382
HOUSING AND HEALTH* BAILUS WALKER, JR., PH.D., M.P.H. Professor of Environmental Health and of Health Policy and Management School of Public Health Sciences State University of New York Albany, New York
T HE BEGINNING OF A NEW DECADE is an appropriate time to review the issues and problems that beset our society. There is no dearth of challenges and of opportunities: the quality of primary and secondary education, abortion rights, developments in biotechnology, the international economy, global warming, and the upheaval today in Germany with ramifications for all of Europe and the world. Beneath that tier of issues or on the same level, depending on one's perspective, is a broad array of other concerns no less troublesome: long-term problems that require for their solution long-term commitments from the private and public sectors. Although it would be useful to address the full range of issues-because they are virtually interrelated-the purpose here is to examine the issue of housing as it relates to current efforts to promote the health and well-being of all segments of our society. It is an issue that signals a mounting health and social deficit as troubling as government budget deficits, the deteriorating physical infrastructure of roads and bridges and the ferment surrounding access to and quality of health care for tens of millions of Americans. Under the broad license given me by the title, the sweep of this presentation is panoramic, blurring an infinity of detail. No detailed epidemiologic analysis is required to conclude that housing is important, not only in its own right but also because it ensures or deters access to public and private advantages. EPIDEMIOLOGY
Curiously, the health problems of housing in many communities are not so much of meeting the basic needs of shelter as they are those secondary matters that arise as a consequence of that attempt: overcrowding, ventilation, lighting, facilities for cleanliness and for the disposal of waste, and the risk of exposure to toxic agents. *Presented as part of a Workshop on Housing and Health: Interrelationship and Community Impact held by the Committee on Public Health of the New York Academy of Medicine November 17 and 18, 1989.
Bull. N.Y. Acad. Med.
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HE
L
H
8
383
It is therefore reasonable to conclude that if exposure to such hazards as allergens, toxic gases and dust, inadequate thermal environment, or noise occurs in that environment, health risks are likely to be significant. The exposure time is prolonged especially in children or in the elderly and infirm, populations at special risk. Psychological stress from these and other factors, such as high spatial and social densities and inadequate maintenance, may also have significant health implications. Having said this, I must now point out that we tread on difficult epidemiological terrain when we attempt to develop a statistically precise analysis of the interrelationship between housing and health. Many of the most important dimensions are not susceptible to measurement, although excellent studies have attempted to do so. In these studies many variables have had to be either measured indirectly or completely ignored. Sometimes analysts have made capricious assumptions. But even with a cursory look back through the long vista of human development, it is not difficult to think that the earliest attempts made in the direction of housing and health were those in which protection and security against the rigors of the climate, sunshine and rain, heat and cold were sought in natural or artificial enclosures. This belief is supported by the many evidences of early cave life among primitive people. However, today the functions of housing are expanded and differentiated, and many distinct types of problems are associated with the home, the school, and various places of public activities. Among these, however, the homethe place of living, of eating, of sleeping, and of rearing a family -is of such basic significance in the health, social, and economic life of the community that the term housing in general is limited to the sheltering of the individual or family; to location, construction, equipment, and maintenance of the home. One may live in a rapidly developing community where jobs are plentiful or in an economically stagnant area where even low-skilled work is scarce. Where one lives and the quality of housing affects his taxes, schools, and the quality of government services -including health services. Of all the public policy issues now on the national agenda, housing policy and housing programs probably have more implications for more people than any other. No personal choice is more carefully weighed, negotiated, debated than housing, at least among those whose income permits them a choice. Public policy -health, social, and economic -principally through federal resources, has had a significant impact on housing choices for all Americans of all income levels. Not only is the federal government indirectly the naVol. 66, No. 5, September-October 1990
384
384
B. WALKER
tion's largest landlord for poor families, it is also the impetus for millions of middle-income families' housing investments. DETERMINANTS
As a public health practitioner, I have found epidemiology -the central discipline of public health research and practice- an important organizing principle for the analysis of housing and health issues. Typically, epidemiologists have available all kinds of statistical data on causative agents of disease. But epidemiology requires more than a knowledge of specific organisms or other primary determinants of disease and dysfunction. It equally requires a knowledge of the contributing factors or secondary determinants the community, the psychology of its people, their social and economic position -and consideration of the possibility that they may operate independently and singly or synergistically. Thus, any exploration of housing and health issues must include a reflection of socioeconomic position-an amalgam of income, education, and occupation-which can be rightly called a true generic "'housing-health risk factor." That poverty and substandard housing are related is a truism but whether this fact means more than that poor people live in poor housing is not clear. Obviously, people are not poor merely because they live in inadequate housing. But it is still possible that the quality of housing itself has something to do with the behavioral, economic, and psychologic