¹Lewis M. Fraad Department of Pediatrics, NYC Health + Hospitals Jacobi, The Albert Einstein College of Medicine, Bronx, NY ²Department of Urban Policy and Health, The New School Parsons School of Art and Design, New York, NY *Corresponding address: Noe D. Romo, 1400 Pelham Parkway Rm 8S7, Bronx, NY 10461, Tel: (718)-975-6358; E-mail: [email protected]

Received Date: November 11, 2020 Published Date: December 07, 2020 Copyright: Romo ND, et al. ©2020 Citation: Romo ND, et al. (2020). The Implications of a Housing Famine on Public Health. Mathews J Pediatr. (5)2:24.

COMMENTARY

In 1967 Dr. Martin Luther King spoke of the presence of two Americas, describing one as “overflowing with the milk of prosperity and milk of opportunity” and another where millions perish“…on a lonely island of poverty in the midst of a vast ocean of prosperity” [1]. Fifty years later, despite the achievements of the Civil Rights Movement, these two Americas persist. While many factors have contributed to this unfortunate situation, the current affordable housing crisis is worsening, and is exacerbated by segregation along racial and class lines. This problem is most pervasive in the keystonecities of Los Angeles (LA), San Francisco (SF) and New York City (NYC). In these areas, decades of underinvestment in housing for poorer people have contributed to a spreading housing famine. This has fueled displacement and gentrification, moving the problems of inadequate housing throughout the urban landscape. The existence of the two Americas and the associated social, political, and health effects of being a divided nation is thereby perpetuated.

The current housing famine grows out of decades of policies, including urban renewal, planned shrinkage, and HOPE VI, the redevelopment of public housing under the Urban Revitalization Demonstration Program. HOPE VI, and other similar initiatives, has destroyed low-income housing without replacing the units lost [2]. A case in point occurred in The Bronx in the 1970’s with a fire epidemic precipitated by NYC’s implementation of a “planned shrinkage” policy². As much as 80% of the housing in some health areas was lost [3]. This precipitated mass displacement that ruptured social networks, resulting in increased rates of infant mortality, premature birth, and communicable disease (tuberculosis, measles) [3]. Coping mechanisms for the increased environmental stress included violent behaviors, intravenous drug use, and unprotected sex. This fueled the homicide, IV drug use, and HIV/STI epidemics [3]. The affected parts of the Bronx are still recovering today. Since the beginning of the COVID19 pandemic in NYC in March 2020, the Bronx is the borough of NYC with the highest rates of COVID19 cases, hospitalizations, and deaths per capita [4].

The ongoing depletion of the nation’s housing infrastructure has contributed to severe shortages, which in turn, have driven costs upward. The costliest home purchases and rental market scan be found in SF, NYC, and LA, making housing unaffordable for low-income populations. In these areas median home purchase prices were one to three times the national cost (SF $1.5million; NYC $916,000; LA $626,000), and median monthly rental prices were two to three times the national median (SF $4,730; NYC $3,200; LA $2,055) pre-pandemic. In the setting of the current COVID19 pandemic rental market prices have dropped in major cities (in particular in NYC). NYC rents have steadily decreased with city real estate prices expected to follow as many urban residents have recently fled crowded cities during the pandemic [5-8].

Both the former and current governors of California, Jerry Brown and Gavin Newsom, and the mayor of NYC, Bill deBlasio, have proposed initiatives to address the housing affordability crisis. They suggest creating income-restricted housing for middle and low-income families within market-rate construction [6,8,9]. Because “affordable housing” is pegged to the very high median income of these geographic regions, these initiatives primarily benefit middle-income families and do little to help low and very low-income families. Construction of new affordable units is associated with rising median rents, which many of the very poor living in those neighborhoods cannot afford. The result is a new wave of “urban renewal”-- popularly called “gentrification”-- that leaves the poor with three options: stay and co-habitate with other families, move further away, or become homeless.

Families co-habitating to pool resources can experience overcrowding which increases rates of communicable diseases (TB, influenza, COVID19) and stress-related disorders [10]. In children, overcrowding is associated with negative effects on physical health, behavior, and academic achievement, contributing to the intergenerational transmission of social inequities [10]. In addition to issues related to overcrowding, recent evidence suggests that poor families staying in gentrified neighborhoods report poorer health outcomes [11]. A study in Philadelphia found that black respondents living in a gentrified neighborhood were more likely than their white counterparts to report poor health, and more likely than their black counterparts living in non-gentrified neighborhoods to report poor health [11]. This study highlighted the possibility that there may be subtle consequences to gentrification yet to be fully elucidated.

