While residential use of lead-based paint has been banned in the U.S. since 1978, millions of homes still have the paint, and the health dangers it brings with it, on their walls. Lead paint has been linked to cognitive and behavior issues as well as anemia and even death, especially in young children because their brains are still developing. But according to the Centers for Disease Control and Prevention, about half a million children ages 1 through 5 have potentially dangerous blood lead levels.

In Philadelphia, according to the 2009 American Housing Survey data, 91.6 percent of the housing units were built before 1978. Exacerbating the issue, close to 30 percent of families live in poverty, which can delay household maintenance and lead to peeling paint—a major lead risk to children in older homes. Studies also show that the number of children in Philadelphia with elevated blood levels is higher than the national average.

“This problem requires a public health solution since [preventing childhood] lead exposure…involves multiple stakeholders, including the child and parents, the property owner, and the local authorities who make and enforce laws, ordinances and codes,” says Carla Campbell an associate teaching professor in the School of Public Health at Drexel University. Campbell is the author of a new study on a lead court established in Philadelphia in 2003. The lead court is designed to speed the cleanup of lead hazards in apartments and rented homes. Campbell’s research was funded by the Public Health Law Research, a project of the Robert Wood Johnson Foundation, based at the Temple University School of Law. Campbell’s study appears in a special issue of the Journal of Health Politics, Policy and Law focused on public health law research.

NewPublicHealth recently spoke with Carla Campbell about Philadelphia’s lead court and the implications of its success for other public health issues.

NewPublicHealth: What did your study find?

Several federal agencies have teamed up for a joint initiative, Advancing Healthy Housing: A Strategy for Action, to reduce home-based injury and illness. Agencies at the table include the Office of the Surgeon General, the Environmental Protection Agency, the Department of Housing and Urban Development and the Department of Energy.

People spend up to 70 percent of their time in a home, according to the group, and millions of homes each year are the source of serious health problems including asthma, lung cancer, unintentional injuries and lead poisoning. Home health hazards can include structural problems, damaged roofs, heating, plumbing and electrical deficiencies, leaks, pests, peeling walls that exposing children to lead-based paint and high levels of radon gas.

The initiative has five goals:

1. Establish healthy home recommendations.
2. Encourage adoption of healthy home recommendations.
3. Create and support training and workforce development to address health hazards in housing.
4. Educate the public about healthy homes.
5. Support research that informs and advances healthy housing in a cost-effective manner.

Surgeon General Regina Benjamin spoke at a press conference to launch the new Action Plan and in 2009 released a healthy homes strategy that the new initiative builds on. This Action Plan dovetails with the National Prevention Strategy, launched two years ago to improve the health of all Americans. Dr. Benjamin told NewPublicHealth, “Health is in everything we do. We need to make it a part of our lives. Our home should be a place you feel safe.”

Substandard housing has been linked to a variety of health problems including higher blood lead levels in children and an increased asthma risk. Now a new study by researchers at the Johns Hopkins Center for Injury Research and Policy finds kids living in poor housing may also be at an increased risk for fire and scald burns. The research was published in the journal Pediatrics.

The researchers surveyed the homes of 246 low-income families in Baltimore with at least one young child, and found homes with more housing quality code violations were less likely to have a working smoke alarm and safe hot water temperatures. "The effect of substandard housing on children’s risk of diseases such as asthma is well-known, however little was known about how it affects injury risk,” says Andrea Gielen, ScD, ScM, the study’s lead author and director of the Johns Hopkins Center for Injury Research and Policy. “The results of this study clearly demonstrate that substandard housing is also related to home injury risks, Gielen adds. "Even more disturbing is the finding that virtually all of the children in our urban sample were living in substandard housing."

Injury is the leading cause of death for young people in the U.S., and is responsible for more than180, 000 deaths annually, according to data from the Centers for Disease Control and Prevention. Deaths from fires and burns are the third leading cause of fatal home injury. Smoke alarms and lower water temperatures reduce the risk of burns, says Gielen, but living in substandard housing appears to be a barrier to having these protective measures in place.

>>Read the study.

>>Bonus Links:

• Read a NewPublicHealth post on how low income families can get free smoke alarms
• Read a NewPublicHealth National Prevention Strategy series interview with Estelle Richman, Senior Advisor to the Secretary of the Department of Housing and Urban Development on the intersection of housing and health.
• Read a NewPublicHealth interview with Andrea Gielen on injury prevention.

How does housing impact health?

A new commentary in the journal Health Affairs tracks the history of health and housing in the United States and says that while a connection between housing conditions and public health has been known since the 1800s, federal housing policy only began during the Great Depression. The Department of Housing and Urban Development (HUD) has increased awareness of that connection since the agency was founded in the 1960s.

