By Diana Hernández, PhD
Diana Hernández’s community-oriented research examines the intersections between the built environment (housing and neighborhoods), poverty, equity, and health, with a particular emphasis on energy insecurity. She is an assistant professor of sociomedical sciences at the Mailman School of Public Health at Columbia University and JPB environmental health fellow at the Harvard T.H. Chan School of Public Health.
“We were intervening too far downstream in the lives of our clients,” said Health Leads’ Rebeccca Onie in her 2012 TEDMED talk. “By the time they came to us, they were already in crisis.”
Onie was describing her days as a young law student fighting for the rights of low-income families. Her clients were grappling with the challenging intersection of health problems and housing problems, such as a man who couldn’t pay his rent because he was paying for his HIV medication or a young girl with asthma who regularly woke up covered in cockroaches. Rebecca took a hands-on approach, visiting her clients’ homes, collecting the cockroaches, and presenting them to the judges in the courtroom. This experience, among others, ultimately led Onie to found Health Leads, an innovative program that enables healthcare providers to prescribe basic resources like food, heat and housing, and then connects patients with those services.
We know that housing—particularly the affordability, adequacy and stability of housing—is one of several areas with vital implications for our health and overall well-being. Affordable housing ensures that residents can meet other basic needs, such as food and medical expenses. Adequate housing conditions help prevent the onset and exacerbation of asthma and other chronic health conditions, and promote better mental health and cognitive development. Stable housing ensures that people have continued social support and institutional ties.
It is imperative that we make health a shared value in the housing sector. There is a growing body of evidence supporting the links between housing and health, but engaging stakeholders in this effort remains a challenge. Three key stakeholders can play a more central role in creating value, particularly in low-income, multiple-unit housing: real estate developers, property managers, and residents.
Affordable housing creates opportunities for low-income individuals and families to maintain a home while on a limited household budget. Real estate developers have benefited from a variety of financing tools, such as low-income housing tax credits and new market tax credits, to create projects that would otherwise not be financially feasible. However, only recently have building standards begun to factor in health. For example, the 2015 Enterprise Green Communities (EGC) Criteria incorporate health into each dimension, from design and material selection to considerations of the neighborhood fabric, and devote an entire section to creating a healthy living environment. These criteria will build a solid foundation for healthy and sustainable affordable housing development, while paving the way for health to be viewed as an important value in the housing sector.
But it is not enough to design buildings for health—they also need to be maintained in ways that protect health over time. For instance, due to limited investment in regular maintenance and necessary upgrades, today’s public housing is dilapidated, jeopardizing the health and dignity of our nation’s most vulnerable residents. The U.S. Department of Housing and Urban Development has recently created the Rental Assistance Demonstration program to allow public housing authorities to preserve and improve properties and “address the $26 billion dollar nationwide backlog of deferred maintenance.” While this investment is crucial, we also need stringent stipulations to avoid a similar crisis in the future. Stricter maintenance policies should also be extended to private housing to ensure that health becomes a priority across all housing types.
Residents themselves also have a vital role to play in this effort—their knowledge and engagement are essential to promoting health. I’m collaborating on a project that is focused on smoke-free housing policy compliance and enforcement, and my community partners and I have implemented a “building ambassador” model. Building ambassadors (BAs) are residents who champion smoke-free living environments and health, acting as liaisons between tenants, the property manager and the research team. BAs are modeled after community health workers, who promote health in at-risk groups by supporting such issues as chronic disease management and reducing environmental triggers that cause asthma. Trained to understand the health consequences of smoking and how smoke-free buildings can help reduce exposures to health risks, the BAs assist with health education activities for their buildings. BAs work to build a Culture of Health right at home by reminding fellow tenants to consider their health and the health of their neighbors.
Greater attention to health as a key value in housing, especially in low-income housing, will increase demand for healthier design and improved maintenance while also driving social support from family and neighbors. Making health a shared value in housing requires the engagement of housing developers, property managers and residents who are charged with creating, maintaining and supporting opportunities for health in a primary physical and social environment—the home.