Written by Katharine Robb
Just across the river from the shiny skyscrapers of downtown Boston is the small, densely populated city of Chelsea, Massachusetts. Most of the city’s 40,000+ residents are people of color, new immigrants, and low-income families, and the housing stock is in poor condition. Many residents face overcrowded, unsafe living conditions, and the threat of eviction. Housing inspectors from Chelsea City Hall proactively enforce the state sanitary code to ensure minimum housing standards are met. Because housing inspectors are required to enter people’s homes, they have an up-close view of the most hidden and dire social and health problems in the city. Inspection focuses on enforcement, not service provision, and on the identification of a narrow set of physical hazards, not psychological or social hazards. Yet, inspectors routinely encounter families in crisis, from problems such a mental illness, substance use, and impending homelessness.
As I learned more about the challenges facing Chelsea residents, I began to wonder — what if we could intervene early to address these social and health problems by leveraging the unique role of housing inspectors?
Housing is a powerful social determinant of health, and cities have tried to break the link between poor housing and poor health for more than a century. In the late 1800s, the role of the housing inspector emerged in response to the high prevalence of fire and disease in burgeoning city slums. Inspectors were charged with not only reducing physical hazards but also improving social and hygienic conditions in the home. Yet, as housing improved over the last century, housing inspection lost its public health approach and took on a narrower role focused on compliance. While great strides in sanitation, ventilation, fire prevention, and social protection have been made over the last 150 years, some of the same challenges of overcrowding and sub-standard conditions remain in today’s cities. Yet, inspectors are limited in the tools to address them.
The Innovation Field Lab:
I began working in Chelsea through the Innovation Field Lab Course at the Harvard Kennedy School, a class that embeds interdisciplinary teams of graduate students within local governments to address housing-related problems. Over a semester, my team and I developed an innovation to respond to the social, safety, and health problems we observed in Chelsea through our conversations with City officials, housing inspectors, and community leaders.
Our idea was this (depicted below): During a routine inspection, an inspector identifies a problem that cannot be resolved through code enforcement alone. These problems range from acute crises (such as impending homelessness) to inadequate access to vital services (such as fuel assistance). If the resident consents, the inspector informs a social service case manager. The case manager then reaches out to the resident to learn more and connect the resident with the appropriate social service. The goal was that residents would receive the help they need and code enforcement could be more effective because the root causes of problems could be addressed.
Through the Innovation Field Lab Summer Fellowship Program, I had an opportunity to spend a summer working within Chelsea City Hall with the goal of making this idea a reality. The work grew into my Doctor of Public Health dissertation. I drew from action research methods, a process of systematic inquiry that is collaborative, reflective, and participatory. It serves both to test hypotheses and effect change. The idea for a social service referral program was not a pre-molded solution that could be implemented through the faithful execution of a plan, but rather, it required an iterative process of acquiring a deep familiarity with the city and fitting the innovation to the context. The housing inspectors were leery at best, if not frankly opposed to the idea of a social service referral program, which they saw as outside their scope and adding to their already high workload. The City Manager saw the innovation as valuable but wasn’t convinced it could work and didn’t think the City Council would fund it. Local community organizations recognized the unmet need, but indicated they needed funding if they were to provide social services.
With these challenges in mind, I drew from strategies for adaptive leadership and change management in my process of building relationships, inspiring a shared vision, and challenging existing processes. The work required developing new capacity within local government, particularly among inspectors, and working with stakeholders across the city to re-imagine the role of housing inspectors in public health. Here are some lessons I learned in taking the innovation from an idea to a reality over the course of a year:
Transforming targets of change into agents of change:
To innovate, I needed to engage housing inspectors in the process of change. I needed to establish trust and learn their processes, challenges, and workflow. Through accompanying inspectors to properties, listening, and observing, I was able to develop personal relationships and understand their commitments and allegiances. I observed why inspectors considered the innovation as adding futile work to their already understaffed team. They saw it as opening a Pandora’s box of problems that they would be expected to solve with uncertain support. I didn’t dismiss their concerns or try to convince them that there would not be pain involved in change. Instead, I listened to their counsel, while sharing a vision for the value of the innovation that was simple and heartfelt. I described issues inspectors knew all too well, such as suspected child abuse in overcrowded living conditions, eviction leading to homelessness, or substance use disorders leading to overdose death as real examples of outcomes that could be prevented with early intervention and linkages to social services. After a few months, inspectors were willing to take a risk and give the social service referral model a try.
