How are Community Development Organizations Helping Build Healthy Places?

by Alina Schnake-Mahl
Gramlich Fellow

The great majority of America’s high-performing community development organizations (CDOs) are actively tackling health challenges in their communities. In a new working paper* published by NeighborWorks® America and the Joint Center for Housing Studies, Sarah Norman (NeighborWorks’ Director of Healthy Homes & Communities) and I examine how CDOs engaged in activities at the nexus of health, housing and community development. 

Drawing on a survey of the 242 high-performing CDOs in the NeighborWorks network, we found that 89 percent of the surveyed organizations reported activities and strategies that explicitly promoted health in 2015 – from green and healthy building standards to on-site, coordinated health services. We also found that 83.3 percent of organizations worked with partners to support their efforts.  Increases in these activities, we noted, have been spurred by recent changes in the American health-care system and philanthropic grantmaking that together have provided new opportunities for CDOs to partner with other community entities to address health challenges.

CDOs used a variety of approaches, many of them focused on healthy homes and access to healthy food. For example, Foundation Communities, a nonprofit affordable housing provider based in north Texas since 1990, addresses the health and social needs of residents through health and wellness classes; smoke-free, green and healthy rental homes; community gardens and walking paths; as well as childcare and after school programming that addresses literacy and physical fitness. An evaluation of these programs showed improvements on measures of quality of life and well-being for program participants.

Photo courtesy of Foundation Communities

Similarly, REACH CDC – an affordable housing developer and property management company serving Portland, Oregon – is a member of a Limited Liability Corporation (LLC) that provides enhanced health and social service coordination for 1,400 residents at 11 federally subsidized, independent-living, affordable-housing properties in Portland. Project elements include an on-site Federally Qualified Health Center; culturally specific services for non-English-speaking residents; food distribution for homebound residents and other residents experiencing food insecurity; health navigators; and free mental health consultations. Multiple evaluations documented improvements in quality of life and well-being for residents as well as cost savings for Medicaid. 

Taken as a whole, the study shows that CDOs have undertaken significant efforts to explicitly improve the health of the communities they serve. Additionally, as the health care system increasingly targets the social determinants of health, there are new opportunities for engagement.  For example, housing-based services could help address gaps between formal medical care and community health to help older residents to age in their communities. More broadly, CDOs’ long-standing relationships with local communities provide a strong base to support cross-sector partnerships to tackle health inequities.

Alina Schnake-Mahl is a doctoral student in the Department of Social and Behavioral Sciences, at the Harvard T.H. Chan School of Public Health.  She was a 2016 recipient of the The Edward M. Gramlich Fellowship in Communityand Economic Development, which is co-sponsored by the Joint Center and NeighborWorks®America.

*The full article is under consideration in Cities & Health; the journal is available online. 

Housing Inadequacy Remains a Problem for the Lowest-Income Renters

Irene Lew
Research Analyst

In the early 1970s, in response to growing concerns about the housing conditions of poor families, the US Department of Housing and Urban Development (HUD) developed a measure of housing adequacy for its American Housing Survey (AHS) that continues to be used by the agency today. This adequacy measure was originally designed to evaluate the extent to which the national housing stock met the standard of “a decent home and a suitable living environment” established by the Housing Act of 1949. While the condition of the housing stock has improved over the past several decades, the rental stock is still three times more likely than the owner-occupied stock to be considered inadequate. And problems persist among the most affordable rentals.

While fairly complex, the AHS adequacy measure factors in various housing problems related to plumbing, heating, electrical wiring, and maintenance. Using this AHS measure, the majority of the nation’s rental housing stock is in physically adequate condition. As of 2013, just 3 percent of occupied rental units were categorized as severely inadequate and 6 percent were moderately inadequate. In fact, the adequacy of the rental stock has improved over the past decade, with the share of rentals categorized as physically inadequate declining from about 11 percent in 2003 to 9 percent in 2013. 

Notes: Inadequate units lack complete bathrooms, running water, electricity, or have other deficiencies. 

Source: JCHS tabulations of HUD, American Housing Surveys.

Stricter building codes have certainly helped to encourage higher quality, particularly the construction of units with complete plumbing and heating systems. As a result, severe physical deficiencies have been rare among the rental stock, especially among newer rentals. Just 1 percent of rentals built 2003 and later was classified as severely inadequate, compared to 4 percent of those built prior to 1960.

