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Housing Is Health Care

      Shelter is a fundamental resource, necessary for survival. The creation of adequate housing permits human beings to live in a wide range of climates and to be safe from stalking predators. The creation of systems of shelter form the foundation for community, as in the myth of the first house, which was not built singly but as one of a collection of houses.
      • Dripps R.D.
      The first house: myth, paradigm and the task of architecture.
      Housing permits us to attend to other goals of life, as per Maslow's hierarchy of needs or George Carlin's riff about home as the place that holds our stuff while we go out and get more stuff.
      • Carlin G.
      A place for my stuffAtlantic Records, 1981.
      That said, in a market economy, housing becomes complicated by money, especially if there is no acknowledged right to housing that ensures housing for all. In the U.S., housing has become confounded thoroughly with the creation of wealth, which helped to fuel a massive increase in housing costs for owners and renters alike. This inflated bubble of housing prices burst in 2005, linked to a crisis of subprime lending and precipitating a major recession. Another source of the housing bubble is a chronic housing famine, started in the 1930s by efforts at slum clearance that destroyed but did not replace the lowest rung of the housing market. Subsequent policies— including urban renewal in the 1950s and 1960s and HOPE VI, which has leveled public housing in the 1990s and 2000s— have also destroyed low-cost housing without replacing it.
      • Fullilove M.T.
      Root shock: how tearing up city neighborhoods hurts America and what we can do about it.
      This housing famine puts pressure on all segments of the housing market and has been an important contributor to the housing affordability issues around the U.S.
      High housing costs might affect health by precipitating homelessness, draining resources from other fundamentals like food and health care, or creating instability. In this issue of the American Journal of Preventive Medicine, Pollack and colleagues
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      report how they made use of the Philadelphia Health Management Corporations (PHMC) 2008 Southeastern Pennsylvania Household Health Survey to test for an association between perception of strain in paying for housing and self-reports of health problems. They found that an important set of items was linked significantly with trouble paying for housing, including self-reports of poor health, hypertension, arthritis, and deferral of healthcare visits and buying medication. The list of negative associations was even longer for those under the most strain: They also reported psychiatric problems and being current smokers. Interestingly, in another publication, Pollack and Lynch
      • Pollack C.
      • Lynch J.
      Health status of people undergoing foreclosure in the Philadelphia region.
      used the PHMC survey as a comparison for a group under extreme strain of housing costs— those in foreclosure. By comparison, the foreclosure group was more likely to meet criteria for major depression, have put off filling prescriptions, and have financial troubles because of medical costs.
      The data in these two studies
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      • Pollack C.
      • Lynch J.
      Health status of people undergoing foreclosure in the Philadelphia region.
      suggest that the number and severity of health problems may go up as the strain of housing costs increases, confirming the link between costs and ill health. There are, however, other pathways between housing and health. In that regard, it is worth considering a set of findings reported by Wallace and colleagues,
      • Wallace D.
      • Wallace R.
      • Rauh V.
      Community stress, demoralization, and body mass index: evidence for social signal transduction.
      who studied distress among young women living in Northern Manhattan. Among study subjects, those women who had suffered from material deprivation, including strain in meeting housing costs, reported very high demoralization scores. The authors did a further analysis by neighborhood in which they divided Northern Manhattan into five areas that were rated for stress using socioeconomic and health indicators. The most demoralization was found among women living in the middle quintile—neither the worst nor the best neighborhoods—but the highest BMIs were found among women in the bottom quintiles. An examination of rent costs showed that rent varied directly with the measure of neighborhood stress, such that women in the worst areas had the lowest rents. Thus, although they were reporting less distress and they were not strained to pay for housing, their weight presaged serious health problems. This entirely different pathway features low housing costs and ill health.
      Pollack and his colleagues