syndrome we define as poverty. To any perceptive observer it is evident that the dimensions of poverty in America have changed over the past three decades. Advances in the civil rights movement made it possible for many working-class and middle-class minorities to move away from the inner city. The decline in jobs for unskilled workers (brought on by transformations in urban areas and the economic functions they perform), deterioration in family stability, and changes in the mix of people and services in inner-city neighborhoods have led to the creation of an underclass a group characterized by a growing separation from the rest of society, its norms, and especially its resources. The group is small compared with how many poor there are in the United States, but it has grown rapidly in recent years. Although the number of people in poverty grew 18% from 28 million in 1967 to 33 million in 1985, the number of poor people living in concentrated poverty has grown rapidly, by roughly 50% between 1970 and 1980.1 A further analysis of these demographic trends points to two significant stories. One is related to the general American economic performance from Bull. N.Y. Acad. Med.
HEALTH HOUSING AND HEALTH
HOUSING AND
385
the early 1970s to the mid-1980s and how it adversely affected income of all young people. From the 1950s to the early 1970s, each successive cohort of young workers could look forward to doing better than its predecessors. Because of the slowdown in American economic growth after 1973, this is no longer true. The second story is the growing split among young adults engaged in the transition from school to work. Since 1973 those with a college education have been able to hold their own and in their late 20s even bounce back from earlier economic troubles. However, young people with only a high school diploma or less have seen their income position continue to erode. By 1986during the fourth year of an economic recovery -young men with only a high school degree actually were earning 7% to 10% less than their counterparts had earned in 1959.2 Another dimension of this issue is the several million families who live below the poverty level even when some of their members work. For example, the working poor made up one third of all people 16 and older who were in poverty. These are the more than six million people whose family incomes were below the official poverty level in 1987 even though they worked or looked for work at least half of the year. Aside from experiencing unemployment or being limited to involuntary part-time work, the working poor have a strong tendency to work in jobs that pay low wages. Much research supports the contention that low pay may be the primary cause of poverty among workers. Behind these statistics lies a complex pattern of social stress and strain. As the median incomes of America's young families have fallen, fewer younger families have been able to realize a vital part of the American dream: owning a home. Those who have not been able to buy have seen the financial burden of renting increase
dramatically. A growing number of young families is completely shut out of the housing market. But the alternative -renting -also is increasingly difficult for young families to afford. The number of households with children headed by an individual 25 to 34 who are renting increased by 42% between 1974 and 1984. As a result, some groups of young families are now paying such a huge share of their incomes in rent that they are at risk of becoming homeless in the event of a sudden new demand on their budget from, for example, a catastrophic illness or accident. Current state and local health surveillance data point to vulnerable families who stretch their household budgets to cover housing costs and, in the process, shortchange such other necessities as food and health care. Vol. 66, No. 5, September-October 1990
386
386
B. WALKER
Increasing rents are a symptom of the growing shortage of affordable available housing units. To be sure, housing construction fell for a second consecutive month during September of 1989, declining to the weakest pace in seven years. In too many urban centers too little is being built to solve community shortages or to replenish the large inventory of dilapidated old structures. One rule of thumb among housing specialists is that at least 1% of the housing stock in older urban centers should be replaced with new construction each year. On this basis, many urban centers, including New York City, which issued fewer building permits in 1988 (10,316) than in 1985 (21,655), are far behind.3 HOMELESS Then there is the deeply troubling issue of homelessness -a problem so serious that it must be discussed in its own right. It is a health, medical, social, economic, and political challenge -a research, prevention, therapeutic, and educational challenge. It is not merely that the problem of housing affordability and availability come together in the growing number of homeless people in urban America or that families with young children are the fastest growing segment of the homeless population. Equally if not more disturbing is the lack of bold new government initiatives to ensure the basic right of every family and individual to a decent home and a wholesome living environment. Yet the epidemiologic basis for a comprehensive and effective approach to the issue of homelessness is above reproach. Here we have proceeded apace with scholarly works on many critical aspects of the homeless problem. The report of the Institute of Medicine: Homelessness, Health and Human Needs,4 the United Hospital Fund's Health Care of Homeless People,5 and the American Public Health Association's Helping Mentally Ill Homeless People,6 to name only three, are examples of efforts to reach an even clearer understanding of the multiple dimensions of this issue. But, however seriously biologists may debate the relative importance of heredity and environment in the development of mental and moral traits and of character, it is quite plain in regard to physical health and well-being that no hereditary endowment is so good that it cannot be wasted away in a bad environment, and rarely one so bad that it cannot be reclaimed, in part at least, by favorable treatment (i.e., quality housing). Thus, our present inquiry takes this form: How can a youngster learn in school when he has not slept the night before or had a quiet place to do homework? How can we prevent the progression of disease and dysfunction Bull. N.Y. Acad. Med.
