Using Housing Codes To Improve Asthma Health Outcomes

By Adem Lewis / in , , , /

Good afternoon everyone. My name is Tracey
Mitchell and I’m filling in today for my colleague Tracy
Washington Enger as the moderator. I work at the Environmental Protection Agency
in Washington DC and I’m a Certified Asthma Educator on behalf of the US EPA.
I’m pleased to welcome you and we are pleased to host you today for an
important and exciting webinar presentation. As one of the developers of
the science that proves the link between asthma and environmental exposures, EPA
has been a committed champion for expanding delivery and sustainability of
in-home asthma care. We’re so pleased to be able to offer today’s webinar to hear
from innovators in the field who have found solutions to ensure the children
who most need in-home environmental asthma care receive it. We’re eager to
learn some to support and to shine a spotlight on our partners stories that
can teach us all so much about how to convince critical partners that proved
asthma care is possible and how to move whole systems to bring the best care to
the people, particularly children, who need it most.
Thank you for joining this important discussion today. If you’ve participated
in previous EPA webinars, you know that our question-and-answer period will take
place on the discussion forum on Asthma immediately
following the presentation, so from 3:00 to 3:30 p.m. Please join us to interact
and ask questions of our speakers to see the discussion forum directly. Now, you
should be receiving a link via our chat feature and you can click on that link
to be able to access the discussion forum to ask questions. You can do that
during our presentation…you can type it into the discussion forum but you first
must be a member of AsthmaCommunity Network(.org), so if you’re not already a
member please take a moment to do so. It’s a very simple and quick process, as
we’d really hate for you to miss out on interacting with our our presenters
after the webinar. As with all of our webinars, this webinar will be archived
on, as well as you’ll have access to the question-and-answers. If you’re unable to join us, you’ll be able to access the discussion
forum at a later date. Before we dive into the presentations, we always like to
get a sense of who’s in our audience so if you would please take our first
polling question and let us know what type of organization you represent. Poll
is open now, so please click on which organization or agency you represent. Perfect. That looks like almost half of
us are federal state or local agency or government employees. We’ve got a nice
representation of community asthma programs and then a pretty large
representation as those who classify as “other”, so I’d be curious to know what
organizations you’re from. Unfortunately we don’t have the ability to ask that
specific of a question, so maybe you can let us know that in the evaluation or in the
question-and-answer portion later. So our learning objectives on today’s webinar—
we feature Amanda Reddy, Executive Director of the National Center for
Nealthy Housing (NCHH) and Robert Curry.
Bob is of the city of Dallas in Texas. Amanda and NCHH have been a cooperative
partner of EPA providing technical assistance to communities across the
country looking for sustainable funding for asthma in-home interventions. One of
the communities they’ve worked with is the City of Dallas and in its
efforts to enact proactive housing code inspection and enforcement strategies
that will improve asthma and other health outcomes. Today we’ll hear about
the experiences in Dallas and focus on the connection between housing codes,
asthma, and health outcomes, so in today’s webinar you’ll learn about communities
including Dallas, but a couple of others as well that have focused on
infrastructure and other housing code strategies to positively impact children
with asthma. You’ll learn about the National Healthy Housing Standard and how
it can be used in housing codes to improve asthma outcomes. You’ll also
learn about NCHH’s experience providing technical assistance and coaching to
communities working to promote access to in-home asthma interventions. So
with that, we have our next polling question: Based on the learning
objectives I’ve just outlined, would you please let us know what you’re most
interested in learning about today? Great. So we have about four
percent who are interested in housing code inspections and enforcement strategies
and about an equal number interested in promoting access to in-home intervention.
I think you’ll walk away from today’s presentation with a lot of useful
information regarding all of these components and so I’m very excited to
get started. Before we dive into our presentation
from our expert speakers, if I could just take a moment to set the stage first.
I’ll provide a very brief background on EPA’s asthma program and I’ll talk about
EPA’s efforts to make sure that community-based programs are delivering
asthma care and are doing it comprehensively and including in-home
interventions. Also, EPA is helping programs with sustainability, focusing on
how those programs are reimbursed and funded. This means looking at building
capacity and systems change. Amanda and NCHH will share their experience and
expertise and the evidence around health outcomes, especially as it pertains to
asthma and sustainable financing. Then Bob will emphasize the importance of
partnerships. You don’t have to be an expert on financing to be able to do
this work. Bob will share how he brought his experience and infrastructure and
his ability to reach out to others in this community and build partnerships
for Dallas. Asthma is the lens that drove the first wave of change in housing
codes, and we feel that this is worth modeling and could serve as an
alternative to other financing models and we’re so pleased to be able to
explore the possibilities today with you. So I think all of us—if you’ve worked in
asthma, you know the burden of asthma— you know it’s a public health challenge
characterized by disparities. You also know we’ve made great progress. CDC
reports that some national indicators are improving. Asthma prevalence among
children has decreased slightly. Asthma attacks have decreased in children of
all races and ethnicity, so this is good news. Asthma-related hospitalizations and
missed school days are fewer when we compare 2013 to 2003.
