Population Health Blog

Population Health Blog

Why It Matters

Water shut-off stimulates debate over ‘right’ to natural resources

By Dennis Archambault

The debate over the water shut-off policy of the Detroit Water & Sewage Department has taken several twists and turns. One outcome of the debate has been the opportunity for citizens to debate what constitutes the right to health-sustaining resources, like water, and how a publicly-administered purification and delivery service should charge its customers who are unable to pay, or at least pay the full charge.

The United Nations weighed in early-on: it is an international human right that anyone who needs water should have it. It hasn’t stated — at least not in the context of the Detroit issue — whether public agencies have a responsibility to deliver water to their constituents, or that they should purify that water. Advocates in Detroit has championed this cause by protesting against the water shutoffs as a violation of human rights, and the rights of Detroit citizens to have access to the largest body of fresh water in the nation. Additionally, they have advocated for public health concerns for physical hydration and personal hygiene. Public health agencies have not formally determined that the situation has reached crisis proportions, but many privately voice concern when you have hundreds of people drinking minimal amounts of water daily and drawing it from potentially unsanitary sources.

Others have disputed whether water is a right at all, and that the “privilege” of having fresh water delivered to your home or apartment comes at a price. And if you don’t pay the freight, the service should be discontinued, as with heat and light.

Dan Calabrese, author of The Politics Blog in the Detroit News, argues that “The founders of the United States identified life, liberty, and the pursuit of happiness as inalienable rights. The modern-day Left wants to expand the category to include things like health care, food, and now even water. But there is a difference between the former group and the latter: Life, liberty, and the pursuit of happiness are things you are born with. No one has to provide them to you. The declaration that they are rights means that no one can take them away. the same goes for other First amendment rights like that of free speech, freedom of assembly, and so on. For you to exercise these rights does not require another party to provide you with anything. You simply wak eup in the morning and start exercising them.

“Then we get into an entirely different category: Stuff you need. The difference between stuff you do and stuff you need is that things in the latter category require someone else to provide them to you — unless, of course, you can grow your own food, do surgery on yourself, or install plumbing that runs from Lake St. Clair to your house. And you can’t. So claiming the stuff you need as rights means another party has to buy your food, buy your water, and potentially take care of you — if not at their cost, then at the cost of a third party with whom the provider will be required to deal in order to get compensation.

“These are not rights you exercise. These are rights you demand, and in order for these rights to be fulfilled, someone else is required to either take an action or an expense. That’s really not a right at all.”

Catarina de Albuquerque, Office of the High Commissioner for Human Rights, articulates the perspective that water is a universal human right. The disconnection of water taps in Detroit, she said, constitutes “a violation of the human right to water and other international human rights. … Because of a high poverty rate and a high unemployment rate, relatively expensive water bills in Detroit are unaffordable for a significant portion of the population. …The households which suffered unjustified disconnections must be immediately reconnected.

“Disconnections due to non-payment are only permissible if it can be shown that the resident is able to pay but is not paying. In other words, when there is genuine inability to pay, human rights simply forbids disconnection.”

Health policy offers Americans a good platform for debating this country’s interpretation of what constitutes a right of citizenship. The question of access to an essential natural resource, and a public agency’s responsibility to provide for its impoverished citizenry, is likely to be an ongoing debate.

Dennis Archambault is director of Public Affairs for Detroit Wayne County Health Authority

Critical Difference: A Healthy Ministry Perspective on the Senior Housing Crisis in Detroit

Note: This is the second part of an essay written by Kathleen Ruth, who is the Faith Community Nurse for St. Aloysius Catholic Church located in Downtown Detroit. St. Aloysius has been an active partner in the Senior Housing and Displacement Coalition.

By Kathleen Ruth, MSN, RN, APHN-BC

I called Paul Novak, an attorney with Milberg LLP in Detroit and member of the St. Aloysius congregation to help with advocating on behalf of residents being relocated from the Griswold Building. Paul and his staff attorneys focused on the issue (pro bono). They met with about thirty residents and took their and my affidavits which were more than enough to bring about a “Verified Complaint for Injunctive Relief” against Griswold Apartments—we were heading to court! On the same day that Paul and petitioners were going to file their complaint in court, the City of Detroit placed a “Cease and Desist” order on the office window of the contractors—all contract work had to stop! Paul Novak, his staff attorneys, the elderly residents, and St. Aloysius made a critical difference!