It is noteworthy, however, that the AHS adequacy measure does not account for certain health-related quality issues such as the presence of mold or structural issues such as holes in the roof or foundation, so housing quality problems may in fact occur at higher rates than the survey reports. And although physical deficiencies have become less common among the nation’s rental housing stock, housing problems disproportionately appear in units occupied by the lowest-income renters. In 2013, 11 percent of units occupied by extremely low-income renters (those with incomes less than or equal to 30 percent of area medians) were physically inadequate, compared to just 7 percent of those with incomes above 80 percent of area medians.

Notes: Extremely low / very low /  low income is defined as up to 30% / 30–50% / 50–80% of area median income. Inadequate units lack complete bathrooms, running water, electricity, or have other deficiencies.

Source: JCHS tabulations of HUD, 2013 American Housing Survey.

The lowest-income households also accounted for the largest share of renters reporting overcrowded conditions and physical housing problems such as toilet breakdowns, exposed electrical wiring, heating equipment breakdowns lasting six hours or more and the presence of rats in the unit. 

Notes: Extremely low / very low /  low income is defined as up to 30% / 30–50% / 50–80% of area median income Overcrowded conditions refer to units where there are more than two people per bedroom. Holes in the floor are those that are about four inches across.  

Source: JCHS tabulations of HUD, 2013 American Housing Survey.

Matthew Desmond’s most recent book, Evicted, vividly captures these statistics, drawing attention to the grim housing conditions of families in low-rent units in inner-city Milwaukee who must live with the constant presence of roaches and other vermin, clogged sinks and bathtubs, holes in their windows, and broken front doors.

Rentals occupied by extremely low-income households in central cities have the highest physical inadequacy rates, especially those located in small multifamily buildings with 2-4 units. Indeed, 16 percent of these units were categorized as inadequate, compared to 12 percent of those in buildings with 50 or more units. As I pointed out in a previous post, small multifamilies are a critical source of low-cost housing because they tend to charge lower rents than those in much larger structures, but much of this stock is rather old and at higher risk of loss from the affordable stock due to deterioration.

As this recent NPR piece suggests, the narrow margins for mom-and-pop landlords operating in low-income neighborhoods do not provide sufficient incentive for landlords to make improvements or repairs in a timely manner. Indeed, according to the American Housing Survey, 13 percent of extremely low-income renters reported in 2013 that the owner of their unit usually did not start major repairs or maintenance quickly enough, compared to less than half that share (6 percent) among higher-income renters with incomes above 80 percent of area medians.

The prevalence of housing deficiencies among units occupied by the lowest-income renters highlights the importance of bolstering building code enforcement efforts at the state and local levels. However, municipalities are often faced with tight budgets that lead to dwindling code enforcement teams. Indeed, according to one estimate in 2013, Cleveland and Detroit, among others, have cut their code enforcement workforce by about half since the middle of the last decade. Cities like Baltimore, Portland, and the San Francisco Bay Area are also facing shortages of building inspectors that make it difficult to deal with building code violations. While increased code enforcement can identify landlords who are failing to maintain their properties, this could also lead to unstable housing situations for current tenants. Renters may withhold rent or call local building inspectors as a tactic to push landlords to make necessary repairs, but this could lead to eviction threats or the initiation of a formal eviction process due to nonpayment of rent.

At the federal level, budgetary constraints have also impacted efforts to address the physical deficiencies among the aging public housing stock, which was largely built before 1970. Federal appropriations for the public housing capital fund fell by 34 percent over the past decade and HUD is faced with an estimated backlog of $26 billion in capital maintenance and repairs (as of 2010). HUD’s housing choice voucher and project-based rental assistance programs, which subsidize rentals for low-income households in the private market, require landlords to pass annual or biennial inspections for housing quality. However, the public housing stock is not subject to regular inspections and has largely been prohibited from using private capital to finance capital needs and repairs. As a result, compared to other types of assisted rentals, physical housing problems are more common among the public housing stock. In 2013, over half (53 percent) of public housing units had more than two heating equipment breakdowns lasting at least six hours and 13 percent of units had water leaks due to equipment failures within the previous 12 months.

Living in unsafe, physically inadequate housing can lead to adverse health and developmental outcomes for low-income families. Indeed, recent research confirms that children exposed to defects such as leaking roofs, broken windows, rodents, and nonfunctioning heaters or stoves were more likely to experience emotional and behavioral problems. Among five housing characteristics studied—quality, stability, affordability, ownership, and receipt of housing assistance—poor physical quality of housing was the most consistent and strongest predictor of emotional and behavioral problems in low-income children and adolescents. Poor housing conditions such as mold, chronic dampness, water leaks, and heating, plumbing, and electrical deficiencies, are also associated with health risks like respiratory illness and asthma. These findings underscore the urgent need for cities to prioritize code enforcement and work collaboratively with nonprofit tenants’ rights groups to deal with landlords who are not responsive to requests for necessary repairs.

