Episode 58: Housing Choice and Public Health with Craig Pollack, MD

Shane Phillips 0:04
Hello, this is the UCLA Housing Voice podcast, and I'm your host, Shane Phillips. This week we're joined by Craig Pollack, a medical doctor at Johns Hopkins University to talk about the medical establishment's growing role in the housing sector, and what we're learning about how housing policy affects individual and community health. The study we're discussing today is specifically about the relationship between the rent assistance program known as Housing Choice, or formerly Section 8, and what happens to children's asthma symptoms when they use these vouchers to move to lower poverty neighborhoods. The results are very, very promising. I'm excited to share this conversation for a few reasons beyond the immediate research. One is that I don't think enough attention is paid to the relationship between housing and public health. As with so many other things, poor access to safe and affordable housing often makes it difficult, if not impossible, to live up to our full potential in other areas, and that includes our own health. A related reason is how, in the US especially, the healthcare system is often very focused on treating symptoms rather than root causes -- this may sound familiar to housing policy folks -- many of which originate outside the medical arena. When an unhoused person receives treatment for an infection in the emergency room, for example, and then is dropped back onto the street a few days later, we know there's a very high chance they'll be back in the ER before too long. The relationship between housing and health presents a challenge, but it's also an opportunity because we spend more money on those two things than pretty much any other part of the economy. So if we can coordinate better and spend more effectively, we can make really big strides. A reminder that we are taking listener questions about the show, us hosts, academic research or real world housing policies, or about UCLA, urban planning and its practice, or anything else you'd like to hear from us. We'd love to feature your question in an upcoming episode, so send them to me at shanephillips@ucla.edu or find me on Twitter and send them there. One last note here before we get to the interview: the Housing Voice podcast will be taking a short break, and we'll skip a couple upcoming episodes as a result. We don't really have seasons, but technically this will be the end of our second season. With this episode coming out on September 6, you can expect our next episode on October 18. Now's your chance to get caught up on the back catalog. We will miss you, I hope you'll miss us. The Housing Voice podcast is a production of the UCLA Lewis Center for Regional Policy Studies, with production support from Claudia Bustamante, Divine Mutoni, and Phoebe Brous. Now let's get to our conversation with Craig Pollack.

Craig Pollock is a medical doctor and professor at Johns Hopkins University, and he's here to talk with us about the influence of neighborhood poverty on public health, and specifically how children's asthma symptoms changed when their families used rent vouchers to move from high poverty to low poverty neighborhoods. Craig, thanks for joining us and welcome to the Housing Voice podcast.

Craig Pollack 3:20
Thanks very much for having me.

Shane Phillips 3:22
And my co-host today is Mike Manville. Hey Mike.

Michael Manville 3:25
Hi Shane, hi Craig.

Shane Phillips 3:26
So as always, let's have you give us a tour of a city or a neighborhood that you know well. Craig, where are we going?

Craig Pollack 3:32
So the place I want to take you to is Berlin, Germany. We moved back from Berlin a few days ago, after spending a year there on sabbatical and working remotely. And there are so many places to go in Berlin, there's going to the symphony for folks that are into that. And there's going to the German parliament building and to the TV tower to see everything you can see for miles around. But there's kind of two types of places that I want to take you to that were really important to my family. The first was the German playgrounds, where we got so much time, and my kids are nine and 12. And I think there's something unique about the German playgrounds from like the pocket parks in our neighborhood to the larger parks like the Dracula's playground that we went to just a few days ago, to the larger what they call adventure parks where kids get to use a hammer and nail and kind of unsupervised. One of the last ones we were at, we saw a kid destroying a grocery cart, just kind of like having a great time doing it. And it was this wonderful sense of freedom. And also the way the playgrounds are really kind of very lovingly crafted as well kind of out of wood with wood chips, and it's just a phenomenal experience for the family and for our kids. The second place though, is the German transportation system, and my 12-year-old does soccer and so she got to ride her bike to the train and take her bike on the train and then ride it to soccer practice on her own and that kind of level of freedom that the transportation system provides did was really wonderful for her. It was wonderful for us as parents not to have to drive her to soccer and also to kind of see her as more independent. So I think kind of both of those things, the playgrounds with their kind of unstructuredness, and the wonderful care that they were given, as well as the kind of the safety and freedom of the transportation were absolutely incredible and absolutely worth seeing.

Shane Phillips 5:24
Mike, have you ever been to Berlin?

Michael Manville 5:25
I have. I was there in 2014, maybe?

Shane Phillips 5:30
I was there a few years after that, and I absolutely loved it. I would have liked to spend closer to a year than the five days I actually got to be there.

Michael Manville 5:38
Oh, yeah. Agreed, agreed.

Shane Phillips 5:40
So the article that we're discussing today, this is our first from a medical journal, The Journal of the American Medical Association, and it came out earlier this year in May 2023, and it's titled Association of a Housing Mobility Program with Childhood Asthma Symptoms and Exacerbations, and you had 12 co authors on this one. You found very significant reductions in asthma for children who moved into low-poverty neighborhoods. And I just want to signpost that primary finding here at the beginning, but we will save the details for later. This study is more focused on medical science than housing but it has a lot of overlap with housing studies that have looked at the impacts of household mobility, especially the impacts of moves made by poor families enabled by the Housing Choice Voucher Program, aka Section Eight. Those studies also often focus on what happens to children when they move to lower poverty neighborhoods and the moving to opportunity, or MTO program is the best known program that helped poor families move to neighborhoods with lower poverty and more resources. And I think in past episodes, we've talked about some of those studies of this program. For those unfamiliar with housing vouchers, they help very low-income renters with rent by paying the gap between 30% of their household income and whatever the actual rent for their unit is up to a fair market rent that varies by location but it's usually set just below the median rent for the area. We have a great interview with Rob Collinson on the design of the voucher program in Episode 17, for anyone interested. But before we go any further, I think we should put some definitions and context on the table here. First, your study focuses on asthma symptoms and asthma exacerbations, so what do those terms mean? And then second, what do we know about the association between high-poverty neighborhoods and worse asthma outcomes? How strong is the relationship and what the researchers believe explains it.