In that same year 10 year period, utilization of asthma action plans has
increased, so this is all good news, but we know that disparities continue.
Children living below the poverty line experience the most emergency department
visits, the most missed school days, and the most hospitalization. These high
utilizers with uncontrolled asthma drive up cost, so we know that asthma is an
expensive disease. It costs the United States over 50 billion—that’s with a “B”—
dollars each year and Medicaid spends more than 10 billion dollars each year
to treat asthma in children and adults. But we also know that asthma is a
treatable and manageable condition. Science informs policy and forms the
foundation for EPA’s program’s approaches. Science tells us that, along with medical
management, there’s a strong evidence base and supporting national guidelines
that recognize the role of environmental triggers and their remediation as an
important part of comprehensive asthma management. We know that eliminating
common indoor triggers like tobacco smoke, pet dander, mold, cockroaches and
dust mites results in decreased symptoms and asthma episodes and improved
outcomes for people with asthma. We also know home visits are a critical
component. Particularly, home visits are important for these at-risk
populations. Families are often in crisis mode and facing many issues and home
visits provide one-on-one time that families need to help their child gain
control over asthma and to help with education and remediation about triggers. As technical experts in the built environment and health, EPA has led
federal effort through non-regulatory strategies that enable communities to
deliver and sustain in-home environmental asthma care aimed at
ensuring access. EPA is making unique contributions to this work through the
five program components represented on this graphic. EPA is meeting communities
where they are. So I’ll quickly just go through these five
components: EPA hosts learning spaces to share, learn, and connect through as well as other national media campaigns. EPA provides
technical assistance through cooperative agreements and partnerships such as the
partnership with NCHH, which we’re highlighting on today’s webinar. EPA
recognizes and leverages excellence through our National Environmental
Leadership Award in Asthma Management. And I’ll quickly plug that we’ll be
launching the 2019 competition very soon, so please be on the lookout for that
announcement. EPA advances national policy through collaboration with the
Asthma Disparities Working Group (ADWG) and our other federal partners, and we
advance the policy locally through regional asthma summits. And EPA
synthesizes and spreads learning through the Community of Practice partnerships
across healthy housing and environmental sectors is an essential lead to success
when delivering in-home asthma management. By identifying best practices
and successful programs like those who are with us today, we strive to
synthesize and spread the learning in order to increase savings, expand the health care workforce, and reduce healthcare costs. The
organizations like NCHH are also providing the technical assistance and
resources for community programs and health payers who are undertaking these
efforts. So now I’d like to turn it over to Amanda Reddy from NCHH for more
about this important work. Great, thank you so much, Tracey, and thank you to all
of you for joining today’s webinar. Before we dive into the role that
housing codes and code enforcement can play and improving asthma outcomes, it
may be worthwhile to just take a step back and set the context for why and how
housing matters for health and how it can be part of the solution. We know
that for many of you that is old information and old news, but we also
know that and this is a topic that’s a little bit different than some of the
webinars that have been offered through before and you
may be newer to the newer to the topic and the conversation.
