Working with Flower City Habitat for Humanity: A Summary of one CHIC project *********** University of Rochester School of Medicine and Dentistry August 27, 2004 When looking at community-level social change, housing seems an obviously valuable piece of the public health puzzle. The availability of clean, safe housing would immediately impact disease burdens such as those caused by lead poisoning from contaminated paints and asthma exacerbated by household pollutants such as cockroach antigens. This list could go on at length to include violent crime, mental health problems, infectious disease, and other chronic medical conditions. Affordability is the difficult aspect to address with any housing intervention. For example, in the surroundings of Rochester, NY, there is plenty of decent housing. The issue is that much of it is in suburbs where lower income families cannot afford to obtain residences. Indeed, substandard housing is a marker of poverty, particularly in urban areas. In many formerly prosperous industrial centers of the mid-western United States, there is a concentration of inadequate housing located within inner-cities.3 According to Griffith’s research, over the past 50 years, many of these cities have shown a gradually decreasing population. Those, who are able, migrate either to suburban areas or to other parts of the country. Consequently, there is a glut of ill-maintained, overcrowded, poor quality real estate where the impoverished are forced to reside. There are broader problems with such housing crises: although Bashir’s introduction seems somewhat dramatic, the dilemma of poor urban living is indeed greater than not having a place to put one’s feet up at the end of a hard working day. A quote from Barbara Ehrenreich used in Northridge’s editorial paints a picture of the more comprehensive problems: “There are no secret economies that nourish the poor. If you can’t put up the 2 months’ rent you need to secure an apartment, you end up paying through the nose for a room by the week. If you have only a room, with a hot plate at best, you can’t save by cooking up huge lentil stews that can be frozen for the week ahead. You eat fast food or the hot dogs and Styrofoam cups of soup that can be microwaved in a convenience store. If you have no money for health insuranceand the Hearthside’s niggardly plan kicks in only after 3 months- you go without routine care or prescription drugs and end up paying the price.”2 Whether chicken or egg, affordable decent housing is a crucial part of being able to maintain health. There are a number of benefits specific to home-ownership as compared to rental occupancy. A homeowner makes a commitment to a property and to the surrounding neighborhood. Whereas a renter would have little inclination to invest in upkeep, an owner would be more likely to take on repairs and renovations to a home where she would presumable continue to live for some time. There is also the incentive of maintaining resale value of the property.3 Concern for resale value is another factor that contributes to a commitment to the neighborhood. Homeowners are less likely to stand for other houses on the same street which are marked by code violations or are eyesores, thus lowering the value of adjacent properties.3 Rather than just the municipality patrolling derelict structures or substandard buildings, the neighborhood would be more likely to self-survey. The city also benefits in the relative increase in tax revenue brought on by increased property ownership. More inhabitants means more property tax, thus increasing the overall resources of a city to help its citizens. The focus of this 4-week project has been to support the work of Habitat for Humanity, a non-profit organization that seeks to provide affordable owner-occupied housing in areas of need. The scope of the work has been two-fold. The first aspect involved building houses through the volunteer program offered by Habitat. The second was to establish a new collaborative relationship between the University of Rochester School of Medicine and Flower City Habitat for Humanity. Started in 1976 by Millard and Linda Fuller, Habitat for Humanity is an international group that builds new homes in areas that need revitalization through affordable, decent housing. These homes are not given away rather they are sold at no-profit and no-interest to qualifying individuals with established need. These future homeowners also contribute to the process by putting in 500 hours of “sweat equity” and thus working to achieve their goal of home ownership. Although low-income, homeowners are provided other means to help them negotiate poverty, such as education about the financial aspect of owning a home and counseling on issues such as debt management. They also learn practical skills of self-maintenance through the act of building the structure, thus they become even more financially self-sufficient.4 The first part of this project succeeded in a number of the learning objectives for this clerkship. Environmental change