A Roadmap to Improve Health Outcomes By Investing In Green and Healthy Homes

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Mark Masselli ( 00:04 ):
Our program focuses on healthcare. So, why are we talking about homes? It's because there's a national
effort underway that's showing how green and healthy homes can make a big difference for the people
who live in those homes.
Ruth Ann Norton ( 00:17 ):
We took that, we went into the Maryland legislature with a plan to reduce and eradicate childhood lead
poisoning that we built on over a decade and a half. We put standards in place. Things that say, "If you
are a landlord, you're not in compliance with the Maryland lead law, you may not collect rent."
Margaret Flinter ( 00:39 ):
We're talking with Ruth Ann Norton, the president and CEO of the Green & Healthy Homes Initiative.
They believe that we can address the social determinants of health through healthy, safe, and energy
efficient homes.
Ruth Ann Norton ( 00:51 ):
Doctors, I call it our work as a Doctor's Relief Act because doctors who are in the business of wellness
want to know that all of the other contributing factors can help them help the patient be better.
Margaret Flinter ( 01:07 ):
This is Conversations on Healthcare.
Mark Masselli ( 01:18 ):
Well, Ruth Ann Norton, welcome to Conversations on Healthcare.
Ruth Ann Norton ( 01:22 ):
It's my favorite conversation to have about housing, so thank you.
Mark Masselli ( 01:26 ):
Well, you run such a great national nonprofit, which is really dedicated to advancing racial and health
equities and opportunities through healthy housing, which are all very important goals. But maybe you
could share with our listeners exactly how you're making this happen.
Ruth Ann Norton ( 01:45 ):
Well, so we've been at it about 31 years and finally feel that a number of things are coming together. I
tell my staff the tide is finally meeting us at the shore on this work. But our approach is to look at the
health of residents and the health of housing and try to address them together. So, we understand that
if we remove lead paint in housing, that we will have children and newborns, right? Who will not be
impacted by the neurological, cardiac, and kidney impacts of lead poisoning. If we improve the
structures of home so that we don't have mold, mildew, moisture, pest issues, better ventilation, we will
reduce the incidence of asthma in children, asthma in our older adult population, improvements in
COPD. Therefore, improving a kid's ability to get in the classroom healthy and ready to learn, and an
older adult's ability to live with greater quality of health as they age.
( 02:51 ):

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We coupled that with injury and fall prevention and energy efficiency work, everything from
weatherization to decarbonization and electrification to solar. And we do that for a number of reasons.
One is economic outcomes. Two are the outcomes on health and quality of life. And three, it better
improvement for not only the value of the home and the stability of the home, but it is better for our
overarching health. And what we know is that we have shown in very hard patient and analyzed data
and cost data that we have massive improvements to our healthcare systems, to the ability to reinvest
and the ability to be tangible and transformational in communities to invest where we have overlooked
and disenfranchised communities for a long time and create better, more resilient, healthier
communities and be able to lead where we have left people on an island in the past. And so, we're really
forward-thinking about, especially the climate pieces of this, to make sure that we do not make the
mistakes of the generations before us.

Margaret Flinter ( 04:13 ):
Well Ruth Ann, you are tackling some of the most persistent problems in health that we have known
about for a long time. So, I want to give you a chance to zero in on a few of your tactical approaches,
your supporters use, your comprehensive housing intervention model and a best practices toolbox. Tell
us about them. How do they work? What's in the toolbox and what's the set of interventions?

Ruth Ann Norton ( 04:39 ):
Well, I think our number one tool is that it's just tenacity, right? On this, but what we are effectively
doing in housing policy. You've seen this pass into legislation in Pennsylvania. We've seen Maryland
transform, many states are transforming to what we call a whole-house approach. In the opening, I
talked about the health of families and residents in the health of housing. Our assessment, which we
developed with HUD, CDC, Department of Energy, EPA and others, and healthcare really looks at how do
we look at the health of individuals, what in their house is impacting their health or their opportunities?
And then how do we look holistically? So, it means that in that comprehensive assessment, we're going
to measure indoor air quality and ventilation and the things that matter about weatherization, about
whether or not we should make measures to decarbonize, if there's carbon emitting appliances, all of
that and how we can upgrade electrical systems.
( 05:47 ):
We are also looking at those things that are hidden dangers, whether it's lead paint, whether it's mold,
mildew, and moisture or other things such as trip and fall, preventable trip and fall injuries in the home.
And we then develop a single scope of work and we don't any longer ask families to go hunt for the 5,
10, 15 different programs that they may need to get to that housing stability and health standpoint. We
also are calculating what are the cost savings that happen. We are tracking whether kids get into the
school better. So, in our study we did for the US Department of Housing Urban Development through
this align braid coordinate approach showed that we improve school attendance to perfect attendance
from chronic absenteeism by 62%. Now, that's not necessarily a health measure, but it's certainly a
social determinant of health measures.