Renters Also Have Healthy Housing Concerns

Elizabeth la Jeunesse
Research Analyst

The Joint Center recently released a working paper highlighting American consumers’ concerns and awareness of “healthy housing” issues, which include indoor air quality, water quality and other indoor environmental concerns. One of the more compelling findings of the study was that renters expressed healthy housing concerns at a higher rate than homeowners. Indeed, 36 percent of renters we surveyed reported some level of healthy housing concerns or suspected risks, while only 24 percent of homeowners did. Indoor air quality issues were most prevalent—including dust, dampness and moisture, lack of sufficient ventilation, and other indoor-air related problems including air pollution from outdoors. Other major concerns included water quality, and basic safety issues such as pests, and concerns about the physical structure.

Notes: Sample size is 820.  Renter households were asked, “In the past few years, how concerned have you been about your current rental home negatively affecting your or another occupant’s health?  This may include but is not limited to concerns related to mold/moisture, indoor air quality, asthma, chemicals in the home, noise insulation problems, light issues or other “healthy housing” issues important to you.“

Source: JCHS tabulations of Healthy Home Renter Survey (Summer 2014), The Farnsworth Group

Renters’ high level of concern is not surprising. Results from the American Housing Survey (AHS) showed that as of 2011 renters scored as worse off than owners across nearly every measure of healthy-home risks and concerns. Renters were more likely to live in inadequate housing conditions, encounter mold, musty smells and second-hand smoke from other units, as well as report hazards (loose railings, broken steps, insufficient illumination for stairs) than homeowners.

Along with these indoor issues, health risks in these places can be compounded with higher outdoor air pollution. Results from the 2013 AHS further showed that renters were more likely to report living close to highways/railroads/airports (20 percent) compared to homeowners (9 percent). Another 7 percent of renters reported living near industrial areas, compared to only 3 percent of homeowners. The higher concentrations of outdoor air pollution in these areas can infiltrate the home when ventilation methods do not allow for adequate air filtration.

Another factor that may contribute to renters’ concerns is the condition of their units. The rental housing stock is older, with a median building age of 43 years, vs 38 years for owner-occupied homes. Many older rental structures were not designed to modern standards for indoor environmental health. For example, many older multifamily buildings lack any basic ventilation systems for cooking with gas-stoves. Renters also tend to live in closer proximity to each other, with over 60 percent of renters living in multifamily buildings (vs. 11 percent of homeowners). The associated wear and tear of higher turnover, and neighbors’ behavior such as smoking indoors, can impact renters’ quality of life.

Rental property owners’ maintenance and upkeep behaviors certainly also influence renters’ satisfaction with their living conditions. But while most state and municipal sanitary and housing codes govern most basic issues such as structural integrity and pests, they rarely incorporate newer research on indoor environmental quality concerns. These concerns include formaldehyde in building products, inadequate or non-existent ventilation for gas-stove cooking, second-hand smoke, and other off-gassing chemicals (e.g., VOCs) from indoor furnishings such as carpets and flooring.

The chart below provides a snapshot of renters’ specific indoor environmental concerns based on our survey results, beyond basic issues typically addressed by housing codes. As it shows, air quality and other indoor issues impacted renters living in both single- and multi-family homes. Dust and moisture concerns were most common. Renters also expressed awareness of chemical issues, including from the building itself but also from interior products/furnishings/carpeting. Among renters living in multifamily structures, noise issues and odors or smoke from neighboring units were also cited frequently.

Notes: N=239, including 80 renters living in single family detached homes and 159 renters living in multifamily or attached homes. Renter households that expressed some basic interest/concern over indoor environmental issues were asked, “Of the following healthy home issues, how would you rate your level of concern/interest over the past few years regarding your current rental home?“

Source: JCHS tabulations of Healthy Home Renter Survey, The Farnsworth Group.

While individual renters can take some minor steps to mitigate indoor environmental risks at home, most renters are limited by the fact that they do not own their units, and therefore have little incentive for—if not an outright prohibition from—making physical modifications to their home. Therefore integrated, long-lasting healthy housing solutions will need to come from multiple stakeholders, including not only property owners, managers and developers, but also building product manufacturers, as well as those who regulate the rental industry. All of these stakeholders should examine ways to incentivize, increase our understanding of, and promote healthier rental housing, including ways to make effective healthy housing strategies for renters more cost-effective.

