WORLD HEALTH ORGANIZATION

PAN AMERICAN HEALTH ORGANIZATION

Abridged version of the PAHO Reference Document

on Health in Housing Policies

Havana, July 2000

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Housing as a Goal

Housing is an entity that facilitates the fulfillment of an specific functions set for the

individual and/or the family. These functions include providing shelter from inclement

weather, guaranteeing safety and protection, facilitating rest, allowing for the use of the

senses to engage in culture, facilitating the storage, processing and consumption of

food, providing the resources for personal and domestic hygiene and sanitation, aiding

convalescence of the sick, care of the elderly and disabled, and the development of

children, and promoting a balanced family life. The development of housing serves to

pull together a social agenda based on the family, an economic agenda based on the

means of making a living, a cultural agenda based on traditions and customs, and an

environmental agenda in the physical context. A typical man spends at least 50% of his

time in the housing environment, compared with only 33% of his time at work or as a

student, and 17% in other areas.

The basis of housing is a house, yet housing is more than a physical structure when it is

incorporated into the concept of the uses that its resident make of it. Given the many

functions that housing should assume, the interior areas tend to be compartmentalized

in order to harmonize structure and function. Areas divided for the fulfillment of specific

activities are called functional housing areas. These include bedrooms, the kitchen,

bathrooms, living rooms, etc. These areas tend to have the furniture and equipment

necessary for the functions that correspond to them. Functional areas thus constitute

sub-environments that facilitate functions. The areas support a regimen for the

concentration of a particular function, yet at the same time they interconnect with other

interior and exterior functional areas.

Every human community is made up of dwellings and their peculiar groupings in

settlements. These settlements usually facilitate access to technical networks that

provide energy, communication, mobility, the drinking water supply, solid waste and

wastewater disposal, proximity to markets, job sites, and community, educational,

medical, and religious services. Thus the area of interest is not only the house or the

basic physical element itself, but also the facilitating environment of the surrounding

area.

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When people are inside their dwelling, they have less resistance to environmental

pressures and react more, to varying degrees, than they would were they facing the

same pressures in another environment. Thus, they are more vulnerable when they are

at home. This in turn means that residents of housing have a greater need for favorable

environmental conditions than do healthy people in other environments. Housing

conditions can thus be considered risk factors for residents or, on the other hand, agents

of health, depending on the level of awareness, desire, and resources of the people who

select the location, design, build, and inhabit the dwelling.

When its functional areas meet the conditions necessary for those for whom they were

designed and when residents use those areas wisely, housing favorably influences

restorative health processes and encourages creative activity and learning. Housing

therefore is of special interest to the field of environmental health and can be tool for

promoting the health of the population.

Housing as a Reality

The housing situation in Latin America is similar to that of other developing countries in

that a high percentage of the population must contend with deficient housing conditions

and services. The housing crisis among the low-income sectors is not isolated from the

economic, political, and social crisis affecting all the countries of the hemisphere. At the

center of the issue of the deteriorating housing situation are other issues such as

migration from the countryside to the city, population growth, growing poverty, the high

cost of rural and urban housing, and the absence of policies needed to mitigate the

housing needs of the poor. The deprivation associated with low incomes and high rates

of unemployment is also seen in low levels of schooling, low life expectancy, and high

infant mortality rates.

The Region is undergoing a demographic transition, a period marked by a pronounced

reduction in total fertility rates, lower infant mortality and increased life expectancy at birth.

However, there remain major differences in levels of socioeconomic development,

particularly in developing countries with sharp social contrasts and higher indicators of

poverty. The developing countries of the Region are concentrated in Latin America and the

Caribbean (LAC).

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In LAC, 41% of households were in a state of poverty in 1994 (36% of total urban

households and 55% of total rural households); and 17% of households were

characterized as indigent (12% of total of urban households and 33% of total rural

households). In 1975, the urban population in LAC was 196 million (61% of the total),

and by 1995 it had reached 358 million (74%). At the regional level, the rural population

has remained constant at about 125 million in recent years, and is even predicted to decline

slightly in the future. This indicates that all the population growth in countries of the region

will be absorbed by cities already suffering from housing and infrastructure shortages.

