Journal of Social Issues, Vol. 59, No. 3, 2003, pp. 637--649
Comment: Housing Policy and Health Ralph Catalano and Eric Kessell∗ University of California, Berkeley
We summarize and comment on the policy sections of the articles in this issue concerned with the health effects of residential environments. We review the implications in the context of public policies implemented over at least the last century to improve the least, as well as most, expensive housing. We make the argument that public policy can reduce but not eliminate the contribution of housing to the differences in health between the wealthy and poor. We conclude that the applied value of work such as that presented in this issue arises from its contribution to sustaining the improvements in health enjoyed over the last century, not from whether it helps eliminate the gap in health between the poor and wealthy. The editors of this issue asked us to comment and expand on the policy speculations included in the foregoing articles. Readers should keep in mind, however, that the authors intended these articles to improve our understanding of the complex relationship between health and housing, not to precipitate policy reforms. Any policy reforms conceived or accelerated due to this issue would be, in our opinion, “icing on the cake.” What have our authors written concerning the policy implications of their work? In the following, we briefly summarize their suggestions. Evans, Wells, and Moch (this issue)—Building, zoning, and design codes can be used to support parenting, neighboring, children’s play, and children’s coping. This can be done by, for example, limiting the height and size of multiple-family housing structures and requiring builders to provide play space for children and shared spaces that encourage interaction among parents. Smith, Easterlow, Munro, and Turner (this issue)—Public policy can help persons with health problems to more effectively participate in the housing market. It can also increase the stock of housing designed to accommodate persons with physical limitations.
∗ Correspondence concerning this article should be addressed to Ralph Catalano, School of Public Health, University of California, Berkeley, CA 94720 [e-mail: rayc@uclink4.berkeley.edu]. 637 C
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Catalano and Kessell Hiscock, Macintyre, Kearns, and Ellaway (this issue)—Public policy that supports home ownership may help to reduce the association between health and income. Standards for public housing should be attuned to the needs of fragile inhabitants. Ahrentzen (this issue)—Public policy should recognize that “shared housing” is an effective but unfairly stigmatized means for persons to find affordable housing in areas with high housing costs. Housing codes that impede shared housing should be reviewed to ensure that they serve legitimate public objectives. Saegert and Evans (this issue)—The social and economic mechanisms that assign the poor and minorities to bad housing and its attendant risks induce, at least in part, the disparities in health across the income strata. Policies and institutional practices that help the poor and minorities to overcome housing segregation can reduce these disparities. Michelson and Tepperman (this issue)—Public policy should recognize that the aging of the population and attempts to reduce health care costs will cause more persons to be cared for at home. Housing policy should make at-home caregiving easier. Hartig, Johansson, and Kylin (this issue)—When public and organizational policies transfer activities into the home, such as paid work, unintended consequences may follow as households confront disruption of the home’s restorative function. In the case of telework, housing codes should reflect the need for separating the work from the restorative function of housing.
We use the space allotted us to make three points related to the above suggestions. First, none requires an expansion of state power to implement because governments in the developed world, defined by the United Nations Population Division (2001) as North America, Europe, New Zealand, Australia, and Japan, already intervene heavily in the housing market (Harsman & Quigley, 1991). We will suggest that governments proceed slowly with housing reform because they fear unintended outcomes and constituent backlash. Second, many of the recommendations will probably come to pass. Reformers may be frustrated with the pace of improvement, but the trend in industrial democracies is clearly to improve the quality of residential environments as wealth increases. Third, none of the recommended actions, whenever implemented, will eliminate the contribution of housing to the positive association between socioeconomic status and health. We believe this to be true whether the association between illness and poor housing results from causation or selection. Universal Intervention in the Housing Market Developed countries have regulated few of their attributes as heavily as housing. We can think of no government in a developed country in the 20th century that pursued a policy of leaving the quality, quantity, and distribution of housing entirely to private transactions (Harsman & Quigley, 1991). This universal use of public power to affect housing implies that all industrial societies implicitly or explicitly accept that the residential environment and a population’s sense of well-being are inextricably connected.
