Population Health Blog

Population Health Blog

Why It Matters

Where’s the political will to create low income housing?

By Dennis Archambault
With the domination of international, political, and sex scandal coverage in the news media (actual and “fake”), it’s difficult to get a reading on domestic U.S. human service policy. For example, what is the Department of Housing and Urban Development (HUD) up to?

HousingWire https://www.housingwire.com magazine offers a glimpse into what HUD Secretary Ben Carson may be up to with an interview in its current edition. Secretary Carson quantifies a problem that has been evident for some time – 11 million renter households in America are severely cost-burdened, spending more than 50 percent of their income on housing. There are nearly 500,000 homeless families and 40,000 homeless veterans. Carson noted that essentially, HUD’s response its Rental Assistance Demonstration https://www.hud.gov/RADprogram, which allows localities to leverage public and private funds to ensure that public housing units are maintained and improved. However, there doesn’t appear to be funding for new development.

There are 11.4 million extremely low income (ELI) renter households in the United States, about 26 percent of all U.S. renter households and nearly 10 percent of all households, according to a 2017 report by the National Low Income Housing Coalition http://nlihc.org/sites/default/files/Gap-Report_2017.pdf. The U.S. has a shortage of 7.4 million affordable and available rental homes for ELI renter households, resulting in 35 affordable and available units for every 100 ELI renter households.

Certainly, many of those households are in Detroit and scattered throughout Southeast Michigan. Yet there doesn’t appear to be any new housing units planned. With all the abandoned apartments in the city, and certainly the gaps in the built infrastructure of the city, there’s plenty of space to house folks. All we need is the political will to make it happen. That requires considerable hope.

Dennis Archambault is vice president, Public Affairs, for Authority Health.

Detroit fugitive dust management ordinance represents necessary tactic for environmental health

By Dennis Archambault

Critics of environmental health advocates will often point to the absence of  “sound science”  or “conclusive evidence.”  The problem is, most advocates don’t have time or money that industry has to evaluate claims.  And conclusive evidence is seldom available. Although the evidence for the human impact on climate change has met the scrutiny of several legitimate scientific authorities, still the critics express doubt and procrastinate as long as profit can be made.

The resistance to an ordinance drafted by Detroit City Council Member  Rachel Casteneda-Lopez to implement tougher regulations on the transportation and storage of carbonaceous materials, such as  “pet coke,” has featured similar complaints: lack of scientific basis, existing federal, state, and county regulations on managing fugitive dust, a lack of complaints, and the potential impact on jobs. The ordinance originated with the discovery of mounds of pet coke stored in the open along the Detroit River.

As one researcher pointed out recently, decisions to act in support of public health should not wait until there is 100 percent certainty of the validity of the risk and the source of the problem. In event of public health and safety, decisions are made with the best information and greatest likelihood they will protect life.

Industry complains that increased regulation is unnecessary, will contribute to reduced profits and/or increased product costs, and possible job loss. Regarding the latter, some residents may question whose jobs would be lost, given that relatively few Detroit residents work for these industries.

The environmental quality in Southwest Detroit/Downriver Delta communities is much better than it was decades ago, but remains bad, especially as it pertains to lung disease. Industry research and development is generally oriented to maximum efficiency of production systems and worker safety. However, it should also include environmental impact. Industry can afford it. Advocates can’t. Academic researchers may contribute with grant-funded research, but by the time permit requests and other environmental actions are posed, there isn’t sufficient time for research to be undertaken.

The action by Council Member Casteneda-Lopez and other Detroit City Council members who passed the ordinance on Oct. 29 takes another step toward protecting their constituents and improving environmental quality for the region. It may cost industry a little more to implement, but it’s the cost of doing business in a healthy community.

For an account of the proceedings, read this Detroit Free Press article: http://www.freep.com/story/news/local/michigan/detroit/2017/10/31/detroit-pet-coke-regulations/817246001/

Dennis Archambault is vice president, Public Affairs, Authority Health.

