health housing who

7/27/2019 Health Housing WHO

1/54

Healthprinciples ofhousing

WORLD HEALTH ORGANIZATIONGeneva 1989


2/54

tsBN 92 4 1561270@ World HealthOrganization 989Publications f the World HealthOrganization njoy copyrightprotection n accordancewith the provisionsof Protocol2 of the UniversalCopyrightConvention.For rights ofreproduction r translationof wHo publications,n part or in toto, application hould bemade to the Officeof Publications.World HealthOrganization,Geneva,Switzerland. heWorld HealthOrganizationwelcomessuch applications.

The designations mployedand the presentation f the material n this publication o notimply he expression f any opinionwhatsoever n the part of the Secretariat f the WorldHealthorganization oncerninghe legal statusof any country, erri tory,city or area or ofi ts authorit ies, r concerning he delimitation f i ts frontiersor boundaries.The mentionof specificcompaniesor of certain manufacturers' roductsdoes not implythat hey are endorsedor recomrnendedy the WorldHealthOrganizationn preferenceoothers of a similar nature that are not mentioned.Errors and omissionsexcepted, henamesof proprietaryproductsare distinguished y init ial capital etters.

TYPESET IN INDIAPRINTED IN ENGLAND

88/7757-Macm illan/Clays-5000


3/54

GontentsPreface vIntroduction viiThe principles viiBackground viiiConditions and constraints ixPART I. Principles related to health needs 1

1. Protection against communicablediseases21.1 Safe and adequate water supply 21.2 Sanitary disposal of excreta 41.3 Disposal of solid wastes 51.4 Drainage of surface waters 61.5 Personal and domestic hygiene 61.6 Safe food preparation 71.7 Structural safeguards against disease transmission 8

2. Protection against injuries, poisonings and chronicdiseases92.1 Structural features and furnishing I2.2 Indoot air pollution 112.3 Chemical safety 122.4 T};.e home as a workplace 123. Reducing psychological and social stresses o aminimum 144. Improving the housing environment 165. Making informed use of housing 186. Protecting populations at special risk 20

PART II. Principles related to health action 237. Health advocacy 247.1 Role of the health authorities 247.2 Role of related groups 257.3 Communicating health messages25


4/54

HEALTH PRINCIPLES OF HOUSING

8. Economic and social policies 279. Intersectoral action for development, planning and

management 299.1 Development planning and management309.2 Urban and land-use planning 319.3 Housing legislation, standards and enforcement 329.4 Design and construction of housing 339.5 Provision of community services 349.6 Monitoring and surveillance 3410. Education on healthy housing 3611. Community cooperation and self-help 38

References 40Annex 1. WHO Consultation on Housing-the Implicationsfor Health 42


5/54

Preface

Over and above their basic purpose of providing shelter againstthe elements and a focus for family life, human dwellingsshould afford protection against the hazards to health arisingfrom the physical and social environments.At its best, appropriate housing promotes physical and mentalhealth. It provides people with psychological security, physicalties with their community and culture, and a means ofexpressing their individuality.Unfortunately, the dwellings in which most of the world'speople live do not enable them to enjoy these benefits to thefull. Indeed, for great and increasing numbers, the availablehousing not only fails to protect them against health risks, butincreases their exposure to environmental hazards, many ofthem preventable. Particularly at risk are those who arecaught up in rapid urban change, accompanied by limitedresources and inappropriate public policies.oThe underlying forces that condemn people to marginal orsubmarginal housing are poverty, inadequate socioeconomicdevelopment, population growth, migration and failure toensure equitable access to land and housing. These forces areinsurmountable for many people, particularly in developingcountries, where housing conditions in many areas aredeclining.This publication outlines the health needs to be met in humandwellings and the steps that governments, communities andfamilies might take to meet them, with particular attention todeveloping countries. The World Health Organization hasstrengthened its support to Member States in this connection,

"See: Urbanization and its irnplications for child. health: potential for action Geneva,World Health Organization, 1988.


