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Office of the Surgeon General (US). The Surgeon General's Call to Action to Promote Healthy Homes. Rockville (MD): Office of the Surgeon General (US); 2009.

Cover of The Surgeon General's Call to Action to Promote Healthy Homes

The Surgeon General's Call to Action to Promote Healthy Homes.

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2The Connection Between Health and Homes

Many factors influence health and safety in homes, including structural and safety aspects of the home (i.e., how the home is designed, constructed, and maintained; its physical characteristics; and the presence or absence of safety devices); quality of indoor air; water quality; chemicals; resident behavior; and the house’s immediate surroundings. The link between these housing features and illness and injury is clear and compelling. Homes’ structural and safety features can increase risk for injuries, elevate blood lead levels, and exacerbate other conditions. Poor indoor air quality contributes to cancers, cardiovascular disease, asthma, and other illnesses. Poor water quality can lead to gastrointestinal illness and a range of other conditions, including neurological effects and cancer. Some chemicals in and around the home can contribute to acute poisonings and other toxic effects. All of these issues are influenced both by the physical environment of the home and by the behavior of the people living in the home.

How Indoor Air Quality Affects Health

Poor indoor air quality can contribute to symptoms ranging from eye, nose, and throat irritation to chronic conditions. Pollution sources such as wood smoke, natural gas combustion, or cigarette smoking that release gases or particles into the air can contribute to indoor air quality problems in homes. For example, secondhand smoke can cause respiratory and heart disease, whereas radon causes cancer. Inadequate ventilation also contributes to poor indoor air quality. High temperature and humidity levels can also increase concentrations of some pollutants. In addition, the use of candles, incense, or home deodorizers can increase symptoms in individuals with preexisting respiratory conditions (National Institute of Building Sciences 2005).

Secondhand Smoke

An estimated 38,112 lung cancer and heart disease deaths annually are attributed to exposure to secondhand smoke (Centers for Disease Control and Prevention 2005b). Secondhand smoke also contributes to respiratory diseases and other health problems. In 2000, more than 126 million U.S. residents ages 3 years and older were exposed to secondhand smoke; for most, the home was the primary site of exposure (U.S. Department of Health and Human Services 2006). The risk for exposure extends beyond the immediate family. Smokers living in multifamily residences (such as apartment and condominium complexes) can affect not only family members, but other residents as well.

Carbon Monoxide

Carbon monoxide is a colorless, odorless, poisonous waste gas produced when any fuel, such as gas, oil, kerosene, wood, or charcoal, is burned. Carbon monoxide exposure in the home can also result when electrical power to homes is interrupted for extended periods, such as after blizzards, ice storms, hurricanes, or tornadoes, and when residents without electrical power use generators or gas grills inside their homes. Carbon monoxide exposure is responsible for approximately 450 deaths and more than 15,000 emergency department visits annually; 64% of these exposures occurred in the home (Centers for Disease Control and Prevention 2005c). Acute exposure to high levels can cause unconsciousness, long-term neurological disabilities, coma, cardiorespiratory failure, and death (Ernst and Zibrak 1998). Chronic low-level exposure can cause viral-like symptoms such as fatigue, dizziness, headache, and disorientation (Centers for Disease Control and Prevention 2008; Raub et al. 2000). A large proportion of reported carbon monoxide exposures occur in the winter. Increased use of home heating systems; use of gasoline-powered generators during and after winter storms; and indoor use of charcoal grills, portable stoves, and space heaters have all reportedly contributed to the increase in carbon monoxide exposures during winter (Centers for Disease Control and Prevention 2005c; Daley et al. 2000). Nearly 60% of unintentional carbon monoxide deaths occur in middle-aged and elderly adults, a population that may be particularly susceptible because of preexisting health conditions (Centers for Disease Control and Prevention 2007a).

