By Loretta Okonkwo
Housing is one of the traditional areas of concern for public health, though it has been relatively neglected over recent decades. But housing is important for many aspects of healthy living and well-being.
The home is important for psychosocial reasons as well as its protection against the elements, but it can also be the source of a wide range of hazards (physical, chemical, biological, etc). It is the environment in which most people spend the majority of their time.
Housing and built environments have a profound impact on human health. In developed and even in developing countries, 80‐90% of the day is spent in built environments and most of this is in the home. Therefore, exposures and health risks in this private setting are of crucial relevance. The role of the home for health is enhanced by the fact that the most vulnerable population groups (poor, sick, children and elderly, disabled…) spend even more of their time in this setting, and are therefore most vulnerable and most in need of healthy living environments.
The exact relationship between poor housing and health is complex and difficult to assess. However, research based on the various sources of housing and health data suggests that poor housing is associated with increased risk of cardiovascular diseases, respiratory diseases and depression and anxiety.
Although the health relevance of the private home is well accepted, health considerations do not represent a major objective in construction and rehabilitation of housing and built environments. There is a wealth of evidence indicating that housing and construction standards are almost exclusively based on technical norms, engineering knowledge and architectural design aesthetics. Consequently, standards of “adequate housing” or “sustainable housing” in the modern era tend to be informed by technological rather than health rationales, despite the fact that many housing laws have their origins in public health concerns. Similarly, building codes and national regulations governing the production and approval of buildings often tend to be vague, requiring buildings to be “safe”, to be equipped with “adequate ventilation options” or “functional systems”. These requirements provide little information on what the minimum standards of healthy housing should be, and what characteristics need to be fulfilled to provide adequate shelter from the perspective of human health. Home is where we feel safe. A safe and comfortable “home,” as a shelter, is a source of identification, a place to rest and relax, and is both a psychological and a physical necessity.
The unfortunate reality is that home often harbors dangers of its own, and the tendency to isolate indoors is shown to have ill effects on family health. Substandard and deteriorating housing contributes to a variety of ailments, from respiratory disease and neurological disorders to psychological and behavioral dysfunction.
House-related hazards that increase the risk of illness include damp, mould, excess cold and structural defects that increase the risk of an accident (such as poor lighting, or lack of stair handrails). 45% of accidents are said to occur in the home and accidents are in the top 10 causes of death for all ages. Cold homes are linked to increased risk of cardiovascular, respiratory and rheumatoid diseases, as well as hypothermia and poorer mental health.
While housing conditions are known to influence health, little has been done to examine the scale of that influence. There is a growing body of evidence on the many ways that inadequate housing adversely affects the health of occupiers.
WHO recognizes that housing comprises four interrelated dimensions –
a.the physical structure of the house (or dwelling),
b.the home (psychosocial, economic and cultural construction created by the household),
c.the neighbour-hood infrastructure (physical conditions of the immediate housing environment) and
d.the community (social environment and the population and services within the neighbourhood).
Each of these four dimensions has the potential to have a direct or indirect impact on physical, social and mental health, and two or more of them combined can have an even larger impact.
Current evidence shows that the home – despite highly developed technologies, materials and construction styles – remains a major cause for ill health through exposure to many hazards/factors, including (but not limited to): home injuries, chemical substances, mould and damp, noise, pests and infestations, poor access to water and sanitation, proximity to pollution sources, or flooding, and inadequate protection from extreme weather. These hazards/factors are further discussed below:
Housing-related hazards include:
a.Home injuries (falls and accidents):
Unintentional home injuries are a serious public health problem. In some countries home injuries were the leading cause of injury death in children under 5 years of age. There are many features of dwellings that increase the likelihood of a physical injury and also features that could increase the severity of such injuries. The injury outcomes may be diverse, ranging from relatively minor cuts or bruises and broken bones to paralysis, long-term physical constraints and even death. They can also include burns and scalds and drowning or near-drowning. The causes include slips, trips and falls, entrapments, collisions, poor lighting and poor ergonomics.
All these can be reduced through adequate building design.
b.Indoor cold/heat and mortality
Deaths from cardiovascular diseases are directly linked to exposure to exces¬sively low indoor temperatures for long periods. It appears that 50–70% of excess winter deaths are attributed to cardiovascular conditions, and some 15–33% to respiratory disease. Low indoor temperatures are a combined result of energy inefficiency of the dwelling (poor thermal insulation and/or inefficient or inappropriate provision for heating), the social or economic status of the household and the cost of energy.
c.Pest infestations: (rodents, cockroaches and their droppings, dust mites etc.)
In warmer climates, infestations pose health threats due to infections and food poisoning. Risks can be significantly reduced by adequate housing conditions. Similarly, great strides are being made in integrated pest management to fight insect and rodent infestation, which remains a serious problem for both urban and rural at-risk families. While insect and rodent infestation is a main trigger for asthma and a host of other ailments, the pesticides being used—and often misused—to fight infestation can contribute to the hazardous environment.