was very tangible as new houses were built on vacant lots. Often, multiple lots are used for a single home, thus reducing the crowding on urban streets and improving the appearance of a neighborhood. Old buildings are demolished by the city, but volunteers under the supervision of Habitat workers conduct each building phase of the new homes. This becomes a very close partnership, as volunteers generally come without construction, electrical, or plumbing skills. Medical school does not directly equip one to pour concrete or hang insulation correctly. This brings to light the partnership, education, and really the outreach to the target population. Since Habitat volunteers work side-by-side with prospective homeowners, building is a collaborative effort. The building experience gives medical students the opportunity to meet the new and current residents of the neighborhood. Through the energy and time investment of all the builders, there is a sense of accountability and a sense of ownership that becomes evident. Something tangible from each volunteer goes into the construction of a house. As environmental change is conducted, there is the opportunity to evaluate the changes in these areas on a daily basis. In the theme of evaluation, part of this project involved traveling to other neighborhoods where Habitat has built, is currently building, and plans to build. Mr. Arthur Woodward, Executive Director of Flower City Habitat, provided a tour of these areas. The future of the organization’s building initiatives leads to the second phase of this project. The University of Rochester, through its Department of Community and Preventive Medicine, has a particular interest in the neighborhood also known as JOSANA, surrounding Public School 17. The University has put a considerable amount of work in establishing relationships with this community by creating a medical clinic at the school and a “drop-in” resource/recreational center for youth in the area. Although those initiatives are outside the scope of this project, the attention to public health in this neighborhood makes housing a viable concern. The City of Rochester has yet to process census data from the year 2000, but according to information from 1990, 45% of the area immediately surrounding School 17 (Tract 96.04) lived in poverty. The median income in this area at the time was 41% of that of the City of Rochester as a whole. 9% of the housing units in the area were vacant while more than half of all the units were part of multi-unit structures rather than single-family homes.9 Early estimates indicate that the more recent data will show unchanged or possibly increased poverty in this zone. Initially, this project worked with Mr. Ralph Spezio, currently involved with Project Believe, who is the former principal of School 17 and a vocal advocate for the residents of this neighborhood. A meeting was held between Mr. Spezio and Mr. Woodward to build a new partnership between the University of Rochester and Flower City Habitat for Humanity. The purpose of this meeting, in addition to overall partnership building, was to see how the University and Habitat could work together on a specific project, namely addressing the housing situation in the JOSANA neighborhood. The consensus from Mr. Spezio and Mr. Woodward was that the next step in any action required communication with the Department of Housing of the City of Rochester. The plans for land acquisition, demolishing derelict structures, and distribution of building responsibilities has to happen through the City. Follow up to this meeting with Mr. Robert Barrows, Manager of Housing for the City, revealed that the timetable for such planning would likely be in mid-September. At that time, representatives from the neighborhood would meet with Mr. Barrow’s office and begin mapping out the proposed changes. Although the meeting was a good first step, a potential collaboration needs more structure and an on-going presence acting as liaison. The hope is that Mr. Spezio will continue his discourse with Mr. Woodward regarding their proposed joint effort in the JOSANA neighborhood, but it will be difficult and frankly inappropriate for another medical student to start this initiative from scratch and utilize the time and efforts of the various parties involved. Partnership building, and evaluation of such initiatives requires longitudinal attention, which a 4-week clerkship by definition prohibits. There are many potential projects, however, which could evolve from this project and would be more suitable for a 4-week medical student initiative. The first step is to utilize the services of a mentor with ties to both the medical community and to Habitat for Humanity. The ideal choice for this is currently Dr. Brook Lerner from the Department of Emergency Medicine. In addition to her appointment also in the Department of Community and Preventive Medicine, Dr. Lerner is on the Board of Trustees for Flower City Habitat, and has worked on many projects with Habitat for Humanity in other U.S. cities