washingtonpost.com
Baltimore takes a holistic approach to unhealthy housing

By Eliza Barclay
Special to The Washington Post
Tuesday, April 6, 2010; HE01

The house on Baltimore's Rutland Avenue wasn't charming or well-maintained -- among other things, the skylights were covered by plastic bags -- but Petrina Taylor assumed it was safe enough.

But after five years there, the 31-year-old mother of three learned that carbon monoxide had been accumulating in the house, its escape hindered by a blocked chimney. Then a blood test revealed that lead dust and paint chips had poisoned her baby daughter.

"Everywhere you could possibly touch in my house tested positive for lead," said Taylor, whose daughter A'Niah is now hyperactive and aggressive.

Taylor moved out in December 2008. Even though her next house was a marked improvement, Taylor found ratholes in the backyard, and her kitchen floor bore evidence of mice, which she learned were inflaming her family's asthma. Then came the bedbugs.

"The lead and asthma and bites due to housing, and living arrangements, it affects your life," Taylor said. "It's very frustrating."

Stories such as Taylor's are increasingly common in cities like Baltimore, where an aging housing stock, poor indoor air quality, and the resurgence of bedbugs are compounding existing health risks in the home. Substandard homes are a big part of the problem, but the renters and homeowners living in them often do not know how to manage risks. And even if help is available from local government agencies, it's often spread out across many offices with little coordination.

Baltimore is trying a new approach.

The city is the site of the Centers for Disease Control and Prevention's first Healthy Homes program, an attempt to coordinate efforts on lead abatement, asthma and injury prevention, indoor air pollution and fire safety.

"It's not unusual for a community health worker to take care of lead only to have a child die in a fire, or fall out the window," said Mary Jean Brown, chief of the Lead Poisoning Prevention branch at CDC. "The Healthy Homes approach recognizes all these things that can happen in homes. So you take your lead prevention army and equip them with tools so that they can address more than one problem at once."

The program is run by Baltimore Assistant Health Commissioner Madeleine Shea, who says her biggest challenge has been training staff members from formerly separate areas to expand their expertise.

"Lead is really complicated, but so is asthma, and we've had to work out over time how to tailor an intervention to a family without burning out our staff," Shea said.

Much of Baltimore's housing stock is nearly a century old. Lead paint and dust still coat the interiors of some homes, though strict abatement laws have resulted in a 97 percent reduction in childhood lead-poisoning cases since the 1980s. But the humid summer climate favors the growth of mold, while fissures in deteriorating structures give pests a way in. And some homes in poorer neighborhoods have no heat source but their gas stoves, which create pernicious carbon monoxide and nitrogen dioxide fumes.

According to the Healthy Homes Division, most of the families it serves are renters dealing with overlapping housing issues. As of August, 39 percent of those families that had a child with elevated blood levels also had a family member with asthma.

In the case of Taylor's family, the first sign that something was wrong came when baby A'Niah started crawling at an unnaturally fast speed and began clawing and scratching the people around her. A blood test revealed lead levels of 20 micrograms per deciliter, double the limit the CDC considers acceptable. A doctor told Taylor the lead was interfering with A'Niah's nervous system, making her hyperactive and aggressive.

The doctor notified the Coalition to End Childhood Lead Poisoning, a local advocacy organization, and the Healthy Homes Division, which dispatched a caseworker to assess Taylor's home. A coalition case manager helped the family secure Section 8 vouchers and relocate to a new home just before Christmas 2008.

But within a couple of months, Taylor was rushing A'Niah to the emergency room to treat a severe asthma attack. They returned four more times in 2009 for the same reason.

Approximately 40 percent of diagnosed asthma among children is attributable to exposure to mold, pets and pests in the home. Patrick Breysse, director of the Center for Childhood Asthma in the Urban Environment at the Johns Hopkins School of Public Health, says that 100 percent of East Baltimore homes have mouse allergens, in the form of airborne urinary proteins, and many children become sensitized to the allergen.

"If you're an asthmatic kid and you're sensitized to mice, and have mouse allergens in the home, our studies show you're at a remarkably higher risk for asthma morbidity," Breysse said.

About 7.5 percent of school-age children nationwide suffer from asthma, but almost half of Baltimore City public schools have higher rates, with many schools reporting 15 to 20 percent. When these children suffer asthma attacks, they often end up in emergency rooms.

Breysse noted that home-based interventions can be effective even as they save money. Asthma medications can run as high as $30,000 a year per child, especially if the condition isn't managed well, he said. But simple measures like trapping mice and cockroaches, vacuuming dust and turning on the hood fan over the stove can drastically reduce the irritants that provoke attacks.

"When you look at the typical costs to manage asthma, the changes that we're talking about are trivial," Breysse said.

Liz Kasameyer, a Healthy Homes nurse, was assigned to help the Taylors figure out what kinds of allergens might be around their new house. She discovered mouse droppings in the kitchen. At no cost to the family, she provided a high-powered vacuum cleaner, several mousetraps and cockroach bait, and taught them what to do. "You can't just give physical tools," she said. "You also have to give insight into how the pest thinks and where to place the traps."

She also recommended replacing harsh household cleaners with less irritating brands and told the family to give up their cat.

Some months later, Taylor and her children began suffering unexplained bites. Kasameyer helped diagnose the problem as bedbugs, and she recommended that an exterminator spray the house. Their landlord paid the bill, which ran about $1,000, but many renters are not so lucky.

The Health Department has seen a 50-fold increase in the number of bedbug calls since 2004, and beginning in 2009, it added bedbug abatement to its Healthy Homes program. The city is now running the first subsidized pest-control model for low-income families in the country.

"Bedbugs are an issue we haven't really dealt with as a society for a while, and we have to reframe it as a public health issue," Kasameyer said. "People don't know what it is and don't know how to fix it anymore."

The D.C. Department of Health started tracking bedbug calls on Jan. 1, 2009, and recorded 182 calls last year. In contrast to the coordinated Healthy Homes approach, Washington's bedbugs and rodents are handled by the Department of Health; lead, fire safety, indoor air pollution, and some asthma services fall under the Department of the Environment; and the National Capital Asthma Coalition provides in-home asthma education and management services for low-income D.C. residents.

According to Brown of the CDC, about 100 cities around the country are beginning to move toward a coordinated Healthy Homes approach, but Washington is not among them.

"I think the city still needs to get very squared away with lead before they take on any new challenges," Brown said.

Today, Taylor says her family's health is more stable than it has been in the last two years, and A'Niah's asthma is relatively under control. Each week, a behavioral specialist from the Kennedy Krieger Institute works with Taylor and A'Niah to manage the child's aggression and hyperactivity. A'Niah has not been to the emergency room for her asthma in four months.

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