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.
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. Yet today housing, health, and environment are all seen as separate and unrelated disciplines (HUD 1999a
; Krieger and Higgins 2002
; Lowry 1991
In the developed world, housing deficiencies still exist, although the context and certain disease outcomes have changed (Matte and Jacobs 2000
). Inadequate ventilation and crowding in housing contributed to the tuberculosis epidemic a century ago in the United States (Stein 1950
) and remains a significant problem in developing countries today, causing 2 million deaths in 2002 [World Health Organization (WHO) 2004
]. Although the tuberculosis problem seemed insurmountable, improvements in lighting, fresh air, and crowding in housing all helped to reduce its prevalence. Today, inadequate ventilation and moisture management in housing still contributes to asthma, mold-induced illnesses, carbon monoxide poisoning, and other diseases and injuries (Krieger and Higgins 2002
; Matte and Jacobs 2000
Although the focus of this mini-monograph is on housing conditions in Europe and the United States, it is worth noting at the outset that substandard housing conditions are truly a global problem. A recent United Nations report shows that more than one-third of all urban dwellers live in slums in developing countries (nearly 1 billion people), and the percentage is increasing rapidly, with the number of slum dwellers expected to double by 2030 (United Nations 2003
Some of the key policy impediments in this field involve the tension between housing affordability and health, privacy issues, lack of clarity in statutory authority, and gaps in responsibility for the built and indoor environments.
Indoor air pollution and the “shared commons” problem
In the United States, the Clean Air Act (1970)
authorizes an intricate system of regulation and oversight to support outdoor air quality and a network of top-down mandates that originates with national legislation and standard setting and extends to states, counties, and localities for execution and monitoring. Generally, the system enjoys broad national support for clean and healthy outdoor air. Yet no such consensus has formed to support the quality of air indoors, where people do more of their breathing.
Indoor air pollution is one of the top four environmental health risks identified by the U.S. EPA and the Scientific Advisory Board authorized by Congress to consult with the U.S. EPA on technical matters (U.S. EPA 1990
). On average, U.S. citizens spend about 90% of their time indoors, where indoor levels of pollutants may be two to five times higher than outside, and occasionally 100 times higher. Indoor pollution is estimated to cause thousands of cancer deaths and hundreds of thousands of respiratory health problems each year. Millions of children have experienced elevated blood levels of contaminants resulting from their exposure to indoor pollutants (U.S. EPA 1997
). Other health effects include irritation of the eyes, nose, and throat, and more subtle neurotoxicologic and behavioral and other adverse effects.
In addition to public health concerns, indoor air pollution accounts for substantial economic costs. Cost–benefit estimates by the U.S. EPA (2001b)
suggest that net avoidable costs associated with indoor air pollution amount to well over $100 billion annually, and more likely between $150 billion and 200 billion (all dollar amounts in this article are calculated in U.S. dollars). About 45% of those costs are attributable to avoidable deaths from radon and environmental tobacco smoke, about 45% from lost productivity, and about 10% from avoidable respiratory diseases.
Indoor air pollution can be defined as chemical, physical, or biological contaminants in the breathable air inside a habitable structure or conveyance, including workplaces, schools, offices, homes, and vehicles (the indoor environment). Indoor air pollution includes the following:
- combustion by-products;
- allergens (including mold spores);
- volatile organic compounds and particulate matter;
- paints, finishes, furnishings, adhesives, caulks, and pressed wood products found in building materials;
- cleaning products, personal care products, air fresheners, pesticides commonly used indoors;
- tobacco smoking, hobbies, cooking, and other occupant activities, including bringing home dry-cleaned clothes;
- bioeffluents; and
- soil gas intrusion (e.g., radon).
To address indoor air quality problems in the United States, national, state, and local legislatures have typically authorized public agencies to conduct voluntary programs intended to raise the public’s awareness about indoor air problems and appropriate actions they can take, alongside mandatory regulatory programs for ambient exterior pollution. The impetus for such contrasting public policies may be found in historical, attitudinal, and technical considerations that may have helped to inhibit the formation of a broad social and political consensus for controls on indoor air quality problems.