The growing market for energy efficient housing may set a precedent for how healthy multifamily solutions might take hold. Recently numerous articles have highlighted the good business sense of pursuing energy efficiency. As a recent McGraw Hill study suggested, multifamily builders find that customers are willing to pay more for “green” units. While energy efficiency also saves on energy bills, healthy-home advancements in rental properties can potentially increase resident retention and satisfaction—both of which are of economic benefit to the rental industry.

With the ongoing, rapid development of research related to healthy housing, as well as the tendency of consumers to seek out information on this topic, we expect to see demand in this area to grow in the future. Indeed, as awareness of healthy housing research and risks grows, renters are likely to increase their demand for healthy housing attributes. Rental property owners who can get out in front of this trend may be better poised down the line to capitalize on the growing demand for health-conscious home environments.

Read the working paper

Three Things We Need To Do To Develop a Healthy Housing Stock

Mariel Wolfson
2012 Meyer Fellow

Our new working paper explores healthy home concerns and behaviors among American homeowners and renters. We show that both groups are interested in improving the indoor environmental health of their homes, but face myriad challenges to doing so. Below, we highlight three important steps we can take toward improving the health of our housing stock.

1. Demonstrate and Respond to Consumer Demand

Healthy housing is becoming more than a niche market. Nearly one in four households in our survey had some concern about health-related issues in their homes, and more than 20% acknowledged uncertainty about whether their homes might contain health risks. Nearly half of American homeowners responding to our survey have some level of interest in healthy home issues. In fact, 60% had already taken action – even if minor – to create a healthier indoor environment at home.

Notes: Sample size is 529.  Households that expressed some basic level of healthy housing concern were asked, "Which general category(ies) best describes your concern about the impact of your home on your household’s health? "Source: JCHS tabulations of Healthy Home Owner Survey, The Farnsworth Group.

The leading concern among respondents was indoor air quality (IAQ). As outlined in our paper, the most important action we can take to improve residential IAQ is to reduce indoor emissions, including the pollution that comes from heating and cooking, as well as from chemicals that are off-gassed by our furnishings, carpets, paint, and the materials used in constructing our homes. It is therefore critical that both consumers and building professionals have more options for non-toxic/less-toxic materials and products.

In a recent example, Home Depot and Lowe’s announced that they would stop selling flooring containing phthalates, a category of chemicals believed to disrupt human hormones. This “retailer gatekeeping” is one way to start shifting away from hazardous products and toward safer ones. As consumer demand grows and is recognized, forward-thinking manufacturers, retailers, and service providers who make healthy building a priority will be in a strong position to serve this market What’s good for health and the environment will also be good for business.

Notes: Sample size is 465. Households that expressed some basic interest in ‘invisible’ healthy housing issues were asked, “Among the healthy home issues that concern your household, please select up to three of them that generate the most concern."
Source: JCHS tabulations of Healthy Home Owner Survey, The Farnsworth Group.

2. Demystify the Problem

One encouraging conclusion of our working paper is that both homeowners and renters are interested in making their homes healthier, especially by improving indoor air quality and water quality. However, these same consumers report that information – including a lack of time to research options – is an obstacle to taking action. They are suspicious of spurious environmental and health claims (“greenwashing”) and aren’t sure where to turn for trustworthy, science-based information on healthy home products and services.

This problem is amplified when the potential project – remediation, remodel or replacement – is costly in terms of money, time, and energy. A homeowner concerned about potential mold or unhealthy insulation might be just as worried and confused about whether remediating the problem can guarantee a healthier home or improve symptoms such as asthma or allergies.

Another dimension of this problem is the sheer volume and complexity of scientific information on indoor air and environmental quality. Cutting-edge research – including such topics such as indoor microbiomes and chemical interactions with moisture and UV light – is truly fascinating. However, it is not actionable for the average consumer.

Moreover, as interesting as research on emerging issues is, it is important that we not lose sight of older yet persistent healthy housing concerns that have affected our housing stock for generations. In fact, the Lumber Liquidators disaster of 2015 was due to high levels of formaldehyde, one of the first three major indoor air pollutants that were identified back in the 1970s, along with radon and combustion pollution from heating and cooking. These are still serious healthy housing issues, as is lead paint. The Lawrence Berkeley National Laboratory has been a leader in indoor air quality research since the 1970s and offers a wealth of resources (designed for the public) on these issues.

Both our survey and the American Housing Survey show that numerous Americans still face basic structural integrity/safety problems in their homes, including insufficient insulation/weatherization, inadequate heating/cooling, electrical and plumbing problems, and pests. More attention to solving basic problems like these would go a long way toward making our housing stock healthier (for example, by helping to reduce the infiltration of outdoor air pollution, particularly in neighborhoods located near highways, airports, or industries.) While increased attention to chemicals and emerging issues is a positive development, we don’t want to neglect these critical basic issues.

