Andrew Saal, Chief Medical Officer of the Providence Community Health Centers
Andrew: Hi, I’m Andrew Saal. I’m a family physician and I am also board certified in a specialty called clinical informatics, which is big data applied to health. Along the journey I’ve also earned a masters in public health policy. I am proud to serve as the chief medical officer of the Providence Community Health Center. We’re the largest community health center in the state of Rhode Island with about 100 clinicians, 12 offices and 80,000 patients. Most of the patients here come from households under the poverty line (household incomes under $30,000 a year). Seventy percent of our patients identify as Latino, and most of our patients are on Medicaid, Medicare, or uninsured.
Olivia: So in your role as chief medical officer are you a program manager? It sounds like you’re doing a lot.
A: I am on the team that tries to reinvent healthcare to improve the health of everyone in our community despite the pandemic and rapidly evolving healthcare market…and I take care of those 100 clinicians. I work on policies, programs, clinical services, and interagency relationships with hospitals and other community agencies. Our goal is to improve the healthcare of all Rhode Islanders whether they’re our patients or not. We’re as nonprofit as you can be and we have an extraordinary mission statement; I keep a copy on my wall and look to it for guidance as we continue to grow and evolve. The Providence Community Health Center (PCHC) is now 54 years old—the eighth oldest among the 1,400 health centers in the U.S. We recognize that if you don’t change the economy you’ll never improve the health of the community. If you don’t address the social determinants of health (food, housing, legal issues, structural racism, etc.) you’ll never improve the health of anyone. We have community health workers, social workers, counselors, and many other resources. When we take care of patients, we’re not just there to help them address a one time problem—we’re there to empower them to change their communities.
“When we take care of patients, we’re not just there to help them address a one time problem—we’re there to empower them to change their communities.”
O: At Brown I participated in Connect for Health, and my client had severe housing issues. It became apparent that basic things really impact your health, including your ZIP code. My next question is what projects related to air quality are you or the community health center working on?
A: We have 25,000 kids under the age of 18. You can find more data about Rhode Island children on KIDS COUNT RI. For us, asthma is a chronic disease of poverty and suboptimal housing that impacts children as well as adults. Dr. Jack Geiger, who founded the community health centers over 50 years ago once said this: “What good have you really done if you treat a kid for asthma but send them back to that cockroach-infested apartment?” Cockroach and mite dander triggers asthma. Bad housing causes asthma, lead poisoning, and other diseases with notable healthcare disparities. Disparities in asthma outcomes are a clarion call challenging us to address the built environment. But let’s move beyond housing—if you can’t prevent asthma, you want to treat it. Okay, you’ve got rescue and preventative inhaler medications. But too few people can afford them…and even if you are lucky enough to have insurance, you may not have access to a vehicle to get to the pharmacy to pick them up. We have to find ways to help people access the healthcare they need to lead happy, productive lives. Our clinical teams work with community health workers, clinical pharmacy teams, and many allied health workers focusing on asthma education and medication access. We focus on transportation, because even if I give you a prescription, can you get to the pharmacy? It is very much a team sport. I’m very good at diagnosing it and treating it, but it takes a team of other people who are more skilled to handle the education and address housing and other social determinants of health.
O: It sounds like you’re doing asthma education, transportation, addressing some housing needs…anything else more specific?
A: I always want to thank our community partners, because it’s not us who performs the thousand-and-one things that it takes to succeed in the community. We have about 25 community partners who address everything from food resources (linking people to food banks) to adequate housing. PCHC collaborates with ONE Neighborhood Builders in Olneyville to rehabilitate and create a viable housing stock. We also work with the Medical-Legal Partnership of Boston and Roger Williams Center for Justice to provide legal resources to help people address landlord issues. The list goes on and on and on. We have an extraordinary group of community health workers who empower patients to try and change the world they live in.
O: I’m always impressed by how many organizations there are in Providence and how they work together.
A: Before the pandemic, we identified one particular neighborhood in South Providence that had twice the rate of ER visits for asthma than a similar neighborhood in Central Providence. Both neighborhoods were adjacent to I-95. So if I-95 puts out the same amount of air pollution regardless of location, why was the ER rate for asthma twice as high in Washington Park? The city has a large heavy industrial zone along the Allens Avenue waterfront—including an asphalt plant, scrap metal yards, a major gasoline depot and hundreds of diesel trucks every day. The additional burden of air pollution from industrial pollution doesn’t stay on the waterfront…it travels a few hundred yards to the Washington Park neighborhood.
O: We’re hoping to find data on that. My background at Brown is in environmental science and environmental justice. I’ve done door knocking, canvassing things for blocking the proposed waste transfer station expansion….I’m really impressed by the work of the People’s Port Authority and Rhode Island Environmental Justice Committee.
Map of Providence redlining in 1935.
A: Have you seen the maps of the redlining? When you see the historical redlining maps of who could get a bank loan, you can see the poorest neighborhoods that today have the worst health disparities. We’re still dealing with the ghosts of structural racism.
O: And some of it is still here, like the pyrolysis bill. How would you summarize asthma issues in Providence?
A: Watching the pyrolysis bill work its way through the legislature and community planning and zoning meetings, I was struck by how many times I’ve heard the same story before. Bruce Springsteen took an old folk song from the 1920s and rewrote it to tell the story of the people who live in the 9th Ward of New Orleans. When Hurricane Katrina hit, those with vehicles and financial resources were able to evacuate. “Them who got / Got out of town. / Them who ain’t got left / And drowned. / How can a poor man stand such times and live?”
