HOUSING AND THE COMMUNITYAuthor(s): Albert RoseSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 76,SUPPLEMENT 1: BEYOND HEALTH CARE: PROCEEDINGS OF A CONFERENCE ON HEALTHYPUBLIC POLICY (May/June 1985), pp. 71-73Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41988948 .

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HOUSING AND THE COMMUNITY

Albert Rose1

The healthy drive

community towards the

began provision

with of the

healthy efforts

housing of members

in a healthy community began with the efforts of members

of the emerging profession of public health in the latter part of the first Industrial Revolution, that is, during the last quarter of the 19th century in rapidly industrializing nations. The quest for a healthy housing policy in healthy communities was much more elusive than the original search and, for the most part, remains to be fulfilled.

Healthy housing must be conceived in both physical and social terms. For the members of a household to grow and develop in both mind and body, there must be sufficient space to permit the household to carry out the essential functions of living, eating, and sleeping and at the same time, there must be sufficient space to permit the parent or parents of the household to have privacy, along with that of the children of different sexes beyond a certain age. For a healthy household, then, their household must permit the fulfillment of both the individual and collective aspects of living together.

A community may be defined as a social group of any size whose members reside in a specific locality, share govern- ment, and have a common cultural and historical heritage. This dictionary definition of community may imply homogeneity on many levels. A healthy community, on the other hand, must mean heterogeneity on many levels. A healthy community contains households of different types, of different levels of income, of different cultural, historical and religious backgrounds, of different ethnic and racial configurations.

The curse of community building during the past sixty- five years since the end of World War I, has been the concentration within local communities - within the com- munity, that is, the public society - of homogeneous eco- nomic, social, cultural, ethnic or racial groups. The result for everyone to see in modern urban societies is a most unhealthy community.

The Major Issues in Providing Healthy Housing in a Healthy Community

In all modern urban societies, whether in Western nations, in Eastern Europe or elsewhere in the industrialized world, the most important issue continues to be the nature and extent of government intervention in the housing market.

Since the early 1930s and particularly following World War II, there has been a degree of government intervention (previously unthinkable) and designed, according to the pronouncements of political leaders and their followers, to

1. Faculty of Social Work, University of Toronto.

May/ June 1985

create healthy housing within healthy communities. In order to focus the attention of public policy-makers upon the concept of a healthy housing policy in the future, the nature of past governmental intervention must be reviewed and understood. In Western societies there is no question that such intervention was primarily for one of two reasons: either to stimulate the entrepreneurial aspects of the con- struction industry which at times suffered from lack of capital and lack of markets, or to stimulate employment in the industry and thus in the national economy.

The consequence has been an enormous increase in the proportion of households who allegedly "own" their hous- ing accommodation, while a number of households cannot meet the requirements of such policies and must rent their housing. These households characteristically must expend (to acquire housing accommodation) what appears to many social scientists and health specialists, to bean unreasonable proportion of their income. The expenditure of such pro- portions of income, commonly in Western countries more than 25% or 30%, may have significant negative effects upon the development of healthy individuals and healthy house- holds in so-called healthy housing.

The fact is, however, that for many persons and families no matter what the level of expenditure may have to be, healthy housing as defined earlier is not obtainable. Moreover, only the public provision of decent, adequate and sanitary housing or the subsidization of such accom- modation in the form of either direct grants to consumers or reduced rental charges, make it possible for a small propor- tion of those who cannot obtain healthy housing with their own resources, to live in decency.

The essential issue is whether government in Western democratic societies can be induced or persuaded to utilize its interventive powers on behalf of those most in need of helpful housing in helpful communities.

The Issue of Healthful Variation Toward a Healthy Community

No matter what government has attempted to stimulate development in the post-war society in Western nations - in Europe, the United Kingdom, and in North America - the result has been segregation. Is it possible to conceive of communities which demonstrate a healthful variety of income groups, household types, ethnic, cultural and racial backgrounds. The growth of our communities in the post- war period has been influenced primarily by personal pref- erences in housing approved and stimulated by governmen- tal action, and by the consequences of local governmental policies in affording publicly provided or publicly subsid- ized housing for those in the greatest need.

