As a fourth grade social studies student, I was taught the difference between a “need” and a “want,” a simple economic concept. Years later, when my children were in elementary school and taught the same concept in their social studies class, we had many rousing conversations around the dinner table debating the difference. Put simply, a need is defined as something people have to have to survive. A want, on the other hand, is something people would like to have but they don’t need it to survive.
We all know that the most essential needs are food, water, and shelter. In civil society, basic human needs also include equitable access to education, health care, jobs, transportation, and a safe and clean environment in which to live. Without food and water we know we can’t survive. Without the rest of these things, though we may survive, we probably won’t thrive. Although my fourth grade social studies teacher might not agree, we now know they are basic needs, and we call them the social determinants of health.
When I was in my twenties, as a Peace Corps volunteer living in rural Honduras, I experienced first-hand how profoundly social and environmental influences impact the health of a population. On a number of occasions, I had the opportunity to serve as translator for US doctors who came and volunteered their time as part of a medical brigade to bring health care to rural areas of the country without it. On the mornings when the US doctors held their clinics, people from miles and miles away would arrive before dawn, hundreds and hundreds seeking a cure for what ailed them and a chance to see the American doctors.
The doctors would work feverishly all day examining patients, doling out advice and aspirin and then send them back on their way. In some cases the doctors were able to diagnose an acutely ill patient — a child with a cleft palette or a person with cataracts — and refer that patient for treatment in the big city. Most of the time, though, the patient was just run down and sick from hard physical labor, lack of nutritious food, and exposure to environmental hazards like cooking fires and unclean water. The antidote boiled down to some pretty basic things like access to clean water, healthy food, and a safe place to live but most of the people who came flooding out of the mountains to see the US doctors believed that medical care was the answer to everything. In 2017 in the United States of America most of us believe this too!
So let’s go back to the “needs” versus “wants” and the social determinants of health. In Public Health we know the impact of good housing and public infrastructure, access to healthy food and good jobs on the health of a population. For example, investments in housing and sanitation during the 19th century helped defeat the communicable disease epidemics of the time. Today, too, there is ample evidence supporting the direct relationship between housing interventions and health outcomes within low-income or otherwise vulnerable populations.
A recent review of seven distinct housing interventions shows that providing housing support for low-income, high-need individuals results in net savings due to reduced health care costs. There is further evidence that the integration of housing with some health care services can further improve health. One of these interventions, the 10th Decile Project in Los Angeles saw a 72% reduction in total health care costs based on two years of observation, from $58,962 per person when homeless to $16,474 per person when housed. Which health effects are related to housing? Many. Studies conducted by Children’s Health Watch found that frequent moving or low-quality housing can increase a child’s risk for obesity, type 2 diabetes, asthma, stunted brain development, and mental health problems such as depression and post-traumatic stress syndrome.
Access to stable and safe housing is certainly a basic human need and one of the social determinants of health. Good medical care is essential but not the primary cause of good health. Good health is nurtured through a healthy environment including a stable place to call home. It is time to re-evaluate our investments in heath and get back to the basics.