Healthy Homes Initiatives to Improve Asthma
01
September

By Adem Lewis / in , , /


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>>>HELLO AND GOOD AFTERNOON. I’M PETER ASHLEY WITH HUD’S
OFFICE OF LADY HAZARD CONTROL AND�– LEAD HAZARD CONTROL AND
HEALTHY HOMES. I’D LIKE TO WELCOME YOU TO OUR
FOURTH IN A SERIES OF HEALTHY HOMES SEMINARS.
TODAY WE’RE GOING TO BE LOOKING AT THE HOME ENVIRONMENT AND
ASTHMA. WE HAVE A GREAT PANEL, SO PLEASE
STAY FOR THE WHOLE WEBCAST AND FOR YOU FOLKS IN THE ROOM,
PLEASE STICK AROUND. I JUST WANTED TO GIVE A LITTLE
CONTEXT TO MY OFFICE AND HOW WE’VE�– OUR CONNECTION WITH
THIS TOPIC OVER THE YEARS. WE STARTED OUR HEALTHY HOMES
INITIATIVE IN `99 AND JUST FROM THE BEGINNING, WE HAD GRANTS
THAT WE REFERRED TO AS HEALTHY HOMES DEMONSTRATION GRANTS, AND
WE OFFERED THOSE OVER THE YEARS, PROBABLY NOT EVERY YEAR IN THIS
RANGE THAT I’M SHOWING, BUT MOST OF THESE YEARS, AND THEY WEREN’T
PRESCRIPTIVE. WE LEFT THE�– WE LET THE
APPLICANT DECIDE WHAT THEY WERE GOING TO DO WITH THESE GRANTS IN
TERMS OF HOME INTERVENTIONS, WHAT THEY WERE GOING TO FOCUS
ON. WE ASKED THEM TO EVALUATE THE
IMPACT OF THEIR INTERVENTIONS, BUT A LOT OF THEM NOT
SURPRISINGLY DID FOCUS ON ASTHMA INTERVENTIONS.
OUR LEAD HAZARD CONTROL GRANTS ADDRESSED LEAD, SO WE ASKED THE
GRANTEES NOT TO ADDRESS LEAD HAZARDS, AND SOME OF THEM
PUBLISHED�– I HAVE A COUPLE OF THEM UP HERE ON THE SLIDE.
ONE OF THEM DID SOME WORK IN PUBLIC HOUSING AND THEY NOTED
THAT CHILDREN WITH ASTHMA MOVING INTO NEW PUBLIC HOUSING BUILT
USING GREEN SPECS SHOWED SIGNIFICANT IMPROVEMENTS IN
THEIR SYMPTOMS. AND THEN WE HAD FOR A FEW YEARS
WHAT WE CALL HEALTHY HOMES PRODUCTION GRANTS AND THEY WERE
MORE SIMILAR TO OUR LEAD HAZARD CONTROL GRANTS IN WHICH THE
GRANTEES IDENTIFIED SIGNIFICANT HAZARDS IN THE HOMES,
COMPREHENSIVELY, AND THEN INTERVENED.
BUT A LOT OF THESE ALSO ADDRESSED HOMES OF CHILDREN WITH
POORLY CONTROLLED ASTHMA. THIS OTHER CATEGORY, ASTHMA
INTERVENTIONS IN POLITIC AND ASSISTED MULTIFAMILY HOUSING WAS
KIND OF AN EXPERIMENT. WE OFFERED THESE FOR TWO YEARS.
TWO OF OUR SPEAKERS TODAY WILL TALK ABOUT GRANTS THEY
IMPLEMENTED FROM THIS CATEGORY, AND THEY FUNDED INTERVENTIONS IN
PUBLIC OR MULTIFAMILY HOUSING, BUT I THINK ALL OF THEM ENDED UP
WORKING IN PUBLIC HOUSING WITH ONE WORKING IN TRIBAL HOUSING,
SO DR.�SANDELL AND HELEN MARGELES WILL TALK ABOUT THEIR
WORK ON THESE GRANTS TODAY. AND THE FINAL CATEGORY, HEALTHY
HOMES TECHNICAL STUDY GRANTS ARE THE RESEARCH GRANTS WE FUNDED
SINCE THE START OF THE PROGRAM. AGAIN, I THINK THERE MAY BE A
COUPLE YEARS WHERE WE DIDN’T OFFER THEM IN THIS RANGE, THIS
POIRKD BUT MOST OF THE YEARS�– PERIOD, BUT MOST OF THE YEARS WE
HAVE. AGAIN, THESE ARE OPEN TO THE
RESEARCHERS ADDRESSING A WIDE RANGE OF HOUSING-RELATED HEALTH
HAZARDS WITH THE GOAL OF IMPROVING ASSESSMENT AND CONTROL
METHODS, BUT AGAIN A LOT OF OUR APPLICATIONS OVER THE YEARS HAVE
BEEN ASTHMA-FOCUSED, AND OUR SPEAKERS TODAY WILL TALK ABOUT
SOME OF THESE TECHNICAL STUDIES GRANTED.
JUST A COUPLE I WANTED TO MENTION.
WE’VE GOT ONE IN MASSACHUSETTS THAT DR.�SANDELL WILL TALK ABOUT
AND IN WHICH THEY’RE DOING AT THE IMPACT OF COMMUNITY HEALTH
WORKER LEAD INTERVENTIONS IN THE HOMES OF LOW INCOME HOMES
WITH�– OF KIDS WITH POORLY CONTROLLED ASTHMA, AND THEN
THERE’S ONE THAT’S SIMILAR THEME IN MARYLAND.
I KNOW DR.�MATSUI IS INVOLVED IN THAT AS A CONSULTANT.
THE ONE IN MASSACHUSETTS SHOULD BE DONE SOON.
AND THEN WE’VE GOT ONE THAT HELEN WILL TALK ABOUT THAT’S
LOOKING AT LONGER TERM BENEFITS OF HOME INTERVENTIONS.
THESE ARE JUST�– THESE ARE SOME OF THE PAPERS THAT HAVE BEEN
PUBLISHED COMING OUT OF THESE�– THE FIRST TWO ARE TECHNICAL
STUDIES GRANTS. THE BOTTOM ONE IS ACTUALLY
INTERAGENCY FUNDING FROM HUD TO EPA.
THE TOP ONE IS KIND OF INTERESTING.
THEY USED OUR TECHNICAL STUD DIAGNOSIS FUNDS TO SUPPLEMENT
LONGITUDINAL STUDY FUNDED BY THE NATIONAL INSTITUTE OF
ENVIRONMENTAL HEALTH SCIENCES AND LOOKED AT THE DEVELOPMENT OF
ASTHMA IN INFANTS RECRUITED AS INFANTS OR EVEN PRENATALLY AND
FOLLOWED OVER TIME AND THEY USED OUR FUNDS TO DO MORE EXPOSURE
ASSESSMENT, AND THEY FOUND THAT THIS ASSESSMENT USING THIS
PARTICULAR INDEX, LOOKING AT MOLDS EXPOSURE DURING THE FIRST
YEAR OF LIFE, WAS THE ONLY ENVIRONMENTAL EXPOSURE THAT WAS
PREDICTIVE OF ASTHMA AT AGE 7 YEARS.
SO THAT WAS KIND OF AN INTERESTING STUDY AND I THINK
QUITE USEFUL. SO I JUST WANTED TO MENTION SOME
OTHER MAJOR ACTIVITIES THAT ARE HAPPENING AT HUD THAT MAYBE
AREN’T SPECIFICALLY ASTHMA-FOCUSED, ALL OF THEM, BUT
WE EXPECT TO HELP CHILDREN AND ADULTS WITH ASTHMA LIVING IN
HUD-ASSISTED HOUSING. SO THE FIRST ONE IS
ASTHMA-FOCUSED AND IT’S�– WE’VE BEEN SPONSORING, ALONG WITH EPA
AND CDC, WHAT WE’VE BEEN CALLING ASTHMA SUMMITS AROUND THE
COUNTRY TO PROMOTE THE IDEA, THE VALUE OF REIMBURSING FOR IN-HOME
INTERVENTIONS IN HOMES OF KIDS WITH POORLY CONTROLLED ASTHMA,
AGAIN TRYING TO GET THE RIGHT PLAYERS TO THE TABLE, MEDICAID,
LOCAL ORGANIZATIONS, ETCETERA. JUST TO POSSIBLY GET THE BALL
ROLLING IN THAT COMMUNITY ON THIS TOPIC.
THEN A COUPLE OF OTHER INITIATIVES AT HUD.
MY OFFICE IS PROMOTING INTEGRATED PEST MANAGEMENT
TRAINING IN PUBLIC HOUSING, A STOP PESTS PROGRAM, AND THEN HUD
HAS HAD A HOUSING INITIATIVE SINCE 2009, THE DEPARTMENT PUT
OUT A PROPOSED RULE THAT WOULD BAN SMOKING IN PUBLIC HOUSING
AND THAT COMMENTS WERE DUE IN JANUARY AND THE DEPARTMENT IS
NOW WORKING ON A FINAL RULE. THIS IS THE WEB PAGE FOR THE
STOP PESTS PROGRAM. AGAIN, THAT’S SPONSORED TRAINING
FOR PUBLIC HOUSING MANAGERS AND STAFF AND ALSO FEDERALLY
ASSISTED HOUSING ON IMPLEMENTING INTEGRATED PEST MANAGEMENT.
THIS IS AN EDITORIAL FROM THE BOSTON GLOBE FROM 2013 THAT
NOTED A REDUCTION IN ASTHMA AMONG ADULTS IN BOSTON PUBLIC
HOUSING. THEY WERE ABLE TO MEASURE THIS,
I THINK IT WAS FROM A PERIOD OF 2008 TO 2012, AND THEY HAPPENED
TO HAVE A LOCAL SURVEY THAT ALLOWS THEM TO MEASURE THIS OVER
THE YEARS. AND YOU CAN’T ATTRIBUTE IT
DEFINITELY TO THEIR IMPROVED PEST CONTROL, BUT IT’S CERTAINLY
PLAUSIBLE THAT THAT WAS CONTRIBUTING.
I THINK MEGAN IS GOING TO TALK A LITTLE BIT ABOUT THAT.
THEN THIS IS THE FEDERAL PLAN TO REDUCE ASTHMA DISPARITIES, HUD’S
A MAJOR PLAYER IN IMPLEMENTING THAT.
THOSE ASTHMA SUMMITS THAT I MENTIONED ARE A KEY ACTIVITY
UNDER THIS FEDERAL PLAN. WE’RE TAKING QUESTIONS DURING
THE WEBCAST. IS THAT RIGHT, RACHEL RILEY?
YES, WE ARE TAKING QUESTIONS, SO IF YOU HAVE ANY QUESTIONS,
PLEASE SEND THEM TO [email protected]
SO WITH THAT, I’D LIKE TO INTRODUCE OUR FIRST SPEAKER
TODAY. THAT IS DR.�ELIZABETH MATSUI.
SHE IS A PROFESSOR OF PEDIATRICS, EPIDEMIOLOGY AND
ENVIRONMENTAL HEALTH SCIENCES AT JOHNS HOPKINS UNIVERSITY.
SHE HAS DEEP EXPERIENCE IN THE CLINICAL INVESTIGATION OF HOME
ALLERGEN AND POLLUTANT EXPOSURE AND ASTHMA AND ALLERGIC DISEASE
AND IS A BOARD-CERTIFIED AND PRACTICING PEDIATRIC ALLERGIST
AND IMMUNOLOGIST. SHE HOLDS A MASTERS IN
EPIDEMIOLOGY AND HAS MORE THAN TEN YEARS OF EXPERIENCE
DIRECTING A DATA MANAGEMENT AND ANALYSIS CORPS THAT IS
RESPONSIBLE FOR STATISTICAL ANALYSIS OF STUDIES RELATED TO
ENVIRONMENTAL EXPOSURES AND ALLERGIC DISEASES.
ELIZABETH IS CURRENTLY SERVING AS THE P.I. OF TWO RANDOMIZED
CONTROL TRIALS OF HOME ENVIRONMENTAL INTERVENTIONS IN
CHILDHOOD ASTHMA AND A OBSERVATIONAL STUDY OF THE
EFFECT OF MOVING TO LOWER POVERTY NEIGHBORHOODS IN HOME
EXPOSURE AND ASTHMA. FOR SOME OF YOU WHO KNOW ABOUT
THE HUD-SPONSORED MOVING TO OPPORTUNITY STUDY, IT WAS A
STUDY THAT LOOKED AT THE IMPACT OF MOVING INNER CITY RESIDENTS
TO AREAS OF GREATER OPPORTUNITY, SO THIS STUDY THAT I JUST
MENTIONED THAT ELIZABETH IS P.I. OF HAS A SIMILAR THREEM.
WITH THAT, LET�– SIMILAR THEME. WITH THAT, LET ME GET OUT OF THE
WAY AND BRING UP ELIZABETH.>>THANK YOU SO MUCH.
IT’S EXCITING TO BE INVITED AND TO SPEAK AND ESPECIALLY TO SPEAK
TO AN AUDIENCE THAT IS AS ENTHUSIASTIC ABOUT ADVOCATING
FOR CHILD HEALTH AND IN TERMS OF HOME ENVIRONMENTS.
SO TODAY, I’M GOING TO FOCUS THE FIRST HALF OF MY TALK ON KIND OF
WHERE WE ARE AND WHAT WE KNOW ABOUT INDOOR ENVIRONMENTS AND
CHILDHOOD ASTHMA, AND THEN I’M GOING TO FOCUS THE SECOND HALF
ON WHAT I THINK THE CHALLENGES ARE FOR OUR COMMUNITIES AND
STAKEHOLDERS IN HEALTHY HOUSING IN TERMS OF TRYING TO MOVE THE
NEEDLE ON HOUSING INTERVENTIONS AND CHILDHOOD ASTHMA.
SO A LITTLE BIT OF BACKGROUND. I THINK THERE’S ALL SORTS OF
HOUSING ACROSS ALL SORTS OF POPULATIONS THAT CAN BE
UNHEALTHY. A LOT OF OUR FOCUS, HOWEVER, HAS
BEEN ON LOW INCOME, URBAN MINORITY POPULATIONS, AND THE
REASON FOR THAT IS REALLY INDICATED IN THE SLIDE.
YOU CAN SEE THAT ASTHMA HOSPITALIZATIONS ARE MUCH HIGHER
AMONG BLACKS THAN AMONG NON-BLACKS, AND THAT THE
DISPARITY HAS PERSISTED OVER TIME.
AND, IN FACT, IT HAS GROWN IN SOME WAYS AS HOSPITALIZATIONS
HAVE DECREASED AMONG NON-BLACKS. AND WE KNOW THAT AT LEAST IN
INNER CITIES, WHICH ARE LOW INCOME, URBAN NEIGHBORHOODS,
THAT RACIAL AND ETHIC MINORITIES ARE THE DEMOM MANHATTAN
POPULATION THERES�– PREDOMINANT POPULATION THERE AND WE KNOW
THERE’S A STRIKING DISPARITY IN ASTHMA FRIEND OF LENS.
NATIONAL PREVALENCE ALONG CHILDREN IS ABOUT 10% AND IN
INNER CITY COMMUNITIES, IT’S AS HIGH AS 25 TO 28%.
IN TERMS OF GHIG WHETHER IN AN INNER�– THINKING ABOUT WHETHER
LIVING IN AN INNER CITY IN AND OF I HAVE IS A RISK FACTOR FOR
MORBIDITY, IT IS. I SHOW YOU HERE IN THIS SLIDE,
WHAT YOU SEE ARE ODDS RATIOS SUCH AS BASICALLY THE RISK OF
BEING HOSPITALIZED, FOR EXAMPLE, WHICH IS THE LAST FIGURE, LAST
DATA POINT ON THE RIGHT, THE RISK OF BEING HOSPITALIZED FOR
INNER CITY CHILDREN COMPARED TO NON-INNER CITY CHILDREN, AND THE
INTERPRETATION HERE IS THAT INNER CITY CHILDREN, AFTER
ACCOUNTING FOR RACE, HAVE A 60% GREATER RISK OF BEING
HOSPITALIZED FOR ASTHMA, 40% GREATER RISK OF HAVING AN
EMERGENCY DEPARTMENT VISIT FOR ASTHMA, AND VERY SMALL INCREASED
RISK OF HAVING AN OUTPATIENT VISIT FOR ASTHMA.
THERE ARE MANY FEATURES OF INNER CITY ENVIRONMENTS THAT LIKELY
CONTRIBUTE TO THIS, AND SO I MENTIONED A FEW ON THE SLIDE.
LOW HEALTH LITERACY, STRESS, POOR ACCESS TO TRANSPORTATION,
FINANCIAL OBSTACLES. THERE ARE MANY, MANY MORE, BUT
THE ONE THAT HAS KIND OF STOOD OUT TIME AND TIME AGAIN IN
STUDIES OVER THE PAST MANY DECADES ARE THE ENVIRONMENTAL
EXPOSURES ASSOCIATED WITH INNER CITY HOUSING.
AND WHY IS THIS? AND I SHOW YOU HERE SOME
PICTURES OF SOME BALTIMORE HOMES.
NOW, BALTIMORE DOES HAVE SOME DISTINCTIVE HOUSING AND THAT
WHAT YOU SEE ARE ROW HOMES, BUT THIS IS COMMON FOR OTHER INNER
CITY AREAS, SOME OF THESE FEATURES.
ONE OF THE THINGS YOU CAN SEE IS THAT THERE IS OCCUPIED HOUSING
THAT’S IN BETWEEN VACANT HOUSING AND THE VACANT HOUSING OFFERS
LOTS OF OPPORTUNITY FOR PESTS TO HANG OUT AND THEN ALSO ENTER THE
OCCUPIED HOME. ON THE BOTTOM, YOU CAN SEE TWO
PICTURES OF HOLES AND CRACKS THAT ARE INDOORS AND THESE ARE
PLACES WHERE PESTS CAN ENTER HOUSING.
AND THERE ARE MORE PROBLEMS THAN JUST PESTS IN INNER CITY HOMES,
BUT I JUST HIGHLIGHT KIND OF THIS ASPECT OF INNER CITY
HOUSING HERE, BUT WE’LL TALK ABOUT INDOOR POLLUTANTS AS WELL.
