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Water service for poor needs a sustainable solution, not just charitable funding

Note: The following letter was adopted by the Population Health Council in response to the debate over how water service should be charged to low income customers of the Detroit Water & Sewage Department. The letter is formally signed by Council co-chairs john powell and Mouhanad Hammami, M.D.

The City of Detroit has drawn international attention by seeking to collect unpaid water bills from thousands of customers, many of whom had fallen behind and owed significant sums. In that action, many low income people who would qualify for means-tested social benefits programs have also been held accountable for bills that they may not be able to pay.

The City of Detroit has revised its approach to this matter by implementing a financial assistance plan for low income customers that draws on funds raised through water bill payments and philanthropic donations. The program assumes that all citizens in Detroit can pay at least some part of their water bills — an assumption that is not made by human service programs, such as Medicaid.

From a public health standpoint, access to clean water is essential to hydration, as well as uses that protect public health through preventing infectious disease: sanitation, cleaning, food preparation, and personal hygiene.

From a health equity standpoint, people who cannot afford to pay their water bill are likely to be more vulnerable in other areas of their life, too. Households with children, people with serious medical conditions and the elderly are more likely to be low income and more likely to need financial assistance with having water service restored and maintained. For example, nearly three quarters of children in Detroit (73%) are living below 150% FPL ($35,775 for a family of four).

Public health agencies have not defined this as a public health emergency. That may be because the population of those made vulnerable by this action is relatively small compared with the overall population. But this is a population health problem.

Free clinics, emergency facilities, and water distribution sites are noting requests for water. News reports have identified people implementing illegal water hook-ups and borrowing water from neighbors and families.

On a broader scale, this issue raises the question of how society provides life sustaining resources to its vulnerable citizens. A financial assistance plan funded through philanthropic sources is not sustainable. The Heat and Warmth Fund, in July, administered a water assistance program that exhausted $800,000 in a few weeks. Financial assistance for water should be assessed and funded in the same way other means-tested programs are funded.

The United Nations framework on water as a human right states that that water must be sufficient, safe, acceptable, physically accessible, and affordable to all. To comply with the affordability criteria, water and water facilities and services costs should not exceed 3 percent of household income.

Even if you accept the criticism of those who cite the percentage of residents who pay cable television and cell phone bills — 66 percent and 72 percent respectively — and not their water bills, about a third of Detroit citizens don’t have those services and can’t pay their water bills. In a city of over 700,000 residents, that’s a considerable number.

The Population Health Council recommends that the State of Michigan work with the City of Detroit to develop a sustaining funding stream to ensure that those residents who qualify for Healthy Michigan also receive water service, subject to annual income reviews. A systemic, sustainable solution is the only way of ensuring water for our vulnerable citizens.


Chronic Stress is Deadly

Cumulative stress, as in cumulative trauma, can be deadly. It turns out that stress of all kinds, particularly the life stress that comes from the pressures of poverty, eventually results in chronic disease.

Carolyn Aldwin, director of the Center for Healthy Aging Research at Oregon State University, says that chronic stress not only causes illness, it can kill you. Increased levels of cortisol, known as the “stress hormone,” not only interferes with learning and memory function, it increases blood pressure, cholesterol, and heart disease. Aldwin’s research will be published in the journal Experimental Gerontology.

For most people in American culture today, stress is the norm. For the affluent and striving middle class, it’s doing more and more to maintain a desired standard of living. For many, stress is a motivator, and addictive. But for those facing constant threat to their lives and property, struggling with transportation, child care, food, and otherwise trying to keep the family together is one stressful day after another. That is one reason for the increase prevalence of chronic disease among low income populations.

NPR’s listeners will find it as a cautionary tale. However, for those who need to endure it to survive every day, it’s a fatal social determinant. Check out the radio interview: http://www.npr.org/blogs/health/2014/09/22/349875448/best-to-not-sweat-the-small-stuff-because-it-could-kill-you.









Water Cut-Offs: A Public Health Issue

By Mary Ellen Howard, RSM

Water is essential to humans for drinking and sanitation.  Research by the World Health Organization (WHO), Centers for Disease Control (CDC), and National Institute of Medicine (NIM), focuses primarily on water contamination and water shortage—the latter resulting from contamination or drought.  I could find nothing in public health literature about situations like Detroit where there is an adequate supply of clean water—which is being denied to poor people because they can’t afford to pay for it.  Last week the United Ways of Michigan released a major report, “ALICE,” which shows that 67 percent of the residents of Detroit cannot afford to meet their basic needs, including water. If we care about public health and the right to life, we need to find a way to provide affordable clean water everyone.

