Public Health Law Research Philadelphia’s Lead Court Is Making a Difference Carla Campbell Edward J. Gracely Curtis Cummings Drexel University Sarah Pan University of Pennsylvania Peter Palermo Retired George D. Gould Community Legal Services of Philadelphia Abstract The Philadelphia Lead Court (PLC) was created as an innovative law enforcement strategy to compel property owners to comply with city health codes to remediate their properties of lead hazards, which had led to elevated blood lead levels and lead poisoning in resident children. This study presents a detailed account of and analyzes the opinions of fifteen key informants drawn from the Philadelphia health and law departments and judicial system that staff and run the PLC in response to a fifteenquestion structured survey. Main themes reviewed include the effectiveness of the PLC as compared with precourt law enforcement strategies and within the context of a specialized court, the use of fines, the impact of grant funding for remediation work, the major advantages and disadvantages of the PLC, and suggested changes to improve court function, followed by key recommendations. The article concludes that our informants found that the PLC has been very effective and successful. This model could be replicated by other cities with similar health code enforcement challenges. Introduction Childhood exposure to lead paint remains a serious public health hazard, especially for low-income families. Despite the passage of decades since This research was funded by the Public Health Law Research Program of the Robert Wood Johnson Foundation. The study team acknowledges the capable assistance provided by the Health and Adult Services Unit of the City of Philadelphia Law Department; Lynda Moore, chief deputy city solicitor; and Gail Austin, legal assistant supervisor and PLC coordinator; and the willing participation of our survey respondents. Journal of Health Politics, Policy and Law, Vol. 38, No. 4, August 2013 DOI 10.1215/03616878-2208585 Ó 2013 by Duke University Press 710 Journal of Health Politics, Policy and Law lead was banned in household paints, the residual exposure in older, rundown homes can be devastating. The condition of lead poisoning and elevated blood lead levels (EBLLs, recently defined as a blood lead level of 5 mg/dL or higher) (ACCLPP 2012; CDC 2012) in children is one of the major environmental problems affecting children in the United States. Virtually every older, inner-city area confronts this problem. Developing and implementing adequate policies to reduce lead paint exposure in low-income neighborhoods remains difficult and elusive. A particular challenge for public health officials has been the difficulty of securing voluntary cooperation from landlords and low-income home owners to remediate lead paint hazards. Understaffed and lacking adequate resources to investigate and then compel compliance with housing codes banning lead paint and demanding remediation of identified lead hazards, public health officials alone have been unable to significantly reduce the long-term EBLL harms facing children at risk. Philadelphia, which ranks among the top US cities in prevalence of and numbers of children with EBLLs, has implemented a new approach— using a specialized lead court to facilitate compliance with the health department’s remediation orders. In this article, we describe the results of a qualitative assessment of the Philadelphia Lead Court (PLC), which was created in 2002. We start with the background of creating the PLC and the role of specialized courts in improving public health. We then report the study results and evaluate the PLC’s effectiveness. Background Children are exposed to lead primarily through ingesting deteriorating leadbased paint and lead-contaminated house dust and soil. Through routine hand-to-mouth activity, infants and toddlers ingest dust and paint chips. This condition, by necessity, requires a public health solution, since childhood lead exposure involves multiple stakeholders, including the child, his or her parents, the property owner, and city, county, or state officials who enact and enforce the relevant laws, ordinances, and codes. Lead poisoning and EBLLs can cause impaired development, behavior, attention, and cognition (leading to decreased intelligence quotient, or IQ points), anemia, and rarely, death. There is now growing evidence that BLLs of less than 10 mg/dL adversely affect intelligence and cognitive function (Binns, Campbell, and Brown 2007; Canfield et al. 2003; CDC 2005; Lanphear et al. 2005; ATSDR 2007; Wilhelm et al. 2010). The Campbell et al. - Philadelphia’s Lead Court 711 Centers for Disease Control and Prevention (CDC) recently agreed with lowering the BLL for which clinical and public health interventions are implemented from 10 mg/dL to a reference value of 5 mg/dL (ACCLPP 2012; CDC 2012). Poor housing conditions have been associated with many adverse health outcomes, a relationship that has been well documented for lead poisoning and EBLLs (Campbell and Osterhoudt 2000; CDC 2004; Dixon et al. 2009; Krieger and Higgins 2002; Sandel et al. 2004). Housing-based lead hazards are the primary source of lead exposure for American children (Lanphear et al. 1998; Levin et al. 2008). Until 1978, when the Consumer Product Safety Commission banned its residential use, US homes were painted with lead-based paint. According to the 2009 American Housing Survey data, 91.65 percent of Philadelphia’s housing units were built before 1978, meaning that most had lead-based paint in the home (US HUD 2009). Also, 57.4 percent of these were pre-1950 units, which generally tended to have more lead paint and more highly concentrated lead paint, and might be in poorer condition as the homes age. Compounding the problem, 27 percent of Philadelphia families live in poverty. Seventy-one percent of families had incomes below 50 percent of the area median income ($46,000/family), and 86 percent of families earned less than 80 percent of the area median income. As a consequence of the aging housing stock and poverty among Philadelphians, some owner-occupants and landlords may defer routine maintenance and repairs, exposing children to lead hazards. Fortunately, the prevalence of children with BLLs of 10 mg/dL has declined dramatically from over 80 percent of Philadelphia children screened in 1989 to 2.9 percent (815 children with first venous lead level) in 2009, and from an estimated national average of 8.6 percent in 1988–1991 to an estimated 1.4 percent from 1999 to 2004 ( Jones et al. 2009; Peter Palermo, Philadelphia Department of Public Health, pers. comm., June 1, 2011). Nonetheless, in 2009 there were still hundreds of children with EBLLs who received inspections of their primary residence to determine the presence of lead hazards. Prior to 2002, attempts to enforce remediation orders through the Philadelphia court system usually resulted in judges ordering the Philadelphia Department