Crafting the case for innovation across the wider system:
However, housing inspectors and public health change exist within a wider system. I also needed to identify a point-person or agency that could receive and respond to referrals from inspectors. Stakeholder engagement across City departments and community organizations was essential. I met with staff from all levels of City Hall, the Police and Fire Department, and Community Organizations. I attended community meetings and events. Through this outreach, I sought to incorporate new perspectives into the innovation, while also convincing stakeholders of the innovation’s value and increasing the feasibility. I learned how the costs and benefits of the innovation were distributed. My most important learning was from those opposed to the innovation — they asked the toughest questions, which helped me tailor the innovation to the context.
Experimenting and Capitalizing on Early Wins:
Through my conversations, I found an enthusiastic ally for the innovation within the Chelsea Police Department: the Community Engagement Specialist. He saw the value of housing inspectors linking residents with social services and was well connected with the social service agencies in Chelsea. He was willing to serve as a point-person for referrals in a proof-of-concept model to show that the innovation might work. Inspectors began making referrals to the Community Engagement Specialist, who worked to connect residents with services.
However, the model did not have funding and the parties involved weren’t amendable to documenting referrals and follow-up activities. With limited accountability, the early wins were tenuous.
Nevertheless, the proof-of-concept model showed City leadership the model could work. In a presentation to City staff, I surfaced the threats to health and wellbeing that inspectors encountered and the toll these took on residents and inspectors. Presenting both a compelling description of the problem and a viable solution in front of a range of City stakeholders (pictured above), reduced complacency with the current system, and created an opening for change.
Months later, an opportunity for the City to fund the innovation arose. The City initiated a sub-contract to a local social service agency, CAPIC, which began in the Summer of 2019. Through this partnership, two case managers deliver direct assistance to solve problems inspectors encounter, such as homelessness, substance use disorders, emergency needs, hunger, hoarding, heating assistance, and others. Inspectors make a phone call to the case manager who then follows up with the resident or accompanies the inspector to the home. Inspectors also have a pamphlet that they can provide to residents at the time of an inspection, detailing services for which they may be eligible.
A New Model for Housing Inspection:
Residents in Chelsea are now being connected with services in new ways that have resulted in the prevention of homelessness and linkages to a range of services. Of the first 15 residents referred by inspectors, only 2 declined. Half of residents referred were over the age of 60, a fifth had young children at home, and half had cognitive or physical disabilities. The pie chart below shows the proportion of referrals for different types of services. The program has reduced the amount of time inspectors spend trying to bring homes into compliance because they now have partners and tools beyond citations.
The conversation about the role of housing inspectors has changed — it is no longer described as solely administrative or enforcement-based, but also as a vital community outreach function. Through this innovation, when inspectors encounter threats to health and safety that cannot be addressed through code enforcement alone, they have a system to link residents to the services they need. The housing-related health problems in Chelsea are not unique. Given the central role that housing plays in the health of individuals and communities, the innovation represents a catalyst to reduce social inequality and improve public health.
About the Author
Katharine Robb studies urban environmental health in the US and low-resource settings abroad. She holds a Doctor of Public Health (DrPH) degree from the Harvard T.H. Chan School of Public Health and a Masters in Global Environmental Health from Emory University. She is currently a Postdoctoral Research Fellow at the Harvard Kennedy School Ash Center for Democratic Governance and Innovation.