So one of the reasons that housing matters is that as Americans,
we spend a lot of time at our home. The national human activity patterns survey
estimates that on average, we spend about 70 percent of our time, not just indoors, but in our home environments and that number can be even greater for certain
vulnerable populations like the very young, the elderly, the disabled, so it’s
very clear that the home environment is a pretty critical setting when we’re
talking about setting the stage for people to have good health. It’s also
important, though, to not just understand that the home environment is important
and that housing matters but understanding that there are a variety
of ways that housing matters. So, we know from decades of research that housing
affects health through multiple pathways. The location of housing and the
physical neighborhood attributes surrounding the house or
the residents, how walkable the community is around it, whether there’s a proximity
to traffic, are there pollution sources?, the outdoor air quality, access to public
transportation, parks, schools and employment opportunities. All of that can
affect a person’s health. We know that affordability is another
important dimension of health and housing. Unaffordable housing can
really not only make it difficult for families to stay in housing and
contribute to residential instability to crowding, but it can also force a
household to make trade-offs between different types of costs. You know, for
instance, the money that’s available for nutritious food and necessary health
care expenses like asthma medications, for instance. We also know that the the
demographics, or the social and community context around a community, the
social cohesion of a neighborhood, and other factors can be really important
for health. At the national center for healthy housing; however, the dimension of
housing that we are most interested in and that we focus on is about housing
quality. We know that housing quality can impact health through also a variety
of pathways. It can impact your physical health, your psychological
health, as well as your safety. Digging a little bit deeper in
how housing quality affects health, there are a variety of different chemical,
biological, and physical exposures that can occur in the home environment. This
is by no means a comprehensive list here, but you can see chemical exposures like
lead and radon may be present in homes either from naturally occurring sources,
such as radon or from, you know, the existence of chemicals that were brought
into homes, for instance through lead paint, through biological pathways like
mold, dander from pets, or pests like cockroaches and mice, or the physical
condition of the home, if there are structural issues with the home, that may
contribute to various health outcomes. The list of health and housing
outcomes and conditions that can arise from housing conditions is quite quite
numerous. We know that disparities and housing
quality can exacerbate disparities in a variety of health conditions, including
asthma and the disparities that Tracey mentioned in her opening remarks. Housing that is full of mold or cockroaches can make it really
impossible for a person to control their asthma even if they’re doing everything
else right. We know that asthma and allergy, other respiratory conditions are
really really connected to health. A variety of other housing conditions may
be impacted and it’s important for you to know even if you’re somebody who
focuses exclusively on asthma. We know that that is true for many of you in
this audience and, for instance as you’re making the case to other partners,
or funders, investors in your work, sometimes it’s helpful to say we really care about asthma. We know we can make an impact on asthma by doing
these interventions, but you should also know that by doing these things we’re
going to affect all of these other endpoints as well. Housing
conditions can also impact lead poisoning, falls and injury prevention,
fire injuries, cancer, cardiovascular events, you can see the entire list here.
I want to also point out mental health outcomes and quality of life outcomes
like school attendance, the ability to go to work,
caregiver quality of life are also highly linked to housing conditions. We know it’s a problem. The natural question is,
what can we do about it? And it turns out that this is a really important question
to ask. The Frameworks Institute, a couple of years ago, conducted some social
science research to understand what sort of the general public understanding of
the term healthy housing meant and sort of to map the gap between what expert
opinion is and the general public’s understanding of that term. One
of the really interesting findings to me that came out of this report, and
you see though the link here on your screen, is that in general, people do
understand that there’s a connection between housing and health and those of
us who are in the field, particularly those of us like like myself who have a
scientific background, we spend a lot of our time messaging around that
problem, that connection trying to convince people that there is the
connection. It turns out people kind of get that already and they don’t need a
lot of help understanding that. They may not know all the specifics, but the
underlying concept is pretty solid. What we have found out through reports like
this is one of the challenges is that people understand it’s a problem but
they think there’s nothing that can be done about it. It’s just such a big
problem, it’s going to cost too much money to solve. It’s just, you know,
they’re greedy landlords. Nobody can do anything about it. They have this
fatalistic attitude about what the solutions are and a lot of the ways that
we go about our messaging can inadvertently sort of trigger that
concept in their mind, the sort of fatalistic attitude. That’s important
for us to know. I think as we think about how we approach potential partners,
funders, investors in our communities so that we can really be sharp with our
messaging and solution focused and not accidentally sort of trigger that
fatalistic attitude. Because it turns out there is a lot we can do about it. The
slide that you see in front of yourself right now comes from the
environmental health playbook. This was put together by the National
Environmental Health Partnership Council and the items that you see in the darker
blue there are critical elements of what the National
Environmental Health Partnership Council articulated as components of a well-functioning,
high-functioning, effective environmental health system in a community. The items that are in that gray or lighter blue are some of these
specific housing strategies that were developed as part of this group’s
attempts to articulate where we should be putting our priority and our emphasis
in terms of improving housing quality to improve housing and health. So, you
can see some of these buckets of collecting and tracking information,
having a well-trained workforce, sustainable funding, having
evidence-based policy and programs, the partnerships, equitable access, these are
should all be familiar terms to many of you who’ve been involved in Asthma
Community Network. It’s a very similar framework. I don’t want you to focus on
all of the details on this slide. What I’d like to just point out is that
those items that are highlighted now in orange on your screen all relates to
housing code and code enforcement. Across all of these different dimensions
and all of the different ways that we talked about all of the different
pathways for how housing can affect health, not just through housing quality,
but all of those different dimensions, look how many of these strategies relate
to code and code enforcement. Let’s take a minute just to think about
why housing codes show up so often as an opportunity to improve population
health and for asthma in particular. First of all, we know not just from
experience and from logic but also from studies like the one you see on your