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387
among children when they live in an unheated, overcrowded shelter or on the street? We should not have been surprised when in 1988 measles gained its strongest foothold, attacking many homeless children, who were most vulnerable to high fever and bronchial infection associated with the disease. Most shelters are not designed or managed to meet the preventive health care needs of children and families. How can a family structure remain strong when parents and children cannot even remain under the same roof? How can we provide effective prenatal care for homeless women who move frequently from bus station to shelters to train stations to abandoned buildings without adequate heat, food, clothing, or sanitary facilities? In welfare "hotels" families are often crammed into a single room, with minimum air flow, while the hallways outside are frequented by drug dealers and prostitutes. In congregate settings, children sometimes share barracks-like accommodations with homeless single adults-many of whom are prone to antisocial behavior. And shelter rules often deprive parents of their decisionmaking power (when to eat, when to go to sleep, for example) that can affect families even after the episode of homelessness has ended. Indeed, homelessness poses distressing dilemmas to families and children already struggling under significant burdens of social and economic deprivation. Beyond any doubt, the trends are ominous. A growing socially and economically deprived subgroup of children necessitating a disproportionate share of our health resources will soon become a growing and under-prepared work force, with a whole range of public assistance, social and economic, and health implications for the entire nation. International, national, and even local competitiveness, as well as harmony among diverse groups, depends in no small measure on our ability to prevent the development of an unproductive underclass and to do so by making uniformly available and readily accessible and affordable current knowledge, skills, and resources to all our citizens. This emphasis on children and families should not obscure the extent to which all groups -infants, early childhood, adolescence, young adulthood, older adults, and the aged -are interconnected. However compelling the special health needs of each distinct group, each remains dependent on the health and well-being of the others. If we rescue young children from the blighting effects of substandard housing or from homelessness, we save Vol. 66, No. 5, September-October 1990
388
388
B. WALKER
billions of dollars in health and social costs -dollars that can be invested in programs to benefit the larger society. INSTITUTIONAL CONCERNS
And, finally, I come to what might be called institutional challenges. First, it is clear that the American people are committed to the basic principle that every family and individual has a basic right to a decent home and a suitable living environment. This commitment is evident in opinion poll after opinion poll, the most recent in which people identified homelessness as a top priority for the national government. Three of four people interviewed said that government should increase spending in this area. Further, by nearly two-toone, taxpayers said they would be willing to pay $100 a year more in taxes if the money were used to address problems of hunger and homelessness. This attitude creates a desirable climate for new housing initiatives such as President Bush's recently announced proposal for a $7 billion, three-year housing program and tax breaks to aid low income families, first-time home buyers, and the homeless. While the president's proposal has many desirable features-and it is indeed welcome after years of relative inattention to the housing problem -we must ensure that there is the national and political will to persist in this effort until the job is done. This is said without rancor, but in simple recognition that our attention span for national problems is growing shorter and shorter. All too often we run hot and cold for issues that need long-term policy and resource commitments. Remember the energy crisis, the farm crisis, the urban crisis, the crisis in education? We will do a grave disservice to families and children if we dispose of the "housing crisis" with something less than a long-term sustained commitment. Indeed, the problem cries out for careful consideration, not quick fixes that have dominated other economic and political debates. The task will also require efforts in the private and public sectors, a variety of methods, and the institutionalization of the thoughtful considerations of interrelated areas, provision for safe, affordable housing, the related activity of planning and implementation of comprehensive health services, specifically community-oriented primary care with a view to evolving effective constructs for prevention of mental disease and dysfunction. MENTAL HEALTH
A further concern in this context is the public mental health system. An analysis by Mechanic and Aiken7 speaks to these issues: "The organization of community care for patients with the most severe chronic mental illness is Bull. N.Y. Acad. Med.