While displacement of the poor has been a major consequence of past policies, current housing prices, even at the extreme ends of reasonable commuting times, are prohibitive for many. The COVID19 pandemic has unearthed persisted socioeconomic inequities, including an already deepening housing crisis. The National Low-Income Housing Coalition reported that prior to the COVID19 pandemic there was no county in the US where a minimum wage earner working fulltime can afford a two-bedroom, market-rate home [12]. Homelessness is often the only option, resulting in three consecutive years of increased homelessness from 2016-2019 [5,13-15]. NYC had the highest estimated homeless population pre-pandemic at 64,000 (61,00 sheltered; 3,000 unsheltered), followed by LA with an estimated total homeless population of 57,9794 (42,828 unsheltered; 14,966 sheltered) [13-15]. The effects of the COVID19 pandemic on unemployment rates is expected to increase the homeless population by an estimated additional 250,000 additional people in 2020 [5]. The pre-pandemicrise in homelessness in both LA and NYC coincided with a 20-30% rise in rents but only a 0-5% rise in median income over the same time period [13-15]. This imbalance left some employed people with no option but to seek refuge in homeless shelters. In NYC, 10% of the homeless shelter population pre-pandemic was employed [13-15].

The disease consequences of homelessness are well-documented [16]. Nearly 40% of homeless individuals report some type of chronic health problem including community acquired pneumonia, chronic obstructive lung disease, tuberculosis, HIV, and cardiovascular disease [17-20]. Mental health issues, including affective and psychotic disorders, also have higher prevalence in homeless populations [17,21]. Homeless populations also have higher prevalence of high risk behaviors predisposing to certain types of cancers (i.e. cigarettes, alcohol, increased sun exposure) [17,18,20]. The higher risk of homeless populations to communicable diseases was the driving force behind NYC’s concerted effort during the COVID19 pandemic to house homeless residents in shelters/empty hotels as a means of decreasing community spread of COVID19 [4]. Given the current low rates of positive COVID19 tests, hospitalizations, and deaths when compared to the rest of the U.S, this along with other prevention efforts has led to the control of the COVID19 pandemic in NYC to date [4,22].

Decades of inadequate investment in the nation’s housing infrastructure has resulted in deleterious public health effects that have worsened in the setting of the current COVID19 pandemic. As physicians and members of the public health community, it is our duty to engage in primary prevention and not wait to institute initiatives for secondary and tertiary prevention. The multifactorial process that has led to the current housing famine and its resulting health consequences will require a multidisciplinary approach involving residents, community leaders, politicians, and public health officials. The COVID19 pandemic has highlighted historical inequities in our social infrastructure that we must address. It is a challenge we all must meet, if we ever hope to bring the one America with “a daily ugliness about it that constantly transforms the ebullience of hope into the fatigue of despair” into the other America where “…people experience every day the opportunity of having life, liberty, and the pursuit of happiness in all of their dimensions.” [1].

KEYWORDS: Housing affordability crisis; Public health; COVID19 pandemic

ABBREVIATIONS: LA-Los Angeles, SF-San Francisco, NYC-New York City.

AUTHOR CONTRIBUTIONS: Noé D. Romo: Dr. Romo conceptualized and designed the commentary, reviewed relevant literature, drafted the initial manuscript, and approved the final manuscript as submitted. Jeffrey Gershel: Dr. Gershel assisted in the re-conceptualization for the commentary paper, helped in it’s organization, and reviewed and revised the manuscript and approved the final manuscript as submitted for this study. Mindy Fullilove: Dr. Fullilove assisted in the conceptualization for the commentary paper, helped in it’s organization and directed the literature review, and reviewed and revised the manuscript and approved the final manuscript as submitted for this study.

FUNDING SOURCE None.

FINANCIAL DISCLOSURE None of the authors have any financial relationships to disclose.

CONFLICT OF INTEREST None of the authors have any conflicts of interest to disclose. All of the authors have complied with adherence to the Principles of the Ethical Practice of Public Health code.

ACKNOWLEDGEMENTS None of the authors have any acknowledgements to disclose.

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