Poor neighborhoods tend to be next to heavy industrial zones and vice versa—that’s not a coincidence. Those lucky enough to be born with more resources have better representation in the zoning process. The most affordable housing in Rhode Island is in the most environmentally polluted neighborhoods. These neighborhoods have the least access to almost every healthcare resource—including lack of healthy food, which triggers obesity, diabetes, heart disease, and other complications of poverty.
O: Providence has so many issues. I’m sure it’s a story repeated in many industrial cities and elsewhere. Last summer I worked on a boat in the Narragansett Bay and reading about all the buried toxins in the Providence River was eye-opening.
A: When we recently built a new clinic in Olneyville, the contractors had to remove about five feet of ash and unstable soil. The soil had to be disposed of in a safe fashion. At other clinical sites, when we convert an old warehouse into office space, we often have to mitigate the asbestos inside.
O: In our study, we’re going to site 25 sensors for one year, collecting data on ozone (O₃), nitrogen oxide and dioxide (NOₓ), carbon monoxide and dioxide (COₓ), and particulate matter of 2.5 microns (PM₂.₅) and some meteorological data to get ideas about the circulation patterns. Do you have any recommendations for how to make this useful?
A: Talk to the Rhode Island Department of Health. I can interpret data but I’m not good at collecting it. The Health Equity Zones (HEZ) are essential community advocates right there in every neighborhood. Those people are talented, multifaceted people.
O: So it seems like air quality isn’t a new topic in Providence. What do you see as strengths and obstacles to reducing air pollution?
“The economic disparities are dramatic especially when you examine healthcare outcomes based upon ZIP codes. ”
A: Strengths: it’s a small state so everyone knows each other. Legislators can be accessed. Weaknesses: like everywhere else in the world, we have a profound sense of NIMBY (Not In My Backyard). The economic disparities are dramatic especially when you examine healthcare outcomes based upon ZIP codes. Olneyville and Central Falls—those two ZIP codes keep me up at night. They are the best and the worst at everything in the state. They have amazing human beings and vibrant culture—but they have very limited political muscle. The dynamic first- and second-generation Americans are extraordinary. But without grassroots organizing, they can be politically invisible. It’s not a surprise when a pyrolysis plant, an asphalt plant, or a solid waste transfer facility wants to expand their operations near neighborhoods with less political voice.
O: Are there any areas you really want to point out as areas of concern?
A: There are several around the state—but right here in Providence it’s Washington Park, South Providence, and Elmwood. Those neighborhoods within a half mile of the Allens Avenue waterfront. The city has a 20-year plan for the waterfront to keep it as a deep-water industrial zone. While concentrating all the polluting activities in one area, there are a few flaws in the plan: it’s a floodplain and it’s outside the hurricane barrier. Sea level rise and storms will happen…and oh yeah, there are 10,000-plus people who happen to live right there in the air pollution blanket. There happens to be a large health center in the middle of that industrial zone with 50 employees and 7,000 patients. No surprises, our staff there cares for the people who live in those same polluted neighborhoods and have twice the rates of ER visits for asthma than anyone else in the city of Providence.
O: I don’t know how old the Port is. The Port of Providence itself is a little unclear because you have ProvPort and then independent industry along Allens Avenue. There’s no centralized authority in the Port, which is a weakness because it makes it hard to legislate. What information do you wish you had about air quality?
A: Our facilities team gets to participate in the annual ProvPort emergency preparedness drills. So, in an emergency how would we evacuate that clinic that happens to be only 100 yards from the fuel terminal or asphalt processing plant? We also get smog alerts from the state health department. “Be aware, wear a mask, stay indoors.” Notification is an important part. But what about prevention? We’re missing regulation and accountability for the sources of the pollution. Some legislators and politicians occasionally say, “We don’t need more rules—we need to enforce the rules already on the books.” Fair enough. Let’s give the state agencies the adequate budgets and regulatory teeth that they need. Regulations don’t mean a thing if the responsible agency has its budget chronically under-funded.
O: That resonates with what I’ve been reading and thinking. What resources do you use if any to stay aware of air quality?
A: I’m more outcome-oriented. For me, one simple measure is the rate of ER and hospital visits for asthma by age. Asthma rates are like the canary in the coal mine for environmental health. As healthcare providers, we’re looking at who is going to the ER unnecessarily. But instead of asking the question, “Can I do anything to better control it so they don’t have to go to the ER?” we need to be asking, “What can I do to prevent the asthma in the first place?”
O: ER visits are not cheap!
A: And the racial and ethnic disparities in visits to the ER are just what you’d think they’d be: more visits for African-American and Latino children. There are large healthcare disparities in the state.
O: It seems like there’s a very obvious thing going on here and not enough political backbone from some folks or resources to address it. Is there anything I haven’t asked that you’d like to talk about?
“Just because something is in someone else’s backyard doesn’t mean you aren’t breathing it. Proximity matters—and air pollution doesn’t check the map before drifting on the breeze.”
A: Here is one of the teaching metaphors we use with our patients to explain secondhand smoke as well as air pollution. When someone says, “But I smoke in the other room,” I get a glass of water and a drop of food coloring. “Well, let’s pretend your kids are in this corner of the glass with clear water…and this drop of food coloring is you smoking in the far corner of the house.” Within a few seconds, the entire glass of water changes color as the food coloring spreads. Air is a fluid and pollution will spread just as easily. We just eat, sleep, breathe, and live in a common airshed. Just because something is in someone else’s backyard doesn’t mean you aren’t breathing it. Proximity matters—and air pollution doesn’t check the map before drifting on the breeze.
