Exploring the Link Between Housing and Health

Despite some efforts made by the U.S. government in response to public pressure to improve housing, many inequities exist. Substandard housing and homelessness are integrally related to poor health. Though there are some ways in which one can attempt to improve his/her substandard indoor living environment, larger societal changes must occur in order to create a more equitable housing system within the United States.

In 1842, Edwin Chadwick established an association between appalling living conditions and poor health. Nineteenth century physician-activist Rudolph Virchow recognized the link between rising rates of infectious disease and crowded, poorly maintained housing. In the absence of diagnostic tools and effective treatments for rampant infectious diseases, many of the advances in health of the 19th and early 20th century were a direct result of improvements in housing, sanitation, and water quality. The Great Depression and the post-World War II era brought increased interest in housing because of the massive influx of people moving to cities in search of jobs.

According to the Universal Declaration of Human Rights, “everyone has the right to a standard of living adequate for health…including food, clothing, housing and medical care.” The Housing Act of 1949 reflected the desire of the U.S. government to meet the housing needs of its citizens. It called for “the realization, as soon as feasible, of the goal of a decent home...for every American family.” The civil rights era of the 1960s and 1970s brought attention to discrimination in housing policies. The Fair Housing Act of 1968 made housing discrimination based on race illegal. Even so, housing inequalities persist, as does overt homelessness.

Despite legislative efforts to address housing inequities, a shortage of affordable housing and homelessness remains rampant, and are important contributors to poor health. Over 7 percent of persons living in the United States have been homeless at some point in their lives, and rates of homelessness have increased over each of the past two decades. An estimated 2.5 to 3.5 million people now experience homelessness each year. Those lacking a home experience higher mortality than the general population. They suffer disproportionately from psychiatric disorders, substance abuse, dermatologic disorders (such as lice, scabies and eczema), respiratory infections, and dental and foot problems.

Consequences of Substandard Housing

Environmental Injustice: Affordable housing shortages and discriminatory housing practices plague many American communities. Low-income housing is frequently substandard, does not meet city inspection requirements, and is characterized by conditions that contribute to poor indoor air quality and adverse health. Such substandard accommodations are disproportionately concentrated in lower-income communities and communities of color. Segregation by income and race limit one’s access to grocery stores, neighborhood parks, and even medications.

Polluting industries are more frequently located in and around poor communities and communities of color, a phenomenon known as environmental injustice or environmental racism. Due to excessive exposure to air and water pollution, such communities bear a higher burden of many diseases. One study found that bad housing and poor neighborhood conditions in African-American communities in St. Louis, Missouri were associated with a 2.5 times increase in the odds of developing diabetes. In Anniston Alabama, there is clear evidence that Monsanto polluted the community with polychlorinated biphenyls (PCBs). People in this city, who are mostly of low-income and minority background, experienced increased incidence rates of infectious diseases, cancer, diabetes and neurobehavioral abnormalities, as compared with a control population not affected by PCB pollution. To make matters worse, members of poor and racially segregated communities often lack access to health care and contain a higher proportion of both documented and undocumented immigrants, whose access to care is extremely limited. Language barriers, housing discrimination that limits choice, poor credit, inadequate public services, unemployment, a relative lack of political power, and stress further limit one’s housing options. Environmental justice is achieved when everyone, regardless of race, culture, or income, enjoys the same degree of protection from environmental health hazards and has an equal role in the decision-making process regarding the siting and operations of polluting industries.

Substandard Housing and Poor Health: Housing is an important social determinant of health not only because it provides safe shelter from the outdoor environment and from crime victimization, but also because Americans spend much of their time indoors. For some, the quality of indoor air that they breathe may exert a greater influence on their health than the quality of air outdoors. The elderly, pregnant women, young children, and the chronically ill are most vulnerable to poor indoor air quality, since they spend the most time indoors. Fetuses and young children are more susceptible to toxic substances because they have greater pound-for-pound exposures; immature, porous blood brain barriers; lower levels of chemical binding proteins, allowing more chemicals to reach target organs; rapidly developing organs which are especially vulnerable to damage; under-developed systems to detoxify and excrete industrial chemicals; and a long future lifespan, which allows more time for adverse effects to arise. The elderly experience increased risks from toxin exposures since they suffer from more co-morbidities, and because the ability to eliminate toxins decreases with age. Those with chronic illnesses are at increased risk of asthma, chronic obstructive pulmonary disease exacerbations, and hospital admissions for acute coronary syndrome and cerebrovascular accidents consequent to exposure to environmental pollutants.