screen, Beck et al., 2014, out of Cincinnati that in places where there
are higher numbers of housing code violations that those places tend to
co-occur with places where the burden of asthma is high. Here we see the density
of asthma-related housing code violations, those are those black
dots, overlaid with asthma related ED visits at the census tract level,
those are the areas with red and purple are areas with higher rates of
asthma-related hospitalizations and ED visits. We know that there’s this
natural connection that there seems to be an association here, but the other
reason that code enforcement I think that EPA was interested in presenting
this topic to you and especially for those of you who are used to coming on
and hearing about how do we build sustainable financing, how do we approach
the healthcare sector, and increase their partnership with an investment in
home-based asthma services, is that code enforcement is one example of how you
can sort of build the infrastructure in a community that can either be a
complement to health care financing of home-based asthma services or in
communities where the health care financing or other types of financing
isn’t in place yet, it can be an alternative to that. It can, when it’s
serving as a complement to existing financing or funding that’s in a
community, it can help expand the number of people that are receiving necessary
services. It can help expand the scope of services that are provided by by
addressing issues that may be a health care funder or partner is not able to
address. It can also help provide, as we see on the slide, some needed data to
help make the case and to help funders really feel like there’s a good
infrastructure in a community. Often in my experience when I’ve spoken to
healthcare funders or payers, one of the things that they really say is they want
to have a plug-and-play infrastructure. They want to be able to not build a
program from scratch but know they’re entering a community where there are robust
resources and a high functioning code enforcement system can certainly be a
key part of that. I’m going to spend a little bit of time on this next slide so
I just want you to know is you’ve not that your webinar froze I’m just going
to spend some time here so that’s by design. To talk a little bit
about how codes can be part of the solution, and I want to highlight this
report that comes out of change lab solutions, another partner who has done
some really great work in this area, NCHH was one of the contributors to the
report that you see the link to at the bottom of your screen describing some of
the steps that can go into making an effective code enforcement program. For
for those of you who might think we have code enforcement in our community, it’s
already set up, we don’t have to listen to any of this, you know we’ve got this
covered, these are probably just already you know just check the box you know
what I’d like to do is just walk through this and talk about the difference
between just having these things in place and really doing them effectively
so you can achieve maximum impact to have that public health impact and
reduce those disparities. Starting with number one, the obvious thing is
that at the start of this you need to have a strong housing code that you can
be working from. One of the things to know here is
that housing code that as it exists in many communities across the country
often uses a lot of really ambiguous phrases. So it’ll use phrases like, “safe”
or “healthy” or “decent housing” that aren’t really really well defined and that
leaves a lot up to the discretion of individual code enforcement officers or
communities in terms of how it’s applied. Many housing codes also don’t properly
address health related threats in the homes like pests, moisture, ventilation, or
chemicals like lead and radon, so there’s certainly an opportunity to take a
critical look at your housing code and see if it can be strengthened. That’s a
really excellent first step as it serves as the foundation for everything else
that follows. Obviously, you need to have adequate funding to have a code
enforcement system in place and that your state and local law may govern
what’s possible in this area, but some very common sources for funding code
enforcement work can be a general fund at the municipal level. Some communities
have been able to leverage community development block grant or CDBG funding
to help support their code enforcement activities. Other typical methods of
raising money for code enforcement can come through permitting or licensing
fees and sometimes through fines and penalties that are levied for housing
code violations, but it’s really important to make sure that it’s well
resourced, otherwise it’s certainly not going to be effective. Having a
well-trained workforce and training your officers is really really important and
while it may be obvious that all of the code enforcement staff need to be
trained and all of the applicable federal, state, and local laws,
I’d like to remind people that is important to first of all train the
wider team that might may be involved, not just the folks that are going out
into the field, but all of the folks back at the office that may be supporting
them or interacting with residents or property owners throughout the process. And to also make sure that they’re equipped with best practices and some of
the softer skills, I know how do you work with landlords and tenants, these are
really emotional and challenging issues in some cases
that we are dealing with so really equipping your code enforcement officers
not just to know what the rule is but how they can effectively work with
people to achieve resolution, how they can find resources to help residents,
it’s going to take your program from, you know, just being in existence sort of
checking a box, yeah we have it, to actually being effective and having maximum
impact partnerships. We’ll hear more about from Bob as Tracey mentioned, but
we cannot be emphasized enough that having these partnerships both within
the community and across agencies within a community, number four and five
on the list here, is very very important. Community-based organizations, if you
work with them, can help or if you are a community-based organization, what
your role can be is that you can help to educate residents, both landlords and
tenants, about their rights and responsibilities, about what the process
is supposed to look like for code inspections and enforcement, but you can
also provide some needed supplementary services: referrals, connections to
mental health, and social service programs that are often needed when you
enter a residence, help with language and cultural barriers, and sometimes even
connections to resources that can help with repairs, you know,
maybe a property owner really wants to do the right thing but they they have
some challenges in making those repairs and those cross agency partnerships can
also really help there. The responsibilities for code enforcement may
sometimes be spread across multiple agencies, which can make the process a
little bit confusing for tenants or lead to duplication of efforts or even worse
than duplication of efforts, I would say is nobody taking responsibility,
everybody assuming that another agency has that covered. It’s really
important to have that cross sector cross agency collaboration. A great
example of this that I like to offer is at the Erie County Department of Health
in Erie County, New York. The inspectors for their Healthy Homes
programs that include asthma components as well as their lead programs at the
local health department the County Health Department have been deputized as
code enforcement officers so when they’re in the home
already doing inspections for lead for asthma for Healthy Homes they can
actually write the citations and initiate the code enforcement procedure
there. They don’t have to go back and send out a code enforcement officer for
a separate visit and that really helps to streamline the process for everyone.