6/54

HEALTH PRINCIPLESOF HOUSING

taking into account the trend towards accelerating urbaniz-ation and the worsening housing situation in many developingcountries. In particular, as part of WHO's contribution to theInternational Year of Shelter for the Homeless.o Consultationon Housing-the Implications for Health, was held in June1"987.0he experts and representatives of international bodiesparticipating in the Consultation reviewed, revised and ap-proved the principles set forth in this publication. They alsoproposed six lines of action for imrnediate attention bygovernments and the international agencies and nongovern-mental organizations concerned."The principles published here represent a distillation of thepolicies pertinent to housing developed over many years bynational health authorities; health information from epidemi-ological and other researchstudies, and technical reviews; thedeliberations of WHO Expert Committees and technicalmeetings; and studies of other international bodies concerned.The principles represent the work of many individuals andgroups. However, special acknowledgementmust be given toProfessor Morris Schaefer, formerly with the School of PublicHealth, University of North Carolina, NC, USA, for his diligentefforts in preparing a working draft of the principles andhelping to edit them during the Consultation. Dr A. E. Martin,formerly Principal Medical Officer (Environmental Health)Department of Health and Social Security, London, England, isalso deserving of thanks for his research efforts and contribu-tions to the working draft. The participants in the WHOConsultation, responsible for the revision and approval of theprinciples, are listed in Annex 1.

oShelter and heolth. Unpublished WHO document, WHO/EHE/RUD/87.1, 1987.bHousing-the implications for heatth. Report of a WHO Consuttation.' UnpublishedWHO doeument, WHO/EHE lRUDl87.2, 1987.cHousing and health: an agenda for action. Unpublished WHO document.


7/54

lntroduction

This publication has been prepared for the use of leaders, officialsand scientists involved in health, housing and socioeconomicdevelopment. Part I gives guidance on basic issues and conceptsconnected with the health aspects of housing and summarizesthe information available on the underlying relationshipsbetween health and housing conditions. Part II describes publichealth approaches to meeting housing-related health needs.In the individual countries, the principles and approaches inquestion can serve as a check-list of the health problems to betackled by health authorities and others involved in socialdevelopment. To meet specific national problems, the informa-tion should be used selectively and adapted as a basis for alogical sequence of activities aimed at improving the situation.

The principlesFor the purposesof this publication, "principles" may be definedas rules for guiding thought and action, based on experimen-tal, clinical or epidemiological findings.As such, they have beendeliberately left general. The evidenceon which they are basedvaries in quality (/). Many of them require situation-specificadaptations, to bring them in line with circumstances(climate,culture), preferences(choices of locations and housing materials),and the availability of resources to provide and improvehousing.The general nature of these principles distinguishes them fromhousing standards (2) and codes, which are usually drawn up bygovernmentson the basis of selectedprinciples, to provide normsthat are applicable to particular communities at specific times.Standards and codes are thus the adaptation of principles toconcrete situations. Further, becauseof the local and continuingnature of much activity connected with housing, the scope and


8/54


applicability of housing standards will always be more limitedthan that of the principles discussed in the following pages.

BackgroundAlong with food and clothing, shelter has long been regarded asa basic need for human life. At a minimum. shelter has toprovide protection against the stressesof the physical environ-ment, as well as satisfying people's psychological requirementsfor a "place" or territory of their own and a focus for theprimary social group, the family.The ways in which human beings meet this basic need aremyriad; a vast range of materials is used in buildings (wood,brick, earth, concrete, stone, foliage, animal skins, ice) andthere is a great diversity of patterns in which structures arespaced,clustered or even moved about. Ownership and tenure ofhousing and land also vary widely, and legal provisions areoften at the root of the exclusion of low-income groups fromadequatehousing. The provision of housing is closely related tooccupation and economic activity, which are themselvesdepen-dent on geographical, technological and climatic factors.Transport is also an important determinant of where and howpeople live, as are political conditions: the levels of stability,security, prosperity and peace. The quality and distribution ofits housing clearly reflects a country's economic status, socialvalues and political character.Housing is intimately related to health. The structure, location,facilities, environment and uses of human shelter have a strongimpact on the state of physical, mental and social well-being.Poor housing conditions and uses may provide weak defencesagainst death, disease,and injury or even increase vulnerabilityto them. Adequate and appropriate housing conditions, on theother hand, not only protect people against health hazards butalso help to promote robust physical health, economic produc-tivity, psychological well-being and social vigour.This document discusses in some detail the relationshipsbetween housing and health. However, the possibilities ofapplying that knowledge to improve health and the humancondition are limited in many countries by a number ofconditions and constraints that must be recognized, understoodand dealt with.