Other characteristics of substandard housing contribute to morbidity and mortality. For example, poor heating or cooling systems can contribute to hypothermia or hyperthermia, respectively, during ambient temperature extremes. The high death toll from the Chicago heat wave of 1995 illustrates the latter problem. Hyperthermia deaths will likely increase with global warming. Inadequate ventilation helps to propagate respiratory infections, contributes to asthma exacerbations, and has historically increased the spread of dangerous diseases such as tuberculosis. Overcrowding in low-income and immigrant communities increases risk of infectious disease transmission. Poor construction using shoddy materials, combined with inadequate heat and ventilation, can facilitate dampness, creating ideal conditions for mold growth. Mold infestation has been linked to respiratory problems, asthma, allergies, and eczema. Cockroaches and other pests can invade poorly-built or -maintained housing, further increasing the risk of asthma and allergies. Tobacco smoke, radon, and the use of cooking and heating equipment also contribute to indoor air pollution. Lead poisoning from old pipes and paint can cause neurological damage, which may result in lower intelligence, disabilities, worsened job prospects later in life, and higher rates of criminal activity. Finally, poor housing quality adversely affects mental health, leading to increased rates of depression and stress.

Affordable Housing: Just as poor housing can cause illness, poor health can lead to poverty, which limits one’s housing options. Those who are physically or mentally ill may be disabled, unable to work, and dependent on supplemental security income. Furthermore, one-fourth of U.S. jobs pay less than a poverty-level wage, and the “minimum wage” is often inadequate to meet basic needs. Those lacking a living wage may find it difficult to obtain a mortgage or to pay rent. Growing awareness of the links between housing and health and of the inadequacy of current governmental housing policies has led to an increasing emphasis on affordable housing. Affordable housing costs should not exceed 30 percent of monthly net household income for families that earn less than 80 percent of the median area income.

A literature review conducted by the Center for Housing Policy found a clear impact of housing on health, education and economic development. By investing in affordable housing, cities and communities can move toward a more equitable society. Achieving equality in housing access, cost, neighborhood conditions, and indoor air quality will help to create a more environmentally just and healthier America. Affordable housing frees up resources for food and health care, reduces stress and stress-related health problems, alleviates over-crowding, and allows access to neighborhood resources. Stable, affordable housing improves the health of seniors and those with disabilities, permitting more effective and consistent methods of delivering home care and other services. A well-managed housing unit will usually contain high quality indoor air. New affordable housing developments often use “green building” techniques, which lead to health improvements by limiting indoor allergen exposures and outdoor air pollutants.

Contributing to Allergies & Asthma

Substandard housing is intimately linked to asthma, the most common chronic disease of childhood. Over 4 million children in the U.S. have asthma, a prevalence of over 5 percent. Approximately 40 percent of doctor-diagnosed asthma cases are a result of residential exposures. Assessing a patient’s environment and identifying indoor air asthma triggers can help to prevent symptoms, prevent emergency department visits, reduce hospitalizations, and decrease the need for medications. The National Environmental Education Foundation publicizes an environmental history form, which healthcare providers can use in the office to help evaluate a patient’s indoor air environment.

The following subsections describe the major indoor air contaminants frequently found in substandard housing that contribute to asthma and allergies, (especially in the pediatric population), along with interventions to minimize exposures.

Pets: Pets produce dander, feces, urine and saliva, all of which can cause allergic reactions and contribute to asthma. Pet allergies and asthma frequently co-exist. To reduce exposure to animal allergens, health care providers should recommend keeping animals out of the home or at least out of the bedroom, and removing carpeting and “animal furniture” if possible. Washing hands and clothes after contact, frequent vacuuming, and bathing pets weekly can help as well.