Margaret Flinter ( 06:53 ):
Absolutely.

Ruth Ann Norton ( 06:53 ):

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We also reduced asthma admissions in the hospital, in Baltimore by 66% in Philadelphia by 70% and
77%, Cleveland by 58%. That is pretty tremendous work. And we have done over 40 feasibility studies
with support from Robert Wood Johnson and the Corporation for National Community Service and GPB
to look at those healthcare dollars, right? What does it translate into? And today we manage programs
for entities like Blue Cross and Molina and AmeriCorps, WellPoint because they see those outcomes. But
in short, we are looking to say what in a home, regardless of what door family came to us, whether it's
need of weatherization, they're cold, kid has exposure to lead, right? There's people going to the
emergency room for asthma, whatever the pathway that brings you to need to have your house
assessed, we look holistically with the family, find that scope, braid the funds, and then measure the
outcomes. And it's a pretty straightforward common sense proposition. The hard work is just moving
systems to align and do this, but we've seen that happen. Whether it's Delaware, New Jersey, Michigan,
it's happening.

Mark Masselli ( 08:30 ):
Boy, there's so much of what you just said that I really like. Also, just thinking about moving systems,
you really provided an organizational roadmap for healthcare providers, right? To think about how they
can move outside of their four walls. I think it's fair to say that a patient's in seeing us for a hundred
minutes a year is sort of what the numbers are, but they're in their home, thousands, tens of thousands
of minutes, right? And that's where you can provide this very important healthcare improvement. And it
increased their wellness by really focusing in on the home.
( 09:12 ):
So, I think you've provided a great tool for healthcare organizations to re-conceptualize the sort of
delivery model. And I really like the point, Margaret, we've been talking about this. You've raised this
whole issue on absenteeism, how that is such a marker for families or young people who may not be
functioning well when that absenteeism is high. So, Ruth Ann lots to digest here, but talk a little bit
about the organizational model and redesign the systems change that you're trying to not only execute
in terms of making homes healthy, but also being an exemplar for healthcare organizations to redefine
their work.

Ruth Ann Norton ( 09:56 ):
Not only healthcare organizations, but Federal agencies, right? Today, the US Department of Energy now
considers health and safety as part of their pre-weatherization, right? They're considering how are we
going to address health and safety and housing as they're considering the $27 billion of investment
they're going to put into greenhouse gas emissions, right? But from healthcare, let's take it from a
couple of ways. So, I've been in my position for 31 years here. We started out looking at lead paint,
right? It started to grow because both the workers that we have in the field, the guides cleaning up
housing, our home visitors and our families that we worked with said, "You can't just clean up lead
because when you leave, we're still unhealthy, we're still at risk." And our data showed that and it
showed housing instability. But what was also happening was the conversation with the doctors at the
Harriet Lane Clinic at Hopkins and other clinics, right? Across the country, which was they write a script
for asthma knowing they're sending a kid back to a place that's only going to exacerbate that problem.
( 11:10 ):
Or we would chelate kids for lead knowing that we're sending them back and they're going to come back
because of the exposures. Doctors, I call it our work is a Doctor's Relief Act because doctors who are in
the business of wellness want to know that all of the other contributing factors can help them help the