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Government interventions into private housing transactions roughly separate into three groups. The first includes land use codes that specify, among other things, uses that can be close to housing, the density of residential development, and the transportation as well as other services, such as police and fire fighting, that residential development must have (Allensworth, 1981). Among the second are building and safety codes that govern the physical characteristics of housing units, such as fire resistance, ventilation, and the performance of electrical, plumbing, and heating systems (American Institute of Architects, 1990). The third group of interventions includes programs intended to affect the supply and cost of housing that meets building and safety codes (Hammond, 1987). These programs range from public construction and management of housing, to tax incentives and outright grants to institutions that finance and build housing as well as to families and individuals to supplement their purchasing power in the housing market. Governments justify all these programs as attempts to make safe and attractive housing available to as many people as possible (Mood, 1986; Wataba, 1977). All the policy interventions suggested in this issue fall into one or another of these categories. Although none of the interventions would require an expansion of government powers in the developed countries, several imply, as described below, unlikely trade-offs. The degree to which governments use their power to affect the housing market varies greatly across states and over time depending on how political institutions account and weigh the costs and benefits, including the political costs and benefits, of intervention (Basolo, 2000). Research such as that included in this issue, therefore, can influence political institutions through two mechanisms. First, the work can make the accounting of costs and benefits more complete by testing theories of how the residential environment affects health and behavior. Second, the work can change the opinions of politically powerful constituents and thereby affect which outcomes of housing policy are accounted and the relative weights assigned to each. An example of the first type of contribution could be the demonstration that indoor air pollution trapped in well-insulated homes may increase the incidence of respiratory disease (McCracken & Smith, 1997). The second type of contribution includes research suggesting, for example, that public housing policies may increase the prevalence of illness among the poor by concentrating them in neighborhoods with relatively more hazards and relatively little social capital (Hiscock, Macintyre, Kearns, & Ellaway, this issue). This type of research, intentionally or otherwise, may raise the salience of housing policy among directly affected and sympathetic constituencies and thereby change the weights assigned to health effects in the utilitarian calculations of political institutions. We argue below, however, that while both types of contributions may reduce the illness induced by the residential environment, neither will fundamentally change the fact that the relatively poor bear more than their proportional share of the burden.
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A Century of Progress With More to Come The three types of interventions identified above emerged from the social reform movement that swept Western Europe and North America in the last half of the 19th century (Cameron, 1874; Girdlestone, 1845). Indeed, concern over the appalling housing conditions associated with early industrial urbanism fueled much of those reforms. Historians of health widely agree that the improved shelter resulting from the reforms has been responsible for a significant fraction of the decline in age-standardized mortality in the developed world over the past 140 or so years (Rosen, 1993). Government rules supposedly reduced mortality by reducing the likelihood of structural collapse, fire, and the presence of indoor air pollution as well as human and animal waste (Rosen, 1993). General agreement that housing affects health, combined with continued, albeit fitful, economic growth, will likely sustain the century-old effort to make housing more salutary even in the poorest countries (Stephens, 1984; World Health Organization, 1989). We anticipate that the improvements will be of two types. The first will be the continued “upgrading” of building codes that define minimally acceptable housing regardless of the intended occupants. These improvements will include better indoor air quality, greater resistance to storm and earthquake damage, better detection of and resistance to fire, better noise control, and improved ergonomics to reduce safety hazards (Building Officials and Code Administrators International, 2000). The second type of improvement, made possible by growing personal and societal wealth, will “retrofit” old and “customize” new housing to better fit the needs of vulnerable or special populations. Work such as Michelson and Tepperman’s (this issue) research, concerned with caregiving in the residential setting, will, for example, be important as the elderly become a larger fraction of the population in the developed world (U.S. Census Bureau, 2003). The cost and communal guilt associated with institutionalizing the frail elderly will, in our opinion, lead to a growing population of older persons living with their children or other relatives. Information describing how these households can make life better for those who give