Master Settlement Agreement in the city’s primary care infrastructure. From 2006 through 2015, the District invested more than $70 million dollars to construct or renovate 14 community health centers in areas of the city with disparate health care access and health outcomes. In 2017 report by the Association of American Medical Colleges, DC had approximately 241 primary care physicians per 100,000 residents in 2016.[28] Though DC has one of the strongest and most comprehensive primary care safety net systems in the nation, not all DC residents are fully engaged in appropriate primary care. Large portions of DC’s population are not engaged in needed primary care services, struggle to access care when and where they want it, and face startling disparities in health-related outcomes despite the availability of health resources.[29] For example, from June 2015–May 2016, only 56% of Medicaid and DC Alliance enrollees had a primary care visit within the 12-month period. Additionally, between 2011 and 2014 the rate of non-emergent ED visits climbed steadily from 325.8 to 342.8 – a 5% increase over four years.[30] All seven of DC’s acute care hospitals provide inpatient services, emergency services, comprehensive outpatient medical specialty and surgical services, with inpatient care being the core service provided. Based on current licensure data DC has a total 2,151 staffed beds.19 Four hospitals (Children’s National Medical Center, Medstar George Washington University Hospital, Medstar Washington Hospital Center, and Howard University Hospital) are all verified Level I trauma centers. The District also has several neonatal intensive care units (NICUs). Children’s National Medical Center and MedStar Georgetown University Hospital are Level IV NICUs, offering the highest level of care for premature and ill children. Level III NICUs are available at George Washington University Hospital, and MedStar Washington Hospital Center (IIIb). Sibley Hospital has a Level II NICU.

Disease Burden

The District of Columbia’s 2016 Behavioral Risk Factor Surveillance System (BRFSS) survey found that residents living in Ward 7 and 8 were more likely to report having fair or poor health, diabetes, heart disease, arthritis, had a heart attack or stroke.[31] About one-third of District adults were reportedly overweight, and an additional 22.6% reported being obese.31 Of those categorized as obese, 37.4% were African American compared to 9.4% who were White.31 In 2016, 14.7% of adults were smokers, with the majority of those residents living in Wards 7 and 8.31 About 14.9% of female residents have not received a pap smear test within the past 3 years, with the majority of individuals identifying as Hispanic/Latino (40.8%) compared to White (11.6%).31 Lastly, 16.7% of District residents reported being diagnosed with a depressive disorder by a health professional, with the majority of residents residing in Wards 5 and 7.31

In 2017, the 10 leading causes of death in the District of Columbia, in ranked order, were heart disease, malignant neoplasms, accidents (unintentional injuries), cerebrovascular diseases, diabetes mellitus, chronic lower respiratory diseases, Alzheimer’s disease, assault (homicide), influenza and pneumonia, and essential hypertension and hypertensive renal disease.[32] These conditions accounted for 73.7% of deaths among DC residents; however, the majority of deaths (55.2%) were attributable to just the top three leading causes.32

The District of Columbia has seen a positive trend in life expectancy at birth. Over the past several years, the District has improved at a faster rate than the U.S with the average life expectancy increasing from 77.4 years in 2009 to 78.5 years in 2015.29 Disparities in life expectancy are evident in DC, with those living in impoverished communities having a lower life expectancy than more affluent residents. Life expectancy estimates for District of Columbia neighborhoods vary by 22.1 years.29 As depicted in the map below, the residents in the upper northwest areas are expected to live longer than those in the southeast.

Population Health Outcomes by Neighborhood Group

Source: District of Columbia Department of Health. Center for Policy, Planning and Evaluation19

Governance

The Home Rule Act of 1973 established the Council of the District of Columbia, the legislative branch of local government. This Act allowed for an elected mayor and Council and limited federal control of DC. The Act was the result of the ongoing push by District residents for control of their own local affairs, however maintains Congressional oversight with provisions that allow Congress to review all legislation passed by the Council before it can become law and to retain authority over the District's budget. The existing local government is the most expanded form of self-government since the establishment of the District as the seat of the federal government. In 1790, when the District was established on land ceded by Maryland and Virginia to the federal government only about 3,000 citizens lived in the area--far less than the 50,000 required to be a state.