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patient be better. So, we are really trying to ensure that when somebody hits that emergency room, that
we are able to go in, do the assessment, clean up the hazards and eliminate if we can, the return to the
emergency room or hospitalization for something like asthma. What we're also doing is helping
healthcare get to a wellness standard. So, many people who work in healthcare, whether they're
doctors or administrators or in plans and programs across the country, have the goal of wellness. And
we're able to align both the return on investment, the economic return with the human outcome return
by this work and be able to use mechanisms like value-based purchasing, right?
( 12:26 ):
Or investments in social determinants of health or hospital community benefit programs to help support
the outcomes for the very reason that people get into healthcare. To make people healthier, right?
We're all on this journey together. We get to do that. And the exciting kind of piece of this is we're in it
for a moral compass reason around health and around outcomes, right? For families. But we can do it
and the business case supports us, the data supports us, and we spent a long time learning how to do
the economic analysis with Milliman who was a partner, who's an actuarial firm, and who eventually
said, "You got this, go do it." So, we are a high-trust audit agency now. We can actually do that analysis
as part of the evaluation and be able to change things in California. We help to change the statutes that
are now allowing Medi-Cal to use the in lieu of statute for doctors to write a script for people who have
asthma and be able to have up to $7,500 where that can include moderate home repair to address the
issues that are causing the asthma. And the ultimate-

Mark Masselli ( 13:53 ):
Margaret, it reminds me-

Ruth Ann Norton ( 13:54 ):
The ultimate dream is that right?

Mark Masselli ( 13:57 ):
Right. It also reminds me of our early days in the Health Center Movement where Dr. Jack Geiger was
writing prescriptions for food. So, this is on the same level.

Ruth Ann Norton ( 14:06 ):
That's it. That's it. Right. And we know this is a healthcare measure in all forms maybe not by all
regulation, right?

Margaret Flinter ( 14:16 ):
Well, I just want to make sure our audience knows how radical the work is that you're doing. And I will
date myself by saying, 50 years ago I started my career as a rural public health nurse and I was out there
measuring lead in the walls and treating children who had lead poisoning. But you are known as the
architect of Maryland's 99% reduction in childhood lead poisoning. That is a story we want to hear, we
all know about is dangers. But to achieve a 99% reduction is really phenomenal. How did that come
about? Why isn't this the national agenda every day? Tell us about that.

Ruth Ann Norton ( 14:55 ):
Well, I'll say 99.4, we're not done yet.

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Margaret Flinter ( 14:56 ):
All right. 99.4.

Ruth Ann Norton ( 15:00 ):
And according to Duke University, for all respect for everybody went to Duke, they're my nemesis
because I went to UNC, but they have reported that we returned in 12 years, we achieved that 98%
reduction and they did a study showing a $44.5 billion economic return to the state of Maryland. And I'll
come back to that in just a minute because that did not improve housing condition per se by itself. So
again, why we are doing this more holistically. What we did was made the case on data, what we did
was made the case on why in the world we're reinvesting state legislative dollars in graduation rates, in
school attendance, in improved educational systems, and not doing the one very tangible thing to
ensure that we could get there, which was not to damage the brains of young children before they could
get to a classroom and fail grade level reading, right? And the downhill slope that goes from that. So, we
went into the Maryland legislature, there was an article headline in the Baltimore Sun that I still have in
my office that said, "Efforts to prevent childhood lead poison war, doomed to fail."
( 16:24 ):
And so, we took that. We went into the Maryland legislature with a plan to reduce and eradicate
childhood lead poisoning that we built on over a decade and a half, we put standards in place, things
that say "If you are a landlord, you're not in compliance with the Maryland lead law, you may not collect
rent in rent court because your house is an illegal rental." It's just the facts of the law. We call it the
clean hand statute. We've put legislation in place to prevent evictions because people have lead
poisoned kids. We stop landlords from asking about lead poisoning. But what mostly, we made the case
to the public in Maryland that we did not want to have a brain-damaged society when we had the tools
to prevent it. And so, even for the opposition in the legislature at the time, we were fighting this out so
much so that my picture was up as a dart board for the people working on the other side.

Margaret Flinter ( 17:34 ):
What an honor.

