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Joshua Sharfstein, MD, Megan Sandel, MD, Robert Kahn, MD, MPH and Howard Bauchner, MD

Joshua Sharfstein, Megan Sandel, and Howard Bauchner are with the Department of Pediatrics, Boston University School of Medicine, Boston, Mass. Robert Kahn is with the Division of General and Community Pediatrics, Children's Hospital Medical Center, Cincinnati, Ohio.

Correspondence: Requests for reprints should be sent to Megan Sandel, MD, Boston University School of Medicine, 91 E Concord St, 4th Floor, Boston, MA 02118 (e-mail: megan.sandel{at}bmc.org).

	INTRODUCTION

TOP INTRODUCTION References

 
Although the link between substandard housing and poor health has been recognized for more than a century,¹ research now demonstrates significant associations between cockroach allergen and asthma,² between lead paint and chronic neurologic damage,³ between substandard homes and fatal fires,⁴ and between unaffordable rent and inadequate childhood nutrition⁵ and growth.⁶

Families who live in housing units subsidized through the federal Section 8 program are protected by annual inspections that document adherence to strict housing codes and spend about 30% of their income on rent. However, the average waiting time for Section 8 was 28 months in 1998, with more than 660 000 families on 18 sampled metropolitan waiting lists.⁷ To our knowledge, the child health implications of waiting for housing assistance have not been studied.

We surveyed families due to receive Section 8 vouchers at the Boston Housing Authority in the summer of 1999. Our survey included standardized questions from the American Housing Survey,⁸ the National Health Interview Survey,⁹ and the National Health and Nutritional Examination Survey.¹⁰ Respondents were also asked, "Do you believe that your living conditions or the expense of your living conditions has affected any of the health problems of [your child]?" We obtained an exemption from the Boston University institutional review board for our survey.

We approached 158 of 170 eligible families; 74 (46.8%) participated. Families reported high rates of 17 housing hazards in their pre–Section 8 living conditions (Table 1). Of 33 families living with more than 2 housing hazards, 24.2% reported a child with fair or poor health status, as compared with 9.8% of 41 families living with fewer hazards (relative risk [RR] = 2.5, 95% confidence interval [CI] = 0.8, 7.5). Thirty-three percent of families living with more than 2 hazards reported a child with limited activity, as opposed to 14.6% of families living with fewer hazards (RR = 2.3, 95% CI = 0.9, 5.5).

Despite this study's limitations, we directly assessed the risks facing families poised to benefit from a policy intervention: the Section 8 voucher. These risks appear to be substantial. In an additional analysis involving data from the 1998 Boston-area American Housing Survey, we determined that families in our study reported significantly worse housing conditions than did Boston-area families already living in voucherassisted apartments (Table 1).

These findings merit attention, given the national crisis in regard to safe and affordable housing. Families in more than 5.3 million households, including 4.5 million children, spend over 50% of their available income on rent, live in substandard conditions, or both.⁷ Policymakers cannot ignore the growing evidence that housing policies have important health consequences.^11–13 This study suggests that expanding access to vouchers may immediately improve the health of America's children.

	Acknowledgments

 
This study was supported by the Joel and Barbara Alpert Children of the City Endowment. The work of Drs Sharfstein and Sandel was supported by a Health Resources and Services Administration Institutional National Service Award (5 T32 HP1001407).

We thank Armando Zapata and Tom Santry of the Boston Housing Authority and our research assistant, Maria Dessert.

	Footnotes

 
J. Sharfstein and M. Sandel conceived and designed the project, coordinated data collection, and wrote the brief. R. Kahn and H. Bauchner contributed substantially to the design of the project and editing of the brief.

Peer Reviewed

Accepted for publication January 10, 2001.

	References

TOP INTRODUCTION References

 
1. Britten RH. The relation between housing and health. Public Health Rep.1934;49:1301–1313.

2. Rosenstreich DL, Eggleston P, Kattan M, et al. The role of cockroach allergen and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. N Engl J Med.1997;336:1356–1363.[Abstract/Free Full Text]

3. Landrigan PJ, Todd AC, Wedeen RP. Lead poisoning. Mt Sinai J Med.1995;62:360–364.[Medline]

4. Parker DJ, Sklar DP, Tandberg D, et al. Fire fatalities among New Mexico children. Ann Emerg Med.1993;22:517–522.[Medline]

5. Meyers A, Rubin D, Napoleone M, et al. Public housing subsidies may improve poor children's nutrition. Am J Public Health. 1993;83:115.

6. Meyers A, Frank DA, Roos N, et al. Housing subsidies and pediatric undernutrition. Arch Pediatr Adolesc Med.1995;149:1079–1084.[Abstract]

7. Waiting in Vain: An Update on America's Rental Housing Crisis. Washington, DC: US Dept of Housing and Urban Development; 1999.

8. US Dept of Housing and Urban Development. American Housing Survey. Available at: http://www.huduser.org/datasets/ahs.html. Accessed May 7, 2001.

9. National Center for Health Statistics. National Health Interview Survey. Available at: http://www.cdc.gov/nchs/nhis.htm. Accessed May 7, 2001.

10. Briefel RR, Woteki CE. Development of food sufficiency questions for the Third National Health and Nutrition Examination Survey. J Nutr Educ.1992;24(suppl):24S–28S.

11. Sharfstein J, Sandel M, eds. Not Safe at Home: How America's Housing Crisis Threatens the Health of Its Children. Boston, Mass: Boston Medical Center; 1998.

12. Matte TD, Jacobs DE. Housing and health—current issues and implications for research and programs. J Urban Health. 2000;77:7–25.[Medline]

13. Katz LF, Kling JR, Liebman JB. Moving to opportunity in Boston: early results of a randomized mobility experiment. Available at: http://www.ksg.harvard.edu/jeffreyliebman/mto060600.pdf. Accessed May 7, 2001.

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