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Housing and Health

John M. Last 1'

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All humans need shelter: protection against the elements, somewho cannot provide for them and must fend for themselves from raise offspring. effects of housing conditions health haveto titution to survive. where to storeThe food and prepare meals, and a on secure place ages as yoeng as 5 or 6 years; many t urn to crime and child prosbeen known since antiquity. Deplorable living conditions in These shanty-towns and periurban slums endanger the urban slums became a political issue in the nineteenth century health and security of many millions in Latin America, Africa, is- when vivid descriptions by journalists, novelists, and social re- and many parts of Asia. Accurate numbers are impossible to ob-1e. formers aroused public opinion. Osler's Principles and Practice tain because the missing services include enumeration by censusojMedicine (1892) and Rosenau's Preventive Medicine and Hytakers and because situations change so rapidly, but in Mexico ss, glen (1913) noted the association between overcrowding and City, Lima, Santiago, Rio De Janeiro, Sao Paulo; and Bogota, common serious diseases such as tuberculosis and rheumatic well over half the total population live in the periurban slums.' fever. In the mid-1980s, there were as many as 30 million periurban slum-dwellers in these six cities alone. Others are even worse off: worldwide, an estimated I 00 million people are entirely h ia: omeless, living on the streets without possessions, often from infancy erOVERVIEW OF HOUSING CONDITIONS onward. Although this is a problem mainly in developing counIN THE WORLD tries, homeless people have increased in numbers in the most afeal fluent industrial nations in fhe last decade, often forced out of their homes by hard economic times. Public health departments nd Housing conditions have greatly improved in the affluent Indusin large cities such as New York and London have been obliged trial nations throughout the second half of the twentieth century, to spend increasing proportions of their budgets on emergency but more than two thirds of the households in the world are in shelter for growing numbers of homeless destitute families. developing countries, the great majority of them in rural areas; Increasing numbers, an estimated 15 million in 1989, live in the most prevalent indoor environment in the world is the same refugee communities' in Africa and the Middle and Far East now as throughout history-huts in rural communities) But this where housing conditions are equally deplorable, sometimes pected to exceed 50%, 2 and in the world as a whole the urban Industrially developed nations are experiencing other chalpopulation will comprise 65a%o or more. Many cities will be very lenging new health problems related to housing conditions. Ris- large (see Table 70-2, Chapter 70). ing land values and the need to provide cheap housing for exMany of these new urban dwellers have terrible living condi- panding populations have led to proliferation of -high-rise, tions. In the last 20 years there has been a great increase in the high-density apartment housing. Publicly supported housing numbers of people living in periurban slums in developing coup- projects economize by restricting living space and providing few tries. They often lack sanitation, clean water supplies, access to amenities. This kind of dwelling creates new sets of problems: health care, and other basic services such as elementary educa- emotional tensions attributable to living too close to the neigh-tion. The proportion of people in such circumstances ranges be- bors, inadequate play areas for children, poor services, and Be-tween 20% and over 80016 in most cities throughout Africa, Latin fective elevators and communal washing machines. Only a small America, and South, South-east and South-west Asia. The plight minority of people, predominantly the educated professional of children is especially deplorable: infant mortality rates exceed classes (such as many readers of this book), enjoy comfortable, 100 in many places.' Children are often abandoned by parents aesthetically pleasing, healthy living conditions. 67 1

