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Try out PMC Labs and tell us what you think. Learn More. Donna L. Poor housing conditions are associated with a wide range of health conditions, including respiratory infections, asthma, lead poisoning, injuries, and mental health. Addressing housing issues offers public health practitioners an opportunity to address an important social determinant of health. Public health has long been involved in housing issues.

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In the 19th century, health officials targeted poor sanitation, crowding, and inadequate ventilation to reduce infectious diseases as well as fire hazards to decrease injuries. Now is the time for public health to create healthier homes by confronting substandard housing.

Housing is an important determinant of health, and substandard housing is a major public health issue. The public health community has grown increasingly aware of the importance of social determinants of health including housing in recent years, 7 yet defining the role of public health practitioners in influencing housing conditions has been challenging.

Housing and health: time again for public health action

Responsibility for social determinants of health is seen as lying primarily outside the scope of public health. The quality and accessibility of housing is, however, a particularly appropriate area for public health involvement. An evolving body of scientific evidence demonstrates solid relations between housing and health. The public health community is developing, testing, and implementing effective interventions that yield health benefits through improved housing quality. Public health agencies have valuable expertise and resources to contribute to a multisectoral approach to housing concerns.

Public health has a long albeit intermittent history of involvement in the housing arena, and this involvement is generally accepted by other housing stakeholders e.

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Housingrelated health concerns such as lead exposure and asthma are highly visible. The public is also concerned about the quality and accessibility of housing as affordable housing becomes scarcer. In this article, we describe some of the evidence linking housing conditions to health, place public health's role in addressing housing issues in an historical context, provide examples of contemporary local public health activities in the housing arena, and conclude with suggestions for public health action in the next decade.

An increasing body of evidence has associated housing quality with morbidity from infectious diseases, chronic illnesses, injuries, poor nutrition, and mental disorders. We present some of this evidence in the following section. Features of substandard housing, including lack of safe drinking water, absence of hot water for washing, ineffective waste disposal, intrusion by disease vectors e. In more recent years, epidemiological studies have linked substandard housing with an increased risk of chronic illness. Damp, cold, and moldy housing is associated with asthma and other chronic respiratory symptoms, even after potentially confounding factors such as income, social class, smoking, crowding, and unemployment are controlled for.

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Ineleven million occupied homes in America had interior leaks and 14 million had exterior leaks. Old, dirty carpeting, often found in substandard housing, is an important reservoir for dust, allergens, and toxic chemicals. Pest infestations, through their association with asthma, provide another linkage between substandard housing and chronic illness. Cockroaches can cause allergic sensitization and have emerged as an important asthma trigger in inner-city neighborhoods.

Children with asthma who are sensitized and exposed to cockroaches are at elevated risk for hospitalization. Inadequate food storage and disposal facilities provide them with opportunities for obtaining food. Dead spaces in walls harbor pests and permit circulation among apartments in multiunit dwellings.

Deviation of indoor temperature beyond a relatively narrow range has been associated with increased risk of cardiovascular disease. Exposure to toxic substances found in homes can result in chronic health problems. The association of passive exposure to indoor tobacco smoke with respiratory disease is well documented.

The importance of deing homes to prevent injuries has received long-standing attention, 60 especially with regard to reducing burns and falls. These hazards are frequently present in temporary accommodations provided to homeless women and young children. Recent analyses of longitudinal cohorts of children have examined the influence of childhood housing conditions on the subsequent development of chronic diseases. A study conducted in Britain demonstrated modest associations of inadequate ventilation with overall mortality respiratory mortality was not specifically examined and type of water supply with coronary heart disease mortality, independent of other measures of deprivation.

Lack of affordable housing has been linked to inadequate nutrition, especially among children. Relatively expensive housing may force low-income tenants to use more of their resources to obtain shelter, leaving less for other necessities such as food. Substandard housing may also adversely affect mental health, although the evidence is more tentative.

Excessive indoor temperature has been linked with irritability and social intolerance.

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High-rise buildings may inhibit social interaction because they lack common spaces. In summary, substandard housing affects multiple dimensions of health. There is evidence that, in part, poor housing conditions contribute to increasing exposure to biological e. In addition, concerns about substandard housing and fear of homelessness are psychosocial stressors that can lead to mental health problems. Preliminary research has suggested that residents' perceptions of their homes e.

For example, excessive noise common in poorly insulated housing units has been associated with sleep deprivation that le to psychological stress and activation of the hypothalamic—pituitary—adrenal axis and sympathetic nervous system. These factors are major contributors to allostatic load the wear and tear accumulated by an organism as a result of physiological responses to environmental stressors.

Beyond the condition of the housing unit itself, the site of the home may be a determinant of health.

