# Building Local Agency Respond Capacity for Indoor Mold Problems & Health Complaints

# 2005 - 2006 

# Environmental Public Health Leadership Institute Fellow:

# Jed M. Waldman, PhD

> *Chief,* Indoor Air Quality Program
>
> California Department of Health Services -- Environmental Health
> Laboratory
>
> 850 Marina Bay Pkwy, G-365/EHLB, Richmond, CA 94804
>
> Phone: 510-620-2864; E-mail: <jwaldman@dhs.ca.gov>

# Mentor:

### **Charles D. Tresser, MPH**

> *Senior Lecturer*, Department of Environmental Health
>
> University of Washington -- School of Public Health
>
> ![](media/image1.jpeg){width="1.3756944444444446in"
> height="0.6368055555555555in"}

# EXECUTIVE SUMMARY:

In California, there is not currently an effective infrastructure for
homeowners, tenants, building managers, or school officials to find help
when faced with indoor mold problems. Unlike other areas of
environmental health, public agencies do not have the necessary
authority or interest to provide either direct service or technical
direction. In local jurisdictions, it is both a lack of staff resources
and definable enforcement authority that weakens agency response. State
legislation gave the California Department of Health Services authority
starting in 2002 to develop state guidelines for exposure, assessment,
and remediation, but, as yet, DHS has not started on implementation of
the statute or a statewide response. This project initiates the
development of a strategic plan to build capacity to respond to indoor
mold problems & health complaints at the local level. The project
identifies key stakeholders and the mental models that have impeded
progress, statutory & regulatory restraints, current political &
budgetary reality, and systems logic models that describe the current
performance problems. The project identifies intervention options to
break the gridlock, which include state/local partnership pilot, a
stakeholder convention, and legislative proposal to regulate the private
assessment and remediation contractors.

# INTRODUCTION/BACKGROUND:

Mold is a recognized asthma trigger, and indoor exposures have become an
important public health issue[^1]. Review of the recent literature has
established a strong causal relationship between building dampness or
moldiness with respiratory health problems such as cough, wheeze, and
asthma exacerbation. Exposures can become particularly high when fungal
growth occurs inside a building. The root cause of indoor mold growth is
building water or moisture problems, and these occur both in new
construction and in older buildings. Faulty building design or
construction can allow water intrusion or inadequate moisture control.
Poor building maintenance is also a key factor in serious indoor mold
cases; delays in fixing small problems that allow major mold
contamination to occur.

####### ***Problem Statement:***

Affected individuals (e.g., homeowners, tenants, building managers,
school officials, etc.) are faced with a complex and often unresponsive
infrastructure for getting needed help when facing indoor mold problems.
Many continue to struggle to find competent technical guidance,
assistance, and/or resources to remedy indoor mold problems in their
facility. Unlike other areas of environmental health, the responsibility
and authority to address indoor mold is ambiguous. The public often
finds it difficult to find an agency provide direct service. Most
jurisdictions lack staff resources and definable enforcement authority,
and this delays agency responses.

####### ***Behavior Over Time of the Indoor Mold Problem:***

Indoor mold has been recognized as a health threat since the people
started living in caves and buildings; reference to it are even found in
the Bible[^2]. In modern time, it was identified as a potentially
widespread health issue following the energy crises of the 1970's --
when energy efficiency dominated buildings design and operation. Very
poor ventilation became commonplace, as well as poor moisture control.
This was the beginning of "sick building syndrome". In the mid-1980's,
new governmental programs were funded to research SBS, its causes, and
other indoor air quality issues, and by the early-1990's, elements of
building design, construction, and furnishing began to address key IAQ
issues. Importantly, codes were modified to raise minimum ventilation
rates again, above the stringent "energy efficient" level (3-fold!)