Radon Gas

Radon is a naturally occurring radioactive gas emitted by the normal decay of uranium, which is found in most soils; some soils have higher levels than others (Centers for Disease Control and Prevention and U.S. Department of Housing and Urban Development 2006). Radon is the leading cause of lung cancer among nonsmokers, causing an estimated 15,400–21,800 lung cancer deaths annually (Committee on Health Risks of Exposure to Radiation [BEIR VI] 1999; Frumkin and Samet 2001; U.S. Environmental Protection Agency 2003). Nearly one in 15 homes in the United States have radon levels above 4 picocuries per liter (pCi/L), the level at which the U.S. Environmental Protection Agency (EPA) recommends taking specific steps to reduce radon levels in the home (U.S. Environmental Protection Agency undated a). Radon gas can enter the home through structural deficiencies such as gaps between basement walls or large cracks in the foundation, and its presence can be detected through a simple test (Field et al. 2000). A house in an upper Midwest or Eastern state, for example, is more likely to have an elevated level of radon compared with a house in the South or on the West Coast (U.S. Environmental Protection Agency undated b). A study in one Midwestern state found that radon levels in 60% of the houses tested exceeded the EPA’s action level of 4 pCi/L (Field et al. 2000).

Map of the United States identifying risk for radon

Map of the United States identifying risk for radon.

Allergens and Asthma

The predominant health outcome studied in conjunction with allergens in the home is asthma. Nearly 15 million asthma-related physician and outpatient hospital visits and almost 2 million asthma-related emergency department visits occurred in 2004. Environmental factors in homes that can contribute to the occurrence or severity of asthma include exposure to pests and pet dander (Akinbami and Schoendorf 2002), airborne and settled dust, dust mites (Institute of Medicine 2004), mold, and other conditions such as excess moisture. Studies show that 84% of U.S. homes have a bedroom with detectable levels of dust mite allergens; many of these have levels that can contribute to allergies or asthma (Arbes et al. 2003). Similarly, 82% of dwellings in the United States have detectable levels of mouse allergens (Cohn et al. 2004), and 63% have detectable levels of cockroach allergens (Cohn et al. 2006). Low-income households and older homes are also among the factors frequently associated with U.S. residences having high concentrations of mouse and cockroach allergens (Cohn et al. 2004, 2006).

Mouse eating a cupcake

Mouse eating a cupcake.

Dampness and the presence of mold are also associated with asthma and other respiratory health complaints. Exposure to dampness and mold in homes is estimated to contribute to approximately 21% of current asthma cases in the United States, at an annual cost of $3.5 billion (Mudarri and Fisk 2007). Moisture in homes supports the growth of mites and mold and the infestation of roaches, rats, and mice—all of which produce allergens that aggravate asthma and other preexisting chronic respiratory conditions, although it is not clear at what levels these contaminants cause allergic sensitization (Bornehag et al. 2004; Institute of Medicine 2004; Krieger and Higgins 2002; Mudarri and Fisk 2007).

How Water Quality Affects Health

In the United States, an estimated 4 million to 33 million cases of gastrointestinal illness associated with public drinking water systems occur annually (Colford et al. 2006; Messner et al. 2006). The presence of contaminants in water can lead to other adverse health effects; for example, pesticides can cause reproductive problems (Casarett and Doull 1991), polychlorinated biphenyls and lead can cause neurological disorders (Chevrier et al. 2007), and nitrates can cause methemoglobinemia or “blue baby syndrome” (Greer et al. 2005). Water contamination has many sources, including naturally occurring chemicals and minerals (e.g., arsenic, radon, uranium), local land-use practices (e.g., fertilizers, nitrates, pesticides, concentrated animal feeding operations), manufacturing processes, sewer overflow, and malfunctioning wastewater treatment systems (e.g., septic systems).

A particular area of concern with respect to water quality is the approximately 40–45 million persons in the United States who rely on private household wells for drinking water. Such systems are more commonly found in rural and suburban communities. Drinking water from public water systems is regulated by EPA, but private wells and small public water systems are unregulated, and testing for contaminants typically is left to homeowners. These wells can be contaminated with biological agents such as Cryptosporidium, E. coli O157:H7, and norovirus, all of which cause gastrointestinal illness. These wells can also be contaminated by chemicals, including pesticides and arsenic (U.S. Environmental Protection Agency undated c). Contamination of a private well is not only the concern of the household served by the well; it is also of concern to households using other nearby water supplies, including those that draw water from an aquifer. The safety of private wells can be improved by attention to issues including proper design, structure, installation, testing, and maintenance (Anderson et al. 2003; Centers for Disease Control and Prevention 1995).