HUD’s housing initiatives have included:

• Prohibitions on lead and gasoline in HUD housing
• Programs to allow HUD tenants to move to more affluent neighborhoods
• Integration of health-oriented policies with other departments  including the Department of Health and Human Services

Authors of the commentary worry that current congressional funding policies lead to “predetermined silos,” which could impede the needed integration of projects among federal agencies. HUD’s adoption of a health in all policies approach, according to the authors, “signals an active recognition that the investments have implications for social determinants of health and ultimately for the health of the populations HUD serves.”

>>Read the full article.

>>Bonus Links: Read a NewPublichealth interview with one of the commentary authors, Raphael Bostic, called “Housing Policy is Health Policy” and an interview from our National Prevention Strategy Series with Estelle Richman, senior advisor to the Secretary of Housing and Urban Development.

The National Prevention and Health Promotion Strategy offers a comprehensive plan to increase the number of Americans who are healthy at every stage of life. A cornerstone of the Strategy is that it recognizes that good health comes not just from quality medical care, but also from the conditions we face where we live, learn, work and play—such as healthy homes, clean water and air and safe worksites. The strategy was developed by the National Prevention Council, which is composed of 17 federal agencies including the Department of Education, the Department of Housing and Urban Development and others.

As the Strategy is rolled out, NewPublicHealth will be speaking with Cabinet Secretaries, Agency directors and their designees to the Prevention Council about their prevention initiatives. Follow the series here.

This week, NewPublicHealth spoke with Estelle Richman, Senior Advisor to the Secretary of the Department of Housing and Urban Development.

NewPublicHealth: Why was it important for the Department of Housing and Urban Development (HUD) to be involved in the development of National Prevention Strategy?

Estelle Richman: HUD’s mission is to create strong, sustainable, inclusive communities and affordable housing for everyone. HUD is more than bricks and mortar. We need to get away from thinking that housing is just about putting a roof over your head. It’s your home, and your family’s health and safety and your children’s education are all dependent on where that home is. HUD views housing as a platform for improving a wide range of outcomes.

That’s what makes HUD dovetail perfectly with the National Prevention Strategy; the whole concept of affordability of housing and the quality of neighborhoods and the understanding of that influence on health. HUD invests about $50 billion annually on affordable housing and community development and these investments impact health. We don’t do it alone and none of our partners can do it alone. But together we can bring significant experience and expertise to the table so that we can truly mitigate and help prevent health hazards.

NPH: What approach is HUD taking to address the challenges of health related to housing?

Estelle Richman: One of the most obvious places where we make a substantial difference is the physical environment of housing, including a focus on lead-based paint hazards, mold and pests and all the many things that contribute to respiratory disease, allergies and other illnesses.

Another factor not always immediately connected is housing affordability and health. Many households are now paying more than 60 percent of their income in order to remain in their homes. And if you’re paying a huge amount of your income just to pay your rent or your mortgage, then you’re cutting something else—such as food, health care, medicine and transportation. That puts people at risk for both physical and mental health problems. Children in families that have been behind on rent are more likely to be in poor health, have increased risk of developmental delays and suffer from food insecurity than children whose families are stably housed.

NPH: What are some of HUD’s key initiatives in helping to foster sustainable, healthy communities?

Estelle Richman: We know that physical and mental health depends on sustainable and economically vital neighborhoods where we have access to transportation, good schools, safe places for children to play and places to go shopping for healthy and wholesome foods.

HUD’s Moving to Opportunity for Fair Housing Demonstration Program has shown that moving to better neighborhood environments is associated with improved mental and physical health for adults, lower rates of extreme obesity, lower rates of diabetes, less psychological stress and less major depression for adult women. So being able to stabilize where you live and the quality of your housing can make a difference.

We’re trying to reach some of these same goals through our Choice Neighborhoods Program, which is part of a partnership between HUD, the Department of Education, the Department of Justice, the Department of Health and Human Services and the Department of the Treasury. Choice Neighborhoods actually builds on the success of Hope VI, which was begun in the 1990s and was set up to transform some of the worst public housing by developing mixed-income communities. In Philadelphia, for example, when they were able to switch to Hope VI, you saw a distinctive change in those neighborhoods. Schools got better, neighborhood stores moved in, transportation became more accessible. When we talk about Choice Neighborhoods now, we consider employment assets, quality education, and a wider range of stakeholders, including nonprofits, private firms, local government and public housing authorities.

NPH: What changes can be made to housing and home standards to help improve home and neighborhood safety?