672

III. ENVIRONMENTAL HEALTH

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such as cleaning fluids, have diverse origins. There is a wide range of other pollutants, such as many organic substances, oxides of nitrogen, sulfur, and carbon, ozone, benzene, and terIndoor climate and indoor air pollution, biological exposure fac- pines. 6 All such toxic substances can be troublesome, especially tors, and various physical hazards encountered inside the home in sealed air-conditioned buildings and most of all when the air is are encompassed by the term indoor environment. recirculated to conserve energy used to heat or cool the building.The indoor climate may be the same as that out of doors, or In combination with fluorescent lighting, these gases and sus- it may be modified by heating, cooling, or adjustment of humid- pended particulate matter can produce an irritating photochemi- ity levels, and often in sealed modern buildings, by all of these. cal smog that may cause chronic conjunctivitis and nasal congestion. Physical Hazards. Physical hazards in the indoor environ- Imperfect ventilation can become a serious hazard if it leads ment include toxic gases, respirable suspended particulates, as- to accumulation or recirculation of highly toxic gas such as car- bestos fibers, ionizing radiation, notably radon and "daugh- bon monoxide; this is especially likely when coal or coke is used ters," nonionizing radiation, and tobacco smoke. as cooking or heating fuel in cold weather and vents to the out Indoor air may be contaminated with dusts, fumes, pollen, side are closed to conserve heat. and microorganisms. The principal indoor air pollutants in inAsbestos was used for many years as a fire retardant and dustrially developed nations are summarized in Table 38-1. insulating substance in both domestic and commercial buildings. Many of these pollutants are harmful to health. Some occur Its dangers to health have led to restriction or banning of its use mainly in sealed office buildings, and others, such as tobacco and to expensive renovations aimed at removing it (see Chapter smoke, in private dwellings. 17). Fibrous glass insulation may present hazards similar to In developing countries, indoor air pollution with products those of asbestos but less severe. of biomass fuel combustion is a pervasive problem (Table 3$-2). Ionizing radiation, in part r, ular radon and "daughters," ,The fumes from cooking fires include high concentrations of recan be a health hazard, especially i t houses arc sealed and air spiratory irritants that cause chronic obstructive pulmonary disrecirculated, in which case there rs greater opportunity for higher ease (COPD) and that sometimes contain carcinogens too. Preconcentrations to accumulate. 'ourees of radon include true mature death from COPD is common among women who from amounts of radioactive material in.orporated in cement used to their childhood have spent many hours every day close to primiconstruct basements. Radon can also be emitted from soil or tive cooking stoves, inhaling large quantities of toxic fumes. s rocks in the environment where the houses are built. The toxic gases specified in Table 38-1 come from many Nonionizing radiation, notably extremely low frequency sources. Formaldehyde is emitted as an off-gas from particle electromagnetic radiation (ELF), has attracted much attention board, carpet adhesives, and urea formaldehyde foam insula- since the observation of cancer uitidence at higher rates than ex- tion; it is a respiratory and conjunctival irritant and sometimes peered among children living close to high soltage power finest causes asthma. It is not emitted in sufficient concentrations to No convincing relationship has been demonstrated between child-constitute a significant cancer risk. Although rats exposed to hood cancer and exposure to ELF from domestic appliances, formaldehyde do demonstrate increased incidence of nasopha- with the possible exception of electric blankets." Microwave ryngeal cancer, there is only weak evidence of elevated cancer ovens and television screens are safe. The nature of the relation-incidence or mortality rates even among persons occupationally ship, if any, between ELF and cancer remains controversial, exposed to far higher concentrations than occur in domestic sethowever. zings. Nonetheless, ureaformaldehyde foam insulation has been Tobacco smoke is often the greatest health hazard attribut-banned in many jurisdictions on the basis of the evidence for car- able to physical factors in the indoor environment. Infants and cinogenicity in rats. Gases and vapors from volatile solvents, children are significantly more prone to respiratory infections,

INDOOR ENVIRONMENT

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ia: ercal nd TABLE 38-1. SOURCES AND POSSIBLE CONCENTRATIONS OF INDOOR POLLUTANTS

Respirable particles

Tobacco smoke StovesAerosol spraysCombustion equipment

0 .0 5-0 .7 mg/m 3

Carbon monoxide Stoves, gas heatersGas cookers Nitrogen dioxide CigarettesCoal combustion Sulfur dioxide Carbon dioxide Formaldehyde Carpet adhesivesInsulationSolvents, adhesives, resin products, aerosol sprays Other organic vapors (benzene, toluene, etc.) Ozone Radon and "daughters" Asbestos Mineral fibers
NOT E:

1 -1 1 5 mg/m3 0 .0 5-1 .0 mg/m 3 0 .0 2-1 .0 mg/m 3 6 0 0 - 9 0 0 0 mg /m 3 0 .0 6-2 .0 mg/m 3

Combustion RespirationParticle board

Electric arcing, UV light sources Building materials Insulation, fireproofing Appliances

0.01-0.1 mg/m 3 0 .0 2-0 .4 mg/m 3 1 0-3 0 0 0 Bq/m 3 1 + fiber/cm3 100-10,000/m3

Tobacco smoke, benzene, radon and daughters, asbestos, and possibly formaldehyde are carcinogens; most others on this list are respiratory, or conjunctivaW irritants. Carbon dioxide is an asphyxiant, carbon monoxide is a lethal poison.