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seriously deficient. Most of these patients depend exclusively on underfinanced, fragmented and often inaccessible public services." This analysis, several national conferences, symposia, and Congressional hearings all suggest that sooner or later we must bring some order, sense of direction, clear purpose, and coherence to our public mental health system. The need for reform is clearly evident in many urban centers where literally thousands of people who have lost control over life circumstances roam the streets and alleys. These mentally ill patients are homeless, impoverished, disoriented, and lack basic coping skills. Many are "products" of deinstitutionalization and of a public mental health system that has failed to carry out its functions and responsibilities. The basic theme here is straightforward: many homeless patients with severe chronic mental illness are not receiving enough help to prevent further progression of their dysfunctions. We realize that the script for improving the system is simple but its execution may, at first glance, appear formidable. Fortunately, the outlines of a community-based strategy for prevention in mental health are already clear. We know enough about community mental needs to structure a comprehensive and effective mental health system. The outlines of this system are contained in proposals of the President's Commission on Mental Health in 1978 and in other documents. Referring to the progress made by public health services in preventing disease and promoting health, the 1978 President's Commission concluded: "The mental health field has yet to use available knowledge in a comparable effort." HOLISTIC APPROACH All too often we tend to establish artificial structures -school systems, health and welfare agencies, economic development organizations, housing and development programs, and other units of government -to deal narrowly with parts of a larger problem. Sometimes the efforts overlap. Sometimes individuals are lost in the process. And often one institution does not know what resources another system has to offer. Similarly, the housing issue and the housing sector itself must be seen as a whole since all housing markets-poor, near poor, and nonpoor -are subject to common social and economic forces and interconnected through the market process. Housing issues must be grapsed within the framework of broader demographic trends and national health policies. However, in the past, housing policies and programs have had too little meaningful, thoughtful, and constructive consideration from within the medical profession itself. This, too, is said without rancor for the situation is understandable. Vol. 66, No. 5, September-October 1990
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The problems are complex; their solution requires the collection and analysis of a large body of information. What is more, the structure of the health care system and its financing mechanisms do not encourage a communityoriented approach to care. Still further, traditional compartmentalization of disciplines and professions often can work against the kind of creative and collegial thinking needed to address such complex problems as housing and health. At the same time, political and other policy makers show a marked tendency toward unidimensional solutions, perhaps even less likely to prove satisfactory in the end. Under these circumstances, the health-medical community has a complex obligation to catalyze public policy through initiative and expertise to stimulate public debate and to encourage the commitment of public and private resources to ensure well-housed communities and the provision of related health and social services. In the decade of the 1990s it will be imperative that the health-medical community awaken all sectors to the importance of permanent housing and health solutions. At the same time it must recognize its limitation as one among a whole set of constituencies with a vital interest in the outcome. REFERENCES 1. Wilson, W.F. and Neckerman, K.M.: Poverty and Family Structure: The Widening Gap Between Evidence and Public Policy Issues. In: Fighting Poverty: What Works and What Doesn't, Danziger, S.H. and Weinberg, D.H., editors. Cambridge, MA, Harvard University Press, 1986. 2. Klen, B.W. and Rones, P.L.: A profile of the working poor. Monthly Labor Rev. 112:3-13, 1989. 3. Lueck, T.F.: New York City's housing pace slows. The New York Times, R-1, August 20, 1989.
4. Institute of Medicine: Homelessness, Health and Human Needs. Washington, D.C., Nat. Academy Press, 1988. 5. Brickner, P., Scharer, L.K., Conanan, B., et al.: Health Care of Homeless People. New York, Springer, 1985. 6. Stefl, M.E.: Helping Mentally Ill Homeless People. Washington, D.C., American Public Health Assoc., 1989. 7. Mechanic, D. and Aiken, L.H.: Improving the care of patients with chronic mental illness. N. Engl. J. Med. 317:163438, 1987.
Bull. N.Y. Acad. Med.