Notes: Sample size is 414. Households that expressed some basic intention to act on specific healthy housing projects were asked, “Among the following healthy home actions your household has taken, plans to undertake or would like to undertake, please indicate how the related health issue(s) and/or risks(s) came to your household’s attention.”
Source: JCHS tabulations of Healthy Home Owner Survey, The Farnsworth Group.

3. Educate and Train Professionals on Solutions

Ever since the oil crisis of the 1970s, demand for energy-efficient homes has grown and building professionals have responded accordingly. Now, the construction/homebuilding/remodeling industry should do the same for healthy home concerns. As discussed in Point #1 above, consumers want their homes to contain fewer toxic materials and have good indoor environmental quality overall, but they need trustworthy expertise, services and information from the industry. Because energy efficiency and indoor environmental/air quality are so intertwined, this creates a natural opportunity for knowledgeable contractors to help their clients integrate both energy and IAQ concerns into upgrade/remodeling projects.

Building professionals who have relevant expertise – which includes knowledge of healthier/non-toxic materials and practices – will have a distinct competitive advantage both with individual homeowners and owners of multifamily buildings. Our paper shows that renters want healthier options, just as they want “green” units.

Fortunately, there is a growing number of initiatives that work to help building professionals develop this expertise, such as Healthy Housing Solutions, which offers training courses, as well as the National Center for Healthy Housing, the Healthy Building Network, the Perkins and Will Transparency project , and the Green and Healthy Homes Initiative. The Department of Housing and Urban Development’s strategy for action is another valuable resource.

Going forward, we hope that a focus on these three areas might go a long way towards improving the nation’s housing stock and the experience of the housing consumer, while also improving the nation’s overall health.

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Read the full paper at Challenges and Opportunities in Creating Healthy Homes: Helping Consumers Make Informed Decisions by Mariel Wolfson and Elizabeth La Jeunesse

Survey: Many Homeowners Concerned about Invisible Health Risks

by Elizabeth La Jeunesse
Research Analyst

What makes a home healthy or unhealthy?  As Mariel Wolfson illustrated in her recent blog, this question is a multifaceted one. Old hazards persist, including lead paint, combustion pollution, formaldehyde, and radon. There is also growing awareness of other invisible pollutants, including volatile and semi-volatile organic compounds and endocrine disrupting chemicals. These elements enter homes not only through household products and goods but, as research from the Healthy Building Network shows, through building materials themselves. Achieving optimal ventilation remains essential to healthy indoor air quality. Attention should also be paid to the surrounding neighborhood, including access to health services and healthy food, walkability and accessibility, and levels of outdoor air pollution. Some communities are disproportionately affected by polluting industries and waste disposal sites in their neighborhoods, making it even more difficult for residents to enjoy a healthy home environment.

Households’ perceptions of health risks influence behaviors and in turn affect the home environment, so the Joint Center recently surveyed homeowners to learn about their ‘healthy housing’ concerns. These include but are not limited to worries about mold/moisture, indoor air quality, chemicals at home, and noise and lighting issues which might affect household health.

We found that roughly one out of four homeowners expressed some level of concern about an aspect of their home negatively impacting their household’s health. One out of ten households described their concerns as ‘moderate’ or ‘major’. High income households (earning $100K or more) were slightly more likely to express concern, as were households with one or more children.

By far the most frequently cited problem was indoor air quality, with more than two thirds of the concerned households identifying it as an issue. Water quality and harmful chemicals/materials followed, with around 30-40 percent of households citing them. As the chart below shows, these indoor health risks ranked even above basic safety issues. Least commonly cited problems were light and noise issues. 

Notes: Sample size is 529.  Households that expressed some basic level of healthy housing interest/concern were asked, “Which general category(ies) best describes your concern about the impact of your home on your household’s health?” Safety or comfort of the structure includes trip hazards, inadequate heating/cooling etc. Other basic safety issues include pests, lack of smoke detectors/locks/child safety features, etc.

Source: JCHS tabulations of Healthy Home Owner Survey, The Farnsworth Group.

When asked to be more specific about the source of their indoor air quality concerns, top issues cited by owners included managing household dust and/or pet dander, air pollution from indoor cooking/heating, and lack of sufficient ventilation. Over half of households concerned about residential indoor health risks identified these as problems. Just under half of those worried about indoor health cited chemicals from interior furnishings and from the building/structure itself as a source of concern.

