Housing as a Determinant of COVID-19 Inequities

As we continue to examine the impacts of COVID-19 on the lives of the communities we serve, for about one third of the US population, housing is a dominant concern. With a chronic shortage of affordable housing before the pandemic, record unemployment rates, and economic uncertainty, it is critical to ensure that the communities we serve are prepared to address housing issues from poor conditions, instability, and loss. To do this, housing must be considered in research studying the effects of COVID-19 on health inequities.

HOUSING IS WHERE THE HEALTH IS

Housing is a multidimensional determinant of health. Affordability, access, and the conditions of the home can all contribute to various health outcomes independently and jointly. Research looking at individual impacts has examined the health implications of access and conditions with most studies focusing on overcrowding and physical conditions like mold, energy efficiency, and toxins, and their health effects including asthma, heart disease, and mortality.¹ More recent research has begun focusing on affordability and housing instability and its health consequences for those affected.² In recent years, there has been more attention on the effects of discriminatory housing policies on these links including the legacy of redlining and its continued effects on communities of color.³ Nonetheless, this evidence establishes the importance of housing as a social determinant of health and, now more than ever, its relevance to the field of public health.

In the United States, housing affordability is defined as household that spends no more than 30% of its income on rent or mortgage, property taxes, utilities, and other costs associated with their incomes, according to the Department of Housing and Urban Development.⁴ Cost-burdened homes are those that spend more than this amount and are left with fewer financial resources for other basic needs including food and medicine. In 2018, 33.8 million (28.3%) of US households were considered cost burdened.⁴ Of these, an estimated 12 million households were considered severely cost burdened by spending more than 50% of their annual income on housing costs.⁴ Low-income populations make up the larger proportion of these cost-burdened households, placing them at higher risk of housing insecurity, which leads to poorer health outcomes. Before the pandemic, a family living on one full-time minimum-wage income was no longer able to afford local fair-market rent for a two-bedroom apartment in any city within the United States.⁵ Furthermore, from the early 2000s until before the pandemic, more than 2 million eviction cases were filed per year with approximately 50% of them resulting in removal of the tenants.⁶

ON THE VERGE OF MASS DISPLACEMENT

As the coronavirus makes its way through the United States, disruptions to work and unpaid sick time will leave a large proportion financially insecure. With more than 40 million jobs lost so far in the pandemic, many face challenges in paying their rents, mortgages, property taxes, and utilities. Although moratoriums on eviction and foreclosures have ensured that people are not becoming homeless during this time, after the pandemic, these programs provide little protection to those who have lost income or are facing financial uncertainty. After the pandemic, we can only estimate that the increasing financial insecurity and the preexisting chronic shortage of affordable housing will affect the poor and the middle class. For low-income households, these financial hardships will result in millions being at risk for losing their homes through evictions and foreclosures. At a time when rehousing will be challenging, homeless populations will increase, a population already deemed as high risk for contracting COVID-19, and more pressure will be placed on already overrun shelters.

While others may not be displaced, financial stress could lead to inadequate housing conditions including no electricity or water, although handwashing has been regarded as one of the most effective preventive measures. Finally, larger household units are more susceptible to transmission given the closer interactions and encounters within a home. As the economic repercussions of the pandemic continue, more households will turn to “doubling up” or sharing living arrangements as strategies to cope with financial stress.⁷

Understanding and examining these hardships will be critical for public health research to develop and implement policies and programs that reduce housing inequities affecting the well-being of communities.

INCORPORATING HOUSING IN PUBLIC HEALTH RESEARCH

At the simplest level, housing instability can be measured by using questions asking participants whether COVID-19 or its financial implications (e.g., unemployment, loss of income) have resulted in housing loss. For additional insight, questions measuring housing instability before and after the pandemic are relevant including scales asking participants how much they agree with the statements “Prior to COVID-19, I worried about being forced to move out of my current home” and “Since COVID-19, I worry about being forced to move out my current home.”

To further account for housing instability risk, financial stress measures like questions or scales identifying ongoing financial strain over a 12-month period or difficulty in paying bills over the past month will provide insight on rising inequities. Furthermore, questions about difficulties in paying utility bills and discontinuation of services can provide insight on not only housing insecurity but also risk for not being able to observe hand-washing precautions or follow stay-at-home orders without difficulties, including disruptions to electricity preventing individuals from storing foods in refrigerators and freezers.

Questions on housing status or tenure (owner vs renter vs other accommodations) are imperative to understand health inequities across and within neighborhoods. Although moratoriums on evictions have helped prevent mass displacement, the long-term impacts of COVID-19 and the associated financial difficulties will result in loss of housing and widen the health equity gap among renters and owners. Research has established better health outcomes among homeowners compared with renters through more stability and accumulation of wealth.

NEXT STEPS

As stay-at-home orders are removed, rents and mortgages will once again be collected and, for some, moving may be the only option. Although tremendous efforts are being taken to prevent this mass displacement from taking place, the long-term effects of uncertainty and possible displacement are important to capture to better understand how individuals, communities, and cities will be affected. At the individual level, housing instability results in poorer mental health including increased anxiety and depression.^1,2 At the community level, housing instability, especially in low-income neighborhoods, could result in long-term vacancy, reducing housing value and increasing blight and potential crime.^2,3 At the city level, with a chronic shortage of affordable housing, displacement can result in the loss of essential workers that contribute to the diverse social fabric needed for cities to succeed.³

The COVID-19 pandemic has exposed existing inequities in the United States and resulted in preventable deaths attributed to long-standing housing-related discriminatory policies that have resulted in communities of color being disproportionately affected by the pandemic. To ensure that communities remain intact and cities do not lose their diversity, housing concerns must be addressed, with the goal of no individual being displaced.