Radio – The links between housing and health

January 20th, 2020

An artwork from the APY lands in South Australia showing a poor living environment. Increased chance of infectious disease.

An artwork from the APY lands in South Australia showing an improved living environment. Improved house function is closely linked to improved health.

Listen to ABC’s RN radio program talking about the links between Housing and Health with:

Paul Torzillo // HH Director // Respiratory Physician
David Jacobs // Chief Scientist, National Center for Healthy Housing, United States


From ABC website;

Originally posted 25 Feb, 2019

Today in New Zealand, the World Health Organisation will launch its guidelines for housing and health. And the link between the two is strong.

Globally there are millions of avoidable deaths each year from respiratory diseases, other infections, lead poisoning, high and low indoor temperatures and fires.

And we in Australia harbour such housing problems especially in Aboriginal communities — but myths abound about what these problems are and what causes them.


Norman Swan: Today in New Zealand the World Health Organisation released its guidelines for housing and health. The link between the two is strong. Globally there are millions of avoidable deaths each year from respiratory diseases, other infections, lead poisoning, high and low indoor temperatures and fires. And we in Australia harbour such housing problems, especially in Aboriginal communities. But myths abound about what these problems are and what causes them. The other day I spoke to the person launching the WHO guidelines, David Jacobs, who is chief scientist at the National Centre for Healthy Housing in the United States, and Paul Torzillo, who is a respiratory physician at the University of Sydney with a long interest in Aboriginal health and housing. David Jacobs:

David Jacobs: We know, for example, in New Zealand that 10% of hospital admissions per year are attributed to household crowding. We know that India recorded over 2,600 deaths in 2012 due to collapsing buildings. In Kurdistan, we have data showing that household crowding causes deaths from tuberculosis.

Norman Swan: And even in Europe quite a high level of disease burden.

David Jacobs: Yes, we know that 15% of a new child asthma cases in Europe can be attributed to indoor dampness and the mould that comes out of it.

Norman Swan: David, what do the guidelines recommend?

David Jacobs: Principally the guidelines deal with crowding, indoor cold and installation, indoor heat, home-based injuries and accessibility.

Norman Swan: Crowding is hard to deal with because that’s an economic issue.

David Jacobs: Well, part of the definition of healthy housing is also affordable housing. It doesn’t make any sense to treat a child with an asthma attack in the hospital only to have that child return to the home environment that made him sick in the first place. We are shifting the costs of inadequate housing to our medical care sector. So ideally what we want to do is prevent the diseases in the first place by modifying housing conditions that produce the disease.

Norman Swan: And how modifiable are you? If you just take Europe, for example, you’ve got a large housing stock which is pre-glasnost which are notorious for being damp, having no installation, no air conditioning, communal heating which often breaks down. So you’re fine having the WHO guidelines but what are you going to do about these massive Leninist apartment blocks? We’ll come to Australia in a minute.

David Jacobs: Well, controlling moisture is tied to how you ventilate housing. There are established procedures for how to do that, preventing leaks through the envelope, dealing with airflow balances so that there isn’t the kind of condensation that might occur, proper insulation, especially in the era of climate change.

Norman Swan: Paul, you’ve spent a lot of your career looking at Aboriginal housing and the health problems that arise from that, and when you talk about Aboriginal communities and you say what’s the one thing that you would have in your community that would make the big difference, they almost always say housing and better housing. What’s the situation in Aboriginal communities?

Paul Torzillo: The situation is still poor. We started to look at this in the 1980s, we tried to define exactly what illnesses do they cause, and what’s the hardware, what’s the stuff you need in a house to help you stay healthy, be able to wash yourself, your kids, your blankets, your bedding, store, prepare, cook food, control temperature.

We’ve then done about 25 years of work and we’ve found remarkably consistent findings. So when you go into an Aboriginal house across the country, we’ve looked at about 9,000 houses in about 230 communities affecting about 60,000 people. You’ve got a functioning shower in about a third of those houses. You’ve got electrical safety in about 11%, and you can store, prepare and cook food in about 8%.

Norman Swan: 8%! And some of these houses are not old houses.

Paul Torzillo: New houses don’t seem to perform much better than old houses.

Norman Swan: So are they badly built to start with?

Paul Torzillo: When you look at this hardware, why does it fail, particularly the electrical and plumbing issues, why do they fail? 8% of them fail because of overuse or damage or anything you might refer to as vandalism. A quarter of this is due to bad installation, poor initial construction, bodgy work, not properly inspected before the houses were built, but 70% is due to a lack of routine maintenance that any house would need.

Norman Swan: So this is stuff that would go wrong in any house but it doesn’t get fixed.

Paul Torzillo: It doesn’t get fixed and that’s because maintenance is not planned or funded or conducted.

Norman Swan: So I built 20 houses in an Aboriginal community, I’ve done my job, move onto the next Aboriginal community and just be proud of the houses you’ve built.

Paul Torzillo: Exactly. So if all we do is build new houses, we won’t fix this problem. And one issue is getting sustainable local maintenance programs happening in a long-term fashion in communities across the country where we do proactive surveillance. So you try and check things before they break down, it costs less to fix, keeps the house healthier. Despite this 25 years of work we’ve not really been able to make a sustainable major impact on housing policy, and Indigenous housing policy remains this intractable, unsolvable problem.

Norman Swan: And the National Partnership on Remote Housing hasn’t been renewed.

Paul Torzillo: It hasn’t been. So one of the things that the Henry Halloran Trust funded…

Norman Swan: Henry Halloran Trust?

