Housing as a determinant of health equity: A conceptual ...

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Abstract

Housing is a major pathway through which health disparities emerge and are sustained over time. However, no existing unified conceptual model has comprehensively elucidated the relationship between housing and health equity with attention to the full range of harmful exposures, their cumulative burden and their historical production. We synthesized literature from a diverse array of disciplines to explore the varied aspects of the relationship between housing and health and developed an original conceptual model highlighting these complexities. This holistic conceptual model of the impact of housing on health disparities illustrates how structural inequalities shape unequal distribution of access to health-promoting housing factors, which span four pillars: 1) cost (housing affordability); 2) conditions (housing quality); 3) consistency (residential stability); and 4) context (neighborhood opportunity). We further demonstrate that these four pillars can lead to cumulative burden by interacting with one another and with other structurally-rooted inequalities to produce and reify health disparities. We conclude by offering a comprehensive vision for healthy housing that situates housing&#;s impact on health through a historical and social justice lens, which can help to better design policies and interventions that use housing to promote health equity.

Keywords:

Socioeconomic factors, Housing, Health status disparities, Residence characteristics, Healthy housing

4.&#;Discussion

An expansive body of literature indicates severe health implications of housing insecurity across four pillars that are disproportionately borne by marginalized populations. The philosopher Norman Daniels () has argued that health care has a special moral importance because it enables normal functioning and thus equality of opportunity; we extend this claim to housing. Given the impacts of inadequate housing on wide-ranging aspects of health and well-being, access to decent housing is essential to opportunity. Further, disparities in access to decent housing did not emerge naturally, but were socially produced and imposed upon the marginalized largely through discriminatory private and governmental actions, inequitable policies, and a failure to create protective policies. Housing disparities are fundamentally unjust and merit remedial action because of their significant impact, their concentration among the most vulnerable, and their socially created and unnatural origins that represent a failure of American government to uphold its responsibilities. Policy interventions that work with public and private housing providers and local authorities to create more equitable housing opportunities are therefore justified and long-overdue.

It is urgent for public health practitioners to act on housing as a tool to reduce, rather than exacerbate, health disparities. To do so, the field of public health should adopt a vision for equitable, healthy housing and identify strategies to achieve it. The vision is articulated as follows:

• Health equity in housing would entail opportunities for all individuals, regardless of race/ethnicity, socioeconomic status, household composition, or zip code, to benefit from developments in modem building, science, fair maintenance practices, community planning, and creative uses of space through programming, to foster a culture of health and social connections.

• Indoors: Homes and buildings would be newly built, renovated, and maintained to reflect standards such as energy efficiency, adequate space, appropriate ventilation, good lighting, and smoke-free policies. Meanwhile, hazards such as lead paint, asbestos, mold and pest infestation would be effectively abated.

• Outdoors: Amenities such as green space, community rooms, play areas, and quiet zones, along with active design elements such as well-lit and easily accessible stairways and walkways, would be standard practice rather than luxury items, afforded to renters and homeowners at all income levels and adapted for multiple housing types (i.e., multiple-unit housing and single-family homes/communities).

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• Health equity in housing would also involve development subsidies to expand affordable housing at a wider range of income levels and siting of affordable housing developments in high-opportunity neighborhoods.

• Lastly, land-use and zoning policies would support health-promoting institutions and recreational opportunities while also retaining stability for local residents and small businesses as new developments are introduced. The distribution of hazardous facilities would be more even across communities.

Housing plus health equity strategies should span all four pillars of housing by: 1) encouraging the physical design and programming of residential space to promote health; 2) adopting a health-in-all-policies approach to housing and community development; 3) preserving, improving and better connecting existing affordable housing; and 4) expanding supportive housing options for populations facing the greatest barriers to access. Additionally, given that the origins of housing disparities are rooted in unjust actions and inequitable neglect by policymakers, effectively-targeted solutions to preventing and alleviating housing disparities must occur at the policy level and should include comprehensive solutions to correct past injustices. Furthermore, because the policies and processes that caused housing disparities emerged from a denial of the full humanity and equality of marginalized groups (or what Atuahene refers to as &#;dignity takings&#;), and because housing disparities continue to be exacerbated by inequalities also caused by this denial, this vision should include more than material compensation, but also pathways towards broader integration and empowerment (&#;dignity restoration&#;) (Atuahene, ).

Admittedly, such a vision of housing is rooted in a normative notion of equity and could raise concerns regarding cost. However, costs may be at least in part mitigated by downstream savings. Investments that ensure decent housing quality, stability, affordability and neighborhood conditions could produce cost-offsets, most obviously in health care, but also in sectors such as energy, education, and the economy (Braubach et al., ). Public administrators who make siloed decisions about housing or healthcare may fail to recognize how deferred costs in one realm may create additional expenses in the other. For example, asthma caused by deficient housing is not only a health issue, but a social and economic problem; one recent study estimates the total cost of asthma in the United States as $81.9 billion per year (Nurmagambetov et al., ). Poorly controlled asthma results in preventable emergency room visits, lost productivity at work (Akinbami et al., ), lower academic achievement, and fewer long-run life chances (United States Department of Labor, Bureau of Labor Statistics, ). By these measures, housing investments may be significantly lower-cost than they appear in the long run.

5.&#;Conclusion

This review offers a conceptual model for the relationship between housing and health equity, identifying key aspects of housing that relate to health, assessing exposure disparities, and demonstrating the origins of this unequal exposure in structural inequality. Historically and contemporaneously, race and class have shaped different housing opportunities for marginalized groups in the U.S., such that low-income and racial/ethnic minority groups are more likely to inhabit substandard housing in neighborhoods with adverse health attributes. They also struggle with residential instability and lack of affordability. These housing issues are associated with a comprehensive range of health consequences, whose impact on marginalized residents is especially severe given the likelihood of multiple simultaneous exposures and individual vulnerability due to chronic stress.

The notion that decent housing is a luxury rather than a right presents a fundamental threat to health and social equity. There is a critical need to shift the present discourse, and even more importantly, practice, such that adequate attention is given to the underlying housing conditions that support health, well-being, and a sense of community. Paramount to achieving health equity is recognizing housing as an important source of health and well-being, not just among stakeholders in public health, but also in the multi-sectorial fields that intersect with housing. Advancing this narrative will require interdisciplinary collaboration between clinicians, public health practitioners, city and regional planners, housing developers, and architects to consider the health impacts of housing affordability, conditions, stability, and the surrounding community.

Acknowledgements

The authors gratefully acknowledge the contributions of Dr. Ronald Bayer in reviewing an earlier draft of this manuscript and Samantha Sawyer for providing editorial support. DH has no conflicts of interest to report. CS reports employment at a wellness real estate and technology company whose work and offerings include the design of indoor spaces to improve the health and wellness of occupants of the space (beginning after the manuscript was drafted). The writing of this manuscript was partially supported by a JPB Environmental Health Fellowship granted to Diana Hernández and managed by the Harvard T.H. Chan School of Public Health Grant; and a Career Development Grant from the National Institute of Environmental Health Sciences (NIEHS) under Grant P30ES.

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