While there is increasing awareness of a housing crisis in Canada, there is little discussion of how housing issues"especially housing insecurity" are related to the health of Canadians. As documented by federal NDP leader Jack Layton in his book Homelessness: The Making and Unmaking of a Crisis (2000), according to many indicators"the number of Canadians who sleep in the streets, who use temporary shelters and who spend more than 30 or 50 percent of their income on housing" Canada’s housing policy has clearly failed to meet the needs of a significant proportion of Canadians.
The purpose of this article is to consider how housing insecurity in Canada can be conceptualized as a social deter- minant of health. In 1986, the World Health Organization’s Ottawa Charter for Health Promotion recognized shelter as a basic prerequisite for health, but it is only recently that researchers have focused on housing as an important deter- minant of health. Reasons for the neglect of housing as a health issue will be considered, and studies that demon- strate the link between housing and health will be reviewed.
Policy changes that have led to the crisis in housing will be reviewed, and new ways of thinking about how housing insecurity is related to health and to a number of other social determinants of health will be presented. Finally, a model of policy change that identifies means by which these kinds of issues can be considered within the context of government policy-making will be outlined and policy solutions offered.
The current housing crisis and associated housing inse- curity being experienced by Canadians are the results of radical changes in housing policy over the last two decades. The problem of affordability in the private rental housing market first emerged as a major issue in the early 1980s, and it remained for the most part not addressed through the 1990s. Housing is now seen as a national disaster. The fed- eral government has even appointed a Co-ordinator of Homelessness. Layton’s book outlines the dimensions of the housing crisis in Canada, and J. David Hulchanski’s December 2002 report for the Canadian Policy Research Network provides a history and analy- sis of the current status of Canadian housing policy.
Many analysts attribute the grow- ing number of homeless and insecure- ly housed Canadians to reduced state involvement in housing. Indeed, J. David Hulchanski notes that Canada now has the most private-sector- dominated, market-based system and the smallest social housing sector of any Western nation, with the excep- tion of the USA. Other factors include continuing high levels of unemployment and lack of affordable rental accommodation. The result is increasing numbers of families and individuals who are underhoused, living in motels, dependent on the shelter system or living on the street.
The 1990s marked the withdrawal of the federal government and many provincial governments from
the provision of social housing. Social housing reflects a ment by the state to support affordable housing for all. One illustration of the process of governments’ withdrawal from the provision of housing for Canadians is the Ontario Progressive Conservative government’s reversal in 1995 of 25 years of commitment by Ontario to providing housing for its citizens. As shown in figure 1, there has not been a single social housing start in Ontario since that time, with the not surprising result that the use of shelters has increased significantly. Layton reports that 1998 saw 1,000,000 overnight stays in emergency shelters in Ontario communities alone.
Shelter use is up across Canada. National data are not available, since not every province collects data on shelter use. In his book on homeless- ness, Layton reports that on an average night shelter use is approximately 300 people in Vancouver, 1,200 in Calgary, 460 in Ottawa, and about 4,000 in Toronto. The numbers have increased in Toronto, Calgary, Edmonton, Hamilton and Mississauga. The Federation of Canadian Municipalities reported that in 1996, 43 percent of households across Canada spent more than 30 percent of their income on rent. That same year, over 21 percent of Canadian households spent more than 50 percent of their income on rent, an increase of 43 percent since 1991.
It hardly seems necessary to argue the case that housing is a health issue, yet surprisingly few Canadian studies have considered it as such. In the UK, where the housing and health tradition is more established, numer- ous studies have shown strikingly high incidences of physical and mental health problems among homeless peo- ple compared with the general popula- tion. Wendy Bines, in The Health of Single Homeless People (1994) reported on the health problems of 1,280 homeless people in the UK. People who used hostels, bed and breakfast accommodation, day centres and soup runs were much more likely to have musculo-skeletal and chronic breath- ing problems, headaches, skin ulcers, seizures and other complaints. Those sleeping in the streets had the most severe health profiles.
The 1992 Street Health Report, a survey of the homeless population in Toronto, found that homeless people were at much greater risk than the general population for a variety of chronic conditions including respira- tory diseases, arthritis or rheumatism, high blood pressure, asthma, epilepsy and diabetes. Despite this evidence, housing issues have not been high on the agenda of most health researchers in Canada. One reason may be the difficulties presented by this area of study for those trained in tra- ditional epidemiological methods.
Epidemiology is defined as the distribution and deter- minants of diseases and injuries in human populations. Epidemiologists aim to identify the unique causal effects of single vari- ables upon health outcomes through various experimental and correlational procedures. The identification of the health effects of housing does not easi- ly lend itself to such a model. Living in disadvantaged housing circumstances clusters with a variety of other indica- tors of disadvantage. Indeed, Mary Shaw and her colleagues argue in The Widening Gap: Health Inequalities and Policy in Britain (1999) that ”œHealth inequalities are produced by the clus- tering of disadvantage"in opportuni- ty, material circumstances, and behav- iours related to health"across people’s lives.”