and receive care will be highly sought after by public and private organizations. Alterations to the neighborhood and home will surely be among the adaptations to caregiving that seek scientific guidance (Gaunt, 1991). At the other end of the age spectrum, research such as that reviewed by Evans, Wells, and Moch (this issue) will probably affect the design of housing intended primarily for families. Indeed, any research dealing with the adverse effects of residential design on parenting and children will likely find interested subscribers among architects and regulators (Landrigan et al., 1998). As Evans et al. (this issue) imply, much of the information provided will support the intuition, if not clich´e, that less high-rise living and more access to safe and attractive outdoor play space will improve children’s psychological well-being. The problem of how to
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provide such access to poorer families given the cost of urban land will remain, of course, a profound impediment to improvement. Literature on the residential environment as a restorative setting (Hartig, Johansson, & Kylin, this issue) will also likely be intellectually and politically, if not practically, influential in the most developed countries. The concept will probably provide an intellectual justification for the fitful coalition between environmentalists and social reformers that, when operating, has appeared politically opportunistic rather than genuine. Hartig, Johansson, and Kylin’s (this issue) discussion of how the work-at-home movement affects health, behavior, and the environment provides a glimmer of the nature of such an intellectual alliance. To their credit, these authors note telecommuting’s benefit of reducing the stress and environmental degradation induced by commuting must be weighed against the cost of lost sanctuary as work encroaches on the home environment. The argument that better residential design can protect residential sanctuary remains to be tested. Ahrentzen’s (this issue) discussion of shared housing typifies work that could improve housing policy in regions struggling with boom and bust cycles. The boom phase of these cycles creates growth nodes where the demand for housing cannot be met even with extraordinary public effort (Housing Assistance Council, 2000). Shared housing inevitably increases in these places and frequently elicits criticism from environmentalists and public health advocates steeped in the societal memory of early industrial urbanism. It appears, however, that shared housing can be both economically efficient and socially supportive. Research on how we can alter the housing stock to increase the salutary aspects of these living arrangements should improve building and zoning codes if political resistance can be overcome. One could characterize the two classes of improvements alluded to above as “raising the floor” and “raising the ceiling.” Raising the floor will require government involvement through zoning and building codes because it will apply to all housing regardless of who owns or occupies it. As such, raising the floor continues the long tradition of making increasingly salutary housing available to as many people as possible regardless of their wealth. Raising the ceiling, on the other hand, is likely to be more a private matter. Government will participate mainly, as Ahrentzen (this issue) notes, by keeping popularly held prejudices against high-density and shared housing out of housing codes. If these prejudices do find their way into code, many individuals will be frustrated in their attempts to get a “fit” between their needs and their shelter. Given sufficient economic growth, wise management of housing regulations, and research such as much of that in this issue, a society should be able to raise both the floor and the ceiling. Doing so would help sustain the improvements in health we have enjoyed in the developed world for over a century.
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Can This Research Eliminate the Contribution of Housing to the “Gradient”? The arguments and optimism in the above sections lead us to ask, can public policy, guided by research such as that described in this issue, eliminate the contribution of housing to the association between wealth and health (Adler & Ostrove, 1999; Deaton, 2002)? Belief that the answer is yes is hardly new. Indeed, the social reformers of the 19th century argued that improved housing would reduce the “gradient” or discrepancy in morbidity between the rich and poor (see, for example, Chadwick, 1843). Much of the research concerning the residential environment and health, including a large fraction of that in this issue, continues in the reform tradition (Andersson, 2002). The work implicitly or explicitly addresses the issue of whether assigning, through market or political mechanisms, poor, but otherwise healthy, people to the least desired housing makes them sick. Little controversy greets the claim (e.g., Evans & Kantrowitz, 2002; Ineichen, 1993; Kasl, 1973) that persons who occupy the least sought-after neighborhoods have relatively high rates of illness. Controversy does arise, however, over how much of the association can be attributed to illness caused by poor housing. Some unknown fraction of the association surely arises because sick persons cannot always earn the money necessary to acquire relatively attractive housing and, therefore, must select poor housing (Burns, 1970; Smith, Easterlow, Munro, & Turner, this issue). The contrast between two contributions to this issue provides a