Linking Public Health, Housing, and Indoor Environmental Policy: Successes and Challenges at Local and Federal Agencies in the United States

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We describe the successes and challenges faced by federal and local government agencies in the United States as they have attempted in recent years to connect public and environmental health, housing, community development, and building design with environmental, housing, and building laws, codes, and policies. These policies can either contribute to or adversely affect human physical and mental health, with important implications for economic viability, research, policy development, and overall social stability and progress. Policy impediments include tension between housing affordability and health investment that causes inefficient cost-shifting, privacy issues, unclear statutory authority, and resulting gaps in responsibility for housing, indoor air, and the built environment. We contrast this with other environmental frameworks such as ambient air and water quality statutes where the concept of "shared commons" and the "polluter pays" is more robust. The U.S. experiences in childhood lead poisoning prevention, indoor air, and mold provide useful policy insights. Local programs can effectively build healthy homes capacity through local laws and housing codes. The experience of coordinating remediation for mold, asthma triggers, weatherization, and other healthy housing improvements in Cuyahoga County, Ohio, is highlighted. The U.S. experience shows that policymakers should adopt a prevention-oriented, comprehensive multidisciplinary approach at all levels of government to prevent unhealthy buildings, houses, and communities. Key words: built environment, healthy housing, housing, indoor air quality, indoor environmental quality, policy, public health. Environ Health Perspect 115:976-982 (2007). doi:10.1289/ehp.8990 available via [Online 25 January 2007]


This article examines policy challenges faced by federal and local governments in the United States as they address the adverse health consequences of substandard housing, buildings, and other indoor environments. Specific experiences at the U.S. Department of Housing and Urban Development (HUD), the U.S. Environmental Protection Agency (EPA), and the Cuyahoga County Health Department (near Cleveland, Ohio) are highlighted as examples of how multidisciplinary approaches can yield important advances in environmental health in an area in which both scientific research and legal authorities remain relatively underdeveloped compared with existing building code, environmental law, and public health practice.

There is renewed interest in the linkage between substandard housing, poor indoor environmental quality, and unsustainable patterns of community development on the one hand and the state of the public's health on the other (HUD 1999a; Sharfstein and Sandel 1998). Sustainability, affordability, and health are all highly related and dependent on one another. At the most basic level, substandard housing and buildings are unhealthy, unsustainable, and unaffordable (Jacobs 2005; Sandel et al. 2004).

Origins of the health and housing connection. Linking housing and health is not fundamentally a new idea. Florence Nightingale said "The connection between health and the dwelling of the population is one of the most important that exists" (Lowry 1991). There is little doubt that improvements in housing in developed countries have greatly advanced the public health. Early housing standards provided for improved ventilation, sanitation, reduced crowding, structural soundness, lighting, and other habitability criteria, partly as a response to the appearance of concentrated slum housing around factories and big cities during the industrial revolution [Riis 1890; Centers for Disease Control and Prevention (CDC) 1976]. The public health movement and the housing movement have common roots a century ago in the sanitation movement that worked to clean up squalid conditions in housing. For example, the provision of indoor plumbing, still lacking in much of the developing world, had much to do with improved sanitation and the control of cholera and other similar diseases in the developed world. …