HOUSING AND HEALTH* BAILUS WALKER, JR., PH.D., M.P.H. Professor of Environmental Health and of Health Policy and Management School of Public Health Sciences State University of New York Albany, New York
T HE BEGINNING OF A NEW DECADE is an appropriate time to review the issues and problems that beset our society. There is no dearth of challenges and of opportunities: the quality of primary and secondary education, abortion rights, developments in biotechnology, the international economy, global warming, and the upheaval today in Germany with ramifications for all of Europe and the world. Beneath that tier of issues or on the same level, depending on one's perspective, is a broad array of other concerns no less troublesome: long-term problems that require for their solution long-term commitments from the private and public sectors. Although it would be useful to address the full range of issues-because they are virtually interrelated-the purpose here is to examine the issue of housing as it relates to current efforts to promote the health and well-being of all segments of our society. It is an issue that signals a mounting health and social deficit as troubling as government budget deficits, the deteriorating physical infrastructure of roads and bridges and the ferment surrounding access to and quality of health care for tens of millions of Americans. Under the broad license given me by the title, the sweep of this presentation is panoramic, blurring an infinity of detail. No detailed epidemiologic analysis is required to conclude that housing is important, not only in its own right but also because it ensures or deters access to public and private advantages. EPIDEMIOLOGY
Curiously, the health problems of housing in many communities are not so much of meeting the basic needs of shelter as they are those secondary matters that arise as a consequence of that attempt: overcrowding, ventilation, lighting, facilities for cleanliness and for the disposal of waste, and the risk of exposure to toxic agents. *Presented as part of a Workshop on Housing and Health: Interrelationship and Community Impact held by the Committee on Public Health of the New York Academy of Medicine November 17 and 18, 1989.
Bull. N.Y. Acad. Med.
HOUSING AND HEALTH
HE
L
H
8
383
It is therefore reasonable to conclude that if exposure to such hazards as allergens, toxic gases and dust, inadequate thermal environment, or noise occurs in that environment, health risks are likely to be significant. The exposure time is prolonged especially in children or in the elderly and infirm, populations at special risk. Psychological stress from these and other factors, such as high spatial and social densities and inadequate maintenance, may also have significant health implications. Having said this, I must now point out that we tread on difficult epidemiological terrain when we attempt to develop a statistically precise analysis of the interrelationship between housing and health. Many of the most important dimensions are not susceptible to measurement, although excellent studies have attempted to do so. In these studies many variables have had to be either measured indirectly or completely ignored. Sometimes analysts have made capricious assumptions. But even with a cursory look back through the long vista of human development, it is not difficult to think that the earliest attempts made in the direction of housing and health were those in which protection and security against the rigors of the climate, sunshine and rain, heat and cold were sought in natural or artificial enclosures. This belief is supported by the many evidences of early cave life among primitive people. However, today the functions of housing are expanded and differentiated, and many distinct types of problems are associated with the home, the school, and various places of public activities. Among these, however, the homethe place of living, of eating, of sleeping, and of rearing a family -is of such basic significance in the health, social, and economic life of the community that the term housing in general is limited to the sheltering of the individual or family; to location, construction, equipment, and maintenance of the home. One may live in a rapidly developing community where jobs are plentiful or in an economically stagnant area where even low-skilled work is scarce. Where one lives and the quality of housing affects his taxes, schools, and the quality of government services -including health services. Of all the public policy issues now on the national agenda, housing policy and housing programs probably have more implications for more people than any other. No personal choice is more carefully weighed, negotiated, debated than housing, at least among those whose income permits them a choice. Public policy -health, social, and economic -principally through federal resources, has had a significant impact on housing choices for all Americans of all income levels. Not only is the federal government indirectly the naVol. 66, No. 5, September-October 1990
384
384
B. WALKER
tion's largest landlord for poor families, it is also the impetus for millions of middle-income families' housing investments. DETERMINANTS
As a public health practitioner, I have found epidemiology -the central discipline of public health research and practice- an important organizing principle for the analysis of housing and health issues. Typically, epidemiologists have available all kinds of statistical data on causative agents of disease. But epidemiology requires more than a knowledge of specific organisms or other primary determinants of disease and dysfunction. It equally requires a knowledge of the contributing factors or secondary determinants the community, the psychology of its people, their social and economic position -and consideration of the possibility that they may operate independently and singly or synergistically. Thus, any exploration of housing and health issues must include a reflection of socioeconomic position-an amalgam of income, education, and occupation-which can be rightly called a true generic "'housing-health risk factor." That poverty and substandard housing are related is a truism but whether this fact means more than that poor people live in poor housing is not clear. Obviously, people are not poor merely because they live in inadequate housing. But it is still possible that the quality of housing itself has something to do with the behavioral, economic, and psychologic syndrome we define