The segregation and structural racism rooted in redlining and other discriminatory housing practices persist in many places today. Efforts to counter the legacy of this injustice include voucher programs that help people move out of high-poverty areas into “opportunity neighborhoods.” Craig Pollack, MD, MHS, MSc, a professor in Health Policy and Management, has conducted research into health outcomes associated with these relocation programs.
In this Q&A, adapted from the June 14 episode of Public Health On Call, Pollack speaks with Stephanie Desmon about a recent study showing that in families who moved with the help of vouchers, children with asthma experienced significant improvements in symptoms. Pollack also explains the need to help people both through relocation programs and place-based strategies to improve neighborhood conditions for people who don’t want to move.
How did this study come about?
For this study, we partnered with the Baltimore Regional Housing Partnership, or BRHP, an organization that started as a result of a fair housing lawsuit that was brought against the U.S. Department of Housing and Urban Development. As part of the remedy for that lawsuit, they created these housing vouchers and a system to help individuals who wanted to move from areas where there was a lot of poverty into lower-poverty or what they called “opportunity neighborhoods.”
We were interested in what happens to the health of families and children, and particularly what happens to kids with asthma, as the families get the chance to move.
This comes back to redlining and housing discrimination that has persisted over the years.
Exactly. This type of program is designed to try to help remedy the ills of our housing system—the systemic racism and segregation that have existed in the past and in many places continue to exist.
What do we know about asthma and what causes it?
We know that about a quarter of kids in urban environments have asthma. It’s a tremendous problem causing a huge number of hospitalizations and emergency department visits, high health care costs, and real problems for children and their families. These are days missed from school and time taken off from jobs.
We also know that there’s a large number of asthma triggers in urban environments, especially mouse and cockroach allergens when we’re talking about Baltimore City. We wanted to know, to what extent does moving change levels of these allergens, these asthma triggers? And what else is going on in the environments that might be causing the changes in asthma exacerbations?
What do you find?
The results were really striking. For every 100 children, we saw there were about 88 severe asthma attacks every year before they moved. After moving, there were approximately 40 asthma attacks per year. That’s a reduction of more than 50%—a reduction on the order of what we see with some medicines we use to treat asthma.
So it was like the equivalent of giving someone a corticosteroid.
Exactly. And we looked into some of the reasons why. We saw that there were reductions in some of the allergens, especially mouse and cockroach allergens, but the study wasn’t designed to look for people who are sensitized to these allergens and to see if the change is a result of these reductions. But we know from a lot of research that these factors are important.
Instead, what we found was that changing levels of stress—and especially stress related to one’s environment, the feelings of safety walking around in one’s neighborhood—seems to be a huge factor in reducing children’s asthma exacerbations. This builds on the idea that stress is important for multiple parts of our health.
How did you measure stress levels?
We did home visits with families when they first entered the BRHP, telephone calls every three months, and home visits every six months thereafter. We were taking careful surveys of their level of stress, how they were feeling about their neighborhood environment very frequently. At the home visits, we also did vacuuming and [took samples from] air filters to measure some asthma triggers we know about. But it was really the parent report that told us about the stress that they and their family were experiencing.
So stressful environments can trigger asthma.
Stressful environments can be one factor that increases people’s risks for asthma. I think this is important to consider, because a lot of our approaches to dealing with asthma are focused on individual home remediation. Those can be important programs, but they fail to address the confluence of other things that are going on outside of people’s homes, in people’s neighborhoods, that may be exacerbating children’s asthma.
What do you think it tells us for the long term?
That’s a great question and something we’re actively studying right now. We’re continuing to follow up with these households and children to understand what happens to children’s asthma as they move in and remain in their homes for longer.
One thing we’re excited about is understanding what happens to children’s lung growth. This is incredibly important because, as my allergy and immunologist colleagues tell me, our lungs continue to grow for a time during childhood and into young adulthood. If you’re able to change the lung growth trajectory—the rate at which lungs grow and the peak lung function they reach—then that can have long-term implications for adult lifespan.
This program helps folks from neighborhoods with very low income move to those with significantly higher income. Can that be done to scale?
These are individuals who signed up for the program, and there’s a long, long waitlist for these vouchers that are offered. This is really about helping families overcome the obstacles to moving—helping them with security deposits, helping them find landlords who will accept vouchers, and a host of other supports. This is not about moving people who don’t want to be moved. It’s creating opportunities that are sometimes systematically blocked.
These types of mobility programs are being tested at a larger scale. The U.S. Department of Housing and Urban Development has a program that’s testing strategies to help people across a number of different cities and seeing what works.
At the same time, there also need to be placed-based strategies. Not everyone can move, not everybody is interested in moving, and not everyone should have to move. There need to be communities and environments that support health, regardless of where you want to live. This research speaks to the fact that we need to think about stress in communities and how to support stress reduction.
Because only a small number of people can benefit from this.
I think that’s on some level a matter of perspective. The Baltimore Regional Housing Partnership has helped about 4,700 families currently, and for those families, it’s quite meaningful. There’s hope that these types of programs can be expanded to create opportunities for families who want to move to a more resourced neighborhood while at the same time building resilience, increasing safety, and reducing levels of stress across the city and other places.
So it’s a twofold thing—helping people who want to move into higher income neighborhoods, and then for the people who are staying, make their lives better by improving their surroundings.
I think sometimes mobility strategies and place-based strategies are pitted against each other in a zero-sum game. We need to recognize that both are possible and that both are important options for families to make the choices they want to make.
What other avenues do you want to pursue in this area?
We’re excited to see what happens to rates of asthma exacerbation over time. We followed people for about a year after they moved. So we’re following up with these group of families for longer to see whether these asthma reductions persist over time. And we’re excited to see what happens to lung function over time again, because of the long-term implications for well-being throughout the life course.
I saw in the commentary that came along with your JAMA article that the authors use the words “housing reparations.” What are your thoughts?
I’m so glad that that commentary came along with that piece to raise these policy issues. This group of children and families we’re studying came about as a result of a fair housing lawsuit trying to redress the wrongs that led to segregation and disinvestment in neighborhoods. I think there have to be ways and approaches—reparations potentially being one of them—to help make the system better and help support children’s health.
I imagine this link between health and poverty is understudied.
There needs to be more recognition that, rather than being an individual problem and an individual household problem, asthma is also a problem of communities. It’s not just about the individual—it’s about places where individuals live.
Stephanie Desmon is the co-host of the Public Health On Call podcast. She is the director of public relations and marketing for the Johns Hopkins Center for Communication Programs, the largest center at the Johns Hopkins Bloomberg School of Public Health.