Among all homeowners expressing concerns related to indoor health, more than half took at least one specific action to remediate their concern. Most frequent actions completed or planned in the near future included water filter installation, choice of paint with no or low airborne toxins, mold removal, and installation of room darkening curtains/shades. Less frequent actions included removal of asbestos and lead paint. 

Over the coming months, the Joint Center will analyze results from similar surveys of renter households, as well as of remodeling contractors, to better understand how healthy housing concerns and behaviors are playing out in the current residential remodeling market.

Wild Frontiers of Healthy Housing Research: Microbes Among Us

by Elizabeth La Jeunesse
Research Analyst

Recently, the Joint Center has been researching what makes a healthy home.  As Mariel Wolfson pointed out in her recent blog, indoor air quality has been a major component of modern healthy home research dating back to the 1970s.  Radon, formaldehyde, and combustion pollution from cooking and heating are traditionally identified as key risks.  One emerging topic that has yet to be understood is how microbial communities living among us affect household health.  As it turns out, these microbiomes (diverse communities of bacteria and other microorganisms sharing space with humans) are not well understood, but have great potential to impact human health indoors.

Earlier this year, I had the opportunity to attend a symposium on Microbiomes of the Built Environment at the American Association for the Advancement of Science (AAAS).  With some astonishment, I discovered there are millions of microbial species on earth, and while some are pathogens that are linked to illness and diseases, the majority are beneficial for humans.  For example, microbes have the potential to educate our immune systems, produce vitamins, energy, anti-inflammatories, and even neurotransmitters.

The squeamish may wince, but the fact remains: humans live in a sea of indoor bacteria—at home, work and in other public spaces—many of which promote human health.  Indeed, a central theme of the conference was that people not only need to be protected from pathogens, but they also need to be exposed to diverse microbes, especially at a young age.

Further research is needed on this front.  The vast majority of these microbes have yet to be classified.  And scientists don’t yet understand what constitutes a ‘healthy’ microbiome in the built environment.  More research is also needed on how to design, properly maintain, and fix buildings to prevent or eliminate problematic microbial indoor communities.  Currently, the Alfred P. Sloan Foundation is investing millions of dollars into a Microbiology of the Built Environment Program to study these and many other questions.  While answers remain far off, I came away from the conference with several takeaways relevant to the residential housing sector:

1.     Building design and management both play a role in the transmission of microbial communities.  In any built environment, the rate and efficiency of air circulation and filtration, as well as disinfection by UV light, all impact transmission of microbiomes. Rooms in same air handling units have similar microbiomes.  Even the type of ventilation—mechanical versus natural—impacts the diversity and composition of microbial communities indoors.  All of this suggests a distant, future role for ‘bioinformed’ design and management of homes and other residential communities.

2.     Building materials, and even appliances and fixtures, impact growth of microbial communities.  Bamboo, for example, widely heralded as a cheap and rapidly renewable building product, also exhibits rapid oxidative aging, enabling mold to grow more rapidly once the wood has been aged for long periods.  Even showerhead design can impact the spread waterborne microbial communities.  Some high efficiency showerheads can put out a fine mist that enters deep into human lungs, the effects of which need to be examined further.  Additional research and understanding is undoubtedly needed on how a variety of materials, fixtures, and appliances impact indoor microbial communities.

3.     Water quality will remain a challenge.  Scientists know surprisingly little about our drinking water’s microbial composition. Additionally, while the quality of U.S. drinking water is exceptionally high by world standards, our water infrastructure is aging and “nearing the end of its useful life,” according to the American Society of Civil Engineers.  The cost for replacement may be as much as $1 trillion over the next several decades.  As concern for water sustainability increases, water may be sitting in pipes longer, which may promote the growth of bacteria.  A prominent example can be seen in the case of hands-free faucets that can pose risks in a hospital setting.

4.     While scientists still don’t understand what a ‘healthy’ indoor microbiome may be, some preliminary findings and suggestions were offered to promote indoor health.  Most prominently, dampness and mold are widely identified as known factors associated with asthma, eczema, and other related health problems under the umbrella of ‘sick building syndrome.’  As Dr. Mark Mendell explained at the conference, films of fungi or bacteria on air conditioning coils are likely responsible for many of these cases.  Identifying and removing extra building moisture, removing settled dust, and properly operating and maintaining HVAC systems were are all recommended for preventing and remediating sick building syndrome.  A helpful 2012 alert from the National Institute for Occupational Safety and Health (NIOSH) contains further guidelines.  In addition to protecting against pathogens, some epidemiological evidence suggests that having dogs at home may actually protect against asthma early in life by facilitating exposure to diverse microbes.