SO REALLY, THE EVIDENCE HAS BEEN PRETTY STRONG OVER A LONG PERIOD
OF TIME THAT PEST ALLERGEN EXPOSURE IS ASSOCIATED WITH
SIGNIFICANT ASTHMA MORBIDITY. THE GREEN BAR IN THE SLIDE
DEMONSTRATES THE HOSPITALIZATION RISK AMONG THOSE WHO ARE BOTH
SENSITIZED AND EXPOSED TO COCKROACH ALLERGEN COMPARED TO
EVERYBODY ELSE, SO THERE’S A MARKEDLY INCREASED RISK FOR
BEING HOSPITALIZED AMONG INNER CITY CHILDREN WHO ARE ALLERGIC
TO COCKROACH AND EXPOSED TO THE HIGH LEVELS OF ALLERGENS IN
THEIR HOMES. WE FIND SIMILAR RESULTS WITH
MOUSE ALLERGEN. THAT STORY HAS KIND OF UNFOLDED
MORE RECENTLY. SO CHILDREN WHO ARE HOUSE
ALLERGIC AND HAVE HIGH�– MOUSE ALLERGIC AND HAVE HIGH LEVELS OF
MOUSE ALLERGEN IN THEIR HOMES HAVE A 50% GREATER RISK OF
HAVING AN ACUTE VISIT FOR ASTHMA AND A 50% GREATER RISK OF
PROBLEMS WITH LUNG FUNCTION. THAT’S WHAT YOU SEE LABELED AS
REVERSIBILITY. THEIR LUNGS ARE DIRECTLY
AFFECTED OUR MEASUREMENTS OF LUNG FUNCTION AND THEY ARE AT
MUCH GREATER RISK OF HAVING AN ACUTE VISIT AND THERE’S A HUGE
RISK FOR HOSPITALIZATION. IN THIS ONE PARTICULAR STUDY,
THERE WERE TEN HOSPITALIZATION OVER THE COURSE OF FOLLOW-UP AND
NINE OF THESE OCCURRED IN CHILDREN WHO WERE BOTH MOUSE
SENSITIZED AND EXPOSED. SO THE PEST ALLERGEN STORY IS A
COMPELLING ONE. WE ALSO KNOW THAT THERE ARE
NON-ALLERGEN EXPOSURE IN THE INDOORS, SO ONE OF THEM IS
PARTICULATE MATTER EXPOSURE. PARTICULATE MATTER EXPOSURE I
LIKE TO EXPLAIN TO PATIENTS, ACTUALLY, THAT WE ARE BREATHING
IN PARTICLES THAT WE DON’T SEE, SO THAT’S AIRBORNE PARTICULATE
MATTER. IT’S HERE IN THIS ROOM, HERE
WHEREVER THE AUDIENCE IS WHO’S LISTENING AND WATCHING THE
WEBINAR, BUT IN INNER CITY HOMES, THE INDOOR PM,
PARTICULATE PART CONCENTRATIONS, TEND TO BE HIGHER THAN THEY ARE
OUTDOORS, SO THEY ARE OFTEN HIGHER THAN WHAT THE EPA
REGULATES OR SETS AS A HEALTHY STANDARD OR A STANDARD THAT WE
NEED TO ACHIEVE FOR OUTDOOR PM. AND THE MAIN CONTRIBUTION TO
INDOOR PM IS SECOND HAND SMOKE EXPOSURE, CIGARETTE SMOKE, SO WE
KNOW THE INDOOR PM IS MUCH HIGHER IN HOMES WHERE THERE’S A
SMOKER AND AMONG CHILDREN WITH ASTHMA LIVING IN INNER CITY
NEIGHBORHOODS, HIGHER INDOOR PARTICULATE MATTER IS ASSOCIATED
WITH MORE SYMPTOMS, SO THEY HAVE 6% MORE DAYS OF COUGH AND WHEEZE
AND CHEST TIGHTNESS SYMPTOMS, SO THAT ADDS UP OVER A YEAR, OVER
365 DAYS, 8% MORE DAYS WHERE THEY’VE HAD TO SLOW DOWN BECAUSE
OF THEIR ASTHMA AND 11 MORE DAYS WHERE THEIR SPEECH IS LIMITED
BECAUSE THEIR ASTHMA IS SO SEVERE, SO THERE’S CLEARLY AN
ASSOCIATION BETWEEN INDOOR PARTICULATE MATTER EXPOSURE,
MUCH OF WHICH IS RECEIPTED TO CIGARETTES IN�– RELATED TO
CIGARETTES IN THE HOME, AND ASTHMA SYMPTOMS.
THERE ARE ALSO NONPARTICULATE OR GASEOUS POLLUTANTS.
THE MOST COMMON ONE THAT’S INDOORS IS NITROGEN DIOXIDE.
NITROGEN DIOXIDE IS A COMBUSTION BYPRODUCT, SO IT’S PRESENT IN
HIGHER CONCENTRATIONS IN HOMES WHERE THERE ARE GAS STOVES AND
GAS HEAT. AND IT’S A KNOWN RESPIRATORY
IRRITANT, AND AGAIN, YOU SEE THAT FOR EVERY 20 PART
PER�BILLION INCREASE IN NITROGEN DIOXIDE, AND WHAT WE TYPICALLY
SEE HALF THE HOMES HAVE MORE THAN 20 PARTS PER�BILLION IN
INNER CITY COMMUNITIES, SO FOR EVERY 20 PART PER�BILLION
INCREASE, THERE’S AN INCREASE IN DAYS OF SYMPTOMS.
SOME INNER CITY COMMUNITIES, CERTAINLY DETROIT AND BALTIMORE,
GAS AS A SOURCE OF FUEL FOR STOVES AND HEAT IS VERY COMMON,
SO PROBABLY 75 TO 85% OF HOMES, SO WE NOW HAVE A STORY OF
ALLERGEN EXPOSURE, ABOUT HALF TO TWO-THIRDS OF THE KIDS ARE
ALLERGIC TO THE ALLERGENS THEY’RE EXPOSED TO.
WE HAVE PM EXPOSURE, HALF OF THE KIDS LIVE A SMOKER IN THE HOME,
AND MORE THAN THREE-QUARTERS OF THE HOMES HAVE A GAS STOVE, SO
WE HAVE A PILING ON OF EXPOSURES THAT CAUSE INFLAMMATION AND LUNG
DISEASE. SO WHAT ARE THE KEY QUESTIONS?
WHAT ARE THE�– CAN WE REDUCE THE EXPOSURES?
AND ONE OF THE REAL CHALLENGES OF WORKING IN THE FIELD OF
ENVIRONMENTAL HEALTH IS THAT COMING AT THIS FROM A PHYSICIAN
PERSPECTIVE, I HAVE COLLEAGUES WHO DO DRUG DEVELOPMENT.
THEIR QUESTION WHEN THEY NEED TO DEVELOP A DRUG IS DOES THE DRUG
REDUCE ASTHMA MORBIDITY OR DOES IT ADDRESS OR IMPROVE A
PARTICULAR HEALTH OUTCOME. WE HAVE TO SHOW THAT WE CAN
REDUCE EXPOSURES AND THAT AS A RESULT OF THAT, THAT THE DISEASE
IMPROVES, AND SO THESE ARE THE TWO KEY QUESTIONS AND THIS IS
WORK THAT’S BEEN GOING ON BY SOME OF THE OTHER SPEAKERS AND
HAS BEEN GOING ON FOR 20 YEARS OR MORE.
SO I’M GOING TO GO THROUGH KIND OF EACH OF THESE EXPOSURES AND
TALK TO YOU ABOUT THE EVIDENCE THAT WE CAN REDUCE IT.
ONE IS SECOND HAND SMOKE EXPOSURE AND ONE CAVEAT HERE IS
THAT A VERY�– THERE’S A WHOLE CRITICALLY IMPORTANT FIELD OF
SECOND HAND SMOKE EXPOSURE REDUCTION THAT ADDRESSES AND IS
TRYING TO UNDERSTAND HOW TO ENCOURAGE FAMILIES TO INSTITUTE
HOME SMOKING BANS AND HOW TO WORK TOWARDS SMOKING CESSATION,
AND THAT IS CLEARLY THE NUMBER ONE GOAL.
SHORT OF THAT, BECAUSE IT’S OFTEN DIFFICULT TO ACHIEVE,
ANNUAL R AND MANY OF THE FAMILIES WE WORK WITH ARE NOT
THE HOMEOWNER OR THE HEAD OF THE HOUSEHOLD, SO THEY DON’T HAVE
CONTROL, THEY’RE NOT THE SMOKER, BUT THEY DON’T HAVE THE
OPPORTUNITY TO LIVE IN ANOTHER KIND OF ENVIRONMENT.
WE HAVE DONE AND ANOTHER GROUP HAS DONE RANDOMIZED CONTROL
TRIAL TO HEPA-LIKE AIR PURIFIERS IN HOMES OF CHILDREN WHO LIVE
WITH SMOKERS AND THE CHILDREN ALL HAVE ASTHMA AND WE DO KNOW
HOW IN TWO RANDOMIZED CONTROL TRIALS, THAT PLACEMENT OF THESE
HEPA AIR PURIFIERS RUSES THE CONCENTRATIONS BY 20 THAT 50%.
ONE TRIAL FOUND THAT THE AIR PURIFIERS REDUCED EXACERBATIONS
AND THE ANOTHER TRIAL FUND THERE WAS A REDUCTION IN THE NUMBER OF
SYMPTOMS DAYS THAT THE CHILDREN WHO HAD RECEIVED THE AIR
PURIFIERS, SO I THINK WE HAVE PRETTY GOOD EVIDENCE THAT WE CAN
GET A 25 TO 50% REDUCTION IN THESE AIR PURIFIERS AND WE HAVE
GOOD EVIDENCE THAT THAT’S ASSOCIATED WITH A HEALTH EFFECT.
WHAT ABOUT NITROGEN DIOXIDE WHICH I MENTIONED?
THIS WAS A STUDY SPONSORED BY HUD, DONE BY A COLLEAGUE OF
MINE, AND IT WAS A STUDY IN WHICH GAS STOVES WERE REPLACED
WITH ELECTRIC STOVES. THERE WERE THREE DIFFERENT ARMS,
SO THERE WAS STOVE REPLACEMENT, THERE WAS PLACEMENT OF AN AIR RU
RI FIRE AND I WANT�– PURIFIER AND I WANT TO SAY SOMETHING
IMPORTANT, THAT THE COMMERCIALLY AVAILABLE AIR PURIFIERS DO NOT
RUSE GASEOUS POLLUTANTS. THIS WAS AN AIR PURIFIER THAT WE
WORKED WITH THE COMPANY TO DESIGN AND ADD EXTRA CARBON IN
THE AIR PURIFIER SO IT WAS DESIGNED TO TRY TO REDUCE O2 AND
THE VENTILATION HOOD BECAUSE THE IDEA IS IF YOU CAN HAVE�– MOST
OF THESE HOMES DOES NOT HAVE AN OPERATING VENTILATION HOOD OVER
THE STOVE AND WHAT MY COLLEAGUES FOUND WAS THERE WAS SIGNIFICANT
REDUCTION IN INDOOR NO2 CONCENTRATIONS IN THE STOVE
REPLACEMENT AND THE AIR PURIFIER GROUP, SO AGAIN, THESE WERE
SPECIALIZED AIR PURIFIERS THAT ARE NOT COMMERCIALLY AVAILABLE.
THE NO2 CONCENTRATIONED DECREASED BY 25 TO 50% AND THIS
WAS NOT A STUDY, AGAIN, BECAUSE WE HAVE TWO DIFFERENT QUESTIONS
WE’RE TRYING TO ANSWER, THIS DID NOT ADDRESS THE EFFECT ON ASTHMA
OUTCOMES, SO WE EXPECTED IT WOULD IMPROVE OUTCOMES, BUT WE
DON’T HAVE A SUBSTANTIAL EVIDENCE BASE HERE.
THE STUDY I THINK THAT MOST PEOPLE POINT TO AND IS ACTUALLY
IN THE NATIONAL ASTHMA GUIDELINES IN TERMS OF KIND OF
THE GOLD STANDARD FOR WHAT’S RECOMMENDED AS A PART OF ASTHMA
MANAGEMENT IS THIS STUDY THAT WAS PUBLISHED BY THE�– IT’S NOW
CALLED THE INNER CITY ASTHMA CONSORTIUM, IT WAS THE INNER
CITY ASTHMA STUDY WHEN IT WAS PUBLISHED, PUBLISHED IN 2004.
THIS IS A BIG MULTI-CENTER STUDY, A RANDOMIZED CONTROL
TRIAL OF SCHOOL-AGE INNER CITY CHILDREN WITH ATOPIC ASTHMA.
THE KIDS WERE SKIN TESTED AND AFTER IDENTIFYING WHAT THEY WERE
ALLERGIC TO, THEY RECEIVED AN INTERVENTION BASED ON THE PANEL
OF THINGS THEY WERE ALLERGIC TO. IF SOMEONE WAS NOT ALLERGY TO
DUST MITE, THEY DID NOT RECEIVE THAT MODULE, BUT IF THEY WERE
ALLERGIC TO MICE, THEY RECEIVE THE MOUSE MODULE, WHICH INCLUDED
ASSISTANCE WITH INTEGRATED PEST MANAGEMENT.
WHAT I WANT TO POINT OUT, THE FIRST QUESTION I MENTIONED, DOES
IT REDUCE EXPOSURE AND YOU CAN SEE IN THE INTERVENTION GROUP
THAT THERE WERE 444 CHILDREN AND THERE WAS ABOUT A 44% REDUCTION
IN COCKROACH ALLERGENS, 59% REDUCTION IN DUST MITE AND SO AN
AND THERE WERE DIFFERENCES. THE INTERVENTION GROUP HAD
GREATER REDUCTION IN THOSE�– IN CERTAIN ALLERGENS THAN THE
CONTROL GROUP AND THOSE CERTAIN ALLERGENS WERE DUST MITE AND CAT
PRIMARILY AND SOME SUGGESTION THAT MAYBE THERE WAS A GREATER
REDUCTION IN COCKROACH ALLERGEN. SO THIS KIND OF INTERVENTION
SEEMS TO WORK IN TERMS OF REDUCING EXPOSURES.
WHAT ABOUT THE EFFECT ON HEALTH OUTCOMES?
THIS HAD A SUBSTANTIAL HEALTH OUTCOME.
THE BLUE LINE IS THE CONTROL GROUP AND ONE TRICKY THING ABOUT
DOING ASTHMA STUDIES IS IF YOU DO NOT HAVE A CONTROL GROUP,
EVERYONE GETS BETTER IN AN ASTHMA STUDY.
SO YOU HAVE A HARD TIME TELLING IF YOU DO A PRE AND POST STUDY
DESIGN WHETHER THE IMPROVEMENT IS BECAUSE�– IT IS BECAUSE WHAT
YOU WOULD EXPECT OF THE NATIONAL HISTORY OF SOMEONE JUST BEING
ENROLLED IN A STUDY EVEN WHEN THEY’RE NOT RECEIVING AN
INTERVENTION, SO THE CONTROL GROUP HERE HAD A REDUCTION IN
SYMPTOMS AND THE INTERVENTION GROUP HAD A MUCH GREATER
REDUCTION IN SYMPTOMS, AND THE EFFECT SIZE WAS ACTUALLY SIMILAR
TO A LOW DOSE OF ASTHMA CONTROLLER MEDICATION AND THAT
WAS THE POINT THAT THE AUTHORS MADE AND THE PAPER I THINK WAS A
VERY IMPORTANT POINT THAT I’LL COME BACK TO.
THE EFFECT PERSISTED FOR AT LEAST A YEAR AFTER THE
INTERVENTION WAS COMPLETE AND I THINK THIS IS ANOTHER VERY
IMPORTANT POINT BECAUSE WE KNOW WHEN YOU STOP MEDICATIONS, THE
SYMPTOMS COME RIGHT BACK AND THE RISK OF EXACERBATIONS AND
HOSPITALIZATIONS COME RIGHT BACK.
AND THE ASTHMA EFFECT CORRELATED WITH THE REDUCTION IN ALLERGENS,
SO THE AGREE OF REDUCTION IN COCKROACH AND DUST MITE ALLERGEN
WAS CORRELATED WITH THE AMOUNT OF IMPROVEMENT THEY HAD IN THEIR
ASTHMA. SO THIS IS REALLY KIND OF
CONSIDERED THE GOLD STANDARD EVIDENCE, AND I THINK REALLY
INFORMS WHAT I TRY TO DO IN MY CLINIC, WHAT ALL SORTS OF PUBLIC
HEALTH PROGRAMS DO AND STOERS A LOT OF WORK THAT’S DONE TRYING
TO TARGET HOUSING AS A PART OF ASTHMA MANAGEMENT IN KIDS, BUT I
THINK WE STILL HAVE SOME CHALLENGES.
I’M ACUTELY AWARE OF THESE BECAUSE WHEN I’M TALKING TO
ANOTHER TYPE OF AUDIENCE, THESE ARE SORT OF THE SKEPTICAL KIND
OF COMMENTS THAT I GET BACK, AND THESE STUDIES THAT I’M SHOWING
UP HERE REFLECT THE SKEPTICISM. ONE, THERE WAS A SURVEY EPA DID
A FEW YEARS AGO AND THEY FOUND ONLY 30% OF PATIENTS OR PARENTS
OF PEDIATRIC PATIENTED IMPLEMENTED WHAT WAS VIEWED AS
ESSENTIAL ENVIRONMENTAL CONTROL MEASURES AND THERE WAS A SURVEY
OF ALLERGISTS. SO ALLERGISTS, OF ALL
PHYSICIANS, REALLY BELIEVE IN THE ENVIRONMENT, SO STH, YOU
WOULD EXPECT THAT THIS IS A GROUP THAT WOULD BE TALKING TO
ALL OF THEIR PATIENTS ABOUT ENVIRONMENTAL CONTROL.
AND ONLY THREE-QUARTERS REPORTED EMPHASIZING THE IMPORTANCE OF
ENVIRONMENTAL CONTROL STRATEGIES AND ONLY TWO-THIRDS REPORTED
PROVIDING EDUCATIONAL MATERIAL ABOUT ENVIRONMENTAL CONTROL.
AND IN THE CONCLUSION, THERE WAS A STRIKING SENTENCE THAT THE
AUTHORS WROTE THAT SAID THE OVERALL EFFICACY AND
PRACTICALITY OF ENVIRONMENTAL CONTROL HAD BEEN QUESTIONED
BECAUSE OF CONFLICTING CLINICAL TRIALS.
AND I’M A BELIEVER THAT WE NEED TO FACE THIS HEAD-ON BECAUSE WE
HAVE TO START TALKING IN THE LANGUAGE OF THE MEDICAL
COMMUNITY AS ONE KIND OF STRATEGY TO ACHIEVE OUR GOAL.
SO I THINK OUR GOAL SHOULD BE WIDESPREAD INCORPORATION OF HOME
ENVIRONMENTAL CONTROL ACROSS MULTIPLE SETTINGS, PUBLIC
HEALTH, HEALTH SYSTEM POPULATION HEALTH SETTINGS SHOULD BE AN
INTEGRAL PART OF INDIVIDUAL LEVEL PATIENT MANAGEMENT, AND
THEN, OF COURSE, SCHOOLS AND OTHER PUBLIC INDOOR SPACES.
WHAT WOULD IT TAKE TO GET THERE? SO I HAVE THE FOUR�– SO THE
TAKE-HOME IS THAT I THINK WE NEED TO THINK LIKE BIOTECH AND
PHARMA, WHICH IS AN UNUSUAL WAY TO THINK FOR PEOPLE WHO ARE IN
THE PUBLIC HEALTH ARENA. AND I LIVE WITH SOMEONE WHO’S AN
ONCOLOGIST AND IS A RESEARCHER, AND THIS IS HOW HE THINKS.
WE HAVE LOTS OF BACK AND FORTH, AND I THINK TRY TO PERSUADE HIM
TO THINK MORE LIKE A PUBLIC HEALTH PRACTITIONERS.
THERE ARE FOUR MAJOR QUESTIONS. DO CHANGES IN THE ENVIRONMENT
MEDIATE THE EFFECTS ON ASTHMA? THIS IS VERY MARRED.
NOT SOMETHING THAT�– HARD. NOT SOMETHING THAT DRUG
DEVELOPERS HAVE TO SHOW. HOW DOES THE ENVIRONMENTAL
COMPARE IN TERMS OF MEDICATION IN TERMS OF COST AND EFFICACY.
SO GET THE HEALTHCARE DOLLAR TO PAY FOR THIS, WE NEED TO BE ABLE
TO START TALKING ABOUT MEDICATION EQUIVALENCY OF WHAT
WE DO AND IT’S A HIGH BAR, BUT I THINK IT’S ACHIEVABLE.
WHAT ARE OTHER STRATEGIES THAT CAN ACHIEVE LARGER AND SUSTAINED
REDUCTIONS IN ENVIRONMENTAL EXPOSURE?
WE NEED MORE REDUCTION AND MORE SUSTAINED REDUCTIONS, I THINK,
TO BE ABLE TO SHOW A LARGER HEALTH EFFECT THAT’S GOING TO
GET THE ATTENTION OF THE HEALTHCARE COMMUNITY.
AND ARE PUBLIC HEALTH POPULATION APPROACHES TO ENVIRONMENTAL
HEALTH INTERVENTIONS EFFECTIVE? WHAT I MEAN BY THAT IS WE THINK
A LOT IN TERMS OF THE INDIVIDUAL PATIENT LEVEL AND BOTH OF THEM
HAVE BEEN THINKING MORE ON THE POPULATION LEVEL.
I HAVE TO WRAP UP HERE, BUT I’M JUST GOING TO POINT A COUPLE OF
THINGS OUT TO HIGHLIGHT. THIS IS A CONTROVERSIAL QUESTION
TO ASK. DO CHANGES IN THE ENVIRONMENT
MEDIATE EFFECTS ON ASTHMA? I’LL SHOW THIS ONE SLIDE.
