Chapter 9 - Reframing health, environment, and housing

ABSTRACT

Three traditional frameworks in health, environment, and housing were reformed because of the new healthy housing experience. Lead poisoning, asthma, mold-induced illness, and other housing-related diseases and injuries were typically classified as “noncommunicable,” because they were associated with behavior, environmental (including housing), and genetic or physiological factors. Yet deficiencies in homes transmitted (“communicated”) certain health problems. “Communicable” diseases are those mainly originating in organisms and transmitted to humans as illnesses. Most health investments went to combatting these communicable diseases. Historically, this framework left housing and health divided, even though early housing codes in the late 1800s were driven largely by communicable disease prevention (cholera, typhoid, and tuberculosis). The successful control of these diseases included better medical treatments and control of organisms, but also changes in housing such as better ventilation, reduced crowding, and improved drinking water supply. The emergence of lead paint poisoning in the mid-1900s, Title X in 1992, and the healthy housing movement in 2000 all demonstrated both the failure of the communicable/noncommunicable framework and the promise of a new one. Most recently, the Covid-19 pandemic led to integrated medical (vaccine) and housing interventions (temporarily ending housing evictions). Social determinants of health (which included housing) increasingly replaced the antiquated communicable disease framework. Similarly, the traditional environmental framework of the “shared commons” and “polluters pay” that underpinned environmental regulations failed in the case of healthy housing, because houses were not traditionally considered to be part of those commons and there were no clear housing polluters. This led to fragmentation. Each municipality developed its own housing code (unlike nationwide environmental and public health standards and laws) and those codes often explicitly refused to address healthy housing hazards. Each housing owner had to pay the remediation cost, and many could not afford them, or chose to ignore them, or did not recognize them at all, with disastrous consequences. Pollution standards were developed for outdoor air and workplaces because they were “shared” spaces that could be measured with scientifically validated methods, but no such standards were developed for housing conditions. Yet the California and Rhode Island lead paint legal cases created a new precedent, in which the cost of lead paint remediation was borne not solely by the public or the homeowners, but instead by the industries that created the pollution and disease in the home. A third traditional framework held that the main purpose of housing policy and programs was to build individual wealth and social stability, but not health or environmental quality, because the latter were neither “communicable diseases” nor “shared commons.” The 2008 financial crisis that originated in housing showed this framework failed and the rising cost of housing also led to health and environmental problems. There was new evidence that higher housing costs resulted in avoided healthcare and environmental degradation. The housing market failed to include health investments in the price of housing, making healthy housing interventions unlike any other housing improvement, a clear market failure. Owners did not make health investments in housing because the owner could not recoup the investment upon sale, even though there were large savings to health, environmental, and other sectors. These three disconnects in health, environmental, and housing frameworks led to widespread social problems and large disparities by race, ethnicity, and income. A new social determinant framework emerged showing that housing, health, and environment could no longer remain confined to different worlds, implemented by different professions with their own specialized training, with their own terminology, studied by different arts of the academy, with differing workforces, policies, programs, and financing systems, with different citizen advocacy groups, with differing philanthropic initiatives, and with budgets far too small and disjointed to meet the need. This new consensus resulted in major reforms in housing, health, and environment, emergence of new environmental justice, health and housing citizen movements, new research agendas, record government appropriations, and larger private sector investment in healthy homes and lead paint remediation.