On the surface, the creation of a new Office for Health Improvement and Disparities (OHID) sounds more than welcome. Like much that sounds welcome from this government, though, it’s likely just another gimmick – a rebranded replacement for the axed Public Health England, this time without any agency given to local authorities. Without proper provision, OHID will provide convenient cover against the need to address the very serious problem of health inequality (note that in OHID, the word ‘inequality’ has been replaced with the less politically contentious ‘disparities’), which shows health to be dependent on social determinants: the economic, political, environmental, and commercial conditions, among others, that govern our lives.
Over the last decade, there has been a widening in the understanding of the social determinants of health. But the government’s latest shortcomings on funding social care, on the housing crisis, and on welfare, to name just three recent failures, sound alarm bells over any real, lasting commitment to reducing health ‘disparity’. The enactment of a ‘health in all policies’ agenda requires a real ideological and economic commitment to put health first – not to leave it as an afterthought. It would, for example, require the health secretary to reconsider the decision to decrease public health grant allocations this year, amid the pandemic.
My hometown of Bilston, in the heart of the Black Country, is a typical working-class area facing decay following deindustrialisation. In 1945, however, Bilston was also the amphitheatre for a radical social experiment. The Viennese philosopher Otto Neurath was deployed by the radical socialist council to pursue one specific goal: ‘to make Bilston happy’. The premise was simple: happiness, therefore health, is generated at home.
Today, the situation facing Bilston and the rest of the country is frighteningly similar to that of 1945. Parallels between World War II and the Covid-19 pandemic have been echoed continuously in the rhetoric used by our politicians; more acutely, we find ourselves in a state of economic disruption and facing the subsequent ‘building back better’. One particular parallel is the housing crisis.
The modern housing crisis is fuelled in various parts by the mass selling-off of social housing, demand-side policies with the lowest level of peacetime housebuilding since the 1920s, and an out of control property market with unrestrained, unaffordable rents. In 2002, the median house price was £104,000, while the median annual income was £20,596: a steady 1:5 ratio. By 2020, just eighteen years later, the median house price had soared to £234,000, while the median annual income was just £31,580: a ratio of 1:8. Consequently, 43 percent of people aged 25-39 are living in a viciously and increasingly exploitative private rental sector, in a state of a kind of neoliberal nomadism.
Just as it was recognised in Bilston of 1945, the housing crisis today continues to be a public health menace. The home takes a multidimensional role in our lives: a venue for contact with the most prominent members of one’s social network, a major financial investment for both renters and owners, and the place in which the vast majority of our day-to-day activities—eating, sleeping, washing, and now for many, working—occur.
For too many young people, the state of their housing denies them good health and wellbeing. According to a study conducted by Shelter in 2017, one in five English adults report housing issues to be negatively affecting their mental health. Research has linked respiratory issues, physical pain, and headaches to poor-quality housing, and with one in three houses in the private rental sector failing to meet the criteria for adequate housing under the Government’s ‘Decent Homes Standard’, the issue is extensive.
This was already a problem before the Covid-19 pandemic, but the virus has exacerbated the inadequacies of housing in Britain. 7.6 million households in England have major housing problems relating to overcrowding, affordability, or poor quality, which leave them without the ability to safely self-isolate. This burden is not shared equally: BAME families, for example, are seven times more likely to live in overcrowded and multigenerational households. Such inequalities have left these communities more vulnerable to Covid-19, and will leave them more vulnerable to future pandemics.
Since health is made at home, good quality housing, on the other hand, improves various health parameters. A recent longitudinal study showed that households in homes of good quality saw a reduction in hospital admissions for cardiovascular, respiratory, and injury emergency problems. The annual costs incurred for the NHS directly by poor housing are £1.4 billion, and the figure is likely higher when accounting for indirect effects. Poor quality housing has also been shown to reduce school attendance and knock back educational achievement, while in contrast, good-quality homes can improve education and facilitate learning, further narrowing inequalities in the future. Acknowledging these connections is the key to approaching the question of health on a society-wide scale.
The last year has seen our understanding of ‘health’ redefined. No longer is health a solitary phenomenon existing in isolation through individual choices and self-governance; after Covid, health is a communitarian science, with the actions of others resulting in direct effects on our own health status. Of this new reconstruction of health, housing must be at the centre. During this process of rebuilding, it’s perhaps worth noting the lessons of Otto Neurath’s Bilston project: ‘We are like sailors who must rebuild their ship on the open sea.’ The housing crisis isn’t something we can put on pause while we tinker around the edges: to save lives, we need to act for decent homes now.