THIS WAS A TRIAL, KIDS WERE RANDOMIZE TO A LOW INTENSITY OR
HIGH INTENSITY INTERVENTION AND OF ALL THE THINGS YOU SEE ON THE
TABLE, ONLY TWO OF THE THINGS WERE REDUCED TO A GREATER EXTENT
IN THE HIGHER INTENSITY THAN THE LOWER INTENSITY INTERVENTION.
BUT THERE WAS A CLINICAL EFFECT IN THE HIGHER INTENSITY
INTERVENTION. SO WAS THE CLINICAL EFFECT A
RESULT OF THOSE TWO OF THOSE 15 THINGS BEING REDUCED THAT ARE
KNOWN TO BE STRONGLY ASSOCIATED IN AND OF THEMSELVES WITH ASTHMA
OR WERE THERE OTHER THINGS GOING ON?
I THINK IF WE CAN UNDERSTAND MORE WHAT MEDIATES THE EFFECTS
OF AN ENVIRONMENTAL INTERVENTION, THAT’S A CURRENCY
THAT IS VALUABLE TO THE HEALTHCARE COMMUNITY.
WE HAVE A TRIAL IN THE FIELD RIGHT NOW TRYING TO UNDERSTAND
WHAT THE MEDICATION EQUIVALENCY IS OF AN INDIVIDUALLY TAILORED
MULTIFACETED INTERVENTION DONE IN THAT MORGAN TRIAL I SHOWED
YOU. WE HAVE, AS PETER MENTIONED, A
STUDY WE’RE PLANNING AND NOT QUITE LAUNCHED YET TRYING TO
LOOK AT HOUSING MOBILITY. IF SOMEONE MOVES FROM AN INNER
CITY NEIGHBORHOOD TO A BETTER NEIGHBORHOOD, AN OPPORTUNITY
MARRIED, WHAT HAPPENS TO THEIR EXPOSURES.
DOES THE ASTHMA GET BETTER AND DOES IT MEDIATE IMPROVEMENT IN
THEIR ASTHMA. WE HAVE A MOUSE SINGLE TARGETED
INTERVENTION IN GALT MORE AND BOSTON.
THE IDEA HERE THAT THERE’S A KNOWN ALLERGEN THAT’S A MAJOR
PROBLEM IN THE COMMUNITY, THAT THIS CAN BE A COMMUNITY LEVEL
EFFORT TO TARGET THAT PARTICULAR ALLERGEN AND YOU MAY BE ABLE TO
BRING DOWN ASTHMA MORBIDITY IN THAT COMMUNITY.
HERE’S SOME CONCLUSIONS AND I THINK THIS SORT OF SEESAW
REFLECTS HOW I VIEW THE INDOOR ENVIRONMENT, WHICH IS THAT THERE
ARE ALL THESE PRO-INFLAMMATORY THINGS.
THEY’RE CAUSING LUNG INFLAMMATION AND WE’RE TRYING TO
GIVE ASTHMA MEDICATION TO COUNTER THOSE.
I’M NOT AT ALL OPPOSED TO GIVING ASTHMA MEDICATION.
I THINK IT’S AN IMPORTANT PART OF ASTHMA MANAGEMENT, BUT IF WE
CAN START THINKING ABOUT THIS PROBLEM IN TERMS OF
DEMONSTRATING THAT WHEN YOU START TO REMOVE SOME OF THOSE
EXPOSURES, YOU START TO REDUCE THE NEED FOR CONTROLLER
MEDICATIONS, I THINK THAT MAKES A LOT OF SENSE.
SO WHAT WE KNOW. I THINK THERE’S GOOD EVIDENCE
THAT THERE ARE CLEAR EXPOSURES THAT ARE ASSOCIATED WITH ASTHMA
MORBIDITY, THAT THERE ARE CLEAR THINGS WE CAN DO TO REDUCE
THOSE, AND THAT REDUCING EXPOSURE TO A MULTIFACETED
INDIVIDUALLY TAILORED HOME INTERVENTION IS ASSOCIATED WITH
IMPROVEMENTS IN ASTHMA MORBIDITY.
AND I WOULD ARGUE THAT TO ATTAIN THE PROPOSED GOAL, SCLS A GOAL
OF�– WHICH IS A GOAL OF WIDESPREAD HOME INTERVENTION, IS
THAT WE NEED TO START THINKING LIKE BIOTECH AND FARM MA.
THANK YOU VERY MUCH. [ APPLAUSE ]
>>WE HAVE TIME FOR A COUPLE OF QUESTIONS.
DO WE HAVE ANY FROM THE AUDIENCE?
>>YOU MENTIONED COCKROACHES AS A CAUSE.
IS THAT ALSO TRUE OF BED BUGS AND MOLDS?
>>THERE’S ONE GROUP I KNOW WHO’S TRYING TO UNDERSTAND
WHETHER BED BUGS MAY BE CONTRIBUTING AND WHAT HE HAS
FOUND SO FAR IS THAT THERE’S EVIDENCE THAT PEOPLE HAVE AN
ALLERGIC IMMUNE RESPONSE TO BED BUGS.
HE’S STILL IN THE PROCESS OF TRYING TO DECIDE OR DETERMINE OR
STUDY WHETHER THE ALLERGY TO THE BED BUGS IS ASSOCIATED WITH
WORSE ASTHMA. I THINK THAT’S NOT CLEAR.
MOLD EXPOSURE HAS BEEN ASSOCIATED WITH WORSE ASTHMA AND
ONE OF THE CHALLENGES IN THE FIELD OF MOLD EXPOSURE, DAMP
HOUSING IN GENERAL, THE STRONGEST EVIDENCE IS DAMP
HOUSING BEING ASSOCIATED WITH ASTHMA.
WE’VE HAD A HARDER TIME FLAILING DOWN WHETHER THAT’S — NAILING
DOWN WHETHER THAT’S REALLY MOLD, WHETHER THAT’S DUST MITES, WHICH
LIKE TO BE IN DAMP AREAS, OR WHETHER THERE’S ANOTHER REASON,
WHETHER IT’S DAMPNESS ITSELF, BUT THE STRONGEST EVIDENCE BASE
IS THERE’S DAMPNESS, THERE IS A RANDOMIZED CONTROL TRIAL THAT
WAS A MOLD REMEDIATION INTERVENTION DONE BY CAROLYN
KIRSCHMAR AND THEY FOUND A SIGNIFICANT IMPROVEMENT IN
ASTHMA WHEN THEY REMEDIATED THOSE HOMES ALONG KIDS THAT WERE
MOLD ALLERGIC.>>WE’RE NOW INSPECTING FOR MOLD
AND WE’RE GETTING PUSH BACK FROM THE OWNERS, SAYING IT’S NOT
MOLD, IT’S DAMP. BUT YOU’RE SAYING THE EFFECT IS
PROBABLY STILL THE SAME WHETHER IT’S JUST DAMP HOUSING OR INDEED
MOLD.>>WE KNOW THAT DAMP HOUSING AS
PROBLEM. WE KNOW THAT DAMP HOUSING CAUSES
WORSE ASTHMA. WE DON’T KNOW WHETHER IT
DIRECTLY CAUSES WORSE ASTHMA OR WHETHER IT’S A MARKER OF A
CONDITION IN THE HOUSE THAT PREDISPOSES TO SOME BAD EXPOSURE
AND I THINK THAT THE MOLD ISSUE IS�– THERE’S CLEARLY A HEALTH
PROBLEM ASSOCIATED WITH MOLD. THERE’S NO QUESTION ABOUT THAT.
TRYING TO UNDERSTAND WHETHER AN INDIVIDUAL HAS A HEALTH PROBLEM
BECAUSE OF A CERTAIN MOLD EXPOSURE IS VERY TRICKY.
YOU HAVE TO�– WE HAVE TO KNOW WHAT THEIR SKIN TESTS OR IGE
RESULTS, WE HAVE TO KNOW WHAT THE OUTDOORS MOLD ALLERGENS
COMPARED TO INDOOR MOLD ALLERGENS.
WE HAVE TO HAVE A SENSE OF WHAT KIND OF STATE THE HOUSING IS IN,
SO FOR ANY INDIVIDUAL FAISH, THERE’S A LOT OF�– PATIENT,
THERE’S A LOT OF CLINICAL JUDGMENT THAT’S INVOLVED.
>>OKAY, MAYBE WE SHOULD MOVE AN AND HOPEFULLY WE’LL HAVE SOME
TIME FOR QUESTIONS�– WE DO HAVE ONE QUESTION FROM THE FIELD.
SOMEBODY�– THROUGH THE ANECDOTAL EVIDENCE, I GREW UP IN
A RURAL SITUATION, AND THEY WERE WONDERING IF THERE HAVE BEEN
STUDIES DONE AS THERE HAS BEEN IN URBAN POPULATIONS, BUT AMONG
RURAL POPULATIONS, THE SAME TYPE OF EXPOSURE.
>>RIGHT. SO THERE ARE TWO ISSUES THAT ARE
GER PLAIN TO THE RURAL�– GERMANE TO THE RURAL QUESTION,
SO I HAVE A COLLEAGUE AND THERE ARE MORE THAN JUST HER, TAMERA
PERRY IN ARKANSAS WHO LOOKED AT EXPOSURE IN PATIENTS AND
FAMILIES WHO LIVE IN THE DELTA REGION, SO MISSISSIPPI AREA.
AND SHE FOUND THAT A LOT OF THESE EXPOSURES ARE COMMON, BUT
IT’S REALLY MOUSE THAT’S MORE COMMON THAN COCKROACH, AND THAT
THERE IS A LOT OF INDOOR PARTICULATE MATTER EXPOSURE
THROUGH SECOND HAND SMOKE. SO THERE’S CLEARLY AN ISSUE
THERE AND RURAL ASTHMA HAS BEEN, I THINK OVERLOOKED.
THE PREVALENCE IN HER POPULATION APPROACHED 25% AS WELL AND THE
POPULATION WAS A LOW INCOME PREDOMINANTLY BLACK POPULATION.
THERE’S A SECOND QUESTION ABOUT RURAL EXPOSURES, WHICH ARE SOME
OF THEM GOOD FOR YOU, AND MANY OF YOU HEARD ABOUT THE HYGIENE
HYPOTHESIS AND THERE’S NOW 10 TO 20 YEARS OF EVIDENCE SUGGESTING
THERE ARE CERTAIN TIME OF FARM EXPOSURES THAT HELP PREVENT MAZ,
WHICH IS A DIFFERENT�– PREVENT ASTHMA, WHICH IS A DIFFERENT
QUESTION THAN IF YOU ALREADY HAVE ASTHMA, WHAT MAKES IT WORSE
OR BETTER. BUT THOSE ARE NOT RURAL HOMES
NECESSARILY. THESE ARE CHILDREN WHO LIVE IN
BAVARIA AND THEY HAVE A BARN TAMPED TO THE HOME AND FROM�–
ATTACHED TO THE HOME AND FROM AN INFANT TIME PERIOD, THEY’RE
PLAYING AROUND IN THE HAY AND TOUCHING THE COW, ETCETERA.
SO THE KINDS OF EXPOSURES THEY HAVE ON A FARM ARE A LITTLE BIT
DIFFERENT THAN WHAT WE MIGHT IMAGINE IN RURAL COMMUNITIES IN
THE U.S.>>OKAY.
>>THANK YOU.>>THANK YOU VERY MUCH.
I THINK MAYBE WE SHOULD MOVE ON. JUST ADDING A LITTLE SOMETHING
TO THAT LAST QUESTION, SOME OF OUR GRANTEES HAVE WORKED IN
TRIBAL COMMUNITIES AND NOTED, OF COURSE, FUEL BURNING STOVES
PRODUCE A LOT OF PARTICULATE AND OTHER CONTAMINANTS, SO IT’S AN
IMPORTANT ASTHMA TRIGGER SOURCE IN RURAL AREAS AS WELL.
SO OUR NEXT SPEAKER TODAY IS HELEN MARGELES.
SHE’S THE DIRECTOR OF COMMUNITY HEALTH INITIATIVES AT SINAI
URBAN HEALTH INSTITUTE IN CHICAGO.
HELEN HAS BEEN INVOLVED WITH A DESIGN, IMPLEMENTATION AND
EVALUATION OF SEVEN INTERVENTIONS TO IMPROVE ASTHMA
OUTCOMES SINCE 2001. CURRENTLY, HELEN IS THE SITE
PRINCIPAL INVESTIGATORS FOR THE CHILDHOOD ASTHMA GAPS IN
OUTCOMES, OR CHICAGO PLAN. A MULTI-SITE ASTHMA
COLLABORATIVE WITH A $4�MILLION, THREE-YEAR CONTRACT WITH THE
PATIENT CENTERED OUTCOMES RESEARCH INSTITUTE.
THE CHICAGO PLAN IS INVESTIGATING HOW HEALTH
OUTCOMES FOR BLACK AND LATINO CHILDREN WITH UNCONTROLLED
ASTHMA PRESENTING TO SIX CHICAGO EMERGENCY DEPARTMENTS MIGHT BEST
BE OPTIMIZED. SHE IS ALSO CURRENTLY THE P.I.
FOR TWO ADDITIONAL HUNDRED DOLLARS FUNDED RESEARCH STUDIES.
HELEN WAS ELECTED TO THE BOARD OF DIRECTORS OF THE CHICAGO
ASTHMA CONSORTIUM IN MARCH 2006 AND SERVED AS THE CHAIR FROM
2009 TO 2010.>>OKAY.
THANK YOU FOR INVITING ME TODAY. I’M REALLY HONORED TO BE HERE TO
PRESENT TO YOU SOME OF THE WORK WE’VE UNDERTAKEN AROUND
DEVELOPING AND TESTING COMMUNITY HEALTH WORKER BASED ASTHMA MODEL
THAT INCORPORATED BOTH MEDICAL MANAGEMENT AND ENVIRONMENTAL
CONTROL TO PREVENT ASTHMA OUTCOMES.
I’LL START WITH BACKGROUND AROUND WHO SINAI HEALTH IS AND
THE KIND OF WORK WE DO AND I’LL TALK ABOUT SOME OF OUR PAST
INITIATIVES TO DEVELOP THIS ASTHMA MODEL AND I’M GOING TO
SPEND SUBSTANTIALLY MORE TIME ON CASE STUDIES AND THAT WOULD BE
OUR MOST RECENTLY COMPLETED, HELPING CHILDREN BREATHE AND
THRIVE IN CHICAGO PUBLIC HOUSING, SO THAT WILL GIVE YOU A
GOOD SENSE OF THE MODEL ITSELF AND THE NEXT STEP WILL BE TO
TALK ABOUT WHAT WE’RE CURRENTLY DOING TO CONTINUE TESTING THAT
MODEL, CONTINUE IMPROVING IT AND TRANSLATING TO NEW POPULATIONS
AND THEN I’LL END WITH LESSONS LEARNED AND NEXT STEPS.
SO THE SINAI URBAN HEALTH INSTITUTE IS PART OF THE SINAI
HEALTH SYSTEM IN CHICAGO. WE HAVE TWO CAMPUSES.
. WE SERVE THE WEST AND SOUTHWEST
SIDE OF THE CITY AND TWO OF THE MOST ECONOMICALLY CHALLENGED
CITIES IN THE CITY OF CHICAGO. OUR PATIENT POPULATION IS BLACK
AND LATINO AND WE WERE ACTUALLY FOUNDED IN 2000 AS AN EFFORT TO
BETTER UNDERSTAND THE COMMUNITY THAT THE SINAI HEALTH SYSTEM
SERVES SO THAT WE COULD IMPLEMENT EFFECTIVE STRATEGIES
TO REDUCE HEALTH DISPARITIES. OUR VISION IS TO SERVE AS A
LEADING URBAN HEALTH RESEARCH INSTITUTE FOR ELIMINATING HEALTH
DISPARITIES AND OUR MISSION TO DEVELOP AND IMPLEMENT EFFECTIVE
APPROACHES THAT IMPROVE THE HEALTH OF URBAN COMMUNITIES
THROUGH DATA, RESEARCH, INTERVENTIONS, EVALUATION AND
COMMUNE ENGAGEMENT. SO AN AREA THAT WE IMMEDIATELY
BEGAN WORKING IN SINCE 2000 WAS ASTHMA AND I DON’T NEED TO TALK
ABOUT THE EPIDEMIOLOGY OF ASTHMA, BUT I WILL JUST SAY WITH
REGARD TO CHICAGO, WE ARE ONE OF THE MOST SEGREGATED CITIES IN
THE COUNTRY AND AS A RESULT, THERE ARE POCKETS OF POVERTY AND
POPULATIONS THAT ARE REALLY EXPERIENCING A HIGH ASTHMA
BURDEN, SO WE DO HAVE PROBLEMS IN CERTAIN NON-HISPANIC BLACK
AND PUERTO RICAN COMMUNITIES AND NOT ONLY IS THE PREVALENCE HIGH,
BUT WE ALSO HAVE EVIDENCE THAT THE ASTHMA TENDS TO BE POORLY
CONTROLLED. THEY HAVE HIGHER HOSPITALIZATION
RATES, HIGHER EMERGENCY DEPARTMENT RATES, HIGHER
MORTALITY/MORBIDITY RATES. WE KNOW IT’S A SERIOUS LUNG
DISEASE, SOMETHING THAT CAN BE CONTROLLED, BUT IT TAKES EFFORT
TO DO THAT. THAT’S WHAT WE’VE BEEN WORKING
ON SINCE 2000 IS REALLY WORKING TO HELP CHILDREN AND MORE
RECENTLY ADULTS UNDERSTAND ASTHMA, CONTROL IT BETTER SO
THEY CAN LIVE FULL PRODUCTIVE LIVES.
A BRIEF OVERVIEW OF OUR WORK OVER THE PAST 16 YEARS.
WE HAVE IMPLEMENTED A SERIES OF NINE COMPREHENSIVE
INTERVENTIONS. OUR GOALS THROUGHOUT HAVE BEEN
TO DECREASE ASTHMA-RELATED MORBIDITY AND MORTALITY TO
IMPROVE EQUAL OF LIFE FOR PEOPLE LIVING WITH ASTHMA AND DECREASE
COSTS AND TO MEASURE THE COST SAVINGS.
EACH OF OUR PROGRAMS IS BUILT ON THE SUCCESSES AND SHORTCOMINGS
OF ITS PREDECESSOR, SO WE CURRENTLY AFTER ALL THIS TIME
HAVE A MODEL THAT WE’RE CONFIDENT IN AND WE’RE TRYING TO
SCALE UP AND TEST IN NEW POPULATIONS.
ALL OF OUR WORK HAS BEEN FOCUSED AROUND THE COMMUNITY HEALTH
WORKER MODEL SO HERE I PUT UP THE DEFINITION THAT THE AMERICAN
PUBLIC HEALTH ASSOCIATION USES, THEY ARE FRONT-LINE PUBLIC
HEALTH WORKERS WHO ARE TRUSTED MEMBERS OF OR HAVE AN UNUSUALLY
CLOSE UNDERSTANDING OF THE COMMUNITIES SERVED.
SO WHAT DOES THAT MEAN? THAT MEANS THAT WE ARE HIRING
COMMUNITY HEALTH WORKERS FROM THE COMMUNITIES WE’RE WORKING
WITHIN. THEY DON’T NEED TO HAVE ANY
PRIOR MEDICAL OR ASTHMA KNOWLEDGE OR EXPERIENCE AS
HEALTH EDUCATORS. WHAT THEY HAVE TO HAVE IS THAT
CONNECTION TO THAT COMMUNITY, THAT UNDERSTANDING OF THE
COMMUNITY, THAT ABILITY TO SPEAK THE LANGUAGE OF THE COMMUNITY
THAT ALLOWS THEM TO BUILD TRUSTING RELATIONSHIPS.