Suburban ‘pockets of poverty’ create new challenge for population health

By Dennis Archambault

Canton, Livonia, Dearborn — you might not think of these suburbs as having residents who are impoverished. It’s been well-known since the last major recession and the collapse of the manufacturing center that employment was slow to recover and many households are struggling nearly a decade later. That struggle translates into critical social determinants that erode access to health and health status overall.

Crain’s Detroit Business asked the question about the role of philanthropy in addressing “poverty quietly growing in the suburbs” (http://www.crainsdetroit.com/article/20171022/news/642721/suburban-poverty-on-the-rise-but-is-philanthropy-following). It might have asked the same about the public and private health system. Community needs assessments are noting these growing pockets of poverty, as are other initiatives like Healthy Dearborn, which has noted areas of food insecurity in that community, which has access to quality produce markets in almost ever sector of its geography.

Poverty is no longer geographically centered in urban centers like Detroit or its working class suburbs like Ecorse, River Rouge, and Inkster. In many cases its invisible, such as the homes of some refugee families that have no furniture. “Low-wage jobs, older housing stock that is less desirable and less expensive and drawing lower-income populations and the loss of jobs tied to the shift from a manufacturing economy are spurring the growth of poverty,” notes Alan Berube, senior fellow at the Brookings Institution.

There certainly is a role for philanthropy. But this is also a growing public health challenge that needs to integrate the resources of the private health system. The Crain’s article suggests that suburban poverty tends to grow, it doesn’t recede, but may be ignored. Health issues driven by the social determinants of poverty affect the neighbors of more affluent people as it does larger communities.

“Detroit is not an island,” notes Tonya Allen, CEO of the Skillman Foundation.

Dennis Archambault is vice president, Public Affairs for Authority Health.

Enduring the culture of crime: calling for resilience

By Dennis Archambault
It’s nothing new; certainly not for communities like Detroit that have been living with high crime rates for decades. You get by or get out. You cope.

The Detroit News is running a series of stories under the categorical heading of “coping with crime.” What is often misunderstood with the focus on statistics – whether or not they are accurate and whether or not Detroit is the number one crime city or somewhere near the top – is that there is a residual erosion of wellness in the community impacted by the knowledge of people who have been victimized and the fear that permeates the culture.
The city has an average of six killings a week, not to mention property crimes. The cumulative effect of knowing this through anecdotes that is near as a neighbor affects people. Even though thousands of Detroiters may not be affected by crime, they are affected by living in a culture of crime and the awareness that it’s happening and could happen to them. This makes you sick, mentally and physically. It diminishes the will to exercise outdoors. It encourages you to eat comfort food which is likely to be detrimental to your health.

Coleen Farm, also with Mothers of Murdered Children, said she’s had a tough time recovering after the fatal drive-by shooting of her son Don Adams Jr. on July 24, 2012.

“It was really overwhelming to deal with,” she said. “I had a major weight loss, sleepless nights. I was edgy — I would go from zero to 100 in two seconds. I would sleep all day. I didn’t want to be bothered with my other children, my family members. I was crying continuously.”

The resilience movement is designed to empower communities to get beyond enduring a crime-ridden culture to creating a community of caring. Impoverished areas enduring a culture of crime and violence can’t sleep well; can’t eat well; can’t learn. Sure, some will overcome and thrive. The social Darwinians would call them among the fittest; the others must fend for themselves. But the ethic of population health suggests that we have a social responsibility to lift all for the greater good.


Dennis Archambault is vice president, Public Affairs, for Authority Health

When it comes to treating chronic stress, it will take a village effort

By Dennis Archambault

I recently had an opportunity to discuss psychotherapy and analysis with a young psychiatrist with a successful practice. He was confident that proper therapeutic intervention really improves the well-being of his patients, many of whom suffer deeply from psychological distress. One of the modalities we discussed was psychoanalysis, an expensive process that has shown to help people recover from severe psychological problems. To be effective, psychoanalysis requires multiple sessions on a weekly basis, often for a long time.