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Neighborhood-level effects on health have been documented; these include elevated rates of intentional injury, 79, 80 poor birth outcomes, 81 cardiovascular disease, 82 HIV, 83 gonorrhea, 84 tuberculosis, 85 depression, 86 physical inactivity, 87, 88 and all-cause mortality 89— 91 in neighborhoods of low socioeconomic status, independent of individual-level risk factors.

Several features of these neighborhoods may contribute to poor health. Air quality may be poor because of their proximity to sources of vehicle exhaust emissions such as major ro, bus depots, airports, and trucking routes. Yet it is possible to de neighborhoods to promote health by considering sidewalk and street de, the presence of green spaces and recreational sites, and the location of schools, work, and shopping within walking distance of homes.

When 5-year-old Jose and his 3-year-old sister Maria suddenly developed breathing problems, their doctor was puzzled. The usual medical treatments didn't work, and the symptoms persisted even after their mother followed instructions to rid the apartment of rugs, dust, and cockroaches. The pediatrician initially disregarded the mother's frustration with her neighbor's smoking—until she realized that the smoke flowed right into Jose and Maria's apartment through a large hole in the living room wall.

Social dimensions of neighborhoods also affect health. Sampson and colleagues examined the relation between collective efficacy a combination of trust, social cohesion, and informal social control and violence in Chicago neighborhoods and concluded that rates of neighborhood violence were lower in areas with high collective efficacy. Exposure to substandard housing is not evenly distributed across populations.

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People of color and people with low income are disproportionately affected. For example, Blacks and low-income people are 1. Disparities in asthma morbidity may be attributable, in part, to disproportionate exposure to indoor environmental asthma triggers associated with living in substandard housing. Clutter stemming from lack of storage space and hazardous cooking facilities also contribute to increased risk of injury from fire. As housing and energy prices continue to climb, low- and moderate-income households make tradeoffs between having enough food, staying warm, and living in adequate housing, with resultant adverse effects on health.

The notion of housing as a public health issue is not new.

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In the middle of the 19th century, pathologist Rudolf Virchow advised city leaders that poorly maintained, crowded housing was associated with higher rates of infectious disease transmission. Interest in housing as a determinant of health has fluctuated in response to housing-related infectious disease outbreaks e.

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Later in the century, the sanitary reform movement was spurred by urban industrialization and growing class conflict. The depression and social unrest of the s brought renewed public health attention to housing. During the post—World War II period, a lack of affordable housing, exacerbated by the return of veterans and migration from the rural South, increased the prominence of the housing issue. In the s through the s, activists addressed racial disparities in housing, the civil rights movement resulted in legislation prohibiting discrimination in housing, and indoor lead exposure became a major public health concern.

Although a comprehensive history of public health involvement in housing is beyond the scope of this article, we next provide several illustrative examples. In the early s, the relation between housing conditions and health was recognized among public health practitioners in the United States — and Europe — and led to the rise of the sanitary reform movement. Industrialization caused a rapid growth in urban populations that was not matched by a sufficient increase in adequate housing.

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Builders, eager to capitalize on the need for housing, built inferior housing in congested areas of cities. The response to this situation established the basis of public health action at the local and national levels and clearly established the link between public health and housing.

In the United States, the sanitary reform movement was carried out by boards of health and in some cases by voluntary health associations consisting of physicians, public officials, and other civic-minded citizens. These reforms succeeded in controlling the epidemics of infectious diseases.

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The recognition of lead-based paint as a health hazard is another important chapter in the history of public health involvement in housing. As early asthe health consequences of lead exposure were discussed in the medical literature. By the mids, there was strong evidence that lead poisoned those exposed to it and was especially harmful to children. It continued an aggressive campaign throughout the 20th century, providing free diagnostic tests for lead poisoning, inspecting houses, requiring the removal of lead by landlords, and mandating the inclusion of warning labels for lead-based paint.

Ultimately, the Consumer Product Safety Commission prohibited the use of all lead paint after InC. He observed. Thirty years ago, our major emphasis was transferred from the physical environment to the individual. Today, we must shift our gaze from the individual back to the environment, but in a broader sense…to the whole social and economic environment in which the individual lives and moves and has his being. He therefore led the Hygiene and Public Health Committee in an examination of the components of healthy housing in terms of physical, physiological, and psychological needs.

APHA has periodically updated these guidelines on healthy housing. Current public health efforts to improve housing conditions include a continuation of these historical activities as well as new strategies based on emerging issues such as indoor environmental quality. The development and enforcement of most housing codes are the responsibility of housing and construction departments. Our health department, like most others, issues and enforces housing codes that address a limited set of concerns e.

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Local codes are based on national uniform codes that set minimal standards for new housing construction, fire safety, plumbing, and mechanical systems. However, these codes consider only a subset of the conditions that affect housing quality.

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