Craig Pollack 7:39
So for the terms, asthma exacerbations, it's kind of what you would expect when kids are having an asthma exacerbation their asthma symptoms are acting up, often they need to go to the doctor or other health care provider to get treatment for it. In the study we'll be talking about later, it's specifically they need to get steroids either as a shot or as a pill in order to treat their asthma exacerbation. Asthma symptoms can be a range of different things that can be from shortness of breath, or wheezing or chest tightness. They can limit kids activities, so they can't play their soccer or other sports because of the symptoms they're experiencing. Or often they're waking up in the middle of the night with some of these symptoms. I just want to like post that these outcomes really matter for families with children. And they impact the kids health, they impact their kids ability to be in school and participate in activities. And they have implications for the parent or caregiver as well who may need to take time off from work. And the impact of these on health care costs is really quite large. So for the for the second part of your question about the evidence about where people live. So this is a growing area of research and really important to look at. So my main collaborators and Co-leads on the project are Elizabeth Matsui and Corinne Key. They're both pediatric allergist, and immunologist. And they've taught me that there's a wide range of factors at play here. So there's things around pests and mold and indoor air pollution, which are qualities of the housing itself that are really important (and) contribute to asthma exacerbations and asthma symptoms. There's stress, which is really an important contributor, and something I hope we'll go into a lot more over this episode. There's things about the neighborhood in terms of outdoor air pollution, which limit outdoor opportunities for play, also contributes to obesity, which is related to asthma outcomes, things around health care access, which can be related to the neighborhood, often related to individuals' socioeconomic status, cigarette smoking, breastfeeding, a whole range of other factors. So these are complicated relationships that are very much multi-causal.

Shane Phillips 9:41
So this study focuses on children. And I think that's fairly common for studies that look at the links between household mobility and health outcomes. Why is that? You know, I assume it's partly just a general heightened concern about children and that early experiences with asthma maybe can impact life out comes into adulthood more, and maybe they're just more physically vulnerable to environmental pollutants. Are those accurate assumptions, and is there more to it than that is? Are there other things, other reasons we are specifically concerned about outcomes for children?

Craig Pollack 10:13
So I think you're absolutely right, Shane, I think it's all of those things, I think that children are susceptible to different environmental exposures. And often we think of lead paint as, you know, one of the key ones where, you know, it's really important around children's brain development, critical periods. I think, when we're thinking about asthma, you know, asthma is more common in children, and so the environmental exposures matter more. And then, as you mentioned, there's this kind of compounding effects over the life course, right? Like the things that happen in people's childhood can have important implications for who they're able to become as adults, how they're able to grow. In the setting of asthma, there's really important implications for lung function growth. And again, my allergist, immunologist colleagues have taught me that kind of your lung function grows over a period of time, and then kind of declines as people get older. And so these trajectories can really matter for long term survival.

Michael Manville 11:05
Yeah, I mean, I think all of that sounds exactly right to me, although, you know, certainly I don't know that much about medical research. But the other thing I would add is just that when we study neighborhoods, and the causal association between neighborhoods, and almost any kind of outcome, it's helpful to study children simply because children generally don't choose their location right? there's always when you study the causal impact of being in a certain place, a selection bias problem, which is that people choose, adults at least, have a certain amount of choice as to where they are. And so, you know, this is why the Moving to Opportunity program was designed the way it was, is to try and overcome this sort of selection bias, which arises, because some skeptic can always say "sure you know, if you live in this place of concentrated poverty, you're going to have lower educational attainment, you're going to have worse employment outcomes, you're going to be more exposed to criminal behavior". But on the other hand, someone who is more prone to criminal behavior, and less likely to work might choose to live in a place of concentrated poverty. I think at this point, the balance of evidence suggests that that sort of selection problem, or sometimes called a reflection problem, is not as large as was once hypothesized. You know, not that many people are just like, you know, guys have some criminal tendencies, I'm going to live in a high-crime neighborhood. But you know, it is something that, you know, if you're going to be a good social scientist, you need to find a way to control for and one way to do that is to identify people in these neighborhoods, who are sort of there randomly, right, because their parents are there. And so now, obviously, what you can introduce into that as this problem of like, well, now you have parental influence, but you can observe at least some parental behavior in a way that you can't observe whatever hypothesized inclination might lead someone to choose to be as an adult in a high poverty neighborhood. And so you just go back to old studies of spatial mismatch studies of residential mobility, that the focus on children I think, is in part to try and get a little bit closer to exogenous variation to to overcome selection bias.

Craig Pollack 13:17
I think it's trickier though, because I think that in the setting of like kids and asthma, right, like one of the influences of kids asthma exacerbations is whether there's cigarette smoking in the house, and you kind of mentioned that about parental behaviors that you can observe. But I think that plays out in a lot of different ways, for example, health care seeking and use of controller medicines. And so I think, as much as I wish that there was like, a better way that we can kind of do the social science design here, I think it's hard that I think that there is confounding that we need to think about as we design our studies.

Michael Manville 13:49
Oh, yeah, the implication here was not that it solves the problem, right?

Craig Pollack 13:53
Absolutely.

Michael Manville 13:54
But that it gets you closer, because, you know, failing anything else, you can always just have a fixed effect for every household, and that that's not a perfect identifier. But I think the confound is just like how do you even identify someone's, you know, sort of, by definition, unobservable tendency to find themselves in a particular neighborhood right? And so I think the idea is not that this solves the problem, just that it's traditionally been a way to sort of get you get you closer.

Shane Phillips 14:21
I'm personally just kind of stuck on the highly self aware person with criminal tendencies who's just like, "you know, what, this is who I am, I'm gonna move to this kind of place".