Paul Torzillo: The Henry Halloran Trust is a philanthropic trust attached to Sydney University that does housing research and facilitated David coming through here. They’ve also funded a Housing for Health Incubator research program led by Professor Tess Lea at Sydney Uni, looking at a number of issues, but particularly looking at why is this such an intractable issue.

Norman Swan: If you talk to Aboriginal communities, they say, ‘You’ve got all these white folks coming in and telling us what to do and don’t actually involve us, and if they actually talked to us we would come up with solutions for you. You’re trying to impose stuff on us rather than working with us.’

Paul Torzillo: Well, I’ve never been to an Aboriginal community where they said ‘we don’t want our toilet to work’. I’ve never been to one where they said ‘we don’t want to be able to be able to wash our kid’. And I’ve never been to one, especially lately, that didn’t say ‘it’s too hot and it costs us too much to control the temperature’. So the question is how do you respond to those requests in a sustainable way?

Norman Swan: Well, I’m looking at you.

Paul Torzillo: There obviously needs to be new housing because there’s a housing deficit, but we think that unless we can implement these local sustainable maintenance programs with access to electricians and plumbers across the country, we are not going to keep these houses functioning and we are going to lose housing stock.

Norman Swan: What are the health consequences of what you’ve just described?

Paul Torzillo: The first is the high rates of infectious disease in Aboriginal kids, order of magnitude greater rates of respiratory infection and ear disease, there’s lots of evidence that they are impacted on hugely by the ability to wash and keep yourself clean. If the hardware doesn’t work, you won’t be able to clean your kids, wash their face and hands. Childhood illness has a big impact on long-term chronic disease, infective inflammatory conditions drive coronary artery disease, early respiratory infection drives chronic lung disease et cetera.

Norman Swan: So describe a community to me in Australia where it’s working.

Paul Torzillo: I think the evidence is that housing hardware is in a pretty poor state right across the country. I think there are a number of communities in New South Wales where it has been improved because New South Wales has been the one state that has really taken up this work and focused on it. And I think one of the reasons is it has been incorporated into the Health Department rather than just left with Housing. Labor and coalition governments have sustained it.

Norman Swan: And what does the WHO calculate is the return on investments in terms of health problems avoided.

David Jacobs: There are returns on investment out of Europe and also out of the United States. There’s basically $1 in cost for a $5 benefit in asthma related home visits. For lead poisoning prevention it’s for each dollar in lead hazard control you get back $1.36. So it makes financial sense. The problem is who pays the cost and who reaps the benefits? Right now we are basically absorbing the costs of inadequate housing in our healthcare system, which doesn’t make sense, but the housing providers don’t make the health investments because they don’t realise a return on that investment. So it’s basically the classic market failure. We need to find ways…and that’s what the WHO guidelines do. We need to find ways to concretely describe the housing characteristics that will have a health benefit.

Norman Swan: Country towns in Australia have shortages of everything, it’s not just doctors and nurses and psychologists, it’s also tradespeople. Is anybody trying apprenticeship schemes in Aboriginal communities so that kids growing up have a trade?

Paul Torzillo: The answer to that is yes, in some places, but it’s simplistic to think that that’s something that’s going to solve the problem. The numbers are small, it is happening around the country, but apprenticeships take a long time, they require someone to keep someone employed for a long time. This is a question of years.

Norman Swan: So are we talking fly in/fly out teams or what?

Paul Torzillo: It will be a mixture. So there will be some places across the country where there will be local people who have got a trade skill and trade accreditation. There’ll be other people where you’ll have to bring people in and out. There has to be work-arounds in different regions across the country which allow you to achieve your goals. Locally employed people looking at hardware, doing daily maintenance, who’ve got access to plumbers and electricians and tradespeople to come in and fix the problems that require tradies. And it will work differently in different places across the country.

Norman Swan: So if there is a tradie listening, and we’ve got lots of trade is listening to Radio National, and they want to help, where can they go and what would they do?

Paul Torzillo: I think there’s lots of opportunities for tradies to help in this sort of stuff.

Norman Swan: But is there an organisation that brings it together?

Paul Torzillo: I guess there are different NGOs. There are groups of plumbers who work, there are groups of engineers who work, there’s probably not an overarching easy access point for the whole of the country. If there is I’m not aware of it.

David Jacobs: In the US we have a National Healthy Housing Training Centre and Network. It’s 20 universities, we train tradespeople, we train code inspectors and housing inspectors on how to recognise and mitigate housing related health conditions. It’s not something that tradespeople usually learn going through their apprenticeship.

Paul Torzillo: And finally, what impact does climate change have on all this?

David Jacobs: The energy consequences are profound. In the US our weatherisation program which adds insulation and air sealing and the like also includes some health interventions. If you think about it’s kind of silly to go ahead and do the insulation but not fix the malfunctioning smoke alarm. So they are increasingly integrated. But our houses and the ventilation in them is a big energy penalty. If we are not smart about it then we’ll end up using more energy than is needed.

Norman Swan: In some Aboriginal communities they are living in summers now where it’s above 45 degrees.

Paul Torzillo: High 40s for a few weeks over this recent summer, places in WA and central Australia with temperatures of 51 and 52. Everybody acknowledges globally that climate change is going to impact on poor populations first and early and hardest. And Aboriginal people in lots of these communities are already being hit by that. The costs of thermal control are going to be prohibitive for those populations, and we need to be thinking about multiple approaches to that right now.

Norman Swan: Thank you very much to you both.

David Jacobs: Thank you.

Norman Swan: David Jacobs who is chief scientist at the National Centre for Healthy Housing in the United States, and Paul Torzillo who is a respiratory physician at the University of Sydney with a long interest in Aboriginal health and housing.