Ruth Ann Norton ( 17:36 ):
Yeah. But now we have such a high rate of compliance, it's better business for the rental property
owners. It's better business for the real estate community. It is a better outcome for our schools. And we
are starting to see the seeds of that in other areas. In the census tracks where we did the work, crime
rates are actually down, housing stability is up, people are investing more in housing. But what we also
did is that in that learning was to understand, to get the lead out, we had to do all of these other things
around housing. If you have a house that is extremely cold and extremely hot because it's poorly
weatherized that will cause underlying paint to chip, peel, flake, and become toxic dust. So, you have to
fix that, not only for the cost but for the envelope of that house.
( 18:39 ):
I would say the Maryland Lead Law, though Margaret is a gold standard beyond any. It just got
replicated in this many years later in part by Rhode Island. The city of Philadelphia has replicated parts
of it. Michigan just followed us in universal blood testing. And the one thing I will say in the commitment
of the state of Maryland, regardless of party of our governors over the past 30 years or our legislature, it
has been the one clear true north that every single governor has had a hallmark piece of advancement
in this work. So, we made it something all of us can own and champion. And as far as I'm concerned, the

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champions are those property owners that clean up their houses are the families who help to report and
clean that up, are the legislatures legislators. We've pushed the idea and we've had the courage to
enforce the law.

Mark Masselli ( 19:47 ):
Speaking of champions, and you've seen over your 31 years, lots of activity going on in the field that
you're in and have been leading. I thinking about Margaret, the opportunity we had to interview the
folks from Flint, Michigan on their lead in the pipes. Joseph Allen from Harvard on Healthy Buildings,
Lindsay Marr from the Green Council there. So, you've got a lot of allies that are happening. How are
you all organizing together and trying to share best practices with each other, so that we can have more
visibility to what works effectively? And I really want to applaud your policy focus and research focus
about measuring and getting good outcomes on these and sharing those. But tell us a little bit about the
larger field and how you're working collectively there.

Ruth Ann Norton ( 20:41 ):
Well, I will tell you that we steal completely from Brené Brown and we call it Data with a Soul, right? The
data and the family story is what matters, right? We just had a family that we did our whole house
strategy, lead paint all the way to electrification, cleaning up all the hazards in between. And for the first
time, a grandmother was able to have her 6-year-old grandchild spend the night for the first time. That's
the stuff that matters. So, we are in a network, GHHI has a network of over 1,700 partners across the
country, but we network this in every level we can, whether it's the National Governor's Association or
the National League of Cities or conference mayors, but mostly we are really on the ground with
nonprofits, mayor's offices, healthcare across the country. And so, we have some pretty wide networks
in our collaborative approach and really focus on what those collaborations that exist in communities to
go in and join underneath, not try to create something new. So in Detroit, we're in the housing task
force community.
( 21:59 ):
We're also the co-manager or working with Enterprise to support them in managing the Detroit Home
Repair Fund, which is funded mainly by the Gilbert Foundation and DTE. We go into communities where
there isn't collaboration, isn't a network and try to build that. We've done that in Mississippi, helping to
create a Healthy Homes network in Mississippi. And then we tie this again through many different
networks, through the grant networks of the Office of Lead Hazard Control and Healthy Housing through
the climate and green networks that exist. So, I would have to tell you, there's not one bullet in that. It's
more about joining and moving this message, this mission into existing collaborations and going where
things don't exist and helping to build up learning networks and action networks to make them be able
to walk and stand and run on their own. We are firmly built to really focus in on this coordinate strategy,
aligned braid, coordinate strategy of housing. So, we also cross sector that at every level, mayor's office,
right? Health and housing, state health and housing, the nonprofit community who can execute that-

Mark Masselli ( 23:33 ):
Housing authorities as well in that?

Ruth Ann Norton ( 23:35 ):
Housing authorities as well for the public housing side.

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Mark Masselli ( 23:37 ):
Yeah.

Ruth Ann Norton ( 23:38 ):
Yeah.

Margaret Flinter ( 23:39 ):
Well, I hope you find a strong partner in the National Network of Community Health Centers across the
country because this is certainly near and dear to their hearts as well. But Ruth Ann, I wonder if I can
ask, it seems to me, because we work in many cities and we obviously have been around the country,
there are neighborhoods in some of our cities where they neglect and all, but abandonment by the
owners of the property have resulted in housing stock that is so deteriorated. I am curious, do you ever
find yourself at the point where your coalitions are making recommendations not to salvage and fix, but
to raise and build new communities for people?