IT’S BASED ON CERTAIN CORE COMPETENCIES WHICH WE’VE GOTTEN
GOOD AT IDENTIFYING. THEY CAN TRAIN THEM TO BE
COMMUNITY HEALTH WORKERS. HERE I PUT UP FOUR OF THE
INTERVENTIONS THAT PRECEDE THE ONE THAT I’LL BE DISCUSSING IN
MORE DETAIL, AND ALL I WANT TO SAY, MOST OF THEM HAVE BEEN
PUBLISHED AND YOU CAN LEARN ABOUT THEM, BUT WE HAD A PROCESS
BY WHICH WE STARTED IN MORE OF A MEDICAL SETTING, UTILIZING
COMMUNITY HEALTH WORKERS WORKING IN A CLINIC AND WE BUILT INTO
MORE HOME ENVIRONMENT�– ACTUALLY, WE WENT INTO THE HOME
AND BEGAN WORKING INDIVIDUALLY WITH FAMILIES LIVING WITHIN THE
HOME WITH CHILDREN WHO HAD POORLY CONTROLLED ASTHMA, BUT IT
WASN’T REALLY UNTIL 2008 THAT WE REALLY STARTED FOCUSING MORE
COMPREHENSIVELY ON ENVIRONMENTAL IMPROVEMENTS IN THE HOME AND HOW
THAT MIGHT ALSO ADD TO THE MODEL THAT WAS PRIOR TO THAT TIME
REALLY FOCUSING MORE ON MEDICAL MANAGEMENT.
THE LESSONS WE LEARNED IN THE PAST NIRCHES THAT LED US TO
WHERE WE ARE NOW IS THAT COMMUNITY HEALTH WORKERS ARE
IMMENSELY EFFECTIVE IN ESTABLISHING RELATIONS OF TRUST
WITH THE FAMILIES THEY SERVE. THE ISSUES THAT IMPEDE A
FAMILY’S ABILITY TO MANAGE ASTHMA ARE COMPLEX AND OFTEN GO
BEYOND WHAT A COMMUNITY HEALTH WORKER CAN DO BY THEMSELVES OR
MEDICAL PROVIDER, AND THAT’S WHERE THE MORE COMPREHENSIVE WE
COULD BE, THE MORE WE CAN WRAP AROUND THE FAMILY’S TRUE NEEDS
AND MORE EFFECT PERSPECTIVE. WE ALSO HAVE FOUND EVIDENCE OF
IMPROVED ASTHMA CONTROL ACROSS THOSE FOUR DIFFERENT
INTERVENTIONS, WE SAW HOSPITALIZATIONS DECREASING
BETWEEN 50 AND 80%, REDUCTION OF SYMPTOMS FREQUENCY, IMPROVEMENTS
IN QUALITY OF LIFE. WE’VE DONE COST SAVINGS ANALYSIS
OF ALL OF OUR INTERVENTIONS AND WE HAVE SAVED BETWEEN THREE AND
EIGHT DOLLARS SAVED PER DOLLAR SPENT DEPENDING ON THE INTENSITY
OF THE APPROACH AND THE POPULATION WE WERE STARTING
WITH. NOW I’M GOING TO GO INTO MORE
DEPTH WITH HELPING CHILDREN BREATHE AND THRIVE IN CHICAGO
PUBLIC HOUSING, OUR FIRST HUD-FUNDED INITIATIVE, BETWEEN
APRIL 2011 AND JULY 2013. ESSENTIALLY BY 2011, WE HAD A
MODEL THAT WE HAD TESTED PRETTY EXTENSIVELY AND COULD CONFIDENT
WE COULD TRANSLATE TO NEW POPULATIONS AND WE SAW THIS CALL
TO PROPOSAL FROM HUD ASKING SPECIFICALLY FOR ASTHMA
INTERVENTIONS TO BE TESTED WITHIN PUBLIC HOUSING SETTINGS,
SO WE APPROACH THE CHICAGO HOUSING AUTHORITY AND ASKED THEM
TO PARTNER WITH US TO SEE IF THE MODEL KEYED SHOWN TO BE
EFFECTIVE IN THE COMMUNITY COULD BE TRANSLATED.
THEY AGREED, WE APPLIED FOR THE GRANT, HAD OPPORTUNITIES TO DO
THIS. THIS WAS BASED ON THE FRAMEWORK
OF OUR ESTABLISHED COMMUNITY HEALTH WORKER HOME VISIT ASTHMA
PROGRAM AND WE TRANSLATED THAT HEALTHY HOMES AS A MODEL TO
CHICAGO PUBLIC HOUSING DEVELOPMENTS.
WE WORKED CLOSELY WITH THE HOUSING AUTHORITY IN DOING THIS
AND ALSO WITH SOME OF THE VENDORS, BUILDING MANAGEMENT
COMPANIES, FAMILY WORKS, THEIR SOCIAL SERVICE PROVIDER, AND
INCORPORATED MEANINGFUL PARTICIPATION BY THE COMMUNITY.
STAYING TRUE TO THE COMMUNITY HEALTH WORKER MODEL, WE
RECRUITED THE HEALTH WORKERS FROM THE TARGETED PROPERTIES WE
WERE WORKING WITHIN. AGAIN, THEY DID NOT NEED TO HAVE
PRIOR ASTHMA KNOWLEDGE, BUT THEY NEEDED TO HAVE THAT CONNECTION
TO THE COMMUNITY AND THAT UNDERSTANDING OF THAT COMMUNITY.
WE THEN PUT THEM THROUGH AN INTENSIVE TRAINING PROCESS.
WE FIRST STARTED WITH A 75-HOUR TRAINING CONDUCTED BY OUR ASTHMA
EDUCATION TRAINING INSTITUTE ON WHAT ASTHMA IS, HOW THE HOME
ENVIRONMENTS IMPACTS IT, HOW TO MANAGE TRIGGERS IN THE HOME AND
CERTAIN COMMUNITY HEALTH WORKER CORE SKILLS THAT THEY NEEDED TO
KNORR. WE HAD NEWLY TRAINED COMMUNITY
HEALTH WORKERS SHADOWED THE MORE EXPERIENCED WORKERS OUT IN THE
FIELD TO GET A BETTER SENSE OF HOW THE MODEL WORKS IN THE REAL
WORLD. WE DEVELOPED A THREE-TIER ROLE
PLAY EVALUATE THAT WE PUT THE WORKERS THROUGH SO IT KEEPS
GETTING HARDER AND HARDER WITH EACH SCENARIO AND THEY NEED TO
EFFECTIVELY PASS THOSE BEFORE THEY MOVE ON AND THE NEXT STEP
IS TO HAVE THEM GO OUT IN THE FIELD AND TEACHED WITH A MORE
SEASONED COMMUNITY HEALTH WORKER OBSERVING THEM UNTIL THEY REACH
A CERTAIN LEVEL OF COMPETENCY AND WE CONTINUE TO DO QUALITY
ASSURANCE CHECKS THROUGHOUT THE INTERVENTION PERIOD.
THE MODEL THAT WE ARE UTILIZING IN THIS INTERSTRENGTHS AND HAVE
BEEN SINCE IS THAT�– INTERVENTION AND HAVE BEEN SINCE
IS WE CONDUCT SIX HOME VISITS OVER A 12-MONTH PERIOD AND THE
COMMUNITY HEALTH WORKER IS LEADING EACH OF THESE HOME
VISITS. THEY’RE EACH ABOUT 90 MINUTES TO
TWO HOURS IN LENGTH GENERALLY, DENYING ON WHAT WE FIND IN THE
HOME. DURING THE VISITS, WE’RE BOTH
PROVIDING HOME-BASED COMPREHENSIVE, INDIVIDUALIZED
ASTHMA EDUCATION THAT INCLUDES EVERYTHING FROM THE PHYSIOLOGY
TO HOW TO RECOGNIZE SYMPTOMS OF ASTHMA QUICKLY AND RESPOND
ACCORDINGLY TO PREVENT URGENT HOSPITALIZATION NEEDS.
TO HOW TO IDENTIFY TRIGGERS IN THE HOMES ENVIRONMENT AND
ELIMINATE THEM. WE DO A COMPREHENSIVE HOME
ENVIRONMENTAL ASSESSMENT AT THE TWO-WEEK VISIT, THE SIX-MONTH
VISIT AND THE 12-MONTH VISIT, SO AT THIS POINT WE’RE LOOKING FOR
EVERYTHING WE CAN FIND WITHIN THE HOME THAT MIGHT BE MAKING IT
MORE DIFFICULT TO MANAGE ASTHMA, SO EVERYTHING FROM PESTS TO
IRRITANTS THAT THE CHILD MIGHT BE EXPOSED TO IN CLEANING
SUPPLIES, TO MOLD AND MOISTURE. AND ANOTHER ROLE THE COMMUNITY
HEALTH WORKER THROUGH THIS PROCESS IS REALLY TO LINK
PARTICIPANTS TO MEDICAL PROVIDERS AND TO MAKE SURE THAT
THEY HAVE STRONG RELATIONSHIPS WITH THE PROVIDERS AND ALSO TO
SOCIAL SERVICES AS APPROPRIATE. THERE’S A TYPO ON THE SLIDE, BUT
ESSENTIALLY WE RECRUITED BETWEEN JULY OF 2011 AND SEPTEMBER OF
2012. WE HAD SOME INITIAL CHALLENGES
IN RECRUITMENT. WE HAD A PLAN GOING IN THAT WE
WERE GOING TO KNOCK ON EVERY DOOR IN THE PROPERTIES AND
IDENTIFY CHILDREN WITH ASTHMA. THAT DID NOT WORK SO WELL.
ON FORTUNATELY WE HAD A RELATIONSHIP WITH CHA AND WE
WERE ABLE TO ESTABLISH A BETTER PROCESS BY WHICH WE WORKED WITH
THE CASE MANAGERS THAT WERE ALREADY IN TOUCH WITH THE
FAMILIES TO IDENTIFY CHILDREN WITH ASTHMA AND HAVE REFER AND
DO A TRANSFER FOR OUR COMMUNITY HEALTH WORKERS.
WE ALSO IDENTIFIED A LOT OF ADULTS WITH ASTHMA.
OUR INITIAL INTENT WAS TO WORK WITH CHILDREN, BUT WE WERE
IDENTIFYING A LOT OF ADULTS WHO DID NOT HAVE CHILDREN WITH
ASTHMA IN THE HOME WHO, IT DOESN’T LOOK�– I MEAN, WE
DIDN’T WANT TO KEEP SAYING NO, YOU’RE NOT ELIGIBLE FOR OUR
PROGRAM, YOU’RE NOT ELIGIBLE FOR YOU ARE STUDY, SO WE ENDED UP
GOING BACK TO HUD AND WERE ABLE TO NEGOTIATE A CONTRACT REVISION
WHICH ALLOWED US TO IMPLEMENT AN ADULT PILOT.
INTERVENTIONS TO THIS POINT HAD BEEN TESTED WITH CHILDREN AND
THIS WAS A GREAT OPPORTUNITY TO COLLECT PILOT DATA ON WHETHER
THEY COULD BE EFFECTIVE WITH ADULTS.
THE CRITERIA FOR THIS INITIATIVE WAS PRETTY BROAD.
WE YOOUS NEEDED PEOPLE TO HAVE ASTHMA AND LIVE IN ONE OF SIX
PUBLIC HOUSING PROPERTIES. SOME OF OUR PAST AND FUTURE
INITIATIVES, WE HAD CRITERIA AROUND THE SEVERITY OF THE
DISEASE, BUT NOT FOR THIS PARTICULAR PROJECT.
WE ENDED UP WITH 262 REFERRALS WITH THE PROGRAM AND WERE ABLE
TO CONSENT TO 158, WHICH MEANS THEY WERE ENROLLED AND THAT’S
60%, ONE OF THE MORE EFFICIENT REFERRAL METHODOLOGIES WE’VE
EVER IMPLEMENTED, SO THAT ENDED UP BEING A SUCCESS.
73 OF THOSE WERE ADULTS AND 85 WERE CHILDREN.
THE ADULTS, WE HAD A CONDENSED SIX-MONTH INTERVENTION THAT WE
WERE PILOT TESTING. OUR LOSS OF STUDY RATE WAS 24%.
WITH REGARD TO DATA, WE HAD A RESEARCHER THAT COLLECTED THE
MAJORITY OF THE DATA. IT WAS COLLECTED AT BASELINE,
THE RESEARCH ASSISTANT ATTENDED THE BASELINE VISIT WITH THE
COMMUNITY HEALTH WORKER TO COLLECT CONSENT AND BASELINE
DATA. THEY THEN CALLED KNOLL OVER THE
PHONE TO�– MONTHLY OVER THE PHONE TO COLLECT ADDITIONAL DATA
AND THEY ALSO ATTENDED THE 12-MONTH VISIT.
THE COMMUNITY HEALTH WORKER DOES COLLECT SOME DATA AND THAT’S
DATA THAT’S HELPFUL AS THEY IMPLEMENT THE INTERVENTIONS, SO
THAT WOULD BE THE HOME ENVIRONMENTAL ASSESSMENT, THE
MEDICATION TECHNIQUE AND SOME ASTHMA KNOWLEDGE SORTS OF
QUESTIONS. SO OUR PARTICIPANTS, HERE YOU
SEE THE CHILDREN IN THE MIDDLE COLUMN AND THE ADULTS ON THE FAR
RIGHT, ESSENTIALLY OUR PARTICIPANTS WERE PREDOMINANTLY
NON-HISPANIC BLACK AND THE CHILDREN WERE, 94% OF THEM FROM
MEDICAID INSURED. THIS IS BEFORE THE
IMPLEMENTATION
OF THE AFFORDABLE CARE ACT.
WHAT WE WERE NOT REQUIRING, THAT PEOPLE ENROLLED IN THE STUDY
HAVE POORLY CONTROLLED ASTHMA. YOU’LL SEE HERE THAT 80% IF YOU
COMBINE THE PURPLE AND LIGHTER BLUE, 80% HAD ASTHMA THAT WOULD
BE DEFINED AS POORLY CONTROLLED PER THE NATIONAL HEART, BLOOD
AND LUNG INSTITUTE GUIDELINES NONMOVING INTO THE OUTCOMES
DATA, I’M GOING TO FOCUS STICK SKAEL TO CHILD DATA.
WE HAD TWO GOALS. ONE OF WHICH WAS TO REDUCE
ASTHMA RELATED MORBIDITY. WE MEASURED THAT BY LOOKING AT
SYMPTOM FREQUENCY AND LOOKING AT URGENT HEALTH UTILIZATION.
THIS IS SHOWING DATA AROUND SYMPTOM FREQUENCY AND ON THE FAR
LEFT, YOU CAN SEE THAT’S FOCUSING ON DAYTIME SYMPTOMS IN
THE PAST TWO WEEKS AND AT BASELINE, THE AVERAGE CHILD HAD
HAD FOUR DAYS OF VISITS OVER�– I’M SORRY, FOUR DAYS OF ASTHMA
SYMPTOMS OVER THE PAST TWO WEEKS.
OVER THE COURSE OF FOLLOW-UP PERIOD, THEY HAD LESS THAN ONE,
SO THAT WAS AN 80% REDUCTION AND IT WAS STATISTICAL SIGNIFICANTLY
AND WE HAD SIMILAR REDUCTIONS IN NIGHTTIME SYMPTOMS AND DAYS
NEEDS RESCUE MEDICATIONS. LOOKING AT URGENT HEALTHCARE, IN
THE YEAR PRIOR TO THE INTERVENTION, 42% OF CHILDREN
HAD HAD AT LEAST TWO OF THOSE, AT LEAST TWO E.D.,
HOSPITALIZATIONS, URGENT CLINIC VISITS.
IN THE YEAR, THAT WAS REDUCED TO JUST 15% OF CHILDREN HAVING TWO
OR MORE HEALTH UTILIZATION EVENTS.
BY THE END OF THE YEAR, 74% HAD NOT HAD ANY URGENT HEALTH
UTILIZATION NEEDS. THE OTHER GOAL WAS TO IMPROVE
QUALITY OF LIFE OF THE CHILD AND THE FAMILY AND WE SPECIFICALLY
MEASURED CAREGIVER QUALITY OF LIFE BECAUSE IT’S BEEN FOUND TO
CORRELATE WELL WITH THE CHILD’S QUALITY OF LIFE.
WE USED A TOOL USED EXTENSIVELY IN ASTHMA RESEARCH AND THIS
QUESTIONNAIRE HAS BEEN STUDIED TO THE EXTENT THAT WE KNOW IF
YOU CAN IMPROVE QUALITY OF LIFE SCORE BY 0.5, THAT’S SSHTED WITH
CLINICAL IMPROVEMENT IN ASTHMA. WE WERE ABLE TO IMPROVE IT BY
0.7, WHICH IS STATISTICALLY SIGNIFICANT AND IT ALSO
REINFORCES OUR OTHER FINDINGS. AND FINALLY JUST THE SLIDE THAT
SHOWS SOME OF THE SORTS OF ENVIRONMENTAL HOME TRIGGERS THAT
WE CAME ACROSS AND WERE ABLE TO ADDRESS.
WE ACTUALLY, OUR COMMUNITY HEALTH WORKERS WILL ADDRESS ANY
ISSUES THAT ARE WITHIN THEIR CONTROL TO ADDRESS, SO IF IT’S
SOMETHING LIKE CLEANING UP MOLD IN A BATHTUB, THEY WILL TEACH
THE FAMILY TO DO, BUT IF IT BECOMES MORE COMPLEX, LIKE A
ROACH INFESTATION IN A BUILDING, WE NEED BRING IN SOMEBODY TO
ASSIST WITH THAT. WE RECEIVED 12E7 REFERRALS THAT
WE HAD�– 72 REFERRALS THAT WE HAD TO REFER OUT TO BUILDING
MANAGEMENT COMPANIES AND WERE ABLE TO SUCCESSFULLY GET 62 OF
THOSE RESOLVED, THIS IS 86%. I THINK ONE OF THE GREATEST
SUCCESSES OF THIS PROJECT WAS THAT WE WERE ABLE TO WORK WITH
THESE BUILDING MANAGEMENT COMPANIES TO DEVELOP BETTER
PROCESSES BY WHICH TO REFER AND GET THINGS ADDRESSED THAT WERE
AFFECTING NOT JUST KIDS WITH ASTHMA, BUT THE PEOPLE LIVING
WITHIN PUBLIC HOUSING. AND THIS IS NOT THE GREATEST
SLIDE, BUT IT DOES SHOW THAT THE PARTICULAR PROJECT WAS
PUBLISHED, SO IF YOU’RE INTERESTED IN LEARNING MORE, THE
CITATION IS HERE. SO NOW I WANT TO JUST TRANSITION
AND TALK A LITTLE BIT ABOUT WHAT WE’VE DONE WITH THE MODEL SINCE
THAT TIME. BEGINNING IN 2013, WE BEGAN
LOOKING AT, WITH ADDITIONAL FUNDING FROM HUD, WE IMPLEMENTED
HELPING CHICAGO’S WEST SIDE ADULTS BREATHE AND THRIVE, SO
NOW WE HAVE PILOT DATA FROM THE PROJECT I JUST DISCUSS
UNDERSTAND ALLOWED US TO SHOW IT DID SEEM THAT THE APPROACH COULD
BE EFFECTIVE WITH ADULTS AND THIS WAS AN OPPORTUNITY TO
REALLY LOOK AT IT MORE FORMALLY, SO THIS IS INNOVATIVE AS IT’S
ONE THE FIRST STUDIES TO ASSESS THE EFFECTIVENESS OF THIS
PROJECT WITH ADULTS. PUBLIC HOUSING IS PART OF THE
POPULATION, BUT WE ARE EXPANDING IT TO INCLUDE THE BROADER
COMMUNITY IN THESE AREAS, AND WE HAVE MULTIPLE EDGE GAUGED
PARTNERS THAT�– ENGAGED PARTNERS THAT HELPING US TO BE
COMPREHENSIVE IN OUR APPROACH. IN RED, YOU CAN SEE ALL THE AREA
WE’RE WORKING WITHIN. WE ARE REFERRING REFERRALS FROM
CHA DEVELOPMENTS, E.D. AND HOSPITALIZATION PRIMARY CARE
PHYSICIANS AND THE INITIAL PHASE OF RECRUITMENT IS DONE AND WE
DID ENROLL 200 ADULTS INTO THE STUDY AND ARE FOLLOWING THEM UP.