When epidemiological research has considered housing, it has tended to focus on aspects of housing and health that can be isolated for meas- urement such as the presence of mould and the impact on respiratory infections in children, or overcrowd- ing and its impact on mental health. But it has used models that attempt to identify the effects of these factors independently of the contextual vari- ables associated with disadvantage in general. Figure 2 is an example of a tra- ditional epidemiological model that could be deployed to examine the rela- tionship between housing and health.
The model identifies the material conditions of housing, such as mould and drafts, as areas of prime interest. Studies attempt to control for the effects of research participants’ personal characteristics. They then distill the unique effects of housing conditions from other potential variables that may influence health. The approach searches for the association between the material aspects of hous- ing independent of personal character- istics and other health determinants.
Unless studies are longitudinal and are based on very large numbers, the results produced by these analyses are frequently exercises in ambiguity. They usually say little about how life situations interact with policy envi- ronments to create these situations of disadvantaged housing. They also say little about the relationship between housing and other social determinants of health. Research that attempts to isolate the effect of poor housing is unable to measure or capture the com- plexity of and interaction among the determinants of health.
Nevertheless, when extensive studies are carried out, housing disadvantage is a unique predictor of poor health outcomes. Alex Marsh and col- leagues reported on these issues in the 1999 UK report Home Sweet Home: The Impact of Poor Housing on Health. They drew upon the very large longitudinal database from the National Child Development Study to study the link between housing and health in more than 13,000 citizens. They found housing played a significant and inde- pendent role in health outcomes.
Greater housing deprivation dur- ing childhood and adulthood each contributed to severe/moderate ill health at age 33 years. Overcrowding was related to respiratory and infec- tious diseases. For those who experi- enced overcrowding in childhood to age 11, there was an increased likeli- hood of experiencing infectious dis- ease. In adulthood, housing depriva- tion is linked to an increased likeli- hood of respiratory disease.
Such studies, while identifying potential relationships, focus on indi- vidual characteristics rather than the broader factors that influence health and well-being. They oversimplify the relationship between housing and health and other social determinants of health. New ways of thinking about housing and its relationship to health are needed.
Geographer James Dunn of the University of Calgary and col- leagues are identifying"with funding from the CIHR Institute of Population and Public Health"gaps in Canadian understanding of the housing and health relationship. They have devel- oped a thoughtful population health framework of housing as a socio- economic determinant of health. Since studies have demonstrated a positive association between social status and health status, Dunn states ”œHousing, as a central locus of everyday life patterns, is likely to be a crucial component in the ways in which socio-economic fac- tors shape health” (see Housing as a Socio-Economic Determinant of Population Health: A Research Framework, 2002). The authors outline three aspects of housing that are especially relevant to populationhealth.
Material dimensions of housing are concerned with the physical integrity of the home such as state of repair; physical, biological, and chemical exposure; and housing costs. Dunn notes that housing costs are critical because they are one of the largest monthly expen- ditures most people face. When housing costs eat up the majority of a person’s income, it affects other aspects of their lives, an issue considered below.
Meaningful dimensions of housing refer to one’s sense of belonging and control in one’s own home. Home is also an expression of social status"prestige, status, pride and identity"all of which are enhanced by home ownership. These dimensions provide surface for the expression of self-identity, and represent permanence, stabili- ty and continuity in everyday life. One would expect living in crowd- ed or substandard housing to have profound health effects, as one would the worse case of being housed in a shelter or living on the streets.
Spatial dimensions of housing refer to a home and its immediate envi- ronment, for example, the prox- imity of a home to services, schools, public recreation, health services and employment. While these include systematic exposure to health hazards"toxins in the environment and asbestos insula- tion"they are also about the geo- graphic availability of resources and services in relation to one’s abode. This consideration intro- duces the need for understanding the policy dimensions associated with the availability of resources and services in communities. These concepts should stimulate new ways of Canadian thinking about and studying the role that housing plays in health.
The availability and affordability of housing plays an important role in relationship to other social deter- minants of health. People can go without many things, but going with- out housing is potentially catastroph- ic. If citizens are required to spend increasing proportions of available resources on maintaining a roof over their head, the resources available to support social determinants of health such as food and educational resources are diminished.
The Daily Bread Food Bank 2002 fact sheet, ”œTurning our Backs on Our Children,” showed that social assis- tance rates have not kept up with rents in Toronto. In 2001, a single parent, usually female, with one child, received 59 percent of Statistics Canada’s low- income cut-offs. The average monthly welfare income of such a single parent would be $957, while rent for an aver- age one-bedroom apartment was $866 and for a two-bedroom, $1027.