However, public attention became again focused on indoor mold in late
1990s, following sensationalized reports about the deaths of infants
tied to "Stachybotris" mold, the rise in law suits for mold, including
several multi-million dollar cases; and widespread cases and
unsatisfactory response. Among building designers, concerns were raised
that modern building materials may be a factor in the rising number of
cases. In reaction, the federal government funded more research studies,
demonstration projects, and scientific reviews on indoor mold. In
California, the "Toxic Mold Protection Act" (SB 732) was enacted in
January 2002[^3]. Following this period, there was the perception that
"problem is being taken care of". The impacts of these events are shown
schematically in Figure 1.

![](media/image2.wmf)Figure 1. History and uncertain future: (a) more
crises; (b) sustained concern; or (c) resolution.

However, in California, little funding trickled to the State or local
level for indoor mold, and the legislature did not appropriate funds
after passing SB 732 for its implementation[^4]. In recent years,
insurance companies unilaterally changed their response to indoor mold
problems by reducing their policy caps for damage claims and testing
costs, and rental property owners began issuing pre-emptive "mold
disclosure waivers". This has left the public even more on their own in
dealing with mold problems.

Additional information is available from two surveys recently conducted
in California related to public concern about indoor mold and the
responses by local Environmental Health agencies[^5]. One confirmed the
significant burden that mold-related calls put on staff resources.
However, while most agencies referred local constituents with mold
problems to guidance and "info sheets", few local agencies (\~20%)
responded with routine on-site assessments or testing. The second survey
tallied calls on IAQ issues to state agencies. Indoor mold concerns
(\~5% in 1986) rose in recent years to over 60% of calls. Our (State)
agency only currently receives 60-100 calls/emails per month. Internet
activity for mold information, especially our infosheet, "Mold in My
Home: What Do I Do?", is among the highest for any environmental health
topic at the State web site -- 10 thousand views per month.

####### ***Causal Loop Diagrams and Archetype***

At present, the public's need for technical guidance and assistance is
being shunted by local agencies to the State Health Department (DHS),
instead of offering help to them directly. In this ***Shifting the
Burden*** archetype, DHS has attempted to respond to queries by building
a phone response program and web site (See Figure 2). However, resources
are not dedicated by the State for this kind of direct response
function; the State's role is to provide technical "back-up" to local
agencies. And DHS' continuing expenditure of its limited resources in
public query response reinforces this ***short-term fix*** (a
**R**einforcing loop) in two ways: (a) prevents the State from
completing higher-level functions (such as SB 732 implementation), and
(b) lowers the impetus for local agencies to develop an effective
response system for their own constituents. Things are not going to
improve for the public if we continue in this way.

The ***long-term fix*** (a **B**alancing loop) involves the state
completing its higher-level functions, which include guidelines,
training and support, but local agencies building the capacity and will
to offer direct response to its constituents. Additional long-term goals
include licensing contractors and improving building design and
maintenance to address mold-resistance.

Included in the casual loop are two sets of mental models: one that
appears to sustain the ***short-term fix***, and a different set to
support a ***long-term fix*** (see Table 1). Another way of looking at
the relationship between local and State agencies is reframing from
fixing the *symptoms* to fixing the *problem* (Table 2).

## When a system needs to be changed, Intervention Options take one of these forms (see Table 3):

## Stop doing certain things 

## Change our approach to doing something

## Start doing something new/different 

**Table 1. Mental Models Embedded in Archetype.**

######### 

**Present**

*Building Occupants*

-   I have no responsibilities regarding mold clean-up

-   There is nothing I can do to or prevent mold problems

-   The landlord/managers should fix all the problems, right away, and
    no matter the cost

*Landlord/Manager*

-   The tenant is making a big deal of a small/non-problem

-   The tenant is causing the problem

-   I don't know how to handle this kind of problem. I don't believe I
    should have to do such extensive repairs. I don't know that the fix
    will actually solve the problem.

*Inspectors*

-   This kind of problem is minor/unimportant

-   I don't have the resources/staff to respond to so many cases of
    "mold" (This is not the kind of problem I am mandated to address)

-   Time spent on this issue takes away from other (more important)
    activities.

-   I can refer people to the State DHS.