9/54

INTRODUCTION

Gonditions nd constraintsThe prospect for "healthy housing for all" is most fundamen-tally affectedby the fact that most existing human dwellings areinadequate to foster optimum health or even to protect peopleagainst avoidable health hazards. The distribution of deficien-cies varies sharply between countries and between economicgroups within countries. Improving the housing situationlargely depends on progressive socioeconomic development,which in many countries is hindered by:. inadequate measures to reduce pouerty, which limits thematerial and social means for improvement;. t}ne growth of populations at rates that outrun the pace ofeconomic development, and the inequitable distribution of thebenefits of development;. restrictions on acbess o land for housing and farming, whichaffects prospects for economic self-sufficiency, as well as foradequatehousing;. rapid urbanizatioz, usually the result of economic changes,

which produces problems that local governments are il lequippedto meet;. inappropriate policies that may, inter alia, perpetuate unreal-istic and obsolete standards that limit access o housing for thepoor;. limited pou)ersof interuentionby local governments, n view ofthe fact that most dwellings are built by those who live in them(3);. inadequate popular knowledge about the health aspects ofhousing and its uses, all the more important becausehousingdecisions and actions are so highly decentralized;. inadequateattention to social deuelopmenf, s it interacts witheconomic development or stagnation; and. unstable political and military conditions that restrict thepossibilities of adequate housing.Despite their negative or limiting effects, these constraintssuggest some criteria on which to base the design of effectivepolicies and programmes o improve the situation. For examplenrecognizing the extent to which the provision of housingdependson individual action suggests hat improvement efforts


10/54


should harness the aspirations and energies of householders andlocal groups; where the forces of poverty and populationpressure are strong, moderate and incremental strategies will bemore effective than radical approaches.


11/54

PARTPrinciples elated ohealthneedsThe relationships etween housing condit ionsandhuman ealth reset orth nsixmajorprinciples,omeofwhich nclude number f subdivisions.hesubjectsof the majorprinciples re:

1. Protection gainst ommunicableiseases.2. Protectiongainstnjuries, oisoningsndchronicdiseases.3. Reducing sychologicalnd socialstresses o amin imum.4. lmprovinghe housing nvironment.5. Making nformed se of housing.6. Protecting opulationst special isk.


12/54

HEALTH PRII{CIPLESOF HOUSING

PRINCIPLEProtection gainstcommunicable iseasesAdequatehousingprovidesprotectionagainstexposure oagentsand vectorsof communicable iseases, hrough. S?fwatersupply,. sanitaryexcretadisposal,. disposalof solid wastes,. drainageof surfacewater,. personaland domestichygiene,. s?fe ood preparation,and. structuralsafeguardsagainstdisease ransmission.In most developing countries, in which the bulk of the world'spopulation lives, communicable diseases continue to cause anexcessive number of illnesses and deaths. Infants and youngchildren are the main victims of these conditions. Immunizationprovides an important countermeasure, but it is limited tocertain diseasesand may be further constrained by inadequatefinancial and technieal resources and by problems of distribu-tion. The domestic environment is therefore a crucial battle-ground for reducing exposure to disease pathogens; where thebattle is not well fought, the dwelling becomesa killing groundof the youngest and weakest.Because so many aspects of the home and the neighbourhoodmay be implicated in the transmission of communicable diseases,Principle No. t has seven subdivisions.Princ ip leNo.1.1Safe and adequatewater supplyAn adequatesupplyof safeand potablewater assists n preven-ting the spread of gastrointestinal diseases, supports domestic