To identify the actions needed to be completed by the Owner to address the whole health needs of the elderly residents, Paul Novak, his staff attorneys, two Griswold residents, a construction manager, the Owner’s representative, and I met. After all was said, the Owner’s representative imparted, “This has humbled me. If we had only known all this was going to happen, we would have done things differently.” I had the opportunity to say to him, “I hear you say that you are humbled and you would have done things differently. As you know, there are several Section 8 apartment buildings in Downtown Detroit; chances are when their contracts with HUD expire (or maybe even before) they will be sold. If what you say is true, will you be a champion for the poor elderly in Downtown Detroit? Will you make sure that the elderly are heard and let them be part of the renewal of Detroit?” He had no reply.

During the process, St. Aloysius Neighborhood Services joined with several other groups to form a Senior Coalition to address moving issues. Our review of the Brownfield Contract for Griswold discovered many items that the Owner was responsible for paying. One of the coalition partners confirmed these items with the Owner. We were then able to give complete and accurate information on the costs that the owner would pay associated with moving. This helped to alleviate anxiety on the part of the elderly residents. We will continue to participate with the Senior Coalition in an effort to influence future building acquisitions and developments.

It is the hope of Neighborhood Services of St. Aloysius that our elderly neighbors in Downtown Detroit, who have their homes in Section 8 apartments, will not experience the heartbreak of the Griswold departure. We have taken action to make a critical difference. Through Wayne State University School of Social Work and the College of Nursing, the former residents of Griswold are participating in research that studies the effects of unplanned relocation stress. Again, it is our hope that the research findings will convince Detroit City Planners and potential investors to include the poor elderly in the social and community renewal of Downtown Detroit so that all can be aboard the Downtown Detroit renewal train.

For our brothers and sisters who have moved, I have their new contact information. They are at the heart of our concern and I will continue to stay in touch as they learn to adjust in their new homes. As always, keep them in your prayers. One more thought, is there a way for you to make a critical difference?

 “There was a father, mother and their children and a grandfather.

This grandfather got his face dirty when he ate soup which annoyed

the father so he bought a separate table for the grandfather to eat at.

But one day the father returned home and saw one of his children

playing with bits of wood and on asking his son what he was doing

was told that he was building a table for Daddy to eat at when he

became old.”

–  Pope Francis, Nov. 19, 2013



‘Critical Difference:’ A Health Ministry Perspective on the Senior Housing Crisis in Detroit

“A Society that Doesn’t Care for Its Elderly Has No Future”

–          Pope Francis in a homily, Nov. 19, 2013

 Note: This year, 115 residents were evicted from The Griswold Building, in Downtown Detroit, forced to find housing elsewhere in the city and Southeast Michigan. The Griswold was being transformed into “The Alfred,” an upscale apartment marketed to young professionals. St. Aloysius Catholic Church, a Downtown church, became involved in this issue. Kathleen Ruth, works on behalf of the congregation as Faith Community Nurse. This is part 1 of an essay she wrote about her church’s involvement in this population health issue, which affects up to 2,000 seniors in other downtown apartments which may convert to market-rate housing over the next five years.

By Kathleen Ruth, MSN, RN, APHN-BC

The renewal of Detroit is evident and life giving to a city that has been struggling for decades. There are joggers and people walking their dogs at all times of the day. Young adults are finding their way to refurbished lofts and apartments as the employment picture in Downtown Detroit improves. Investors are purchasing buildings hoping to be part of this renaissance. The renewal train of Detroit is picking up momentum; but the long-time residents, our elderly neighbors, were never invited aboard.

About a year ago the elderly residents who lived in the Griswold Apartment Building in Downtown Detroit received the official news that they would have to move out. The Section 8 Housing Contract between Griswold and HUD had expired and a new owner had purchased the building.

The news traveled fast—anger and sadness penetrated the community. People struggled with questions of “why?” Many of the elderly have lived in their apartment for over 30 years, and quite frankly had said they hoped to die there. Stress and loss of self-worth was taking its toll. How could St. Aloysius serve?

In August of 2013, I contacted Garbette Garraway, PhD who is a retired U of D Mercy Psychology Professor; he also has a very active counseling practice. I shared with him the anguish of our elderly neighbors—he volunteered his time and expertise immediately. Dr. Garraway and I had opportunity to meet about 20 people in the Griswold community room. It was there that he began counseling the elderly residents. He met with them as a group and as individuals every Wednesday afternoon beginning in August; he did this faithfully (and pro bono) through December. Those who participated worked through their grief; the door to healing was open—Dr. Garraway made a critical difference.

