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Princeton Study: Being Black Doesn’t Cause Asthma; the Neighborhood Does

By Mary Caffrey

The numbers didn’t lie, but they were hard to explain: black children are twice as likely as others to develop asthma.

There was evidence that low birth weight was a culprit, but could “being black” be a risk factor in asthma, as some believed?

Two scholars from Princeton University have concluded that it’s not race, but living conditions, that accounts for the disparity. The data are compelling, alright: they show the effects of ongoing segregation, which trap African American children in poor neighborhoods, surrounded by pollution.

Janet M. Currie, PhD, professor of economics and public affairs at Princeton, and Diane Alexander, PhD, of the Federal Reserve Bank of Chicago, made this finding after examining New Jersey health data for low birth weight children of all races living in zip codes where more than half the population was African American.

Within these neighborhoods, the racial disparities vanished: all low birthweight children had a higher risk of asthma.

Children with a low birth weight may be premature, which increases the risk for lung problems. The trigger for asthma comes from things found in aging neighborhoods with older housing: mold, rodent infestation, or air pollution. Being around people who smoke also causes asthma, even if a baby’s mother does not smoke. According to CDC, black men have much higher smoking rates (20%) than the overall population (15%), and the authors find that black women are more likely to smoke during pregnancy than white women.

New Jersey’s industrial history means many black residents live near pollution sources or close to highways that produce harmful soot. Housing in these areas is, on average, 7 years older than housing elsewhere. Currie said these conditions can cause women to have low birth weight babies in the first place.

“The United States continues to be highly racially segregated,” Currie said in a statement, “with African-American neighborhoods suffering higher poverty, lower average educational attainments, higher unemployment, higher exposure to pollution, and other ills.”

The authors state, “Our results suggest that the racial gap in asthma rates arises for three reasons: because African-American children are more likely to be low birth weight, because they are more likely to come from families with other characteristics that are associated with poorer health (such as maternal smoking and poverty), and because of where they live.”

African Americans of all ages tend to have poorer health than whites, and neighborhood divides may play a part. New Jersey, in fact, has spent decades trying to comply with a series of 1980s court rulings that called for creating more affordable housing in the suburbs, but those battles are still being fought.

The findings have widespread policy implications, if it means that investments in better housing could cut Medicaid costs over a child’s lifetime. A 2016 report from Express Scripts finds that Medicaid is the largest payer for asthma-related hospitalizations among children and adults, and asthma medications are in the top 3 spending classes, per member per month, at $62.73.

There has been some progress to improve the health of poor children in urban housing. In 2014, a study by CDC found that ending smoking in public housing would save $497 million a year, including $310 million in medical costs. In response, in November 2016, the Obama administration imposed a rule to ban smoking in all public housing.

The study covered New Jersey health data for children born from 2006 to 2010 and records from emergency department visits from 2006 to 2012, which let the researchers see which children were treated for asthma. The zip codes that included areas that were more than 50% African American covered 63% of all African American children born in New Jersey, as well as 16% children of other races.

Currie’s and Alexander’s article appears as a working paper in the National Bureau of Economic Research and will be published in the Journal of Health Economics.

Your ZIP Code Might Be As Important To Health As Your Genetic Code

By Kristian Foden-Vencil

When a receptionist hands out a form to fill out at a doctor’s office, the questions are usually about medical issues: What’s the visit for? Are you allergic to anything? Up to date on vaccines?

But some health organizations are now asking much more general questions: Do you have trouble paying your bills? Do you feel safe at home? Do you have enough to eat? Research shows these factors can be as important to health as exercise habits or whether you get enough sleep.

Some doctors even think someone’s ZIP code is as important to their health as their genetic code.

That’s why Shannon McGrath was asked to fill in a “life situation form” this spring when she turned up for her first obstetrics appointment at Kaiser Permanente in Portland, Ore. She was 36 weeks pregnant.

“When I got pregnant, I was homeless,” she says. “I didn’t have a lot of structure. And so it was hard to make an appointment. I had struggles with child care for my other kids, transportation, financial struggles.”