That brings us to number six developing a cooperative compliance model and this
is really about transforming the traditional us-versus-them dynamic that
can exist in code enforcement transactions and equipping your code
enforcement team with tools for how to work with and really support property
owners throughout the process from why it’s important to how it can be fixed
and how they can get connected to resources and certainly enforcement too,
if it’s needed. The beauty of a cooperative compliance model is if it’s
done well and effectively and as it becomes embedded in a community over
time, your reliance on enforcement mechanisms they have to lessen because
people are not only incentivized but supported in doing the right thing. Enforcement is always going to be important though and that’s why number
seven is about enforcing the local code here. There are three main categories of
enforcement and the most common is administrative action. This includes
actions like written notices, fines, departmental hearings, putting a lien on
a property, etc. Sometimes things are escalated to civil action. This is
working through the court system to, for instance, compel a property owner to make
repairs or pay fine or damages for a violation and then in fewer cases
but in some states actually do allow for criminal charges to be filed for some
types of violations, usually as a misdemeanor or an infraction. It’s worth
noting that court options are more costly and are usually used as a last
resort, so those administrative actions are where most communities
actually see the process working. When we get to number 8, we’re really talking
about model communities here who have really taken a step and not just have a
really robust sort of standard code enforcement system but are working to
actually get ahead of the problem. Proactive rental inspection program is one way to do this. Traditional code systems are complaint-based. They wait for a tenant or a neighbor or somebody in the community to
call and say, “I think there’s something going on at this property. Please come
come check it out.” Under a proactive rental inspection program, all of the
units are inspected on a periodic basis. This doesn’t replace the complaint-based system, certainly if something comes up, the complaint-based system is
working side by side, but a proactive rental inspection system can help
renters, undocumented residents, others who may be unaware of their rights or
afraid to exercise them, really access their right to safe and healthy housing.
It has three major components: a registration process, this may be like a
certificate or a license for occupancy, periodic inspections, these can happen
every few years varies from community to community, maybe every two years or three
years or five years, and then enforcement for those who fail to meet the standards
that are set out there. Number nine, if you have all of these things in place is
to put in place supplementary programs and again this is related to some of
those earlier points about really making sure that residents, the code enforcement
officers, everybody is supported through the process that we really make it easy
and possible for people to do the right thing. Making sure there are
educational programs in place so that people know their rights and
responsibilities, the process and that there are resources to subsidize or pay
for repairs, to provide relocation assistance, if that’s needed, etc. and then
number ten is about evaluating the code enforcement program. I’m an
epidemiologist by training so I love this part of it and it’s really
important to help monitor the functioning, to know what’s working, where
you can improve, but also to justify resources. You can have a model
system in place and it’s running but, you know, something in your political
landscape changes the champion who a person who you know put this in place
and was a champion for it every day decides to retire and you don’t want it to fall apart so it’s really important that you always have on
hand the data to talk about why your system
is working and having impact and is important to continue. I’ll just say a
few words then about also some of the tools that are available to help get
you started on some of those early steps. The first step was about
establishing a strong local housing code. In 2014, the American Public Health
Association and NCHH together with a large panel of experts published a set
of performance standards for existing housing called the National Healthy
Housing Standard. What this is really about is bringing public health
rationale into building code parlance, bridging that gap, and creating a set of
model codes that communities could adopt to make their housing codes more
protective of health and it’s comprised of a set of core and stretch provisions
in different categories. There is a link to the tool there, it’s available
online. Over the years, we have worked with a number of communities to put this
this tool into action and one of the things that can be a really easy first
step is to take the National Healthy Housing Standard and compare it to your
local code so here’s a sample sort of visualization of what can happen if you
go through that process. You can compare your local code here that’s shown for
this, anywhere USA by the blue bars and compare that to the international property maintenance code the, IPMC,
that is a very common code that is adopted in part or in whole by many
communities. That’s shown by the red dotted line here, compared to again then
the core provisions of the National Healthy Housing Standard shown by that
purple line and then the stretch provisions as sort of the best gold
standard of the National Healthy Housing Standard that’s that green line at the top
here and this kind of visualization makes it really easy to see, you know,
where is your community strongest, where is their opportunity for improvement. We
had done this comparison in about 25 different jurisdictions. Many of those
codes, these visualizations, and the results of that are published online and
given them not only customized recommendations of where they can
improve, where they’re strong but because we have the standard that