as poverty. To any perceptive observer it is evident that the dimensions of poverty in America have changed over the past three decades. Advances in the civil rights movement made it possible for many working-class and middle-class minorities to move away from the inner city. The decline in jobs for unskilled workers (brought on by transformations in urban areas and the economic functions they perform), deterioration in family stability, and changes in the mix of people and services in inner-city neighborhoods have led to the creation of an underclass a group characterized by a growing separation from the rest of society, its norms, and especially its resources. The group is small compared with how many poor there are in the United States, but it has grown rapidly in recent years. Although the number of people in poverty grew 18% from 28 million in 1967 to 33 million in 1985, the number of poor people living in concentrated poverty has grown rapidly, by roughly 50% between 1970 and 1980.1 A further analysis of these demographic trends points to two significant stories. One is related to the general American economic performance from Bull. N.Y. Acad. Med.
HEALTH HOUSING AND HEALTH
HOUSING AND
385
the early 1970s to the mid-1980s and how it adversely affected income of all young people. From the 1950s to the early 1970s, each successive cohort of young workers could look forward to doing better than its predecessors. Because of the slowdown in American economic growth after 1973, this is no longer true. The second story is the growing split among young adults engaged in the transition from school to work. Since 1973 those with a college education have been able to hold their own and in their late 20s even bounce back from earlier economic troubles. However, young people with only a high school diploma or less have seen their income position continue to erode. By 1986during the fourth year of an economic recovery -young men with only a high school degree actually were earning 7% to 10% less than their counterparts had earned in 1959.2 Another dimension of this issue is the several million families who live below the poverty level even when some of their members work. For example, the working poor made up one third of all people 16 and older who were in poverty. These are the more than six million people whose family incomes were below the official poverty level in 1987 even though they worked or looked for work at least half of the year. Aside from experiencing unemployment or being limited to involuntary part-time work, the working poor have a strong tendency to work in jobs that pay low wages. Much research supports the contention that low pay may be the primary cause of poverty among workers. Behind these statistics lies a complex pattern of social stress and strain. As the median incomes of America's young families have fallen, fewer younger families have been able to realize a vital part of the American dream: owning a home. Those who have not been able to buy have seen the financial burden of renting increase
dramatically. A growing number of young families is completely shut out of the housing market. But the alternative -renting -also is increasingly difficult for young families to afford. The number of households with children headed by an individual 25 to 34 who are renting increased by 42% between 1974 and 1984. As a result, some groups of young families are now paying such a huge share of their incomes in rent that they are at risk of becoming homeless in the event of a sudden new demand on their budget from, for example, a catastrophic illness or accident. Current state and local health surveillance data point to vulnerable families who stretch their household budgets to cover housing costs and, in the process, shortchange such other necessities as food and health care. Vol. 66, No. 5, September-October 1990
386
386
B. WALKER
Increasing rents are a symptom of the growing shortage of affordable available housing units. To be sure, housing construction fell for a second consecutive month during September of 1989, declining to the weakest pace in seven years. In too many urban centers too little is being built to solve community shortages or to replenish the large inventory of dilapidated old structures. One rule of thumb among housing specialists is that at least 1% of the housing stock in older urban centers should be replaced with new construction each year. On this basis, many urban centers, including New York City, which issued fewer building permits in 1988 (10,316) than in 1985 (21,655), are far behind.3 HOMELESS Then there is the deeply troubling issue of homelessness -a problem so serious that it must be discussed in its own right. It is a health, medical, social, economic, and political challenge -a research, prevention, therapeutic, and educational challenge. It is not merely that the problem of housing affordability and availability come together in the growing number of homeless people in urban America or that families with young children are the fastest growing segment of the homeless population. Equally if not more disturbing is the lack of bold new government initiatives to ensure the basic right of every family and individual to a decent home and a wholesome living environment. Yet the epidemiologic basis for a comprehensive and effective approach to the issue of homelessness is above reproach. Here we have proceeded apace with scholarly works on many critical aspects of the homeless problem. The report of the Institute of Medicine: Homelessness, Health and Human Needs,4 the United Hospital Fund's Health Care of Homeless People,5 and the American Public Health Association's Helping Mentally Ill Homeless People,6 to name only three, are examples of efforts to reach an even clearer understanding of the multiple dimensions of this issue. But, however seriously biologists may debate the relative importance of heredity and environment in the development of mental and moral traits and of character, it is quite plain in regard to physical health and well-being that no hereditary endowment is so good that it cannot be wasted away in a bad environment, and rarely one so bad that it cannot be reclaimed, in part at least, by favorable treatment (i.e., quality housing). Thus, our present inquiry takes this form: How can a youngster learn in school when he has not slept the night before or had a quiet place to do homework? How can we prevent the progression of disease and dysfunction Bull. N.Y. Acad. Med.