of Public Health (PDPH) to complete the remediation itself, absent either supplemental funding or established abatement priorities (i.e., based on children’s BLLs or other factors). In April 2002 there was a backlog of fourteen hundred properties housing children with EBLLs for which lead abatement or remediation work had been 712 Journal of Health Politics, Policy and Law ordered but not completed.1 The PDPH could enforce its orders only by taking the owners to court, as described above; it could not levy fines or other penalties on its own authority. In response to increased community concern about lead poisoning and failure to remediate (or abate) identified lead hazards, the PDPH developed the Philadelphia Lead Abatement Strike Team (LAST) Program in 2002. Philadelphia’s Managing Director’s Office convened a LAST health and housing policy work group that brought together bimonthly the health commissioner, other PDPH staff, high-level staff from the key city housing agencies, representatives from the Department of Licenses and Inspections, and other relevant agencies, and the city’s Law Office (Campbell et al. 2005). Key goals of the LAST policy group included improving health code enforcement (for lead hazards); developing an infrastructure for lead hazard remediation (creating a bank of certified lead abatement contractors) and for temporary relocation of affected occupants; planning for continued funding of lead hazard remediation work; and long-term planning to improve the quality of city housing and make it lead safe (Campbell et al. 2005). Health code enforcement was strengthened considerably with the November 2002 development of the Philadelphia Lead Court (PLC), a judicial court created specifically for cases involving property owners’ noncompliance with PDPH lead hazard remediation orders under sections 5-301(b) and 6-403 of the Philadelphia Health Code (Campbell et al. 2005; City of Philadelphia 2002; PCCY 2008). PLC represented a partnership between the PDPH, the Office of the City Solicitor, the Court of Common Pleas, and other agencies. It was modeled after the Tuberculosis Court, another specialized court created in 1992 to encourage patients to take their antitubercular medications, although lead poisoning is a more complex public health problem. In preparation, judges hearing and city lawyers prosecuting these cases received training on childhood lead exposure and poisoning, its prevention, and treatment. Following an initial failed home inspection and a ten-day reinspection, a hearing is scheduled if the reinspection reveals noncompliance and lack of remediation plans. After the hearing date is set, the complaint is hand-delivered to the property owner, who is expected to appear in court or face significant fines. Occasionally, 1. In general, lead abatement is the removal of a lead-containing building component, of the lead-based paint itself, or the permanent enclosure of lead-based paint hazards, with the term permanent implying an elimination of exposure to lead hazards for at least twenty years. The terms lead remediation and lead hazard control are generally used to imply removal of recognized lead hazards, but they may represent a less complete and permanent response than lead abatement (HUD 2012). Campbell et al. - Philadelphia’s Lead Court 713 if work is not progressing, the judge can order the PDPH to complete the lead remediation at the owner’s expense.2 The PLC is a specialized court, meaning one that was created solely to hear legal cases of a particular type. Casey and Rottman (2000) provide background on specialized courts, which include community-focused courts, drug courts, mental health courts, and family courts, to list a few. Specialized courts often handle cases with sociological and/or psychological problems that might challenge the processes of typical courts. Casey and Rottman (2000) also suggest that when there is a need to integrate public health or mental health community services into the legal process, specialized courts allow for more frequent contact between community workers and court and legal staff, as they often work through many similar cases together. This may help better connect those coming to court needing treatment and social services with the available resources in a given community (Casey and Rottman 2000). A recent review of specialized courts examines their pros and cons. The pros include not only the potential expertise a specialized judge brings that can result in better decisions but also the increased efficiency of these courts given their greater familiarity with the context in which the case arises. The cons include the possibility that specialized courts might have inferior judges and that these courts might lead to insularity, skepticism about the value of expertise in the area of law, and problems over boundaries with the separation of specialized court cases from the broader court system (Oldfather 2012; Peters 2008). Casey and Rottman (2000) suggest that the limitations include the possibility of defining an area of law too narrowly or broadly, the prospect of judge burnout with many difficult cases, and decreased opportunities for advancement for judges. Oldfather (2012) concluded that determining whether judicial specialization makes sense is a complex question with no clear outcome. An older review of these courts also notes the complexity of examining judicial specialization and suggests that specialized courts might be particularly beneficial when judicial process delays could be ‘‘costly in monetary terms, as in bankruptcy, or in human terms, as in family matters’’ ( Jordan 1981). This argument can be extended to a child residing in a home with lead hazards where a faster court resolution leads to decreased lead exposure. Mello and colleagues (2006) have written about the utility of 2. It is important to note that the PLC is used for secondary prevention of lead exposure, after children are found to have EBLLs, to prevent further exposure, but the initial harm from exposure had already occurred. 