I explained to the psychiatrist that I represent an organization that promotes population health among low income, vulnerable populations where there isn’t sufficient access to mental health services and a lack of financial resources to afford more involved therapies like psychoanalysis, not to mention access to transportation to reach a psychoanalysis. He acknowledged the cost issue, but went further to confirm that people living in the lower economic strata of society endure such depth and breadth of cumulative trauma, that individual psychotherapy wouldn’t be effective.
That message came out of a conference on “Building a Resilient Community,” sponsored by Starfish Family Services http://www.starfishfamilyservices.org/ earlier this year. One of the concepts discussed was a form of community psychology, “trauma-informed community building.” While individual counseling is helpful , care must come through the ongoing reinforcement of a healthy community – specifically family and neighbors.

The State of Michigan offers a good resource list on “Building Trauma Informed Communities” http://www.michigan.gov/mdhhs/0,5885,7-339-73971_4911_69588_80205—,00.html. One of the sources cited was a Robert Wood Johnson Foundation program in Washington, promoting the “self-healing” of the community, which promotes collaboration across sectors of resources, empowers local leadership to think systemically, use data to focus initiatives, and ultimately “instill a real sense of hope in communities that had given up on the prospect of a better world for their children.”

In the absence of a progressive health policy at the national level, local solutions like trauma informed communities and support networks are worth pursue. But, to reference a familiar adage, it will take a village.

Dennis Archambault is vice president, Public Affairs, for Authority Health

Healthy community design requires resilience in the face of chronic stress

By Dennis Archambault

Chronic stress is increasing throughout society, but is becoming an oppressive force among safety net populations. This has been a topic of discussion among mental health and public health professionals for some time. Authority Health’s population health program, this year, is focusing on chronic stress and the application of resilience as a public health strategy.

The Rockefeller Foundation is in the midst of a “resilient cities” initiative http://www.100resilientcities.org/, supporting the work of 100 cities worldwide to become more resilient to the physical, social, and economic challenges that are part of the new reality of the 21st century. The foundation defines building urban resilience as “the capacity of individuals, communities, institutions, businesses, and systems within a city to survive, adapt, and grow no matter what kinds  of chronic stresses and acute shocks they experience. Acute shock is defined as sudden, sharp events such as earthquakes, floods, disease outbreaks, and massive violent experiences. Chronic stress is cumulative, like high unemployment, poverty, violence, and persistent physical and natural environmental disasters.

Resilience thinking demands that cities look holistically at their capacities and their risks. Society is learning that individuals can adopt resilient strategies for surviving repeated onslaughts of pressure points, but perhaps the most challenging lesson — and one that is directly related to healthy community design — is developing collective impact from the cohesion of a resilient culture. That will take some work.

Dennis Archambault is vice president, Public Affairs, for Authority Health.

Hospital mobile van addresses disparities, but what about causes?

By Dennis Archambault

Norwegian American Hospital in Chicago, one of the awardees in the 2017 American Hospital Association Nova Awards program, was credited with helping reduce health disparities among children on Chicago’s Westside through a mobile clinic. While access to transportation may be one of the social determinants addressed through the project (it wasn’t mentioned in the award narrative), other social determinants such as environmental quality, interior household and school air quality, lead abatement programs, and school health and fitness programs were not addressed.

The first two paragraphs of the narrative are revealing:

“Norwegian American Hospital serves some of Chicago’s neediest zip codes. The average per capita income in its core service neighborhood is $13,391, while the unemployment rate stands at 12 percent.

“Those numbers translate into health problems, such as childhood asthma, elevated blood lead levels and high rates of childhood obesity and teen pregnancy. Because they lack regular medical care, many children in the community can’t meet the vaccine requirements for public school registration.”

Norwegian American Hospital certainly is contribution to the public health infrastructure of Chicago through the mobile clinic, but what if it had approached the health issues addressed in the first two paragraphs – asthma, related to internal and external air quality; elevated blood lead levels related to lead-based paint in old housing stock; and high rates of childhood obesity and teen pregnancy. These are social issues the hospital could partner with public health authorities in its community benefit investment. Depending on your source, household air quality is a major contributor to up to half of asthma cases. (Locally, one community development corporation notes that during the winter, houses with forced air push contaminated dust up into the breathing space of children, increasing their risk to lung ailments.)