Michael Manville 14:29
Yeah, and in fairness, you know, you could craft sort of selection bias stories that aren't quite so simplistic, right, but just, you know, like attracts like, on some level. Or if you are someone who has a hard time keeping a job, you're going to end up in places where the cost of housing is lower, and maybe you're going to find that there's other people around there who also have a hard time keeping a job. And a naive correlation would find that that neighborhood is causing unemployment somehow where as the actual mechanism was that people have a hard time being employed find themselves in that neighborhood.

Shane Phillips 15:04
Yeah, yeah. So Craig, you also note something in the very first sentence of your article, which I take as a real motivation for this research, which is that black children have two to three times the prevalence of asthma as white children, and twice the risk of asthma related ER visits and hospitalizations. What do we know about the causes of that disparity? Does this mostly come down to housing and neighborhood characteristics? Or are there other major associations here?

Craig Pollack 15:33
So I think a lot of the factors that we talked about with neighborhood influences and housing influences really matter here. So socio-economic status, and including poverty is a really crucial factor associated with asthma outcomes among children, talk about access to care health behaviors, and these environmental exposures in the home and in the neighborhood, I think layered onto this, and something that we need to really lift up is the role of systemic racism, that led to the increased risk of these exposures and continues to lead to the increased risk of these exposures experienced by black children with asthma.

Shane Phillips 16:08
So I'm not sure how much of this history I have shared on the show before, but I effectively dropped out of high school. And when I came back, I was about 21. And I, for some reason, planned to become a physician. I ended up getting my bachelor's degree in biochemistry, I took the MCAT between my junior and senior year, I was working in a microbiology and genetics lab for several years while interviewing at med schools. I bring this up because one of the earliest memories of urban planning that I have was reading about doctors who were prescribing walks for their patients. This was maybe 10, a little more than 10 years ago, where this started getting some attention. They were just prescribing their patients who were unhealthy in one way or another, to just get out of the house for a 30-minute walk every day. Obviously, this is not a replacement for chemotherapy or anything like that, but just kind of general, sedentary lifestyles, and then negative consequences that can come from that. That led me to learning about the barriers people face getting around on foot or bike. And you know why people tend not to go for 30-min, hour long walks every day, and I started experiencing more of that myself after getting rid of my car and moving to Seattle in my early 20s. And long story short, here I am, a decade later, more than a decade later working in the UCLA Department of Urban Planning, not as a doctor, and no offense, but I'm very happy about that. Correct me if I'm wrong, but I'm guessing you also didn't start out your medical career thinking you'd be worrying about housing policy or doing an interview on a housing policy research podcast so what led you here?

Craig Pollack 17:48
So as part of my undergraduate I was pre-med, but at the same time majored in history and became really interested in the language of memorials. So it's really interested in World War One memorials that were erected in England after the Great War, and then memorials that were being erected for gay men who had died of AIDS and others who had passed away from AIDS and HIV. And so kind of the similarity of language of mourning over time led me to kind of continue wanting to study this. And I found myself in med school at Berkeley, working with folks from the Human Rights Center, and had heard about a memorial being built in Bosnia, and so went to go study it. And when I went to Bosnia to study this memorial that was being built for the massacre at Srebrenica couldn't really understand exactly what was happening with the memorial, the money wasn't there at the time. And people instead wanted to talk about their housing and rites of repatriation. And so this connection between housing and repatriation and their health became really interesting to me. And so that has become a through line and in the work that I've done, and it's kind of come in different ways and studying foreclosure crisis and studying eviction and studying the work that I'm talking about kind of where people live and how they make meaning and how it gets into their body and impacts their health.

Shane Phillips 19:07
Is it something you've seen in the medical field more generally a kind of increasing interest in not just socioeconomic factors and race and ethnicity, which I think has been kind of increasing attention paid to that for quite a while, but also the stuff on housing, the built environment, that kind of thing?

Craig Pollack 19:26
Yeah, I think there's been a tremendous amount of interest recently, and how these social factors impact health and wellbeing. And I think that comes for a lot of different reasons. Some of it is, you know, the housing crisis has touched so many people's lives, so many of our patients lives. I think there's also changes in the way that we pay for health care and the move towards global budgets or move towards kind of having incentives that promote quality of care, that make health systems more interested in it. And so I think you're starting to see health systems begin to experiment at least with screening for health-related social needs and thinking about how'd you connect people to address them? And then you also have there's this kind of health-related social needs, like what are patients are experiencing at the bedside, but also thinking about kind of social determinants more broadly. And I think there's a lot of interest in what role should healthcare systems, should positions, should other healthcare providers play in trying to kind of advocate and address those broader social structures.

Shane Phillips 20:22
Just, you mentioned global budgets, and I think this might have a little bit of relevance here, or just is worth kind of defining, I think what you're talking about is essentially, instead of fee for service, every intervention or test that a doctor runs the hospital, or the doctor themselves gets paid for that thing. And instead, it's this more holistic approach where someone comes in with cardiac arrest or something, and there's just a budget, that the hospital is paid to treat that holistically. And if the hospital is efficient, and the patient doesn't have to come back multiple times after the initial surgery, the hospital is probably going to make a decent amount of money if the hospital does a bad job, but also if you know, the social determinants of health are not really in the right place, and people are just because of you know, obesity, or sedentary lifestyles or other outside factors, they're more likely to come back to the hospital cost more, and the hospital may actually lose money in that, is that sort of the global budget thing that you're talking about? And can you say more about that how this all links together?

Craig Pollack 21:27
Yeah, I should probably take a step back and say, it's less global budgets, which is like a specific form, which is true in Maryland, and instead different types of what are considered advanced payment models. And so some of the advanced payment models are trying to move away from this fee-for-service model, where every time we do more for a patient, we get paid more, and instead say we're going to try to think about incentivizing quality, or think about kind of coordination of care. And so a good example of that is like bundled payment models for knee replacements saying that, you know, what, if you get your knee replaced, and you end up coming back with an infection under a bundled payment model, then maybe we're not going to pay for your readmission to the hospital. And you can imagine in case like that, where it matters, where somebody's going home to write, if they don't have a home to go to, if they don't have a place where they can rest and recuperate that, like their likelihood of coming back in, and the hospital being on the hook for that could be much greater.

