Facts of Life
Facts of Life:
Issue Briefings for Health Reporters
Vol. 8, No. 6
June 2003
Shouting from the Rooftops:
Where We Reside Can Affect Our Lives
The Issue
The Facts
Interview with Mindy Fullilove, M.D.:
Dwelling on Dwellings:
The Importance of Housing in Community Health
Interview with David Berrigan, Ph.D.:
Talking the Talk, Walking
the Walk: How Neighborhood Design Affects Residents’ Exercise
Health Problems Associated With Homelessness
The Story Behind the Subsidy: How Public Housing Works
Safe at Home: Making the Household a Healthy Place
Bibliography
The Issue:
Shelter is a basic human need. Our residential environment — homes,
neighborhoods and communities, plays an important role in health. Neighborhood
designs can affect choices about exercise and other health-promoting activities.
Not having access to affordable housing and being homeless also can lead
to increased health risks. Health behavior researchers are beginning to
investigate how the residential environment influences individual and community
health and how to intervene to improve health.
The Facts:
- Housing and neighborhood characteristics affect physical activity.
Urban and suburban residents of homes built before 1974 are more likely
to walk a mile or more at least 20 times a month compared to newer home
residents. [1]
- More than 12.5 million people in the United States, including more
than 4 million children, live in substandard housing or pay more than
50 percent of their income for housing costs. [2]
- Unaffordable rent is associated with inadequate childhood nutrition
and growth. [2] Children in substandard housing are at higher risk of
asthma, burns and other types of injuries. [3] Also, lead-based paint
has been linked to neurological damage in children. [4]
- Lead poisoning can result in lower IQs, behavior problems and growth
problems. Approximately 434,000 U.S. children under age 5 (about 2 percent)
have elevated blood lead levels. [5] Most at risk are kids who are African-American
or impoverished or live in older homes. [6]
- Asthma affects almost 5 million
children 18 and under in the United States. The cost of treating children’s
asthma is about $3.2 billion yearly. [7]
- In one study, 37 percent of children in inner cities reacted to cockroach
allergen; 50 percent of their bedrooms had dust with high levels of cockroach
allergen, which is associated with hospitalizations and medical visits
for asthma. [8]
- At current levels, the minimum
wage is not sufficient in any state to enable a family with one full-time
worker to afford the federal fair
market rate for a two-bedroom apartment while spending no more than
30 percent of the worker’s income. [9]
- In 1998, more than 660,000 families were on waiting lists in 18 metropolitan
areas for the federal Section 8 housing assistance program; average waiting
time was 28 months. Their housing conditions while waiting were significantly
worse than the conditions of voucher-assisted housing, potentially endangering
the health of their children. [3]
- Homeless children in New York City are less likely to have received
appropriate immunizations (61 percent of homeless 2-year-olds had not
received full immunization, compared to 23 percent of all 2-year-olds)
and are four times more likely to have asthma. Homeless children also
suffer from ear infections at rates that are 50 percent higher than the
national average. [10]
- Homelessness is also associated with severe hunger in preschool and
school-age children. [11]
- Six percent of elderly people in the United States (1.45 million households)
live in homes in need of repair and rehabilitation. Of these, one-third
live in housing that threatens their health and well-being because it
is severely substandard. [12]
Interview:
Dwelling on Dwellings: The Importance of Housing in Community Health
with Mindy Fullilove, M.D.
Mindy Fullilove, M.D., is a professor of clinical psychiatry and
public health at the New York State Psychiatric Institute at Columbia
University.
She conducts research on the relationship between the structure of cities
and residents’ mental health and is also completing work on urban
renewal in the United States.
Q/ How is housing related to health?
A/ Housing is a basic
human need, both physically and psychologically. A house provides shelter
from the elements
and protection against health threats, such
as communicable diseases, chronic diseases and psychological and social stresses.
But it also is a source of identity — we identify with and become attached
to our homes. A house is important because it’s a place where a family
or household establishes itself in society. Beyond the level of the individual
home, housing is also important because housing units are set in relation to
each other. This creates neighborhoods and communities, which form the physical
infrastructure of group life. [9, 13]
Q/ Are there other ways that housing affects health at the community level?
A/ One pressing health
issue is residential segregation. Residential segregation by income, social
class
and race and ethnicity is increasing. The number of
low-income residents living in extreme-poverty neighborhoods in central city
areas has also risen. The reality in cities is that poor people are living
in some parts and the rich are living in others. In addition, suburbs tend
to be stratified by income. Rather than being built with mixed price ranges,
many suburban subdivisions are very homogeneous in terms of housing prices.