This is a major risk for social pathologies and mental symptoms and increases the risk for infectious disease transmission. Problems due to lack of space can be modified by housing design and usability. Whether a family lives in owner-occupied housing, privately rented housing, or public housing has a significant relationship to their health. Not only are health outcomes affected in terms of childhood asthma and lead poisoning, but studies have shown that overcrowding in childhood homes can be connected to a variety of serious diseases later in life. Overcrowding and poor-quality housing have a direct relationship to poor mental health, developmental delay, heart disease, and even short stature.
One of the major public goods to be provided in or near the home and the biggest cause of child mortality – as well as the main requirement for any healthy home. Homes should have sufficient supply of water for routine tasks such as laundering, bathing and other personal needs of the family. Water is one of the precious gifts to mankind, lack of access to potable drinking water and basic sanitation is one of the problems affecting billions of people around the world.
f.Traffic noise and ischaemic heart disease:
Noise is a stressor that produces both physical and psychological outcomes, with adverse effects on the nervous, gastrointestinal, immunosup¬pressive and cardiovascular systems. There are three possible approaches to protecting residents from road traffic noise: the first directed at reducing the noise sources from vehicles; the second directed at the modification of housing (better sound insulation and attenuation) and the third directed at reducing the possibility of noise reaching residential buildings by barriers or through adequate urban plan¬ning measures (location/selection of residential sites for urban development based on an assessment of environmental risks (flooding, pollution sources etc.) is crucial to avoid extreme exposures).
Controlling exposures to lead in housing is known to be effective, including a combination of cleaning, covering and/or removing lead painted surfaces and removing lead-contaminated dust and soil. New housing should not use any materials containing lead. Even low-level exposure to lead has cognitive, developmental, neurological, behavioural, cardiovascular and other effects, and higher exposure levels can result in acute poisoning.
h.Household carbon monoxide poisoning:
Carbon monoxide poisoning is a major cause of home poisoning related to the combustion of carbon-based fuels such as gas and solid fuels. Carbon monoxide exposure in indoor settings can quickly reach lethal levels but reliable, measured data on domestic exposure are rare. Poisoning by carbon monoxide occurs as the result of poorly ventilated and maintained combustion sources (gas boilers, fires etc). Children and fetuses are particularly vulnerable.
i.Indoor smoke from solid fuel use:
The use of solid fuel for cooking or heating in open fires or inadequately vented stoves and ovens and in dwellings with poor ventilation produces high concentrations of air pollutants such as particulate matter and carbon monoxide. These pollutants have been linked to chronic obstructive pulmonary disease and lung cancer in adults and to pneumonia in children.
j.Indoor dampness and mould:
Reducing exposure to damp and mould would be extremely beneficial to public health and prevent or reduce a large proportion of asthma among adolescents and adults. The cause of dampness and associated mould can be related to the design, construction, maintenance and use of the building. Good design and proper construction can help prevent problems from occurring. Timely mainte¬nance, including speedy response to flooding or a plumbing malfunction, will help keep the dwelling in a sound condition. Also, making occupiers aware of how and when moisture is generated and how the use of ventilation can contribute to avoiding a build-up of moisture will also minimize health problems.
It may not be possible to avoid acute occurrences such as extreme weather events (e.g. storms and floods) but there should be effective responses to deal with the aftermath.
Other housing related hazards with some health effects include:
•Asbestos and Man-made mineral fibres (MMMF) – a common material in older dwellings, but usually causing low level exposure unless disturbed
•Location of settlements in an unsafe areas,
•Entry by intruders
•Hot surfaces and materials
The relationship between housing and health is multi-faceted. A healthy home needs to have sound structure, to be free of hazards, to provide adequate facilities for sleeping, personal
hygiene, the preparation and storage of food, to be an environment for comfortable relaxation, for privacy and quiet, and to provide the facility for social exchange with friends, family and others. The local environment is also important in determining such factors as fear of crime, access to local services and facilities and in promoting social interaction, but clearly the control of housing should ensure the full range of safe and healthy conditions, with all necessary facilities and amenities. To be effective, the controls should be in the form of legislative and regulatory codes, capable of being properly applied and enforced and backed by effective sanctions in the case of non-compliance.
In addition to controls on the design and construc¬tion of individual dwellings, there should be effective planning. These measures should include ensuring that housing is protected from noise sources, either by separation from roads and other potential sources or by the provision of barriers. There should be programmes directed to the provision of affordable housing. The number and size of housing units should take account of local and national demands and trends. This can limit crowding and the associated risks to health that are not caused by the building itself but by a mismatch between the size of the building and the characteristics of the household.