Governments recognize that income distribution, more concentrated and inequitable

today than at the end of the 1970s, is a serious obstacle to progress in reducing urban

and housing deficiencies in the region. The free market laws of supply and demand

regulate housing production and distribution in almost all of Latin America. The high cos t

of housing leaves a large proportion of households outside the housing market. The crucial

problem is to reconcile the recovery of economic growth with measures and programs that

can improve the status of the poorer strata of the population, that is, to achieve

development with equity.

In many Latin American countries, the private sector is the primary force in promoting

and implementing housing solutions for both the formal and informal sectors. Loans

through private banks, housing cooperatives, savings and loan associations, and

housing mutuals are the options for high income and moderately-high income families.

Squatting and multi-family buildings are the solutions for the poor. In rural areas, people

build their own dwellings with self-help schemes.

In recent decades, different housing solutions have been attempted for low-income

groups with the help of external credit operations. But these programs have not always

been successful in reducing housing shortages. Some policies, such as excessively

restrictive or unrealistic standards, have hindered the availability of housing; the same

thing has occurred when price controls have been set on rents or building materials. The

problem with international cooperation in housing is that the technical and financial

assistance entails a series of implicit demands. In Latin America, various projects seem

to have failed because the proposals were not adapted to the realities of the

circumstances under which they were implemented. Pilot projects did not employ

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multiplier effects. The solutions are not universal. Financial resources are not available

to sustain systematic research and extended studies.

On the other hand, the combined efforts of government-sponsored public programs with

individual and community initiatives have had positive results. Microcredit is one

alternative. It could be mentioned, as successful strategies , the gradual improvements in

neighborhoods and residential lots through the provision of services. The key to these

solutions is the full use they make of the capacities of the interested parties in

organization, management, and investments.

A comparison of censuses shows that the formation of new homes continues to increase at

around 3% annually, despite slower population growth. This increase is related to the

progressive reduction in the average size of households in the region as the demographic

transition advances and families in the different countries adopt a form of urban life. In the

countries of the Southern Cone, the relative aging of the population due to decreased

fertility and the increase in life expectancy has raised the number of one- and two-person

households, which are primarily made up of elderly people. There has also been an

increase in the number of families headed by women. Solutions are being developed to

stop the growth of the deficit.

The Particulars of Precarious Housing

From various perspectives, housing represents the family much as a wardrobe

represents the individual. Both are pragmatic but nevertheless symbolic expressions of

the person's or family's social values. Housing thus reflects social structures, and with it

the hierarchies and systems of privilege that lift some individuals over others.

Meanwhile, the current economic globalization process perpetuates centralized

economic power, not only denationalizing large-scale production, which is now based on

a macrogeographical view, but pushing local initiative toward the informal sector. This in

turn encourages a productive, service, and trade sector with limited resources that uses

housing as a focal point for its development. So, to the traditional functions of housing

are now added new functions associated with the informal sector. This is creating a type

of housing/workshop, housing/warehouse, housing/trade arrangement that accentuates

and complicates the impact of housing on health.

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The urbanization process is not usually dictated by physical planning principles. Most

poor people live in crowded, low-quality dwellings, many of them poorly built by the

residents themselves with inappropriate materials, partially or entirely disconnected from

urban technical networks, and constructed on land that are legally and geologically

insecure. This marginal housing in informal settlements can account for as much as half

of total construction in some cities. Informal settlements can encompass up to 90% of

low-income housing.

Informal settlements often stand on land that has been illegally appropriated on the

outskirts of the city. Dwellings in these settlements are usually of poor quality and are

easily accessible to vectors. These vectors reproduce in the waste commonly found in

the vicinity. Conditions in these settlements are often extremely precarious in terms of

hygiene, lacking running water, indoor bathrooms, and sanitary disposal of human

waste. The land is generally not suitable for the construction of dwellings and for the

most part has not been legally subdivided. In the absence of technical networks, there is

no appropriate sanitary drainage of domestic sewers; nor is there drainage for rainwater.