We don’t, in general, mix people of different economic groups together.
Q/ What are the health effects of this type of segregation?
A/ Residential segregation
has several different types of health consequences. Around our homes — in our neighborhoods and communities — there
are resources that we get to use because they’re close by. The array
of available resources changes with investment and disinvestment in the neighborhood,
and housing sets the boundaries of what’s available. For example, is
food easily available in your neighborhood? What kind? From what types of stores?
What are the prices like? What is taken for granted in one neighborhood may
not be accessible in another.
Residential segregation also is an issue in terms of the environment. Toxins
and poisons are more likely to be found in lower-income neighborhoods, so residential
segregation affects who is exposed to health-threatening substances and materials
Q/ Are the effects of residential segregation on health pretty much the same
everywhere?
A/ The health effects of stratification depend on the history of the specific
place and the time period. In inner cities now, for example, violence, infant
mortality and maternal mortality are worse for marginalized people. But the
specific health problems can differ over time.
In 1970, most marginalized
communities would not have had the AIDS epidemic or the crack epidemic because
those
problems hadn’t entered our communities
yet.
But the marginalization of specific groups, in general, produces worse health.
The health problems that characterize a particular time and place will be worse
for marginalized people.
Q/ Are there specific neighborhood characteristics or factors that have been
identified as contributing to better or worse health?
A/ There are several different
conditions that are reflected in what have been called “neighborhood effects.” These
include things such as the availability of employment, the quality of the
physical environment and,
as I mentioned before, the quality and availability of services in the neighborhood.
One other factor that has been identified is social cohesion.
Q/ What is social cohesion?
A/ Social cohesion refers
to the ways in which people work together and depend on each other. Some
of the
ways this happens are not so obvious. For example,
our health depends on the people who keep the sewers in good shape, but we
don’t often think about them — they can be invisible.
We also work together and depend on each other in more obvious ways, through
our involvements with churches and schools, for example. In the best of all
possible worlds, we would value the work of everyone who contributes to social
well-being.
Q/ How does social cohesion affect well being?
A/ As societies are segregated by income, breakdowns occur in social connections.
This makes it more complicated for people to work together.
Stratification negatively
affects the people who are marginalized but it also has negative effects
on everyone;
it has consequences for those who appear
to be privileged as well. If social cohesion is poor, if we are not working
together and depending on each other and there is not good sharing of resources,
those who are not marginalized may feel that they need protections — things
like high walls and guard dogs.
If people feel they have enough and there is good sharing, then there is no
need to take stuff away, no need to protect what we have. Under those conditions
people tend to feel safer and freer.
Q/ Are there other examples of how health is influenced by the patterns or
social structure of housing in our society?
A/ There is an astounding
insufficiency of low-income housing. Many people can get housing only way
outside their
price range, requiring 40 percent or
50 percent or more of their income. They then have to use money for other necessities,
such as health care and can’t pay the rent. As a result, they lose their
housing.
We found in a recent study in Harlem that 25 percent of the current residents
in a housing complex had at one point been homeless, which in turn is associated
with many kinds of health problems. The risks are generational.
You love your home, and
if you lose it that creates psychological problems that will affect your
whole life and
the lives of your children. Losing your
home and becoming homeless creates complex psychological wounds that don’t
heal easily.
Q/ Why is affordable housing so unavailable?
A/ In part this is because of the systematic destruction of low-income housing
through urban renewal without the construction of replacement housing. Title
I of the federal Housing Act of 1949 funded urban revitalization efforts. By
1967, urban renewal had destroyed 400,000 housing units and built 10,000. High-rise
projects are still being destroyed with no one-to-one replacement. These projects
are often replaced with housing for middle-income families. An array of very
specific policies has created a crisis, in part because we have failed to think
of housing stock as precious resource of our society. The result is insufficient
and unaffordable housing.
Q/ Who is especially vulnerable to housing-related health problems?
A/ One group is baby boomers.
Baby boomers are getting ready to retire and we have no place to put them.
Given
the cost of housing and taxes, many people
won’t be able to sustain themselves in their homes. What’s going
to happen over the next 30 to 40 years? This group will experience the increasing
disability and other types of health problems that occur with age in a society
in which there is not enough housing for everyone. It puts pressure on everyone.
