The Lancet
Home as a fundamental social determinant of health. Making housing a priority public health intervention is a moral imperative. The health of our communities depends on it (1).
The fact that our homes are inextricably linked to our health is nothing new. “One might have imagined that science and common sense would eventually appreciate the importance of such considerations,” we read a letter on housing and health published on The Lancet in 1922. Access to adequate housing is recognized as a fundamental human right under law. Why then do we continue to allow so many people to live in unhealthy housing conditions? The United Nations Statistics Division estimated that as of 2022, more than 1 billion people lived in urban slums or slum-like conditions, and this figure is expected to triple by 2050. The World Bank’s Adequate Housing Index highlights stark disparities, with a third of homes in emerging economies failing to meet suitability standards. The urgency of achieving Sustainable Development Goal 11.1 – ensuring access to adequate, safe and affordable housing for all by 2030 – is clear, but we are far from the goal.
We know that unhealthy housing correlates with poor health outcomes. A systematic review found that housing improvements, such as: ensuring adequate ventilation, humidity control, heating-cooling, and insulation to mitigate humidity, mold, indoor air pollution, and exposure to extreme temperatures reduce the risk of respiratory diseases, cardiovascular diseases, cancer and mental health problems. Unhealthy housing conditions are not unique to emerging economies. In Belgium , between 1991 and 2020, inadequate housing was associated with nearly one in five deaths. Housing problems disproportionately affect vulnerable populations, perpetuating health inequities across gender, race, ethnicity, dispossession and disability. In 2021, 53% of Inuit who lived in Nunavut, a remote northern territory of Canada, lived in crowded housing, with cases of families of eight sharing a two-bedroom unit. Although the WHO guidelines on housing and health promote adequate housing to improve health, many governments are slow to act.
Despite the evidence, improving housing is rarely a priority in global public health thinking. Financial constraints undoubtedly explain inaction in some contexts: building and maintaining safe housing requires long-term commitment and investment. Furthermore, substantial gaps remain in data availability, hindering a full understanding of the scope of the problem and preventing the development of appropriate policies. Some of the inaction stems from a simple lack of political will. Governments that have prioritized housing have seen rapid and profound benefits. The approach Finnish Housing First , for example, provides small apartments to people with financial, mental health and addiction problems, and ensures their maintenance. This approach reduced long-term homelessness by 71% between 2008 and 2020 and consequently resulted in fewer emergency visits, hospital admissions and shorter hospital stays among recipients. Clearly, long-term investments in housing represent an effective public health intervention.
Rights-based philosophies underpin such interventions. To promote respect for the right to housing for all, in August 2023, the United Nations Special Rapporteur on the right to adequate housing called for urgent action to address homelessness and inadequate housing worldwide, underlining the need for comprehensive policies, increased funding and a human rights-based approach. Developing strong coordination across sectors – public health, healthcare, housing policy and community organizers – will be essential. Policy makers must make access to adequate housing a key determinant of health and consider housing as a fundamental public health intervention.
Health workers have a vital role to play. While screening approaches exist to help identify housing instability, tools for assessing poor housing conditions are lacking. Developing these strategies would allow health care providers to identify unhealthy housing along with assessment of other health determinants, such as smoking and substance use, and connect patients to systems and resources. Access to adequate and reliable housing facilitates continuity of care and enables people to safeguard and prioritize their own health and well-being and that of their families.
As a human right, housing requires greater priority. Support, including from the medical and public health sectors, must drive systemic change. With the urban population expected to more than double by 2050, combined with rising housing costs, worsening climate change, ongoing conflicts and natural disasters, the need for adequate housing will continue to grow, widening health inequalities. Making housing a priority public health intervention represents not only a critical opportunity, but a moral imperative. The health of our communities depends on it.
Editorial, Lancet, Vol 403, May 4, 2024, 1723. Our translation, as title and subtitle. Housing- an overlooked social determinant of health,