Drinking water, often untreated or ineffectively treated, must be taken from nearby

reservoirs or transferred by tanks or cisterns using vehicles or domestic animals.

With regard to slums --antiquated single-family dwellings actually shared by many

independent families--, these buildings can accommodate a family unit in a cubicle that

serves as a bedroom and exceeds the index of overcrowding, resulting in the use of

common areas for the kitchen, washroom, and sanitary services. Because of the limited

space per person, rudimentary structures are often built between floors in order to

redistribute space, however precariously. The state of these buildings is usually

deplorable because they are old, deteriorated, and lack maintenance, and because of

the heavy burden produced by the overuse of their facilities.

Residents of low-income rural housing that is not part of settlements lack safe water

sources and must find ways to dispose of their waste on their own. Surface or well water

used for consumption is often not treated to remove microbiological contaminants, much

less chemical contaminants. The environment can be contaminated by decomposed

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matter, domestic waste, odors, and the proliferation of insects and other vectors that can

become reservoirs and transmitters of diseases.

Health Impacts and Stress Factors from Housing

The impact of housing conditions on health can be described in terms of disorders

related to basic sanitation --primarily water-borne diseases such as diarrhea, vomiting,

gastroenteritis, cholera, typhus, as well as skin and eye problems-- that are the result of

bacterial pathogens, enteric viruses, protozoa, and parasitic helminths in drinking water.

Improperly handled food can transmit bacteria. Indoor air pollution, particularly smoke

from poorly ventilated kitchens and from cigarettes, contributes to the severity of

respiratory infections such as bronchitis and pneumonia, particularly in infants,

increasing the risk of cancer. The zoonoses of domestic animals and the diseases

transmitted by vectors, insects, and rodents cause malaria, dengue, filariasis, and

Chagas’ disease. Airborne transmission of viral diseases is exacerbated by

overcrowding and poor ventilation. There are also diseases linked to bioaerosols, which

provoke asthmatic attacks and dermatitis caused by allergens, toxic substances, or

irritants. Moisture is the main factor in fostering or limiting microbial growth in housing

systems or surfaces. In rural housing, people can become sick from contact with

agricultural chemicals and pesticides with toxic enzymatic effects.

Housing also has an effect on noncommunicable diseases. Counted among these are

household accidents, which primarily involve children and the elderly. These accidents

can produce a wide range of injuries, including potentially fatal contusions, cuts, burns,

poisonings, falls, respiratory obstruction, suffocation, and strangulation. One out of three

fatal accidents occurs in the home, and most involve children under 5, primarily because

they are most vulnerable and most often in the home. There is also the problem of

domestic violence, with its traumatic psychosomatic impact. Domestic violence comes in

various forms: gestures, how people treat one another, verbal abuse, lack of interest in

communicating, refusal to help and support someone to the point that it damages their

spirit, customs, accepted lifestyles, prevailing values, property, and personal physical

integrity.

Low birthweight is among the disorders related to the quality of housing. In many cases,

the problems are the result of stress, are linked to neurosensory overload and

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decompensation by the body, and are manifested as nonspecific psychosomatic effects

whose preclinical manifestations are compensatory-adaptive physiological reactions.

The principal stress factors in housing are related to ownership, the condition of the

dwelling and its surroundings, social relations, and income. Stress is present to varying

degrees in all the environments where people function, but its impact is more

pronounced in settings where people are most susceptible, particularly housing. To this

most be added the inequity in the degree of exposure, since the broad spectrum of living

conditions in the different social strata presupposes a tension gradient that changes with

those conditions.

