Public Health for All: Rethinking the Legacy of Public Health & Housing

Saneta deVuono-powell, Allison Allbee, and Juell Stewart

The state of housing in this country poses a public health crisis, not just because of issues like lead or asthma triggers, but due to the underlying instability and continued segregation that many families live with every day. In many instances, housing and neighborhood conditions are at the core of individual and community health. It’s imperative that the public health community prioritize comprehensive healthy housing as part of their strategic approach — housing that is safe, stable, affordable, and located in neighborhoods rich in opportunities for a healthy and prosperous life.

Although the importance of housing to health and wellbeing has been long understood, new research has deepened our understanding of how connected health is to a variety of factors, such as housing location, affordability, quality and stability.

Comprehensive healthy housing has immense potential to reduce poor health and increase individual and community stability and well-being.

The health benefits of housing are so extensive that doctors have started referring to safe, stable, affordable housing as a type of vaccine. We now know that housing location predicts life expectancy.[1] Research has shown that people who experience evictions are also more likely to experience long term material hardship, depression, and suicide than those who feel secure about their homes.[2] Unaffordable housing leads people to live in unsafe conditions or forego basic necessities like food, medicine, or utilities.[3] For babies, the effects of homelessness are profound. Researchers indicate that babies have a “dose-response” to the experience of homelessness, meaning the longer babies experience homelessness, the more serious their health risks.

These risks are not evenly distributed; low-income communities of color disproportionately bear the negative health impacts of housing segregation and disinvestment, which act as a wedge in our communities.[4] The history of public health’s role in promoting access to safe, stable and affordable housing is also uneven. While many housing practitioners are familiar with the ways that exclusionary financing mechanisms like redlining (not to mention its more recent, insidious cousin, subprime mortgage lending) have affected urban and suburban communities, the public health policies and contributions that enabled enduring forms of neighborhood segregation are less well known.

Looking to the past shows that public health practitioners played an important role in promoting policies that both increased and impeded access to healthy housing, making it hard to separate their successes from their missteps. Public health efforts to implement housing policies have led to some important innovations, such as building codes to limit the spread of disease and the risk of injury; but at the same time these policies codified a system of housing inequities that contributed to many of the health disparities we see today.

By taking a full account of public health’s role in exclusionary housing practices, we can gain insight about how to move towards smart decisions and even perhaps reverse past injustices.

In New York City in the 19th century, urban planners and public health practitioners responded to the rapid urbanization and industrialization of the city by introducing trash collection, sewer infrastructure and regular sanitation that would mitigate the effects of communicable disease outbreaks. These efforts were instrumental in eradicating diseases like cholera and typhoid, and the two disciplines emerged and flourished as a result. Buoyed by the success of early city planning and public health efforts, practitioners looked for other ways to reduce disease and health risks through planning. Reforms included developing housing codes to ensure minimum construction standards around sanitation, light and ventilation, and zoning codes.

Zoning codes were developed to separate residential land uses from industrial and commercial ones, as an attempt to limit neighborhood exposure to unhealthy pollutants. However, as always, the professionals in these fields were subject to the prejudices of their times. Zoning was also often used to promote and enforce residential segregation. Cities like Baltimore used zoning to impose racial segregation based in part on the unscientific notion that African Americans were more likely to carry communicable diseases.[5] Though explicitly race-based zoning was struck down by the courts in the 1917 case Buchanan vs Warley, cities continued to come up with new ways to codify residential segregation through zoning.[6] After the Buchanan decision, covenants and comprehensive planning became primary tools for enforcing residential segregation. Residential communities of color were often down-zoned to permit industrial land use, which lowered the land value and increased community exposure to toxins through a process York Rabin calls expulsive zoning.[7]

As scholar Richard Rothstein notes in his book The Color of Law, the combination of exclusive and expulsive zoning led to the simultaneous creation of “exclusive white suburbs” and “urban African American slums.”[8] In response, public health practitioners began to focus on fixing these “slums” through blight remediation. In 1937, the American Public Health Association organized the Committee on the Hygiene of Housing (APHA-CHH), which published guidelines for healthy housing and advocated for new housing construction to advance healthy communities by demolishing units that had fallen into disrepair.[9]

This and other factors paved the way for a national housing construction effort that would produce 13 million new units in the period between 1937 and 1945.[10] As World War II came to an end, incremental improvements in urban neighborhoods gave way to massive upheaval; entire tenement districts were cleared in an effort to completely overhaul them — all under the guise of improving health conditions. By 1948, APHA-CHH formalized guidelines for inspecting housing and neighborhoods in cities across the nation, which were then used to declare these city neighborhoods blighted.[11]

These same guidelines elevated the sprawling suburban single-family home growth over the multifamily units or small one- and two-family buildings that were typical of urban communities, where low-income people and people of color lived. Although the guidelines did encourage access to public transportation, jobs, parks and public services, they were clearly biased against traditionally dense, urban neighborhoods for subjective reasons that were tied into deeply ingrained value judgements of practitioners. For example, the guidelines states that multi-use buildings should be discouraged while promoting minimum lot sizes of 6000 square feet. These guidelines and standards paved the way for massive redevelopment and neighborhood clearance through what came to be known as urban renewal.[12]

