Growing up in Kingston, Jamaica, Peter Williams took for granted the holes in the wood floors of his house — and the rats that crawled through them. But when his father contracted a bacterial infection that left him paralyzed, Williams, a budding architect, began to recognize the connection between shoddy housing and ill health.
"The disease was directly attributed to the fact that the house was poorly constructed," says Williams, 35. "I saw firsthand how housing was both responsible for his illness and also incapable of meeting his care needs, given that he was quite immobile."
If the link between housing and health seems obvious (think cholera spread in refugee camps, or lead poisoning in homes containing lead paint), it's one that Williams says is woefully neglected. To a large extent, public health programs focus on disease outcomes, and urban planners talk of units built, but their missions rarely intersect. Big health donors such as governments and foundations prioritize vaccines, drugs and medical services; architects are drawn to large infrastructure projects like hospitals and health centers. Those narrow focuses, Williams believes, minimize the overcrowding, dirty water and disease-carrying insects that cause so much illness in both developing and industrialized countries.
Williams is pushing for home design to be a key strategy in curbing disease through his nonprofit, Architecture for Health in Vulnerable Environments (also called the ARCHIVE Institute). The group is building five prototype homes intended to reduce tuberculosis transmission in Saint-Marc, Haiti, the destination of many refugees from the January 2010 earthquake. Later this year, ARCHIVE will build houses in Cameroon's North Province engineered to reduce their inhabitants' exposure to malaria-carrying mosquitoes. The goal is twofold: to demonstrate an association between design features and good health, and to prove that healthy homes are affordable on a mass scale.
"Without addressing root causes of poor health, such as unsuitable living conditions and lack of suitable sanitation, economic and human resources will continue to be spent by prioritizing treatments for people who get ill rather than on prevention," Williams says. "This approach is inherently unsustainable."
Williams' mission is inextricably tied to growing up in the prefab sprawl of Kingston's working-class Duhaney Park neighborhood — and to the disconnect he later felt as a lead designer working on "dream projects" for giant architecture firms in New York and Singapore. Although his father's illness was a singular event in his personal life, Williams became aware of the connection between housing and well-being only gradually.
The Williams family's home was a single-story, stand-alone unit, one of about 1,000 he says were built in the late 1960s to house teachers and nurses. By Williams' childhood, that area of Kingston had fallen into disrepair: Squatter settlements had sprung up around the periphery, and residences harbored mold and broken windowpanes. The units were often dark and overcrowded.
Unlike homes built in communities that have money, where construction has start and end dates, shelter in poor areas is often built incrementally, one wall at a time. During walks with his father, 8-year-old Peter was taken by endless scenes of men mixing concrete on the side of the road. "I want to do that, Dad," Williams told his father on one of those walks. But Williams' dad had grander ambitions. "What you really want to be," he said, "is an architect."
"You didn't have to go far to see very, very poor housing conditions," Williams says. "One thing that reinforced my belief and conviction on this issue was that I knew we weren't the poorest in the country; people were surviving on much less. Public health — something not very visible — is very often sidelined."
Williams worked his way through an undergraduate degree at City College in New York before going on to graduate school at Columbia and Oxford. During his time as a job captain at the firm Gensler, he was granted a sabbatical to study the relationship between housing and HIV in South Africa, courtesy of an award from Columbia. The experience lingered when he went to RDC Architects in Singapore, where he was lead designer on the development of a residential community of 80,000 people in the Al Khor region of Qatar, on the master plan for the expansion of King Fahd University in Saudi Arabia, and on upscale residences in Mumbai.
Since its founding five years ago, ARCHIVE has conducted workshops to teach residents of overcrowded housing stock in London techniques to reduce the spread of germs inside the home, such as trying to lower humidity through ventilation and limiting the number of people living in a unit. This year, using the winning designs from a contest it sponsored, the nonprofit will test whether building homes that emphasize light, ventilation, sanitation and uncrowded conditions can be constructed in the developing world at prices comparable to shelter without those features. The nonprofit also will evaluate whether the designs are doing what they're supposed to (for example, fostering air flow) and monitor the health of the homes' inhabitants.
The organization's operating budget is a slim $200,000, raised through government, commercial and anonymous donations; its 20 staffers in New York and London, including Williams, are volunteers.
"We're trying to connect the dots for designers," Williams says. "The future of health care, particularly among the poorest, is not institutional care. We're working one community at a time by addressing immediate, micro-level conditions and how we can use targeted improvement on the house as a key strategy for improving health."
Worldwide, nearly 830 million people live in slums, a population expected to rise to 2 billion by 2030, according to U.N. Habitat, a part of the United Nations dedicated to studying settlement patterns. The U.N.'s Millennium Development Goals include improving the lives of 100 million slum-dwellers by 2020.
The characteristics of slums — lack of clean water and toilet/sanitation facilities, shoddy construction and severe overcrowding — are linked to a slew of infectious diseases, according to the World Health Organization. Cholera is spread through contaminated water and food. Overcrowding quickens cholera's transmission, as it does for flu and whooping cough. Malaria, dengue and yellow fever are transmitted by mosquitoes that reproduce in standing water and infiltrate homes unprotected by screens. Respiratory diseases, including TB, can be made worse by mold and poor ventilation, according to the nonprofit Partners in Health.
Despite the clear connection between slums and disease, in international aid circles, housing and health are usually treated as separate endeavors, Williams says. The Obama administration requested nearly $9.4 billion in foreign assistance for health last year, but specific infectious diseases commanded most of the pot. Water and sanitation, which are essential to healthy housing but not surrogates for shelter itself, occupied $239.5 million of the administration's foreign assistance health request. There is no distinct funding stream for shelter from the State Department or the U.S. Agency for International Development — by, it seems, design.
