Housing as a Social Determinant of Health: A Q&A with Epidemiologist Earle Chambers
Lisette Vegas and Maya Brennan contributed to this post
Housing—as a physical structure, a source of stability or stress, and a part of a neighborhood and community—affects residents’ health. Health and housing partnerships are rooted in evidence that improvements in housing can support physical, mental, and behavioral health. By studying health patterns and determinants at the community or population group level, epidemiologists can help expand results from health and housing partnerships to serve entire areas or groups with disparate health outcomes.
To understand more about housing from an epidemiologist’s perspective, we spoke with Earle Chambers, an associate professor in the Department of Family and Social Medicine at the Albert Einstein College of Medicine. Chambers has documented the connections between housing and neighborhood conditions and health disparities among low-income Latinos in the Bronx.
1. Your research has connected housing with cardiovascular health, depression, sleep disorders, asthma, and obesity. How did you come to view housing as such an important social determinant of health?
I view housing as a linchpin social determinant of health that influences many others. If you intervene on housing, you have the chance of affecting other social determinants of health. Many chronic health conditions have long latent periods where there can be windows to intervention. Scientists interested in social determinants of health look upstream of the presentation of disease to try and determine where these windows to intervention are and how these social conditions contribute to health outcomes.
My interest in housing came from a desire to understand the distribution of more studied social and economic risk factors for disease, like education, occupation, and income, as well as understanding the context for health behaviors, such as diet and physical activity. Low-income neighborhoods and neighborhoods that are predominantly Black or Hispanic are more likely to have fewer options for healthy eating and physical activity. The housing policies that influence where people live, the stability of their housing, and the quality of that housing provide a context to understanding many of the social and economic risk factors that we have come to know influence chronic health conditions and contribute to significant disease burden and death. For example, the practice of redlining that started in the 1930s, responsible for racially segregating large US cities and concentrating poverty in these areas, set the stage for the targeting of these same populations by banks for high-risk loans that characterized the housing collapse in the US around 2006–07. If one were to just look at the relationship between access to resources in these neighborhoods and healthy options today, it would be clear that these areas lack healthy options. However, one would miss the historical context where racist housing policy is how generations of people got there in the first place, and racist practices continue to limit housing options for these same populations of people. This is important because as we consider interventions to increase healthy options for communities, it is important to consider interventions that simultaneously address the inequity in housing options.
2. What aspects of housing matter for population health? For example, how much do you focus on health determinants in the physical home, the neighborhood, other housing-related factors, or a combination thereof?
I find that thinking about the extreme case of housing insecurity—homelessness—to be an effective way to think about how housing affects health. If you are homeless, it is difficult to access preventive health care, to access employment, to access educational options, to access healthy food, and so on. In this extreme case, almost any housing is better than no housing at all. As a society with the ability to house its population, we should dedicate resources to ensuring that all have a place to live. Beyond this most extreme case, we can discuss the other aspects of housing that matter for health. Where housing is located, the resources around it, the quality of that housing, the stability of that housing, including how much it costs, are all important in determining how housing affects health. It can be difficult to study all of these aspects simultaneously, so many studies focus on one or two of these. Which aspects of housing affect health conditions more also depends on the health outcomes being examined. For example, in our study of sleep problems, we showed that the type of rental subsidy used by residents—that is, rental voucher use versus public housing—wasn’t the major determinant but rather the conditions of the home and the surrounding environment that affected the quality of sleep. The short answer to this question is that they all matter, and they matter together.
3. While doing your research, what have you found are some distinct housing challenges Latinos face in the Bronx? Can the rest of the US build on these learnings, or would you expect the challenges and opportunities to differ in meaningful ways in other geographic contexts?
The high cost of rent in NYC is a challenge for many, and our Latino population is not immune to the housing insecurity this can cause. Homelessness is on the rise in our city, which is of particular concern for our Black and Latino residents, as they are more likely to find themselves without a home. In a county like the Bronx, where the majority of residents are Black or Latino, coupled with a high rate of poverty, the challenges of racial discrimination and poverty intersect to pose many challenges for our residents. But as a health scientist, my work examines the health consequences resulting from insecure and poor-quality housing among our most vulnerable residents. Some cities do a better job of protecting residents from losing their homes than others. NYC has many renter protections, but the need for affordable housing is enormous. As a country, we should be investing in housing protections that keep our low-income residents in stable, quality housing. We should enforce laws that protect against housing discrimination based on race, color, national, origin, religion, sex, familial status, and disability and expand the protections to include sexual orientation and gender identity. Poor-quality housing places residents at risk for health problems, and insecure housing undermines health-related interventions to address preventable health conditions. Because many of our Latino residents find themselves in insecure housing and living in poor-quality housing, associated poor health outcomes are a big concern.
4. What sort of opportunities do you see for greater collaboration both within the health profession (for example, between public health professionals and clinicians) and between the health and housing professions to eliminate health disparities by race, ethnicity, and socioeconomic status?
Racial residential segregation, housing discrimination, and disinvestment in communities of color has a history in this country, and finding solutions that solely address income and not racism is problematic. I think that an equity focus to these collaborative efforts will find that the way forward involves reducing the barriers to quality housing and neighborhoods of opportunity for all residents, acknowledging that racism is an important component to access. As housing and health care become more connected, it will be important to remember that preventing disease is a part of healthy communities, as well as getting sick people well again. There are initiatives to look at the benefits of housing homeless patients, which has the potential to help many high-risk patients. But also making sure primary prevention along the housing continuum remains a part of the overall housing and health conversation is imperative. Aligning goals between public health and primary care by sharing data can be a way to get a fuller picture of how patients are reflective of the communities they live in and receive health care within.
5. What questions do you hope to address in future research?
I think the health burden of residential displacement because of neighborhood changes such as gentrification is understudied. I am currently working on a project to determine whether there are health-related consequences to frequent residential mobility, particularly among low-income Latino residents. The project will look more closely at whether moving from home to home is related to health care utilization. Housing stability among senior residents is becoming more of an issue in recent times, which can make aging in place more difficult for older adults to achieve. The physical and mental health toll that housing insecurity can have among older adults is a public health concern. I also think climate change and the size and frequency of superstorms is going to have large implications for how we stably house our most vulnerable residents and address their health care needs as a result. These are just a few areas where I think more research is needed.
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