SDOH-Listserv Bulletin No. 6, March 3, 2004
Housing as a Social Determinant of Health
This Bulletin is contributed by Toba Bryant, PhD of York University in
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Housing and Health: Not a New Phenomena
A pamphlet published in 1944 quotes the Chief Medical Officer at the
then new Ministry of Health in United Kingdom at the time on the three
"evils" of inadequate housing: "There is diminished personal cleanliness
and physique leading to debility, fatigue, unfitness, and reduced powers of
resistance. A second result of bad housing is that the sickness rates are
relatively high, particularly for infectious, contagious, and respiratory
diseases. Thirdly, the general death-rates are higher and the expectation
of life is lower. The evidence is overwhelming, and it comes from all parts
of the world - the worse people are housed the higher will be the death
rate."
- J.N. Morris, Health. No. 6, Handbooks for Discussion Groups. London:
Association for Education in Citizenship. Reprinted in M. Shaw, Health and
housing: A lasting relationship. Journal of Epidemiology and Community
Health 2001; 55:291.
The Ottawa Charter for Health Promotion recognizes shelter as a basic
prerequisite for health (WHO, 1986). Yet, Canadian political leaders and
the housing policies they offer are failing to meet the housing needs of
many Canadians. As documented in Federal NDP leader Jack Layton's book on
homelessness, the number of Canadians who sleep in the streets, use
temporary shelters, or spend more than 30% and/or 50% of their income on
housing is increasing at alarming levels (Layton, 2000). These developments
have clear implications for the health of Canadians.
Housing and Health
A recent review of the housing and health literature concluded that
research has focused on, and identified findings in, four key areas (Dunn,
2000). Homeless people experience poor health status and have limited
access to health care. Problematic dimensions of dwellings are associated
with adverse physical and mental health outcomes. Stresses linked with
unaffordable and/or inadequate housing can affect health status. Unhealthy
individuals are disadvantaged in the housing market and are directed into
substandard housing conditions.
The focus here is on three variants of these issues: the health effects of
homelessness, how poor housing conditions influence health, and how
spending excessive amounts of available income on housing influences
health. The experience of homelessness and poor housing conditions are
placed into a broader context of how individuals in Canada systematically
differ in their access to economic and social resources. Poor housing is
just one indicator of potential disadvantage in Canadian society. The link
between one's housing situation and health seems obvious. Homelessness,
inadequate and insecure housing have effects on health and well-being.
While most of those who are homeless appear to be men, most of those living
in poor housing conditions or insecure situations are women with children.
Homelessness and Health.
It would hardly seem necessary to argue the case that housing - and
homelessness in particular - are health issues, yet surprisingly few
Canadian studies have considered it as such. In the UK - where the housing
and health research tradition is more established - numerous studies have
shown strikingly high incidences of physical and mental health problems
among homeless people as compared to the general population. Among 1280
homeless people in the UK who used hostels, bed and breakfast
accommodation, day centres and soup runs, numerous health problems, such as
respiratory and musculoskeltal conditions, were more common than among the
general population (Bines, 1994).
Many other studies find much greater incidence of a variety of
conditions and ailments among the homeless population (see Hwang, 2001).
These include greater incidence of mental illness, HIV infection and
physical violence (Dunn, 2000). A Toronto survey of homeless people found
much higher risk than the general population for chronic respiratory
diseases, arthritis or rheumatism, hypertension, asthma, epilepsy, and
diabetes (Ambrosio et al., 1992). Tuberculosis is more common among the
homeless in the UK (Ramsden et al., 1988) and Canada (Hwang, 2001).
Homeless people are at greater risk of premature death (Shaw,
Dorling, Davey Smith, 1999). In the USA, being without housing shortens
life expectancy by 20 years. The average age of death of homeless people in
Boston is 47 years and in Georgia, 46 years. In the UK, it is 42 years. In
Toronto homeless people die at a younger age than the general population.
Between 1979 and 1990, 71% of homeless people who died were less than 70
years old as compared to 38% in the general population (Kushner, 1998). A
study of 9,000 men who used shelters in 1995 showed young homeless men in
Toronto were eight times more likely to die than men of the same age in the
general population (Hwang, 2000). Keyes and Kennedy found UK homeless
people to be 34 times more likely to commit suicide while Grenier reported
a greater risk of suicide among the homeless of 35 times (Shaw, Dorling,
and Davey Smith, 1999).
It is sometimes argued that these health outcomes cannot be clearly
attributed to being homeless as their presence may precede the experience
of homelessness. It is clear that "While some health conditions may precede
homelessness, it certainly is the case that the daily conditions of
homelessness, both material and psychosocial, compound existing health
problems, cause additional problems, (such as problems with feet and
respiratory illness), and make access to health care more problematic
(Shaw, Dorling, and Davey Smith, 1999, p. 232).