January came and major problems were about to erupt for the Griswold residents. It was the last week in January when Johnny came to my office. He had some questions about his medications—a routine office visit. But this routine office visit became a critical event when Johnny said, “You know Kathy, it is getting hard to breathe in my apartment. They started doing major construction in our building and there is dust everywhere—I can’t take it, Kathy.”

I immediately called another resident and it was confirmed. Johnny wasn’t the only person suffering. Many of the elderly residents had chronic illnesses and now were facing exacerbation of their illnesses related to the filth. Moreover, two elevators in Griswold were not dependable, and now one of the elevators was dedicated to only construction workers. Imagine if you have an appointment for kidney dialysis or with your doctor and the only available elevator is not working! Imagine if you must use a motorized scooter and the elevator doesn’t work! Imagine being on supplemental oxygen and trying to breathe in your dust-filled apartment and hallways. Our elderly neighbors were not considered at all when this construction work began. How could this happen?

I made numerous complaint calls to the City of Detroit Building Department and spoke with division managers. Promises were made to send an inspector out. Simultaneously, the elderly residents of Griswold also made complaints. But a critical difference happened when Deacon Don remembered when a St. Aloysius parishioner said to him, “If you ever need my assistance, please contact me.” I was given this person’s contact information: I called Paul Novak, an attorney with Milberg LLP in Detroit.

The second part of this blog will appear tomorrow.

Non-Alcoholic Fatty Liver Disease: Consequences of Childhood Overweight & Obesity

By Sarah Lewis

The long term effects of childhood overweight and obesity include such well known diseases as Type 2 diabetes and cardiovascular disease.  Another chronic condition associated with excess body weight on the rise in both children and adults is Non-Alcoholic Fatty Liver Disease (NAFLD), a spectrum of diseases characterized by excess fat deposition in the liver. There is currently no medical treatment for the condition, making weight loss the only option for improvement.  Untreated NAFLD may progress to an inflamed and eventually poorly functioning liver, including cirrhosis and liver cancer.  One study estimates that the advanced form of NAFLD, known as NASH or Non-Alcoholic Steatohepatitis, is expected to be the leading cause of liver transplants by 2020; in 2001 it accounted for only one percent of them.

Among children and adolescents, NAFLD prevalence has increased more quickly than overweight and obesity prevalence.  While excess weight is not the only cause of NAFLD, the American Liver Foundation reports that in the United States about 10 percent of all children and 38% of obese children have NAFLD, placing it squarely at the intersection of endocrinology and pediatrics. As shown in the graph below, the Centers for Disease Control and Prevention estimate that childhood obesity has more than doubled in children and quadrupled in adolescents in the past three decades.

Understandably, teenagers have a higher prevalence of NAFLD than younger children and adolescent prevalence has more than doubled in the past two decades. Overall, 12 percent of high school students in Michigan are estimated to be obese and another 14 percent are overweight. Youth Risk Behavior Survey data compiled by the MOTION Coalition (see http://dwcha.org/michigan-organizations-to-impact-obesity-and-nutrition-coalition.html) show that middle and high school students in the southeastern Michigan counties of Macomb, Washtenaw and Wayne have higher rates of overweight and obesity than the state average. For example, 17% of Wayne County high school students are overweight and 14% are obese.

Dr. Stacy Leatherwood, pediatrician at Henry Ford Health System and Physician Champion for Childhood Wellness at LiveWell (see http://www.henryfordlivewell.com/letsgethealthy), explains that a large segment of kids are at risk because of diets high in saturated fats and sugars that lead to obesity. Once children and adolescents hit the overweight mark, “you start seeing changes in the liver at the cellular level.”

Besides excess weight, male sex and Hispanic race/ethnicity can increase risk for NAFLD, even after adjusting for factors such as age, income, education, body mass index and diabetes status. Dr. Leatherwood confirmed that Hispanic children, especially boys, register an especially high rate of NAFLD. Importantly, some Hispanics have a genetic predisposition to store excess fat in the liver due to overproduction of triglycerides.  Furthermore, 17 percent of children and adolescents are obese, but Hispanic and black youths are significantly more likely to be obese than others (22.4 percent and 20.2 percent, respectively versus 14.1 percent).

Being diagnosed with NAFLD and related conditions such as Type 2 diabetes at a young age means “these children will live with this illness for a lifetime, and are more likely to experience the associated complications,” says Dr. Leatherwood. The good news is that NAFLD presents not just a challenge but an opportunity to intervene at multiple points. The only known way to reduce fat in the liver is gradual weight loss through eating healthier and increasing physical activity, so NAFLD implies a multisectoral approach in which communities, schools and health care systems can all play a role.