Shane Phillips 22:20
Yeah, it does seem difficult, because like, hospitals only have so much control over this kind of thing. You see the same thing with education, for example, where the struggles that children face because of their home life, and doesn't matter how good a teacher you are, you can only overcome so much.

Craig Pollack 22:36
Right, and these things are complicated, right? Like you can imagine a world where hospitals might say, "you know what, like, this is somebody that I'm not going to operate on, because I'm worried about being on the hook", right? Like there's potential unintended consequences, and so thinking about how to incorporate the social factors into the risk adjustment, for example, is something that there's been a lot of discussion on; like, do you say we're going to have a lower benchmark for hospitals that are treating a lot of patients that have a lot of social needs? Or do you say, actually, we need to make sure everyone's getting the same high level of care, and you can easily do a whole episode on kind of how do health care systems think about these social needs and these social factors, and like, what's driving some of this change?

Shane Phillips 23:16
Yeah, we'll let the weeds do that one. So your study relies on self-reporting of asthma symptoms and exacerbations by children's caregivers, which I understand is standard practice. The largest study of the Moving to Opportunity Program, which was back in 2011, the study itself was 2011, found no effect on self-reported asthma symptoms among children. But later work by Raj Chetty and colleagues found that MTO did have positive impacts on younger kids specifically. And so kind of actually negative impacts or no impacts for older kids were washing out those findings. I assume that that work influenced your team's interest in this association between housing mobility and asthma for kids. But were there other developments, other research progress that has happened over the past decade or so that made you want to investigate this further? What made you think earlier studies might have missed something or there was something more to add here?

Craig Pollack 24:14
So our team has also gone back and investigated MTO. And what we did was we linked individuals in MTO, with objective measures of their healthcare use. So we got data from state Medicaid agencies, we got data from different all payer claims. So like, whatever your insurance company was when you went to the doctor, and we got it for patients up to 20 plus years, and what we found there was pretty striking. We didn't see really any effect among the adults that that moved, but among children whose family who received a voucher, we saw that there was a significant reduction in hospitalizations. And when we dug into it further, we saw that there was a significant reduction in asthma related hospitalizations. So one of the things about MTO is that there were three groups; there was a control group and then there was two ditional voucher group at the time of Section Eight voucher. And then the third group was a voucher that had to be used in low-poverty neighborhood. And kind of overtime, the experiences of those two voucher groups were really pretty similar. And so in this study, we ended up analyzing them together. But in talking to advocates into our community partner, they were saying, "you know, what we're seeing and similar to what you're finding significant reductions in asthma, families are saying that there's reductions in asthma among the children". And also they were saying that, you know, MTO, as an experiment, didn't work that well, because a lot of families who got the experimental voucher to move to a low-poverty neighborhood weren't able to move to a low-poverty neighborhood with it, they weren't able to find housing. And then a lot of people who ended up moving ended up moving back to higher poverty neighborhoods over time. And our community partner, house mobility partner saying, you know, what, actually, we've learned a lot from that. And I think some of the work by creating moves opportunities shows that they've been able to help people lease up, a higher proportion of people lease up, in opportunity neighborhoods. And so it seemed to us like something important to continue to investigate and get better data on.

Michael Manville 26:08
Yeah, I think the point about sort of what we've learned from MTO, and haven't learned from MTO, where it worked, and where it didn't, it goes back, I think, to this point about studying children, right, which is that the initial evaluations of MTO looked quite disappointing, and especially in terms of things like income and social services and stuff like that. And what Raj Chetty and his team did was go back and look at specifically the younger group of children. And I think this goes back to the point we discussed earlier, which is that, in principle, children have less control over their location. But of course, as kids get older, they get more agency about where they are. And one of the things that's been documented in the evaluations of MTO is that older kids, if you moved when you were 14, or 15, not only did you have a strong friendship network, where you moved from, in that high poverty network neighborhood, but within a year or so, you had the ability to go back there probably and spend most of your time there, right? And so one of the things about young kids especially is that relative to other members of our population, they really are much more likely to spend most of their time in that neighborhood. Whereas with almost anyone else, they might have a residence in a particular neighborhood, but it's much harder to know exactly how much of their life they're actually in that neighborhood, especially when you have long commutes, people working long hours, you have friends in other places. Whereas you know, maybe your standard five-year-old is more likely to actually spend a lot of time there, right, more likely doesn't mean they spend most of their time there but more likely.

Shane Phillips 27:41
Mhmm Craig, you said that households in the MTO program were not able to move to low poverty neighborhoods, and I want to kind of interrogate that language. Is it true that they were unable to or... what I'm getting at is the counseling research that was done later, and whether this is a matter... and maybe this is just semantics a little bit, but are people unable to move to low poverty neighborhoods or is it that because of a lack of social networks, just education generally awareness of what their other options are, that people they struggled to take advantage of the option of moving to low-poverty neighborhoods? Can you talk about the housing counseling research that has followed, and what role that may have played in your own research design and plans here?

Craig Pollack 28:29
Sure. I think the way I'd like to answer that is by talking about our community partner, the Baltimore Regional Housing Partnership. And Baltimore regional Housing Partnership is a really phenomenal organization. And I think we'll talk about kind of how it developed as a result of a fair housing lawsuit. And they have a tremendous amount of experience working with their clients to try to overcome the barriers that prevent people from moving. So it's not... you know, they have a long waitlist for the program. This is about giving people choice who say, "Yes, I'm interested in moving, I'd like to sign up to get a voucher and move". But we also recognize that the housing market can be very difficult for people to navigate. And so there's a lot of pre-move counseling that the Baltimore Regional Housing Partnership does to help families who want to move, overcome those obstacles. And those can be identifying landlords who are interested in renting to voucher holders, working to help with the security deposit, working to help individuals improve their credit scores, so a bunch of different things that are really important. In addition, they work after families moved to help make sure that families are able to stay living in the neighborhoods that they're interested in living in. So I think that these kinds of more robust supports that are available are incredibly important, and I think we're seeing the US Department of Housing and Urban Development, test some of these in the Community Choice demonstration project. So I think it's exciting to see how this is continuing to play out.