How Residential Chemicals Affect Health

Chemicals in and around the home can contribute to poisonings and other health effects. Every 13 seconds, a poison control center in the United States fields a call about a potential poison exposure; more than 90% of these exposures occur in the home (Watson et al. 2004). Non-pharmaceutical products account for most poison exposures among children (McDonald et al. 2006). Most common among adult exposures are pain relievers, prescription medications, sedatives, cleaning products, and antidepressants (McDonald and Gielen 2006).

The long-term health effects of pesticide exposure are unknown (Lu et al. 2001), but some studies suggest links between chronic exposure to pesticides and attention and behavioral problems and other neuropsychologic deficits as well as increased risk for asthma among children exposed during the first year of life (Chanda and Pope 1996; Rice and Barone 2000; Salam et al. 2004). In an estimated 74% of U.S. households, pesticides are used to prevent or exterminate insects and rodents (U.S. Environmental Protection Agency 2004). No national estimates of home pesticide exposure prevalence are available (U.S. Environmental Protection Agency 2007). However, in Washington State, 48% of reported pesticide-related health complaints were the result of pesticide use in and around the home or on food (Washington State Department of Health 1998).

In general, household cleaning products are safe when used as directed. Still, even when used as intended, detergents, bleaches, and a variety of other household cleaning products represent chemical exposure and may contribute to poor indoor air quality. For many household chemicals, a “safe” frequency and quantity of use in homes has not been established.

Infants and young children are most susceptible to the adverse health effects from use of household chemicals because they may be more likely to be exposed—they spend more time indoors, they have more hand to mouth behaviors—and their smaller and still developing bodies may be more susceptible (U.S. Environmental Protection Agency 1998). Under the age of thirteen, more males are victims of poison exposures, but among teenagers and adults, more females are involved (McDonald and Gielen 2006).

How Housing Structure and Design Affect Health

A home provides shelter, privacy, and safety and protects our physical and mental health. A residence that fails to offer these essentials through adequately designed and properly maintained interiors and exteriors is not healthy housing. How homes are designed, constructed, and maintained; their physical characteristics; and the presence or absence of safety devices have many effects on injury, illness, and mental health. Home conditions also influence the ability of people to participate fully in their community.

Injuries

In residential settings approximately 18,000 injury deaths occurred each year from 1992–1999 (Runyan et al. 2005a). Unpublished National Vital Statistics System data show that nearly twice as many residential unintentional injury deaths were reported in 2005. It is estimated that 12 million nonfatal residential injuries occur each year (Runyan et al. 2005b). Among children and adolescents younger than 20 years of age, an estimated 55% of unintentional deaths from injuries occur at home (Nagaraja et al. 2005). Children younger than 15 years and adults over age 70 years are at high risk for injuries in the home. Among children ages 0–14 years, the leading causes of home injury deaths are fire/burns, choking/suffocation, drowning/submersion, firearms, and poisonings.

Falls

Falls alone account for 53.7% of all unintentional home injury deaths (Runyan et al. 2005a), 36%–45% of all nonfatal home injuries (Runyan et al. 2005b), and almost 4 million emergency department visits annually (Runyan et al. 2005b). More than one-third of all adults 65 years of age and older fall each year—with women 67% more likely to have a nonfatal fall than men (Centers for Disease Control and Prevention 2006; Rubenstein et al. 2007). As a result of falls, many elders experience devastating consequences such as broken bones and head injuries (Rubenstein et al. 2007). An estimated 1.5 million fall injuries among children under age 15 years occur in the home and require medical attention each year (Runyan et al. 2005b). Fall rates among children under age 5 years are second only to those observed in the elderly population (Casteel and Runyan 2004). Important fall-related hazards for children in the home include baby walkers, stairways, windows above ground level, and furniture (McDonald and Gielen 2006). Beds have been identified as the leading product in the percentage of nonfatal home injury costs for children under age 5 years, followed by stairs, floors, and tables (Zaloshnja et al. 2005). Outside play equipment, including play sets and trampolines, can also be dangerous for children. Most injuries occur when a child falls from the equipment onto the ground (MacKay 2003).