714 Journal of Health Politics, Policy and Law health courts, specialized courts that provide a system of administrative compensation for medical injuries utilizing specially trained judges. In a limited review of studies of several specialized courts, we found some courts with seemingly more positive results than a mainstream court might achieve. For example, Gover, Brank, and MacDonald (2007) found that a domestic violence court leads to improved enforcement and more victim safety. McNiel and Binder (2007) found that a mental health court reduced subsequent criminal recidivism and violence carried out by defendants with mental disorders. And Haack et al. (2004) suggest that family drug courts in three different cities improved access to drug abuse treatment, may have increased drug abstinence rates, and may facilitate family reunification in drug-related child abuse cases. But at least one study showed no better outcomes for specialized courts. MacDonald et al. (2007) report a study of a driving under the influence (DUI) court with no better results than a mainstream court. Many cities find that enforcing remediation orders is difficult for multiple reasons, such as the cost of remediation, the need to ensure inhabitants’ safety during the remediation process, and the need for rapid remediation to prevent further lead exposure. To our knowledge, there are only a few other comparable programs in the country. A similar court in Chicago, Illinois, is run within the Housing Court division and was estimated to have an 85 percent compliance rate (Evens, Gard, and Brown 2005). The Mahoning County (Ohio) Common Pleas Court hears cases against owners of rental units that were not remediated of lead hazards (Diorio, Mikulka, and Stefanak 2011). Evens, Gard, and Brown (2005) discuss strategies for enforcement, highlighting activities in Chicago and Indiana, where a combination of ‘‘carrots’’ (incentives) and ‘‘sticks’’ (enforcement activities) is used. The incentives include education on lead paint hazards and provision of federal and local grant funds (Evens, Gard, and Brown 2005). Philadelphia has been able to offer property owners similar education and incentives, mostly in the form of grants from the US Department of Housing and Urban Development (HUD) for lead hazard control work or local low-interest loans available to low-income owners. Brown (2002) conducted a decision analysis that suggested that strict enforcement (over limited enforcement) of housing policies to prevent childhood BLL elevation decreased societal costs by avoiding special education and medical costs and increasing children’s productivity. In an earlier study, Brown et al. (2001) found that the risk of identifying one or more children with EBLLs in a property already identified with lead hazards was four Campbell et al. - Philadelphia’s Lead Court 715 times higher in a state with limited lead abatement enforcement versus a state where statutes were more strictly enforced, and included criminal and civil penalties against property owners who failed to remediate lead hazards. Jacobs et al. 2000 and Jacobs, Kelly, and Sobolewski 2007 reviewed various data demonstrating that the cost of lead hazard control work is far less than the cost of benefits reaped. They estimate the elimination of lead-based paint hazards in all high-risk US housing from 2000 to 2010 at $2.3 billion, with benefits estimated at least at $11.2 billion; these benefits would include the savings on medical care (for children with EBLLs) and special education, the increased lifetime earnings based on improved cognitive ability, and the market benefits of improved housing. The PLC Study To evaluate the PLC’s effectiveness, the PLC study conducted both quantitative and qualitative assessments (Campbell et al. 2013). Several previous reports had looked at aspects of PLC but had not conducted a full evaluation (City of Philadelphia 2002; PCCY 2008). The quantitative analysis found a total of 4,167 cases were filed for a first court hearing between September 2, 2002, and December 31, 2010. Under the PLC, 76.8 percent of properties were remediated within one year of the initial failed home inspection, versus 6.6 percent during the precourt period. Four years after the failed inspection, only 18 percent of precourt properties had attained compliance, compared with 83.1 percent from the PLC period. In general, BLLs decreased over time, from six months prior to six and twelve months after compliance, regardless of whether compliance came during the precourt or court period. Thus the PLC effectively improved the city’s environment (decreasing the number of properties with lead hazards) and improved children’s health (reducing exposure to lead in individual housing units). The qualitative study was designed to explore why and how the partnership between public health and law departments has been effective, learning from some of the key court participants who had a day-to-day knowledge of the specific process. A corollary was to learn why precourt enforcement procedures were not effective. Our study focused on court employees and city staff involved with the PLC and chose not to interview defendants or family members of the EBLL children. This was because of the study’s limited resources and the perceived complexity of doing these interviews, involving sensitive issues of obtaining actual names from the court system, proper permission to interview, and institutional review board approval. 716 Journal of Health Politics, Policy and Law Methods The qualitative analysis examined the court process through interviews with key PLC participants. We created a structured survey of fifteen questions that addressed the effectiveness of remediation enforcement in properties with EBLL children prior to and during the PLC; using fines in the court process; the PLC’s advantages and disadvantages; and suggestions for changes. Most of our questions were general, intended to explore various impressions and attitudes toward the PLC. We also wanted to assess how some specific aspects worked, such as using a preprinted form for case disposition and obtaining HUD grants for lead hazard control work. Lastly, we explored whether participants had ideas for improving the court’s functioning. There were seven questions with responses based on a Likert scale, where respondents were asked to rate the extent of their reply. They were also asked to explain their answer verbally in an open-ended format. Another eight questions did not have a scale-based response as part of the question and were open-ended only. A sample of fifteen key participants of PLC, with respondents including judges from the court and staff members of Philadelphia’s health and law departments who had spent significant time in the PLC (for at least one year), participated in the interview surveys. Sixteen subjects were approached; one potential subject declined to participate. To ensure uniformity and consistency, the principal investigator conducted all the interviews. These took place in person, involved only one respondent at a time, and lasted one to two hours. The survey responses were transcribed and then analyzed for content. Two of the questions were not applicable to all the subjects; these asked about pre-PLC enforcement and the Philadelphia Tuberculosis Court. The numerical responses to the Likert scale questions were tabulated. The principal investigator analyzed the major themes for each question, which a study team member then reviewed and suggested additional analyses as appropriate. Because of the low number of participants, results were not analyzed by type of respondent (staff member of health department, law department, etc.). The institutional review boards (IRBs) felt that doing so might identify the subject and result in emotional stress. The IRBs of Drexel University and the Philadelphia Department of Public