The roots of public health as a discipline lie deep in the history of social reform movements that sought to improve the physical living conditions of the urban working classes during a period of rapid industrialization and social change. By addressing squalor, dilapidated housing, contaminated water, and unsanitary sewage systems, these early public health care practitioners recognized the need for social and political changes to combat the source of disease.
According to A. L. Fairchild, public health has “jettisoned its social mission in favor a science-based identity” that, while posing as objective, leaves institutional systems that help to generate the health inequities that it studies and purportedly deals with intact.1 Rather than lament how much the profession has strayed from its reformist lineage, public health can reconceptualize existing practice with a social justice and health equity framework. Healthy homes programs provide a case study on how to retool existing practice for 21st-century public health.
The Department of Housing and Urban Development (HUD) established the Healthy Homes Initiative after a 1999 congressional directive to implement programs that would address the multiple housing-related problems affecting child health. The HUD Healthy Homes Initiative addresses multiple hazards (radon, lead, mold, etc) rather than just a single risk factor—an advance over the traditional single-issue programs. The Healthy Homes Initiative at the Centers for Disease Control and Prevention (CDC) also fosters a more holistic approach, including research into the relationship between substandard housing and adverse health effects.
Federal funding from the HUD and the CDC as well as general funds from state and local governments offer opportunities for local health departments (LHDs) to shape initiatives that foster environmental justice and health equity. Recognizing that healthy homes are designed, constructed, maintained, and rehabilitated to keep occupants healthy, leading public health care practitioners are increasingly focusing on policy and systems change strategies to prevent substandard housing and associated housing-related risk factors.
The Multnomah County (Oregon) Public Health Department provides an illustrative example of leadership in this area. Its environmental services unit, Multnomah County Environmental Health (MCEH), has developed an approach to healthy homes on the basis of the socioecological model.2 A key objective of MCEH's approach is to reduce health inequities associated with substandard housing at individual, interpersonal, community, and policy/organizational levels. At the individual and interpersonal levels, the MCEH includes a nursing and environmental in-home case management program for families with children with asthma. The home visits in the program include trigger identification, intervention implementation, asthma education, and information/referral. At the community level, the MCEH provides education and outreach in culturally competent and empowering ways. For example, MCEH's focus on substandard and low-income housing was based on a community participatory community assessment process, Protocol for Assessing Community Excellence in Environmental Health.3 The community engagement process that began with Protocol for Assessing Community Excellence in Environmental Health continued with a Healthy Homes Coalition charged with identifying community concerns and identifying resources to address housing assets along a continuum of need.
At the policy/organizational level, the MCEH convened a Healthy Homes Summit, where community-based organizations, elected officials, academia, and community members identified policies, programs, and interventions. The relationships cultivated in the Healthy Homes Coalition and at the Healthy Homes Summit led to a common vision for housing code changes to support tenants and improve housing quality. Because of the success of MCEH's holistic approach to healthy homes and substandard housing, the National Association of County & City Health Officials (NACCHO) now recognizes its approach as a model practice, a resources that other public health agencies can use.*
In addition to using this particular practice as a tool, LHDs can consider reconceptualizing and implementing other public health initiatives with greater consideration of social justice and health equity. Recognizing the artificial assumptions in current practice and using the insight from systems science is a place to start. Multnomah County explicitly incorporated the multiple ecological factors that impact individual health. Health was not just a matter of the toxic exposures in the house, as emphasized in traditional healthy homes programs, rather the conditions of the house and the social factors that determined the housing conditions were a key site for public health intervention.
Another assumption public health care practitioners could consider is the artificial distinction between a house and its surrounding neighborhood. Homes are porous, and pollution from nearby factories enters the home through windows. Perhaps, healthy homes programs could be expanded to focus on the conditions of the neighborhoods in which substandard and low-income housing are imbedded. A wide variety of healthy community initiatives funded by public and private agencies could potentially benefit from the experience and expertise of healthy homes practitioners.
Multnomah County focused on the policies and systems that give rise to substandard housing. A systems approach4 recognizes that a wide variety of institutional and individual agents determine community design, housing conditions, and access to amenities critical for health. Some of these amenities include access to affordable, high-quality produce; safe green spaces for recreation, physical activity, and play; and multimodal forms of transportation to jobs. The individual and institutional agents who determine housing quality and neighborhood conditions are linked in systems of relationships that lead to phenomena that coemerge as part of a complex social process. Thus, substandard housing, toxic home environments, poor quality playgrounds, and food deserts go hand in hand. When housing managers fail to fix a leaky roof, mold arises, which can lead to asthma attacks. Residents and absentee landlords from these areas are not usually involved in decisions that place polluting factories or bus depots in the neighborhood—which leads to the pollution that can exacerbate asthma. In other words, one of the most often neglected resources in such communities is the power to affect change in the very systems that determine the quality of housing, community design, and access to neighborhood resources and amenities. By developing strong relationships and coalitions with community residents as equal partners, rather than as clients or patients, public health care practitioners can strengthen their ability to bring about long-term, effective systems change.
Implementing new public health practice may seem unattainable, given the current available resources. However, Multnomah County provides a case study in creative financing. By combining funding streams from the HUD, the CDC, general revenues, Medicaid reimbursement, and coordinating resources with other stakeholders, Multnomah County was able to implement a complex, multilevel initiative. Other LHDs might consider cross-training community health workers that are engaged in healthy homes visits to assess neighborhood conditions, including housing, transportation, access to food, parks and green space, and safety. This could facilitate greater integration (with potential cost savings) between environmental health and health promotion staff, who often are located in separate administrative units.
Public health practice must be both an art and a science to address 21st-century threats to the public health. Public health care professionals can “reform” the public health discipline with a greater emphasis on social justice and health equity by considering how artists shape a mold of clay. They should consider where to carve out of, slap on to, or reshape what currently exists as public health practice while maintaining a vision for social justice and health equity. In this way, they can refashion existing public health practice to further our profession while empowering the communities we serve. It could be our masterpiece.
1. Fairchild AL, Rosner D, Colgrove J, et al. The exodus of public health. What history can tell us about the future. Am J Public Health. 2010; 100(1):54–63.
2. Stokols D. Translating social ecological theory into guidelines for community health promotion. Am J Health Promot. 1996; 10:282–298.
3. National Association of County and City Health Officials and National Center for Environmental Health. PACE-EH: Protocol for Assessing Community Excellence in Environmental Health: A Guide for Local Health Officials. Washington, DC: National Association of County and City Health Officials and National Center for Environmental Health; 1998.
4. Mabry O, Olster D, Morgan G, et al. Interdisciplinary and systems science to improve population health: a view from the NIH Office of Behavioral and Social Sciences Research. Am J Prev Med. 2008; 35:S211–S224.
*More information about NACCHO's Public Health Model Practice awards and database can be found at NACCHO's Web site at http://www.naccho.org/topics/modelpractices/.