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Housing is a health issue too

Rent Week 2018: Māori and Pacific kids are sick of cold, damp, crowded houses. So when are we going to start treating poor quality housing as the health crisis it is, asks general practitioner Bryn Jones.

This week Simon Bridges acknowledged that the National government might not have “shown it was doing enough on housing” and while he refused to call it a crisis, he accepted that it might be one “for those it affects”. There’s an uncomfortable implication in his words that it’s no big deal because only a few, less deserving New Zealanders are affected – an assumption which belies the gross unfairness of Māori and Pacific kids ending up in hospital for conditions that decent quality housing can protect against.

Tamariki Māori are far more likely to be hospitalised for asthma and respiratory or skin infections than Pākehā children. Pacific kids have it even worse. Ministry of Health figures show that these inequities have worsened over the past five years. As a parent of children who have both Māori and Pacific whakapapa, it is hard not to feel angry that our health system allows this. As a GP who has worked in a public policy environment for most of those five years, I feel ashamed, and want to share my thoughts about why so little has been done, and what must change.

How renting makes things worse

The quality of the home environment is a major factor in these hospitalisations. For an increasing number of Māori and Pacific children and families, the home environment is largely beyond their own control because they live in rental accomodation. The Housing Stocktake report commissioned by Minister Phil Twyford in November of last year was published this month. It highlights falling home ownership rates which have “had most effect among young Māori and Pacific children”.

Housing quality in NZ overall is pretty crappy – only about two thirds of houses here have any insulation whatsoever. Private rentals are in worse shape again, being significantly less likely to have adequate insulation. A housing shortage means that landlords have no imperative to spend money to improve the quality of their rental properties; demand is already very strong. Those renters fortunate enough to secure accommodation are rarely in a position to demand a warm, dry house with enough bedrooms for the whole family.

Pre-schoolers spend approximately 90% of their lives at home. It is almost as if their home is their entire environment, and I believe these kids all deserve to live in healthy environments, irrespective of their parents’ income or ethnicity.

Trust me – I’m a doctor

Water quality has long been seen as a civic responsibility and public health issue, as exemplified by the Broad Street pump story of how John Snow (not that one) traced a cholera outbreak in London to the city’s water supply. Since that moment in the mid 1800s, health authorities worldwide have recognised the importance of clean drinking water – and taken responsibility to ensure everyone has it.

I’d argue that damp, cold, crowded houses are the Broad Street pump of public health today. We know that these environments put people at risk of illness and disease. In contrast to clean drinking water, however, it seems that not everybody is equally deserving of healthy home environments. As a colleague recently said on the subject of Māori and Pacific kids getting sick at alarming rates: “It’s like the health system is frozen in time.”

The solution is better housing, rather than more medical care. We wouldn’t treat people for waterborne illness and knowingly send them back to drink the same contaminated water. Yet GPs and hospital doctors routinely dish out antibiotics, steroids and asthma inhalers to kids, then return them to the very housing that is making them sick. The common sense understanding that safe, dry, warm, secure housing is fundamental to good health is the elephant in the examination room.

The medical profession needs to be a better advocate for Māori and Pacific children and ask ourselves why we have so spectacularly failed to tackle ‘healthy housing’ as a health issue, or to consider housing interventions as ‘health interventions’?

Is it because we don’t have interventions to offer which require our “medical expertise”?

Is it because we celebrate ‘heroic’ high-tech treatments, but don’t authentically value prevention?

Is it because our privilege blinds us (my home is warm and dry), or that we make value judgements about who is deserving of decent quality housing?

Is it just a narrow and outdated illness-centred view of health reinforced by Western medical training which is no longer fit-for-purpose and continues to under-emphasise the social determinants of health?

Is it self-interest in an industry which financially benefits us? To quote Upton Sinclair: “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

Housing interventions work – so let’s implement them effectively

New Zealand has been a leader in the area of housing health and contributed to the international knowledge base about effective healthy housing interventions. Improving housing quality is the right thing to do from both an ethical and an economic perspective. The evaluation of the Warm Up New Zealand initiative showed the retrofitting of insulation to have an excellent benefit:cost ratio (of almost 4:1, and up to 6:1 in households with young children or susceptible elderly). University of Otago public health professor Philippa Howden-Chapman rightly described the evaluation as “probably the strongest evidence the government has about social investment”. We know that this is an intervention that works. It keeps kids healthy, in education, out of hospital, enables their parents to work, and enables their families to fulfil their potential – giving them and New Zealand a brighter future. It makes good economic sense. It is humane. It is pro-equity and it values the health and lives of our children.

However, public policy ‘experts’ have failed to adequately incentivise these simple, cost-effective housing interventions. There has been incredibly disappointing uptake of Healthy Homes insulation subsidies by private landlords, and little has been done to turn that around. The programme is due to end in June this year. It seems naive to blame landlords for making rational economic decisions not to retrofit insulation, when local and central governments haven’t provided the right incentives to do so. A voluntary rental WOF introduced in August 2017 by the Wellington City Council is a good example of such poorly considered policy. So far, just two houses have obtained the WOF.

So what next then?

Maybe the lack of progress in housing-related health shouldn’t come as such a surprise. Those most affected are the same old groups with the least agency. They’re the the ones who our public policies and services consistently fail: low-income Māori and Pacific families, particularly those with young children.

So what can be done differently?

We must start putting these families at the centre of our public policy thinking and actually include them in the conversation about problems and solutions – call it a ‘health equity in all policies’ approach. To selectively use Simon Bridges’ words, if we don’t solve the housing crisis for “those it affects” then we won’t have solved anything. Conversely, we can only fix the inequity in housing-related hospitalisations for Māori and Pacific kids by really addressing the housing crisis. Making health equity our objective will guide us towards appropriate actions.

Doctors and health officials must combat our bias towards medical interventions and solutions. When thinking about health interventions we need to think about all determinants of health. If retrofitting insulation to cold damp houses is a better investment than medical care (and I say it is), then let’s spend our health dollars on that instead. It’s unethical to continue to ignore the things that matter most to health (like housing, education and employment), while doubling down on medical solutions which don’t work for the people who need our health system the most.

Dr Bryn Jones (Ngāti Kahungunu ) is a GP with a background in hospital medicine, central government policy and governance roles.

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