The Mayor of the District of Columbia is the head of the executive branch of DC’s government. The Mayor has the duty to enforce city laws, and the power to either approve or veto bills passed by the Council. In addition, the Mayor oversees all city services, public property, police and fire protection, and most public agencies. There are more than 20 District agencies (or departments) divided into five clusters (Planning and Economic Development, Health and Human Services, Education, Economic Opportunity and Public Safety and Justice). Each cluster is led by a Deputy Mayor who reports to the City Administrator. Sworn in on January 2, 2015, Muriel Bowser serves as Washington, DC’s seventh elected Mayor.

The Council of the District of Columbia is the legislative branch of local government. The Council is composed of a Chairman elected at large and twelve Members--four of whom are elected at large, and one from each of the District's eight Wards. A Member is elected to serve a four-year term. The Council’s central role as a legislative body is to make laws. However, its responsibilities also include oversight of multiple agencies, commissions, boards and other instruments of District government. Working with the Mayor and the executive branch, the Council also plays a critical role in maintaining a balanced budget and the fiscal health of the District of Columbia government.

The District of Columbia has historically enacted fairly progressive legislation to support the health and wellbeing of women, children and families residing in the District. Several recent examples are listed below:

Pre-K Enhancement and Expansion Act (2008) expanded access to high-quality pre-K programs for all three- and four-year-olds in DC. The law formally places pre-k as the foundation for school reform — thus ensuring children a great start in school and in life.

Healthy Schools Act (2010), designed to improve the health and wellness of students attending D.C. public schools by enhancing standards for breakfast/lunch access, school nutrition, farm to school food policies, physical activity and education, and health education.

The Food, Environment and Economic Development in the District of Columbia (FEED DC) Act (2010) offers incentives to attract full-service grocery stores into low-income “food deserts”, and also provides funding for a Healthy Food Retail Program, which helps small grocers and markets sell fresh produce and other healthy foods.

Youth Bullying Prevention Act (2012) requires the establishment of a bullying prevention task force, and the implementation of bullying prevention policies at District agencies and educational institutions.

The Healthy Tots Act (2014) is designed to incentivize early care and education facilities to adopt higher nutritional standards and fund sub-grants for physical activity and nutrition programs.

Prohibition Against Selling Tobacco Products to Individuals Under 21 Amendment Act (2015) amends District law to prohibit the sale of cigarettes to those under 21 years of age.

DC Universal Paid Leave Amendment Act (2016) establishes a paid family leave program administered through the District of Columbia. The Act provides eight weeks of leave for caring for a newborn or newly adopted child, six weeks for tending to a sick relative and two weeks for taking care of personal medical needs for any worker employed by a private business in the District.

District of Columbia Minimum Wage Act (2017) gradually increases the minimum wage to $15.00 per hour by July 2020. The Act also provides for a gradual increase in the minimum cash wage to tipped employees to $5.00 by July 1, 2020.

D.C. Maternal Mortality Review Committee Establishment Act (2018) establishes a Maternal Mortality Review Committee to examine the causes associated with maternal mortalities of District residents and to help create a strategic framework for improving maternal health outcomes for racial and ethnic minorities in the District.

Defending Access to Women’s Health Care Services Amendment Act (2018) allows pharmacists to prescribe and dispense self-administered contraceptives and also requires insurers to cover certain health care services without cost-sharing, including breast cancer screening and counseling, screening for HIV and counseling for sexually transmitted infections.

The District’s current Mayor, Mayor Bowser, has emphasized creating pathways to the middle class for residents, and plans to foster a culture of inclusion, transparency and action. One of her top priorities is addressing homelessness and affordable housing. In her first budget, she directed $100 million to the Housing Production Trust Fund, putting a number of affordable housing units into the pipeline, and has released plans to replace the city’s largest aging family shelter with smaller family housing in all eight Wards. Other priorities include: investments in education to accelerate the pace of education reform; strengthening job training programs; attracting and retaining jobs in the District; creating a more transparent and open government through an open data policy; and launching an inclusive technology program to support startups and entrepreneurs offering products and services to underserved communities.

The Preterm Birth Reduction Pilot Program (2019) established a two-year pilot program to reduce preterm births by increasing access to Progesterone (17P) for women with a history of preterm births. The pilot program is in its first year of implementation.