I showed on the previous slide, there’s a model code they can adopt if they decide
that they want to take on moisture and pest management, there are codes that
they can go and just adopt without having to create that. We’ve seen
this lead to change in at least two communities. There are two case studies
published on this in the city of Tukwila. Back in 2015, the Tukwila City
Council, this is in the state of Washington, adopted an ordinance that
incorporated the National Healthy Housing Standard wholesale within their
local property maintenance code. I’m about to turn it over to Bob in a few
minutes from Dallas, who’s going to talk about the process that they used to not
only update their housing code using the National Healthy
Housing Standard as a guide to really focus on some of the issues that are very
relevant for respiratory conditions like pests and moisture and excessive
temperatures, but how they also took that opportunity to put in a proactive rental
inspection program at the same time. Before I hand it over to Bob, I just want
to acknowledge that there are some common challenges that we see associated
with this work, that there can be sometimes a lack of data that’s
available. We’ve already talked about the some of the financing challenges that
many code enforcement offices are under-resourced already I’m so asking
them to do more um can sometimes be a challenge one of
the ways we can get around that is again through that partnership and that cross
agency collaboration. Again, I love that example from Erie County about
deputizing folks and that already may be going into homes so that they can
help with that that work. Poor enforcement mechanisms is a challenge in
many communities, that they don’t exist or not applied
evenly or well, so that’s certainly an area of work that needs to be addressed
in many communities. There’s a lot of concern frequently when people want to
take this on about the fear of opposition or perceived costs of
improving housing quality, that you’re going to get a lot of pushback from
folks in the community or have a lot of unintended consequences as a result of
putting this in place that we don’t want to affect, for instance, the supply of
affordable housing in a community. These are all real challenges but because
they’re real challenges that means others have struggled with them as well. As a result, there are tools to helps. So, as Tracey mentioned at the
beginning, there are a number of organizations, not just NCHH but many
who are available to help connect you to those communities and learn from their
stories so that you can overcome those challenges, as well as to tools that
have been published to help you dig into these problems. I want to highlight
particularly change lab solutions. You see a number of their resources
highlighted on the screen here. They have some excellent resources in this area at
the National Center for Healthy Housing. We also host an entire page related to
housing code tools and before I hand it over the last tool that I’ll mention for
something that may be released this month was coming soon is that,
for communities that are interested in doing that comparison taking, that first
step of comparing their local code to the National Healthy Housing Standard, we
decided we didn’t want to be the thing that stood in their way, that we didn’t
want to have to wait for us to get more funding to help communities do that. We
wanted to make it easy for anybody within a community to be able to do that
kind of comparison. We bought we’ve put together an online tool called Our
Code Comparison Tool that we like to think of as TurboTax for housing codes.
It’s very easy to access tools. It tells you how to find your housing codes, what
to look for, and then there’s a lot of tools and hints throughout. You’re guided
through a question by question to rate your housing code and then a customized
report with a visualization is generated for you referencing where in the
National Healthy Housing Standard you can go to find support for
strengthening your housing code. I’m sure there’s there’s lots more to talk
about here, but I want to make sure that we have adequate time to hear Bob’s
story. So, I’ll turn it over to Bob. Well, thanks Amanda. I’m always refreshed when
you give that presentation because I always learn it all over again and
you’re quite eloquent in how you talk about it. I work with the city of Dallas.
I work in a neighborhood code compliance section of our city.
I do special projects and one of those over the last several years has been the
change in our minimum housing standards. There are two different codes that we differentiate between. Many of
you are probably familiar with building codes. These are the ones that regulate
predominantly new and new construction and major remodeling. These are the ones
you have to go down to the city or your jurisdiction and get a permit. It
regulates all aspects of the construction. These are put out primarily by the International Code Council and they’re
adopted by jurisdictions, sometimes modified when they’re adopted, but that’s
where they come from. They’re based on experience of what happens to
structures over time. So, if you have a fire that’s caused by an electrical
situation, that’ll get studied, it will get evaluated, and see if there needs to
be change in the codes themselves. One example of that, you know number of years ago, we used to use a lot of aluminum in wiring and houses and found out that the incidence of fire in those structures was greater than that if they
used copper. They had to change the code ordinance regarding that particular
technical aspect. The maintenance codes are different and while the Code
Council has developed the International Property Maintenance Code as Amanda has
talked about, it isn’t necessarily the gold standard. It’s pretty good and
if you have nothing else certainly start with it, but the maintenance code does
exactly that. What happens is, common sense tells you, if you’re
building something, it ages over time. Components will deteriorate, they need to be replaced if you own a property or in your life you know that
you have to budget to $300 a month over 20 years to make everything stay
reasonably safe and sound. So the deterioration of structure is the big one.
