Despite legal emancipation, discriminatory practices of the past contribute to housing and health inequities today.
Health researchers Diana Hernandez and Carolyn Swope from Columbia University have recently published two important articles that connect housing with health.
We have much more access to information about health than we did 30 years ago. Health researchers have risen to the challenge of sorting out the data that is important and what it means. For the purposes of this post, there are three important terms: social determinants of health, health inequalities and health inequities.
Social determinants of health
In the late 1980’s, people were spending a significant amount of money on health care and there was general agreement that the amount we would spend would keep going up. This was true for government funded health care and for private insurance plans. Decision makers looked for ways to control the costs, including cutting programs and shifting the cost to health consumers.
At that time, global population statistics became more available and decision makers had access to data. Researchers were able to make comparisons about individual health status between countries using the basic population statistics of morbidity (likelihood of illness) and mortality (how long people lived). There were some interesting surprises. People living in Sweden, Denmark and Japan were less prone to illness and lived longer than people in the US. Not only that, the per capita spending for health care in Sweden, Denmark and Japan was far less than in the US.
These findings triggered extensive comparisons of a range of conditions between countries, while keeping an eye on morbidity and mortality. Evidence that correlated social and economic conditions with health status began to pile up. By the beginning of the 1990’s there was enough evidence to identify social determinants of health, factors which were demonstrated to shape individual health status.
The determinants included income, education level, the income gap between the richest and poorest in a country, early childhood development and robust social networks.
It was some time before housing began to be identified as a determinant of health. Four separate factors of housing were eventually found to affect individual health: cost, condition, consistency and context.
- Cost – the cost of housing affects decisions about other expenditures, including paying for prescription medications and health care. Household heads where housing costs are high compared to income also have higher levels of stress and anxiety.
- Condition – the quality of housing materials affect chronic health conditions. Asbestos and lead pipes are two known examples. Also, exposed wiring and poor maintenance contribute to trips and falls, especially amongst older adults.
- Consistency – this is about stability. Evictions, foreclosures and other forms of forced moves contribute to anxiety and elevated stress levels. This includes living arrangements with the potential for an unplanned move, for example where landlords do not need a reason to evict sitting tenants.
- Context – This refers to the features of a neighbourhood. Walkable neighbourhoods support healthy life choices, access to fresh food, places to meet neighbours and to exercise outdoors. When these features are missing, residents face higher levels of stress and live with a greater risk to personal safety.
It is important to note the strength of the research that identified these factors. Each one has been determined to affect health independent of other factors or considerations.
At the same time as the determinants of health work was going on, others were investigating other the data health outcomes from another perspective.
They found that illness and premature death was more prevalent in some groups than others. In other words, there were health inequalities between whole groups of people.
Examples of groups included visible minorities, people who were gay, lesbian, bisexual, queer, or two spirited and people with low incomes. The groups that experienced health inequalities were termed ‘disadvantaged’.
It was also discovered that if someone was in more than one disadvantaged group, the prevalence of illness and shorter lifespan was greater than if they were in only one group. For example, the white straight male with a low income is in one group. He has better health prospects than a two spirited person with a low income, who is in two groups.
Black people form one of the disadvantaged groups in the US. Compared with their white counterparts, black people have not had the same access to health care. They were also more likely to live in housing where one of the social determinants of health that contributed to chronic disease, stress and other health conditions was present.
The discovery that the social determinants of health corresponded with disadvantaged groups sparked another direction for research. Health inequity research looked into whether changes to health and social systems and practices could undo the health effects that disadvantaged groups experienced. This area of investigation also looked at the kinds of practices that would improve health outcomes for disadvantaged groups.
In their research Swope and Hernandez connect the dots between housing and health in two different ways.
First, they looked into the historic context of current health status. They surveyed a broad range of literature in the fields of urban planning, history, public policy and sociology. According to the authors, this is a significant step because health equity research hasn’t looked to these other fields for insight.
The investigation turned up longstanding discriminatory programs and practices. Hernandez and Swope traced the ways this discrimination contributes to the housing patterns and health conditions people experience today. They argue that systems need to change so that many people can see real improvement with chronic conditions and other health challenges.
They also developed a theoretical model to integrate the results of findings from other disciplines in health equity research.
Second, they looked into what happens when the housing factors that affect health independently (cost, condition, consistency and context) occur at the same time. Swope and Hernandez provide a practical example of how this works using asthma, a health condition that is particularly pervasive among disadvantaged groups. When the housing factors are combined, there is evidence that health effects are exponential, rather than cumulative.
Why does this research matter?
Hernandez and Swope have provided the link to show that people in disadvantaged groups have been systematically denied access to housing and this denial has negative impacts on their health. The link allows policy advisors, decision makers, practitioners and volunteers in the health sector to support changes to housing programs that currently reinforce existing discriminatory practices. It offers people in other fields an entrée to the health sector and a way to develop alliances.
This research also paves a way to investigate the complex connection between housing and health by suggesting future areas for research.
For more on these two studies, see: Social Science & Medicine: Housing As A Determinant Of Health Equity: A Conceptual Model
American Journal of Public Health: Housing As A Platform For Health And Equity: Evidence And Future Directions
Both Social Science & Medicine the American Journal of Public Health have restricted access. For further information on this first article, you can contact Carolyn Swope at firstname.lastname@example.org
For more on the second article, you can reach Diana Hernandez at email@example.com