demonstration of the controversy. Hiscock, Macintyre, Kearns, and Ellaway (this issue) provide an excellent summary of the literature and conclude it “suggests that the relationship between tenure and health may not be solely due to the personal characteristics of inhabitants, and that features of housing may play a role” (p. 530). Smith, Easterlow, Munro, and Turner (this issue), on the other hand, argue that although poor housing may affect health, nearly all the mechanisms by which persons become homeowners, at least in the United Kingdom, select on health. We suspect that few political leaders believe that either selection or causation entirely accounts for the association between the attractiveness of housing and the health of occupants. This suspicion arises from two facts. First, all developed countries intervene in the housing market, as noted above, to reduce the illness that bad housing would otherwise cause (Harsman & Quigley, 1991). Second, all developed countries also transfer income from the healthy to the disabled to reduce the selection of the latter into poverty and poor housing (Aarts & de Jong, 1992). There are obvious mechanisms through which the physical housing environment leads to illness; hazards such as mold, lead paint, or inadequate heating and cooling can contribute to poor health (e.g., Morawska, Bofinger, & Maroni, 1995). These tangible factors, however, are unlikely to explain all of the excess disease
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suffered by those living in poor housing. “Raising the floor� through stricter building codes is unlikely to change the health gradient if some other illness-inducing aspect in the environment remains unchanged. Many in urban planning and public health have begun to examine the role of the neighborhood in health outcomes. The social environment, access to recreational spaces and healthy food, proximity to work, and neighborhood cohesion have all been suggested to play a role in residents’ health (Yen & Syme, 1999). The relative contribution of these factors to the incidence of disease remains controversial, but the implications of this line of research are clear: How we construct our neighborhoods will impact our wellbeing in ways beyond the architectural features of the building in which we live (Hinkle & Loring, 1979). As Hiscock, Macintyre, Kearns, and Ellaway (this issue) document, research into the association between neighborhood and health has grown in volume and sophistication in recent years. The work, however, does not converge on an estimate of the relative contribution of selection and causation. We think it fair to characterize the findings as evidence that persons more sick than expected from their personal risk factors tend to live in poorer neighborhoods than expected from their income. Or, conversely, persons healthier than expected from their personal risk factors tend to live in richer neighborhoods than expected from their income. These empirical circumstances cannot discriminate between selection and causation. While certainly consistent with the notion that living amid poverty induces illness, the economic effects of poor and good health could explain at least part of the association (Portney, 1981). Even in countries with universal health insurance, the sick bear costs (e.g., copayments, transportation) that the healthy do not (Burstall, Reuben, & Reuben, 1999). The sick, therefore, have less to spend on housing than do the healthy with the same income. Conversely, the healthy have fewer illness-related costs and, therefore, more to spend on housing than do the sick with the same income. Housing Research and the Causation Argument Interventions based on the belief that living in undesirable housing causes illness in poor people include all efforts to raise the floor. The most important interventions in this group include the building, safety, and zoning codes alluded to above. We can make these codes more salutary by heeding research such as that described by Hiscock, Macintyre, Kearns, and Ellaway (this issue). These authors conclude in their policy section that research suggests that the collective can do more to make the homes and neighborhoods occupied by poor persons less risky. Despite the optimism expressed above for raising of the floor, we suspect that the pace of improvement will frustrate reformers. Government codes rarely, if ever, reflect the most recent research or require the most advanced interventions. Many argue that this deliberate implementation of reforms demonstrates the indifference
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of powerful elites to the plight of the relatively poor (Gungwu & Yongnian, 2000; Joint Committee on Housing, 1948; Skellet, 2002). Reformers, however, should consider the rival hypothesis that governments will be reluctant to implement housing codes based on the most current research because requiring the best can preclude production of the good (Mayer, 1997). Codes requiring much innovation could reduce the construction of new units because only a small fraction of the population could afford them. Units not up to the very strict standard, but safer than those occupied, could not be legally built if the strict standard were in place. The population, therefore, would remain in the least safe circumstance. Governments typically choose not to drive down production of the good by requiring the best (Mayer, 1997). Instead, they intentionally or intuitively make housing codes and policies incrementally stricter as societal wealth increases. The result is that although the average quality of