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Full Coverage: Stuck in Squalor

The effect of squalid housing on people’s health is difficult to determine in Sonoma County because there is no study, stockpile of data or government agency that tracks illness in connection with living environments.

Though doctors and scientists are building consensus through research, the connection remains largely anecdotal, witnessed by physicians or reported by tenants’ rights advocates on a case-by-case basis, The Press Democrat found as part of a yearlong investigation into substandard housing in the county.

Sonoma County’s lead health agency, a $247 million department overseeing public health and welfare initiatives for nearly 500,000 residents, does not keep track of housing violations that state officials say can present dire health and safety threats for people who live in slum conditions. County health officials also rarely get involved with investigations into substandard housing allegations.

The county’s Department of Health Services is charged with inspecting restaurants to ensure food is safe, for intervening in mental health and psychiatric crisis and for preventing the spread of infectious diseases, among other mandates.

But county public health officials say they have little role in overseeing housing stock and ensuring its safety. They also have no data on how squalid housing affects the health of local renters.

“We are not the enforcement agency,” said Karen Milman, the county’s public health officer, who pointed out that county and city code inspectors are in charge of state health and safety investigations on housing. “But we’ll come in and write a letter if we’re asked.”

Milman said health department officials sometimes write letters of support for open code enforcement investigations, but their input is not used as a primary tool to assist tenants or force landlords to make repairs in housing units that are found to be substandard. Milman said health officials get involved in roughly 10 substandard housing cases per year.

By comparison, city and county agencies last year were handling more than 250 unresolved cases on substandard housing.

“We get involved when we’re asked, but not everyone always complains, so our hands are a little tied on this,” she said, referring to instances in which health officials join code enforcement officials on routine inspections.

Few if any local governments around the United States track the health effects of substandard housing because of the expense, patient privacy issues and the difficult of coordinating with medical providers.

Milman said she was aware of just one jurisdiction, King County in Washington, that had done such work.

“That was a clinical trial, so they had specific asthma research funding,” Milman said. “I’m certainly concerned about the effect substandard housing can have on someone’s health, but it’s hard to quantify the magnitude of the problem.”

Slum housing conditions — including mold, vermin and insect infestations, faulty plumbing and shoddy electrical wiring — can risk tenants’ physical safety and contribute to lasting health problems — especially in the young and the old, according to peer-reviewed studies and U.S. experts in public and environmental health. Such conditions also can lead to mental health problems, including depression, stress and anxiety, the experts say.

One of the most pressing repercussions is respiratory illness, health experts said. In Sonoma County, more than 18 percent of the population has been diagnosed with asthma, higher than the statewide average of 14 percent, according to county health data.

Medical research has not concluded that mold and other housing problems cause asthma. But the chronic disease has a range of environmental triggers, including outdoor pollens, air pollution and cigarette smoke, as well as indoor mold, which can make the disease worse.

Asthma researchers also are beginning to establish a link with cockroaches and rodents in housing.

“The evidence is really strong and clear,” said James Krieger, a Seattle-based doctor and leading health researcher on the matter. “Problems in the home, with mold and cockroaches … trigger asthma, and kids are more at risk because their bodies are so small.”

Krieger, the former King County chief of chronic disease and injury prevention, found in a 2010 study published in the journal Pediatric Allergy, Immunology and Pulmonology that 40 percent of the asthma risk for low-income children and nonwhite children is attributable to residential allergens associated with substandard housing conditions.

“If you’re a poor person of color, you’re more likely to be exposed to these asthma sensitizers found in homes,” Krieger wrote.

The toll has broad implications for the nation’s health care system.

“We’re going to end up paying for this one way or another,” Krieger said an interview. “It’s more hospitalizations and emergency room trips.”

Local doctors who care for poor people in Sonoma County said they recognize the problem.

“I see this all the time, especially in kids and low-income populations,” said Brian Prystowsky, a pediatrician at Vista Family Health Center in Santa Rosa. “It’s really horrible because it makes a lot of people sick.”

Some doctors suggested that because county public health officials do not track such data, the problem is vastly understated.

“We serve a low-income, marginalized part of the community, so by definition, we see a lot of these kids who have chronic medical conditions like asthma,” said Douglas Jimenez, a doctor at Vista. “I hear this stuff regularly, but it’s really an invisible problem because it’s so hard to prove causality.”