Among the risk factors related to housing conditions is noise, which can cause somatic

and psychological problems. Vibration can also produce vestibular effects and cause

nervousness, lumbalgia, and failures in blood irrigation. Caloric overload or deficit

caused by the microclimate and the ventilation in housing can induce neuropsychic and

metabolic symptoms with cardiovascular problems. The risk of lung cancer is increased

by ionizing radiation from concentrations of radon in the air of the residence, and by

gases from the geological substrate. Lack of protection against ultraviolet rays poses the

risk of cancerous lesions, photokeratitis, and cataracts. Poor lighting can cause fatigue,

nystagmus, and vertigo. Uncontrolled infrared radiation carries the risk of burns and

cataracts. Depending on the frequency, non-ionizing electromagnetic fields from electric

lines, household appliances with radio frequencies and microwaves, all catalysts of

electric currents linked to the interior of the human body or production of heat in the

tissues, have prompted controversial reports of leukemia and malignant tumors of the

nervous system. A deficit or excess of concentrations of light aeroions in indoor air can

affect the tone of the immune system.

The infiltration of outdoor air into housing imports various chemical pollutants, such as

carbon monoxide (which causes hypoxia), sulfur dioxide, ozone, nitrous oxides, and dust

from fixed urban sources and automotive traffic, affecting respiratory functions. To these

can be added pollutants from domestic sources, such as formaldehyde, a carcinogen

that comes from pressed wooden furniture; the vitreous fibers and asbestos in building

materials associated with lung inflammation and fibrosis; benzene, a possible

consequence of smoking indicated as hepatotoxic; the lead from plumbing, paints, and

sumptuary objects, carcinogens that primarily affect the nervous system; and the volatile

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organic compounds related to the so-called sick building syndrome, which causes

tearing of the eye, irritation of the skin and mucous membranes, neurological symptoms,

and alterations in taste and smell. Polluting chemicals in housing can also be found in

foods, cosmetics, and cleaning products, depending on their composition, storage,

distribution, and use.

Sensory overload and the continuous tension and change inherent in social life, referred

to as psychosocial stresses, bring instability into modern life that sometimes has an

impact on the family. In housing, the level of stress increases feelings of anxiety and

uncertainty, particularly in those who are most vulnerable, and fosters intolerance,

willfulness, erratic behavior, impulsiveness, deteriorating family relations, and the loss of

moral values and affection toward one another. Stress can strengthen pragmatism and

cause people to focus only on short-term results at the expense of behavior guided by

lifelong ideals

Housing is a particularly easy target for natural and man-made disasters, given that

crowded buildings with lower investment have fewer safety features. The type of

construction and the density of the population in threatened areas constitute elements of

vulnerability.

People living in deficient housing have a greater risk of being suffering diseases related

to housing and the environment. For this reason, housing can be said to be a

determinant of health. Gender, childhood, old age, and disability are factors that

influence vulnerability to the conditions of housing and its surroundings. Because of

today's accepted social division of labor, homemakers are more exposed to the risk

factors of housing than are other members of the family. The physically disabled and

handicapped, the sick, children, the elderly, and women can be considered risk groups,

inasmuch as they are the ones primarily affected by poor housing conditions. The lack of

economic resources is a strong psychosocial deprivation factor and a determinant of the

precarious quality of life in housing. Thus, the poor should also be considered a risk

group. The most significant impacts are associated with difficulties in access to housing,

since there is a housing shortage, followed by the precariousness of housing conditions.

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Among the physiographical aspects to consider in the specific localization of housing is

the extent to which the land can safely sustain the building and its connections, low

geographical risk from disasters, and the beneficial influence of the surrounding area.

Vulnerability is heightened in endemic areas of vector-borne diseases transmitted --such

as Chagas’ disease, malaria, dengue, and yellow fever-- as well as in areas where there

are etiologic agents of gastrointestinal and respiratory disorders. All these diseases are

related to deficient housing, including the type of materials used on the floors, walls, and

ceilings, as well as the lack of ventilation, sanitation services, and protective barriers

against insects and rodents.