Fire and Burns

Housing design and construction materials can directly influence occupants’ level of injury risk from fires (Krieger and Higgins 2002). In 2006, house fires were responsible for approximately 2,580 deaths (Karter 2007) and injuries to another 12,925 persons (not including firefighters) (Karter 2007). Most fire victims do not die from burns, but from smoke or toxic gases (Hall 2001). A primary risk factor for death and injury in residential fires is absent or nonworking smoke alarms (Ahrens 2004; Istre et al. 2001). Studies show that even though 90% of homes have smoke alarms, only about three-quarters of the alarms are functioning (Ahrens 2007; Smith 1993). When a fire occurs in a home with a functioning smoke alarm, the risk for death is decreased by 40%–50% (Ahrens 2004). Children, persons with disabilities, and those who live in poverty and in rural areas are the groups most likely to live in homes without working smoke alarms (Ballesteros and Kresnow 2007) and, as a result, to die in house fires or suffer serious fire-related injuries (Istre et al. 2001; Warda et al. 1999). Older residents are at especially high risk for dying in a smoking-related house fire (U.S. Fire Administration 2006). Additional groups at high risk for dying in a house fire include African Americans and people who live in substandard homes where emergency egress is often compromised (Hannon and Shai 2003).

Scalds and thermal and electrical burns also contribute to home injuries. In 2007 an estimated 38,647 children less than 5 years old were seen in U.S. emergency departments for a burn that occurred at home (U.S. Consumer Product Safety Commission undated a). Exposure for 2 seconds to water at a temperature of 150°F can result in a full thickness burn (Moritz and Henriques 1947). Environmental modifications can, however, ameliorate many of these scald burn injuries.

Drowning

Swimming pools account for 60%–90% of drownings among children 0–4 years old, and each year about 300 children under 5 years old drown in swimming pools, usually a pool owned by their family (U.S. Consumer Product Safety Commission undated b). More than half of drownings among those ages 5–24 years are in the victim’s home pool, and 22% are at the homes of friends, neighbors, and relatives (Saluja et al. 2006). Among infants, the majority (78%) of drownings occur in the home, with 71% of these in bathtubs and 16% in buckets (Brenner et al. 2001).

Suffocation and Strangulation

Children sustain approximately 18,000 suffocation injuries each year (Centers for Disease Control and Prevention 2007b). More than half (60%) of infant suffocation occurs in the sleeping environment (McDonald et al. 2006). Cribs and playpens are responsible for half of all nursery product-related deaths among children ages 5 and under (McDonald 2002). Strangulation deaths from window cords happen most often when children are in places their parents think are safe, such as in a crib or in a child’s bedroom. From 1991 to 2000, the U.S. Consumer Product Safety Commission received reports of 160 strangulations involving cords on window blinds (U.S. Consumer Product Safety Commission undated c). Fatal window-cord strangulations have a mortality rate of 0.14 per 100,000 persons per year in the United States (Rauchschwalbe and Mann 1997).

Firearms-related Injuries and Deaths

Between 1990 and 2000, an estimated 11,509 unintentional firearm deaths occurred (Miller et al. 2005). Nearly 600 unintentional firearm-related deaths occur annually in homes (Runyan 2005a). Studies indicate that for each 1% increase in the number of homes in a community where firearms are safely stored, the unintentional firearm death rate decreased by 4%.

Elevated Lead Levels

Between 1999 and 2004, an estimated 240,000 children 1–5 years of age had blood lead levels ≥ 10 micrograms per deciliter (μg/dL), and most of these elevated levels were a result of lead paint hazards in and around their homes ( Jones et al. 2009). Lead exposure can result in lasting impairment of a child’s development and behavior such as decreased IQ and attention span and increased risk for delinquent behavior (Centers for Disease Control and Prevention 2005d). Although in the United States lead has been banned from paint intended for residential purposes since 1978, older houses with lead paint remain. These homes can expose children to lead when maintenance is deferred and the paint deteriorates, or when the property is renovated or painted without using lead-safe work practices to control dust and soil contamination. In the United States in 2000, an estimated 1.2 million housing units with lead-based paint hazards were home to children younger than 6 years of age ( Jacobs et al. 2002). Other sources of lead exposure in the home include lead water pipes and solder used in plumbing, as well as toys and ceramics (Levin et al. 2008). Children of minority race/ethnicity and children whose families are poor are much more likely to be exposed to lead in their homes.