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Most of our neighbourhoods, both those which existed prior to 1940 and those which have developed since 1945, have been segregated by income and thus substantially by social class. Income is the major dictate of homogeneity in all of the other characteristics of our segregated communi- ties. There are children who grow to adult status without ever seeing an older person; or without seeing more than a handful of households in their community which include more than one parent; or without seeing more than a hand- ful of household heads who work for the income to maintain the health of their families; or without seeing in their com- munities more than a small proportion of persons who differ from them in race or colour or ethnic background or religion.

To the extent to which homogeneity is a consequence of past public policy in the provision of housing and in the stimulation of urban community planning, the real question is whether in the next decade or two a healthy housing policy by government at all levels can be constituted on the notion that a healthy community is a heterogeneous community, not a segregated community.

In the field of public housing the original intention to develop variation within this substantial groups of house- holds accommodated in housing projects, has long since gone by the board. In recent years the key words were priority on the grounds of lack of affordability, and the provision of publicly subsidized housing for those in the greatest need. The greatest need among the households in North America and in Western Europe today rests within the households of single parents who for the most part are not employed, and are often not capable of employment by virtue of lack of education, lack of training, lack of work experience, and combinations of these factors. Can government be persuaded to increase the supply of housing to be provided for those in need, without falling into the trap of segregated homogeneity?

The Issue of Housing for Special Groups At a time of increasing public social concern about the

community's failure to offer healthy housing to a great many households disadvantaged primarily by lack of income and lack of family stability, the requirements of a number of "special groups" have emerged as demand units for scarce accommodation. Individuals and voluntary groups -

sometimes, public agencies - have put forward in recent years the needs of such persons and households as dis- charged mental patients, the physically disabled, the hard- of-hearing and members of other categorical groups.

This tendency has been compounded by the actions of governments in their apparently unplanned or poorly planned programs of de-institutionalization - of mental patients, of incarcerated offenders, of young adults no longer able or capable of residing within their parental households, of single homeless men and women. The urgent claims upon the scarce resources of publicly provided hous-

72 Canadian Journal of Public Health

ing have been magnified by these new demands, for in truth, the public authorities do not employ the trained social and medical staff resources to provide the fundamental needs of these newly disadvantaged persons. Thus, the unhealthy community is afraid that it will become even more unhealthy if it shares its scarce resources with more visibly disadvan- taged households.

The Dilemmas of Public Policy in Healthy Housing The major dilemmas which face governments at all levels

in our society with respect to the development of healthy housing in healthy communities are instrumental in framing the issues for the future. Governments face the fact that the residential construction industry is an important part of the economies of most nations in the developed world. In recent years the problem of unemployment has become increas- ingly serious and yet the pressures on government are to regard housing policy as a social rather than an economic issue. The two concerns - the maintenance of employment in the construction industry and the drive toward healthy housing within healthy communities - may conflict sharply and in fact have often done so during the past four decades. How to reconcile the conflicting economic and social demands within housing policy is a most important issue in our society.

A further dilemma which governments at all levels face, is the widening gap between human need for healthful housing on the one hand and the increasing scarcity of available financial resources, on the other. Given the possibility that government intervention in the housing market will take new forms and may be substantially increased during the next two decades, the real question is for whom such inter- vention is intended. If the intention is to create housing which can only be afforded, that is purchased, by the upper third or upper half of households in the national income distribution, then those in the lowest or the third quartile will be even more disadvantaged than they are at present. Yet the objective of creating healthy communities is not necessarily met if governmental intervention is intended to aid only the neediest of the needy, which in most developed societies today means households headed by a single parent, usually a woman.

There is the further dilemma, already enunciated, of the homelessness of the specially disadvantaged person or fam- ily. It is clear that their requirements could absorb all of the available publicly assisted housing. If this accommodation is shared, even to a modest degree, many family households will wait longer to attain healthy housing. If it is not shared, the only response can be new or old forms of segregated housing for special groups.