The form asked about her rent, her debts, her child care situation and other social factors. On the strength of her answers, Kaiser Permanente assigned her what is called a “patient navigator.”

“She automatically set up my next few appointments and then set up the rides for them, because that was my No. 1 struggle,” McGrath says. “She assured me that child care wouldn’t be an issue and that it would be OK if they came. So I brought the kids and everything was easy, just like she said it would be.”

McGrath’s navigator helped her get in touch with local nonprofits that helped her with rent, a phone and essentials for the baby — such as diapers and bottles — all in the hope that making her life easier might keep her healthier and, in turn, keep Kaiser’s medical costs lower.

McGrath says her patient navigator, Angelette Hamilton, was a bureaucratic ninja, removing paperwork obstacles that kept her from taking care of herself and her family.

Patient navigators have been around for a while. What is new is the form that McGrath filled out and how hospitals are using the socioeconomic and other data the forms glean to serve patients. The details now go into a patient’s file, which means providers such as Dr. Sarah Lamberthave more information at a glance.

“I find it incredibly helpful because it can be very hard to find out,” says Lambert, who is McGrath’s OB-GYN and works at Kaiser Permanente Northwest. “Having it coded right there — we have this problem list that jumps up — really can give you a much better understanding as to what the patient’s going through.”

Federal officials introduced new medical codes for the social determinants of health a few years ago, says Cara James, director of the Office of Minority Health at the Centers for Medicare and Medicaid Services.

“More providers are beginning to recognize the impact that the social determinants have on their patients,” she says.

Nicole Friedman, a regional manager at Kaiser Permanente Northwest, agrees. But she goes one step further.

She hopes giving doctors more information about the home life of each patient will push health care in a new direction — away from more high-priced treatments and toward providing the basics.

“My personal belief is that putting more money into health care is a moral sin,” she says. “We need to take money out of health care and put it into other social inputs like housing and food and transportation.”

Linking health organizations like Kaiser with nonprofit social services such as the Oregon Food Bank will help governments and medical providers see where their money can make the biggest difference, Friedman says.

For example, spending more on affordable housing for homeless people can also have health benefits, in turn saving the government money down the line.

Friedman says that when Kaiser started addressing people’s social needs, one study found a 40 percent reduction in emergency room use.

McGrath was initially skeptical when doctors offered to help her with things like rent and transportation.

“I didn’t want someone to see my situation and have it raise alarms,” she says.

But ultimately she was glad to have shared that information.

“I’m able to look at life and not feel overwhelmed or burdened,” she says, “or like I’ve got the whole world on my shoulders.

This story is part of NPR’s reporting partnership with Oregon Public Broadcasting and Kaiser Health News, which is an independent journalism organization and not affiliated with Kaiser Permanente.

Health Department’s New Response to Climate Change

By Catalina Jaramillo

It wasn’t too difficult for the crowd of around 40 seniors gathered at the McPherson Public Library in Kensington on Wednesday to get into the right mindset for the evening’s discussion: How to prepare for emergencies caused by climate change.

Thermometers read 90 degrees in Philadelphia, but it felt like 96. There were heavy rains and thunderstorms scattered throughout the day. And the entire metro area was hit with a Code Orange air quality alert, meaning unhealthy air pollution concentration for people with asthma, heart or lung diseases, children, and the elderly.

That might explain why seniors came from all across the city to attend the extreme heat workshop.

“Have you experienced expressions of climate change first hand?” Drexel University’s Alison Kenner asked the audience.

They replied with loud yes. It’s hotter, one said. It’s wetter, another added. I’ve had health issues, one woman said. I’ve had more asthma, agreed someone else.

“I have asthma and I’m trying to find what I can do [when it is] so hot and muggy,” attendee Sharon Williams said. She doesn’t have air conditioner at home, so she comes to the library whenever it’s really hot. “It affects my breathing,” she said.