Estelle Richman: We believe the home environment is a major influence on health and well-being and that threats to housing quality include everything from excess moisture, mold, allergens, and poor indoor air quality, to structural deficiencies and lead contamination.

NPH: And what is the approach to minimizing risks such as lead poising from lead-based paint?

Estelle Richman: Our Office of Healthy Homes and Lead Hazard Control is looking at this. We know that housing that was built before 1978 may have lead-based paint, with homes built before 1940 having the highest levels of lead in paint. So it really doesn’t matter if you make a million dollars—if you’re living in a house built before 1978, the odds that there’s lead somewhere in that house is high enough that everyone needs to be concerned about their children. So the standard has to be set high enough that we protect everyone.

NPH: What is HUD doing in the area of secondhand smoke in homes and who are your partners?

Estelle Richman: That is a big agenda items for many divisions of the Department.

Our partners in this are the Housing Authorities, some of the landlords, and just about anyone else who’ll talk to us. My best example of this is the Boston Housing Authority, which is on track to now to implement a total smoke-free policy this fall. They found that their asthma rates were twice as high as those for residents living in non-subsidized housing. They have done a lot of work over the last several years educating themselves, their clients, and offering folks as much support as possible to stop smoking, and now they’re ready to implement a smoke-free policy.

There are several other cities that have announced that they are looking at instituting smoke-free policies—San Antonio, Minneapolis, Portland, Oregon and all of the housing authorities in the State of Maine are among them. We’re offering whatever technical assistance we can to help them do it. We’re working in partnership with HHS, the American Academy of Pediatrics and the American Lung Association and trying to gather many other community supporters.

As we push, I think we will always find folks who believe that they want to continue to smoke, but we’re also finding that there are many people who are ready for smoke-free policies in their housing.

NPH: What are some current efforts of working across sectors to improve housing and better health in that housing?

Estelle Richman: Our Section 811 Project Rental Assistance Demonstration Program is a rental demonstration program to provide housing for people who have disabilities. It provides $85 million in funding to state housing agencies and other appropriate entities to provide long-term housing rental assistance for approximately 2,800 people. Many of these folks will have physical disabilities and will often need assistant care or assistive technology in order to live in the housing, which means that most of them will also be involved with the state Medicaid Agency, as well as their state Health and Human Services Agency.

To develop the program we worked hand in hand with the Centers for Medicare and Medicaid Services. I can’t tell you the number of positive emails I received. People were anxiously awaiting it. It is fully integrated with non-disabled populations, which was critical to the disabled community. To be a part of the program, a state housing agency must partner with the state Medicaid agency to submit a grant. So this is a true partnership. It’s integrated housing, it’s supportive housing and it helps get people out of institutions.

NPH: What are examples of partnerships you have within the Federal government?

Estelle Richman: We meet with our partners at HHS every week. We talk about our joint projects and about projects that we would like to work on together. We’re also a very strong partner with the Department of Veterans Affairs (VA). You may know that we’re working with the VA around eliminating veterans' homelessness by 2015. There is also an HHS part of it so that we can know that our veterans who are coming home not only have good health care, but they also have a place to live. As I’ve said, we all have to have partners and it is, in essence, the core of that partnership that helps us make progress. The National Prevention Council has actually brought these partners together and I credit them for being part of what keeps us working together. It’s very easy in some of these very large bureaucracies to drift off and do your own mission and I think one of the things the National Prevention Council does is help us all realize that we all share prevention, we all work on it together.

NPH: What are some of the other critical partners in communities?

Estelle Richman: In any level of government, the level you need to get to is the level of where the people are. So you need to get down to neighborhoods, you need to get to communities and when you go down in communities, you really need to talk to your hospital and health care systems, community neighborhood groups, schools and PTAs. Also what rises to the top of the page real quickly is transportation. If you have not figured out how to get transportation as a partner then you’re going to have a hard time getting prevention, promotion and health care to work outside the city center.

Each community is different. You need to talk to the folks and get a feel for what’s going to make a difference in that particular community.

NPH: Tell us about the Partnership for Sustainable Communities.

Estelle Richman: It is a multi-partner collaboration among HUD, the Department of Transportation and the Environmental Protection Agency. These two agencies have not always been traditional partners for HUD. Through the Partnership, we are coordinating federal housing, transportation, and environmental investments and looking at things like water infrastructure, roads, sidewalks, transit lines, and job creation opportunities as all of those things are necessary for a healthy and vibrant community life. Several of the Sustainable Communities grant recipients are partnering with the public health sector, including in conducting health impact assessments, increasing access to fresh foods, and encouraging active living that includes opportunities for exercise in one's daily commute and routine. They’re realizing that to improve public health, it’s critical to actually support and create the communities that are not only going to be economically sustainable, but that also maximize environmental, energy-efficient and socially sustainable design and development strategies.