It is difficult to imagine how it would be possible for such a family to cover other important expenses such as food with that after-rent income. Plentiful evidence is available to indi- cate that lack of material resources con- tributes to illness and disease, a situa- tion made worse by the stress and uncertainty of living in such condi- tions. This process is shown in Figure 3.
Unaffordable housing and housing insecurity do not occur in a vac- uum. Figure 4 shows how policy deci- sions create the conditions that influ- ence the availability and affordability of housing and other social determi- nants of health. The availability and cost of housing has direct material effects on health. Policy decisions can also reduce financial resources, with direct material effects on health. Both types of policy decisions contribute to housing insecurity, increased stress and increased incidence of social exclusion, illness and disease. This model identifies neoliberal ideology as being responsible for the declining availability of affordable housing and financial resources for many citizens.
We need to understand how these developments have come about and to develop some means to new policy approaches toward housing. The policy framework in figure 5 was used to con- sider how the Ontario government used information to remove rent control.
I devised this conceptual frame- work as part of my dissertation research at the University of Toronto to guide case studies on housing policy and health policy change in Ontario since 1995. It incorporates elements of different forms of knowledge, the means by which this knowledge can be applied, and those who are likely to apply such knowledge. This framework can serve as a template for analyzing the policy change process on a case-by- case basis. It also provides insights into a government’s general approach to policy change over time. It was used to consider how the Ontario government formulated its housing policies.
In Ontario, the government’s polit- ical ideology emerged as a significant barrier to progressive housing policy change. Housing policy was found to be especially sensitive to political ideology, as the government’s strong pro-privati- zation and pro-market agenda made housing a ripe area for such activity. The Harris-Eves government perceived rent control and social housing as unfair impediments to private rental housing construction and considered the market to be the best allocator of rental housing.
The government’s strong ideologi- cal bent predisposed it to ignore voices that opposed its policies. As a result of these policies, homelessness and housing insecurity in Ontario have exploded, while the govern- ment’s predictions that the incentives of the removal of rent control would spur the construction of affordable housing have been found to be pathetically false.
The housing situation in Canada requires a national housing strate- gy that recognizes that housing affects the population’s health and other social determinants of health. By defi- nition, the social determinants of health require intervention by all three levels of government. Risks asso- ciated with basic human needs require institutional or collective responses to social provision. We cannot rely on the market to concern itself with the determinants of health.
Housing advocacy groups have brought forward solutions to the hous- ing crisis, in particular, to increase the availability of affordable housing and eradicate homelessness. The Toronto Disaster Relief Committee (TDRC) pro- posed the ”œOne Per Cent Solution” to end the housing crisis. The TDRC argues that if all governments increased their spending on housing by 1 per cent of overall spending, the homelessness crisis could be eliminat- ed in five years. The solution consists of three recommendations:
Annual funding for housing of $2 billion from the federal govern- ment and another $2 billion from the provinces and territories
Restoration and renewal of national, provincial and territorial programs aimed at resolving the housing crisis and homelessness disaster
Extension of the federal home- lessness strategy (Supporting Community Partnerships Initiative) with immediate funding for new and expanded shelter and services across the country Governments must be pressured to consider the social determinants of health in general and housing in par- ticular as essential components of the policy-making process.
The federal and provincial governments have signed hous- ing agreements that commit them to building more social housing units. Nevertheless, in December of 2002 the National Housing and Homeless Network reported that outside Quebec, less than 200 new housing units have been built since the hous- ing agreement was signed in November, 2001.
Indeed, Canadians see little governmental activity to address these social determinants of health besides policy proclamations on housing and the other social deter- minants of health. Instead, emphasis continues to be placed on individual responsibility for health and the mar- keting of lifestyle approaches focused on tobacco use, diet and exercise. The reduction or dismantling of public programs that in the past responded to the needs of Canadians continues.
In spite of the ample evidence regarding the relationship between housing and health, government actions are frequently at odds with a social determinants approach to health. Governments are not seriously addressing social and health inequali- ties and the role played by housing policy in widening these inequalities. Political strategies are needed to high- light how these health and social inequalities threaten the health of all Canadians. To illustrate the difficulties to be surmounted, in 1991 Paul Martin"in all likelihood the next prime minister of Canada"authored a Liberal Opposition task force on hous- ing, in which he stated:
The federal role in housing must not be a residual one. The con- nection between housing and other aspects of both social and economic policy means that the federal government must take a lead role…Our market housing system has not responded ade- quately to all of society’s needs…The Task Force believes that all Canadians have the right to decent housing, in decent surroundings at afford- able prices.
After becoming finance minister, where he was well positioned to take action on the housing crisis, Martin chose not to implement the recom- mendations of his own task force.