Because they are poor and disproportionately from communities of color, residents of public housing are more likely than the population as a whole to face health challenges. Yet across the country, studies specifically designed to assess their needs, and targeted initiatives to address them, have been rare. The Boston Public Health Commission partnered with academic researchers to collect data about the health of people living in the city’s public housing, and then collaborated with the Boston Housing Authority (BHA) and the Boston Medical Center (BMC) to turn that knowledge into action.
Uncovering Health Challenges in Public Housing
A package of research, a few somewhat adversarial encounters, and an openness to change among many stakeholders provided the seeds for Breathe Easy at Home, a Boston-based initiative designed to reduce mold, leaks, pest infestations and other housing-related risk factors for asthma.
That project began with a simple survey question: Do you live in subsidized housing?
Beginning in 2001, the Boston Public Health Commission sought that information through its bi-annual Behavioral Risk Factor Surveillance System, asking: “Are you: 1) a public housing resident in a building owned by the Boston Housing Authority; 2) part of a household that receives rental assistance such as Section 8 or any other rental assistance program; or 3) neither of the above?”
By analyzing the answers, the health department was able to tease out some of the specific health challenges that public health residents are likely to face. The data revealed glaring disparities. Almost one-third of those living in subsidized housing ranked their health as fair or poor, compared to less than 10 percent of other city residents. Rates of hypertension, diabetes, and obesity were also dramatically higher, as was the incidence of asthma – almost one-quarter of adults served by the Boston Housing Authority had asthma, compared to less than 10 percent citywide (Use of a Population-Based Survey to Describe the Health of Boston Public Housing Residents).
“All of a sudden we were privy to information about health disparities between our residents and those of the city of Boston. That was a great turning point for us as an organization.” — John Kane, Boston Housing Authority
Recognizing the power of the newly available data, a team of researchers from Harvard, Tufts and Boston University asked BHA’s permission to further document the asthma problem among residents, assess potential interventions, and offer recommendations. Despite some anxiety about how the process would unfold, the housing authority gave its consent.
“There was concern that these folks from the Ivory Tower would come and tell BHA what it is doing wrong and offer a solution that costs a ‘zillion dollars’ we didn’t have. And then we would end up on the front page of the local newspaper or in court, and panic residents,” acknowledged John Kane, MPP, senior program coordinator at the Boston Housing Authority.
Early meetings were a bit uncomfortable. “It took a while to find our groove where it could be mutually beneficial,” Kane acknowledged. “There was an aspect of PhDs writing papers and talking down to the operations staff at BHA.” The health commission eventually assumed managerial responsibility for the convenings, rather than having them led by academics, and BHA felt that helped the tone became more collegial. Findings were well-documented, said Kane. “We all learned from it and developed a better understanding of the links between health and housing, asthma and pest management.”
As that work was unfolding, the housing authority was under legal pressure to correct building code violations identified by the Inspectional Services Division (ISD), the city’s enforcement authority. Eager to avoid the lawsuits that were becoming standard practice, BHA leadership decided it was time to take a new approach and signed a Memorandum of Understanding with ISD that opened the door to greater cooperation. BHA and ISD officials put procedures in place to handle complaints as they came in, meeting together at housing units of concern to discuss remediation strategies, and agreeing on a timetable for completing the work.
Such was the backdrop against which three partners — the Boston Health Commission, ISD, and the Boston Medical Center — launched Breathe Easy in 2005. It was a tool to, essentially, “write a prescription that allows someone to go home to a pest-free apartment,” as one physician put it. Through a web-based referral system, clinicians at participating health institutions can ask ISD to inspect either publicly owned or private housing units they believe might have conditions contributing to asthma, and to conduct follow-up inspections to ensure substandard conditions are resolved. Instead of adopting a defensive posture, BHA recognized Breathe Easy as a pro-active, cost-effective action strategy.
“We wanted to have a system in place where we could work together and be more productive and do the remediation that need to get done, with a focus on the health and quality of life of the residents” — John Kane, Boston Housing Authority
Separate Missions, Common Goals
Along with developing and sharing data, the Boston Health Commission’s continuing contribution to health and housing issues has included building public awareness, engaging the community, testing interventions, and guiding cross-sector convenings. “Some of the things that public health does aren’t necessarily in the missions of other organizations,” said Margaret Reid, RN, MPA, who directs the commission’s Office of Health Equity. “These are functions we could really offer up.”
Since 2010, the health commission has also sponsored an annual meeting that brings its own staff together with representatives from the Boston Housing Authority, ISD, and Boston’s Office of Fair Housing and Equity. “The main goal of the convening is to align our resources and how we actually provide services to residents in both public and private housing,” Reid explains.
“Each of us can identify what we bring to the table and how this benefits us in advancing our particular mission.” – Margaret Reid, Boston Public Health Commission
That kind of intentional discussion honors the primacy of each stakeholder’s mission while highlighting their distinct, but interrelated roles. The core mission of the Boston Housing Authority, for example, is to keep units on line and occupied, said Kane. “We are the housing authority, we have to focus on housing. We can’t provide the nursing and the medical care that the residents need.” But for that very reason, BHA partners with providers who can.
Often, self-interest and the public good overlap. After spending large sums of money on pest control, without effectively eliminating pests, for example, BHA saw that it made more sense to address the structural causes of a building’s infestation by sealing up cracks and crevices and providing education to encourage residents to report any early signs of pests.
Likewise, the housing authority had financial as well as health reasons for barring smoking from its apartments. Considerable resources were being consumed to pull up carpets, repaint apartments, field complaints, and turn over units that had housed a smoker. Based on data showing that units in which people smoke are more expensive to turn over, as well as a recognition that there is no way to stop the spread of secondhand smoke in a building, BHA became the first public housing authority of its size in the country to go smoke free in 2012.
“We can not go to a partner and say ‘you should do something because it’s the right thing to do.’ We can’t just be health driven. But if BHA has a totally limited operations budget and is spending money ineffectively, that is a touch point. Why not do it differently?” – Margaret Reid, Boston Public Health Commission
The Boston Medical Center, too, has also recognized the benefits of moving upstream. In 2017, BMC launched a five-year, $6.5 million investment to increase the city’s supply of stable and affordable housing. The move responded to state requirements that the medical center dedicate a percentage of any proposed new building’s cost to assess and meet community needs – and also reflected BMC’s understanding that the future of health care lies, at least in part, in community-level interventions.
“Each of the housing partnerships that the hospital has been engaged in — with the public health community, with the affordable housing community — has deepened over time,” said Megan Sandel, MD, MPH, associate director of the GROW Clinic for Children at the Boston Medical Center. “We’re asking ‘how does a neighborhood make you sick? And can housing become a platform for community development as a means to improve health?’”
Strategic cross-sector communication is key to finding the right answers. “We are having a lot of conversations and training about this,” says Reid. “We are thinking about, how do we speak in plain language? How do we be compelling? How do we communicate our data so other sectors feel it is relevant?” Simply acknowledging the value of developing the skill set to do all of that, she says, is an early and essential part of that process.