Measures are prescribed within the environmental health framework that supports

healthy housing conditions. The design aims to provide the best solution in terms of

space, implementation, and environment in order to effectively and efficiently perform

the functions that should be facilitated in a specific place and setting. The materials

selected should on one hand meet the criteria of availability, access, adaptation,

formation, and economy. On the other, they should be adapted to facilitate the securing,

support, structuring, insulation, or communicability of the architectural structures as

needed to withstand intemperate conditions, as well as provide facings and finishings

acceptable to residents.

The essential properties of construction work involve its soundness and resistance to

natural elements and social problems such as delinquency; its sustainability and the

extent to which it accommodates and facilitates domestic activities, including cooking

and food storage; its microclimatic modulation of intemperate weather; its insulation from

undesirable events and its capacity to transmit pleasant events related to the exterior

environment; the interconnection of its functional areas in terms of facilitating mobility,

even for those with limited capacities; its flexibility in accommodating work or service

functions within the framework of housing; the extent to which it guarantees personal

safety and the protection of property; and its adaptability to satisfy the particular needs of

family and personal life. The treatment of furniture, furnishings, and finishes should be

governed by criteria for hygiene in housing. The neighborhood where housing is located

contains factors and forces that can be positive examples in terms of the social

cooperation of the community. However, it also contains factors and forces that run

contrary to a sense of community and well-being, such as when criminals and

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delinquents threaten the moral and physical safety of residents and property.

Neighborhood contains interface items between dwelling and its landscape, such as

technical networks and roads , for instance.

Policies for Healthy Housing

“Healthy spaces” refers to the succession of environments or scenarios that people

habitually face, or with which they coexist during the course of the life cycle: housing,

school, work, the city, and their locality. If these environments have risk factors that are

controlled or preventable, and if they include elements that promote health and

well-being, then the environmental interactions of the people there will be favorable to

the development of health and well-being, conceived as dynamic entities that facilitate

the development of people's capacities and creative potential. Thus, the concept of

health promotion becomes operational, and "healthy housing" is therefore an expression

and context of "healthy spaces."

It is impossible to meet the goal of a healthy city or locality if health in housing objectives

have not been first attained. At the same time, meeting the goal of a healthy city or

locality implies having achieved healthy housing objectives. They are simply different

scales of the same phenomenon, scales superimposed and not compartmentalized,

interactive and strong, complementary but without precise borders. To take action on

one scale, then, is in effect taking action on the others. Proceeding along these

conceptual lines requires harmonizing procedures related to actions on the environment

and health, since human health is all --encompassing-- that is, it is found in housing, in

cities, and in localities. In the meantime, all the levels along the above-mentioned scale

jointly influence health, while health actions in turn should be directed toward all levels

along the scale.

Primary environmental care (PEC) takes place within a framework parallel to primary

health care, sharing the concept of an intersectoral approach, resources,

decentralization, coordination, community involvement, education, prevention, a

systemic and integral approach for identifying risk factors through epidemiological

evaluation, and the implementation of participatory studies and diagnoses of physical,

psychosocial, and environmental settings. Healthy housing, as an strategy, should share

available PEC resources and objectives. The emphasis is on the need to coordinate

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actors who wield political power, on the technical units of institutions, on the provision of

resources, and on community participation.

Creating and attaining healthy housing means developing adequate housing that

provides protection against communicable diseases, avoidable injuries, poisonings,

thermal exposure, and other types of risks that cause or contribute to disease or chronic

illness. Adequate housing aids in people's social and psychological development and

minimizes the psychological and social tensions related to the home environment. It also

provides access to places for work, education, necessary services, and pleasurable

activities that promote good health. The use that residents make of their housing

maximizes its positive impact on health, promoting family and domestic hygiene,

avoiding risky behaviors, and preventing substance abuse.

Among the positive impacts of housing are the fulfillment of biological needs, aesthetics,

information, and communication. Housing also facilitates education, domestic tasks,

family development, and attainment of the accessory purposes of people's lifestyles,

personal welfare, and the promotion of health. The goal of providing healthy housing is

an intersectoral and multidisciplinary effort that involves community participation. There

is also an important role for institutions and leaders, sources of financing, and assistance

from technical institutions.