Poor Housing Conditions and Health
An extensive review of the health effects of housing categorized
findings as being either definitive, strong, possible, or weak (Hwang, et
al., 1999). Definitive findings were seen for health effects associated
with the presence of lead, asbestos, poor heating systems, and lack of
smoke detectors. Strong/definitive findings were seen for presence of
radon, house dust mites, cockroaches, and cold and heat. Strong findings
were seen for environmental tobacco smoke. Possible findings were seen for
dampness and mold, high rise structures, overcrowding and high density,
poor ventilation, and poor housing satisfaction. This review used a narrow
set of criteria for isolating the effects of these factors independent of
the presence of other factors, an issue discussed in following sections.
Many studies have investigated the effect of poor housing conditions
such as inadequate heating and dampness on health. A UK survey of older
people reported 25% were not using as much heat as they would have liked
because of cost (Savage, 1988). Studies have confirmed that dampness in
homes contributes to, and exacerbates, respiratory illness. Strachan (1988)
found children living in homes with damp and mould in Edinburgh had
increased risk of developing wheezing and chest problems. Another study
found higher levels of several symptoms for both child and adults in damp
and mouldy houses as compared to those living in dry dwellings (Platt et
al., 1989).
It is difficult to separate the effects of any single variable or
sets of variables upon health, as indicators of disadvantage - poverty,
poor housing, preexisting illness - frequently cluster together. One study
was able to do this. In Home Sweet Home: The Impact of Poor Housing on
Health, Marsh and colleagues (1999) used a lifespan approach to examine the
link between housing and health. The study was based on an analysis of
longitudinal data that examined the link between housing and health among
more than 13,000 citizens. Housing conditions played a significant and
independent role in health outcomes.
Greater housing deprivation shows a dose-response relationship - the worse
the conditions, the greater the health effects -- to severe/moderate ill
health at age 33. Those who experienced overcrowded housing conditions in
childhood to age 11 had higher likelihood of infectious disease as adults.
In adulthood, overcrowding was also linked to increased likelihood of
respiratory disease. Living in poor housing in the past and in the present
make independent contributions to the likelihood of poor health.
Another study of childhood housing conditions and later mortality
showed poorer housing conditions to be generally associated with increased
adult mortality in selected areas in the UK (Dedman et al., 2001).
Statistically significant associations were found between lack of private
indoor tapped water supply and increased mortality from coronary heart
disease, and between poor ventilation and overall mortality.
The Effects of Excessive Spending on Shelter on other Social Determinants
of Health
When spending on housing becomes excessive there is less money
available for other needs. A Canada Mortgage and Housing Corporation survey
compared welfare incomes with rental costs in Toronto (CMHC, 2001). The
average monthly gross welfare income in 2001 for a single adult with one
child aged 1 to 12 years was $957. For two adults with two children, it was
$1,178. At the same time, rent for an average 1-bedroom apartment was $866
and for a 2-bedroom apartment was $1,027. This left less than $100 a month
to cover food and other expenses. Clearly, having little after-rent income
makes it difficult to cover other important expenses such as food, thereby
contributing directly to food insecurity as well as housing insecurity,
malnutrition and consequent poor health. Excessive spending on housing,
reduces amounts to be spent on other social determinants of health.
This situation was clearly described in a recent report on the
impacts of housing insecurity upon children's health (Watt, 2003). Thirty
percent of Canadian families who rent have affordability problems; that is,
less money than needed for other expenses. Fifty-eight percent of
lone-parent - usually female-led -- families who rent have affordability
issues and if the parent of these lone-parent families is under 30 years of
age, the figure rises to 76%. The striking rise in food bank use in Canada
is also being attributed to continuing housing inadequacy and its impacts
upon available monetary resources among the working and non-working poor
(Daily Bread Food Bank, 2002).
Little housing research places the experience of homelessness or
insecure housing into this broader context (Bryant, 2003). There is little
research that considers how insecure housing and related health effects are
integral to issues related to inequalities in material resources that exist
among the population. Another way of putting this is to ask the question
How does the experience of poor housing reflect the general experience of
being materially deprived within a society? This places the issue of the
clustering of disadvantage among individuals into focus and how poor
housing is part of a common pathway to poor health together with other
indicators of economic and social disadvantage (Dunn, 1998; Hwang et al.,
1999; Shaw et al, 1999).
There are significant health inequalities across the entire
socioeconomic spectrum in Canada. These inequalities are related to
differences in access to material resources necessary for health including
housing. Housing research has tended to focus narrowly on the concrete
aspects of housing such as homelessness and material aspects of housing
(Dunn, 2000). There is a need for research that recognizes that housing is
both part of and contributor to the social gradient in health. The goal is
to understand the sources of disadvantage that manifests itself across the
socioeconomic spectrum.