housing improves over time, a distribution around the average persists. The demand for above-average housing typically outstrips supply so some allocation mechanism becomes necessary. Nearly all societies use the market to allocate much, but never all, of the housing stock (Harsman & Quigley, 1991). Using the market means that although the absolute risk of illness induced by housing may go down over time for everyone, the relative risk persists, implying that the poor remain most likely to suffer housing-induced illness. One response to the problem of relative risk has been for the collective, through government, to build and maintain safe housing for the poor (Harsman & Quigley, 1991). Public housing for the poor can supposedly be better than that provided by the market because the government need not make a profit to go on functioning. The state uses taxes extracted from those in the most attractive housing to improve the safety of housing for those with the least money. The impatience of advocates who believe politicians have failed to provide safe and aesthetically pleasing housing for the poor should be tempered by the realization that few elected governments would likely survive using taxes to make public housing as desirable as that enjoyed by those who pay most taxes (Basolo, 2000). There are exceptions, typically having to do with the elderly, but these are few. Owners of housing occupied by the poor typically do not accept the common wisdom that political tolerance for less than the best housing adds to society’s burden of illness. The owners, including many governments, compare less expensive housing not to the best alternative but the worst. Indeed, government officials continue to deny that publicly supported housing adds to the prevalence of sickness (see, for example, Dobson, 1997). And, of course, they are correct if the occupants would otherwise be in worse housing. This, of course, leaves open the question of how steep the “gradient� would be if public housing were better. We should remember also that human risk taking limits the extent to which codes can make housing units safer. Batteries in smoke detectors frequently remain discharged. Residents disconnect springs in self-closing doors. We often store
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combustibles and toxics, despite official prohibition, in residences (e.g., Ontario Office of the Fire Marshal, 1999). A second group of interventions intended to reduce the relative risk induced by market allocation of housing includes direct subsidies that allow the relatively poor to participate in the “private” housing market. The Moving to Opportunity Program described positively in the Saegert and Evans (this issue) article, for example, uses such a subsidy in conjunction with assistance in finding housing. These programs not only improve the housing occupied by poor persons, but also provide access to public and private services of higher quality than typically available in poor neighborhoods. The overall effect may be to improve health and increase upward mobility. As economists, we do not expect to see wide use of programs such as Moving to Opportunity in the industrial democracies. We suspect that taxpayers do not want money extracted from them given to persons with whom they must compete for housing (Cook & Spellman, 1992; Federation of Canadian Municipalities, 2002). We know of no successful political party that has campaigned on the policy of using income redistribution to achieve equality in housing. Governments will therefore pursue subsidies to improve the absolute, but not relative, quality of housing occupied by the poor. This may help sustain the secular improvement in the health status of the poor, but it does little to reduce the health differences between the poor and the remainder of society. While interventions such as Moving to Opportunity may be rare, research into the health of persons participating in them will be very important for scholarly, if not applied, reasons. As Saegert and Evans (this issue) describe in their article, such interventions allow researchers to compare, over time, the health experiences of participants to those of similar persons who probably would have participated in such programs if the opportunity arose. This would give us leverage on the causation versus selection controversy as well as an estimate of the costs of not pursuing more programs like Moving to Opportunity. Housing Research and the Selection Argument The above discussion invites identifying alternatives to the market for the allocation of desirable housing. We could allocate housing on rules derived from ethical considerations such that the least vulnerable people get the riskiest housing and the most vulnerable get the least risky (Bengtsson, 1995). These considerations supposedly guide allocations of public housing in many developed countries, although much unhappiness arises from how authorities construe vulnerability (Brown, 2000; Melaugh, 1992). Political institutions devise and implement allocation rules in such systems. One of us (i.e., Catalano) is reminded of visiting Prague immediately after the “Velvet Revolution” and being told that considerable rancor toward the old regime arose from blatant corruption in the allocation of