It makes everyone vulnerable. The runaway leaps and bounds in housing prices
that we’ve seen in recent years put strain on everyone.
Q/ What is the relationship between urban planning and public health?
A/ There has been little appreciation within public health of the ways in
which housing is part of the social and ecological system and balance of cities.
The concept of blight, which led distressed communities to be destroyed, has
created ecological damage to cities. People in public health have been interested
in housing and housing reform as way to improve health. But though they were
interested in destroying what they thought was bad housing, they were less
able to produce housing that was good. There has been no strong voice within
public health for the creation of affordable housing. From the urban planning
side, planners say that public health concerns about housing put unnecessary
constraints on builders. Much of what has been done in past should be thoughtfully
scrutinized.
Q/ What does the future hold in terms of the involvement of public health
in urban planning issues?
A/ People in some communities, such as the Pittsburgh History and Landmark
Foundation, are providing brilliant leadership around community development.
They are working with residents and making investments in the community.
People in public health need to acknowledge that they are not the experts.
They do not appreciate housing as part of the ecosystem of cities. Until they
appreciate this, they need to stay out of housing debates.
Interview: Talking
the Talk, Walking the Walk: How Neighborhood Design Affects Residents’ Exercise
with David Berrigan, Ph.D.
David Berrigan, Ph.D., M.P.H., is a cancer prevention fellow in the
Applied Research Program at the National Cancer Institute, National Institutes
of Health. He earned a doctorate in ecology from the University of Utah
and a master of public health degree from the University of California,
Berkeley. The focus of Berrigan’s research is on the environmental
effects on physical activity.
Q/ How is cancer prevention tied to housing?
A/ The link is through
the possible influence of housing and neighborhoods on people’s levels of physical activity. The evidence from epidemiological
studies indicates that obesity and sedentary behavior increase the risk of
several different types of cancer, including prostate, bladder, breast and
colon cancer.14 There are both indirect and direct effects of physical exercise
on cancer. Physical exercise has an indirect effect on cancer because increased
levels of activity lead to weight loss or the prevention of weight gain. There
is also a direct effect of physical activity independent of weight loss — for
example, some research indicates that physical activity has a protective effect
for colon and breast cancer.
Q/ Aren’t
there many different factors that influence physical activity?
A/ Yes, there are several
types of influences on whether people are active or not. At the individual
level,
characteristics like age, the kind of job
a person has, whether or not they have children, and psychological attitudes
toward physical exercise are one type of influence. At the cultural level,
factors such as whether exercise is considered a positive or negative thing
may influence an individual’s choices regarding physical activity. Then
there are environmental factors, such as temperature, neighborhood characteristics,
safety and other elements that may affect choices regarding physical activity.
Q/ What aspects of neighborhoods seem most important in promoting physical
activity?
A/ Three components have
been identified as most relevant. These are the density, diversity and design
of the environment.
Density means how far apart or close
things are to each other — if things are far apart, it may not be convenient
to walk the kids to school or walk to the market or to work. Diversity refers
to the mix of residences, businesses and services in the neighborhood. If there
are no schools or stores or workplaces, then it’s not possible to walk
to them. Design pertains to the existence and arrangement of the elements of
the neighborhood or area. Are there sidewalks and streetlights? What’s
the relationship of businesses, schools, etc. to the street? If there is a
big parking lot between you and the store, it’s not as inviting or conducive
to walking as having multiple storefronts with sidewalk access.
Q/ You have looked at the age of housing as an indicator of other neighborhood
characteristics that might affect levels of physical activity. Why housing
age?
A/ The study that we did was based on an existing survey that included questions
about home age, possibly because of the use of lead paint in older homes and
the association of lead with health problems. [1] We thought that home age
might be proxy measure of some important environmental characteristics. For
example, older homes are likely to be in areas of higher density and more diversity.
Q/ What questions did you specifically want to examine?
A/ Our hypothesis was
that neighborhood characteristics are associated with walking behavior. We
found an association
between home age and walking in urban
and suburban areas. People living in the older homes didn’t say that
they did more of other types of physical activities, so the relationship appears
to be specific to walking, which supported our hypothesis.
Q/ So it appears that the way neighborhoods are designed may have an effect
on cancer rates because of influences on activity levels?