In her experience, Dr. Leatherwood considers at least three points of intervention: the doctor-patient relationship, school-based programs, and community-based programs and policies such as nutrition labeling to make healthier choices. Tools such as “5-2-1-0” allow people to start small by incorporating tangible behavior changes that lead to healthy lifestyles. Effective behavior change can happen when people are targeted and then supported “in as many different areas of their life as possible.”


American Liver Foundation: “Pediatric Non-Alcoholic Fatty Liver Disease”http://www.liverfoundation.org/chapters/rockymountain/doctorsnotes/pediatricnafld

CDC: “Childhood Obesity Facts”http://www.cdc.gov/healthyyouth/obesity/facts.htm

2009 Michigan Youth Risk Behavior Survey https://mdoe.state.mi.us/schoolhealthsurveys/ExternalReports/CountyReportGeneration.aspx

New York Times: “Threat Grows From Liver Illness Tied to Obesity” http://well.blogs.nytimes.com/2014/06/13/threat-grows-from-liver-illness-tied-to-obesity/?_php=true&_type=blogs&_php=true&_type=blogs&_php=true&_type=blogs&_r=2&

Sarah Lewis is the Kellogg Population Health Fellow at the Detroit Wayne County Health Authority

Building the Literacy Infrastructure in Health Literacy

By Dennis Archambault

The connection between health and literacy has been validated in various ways through social research in the past decade. Today, however, when you hear the term “health literacy” spoken by advocates, it’s an informational process to help people navigate the new health insurance system. It may even be an effort to help the newly-insured Medicaid population who may have led an entire adult life without a relationship with the health care system, much less practicing health behavior

With around 50 percent of the adult population having limited literacy and quantitative skills, according to a review of medical and public health literature conducted by Rima E. Rudd, a Harvard professor who has written and lectured widely on health literacy, and colleagues Barbara A. Moeykens, and Tayla C. Colton http://www.ncsall.net/index.html@id=522.html.

“Educational attainment and health educational attainment has become the most convenient and commonly used indicator of socioeconomic status, and the association between years of schooling and health is well established…suggesting that education is the most judicious socioeconomic measure for use in epidemiological studies.” Education, the writers summarize, “influences work and economic conditions, socio-psychological resources, and a healthy lifestyle.”

“Literacy influences the ability to access information and navigates in literate environments, has an impact on cognitive and linguistic abilities, and affects self-efficacy.” In a clinical environment, one’s oral communication skills and reading ability may prevent them from communicating effectively with their caregiver, understanding their discharge orders, and being proactive in thinking their health concern. “Patient’s literacy directly influences their access to crucial information about their rights and their health care, whether it involves following instructions for care, taking medicine, comprehending disease-related information, or learning about disease prevention and health promotion.”

The relative urgency of health care communication – in reaction to disease and injury – precludes addressing the underlying problem of illiteracy.  The tactical answer is adjusting the reading and visual style of information presentation, not dealing with the long-term issue of social illiteracy. But as we grapple with helping thousands of newly-insured Healthy Michigan clients navigate the system, we need to deal with the deeper issue – bridging traditional literacy programs to include “functional health literacy.”

Educators can take this on as a kind of applied literacy challenge. By improving language and quantitative skills, they can “increase health literacy, promote healthy lifestyle choices, and support health-promoting community actions.” Likewise, health educators can employ essential literacy skills-building in their counseling of low-literacy clients.

The Harvard University School of Public Health is doing some interesting work integrating literacy into adult education.  http://www.hsph.harvard.edu/healthliteracy/practice/training/

As more of our complex social problems require cross-disciplinary collaboration, health literacy also could benefit from the interaction between educators, literacy volunteers, and health professionals. Health literacy is more than basic behavioral navigation.

Dennis Archambault is director of Public Affairs for the Detroit Wayne County Health Authority


Different Perspectives On The Water Issue

Detroit has been preoccupied with efforts by the Detroit Water & Sewage Department to collect unpaid water bills, to the detriment of many low income households that have either lost water service or at risk of losing it when the shut-offs resume. Environmental quality is another issue of concern. Earlier this year, there was considerable discussion about the risk of leaving pet coke ash uncovered along the Detroit River, risking contamination of air and water when dust is blown from piles. Recently, water quality has once again come into question with the concerns of Michigan and Ohio counties bordering Lake Erie, which has high levels of algae blooms, which release the toxin microcystin, largely related to run-off from lawn and agriculture fertilizer.