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housing. The government, for example, allocated houses above the smog level in Prague to Communist Party functionaries rather than to persons vulnerable to air pollution. A “thought experiment” for housing researchers would be to devise a mechanism that avoids the indifference of the market and the corruption of politics. Random assignment to housing that occupants could not pass on to their children probably occurs to those of us trained in experimental design. Considering this highly improbable mechanism for a moment helps us make our final point that no system we, at least, can imagine would eliminate all housing-induced health differences between the rich and poor. In order to negate the effect of housing on health, even a scheme based on random assignment would have to preclude the relatively wealthy from using their money to improve the housing assigned to them. This would be the equivalent of raising the floor but constraining the ceiling. Does anyone among us believe such a draconian scheme could survive democratic processes? In reality, of course, the wealthy and politically influential can use their wealth and influence to make whatever neighborhood they live in more salutary than that occupied by the poor and less powerful. The fact that individuals and families use their resources to improve the fit between their needs and the places in which they reside implies that those with more resources will always enjoy a better fit. Under this logic, the ability to manipulate one’s residential environment will continue to contribute to differences in health between rich and poor. Indeed, research such as that in this issue will guide the private efforts of the better off and the powerful to improve their residential environments. Are we to abhor this? If so, what would we do about it? Governments have attempted to reduce the selection of ill persons into the worst available housing. These interventions are typically part of income transfer programs intended to keep the chronically ill from falling into poverty (Aarts & de Jong, 1992). The transfers, even in the most generous countries, do not make their recipients wealthy. This implies that ill persons who neither inherit wealth nor accumulate it before becoming ill will be at a disadvantage in any housing market. Governments have implemented special requirements for dwelling units intended for groups likely to be ill. Housing for the elderly, for example, often has “enabling” design requirements intended to make persons with limited mobility safer and more independent than they would be in standard housing (Regnier, 1993; U.S. Department of Housing and Urban Development, 2003). The Smith et al. article in this issue touches on the concept of enabling design. We should probably pay more attention to this concept because doing so would force us to deal with the notion that illness is, to an unknown degree, socially constructed (Lachmund & Stollberg, 1992; Sarbin & Kitsuse, 1994). The construction usually turns on whether a physical or behavioral characteristic of an individual
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makes it difficult for him or her to function in modal environments. If it does, we typically label the characteristic an illness. Persons with the money needed to have their homes tailored to their limitations will less likely be hindered in their residential functioning. We, therefore, will attribute less illness to them. This possibility, inferred from the selection argument, leads us back to the same conclusion implied by the causation argument. That is that the ability to choose and manipulate one’s residential environment will continue to contribute to differences in health between rich and poor. The above argument implies that we will not eliminate the contribution of housing to the association between socioeconomic status and health through housing reforms. It makes no difference whether that contribution comes predominantly from causation or selection. Persons who are healthy and better off will use their wealth to “raise the ceiling” by making their housing less risky than that of the healthy poor. Those who are ill and better off will similarly “raise the ceiling” by using their wealth to make their housing more enabling than that of the ill poor. Using the power and wealth of the collective to bring the floor closer to the ceiling would reduce the contribution of housing to the gradient. Eliminating the contribution, however, would probably require using the power of the state to prohibit or retard raising the ceiling. We do not think such a policy could withstand democratic processes. Conclusion The standard for attributing policy relevance to research like that in this issue should not be that the work help eliminate the contribution of housing to the disparities in health between rich and poor. Freedom to improve one’s housing will contribute to such differences, and democratic societies will not deny that freedom. The appropriate standard should be whether the research helps us sustain or accelerate the improvement in health enjoyed across the income strata over at least the last century. References Aarts, L., & de Jong, P. (1992). Economic aspects of disability behavior. Amsterdam: North Holland. Adler, N., & Ostrove, J. (1999). Socioeconomic status and health: What we know and what we don’t. Annals of the New York Academy of Sciences, 896, 3–15. Allensworth, D. (1981). Land planning law. New York: Praeger. American Institute of Architects. (1990). An architect’s guide to building codes and standards. Washington, DC: Author. Andersson, R. (2002). Response: Some reflections on housing and family well-being. Housing Studies, 17, 27–31. Basolo, V. (2000). City spending on economic development versus affordable housing: Does inter-city competition or local politics drive decisions? Journal of Urban Affairs, 22, 317– 332.