Absent data, studies can shine a light on how poor housing affects health. For example:

A March 2015 study published in the journal Pediatrics found that children exposed to moisture damage and mold at an early age were at risk of developing asthma and respiratory illnesses during the first six years of life.

A 2005 study in the journal Environmental Health Perspectives reported that “substantial scientific evidence gained in the past decade has shown that various aspects of the built environment can have profound, directly measurable effects on both physical and mental health outcomes ... particularly in low-income communities.” In addition, “dilapidated housing is associated with exposures to lead, asthma triggers such as mold, moisture, dust mites and rodents, and mental health stressors such as violence and social isolation,” the study found.

Tracking patient health is another way to show how a poor living environment can cause health problems.

Aaron Valdovinos, an 11-year-old boy, lived in an apartment on Hoen Avenue in Santa Rosa that was riddled with mold and asbestos, according to city inspection records. During the nine years he lived in the apartment, he had severe asthma flares and was routinely taken to the hospital, his doctors said.

The boy’s health improved when the family moved last year. He is now able to play outside and has only been to the doctor once over the past 11 months for a checkup, said his mother, Juana Paniagua.

An effort underway at hospitals, clinics and public health departments across the country to gather better data on substandard living conditions and health could help establish the link between the two, said Mary Maddux-Gonzalez, the former public health officer for Sonoma County, now chief medical officer for the Redwood Community Health Coalition, a network of local clinics.

“It’s hard to prove cause and effect. … There is no equivalent to a cancer registry for substandard housing and health outcomes,” Maddux-Gonzalez said. “It’s challenging because many of our patients may not know they’re living in substandard housing, how to address it if they are or how to get over that fear of reporting it.”

The impact of unsafe housing conditions can ripple outward and jeopardize public health, public health researchers and tenants’ rights attorneys said.

“These are people who are working in our service industry, working in our restaurants and whose kids go to school every day,” said Edie Sussman, a Santa Rosa attorney who specializes in substandard housing cases. “If we’ve got people living in conditions like this, with mold and rats and improper sanitation, it’s going to be impossible to keep disease from spreading. That’s the whole idea behind our public health laws — preventing serious health hazards.”

Indoor problems with rats and cockroaches, as well as lack of hot water and a functioning sewer system, contribute to the spread of infectious disease, according to Krieger, the Seattle public health expert.

Doctors at Santa Rosa Memorial Hospital, the largest hospital in the county, are beginning to screen for health issues that could be tied to poor living conditions.

“Of course, our housing contributes to our health. Where we live is where we spend the most of our time,” said Rachel Marek, medical director of the pediatrics unit at Memorial Hospital. “There is no good data proving a health outcome is the result of unsafe housing … but we’re starting to ask those questions.”

A three-year county assessment of the most prevalent and severe local health problems mentioned that living environments can contribute to health disparities, but it did not elaborate.

Some local physicians characterized the lack of data as a shortfall on behalf of the county health department. Without efforts to gather data and track cases, the county cannot adequately gauge the health of its population, the doctors said.

“You don’t know what public health problems you have until you start collecting data,” said Lisa Ward, chief medical officer for the Santa Rosa Community Health Centers, a network of nine health clinics that serves 50,000 patients per year — the vast majority of whom are living in poverty.

Patient care could benefit from collecting information on substandard housing conditions and poor health outcomes, Ward said.

“I ask these questions, and with one of my patients who has severe eczema and severe asthma, I called the health department to ask them to send over a public health nurse to the patient’s home to look for allergic triggers, but they said they don’t offer those services.”

Other doctors said local governments have been slow to recognize or act when health conditions related to poor living environments become apparent. Short of government action, doctors said they do their best to urge landlords to address problems.

Prystowsky, the Vista Clinic doctor, said he often writes notes for his patients who have asthma and other conditions associated with cockroaches, rats and mold to alert landlords of potential home hazards.

“People will have all these repeat doctor visits, hospitalizations and emergency room trips,” Prystowsky said. “And then sure enough, so often it turns out to be their living environments that are triggering the health problems.”

This report was produced as a project for the California Health Journalism Fellowship, a program of the Center for Health Journalism at the USC Annenberg School of Journalism. You can reach Staff Writer Angela Hart at 526-8503 or angela.hart@pressdemocrat.com. On Twitter @ahartreports.

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