WHO says that water has a profound influence on human health.  At a very basic level, we have to take in a minimum amount of water daily for survival.  Water is essential for life. The quantity and quality of the water available to the community are important determinants of public health.  But so is the cost, and the ability to pay.

I would like to share three stories on how this water issue has touched my life in Detroit.  I am on the board of a school-based health center in a Detroit Public School.  The social worker reported that the biggest public health problem the staff was dealing with was hygiene of the children.  These middle school kids have dirty clothes and body odor.  She put together hygiene kits and was handing them out to the kids when she discovered that the real problem was no water in the home.  Another board I serve on reported that they had held a baby shower for new Moms in the community.  When asked to name challenges in their lives, several reported that they had no water to make formula for their babies.  A family down the street from us had their water turned off and for more than a year they got their water in buckets from the tap at the side of our house.  Once a week they dropped off their laundry and we did it for them.  This is not in Afghanistan or the South Sudan; this is on my block on the east side of Detroit.  I don’t know how these families survive, but I do know that they are at risk for disease.

The NIM says that developing countries that do not have adequate supplies of fresh water and basic sanitation carry the highest burdens of disease which disproportionately impact children under five years of age, and cause 20 percent of deaths below age 14.  Lack of access to clean water also influences the work burden, safety, education, and equity of women.  This is true also for the women and children of Detroit.

So what happens when you don’t have water to drink, when you can’t flush your toilet, or bathe, or do laundry, or rinse off fruits and vegetables before eating them, or keep your household clean of solid waste?  We know that hand-washing is one of the most effective ways to prevent the spread of communicable disease, in hospitals, restaurants, and everywhere.  Where there is no water and no hand-washing, disease will spread.

What are the diseases related to the availability of water for cleaning, sanitation, or hygiene?  It’s a nasty list: dysentery, enteroviral diarrhea, paratyphoid fever, pinworm, scabies, skin sepsis, lice, typhus, trachoma, conjunctivitis, and hookworm.

Water is a human right, necessary for human life and for public health.  Water must not only be clean; it must also be available and affordable. We have no excuse here in Detroit.  We have the water and we have the means to make it affordable and available.  We must also have the will to make sure no one goes without water.  Our humanity and our lives depend on it.

Mary Ellen Howard, RSM, is a public policy advocate with the St. Frances Cabrini of Most Holy Trinity Church, Detroit. She delivered this statement at a news conference opposing water shut-offs in the city. Sr. Mary Ellen is also a member of the Detroit Wayne County Health Authority Board of Directors.

Graduate student’s cookbook for SNAP recipients shows how to stretch the dollars allotted to low income families in an nutritious way

Last  year, Michigan Rep. Sander Levin was among 30 Democratic Congress members to take the “Food Stamp Challenge” in debating SNAP Program cuts in the Farm Bill. He made a good chicken soup, had peanut butter with white bread, tuna salad, and generally was unsatisfied throughout his month of what might be called “budget fast.” Rep. Levin recalled, “I met a woman in a wheelchair a couple of weeks ago in Michigan. She is on food stamps and many weekends she runs out of food so then she lives on bread alone,” Levin says. “Does that motivate me? Surely. You have to try to get in the shoes of people and feel what it is like to be hungry.”

Leanne Brown, a writer with a master’s degree in Food Studies from New York University, empathizes with those who struggle to feed themselves and their families on $126 per month — something most middle class people pay in a week, even more. But she challenged herself, and ultimately the 47 million Americans receiving SNAP benefits to make the most of a difficult situation. She created Good and Cheap: A SNAP Cookbook, which teaches people how to eat well — as in “nutritious” — on about $4 per day.

Bobbie Lewis, a columnist with ReadTheSpirit.com, who writes about spirituality and food, reviewed Brown’s book recently http://www.readthespirit.com/feed-the-spirit/good-and-cheap-and-a-savory-summer-cobbler/

Lewis says the book is a “great source for anyone living on a tight budget.” Reflect Rep. Levin’s observation of the woman in a wheelchair, Brown admits, “there are thousands of barriers that can keep us from eating ina  way that nourishes our bodies and satisfies our tastes. Money just needn’t be one of them. Kitchen skill, not budget, is the key to great food.”

Take the suggestion of saving money by selecting unwashed spinach and washing it yourself. How about peeling carrots yourself? And advice we all could use, making a list before going to the store to avoid impulse shopping.

As we refine the fresh food distribution network and more cooking skills programs make their way into the lives of low income Americans, it’s good to know there are young scholars coming up with new ideas to teach people how to stretch reduced SNAP benefits and make the most of it — not just to be filled, but to have nutritious and satisfying experience.

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



Happiness: A New Health Indicator?

