In the mid nineteenth century, English social reformer Edwin Chadwick established an association between appalling living conditions and poor health. Soon thereafter, Rudolph Virchow, the founder of both modern pathology and the field of social medicine, recognized the link between rising rates of infectious disease and crowded, poorly maintained housing. In the absence of diagnostic tools and effective treatments for rampant infectious diseases, many of the advances in health of the 19th and early 20th century resulted from improvements in housing, sanitation, and water quality. The Great Depression and the post-World War II era brought increased interest in housing because of the massive influx of people moving to cities in search of jobs.
The United States is a signatory to the 1948 Universal Declaration of Human Rights, which states: "Everyone has the right to … food, clothing, housing and medical care and necessary social services.” The explicit nature of the nation's societal contract to meet the housing needs of its citizens is spelled out in the Housing Act of 1949, which stipulates “the realization as soon as feasible of the goal of a decent home … for every American family." In 1968, The Fair Housing Act made discrimination on the basis of race in the housing market illegal. Regrettably, neither the Universal Declaration nor these landmark laws have solved the problem of homelessness, substandard housing, and racial profiling by sellers and realtors.
In the late 1970s, de-institutionalization of the mentally ill (unaccompanied by promised outpatient psychiatric and social services), along with a massive disinvestment in developing affordable housing, led to a large increase in the homeless, mentally ill population. The number of homeless grew in the 1980s, as housing and social service cuts increased. This was in part a consequence of the transfer of federal dollars to a huge military buildup (including the spectacularly wasteful and unsuccessful "Star Wars" strategic missile defense initiative) and consequent large budget deficits.
Fortunately, public compassion soared, and in 1986, 5 million Americans joined hands across the country to raise money for homeless programs. In 1987, the McKinney-Vento Homelessness Act authorized millions of dollars for housing and hunger relief, yet despite reauthorizations, its implementation has not been uniform or consistent across all 50 states.
Two decades later, many families lost their homes and/or went bankrupt during the financial meltdown of 2008, which was caused by a proliferation of sub-prime mortgages and the de-regulation of banks, insurance companies, and financial services companies, consequent to repeal of Glass-Steagall Act, but really, at its root, greed. Huge government bailouts were allotted mostly to financial institutions, which have recovered and indeed profited handsomely, rather than to homeowners or the newly homeless.
Despite legislative efforts to address housing inequities, a shortage of affordable housing persists, as does the problem of homelessness. Over 7 percent of persons living in the United States have been homeless at some point in their lives. An estimated 3 million people experience homelessness each year. Nationally, in 2017, there were 553,742 counted as experiencing homelessness on just one night in January, although such counts can miss large numbers of homeless people.
Nationally, 1 in 4 people experiencing homelessness is a veteran. More than 50% of all homeless women and children become homeless as a direct result of fleeing domestic violence. The availability of domestic violence shelter beds in the US is poor, and funding inadequate; most women and children are turned away on any given night.
The homeless suffer disproportionately from numerous medical and psychiatric disorders. which will be the subject of a future program. Homeless adults face higher overall and disease-specific mortality, as well as higher medical costs. They often lack adequate health insurance, and all suffer from the pressure to fulfill competing nonfinancial needs, such food, clothing, and temporary shelter, while facing misconceptions and prejudices from many of their fellow human beings. In 2016, 80 people died on the streets of Multnomah County, here in Portland, Oregon, and another 311 in 2017 on the streets of New York City. Deaths among the homeless have been increasing, fueled by the opioid epidemic and the government’s tepid, uncoordinated response.
Affordable housing shortages and discriminatory housing practices plague many American communities. Low-income housing is frequently substandard, does not meet city inspection requirements, and is characterized by conditions that contribute to poor indoor air quality and adverse health. Such substandard accommodations are disproportionately concentrated in lower-income communities and communities of color. Segregation by income and race limit one’s access to grocery stores, neighborhood parks, and quality schools. Polluting industries are more frequently located in and around poor communities and communities of color, a phenomenon known as environmental injustice or environmental racism. Due to excessive exposure to air and water pollution, such communities bear a higher burden of many diseases.
Quality housing is an important social determinant of health not only because it provides safe shelter from the outdoor environment and from crime victimization, but also because Americans spend much of their time indoors. For some, the quality of indoor air that they breathe may exert a greater influence on their health than the quality of the air outdoors. The elderly, pregnant women, fetuses, young children, and the chronically ill are most vulnerable to poor indoor air quality and to toxic substances in the home. Poor heating or cooling systems, inadequate ventilation, overcrowding, and poor construction can cause and/or exacerbate many health and safety problems. Lead poisoning from old pipes and paint can cause neurological damage, which may result in lower intelligence, disabilities, worsened job prospects later in life, and higher rates of criminal activity. Finally, poor housing quality adversely affects mental health, leading to increased rates of depression and stress.
The Center for Housing Policy and many other groups have found a clear impact of housing on health, education and economic development. By investing in affordable housing, cities and communities can move toward a more equitable society. Achieving equality in housing access, cost, and neighborhood conditions (such as educational opportunities and good community-law enforcement relationships) will help to create a more just and healthier America. Affordable housing frees up resources for food and health care, reduces stress and stress-related health problems, alleviates over-crowding, and allows access to neighborhood resources. Stable, affordable housing can be lifesaving for victims of domestic violence. It improves the health of seniors and those with disabilities, permitting more effective and consistent methods of delivering home care and other services. Sadly, only one in four people nationally who are eligible for rental assistance receive it.
According to the Universal Declaration of Human Rights, “everyone has the right to a standard of living adequate for health…including…housing.” Despite our government’s promise, through the Housing Act of 1949, to create the conditions to house every American family, the high numbers of homeless and those living in substandard, even dangerous, housing is a national disgrace. This is especially noteworthy, given the health consequences and high socioeconomic and quality of life costs we all share when so many of our citizens lack basic necessities. It is also both galling and embarrassing, since we are the wealthiest country on the planet.
There is much that can be done at the local, state, and federal levels to ameliorate the lack of safe and affordable housing and to provide assistance to those who, whether through physical or mental illness, interpersonal violence, disability, military service, poverty and substandard wages, or other socioeconomic barriers are unable to afford a place to stay. For many Americans, homelessness is one paycheck, medical crisis, military deployment, or domestic assault away.
Holocaust survivor and author Primo Levi wrote, “A country is considered the more civilized the more the wisdom and efficiency of its laws hinder a weak man from becoming too weak or a powerful one too powerful.” If we are to become a more civilized society, then we must heed his advice and work together to confront social injustices through voting, changes in legislation, and activism.
Bio: Martin Donohoe, MD, FACP practices internal medicine and is the author of Public Health and Social Justice (Jossey Bass/Wiley) and the host of the cable television program “Prescription for Justice.” See http://publichealthandsocialjustice.org or http://www.phsj.org for further information.