Dust Mites: Dust mites are 0.15 mm long relatives of spiders, feed off dead skin cells, and thrive under conditions of high humidity. Dust mites live in bedding, pillows, mattresses, upholstered furniture, carpets, and drapery. Dust mites not only exacerbate existing asthma, but may cause asthma to develop in the first place. Dust mite control involves encasing pillows and mattresses in allergen-impermeable covers, moving mattresses off the floor, washing bedding weekly in warm water, and air drying or using a clothes dryer to remove all moisture. Keeping humidity in homes below 50 percent, removing carpets from the bedroom, and avoiding upholstered furniture can help to minimize dust mite exposures. Childrens’ stuffed toys should be washed weekly in hot water and dried thoroughly.

Cockroaches: Cockroach allergens arise from saliva, feces, and dead body parts. Over 60 percent of asthmatic children are allergic to cockroaches. When such children suffer from asthma and are exposed to cockroaches, they tend to get more severe asthma attacks and miss more school days than those not exposed. Homes with no sign of living cockroaches still may have measurable amounts of cockroach allergens. Minimizing cockroach and other pest infestations requires fixing plumbing leaks and other moisture problems, removing piles of boxes and newspapers from the home, sealing all entry points, storing garbage in containers with secure lids, and removing trash daily. If possible, poison baits, boric acid, and insect traps should be used in lieu of pestcides.

Mold: Molds have been linked to respiratory complaints, asthma, allergies, and eczema. Mold grows anywhere excess moisture exists, including on wood surfaces, within insulation materials, beneath carpets, and under bathroom tiles. Three causes of excess moisture can lead to mold: overall high humidity, cold walls, and water infiltration. Improving ventilation and increasing air circulation (such as through the use of ceiling fans), along with using a dehumidifier, can decrease humidity and prevent mold growth. Leaks and spills should be completely dried within 24-48 hours. The Environmental Protection Agency recommends scrubbing hard surfaces with detergent and water and drying completely to remove mold, but absorbent or porous materials, such as ceiling tiles and carpet, may have to be thrown away.

Household Appliances: Many household heating appliances emit smoke and gases, including particulate matter, sulfur dioxide (SO2), and nitrogen dioxide (NO2), which cause lung irritation and increase one’s sensitivity to other asthma triggers. Heating systems should be inspected annually and chimneys kept clean. Avoid using wood-burning fire stoves for heating, as they can increase a number of toxic air pollutants. Kitchen exhaust fans help to dissipate smoke pollution and control excess humidity.

Volatile Organic Compounds: Volatile organic compounds (VOCs) are found in a variety of household items, including cleaning supplies, fragrances, candles, and paint. Domestic exposure to VOCs may increase the risk of childhood asthma. Such items should be replaced by low VOC products. Consider a cotton ball soaked in vanilla as an air freshener, or heating water with lemon and cloves to provide a pleasant fragrance without emitting VOCs.

Other techniques to minimize indoor air pollutants include decreasing the amount of carpeting, vacuuming 1-2 times/week, drying after damp mopping, using air conditioners with clean filters, installing dehumidifiers in high-humidity areas, and using HEPA filters to reduce indoor allergens. Unfortunately, many of these interventions are expensive and require significant installation efforts or even structural changes.

Conclusion

Housing quality is an important social determinant of health and a marker of class- and race-based inequities in U.S. society. Poor housing contributes to a variety of adverse health outcomes, particularly among children. Though it is important to attempt to minimize indoor air pollution in individual homes, more widespread and equitable change will come through community- and policy-level initiatives and stronger legislation to require healthier homes and neighborhoods. Public health professionals and health care providers must fight to create universal, equitable housing policies that benefit our most vulnerable populations.

Z

Martin Donohoe MD is adjunct associate professor at the School of Community Health Portland State University and senior physician of Internal Medicine at Kaiser Sunnyside Medical Center. Safina Koreishi is clinical director of quality and will be family physician for Neighborhood Health Centers starting November 2011. Lila Wickham is Environmental Health Director for the Multnomah County Health Department, working on related issues--food, water, housing, vector borne diseases, and health threats like global climate change. Z apologizes for omitting Koreishi and Wickham as co-authors in the print version of Z.
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