Health Disparities, Health Equity and Social Determinants of Health hosted by the Region 2 Public Health Training Center

Housing as an Intermediary Determinant of Health and Points of Intervention to Reduce Disparities Angela Aidala, PhD Associate Research Scientist

Robert E. Fullilove, EdD Associate Dean for Minority Affairs July 5, 2016 12:00-1:00PM ET 1.0 Category I CHES Continuing Education Credit Available for this webinar

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB6HP27878-01-00, Affordable Care Act (ACA) Public Health Training Centers for $705,000.00. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. 1

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@Region2_PHTC Collaboration of: – Columbia University Mailman School of Public Health www.facebook.com/region2phtc – Rutgers School of Public Health – University of Puerto Rico Graduate School of Public Health – University of the Virgin Islands Community Engagement and Lifelong Learning Center – New York State Association of County Health Officials

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Mission: – Enhance the public health workforces’ ability to effectively deliver the Essential Public Health Services to the populations in NY, NJ, PR and the U.S. Virgin Islands.

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National public health content area: – Health Disparities, Health Equity, Social Determinants of Health

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB6HP27878-01-00, Affordable Care Act (ACA) Public Health Training Centers for $705,000.00. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. 2

Health Disparities, Health Equity and Social Determinants of Health hosted by the Region 2 Public Health Training Center

Housing as an Intermediary Determinant of Health and Points of Intervention to Reduce Disparities Angela Aidala, PhD Associate Research Scientist

Robert E. Fullilove, EdD Associate Dean for Minority Affairs July 5, 2016 12:00-1:00PM ET 1.0 Category I CHES Continuing Education Credit Available for this webinar

 Following the webinar, Drs. Aidala and Fullilove’s slides and recommended reading will be emailed to registrants.  When the edited video has been uploaded to our website, registrants will receive another email with this link. 3

“Health inequities arise from the societal conditions

in which people are born, grow, live, work, and age” How can public health address fundamental social determinants of health – shaped by distribution of money, power, and resources at the global, national, as well as local levels ? • Understand the importance of housing and ‘housing systems’ as intermediary determinants of health • Identify opportunities for public health policy and programmatic points of action in housing and housing systems to improve individual and community health • Learn from cross-sectoral initiatives involving local and state health departments that have targeted housing and residential environments as strategic points of intervention 4

INTRODUCTION Housing is an (intermediary) social determinant of health and health equity • Fundamental determinants of health are macro level social,

cultural, economic, political policies and dynamics that affect

• Socioeconomic positions of individuals, groups, communities within society

- determines access to education, work, income

- Influenced by gender, race/ethnicity, other bases of social inclusion/ exclusion

• SES and underlying social determinants of health operate

through a set of ‘intermediary’ determinants to shape health outcomes

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Housing as strategic intermediate determinant Housing links upstream economic, social, cultural determinants to the more immediate physical and social environments in which we carry out our day-to-day lives  Housing is where our economic, social, and personal lives

come together

"Our health is determined by resources and supports available in our homes, neighborhoods, and communities" --Healthy People 2020

 The ‘housing system' as well as the health system affects

exposure and vulnerability to broader social determinants of disease or injury as well as their consequences

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FUNDAMENTAL AND INTERMEDIARY DETERMINANTS OF HEALTH

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Direct and Indirect Housing Effects Lack of stable, secure, adequate, affordable housing • Lack of protected space to maintain physical and psychological well-being

• Constant stress producing environments and experiences • Neighborhoods of disadvantage and disorder • Compromised identity and agency • Unaffordable housing costs diverts resources • Press of daily needs - barrier to service use when available

• Structuring the private sphere – lack of housing is barrier to forming stable intimate relationships and networks of support 8

Adapted from Human Impact Partners; The PEW Charitable Trusts 9

• Health depends on homes that are safe, dry, ventilated, free from physical hazards, pest and contaminants - Lead poisoning irreversibly affects brain and nervous system development – over 300,000 children have elevated levels - Leaks, poor ventilation, mold, vermin affects risk and exacerbates respiratory conditions – over 20 million in U.S. - Extreme temperatures associated with CVD, increased mortality - Carcinogen exposures – tobacco smoke, radon, asbestos, toxins • Sense of security, privacy, stability, control also important - Crowding, doubling up linked with infectious diseases and stress and poor mental health outcomes for children and adults 10

• Neighborhood conditions have major health effects - Physical, social, economic features of neighborhoods linked with

general health status, disability, birth outcomes, chronic conditions, health behaviors, violence and trauma, injuries, mental health indicators

- Direct exposures to health promoting resources or risks, barriers - Major influence on health behaviors – smoking, drinking, diet, exercise, sexual behavior, follow recommended medical care - Housing location affects access to employment opportunities and schools, parks, transportation, police & fire, medical care

• Concentration of sub-standard housing in disadvantaged neighborhoods compounds SES and race health disparities 11

• Social relationships among the wider residential community associated with mental and physical health outcomes - Neighborhoods free from segregation and concentrated poverty and/or high rates of transiency have more social capital and collective efficacy which is health promoting - Neighborhoods in which there is a degree of familiarity, mutual trust, feelings of connectedness among neighbors more likely to work together for common goals - Positive social networks and more exchange of information about resources that affect health

- Maintain informal social controls discouraging crime or other undesirable behaviors 12

• Housing affordability limits where we can live – affecting housing quality, housing stability, neighborhood risks and resources • Cost burden of unaffordable housing prevents families from meeting other basic needs placing many families under tremendous and constant financial strain • High housing-related costs force trade-offs between food, heating and other needs – 50% of all households in past years - Postpone/ forgo medical care visits, prescriptions – more ER use • Housing cost burden associated with worse health, self- reports of poor health, hypertension, arthritis, depression, anxiety • Move frequently associated emotional, behavioral, academic problems among children, substance use and depression 13

More than 50% of All Renters are Cost Burdened

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As need gone up, getting assistance gone down

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What can public health do?