By Dennis Archambault

Few would argue that happiness factors into well-being. It may be spiritual or strictly secular, but the degree to which one feels good about themselves and their environment is a factor in their health — and how they define their health.

A survey conducted by Jasmine Page, the Health Authority’s summer administrative intern, found that Detroit Nurse-Family Partnership clients responded “fair” or “good” when asked to assess their health status, not “great.” While their perception may factor in physical and mental infirmities that compromise their health status, their attitude regarding their environment and personal psychology is likely to influence their sense of well-being. They may be unhappy about their situation, so how could their health status be “great?”

The correlation between health and happiness is interrelated. Happiness positively influences health and health contributes to happiness. The wellness site, Sharecare, covers this topic extensively http://www.sharecare.com/health/stress-reduction/article/happiness-and-your-health. Happy people tend to have better physiology — stronger hearts, quicker recovery from surgery, higher pain tolerance — and have stronger immune systems. At the same time, happy people are more inclined to assume healthy behaviors, thereby promoting their health status. The article notes that up to 50 percent of a person’s genetic make-up predetermines the capacity for happiness. It also notes that “economists have jumped on the happiness bandwagon, too, hoping to calculate the value of happiness within a sociopolitical context.”

An Aug. 7 New York Times article http://www.nytimes.com/2014/08/07/health/pleasure-factor-may-override-new-tobacco-rules.html?_r=0 posed a dilemma for public health officials: “Rarely has the concept of happiness caused so much consternation in public health circles.” The article headline summarized the dilemma: “It’s health gained vs. pleasure lost.” Specifically, the reporter noted a cost-benefit calculation that is being considered in the federal government’s new tobacco regulations: “the happiness quotient.” According to the article, the health benefits of smoking cessation — reduced lung and heart disease — have to be discounted by 70 percent to  account for the loss of “pleasure” smokers surrender in abandoning the habit. It’s referred to as the “welfare gain ratio.” That’s a hard pill to swallow, especially for health advocates that have been involved in the protracted war on smoking over the past half-century.

The Times takes more of a business slant, than a discourse on health philosophy. If success in reducing smoking behaviors is discounted by the relative unhappiness of former smokers in coping with their withdrawl and loss of pleasure that came with smoking, the economic benefit equation would be lessened. That gives the tobacco lobbyists an opportunity to question regulation that limits tobacco consumption.

“The idea of lost happiness is new for health regulation,” the article notes. It policy stems from a ruling that first occurred under President Clinton, requiring federal regulations with more than a $100 million effect on the economy needs an analysis to assure that the regulations don’t create unintended costs and reduced social benefit. The requirement has implications for a proposal to extend the Food and Drug Administration’s authority to regulate electronic cigarettes and other tobacco products such as cigars and pipe tobacco.

As Americans are prone to endlessly debate and analyze what it means to have the right to “life, liberty, and the pursuit of happiness,” the latter ideal offers plenty of fodder for public health discourse.

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

United Way Michigan report points to impact of income disparities on health and well-being of low income families

A new study published by the United Way organizations has provided even stronger evidence that the declining economic status of working families in Michigan is impacting their ability to meet basic needs. This has tremendous implications for population health — not simply whether someone is able to afford disease prevention and health promotion activities — but whether they can afford water service, healthy food options, a house or apartment in a safe place, transportation. Income, alone, doesn’t determine one’s health and well-being, but it certainly is a major determinant. And the trend is going the wrong way.

Low income households in Michigan “are forced to make difficult choices,” the United Way report, “ALICE – Asset Limited, Income Constrained, Employed,” notes. “There are serious consequences for both ALICE households and their communities when these households cannot afford the basic necessities. ALICE households are forced to make difficult choices, such as skipping preventative health care, accredited child care, healthy food or care insurance. These ‘savings’ threaten their health, safety, and future — and they reduce Michigan’s economic productivity and raise insurance premiums and taxes for everyone.”

This report examines people who might also be referred to as the working poor: retail workers, truck drivers, nursing assistants and other human service workers. “The core problem is that these jobs do not pay enough to afford the basics of housing, child care, food, health care, and transportation.” The report notes that 1.54 million households in Michigan — 40 percent — are struggling to meet basic needs. Nearly 70 percent of households in Detroit are struggling.

“A decade-long economic decline capped by the Great Recession hit Michigan’s communities with hurricane force, hobbling the auto industry, bruising wages, and destabilizing families statewide,” noted Scott Dzurka, president and CEO of the Michigan Association of United Ways.”

Elected officials, particularly those running for office in this election cycle, would be wise to be briefed on the implications of this report for Michigan. Population health advocates will find the material helpful in framing arguments regarding the economic determinants of health and health behavior.