Hot and muggy summers in Philadelphia are not new. And for years, the Philadelphia Department of Public Health has run heat awareness campaigns, stressing the health impacts it can have on vulnerable populations and advising citizens to “stay cool” during extremely hot and humid days.

What’s new is the Health Department explicitly connecting the health impacts from excessive heat to climate change. Local health departments in the whole country are only now beginning to expressly make that connection. But according to the U.S. Climate and Health Alliance, the Philadelphia Health Department is ahead of many of their peers.

“Summers in Philadelphia have always been hot, but now they’re getting hotter and wetter,” Health Department’s Marialisa Ramirez said on the workshop.

Philadelphia’s Health Department is one of 12 local health departments participating in a national Climate and Health Learning Collaborative for urban health departments. And a team lead by preparedness manager Jessica Caum has been working with community associations and city agencies to coordinate efforts through a Climate Change and Health Advisory Group.

Wednesday’s “staying cool in a climate change” workshop, one in a series of three held in south, west and north Philadelphia, was one of the products of that.

Clear Air Council’s Russell Zerbo said this is the first time the Health Department is coming out to communities and saying, explicitly: Climate change may impact your health.

“The news is really the Health Department walking into cooling centers and saying: This is a cooling center, we want you to be safe this summer because of climate change,” Zerbo said. “It’s sort of putting them in a service base position, which was not, I don’t think, before.”

Cooling centers are public spaces with air conditioning. They can be libraries, recreation centers, senior centers, or other cool, public buildings. But the Health Department does not publish an active list of them because sometimes the air conditioning in a given building might not working. Ramirez recommended that the audience call 311 before heading to a nearby library or rec center.

Zerbo said until this year, the department was announcing the health impacts of climate change through their website or in the news, sending people to the heatline (215-765-9040) “but in terms of physically going out and doing it, that wasn’t happening.”

In an email, the Health Department’s James Garrow confirmed this was their first time participating in these events.

“While working with the Office of Emergency Management to update the City’s heat response plan, we heard about these types of events and thought we could use them to help further our existing efforts to distribute information about excessive heat and what Philadelphians can do to help survive the heat,” Garrow said.

Zerbo doesn’t blame the department for not directly talking with the communities before about the connection between the dangers of heat and climate change. Climate change is a really complex issue, he said, and a lot of organizations are struggling on how to communicate its impacts and solutions. Drinking more water or keeping an air conditioner on full blast are not real solutions for climate change, he said. They only address the symptoms, not the underlying predicament.

The workshop addressed that problem through different angles. The audience was told staying hydrated and cool is vital, but experts also mention that air conditioners could be creating more of a problem by making cities get hotter.

Julia Menzo from Liberty Lutheran spoke about the importance of establishing ways to contact your family and have enough food and water in cases of power outages. Deepa Mankikar from the National Nurse-Led Care Consortium told people how to keep healthy indoor environments avoiding toxic cleaning products and keeping pests away. And Thomas Flaherty from the Energy Coordinating Agency offered tips for reducing energy conservation, like painting your roof white or disconnecting appliances when they’re not in use.

Drexel’s Kenner has been doing this workshops, independently, for four years. She said there’s three things she’s learned from them. First, that people appreciate someone breaking climate change down and bringing it to a neighborhood scale, showing them how they will be affected. Second, how difficult it is for renters to negotiate things like windows painted shut by their landlords. And third, that difficulty breathing is one of the first issues people mention.

“Changes in weather also trigger asthma attacks,” said Keener, who is writing a book about asthma and climate change. “Because the climate is changing and ecology is changing, people who have lived with asma their whole lives, may be unprepared for new environmental conditions.”

Gloria Marrero has had asthma since she was 14 years old. “Heat leaves me with no air,” she said in Spanish. “That’s why we came, searching for answers.”

According to a index, Philadelphia ranks number 10 among cities that will feel the impact of climate change the most. And the Asthma and Allergy Foundation of America says Philly is the third most challenging city to live with asthma in the country.