13/54

PART I: PRINCIPLES ELATED O HEALTHNEEDS

and personal hygiene and provides an improved standard ofliving.Because water is essential to life itself, people must be protectedagainst biologically contaminated water, which may carry suchharmful microorganisms as shigellae, salmonellae, enteropatho-genic Escherichia coli, probably certain enteroviruses, and variousprotozoal and helminthic parasites. Water-borne diarrhoealdiseases affect young children particularly and, in somedeveloping countries, may account for as many as a third of alldeaths of children under five years of age. The severity of thesediseases increases markedly when exposure is combined with theeffects of malnutrition. Water in a reasonable quantity is requiredfor adequate personal and domestic hygiene (4), and if providedin a convenient way will serve to promote such uses, as well asincreasing family productivity and the safety of food prepara-tion.Large numbers of people are without access to safe andadequate water supplies. An estimate by WHO at the end of 1985indicated that 23o/oof urban and 64oh of rural dwellers lack suchaccess, and it is estimated that 1200 million people will still bewithout it in 1990 (5).While a protected water supply piped into the dwelling is thebest means of providing adequate quantities of safe water, thiswill be impossible to achieve in the near future for most ruraldwellers and many urban dwellers in developing countries.Having to carry water from a distance almost always means thatthere will be inadequate quantities in the home and an addedrisk of contamination.Water may be supplied from a variety of sources: springs,streams, ponds and lakes, surface wells or deep boreholes.Sources should be protected against contamination; protectionmay involve both structural barriers and the reduction ofcontamination from insanitary human and animal behaviour.Even so, the degree of contamination will vary, and treatment-commonly by filtration or chlorination-will often be needed toensure that the water is safe. To ascertain what needs to bedone requires the regular examination of water samples todetect contamination by microorganisms. In both town andcountry, operation and maintenance work is required to ensurethe continuing safety and availability of water.


14/54

HEALTHPRINCIPLES F HOUSING

Hygienic user behaviour, based on correct information, isessential to protect water from contamination during itstransport to, and storage in, the home. The use of clean, closablecontainers to carry and store water and clean vessels to drink itfrom could improve the protection of perhaps a thousand millionpeople in the world against water-borne diseases.

Princ ip leNo.1.2Sanitary disposal of excretaSanitarydisposal of excreta reduces the faecal-oral transmis-sion of disease and the breeding ol insect vectors.A prime source of the biological contamination of water, foodand soil is human faeces. Contamination may occur near houses,as when people defecate on the ground or in areas whgre food isgrown, or when latrines are improperly located in relation towells, set in soil lacking satisfactory drainage, or inadequatelymaintained. Overflow from latrines results in insanitary muddyconditions that expose people directly to helminthic andprotozoal parasites and other pathogenic organisms, as well asencouraging flies. Exposure may also be less direct, as whenuntreated excreta are introduced into water sources and theninto the food chain, transmitting pathogenic organisms to peopleat some distance from the original site of contamination (6).These hazards are worse in conditions of overcrowding, whetherin slums, periurban settlements or temporary camps, wherefacilities for excreta disposal are absent, insufficient or badlymaintained.The global picture remains threatening. In 1985, WHO estimatedthat 40oh of urban and, 84o/o of rural dwellers were withoutadequate sanitary facilities and that the anticipated improve-ment by 1990 would still leave 1800 million people in thatcategory. The situation in regard to sanitation is therefore evenworse than in regard to water supply (5).The main problem is not a technical one. Technologicalalternatives of various degrees of sophistication are availablefor the sanitary disposal of excreta, some relying on house-holders and others on community services or facilities. There isincreasing interest in processes that can convert human wastesinto useful agricultural soil conditioners and energy products;


15/54

PART I: PR]NCIPLES ELATED O HEALTHNEEDS

however, careful hygiene and supervision are required to makesure that the processesdestroy pathogenic organisms (7-9).

