What does a "renter's utopia" in Vienna have to do with optimal treatment of asthma?
Francesca Mari's recent New York Times Magazine article about public housing in the capital city of Austria features images of beautiful, well-maintained apartment buildings with rooftop swimming pools, lots of green foliage and attractive playgrounds. 80 percent of the city's residents qualify for public housing, a staggeringly high percentage that might imply to an American that the vast majority of people living there are poor. Actually, Vienna makes its plentiful supply of municipal housing (which they call "social housing") available to a large portion of the middle class, and tenants cannot be turned out no matter how much their incomes increase after signing the initial rental contract.
To American eyes, the whole Viennese setup can appear fancifully socialistic. But set that aside, and what’s mind-boggling is how social housing gives the economic lives of Viennese an entirely different shape. ... Imagine having to think about [housing expenses] to the same degree that you think about your restaurant choices or streaming-service subscriptions. Imagine, too, where the rest of your income might go, if you spent much less of it on housing. Vienna invites us to envision a world in which homeownership isn’t the only way to secure a certain future — and what our lives might look like as a result.In contrast, wrote Mari, one of several "fatal" compromises to the real estate industry in the Housing Act of 1937, restricted eligibility for public housing in the U.S. to "those so poor that they could never secure decent housing in the private market." These units were deliberately underfunded and poorly constructed. As millions of past and current residents of American urban housing projects could testify, "America's public housing was designed to fail: to be unappealing to anyone who could afford to rent."
Which brings me to patients with asthma who live in American public housing projects or neighborhoods in similar states of disrepair. In West Philadelphia, the Children's Hospital of Philadelphia (CHOP) partnered with community organizations to implement Community Asthma Prevention Program Plus, a program that performed home inspections of CHOP patients with asthma and completed repairs to 97 homes that were deemed likely to benefit these patients, including carpet removal, roof and plumbing repairs, improving ventilation, and eradicating mold.
That's great, but what if the home is located next to an interstate highway, factory, or power plant emitting pollutants that can't be easily remediated by a contractor? Or if these patients' asthma exacerbations are triggered by the stress of living in a violent neighborhood? The logical next step is to move to a different home. The case settlement for a 1995 lawsuit against the U.S. Department of Housing and Urban Development for discriminatory public housing practices created the Baltimore Regional Housing Partnership (BRHP), which as of October 2020 had provided housing vouchers to more than 5,200 households to move to privately-owned housing in low-poverty neighborhoods. A research team followed 123 children with persistent asthma whose families moved with BRHP's assistance from 2016 to 2020. Compared to a control group, these children experienced fewer exacerbations, fewer days with symptoms, and lower measures of stress.
Hospitals and health systems are now investing in affordable housing to improve health in many areas of the country, reasoning that being homeless or housing insecure presents a huge obstacle to attaining control of asthma, diabetes, and other chronic diseases. Health care payers are also taking notice. In an ambitious experiment, California's Medicaid program is spending $12 billion over the next 5 years on "a new kind of safety net that provides housing and other services for [145,000] people who are homeless or at risk of becoming homeless and have complicating conditions like mental illness or chronic disease." Whether the experiment will achieve its aim of moderating the program's soaring health care costs remains to be seen, but even if it doesn't, giving people access to decent housing is a worthy end in itself. Kudos to Philadelphia, Baltimore, and California for thinking outside of the health care box, but I'd rather be in Vienna: a city where grinding poverty and housing vouchers aren't necessary for persons of modest means to afford a clean and safe apartment for as long as they want to live there.