Housing Policy is Health Policy: Q&A with HUD's Raphael Bostic

Dec 15, 2011, 10:00 AM, Posted by NewPublicHealth

Where you live—your zip code, your neighborhood, and even your home—may have just as much or more impact on your health as what goes on in the doctor’s office. “You can predict the life expectancy of a child by the zip code in which they grow up. This is wrong,” said U.S. Department of Housing and Urban Development (HUD) Secretary Shaun Donovan (as quoted in an opinion piece in today’s Roll Call and in a recent commentary, together with U.S. Department of Health and Human Services Secretary Kathleen Sebelius, “How Housing Matters”).

Recent research on a HUD demonstration project found that poor women who were given the opportunity to live in safer, more affluent neighborhoods had lower rates of obesity, diabetes, psychological distress, and major depression. The Roll Call opinion piece, jointly authored by Raphael Bostic, PhD, Assistant Secretary, Policy Development and Research at HUD and Risa Lavizzo-Mourey, MD, MBA, President and CEO of the Robert Wood Johnson Foundation, looks at the role of housing in health, and new collaborations across sectors that recognize that providing healthier, more affordable housing can lead to significant health outcomes.

NewPublicHealth caught up with Raphael Bostic to get his take on changes at HUD to integrate health in all policies, some of the innovative housing programs from the field and how the health field can better support this work. Bostic addressed similar topics a recent conference hosted by the Federal Reserve Bank of San Francisco, RWJF and The Pew Charitable Trusts.

NewPublicHealth: Why is HUD looking at health and how does this fit with HUD’s more central mission?

Raphael Bostic: One of the things that has really been interesting for us as we’ve looked at our programs and our activities is the intersection between housing and a whole host of other areas—health care, school performance, job attachment—they all seem to be pretty closely linked to how well people were housed. We started down this route to pay specific attention to those intersections, and have that as a central platform in our strategic plan.

We’ve been running a demonstration project called Moving to Opportunity, and some of preliminary results of that study, which started in the early 1990s, suggested that health benefits were going to emerge as one of the biggest benefits of people getting housed well. The experimental research really did guide us in a significant way.

NPH: Did this Moving to Opportunity study represent a turning point in how HUD thought about health and housing?

Raphael Bostic: There’s always been some intuition in this building that housing played a role in health, but the experimental results made it concrete and something that we could act on. It also made it easier for us for us to talk to our partners, our stakeholders and grantees to let them know they should be thinking about health, and to think about how the programs they’re designing affect health. That’s been a good conversation to be able to have and point to real findings that say when people get housed better, they wind up healthier.

We’re starting to see some other efforts in this area as well. Asthma is a huge problem, and a costly problem, especially for young people. The quality of housing and how well the housing is built and kept plays a huge role in the incidence of asthma. There are a number of efforts to have joint interventions where health organizations use their resources to do interventions to get housing up to better quality standards, which will then save them money because they don’t have to treat uncontrolled asthma. That really falls in line with the idea that we have that housing policy is health policy.

NPH: How is HUD’s outlook different now than in the past?

Raphael Bostic: One, we’re thinking much more broadly about what success for our program looks like. It used to be success for us was that someone had a voucher and was in a house. We didn’t look much beyond that to say are other parts of their quality of life changing significantly. This has allowed us to focus much more broadly on what success means.

It has also made us be more proactive in finding partnerships with our sister agencies in the federal government. Our partnership with the Department of Health and Human Services has been significantly strengthened and deepened. Similarly, we’re working closely with Department of Education around educational outcomes—it’s really allowed us to be much more integrated, hopefully to get a holistically better set of outcomes.

NPH: What are some of the innovative programs that are working?

Raphael Bostic: Some of our most basic programs have a viewpoint on health embedded in them. There’s Choice Neighborhoods, which is a program where we take some of the worst of our public housing and we convert it into higher-quality, mixed-income, mixed-tenure (rental and ownership) developments. We take those places where we know health is as bad as it’s going to be from a housing perspective and convert them into places where there’s much healthier lifestyles—you have sidewalks, you have walkable neighborhoods, you have amenities and the like. That’s one where I think we will see significant improvements in health because of the housing policy.

Another initiative is the Sustainable Communities Planning Grant. What we’re trying to do is facilitate and incentivize regional planning and more coordinated development of housing that is more sustainable, more walkable, closer to jobs and helps to make living easier, which should translate into real health benefits.

Our basic programs, including support through the Housing Choice Voucher program, where we help people have some mobility to choose the neighborhood they live in, has allowed people to get away from the neighborhoods that were a source of stress and lack of safety—so we’re seeing significant psychological benefits.

And our Housing Opportunities for Persons With AIDS program has been extremely beneficial. One of the most sobering statistics I heard at our conference in September was that for people with HIV/AIDS, if you had 100 people and didn’t get them quality housing, only 25 were still alive five years later. If you got them housing, 95 of them were still alive three to five years later. Talk about an “aha moment.”

NPH: What challenges does HUD face in looking at health-related effects of its work?

Raphael Bostic: Health is a very specialized field. A lot of the housers aren’t aware of what good interventions look like and they don’t really know who to talk to in getting that information. You wind up with a very siloed atmosphere. I think that’s the biggest challenge, is getting the experts to talk to people beyond the usual suspects and get them to understand that we need to be a broader and more integrated community. We’re trying to start facilitating those conversations about health and housing.

NPH: What can the health sector do to help and to work together?

Raphael Bostic: Figure out what sorts of activities are going on in communities that could be informed by health considerations. There’s a movement afoot where people are trying to get health professionals on planning commissions and on code boards so that when zoning decisions come up, we think about them in terms of their health impact. I think that’s an interesting way to make sure health is thought about in all the situations where it’s relevant.

The partnerships we’ve formed with HHS and other agencies here have been extremely positive—it’s really my hope that those collaborations happening on a national level will eventually diffuse down. If we integrate health and housing policies at all levels, that will be very exciting.

NPH: What other organizations or sectors need to be involved in these collaborations to really make an impact on health?

Raphael Bostic: Community development organizations have become increasingly interested, particularly in minority and low-income areas, in the health of their communities. If there are ways to improve health, it improves employability and a whole host of things. How communities are constructed, how neighborhoods are laid out, and how we plan for new, transit-oriented developments—those are all broader community development concerns that have real positive implications, if done well, for how people are housed. A number of community development professionals get this already. There’s a lot of work to be done. Some studies have showed that how communities are zoned and constructed can have direct impacts on obesity, diabetes, hypertension and other health issues. I think there’s more research to be done to better understand those relationships.

>>Read more on the link between housing and health.

This commentary originally appeared on the RWJF New Public Health blog.