PROVIDENCE – In Baltimore, in the aftermath of the death of Freddie Gray while in police custody, there were two excellent stories written by Washington Post reporter Terrence McCoy, which are considered favorites to win the Pulitzer Prize this year. 

The first, published on April 29, 2015, looked at the life of Freddie Gray as “a study of the effects of lead paint on poor blacks.”

The second, published on Aug. 25, 2015, explored “how companies make millions off lead poisoned, poor blacks.”

The two stories documented the intimate connection between the social, racial and economic disparities of housing, education and health care as a consequence of lead poisoning.

In the aftermath of tragedy and travesty of the potential lead poisoning of a generation of children of Flint, Michigan, the stories make for compelling reading. [See links to the stories below.]

A third story, published on Feb. 16 by Kaiser Health News, examined the disparities in health outcomes in Baltimore. Entitled “In Freddie Gray’s neighborhood, the best medical care is close but elusive,” the reporters attempted to answer the question: “In a city with some of the finest health institutions in the world, how could there be such enormous disparities in health outcomes?” [See link to story below.]

Dr. Leana Wen, the public health commissioner for the city of Baltimore, recently wrote a letter to The Baltimore Sun, attempting to reframe the question as something broader than just access to health care.

Wen wrote: “Focusing only on access to medical care does not go far enough. While 97 percent of health care dollars are spent on hospital and clinic-based medical care, only 10 percent of what determines life expectancy takes place within the four walls of the exam room.”

Wen continued: “We must address the upstream factors – income levels, access to healthy food and exposure to smoking and environmental hazards – that shape people’s lives.”

“We don’t need statistics to know that a patient will be healthier if they have heat in the winter and nutritious food on the table,” she continued, saying that children who are food insecure or whose families need fuel assistance are 30 percent more likely to be hospitalized by the age of 3.

As the health care delivery system attempts to shift from fee-for-service to accountable care entities that are reimbursed for outcomes achieved across a continuum of care provided to patients, there are a number of unresolved questions: does the delivery of health need to be reorganized around community needs, and just provider and health system needs? What gets counted, measured and reimbursed – and what doesn’t – needs to become a more inclusive part of the conversation.

Lead poisoning – a totally preventable man-made scourge – offers a window to look at how to remake health care delivery.

The Rhode Island equation
In Rhode Island, Sen. Sheldon Whitehouse convened a news conference on Feb. 22 at Progreso Latino in Pawtucket to announce his plans to introduce new legislation to create a federal tax credit of $3,000 to help with the expenses to remediate lead in housing.

Ironically, it was 10 years to the day – Feb. 22, 2006 – that a lawsuit originally brought by then R.I. Attorney General Whitehouse to hold lead paint companies accountable for the damages from lead paint to Rhode Island residents won a victory in Superior Court. That decision was overturned two years later by the Rhode Island Supreme Court.

The news conference featured numerous elected officials, agency officials and advocates, including: Pawtucket Mayor Donald Grebien, Central Falls Mayor James Diossa, Rhode Island Housing Director Barbara Fields, and Green & Healthy Homes Initiative President and CEO Ruth Ann Norton. Together, they shared space with a pre-school class from Progreso Latino. The Childhood Lead Action Project served as convener of the gathering.

Under the new legislation, the “Home Lead Safety Tax Credit Act of 2016,” co-sponsored with Sen. Chuck Schumer, attempts to address the fact that some 23 million homes nationwide still contain lead-paint related hazards.

Whitehouse began by remembering the short-lived victory in the lawsuit and then the decision by the R.I. Supreme Court to overturn the verdict. “It’s still inexplicable to me; it was, and is, heartbreaking,” he said. The lead paint industry, which has a huge share of the blame, has had zero share of the clean up.”

As a result, he continued, the burden of removing the hazards of lead falls to municipalities and states. The new bill is based upon legislation that was originally filed by then Sen. Hillary Clinton, Whitehouse said, but that legislation failed to pass the Senate, in part because of a lack of bipartisan support.

Whitehouse said that he hoped, because of the new attention on lead as a result of Flint, that the legislation becomes part of the conversation in the Senate. [Interestingly, a hold placed by Sen. Ted Cruz on legislation to address potential remedies to Flint and other communities, the “Drinking Water Safety and Infrastructure Act,” was removed on Feb. 26.]

In an interview with ConvergenceRI before the news conference, Norton, who had flown up from Washington, D.C., just to participate, explained the importance of the legislation: “There is simply not enough grant money available for all the low-income housing needs [for lead removal], so this allows for rental property owners and low-income property owners to do the work and capture a tax credit, to spur more prevention.”

Prevention is key, Norton continued, “Because there is no cure for lead poisoning, the effects are irreversible, dramatic and life-long.”

The proposed legislation, she added, is “a really smart way of adding to the tool box of lead poisoning prevention.”

When ConvergenceRI asked her about the $221-to-$1 return on investment achieved by her organization in lead removal work, Norton responded: “That return on investment is documented by the federal government, so it’s not just our figures. Lead removal is probably one of the highest returns on investment that we can make for government, and one of the best public health investments we can make, too.”

Reinventing health care delivery around community needs
Amidst all the noise about Medicaid reinvention, the State Innovation Model to transform health care delivery, the launch of the HealthFacts RI, the proposals underway for the federal Accountable Health Communities initiative, there are two ongoing efforts underway to establish what’s known as Neighborhood Health Stations, an initiative championed by Dr. Michael Fine, the former director of the R.I. Department of Health.

One effort is in the urban square-mile city of Central Falls, the second is the more rural community of Scituate.

They are works in progress, but ConvergenceRI recently spoke with Lynn Blanchette, Ph.D., RN, BSN Program Director at Rhode Island College, School of Nursing, who is one of the founding members of the Scituate Health Alliance.

Blanchette said that the Scituate Health Alliance was in conversations with WellOne community health center in Pascoag to establish a working partnership to develop a rural Neighborhood Health Station.

Blanchette drew a distinction between the notion of population health in a practice, a group of people who self-select into the group, versus a population of people who share a geographic area, neighborhood or town.  In the second case, the things that determine people's health are more related to the environment, the access to healthy food and safe places to exercise, places where neighbors support one another. 

“It’s not about following the numbers and the money,” she said. Rather than measuring whether or not the A1C rates have been captured and recorded for all diabetic patients, the work of a neighborhood health station may be about interventions around preventing social isolation.

Blanchette continued, “The question is: for those people who might develop diabetes or have diabetes, can we develop community supports to help people live a healthier lifestyle, and if those patients need support, the medical providers are available when they need them.”

Another part of the effort now under discussion is how to devise a more cost-effective approach to urgent care needs and emergency transport. Stay tuned.