The ultimate irony in this case is that the mobile clinic addresses a major social determinant – transportation. Providing a mobile clinic financed through philanthropy – an unsustainable funding model – has limited applications. However, funding an alternative transportation system that provides patients access to primary care medical homes might be more cost efficient.
Speaking of funding, it’s curious that the program is entirely funded through philanthropy: children’s Care Foundation, Northern Trust Co. Charitable Trust, the Col. Stanley McNeil Foundation, and the Illinois Association of Free and Charitable Clinics. There doesn’t appear to be an investment by the hospital itself.

A mobile clinic connected with schools in underserved communities is a good idea and could deliver much primary care than would otherwise be provided to this community. But what if Norwegian American Hospital and its competitors found common purpose in this or other health disparities and decided to improve the social systems that helps create the health disparity? Is that still a radical concept for hospitals?

Dennis Archambault is vice president, Public Affairs, for Authority Health.

‘Fugitive Dust’ ordinance is a good step toward health in all policies

By Peter J. Hammer
In 2013, Detroiters awoke to the shock of finding mountains of pet coke looming over the riverfront. The pet coke incident triggered a growing awareness of the environmental and public health consequences of what is more generally known as “fugitive dust.” The incident also highlighted the absence of effective legal tools to address the problem.This is no longer the case. Detroit City Council is about to consider a comprehensive ordinance to better monitor and control fugitive dust. This ordinance has important symbolic and substantive significance as Detroit chooses what type of future it will embrace.

Detroit is at a crossroads that will determine the type of economy, environment and community that will define its future. Policy makers should work constructively to attract and retain businesses that seek to grow their enterprises in a manner that is good for them, but also respects considerations of public health and the environment. It is equally important that we send a clear message that Detroit will not accept a strategy, particularly in the neighborhoods, that permits business to sacrifice the health and well being of historic Detroiters in the name of economic development.
City Council has been working on an ordinance to control sources of fugitive dust that embodies these principles. Fugitive dust is a serious environmental and public health concern that requires appropriate control. The ordinance also sends a signal that Detroiters have high expectations for how business should be done and the types of future economic development that should be encouraged.

Fugitive dust is an elastic term describing particulate matter suspended in the air by wind and human activity. The dangerous dust emanating from the mountains of pet coke provide a good intuitive illustration of the problem, but fugitive dust can be associated with large piles of other solid bulk material, such as asphalt millings, gravel, sand, and limestone. Depending on location, fugitive dust can create highly-localized hot spots of particulate matter pollution due to wind blowing dust into nearby neighborhoods, schools and homes.

Even short-term increases in particulate matter pollution can negatively affect some of our most vulnerable residents. Scientific studies have linked particulate matter pollution to increased rates of respiratory-related hospital visits and the exacerbation of asthma symptoms among children. This is particularly concerning because the Michigan Department of Health and Human Services labeled Detroit the state’s “epicenter of asthma” based on its findings that the rate of asthma-related hospitalizations in Detroit is three times the state average.

The Fugitive Dust Ordinance outlines common sense control for facilities that have large piles of bulk solid materials, including development of fugitive dust plans subject to the approval of the Building Safety Engineering and Environmental Department(BSEED), maintaining monitors upwind and downwind locations at the facility, and controlling dust being emitted from trucks transporting materials. Additional controls exist for facilities that store any pet coke, coke breeze, met coke, or nut coke. Finally, facilities may apply to BSEED for variances from ordinance requirements where appropriate. These provisions are very similar to fugitive dust controls that exist already in Chicago.

The Fugitive Dust Ordinance is also significant for symbolic reasons. The ordinance establishes an important template for the type of growth we want for Detroit. The “tale of two cities” is increasingly fact, not fiction. While downtown is being built up with new businesses and a shiny new trolley car, the danger is that the neighborhoods will be slated for various forms of exploitative development. The U.S. Ecology proposed expansion in capacity to process 64,000 gallons of toxic waste to nearly 666,000 gallons and the need to brow beat Marathon Oil to invest in basic technology to control air pollutants should be seen as warning shots across the bow. Impoverished neighborhoods have historically been vulnerable to environmental exploitation and the lives of their residents seen as expendable.