The Better Access for Babies to Integrated Equitable Services Act (2018) eliminated stand-alone screening programs and consolidated all newborn screenings (metabolic, hearing, and CCHD) to provide a comprehensive program that establishes quality measures, and ensures accountability, regardless of whether the baby is born in a hospital, maternity center, or at home. This bill was not approved by DC Council.  In its place, the Community Health Omnibus Amendment Act of 2018 was signed by the Mayor on January 30, 2019. The Act is currently before Congress, with a projected law date of April 11, 2019.

The following legislation was brought before DC Council for review:

• Maternal Health Care Improvement and Expansion Act (2019) requires individual and group health insurance plans, Medicaid, and the DC Healthcare Alliance to cover a minimum of 2 postpartum healthcare visits, and cover home visits, fertility preservation services, and stipends for travel to and from prenatal and postpartum visits.  In addition, pregnant residents who meet income eligibility requirements would receive Medicaid coverage for one year postpartum. The legislation also establishes a Center on Maternal Health and Wellness.
• Perinatal Health Worker Training Access Act (2019) requires DC Health to provide grants to implement a perinatal health worker-training program to train residents in Wards 5, 7, and 8, to provide culturally congruent nonclinical care to women during their perinatal period.  
• Postpartum Coverage Act (2019) seeks to amend the Medicaid State Plan to cover inpatient and outpatient maternity and newborn care to at least a year after childbirth.
• Baby Friendly Hospital Initiative Act (2018) requires all general acute care hospitals and special hospitals that have a perinatal unit to adopt the “Ten Steps to Successful Breastfeeding” as adopted by Baby Friendly USA, or an alternate process adopted by a health care service plan that includes evidenced-based policies, practices, and targeted outcomes, or the Model Hospital Policy.

[1] United States Census Bureau: American Fact Finder (2018). Annual Estimates of the Resident Population for Incorporated Places of 50,000 or More, Ranked by July 1, 2018 Population: April 1, 2010 to July 1, 2018 - United States -- Places of 50,000+ Population 2018 Population Estimates. Retrieved from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk

[2] United States Census Bureau. (2018). Quick Facts: Washington city, District of Columbia. Population estimates, July 1, 2018. Retrieved from https://www.census.gov/quickfacts/fact/table/washingtoncitydistrictofcolumbia,US/PST045218

[3] U.S. Census Bureau (2017). American Community Survey 5-year estimates. Retrieved from Census Reporter Profile page for Ward 1, DC <http://censusreporter.org/profiles/61000US11001-ward-1-dc/>

[4]U.S. Census Bureau (2017). American Community Survey 5-year estimates. Retrieved from Census Reporter Profile page for Ward 2, DC<http://censusreporter.org/profiles/61000US11002-ward-2-dc/>

[5] U.S. Census Bureau (2017). American Community Survey 5-year estimates. Retrieved from Census Reporter Profile page for Ward 3, DC<http://censusreporter.org/profiles/61000US11003-ward-3-dc/>

[6] U.S. Census Bureau (2017). American Community Survey 5-year estimates. Retrieved from Census Reporter Profile page for Ward 4, DC<http://censusreporter.org/profiles/61000US11004-ward-4-dc/>

[7]U.S. Census Bureau (2017). American Community Survey 5-year estimates. Retrieved from Census Reporter Profile page for Ward 5, DC<http://censusreporter.org/profiles/61000US11005-ward-5-dc/>

[8] U.S. Census Bureau (2017). American Community Survey 5-year estimates. Retrieved from Census Reporter Profile page for Ward 6, DC<http://censusreporter.org/profiles/61000US11006-ward-6-dc/>

[9] U.S. Census Bureau (2017). American Community Survey 5-year estimates. Retrieved from Census Reporter Profile page for Ward 7, DC<http://censusreporter.org/profiles/61000US11007-ward-7-dc/>

[10] U.S. Census Bureau (2017). American Community Survey 5-year estimates. Retrieved from Census Reporter Profile page for Ward 8, DC<http://censusreporter.org/profiles/61000US11008-ward-8-dc/>

[11] U.S. Census Bureau, 2013-2017 American Community Survey 5-Year Estimates.