TABLE 38-2. INDOOR AIR POLLUTION FROM BIOMASS FUEL COMBUSTION IN DEVELOPIA_ SPM .c ` 11102 3 (mg/m 1 Dal
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Other

9geria, Lagos 1076 Papua New Guinea 0.84 K"a Highlands , Cattle dung Dungand wood tide, Gujarat Monsoon 56,6
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Benzene, 86 ppm Phenols, 1.0 g/m3Acetic acid, 4.6 pg/m3

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ueta from de Koning et al 1985 and WHO: Air Quality Gurdelin Regional Reports series 23 Copenhagen: WHO 1987 .,,

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and nonsmoking spouses are more prone to chronic respiratory illnesses and to tobacco-related respiratory cancer when living in the same house as a habitual cigarette smoker. Cigarette smoking is a hazard in another way as well: about 2076 to 25% of deaths in domestic fires are a result of smoking. the lowest depths of the slums or become homeless street people. inept include many varieties Biol of pathogenic microorganisms. Mvmbacterium tuberculosis survives for long periods in dark and .

tionship between mental health and social class." Those who cannot cope with the competitive pressures of industrial and commercial civilization because they suffer from such disorders as schizophrenia, alcoholism, or mental retardation and have inadequate family and social support systems drift downward to
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less mentally ill persons in the United States." Schizophrenia and alcoholism have maximum prevalence in slums and skid row

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. air conditioning systems, ttalis, infrequently swept floors cause asthm as may many organic dusts and pollen by the fecal-oral route, occur often when homes are dirty, Many othermost infection verminou should be ,kept scrupulously clean at all times because many varicause food scraps can he an excellent culture medium for many dies of disease-carrying vermin are attracted by filth and bepathogens that cause food poisoning or other diseasess

Behavior disorders such as adolescent delinquency, vandalism, , terry suburbs occupied mainly by low-paid workers, where recreschools are often of inferior quality. Bad housing does not cause theseems; the cial pathology. of p factors to m the p r o b l y a rA e different u s u a l l y set s ym t o m s contribute o f mo r e co p lsynex drome called "suburban neurosis," which occurs among women who remain housebound for much of the time while their hiss

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bands are at work and their children are at schoo related to the quality of housing in many ways, some already al; this condi Sodotconomie Conditions. Socioeconomic conditions are l and voices into the house relieves loneliness. Crowding always tends to be greater among the poor laded to. than among the rich; this increases risks of transmitting communicable diseases and often imposes additional emotional stress that probably contributes to domestic violence. Street accidents involving children are more common in poor than in wealthy HOUSING STANDARDS neighborhoods because the children often have no other place than the street to play. Poor people generally live in poorly Public health workers are directly concerned about the quality of equipped and maintained homes, adding to the risk of domestic housing because of the many ways it can affect health. Local accidents ranging from falls down poorly lit stairwells to electro- health officials have special powers to intervene when health is cution. Lead poisoning is a particular hazard for children in di- threatened by inadequate housing conditions. A handbook fre-lapidated houses where they are likely to ingest dried out flakes quently revised by the Centers for Disease Control and the of lead-based paint. Emissions from factory smelter stacks con- American Public Health Association, Housing and Health; tribute to environmental lead and other toxic metal contamina- APHA-CDC Recommended Minimum Housing Standards, 14 don, also more often present in poor than in well-to-do neigh- sets out specific details on basic equipment and facilities, fire borhoods, because the former are more often located in or close safet , lightin to heavily industrialized areas. space requirements (occupancy standards), and the special re,

HOUSING CONDITIONS AND MENTAL HEALTH

quirements for rooming houses. This valuable reference spells out general guidelines that can be used by local authorities as the basis for, regulations, but there are no universal legally enforcible

standards until local jurisdictions introduc them. Heal4h Princirange of behavioral factors that can influence health In relation Many descriptive studies by social epidemiologists and psychia- to housing conditions, for example, by providing guidelines on trists have demonstrated a consistent association between mental ways to reduce psychological and social stresses by ensuring pri-disorders and urban living conditions? There is also a close rela- vacy and comfort and on the housing needs of populations at

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Both these booklets should be part of the library sites, and other forms of urban blight." From modest bcyt of every local health officer. nings the Healthy Cities movement has spread all over the word, and in some places has extended beyond cities to embrace rod communities," Since the environment in which people foe, grow, work, and play so manifestly influences their health aid STATISTICAL INDICATORS OF happiness, the Healthy Cities initiative is potentially among *c most valuable means at our disposal to make this environmae HOUSING CONDITIONS healthful.

111. F`s %Iko\M F\IAL HL A L.1I special risk such as pregnant women, the handicapped, and the eradicate urban wasteland, industrial pollution, toxic dMV elderly infirm.