Health approved the study. Results Profile of Respondents The survey respondents had worked with the PDPH for twenty-two to thirty-five years, the law department five to twenty years, or as court judges Campbell et al. - Philadelphia’s Lead Court 717 nine to thirty-one years; all had considerable experience in their respective positions at the time of the survey. Most were not involved in enforcement of orders to remediate lead hazards until the creation of the PLC. Their descriptions of the work for the PLC involved obtaining and verifying information needed on the status of the lead hazard violations for each property reviewed and participating in the court process itself. In this section, we focus on providing major themes mentioned in the respondents’ replies. Likert Scale Question Responses Table 1 shows the fifteen survey questions. Table 2 shows the responses on a scale of one to five for six key questions about PLC function. Each result is discussed within the topic area of concern. Effectiveness of Precourt Enforcement Strategies When respondents were asked to rate the pre-PLC enforcement strategies from not at all effective (1) to extremely effective (5), the overriding opinion was of ineffectiveness, with a mean reply of 1.4, median of 1.0, and range of 1–2. Many respondents indicated that prior to the PLC, owners were not paying attention to the health department and that the PDPH lacked the clout to enforce its remediation orders. ‘‘The work was not getting done, the health department had been sending out notices. However, home owners were not complying with the health department.’’ Another concern was that prior to the PLC, cases were sporadically brought through the general Philadelphia court system. Several respondents noted that ordering the PDPH to do the work was not effective, as it did not have the resources to handle all the cases. ‘‘Previously . . . the efforts to handle enforcement matters were very poor and there was really no mechanism in place to deal with lead hazards found in homes. . . . Previously we would take the owner to court and the judge would order the city to remediate, and the city health department did not have the dollars to do the work.’’ Eventually, fewer cases were brought to court: ‘‘And there was no effort made to pursue. Once you drop using court at all, you had no hammer to go after the owners of the property to make them see that there’s work to be done, that they needed to make this kind of an investment.’’ The PLC’s Effectiveness We asked respondents to assess the PLC from not at all effective (1) to extremely effective (5). The result was overwhelming support for the court’s 718 Journal of Health Politics, Policy and Law Table 1 Survey of Lead Court Participants 1a. What is/was your role in Lead Court? Law Department staff___ Court judge___ Health Department staff___ 1b. Describe your specific role in the Lead Court process and the years in which you worked in Lead Court: 1c. Describe your specific role in any activity prior to the creation of Lead Court in November 2002 involving enforcement of city-ordered remediation of properties identified with lead hazards. 1d. How long have you been a lawyer, a judge, or an employee of the Philadelphia Health or Law Department? 2a. How effective has Lead Court been in enforcing orders to property owners to remediate identified lead hazards in housing? Extremely effective 5 4 Not at all effective 3 2 1 2b. Explain your answer: ________________________________________________ 3a. To the extent of your knowledge, how effective were the previous enforcement strategies prior to Lead Court in enforcing orders to property owners to remediate identified lead hazards in housing? Extremely effective 5 4 Not at all effective 3 2 Don’t know 1 9 3b. Explain your answer: _______________________________________________ 4a. How effective is Tuberculosis (TB) Court (upon which Lead Court was modeled)? Extremely effective 5 4 Not at all effective 3 2 Don’t know 1 9 4b. Explain your answer: ________________________________________________ 5a. How helpful is having a pre-printed menu of Court actions in directing the appropriate outcomes of a Lead Court hearing? Extremely helpful 5 4 Not at all helpful 3 2 1 5b. Explain your answer: ________________________________________________ Campbell et al. Table 1 - Philadelphia’s Lead Court 719 (continued ) 6a. How helpful is the availability of funding through a HUD grant for Lead Hazard Control Work in assisting property owners to comply with Lead Court–ordered remediation of identified lead hazards? Extremely helpful 5 4 Not at all helpful 3 2 1 6b. Explain your answer: ________________________________________________ 7a. Assuming it is an owner-occupied property, if a property owner does not obtain a HUD grant for Lead Hazard Control Work how difficult is it to carry out the Lead Court–ordered property remediation work? Extremely difficult 5 4 Not at all difficult 3 2 1 7b. Explain your answer: ________________________________________________ 8a. Assuming it is a tenant-occupied property, if a property owner does not obtain a HUD grant for Lead Hazard Control Work how difficult is it to carry out the Lead Court–ordered property remediation work? Extremely difficult 5 4 Not at all difficult 3 2 1 8b. Explain your answer: ________________________________________________ 9a. Under what circumstances do you think the Court orders the defendant (property owner) to pay fines? Explain your answer: __________________________________________________ 9b. If the Court issues a fine, when is it more likely to be an absolute fine, rather than a conditional fine? Explain your answer: __________________________________________________ 10. What are 3 advantages of having a Lead Court process in Philadelphia? 11. What are 3 disadvantages of having a Lead Court process in Philadelphia? 12. What aspects of Lead Court work well? (Be specific) 13. What aspects of Lead Court do NOT work well? (Be specific) 14. What are 3 changes that could be made to the Lead Court process in Philadelphia that you think would improve its function? 