HOUSING AND HEALTH
387
among children when they live in an unheated, overcrowded shelter or on the street? We should not have been surprised when in 1988 measles gained its strongest foothold, attacking many homeless children, who were most vulnerable to high fever and bronchial infection associated with the disease. Most shelters are not designed or managed to meet the preventive health care needs of children and families. How can a family structure remain strong when parents and children cannot even remain under the same roof? How can we provide effective prenatal care for homeless women who move frequently from bus station to shelters to train stations to abandoned buildings without adequate heat, food, clothing, or sanitary facilities? In welfare "hotels" families are often crammed into a single room, with minimum air flow, while the hallways outside are frequented by drug dealers and prostitutes. In congregate settings, children sometimes share barracks-like accommodations with homeless single adults-many of whom are prone to antisocial behavior. And shelter rules often deprive parents of their decisionmaking power (when to eat, when to go to sleep, for example) that can affect families even after the episode of homelessness has ended. Indeed, homelessness poses distressing dilemmas to families and children already struggling under significant burdens of social and economic deprivation. Beyond any doubt, the trends are ominous. A growing socially and economically deprived subgroup of children necessitating a disproportionate share of our health resources will soon become a growing and under-prepared work force, with a whole range of public assistance, social and economic, and health implications for the entire nation. International, national, and even local competitiveness, as well as harmony among diverse groups, depends in no small measure on our ability to prevent the development of an unproductive underclass and to do so by making uniformly available and readily accessible and affordable current knowledge, skills, and resources to all our citizens. This emphasis on children and families should not obscure the extent to which all groups -infants, early childhood, adolescence, young adulthood, older adults, and the aged -are interconnected. However compelling the special health needs of each distinct group, each remains dependent on the health and well-being of the others. If we rescue young children from the blighting effects of substandard housing or from homelessness, we save Vol. 66, No. 5, September-October 1990
388
388
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billions of dollars in health and social costs -dollars that can be invested in programs to benefit the larger society. INSTITUTIONAL CONCERNS
And, finally, I come to what might be called institutional challenges. First, it is clear that the American people are committed to the basic principle that every family and individual has a basic right to a decent home and a suitable living environment. This commitment is evident in opinion poll after opinion poll, the most recent in which people identified homelessness as a top priority for the national government. Three of four people interviewed said that government should increase spending in this area. Further, by nearly two-toone, taxpayers said they would be willing to pay $100 a year more in taxes if the money were used to address problems of hunger and homelessness. This attitude creates a desirable climate for new housing initiatives such as President Bush's recently announced proposal for a $7 billion, three-year housing program and tax breaks to aid low income families, first-time home buyers, and the homeless. While the president's proposal has many desirable features-and it is indeed welcome after years of relative inattention to the housing problem -we must ensure that there is the national and political will to persist in this effort until the job is done. This is said without rancor, but in simple recognition that our attention span for national problems is growing shorter and shorter. All too often we run hot and cold for issues that need long-term policy and resource commitments. Remember the energy crisis, the farm crisis, the urban crisis, the crisis in education? We will do a grave disservice to families and children if we dispose of the "housing crisis" with something less than a long-term sustained commitment. Indeed, the problem cries out for careful consideration, not quick fixes that have dominated other economic and political debates. The task will also require efforts in the private and public sectors, a variety of methods, and the institutionalization of the thoughtful considerations of interrelated areas, provision for safe, affordable housing, the related activity of planning and implementation of comprehensive health services, specifically community-oriented primary care with a view to evolving effective constructs for prevention of mental disease and dysfunction. MENTAL HEALTH
A further concern in this context is the public mental health system. An analysis by Mechanic and Aiken7 speaks to these issues: "The organization of community care for patients with the most severe chronic mental illness is Bull. N.Y. Acad. Med.