Shane Phillips 29:52
Yeah, yeah. And I don't mean to imply that you know, these are not real barriers. And you know, your example actually of landlords not accepting is like an actual like, I literally cannot move there, it's not even just a matter of I'm not really aware of what the options are in that neighborhood because I've never been there. I've never lived there in the past and don't know no one there.

Michael Manville 30:11
And a lot of low poverty neighborhoods in the United States don't have rental housing.

Shane Phillips 30:15
True, yeah. So your study was not of the MTO program, but was another housing mobility study run by the Baltimore Regional Housing Partnership, which you talked about, that came out of a lawsuit against HUD that charged it had, "perpetuated systemic racial segregation in Baltimore's family public housing", and violated the 1968 Fair Housing Act. The judge said that HUD used the city of Baltimore as, "an island reservation for use as a container for all of the poor of a contiguous region". And I will just add that Baltimore was home of the first racial zoning ordinance in the country in 1910, which explicitly restricted black residents to living on specific blocks. So this is all part of a very long legacy. Can you now tell us about the housing mobility study you did, which is called the Mobility Asthma Project, what was the hypothesis you wanted to test with this? Who did you recruit for the study? And what distinguishes this project from previous research, tell us about how you put this all together?

Craig Pollack 31:19
That Mobility Asthma Project, or MAP is a cohort of families that were participating in the Baltimore regional Housing Partnership. And what we 7did is our team recruited families as they were entering into the Baltimore regional Housing Partnership Program, as we mentioned, that the counseling process can be a long process. And so we kind of got the families as they were joining, as they were going to their initial meetings to understand more about the program, and we asked them if they wanted to take part in this study. And then we follow them before they moved and continued on for up to 12 months after they moved. We were really interested in understanding what's the impact of participating in a housing mobility program on children's asthma exacerbations and their asthma symptoms. And we wanted to understand what was it about their home environments that was changing that might contribute to these changes. And so in order to get at that we really needed to do careful environmental assessments. So we went in at their initial visit. And then every six months, we went into the family's homes, we did dust collections to look for different allergens that can trigger asthma. We collected air samples, we did breathing tests, a whole bunch of different factors that we studied to try to understand what was changing. We also did phone calls every three months, kind of intervening to see what was happening with children's asthma exacerbations and their symptoms.

Shane Phillips 32:43
And we'll get to the results here in a minute but out of a final sample of 123 children, 106 kids or 86%, ended up moving during the follow-up period, and only one of those children who moved still lived in a high poverty census tract at that point. How did you end up with so many people moving to low-poverty neighborhoods, we've kind of talked a little bit about the barriers and how, frankly, uncommon it is for families in these voucher programs using these vouchers to move to low-poverty neighborhoods. So it seems astounding that you got almost 100% of the participants are they were helped into these low poverty neighborhoods.

Craig Pollack 33:24
Yeah, I would say that it wasn't me that helped them. It was the Baltimore regional Housing Partnership, which is just a really phenomenal organization and a wonderful partner for this research. They got a tremendous number of families that they've helped in the past and tremendous experience in helping families move to low poverty neighborhoods. So really all credit goes to them. And it was, for me, that was a really important to be able to kind of understand among the families that ended up moving right, like what happens. And so for some of the kids, we didn't observe them in their new home yet, but we're still following up this cohort to see what happens for some of those families as well as have longer term follow up.

Shane Phillips 34:00
So with all of that covered, let's get into the results here. I tease that the impacts were large but let's get into some details. For each of the outcomes you studied, how big were the effects of moving from a high-poverty to a low -poverty neighborhood compared to the control group of children who didn't move and we'll talk about the control group a little bit later.

Craig Pollack 34:23
The effects for each outcomes were really large. So when we look at asthma exacerbations, imagine a sample of 100 kids. So before moving there were about 88 severe asthma attacks, asthma attacks required them getting steroids in a year. After moving there were about 40 asthma attacks per year so that's a reduction of 54% reduced odds of exacerbation associated with moving. Just to put that in perspective, so this is larger than the effect size of inhaled corticosteroids medicine that we often use to treat asthma and kind of online with some of the effect sizes that we see with biologic agents. By turning to asthma symptoms, we ask kind of what were your number of days, you had asthma symptoms in the past two weeks. And it was on average about five before moving and came down to 2.7 after moving so about two and a half, 2.4 days difference in asthma symptoms. So really meaningful if you think about kind of what's the impact of the symptoms on children's lives on their caregivers lives.

Shane Phillips 35:23
Yeah, those are those are very, very large impacts. And presumably, all these other treatments with the corticosteroids and so forth, are still contributing and adding on to that benefit.

Craig Pollack 35:34
So that's just to give you a sense of the effect size, we looked at kind of is it that their medication is just being intensified, they're moving to a new neighborhood, and they're getting more medicines. And that didn't seem to be the case that wasn't explaining our findings.

Shane Phillips 35:46
Yeah, yeah. So you address the question of whether these findings are maybe just the result of moving into a nicer home, rather than a lower poverty neighborhood. So maybe the homes people are moving into just have fewer indoor allergens from insects, or rodents, for example, what did you find there?

Craig Pollack 36:03
So we did find that mouse and cockroach allergens, which are two key drivers of asthma exacerbations, they both were lower after families moved. At the same time, we found that dust and pet allergens increased a little bit after moving. In the end, we looked at to what extent these factors seem to mediate the findings do they explain the findings, and we didn't find that these allergen levels really explained a lot of the changes in exacerbations. I should caveat this to say that we know that mouse and cockroach allergens really do matter. And in our study, there was a really small sample of kids that were both sensitized to these allergens, meaning that their body was reactive to these allergens, these mammals and cockroach allergens, and were exposed to high levels of the outset. So we're not saying that these factors do not matter but in this overall sample, it wasn't the key driver.