15. Are there any other thoughts you would like to share with me about your experience with working in Lead Court? Feel free to discuss whatever topics come to mind about this. 720 Journal of Health Politics, Policy and Law Table 2 Survey Responses of Lead Court Participants (N = 15) Question 2a: How effective is Lead Court: (5 = extremely effective to 1 = not at all effective) Mean Median Range 4.5 4.0 4–5 Question 3a: How effective were the Pre-court enforcement strategies: (5 to 1, as above) Mean Median Range 1.4 1.0 1–2 Question 5a: How helpful is the pre-printed menu of Court actions: (5 = extremely helpful to 1 = not at all helpful) Mean Median Range 4.8 5.0 4–5 Question 6a: How helpful is the availability of HUD grant funding in assisting property owners to comply with orders to remediate lead hazards: (5 = extremely helpful to 1 = not at all helpful) Mean Median Range 4.6 5.0 4–5 Question 7a: For an owner-occupied property, if the owner doesn’t obtain a HUD grant, how difficult is it to comply with orders: (5 = extremely difficult to 1 = not at all difficult) Mean Median Range 3.3 3.0 1–5 Question 8a: For a tenant-occupied property, if the owner doesn’t obtain a HUD grant, how difficult is it to comply with orders: (5 = extremely difficult to 1 = not at all difficult) Mean Median Range 3.2 3.0 1–5 effectiveness, with a mean reply of 4.5, median of 4.0, and range of 4–5. One person observed that some cases were not resolved because of failure to establish actual property ownership, particularly for a situation with a deceased owner and no clear probate determining subsequent ownership. A common reason for the PLC’s effectiveness was the fact that orders were now being enforced. ‘‘For the persons who appear in Lead Court it appears that having a judge order them—issue an order telling them to do something—has had an impact on the results. They’re more inclined to clear the property rather than when just the health department orders this.’’ Several respondents noted the consequences for failing to comply with court decisions, which were not present in the precourt period. ‘‘I think the Lead Court has been doing a great job in keeping the compliances mainly because . . . the owner knows that we’re serious and there are fines that can be Campbell et al. - Philadelphia’s Lead Court 721 levied on them. So we are seeing a lot of properties coming into compliance even before they get to court.’’ Another representative response indicated the importance of educating judges about the public health aspects of childhood lead poisoning and the negative consequences of delayed remediation. ‘‘The Lead Court was effective as a procedure . . . that was created to educate and sensitize judges hearing lead enforcement cases coming before them, so the judges could understand that when a property owner was asking for additional time in which to carry out the abatement or a postponement, that the judge understood that, effectively, the child would continue to be exposed to that [lead] hazard, and the judge would take that into consideration in deciding whether to grant an extension of time or continuance.’’ Other reasons for the PLC’s effectiveness include the use of specific forms and conditional (fines levied if a condition is not met, such as failure to perform the remediation) and absolute (fines levied at the time they are ordered) fines. When respondents were asked about how helpful the preprinted form with a menu of court actions was, from not at all helpful (1) to extremely helpful (5), the mean reply was 4.8, median of 5.0, and range of 4–5. The form allowed the judge to quickly indicate the results of the hearing and the next steps. The fifteen options, indicated with checkboxes, include giving the city’s health department permission to enter the property; ordering the owner to bring the property into full compliance prior to the next court date (with an option to order relocation of the tenants); authorizing the health department to enter and abate the property; authorizing the city to place a lien on the property for the cost of abatement expenses; imposing both conditional and absolute fines; referring the property to the Department of Licenses and Inspections; and declaring that the matter is discontinued and ended when full compliance has been achieved. The form was then copied, with a copy given to all involved, thus avoiding delays in officially notifying the defendant of the decision. Respondents observed that the form improves the PLC’s functioning, provides education to the defendants as to the court’s expectations, and helps the judges move the cases through more quickly. For instance, a respondent observed that ‘‘having a preprinted menu is good on three levels. First, it allows everyone to know exactly what’s going on, everyone sees the same thing. It has sped up court in that the judge can usually select one of the choices, and it also has allowed the court papers to be processed right there in court and be given to the person coming to court, so they know exactly what’s required of them.’’ Question 9a inquired about court orders to pay fines, which were generally imposed for a defendant’s failure to appear in court and failure to abate the 722 Journal of Health Politics, Policy and Law property. Fines were used as an incentive (several respondents used the term hammer) to make the owner appear and cooperate. As one respondent noted, ‘‘The primary purpose of the fine was to be a hammer, to be an incentive to get the property owner to understand that they needed to do it [abate and remediate the property]. And so, for probably 95 to 98 percent of the fines, we eliminated them once the property was abated. It was not a moneymaker [or] anything like that. The primary goal was to get the owner to realize that that was going to be a real problem and we were not going away, that they needed to comply with the order. And once people got those fines and started to panic then we would make them understand that if they got it abated, we would reconsider those fines at the next hearing. And that almost always worked. So it was sort of a hammer that then became a carrot later on.’’ Influence of HUD Lead Hazard Control Grants on Property Owner Compliance Question 6a asked respondents how helpful the availability of funding through a HUD grant for Lead Hazard Control Work is in assisting property owners to comply with PLC-ordered remediation. The possible responses ranged from not at all helpful (1) to extremely helpful (5). The responses of the interviewees had a mean reply of 4.6, median of 5.0, and range of 4–5. Therefore most felt the grants were very helpful in getting property owner compliance. A common theme was the observation that many owners could not have done the work without the grant, as the following response suggests. ‘‘First, the property owners . . . that had the greatest problem with lead were in the worst positions to be able to take care of those properties themselves. . . . If I recall correctly, I think the average cost of total remediation was somewhere around $15,000 per home. And we’re talking about homes, many of which had values of less than $15,000. So . . . [the grant] is extremely helpful. Second, . . . the city had a very real interest in helping the children . . . that had been exposed to lead and were showing elevated lead levels. The city also had no interest at all in making people homeless. . . . So a situation where they order people out of homes, which would have created a problem that I think, both morally and politically, was not something the city wanted to do.’’ Another theme among respondents was that the health department was very proactive in educating owners about the availability of the HUD grants and how to apply. ‘‘There wasn’t a day that we didn’t have somebody there assisting people with figuring out a way to solve a problem if they didn’t have the money. . . . They—the Health Department really made Campbell et al. - Philadelphia’s Lead Court 723 people understand how they could qualify for it [HUD grant].’’3 Some occupants had problems with getting clear title to the property, which is one of the requirements for the HUD grants (doing so takes time, money, and legal representation), and some noted that having more funding (HUD and otherwise) available would be helpful in removing the hazards. Question 7a asked respondents to determine how difficult it would be for owners of owner-occupied properties to comply with a court order if they could not obtain a HUD grant, with responses ranging from not at all difficult (1) to extremely difficult (5). The mean response was 3.3, and the median was 3.0, with a range of 1–5. Respondents suggested that the situation depended on the owner’s income and time availability for completing remediation work; if the work was not done, the health department would be charged with doing the remediation and a lien would be placed on the property. One reply discussed the priorities and realities of owner-occupants. ‘‘It comes down to finances. I don’t think anybody really wants to disobey a court order. . . . I understand the health of children is high up there, but not everybody has a means. Some people don’t have jobs; some people are not in the health to do that.’’ Respondents commonly cited the lack of clear title to the property as a reason why owners did not qualify for the grant. Question 8a focused on tenant-occupied properties. Specifically, it asked respondents how difficult it would be for landlords to comply with PLC remediation if they could not obtain a HUD grant, with responses ranging from not at all difficult (1) to extremely difficult (5). For this question, the mean response was 3.2, and the median was 3.0, with a range of 1–5. Respondents indicated numerous difficulties facing landlords. The tenant must allow entry to the property, and sometimes the tenant prevents this. Sometimes the child (with an elevated BLL) is not listed on the lease as an approved occupant, but the owner is required to remediate the property. It is harder for those with a small number of properties, as they have less money in reserve for repairs. If the tenant is withholding rent, as is allowed when there is owner noncompliance with the remediation order, this acts as an incentive for the owner to get the work done. Finally, it is difficult to obtain a HUD grant if the owner lacks clear title to the property, which was a recurring theme. The Advantages of the PLC and What Works Well When asked in question 10 to identify three advantages of having the PLC, respondents offered various achievements. A large number of responses 3. There were income qualifications for the HUD grants. 724 Journal of Health Politics, Policy and Law cited educating and informing (about the health department order letters and the law on lead paint, about the availability of HUD grants and how they improve properties, how to do the remediation work, how children get lead poisoning, how to prevent this, etc.). At some point in the process, everyone received education and information. Respondents also noted consistent enforcement for properties with lead hazards. ‘‘For my program [PDPH], it provides a means of enforcement, so that is one of the main advantages is that I actually have an enforcement capacity to require compliance with the health code.’’ A similar observation was, ‘‘I think the biggest advantage is having the process pass from the PDPH into the hands of the court system. This is no longer the PDPH telling me, ‘you need to do this,’ this is a judge telling me, ‘you have to do this.’ This has made the world of difference. And people, whether willingly or not, brought properties into compliance at five times the rate they were before.’’ The PLC was deemed a motivating factor to accept judicial action regarding remediation. ‘‘Another advantage is that it has set a precedent and put word out on the street so that home owners understand that if they don’t do the work that the PDPH has asked them to do they will show up in PLC and have to explain that to a judge.’’ Some respondents commented that it speeds up the lead control work process and decreases children’s lead exposure, thus improving their health and promoting healthy homes for children. For example, one respondent commented on the quick response time from the legal and health department staff, leading to quicker case resolution. An important advantage is that the PLC fosters cooperation and collaboration among groups of people. As one respondent observed, ‘‘It provides effective interdisciplinary use of health and law together; where the doctors were noticing that a kid had a lead problem and were communicating that to the court so that things could be done.’’ To another respondent, ‘‘That type of cooperation— . . . trying not to penalize people but trying to help people—[is] probably one of the best things I’ve seen in the city and in the court systems.’’ The most common observation from respondents was praising collaboration, ‘‘I think that the whole process of the health department and the law department working together works very well. We [the PDPH] have a clear, streamlined process for providing the necessary paperwork and the necessary inspections for the court process to work. And on the flip side, the law department has a very clear process in getting clients to appear in the court and in enforcing the code.’’ One respondent eloquently summarizes the complexity of childhood lead poisoning and makes a case for specialized courts. ‘‘It’s a public health matter of extreme urgency, it’s a housing issue, it’s a social-economic issue, Campbell et al. - Philadelphia’s Lead Court 725 it’s a child welfare issue, it’s a landlord-tenant issue, and it’s also a housingstock issue, all of which in old cities like Philadelphia get wrapped into one. . . . The clear advantages of having court sensitized to the issues that are peculiar to various types of cases and to childhood lead poisoning in particular, have been invaluable in moving remediation and resolution in public health intervention quickly so that the child can be protected.’’ In response to question 12, which queried what works well about the PLC, some main themes emerged. At least seven of the respondents felt that all aspects work well. As one respondent said, ‘‘It works well, because we track people, we make sure that the home owners are doing what the health department had asked them to do. And also we make sure that the tenant is cooperating with the owner, allowing the owner to do what the court has asked them to do. . . . So it makes people adhere to what they’re supposed to be doing.’’ Another respondent put it succinctly: ‘‘Well, I’ve worked with Lead Court since its inception. . . . And it’s helped a lot of children and home owners. I mean the program works, the program works!’’ The Disadvantages of the PLC and What Does Not Work Well Questions 11 and 13 asked for disadvantages to the PLC process or what did not work well. In contrast to the question on advantages, five respondents could not think of disadvantages, and several respondents struggled to find anything negative. Of those with comments, one argued that having an effective court system in place could increase discrimination: ‘‘There are probably landlords who decide that they’re not going to rent to people with children because they’ll end up getting, you know, an order to fix the property.’’ Another was concerned about the impact some court orders have on the PDPH, which is sometimes required to remediate properties itself and is trying to do what it can with limited resources. The entire process requires considerable staff time and resources for inspections and the ensuing paperwork. One interesting comment was that ‘‘the only disadvantage . . . is that it takes judicial . . . time away from hearing criminal cases.’’ Other responses to this question describe ways the court (and the system as a whole) are less than optimal, rather than disadvantages of the PLC, especially compared with what was previously in place. For example, some owners lack the resources to do the work and cannot really afford to own the property. As such, more dedicated lead hazard control work funding from HUD is needed. Other respondents described the difficulty of holding absentee landlords accountable and bringing them to court, although they 726 Journal of Health Politics, Policy and Law could be compelled to attend through a subpoena. ‘‘A lot of people . . . own a property in Philadelphia, [but] they live in Miami. They get sent a regular check by the tenant who’s never seen them. It’s all done over the telephone and nobody has an actual address; it all goes to the post office box.’’ A theme expressed by some was that the process took too much time, delaying compliance during which lead exposure of the child continues, although others thought the process had become quicker, as mentioned previously. Some suggested that if judges had longer terms in PLC, for at least a year, they might have better appreciation for the urgency of undertaking the remediation work. Suggested Changes to the PLC Question 14 asked respondents to identify three changes to improve the court functioning. A common theme included providing more remediation funds. Although most respondents agreed that education of all parties involved was an advantage and strength of the PLC process, one respondent described this as an important function of the PLC that improved over time but was still in need of some improvement. ‘‘The major thing that . . . could be improved . . . is the public education component of it. . . . Explaining why we were there, what the cases were about, if they had questions, that they could talk to the health department who might be able to help them resolve a problem. . . . When we started doing that more, I noticed a complete change in the people in the courtroom. They were much more willing to be there. They were much more interested in how they could get things done. . . . But I think that . . . you just go—you always got thirty cases, let’s just get through them and forgot to kind of take into account that this was their only time in court, and . . . it was a perfect teachable moment about why they were there and could carry on to their neighbors and friends and other children.’’ Another common suggestion was the need for judicial education and training so that judges have enough background in the topic to be effective. But it is important to note that education about childhood lead poisoning was recently provided to a group of Philadelphia judges and is offered regularly for new PLC judges. The importance of education was also raised in the question asking for additional comments. Not surprisingly, respondents suggested the need to speed up the judicial process, as discussed above. One respondent had a very practical suggestion: ‘‘One thing I would like to see is that we have a problem coordinating data and it would be a lot better if we had common databases . . . that would Campbell et al. - Philadelphia’s Lead Court 727 speak to each other or if we had a way to electronically transfer some of the information.’’ Some felt the PLC model should be replicated, as a model of a specialized court, and that other topics associated with healthy homes, such as controlling asthma triggers, could be included. A participant observed, ‘‘This should be everywhere. It’s cost-effective in terms of really addressing a huge public health issue. . . . The thing that comes to mind is, ‘how can we use this to address other public health problems?’ So in addition to other cities using lead paint court . . . it could be used for some other public health problems to kind of expedite solving the problem with less money and to educate people about what the problem is. It sort of does all of those together.’’ Many respondents reported that they enjoyed their experience of working in the PLC. The process for bringing cases through court impressed one respondent. ‘‘When it was time for me to be reassigned to a different group of cases, I think the one I missed the most was the Lead Court. . . . It was such a pleasure to watch everyone interact with . . . the clients that came in and the parties that came in, and how they dealt with people. It was just a real pleasure.’’ Another respondent focused on the end result, saying, ‘‘I felt like from this experience I was doing something for the betterment of the children. That’s what matters to me. The children. And they’re better off for it, too.’’ Discussion This qualitative study built on our previous quantitative work evaluating the PLC’s effectiveness in lead hazard remediation. By interviewing fifteen principal informants who played key roles in the court’s operation, we gained much greater knowledge about how the PLC functioned, how it compared with other courts, and we were able to extract common themes and opinions, as well as differences of opinion, about the value of the court process. In general, the participants agreed that the PLC was very effective, particularly in comparison with attempts at health code enforcement prior to initiating the court. Many respondents offered the opinion that one of the court’s main functions was to educate and inform both those working in and those appearing before the court. Respondents praised the utility of processes that helped the court run more smoothly, such as the preprinted court disposition form and materials for HUD grant applications. There were no negative comments about the form, and some respondents suggested it was useful in efficiently focusing judges on the various options available for deciding the 728 Journal of Health Politics, Policy and Law case. There is always room for improvement, and respondents offered advice as to how the