Outdoor stairs to a house featuring a banister with badly peeling paint

Outdoor stairs to a house featuring a banister with badly peeling paint.

Mental Health

Poor housing conditions, including crowding and inadequate lighting, are associated with risk for poor mental health. Poor-quality, overcrowded, multifamily homes are associated with outcomes that include aggression and withdrawal, lower general health status (Dunn et al. 2004; Evans et al. 1996; Lepore et al. 1992; Regeoczi 2003), and psychological distress, particularly among women and children (Evans et al. 2001). Lack of light (e.g., from inadequate number and placement of windows) is related to depression (Golden et al. 2005; Kripke 1998). Although some studies have suggested an association of dampness or mold with depression (Shenassa et al. 2007), the Institute of Medicine concluded that evidence is insufficient to determine whether an association exists between either damp indoor environment or presence of mold and neuropsychiatric symptoms (Institute of Medicine 2004).

Structural Deficiencies

In 2005, about 2 million people in the United States lived in severely inadequate homes (U.S. Department of Housing and Urban Development 2007). The U.S. Census Bureau defines severely inadequate housing as homes without heat, hot water, or electricity, or housing with significant upkeep problems and structural defects (U.S. Census Bureau 2006). Although wear typically increases as homes age, these problems are not limited to older homes. Some modern building practices, inferior building construction, and poor building design also can exacerbate conditions that threaten health. For example, water incursions in structures that lack adequate ventilation and drainage increase the risk for mold growth, which is associated with increased risk for asthma and perhaps other health problems (Institute of Medicine 2000, 2004; U.S. Department of Health and Human Services 2005a). Poor design and maintenance of both old and new homes can result in injuries, poisoning, and poor mental and physical health.

Accessibility

For the elderly and for persons with disabilities, home design and construction can hamper—sometimes substantially—ease of mobility and interfere with access to important features of the house like toilets, sinks and bathtubs, and shelving in cupboards and closets. Approximately 5.5 million disabled persons in the United States face barriers to community participation because of building design or because of the absence of sidewalks (Hendershot 2004). Additionally, inappropriate design and construction can increase the possibility of injury from falls among older adults and can deny some the opportunity to remain at home and more comfortably “age in place” rather than move to an assisted-living facility or nursing home.

How Behaviors Contribute to Adverse Health Related to Homes

Individual resident behavior is an important aspect of healthy and safe home environments. Yet a large gap exists between what we know about how to make homes healthier, and what we actually do. For example, research indicates that although parents say they support injury-prevention behaviors, their home lives do not reflect adequate injury-prevention practices (Gielen et al. 1995). In a survey of parents, 59% reported they did not use stair gates; only 37% had their water heater temperature set at 125°F or less, and 27% did not have smoke alarms (Gielen et al. 1995).

Disparities in Access to Safe and Healthy Homes

Many of the disparities in health status among subpopulations may be linked to poor access to safe and healthy homes, which is most prevalent among lower income populations, populations with disabilities, and minority populations. In 2005, 6% of all U.S. residents and 14% of low-income renters lived in homes with severe or moderate physical problems, such as water leaks that can cause mold growth and trigger allergic reactions and asthma attacks (U.S. Census Bureau 2006). Low-income minority renters in nonmetropolitan areas have a higher incidence of housing quality problems compared to other renters or homeowners ( Joint Center for Housing Studies of Harvard University 2008). Minority parents also are substantially less likely than are white parents to have safety measures in their homes such as stair gates, safety latches on cabinets, or lower hot-water thermostat settings (Flores et al. 2005).

Housing-related illness and injury are not, however, the exclusive domain of lower-income groups. Higher income populations also experience housing-related health problems. In some communities, more than 40% of the middle-class suburban population lives in homes with elevated levels of cockroach allergens (Matsui et al. 2003). High-density housing may be associated with negative psychological consequences for the affluent, as well as for poorer populations (Evans et al. 2000).

Venn diagram describing rent burden and inadequate homes showing the intersection between unassisted very-low-income renters and (a) renters with severely inadequate housing, (b) renters with severe rent burden, and (c) the worst case needs, the majority of whom are unassisted very-low-income renters

Venn diagram describing rent burden and inadequate homes showing the intersection between unassisted very-low-income renters and (a) renters with severely inadequate housing, (b) renters with severe rent burden, and (c) the worst case needs, the majority of whom are unassisted very-low-income renters.