THE STRUCTURE OF THE INTERVENTION APPROACH IS SIMILAR
TO WHAT IT WAS FOR THE CHILD INTERVENTION I DISCUSSED, SO SIX
VISITS OVER 12 MONTHS. WE PROVIDE ASSISTANCE IN
ENROLLING INSURANCE AND ESTABLISHING A MEDICAL HOME AND
SUBSTANTIAL CASE MANAGEMENT, HOUSING REFERRALS AND SMOKING
CESSATION AND REDUCTION SUPPORT. I DON’T HAVE TIME TO GO INTO THE
OUTCOMES THAT WE’RE BEGINNING TO LOOK THE, SO THE PRELIMINARY
OUTCOMES DO SUGGEST WE’RE SEEING EFFECTS SIMILAR TO THE PEDIATRIC
STUDIES. MOVING ON FROM THERE, I’M REALLY
EXCITED ABOUT THIS PARTICULAR GRANT THAT WE’VE MUCH MORE
RECENTLY BEGUN WORKING ON. BEGINNING OCTOBER 2015, WE
RECEIVED ANOTHER GRANT FROM HUD TO EXPAND THE ADULT STUDY TO
INCORPORATE A RANDOMIZED STUDY OF MAINTAINED EFFECT.
THIS IS THE SAME QUESTION. WE AND OTHERS HAVE SHOWN THAT
THESE MODELS SEEM TO BE EFFECTIVE WITH CHILDREN, MORE
RECENTLY POSSIBLY WITH ADULTS, AND WHAT HAPPENS WHEN THEY GO
AWAY AND IS THERE SOMETHING WE CAN DO THAT MIGHT BE LOWER
INTENSITY THAT WOULD HELP US TO MAINTAIN THE OUTCOMES FROM A
LONGER TIME AND TRULY MAKE A LONGER TERM IMPACT ON HEALTH?
SO THAT’S WHAT WE’RE TRYING TO ANSWER HERE WITH THE STUDY AND
WE’RE REALLY EXCITED TO HAVE STARTED THIS AND THAT HUD WAS
FORWARD THINKING IN FUNDING THE STUDY.
WE ALSO HAVE WORKED EXTENSIVELY SINCE 2011 TO BEGIN SCALING THE
MODEL UP AND BEGINNING IN 2011, WE LAUNCHED THE ASTHMA CARE
PARTNERS PROGRAM. INITIALLY THERE WAS A
PARTNERSHIP BETWEEN SUI AND FAMILY HEALTH NETWORK, A
MEDICAID MANAGED CARE ORGANIZATION IN CHICAGO, AND
THAT MODEL CONTINUES TO BE IN PLACE.
WE HAVE TO DATE WORKED WITH 583 ADULTS AND CHILDREN IN THIS
PARTICULAR MODEL AND HAVE SHOWN THAT WE CAN WORK WITHIN MEDICAID
MANAGED CARE TO IMPLEMENT THAT’S SORTS OF MODELS AND WE’RE SEEING
SIMILAR EFFECTIVENESS IN THAT POPULATION.
MORE RECENTLY, WE’VE BEGUN EXPLORING ADDITIONAL
POSSIBILITIES WITH SEVERAL ADDITIONAL MEDICAID AND MANAGED
CARE ORGANIZATIONS THAT ARE EXPRESSING AN INTEREST.
FINALLY, I DON’T HAVE TIME TO TALK ABOUT THIS.
IT WAS MENTIONED IN THE BIO, BUT ESSENTIALLY WE ARE PART OF A
FUNDED STUDY, COORDINATED HEALTHCARE INTERVENTIONS FOR
CHILD ASTHMA GAPS AND OUTCOMES, WHICH IS COMPARING THE RESEARCH
STUDY THAT’S LOOKING AT THE MODEL NOW, THE COMMUNITY HEALTH
WORKER MODEL BEING ONE OF SEVERAL COMPARED WORKING OUT OF
EMERGENCY DEPARTMENTS AND THAT’S PRETTY EXCITING.
SO JUST SUMMARIZING ALL THE EVIDENCE THAT WE’VE HAD, IN OUR
15-YEAR HISTORY, WE WORKED WITH OVER 1700 CHILDREN AND ADULTS.
WE’VE HAD CONSISTENT EVIDENCE OF IMPROVED ASTHMA CONTROL.
WE’VE ALSO HAD CONSISTENT IMPROVEMENT IN INTERMEDIATE
OUTCOMES SUCH AS THE PRESENCE OF HOME TRIGGERS, SELF EFFICACY AND
MEDICATION TECHNIQUE. WE LOOKED AT COST SAVINGS AND WE
AVERAGED ABOUT FIVE DOLLARS SAVED PER DOLLAR SPENT AND WE
HAVE COUNTLESS PERSONAL STORIES TO SUPPORT THE MODEL BEING WELL
RECEIVED AND EFFECTIVE. JUST SOME LESSONS LEARNED AND
CHALLENGES AROUND COMMUNITY HEALTH WORKERS.
THEY ARE HIGHLY EFFECTIVE IN IMPLEMENTING THESE SORTS OF
MODELS AND IMPROVING ASTHMA, I BELIEVE IN IMPROVING OUTCOMES
WITH PEOPLE THEY WORK WITH. HOWEVER, EFFECTIVE HIRING AND
TRAINING PROCESSES ARE IMPORTANT AND WE’VE DONE A LOT OF WORK IN
THIS AREA, MORE RECENTLY LOOKING AT BEST PRACTICES FOR
IMPLEMENTING AND EVALUATING COMMUNITY HEALTH WORKER
PROGRAMS. PARTICIPANTS WORKING WITH HAVE A
LOT OF TRUE COMPETING PRIORITIES, SO ASTHMA IS NOT
ALWAYS AT THE CENTER OF THEIR LIVES.
AGAIN, I THINK THAT’S WHERE COMMUNITY HEALTH WORKERS CAN BE
IMPORTANT IN UNDERSTANDING WHERE A PERSON REALLY IS IN THEIR LIFE
AND DEALING WITH THE ISSUES THAT THEY’RE FACED WITH.
COLLABORATION IS KEY. THERE’S BEEN A NEED FOR LEGAL
HOUSING AND SOCIAL SERVICE REFERRALS THROUGHOUT, SO IT’S
IMPORTANT TO HAVE THE RIGHT PARTNERS THIS PLACE AND ONE OF
THOSE PARTNERS SHOULD ACTUALLY BE THE COMMUNITY.
SO IN CONCLUSION, WE’VE MADE A LOT OF PROGRESS AND WHAT WE’RE
REALLY WORKING ON RIGHT NOW IS TRANSLATING THE MODEL TO NEW
POPULATIONS, TESTING WITH ADULTS AND NOW WITH DISSEMINATION
MODELS AND ANOTHER MODEL I’D LIKE TO START WORKING ON AND I
KNOW THE NEXT PRESENTER WILL TALK ABOUT IS STARTING WITH
HOUSING AS A FOUNDATION OF THE WORK INSTEAD OF THE DISEASE AND
WORKING TO MORE COMPREHENSIVELY BUILD IN HEALTH MORE
COMPREHENSIVELY. WITH THAT, THIS IS JUST ONE OF
MY COMMUNITY HEALTH WORKERS WHO LIKES TO SAY TEAMWORK MAKES THE
DREAM WORK AND YOU SEE PICTURES OF THEM.
SO THANK YOU. [ APPLAUSE ]
>>DO WE HAVE A QUESTION FOR HELEN?
>>YES, IF YOU COULD USE THE MIC SO THE PARTICIPANTS IN THE
WEBCAST WILL BE ABLE TO HEAR.>>DO YOU KNOW HOW MUCH IT COST
TO TRAIN THE COMMUNITY HEALTH WORKER AND THE COST OF EMPLOYING
THEM PER YEAR? JUST A ROUGH.
>>IN TERMS OF EMPLOYMENT, IT’S GOING TO VARY DEPENDING ON, YOU
KNOW, WHERE YOU LIVE AND WHAT THE COST OF LIVING IS.
BUT WITH BENEFITS, YOU’RE LOOKING AT PROBABLY LIKE $50,000
A YEAR. POSSIBLY.
AGAIN, EXPERIENCE LEVEL OF THE COMMUNITY HEALTH WORKER PLAYS
INTO THAT. IN TERMS OF TRAINING, IT DEPENDS
ON HOW YOU GO ABOUT IT. WE HAVE A COMPREHENSIVE
APPROACH, SO WE HAVE BEGUN TO BE CONTRACTED OUT QUITE A BIT TO
TRAIN OTHER COMMUNITY HEALTH WORKERS IN OTHER INSTITUTIONS
AND SO I CAN SPEAK A LITTLE TO THAT.
THAT’S ONE WAY OF DOING IT. IF YOU’RE GOING TO DO IT
IN-HOUSE, IT DOES TAKE ABOUT THREE MONTHS TO REALLY
EFFECTIVELY TRAIN A COMMUNITY HEALTH WORKER.
>>ANY MORE QUESTIONS?>>I HAVE ONE.
WITH THE COMMUNITY HEALTH WORKER MODEL, IS IT REALISTIC TO TRAIN
THEM TO ADDRESS MULTIPLE HEALTH OUTCOMES?
HAS THERE BEEN RESEARCH ON THAT?>>THAT’S ANOTHER AREA ACTUALLY
I DIDN’T GET A CHANCE TO GO ON THE NEXT STEPS, BUT THAT’S
ANOTHER AREA WE’RE BEGINNING TO THINK MORE ABOUT.
WHETHER YOU’RE TRAINING�– IT’S DEFINITELY POSSIBLE YOU CAN
TRAIN ONE COMMUNITY HEALTH WORKER TO WORK ACROSS MULTIPLE
HEALTH CONDITIONS, BUT IT MAKES MORE SENSE TO HAVE A TEAM-BASED
APPROACH WHERE YOU HAVE A VARIETY OF COMMUNITY HEALTH
WORKERS WITH VARIOUS AREAS OF EXPERTISE TRAINED IN DIABETES OR
OBESITY OR ASTHMA AND COPD OR WHATEVER IT MIGHT BE AND THAT
TEAM YOU CAN SORT OF COMPREHENSIVELY USE TO IMPROVE
OVERALL HEALTH.>>THANK YOU VERY MUCH.
CAN YOU SUGGEST HOW THE COMMUNITY HEALTH WORKER HAS A
REPORTING RELATIONSHIP WITH THE REST OF THE HEALTH COMMUNITY?
>>YES. SO WHEREVER I GET TOLD BY
SOMEBODY THAT THEY TRIED TO USE COMMUNITY HEALTH WORKERS IN A
HEALTHCARE SETTING AND IT DIDN’T WORK, IT ALMOST COMES BACK TO
WHO’S SUPERVISING THE COMMUNITY LELT WORKER THAT’S THE ISSUE, SO
THAT’S A GREAT QUESTION. WE, WHENEVER WE CAN, WE TRY TO
USE FORMER COMMUNITY HEALTH WORKERS, SO TO HAVE A CAREER
PATH SO THE COMMUNITY HEALTH WORKER CAN BECOME A SUPERVISOR
AND THAT COMMUNITY HEALTH WORKER SUPERVISOR IS REPORTING TO A
PROGRAM MANAGER OR NURSE OR WHOEVER IS APPROPRIATE IN THAT
PARTICULAR SYSTEM. I THINK THE MOST IMPORTANT
THING, AND THIS IS AN AREA WE’RE NOW TRYING TO STUDY MORE AND
LEARN MORE ABOUT AS WELL, WE ALSO CAN TRAIN SUPERVISORS OF
COMMUNITY HEALTH WORKERS, TO BETTER UNDERSTAND HOOT COMMUNITY
HEALTH WORKER IS, WHAT THEY’RE BRINGING TO THE TABLE, WHERE
THEY MIGHT NOT HAVE SKILLS THAT YOU HAVE TO TEACH THEM, BUT THEY
HAVE OTHER SKILLS THAT YOU CAN’T TRAIN SOMEBODY ON.
I THINK WE’RE DOING A LOT OF WORK TO TRY TO HELP EVERYBODY
UNDERSTAND WHO COMMUNITY HEALTH WORKERS ARE AND WHAT VALUE THEY
BRING AND, THEREFORE, SUPERVISE THEM APPROPRIATELY.
DID THAT ANSWER YOUR QUESTION?>>THANKS VERY MUCH, HELEN.
I JUST WANTED TO MENTION THAT WE’LL MAYBE EXTEND THIS TEN
MINUTES OR SO IF WE HAVE ENOUGH Q&A.
SO THOSE WHO ARE ON THE WEBCAST, JUST TO LET YOU KNOW AND THOSE
IN THE ROOM. IT’S A PLEASURE TO INTRODUCE OUR
LAST SPEAKER, DR.�MEGAN SANDELL. MEGAN HAS BEEN INVOLVED IN THE
HEALTH HOMES MOVEMENT SINCE THE START, SO WE’VE KNOWN HER FOR A
LONG TIME AND HAVE BEEN WORKING TOGETHER BECAUSE OF THAT.
DR.�SANDELL IS AN ASSOCIATE PROFESSOR OF PEDIATRICS AT THE
BOSTON UNIVERSITY SCHOOLS OF MEDICINE AND PUBLIC HEALTH.
SHE’S A MEDICAL DIRECTOR OF NATIONAL CENTER FOR MEDICAL
LEGAL PARTNERSHIP, AND IS THE PRINCIPAL INVESTIGATOR WITH
CHILDREN’S HEALTH WATCH. SHE SHE IS THE FORMER PEDIATRIC
MEDICAL DIRECTOR OF BOSTON HEALTHCARE FOR THE HOMELESS
PROGRAM AND IS A NATIONALLY RECOGNIZED EXPERT ON HOUSING AND
CHILD HEALTH. IN 1998, SHE PUBLISHED WITH
OTHER PHYSICIANS AT BOSTON MEDICAL CENTER THE DOCS FOR KIDS
REPORT, A NATIONAL REPORT ON HOW HOUSING AFFECTED CHILD HEALTH,
AND OVER THE COURSE OF HER CAREER, DR.�SANDELL HAS WRITTEN
NUMEROUS PEER-REVIEWED SCIENTIFIC ARTICLES AND PAPERS
ON THIS SUBJECT. SHE HAS SERVED AS THE P.I. FOR
NUMEROUS NIH, HUD, AND FOUNDATION GRANTS WORKING WITH
THE BOSTON PUBLIC HEALTH COMMISSION AND THE MASSACHUSETTS
DEPARTMENT OF PUBLIC HEALTH TO IMPROVE THE HEALTH OF VULNERABLE
CHILDREN, PARTICULARLY THOSE WITH ASTHMA.
SHE HAS SERVED ON MANY NATIONAL BOARDS AS WELL, INCLUDING
ENTERPRISE COMMUNITY PARTNERS AND THE AMERICAN ACADEMY OF
PEDIATRICS.>>SO THANK YOU SO MUCH, PETER.
I REALLY�– IT’S SUCH A PLEASURE TO BE HERE TODAY BECAUSE IN MANY
WAYS, I’M NOT SURE WHERE MY CAREER PATH WOULD BE WITHOUT HUD
AND THE SUPPORT THAT I’VE RECEIVED OVER THE YEARS, SO I
JUST AM REALLY PLEASED TO BE HERE AND TO THANK MANY OF YOU
FOR YOUR SUPPORT. SO I’M GOING TO�– AS KIND OF OF
THE CLEAN-UP HITTER OF THE LINE-UP HERE, I’M GOING TO GET
TO TRY AND TALK A LITTLE BIT ABOUT IDEAS AROUND PLACE-BASED
INITIATIVES TO IMPROVE ASTHMA AND HEALTH, PARTICULARLY
FOCUSSING ON PUBLIC HOUSING, AND I’M GOING TO HOPEFULLY TALK FROM
A POPULATION HEALTH AND POLICY PERSPECTIVE, PARTICULARLY
REFLECTING ON WHAT WE’VE BEEN ABLE TO DO IN BOSTON WITH HUD’S
SUPPORT AND OTHER FEDERAL SUPPORT AROUND THINKING ABOUT A
LOT OF DIFFERENT WAYS IN WHICH WE CAN MAKE REALLY HOUSING TO BE
A PLATFORM FOR HEALTH. AS PETER MENTIONED, ONE OF THE
STUDIES THAT I’VE WORKED WITH HAS BEEN WITH THE DEPARTMENT OF
PUBLIC HEALTH CALLED THE READY STUDY, WHICH IS RUSING ETHNIC
AND RACIAL ASTHMA DISPARITIES IN YOUTH.
THE MASS DEPARTMENT OF PUBLIC HEALTH UNDERTOOK THIS STUDY
REALLY BECAUSE IT VIEWED COMMUNITY HEALTH WORKER STUDIES,
MANY LIKE WHAT HELEN TALKED ABOUT, AS ONE WAY TO REDUCE THE
REALLY AWFUL ASTHMA DISPARITIES THAT WE SEE, KIDS HAVE FOUR
TIMES THE RATE OF E.R. VISITS THAN SIMILAR WHITE CHILDREN, AND
SO WE TALKED ABOUT FOCUSING ON YOUNG CHILDREN AND USING THE
COMMUNITY HEALTH WORKER INTERVENTION FIRST REALLY
PIONEERED IN SEATTLE WITH SOME HUD FUNDING THAT REALLY BECAME A
REALLY IMPORTANT MODEL FOR US TO TRANSLATE TO MASSACHUSETTS.
WE REALLY HAVE FOCUSED A LOT, PARTICULARLY WITH THE MASS
DEPARTMENT OF PUBLIC HEALTH, ON SUSTAINABILITY, HOW DO WE MAKE
THAT THE STANDARD OF CARE SO WHATEVER HOSPITAL OR HEALTH
SENIOR YOU WALK INTO, YOU HAVE�– CENTER YOU WALK INTO,
YOU HAVE THAT AVAILABLE. TWO OF THE HOSPITALS WERE
INVOLVED IN THE INTERVENTION, BOSTON MEDICAL CENTER WHERE I
WORK AND BAY STATE MEDICAL CENTER IN THE WESTERN PART OF
THE STATE IN SPRINGFIELD. WE CONDUCTED THE INTERVENTION
AND ASSISTED IN DEVELOPING A CASE STUDY.
ONE OF THE INTERESTING NOTES IS WE ACTUALLY HIRE THE COMMUNITY
HEALTH WORKERS OUT OF OUR MEDICAL HOME, SO INSTEAD OF
BEING MORE PUBLIC HEALTH DEPARTMENT BASED, WE WERE TRYING
TO TEST THAT. JUST TO GIVE YOU A FLAVOR OF THE
INTERVENTIONS, WE DID NOT DO THIS AS A RANDOMIZED CONTROL
TRIAL DESIGN BECAUSE WE FELT LIKE THAT HAD BEEN DONE BY
SEATTLE. IT WAS ABOUT COULD WE TRANSLATE
AND GET THE SAME EFFICACY AND GOOD NEWS, WE DID.
WE SAW A HUGE REDUCTION IN E.D. VISITS FROM OVER 60% DOWN TO 27%
REDUCTIONS IN HOSPITALIZATIONS, 27% DOWN TO 4%, REDUCTIONS IN
URGENT CARE USE AND ORAL STEROID MEDICATION, AND REALLY FOCUS ADD
LOT ON KIND OF THE QUALITY MEASURES OF HOW DID PEOPLE
UNDERSTAND THEIR ASTHMA, SO NOT ONLY HIGHER RATE MUCH HAVING AN
ACTION PLAN, BUT THEY SAID THEY REMEMBERED THAT THEY HAD, BUT
THEY ACTUALLY USED IT AND IT WAS SOMETHING THAT BECAME KIND OF
THE ROADMAP FOR THEM MOVING FORWARD.
BUT I’M GOING TO ACTUALLY FOCUS ON MORE ON WHAT WE HAVE DONE IN
PARTNERSHIP AROUND A PLACE-BASED COMMUNITY HEALTH WORKER APPROACH
AND I JUST WANT TO REALLY CALL OUT PARTICULARLY BOSTON HOUSING
AUTHORITY AS BEING REALLY A DECADES NOW PARTNER IN THIS.