Under the banner of urban renewal, about a third of American cities adopted APHA’s guidelines, which provided recommendations on which neighborhoods to raze under the guise of creating healthier communities.[13] Housing historian Rodger Biles notes that, “between 1949 and 1968, the program focused on “remediating blight” and razed 425,000 units of housing but constructed only 122,000 units nationwide (the majority of which were luxury apartments).”[14] It was estimated that 80% of the people displaced by urban renewal were African American. By 1962, over 600 cities had federally backed urban renewal projects that were on track to displace 4 million people. According to Mindy Fulillove, an estimated “1600 black neighborhoods were demolished by urban renewal.”[15]

Today, in the wake of the housing foreclosure crisis, there is no state within the US where a full-time worker earning what is termed as minimum wage can afford to rent a two-bedroom apartment at market rate.[16] As housing costs soar, more Americans are faced with destabilizing tradeoffs to pay their rent, as well as increased housing instability. It is unsurprising that in this landscape the racial wealth and health disparities continue to widen.

Just as public health played an essential role in the housing policy of the 19th and 20th centuries, it needs to play an essential role today.

In fact, if public health advocates are serious about addressing racial health disparities, they must engage with housing and the legacy of segregation.


[1] L Dwyer-lindgren, A Bertozzi-Villa, RW Stubbs, C Morozoff, JP Mackenbach, FJ van Lenthe, AH Mokdad CM. Inequalities in Life Expectancy Among US Counties , 1980 to 2014. JAMA Intern Med. 2017;177(July). doi:10.1001/jamainternmed.2017.0918.

[2] Desmond M. Evicted. New York, NY: Penguin Random House LLC; 2017: 297–298.

[3] N Maqbool, J Vivieros, M Ault. The Impacts of Affordable Housing on Health: A Research Summary. Insights from Housing Policy Research. 2015 (April)

[4] “Ethnoburbs ”: The Public Health Impact Of Segregation In Suburbia. Public Health Watch. September 2, 2014. https://publichealthwatch.wordpress.com/2014/09/02/ethnoburbs-the-public-health-impact-of-segregation-in-suburbia/.

[5] Pietila A. Not in My Neighborhood: How Bigotry Shaped a Great American City. Chicago, IL: Rowan & Littlefield Publishing Group; 2010.

[6] It is worth noting the rationale for striking down Baltimore’s racial zoning is that it violated the rights of private property owners to sell their home to whomever they wanted. This decision preserved communities right to create covenants that restricted home sales based on race, ethnicity or religion, which many did until 1948, when the courts ruled that the states could not enforce these covenants. During this time, the FHA gave developments that had racially restrictive deeds higher ratings and often refused to finance integrated housing developments.

[7] Cole L, Foster S. From the Ground Up: Environmental Racism and the Rise of the Environmental Justice Movement. New York, NY: New York University Press; 2000:43.

[8] Rothstein R. The Color of Law. New York, NY: Liveright Publishing Corporation; 2017:57.

[9] Lopez RP. Public Health, the APHA , and Urban Renewal. Public Heal Then Now. 2009;99(9):1603–1611. doi:10.2105/AJPH.2008.150136.

[10] Lopez RP. Public Health, the APHA , and Urban Renewal.Public Heal Then Now. 2009;99(9):1603–1611. doi:10.2105/AJPH.2008.150136.

[11] American Public Health Association. An Appraisal Method for Measuring the Quality of Housing: A Yardstick for Health Officers, Housing Officials and Planners. New York, N.Y: American Public Health Association, Committee on the Hygiene of Housing; 1945.

[12] Lopez RP. Public Health, the APHA , and Urban Renewal. Public Heal Then Now. 2009;99(9):1603–1611. doi:10.2105/AJPH.2008.150136.

[13] Bauman JF, Biles R, Szylvian KM. Public Housing in the Postwar Urban Renaissance, 1949–1973. In: From Tenements to the Taylor Homes: In Search of an Urban Housing Policy in Twentieth-Century America. University Park, PA: The Pennsylvania State University Press; 2000:143–162.

[14] Bauman JF, Biles R, Szylvian KM. Public Housing in the Postwar Urban Renaissance, 1949–1973. In: From Tenements to the Taylor Homes: In Search of an Urban Housing Policy in Twentieth-Century America. University Park, PA: The Pennsylvania State University Press; 2000:143–162.

[15] Fullilove MT. Root Shock: How Tearing Up City Neighborhoods Hurts America, and What We Can Do About It. New York, NY: Ballantine; 2005.

[16] A Aurand, D Emmanuel, D Yentel, E Errico, M Pang. Out of Reach 2017: The High Cost of Housing. Washington, D.C.: National Low Income Housing Coalition; 2017. http://nlihc.org/sites/default/files/oor/OOR_2017.pdf.


Saneta deVuono-powell, JD, MCP, and Allison Allbee, MCP, MS Arch, are the curators of The BLOCK Project. Juell Stewart is a former planner at ChangeLab Solutions.

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