The Fugitive Dust Ordinance suggests a brighter and more sustainable path forward. The ordinance gets out ahead of a growing problem. The ordinance adopts national best practices and applies them to Detroit. The ordinance makes clear that while Detroit is open for business, development must respect the environment and the public health of all residents.

As democratic institutions begin to reassert themselves in the wake of bankruptcy and emergency management, this is exactly the type of common sense action we should expect of the City Council.

Peter Hammer is director of the Damon J. Keith Center for Civil Rights at the Wayne State University Law School and member of the Population Health Council

When health becomes a factor in paying bills

By Dennis Archambault

“I can’t pay my taxes!…”
– Marvin Gaye

Marvin Gaye’s exasperation in “Inner City Blues,” a generation ago, is sadly relevant today as households need to come to terms with which bill to pay and when. Or which not to pay and what are the consequences? Is it the heat bill? The cell phone bill? The rent or mortgage? The car note? Water bill? Assuming the best money management, many working class households face this stress every day. Decisions may be made rationally or irrationally, and with those decisions come consequences.

Utilities like water and heat are essential to life. But they are considered services for which consumers are responsible to pay. There a population – likely served through the Healthy Michigan expanded Medicaid program, but also including some of the lower income levels in the commercial insurance market – that is making choices about which bills to pay. Those choosing to not pay their water bill find ways to get by – borrowing water from friends and family, buying bottled water, and likely not having enough for proper hygiene or hydration.

Prolonged absence of regular access to clean water results several public health concerns, according to
Dr. Wendy Johnson, a public health professional who directs La Familia Medical Center in New Mexico, weighed in on the Detroit issue at a news conference recently:
• Dehydration, which causes a litany of problems, specifically for elderly and young people and those with chronic diseases.
• Poor hygiene, which can help spread and create water-related problems like the skin disease MRSA, as well as various GI issues.
• Unhealthy choices that can cause other health problems. If someone is without water, he or she cannot cook, which means he or she is eating cheap fast-food and drinking sugary beverages, which are less expensive than bottled water.
• Mental health issues. For example, she said, the inability to bathe negatively affects one’s sense of self-worth, as well as the ability to concentrate at school or work.
• Ripple effects; many of the water-borne diseases are contagious.

The Population Health Council has taken a clear position on this issue as being consistent with the federal commitment to providing a level of health care for a level of society struggling with the effects of poverty. Access to water should be provided for populations served through the Medicaid program, not as a consumer service.

Payment assistance, funded through philanthropic funds, may seem compassionate and appropriate, but philanthropic priorities change and demand will increase during economic downturns. Beyond the practicality of charity, it comes down to a systemic argument: Can a society afford to underwrite the cost of water service in a managed access system like Medicaid? And if so, should it?

Dennis Archambault is vice president, Public Affairs, Authority Health

A definition for health equity: new, improved, and universal…

By Dennis Archambault

This May, after months of research, reflection and consultation among the nation’s leaders in health disparities and health equity research and policy, under the auspices of the Robert Wood Johnson Foundation, a unified definition of health equity was arrived at:

“Health Equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”

Paula Braveman, a physician and public health practitioner, the director of the Center on Social Disparities in Health, was one of the framers of this definition. She writes in a recent Health Affairs journal blog post, “The growing interest in health equity – and in getting clearer about a definition – signals readiness for a paradigm shift in the focus of health equity research and action in this country… and a willingness to say: This is about core values – namely, fairness and justice.”

Dr. Braveman adds that while this is a time when health policy experts are willing to have tough conversations about the policies and programs that have led to inequitable gaps in health, “Unfortunately, the current national political context is more hostile to health equity – and to justice in general – than any other during my lifetime. And that makes it all the more crucial for us to be crystal clear and strategic in our words as well as our deeds.”

Dennis Archambault is vice president, Public Affairs, for Authority Health.