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Bengtsson, B. (1995). Politics and housing markets—Four normative arguments. Scandinavian Housing and Planning Research, 12, 123–140. Brown, T. (2000, June). Needs versus choice in social housing allocation systems. Paper presented at the European Network for Housing Research conference, G¨avle, Sweden. Building Officials and Code Administrators International. (2000). International building code. Country Club Hills, IL: Author. Burns, L. S. (1970). What economists think of housing and health. Los Angeles: University of California, Graduate School of Business Administration. Burstall, M., Reuben, B., & Reuben, A. (1999). Pricing and reimbursement regulation in Europe: An update on the industry perspective. Drug Information Journal, 33, 669–688. Cameron, C. A. (1874). A manual of hygiene, public and private, and compendium of sanitary laws; for the information and guidance of public health authorities, officers of health, and sanitarians generally. Dublin, Ireland: Hodges, Foster, & Co. Chadwick, E. (1843). Report on the sanitary conditions of the labouring population of Great Britain. A supplementary report on the results of a special inquiry into the practice of interment in towns. Made at the request of Her Majesty’s principal secretary of state for the Home department. London: W. Clowes and Sons for H. M. Stationery Office. Cook, D., & Spellman, L. (1992). Taxpayer resistance, guarantee uncertainty, and housing finance subsidies. Journal of Real Estate Finance and Economics, 5, 181–195. Deaton, A. (2002). Policy implications of the gradient of health and wealth. Health Affairs, 21, 13–30. Dobson, F. (1997). Healthy homes for healthy lives: Frank Dobson addresses National Housing Federation (97/282). London: Department of Health Releases. Evans, G., & Kantrowitz, E. (2002). Socioeconomic status and health: The potential role of environmental risk exposure. Annual Review of Public Health, 23, 303–331. Federation of Canadian Municipalities. (2002). Presentation on fiscal sustainability to the House of Commons Standing Committee on Finance. Retrieved January 15, 2003, from http:// www.fcm.ca/newfcm/Java/laytonjune.htm Gaunt, L. (1991). The family circle: A challenge for planning and design. Journal of Architectural and Planning Research, 8, 147–163. Girdlestone, C. (1845). Letters on the unhealthy condition of the lower class of dwellings, especially in large towns founded on the first report of the Health of Towns Commission, with notices of other documents on the subject, and an appendix, containing plans and tables from the report (inserted by permission). London: Longman, Brown, Green, and Longmans. Gungwu, W., & Yongnian, Z. (Eds.). (2000). Reform, legitimacy and dilemmas: China’s politics and society. Singapore: Singapore University Press. Hammond, C. (1987). The benefits of subsidized housing programs: An intertemporal approach. Cambridge, MA: Cambridge University Press. Harsman, B., & Quigley, J. (Eds.). (1991). Housing markets and housing institutions: An international comparison. Boston: Kluwer Academic Publishers. Hinkle, L. E., Jr., & Loring, W. C. (1979). The effect of the man-made environment on health and behavior. London: Castle. Housing Assistance Council. (2000). Rural boomtowns: The relationship between economic development and affordable housing. Retrieved December 18, 2002, from http://www.ruralhome.org/ pubs/hsganalysis/boomtowns/btsummary.htm#intro Ineichen, B. (1993). Homes and health: How housing and health interact. New York: E & FN Spon. Joint Committee on Housing. (1948). The ruins of their postwar dream homes: Study and investigation of housing: Hearings before the Joint Committee on Housing, 80th Congress, 1st Session, Proceedings at New York, N.Y., November 10, 12, and December 29, 1947. Washington, DC: U.S. Government Printing Office. Kasl, S. V. (1973). Effects of housing on mental and physical health. In National housing policy study papers. Washington, DC: U.S. Department of Housing and Urban Development. Lachmund, J., & Stollberg, G. (1992). The social construction of illness: Illness and medical knowledge in past and present. Stuttgart, Germany: F. Steiner. Landrigan, P. J., Carlson, J. E., Bearer, C. F., Cranmer, J. S., Bullard, R. D., Etzel, R. A., Groopman, J., McLachlan, J. A., Perera, F. P., Reigart, J. R., Robison, L., Schell, L., & Suk, W. A. (1998, June).
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RALPH CATALANO is Professor of Public Health and Director of the Ph.D. program in Health Services and Policy Analysis at the University of California, Berkeley. He holds a Ph.D. from the Maxwell School of Syracuse University. His research focuses on the health and behavioral effects of ambient stressors, including unemployment and communal bereavement. In addition to his academic training, he has practical experience with municipal governance and policy formulation, gained as a member of the city council and mayor pro tem of Irvine, California. ERIC KESSELL is a doctoral student and Dowdle Fellow at the School of Public Health at the University of California, Berkeley. He holds a B.A. in Economics from the University of Michigan.