## 

## Building designers

-   It isn't my fault; I am following the code

-   No one has a good fix that works

*Builders*

-   I need to cut costs

-   I can't get the best workers

-   I don't want to be called back to do repairs...or be sued

-   Being called back and sued is inevitable.

*Mold consultants*

-   "Mold is Gold" -- there is a lot of money in this work

-   We need to make sure we solve the problem, and not worry about
    over-kill

-   I work for the insurance company/property owner, not the occupant

**New for Changing Behaviors**

*Building Occupants*

-   I have to be vigilant about identifying small problems before they
    get bigger.

-   It is best to communicate with the landlord in a non-adversarial way

-   I need to work with landlord/managers to make cost-effective
    choices.

*Landlord/Manager*

-   It is important to investigate indoor mold problems

-   It is more effective to take tenant complaints seriously than ignore
    them or responding slowly.

*Inspector*

-   Investigating these problems is part of my job

-   I have the necessary authority

-   There are clear guidelines to follow

-   I have the needed training

*Building designers*

-   Preventing water intrusion problems is a very high priority

*Builders*

-   Preventing water intrusion problems is a very high priority

*Mold consultants*

-   We need to use cost-effective methods, plus educate the building
    owner & occupant about prevention.

-   State (or 3^rd^ party) credentialing will yield more profits by
    reducing "bad" firms and establishing accepted standards

**Table 2. Reframing the Issue from Fixing the *Symptoms* to Fixing the
*Problem***

***Local Agency View:***

Symptom: Building occupants complain about indoor mold

Symptom fix: Refer complaints to the State

Problem fix: Develop & enforce mold-free building policy (prevention &
response)

***State Agency View:***

Symptom: Local constituents ask State to help when local agencies will
not provide help.

Symptom fix: Increase staffing for phone & web response (guidance)

Problem fix: Work with stakeholders to assist (direct/force) local
agencies to develop & enforce mold-free building policy

#### Table 3. Loop Intervention Options 

**State DHS**

-   *Stop offering service[s]{.underline}*: responding to calls;
    maintaining/updating web site

-   *Change how we respond*: refer every caller back to their local
    agency; work with agency staff

-   *Start SB 732 implementation*: Convene Stakeholder group; craft
    guidelines for exposure, assessment, etc.; establish outreach and
    training

-   *Start "certification" of mold consultants*: establish regulatory
    authority *or* partner with 3rd-party organization.

-   *Start to offer more direct service*: acquire resources to give
    local agencies the ability to take lead responsibility for indoor
    mold problems

***Changes that the State needs to encourage***

**Local Agencies**

-   *Change their mandate*: Amend the H&S Code to establish clearer
    authority to order "mold abatement"

-   *Increase their response capacities*: Offer training to give them
    greater expertise; help get them greater resources (how? fees?)

#### Building Owners

-   *Change their motivation*: Carrot (insurance premium breaks for
    "dry" buildings) & Stick (more enforcement)

#### Public 

-   *Change their expectations*

#### Private Contractors

## Start training

## Change their accountability 

####### ***10 Essential Environmental Health Services***

While addressing any problem as multifaceted as indoor mold incorporates
all of the 10 Essential Environmental Health Services[^6], for
developing the program described in this project, we particularly
focused on the following subset:

> 5\. Develop policies and plans that support individual and community
> EH efforts:
>
> *Provide authoritative guidance for assessment and remediation*.

7\. Link people to needed EH services and assure the provision of EH
services when otherwise unavailable:

> *Direct local constituents to local agencies, and help build local
> agency capacity.*
>
> 8\. Assure a competent environmental health workforce:
>
> *State licensing mold assessment and mold abatement contractors.*

####### ***National Goals Supported*** 

Ensuring *Healthy Homes* is a core item for the Centers for Disease
Control (CDC) and U.S. Environmental Protection Agency (EPA). However,
addressing indoor mold problems is not listed explicitly in the *Healthy
People 2010*[^7] goals. It is not considered in its own right, but,

as a health issue, mold is grouped with other asthma triggers. Table 4
lists the CDC goals relating to indoor mold. U.S. EPA Indoor Environment
Program also identifies reducing indoor asthma triggers as one of its
chief objectives. Interestingly, even though not explicitly identified
as a goal by either agency, providing technical guidance on addressing
indoor mold is quite prominent on both agencies web sites[^8].