court’s function could be improved. For instance, respondents’ suggestions included increasing remediation funds, speeding up the court process, and continuing to educate judges and courtroom attendees. These ideas should prove useful for PLC judges and administrators. Although PLC is a specialized court created to issue and enforce lead hazard remediation orders, our results may be relevant to other specialized courts. Thus it was noteworthy that while respondents noted disadvantages and areas that did not work as well, the evidence from the interviews seems to be mostly positive about the way the PLC facilitated the remediation process. This positive perception is consistent with the huge increase in the number and percentage of remediated properties documented in the quantitative study. Some of the stated advantages of specialized courts included improved ability to integrate public health resources into the legal process, ability to deal with issues that are sociologically complex, and ability to minimize delay when speed of the process is desirable. These advantages seem particularly appropriate for policy makers to consider in establishing other specialized courts. Interestingly, some disadvantages that we anticipated, such as judge burnout, were not mentioned in the interviews. The PLC judges appear to be rotated periodically, so there does not seem to be as much concern for insularity or lack of judicial career advancement. Lastly, the focus on lead hazard remediation and compliance did not seem either too narrow or too broad for the court. The respondents frequently mentioned a collaborative and collegial process between the legal and health departments and the court, with many having good memories of their time working in the PLC. This partnership seemed to allow for greater understanding of the cases and more efficiency in case processing. Another interesting observation was the balance of carrot and stick approaches, with enough sticks (court fines, placing a property lien if the city did the remediation work) to spur action as well as a few carrots (avoiding fines, HUD grant funding, providing information about remediation techniques and available contractors, being congratulated by the court for compliance, ending a child’s lead exposure) to encourage desirable actions. In contrast, precourt cases did not seem to utilize incentives to any degree. To the extent possible, the PLC helped defendants find needed resources to overcome compliance barriers. There may have been better outcomes in part because the enforcement actions had a common public health goal to improve children’s home conditions and health, rather than simply punishing people for their misdeeds, which occupies many courts. Campbell et al. - Philadelphia’s Lead Court 729 When reviewing the types of specialized courts that have been established, it appeared that many are organized around public health issues, such as mental illness, drug abuse, child abuse, and tuberculosis. For public health problems, in which one person’s actions can have an impact on many people, specialized courts provide a more comprehensive court process with representation of community groups that can provide context, support, and services that may improve outcomes. Since education is a major component of public health work, it is not surprising that the PLC offered education about the lead exposure hazards and the specifics of lead remediation work to staff, judges, and those appearing in court. That way, defendants could understand why the judge was ordering a particular action instead of just blindly complying with it. In summary, for the specific problem that the PLC addresses, the advantages of a specialized court seem to outweigh the disadvantages. A major limitation of this study was the small sample size and the fact that the participants were all working for some city agency or within the court system. This may have introduced selection bias into the study, as major stakeholder groups outside the city infrastructure (such as the defendants and family members of the affected children) were not represented. Although it would have been desirable to interview other stakeholder groups to gain their unique perspective, the study team decided that increasing the interviewed group with other stakeholders was beyond the resources allocated for this study. Recently, the Philadelphia City Council enacted a law to require a certain standard of property condition for rental properties. Before a property can be rented, it must pass an inspection designed to prevent lead exposure. The bill furthers primary prevention of lead exposure and poisoning, as opposed to the PLC’s secondary prevention occurring after children develop EBLLs. The benefit of primary prevention is to remove lead hazards prior to a child’s exposure. Presumably, such a policy in the past would have avoided the need for much of the lead remediation work identified in this study. Since at least 2004, the CDC (2004, 2005) has recommended that local and state governments pursue primary-prevention strategies. The Philadelphia Department of Public Health has run several prevention programs for high-risk children, families, and communities. In December 2011 the Philadelphia City Council enacted Bill No. 100011-A, requiring the inspection and declaration of a lead-safe status (following lead remediation work, as needed) for rental properties housing children younger than six years old. The original bill called for all rental properties, but in a compromise agreement it was ultimately limited to 730 Journal of Health Politics, Policy and Law properties with young children. This new ordinance, which went into effect on December 21, 2012, is expected to decrease the incidence of EBLLs and may be expanded to all properties at some point. Nonetheless, the PLC will continue to provide enforcement of remediation orders for those properties in which a child does get exposed to lead. Conclusions and Recommendations This survey of a small group of important PLC stakeholders found the PLC to be very effective. In contrast, precourt enforcement strategies were judged to not be effective. Based on the study results, we recommend periodic educational sessions to inform Philadelphia judges and PLC staff about childhood lead poisoning, how this relates to housing and landlord-tenant issues in court, and how lead exposure can be stopped and prevented in the future. With time, there will be less need for secondary prevention of lead exposure when more primary-preventive measures are taken, but the PLC will serve as a safety net for cases where lead exposure could not be prevented. Based on our study results, we believe that the Philadelphia PLC can serve as a model for other cities facing similar lead hazard exposure, if other enforcement mechanisms have not proved effective. References Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP). 2012. 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