If and when scientists do eventually unravel the complex riddle of what constitutes a healthy indoor microbiome, further questions and challenges will remain.  How can healthy, bioinformed buildings be designed and maintained?   Perhaps an even greater challenge will be what to do from a policy perspective. Should architects, building scientists, and policy makers take steps to promote certain bacterial communities in buildings?   As Dr. Jeffery Seigel pointed out at the conference, public perception could be tricky—for instance, if people get sick inside a building designed to promote certain bacteria, they could assume it’s because of the particular microbiome in the building. 

Study of microbiomes in the built environment is a challenging and wild frontier in the realm of healthy housing research, but findings relevant to residential health likely will inform consumers’ future home improvement behaviors and spending.  Indeed, according to a recent Joint Center survey, one out of every four homeowners expressed concern about some aspect of their home negatively impacting their household’s health. And among owners specifically concerned about ‘invisible’ risks, such as indoor air or water quality, more than half took at least one specific action to remediate their concern, including installation of water filters, mold removal, and choice of paints with low- or no airborne toxins.  In other words, U.S. consumers’ perception of invisible health risks and problems, and their growing knowledge of best practices in healthy housing, impacts their home improvement behavior.  Further developments in healthy housing research likely will impact their choices of remodeling projects and materials, and may even influence how they go about choosing remodeling contractors who they feel will best protect and even promote their households’ health.

Healthy Housing Today: A View from the National Healthy Homes Conference

by Mariel Wolfson
Meyer Fellow

This Spring, I attended the National Healthy Homes Conference in Nashville, Tennessee. The three-day conference attracted over 1,000 attendees, including more than 150 speakers who presented on a wide variety of topics, and was jointly organized by the U.S. Department of Housing and Urban Development (HUD) and Rebuilding Together, a national nonprofit organization that provides critical home repair services to low-income homeowners. From asthma interventions in low-income housing to the latest lead-abatement technologies to green architecture, the conference’s range of educational sessions reflected the diversity of today's healthy housing field. But before I describe today's healthy housing "scene,” let me provide a brief background.

The modern American healthy housing movement has its origins in late 19^th-century New York City, when reformers worked to improve the unsafe and unsanitary living conditions in tenement buildings, particularly for immigrants living on the city’s Lower East Side (conditions famously captured by the photographer Jacob Riis in his book How the Other Half Lives, published in 1890 and pictured below). In 1901, the Tenement House Act outlawed the severe overcrowding and fire hazards endemic to these buildings, and required such basic "amenities" as toilet facilities and windows providing natural light. These housing-focused reforms coincided with the emergence of public health as a professional discipline in the United States (the American Public Health Association was founded in 1872 and its core publication, the American Journal of Public Health was first published in 1911). Thus, interest in the relationship between housing and health has a long and rich history.

A second major healthy-housing turning point in the United States came in the winter of 1973–1974, with the OPEC oil embargo. Although perhaps most memorable because of the long lines it caused at gas stations, this fuel shortage had a lasting impact on the typical American home. Newly built houses achieved unprecedented "tightness" and energy savings. However, they were soon found to have high levels of indoor pollutants, especially combustion pollution from heating and cooking, formaldehyde, and radon. As a result, scientific research into residential indoor air quality began in earnest in the mid-1970s, with the goal of keeping homes both healthy and energy-efficient. The post-oil embargo preference for energy-saving homes did not create the problem of indoor air pollution; we’ve had pollutants in our homes for as long as we’ve been heating them and cooking indoors. But the zeal for saving energy did exacerbate some indoor pollution problems and – most important – it catalyzed scientific, popular, and governmental concern about indoor air.

Since that time, knowledge of indoor air quality has expanded exponentially. But as multiple conference speakers emphasized, we still have a lot to learn and accomplish, and we are now also focused on newer issues, such as the effects of climate change on our homes, pest management, asthma prevention, and recent technologies to save energy and manage pollutants. Below, I've outlined what I consider to be five salient themes of the conference:

1. Old hazards persist.

Lead paint, banned in 1978 but still present in older homes, is a “classic” healthy-housing problem that has been the focus of government attention for decades and remains a pressing issue affecting Americans at all income levels. Similarly, combustion pollution and radon, two of the major pollutants on the original IAQ research agenda of the mid-1970s, are still significant contributors to indoor air pollution. (You can learn more about combustion pollution from cooking and help Berkeley Lab researchers by completing a citizen science survey.) Even as scientists and the public grow increasingly aware of important new hazards (such as endocrine disrupting chemicals) it is important to remember that we have not eliminated older threats.