Plumbing leaks happen that brings on the whole situation with mold that we know so much about and how it ties in with asthma. Insect infestation very
few houses especially the older ones are sealed in a way to keep bugs in or out. So we tend to see them, especially you get down here in warmer climates you
tend to have ants in certain times of the year. Up north maybe it’s more
termites, but insects or infestation wherever we are and we’ve adopted things
in our code here to really deal with that. When we started this, we
did it from non-health perspective, quite frankly. You know, we looked at the problems
we were having enforcing codes on structures and found out that our codes
were hard to understand. If any of you ever read a city ordinance, you’ll
know what I’m talking about. It’s like written into the language not known on
this planet and then we expect people to obey it and they can’t even understand
it. So, what we did was we looked at the common problems we have an enforcement
and then we looked at the code compared it with international property maintenance
code see how we could make improvements. The key and IPMC, International
Property Maintenance Code, if we’re gonna use that fine, personalize it to your
part of the country in your jurisdiction. Dallas started doing the physical
part of the property maintenance code just with definitions, clearing up a lot
of mischief in the code that sort of thing, but coincidentally about the same
time the Children’s Hospital here created a Health and Wellness Alliance
in 2013. It was really cross collaborative it was people from EPA,
people from the American Public Health Association, others that had an interest
in the health of children. Because what the Children’s Health
Hospital noticed was a spike in asthma admissions back in 2012-13 and they did
some research on it and found out what Amanda has really brought to our
attention. You know, you tend to have more asthma where you have people that are
poorer. There’s a lot of the affordable housing in Dallas and I think around the
country tends to be older pieces of property that maybe aren’t maintained as
well. So they knew they had a problem and they wanted to figure out how to
address that particular issue because we found, as I’ll point out in another slide,
the tremendous cost and impact on the city. Amanda mentioned that
nationally built and drilled down into our community. Through this
alliance, the city of Dallas Code Compliance where I work and the
Community Prosecution Division of the City Attorney’s Office, they’re really a
community-based component of the city attorney, began working in 2014 to look
at how we could do the job better. It’s a huge project if you want to keep
herself busy for a year to take on that task. We did, it took two years, starting in roughly
2014 passing 2016, we did council breathing and stakeholder meetings and
quite a number and passed the ordinance in in September 2016. It went
into effect just last year. We had many many partners in this. This is just an
overview. In the upper right, you’ll see the Environmental Protection Agency
region six here has been a persistent supporter in bringing more helpful
listening to our area. We partnered early on through the Health Alliance, they said, you know you really need to talk to this National Center for Healthy Housing.
They’re doing this new comparison tool that Amanda described to you and maybe
they can help you out. Sure enough got on the phone, exchanged documents, and
they looked at our early code. I think we scored around 30% out of a hundred on our standards compared to theirs. We involved
the Apartment Association because Dallas has 40% of its population lives in
apartments here. It’s higher than many places around the country so we had
to recognize that. Similarly, we knew from census data that
about 20% of our population lives in a single family or condo unit, which yeah
do the math you had 60 percent of our population living in rental property.
That’s pretty high compared to other places. There were some other
organizations that got involved early on. The Dallas area interfaith, which is part of a nationwide movement, but they have a representative on the ground here and
they represented a group of apartments in one part of the city that are
predominantly occupied by Latino or Spanish-speaking people. That was
partnered with a local synagogue and the Unitarian Church and they formed a real
powerful voice for tenants there. Along with that was the
Texas Tenants Union, say that 25 times fast, and they really had a very strong
voice on things that they thought needed to be done. It was very
collaborative with the city of Dallas, several different departments, building
inspections, and code compliance, the tenants, the EPA, National Organization’s Center for Community Progress, that Amanda mentioned and we all brought them
together to put energy into this. That process was thorough, quite extensive. We
knew that we had a big problem. We had been studying the issue of urban blight
like many cities have done and when this asthma thing came forward, the Children’s
Alliance documented that about 60,000 people, young people in
city of Dallas, were being affected by asthma at a cost of sixty million
dollars, mostly coming out of taxpayer funds. We don’t have a state income tax
here, it all comes out of property tax for the most part and the majority of
the property tax in Dallas isn’t imposed by the city expenses, it’s really
schools and hospital. They documented, Children’s documented the
amount of emergency room trips per thousand and you can see it on the
drawing there. The dark red diagrams interestingly
correlate with some impoverished areas of the city. The one right in the middle
is near just south of downtown. It’s been a negatively impacted from both a
economic view and and states segregation issue for decades. So, we knew we had a
problem there. In our working group with the Children’s Hospital, we
identified the things we thought need to be changed. One of the things that
was brought up, we looked at the things that we could change that would
give the most impact with the least hassle. As Amanda mentioned
earlier, you know, you can have push back. You go into an apartment complex in
tell them they got to rebuild it and watch the hair stand on the back of the neck.
