Post From Expert Insights
On a Friday afternoon, a 3-year-old girl sat quietly in my clinic with her parents. She wore a beautiful, dimpled smile and sported a purple dress with ruffles, her dark, curly hair pulled back in a tight ponytail. I opened a book and asked her about the pictures. She turned the pages with me, smiling, but said nothing. Her parents expressed concern that she still didn’t speak. They later shared with me that they were sleeping on the floor of a friend’s house, unable to find a place they could afford.
When parents come into my office, most of their questions are what one might expect: How do I get my children to behave? Which foods are the healthiest? How do I get them to sleep through the night? However, this family exemplifies an added struggle that is all too common among our families: How do I find and afford a place to live? I write prescriptions for medications and refer patients to services, but I can’t offer what my patients really need: a stable home.
The Department of Health and Human Services defines housing insecurity as “high housing costs in proportion to income, poor housing quality, unstable neighborhoods, overcrowding, or homelessness.” While the Boston Public Health Commission estimates that over 3,000 individuals and over 1,500 families were homeless in 2015, representing a 25 percent increase in homeless families from the year prior, it is much more difficult to quickly measure the number of families who are at risk of being unable to pay rent, double up with relatives and friends, or crowding, and/or move multiple times in one year. This makes this vulnerable population less visible than those we traditionally think of as “homeless.” As with other aspects of our patients’ lives, we can only find out if we ask the right questions.
In studies conducted by Children’s HealthWatch in Boston, researchers used overcrowding and multiple moves in one year as indicators. These and other studies show that housing insecurity and residential mobility are linked to poor child health outcomes on a wide variety of measures: developmental delay, behavioral disturbances, earlier drug use, and increased teen pregnancy and depression. Housing insecurity was also linked to a higher likelihood of food insecurity, which independently is associated with greater risk of hospitalization and poor child health.
As part of my public health training, I conducted a health impact assessment in Phoenix, Arizona, examining the myriad ways in which affordable housing affects not only the health outcomes of residents, but of the surrounding community as well. Since beginning pediatric training, my clinical experiences have only affirmed the importance of placing housing squarely within health and vice versa—health cannot be assured without stable housing. With this lens, housing insecurity is more than a social, economic, or legislative issue; it is a children’s health issue that calls pediatricians to action. Children deserve the right to stable housing, and as pediatricians we must identify, advocate for, and support this often-invisible population.
These housing prescriptions can include a subsidized housing unit or may provide case management and legal services, all with the goal of helping families avoid housing instability and insecurity.
If stable housing is necessary for health, how do we make it widely available? The only sustainable solutions are to actually provide more affordable housing options, or to help people afford the housing that is currently available. This can take several different forms, whether engaging the community development sector to build more affordable housing units, forming a collaborative of affordable housing organizations to integrate health services into affordable housing, or encouraging local and state agencies to offer subsidies to make unaffordable housing more accessible for low- and moderate-income families. Researchers led by pediatrician Megan Sandel at Boston Medical Center are trying a new approach: providing housing prescriptions to protect children’s development and health, just as one would administer a preventative vaccine.* These housing prescriptions can include a subsidized housing unit or may provide case management and legal services, all with the goal of helping families avoid housing instability and insecurity.
Just a few decades ago, the world watched as children were decimated by communicable diseases. Now that vaccines have vastly reduced the morbidity of infectious diseases and new therapies have ensured that HIV is no longer a terminal diagnosis, housing instability and poverty represent the urgent public health problems facing our children. With the help of researchers, thoughtful leaders, and dedicated funds, pediatricians can lead the way in addressing housing instability and child poverty. By investing in innovative solutions that ensure stable, affordable housing, we can ensure that all children have the opportunity to live happy, healthy lives.
*Sandel M et al. Housing Prescriptions as Health Care. https://clinicaltrials.gov/ct2/show/NCT02816294