2. Healthy housing is about more than IAQ.

Indoor air quality is one vital aspect of healthy housing, but is not the definition of healthy housing. For many Americans, issues of basic safety are more immediate. According to Rebuilding Together, 2.6 million low-income homeowners live in structurally unsafe homes. Other concerns are best described as problems with “indoor environmental quality.” For example, as we explored in an as-yet unpublished Joint Center survey of homeowner concerns, noise and light pollution may not be getting sufficient attention. Finally, some conference sessions emphasized the role of neighborhoods in shaping healthy housing. This includes such factors as pedestrian-friendliness, access to exercise facilities, and access to healthy food. In fact, the conference’s motto was “leading the nation to healthy homes, families, and communities.” So, while IAQ is a rapidly expanding field of research with important implications for our homes, I am in favor of a more comprehensive and holistic definition of healthy housing.

3. The Ventilation Conundrum

Adequate ventilation is a requirement for any healthy home. Indeed, “well-ventilated” is one of the eight healthy-home criteria contained in HUD’s new Strategy for Action. But defining and achieving adequate ventilation is not always straightforward, as a home’s ventilation needs are influenced by many variables: number of residents, location, local climate, indoor pollutant sources, pressure changes in the home, and more. Both natural and mechanical ventilation are important: natural ventilation is the normal movement of air in any building, through its envelope, doors and windows; mechanical ventilation takes many forms, including kitchen and bathroom exhaust fans, and a variety of heating and cooling systems that aim to control temperatures while conserving energy. Henry Slack, of the United States Environmental Protection Agency, cited research demonstrating improved decision-making performance among office workers and school children when buildings were well-ventilated, but explained that while the EPA has studied numerous ventilation technologies and strategies, the Agency does not have a “prescription” for achieving healthy IAQ.  In 2003, the American Society of Heating, Refrigeration, and Air-Conditioning Engineers (ASHRAE) introduced its much-debated Standard 62.2 for airflow in residential buildings, but debate continues surrounding the standard’s applicability and utility. Architect Peter Pfeiffer reminded all of us that the goal for any house is “healthy air,” not simply adherence to the ASHRAE standard.  Achieving optimal ventilation, he explained, really is a “conundrum” that requires consideration of multiple variables, including a home’s location and its number of residents.

4. Behavior is a Crucial Factor in the Healthy Home

A home – whether a single-family detached suburban house or an urban apartment – is living and dynamic, its air quality changing in relation to occupant activities (such as smoking and use of chemical-laden furnishings and products), season of the year, and more. A consistent theme among conference presenters was that occupant behavior can trump any technological innovation, even the most sophisticated, energy-efficient heating and cooling system. Residents who are uncomfortable with their home’s temperature and do not understand how to use a new type of thermostat, for example, will prevent it from functioning as intended. Building professionals at the conference commented that some state-of-the-art heating/cooling systems require frequent and expensive maintenance, which is yet another obstacle to their adoption and effectiveness. Engineers and designers need to be aware of installer and user needs when creating the next generation of home technologies: technology alone is not enough, and humans are unpredictable!

5. Reasons for Optimism: Healthy Housing is a National Priority

I was impressed with the number and diversity of organizations and individuals working to ensure safe and healthy homes for Americans of all income levels. From the Federal to the local level, there is significant interest in and commitment to, in the words of the conference organizers, “utiliz[ing] housing as a platform for improving the quality of life.” This indicates a desire to go beyond the basics of lead-abatement and pest control, and to promote housing where families can thrive, not just survive. This approach is reflected in the government’s new Strategy for Action on healthy homes, developed by the interagency Healthy Homes Work Group and presented by former HUD Secretary Shaun Donovan in his plenary address.

Although the conference brought together an impressively diverse group of people, organizations, and topics, I believe we can still identify two general movements:

One – Bringing substandard American homes up to a basic level of safety and protecting children from persistent hazards like lead poisoning. One major facet of this movement focuses on public housing, and protecting its residents from serious health hazards like tobacco smoke. However, plenty of privately-owned homes are also in serious need of repair.

Two – It is clear that many Americans who already live in safe and seemingly healthy homes are concerned about the increasing number of chemicals we use in building, furnishing, and cleaning our homes, especially as we learn more about the long-term consequences of exposure to endocrine disruptors and other hazards. Creating a non-toxic (or less-toxic) home is one way to reduce our overall exposure to environmental risks, and I expect that we will see much more interest in this in the coming years and decades.

Photos 2 & 3 courtesy of Rebuilding Together