Princ ip le o.1.3Disposalof solid wastesAdequateand safe disposal ol solid domestic wastes reduceshealth risks andhelps o providea morepleasant iving environ-ment; appropriate methodsof storageand disposaldiscourageinsect and rodent vectorsof diseaseand protect peopleagainstpoisonous substancesand objects likely to cause accidentalinjury.Predominantly a phenomenon of urban settlements, large andsmall, inadequate storage, collection and disposal of solid wastescan generate a number of health hazards, including the spreadof gastrointestinal and parasitic diseases, especially whenhuman excrement is mixed with other organic wastes. Primaryprevention calls for reducing the insect and rodent vectors ofdisease, for which organic and other refuse provides a foodsupply, nesting places and breeding sites. Carelessly discardedappliances, vehicles, bedding and toxic substances increase therisk of fatal accidents, poisonings, suffocation, cuts and otherinjuries, with accompanying infections, especially for unwarychildren.Alt these hazards increase with urbanization and economicdevelopment, as consumption becomes more varied and wastesinclude an increasing proportion of packaging materials, paper,cardboard, tins, bottles, and discarded appliances, machinery,and building materials. Where cities are growing faster than thehbility of local authorities to provide services, which is the casein many urban communities in developing countrieso theincreases in health hazards from solid wastes are out of al lproportion to the increases iir population.Efficient ways of dealing with solid wastes are well known (/0)and well established in industrialized countries. Developingcountries, however, face severe difficulties in organizing,financing and providing services, which often have a lowpriority in public budgets. Moreover, poor people who dependfor a living on scavenging discarded materials constitute agroup at special risk of injury and infection and may requireadvice on how to limit the dangers.


16/54


Princ ip leNo.1.4Drainageof surface watersElficientdrainage ol surlace waters helps to control communi-cable diseases, safety hazards, and damage to homes andpropefi.Inadequate drainage of surface waters - including domesticwastewater-results in pools or muddy and marshy areas thatprovide breeding places for mosquitos, flies and other insectvectors of disease. Standing waters near wells, latrines andkitchens are of special concern, as they are important loci ofbiological contamination. Vector breeding sites, as well asunpleasant conditions, may result when inadequately main-tained drainage systems become clogged and out of order.Periodic flooding of wells,.roadways, homes and other properties(including food stores) likewise creates hazards to public healthand safety.

Princ ip leNo.1.5Personaland domestichygieneAdequatehousing includes acilitiesfdr personaland domestichygiene, and people should be educated n hygienicpractices.If a safe water supply and sanitary disposal of excreta are to befully effective in controlling communicable diseases, they mustbe accompanied by good habits of hygiene. Bodily cleanliness,particularly washing the hands after defecation, is a necessaryfactor in breaking the chain of various infections and reducingthe incidence of skin complaints (irritations, sepsis, dermatitis,eczema), and eye diseases (trachoma, conjunctivitis). Personalhygiene will obviously be easier to promote once there areadequate supplies of water on tap in houses, with properdisposal of wastewater.Cleanliness and tidiness of dwellings, their furnishings and theirsunoundings will help to red.uce direct exposure to micro-organisms and to control "insect and rodent pests and diseasevectors. Water standing in open containers or puddles providesbreeding places for the mosquito vectors of several parasiticdiseases, and inadequately cleaned and maintained housingprovides nesting and breeding sites for pests. Badly stored food


17/54

PART I: PRINCIPLES RELATED TO HEALTH NEEDS

and careless disposal of food wastes likewise encourageflouri'shing populations, of pests. :Rural families engaged in animal husbandry are exposed tospecial hazards. The faeces and urine of animals kept insidedwellings may harbour pathogens and increase the difficulty ofmaintaining cleanliness, thus increasing exposure to insect andanimal disease vectors. Stabling must be at a distance fromdwellings and pets must be kept pest-free in order to reduce thetransmission of disease, especially to children.Personal and domestic hygiene depends on hygienic behaviouras much as on hygienic facilities. While only few have thebenefit of the best of facilities, education in the best hygienicuse of the facilities that do exist can contribute to protectionagainst disease-one example of how health can be promoteddespite the finaneial constraints on improving structures andamenities.

Princ ip le o .1 .6Safe food preparationHealthydwellingsprovidefacilities or the sate preparationandstorage of food, so that householders an employsanitary ood-handlingpractices.Eating habits in the home are of dual importance for communityhealth. On the one hand, a personos nutritional status is closelyrelated to his or her resistance to disease-indeed, nutritionmay be the most powerful determinant of health status (I/);facilities for food preparation affect nutritional practices andstatus (4). On the other hand, contaminated food is a mediumthrough which a number of bacterial, viral, protozoan andhelminthic diseases may be transmitted. Although some sourcesof contamination lie outside the home (natural toxins, chemicalresidues, food adulteration, unsanitary storage and marketing),significant domestic hazards can be attributed to the use of non-potable water in growing food, freshening it up and cooking it,to unhealthy ways of drying, storing, handling and preparing it ,to inadequate cooking and to poor personal and domestichygiene, including inadequate cleaning of vessels and utensils(12).To be able to select, prepare, store and handle food properlyrequires both facilities (especially safe water, cooking equip-


18/54

HEALTHPRINCIPLESFHOUSING

ment, and suitable storage space) and informed culinary andhygienic practices (notably hand-washing after defecation).