NPH: What had the National Prevention Council brought to the table that was not there before?

Estelle Richman: When you have an initiative like the National Prevention Council, you set goals, you set measurable outcomes and you also have skin in the game of what the big group is doing. You’re held accountable, but you’re asking to be held accountable. And it’s not accountable to your silo, it’s accountable to the larger group.

And I think it’s that choice of accountability to the larger group for health care that affects all of us. The concern about health care is not an issue just for struggling families or folks in foreclosure or families that are in the lower incomes. Health care is something we are all concerned about. In the end, it holds us all accountable for better communities.

>>Catch up on the rest of the National Prevention Strategy series on NewPublicHealth.

JAMA Study Raises Concerns about Quality of Clinical Trials

A new analysis of three years of clinical trial data published on ClinicalTrials.gov, a registry maintained by the National Institutes of Health, found that many of the trials were too small and of too poor quality to provide sufficient results for practitioners. The study authors, who published their findings in the Journal of the American Medical Association, reported that their “analysis raises questions about the best methods for generating evidence, as well as the capacity of the clinical trials enterprise to supply sufficient amounts of high-quality evidence needed to ensure confidence in guideline recommendations.”

Read more on medical research

HUD Awards Grants to Increase Housing and Improve Infrastructure in Tribal Communities

The Department of Housing and Urban Development has awarded more than $56 million to 76 tribal communities to improve housing conditions and promote community development. Funding can be used for a variety of projects such as rehabilitating housing , building new homes, to purchase land to support new housing construction, to build infrastructure such as roads, water and sewer facilities and to build community and health centers.

Examples of the new projects include:

• The Caddo Nation in Oklahoma will build a community facility for elderly low income residents.
• The Ho-Chunk Nation in Wisconsin will install solar photovoltaic panels on low-income single-family home and apartment rental units to decrease resident energy costs by 24 percent, and to decrease emissions.
• The Cook Inlet Tribal Council in Alaska will help build a group home for Alaska Native youth to reduce the number of homeless youth and increase academic stability and support.
• The Chemehuevi Indian Tribe of California will use its grant to upgrade the reservation’s old sewer lines.

Read more on housing

May is Older Americans Month

The theme of Older Americans Month 2012 is “You’re Never Too Old to Play.”

Seniors can find resources for mental and physical health-related activities on this site, maintained by the National Institute on Aging.

Read more on senior health

Long-Term Exposure to Air Pollution Increases Risk of Chronic Diseases in Older Adults

Older adults may be at increased risk of being hospitalized for lung and heart disease, stroke, and diabetes after long-term exposure to fine-particle air pollution, according to a new study by researchers at Harvard School of Public Health. The study, published in PLoS One, is the first to look at the link between long-term effects of exposure to fine particles in the air and rates of hospital admissions.

Read more on air pollution.

Increase Found in Opiate Use by Pregnant Women

Between 2000 and 2009 in the United States, the annual rate of maternal opiate use increased nearly fivefold and diagnosis of drug withdrawal syndrome among newborns increased three-fold according to a new study in the Journal of the American Medical Association. Use of opioids and other illegal drugs is associated with a significantly increased risk of adverse neonatal outcomes including low birth weight and death, according to the study authors. The research was supported by a grant from the Robert Wood Johnson Foundation Clinical Scholars Program.

Read more on prenatal care.

Justice Department Settles Maternity Housing Discrimination Suit

The Department of Justice has announced that it has settled its lawsuit against the Mortgage Guaranty Insurance Corporation for discriminating against women on maternity leave in violation of the Fair Housing Act. The settlement is the department’s first involving discrimination against women and families in mortgage insurance.

The lawsuit was filed in July 2011 and alleged that MGIC required women on maternity leave to return to work before the company would insure their mortgages, even for women who had a guaranteed right to return to work after the leave.

Read more on housing and health.

The connection between health and energy consumption is an area just beginning to be understood, but when some people are forced to choose between paying their energy bill and paying for food or medicine, it becomes critical. The Health Impact Project has just released a new health impact assessment (HIA) of a pilot program run by Illinois' largest electric utility, Commonwealth Edison. The HIA looked at the health effects of implementing "smart metering," which replaces existing mechanical meters with digital meters that record customer usage in 15-minute increments. The new meters are coupled with a new two-way communication system that allow a utility company to remotely connect and disconnect service, as well as get real-time, detailed customer usage. The purpose of this HIA was to evaluate the potential health impacts of smart metering for residential customers in the ComEd service territory in Illinois.