They don’t want to do it. Almost any property owner doesn’t want to spend
more money than they need to. So, we picked fairly simple things. We used to
have an ordinance here that enforced a maximum indoor temperature only a few
weeks during the summer. We changed it to year-round and we made it a uniform 85
degrees. We said, although we’d like to put in integrated pest management, that
requires a lot of effort on the part of the tenants, but if we just took changed
a minor thing and said, if you’re going to use pest control, it has to be done by a
licensed operator as opposed to simply specifying that it has to be done
by approved technology, it makes it a little more tighter. Finally, we had a
provision there to adjust the sources of mold, which is most of you know is
moisture. Putting together the code was fairly simple compared to getting it
sold and I’m a sales person by background, so that’s how I would look at it. We
did over 30 community meetings throughout the city and brought people
together typically 30 to 70 people showed up in each one of those. We did six
briefings, full briefings, formal briefings for the City Council Housing
Committee. This council then required a full briefing to them
and they said we need to have a public hearing. We had like 400 people show up
at the public meeting and made their voices heard. A lot of those were tenants. We met with individual council members and we encouraged all the stakeholders
as well to meet with them. That was the selling process, it took about a year
year and a half. As I said, we went into effect on January 1st and we’re just
starting to measure the health results and we’ve also learned some things,
hopefully. Identifying the possible landlords and single-family takes time.
We use council appraisal data. More recently, we’re now using utility
connection data, but when you don’t have a program for people that identifies them
as landlords, it’s tough, so we had to kind of dig it out and that’s what we’re
still in the process of doing. Getting the word out to these people was more
difficult than we expected, quite frankly. You know, you kind of hope you put an
article in the paper and people line up to register. Well, they don’t do that. We
got the word out through social media and other things. As of this week, we have
about 17,000 of our expected 50,000 single family owners register. We found
out the online registration is too complicated. We need to simplify it. We’re
in the process now doing that. We’ve inspected about
eight or nine thousand of the properties that have been registered. It requires an
additional training or use of third-party inspectors. We’ve done it
with training so far and we’ve begun to revise the ordinance to simplify it. It’s
been a very interesting process, not necessarily easy, but well worth doing. That’s the end of my presentation. We’ll now get into the questions and
answers. Perfect. Great, thank you both so much Amanda and Bob. I just like to say,
you know, a couple of the takeaways. Amanda, I really love how you talked
about code enforcement as being a complement to an existing financing
system and being able to expand your scope of services or your scope of the
numbers of served by using code enforcement. Bob, you tell a
great story. You have an impressive list of partners and I think one of the
takeaways for me was persistence. It definitely takes time and requires lots
of buy-in, so I’d love to invite you both to come back I think we could probably
spend several more hours learning from you, talking about a new online
comparison tool that NCHH has developed. Bob,
you’re going to have, I’m pretty sure, some impressive outcomes to be able to report,
so I’m hoping that maybe we’ll hear from you and on a future webinar. Thank you
both. Before we close, we’ve got just a minute to
do our final polling question. We’d like to get a little bit of feedback from our
participants. Based on what you heard today, what action are you most likely
to pursue? Would you be accessing Asthma Community Network to learn more about
housing codes and health? Will you be accessing an NCHH’s National Healthy
Housing Standard and learning more about that? Will you be looking to connect with
colleagues about building partnerships specifically around maybe housing codes
or something else? So, it looks pretty evenly split between learning more about housing codes and health on Asthma Community Network and about learning
more about the National Healthy Housing Standard. It’s great to see so many of
you are interested in building partnerships and connecting with
colleagues, as we’ve heard from both Amanda and Bob, that’s really a key into
being successful with this work. I’d like to thank all of you for your
participation today, being a great audience and I’d like to invite you now
to join us at the question and answer session on,
the discussion forum you see on your screen, the directions for accessing
the Community Network and the discussion forum, and so, we’ll be signing off here
and heading over to Asthma Community Network right now. That concludes our
webinar. Thank you, again.

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