as well as Central America. She has expressed a willingness to support and guide a medical student during a clerkship. A potential project that would involve advocacy, outreach, and evaluation would be to work with those members of Habitat who recruit new homeowners. It could potentially be very educational to learn about the selection and education process of new candidates. This would help to understand the need in the community, and maybe elucidate the various ways in which Habitat aids the underserved in addition to building houses. The issue of selection brings the possibility of finding a new target audience. Many potential homeowners are in need of homes. After learning how Habitat finds and selects it candidates, a student could organize an awareness or educational initiative that would teach potential homeowners about the resources and offerings of Habitat. Dr. Lerner proposed targeting support staff members of Strong Memorial hospital, thus creating another type of bridge between the hospital community and Habitat. Other possible work for a medical student could be to organize a group consisting of primarily first and second year students to volunteer for Habitat. On a basic level, this would provide a good crop of builders, but a possible long-term goal would be to organize a fund-raiser and sponsor the building of a house. Many organizations such as churches do this sort of sponsorship and more information could be obtained from Habitat concerning the mechanics of this. Such a sponsorship would get a large segment of the medical community involved with Habitat and would thereby establish another link between the two groups. These proposals will hopefully give the next medical student some direction and structure. This project was marked by difficulty in identifying important contacts, vague recommendations about partnership building, and unrealistic goals proposed at the outset. Lack of clear structure within the clerkship itself, in addition to a lack of understanding of the mechanics of outreach and partnership building from certain advisors, made delineating the tasks of the project unclear. However, in addition to accomplishing the aforementioned learning objectives, this project had a good deal of merit and was educational in other ways. The topics of urban planning, urban renewal, and the administrative factors involved with building in a city were quite revealing. The fact that this project went from The Department of Community of Medicine, to City Hall, to indigent neighborhoods around Rochester allowed for a wide variety of perspectives and community contacts. The project dealt with a major issue in public health from academic, municipal, and community-based backgrounds. The chance to build and to directly serve people is incredibly rewarding and should not be undervalued. Although finishing drywall and shoveling dirt may not be academic or clinical pursuits, the lessons learned, the productivity, and the human interaction are all as worthwhile as any research initiative for a fourth year medical student. Finally, this project introduced Habitat for Humanity, a well-administrated, high-functioning organization that heretofore had no real connection to the medical community in Rochester. It is hoped that the work done on this project was as beneficial for others as it was a valuable learning experience. Sources: 1. Bashir, SA, “Home is where the Harm is: Inadequate Housing as Public Health Crisis,” American Journal of Public Health, 92(5); 2002. 2. Ehrenreich, B., Nickel and Dimed: On (Not) Getting By in America Metropolitan Books, New York, 2001. 3. Griffith, Heather, “The Role of Homeownership in Central City Revitalization: Housing Programs in Rochester, NY,” Masters Thesis in Urban Planning, University at Buffalo; 2003. 4. Flower City Habitat for Humanity Web Site, http://www.habitat.org/script/link.asp?url=www%2Erochesterhabitat%2Eorg. 5. Kim, DT et al, “Relation Between Housing Age, Housing Value, and Childhood Blood Lead levels in Children in Jefferson County, KY,” American Journal of Public Health, 92(5); 2002. 6. Krieger, J, Higgins, DL, “Housing and Health: Time Again for Public Action,” American Journal of Public Health, 92(5); 2002. 7. Northridge, ME, “Housing and Health,” American Journal of Public Health, 92(5); 2002. 8. Thomson, H, Petticrew, M, Morrison, D, “Health effects of housing improvement, systematic review of intervention studies,” BMJ, 323; 2001. 9. US Census of Population and Housing, http://factfinder.census.gov. Special Thanks To: Mr. Robert Barrows, Manager of Housing, Department of Community Development and the Bureau of Housing and Project Development, City of Rochester, NY. Dr. Brooke Lerner, PhD, Assistant Professor, Department of Emergency Medicine, Department of Community and Preventive Medicine, University of Rochester. Mr. Ralph Spezio, Community Liaison Officer for Project Believe. Ms. Diane Woodward, Resource Manager, Flower City Habitat for Humanity. Mr. Arthur Woodward, Executive Director, Flower City Habitat for Humanity.