Reasons for the Neglect and Narrow Focus of Housing and Health Research
Despite such calls for an expanded analysis of housing and health
issues, such research is uncommon in Canada. One reason may be the
difficulties such research presents for those trained in traditional
epidemiological methods. Epidemiological models attempt to understand the
relationships between housing and health, but existent models may be
insufficient to capture the complexity of these relationships.
Epidemiologists argue that to identify remedies to disease it is necessary
to isolate specific causes of an outcome such as poor health status. In the
case of housing and health, this can be difficult, if not impossible, as
housing disadvantage is associated with numerous other indicators of
disadvantage.
The relationships investigated in such models do not explain how
people end up in poor housing and the effects of housing on the other
determinants of health. Attempts to identify the unique effect of poor
housing are unable to measure or capture the complexity and interaction
among the social determinants of health. "Some of these problems occur as a
result of the rigid criteria of bio-medical research, particularly in
establishing causal mechanisms, which contradicts the more ethnographic
nature of research on the social causes of illness" (Wilkinson, 1999, p.
3). These models also focus on individuals instead of considering the
effects of various policies and programs on groups within society. They
rarely consider the effects of income on both housing quality and health.
They may end up blaming individuals for their poor housing conditions
instead of addressing larger structural issues -- such as housing policy --
that may contribute to their housing circumstances.
Income affects the type of housing people have. If people have low
income, they are likely to live in poor housing. High income increases
choices for housing and influences general living conditions. Income and
housing insecurity also create stress.
Stress and the Housing and Health Relationship
There is overwhelming evidence that social and environmental
conditions determine the presence of health-damaging stress (Brunner and
Marmot, 1999). Especially important conditions are the availability of
adequate housing and income. Lack of monetary resources is frequently
related to public policy decisions that reduce the availability of both
affordable housing and monetary resources.
Researchers in Britain are leaders in investigations of how
material deprivation creates health damaging stress (Davey Smith, 2003). In
fact, Brunner and Marmot (1999) report that social and psychological
circumstances can "seriously damage" health in the long term. Chronic
anxiety, insecurity, low self-esteem, social isolation, and lack of control
over home and work weakens mental and physical health. The human body has
evolved to react to emergencies. This reaction triggers a whole range of
stress hormones that affect the cardiovascular and immune systems.
The ability to respond to a crisis is highly adaptive and can
save life in the short term. However, if the biological stress reaction
system is triggered too often and for too long, as it is for people living
in poor or insecure housing and on low income, it results in considerable
health damage. This includes depression, vulnerability to infection,
diabetes, high blood pressure, and build up of cholesterol in blood vessel
walls, with the related risks of heart attack and stroke. Individuals who
are materially disadvantaged and experience income, housing, and food
insecurity experience greater stress with associated increased risk of
morbidity and premature death.
Understanding the Complexities of the Housing and Health Relationship
James Dunn and others identified knowledge gaps in the understanding
of the housing and health relationship (Dunn et al., 2002). Dunn argues
that, "Housing, as a central locus of everyday life patterns, is likely to
be a crucial component in the ways in which socio-economic factors shape
health (p. iii)." The framework identifies three housing dimensions
relevant to health.
a) Material Dimensions refer to the physical integrity of the home
such as the state of repair; physical, biological, and chemical exposures
in the home, and housing costs. Dunn notes that housing costs are critical
because they are one of the largest monthly expenditures most people face.
When housing costs eat up most of people's income, it affects other aspects
of their lives.
b) Meaningful Dimensions refer to sense of belonging and control in
the home. Home is also an expression of social status - prestige, status,
pride and identity - all of which are enhanced by home ownership. These
dimensions also provide for the expression of self-identity, and signify
permanence, stability, and continuity in everyday life.
c) Spatial dimensions refer to a home and its immediate environment.
For example, the proximity of a home to services, schools, public
recreation, health services and employment. This also includes systematic
exposure to health hazards - toxins in the environment, asbestos
insulation, etc. This dimension introduces the need for understanding
geographic aspects of neighbourhoods and the kind of housing that is found
within them. These concepts should stimulate new ways of Canadian thinking
about and studying the role that housing plays in health.
Inter-relationships among housing and other determinants of health
must be considered, as should policy decisions that affect the presence of
material resources such as income and affordable housing. Ethnographic
studies of people's housing experiences could document the meaning that
housing provides to people and how these affect health. Finally geographic
studies are necessary to consider the spatial dimension of housing and how
these interact with other health determinants to influence health.