Ruth Ann Norton ( 24:23 ):
A hundred percent. I mean, I think there is a point at which we care deeply on this issue across the
board, but let me talk about lowest income homeowners who sometimes get left on an island in
communities because the disinvestment is so high and they've aged and the ability to salvage housing
situations. We look at that aspect of ownership, right? Of the ability to make the investments within
reason, and sometimes it'll be higher than what we would want on average. But if you can invest
$65,000 into a home, that then can be assessed at $250 to $300,000 or even $150,000, the question is
the value of that. But the value in stabilizing neighborhoods in the value of what people own and not
them losing their asset is critical to this. But certainly we wrote the national standard on lead safe
demolition and environmentally safe demolition because we do understand that some housing is so far
gone that it has to come down.
( 25:48 ):
And we modeled that behavior in East Baltimore where there was a determination made between the
city, the state, and nonprofits to really look at a community and we relocated the families that were kind
of left on the island and in the heart of East Baltimore. And they were given money to buy a home, to
support that or to move into better housing situations and the ability to come back to the community
when new things were rebuilt. It's a dramatic choice to make. It's a hard choice for mayors to make, but
the goal is will people be healthier? But you have to take many things into account when you move an
elderly population that could possibly accelerate their mortality because you are ripping away emotional
supports, not only unhealthy housing issues, you have to ensure that where people are given an
opportunity to go is important.
( 27:03 ):
But also there is strategically the choice to take down some vacant housing in neighborhoods because
it's being occupied illegally, it's unhealthy, it could cause a fire hazard, it could cause other hazards. And
we can make a better choice of reinvesting in different ways. But we look hard at this to say, if it can be
saved, right? And we can make it healthier and we can invest and not continue to let it go, we can
prevent foreclosures. We did a study for Open Society a number of years ago showing that we can build
vitality, we can build health, but it takes a cooperative judgment on that.

Mark Masselli ( 27:48 ):

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Let me get one last question in, because you got some good news recently from the Environmental
Protection Agency selecting your organization, I think 11 total to direct part of the Environmental Justice
Thriving Communities Grant Making Program. I think about $50 million that you're sharing. Tell our
listeners about the program and what we can look forward to.

Ruth Ann Norton ( 28:10 ):
Yeah, so we were awarded $50 million for Region 3, which is Pennsylvania, Delaware, Maryland, West
Virginia, Virginia District of Columbia. And in that region and in the region where both I am sitting, we
will be helping to build the capacity of organizations around the environment, environmental health,
environmental justice, and the Justice 40 initiatives to lift in disinvested communities, a health and
environmental health forward and justice message. GHHI believe was chosen because we have grown in
stature. We've been through the journey of starting with one person and $17,000 to now being $20
million a year in our work across the nation.

Mark Masselli ( 29:08 ):
Wonderful.

Ruth Ann Norton ( 29:08 ):
And I think we have a particular understanding of the resources that it takes, the supports it takes. So,
we will be running competitions to give out grants, $350,000, $250,000, and $75,000 over the next three
years across the region to lift up this work. But we're also going to try to work with philanthropy to
match fund this where we can to help train people how to work with healthcare, how to do many of the
things that whether it's improving their waterways, their byways, their homes. It's an incredible honor
for us to be in this position, to have the mission that we have. Building the capacity of others is the way
that we all build health together, and we're big believers in that. But I'm just thrilled to have time to
spend with both of you today. I appreciate the time that you've given us.

Margaret Flinter ( 30:11 ):
Great. Well, Ruth Ann Norton, thank you for joining us for this great conversation. Thanks to our
audience for being here. Be sure to subscribe to our videos on YouTube. As always, you can go online to
CHCradio.com to sign up for email updates, and please share your thoughts and your comments about
this program. Ruth Ann, thank you again. Congratulations on all the accomplishments and I know much
more work to be done.

Ruth Ann Norton ( 30:36 ):
Indeed. Thank you so much. Grateful to both of you.

Margaret Flinter ( 30:43 ):
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The views expressed by guests are their own, and they do not necessarily reflect the opinion of
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