Susan Klitzman

Healthy housing: a structured review of published evaluations of US interventions to improve health by modifying housing in the United States, 1990-2001.

We sought to characterize and to evaluate the success of current public health interventions related to housing. Two reviewers content-analyzed 72 articles selected from 12 electronic databases of US interventions from 1990 to 2001. Ninety-two percent of the interventions addressed a single condition, most often lead poisoning, injury, or asthma. Fifty-seven percent targeted children, and 13% targeted seniors. The most common intervention strategies employed a one-time treatment to improve the environment; to change behavior, attitudes, or knowledge; or both. Most studies reported statistically significant improvements, but few (14%) were judged extremely successful. Current interventions are limited by narrow definitions of housing and health, by brief time spans, and by limited geographic and social scales. An ecological paradigm is recommended as a guide to more effective approaches.

The effect of lead-based paint hazard remediation on blood lead levels of lead poisoned children in New York City.

Despite the widespread use of lead paint hazard control for children with lead poisoning, few controlled studies that estimate the effect of such control on childrens blood lead levels have been published. This retrospective follow-up study examined the effects of lead hazard remediation and its timing on the blood lead levels of lead-poisoned children. From the New York City child blood lead registry, 221 children were selected who had an initial blood lead level of 20-44 micro g/dL between 1 July 1994 and 31 December 1996; were 6 months to 6 years of age; had a report of a follow-up blood lead test between 10 and 14 months after the initial test; had a lead-based paint hazard identified in the primary dwelling unit prior to the 10- to 14-month follow-up blood lead test; had resided or spent time at only one address with an identified lead-based paint hazard; and were not chelated. The decline in geometric mean blood lead levels from baseline to 10-14 months later was compared for children whose homes were remediated and whose homes were not remediated during the follow-up period. Regardless of remediation, geometric mean blood lead levels declined significantly from 24.3 micro g/dL at the initial diagnosis to 12.3 micro g/dL at the 10- to 14-month follow-up blood lead test (P<0.01). Among the 146 children whose homes were remediated the geometric mean blood lead levels declined 53% compared to 41% among the 75 children whose homes were not remediated by the follow-up blood lead test, a remediation effect of approximately 20% (P<0.01). After adjusting for potential confounders, the remediation effect was 11%, although it was no longer significant. Race was the only factor that appeared to confound the relationship: Black children had higher follow-up blood lead levels even after controlling for other factors, including the natural logarithm of the initial blood lead level. The effect of remediation appeared to be stronger for younger (10 to <36 months old) than for older (36 to 72 months old) children (P=0.06). While children in homes with earlier remediation (within less than 3 months) appeared to have greater declines in blood lead levels at the follow-up test than children in homes with later remediation (after 3 or more months), this trend was not significant when controlling for confounding factors. The findings of this study suggest that early identification of lead-poisoned children and timely investigation and abatement of hazards contribute to reducing blood lead levels. However, the apparent effect is modest and further research is needed to systematically test and improve the effectiveness of lead hazard controls.

Lead poisoning among pregnant women in New York City: risk factors and screening practices.

This article presents information on pregnant women with incident blood lead levels (BLLs) of 20 μg per deciliter or greater as reported to the New York City Department of Health between September 1996 and June 1999 (n=33). Almost half of the women were diagnosed during their third trimester of pregnancy, often at their first prenatal visit. The median BLLs at incidence and at last report among women who were retested were 25 and 15 γ/dL, respectively, a 40% decline. The median incident BLL among newborns (n=25) was 12 μg/dL. The BLLs were inversely associated with maternal age and length of time in the United States and directly associated with gestational age and pica behavior. Cases were more than twice as likely to be foreign-born women than all women who gave birth in New York City. Prenatal care facilities employing a policy of universal blood lead testing of all pregnant women at the time of their first visit reported disproportionate numbers of cases, accounting for 77% of cases yet only 11% of all births citywide. The findings suggest that (1) the promulgation of recent rules and guidelines for lead risk assessment and screening among pregnant women appears to have been effective in identifying cases that might not have otherwise come to light; (2) case management and environmental interventions were initiated promptly; (3) cases experienced, on average, significant BLL reductions over time; and (4) there is a need for additional public health interventions for pregnant women in urban, multicultural centers. While the data suggest that universal screening may increase case finding among high-risk, immigrant populations, further studies and surveillance are needed to determine systematically the most effective approach.

Implications of the World Trade Center Attack for the Public Health and Health Care Infrastructures

The September 11, 2001, attack on the World Trade Center had profound effects on the well-being of New York City. The authors describe and assess the strengths and weaknesses of the citys response to the public health, environmental/ occupational health, and mental health dimensions of the attack in the first 6 months after the event. They also examine the impact on the citys health care and social service system. The authors suggest lessons that can inform the development of a post-September 11th agenda for strengthening urban health infrastructures.

Prevalence and predictors of residential health hazards: a pilot study.

Abstract This article reports the results of a pilot study designed to ascertain the prevalence of lead-based paint (LBP), vermin, mold, and safety conditions and hazards and to validate observations and self-reports against environmental sampling data. Data are based on a convenience sample of 70 dwellings in a low-income, urban neighborhood in Brooklyn, New York. The vast majority of residences (96%) contained multiple conditions and/or hazards: LBP hazards (80%), vermin (79%), elevated levels of airborne mold (39%), and safety hazards (100%). Observations and occupant reports were associated with environmental sampling data. In general, the more proximate an observed condition was to an actual hazard, the more likely it was to be associated with environmental sampling results (e.g., peeling LBP was associated with windowsill dust lead levels, and cockroach sightings by tenants were associated with Blatella germanica [Bla g 1] levels). Conversely, the more distal an observed condition was to an actual hazard, the less likely it was to be associated with environmental sampling results (e.g., water damage, alone, was not statistically associated with elevated levels of dust lead, Bla g 1, or airborne mold). Based on the findings from this pilot study, there is a need for industrial hygienists and others to adopt more comprehensive and integrative approaches to residential hazard assessment and remediation. Further research—using larger, randomly drawn samples, representing a range of housing types and geographical areas—is needed to clarify the relationship between readily observable conditions, occupant reports, and environmental sampling data and to assess the cumulative impact on human health.

Teaching Urban Health

This review has suggested priorities for the education of urban health professionals. First, researchers, practitioners and policy makers need to define the scope of the field of urban health and encourage the development of theories, models and concepts that bring together the diverse disciplines working to improve the health of urban populations. Second, universities and other training programs should broaden the diversity of the students they educate to be urban health professionals and the faculty who teach them. Third, teachers should continue to develop pedagogical strategies uniquely suited to developing the competencies that urban health professionals will need to master. Fourth, universities need to consider various organizational frameworks for teaching urban health and select the options that best match their resources and mission and meet the personnel needs of the region they serve. Finally, universities, health departments and accrediting agencies need to identify new opportunities for collaboration to create the health workforce needed to improve the health of urban populations in the 21st century.

Keeping the “Public” in Schools of Public Health

In this article, we compared the characteristics of public and private accredited public health training programs. We analyzed the distinct opportunities and challenges that publicly funded schools of public health face in preparing the nations public health workforce. Using our experience in creating a new, collaborative public school of public health in the nations largest urban public university system, we described efforts to use our public status and mission to develop new approaches to educating a workforce that meets the health needs of our region and contributes to the goal of reducing health inequalities. Finally, we considered policies that could protect and strengthen the distinct contributions that public schools of public health make to improving population health and reducing health inequalities.