**Table 4. *Health People 2010* Goals relating to Indoor Mold**

###### Environmental Health -- Healthy Homes and Healthy Communities

######## Promote health for all through a healthy environment

16. *Indoor allergens*: Reduce indoor allergen levels.

17. *Office building air quality*: Increase the number of office
    buildings that are managed using good indoor air quality practices.

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20. *School policies to protect against environmental hazards*: Increase
    the proportion of the Nation's primary and secondary schools that
    have official school policies ensuring the safety of students and
    staff from environmental hazards, such as chemicals in special
    classrooms, poor indoor air quality, asbestos, and exposure to
    pesticides.

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23. *Substandard housing*: Reduce the proportion of occupied housing
    units that are substandard.

**Respiratory Diseases -- Asthma**

Promote respiratory health through better prevention, detection,
treatment, and education efforts

24-1/5 Reduce asthma-related mortality/morbidity/hospitalizations/ER
visits/reduced activity/lost work/school days, etc.

7.  Persons with asthma who receive assistance with assessing and
    reducing exposure to environmental risk factors in their home,
    school, and work environments.

####### 

####### ***Project Logic Model:***

I found it vexing to try to insert the components of the indoor mold
problem into the Project Logic Model proffered in the EPHLI curriculum.
I believe this is because this is an EH problem for which the scope of
its objectives has not yet been well-defined: the scientific link
between exposure and disease is limited, and the policy structure for
indoor mold-related EH services is unclear and unfocused.

As a idealized approached, I used the broadest brush to conceive
activities my program could tackle, and generated a broad set of
Activities/Outputs/Outcomes to reach the Health Outcome goal (see Figure
3). In reality, four years have passed since the California Legislature
enacted its Toxic Mold Protection Act, and little progress has been made
in its implementation. Hence, this project would need to be, by
necessity, more modest; a major part of the project remained defining
realistic objectives for EH services.

# PROJECT OBJECTIVES/DESCRIPTION:

Attempting to inject systems thinking into this seemingly intractable
problem offered some keen insights, based on the archetype and dynamics
of interventions. At the same time, the overlay of logic modeling was
more frustrating, but it made clear the challenge of defining realistic
objectives for EH services.

At the start of the EPHLI, I was unfamiliar with the Essential Services
model for EH. My program is works primarily on the "research" spoke, and
we do not offer more than a very limited menu of other services. In
fact, the research I do primarily looks at engineering problems. Hence,
I found it satisfying constructing a project plan, perhaps for the first
time, by following the sequence: GoalHealth ProblemOutcome
ObjectiveDeterminantsImpact ObjectiveContributing FactorsProcess
ObjectiveEventsActivities.

The following Indoor Mold Project Plan was developed:

####### ***Program Goal***

To reduce asthma and allergic airway disease by preventing and
remediating indoor mold contamination in residences, schools and
workplaces.

***Health Problem***

Indoor mold contamination problems are not being rapidly or effectively
resolved.

####### ***Outcome Objective***

Californians with queries and complaints related to indoor mold will
receive timely information, guidance, referral, and/or enforcement
services from their local agency.

####### ***Determinant***

Number (percentage) of affected individuals who contact their local EH
agency and receive information, guidance, referral, and/or enforcement
services that resolves their indoor mold problem.

####### ***Impact Objective***

By \[date pending funding\], requests for services relating to indoor
mold problems to a local EH agency (pilot) will be monitored, and
responses will be coordinated by staff augmented by demonstration
project funding and/or voluntary/state staff.

####### ***Contributing Factors***

1.  Confusion among agencies because of cross-cutting impacts and
    responsibilities (e.g., health departments monitor impacts to
    sensitive occupants; building inspector enforcing code compliance),
    and the lack of definitive guidance on assessment, remediation, and
    post-clean-up clearance.