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Cross-sector collaboration • Public health louder at the table • Collaboration between the health, housing and community development sectors

• Health Impact Assessments Policy decisions that affect housing quality, affordability, and location as well as neighborhood can influence if effects will be health promoting or detrimental to community health and can contribute to reduction of health risks, health outcomes, and health disparities

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Strategic time and opportunities • Affordable Care Act (ACA) - hospitals and managed care programs can now incorporate healthy housing into their planning for community benefits agreements - Community-level strategies for prevention and reduction of health inequities in chronic diseases - Opportunities for innovative financial solutions to housing problems

• Affirmatively Furthering Fair Housing (AFFH) rule explicitly considering structural disinvestment and lack of housing in communities of opportunity - Assessment and remediation to encourage more inclusive housing, planning, and investment 18

some suggestions

Healthy Communities of Opportunity: An Equity Blueprint to Address America’s Housing Challenges Policy Link (2016) https://www.policylink.org/sites/default/files/HCO_Web_Only.pdf

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Healthy Housing • Drive health-care spending to healthy housing • Mitigate toxic exposures to environmental hazards outside the home • Remove health hazards from inside homes – lead, mold etc. • Map data to track environmental harms that differentially affect communities

• Promote green building rehabilitation to promote resident health • Offer energy efficiency upgrades • Increase inspection and enforcement of housing code violations 20

Housing affordability & neighborhood • Condition state/federal infrastructure investment on increasing housing affordability • Enact strong tenant protections and move housing off market to land trusts, nonprofit ownership • Dedicate public land to affordable housing development • Zone for affordable multifamily housing near transit hubs • Extend affordability term for expiring subsidized housing • Support the National Housing Trust Fund, cap & trade, acquisition funds • Leverage AFFH rule to address health equity outcomes 21

An Environmental Scan of Recent Initiatives Incorporating Social Determinants in Public Health Joint publication of Preventing Chronic Disease and the National Academy of Medicine (2016) https://www.cdc.gov/pcd/issues/2016/16_0248.htm

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Cross-sector initiatives • Community-generated initiatives – often led by the health department or local coalition that includes health department • Data metrics initiatives – data plays crucial role in setting goals and measuring the health of communities • Toolkits and training – provide practical tools, examples of successful efforts • Health campaigns supporting community health – group of people or organizations working to inspire multi-sector effort to improve health of a community • Federal initiatives – sponsored by HHS and/or HUD, Dept of Transportation, the Federal Reserve • Philanthropic initiatives - RWJ CuIture of Health; MacArthur Housing Matters, Kresge Foundation, Kellog Foundation 23

Case studies

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Gentrification and Public Health: the Role of Departments of Health ROBERT E FULLILOVE MAILMAN SCHOOL OF PUBLIC HEALTH

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What is gentrification? • Gentrification is characterized by declines in the number of low-income, people of color in neighborhoods that begin to cater to high-income workers willing to pay higher rents”

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What is gentrification? • Gentrification is driven by private developers, landlords, businesses, and corporations, and supported by the government through policies that facilitate the process of displacement, often in the form of public subsidies.” From: Development without Displacement: Resisting Gentrification in the Bay Area, Causa Justa: Just Cause

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The Public Health Consequences of Gentrification • Gentrification has the potential to bring investment, commercial services, and infrastructure improvements to a community • Problem: those most in need of these improvements will be displaced before they can benefit from them

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The Public Health Consequences of Gentrification • The displacement of neighborhood residents by gentrification often results in resettlement in other, economically disadvantaged neighborhoods • Overcrowding, a lack of appropriate health care resources in the resettled neighborhood, and a decline in community health often result

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The Public Health Consequences of Gentrification • The financial burdens of displacement include the costs of moving, increased rent burden, and significant increases in psychological stress • Families may be forced to sacrifice basic needs such as health care, transportation, healthy food, and intimate social relations in order to meet the costs of displacement

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Displacement Prevention: the Role of Public Health • Gentrification and displacement have health consequences that can be measured and predicted • A community health impact analysis should be conducted including a specific assessment of the potential impacts of displacement

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Displacement Prevention: the Role of Public Health • Community residents and those likely to be impacted by gentrification/displacement must be involved in the assessment of the health impacts of displacement • “No planning without health assessments” should be the theme guiding the work of public health advocates and agencies

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Final thoughts • “Gentrification does not solve the problems of poverty and ill health in the city, it simply displaces them.” • “Public health departments can disseminate research on health impacts of displacement and support policy change to promote community stability” •

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Development without displacement: resisting gentrification in the Bay Area: CUSA JUSTA:: JUST CAUSE

Questions?

Please type your questions into the chat box.

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Thank you! Health Disparities, Health Equity and Social Determinants of Health hosted of by the Please complete our evaluation this webinar at:

http://tinyurl.com/July5Eval Region 2 Public Health Training Center

No webinar in August Next webinar: September 6, 2016 12:00-1:00PM ET

TBC 35