Princ ip leNo.1.7Structuralsafeguardsagainstdisease ransmissionAdequate housing provides structural safeguardsagainst thetransmissionof disease, ncludingenoughspaceto avoid over-crowding.The design,structural characteristics,maintenanceand roomi-ness of a dwelling affect the degreeto which those who live in itare protected against communicable diseases. Dirt floors notonly make domestic hygieng difficult, but may harbour hel-minths. Certain structural features may favour the breeding andnesting of diseasevectors, particularly if they are allowed to fallinto a state of disrepair, and window and door openings mayneed to be screened o reduce exposureto insect-bornediseases.Overcrowding, particularly in conjunction with poverty andinadequate facilities, has been shown to increase the transmis-sion rates of such communicable diseases as tuberculosis,pneumonia, bronchitis and gastrointestinal infections. Personssleeping in close proximity in poorly ventilated rooms are moreexposed o the spread of airborne infections, including meningo-coccal meningitis, rheumatic fever, infiuenza, the common cold,measles,rubella and pertussis.


19/54

PARI l: PRINCIPLES RELATED TO HEALTH NEEDS

PRINCIPLE O.2Protection gainst niuries'poisoningsand chronicdiseasesAdequate housing provides protection against injuries,poisonings and thermal and other exposures that maycontribute o chronic disease and malignancies;specialattentionshouldbe paidto. structural eaturesand urnishings,. indoorair pollulion,. chemicalsafety,and. the useof the home as a workplace.As well as sheltering people against the elements and providinga suitable thermal environment, dwellings should afford pro-tection against accidents and against hazardoussubstances hatconstitute immediate or long-term hazards to health. As in thecase of other principles, meeting these requirements dependsboth on structural features and on human behaviourtimes culturally determined-in the use of housing (13,14).

Princ ip le o.2.1Structural eaturesand furnishingTheproper siting, structureand furnishingof dwellingsprotectshealth,promotessafetyand reduceshazards.The type of housing available dependson climatic and economicconditions, as well as cultural preferences.While adapting tosuch constraints, building design, materials and constructiontechniques should produce durable structures that provide asafe, dry comfortable abode that shelters residents againstvermin, extremes of temperature and recurring hazards ofnature (earthquakes,hurricanes, winds). The siting of dwellingsshould reduce to a minimum exposure to noise, industrialpollution and hazards from dumps of chemical and food-


20/54


processing wastes, as well as direct and indirect dangers fromflooding and landslides.Climatic extremes may cause increases in morbidity andmortality. Their effects can be diminished by sound structures,insulation, efficient heating in cold weather, and adequateventilation and air-conditioning in hot. The incidence ofcommunicable diseases and gastrointestinal infections is gen-erally greater in hot, humid weather. Hypothermia, particularlyamong the very young and very old, is a threat in cold weather,especially when temperatures are lower than the prevailingtypes of building can cope with. For the poor, good housing mayneed to be supplemented with education in self-protection andwith community assistance in the form of fuel and temporaryshelter (15,16).High-rise buildings, designed to economize on land use, maypresent special hazards, some of which increase directly withbuilding height. Particularly if housing standards are weak andtheir enforcement is lax, structural weaknesses may be a directthreat to life and limb. Upper-storey residents in high-riseblocks may be at extreme risk in case of fire or explosion; thebreakdown of the lifts as a result of mechanical failure or powercuts may impose additional stresses, especially on the aged andinfirm. Wind turbulence and excessive stormwater run-off mayadd to the problems. Psychosocial problems in high-rise blocksmay arise from excessive noise and limited privacy in poorlysound-proofed apartments, from lack of access to safe play andrecreation areas, and from limited egress. For children, thechoice may be between isolation in the apartment or play in thestreet out of contact with the parents, while the elderly andphysically disabled may be condemned to isolation.In most apartment blocks, safety may be improved by buildingstairways so as to reduce the dangers of falls, by settingwindows high enough to prevent people falling out, and bydesigning and siting heating devices (particularly those withopen flames or heating elements) in such a way as to lessen therisk of fire and the escape of noxious gases, such as carbonmonoxide. In buildings and in consumer products, extremecaution should be exercised to prevent exposure of individualsto known toxic materials, such as lead paints, asbestos, creosoteand certain plastics, polymers, and synthetics liable to give offtoxic fumes. Work areas-notably kitchens-should be de-signed and equipped for safety as well as for efficiency. Lighting,both natural and artificial, should be adequate for people to