2.  Insufficient staff resources funding in local EH agency to provide
    direct services relating to indoor mold claims and complaints, such
    as inspections, enforcement, and follow-up.

####### ***Process Objectives***

1.  Issue science-based guidelines on assessment, remediation, and
    post-clean-up clearance. Develop definitive guidance for
    cross-cutting response. Consider implement of SB 732.

2.  Acquire funding for demonstration project to develop an effective
    partnership among State and local health and environmental health
    agencies in providing indoor mold assessment and remediation
    guidance and assistance to constituents.

# METHODOLOGY and RESULTS:

Because of the evolution of this project topic, and the nature of my
program, my aim at this time has been to simply reframe the problem in
new ways. That is, the methodology is the result. It was not possible to
pursue the Process Objectives without new resources -- an idealized
outcome of this planning is a cogent plan to acquire funding to do so.

# NEXT STEPS:

Under the two objectives, I've identified a preliminary set activities.

***Process Objective 1:*** Issue science-based guidelines, etc.

[Activities]{.underline}

-   Survey stakeholders on needs

-   Review available models for addressing indoor mold problems among
    States (and at local level).

-   Identify roles of stakeholders (partners, opponents, etc.)

-   Convene technical team and coordinate with Federal, other State, and
    municipal experts.

-   Evaluate professional mold assessment and remediation services and
    licensing.

-   Analyze insurance claims and lawsuit settlements.

-   Enhance web-based outreach to disseminate public education materials

***Process Objective 2:*** Acquire funding for demonstration project,
etc.

[Activities]{.underline}:

-   Identify Partners/Formulate partnerships/Define roles

-   Identify funding opportunities

-   Define project goals:

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-   coordinate responses across state, county and city jurisdictions to
    ensure that timely assistance is provided to those with building
    mold problems,

-   optimize communication among agencies and between agencies and
    communities or individuals with building dampness or mold problems,

-   establish clear authority and responsibility for addressing mold and
    building dampness issues,

-   optimize resources to support these issues, and

-   evaluate private sector functions, including professional mold
    assessment and remediation services and insurance claim adjustments.

# CONCLUSIONS:

The fact is that indoor mold calls and complaints continue to fall
outside the scope of most local EH programs. In some fundamental ways,
the problems of indoor air quality are resistant to an EH services
approach. The exceptions are notable (e.g., carbon monoxide, lead,
environmental tobacco smoke), which represent IAQ issues with (a) more
direct health-exposure links and (b) more easily managed interventions
or controls. It may simply be that the public health response to indoor
mold is in an earlier stage in its development.

The aim of my project was to uncover new approaches to building local
capacity in California for responding to indoor mold problems and health
complaints. While State and Federal agencies can provide leadership,
delivery long-term of EH services relating to indoor mold
(investigation, assessment, and enforcement, as well as education) must
become a local function. There remains a great deal more to do to
demonstrate to them *workable models* for building local capacity into
viable systems. The Next Steps include providing leadership in building
strategic alliances and acquiring funding for demonstration projects.

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

Participating in the inaugural EPHLI has been both extremely rewarding
and, at the same time, personally dissatisfying. In both regards, it has
reflected the adage: *you get out what you put in.* I recognized from
the beginning that I was somewhat a fish out of water -- I am a research
scientist/supervisor working on environmental health issues, but my work
does not have include the mainline environmental health activities.
After raising this concern when I applied, we agreed that there was an
opportunity for all to learn from the challenges of the marginal fit.

This project evolved after changing my topic at a late point in the
term. The decision was made as I learned more about the essential
services approach to EH, and as I recognized that my original topic --
and much of what I do at my job -- was not the best match to this
approach. My original project topic -- Shaping policy to reduce chemical
emissions from building materials used in homes, offices, and schools --
was too narrow in scope, and it relies too heavily on the specialized
technical components of my program. Ironically, in the past six months,
I made significant progress on my original topic, as it is more closely
aligned with my job focus and I have had substantial staff resources to
apply. Nonetheless, I chose the new project topic, as it has been a
"burr under my saddle" for much of my time at the State Health
Department (10 y). I felt stuck in addressing it, so it begged for new
skills, fresh approaches, and renewed motivation. As the training and
project come to an end, I have more questions (and more frustration)
about how I should approach this problem. Nonetheless, the EPHLI has
given me a valuable new set of tools that, with practice, will certainly
help me face the challenges of this and future problems.