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      were not able to carry out such a thorough multilevel analysis. They noted, “People who report unaffordable housing costs were also more likely to report worse perceived neighborhood quality.” The perception of neighborhood quality is key here, in light of Wallace et al.,
      • Wallace D.
      • Wallace R.
      • Rauh V.
      Community stress, demoralization, and body mass index: evidence for social signal transduction.
      as the people who are unhappiest with their situations may not be those living in the worst situations, measured by objective data. Pollack and colleagues
      • Pollack C.E.
      • Griffin B.A.
      • Lynch J.
      Housing affordability and health among homeowners and renters.
      did not have such objective data to weight against the perception of neighborhood quality. Studies able to examine multiple levels of scale will be helpful in deepening our knowledge of the ways in which various pathways from housing to illness contribute to population-level health.
      In the meantime, this study of housing affordability appears at a time when much policy effort is directed at stabilizing the housing markets. The link Pollack's team has demonstrated between housing and ill health provides support for policies that ensure access to housing. Some work has been done to assess the evidence for housing interventions that improve health. One such study was carried by national, nonfederal Task Force on Community Preventive Services, which recommends
      tenant-based rental assistance programs on the basis of sufficient evidence of reductions in exposure to crimes against person and property and decreases in neighborhood social disorder.
      • Anderson L.M.
      • St. Charles J.
      • Fullilove M.T.
      • et al.
      Providing affordable family housing and reducing residential segregation by income: a systematic review.
      Despite their proven effectiveness, voucher programs alone are not enough. Until we resolve the chronic housing famine, the nation will be unable to provide housing to all its citizens. Those not housed, precariously housed, or paying too much for their housing will suffer worse health. The recognition of these facts led a group of AIDS activists to proclaim that “housing is healthcare” (www.renaldi.com/portfolio/index.html). This concept was taken up by the National Health Care for the Homeless Council (NHCHC).
      National Health Care for the Homeless Council
      Housing is health care.
      In a policy brief, NHCHC's executive director John Lozier wrote, Housing improves health for the same reasons that homelessness is deleterious. A clean, dry, secure environment is fundamental to personal hygiene (including wound care and dressing changes), medication storage (refrigeration of insulin, safe storage of needles), and protection from assault and the elements. Private space allows for the establishment of stable personal relationships; housing has been shown to reduce risky sexual behaviors. A stable residence facilitates effective interaction with others, including treatment providers and social support systems, and increases adherence to treatment plans including regular meals and keeping appointments. Housing may reduce anxiety and consequently reduce stress-related illnesses. In these ways, housing both promotes health and prevents the onset of new illnesses.
      • Dripps R.D.
      The first house: myth, paradigm and the task of architecture.
      As Pollock and colleagues point out, one crucial proviso is that the housing has to be affordable. These are worthy goals for a society.
      No financial disclosures were reported by the author of this paper.

      References

        • Dripps R.D.
        The first house: myth, paradigm and the task of architecture.
        MIT Press, Cambridge MA1997
        • Wikipedia
        • Carlin G.
        A place for my stuffAtlantic Records, 1981.
        • Fullilove M.T.
        Root shock: how tearing up city neighborhoods hurts America and what we can do about it.
        Ballantine Books, New York2004
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        • Griffin B.A.
        • Lynch J.
        Housing affordability and health among homeowners and renters.
        Am J Prev Med. 2010; 39: 515-521
        • Pollack C.
        • Lynch J.
        Health status of people undergoing foreclosure in the Philadelphia region.
        Am J Public Health. 2009; 99: 1833-1839
        • Wallace D.
        • Wallace R.
        • Rauh V.
        Community stress, demoralization, and body mass index: evidence for social signal transduction.
        Soc Sci Med. 2003; 56: 2767-2778
        • Anderson L.M.
        • St. Charles J.
        • Fullilove M.T.
        • et al.
        Providing affordable family housing and reducing residential segregation by income: a systematic review.
        Am J Prev Med. 2003; 24: 47-67
        • National Health Care for the Homeless Council
        Housing is health care.