Shane Phillips 36:53
And you also looked at these measures of social cohesion, safety, urban stress, can you talk about the findings there as well?

Craig Pollack 36:58
Yeah, here the the findings were really striking. So we found that as families move, their sense of social cohesion increase, their sense of being safe in their neighborhood during the day and at night, and their level of stress was lower. And here, we found that these different factors, were actually related to their asthma exacerbations and helped explain about a quarter to a third of the effect that we were seeing, so really significant. And I think there's a lot of reasons why stress can be a key mediator here, including like kind of biologic mechanisms around inflammation, as well as things around health care, changing measures, allowing people to seek better care, allowing them to spend more time outdoors potentially being exposed less to allergens in the home, and factors like that. So I think this is a really, really critical binding

Michael Manville 37:49
Just for our listeners, because I think that one of the big meats of your findings, Craig, is this idea that something that mediates the asthma effect is the combination of reduced stress and increased social cohesion? I wonder if you could just say, kind of in in sort of plain language, how that might play out for a household, right, because I don't think that you know, we have a bunch of housing listeners, and they may not understand how feeling a little bit better about your neighborhood or feeling a little less stress is going to translate into your child has a better set of asthma outcomes.

Craig Pollack 38:21
I think there's direct biological impacts with changes in inflammation, and that's not something I know very much about or would go into here. And I also think there's indirect ways. So I think that stress can change, for example, health behaviors, we looked at smoking in our study and did find that kids were exposed to usually variable levels of smoke. There was some reduction in smoke exposure after they moved but that wasn't a key mediator in our asthma symptoms. You can think about neighborhood safety, and the amount of time that kids spend outdoor, and how many exposures they're exposed to indoors. I think time spent outdoors can have lots of different effects in terms of physical activity. And you kind of going into into that. I also think it can impact kind of your ability to get advice and to seek health care resources. So I think the ways here I think we haven't totally delved into yet, but I think that this idea that stress is a key factor in our health and well being and that neighborhoods can shape the amount of stress that we're exposed to. I think that's incredibly important.

Michael Manville 39:22
I agree with that 100%. And if I'm putting words in your mouth, please correct me immediately. But it sounds like what you're you're sort of positing is almost bi-directional, not bi directional but there's two different things going on. One is that there's just less stress. And so as a result of that there's going to be better health outcomes, but also that maybe in your study, the self reported lower levels of stress might represent a series of other actions that we can't see right now right, that themselves have positive health outcomes, whether that's more outdoor exercise, whether that's being able to and also taking advantage of the opportunity to bring the kid to the doctor more often or things like that, is that kind of the gist of it?

Craig Pollack 40:02
Right, these benefits are not just for asthma, right? Like we studied asthma, because that's what we heard was an important factor that was changing, and one that we could look at as an indicator, but that there's so many other things that that are changing, that have implications for different aspects of health. And here, we focused on the one kid with asthma, but often these families had multiple children, right? And there's potential for influence on the adult health. So I think, you know, the true impact of this, if we were to quantify, like, what's the benefit for asthma exacerbations, and the cost of the medicines associated with that, or the cost of the hospitalizations would be a dramatic undercount here?

Shane Phillips 40:38
So those are really impressive results. And, I mean, they're just very large results, hard to discount, but we should spend some time on the limitations of the study that might call these into question at least a little bit. And I think the lack of randomization in the study is probably the biggest and this is to be clear, something you acknowledge in your article as a limitation. Could you talk about the control group, how they were selected? And why you think, despite the lack of randomization, your results are still showing a real impact from housing assistance, and relocation, counseling, and any other limitations you think are worth mentioning in the study.

Craig Pollack 41:15
So I think that's right. There's a lot of limitations to this research. And we know that asthma often gets better over time. So we wanted to make sure we had a comparison group. And the way we did that is we matched the people in our study to kids in a birth cohort, we kind of were really careful in the way we matched a different demographic characteristics, different ways of measuring asthma severity. And then we kind of gave those kids in the comparison group, a fake move date to see whether or not those kids are getting better after their fake move versus the kids in our cohort who had a real move. And we found that the results were really significant, they remained stable after comparing to this other group. I think that's one really important limitation.

Michael Manville 41:56
Just for our listeners, just to just say a little bit more about sort of what it means to take advantage of a large birth cohort. And are these the kids in the control group, these are not kids you're working with in the same way you're working with the treating kids, right?

Craig Pollack 42:11
No, exactly right. These were kids that were recruited into a sample and followed over time to understand kind of their health trajectories. And they were followed in a way that was actually pretty similar to our asthma cohort, where they had frequent home visits, where they had tests to see what they were allergic to, where they had evaluation of their asthma symptoms and exacerbation, so we could kind of create a good comparison group with this existing registry of patients.

Michael Manville 42:35
And were they mostly from similar area in the metro or from all around or...

Craig Pollack 42:41
So they were from a number of different cities, including Baltimore is one of them. So there were several other limitations. So this, this study was done in Baltimore, right, which has a particular housing environment, particular housing mobility program, and so I think, you know, we need to think about the generalizability of this program. And then I think another issue is that when studying these different allergen levels, or different particulate matter, or different things that we were looking at, that potentially mediated the effect, that a lot of these factors are really related to one another. So the different measures of stress are all highly correlated. So I don't think we can say it's really about social cohesion, and it's not about safety. But these factors are related in important ways.

Shane Phillips 43:21
Yeah, I do actually want to highlight something, which is that, you know, Baltimore is a relatively low income city with pretty affordable housing, it's got a lot of vacancies. And so, you know, I think we should be at least a little bit careful thinking about how housing mobility program might work in a city like that, where despite, you know, very high segregation, and the barriers that imposes, the cost of housing is not necessarily so much of a barrier, as it might be like here in Los Angeles, just the ability to move to a low poverty neighborhood if you have the financial resources and counseling, it might be a little easier in Baltimore than some other places. That could be wrong. Maybe that's not the case but I think it's very possible, and we should keep that in mind as well.