I THINK THEY REALLY HAVE SERVED AS A MODEL FOR HOW A LARGE
PUBLIC HOUSING AUTHORITY CAN REALLY TAKE THAT ON AS A
MISSION. FOR THOSE THAT AREN’T FAMILIAR,
BOSTON HOUSING AUTHORITY IS THE LARGEST PUBLIC HOUSING AUTHORITY
IN NEW ENGLAND. IT’S THE LARGEST PROPERTY OWNER
IN BOSTON AND IT ACTUALLY HOUSES CLOSE TO 10% OF ALL OF BOSTON’S
RESIDENTS. ABOUT 50,000 PEOPLE.
AND FOR THOSE THAT WOULD SAY, WHY WOULD YOU PARTNER WITH
BOSTON HOUSING AUTHORITY FOR THIS?
THIS IS A MAP OF THE CITY OF BOSTON AND WHAT YOU SEE IN THE
DARK GREEN CENTER AREA OF THE INNER CITY IS THE HIGHEST RATES
OF ASTHMA, SO IN THE DARKEST AREA IN THE CENTER IN ROXBURY,
ONE OF THE NEIGHBORHOODS OF BOSTON, 22 PER THOUSAND KIDS ARE
HOSPITALIZED WITH ASTHMA RELATIVE TO THE STATE AVERAGE OF
ONLY 4 PER THOUSAND KIDS. SO WHEN YOU START THINKING ABOUT
WHERE ARE YOU GOING TO CONCENTRATE YOUR EFFORTS IN KIND
OF THE PUBLIC HEALTH WORLD, WE CALL IT HOT SPOTTING, RIGHT?
THIS IDEA OF WHERE ARE YOU GOING TO FOCUS?
YOU WANT TO LOOK AT YOUR NAP AND WHEN YOU LOOK AT THAT MAP, YOU
WANT TO DOT THE PUBLIC HOUSING AUTHORITY PUBLIC HOUSING AND
THERE’S A LOT OF CONCENTRATION IN THESE HIGHEST AREAS.
WE REPLICATED THE COMMUNITY HEALTH WORKER MODEL SIMILAR TO
WHAT HELEN TALKED ABOUT WHERE YOU FIND THE ASTHMATICS FIRST
AND THEN YOU GO TO YOUR HOMES. WE WANTED TO FLIP THAT AROUND
AND SAY WHAT IF WE FOUND THE HOMES FIRST AND THEN TRIED TO
FIND THE ASTHMATICS, AND SO WHY WOULD YOU WANT TO FOCUS ON
PUBLIC HOUSING RESIDENTS? THE OTHER THING I THINK IS
REALLY IMPORTANT TO THINK B THESE RESIDENTS ARE ON AVERAGE
MUCH SICKER THAN THE AVERAGE POPULATION AND SO IN
MASSACHUSETTS AND PARTICULAR IN BOSTON, WHEN WE DO REGULAR
SURVEILLANCE, SOMETHING CALLED THE BEHAVIORAL RISK FACTOR
SURVEY, WE ADDED A QUESTION PRETTY�– YOU KNOW, IN THE LAST
TEN YEARS, WHICH WAS DO YOU LIVE IN PUBLIC HOUSING, YES, NO.
DO YOU LIVE IN OTHER SUBSIDIZED HOUSING, YES, NO.
WHAT THAT NOW ALLOWS IS FROM THE PUBLIC HEALTH DEPARTMENT, WE CAN
LOOK AT THE POPULATION THAT LIVES IN PUBLIC HOUSING RELATIVE
TO OTHERS THAT ARE REFERRING OTHER FORMS OF RENTAL ASSISTANCE
RELATIVE TO THE GENERAL POPULATION THAT’S NOT IN PUBLIC
HOUSING. WHEN WE LOOK AT SOMETHING THAT’S
PRETTY PREDICTIVE OF POOR HEALTH OUTCOMES AND HEALTH UTILIZATION,
THIS IS A SIMPLE QUESTION, HOW DO YOU RATE YOUR HEALTH.
YOU CAN SAY EXCELLENT, VERY GOOD, GOOD, FAIR OR POOR.
WHAT WE SEE IS THAT 33% OF THE BOSTON HOUSING AUTHORITY
PATIENTS SAY THEY’RE IN FAIR OR POOR HEALTH.
AND THAT IS BEING SHOWN TO BE PREDICTIVE OF BAD HEALTH
UTILIZATION, INCREASED MORTALITY, JUST A VERY VALIDATED
QUESTION. SIMILARLY, WE LOOKED AT POOR
MENTAL HEALTH AND OVER 20% OF THE BOSTON HOUSING AUTHORITY
POPULATION IS SAYING THEY’RE IN POOR MENTAL HEALTH RELATIVE TO
ONLY 7% OF THE GENERAL POPULATION.
AND WE TALKED ABOUT SMOKING. SMOKING IS SOMETHING THAT’S
HIGHER IN RENTAL ASSISTANCE AND BOSTON HOUSING AUTHORITY AND I’M
GOING TO TALK A LITTLE BIT ABOUT HOW BOSTON THAT IS KIND OF
ATTACKED THAT�– HAS KIND OF ATTACKED THAT.
WHAT WE DID IS WE SAID, OKAY, WE KNOW SOME OF THE SICKEST PEOPLE
LIVE IN BOSTON HOUSING AUTHORITY AND WE KNOW THERE’S SOME
NEIGHBORHOODS WITH HIGHER RATES OF ASTHMA AND HAVE MORE HOUSING
DEVELOPMENTS AND OUT OF THAT CAME WHAT WE CALLED PROJECT
LEAP, WHICH WAS REALLY DOING PUBLIC HOUSING-BASED COMMUNITY
HEALTH WORKERS AND USING THAT AS A PLACE-BASED APPROACH TO
IMPROVE HEALTH AND ASTHMA. AND SO WE CALLED PROJECT LEAP, I
WAS LIVING ENVIRONMENTAL ASSESSMENTS PROJECT, AND SO
WHAT’S INTERESTING HERE IS WE ACTUALLY DID ENVIRONMENTAL
ASSESSMENTS AND INTERVENTIONS ON EVERYONE.
EVEN IF THEY DIDN’T HAVE ASTHMA. BECAUSE THE THEORY WAS, THAT THE
ASTHMATIC FAISH WAS LIVING FLEX TO�– PATIENT WAS LIVING NEXT TO
SOMEBODY WHO MAY NOT BE TAKING CARE OF THEIR ENVIRONMENT AND
THEREFORE THE PESTS WERE GOING BACK AND FORTH BETWEEN THE
WALLS, THE MOLD WAS AN ISSUE, THE SMOKE WAS TRAVELING, AND SO
WE WERE TAKING A BUILDING-WIDE APPROACH TO IT.
AND SO WE REALLY FOCUSED NOT ON PUTTING ASTHMA IN THE NAME OF
THE TITLE, BUT REALLY FOCUSING ON LIVING ENVIRONMENTS AND BEING
ABLE TO MAKE THAT WORK. AND SO THIS WAS IN PARTNERSHIP
WITH THE HOSPITAL I WORKED A, BOSTON MEDICAL CENTER, AND THE
BOSTON PUBLIC HEALTH COMMISSION AND WE WERE ENROLLING 160
FAMILIES. AS YOU CAN IMAGINE, WE FOCUSED
ON TWO HOUSING DEVELOPMENTS THAT WERE AMONG THE OLDEST IN THE
BOSTON HOUSING AUTHORITY PORTFOLIO THAT WERE IN THE
NEIGHBORHOOD OF ROXBURY THAT I MENTIONED.
ONE OF THEM IS LENOX-CAMDEN. THE LENOX SIDE DATES BACK TO
1939 AND THE CAMDEN SIDE BACK TO 1949.
HIGH RATES OF HISPANIC AND BLACK POPULATIONS, ABOUT 375 UNITS,
650 PEOPLE IN TOTAL. THE AVERAGE INCOME IN THE
DEVELOPMENT IS ABOUT $13,000 AND ABOUT 40% OF THE PEOPLE THAT ARE
LIVING THERE ARE KIDS, 0 TO 18. THE ALICE TAYLOR DEVELOPMENT IS
A LITTLE BIT YOUNGER, 1951 WHEN IT WAS BUILT, BUT AGAIN, VERY
SIMILAR RATES OF HISPANIC AND BLACKS.
366 UNITS, ABOUT 850 PEOPLE, A LITTLE BIT DENSER, A LITTLE BIT
HIGHER IN THE INCOME RANGE, ABOUT 15,000, AND AGAIN, ABOUT
36% WERE YOUNG KIDS. WE TOOK THESE TWO HOUSING
DEVELOPMENTS AND WE HIRED THE COMMUNITY HEALTH WORKERS FROM
PEOPLE WHO LIVED IN BHA HOUSING. WE ACTUALLY MADE A CONSCIOUS
DECISION NOT TO HIRE PEOPLE WHO LIVED IN THOSE DEVELOPMENTS, BUT
PEOPLE WHO LIVED IN OTHER DEVELOPMENTS, AND WE DID THAT
BOTH IN TERMS OF WANTING TO OFFER A CAREER PATH FOR PEOPLE
WHO LIVED IN BHA HOUSING AND I’LL TALK A LITTLE BIT ABOUT HOW
WE LEARNED FROM THAT, BUT ALSO THAT WE KNEW THAT PEOPLE WHO
LIVED IN PUBLIC HOUSING WOULD BE ABLE TO TALK TO OTHER PUBLIC
HOUSING RESIDENTS, HOPEFULLY N A WAY THAT WAS CULTURALLY
APPROPRIATE AND THAT IS SOMETHING THAT IS VERY MUCH PART
OF BEING A COMMUNITY HEALTH WORKER.
AND SO REALLY OUR STUDY OBJECTIVES, THE GOALS WERE TO
SAY WHAT’S THE EFFECT OF A COMMUNITY HEALTH WORKER IN A
PLACE-BASED MODEL WHERE YOU’RE TRYING TO START FROM THE PLACE
FIRST AND THEN FIND THE PEOPLE SECOND.
WE WANTED TO SEE WHETHER WE COULD REDUCE EXPOSURE TO
TRIGGERS, PARTICULARLY IN VERY OLD PUBLIC HOUSING DEVELOPMENTS,
AND THEN WE WANTED TO SEE WHETHER OR NOT WHAT THE EFFECT
OF THE HOME-BASED ASTHMA ENVIRONMENTAL EDUCATION WAS ON
ASTHMA CONTROL. I WANT TO SAY THE IMPORTANT
THING OF NOTE WAS WE DID NOT DO ASTHMA EDUCATION WITH PEOPLE.
WE DID MOSTLY ENVIRONMENTAL REDUCTION.
IF PEOPLED THAT UNCONTROLLED ASTHMA AND NEEDED CONNECTION
BACK TO THEIR MEDICAL HOME, WE DID DO THAT, BUT I’LL BE TALKING
ABOUT JUST THE EFFECT OF ENVIRONMENTAL ONLY EDUCATION ON
ASTHMA CONTROL TODAY. SO WE ENROLLED 160 PEOPLE.
THE INTERVENTIONS WERE THINGS LIKE, AS I SAIDINGS EDUCATION
AROUND ENVIRONMENTAL TRIGGERS. WE ACTUALLY DID FACILITATION
AROUND ORDERING WORK ORDERS, SO SIMILAR TO WHAT HELEN TALKED
ABOUT IS THE NICE THING WAS YOU WERE PARTNERING WITH THE
LANDLORD. YOU KNEW HOW TO DUTY WORK ORDERS
TO GET THE CONDITIONS FIXED. WE DID A LOT OF ADVOCACY FOR
THINGS LIKE FOOD, AFFORDING MEDICINES, REFERRAL TO FREE
LOCAL RESOURCES, CONTINUOUS SUPPORT, PARTICULARLY AROUND
PHONE SUPPORT BETWEEN VISITS AND THEN FOLLOW-UP OVER TIME.
I SHOULD NOTE WE DID THREE VISITS OVER THE TIME PERIOD,
GENERALLY BETWEEN THREE TO SIX MONTHS.
ABOUT 80% WERE FEMALE HEAD OF HOUSEHOLDS, AND THE RACE
ETHNICITY REFLECTED THOSE OF THE DEVELOPMENTS, 40% HISPANIC, 30%
BLACK NON-HISPANIC, ONE% WHITE AND 12% OTHER.
THE EDUCATION CAN VARY. ABOUT 26% DID NOT HAVE A
GRADUATED HIGH SCHOOL EDUCATION. ABOUT 55%, HIGH SCHOOL OR G.E.D.
GRADUATE. 12% HAD SOME COLLEGE.
THE AVERAGE AGE WAS 39, THOUGH IT RANGED FROM 20 UP TO 74.
I WANT INTERESTING, WE THOUGHT WE WOULD FIND MORE ASTHMATICS
THAN WE THOUGHT, MOSTLY BASED ON PREVIOUS RESEARCHED THAT SHOWED
UP TO 50% OF BOSTON HOUSING AUTHORITY RESIDENTS COULD HAVE
ASTHMA. WHAT WE FOUND WAS ACTUALLY ABOUT
27% OF THE 160 UNITS HAD AT LEAST ONE ASTHMATIC AND MANY OF
THE HOUSEHOLDS HAD MORE THAN ONE.
IF YOU HAD MORE THAN ONE ASTHMATIC IN A UNIT, WE ACTUALLY
WOULD ENROLL THEM TOO, SO 64 TOTAL ASTHMATICS, REFLECTING 27%
OF THE UNITS. BUT THEY WERE FAIRLY POORLY
CONTROLLED, SO WITHOUT USING POORLY CONTROLLED AS AN ENTRY
CRITERIA, WHICH OFTENTIMES A LOT OF COMMUNITY HEALTH WORKER
STUDIES ARE FOCUSED ON HIGH-RISK ASTHMATICS, WE STILL FOUND THAT
ALMOST 60% OF THEM WERE NOT WELL OR POORLY CONTROLLED.
ONLY ABOUT 40% HAD A WELL CONTROLLED ASTHMA CONTROL TEST
SCORE. 12% REPORTED AN ASTHMA RELATED
HOSPITALIZATION AND 36, SOME TYPE OF EMERGENCY OR URGENT CARE
VISIT. WITHOUT TRYING, WE FOUND PRETTY
SICK ASTHMATICS PRETTY QUICKLY. ONE OF THE THINGS THAT I ADDED
TO THIS STUDY WAS ACTUALLY LOOKING AT STRESS AND THE FIVE
YEARS THAT THERE’S MORE AND MORE EVIDENCE THAT HOUSING QUALITY
CAN BE RELATED TO MENTAL HEALTH OUTCOMES, THERE’S REALLY NICE
RESEARCH THAT WAS SUPPORTED BY THE MacARTHUR FOUNDATION OUT OF
BOSTON COLLEGE, THAT SHOWED THAT HOUSING QUALITY WAS THE
STRONGEST PREDICTOR OF KIDS’ ACHIEVEMENT IN SCHOOL AND
PARENTAL MENTAL HEALTH AND DISTRESS.
OUTSIDE OF THE OTHER TYPICAL THINGS THAT YOU WOULD EXPECT.
SO WE ACTUALLY SHOWED THAT OVER THREE VISITS, WE WERE ABLE TO
DECREASE THE PERCEIVED STRESS SCORE FROM 17 DOWN TO 15.8 OVER
THAT TIME PERIOD. SO AGAIN, BEING ABLE TO TALK
ABOUT HOW ENVIRONMENTAL CONTROL CAN ACTUALLY HAVE DIFFERENT
HEALTH OUTCOMES BEYOND JUST WHAT THE ASTHMA OUTCOMES WERE.
AND THEN WE DID SEE REDUCTION IN TRIGGERS.
THESE BEING VERY OLD DEVELOPMENTS, MOLD IS ACTUALLY A
VERY HIGH RATE. OVER 90% OF THE HOMES HAD SOME
TYPE OF A MOLD OR DAMPNESS TRIGGER.
WE WERE ABLE TO GET THAT DOWN TO 75%.
WE REDUCED FEST INFESTATIONS BY 24% DOWN TO 16% AND CHEMICAL
USE, WHICH IS VERY COMMON, ABOUT 62%, WE GOT THAT DOWN TO ABOUT
52%. THERE WERE LOWER LEVEL EXPOSURES
OF DUST, PETS AND SMOKE. WE WERE NOT ABLE TO MAKE ANY
TYPESES OF MOVEMENT ON THOSE. I THINK IT REFLECTS P I THINK A
LITTLE BIT FOCUS ON THE OTHER TRIGGERS.
WE WERE ABLE TO IMPROVE ASTHMA CONTROL OVER THE COURSE OF THE
STUDY, SO WE WENT FROM 40% TO CLOSE TO 60% OF PEOPLE WELL
CONTROLLED JUST BY FOCUSING ON ENVIRONMENTAL, NOT NECESSARILY
ASTHMA EDUCATION. SO THIS IS ONE OF OUR
PARTICIPANTS, PROJECT LEAD, A VERY GOOD PROGRAM.
THEY HELP ME OUT AND STILL ARE. ONE OF THE THINGS WE UNCOVERED
WAS THE WORK ORDER SYSTEM. ONE OF THE THINGS THAT CAME OUT,
NONE IN THE WORK SAID SYSTEM SPOKE SPANISH.
IT’S HARD TO CALL IN WORK ORDER. YOU’RE TRYING TO YELL OVER THE
PHONE IN ENGLISH BACK TO SOMEBODY, SOS WOFRT THINGS THAT
HAPPENED, ONE OF OUR COMMUNITY HEALTH WORKERS WAS HIRED AWAY
FROM US TO WORK IN THE WORK ORDER SYSTEM BECAUSE SHE SPOKE
SPANISH AND ENGLISH, AND WE CONSIDER THAT ONE OF OUR SUCCESS
STORIES. I THINK PLACE-BASED RECRUITMENT
IS THE RIGHT WAY TO GO, THOUGH THERE ARE SOME PROS AND CONS.
ONE OF THE THINGS WE NOTED BETWEEN THE TWO DEVELOPMENTS WAS
DIFFERENT RESIDENT ADVISORY BOARDS, SO THE TENANT TASK
FORCES IN EACH OF THEM WERE QUITE DIFFERENT AND ONE OF THE
DEVELOPMENTS THAT DIDN’T HAVE AS GOOD OF A RESIDENT TASK FORCE,
IT WAS MUCH HARDER TO GET REFERRAL WORD OF MOUTH BECAUSE
THERE WASN’T AS MUCH SOCIAL COHESION IN THAT PARTICULAR
DEVELOPMENT, WHEREAS ONLY LITERALLY TWO BLOCKS AWAY WAS
ANOTHER DEVELOPMENT WITH A MUCH MORE ACTIVE RESIDENT TASK FORCE
AND WE HAD INSTITUTED A REFER A FRIEND PROGRAM THERE, OUR
INSTITUTIONAL REVIEW BOARD SIGNED OFF ON WE COULD
REIMBURSES SOMEONE IF THEY REFERRED SOMEONE WHO ACTUALLY
ENROLLED IN THE PROGRAM, SO THAT WORKED A LOT BETTER IN THE
SECOND DEVELOPMENT AND THAT WAS BECAUSE THE RESIDENT TASK FORCE
KNEW MOST PEOPLE AND THEY KNEW WHERE SOMEBODY HAD A KID WITH
ASTHMA. AND THEY WOULD SAY, I’M GOING TO
CALL THEM FOR YOU, GET THEM IN THE NUMBER, SO IT’S AN
INTERESTING KIND OF IDEA OF AROUND THE SOCIAL NETWORKING
THAT CAN SOMETIMES MAKE OR BREAK A PLACE-BASED APPROACH.
THE OTHER THING IS THAT WE HAVE NOW HAD�– WE TRAINED FIVE
COMMUNITY HEALTH WORKERS IN TOTAL OVER THE THREE YEARS OF
THE STUDY AND EACH OF THEM ARE NOW WORKING IN SOME RELATED
COMMUNITY HEALTH WORKER STYLE FIELD, WHETHER THEY BE HELPING
WITH FACILITATION OF THE WORK ORDER SYSTEM.