The HIA looked at three key issues:

• Whether smart metering will raise customer rates for electricity service because of the additional infrastructure investment costs;
• Whether new energy pricing programs enabled by smart metering will provide benefits to customers or increase costs to vulnerable customers at a time when they can least afford it; and
• Whether the use of a remote service switch to connect or disconnect service, particularly in the case of disconnection for non-payment, will have adverse impacts on vulnerable populations

NewPublicHealth spoke about the new HIA with lead researcher, Megan Sandel, MD, MPH, who is the interim executive director of the National Center for Medical-Legal Partnership.

NewPublicHealth: Why is energy a health issue?

Megan Sandel: Understanding how energy and health are connected is a burgeoning field. We understand that the cost of energy can sometimes be particularly important because families may have to make tradeoffs, such as trading off between paying for their heat and necessarily eating enough. Or they’re trading off between paying for their heat or their electricity bill and being able to pay for medicine. And while some people may see the potential concern for some users over heating costs, they may not connect those similar problems can occur with cooling costs. People have actually died in heat waves because they were not able to access their energy needs in a timely way. And so, we were interested looking at this energy proposal and being able to add in possible health implications.

NPH: What populations are most vulnerable or affected due to a lack of affordable energy and why is that?

Last week’s inaugural National Health Impact Assessment (HIA) Meeting held in Washington, discussed the impact of decisions in a broad range of sectors on the health of individuals and communities, and housing sector decisions featured prominently. In a recent interview with NewPublicHealth, Aaron Wernham, MD, MPH, director of the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and the Pew Charitable Trusts, said he was excited to see the growing number of housing HIAs, which he called “very important to health.” Among the housing HIAs presented at the conference were two on low-income rental housing inspections—one on a rental housing inspection program in Portland, Ore. and the other on interagency housing inspection coordination based out of Ohio. NewPublicHealth spoke with lead authors of both HIAs.

>>Follow our coverage from the National HIA Meeting.

Ohio Housing Inspections

Ohio currently has a proposal on the books to streamline the rental housing inspection program on affordable housing units, including improved interagency coordination. An HIA is underway to help inform decisions on the proposal. Right now, separate individual inspections are conducted or required by local housing authorities, the U.S. Department of Housing and Urban Development (HUD), the Internal Revenue Service, and the U.S. Department of Agriculture (USDA) to help identify and repair substandard physical conditions such as water leaks and mold, pests, peeling paint and structural hazards, which can contribute to a wide range of health problems including asthma, injury and burns, and mental illness.

NewPublicHealth spoke with Holly Holtzen, PHD, Strategic Research Coordinator at the Ohio Housing Finance Agency, about the HIA.

NewPublicHealth: What is the goal of the HIA?

Safe, vibrant neighborhoods are vital to health. The community development industry—a network of nonprofit service providers, real estate developers, financial institutions, foundations and government—brings together public and private funds and directs them into investments that transform impoverished neighborhoods into better-functioning communities.

Last week, Nancy O. Andrews, President and CEO of the Low Income Investment Fund, recently moderated a panel on “Healthy Communities” at the National Interagency Community Reinvestment Conference, a premier biannual conference for community development professionals. Andrews previously moderated several sessions on the intersection of community development and health at a series of “Healthy Communities” conferences co-sponsored by the Federal Reserve Bank of San Francisco, The Pew Charitable Trusts and the Robert Wood Johnson Foundation. [Watch an archived video of the “Capital Systems Change” session at the Healthy Communities Conference in November 2011 here.]

NewPublicHealth: What is the connection between community development and human development, particularly when it comes to health? Or, how does investment in a community actually improve the health of the people living there?

Nancy Andrews: Human development, community development and health are inseparable. There is a growing body of knowledge that makes it clear that the communities we live in can help us or hurt us in every conceivable way. The effects of living in poverty can be life-long and can affect one’s ability to be physically, mentally and emotionally healthy. Just in the last six months there have been new data from a 10-year study by the Department of Housing and Urban Development that demonstrates that living in quality housing in a good community reduces obesity and diabetes by as much as 20 percent – that’s an impact a great as a medical intervention! We also know medical interventions can solve only about 10 percent of our health issues. Much, much more of a person’s health outcomes are a result of our environment, our upbringing and our habits. It is almost impossible to overstate how important the environment is on our ability to lead healthy, quality lives.

NPH: You recently led the "Healthy Communities" panel at the National Interagency Community Reinvestment Conference. What did this session cover?