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seriously deficient. Most of these patients depend exclusively on underfinanced, fragmented and often inaccessible public services." This analysis, several national conferences, symposia, and Congressional hearings all suggest that sooner or later we must bring some order, sense of direction, clear purpose, and coherence to our public mental health system. The need for reform is clearly evident in many urban centers where literally thousands of people who have lost control over life circumstances roam the streets and alleys. These mentally ill patients are homeless, impoverished, disoriented, and lack basic coping skills. Many are "products" of deinstitutionalization and of a public mental health system that has failed to carry out its functions and responsibilities. The basic theme here is straightforward: many homeless patients with severe chronic mental illness are not receiving enough help to prevent further progression of their dysfunctions. We realize that the script for improving the system is simple but its execution may, at first glance, appear formidable. Fortunately, the outlines of a community-based strategy for prevention in mental health are already clear. We know enough about community mental needs to structure a comprehensive and effective mental health system. The outlines of this system are contained in proposals of the President's Commission on Mental Health in 1978 and in other documents. Referring to the progress made by public health services in preventing disease and promoting health, the 1978 President's Commission concluded: "The mental health field has yet to use available knowledge in a comparable effort." HOLISTIC APPROACH All too often we tend to establish artificial structures -school systems, health and welfare agencies, economic development organizations, housing and development programs, and other units of government -to deal narrowly with parts of a larger problem. Sometimes the efforts overlap. Sometimes individuals are lost in the process. And often one institution does not know what resources another system has to offer. Similarly, the housing issue and the housing sector itself must be seen as a whole since all housing markets-poor, near poor, and nonpoor -are subject to common social and economic forces and interconnected through the market process. Housing issues must be grapsed within the framework of broader demographic trends and national health policies. However, in the past, housing policies and programs have had too little meaningful, thoughtful, and constructive consideration from within the medical profession itself. This, too, is said without rancor for the situation is understandable. Vol. 66, No. 5, September-October 1990
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The problems are complex; their solution requires the collection and analysis of a large body of information. What is more, the structure of the health care system and its financing mechanisms do not encourage a communityoriented approach to care. Still further, traditional compartmentalization of disciplines and professions often can work against the kind of creative and collegial thinking needed to address such complex problems as housing and health. At the same time, political and other policy makers show a marked tendency toward unidimensional solutions, perhaps even less likely to prove satisfactory in the end. Under these circumstances, the health-medical community has a complex obligation to catalyze public policy through initiative and expertise to stimulate public debate and to encourage the commitment of public and private resources to ensure well-housed communities and the provision of related health and social services. In the decade of the 1990s it will be imperative that the health-medical community awaken all sectors to the importance of permanent housing and health solutions. At the same time it must recognize its limitation as one among a whole set of constituencies with a vital interest in the outcome. REFERENCES 1. Wilson, W.F. and Neckerman, K.M.: Poverty and Family Structure: The Widening Gap Between Evidence and Public Policy Issues. In: Fighting Poverty: What Works and What Doesn't, Danziger, S.H. and Weinberg, D.H., editors. Cambridge, MA, Harvard University Press, 1986. 2. Klen, B.W. and Rones, P.L.: A profile of the working poor. Monthly Labor Rev. 112:3-13, 1989. 3. Lueck, T.F.: New York City's housing pace slows. The New York Times, R-1, August 20, 1989.
4. Institute of Medicine: Homelessness, Health and Human Needs. Washington, D.C., Nat. Academy Press, 1988. 5. Brickner, P., Scharer, L.K., Conanan, B., et al.: Health Care of Homeless People. New York, Springer, 1985. 6. Stefl, M.E.: Helping Mentally Ill Homeless People. Washington, D.C., American Public Health Assoc., 1989. 7. Mechanic, D. and Aiken, L.H.: Improving the care of patients with chronic mental illness. N. Engl. J. Med. 317:163438, 1987.
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