21/54

PABT I: PBINCIPLES ELATED O HEALTHNEEDS

function properly, to enjoy the home setting and to avoidaccidents. It should not be so bright or so dim as to damage theeyesight.Furnishings should likewise be chosen with a view to safety.The use for upholstery, curtaining and carpets of syntheticmaterials that can easily catch fire and/or emit toxic fumesshould be avoided. Children particularly should not be exposedto sharp edges and corners.Structures, surroundings and furnishings should be kept in goodrepair to avoid injuries, particular-ly among children and theelderly, for whom accidents of various types are often theleading cause of death.

Princ ip leNo.2.2Indoorair pollutionAdequatelydesigned,constructedandYentilated wellings, reeof toxic and irritating substances, educe the risks of chronicrespiratorydlseasesahd malignancies.Air pollutants in the home may include nitric oxide, carbonmonoxide; radon g&s, formaldehyde, sulfur dioxide, carbondioxide, ozone, mineral fibres, creosote, organic compounds andtobacco smoke. Some of these pollutants come from building andinsulating materials, and may become more dangerous as thesematerials deteriorate with age (asbestos is an example) (17).By far the most common problems arise from fuel combustioninside dwellings, whether from inadequate venting of heatingand cooking devices or from the burning of biomass fuels(firewood, charcoal, crop residues, animal dung) in open fires.Such fuels produce a complex of pollutants, which affecthundreds of millions of people in developing countries (/8).Pollution hazards may be intensified by the use of recirculatingforced-air heating systems in tightly insulated structures (the"sick building syndrome") (19), and pollutants from outdoorsmay be found in higher concentrations once they are trappedinside (20). On house sites subject to persistent high humidity oreven waterlogging, the selection of appropriate materials and asuitable design may help to reduce adverse effects.

1 1


22/54

12 HEALTHPRINCIPLES F HOUSING

Princ ip le o .2 .3ChemicalsaletySensibleprecautlons n the household educeexposure o haz-ardous chemicals.The increasinguse of chemicalsn all countriesand communi-ties poses erious hreats to safetyand health. Exposure o toxicand caustic substances may lead to poisonings and burns and tochronic effects, not all of which are known. Children may beexposed to hazardous household products used for cleaning andother purposes, as well as to drug poisoning. Pesticide residuesin food may endanger the whole family, and on farms there maybe direct hazards from airborne agricultural chemicals and theirresidues on clothing and footwear. Chemical contamination ofsurface and ground water sources by emissions and faultydisposal of hazardous materials, is an increasing public healthproblem. Concentrated chemicals may be found in the homewhen it is also used as a workplace (see Principle 2.4).Among the many facets of a chemical safety programme,teaching householders how to protect the family from chemicalhazards is of increasing importance. There should be means ofpreventing the access of young children to chemicals in thehome and the whole family should be informed about chemicalhazards and safety precautions.