Health planning requires every kind of information pertinent to community health, including statistics on housing conditions, SPECIAL HOUSING NEEDS Useful information is routinely collected at the decennial census on density of occupancy (persons per bedroom), cooking and refrigerating facilities, and sanitary conditions. Perusal of tables Elderly and handicapped people require accommodation 11* :o: showing these and other housing statistics enables health plan- has been adapted to enable easier access (ramps, handrails, wide ners to identify neighborhoods at high risk of diseases associated doors to permit passage of wheelchairs), to facilitate storage a d with crowding and poor sanitation. preparation of food (low-placed cupboards and stoves wit Census tables also enable health planners to identify less obfront-fitted switches, which are inadvisable in homes where there latrusive health hazards, such as proportions of elderly persons livare small children), and with special equipment for bathing and :r, ing alone, whether in small apartments or multiple-room dwelltoileting (strong handrails, wheelchair access). Special atxaf ings that perhaps were once the family home before all the others modation of this type is often segregated, which tends to set the ea in the family moved away or died, leaving an elderly person as occupants apart in an urban ghetto for the elderly and hand& sole resident. Once such neighborhoods are identified, public capped. Integrated special housing is preferable, as examples. ~shealth nurses and other community health workers can more easDenmark, Sweden, and the United Kingdom have demos ily locate the individuals at risk, who may need but have not yet strated; in this setting, elderly, infirm, and younger handicapped le asked for help. persons live among healthy families, which many of them prefer ia: In addition to census, tables, there are other useful sources and which helps to accustom healthy people to making allowof information on neighborhoods with a high incidence of social antes for their less fortunate fellow-citizens. ispathology. Fire departments record false alarms and fires delibte. erately lit; police departments record details of vandalism and calls to settle domestic disturbances, and schools record absenCONCLUSION ss, teeism and truancy. All can be analyzed by area, thus pin-pointing high-risk neighborhoods; this. method has been used as part of a program aimed at improving the chances of getting a good This is a brief summary of a complex and diverse field. The esstart in life for children from disadvantaged homes. There is a sential requirements of the domestic environment have beet+ la' high correlation between these indicators of social pathology in a stressed, along with some of the obvious adverse effects of unsalneighborhood, such as a high-rise, high-density apartment comisfactory housing. erplex for low-income families, and the incidence of emotional disThe home should provide more than mere shelter and a safe turbances and similar behavioral upsets among young and teenplace to raise children. It should be the setting in which the fats cal aged children. 16 ily lives and grows together, where bonds of affection .and mutual trust are formed and strengthened, where socialization into nd the prevailing culture and intellectual stimulation are occurring, and where privacy is available when it is wanted and needed. HEALTHY COMMUNITIES AND Doxiadis20 coined the term ekislics, meaning the science of HEALTHY CITIES human settlements, to encompass the many interactive factors that make living space compatible with good physical, mental, emotional, and social health and well-being. The arrangementof As part of the initiative for "Health for all by the year 2000" dwelling units, their relationship to the natural and to the manthat followed resolutions passed at the World Health Assembly made environment, and their interior structure and function am 17 in 1977, health planners in many nations, notably in the Europlay a part in creating a housing environment conducive to good pean Region of WHO, began active planning for health promohealth. Many less easily described and unmeasurable factors, tion (to be distinguished from disease prevention). Health prosuch as the innumerable ways that people can interact, also conmotion (see Chapter 1) requires action by many individuals and tribute to the ambience of the living space. These intangible facgroups not usually identified with care of the sick or prevention tors would receive more attention in a better world than this if
we of disease.

The definition of health promotion, "the process of enabling people to increase control over and improve their people may often have to take action aimed at improving their living conditions. The Healthy Cities movement is a coordinated program involving community health and a wide variety of community groups who collectively seek to upgrade living conditions. Initially, some of the participating cities were relativelyhealthy places to live (e.g., Toronto, Canada) while others, (e.g., Liverpool, England) were not. The Healthy Cities initiative emphasizes activities that could be expected to enhance good ^eallp, such as provision of improved recreational facilities, services for children and their mothers (including basic education for the mothers as well as the children), and aggressive action to

were really intent on applying all possible means to the end of promoting and preserving the public's health. health," implies that REFERENCES workers, local elected officials in urban affairs, I. de Koning HW, Smith KR, Last JM: Biomass fuel combustion and health. Bull WHO 63,11-26,1985 2. Tabibzadeh 1, Rossi-Espagnet A, Maxwell R: Spotlight on thecitiex Improving urban health in the developing world. Geneva: WHO,
1989 3. Urbanization and its implications for child health. Geneva: WHO

and UN Environmental Programme, 1988