It is an incredible dilemma to conceive of a healthy hous- ing policy intended to create healthy communities which will accommodate only a modest proportion of those in the greatest need, and equal proportions of those whose needs are theoretically somewhat less, when nudged by income,

Supplement one to Vol. 76

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but equally great in social terms. If this dilemma is not solved, the number of segregated communities will continue to grow and the negative reaction of the majority of the citizens in developed countries toward the housing require-

ments of the most needy and the communities in which they live can only worsen.

CARE IN THE COMMUNITY

Marten Lagergren, Ph.D.1

Introduction

Health tradition. promotion

However, and

since disease

World prevention

War II there have

has a been long

tradition. However, since World War II there has been a tendency in politics and in the popular mind to confuse the concepts of health and health care services. Health politics have been dominated by the belief that health can be bought by spending money on the health care services' 2. This dis- mantling of this fundamental misunderstanding is the first important step in the direction of a new, efficient health policy. The situation is illustrated by Fig. 1 , which shows the relationship between health and care. Health is affected by several factors: physical and psycho-social environment, lifestyle, heritage and - for curable diseases - health care. Care on the other hand has many other purposes besides improving health - providing security, easing pain, com- forting, establishing social control, etc. Care will perhaps not provide much health but no matter how healthy a com- munity the need for care will always be there. Helplessness, disablement and disease will never be completely eradicated - at least not in the beginning and the end of the lifecycle. No matter how efficient the health promotion policy it is still important to reflect upon the ideal conditions for the provi- sion and organization of care in the community.

The Different Sub-Systems of Care

Traditionally care is given in two separate sub-systems: the "formal", organized professional care services - private or public - and the "informal" everyday care in the social networks. As illustrated by Fig. 2 these two sub-systems interact and they are also influenced by the conditions of society. When the capacity of the informal systems is insuffi- cient - in quality or quantity - a need for formal care will express itself. On the other hand the formal care systems might have a tendency to deplete the informal, e.g. by declar- ing that care of a certain kind or to a certain group of recipients demands a special knowledge or technique that only can be provided by the professionals. Both formal and informal care are heavily dependent upon the conditions of society. Demographic and social patterns, women's propen- sity to work outside home, working hours etc. will shape the 1. Secretariat for Future Studies, Stockholm Sweden

Box 6710, 1113 85 Stockhold, Sweden, Tfn 08/15 15 80

May/ June 1985

conditions for informal care. Economic resources and tech- nological advancement, concepts of manhood and solidar- ity, professional ambitions and power etc. will together form the formal care services systems.

During the post-war era formal care has grown at a tre- mendous rate in all advanced Western societies. To a certain extent informal care has been substituted for formal care services. But the formal care systems today also contain a range of services that earlier simply did not exist for eco- nomical, technical, social or cultural reasons. Care services have been industrialized and largely concentrated to big "care-factories" outside the community. The rapid cost increase is now forcing political decision-makers to think again about the systems for care3. Is it possible to continue to provide care services on an equitable basis? Should we try to go back to informal care? Will health promotion render reparative health care obsolete and thereby provide the solution to the care dilemma?

Is Prevention the Solution to the Care Dilemma? As mentioned above the last solution is unlikely to mate-

rialize. The last years of life inevitably mean that different functions decline. Help in some form or another becomes necessary. Death can never be prevented and we do not substitute causes of death connected to long nursing requirements with shorter or less care-consuming decline periods. If anything prevention works the other way. How- ever, a lot of health care is spent on society - or self- inflicted diseases, which bring too early death or destroy or reduce quality of life. The value of prevention rests more upon the quality-of-life in years gained than on reduction of health care costs. Regardless of cost reductions health pro- motion and disease prevention remain the most important concepts in striving towards a healthy community. But the problems of care remain to be solved4.

Can We Return to Informal Care?

Going back to informal care in the modern post-industrial society is easier said than done. No one seems to be seriously interested in turning one's back to the benefits of technology and professional knowledge. And women tend to be suspi-

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