# ABOUT THE EPHLI FELLOW:

Dr. Jed Waldman has worked at the California Department of Health
Services since 1996 as chief of the Indoor Air Quality Program, located
at the Richmond Laboratory Campus. He is responsible for research,
training, and public outreach on the full range of IAQ issues, including
building design and ventilation, volatile organic compounds, asbestos,
bioaerosols, and environmental tobacco smoke. Most recently, he directed
studies of environmental health conditions in public school classrooms
and chemical emissions from building materials. Dr. Waldman chairs of
the California Interagency Working Group on IAQ and heads their work
group on indoor environmental quality in schools. He has served on
advisory panels for the U.S. EPA, Health Effects Institute, the American
Lung Association, and the Environmental Law Institute, and he currently
serves on U.S. EPA's Science Advisory Board 's Integrated Human Exposure
Committee. He was a visiting professor at the University of California
at Berkeley School of Architecture in 2001 and 2003 and co-taught (with
Rick Diamond of LBNL) *Healthy Building Design*. Prior to 1996, he was
an associate professor in Department of Environmental & Community
Medicine at the Robert Wood Johnson Medical School in Piscataway, NJ. He
was trained in civil/sanitary engineering at the University of Florida,
and holds a PhD in environmental engineering science (atmospheric
chemistry) from the California Institute of Technology.

# REFERENCES

[^1]: . Institute of Medicine (IOM), 2000. *Clearing the Air: Asthma and
    Indoor Air Exposures*. Committee on the Assessment of Asthma and
    Indoor Air. National Academy Press, Washington, DC.
    (<http://books.nap.edu/books/0309064961/html/index.html>).

[^2]: . **Leviticus 14:45** "A house desecrated by mildew, mold, or
    fungus would be a defiled place to live in, so drastic measures had
    to be taken".

[^3]: . SB 732 charged DHS to determine the feasibility of adopting
    permissible exposure limits for indoor molds and, undertake a series
    of complex tasks to develop new standards or guidelines that:

    assess the health threat posed by the presence of indoor molds,

    determine valid methods for fungal sampling and identification,

    provide practical guidance for mold removal and abatement of water
    intrusion,

    disclose the presence of mold growth in real property at rental or
    sale, and

    assess the need for standards for mold assessment and remediation
    professionals.

[^4]: . California Department of Health Services (DHS), 2005. Report to
    the California Legislature: Implementation of the Toxic Mold
    Protection Act of 2001. Environmental Health Investigations Branch,
    Richmond, CA,36 pp
    (<http://www.cal-iaq.org/MOLD/SB732_LegReport_Final.pdf>)

[^5]: . *Waldman JM*, Macher JM, McNeel S, Wersinger E, Gilliss, D,
    2002. How public agencies address indoor mold hazards in California.
    Proceedings of the *9th International Conference on Indoor Air
    Quality and Climate*, Monterey, California, June 30-July 5, 2002,
    Hal Levin (ed.), Vol. II, pp 38-43.

[^6]: . Osaki, C. *Essential Services of Environmental Health.*
    Northwest Center for Public Health Practice, University of
    Washington School of Public Health and Community Medicine, Seattle,
    WA. July 2004.

[^7]: . U. S. Department of Health & Human Services, 2000. *Health
    People 2010: Understanding and Improving Health* 2nd ed. Office of
    Disease Prevention & Human Services, Washington, DC.
    (<http://www.healthypeople.gov/Document/tableofcontents.htm>.

[^8]: . U.S. EPA: <http://www.epa.gov/iaq/molds/index.html>

    CDC: <http://www.cdc.gov/mold/default.htm>