A/ Yes, it’s possible, but there hasn’t been enough research to
say that definitively. A point I want to highlight is that although it’s
possible that neighborhoods influence people’s behavior, it also could
be that people sort themselves out into different neighborhoods by what they
like to do. So we have to consider the possibility that people who like to
walk cluster in neighborhoods where they can walk. We just don’t know
at this point, because the studies haven’t been done.
Q/ Are there other factors, such as socioeconomic status, that affect or constrain
clustering or sorting into neighborhoods?
A/ Yes, economic barriers
are likely to be particularly important as a constraint to neighborhood choice:
If housing
is not affordable in the neighborhood where
someone would like to live, they can’t live there. This raises the question
of why there aren’t more neighborhoods that are diverse, aesthetic and
affordable.
Q/ Why do you
think there aren’t
more neighborhoods like that?
A/ This is a policy issue,
but it’s
also hard to develop neighborhoods of that type. There are signs that the
planning community is trying to build
these kinds of neighborhoods. This approach has been called by several different
names, including neo-traditional design or new urbanism. But the intent is
to design communities that are characterized by land use mix and greater density.
Many of those communities have been quite successful, as indicated by the fact
that the housing in them has become quite expensive.
Q/ Has the design
of these neighborhoods had an effect on residents’ physical
activity?
A/ We don’t know. No one has studied these communities to see if people
are walking more. There have been some studies of transportation behavior,
but no studies of physical activity or of different kinds of walking behavior — for
example, walking to stores, restaurants, and other businesses, or of leisure
time walking. Not all people who live in this type of neighborhood do so for
physical activity reasons. We don’t know whether that kind of environment
influences people’s behaviors or not. It would be useful to have the
kind of information that studies of physical activity in these neighborhoods
would provide.
Q/ So there is
still some uncertainty about whether it’s possible to
intervene using neighborhood design to promote more physical activity?
A/ That’s right. The question is, if you change something about a neighborhood,
will that change actually affect physical activity? Take people’s walking
behavior for example. People walk for many different reasons — as part
of a commute, as a way to do errands, for the exercise or simply for pleasure.
That means that different environmental features are going to matter for different
kinds of walking behaviors. In neighborhoods where a land use mix already exists,
that is, where there is a mix of residential properties and businesses and
services, it’s fairly straightforward to encourage walking for daily
living tasks, for errands. Where no land use mix exists, it’s not likely
that it would be possible to put up stores and businesses, but you might be
able to influence leisure time walking. This might be possible by putting in
paths, lighting and other environmental features that are relevant to leisure
time walking. It’s critical to understand that different environment
features are relevant in different situations.
Q/ What can we learn from existing neighborhoods?
A/ Neighborhoods that
appear to encourage walking — that are characterized
by land use mix and density and design elements that are conducive to walking — develop
over the course of time in an organic way. It’s hard to look at existing
land or existing development and think about how to change it to the kind of
neighborhood that we hypothesize would change people’s behaviors. We
don’t know exactly what will change people’s behavior.
Even if we were sure we knew what would be good, it would be very difficult
to know how to make that happen because then we are moving into the policy
arena. Policy decisions about building are particularly challenging because
they are fraught with conflicts about how best to proceed with development.
There are legitimate points of view both supporting and opposing the types
of interventions that hypothetically may be helpful in promoting physical activity
and public health. But more studies are needed to provide the evidence that
would help guide these decisions.
Q/ Is there much communication between urban planners and health behavior
researchers about these issues?
A/ We are just at the
beginning of forming collaborative partnerships between urban planners and
health researchers
to conduct research. Right now, the connections
between urban planners and people who study health behaviors are not very good — there
hasn’t been good effort to link up studies of urban environment and studies
of people’s behaviors. But it is starting to happen more, and support
for these types of collaborative partnerships in research and intervention
is increasing.
Q/ Who is supporting these efforts?
A/ The Centers for Disease
Control and Prevention (www.cdc.gov) and the Robert Wood Johnson Foundation
(www.rwjf.org)
have been spearheading efforts to move
research ahead to support intuitions about the effects of the built environment
on people’s health behaviors. One especially important program has been
the Active Living by Design program sponsored by the Robert Wood Johnson Foundation
(www.activelivingbydesign.org).
Health Problems Associated
With Homelessness
Many people, including families with young children and the elderly,
end up homeless because they cannot find affordable housing or because
they must choose between paying for necessities such as health care,
medications and food and paying for housing.