Low-Income Homeowners and Renters are Similarly Burdened by Housing Costs

Data reveals that homeownership does not protect low-income homeowners from experiencing severe housing cost burdens. Homeowners are less likely to be low-income than renters. But with equally low incomes, renters and homeowners suffer from similar severe housing cost burdens. Extremely low-income and very-low income homeowners are just as vulnerable to severe cost burdens as renters at the same income level. And while the cost burden looks similar for renters and homeowners at these income levels, the household composition does not. Severely burdened homeowners tend to be elderly, while severely burdened renters tend to have young families.

While renters experience the bulk of severe housing cost burdens, the data from How Housing Matters shows us that low-income homeowners, a predominantly elderly group, share some of these struggles. Since the households of very low-income renters and homeowners differ, policy solutions to address their challenges must as well.

Housing Assistance Can Benefit Health

Having access to stable and affordable housing may lead to increased utilization of healthcare, including insurance, according to a new study published by Health Affairs.

Individuals who received subsidized housing assistance were more likely to be insured and less likely to have unmet healthcare needs compared with low-income individuals not receiving the assistance. Specifically, the authors discovered that only 31% of individuals receiving assistance from the US Department of Housing and Urban Development (HUD) were uninsured compared with 37% of those on a wait list.

Included in the study were data for adults in the National Health Interview Survey, which was then linked to HUD data from 2004 to 2012. All participants ranged in age between 18 and 64.

“We found that the benefits of giving people subsidized housing go beyond simply having access to affordable housing,” said researcher Andrew Fenelon, PhD. “Housing is good in and of itself, but even better is that with improved access to housing, you get improvements in access to health care, and ultimately better health outcomes.”

Housing assistance programs funded by HUD provide low-income Americans with access to affordable, stable housing. Individuals who receive the assistance typically have poor health and require care for mental health conditions or chronic diseases, according to the study.

Previous studies have found that access to care greatly improves health, while housing instability has been linked to poor access to healthcare. Few studies have investigated whether housing assistance can lead to improved health.

The authors discovered that nearly 50% of patients who received the HUD assistance had unmet healthcare needs, while a little more than 40% of patients receiving the assistance had unmet needs, according to the study.

Additionally, the authors discovered that patients receiving housing assistance were more likely to have a usual source of care compared with those not receiving the subsidies.

These findings suggest that HUD housing subsidies may lead to improved health among low-income patients. Currently, qualified individuals may have to wait to receive a housing choice voucher to obtain a housing arrangement, which may place them at risk of poor health, according to the authors.

“There are many reasons why having access to housing may enable people to obtain health insurance and access needed care,” Dr Fenelon said. “With the increased stability that comes from having a home and reduced financial burdens, and being introduced into the social service system and the access to other support services it provides, people receiving housing assistance are getting improved access to primary care health services. This is a clear demonstration that housing is one of the so-called ‘social determinants’ of health. The value of this program should be carefully considered in light of the far-reaching benefits it may have beyond its face value.”

Low-Income Homeowners and Renters are Similarly Burdened by Housing Costs

by Laurie Goodman and Bhargavi Ganesh

With limited supply and skyrocketing housing costs, renters and homeowners face severe housing affordability issues. A higher share of renters face severe housing cost burdens. Over a quarter of renters, or 11.1 million households, are severely cost burdened, spending at least half their income on rental housing.

In contrast, only 10 percent of homeowners (7.6 million) are severely cost burdened. Renters’ generally lower incomes explain most of this difference. But a close look at the data makes it clear that homeownership doesn’t protect low-income homeowners from the same cost burdens as low-income renters.

Lower incomes make renters more cost burdened than homeowners

Homeowners are less likely to have extremely low or very low income. Eight percent of homeowners have extremely low income (30 percent or less of area median income, or AMI), and 7 percent have very low income (31 to 50 percent of AMI). Twenty-six and 15 percent of renters, on the other hand, have extremely low income or very low income, respectively.

Homeowners are also more likely to be wealthy. Forty-five percent of homeowners are in the highest income group (over 120 percent of AMI), compared with 18 percent of renters.