The Policy Dimension in the Housing and Health Debate
Housing affordability does not occur in a vacuum. Policy decisions
create the conditions that influence the availability and affordability of
housing and other social determinants of health. The availability and cost
of housing has direct material effects on health. But the availability of
both affordable housing and other economic resources are directly
influenced by policy decisions made by governments. Both types of policy
decisions contribute to housing insecurity, increased stress, morbidity and
mortality, and increased incidence of social exclusion, illness and
disease.
Housing advocacy groups have brought forward solutions to the housing
crisis, in particular to increase the availability of affordable housing
and eradicate homelessness. The Toronto Disaster Relief Committee (TDRC)
developed the 1% Solution to end the housing crisis (TDRC, 1999). The TDRC
argues that if all governments increased their spending on housing by 1% of
overall spending, the homelessness crisis could be eliminated in five
years. The 1% Solution calls for three actions by government:
1) Annual funding for housing of $2 billion federally, and another $2
billion among provinces and territories;
2) Restoring and renewing national, provincial and territorial
programs to resolve the housing crisis and homelessness disaster;
3) Extending the federal homelessness strategy with immediate funding
for new and expanded shelter and services across the country.
Diverse policy strategies must be explored to address the housing
crisis. Layton (2000) outlines several strategies developed as part of a
Federation of Canadian Municipalities task force. A healthy housing sector
should have four components: rental housing; ownership housing; social
housing with mixed incomes; and support for people with special needs to
enable them to live independently. The National Affordable Housing Strategy
should consist of the following:
1) Flexible Capital Grant Program for Housing: a locally designed and
administered program of initiatives financed by federal or joint
federal/provincial/territorial capital fund;
2)Private Rental Program to stimulate private rental production;
3)Investment Pools of Money to create Affordable Housing by
attracting new funding for the development, acquisition or rehabilitation
of affordable housing; and
4.) Provincially Administered Income Supplement Programs to assist
tenants who cannot afford private market rents. The program would
complement capital grants to reach those most in need.
In the case of Canadian housing policy, political ideologies of
governments are significant barriers to progressive housing policy change.
Housing policy appears to be especially sensitive to political ideology.
Since federal and many provincial governments now have a strong
pro-privatization and marketization agenda, housing is vulnerable to this
agenda since it can be privatized and the public perceives it as a market
issue (Bryant, in press).
Also important is the extent to which governments subscribe to neo-liberal
approaches that see the market economy as the best allocator of resources
and wealth (Coburn, 2000). The ideology of individualism espoused by
Canadian governments and most western nations is strongly associated with
notions of "deservingness." Jenkins (1982) argues that individualism can be
defined as "a way of looking at the world which explains and interprets
events and circumstances mainly in terms of the decisions, actions and
attitudes of the individuals involved" (p. 88). In other words, this
ideology pathologizes individuals with social problems. This is relevant in
the case of people living under conditions of poor or no housing.
The notion of collective responsibility for social responsibility to
vulnerable populations is no longer part of the political discourse.
Although some consider neo-liberalism to be extreme and therefore
temporary, the development of social policy that addresses the housing
crisis and other social policy issues has yet to be seen. To date, only
municipal governments have taken a strong stand to address housing and
homelessness in Canada (see Sandeman et al., 2002; City of Calgary, 2002).
Also influencing housing policy is public perceptions of housing.
Housing is an expense that most people are expected to cover themselves.
Many low-income Canadians will be life-long tenants. These populations are
particularly vulnerable to policy changes in housing and to policies that
affect other social determinants of health. They also tend to have poorer
health than the general population and homeowners in particular. The
current political environment is not receptive to their concerns and
impedes action on the social determinants of health such as housing from
which these groups would benefit.
Conclusion
In spite of the ample evidence on the relationship between housing
and health, government actions at times are at odds with a social
determinants approach to health. Governments are not seriously addressing
health inequalities and the role housing policy plays in widening these
inequalities. Political strategies are needed to highlight how these health
inequalities threaten the health of all Canadians.
Figures associated with the content of this Bulletin can be accessed at:
http://www.irpp.org/po/archive/mar03/bryant.pdf
The content of this Bulletin is drawn from the following works:
Bryant, T. (2003). The current state of housing in Canada as a social
determinant of health. Policy Options 24:3, 52-56. On line at
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Bryant, T. (in press). The role of political ideology in rental
housing policy in Ontario, Canada. Housing Studies.
Bryant, T. (April, 2004). Housing as a social determinant of health.
In Hulchanski, D. & Shapcott, M. (eds), Policy Options For An Affordable
Rental Housing Strategy for Canada. Toronto: Centre for Urban and Community
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Bryant, T. (July, 2004). Housing and health in Canada. In Raphael, D.
(ed), Social Determinants of Health: Canadian Perspectives. Toronto:
Canadian Scholars Press.
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