Relationships among Community Characteristics, Health, and Homes

Broader community characteristics have important effects on homes and their residents. Homes also have effects on the broader environment.

Weather and Natural Disasters

Regionally specific health concerns tied to housing include extreme weather (e.g., heat waves and winter storms) and natural disasters, including tornados, hurricanes, earthquakes, volcanic eruptions, floods, and wildfires. Forest fires and volcanoes harm air quality. Hurricanes and floods can contaminate water supplies and damage wastewater facilities. Any of these disasters can spread contaminated materials into the home environment. Additionally, some areas of the United States are prone to floods, tornadoes, or wildfires—such extreme weather events commonly cause serious injuries and fatalities. Residents unable to keep warm during cold weather or to keep cool during very hot weather are exposed to conditions that can lead to serious illness and even death. Since 1995, hundreds of deaths during heat waves have been documented, with mortality most prevalent among the elderly, the socially isolated, and those living in homes without air conditioning (Naughton et al. 2002). Improper siting and design of homes can contribute to the adverse health consequences related to extreme weather and natural disasters.

Noise

At very high levels, the most obvious effect of exposure to excessive noise is hearing loss. There is concern that hearing loss may not just be the result of occupational exposure but may result from exposure to noise in the living environment (Passchier-Vermeer and Passchier 2000). Noise levels that commonly occur in homes may also result in sleep disturbances, cardiovascular and psychophysiological problems, performance reduction, increased annoyance responses, and adverse social behavior (Centers for Disease Control and Prevention and U.S. Department of Housing and Urban Development 2006). Exposure to noise disproportionately affects low-income children and is likely caused by poor urban planning that places homes adjacent to airports, railroad yards, highways, and other sources of noise. Living in crowded neighborhoods and in substandard or poorly designed homes have also been implicated as contributing to noise in homes (Evans and Marcynyszyn 2004).

Green Homes

Green homes are designed to use less energy and fewer natural resources than standard homes and to create less waste; they also may be healthier for residents. A green home incorporates smart design, technology, construction, and maintenance elements to improve the health of those who live inside and to reduce negative impacts on the environment.

Compared with a standard home, a green home should protect the environment through reduced use of energy, water, natural resources, and reduced production of waste. For example, buildings represent 39% of primary energy use in the United States and consume 70% of electricity generated (National Center for Healthy Housing 2008; U.S. Department of Energy 2006). Efficient plumbing and bathing fixtures, drought-tolerant landscaping, and water-conserving irrigation systems help green homes use, on average, 50% less water than used by standard homes. Construction of a green home generates 50% to 90% less construction waste that usually ends up in landfills. Green homes may also be healthier for residents if, for example, they produce less indoor air pollutants, however the extent to which green technologies promote health of residents is still an area that requires much more research.

Housing Instability and Homelessness

People with low-household incomes, the elderly, people with disabilities, and minority populations are least likely to have access to safe, healthy, affordable, and accessible homes. Each year in the United States, an estimated 2.1 million adults and 1.3 million children are homeless (Burt et al. 2001). For those who are homeless, the lack of a place to live is a daily, distressing fact of life. For approximately 2 million families at the bottom of the socioeconomic ladder, housing is so severely deficient that it is barely adequate ( Joint Center for Housing Studies of Harvard University 2004). For nearly 18 million Americans, more than 50% of family income is consumed by housing costs. Consequently, these families cannot meet expenses for other basic needs such as medical care, childcare, heating and gasoline, and food ( Joint Center for Housing Studies of Harvard University 2008), and with fuel costs rising, their ability to meet these expenses may be further compromised.

People with low incomes may not be able to secure adequate, affordable homes and may be forced to move often. This housing instability also contributes to adverse health outcomes, including increased asthma morbidity, tuberculosis, and developmental delay, as well as school failure and delinquency (Buckner 2008). Those who are both homeless and chronically ill are confronted by a unique set of problems as they try to maintain medical regimes related to asthma, diabetes, or AIDS (Leaver et al. 2007; Matte and Jacobs 2000). Without an adequate supply of affordable homes, healthy homes cannot be achieved.