ONE OF THEM IS ACTUALLY WORKING ON ANOTHER PLACE-BASED APPROACH
TO DECREASE USE OF SUGAR-SWEETENED BEVERAGES IN THE
SAME HIGH DENSITY NEIGHBORHOODS THAT HAVE THESE REALLY HIGH
RATES OF OBESITY AND OTHER PROBLEMS.
SO I JUST WANT TO STEP BACK AND REFLECT A LITTLE BIT ON A
TIMELINE OF WHAT IS HAPPENING IN BOSTON AROUND HEALTHY HOMES
COLLABORATIONS AND A LOT OF IT IS WITH SUPPORT OF HUD AND SO
THAT IN 1999, WE ACTUALLY FOUNDED AN ASTHMA OFFICE AND A
HEALTHY HOMES OFFICE AT THE BOSTON PUBLIC HEALTH COMMISSION
WITHES WOULD OF THE FIRST HEALTHY HOMES DEMONSTRATION
GRANTS. IN I HAVE TWO WE STARTED A�–
2005, WE STARTED A PROGRAM CALLED BREATHE EASY AT HOME
WHICH IS A DIRECT REFERRAL TO CODE ENFORCEMENT, THE
INSPECTIONAL SERVICES DEPARTMENT IN THE CITY OF BOSTON WHERE WHEN
I SEE A PATIENT IN MY OFFICE NOW, I CAN LOG ON TO THE WEB AND
REFER DIRECTLY TO CODE ENFORCEMENT TO TRY AND GET THAT
HOME IMPROVED. WE’LL TALK A LITTLE BIT ABOUT
HEALTHY PEST FREE PUBLIC HOUSING, WHICH IS AN INITIATIVE
STARTED AT BOSTON HOUSING AUTHORITY SHOWING YOU CAN DO
ACTUAL PEST CONTROL AND ACTUALLY ACHIEVE A PEST-FREE STATUS.
WE’LL TALK ABOUT THE FIRST LARGE PUBLIC HOUSING AUTHORITY TO GO
SMOKE FREE AND TALK ABOUT SOME OF THE NEWER THINGS.
THE RENTAL INSPECTION ORDINANCE AND THE OFFICE OF FAIR HOUSING
WHICH NOW IS THE OFFICE OF FAIR HOUSING AND EQUITY.
SO BREATHE EASY AT HOME IS NOW A REALLY NATIONALLY AWARD WINNING
PROGRAM ACKNOWLEDGED BY EPA AND THE NATIONAL ASSOCIATION OF CITY
AND COUNTY OFFICIALS. IT’S WHERE THE INSPECTIONAL
SERVICES DEPARTMENT HEALTH INSTITUTIONS LIKE BOSTON MEDICAL
CENTER AND THE BOSTON PUBLIC HEALTH DEPARTMENT WORK TOGETHER
TO TRY AND MAKE HEALTHY HOMES SOMETHING THAT DONE, MORE
ACHIEVED, SO IF YOU LIVE ANYWHERE IN THE CITY OF BOSTON
AND YOU’RE SEEN AT ANY OF THE HEALTH CENTERS, YOU CAN ACCESS
WEB-BASED REFERRAL DIRECTLY TO CODE ENFORCEMENT AND WHAT
HAPPENS IS THE INSPECTIONAL SERVICES DEPARTMENT THEN WILL
PUT EMAIL UPDATES BACK TO THE REFERRAL SOURCE SO YOU KNOW WHAT
HAPPENED. SO WHAT WE’VE SEEN IS NOW THE
REFERRALS HAVE KIND OF TAKEN OFF OVER THE YEARS FOR THAT FIRST
YEAR IN 2005 WHERE WE PILOTED JUST 16 TO MOST RECENTLY CLOSE
TO 250 REFERRALS A YEAR. WE ACTUALLY HAVE STARTED TO LOOK
AT THIS AGAIN AND THINKING ABOUT WHAT WE CALL BREATHE EASY 2.0.
WE THINK THE NUMBERS SHOULD BE CLOSER TO A THOUSAND KIDS
ACTUALLY IN BOSTON, SO WE’RE DOING NOW QUALITY IMPROVEMENT TO
THINK ABOUT WAYS IN WHICH WE CAN DO A BETTER JOB AND WHAT’S
INTERESTING IS WE THOUGHT A LOT ABOUT WHERE THE FAILURES IN OUR
SYSTEM ARE, AND ACTUALLY THE BIGGEST FAILURE IS WE AS
PHYSICIANS DON’T ASK, RIGHT? IF WE DON’T ASK, THEN YOU DON’T
MAKE THE REFERRAL, AND SO WE’RE THINKING ABOUT WAYS IN WHICH WE
MAY ACTUALLY SKIP THE ASKING PART AND JUST SAY, YOU LIVE IN A
NEIGHBORHOOD NA HAS A LOT OF OLD HOUSING AND OTHER THINGS, WE
SHOULD JUST AUTOMATICALLY REFER YOU TO THIS PROGRAM.
HEALTHY PEST-FREE PUBLIC HOUSING WAS SOMETHING SUPPORTED
INITIALLY BY HUD AND THEN BY THE W.K. KELLOGG FOUNDATION.
A PARTNERSHIP BETWEEN BOSTON PUBLIC HEALTH COMMISSION, BOSTON
HOUSING AUTHORITY, A TENANT RIGHTS ORGANIZATION, COMMITTEE
FOR BOSTON PUBLIC HOUSING AND THE BU SCHOOL OF PUBLIC HEALTH.
IT WAS A MULTIPRONGED INTERVENTION LOOKING AT
STANDARDIZED INTEGRATED PEST MANAGEMENT CONTRACTS USING
DEVELOPMENTS AND RESIDENT EDUCATION AND DOING PESTICIDE
BUY BACK AND THEY CAN DOCUMENT A REDUCTION IN WORK ORDERS BY
PESTS. ONE OF THE TECHNICAL STUDIES IS
ACTUALLY NOW LOOKING AT WHAT WAS THE DIFFERENT DOSES OF THE PEST
MANAGEMENT THAT WAS DONE IN THE DIFFERENT DEVELOPMENTS AND
LOOKING AT THE LONG-TERM HEALTH AND MENTAL HEALTH, NOT ONLY
PHYSICAL HEALTH, BUT MENTAL HEALTH OF THE RESIDENTS.
SMOKE-FREE PUBLIC HOUSING IS SOMETHING WHERE, THROUGH A LOT
OF COLLABORATION, BOSTON HOUSING AUTHORITY BEGAN THE PROCESS OF
GOING SMOKE-FREE IN RENTAL HOUSING IN 2010 AND FULLY
IMPLEMENTED IN 2012. AGAIN, THIS WAS A CROSS ALREADY
SECTOR COLLABORATION BETWEEN�– CROSS-SECTOR COLLABORATION
BETWEEN BOSTON PUBLIC HOUSING AUTHORITY, AND WE WANTED TO DO
RESIDENT OUTREACH AND EDUCATION TO SAY THIS IS WHY WE’RE DOING
THIS, THIS IS WHY IT’S IMPORTANT.
I THINK WHAT’S ALSO COOL IS THE BOSTON PUBLIC HEALTH COMMISSION
AT THAT POINT STARTED A SMOKE FREE HOUSING REGISTRY, SO ASIDE
FROM BOSTON PUBLIC HOUSING YOU WANTED TO RENT AN APARTMENT, IT
WAS OFFERED AS A FREE SERVICE TO LANDLORDS TO LIST THEIR
APARTMENTS AS SMOKE FREE AND PROVIDE TECHNICAL ASSISTANCE AND
TRAINING TO OTHER LANDLORDS WHO WANTED TO GO SMOKE FREE.
PETER ALLUDED TO THIS AND THIS IS A TREND WE HAVE NOW SEEN OVER
THE LAST COUPLE OF YEARS. THE BEHAVIOR RISK FACTOR
SURVEILLANCE SURVEY TRACKED PEOPLE WHO LIVE IN PUBLIC
HOUSING, OTHER RENTAL ASSISTED HOUSING AND THOSE IN REGULAR
HOUSING IN BOSTON AND WHICH WAS NOTED IN 2006, THE REPORTED
ASTHMA RATE IN ADULTS WAS ABOUT 23%.
IN 2008, WE SAW IT DROP TO 16% AND 2010, IT DROPPED TO 13%.
WHAT’S OF NOTE IS OVER THE SAME TIME PERIOD, OTHER ASSISTED
HOUSING DID NOT SEE THAT DECREASE.
YOU SAW A CONSISTENT RATE OF SOMEWHERE BETWEEN 22 AND 23%
THAT HAD ASTHMA AND YOU SAW NO CHANGE IN THE ALL OTHERS, SO
PART OF THIS IS ACTUALLY ATTRIBUTED TO MUCH OF THE WORK
THAT WE’RE TALKING ABOUT. PEST FREE HOUSING, SMOKE FREE
HOUSING, OTHER WAYS YOU START TO SEE THAT.
JUST OF NOTE, THE INSPECTIONAL SERVICES DEPARTMENT HAS REALLY
EMBRACED ITS PUBLIC HEALTH MISSION, SO THEY GOT PASSED BY
THE CITY COUNCIL IN 2012, A PRO ACTIVE RENTAL INSPECTION
ORDINANCE, SO AND WHAT THE COMMISSIONER SAID TO ME IS LET’S
NOT WAIT UNTIL SOMEBODY COMES TO YOUR OFFICE AND HAS A PROBLEM
WITH ASTHMA. LET’S MAKE SURE EVERY SINGLE
HOME IS ASTHMA SAFE TO START WITH.
SO NOW 150,000 UNITS IN THE CITY OF BOSTON NEED TO BE CERTIFIED
EVER ‘. THE OFFICE OF HOUSING HAS ADDED
THE WORD EQUITY BECAUSE IT VIEWS THAT A LOT OF WHAT IT’S DOING IS
THIS PRINCIPAL OF ADVANCING EQUITY.
VERY CONSISTENT WITH WHAT THE AFFIRMATIVE RULE ON FAIR HOUSING
THAT HUD IS NOW REALLY PUSHING FORWARD, AND NOW IT HAS TAKEN
OVER THE SMOKE FREE HOUSING REGISTRY AND DOING A LOT OF
RESIDENT AND LANDLORD OUTREACH. SO NOW WHAT I SHOWED AS A
TIMELINE IS REALLY A CONSORTIUM OF YOU HAVE HEALTH INSTITUTIONS
LIKE MINE, BOSTON MEDICAL CENTER.
YOU HAVE THE BOSTON PUBLIC HEALTH COMMISSION, THE CITY’S
PUBLIC HEALTH DEPARTMENT, INSPECTIONAL SERVICES
DEPARTMENT, THE BOSTON OFFICE OF FAIR HOUSING AND EQUITY, AND
THEN YOU HAVE BOSTON HOUSING AUTHORITY AS A CONSORTIUM THAT
ARE REALLY TRYING TO THINK ABOUT THESE ISSUES AS A WAY TO IMPROVE
POPULATION HEALTH IN BOSTON AND I THINK THIS HOPEFULLY CAN SERVE
AS A MODEL ACROSS THE COUNTRY OF WHAT YOU CAN DO WITH THE
INVESTMENTS. WITH THAT, I JUST WANT TO THANK
YOU AGAIN AND OPEN FOR QUESTIONS.
[ APPLAUSE ] WITH.
>>DO WE HAVE ANY QUESTIONS FOR MEGAN?
>>I’VE GOT ONE. YOUR PLACE-BASED APPROACH, YOU
WENT INTO UNITS OF HOUSEHOLDS WITH NO ASTHMATIC CHILD OR
ADULT. WHAT’S THEIR INCENTIVE TO CHANGE
AND WHAT WAS THE DIFFERENCE BETWEEN THE TWO?
>>YEAH. I THINK IT’S INTERESTING.
SO AS I ALLUDED TO, I’VE DONE BOTH MODELS.
I’VE DONE THE FIND THE ASTHMATIC FIRST AND GO TO THEIR HOME AND
IN THIS CASE, WE WERE GOING TO THE UNIT FIRST AND THEN TRYING
TO FIND THE ASTHMATICS. WHAT’S INTERESTING IS THAT
TYPICALLY IN AN ASTHMATIC KID UNIT WHERE WE’RE DOING THIS
ENVIRONMENTAL EDUCATION, WE ACTUALLY SEE LARGER REDUCTIONS
IN THE ASTHMA CONTROL, SO TYPICALLY WE SEE ABOUT AT LEAST
ONE TRIGGER OF THE SIX THAT I MENTIONED, THAT GETS REDUCED.
IF THIS STUDY, WE SAW A LOWER REDUCTION, ABOUT HALF OF THINGS
THAT WERE CHANGED. I THINK PARTICULARLY OF NOTE,
CHEMICALS IS A VERY COMMON TRIGGER THAT ACTUALLY FAIRLY
MODIFIABLE ONCE YOU CAN ENGAGE SOMEONE IN THE FACT THAT THERE
ARE EASIER WAYS TO CLEAN THAT ISN’T BLEACH AND THINGS LIKE
THAT. IN THIS CASE, IT WAS A MORE
DIFFICULT SELL BECAUSE YOU DIDN’T HAVE THE ASTHMA AS KIND
OF THE DRIVING FACTOR. THE OTHER PIECE IS THAT
TYPICALLY WHEN WE DO THE COMMUNITY HEALTH WORKER
INTERVENTIONS WITH KIDS WITH ASTHMA, WE’RE IDENTIFYING KIDS
WITH AN E.R. HOSPITALIZATION TYPICALLY RECENTLY, TENDS TO BE
A TEACHABLE MOMENT IN A FAMILY’S LIFE WHERE THEY DON’T WANT THAT
TO HAPPEN AGAIN, SO I DO THINK IT MEANS THERE MAY BE A HIGHER
DOSE. I REALLY LIKE WHAT ELIZABETH
TALKED ABOUT AROUND THIS IDEA OF WE NEED TO THINK LIKE PHARMA.
PHARMA THINKS ABOUT DOSING ALL THE TIME.
WHAT’S THE HIGH DOSE EFFECT, WHAT’S THE LOW DOSE EFFECT, DO
SOME PEOPLE NEED A LONGER DOSE AND WE NEED TO THINK MORE ABOUT
TAILORING AND THINKING ABOUT IT. THE OTHER PIECE THAT I’VE BEEN
MORE INTRIGUED WITH RECENTLY IS THE IDEA COMMUNITY WIDE
EDUCATION. I THINK THAT INTEGRATED PEST
MANAGEMENT IS A NICE WAY OF THINKING ABOUT THOSE COMMUNITY
WIDE INTERVENTIONS AROUND YOU CAN BE PEST FREE, WE NEED TO GET
RID OF THE PESTICIDES, DO A BETTER JOB, YOU NEED TO REPORT
WHEN YOU HAVE PESTS BECAUSE THAT’S FEEDBACK THAT THE
CONTRACTOR IS NOT DOING THEIR JOB AND AS THAT KIND OF
COMMUNITY WIDE EDUCATION WAS DONE, I THINK IT PROVED TO BE A
LOT MORE EFFECTIVE.>>THANK YOU.
AND THEN ONE MORE. ANYBODY ELSE COME UP WITH A
QUESTION IN THE MEANTIME? ONE STATISTIC I SAW, I
NOTICED�– I THINK IT IT WAS ONE OF YOUR SLIDES, REDUCTIONS OF
MOLD FROM 94%�– BUT IT’S STILL 75%.
WHAT’S GOING ON THERE. MAYBE OUR FRIENDS FROM OFFICE OF
PUBLIC HOUSING MIGHT HAVE SOMETHING TO SAY ABOUT THAT.
I KNOW FUNDS FOR MAINTENANCE, CAPITAL EXPENDITURES HAVE BEEN
CUT. WE HEARD THAT A LOT FROM HOUSING
AUTHORITIES, BUT DID YOU GET ANY INSIGHT ABOUT WHAT’S UP?
>>IT’S REALLY INTERESTING. SO AS I NOTED, THAT
PARTICULAR�– THE FIRST HOUSING DEVELOPMENT WE STARTED WITH WAS
LENOX-CAMDEN, SO 1939, 1949. ONE OF THE THINGS THEY HAVE, AND
I THINK THAT BOSTON HOUSING AUTHORITY HAS TRIED HARD TO DO
THIS, TRYING TO MARRY ENERGY DOLLARS WITH RENOVATION DOLLARS
TO TRY AND DO THAT, SO LENOX-CAMDEN HAS RECENTLY
UNDERGONE REPLACEMENT OF THE ROOF AS PART OF AN ACTUAL
GREENING AS A WAY TO TRY AND IMPROVE THE ENERGY EFFICIENCY OF
THE PLACE, BUT THAT ALSO CAN BE SOMETHING THAT CAN ADDRESS IT.
I WILL SAY, I FEEL LIKE I LEARNED SOMETHING NEW EVERY TIME
I DO STUDIES AND I LEARN MOST THINGS JUST BY LISTENING, SO THE
TWO FUN I DID STORIES I CAN SAY ABOUT LENOX-CAMDEN, AT THE END
OF STUDY WE WERE DOING A REFLECTION BACK AND ONE OF THE
THINGS THAT BECAME CLEAR WAS THEY HAD DONE THE GREENING WHERE
THEY CHANGED IT SO YOU HAD A PRE-PROGRAMMED THERMOSTAT, SO
YOU WENT FROM OLD STEAM RATER HEAT TO A PREPROGRAMMED
THERMOSTAT THAT WAS GOING TO BE 68 IN THE MIDDLE OF THE NIGHT
AND 72 DURING THE DAY AND THEY LITERALLY, MORE THAN ONE
SIGNIFICANT TALKED ABOUT THE HEAT BEING OUT AND NEEDING TO DO
THE HEAT BEING OUT WORK ORDERS WHEN IT BECAME CLEAR THAT THE
HEAT WASN’T OUT. THEY WERE JUST USED TO IT BEING
85 TO 90 DEGREES WITH THE STEAM RADIATE TORE, SO THERE WAS HUGE
EDUCATION THAT NEEDED TO BE DONE AROUND THIS IS WHAT NORMAL
TEMPERATURE SHOULD BE LIKE AS WE WERE KIND OF PROGRESSING.
THE OTHER ONE THAT WAS REALLY INTERESTING WAS THAT WHEN WE
TALKED ABOUT PRIORITIZATION OF WORK TO BE DONE AND TALKED ABOUT
THE FACT THAT ROOFS WERE GOING TO BE REPLACED AND THINGS LIKE
THAT, WHAT RESIDENTS ACTUALLY WANTED WAS BUZZERS AT THE BOTTOM
OF THE STAIRWELL FOR SAFETY. THAT WAS MORE IMPORTANT TO THEM
THAN ACTUALLY THE ROOF BEING REPLACED AND THE MOLD BECAUSE
THEY�– BECAUSE SAFETY WAS A BIGGER DEAL.
SO I DO THINK THAT TO AN EXTENT, I NOW MORE AND MORE TALK ABOUT
ENVIRONMENTAL AS BEING BOTH PHYSICAL AND SOCIAL ENVIRONMENT
AND THAT WE NEED TO MORE AND MORE ACCOMMODATE AND THINK ABOUT
DIFFERENT WAYS TO DO IT IN TERMS OF MOVING FORWARD.
BUT I DO THINK THIS HIGHLIGHTS THE CHALLENGES OF DOING HOME
ENVIRONMENTAL REMEDIATION IN EXTREMELY OLD UNITS WITH A LOT
OF DEFERRED MAINTENANCE. I MEAN, BHA ALONE ESTIMATES
$2�BILLION OF DEFERRED MAINTENANCE THAT WE’RE NEVER
GOING TO CATCH UP ON, SO WAYS IN WHICH WE NEED TO START THINKING
ABOUT IT WITH A MORE HOLISTIC SOLUTION INSTEAD OF PIECEMEAL.
>>THANK YOU, MEGAN.>>WE HAD A QUESTION FROM THE
FIELD. DID THE HOUSING AUTHORITY STAFF
ALSO RECEIVE TRAINING ON ENVIRONMENTAL INTERVENTIONS SO
THAT WHEN THEY’RE DOING MAINTENANCE, THEY CAN FOLLOW UP
WITH STUFF ALSO?>>YEAH.