Michael Manville 44:06
I think that's right, although I don't know that that necessarily is a caution against the findings of this paper.

Shane Phillips 44:12
No, no

Michael Manville 44:13
Right, I mean, it basically says that, you know, your voucher dollar goes farther in Baltimore, than in Los Angeles, which I don't think anybody would necessarily dispute. But the basic idea that if you get someone to and into an environment where they have fewer stressors and fewer exposure, you can get some good health outcomes. There's nothing about LA's high housing prices that would suggest that's not true.

Shane Phillips 44:32
Right, it's just a matter of how much more challenging it might be to get people to those environments. But the benefits of those environments, I think, this doesn't discount those at all.

Craig Pollack 44:42
But I do think those benefits might vary, right? Like, in Baltimore, there's a lot of row houses, there's different levels of vacant and abandoned houses. And so, some of those factors could be related to the exposures that kids with asthma is facing in those environments. So, you know, I think it's important to kind of see how this extends to other Are other areas and other neighborhoods.

Michael Manville 45:02
So I was somewhat related to that, I guess I had a question about measures of potential outdoor air pollution. You know, one, one thing we are very aware of in Southern California is just the sheer amount of pollution that comes from busy arterial roads, proximity to highways and things like that. And much of our lower income housing is built in closer proximity to freeways, closer proximity to large, busy, arterioles, and so forth. And some folks here at UCLA have documented that that seems to have a pretty strong association with asthma as well. were you guys able to measure sort of the difference in proximity to sources of air pollution external to the home that would have potentially contributed to these outcomes or you're further from a freeway or further from a six lane arterial or, you know, in Southern California an oil refinery?

Craig Pollack 45:51
So that's such an important question. And it's definitely something we're exploring as a next step. So we're working to analyze that type of data as we speak. I would also say that we did collect particulate matter data for inside the home. And we know that one of the big contributors to indoor particulate matter is what's happening outside and we didn't see that indoor particulate matter was a key contributor to asthma exacerbations in this cohort.

Shane Phillips 46:17
So for last couple of questions here, first, I just want to hear what you think the takeaway is, or takeaways are, from all of this? You know, a question it raised for me and I, I've already gotten pushed back in our in our pre-interview Google doc questions, and so I know what Mike at least will say to this, but I want to put this idea out there, because I think other people might be thinking something similar. One thing I wondered is, if this is just kind of shuffling around, who suffers from these higher rates of asthma symptoms, and exacerbations? You know, one possibility I can see is that if helping low-income households move into low poverty neighborhoods leads to a sort of integration, where there isn't such a large divide between rich and poor neighborhoods, maybe everyone's a little better off wherever they live. But if having a bunch of poor households in a community is really just downstream of other neighborhood characteristics, like proximity to polluting highways, limited park access, few jobs, then even if some households leave to healthier neighborhoods, lower poverty neighborhoods, someone else is just going to take their place. Again, I don't want to take anything away from the benefits to that family who moved. But if that latter case is what's happening, it feels more zero-sum. Those are just a couple possibilities, and they aren't even entirely mutually exclusive from each other, I don't think, but I'm curious to hear how these results, inform your views on policy on housing policy, mobility policy, those kinds of things.

Craig Pollack 47:48
So I think this is such an important topic. And I want to try to avoid the dichotomous thinking of you're either helping families move, or you're investing in places because I think the mobility and the place-based strategies are often pitted against one another as a zero-sum game. And I think we just need to reject that thinking, I think you can help families who are interested in moving to overcome the barriers that keep them constrained to particular places. And at the same time, I think we should be investing in place-based strategies to help families that want to live in particular neighborhoods, be able to live in those in a way that's going to be healthy for themselves and their families. So I think it can't be an either or situation. I think it needs to be a both and.

Michael Manville 48:28
And I would just add, since we referenced my pushback in the earlier thing, you know, I think it, and I completely agree with Craig to start, which is that there's nothing about doing housing mobility that says that you throw up your hands and do nothing about you know, these sort of sending neighborhoods, right? I mean, there's there's lots to be done. There's certainly lots to be done to just make our streets less heavily polluting, right? I mean, these are in the grand scheme of things, relatively low-hanging fruit. But even specifically, I think, you know, this is an instance where the perfect can't be the enemy of the good. And unless you know where someone is coming from, who's moving into this neighborhood someone just moved out of, it becomes hard to conclude that there's no net benefit at all. You know, if someone moves out of a high poverty neighborhood that has a lot of pollution in Baltimore, and gets to a nicer suburban location, well, they're better off. And then if someone moves into the apartment that they vacated from Haiti, right? I mean, does anyone seriously think that person isn't better off despite the fact that they're going to be exposed to a little bit more pollution? I mean, people come to the United States from all over the world for the simple reason that like, even though that when they arrived, they often live in conditions that people who work in universities would not particularly want to live in, they're objectively better off and they do know what's good for themselves. And so it really is important to understand that like, a lot of people when they make a move, they're doing what we would probably do in their shoes right? And so they probably are at least as well off as they would be from their next best option. And our understanding as planners for you and I, as planners, and Craig, as medical professionals that like one thing we want to do is expand their range of options. In a better world, that wouldn't be their best option. But if it is their best option, and it is an improvement over what they would do otherwise, I don't think it's fair to call a program like this zero-sum.

Shane Phillips 50:25
Yeah, and I think there are also probably some distributional impacts here, which we might see as positive, where even if it were the case that because a low-income household got a housing voucher, and it was able to move into a low-poverty neighborhood, and the like middle income or working-class household who would have lived in that unit in the low poverty neighborhood, instead has to live where the voucher recipient was, there might actually be some kind of positive equalizing benefit there. But I think we don't have to go down that road, really, because I think you're right, that it is not a zero-sum, just trading one household for another kind of thing.

