In the United States, the traditional approach to health care has focused resources on treating people when they are sick rather than paying to keep people healthy. Once people are sick, they have the added trouble of finding affordable treatment. Massachusetts has been heralded for being at the forefront of national health reform; their 2006 health care reform not only laid out the framework for Obamacare, but a recent study has also shown that it has a proven impact on health. Now, the state has a chance of paving the way for a new model of health care, with a focus on prevention. For many low-income and minority residents in Boston that are suffering disproportionately from preventable conditions such as asthma, could this grant be the solution they are looking for?
The Massachusetts Department of Public Health’s Prevention and Wellness Trust Fund is an innovative new grant that has been declared the first of its kind, and operates under the assumption that cutting health care costs and preventing illness go hand in hand. On January 28th the Trust awarded the Boston Public Health Commission (BPHC) and its partnering organizations $250,000 as part of a larger, $60 million state-wide fund that emerged from a one-time tax to larger state insurers and hospitals. Mayor Walsh issued a statement saying this grant “will allow us to focus on the neighborhoods where our residents are most impacted by health inequities, and leverage our network of community health centers to provide better access and proactive care.”
In Boston, BPHC will coordinate efforts concentrated in the neighborhoods of Roxbury and North Dorchester, where Black and Latino residents make up 65 percent of the population, and almost 30 percent of residents live below the poverty level. In these neighborhoods asthma rates are five times greater than the rest of the state and asthma hospitalization rates are 80 percent higher than that of the rest of the city. Environmental justice (EJ) advocates point to the poor indoor and outdoor environments in which residents live as the causal factor for these health inequities.
Even a cursory look at the built and natural environment of these neighborhoods reveals why the residents are in poor health. Roxbury and Dorchester are historic neighborhoods, where it is typical to have homes built before the 1940s. However, without proper inspection these homes become susceptible to pests, mold, and a host of other asthma triggers. Stepping outside, main thoroughfares cut through both neighborhoods, and the combination of commuter exhaust and diesel bus traffic perpetuates elevated asthma rates. This is all coupled with a lack of green, open spaces.
While asthma is often associated with inhalers, these types of treatment methods have skyrocketed in price. Today, it costs upwards of $175 for an inhaler and $50 to $100 for each additional Albuterol inhalant cartridge. The Trust’s focus on dynamic community-level public health partnerships and strategies is its strongest asset and a welcome departure from these conventional public health solutions, which tend to channel money into specific chronic disease treatment.
In contrast, local organizations and activists have emerged over the years to combat the same issues by tackling them at their roots. Educating residents, working with the city to enact new housing policies, and protesting the creation of toxic environments are just a handful of strategies that focus on preventing poor conditions from emerging in the first place. However, their battles continue.
Inconsistent funding has been a roadblock for many local organizations working on EJ issues in Boston. Additionally, when these organizations do get funding, it is often in the form of short-term grants lasting no more than a year or two, which impedes long-term goals and projects. This new grant is an improvement, as it could amount to $900,000 to $1.5 million after its first year. But there is more to the equation than its initial funding.
While four years may be longer than many of the short-term grants local organizations often receive, it remains a short time to combat the systemic problems underlying the environmental burdens plaguing many of these neighborhoods. Furthermore, because this is a somewhat experimental grant there is little guarantee that follow-up measures will take place after the four years have passed to ensure that prevention remains a focus within city organizations.
The type of community-level collaboration that makes this grant so unique also makes it more difficult to implement goals. The BPHC is one of seventeen partnering organizations that will be sharing the grant (others include: Health Resources in Action, Boston Public Schools, and Codmon Square Health Center.) While the participation of municipalities, community-based organizations, and health care providers is key, in practice this means that each organization will only be receiving a small fraction of grant money to focus on different aspects of the problem.
While this grant may not be a silver bullet solution for poor environmental health in North Dorchester and Roxbury it is certainly a step in the right direction. Most importantly, it highlights an important shift in public health priorities as the Massachusetts moves from being primarily treatment-based to focusing on community level prevention. In order for this initiative to have an impact similar to the state’s 2006 health reform, Massachusetts will need to find support and ensure long-term, sustained commitments. Only then can we move towards ensuring a healthy environment for everyone.