ONE OF THE NICE THINGS WAS THE COMMUNITY HEALTH WORKERS THAT
WERE PART OF THE PROGRAM WERE NOT ONLY BHA RESIDENTS, BUT THEY
ACTUALLY BECAME BHA EMPLOYEES AND THEY WERE ABLE TO
COMMUNICATE DIRECTLY WITH MAINTENANCE STAFF AND THE
MANAGERS SO THAT THEY WERE ALL ON THE SAME SYSTEM, THEY WERE
ALL ABLE TO CHECK ON THINGS AND THINGS LIKE THAT.
YES, THE NICE THING ABOUT BOSTON IS THAT WE TRY AND DO
COLLABORATION MEETINGS OFTEN, AND SO THE BREATHE EASY AT HOME
CONSORTIUM, FOR INSTANCE, HAS HAD�– WE LIKEN IT TO A WEDDING
WHERE EVERY YEAR YOU HAVE A MEETING WHERE AT THE TABLE IS
THE INSPECTOR THAT’S ASSIGNED TO THE DISTRICT, THE MAINTENANCE
STAFF THAT ARE ASSIGNED TO THE DEVELOPMENTS IN THAT DISTRICT,
AND THEY ALL SIT TOGETHER WHEN WE DO EDUCATION AROUND HEALTHY
HOMES, ASTHMA, OTHER TYPES OF THINGS, AND SO CERTAINLY THE
INSPECTORS AND MANY OF THE MAINTENANCE STAFF HAVE GONE
THROUGH SOME OF THE NATIONAL CENTER FOR HEALTHY HOUSING
TRAINING INSTITUTE ESSENTIALS FOR HEALTHY HOUSING AND OTHER
THINGS. THERE ARE ALWAYS GOING TO BE
IMPROVEMENT MANY, THERE’S NO DOUBT, BUT I THINK THE RIGHT
KIND OF TOOLS OF HOW TO DO GOOD MAINTENANCE ARE THERE.
THAT BEING SAID, THE COMMUNITY HEALTH WORKERS DID SOMETIMES
HAVE TO DOG CASES WHERE THEY WERE LIKE, THE WORK ORDER WASN’T
DONE RIGHT, WE’RE GOING TO PUT IT IN AGAIN.
>>MEGAN, MY QUESTION HOPEFULLY IS SHORT.
I WANTED TO KNOW IF A PUBLIC HOUSING AUTHORITY OR ANOTHER
ASSISTED HOUSING OWNER OR MANAGER IS INTERESTED, THEY MAY
KNOW THAT THEY HAVE RESIDENTS THAT HAVE ASTHMA AND THEY’RE
INTERESTED IN FOLLOWING THE COMMUNITY HEALTH WORKER MODEL,
WHERE WOULD THEY BEGIN?>>SO I DO THINK THAT A LOT OF
PUBLIC HOUSING DEPARTMENTS HAVE REALLY EMBRACED THIS, CERTAINLY
BOSTON PUBLIC HEALTH COMMISSION, MASSACHUSETTS DEPARTMENT OF
PUBLIC HEALTH, THE MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
ACTUALLY IS CREATING A BOARD OF REGISTRATION FOR COMMUNITY
HEALTH WORKERS THE SAME WAY I AS A PHYSICIAN NEED TO REGISTER
WITH THE BOARD AROUND BEING A DOCTOR AND GOING THROUGH THAT
CERT CERTIFICATION. THEY’RE DOING THE SAME THING FOR
COMMUNITY HEALTH WORKERS HOPEFULLY TO GET IT REIMBURSABLE
UNDER THE AFFORDABLE CARE ACT, BUT I WOULD SAY THAT TYPICALLY
THERE IS NOW A RECOGNIZED JOB DESCRIPTION UNDER THE DEPARTMENT
OF LABOR SO THEY CAN ACTUALLY LOOK AT WHAT THE JOB DESCRIPTION
LOOKS LIKE. I DO WANT TO KIND OF REALLY
EMPHASIZE WHAT HELEN SAID. THEY’RE NOT ALL CREATED EQUAL,
SO YOU NEED TO REALLY GO THROUGH TRAINING AND I REALLY�– THERE
IS CERTIFIED TRAININGS IN ALMOST ALL THE STATES, I THINK, AROUND
BECOMING A COMMUNITY HEALTH WORKER AND THEN THERE ARE
SPECIFIC ONES RELATED TO ASTHMA. THE NATIONAL CENTER FOR HEALTHY
HOUSING HAS AN ASTHMA COMMUNITY HEALTH WORKER TRAINING JUST TO
BE ABLE TO UNDERSTAND THESE TYPES OF THINGS AND I DO THINK
THAT IT’S INTERESTING. IN SOME WAYS, THE TERM COMMUNITY
HEALTH WORKER ENCOMPASS AND LOT OF OTHER TERMS.
OUTREACH WORKER, HEALTH EDUCATOR, OUTREACH�– YOU KNOW,
HEALTH OUTREACH WORKER, WHATEVER, BUT I DO THINK THAT
THAT PARTICULAR DESIGNATION PUTS YOU IN LINE WITH A LOT OF OTHER
HEALTH WORKFORCE THAT MAY BE REALLY IMPORTANT FOR A HOUSING
DEVELOPMENT TO TAKE ON.>>FOR THE PANEL, TWO OF OUR
PROGRAMS, DO YOU KNOW OF ANY TRACKING OF PUBLIC HOUSING
AUTHORITY THAT’S GONE SMOKE FREE AND ASTHMA PREVALENCE?
>>BESIDES BOSTON? YES.
>>IT’S A GOOD QUESTION. SO THE WAY THAT BOSTON WAS ABLE
TO DO IT WAS BECAUSE IT ACTUALLY CREATED THAT QUESTION IN THE
BEHAVORIAL RISK FACTOR SURVEILLANCE SURVEY.
I’M NOT AWARE HOW MANY OTHER PLACES HAVE DONE IT, RIGHT?
WHERE THEY’VE BUILT IN A HEALTH TRACKING SYSTEM THAT’S
SPECIFICALLY ABLE TO SUBSET OUT POPULATIONS SO THAT IT CAN TRACK
IT ITSELF. I WILL SAY AND THIS I THINK
SPEAKS TO ACTUALLY BOTH WHAT ELIZABETH AND HELEN WERE TALKING
ABOUT IS, I ACTUALLY THINK PAYMENT REFORM AND THE
AFFORDABLE CARE ACT ARE OPPORTUNITIES FOR US TO TALK
ABOUT WHAT ESSENTIALLY IS THE EQUIVALENCY OF CARE THAT CAN BE
FROM ENVIRONMENTAL REMEDIATION VERSUS MEDICATION, AND SO ONE OF
THE THINGS THAT WE DID AT BOSTON MEDICAL CENTER WAS WE ASKED BHA
FOR ALL THEIR ADDRESSES AND WE SAID, GIVE US THE, YOU KNOW, THE
EXCEL SPREADSHEET OF ALL YOUR ADDRESSES.
WE RAN THEM THROUGH OUR ELECTRONIC HEALTH RECORD AND
WE’VE GOT 10,000 KIDS THAT GET CARE AT BOSTON MEDICAL CENTER IN
THE SIX OR SEVEN AFFILIATED COMMUNITY HEALTH CENTERS THAT
LIVE IN BOSTON HOUSING AUTHORITY HOUSING.
SO IF YOU’RE AN ACCOUNTABLE CARE ORGANIZATION, YOU OWN KIND OF
THOSE 10,000 KIDS FOR WHAT THEIR HEALTH OUTCOMES ARE, IT’S KIND
OF A NATURAL PARTNER TO GO TO BOSTON HOUSING AUTHORITY AND SAY
LET’S WORK TOGETHER AND FIGURE OUT WAYS TO DO THIS.
WHERE I THINK�– AND THIS IS SOMETHING THAT ELIZABETH AND I
TALKED ABOUT IN THE LOBBY. THE KEY WITH THE HEALTH DOLLAR
IS THERE ARE DIFFERENT VERSIONS OF IT, SO THERE’S THE HEALTHCARE
DOLLAR TIED TO PAYER AND/OR PROVIDER.
THERE ARE ALSO IS THIS OTHER DOLLAR CALLED THE COMMUNITY
BENEFIT DOLLAR WHICH IS THE AMOUNT OF TYPICALLY HEALTH
SYSTEMS ARE NOT FOR PROFITS. THEY DON’T PAY MONEY TO THE IRS
ON THE PROFITS THAT THEY MAKE AND SO THEY’RE SUPPOSED TO DO A
COMMENSURATE AMOUNT OF COMMUNITY BENEFIT.
OF NOTE, THE IRS HAS RECENTLY RULED IN DECEMBER OF LAST YEAR
THAT CLEAN AND SAFE HOUSING COUNTS AS A COMMUNITY HEALTH
IMPROVEMENT ACTIVITY, AND SO THAT THERE ARE WAYS NOW OF WHICH
THAT’S BEEN, YOU KNOW, PUT OUT AS A DEFINITIVE STATEMENT.
SO NOW I THINK THERE ARE WAYS IN WHICH YOU CAN GO AT A HEALTH
SYSTEM A COUPLE DIFFERENT WAYS, NOT ONLY AROUND THE HEALTHCARE
DOLLAR, WHICH HAS A VERY HIGH BAR OF EVIDENCE THAT SOMETIMES
IS HARD TO REACH, AND THEN MORE WHAT I WOULD CONSIDER A SOFTER
AMOUNT OF EVIDENCE THAT THIS IS A COMMUNITY HEALTH IMPROVEMENT
ACTIVITY AND THEREFORE IT MAY BE IMPORTANT TO THINK ABOUT.
>>I ALSO WANTED TO, YOU KNOW, BE BROUGHT UP�– IS THIS ON?
>>GO AHEAD.>>I WANTED TO ADD THAT THERE’S
A LOT OF VARIABILITY FROM CITY TO CITY IN TERMS OF HOUSING
AUTHORITY AND IN MANY CITIES, THEY ARE NOT AS POLITICALLY
MOTIVATED, AND THE INFRASTRUCTURE MAY NOT BE THERE.
AND THE WONDERFUL THING ABOUT WHAT’S GOING ON IN BOSTON IS
IT’S A GREAT, I THINK, BENCHMARK AND MODEL TO ACHIEVE BECAUSE I
DO KNOW THAT AT LEAST MY EXPERIENCE IN BALTIMORE AND WITH
OTHER COLLABORATORS IN OTHER CITIES, GETTING A LIST OF
ADDRESSES AND MATCHING THEM UP WOULD NOT BE POSSIBLE.
SO I�– THE GREAT THING ABOUT THIS IS YOU HAVE KIND OF PROOF
OF CONCEPT AND IT’S SOMETHING TO AIM FOR.
>>I HAVE A QUESTION FOR HELEN. THERE WAS A QUESTION EARLIER
ABOUT WHETHER STAFF AT BOSTON HOUSING AUTHORITY BECAME MORE
AWARE OF THE HOUSING AND HEALTH ISSUES.
DID YOU FIND THAT IN CHICAGO BY WORKING THERE IN THE HOUSING
AUTHORITY? IS THERE ANY EVIDENCE THAT
MANAGEMENT AND STAFF MAYBE GAINED A LITTLE BIT OF THAT
KNOWLEDGE?>>WELL, I WILL SAY, AND I DON’T
OFF THE TOP OF MY HEAD KNOW THE NUMBERS, BUT CHA IS HUGE, SO
WE’RE TALKING ABOUT A MUCH DIFFERENT SIZED ENTITY THAN
BOSTON HOUSING AUTHORITY. SO SCALE IS MUCH HIGHER, SO
DEFINITELY WITHIN THE PROPERTIES THAT WE’RE WORKING WITH AND
WITHIN THE STAFF THAT WORKED WITH THOSE PROPERTIES, WE DID
SEE THAT SORT OF AN EFFECT AND CHA REMAINS VERY ENGAGED IN
CONTINUING TO BUILD ON THE MODEL AND I THINK ULTIMATELY, YOU
KNOW, LOOKING AT STARTING WITH PROPERTIES AND BUILDING IN
HEALTH MORE COMPREHENSIVELY. SO I DON’T KNOW HOW IF THAT
ANSWERED THE QUESTION VERY WELL, BUT THERE’S DEFINITELY INTEREST
AND WE’VE MOVED THE NEEDLE, BUT WE’RE NOT WHERE BOSTON IS.
>>THANK YOU. ANY FINAL QUESTIONS FROM THE
AUDIENCE OR THE FIELD? I DO HAVE ONE FOR MEGAN.
I THINK YOUR STUDY OVERLAPPED THE IMPLEMENTATION OF SMOKE FREE
HOUSING IN BOSTON. DID YOU SEE THAT IN TERMS OF
BEHAVIORS THAT LOOKED LIKE THERE WAS SOME COMPLIANCE WITH�–
>>YES. AS I SAY, YOU’RE RIGHT, WE RAN
IT FROM 2011 THROUGH LIKE 2014 AND SO IT WAS FULLY IMPLEMENTED
IN 2012. SO THERE WERE DEFINITELY LESS
SMOKING THAN ON AVERAGE, SO THE AVERAGE IN BHA WAS AROUND 20%.
I THINK WHAT’S INTERESTING AROUND SMOKING IN GENERAL IS IT
IS SOMETHING THAT MORE AND MORE WHEN WE THINK ABOUT IT AS AN
EXPOSURE, WE HAVE TO BE REALLY CONSCIOUS OF THE INTERVENTION
THAT GOES ALONG WITH IT, RIGHT? AND SO THAT ONE OF THE THINGS
THAT A COLLABORATOR AT THE BU SCHOOL OF PUBLIC HEALTH STARTED
TO PUT IN PLAY IS ACTUALLY PLACE-BASED SMOKING CESSATION,
SO ONSITE SMOKING CESSATION AT THE PUBLIC HOUSING DEVELOPMENTS.
BUT YOU END UP WITH THAT SAME KIND OF, IN SOME WAYS, VICIOUS
CYCLE. THE PLACES THAT DO WELL WITH
THAT ARE THE PLACES THAT HAVE GOOD SOCIAL COHESION THAT CAN
ACTUALLY PUT THAT INTO EFFECT. I HAVE ACTUALLY MORE AND MORE
PUT AT THE END OF MY SLIDE DECKS WHAT I CALL THE QUALITY VERSUS
EQUITY SLIDE AND SO I DIDN’T PUT IT IN THIS SO YOU’RE GOING TO
HAVE TO WATCH MY HANDS AS I PUPPET IT OUT.
SO EQUALITY IS THE CONCEPT WHERE YOU TREAT EVERYONE THE SAME, AND
SO IF YOU START FROM DIFFERENT PLACES, WHICH IN THE
VISUALIZATION I LIKE IS DIFFERENT HEIGHTED PEOPLE TRYING
TO REACH THE APPLE OF OPPORTUNITY ON THE TREE, AND SO
IF YOU TREAT EVERYBODY THE SAME, THE TALL PERSON STANDING ON THE
SAME SIZE BOX, THE MEDIUM HEIGHT PERSON ON THE SAME SIZE BOX, THE
SHORT PERSON ON THE SAME SIZE BOX, THE ONLY PERSON THAT
ACTUALLY REACHES THE APPLE OF OPPORTUNITY IS THE TALL PERSON.
IN MANY WAYSES BY TREATING THEM EQUALLY, YOU PERPETUATE THE
DISPARITY BETWEEN ALL THREE, YOU DON’T ACTUALLY END IT, WHEREAS
EQUITY IS THE IDEA OF YOU IMMEDIATE PEOPLE WHERE THEY’RE
AT AND YOU GIVE THEM WHAT THEY NEED IN ORDER TO ACHIEVE THE
OUTCOME. AND SO THE TALL PERSON STANDS ON
ONE BOX. THE MEDIUM HEIGHT PERSON STANDS
ON TWO BOXES. THE SHORT PERSON STANDS ON THREE
BOXES AND IF YOU DO, IS THAT ALL OF THEM REACH THE APPLE OF
OPPORTUNITY SO THAT YOU ACTUALLY HAVE TO BE OKAY WITH TREATING
PEOPLE UNEQUALLY IN ORDER TO GET TO THE EQUAL OPPORTUNITY.
YOU HAVE TO GIVE SOME PEOPLE MORE IN ORDER TO GET THERE.
AND I THINK THAT MORE AND MORE, WE DON’T ACKNOWLEDGE THAT.
I’LL END ON ONE OTHER THING. I’VE SEEN A VERSION OF THIS
SLIDE, WHICH IS ACTUALLY HEIGHTED PEOPLE LOOKING OVER A
FENCE AT A BASEBALL GAME AS ANOTHER WAY TO LOOK AT THIS.
I DON’T LIKE PEOPLE LOOKING OVER FENCES.
I LIKE THEM REACHING APPLES OF OPPORTUNITY, BUT IT’S
INTERESTING. THE SLIDE DECK IS EQUAL, RIGHT,
WHERE EACH ARE THE SAME AND ONLY TWO OF THEM ACTUALLY GET TO LOOK
OVER THE FENCE, THE SHORT PERSON DOESN’T GET THERE.
EQUITY IS THAT THEY ALL GET THE RIGHT HEIGHTED BOX IN ORDER TO
LOOK OVER THE FENCE AND THEN THEY HAVE ONE THAT’S CALLED
REALITY. AND REALITY IS WHERE THE TALL
PERSON HAS SEVEN BOXES TO STAND ON AND THEN THE MEDIUM HEIGHT
PERSON HAS ONE TO LOOK OVER THE FENCE AND THE SHORT PERSON NOT
ONLY DOESN’T HAVE A BOX, THEY’RE STANDING IN A HOLE.
RIGHT? AND SO WHEN WE THINK ABOUT THAT,
I DO THINK�– THAT’S WHERE I LIKE TO START NOW TALKING ABOUT
BOSTON HOUSING AUTHORITY PATIENTS ARE SICK.
THEY ARE ESSENTIALLY DISABLED IF NOT QUASI-DISABLED.
YOU’RE STARTING FROM THE HOLE, RIGHT?
AND SO YOU’RE STARTING WITH BUILDINGS BUILT IN 1939 AND SO
YOU’RE�– I FEEL LIKE WE SOMETIMES, LIKE WE WANT TO REACH
THAT APPLE OF OPPORTUNITY AND WE’RE NOT ACKNOWLEDGING WHERE
WE’RE STARTING FROM, AND SO I DO THINK THAT MORE AND MORE, FOR
THOSE WHO HAVEN’T SEEN IT, I’M VERY PROUD TO BE A PEDIATRICIAN,
SO IS ELIZABETH. WE JUST PUT OUT THE ACADEMIC
PEDIATRIC ASSOCIATION HAS A JOURNAL CALLED ACADEMIC
PEDIATRICS MANY, WE JUST PUT OUT A CHILD POVERTY SUPPLEMENT AND I
WROTE THE ARTICLE ON�– WITH MANY OTHERS, AROUND NEIGHBORHOOD
LEVEL INTERVENTIONS TO LIFT KIDS OUT OF POVERTY AND INTO
OPPORTUNITY, AND I LOVE YOU GUYS TO CHECK IT OUT.
THANKS.>>OKAY.
WHAT A GREAT WAY TO END. I JUST WANTED TO THANK OUR
SPEAKERS ONE MORE TIME AND THANK YOU FOLKS FOR COMING IN TODAY.
[ APPLAUSE ] THOSE OF YOU VIA THE WEBCAST,
GREAT DISCUSSION. WE COULD HAVE CONTINUED FOR
ANOTHER HALF HOUR IF WE HAD COFFEE, I GUESS.
SO THANKS AGAIN. THIS WEBCAST WILL BE ARCHIVED,
SO FOLKS CAN GO BACK AND PULL IT UP.
AND WE’LL CONTINUE WITH SOME DISCUSSION UP IN OUR OFFICE IN
ONE OF COMPS ROOMS IF ANYBODY WANT�– CONFERENCE ROOMS IF
ANYBODY WANTS TO JOIN US. THANK YOU.
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