On the West Coast, of course, the scarcity of water has added an additional perspective. Coupled with the risk of pollution there and you have a much higher level of anxiety over this essential component for life. David S. Beckman, executive director of the Pisces Foundation, an environmental philanthropy, and former director of the water program at the Natural Resources Council, references the water quality in Lake Erie in his commentary, “The Threats to Our Drinking Water,” published in the New York Times yesterday. It’s worth reading:

Those of us who live in the United States are fortunate; generally we don’t have to give a lot of thought to the safety of our tap water. This makes our collective experience with water very different from that of hundreds of millions of people across the globe who lack access to clean water.

But twice this year the water supply for a major American city was interrupted for days by water pollution. In January, a chemical used in the processing of coal leaked from a ruptured storage tank into the Elk River, contaminating the water supply for about 300,000 people in and around Charleston, W.Va., the state’s capital and largest city. Then, last weekend, the water supply for over 400,000 people in Toledo, Ohio, was declared unsafe because of the presence of microcystin, a toxin released by algae blooms in nearby Lake Erie, the source of the city’s water.

While the circumstances in each situation are different, there are notable similarities. In each case, the pollution could not be adequately treated by the local water plants. Sudden “do not drink” (and, in some cases, “do not bathe”) warnings resulted. And in each case, activities in or near the communities caused, or partially caused, the problem. In Charleston, it was an upstream industrial spill; in Toledo, polluted runoff, including from agriculture, along the Great Lakes stoked the slimy, fluorescent algae blooms that sent residents flocking to supermarkets for bottled water.

Those events offer two important reminders about water in the United States.

The first is that while our country has made huge strides in reducing water pollution since the 1970s, when Congress passed federal laws like the Clean Water Act and the Safe Drinking Water Act, controlling water pollution is not a “set it and forget it” endeavor. Those statutes set broad goals but depend on states and the Environmental Protection Agency to design and update programs to keep the water clean.

Charleston underscores the imperative of ensuring that clean water policies are fully implemented and strengthened where necessary. Toledo reminds us that threats are not static and neither is the environment. Polluted runoff was not a primary focus in 1970, and the consequences of climate changewere not considered then. But now we recognize that runoff from farms, lawns, streets and parking lots is a major problem across the country and more difficult to control because of its ubiquity. And we also now know that climate change doesn’t just warm the air, it can warm water — resulting in more algae blooms.

A second takeaway is that while the current drought gripping parts of the nation can make us think water scarcity is a function of the absolute quantity of water available, practically speaking it is actually a function of quantity and quality. Toledo was without potable water for several days even though it sits beside the Great Lakes, the largest surface freshwater system on earth.

So what should we do?

There are specific steps that would make a difference, including providing water utilities with broader authority to address threats found in watershed surveys; beefing up pollution prevention requirements for chemical tanks to include uniform rules for storage of hazardous substances; and updating outmoded state and federal rules on runoff to include clear reduction targets, which are lacking today.

Equally important, because almost all of us live downstream of somewhere, uncertainty created by a set of Supreme Court decisions about whether all of the nation’s waters are protected by the Clean Water Act needs to be resolved so that upstream pollution doesn’t cause downstream havoc.

Actions like these will almost certainly need to be paired with an increase in financing. The Environmental Protection Agency says the capital needs of water utilities over 20 years amount to $384 billion to keep tap water clean and another $298 billion to address wastewater and runoff. By comparison, over the last 25 years, the E>P>A>’s primary wastewater grant and loan program distributed over $100 billion, a fraction of the investment the nation needs to make now.

Just as important, this moment also calls for a change in thinking about how we can best achieve our nation’s clean water goals. Traditionally, water policy has dealt with issues of quality and quantity separately. This approach must be replaced by an integrated strategy that addresses both together. Neither plentiful, polluted water nor scarce, clean water will meet our needs.

The “green infrastructure” movement taking hold across the nation includes a water management approach that uses natural systems like wetlands and green buffers to reduce runoff, enhance water supply and improve community aesthetics. We need more of this kind of integration and the thinking that animates it.

When we ignore the weaknesses in our current approaches to safeguarding our drinking water supplies, we take a significant risk. If the sudden absence of drinking water in Charleston and Toledo serves to refocus the country on the importance of protecting water with a seriousness that reflects its indispensability, that will be a very good thing.