Craig Pollack 51:02
And so I just want to caution, I think that we need to be careful against kind of paternalism and how we're thinking about this, because I think that these programs, these mobility programs came about out of Fair Housing lawsuits, trying to increase opportunity and choice in ways that had been systematically denied to individuals, and to groups of individuals. And I think that, in my mind, kind of working to address some of those issues is so critically important, and really speaks to the role of housing mobility, in addition to kind of the programs that we're doing to help individuals who want to remain in other places. And I think, as we were thinking about kind of like shuffling people from one place to another, first of all that, like, people have a lot of agency in this, and we should work to increase the agency. And then also thinking about, you know, kind of what's the role of housers in this world, and also kind of how public health individuals work with housers to, for example, remediate home exposures, which can be really challenging, but also kind of can be incredibly important.

Shane Phillips 52:01
Yeah, yeah, I think that's a great point. And it really is true that just giving people additional choices has value in itself like that is that is a benefit to the individual household to be able to choose from a wider range of places they want to live, it increases their their own agency and options, which I think we shouldn't dismiss it all. So bigger picture, not just limiting ourselves or yourself to asthma, or to household mobility unnecessarily. Have you seen any promising reforms or programs beyond the Baltimore Regional Housing Partnership that are at this intersection of housing and public health? Is there anything we should be on the lookout for, or the things that are not happening yet, but you would like to see?

Craig Pollack 52:46
So I know, you said not to limit myself to Baltimore, and housing mobility, but I do want to highlight at least one program in Baltimore that's trying to address housing mobility. So Baltimore Regional Housing Partnership got some funding to do a pilot program, where they're allowing healthcare providers, pediatric clinics, pediatric emergency room providers, to refer patients whose families may benefit from their moving from the receipt of housing mobility services to get those services. And so they've been developing a process to get these referrals, and then to provide counseling for families that have vouchers to use their vouchers in opportunity neighborhoods and more resource neighborhoods. I think it's really exciting. I think there's interesting things to work out with how do you kind of do those referrals? How do you integrate them into medical care? And I think it points to this broader issues around how do health-related social needs, these factors related to housing, food security, and the like, kind of get into the clinical setting and whether they should get into the clinical setting. Some people say like, ah, healthcare hasn't done such a great job in many ways. So maybe they've had their chance, and it should be someone else. You know, and I understand that kind of some skepticism. But I also think there really is a tremendous opportunity here to help screen patients who might benefit and get them the services they need. I think there's a number of programs that are out there that have been testing that, the Accountable Health Community Program is one program that was being run by the Centers for Medicare and Medicaid Services to see about this screening and referral process. I think there's different payment reforms as well. There's different Medicaid waivers that are being tested in California and North Carolina, Baltimore, and a lot of other states to see whether or not we can help address patient's housing needs, and whether that has implications for healthcare spending.

Shane Phillips 54:32
Can you talk more about that? I think that's a really interesting direction things are going in part because, you know, I think cities are often the jurisdictions tasked with you know, "solving homelessness or addressing homelessness", but a lot of the cost and you know, we shouldn't focus solely on cost, but a lot of the cost of homelessness is borne by the healthcare system and the criminal justice system, which is generally funded at the county level and also the federal government has Medicaid, which provides a lot of the funding here too. And so there's this sort of misalignment of incentives, and you know, I just want to call out a program here in LA County, the Housing for Health Program, which is run out of the County's Department of Health Services. I don't have all the details, but I will provide a few links. This invests in supportive housing for unhoused residents, presumably services as well, people who are frequently using these county services. Just a quote here that I found was county service costs were on average 38,000, $146 per participant for the year prior to housing, and fell to $15,358 for the year after being housed. And so, in addition to just doing kind of the morally right thing, and helping people back into homes, it seems to be a financially smart decision as well, a good investment. And so are you seeing more of that elsewhere, it sounds like maybe that's kind of what you were talking about at the Center for Medicare and Medicaid Services or whatever CMMS stands for? I don't know my federal acronyms.

Craig Pollack 56:08
So yeah, CMS, I don't know where the extra M goes. So I think you're absolutely right, I think there is often the wrong pocket problem when we think about kind of spending on housing that then would potentially benefit the healthcare system, and the savings would accrue to the healthcare system. And so how do you get those back into the pocket of creating housing and helping people live in stable homes, and people are trying to work that out. And I think some of the kinds of different payment models are around that. It's tricky. So we've been doing some work in Maryland Medicaid waiver, which has some supportive housing and other housing supports for individuals, they tend to focus on housed individuals, and trying to get housers to build Medicaid for their services or to work in the healthcare system can be really tricky. And so I think it's a really exciting development, and one that's going to be hard to implement. I also want to say I think a lot of the movement here has been on kind of the chronically homeless, chronically unhoused individuals that have high health care costs. And I think that's an incredibly important population to focus on. And it often kind of comes into this language of health care savings. And I both agree with that but also want to pause for a second and say we give people insulin, not because insulin is free, and it saves healthcare system money, but because it's the right thing to do. And I think as we think about housing as a health intervention, we need to also think about that it's not necessarily saving money, but still might be the right thing to do or still is the right thing to do. And so to kind of move away from simple like saving money to thinking about it more from a cost-effectiveness and from a moral argument.

Shane Phillips 57:49
Yeah, yeah 100%. I mean, especially because there is a population for which investing in supportive housing and services does save the system money. But there are a lot of people for whom that's not true. They're not costing that much, but it is still bad, we should still feel bad that they are unhoused and feel some obligation to do something about it. So I think it's a really important point. Craig Pollack, thank you so much for joining us on the UCLA Housing Voice podcast.

Craig Pollack 58:16
My pleasure. Thanks for having me.

Shane Phillips 58:20
You can read more about Craig's work on our website, lewis.ucla.edu. Show notes and a transcript of the interview are there too. Once again, don't forget to send us your listener questions while we're on break. You can send them to shanephillips@ucla.edu. Thanks for listening, we'll see you in six weeks.

Transcribed by https://otter.ai