By Dr. Scott Morrow
“When I first started my job managing the San Mateo County Health System’s Asthma Management Program, I knew I would be dealing with mold and other common triggers that cause children’s asthma attacks,” says San Mateo County Public Health Nurse Vera Williams, “but none of us realized how big a component housing would be in the health of our clients.” Williams says that about half of her asthma clients live in unsafe conditions that exacerbate their symptoms. And they are not alone. Faced with the Peninsula’s increasingly high rents, many people in San Mateo County have been forced to accept substandard housing, crowd into units with two or three families, move to other counties, or become homeless—all of which expose them to a host of negative health impacts.
The San Mateo County Health System helps county residents and workers live longer and better lives. We do this by providing excellent healthcare services; but also work to reduce people’s need for these services by creating healthy places with safe housing, sidewalks, good transit, nutritious food, open space, and a vibrant economy. When we succeed in creating healthy places, however, housing costs tend to increase—sometimes pushing out the very people whose health we are trying to improve. Housing stability is therefore a fundamental element of the Health System’s commitment to healthy places. This article explores this issue and its effects on health, highlights the need for action, and suggests a framework for moving forward.
Housing and Health Crisis on the Peninsula
San Mateo County undoubtedly faces a housing crisis. Rents have shot up 70 percent in the last five years.1 Each week brings news of another building evicting tenants. This is due in part to the booming economy, which has produced 57,000 new jobs in 10 years.2 While much of the growth is in tech and other high-wage sectors, many low-wage jobs have also been added.3, 4
Housing production has not kept up with the soaring job market. Cities across the county have some of the worst records in the Bay Area for building homes for very low-income families. Over the last eight years, cities have given permits for just over half the homes needed across affordability levels. While 93 percent of the need for above-moderate-income housing has been permitted, only one-fifth of the housing needed for very low-income households has been permitted.5 Today, there is only one affordable housing unit for every four low-wage jobs.6
Faced with this dramatic shortage, workers are forced to stretch their housing budgets to the breaking point. Almost 50 percent of San Mateo County renters spend more than they can afford (30 percent or more of their income) on housing. This cuts across race and class, and impacts low-income people and people of color hardest: 80 percent of very-low income renters and almost 60 percent of Black and Latino renters spend more than they can afford on housing.7 When residents pay too much for housing, they have less money to spend on healthcare, healthy food, and health-related activities.8, 9, 10
People who experience housing instability are at risk for significant mental health impacts. When displacement seems imminent, residents can experience anxiety and depression.11 They may also double or triple up families in crowded conditions or accept unhealthy and/or unsafe housing conditions, causing greater susceptibility to diseases such as asthma and coronary artery disease.12, 13
When residents are displaced they face poor health effects from social isolation, disconnection, and loss of political voice.14, 15, 16 Children who have been displaced have worse developmental outcomes, such as lower academic achievement and a greater lifetime risk of depression.17,18 Some San Mateo County families who lose their housing end up homeless, which dramatically impacts their health.19
Additionally, the housing crisis feeds traffic congestion, which affects nearly everyone who lives or works in the county. Every morning, over 100,000 workers wait in traffic to cross the county’s bridges and highways.20 More than 60 percent of workers commute in—the second highest rate of in-commuting in the Bay Area21—leading to more inactive commuting time, more air pollution and congestion, and increased chances of traffic collisions, injuries, and fatalities.22
Some commuters are former residents who can no longer afford to live here, and many more are workers who cannot consider moving closer to their jobs because housing costs are so high. Virtually no research follows households after they’ve been displaced, so we don’t yet know where residents go when they are forced to leave San Mateo County. We do know that they leave behind a county rich in health supportive amenities such as high-quality schools, local parks, and good jobs. Research shows that growing up in high-opportunity areas improves a child’s chances of success later in life.23 For adults, moving away from San Mateo County can mean leaving a jobs-rich environment or commuting many miles back every day for work.
Taking Action: Start with the Five Ps of Housing Stability
Health begins where people live, learn, work, and play. Get Healthy San Mateo County is a local collaborative of community-based organizations, county agencies, cities, schools, and hospitals working together to advance policy change to prevent diseases and ensure everyone has equitable opportunities to live a long and healthy life. The collaborative is facilitated by the San Mateo County Health System.
The health consequences of housing instability and displacement are widespread, serious, and difficult to resolve. But displacement is not inevitable. Get Healthy San Mateo County proposes five principles that can help achieve housing stability:
- Protection of existing residents to ensure that they can remain in their homes and do not experience the health impacts of housing instability.
- Preservation of existing housing at all affordability levels whenever possible despite changing economic conditions, or replacing lost units at the same affordability levels for current residents.
- Production of new housing units at diverse affordability levels in line with housing needs through regulations and incentives for developers, as well as through a commitment to using public resources for housing.
- Participation of residents and community leaders in decision-making processes that impact their housing stability.
- Placement of new housing near amenities, jobs, transit, and healthy food and away from sources of pollution.
These principles are a starting point for cities and communities in San Mateo County to limit housing instability and ensure health and housing for all. See www.GetHealthySMC.org/healthyhousing, sign up for our e-newsletter, and follow #HealthyHousingSMC to get involved.
Scott Morrow is a board certified physician in Public Health and General Preventive Medicine, and a Fellow of the American College of Preventive Medicine, with almost 30 years of experience in medicine and public health. He has served as Health Officer for San Mateo County for the past 23 years with a passion for the prevention of substance abuse and childhood obesity, changing the built environment to provide health equity, and promoting a local and sustainable food system.
1. San Mateo County Department of Housing, San Mateo County Housing Indicators (June 2010-June 2015). Available at: https://housing.smcgov.org/housing-statistics, and https://housing.smcgov.org/housing-statistics-archive.
2. LED Extraction Tool-Quarterly Workforce Indicators. Job Change (Stable): Net Change. Available at: http://ledextract.ces.census.gov/.
3. United States Census. Longitudinal Employer-Household Dynamics. On the Map. Available at: http://onthemap.ces.census.gov/.
4. Benner, C. Center for Regional Change, UC Davis. Jobs-Housing Fit Analysis dataset. Available at: http://interact.regionalchange.ucdavis.edu/roi/data.html.
5. ABAG, Bay Area Progress in Meeting 2007-2014 Regional Housing Need Allocation (RHNA) as of 3/27/15. http://abag.ca.gov/files/RHNAProgress2007_2014_032715.pdf
6. Benner, C. Center for Regional Change, UC Davis. Jobs-Housing Fit Analysis dataset. Available at: http://interact.regionalchange.ucdavis.edu/roi/data.html.
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9 Kushel M, Gupta R, Gee L, Haas J. Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med. 2006; 21: 71–77.
10. Joint Center for Housing Studies of Harvard University. The State of the Nation’s Housing. 2013. Available at: http://www.jchs.harvard.edu/sites/jchs.harvard.edu/files/son2013.pdf.
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20. United States Census. Transportation Planning Package. 2010 Data.
21. United States Census. Transportation Planning Package. 2010 Data.
22. Department of Public Health, City and County of San Francisco. Traffic density. 2014. Available at: http://www. sfindicatorproject.org/indicators/view/46.
23. Harvard University, Equality of Opportunity Project. Available at: http://www.equality-of-opportunity.org/.