Historically, the legal structure for the environmental movement in the United States stands on two fundamental principles of English common law: “Shared Commons” and “The Polluter Pays” (Hardin 1968
). Shared Commons is derived from medieval practice governing community use of a public resource. Although everyone’s cattle may graze on the common green, nobody’s cattle may overgraze the resource and deprive others of its use. In its current legal application, this principle means the community may act to protect its interest if private activity deprives the public of its right and reliance on a shared resource, for example, breathable exterior air. The Polluter Pays principle holds that it is the originator of the pollution, not the injured public, who bears responsibility for the cost of its control.
Against this intellectual and legal backdrop, in the late 1960s, a number of historical developments and emotionally charged episodes fed growing public outrage against the increasingly obvious outdoor pollution. For instance, in 1969, the Cuyahoga River in Cleveland, Ohio, burst into flames because of the combustible waste it was carrying routinely. Although the fires were quickly doused, the spectacle was dramatic enough to generate national press coverage of exterior environmental degradation in many other sectors of American national life. With respect to exterior air quality, around the same time, private charities called “Fresh Air Funds” were widely supported because of their promise to send urban children to camp for a week, allowing some to escape, if only for a brief interlude, the increasing choke of urban exterior air pollution.
With such incidents firing the revulsion of common citizens to increasingly visible environmental insults, the first Earth Day in 1970 brought millions into the streets to express broad and deep public outrage over the problem. President Richard Nixon responded by establishing the U.S. EPA by Executive Order in December 1970 (Office of the President 1970
). By that time, the U.S. Congress had already passed the Clean Air Act (1970)
, which it supplemented with the Clean Water Act (1972)
, to authorize urgent measures to address the exterior environment.
Contrast this scenario with the case of indoor air and indoor environments generally. Here, there is not a perceived Shared Common for which the public feels a communal benefit and responsibility. Interior air, whether clean or contaminated, sits within the enclosed space of one’s own home or another discrete building. Typically, a polluter cannot be easily identified and tasked with payment for remediation. If the ambient exterior air is a shared common “owned” by everyone, ownership of indoor air is a far more ambiguous matter.
Consequently, for indoor air, we have had no dramatic moment of recognition such as a river on fire to galvanize public action despite a series of well-publicized serious indoor issues, such as childhood lead poisoning, radon, asbestos, mold, and so on. Furthermore, responsibility for buildings is diffuse, including architects, maintenance personnel, designers, employers, code and building inspectors, occupants, and others. In the absence of a clear-cut villain on whom the burden of correction can be laid, there has been less public support to demand mandates to control indoor pollution.
This is not to say there is neither outrage nor perceived villainy when it comes to indoor air. But in this context, the aggrieved are typically individuals acting for themselves or in small groups rather than an inflamed public acting through the political process. For these reasons, owners of private residences or tenants of buildings typically turn to the courts for redress of specific injury rather than to the legislature for the enactment of broad standards applicable across all occupied spaces. Despite these obstacles, an increasing number of local housing and health code enforcement agencies are adopting local ordinances to improve indoor air quality (Environmental Law Institute 2003
), and foundations have increasingly championed “green” communities (Enterprise Foundation 2004
Indirectly, federal U.S. laws and regulations do address indoor environmental quality. The U.S. EPA administers the Toxic Substances Control Act (1976), the Federal Insecticide, Fungicide, and Rodenticide Act (1996), and the Safe Drinking Water Act (1974)
, each of which limits the harmful quality of substances brought into the indoor environment, though not indoor air itself. As far back as 1937, the U.S. Housing Act (1937)
called for “decent, safe and sanitary housing,” and Congress enacted the Lead-Based Paint Poisoning Prevention Act (1971)
and the 1992 Residential Lead Hazard Reduction Act (Title X 1992
). The Consumer Product Safety Commission has established regulations prohibiting the sale of lead-based paint and other dangerous consumer products. Most local jurisdictions have health or housing codes that contain prohibitions against broadly defined public health nuisances.