"Housing doesn't fall under the health portfolio by any means," says Ryan Cherlin, a USAID spokesman. "While there are undoubtedly correlations between poor housing and ill health, our health programs focus on specific diseases and health services. Allocating global health funds for housing purposes would violate current legislation."
With the exception of a homeless program in the Pacific Northwest, shelter isn't included in the Bill and Melinda Gates Foundation's programming either, despite the philanthropy's huge investment in vaccines, reproductive and global health. Nor is it part of programming at the Wellcome Trust, another large funder of studies into the origins and treatment of diseases in developing countries.
The disconnect is curious, says Paul Pholeros, director of the Australian nonprofit Healthabitat, which has been touting the link between housing and disease for 26 years. Historically, he says, housing codes tend to be based on health outcomes. Hospitalizations for infections plummeted by 40 percent over a decade among Aboriginal households that were upgraded to Healthabitat's healthy housing principles, according to a report published last year by the New South Wales Health Department, which noted that "the results exceeded expectations with regard to health benefits."
Research published last year in Social Science & Medicine estimated that waterborne illness fell from 32 to 14 percent between 2001 and 2008 after a slum in Ahmedabad, India, was upgraded. Replacing dirt with concrete floors in Mexico resulted in a 78 percent decrease in parasitic infections and a 49 percent reduction in diarrheal diseases among those homes' inhabitants, according to a 2007 report by the World Bank. And in the U.S., homeless people with AIDS who received housing assistance were less likely to be hospitalized or use the emergency room over 18 months than patients who didn't get that help, a 2009 study in the Journal of the American Medical Association reported.
Others argue that it may cost less to boost health by spending money on vaccines and health care than on housing, partly because the health-promoting qualities of specific design elements are still being quantified. "This is a complex subject with no simple answers," says Roger England, chairman of Health Systems Workshop, a nonprofit that reviews health care finance and delivery, in an e-mail. "Housing can have health-improving qualities, but we do not know how much 'better housing' results in 'better health.' To even begin to look at this we need to take housing apart — what are its components and which of them make the most difference?"
At University College London's Healthy Infra-structure Research Center, where Williams is a visiting scholar in civil, environmental and geomatic engineering, scientists are indeed taking housing apart through research. With more than $1.5 million in grant funding, UCL recently launched the center on the premise that infectious disease is connected to architecture. A structure can house pathogens (for example, the bacteria legionella multiplying in ventilation systems), and conversely, it can be designed to kill or otherwise get rid of them (via disinfection systems). Infrastructure can help disease spread; the transmission of SARS in Hong Kong was partly blamed on the failure of drainage systems in buildings there, says the center's director, Ka-Man Lai. Finally, design can control infection indirectly by, say, placing a tap in a location most likely to make people pause to wash their hands.
The center's scientists are now studying these and other connections between design and disease in commercial, outdoor and residential structures, including the prototype homes ARCHIVE will build in Haiti. The homes will collectively house 20 people with HIV/AIDS, who are vulnerable to infections such as tuberculosis. Each house will have a concrete foundation and will be designed to maximize ventilation and access to sanitation and clean water.
While designs for the Cameroon homes will be selected through another contest, certain architectural features are known or thought to affect mosquitoes' ability to get inside homes and breed, Williams says, including: elevating homes (certain mosquitoes fly close to the ground), using insect-repellent paint, screening windows and installing ceilings to prevent mosquitoes from flying through porous roofs and into living spaces.
In addition to tracking the ventilation patterns inside the Haiti prototype houses, ARCHIVE will measure indoor particles, such as those from smoke that can compromise breathing. It will track tuberculosis and other bacteria and the fluctuation in relative humidity, a factor in TB transmission. The group also will monitor carbon dioxide levels, a marker for overcrowding. A Haitian organization will monitor the residents' health.
Simultaneously, Williams hopes to show that the homes can be built for prices comparable to typical Haitian construction. Though construction prices in Haiti are fluctuating in the wake of the earthquake, Williams says, he expects the houses to cost around $30,000 each. (Costs would fall should the designs be replicated, he says.) In Cameroon, he expects the prototype homes to cost about $5,000 apiece.
Not everyone is convinced that the prototypes ARCHIVE is building will be specifically health-promoting or make a big impact on their own. "A lot of it is dependent on the overall planning of the area as well as what the neighborhood looks like," says Sandhya Janardhan, program coordinator for the volunteer group Architecture for Humanity. "More often than not, the issue is not just spaces but the education of the population, that they aren't aware of how disease gets transmitted, that they don't engage in hygienic practices when it comes to cooking, cleaning up surroundings or just living a healthy lifestyle."
Williams has a different view. "One falls into this trap of making sharp distinctions between these things. We believe it's all of those things combined to provide sustainable improvement," he says. "The current challenge of individuals living in poor housing conditions exists — that is a fact. It's not as though education can somehow address that — people need to live somewhere." Late last year, Habitat for Humanity published a report highlighting the need to incorporate health priorities in the construction of new housing. Hard-surface floors and roofs, screened windows and adequate space, it said, "should become routine."
In 2009, then-acting U.S. Surgeon General Steven Galson issued a "call to action" for more research into the health outcomes from specific housing designs, noting that many of the leading causes of preventable deaths and disease, such as falls, fires, burns, drowning, asthma and lead poisoning, occur in the home. The Department of Housing and Urban Development issued a complementary report, asserting that a more holistic approach to construction that addressed causes of ill health — mold, pests, poor structural safety and lead paint, for example — would be the most cost-effective way to address health risks such as asthma, allergies, poisoning and accidents. "A comprehensive, coordinated approach to healthy homes," Galson wrote, "will result in the greatest public health impact."
For his part, Williams is content to be methodical in showing that such an approach can make practical sense. "Success," he says, "is literally one household at a time."