COVID-19 Exposes the Cracks in our Housing System

                                                                                                              By Kelby Brown and Julian Xie 

Every Sunday morning, Mike Harris*drinks his coffee from the same seat in the right corner of church. You can count on him to ask how you’re doing and tell you to “stay blessed.” His wife, Melanie, bounces around the refreshment table in the back room, organizing donated food from a local bakery that she picked up the night before. Their children sit among friends until the youth are dismissed. While social distancing has kept most of the family out of the pews, Mr. Harris, a church board member and custodian, still shows up to keep the old yet intimate building in order.

The Harrises never advertise that housing in Durham is unaffordable for them.Their ever-changing neighbors share their struggle of trying, and at times failing, to resist the known consequences of housing insecurity: chronic stress, mental illness, poor educational attainment, childhood behavioral problems, physical disease, shorter life expectancy—the list goes on. While no one would want to live in these toxic conditions, the adage holds true that the choices one makes are determined by the choices one has.

As such, the Harrises have been residents of the Durham Housing Authority (DHA), Durham’s public housing agency, for over 12 years. After their son was rushed to the hospital for carbon monoxide poisoning a decade ago, they relocated to a different public housing facility. In March 2020, they were forced to relocate again for their own safety. Now their choices are to move into yet another facility, one they know to be even less safe than their prior home, or to cram into a one-bedroom apartment with their son and daughter-in-law. They have chosen the latter while they continue their search for better options–a search now far more challenging thanks to COVID-19.

Durham faced a housing crisis long before the pandemic reached our city’s borders. On January 3rd, 2020, DHA began relocating 270 families from McDougald Terrace, Durham’s largest public housing venue, after several carbon monoxide poisonings prompted inspections that revealed dangerous levels of carbon monoxide radiating from outdated appliances. Residents were displaced for four months, staying in hotels or with family, while DHA worked to address the maintenance issues.

But while the agency fixed the gas leaks with pipe wrenches and sealant, DHA’s executive director, Anthony Scott, knows he will need far more to repair decades’ worth of damage caused by a failing support system. In an interview with a local newspaper one month into the McDougald Terrace crisis, Scott highlighted the $57billion in underfunding to housing authorities nationally by the US Department of Housing and Urban Development (HUD). “So, yes, there is responsibility at a national level and then is definitely responsibility here...” Mr. Scott said. “So, we're trying to take care of business here.”

Co-chair of the Partnership for a Healthy Durham’s (PHD) Health and Housing Committee, Caressa Harding, compares the national attention McDougald Terrace has received to the amount of publications that the Tuskegee Syphilis Study produced. Both were simply the most publicized examples of their respective failing systems, affordable housing and biomedical research.

The root causes of Durham’s housing crisis are multifaceted and interrelated. Durham’s increasingly expensive housing market, caused in part by other systemic problems like gentrification and housing segregation, has resulted in 40% of Durham residents being cost burdened (i.e.,paying more than 30% of their monthly wages towards rent). To pay less than 30% of monthly income for the average two bedroom apartment in Durham, a family must earn over $20 per hour for a full-time job –nearly 3 times the state’s minimum wage. The resultant financial fragility manifested as the worst eviction rate among NC’s most populous counties in 2018 (1 in 278 residents) and a 25% increase in homelessness compared to NC’s 11% decrease from 2011-2015. And with over one million unemployment claims in the state since March 16th due to COVID-19, housing has only become more of a burden.

When one experiences homelessness, the first safety nets are emergency shelters, such as Urban Ministries of Durham. Such organizations provide valuable services, but are struggling to meet the growing levels of need in the area, especially while adhering to social distancing protocols. People who need longer-term assistance apply for public housing through DHA, but often find the conditions to be hardly livable due to the systemic problems described earlier.

Residents have the option to apply for one of DHA’s 3000 housing choice vouchers(formally known as Section 8), which allow them to select their own housing and pay rent at 30% of their monthly incomes. The waitlist for vouchers is capped at 1500 and less than 50 applicants receive vouchers each month; wait times occasionally approach a decade. Even if the Harris family gets the voucher they have been patiently waiting for, they would then begin the often harder process of finding a landlord who will accept it in a housing system that incentivizes discrimination. Many Americans, just like the Harris family, fall through these cracks of our housing system.

Housing insecurity drives poor health through four primary pathways: 1) instability, whether it be chronic homelessness or frequent moves; 2) poor quality housing, with exposures to lead, mold, pest infestations, carbon monoxide, and crowding hazards; 3) lack of affordability, causing financial strain on households; and 4) environmental toxicity, stemming from proximity to busy roads, noise pollution, unkept buildings, overgrown lots, and lack of access to fresh foods and safe spaces. And the health consequences of these effects, even if experienced only in utero, are drastic. For families like the Harrises, in which the father suffers from diabetes, cardiovascular disease, and lung disease, the mother from chronic pain, and everyone else from asthma, their housing struggle only exacerbates these issues.

Housing insecurity intersects with food insecurity and chronic disease (see Xie et al. reflection),mental illness (see Neptune and Nguyen reflection), health inequities, and poverty (see Holtzman, Nikpour, and Brown reflection), and the current pandemic only complicates them. Along with making access to healthcare (see Durbha, Holtzman, and Matula reflection) more difficult, COVID-19 has disproportionately affected already disadvantaged populations like those trapped in tenuous housing circumstances.

Mr. Harris has lost three family members to the virus. While wedged eight people deep into a tiny apartment, the Harrises are alternating nights on the lone mattress while trying to follow social distancing measures. “I can’t really put it into words,” Mr. Harris said when asked about the impact of COVID-19 on the family. “It’s been very stressful on all of us.” The Harrises have first-hand knowledge of the sinking house that is Durham’s crisis. But for those of us who had only seen the cracks in the wall, COVID-19 has forced a closer inspection and, indeed, the foundation is flooding.

As health professionals, most diseases we diagnose are actually just the symptoms of larger societal ills. We treat the fallout from Durham’s housing crisis in our emergency rooms and on our operating tables with band-aid solutions. But to truly stop the bleeding, we need to address the root problem:the flooded foundation. When Durham residents identified affordable housing as the top health priority in 2017, PHD established the Health and Housing committee to coordinate the efforts of dedicated community members and organizations. Now is the time for health professionals to join this work of building a future where housing is a human right, and where families like the Harrises can expect to feel safe and secure at home.

*The names of some individuals have been changed to protect their identities.

This reflection was authored by some of the 2019-2020 Duke University Margolis Scholars as part of a five-part series reflecting on the disparate impacts of the COVID-19 pandemic on the health of the Durham community. Each of the five reflection pieces centers around one of the five top health priorities in Durham, identified by the community in the 2017 Durham County Community Health Assessment. For more information, visit https://healthydurham.org/.

Acknowledgements

The authors want to thank Duke MD/MBA student Willis Wong and MD student Tamar Chukrun for their time and input, as well as Marissa Mortiboy, Caressa Harding, and Dr. Donna Biederman from Partnership for a Healthy Durham for contributing their expertise.