For both renters and homeowners, the severely cost burdened are generally in the lowest income categories. Ninety-two percent of cost-burdened renters and 72 percent of cost-burdened homeowners are from the extremely low–income or the very low–income groups.

When incomes are equally low, renters and homeowners have similar rates of severe cost burden

When controlling for income, a similar proportion of low-income homeowners and renters are severely cost burdened. Extremely low–income and very low–income homeowners are just as vulnerable to severe housing cost burdens as renters at the same income level.

In the extremely low–AMI group, 66 percent of homeowners and 70 percent of renters are severely cost burdened. And in the very low–AMI group, 30 percent of homeowners and 34 percent of renters are severely cost burdened. Although renters may face greater instability than homeowners, housing presents both groups with difficulties in meeting nonhousing needs.

Extremely low–income and very low–income homeowners tend to be elderly

Although low-income homeowners and renters have similar rates of severe cost burden, the composition of these households differs significantly. Poor, severely burdened homeowners tend to be elderly, while severely burdened renters tend to have young families.

In the lowest AMI group, 37 percent have an elderly household head, and 57 percent have a child in their household. But cost-burdened homeowners are approximately twice as likely as cost-burdened renters to be elderly (54 versus 27 percent), and renters are more likely to have at least one child under age 18 than homeowners (68 versus 38 percent).

The same pattern holds true for the low-income category overall. Severely cost-burdened homeowners are more likely to be elderly and less likely to have children in the home than their renter counterparts.

When incomes are low or very low, renters and homeowners have different rates of moderate cost burden

The figure below shows that for extremely low–income households, a similar share of homeowners and renters face a moderate cost burden (spending 30 to 49 percent of their income on housing). But the benefits of homeownership kick in at the very low–income and low-income levels, where fewer households spend 30 to 49 percent of their income on housing.

Many low-income homeowners, especially low-income elderly homeowners, do not have a mortgage. For extremely low–income borrowers, the burden of property taxes, maintenance, utilities, and homeowners’ insurance overwhelm income, whereas those costs are less overwhelming on a slightly higher budget. Cost burdens equalize again between owners and renters at higher income levels (albeit at much lower burden levels), likely because some higher income owners are carrying a sizeable mortgage relative to income.

Although renters shoulder the bulk of the severe housing cost burdens, our data show that low-income homeowners, a predominantly elderly group, struggle as well.

Higher cost burdens for elderly homeowners  reflect their lower incomes following retirement. But we need to understand more about this group and what kind of impact this severe cost burden has on low-income, elderly homeowners. How does this decline in the portion of their income available for non-housing uses impact their quality of life? Can they still buy food and necessary medication, pay utility bills, maintain their home, and pay for transportation?

As populations of low-income renters and homeowners differ, the policy solutions for these challenges will likely differ as well.