Homeless adults and children are more likely than the general population to
suffer from a variety of chronic and acute health problems. Poor access to
care makes it difficult to treat or control conditions like HIV/AIDS, tuberculosis,
diabetes, addictive disorders and mental disorders in homeless individuals.
The homeless are also at greater risk of experiencing personal violence, such
as muggings, beatings and rape. [15] In addition, approximately 20 percent
to 25 percent of people who are homeless have serious mental illness, a rate
that is five to six times as high as that in the general U.S. population. [16]
Homelessness does not affect only single adults. Increasing numbers of families
with children are homeless in both urban and rural areas. Families make up
a growing percentage of the homeless population. Flight from domestic violence
is one factor contributing to homelessness. [17]
Members of racial and ethnic minority groups are also homeless in disproportionate
numbers. It is estimated that the homeless population is 50 percent African-American,
35 percent white, 12 percent Hispanic, 2 percent Native American and 1 percent
Asian. [17]
Rural homelessness is less visible than urban homelessness but may pose a
greater health risk. The health of rural residents is in general not as good
as the health of urban residents. In addition, the rural homeless are likely
to have very little or no access to health care. Reports from clinicians indicate
that the health problems they see in both rural and urban clients tend to be
more advanced in the rural homeless, who often do not receive treatment for
their chronic health problems. [18]
The Story Behind the Subsidy: How Public Housing
Works
Publicly supported
housing in the United States takes two primary forms. The first — commonly
known as public housing — consists of physical housing
for low-income people. This housing is subsidized by the government
and rented to low-income households by a local housing authority.
About 1.3 million units of public housing were occupied in 1997.
[19]
The second is housing assistance, or Section 8 vouchers, a federal
program administered by the U.S. Department of Housing and Urban
Development in cooperation with local housing authorities. Section
8 vouchers can be used by low-income people to rent dwellings on
the private market; this assistance takes the form of direct payments
to private landlords by a local housing authority. [20]
Access to
health care is a concern for many residents of publicly assisted
housing.
The federally sponsored Public Housing Primary
Care program, operated by the Bureau of Primary Care of the Health
Resources and Services Administration of the Department of Health
and Human Services, improves access to care. The program supports
20 community-based health centers serving residents of public housing.
These centers provide primary health care services, health education
and disease prevention services. The program’s priorities
include involving public housing residents in program development
and implementation, addressing the special health needs of public
housing residents through innovative services, and collaborating
with other organizations providing health, education and other
community services. [22]
Safe
at Home: Making the Household a Healthy Place
Threats
to health exist inside the home as well as at the neighborhood or
community level. Lead, tobacco smoke, mold, cockroach allergens,
pesticides and some household products have been identified as posing
health risks.
Information
about how to take steps to reduce these health risks is available
from
ToxTown. An interactive site that was developed
by the National Library of Medicine of the National Institutes
of Health, ToxTown provides consumers with information about toxic
substances, health and the environment. The site offers information
about health risks both in the home and the larger community. It
also provides links to other sources of information, including
topic-specific links to MedLine Plus, the National Library of Medicine’s
consumer health information service. Visit http://toxtown.nlm.nih.gov/index.html
Other sources of information about steps to take to reduce health
risks in the home include:
Children’s
Environmental Health Coalition:
HealtheHouse, an interactive resource with information about how
to reduce environmental health risks in the home.
www.checnet.org/healthehouse/virtualhouse/index.asp
Housing and Urban Development publications:
Help Yourself to a Healthy Home: www.hud.gov/offices/lead/healthyhomes/healthyhomebook.pdf
Is Your Home a Healthy Home for Children? (English and Spanish):
www.hud.gov/healthy/index.cfm
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The Center for the Advancement
of Health is an independent nonprofit organization that promotes
greater recognition of how psychological, social, behavioral,
economic and
environmental factors influence health and illness. The Center advocates the highest
quality research and communicates it to the medical community and the public. The
fundamental aim of the Center is to translate into policy and practice the growing body of
evidence that can lead to the improvement and maintenance of the health of individuals and
the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation
and the Nathan Cummings Foundation, which continue to provide core funding. Funding for
this series was provided by the Robert Wood Johnson Foundation.
For Information Contact:
Kristina Campbell
Editor, Health Behavior News Service
Center for the Advancement of Health
2000 Florida Ave., NW, Suite 210
Washington, DC 20009
p. 202.387.2829 / f. 202.387-2857
press@cfah.org
http://www.cfah.org
© Copyright 2003, Center for the Advancement of Health
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