[12] U.S. Bureau of Labor Statistics (2019). Local Area Unemployment Statistics Map. Retrieved from https://data.bls.gov/lausmap/showMap.jsp;jsessionid=40D9CCC626CF899CCED6237DF9424BBD

[13] Department of Employment Services, Office of Labor Market Research and Information. (2017). Ward labor force, employment, unemployment and rate. Retrieved from https://does.dc.gov/sites/default/files/dc/sites/does/page_content/attachments/Ward_2017_BM.pdf

[14] U.S. Census Bureau (2017). American Community Survey 1-year estimates. Retrieved from Census Reporter Profile page for District of Columbia, DC <http://censusreporter.org/profiles/05000US11001-district-of-columbia-dc/>

[15] Kids Count Data Center. Families headed by a single mother by ward in District of Columbia. Retrieved from https://datacenter.kidscount.org/data/tables/7162-families-headed-by-a-single-mother-by-ward#detailed/21/1852-1859/false/870,573,869,36,868,867,133,38,11/any/any

[16] District of Columbia Office of the State Superintendent of Education. (2018). 2017-2018 Adjusted cohort graduation rate. Retrieved from https://osse.dc.gov/publication/2017-18-adjusted-cohort-graduation-rate

[17] U.S. Census Bureau, Housing and Household Economic Statistics Division (2012). Historical census of housing tables. Retrieved from https://www.census.gov/hhes/

www/housing/census/historic/values.html

[18] Zillow. (2019). Washington home prices & values. Retrieved from  https://www.zillow.com/washington-dc/home-values/

[19] District of Columbia Department of Health, Office of Health Equity. (2018). Health equity report: District of Columbia 2018, the social & structural determinants of health. Retrieved from https://app.box.com/s/yspij8v81cxqyebl7gj3uifjumb7ufsw

[20] Kids Count Data Center. District of Columbia indicators. Retrieved from https://datacenter.kidscount.org/data#DC/3/0/char/0

[21] District of Columbia Policy Center. (2017). Food access in D.C is deeply connected to poverty and transportation. Retrieved from https://www.dcpolicycenter.org/publications/food-access-d-c-deeply-connected-poverty-transportation/

[22] DCist. (2017). Report: wards 7 and 8 have three grocery stores for 149,750 people. Retrieved from http://dcist.com/2017/06/report_wards_7_and_8.php

[23] DC Hunger Solutions. (2016). Closing the grocery store gap in the nation’s capital. Retrieved from https://www.scribd.com/document/350532395/Closing-the-Grocery-Store-Gap-in-the-Nation-s-Capital#from_embed

[24] Kaiser Family Foundation analysis of 2013, 2016, and 2017 American Community Survey (ACS), 1-Year Estimates.

Retrieved from: https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/

[25] Kaiser Family Foundation (2017). Health insurance coverage of the total population. Retrieved from https://www.kff.org/other/state-indicator/total-population/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

[26] Kids Count Data Center (2017). Children who have health insurance by health insurance type in District of Columbia. Retrieved from https://datacenter.kidscount.org/data/tables/10183-children-who-have-health-insurance-by-health-insurance-type?loc=10&loct=3#detailed/3/10,55-56,58-61,64-77,79-84,86,88-94,96-109,9428-9429/false/871/4847,4848,4849,4153,2807,2811/19706,19707

[27] Azimeraw, M. & Phillips, J. (2012). District of Columbia state data center monthly brief November 2012. Retrieved from https://planning.dc.gov/sites/default/files/dc/

sites/op/publication/attachments/November%25202012%2520Briefing%2520Report%2520Health%2520Insurance.pdf

[28] Association of American Medical Colleges (2016). District of Columbia physician workforce profile. Retrieved from https://www.aamc.org/download/484526/data/districtofcolumbiaprofile.

[29] District of Columbia Department of Health. (2017). District of Columbia health systems plan 2017. Retrieved from https://dchealth.dc.gov/sites/default/files/dc/sites/doh/

publication/attachments/DC%20Health%20Systems%20Plan%202017_0.pdf

[30] District of Columbia Department of Health. (2018). Primary care needs assessment. Washington, DC.

[31] District of Columbia Department of Health. (2016). Behavioral risk factor surveillance system 2016 annual report. Retrieved from https://dchealth.dc.gov/sites/default/files/dc/sites/doh/publication/attachments/BRFSS%202016%20Annual%20Report.pdf

[32] Centers for Disease Control and Prevention, National Vital Statistics System. (2017). Deaths, percent of total deaths, and death rates for the 15 leading causes of death: United States and each state, 2015 - 2017. Retrieved fromhttps://www.cdc.gov/nchs/data/dvs/lcwk/lcwk5_hr_2017-508.pdf