City Bulletin Updates on New Grant Program

On May 17, Mayor Kenney, City Council President Darrell L. Clarke, City Councilwoman Cherelle Parker, and Philadelphia Housing Development Corporation (PHDC) celebrated the first of many residents receiving services because of the $100 million in bond funds issued by City Council. These funds are designated to eliminate the current waiting list for the City’s home preservation programs. In December of 2016 Philadelphia’s City Council approved the issuance of $100 million in bond funds. These funds will help eliminate the waiting lists Bond Issuance Reduces Resident Waitlist for PHDC Housing Preservation Services of PHDC’s Basic Systems Repair Program (BSRP), Adaptive Modifications Program (AMP), and Weatherization Assistance Program (WAP). The waiting lists for these programs are currently 3-4 years, with over 7,000 Philadelphians waiting for services and repairs. City officials and affordable housing advocates spoke outside the home of Hagar Redmond, who was receiving plumbing and insulation repairs more than three years after being approved for BSRP assistance.“These programs are very important to our most vulnerable neighbors,” Mayor Kenney said. “These funds help repair roofs, fix heaters, replace sewer pipes, and enable other repairs that not only help a homeowner’s quality of living, but help keep them in their homes by providing these much needed repairs that may be prohibitively expensive otherwise.”
“Since January, PHDC has been hiring and training additional staff and partnering with additional contractors to develop an effective strategy to administer these additional funds to the existing waiting list,” said Fred Purnell, Deputy Director for Housing and Community Development. “We are excited to be here today to serve this resident, and look forward to serving many Philadelphians in significantly less time.”“Housing preservation assistance is a costefficient and highly effective way to create jobs, prevent homelessness and displacement, and stabilize neighborhoods at risk for decline,” Council President Clarke said. “With the help of committed partners in the Administration and the affordable housing advocacy community, Philadelphia can be an example to other cities of managing growth in an equitable way. Homes are not islands; we should all care about our neighbors and about making sure every Philadelphian is able to live in a community of choice.” “As a longtime advocate for housing preservation, I am pleased to have one of the first homes impacted by these additional funds be in the 9th District,” said City Councilwoman Cherelle Parker. “Residents in this district, and across the City, have been waiting for services, but funding has been very limited. These additional funds give PHDC the ability to positively impact so many homeowners across our great city! I am glad to be a part of that today.”The Division of Housing and Community Development (DHCD), Philadelphia Redevelopment Authority (PRA), and Philadelphia City Councilwoman Jannie Blackwell joined community members, public officials, and community partners to celebrated the completion of Phase II renovations for Mt. Vernon Manor on April 19, 2017. Mt. Vernon Manor II is located in the Mantua section of Philadelphia at 34th and Wallace Streets. Mt. Vernon Manor II is 46 affordable apartments. The mission of the project is to preserve affordable housing options in the rapidly changing Mantua neighborhood.“Mt. Vernon Manor is the type of investment the 3rd District needs,” said Councilwoman Jannie Blackwell. “I support this project because it gives the community access to quality affordable housing. I know how hard people are working to support their families, and they deserve to live in a decent neighborhood that they can call home.” “The former design and operations of the apartment buildings were a deterrent to the community,” said Michael Thorpe, Chairman of the Mt Vernon Manor Board. “This project encourages businesses, homeowners, and Sustaining Affordable Housing in Mantua section of Philadelphia.” BSRP provides free repairs to roofs, electrical, plumbing and heating systems for owner-occupied homes in Philadelphia. AMP is designed to help Philadelphians with permanent physical disabilities remain in their homes. WAP provides free weatherization and energy-efficiency improvements to owner-occupied houses and tenant-occupied rental units located in the City of Philadelphia. Each program has income requirements and other criteria for participation.

Philadelphia Childhood Lead Poisoning Advisory Group Releases Final Report

Philadelphia has a persistent childhood lead poisoning problem. In December 2016, Mayor Jim Kenney released a plan called “Lead Free Kids” to improve the city’s efforts to prevent lead poisoning. Along with this plan, the Mayor convened a Childhood Lead Poisoning Prevention Advisory Group. A coalition with representatives from city and state government, healthcare providers, landlord organizations, advocacy groups and other stakeholders, the Advisory Group worked to craft final recommendations to help guide the city’s ongoing work to address the problem of childhood lead poisoning.

To expand upon the city’s current plans, the Group offers three recommendations for primary prevention: to expand the Lead Paint Disclosure Law to all rental units built before 1978, increase funding for landlords to remediate properties if they show financial hardship, and explore a pilot program for proactive housing inspections in high-risk areas. For secondary prevention, the group recommends seeking state cooperation to submit a Medicaid waiver to increase funding for home remediation (along with maximizing billing of Medicaid under current rules) and monitoring research on lead exposure to modify PDPH protocols as appropriate.

Lead poisoning is a serious problem for many Philadelphia children. With Mayor Keeney’s “Lead-Free Kids” plan and the recommendations from the Advisory Group, the City hopes to reduce the number of children with blood lead levels greater than or equal to 5 μg/dL by 40% from 2,106 children in 2011 to 1,200 children in 2020.