Princ ip leNo.2.4The home as a workplaceIthere a dwelling s also usedas a workplace, hose who live in itshould be protec,ted gainst hazardsand contamination.In agricultural settings, he dwelling is often closelyconnectedwith the family's occupation and with concomitant hazards frommechanical, chemical and animal sources. Adequate separationof stabling and working premises from living areas, andobservance of the rules of good hygiene are necessary forprotection against disease, poisonings and fires.In both urban and rural areas, houses may be used for a widerange of cottage industries or for piecework. This may involvethe use of volatile or other hazardous substances, produceharmful levels of noise, generate fumes and smoke or require the


23/54

PART I: PRINCIPLESRELATEDTO HEALTHNEEDS

use of open flames or devices that pose the threat of fire andexplosions. The hazards are increased where such activities arecarried out in multi-unit houses.Protection of workers and theirfamilies and neighbours may require intervention by properlyinformed municipal authorities or neighbourhood associationswith a view to reducing or eliminating risks to safety and healthand educating the workers themselves in safety precautions.


24/54


PRINCIPLEReducingpsychological ndsocialstresses o a minimumAdequatehousinghelpspeople'ssocial andpsychologicaldevelopment ndreduces o a minimum he psychological*?rd social stresses connectedwith the housingenviron-ment.From earliest times, people have felt the home to be a refuge, ahaven from physical danger and animal foes, from the rigours ofeveryday work, and from the stresses of social interaction-aplace for privacy and intimacy. The nature of the stresses andtheir psychological impact have changed in many cultures, butthe concept of home as a refuge endures. In the course of historypeople have also developed patterns of personal and socialinteraction that are facilitated bv the environment in theirhouses and neighbourhoodsParticularly in urban settlements, the housing situation may notbe conducive to good mental health, which is related to thenotion of home as a refuge and to the sociocultural functions ofspace. Overcrowding in dwellings and settlements, uncertaintyof tenure, excessive noise, the struggle for survival, the fear ofcrime and other threats to physical security, squalor, physicaldiscomfort and the ugliness of the surroundings are frequentsources of psychological stress (21, 22).Such stresses are all the greater for those-and there aremillions of them in some developing countries-who are makingthe transition from rural to urban life; for them, the "moderniz-ation syndrome" requires adjustment to radically different lifestyles, diet, occupation, social relationships (or the lack thereof)and social status, often coupled with a disruption of familyassociations and supports; without social networks to sustain!h"-, people are more vulnerable to disease. Depressing anddeficient housing conditions not only fail to provide the refugesought,. but may also aggravate the difficulties of adjustment(23, 24). As those who live in these usually urban dwellings in


25/54

PART !: PRINCIPLES RELATED TO HEALTH NEEDS

most cases rent their accommodation, fears of arbitrary evictionand unrestrained exploitation by landlords constitute a specialsource of emotional stress.To reduce unhealthy psychosocial stresses to a minimum,dwelling environments should:. provide adequate living space, properly ventilated and lit,decently equipped and furnished, with a reasonable degree ofprivacy and comfort;o provide a sense of personal and family security, reinforced bythe community structure;. pqovide space for children's play, sports and recreation, withminimum risks of injury and infection;. be so sited as to reduce exposure to noise, provide contactwith greenery and enable people to have access to communityamenities; and. be easy to keep clean and in good order.In addition to a congenial home kept in good condition, people'smental health may be improved by sharing in activities withothers, especially activities that serve to diminish the feelingof powerlessness that so often affects the urban and ruralpoor, and aimed at improving the circumstances in which theylive (3).

1 5


26/54

HEALTHPRINCIPLES F HOUSII{G

PRINCIPLElmproving he housingenvironmentSuitable housingenvironmentsprovideaccess o placesofwork, essentialservices and amenitiesthat promote goodhealth.Dwellings exist in a setting; that setting may present both socialhazards to health and possibilities of protecting and promotinghealth. The potentials of the housing environment may bealtogether different in urban and rural areas.Urban populationsface problems of overcrowding, noise, air pollution, crime,poverty, traffic congestion and traffic hazards, and socialisolation, although generally they have better access o servicesand amenities. In rural areas,physical isolation, poverty and thelack of financially viable sanitary and support services mayincrease risks to health.The housing environment should provide not only the servicesrequired for maintaining health and socioeconomic activities"such as water supply, sanitary disposal of excreta, refuse andother wastes. surface water drainage and control of pollution,but also a setting and amenities that promote well-being: anaesthetically pleasing environment that provides space andfacilities for play and recreation, access to work, commercialand cultural facilities, affordable transport services and formaland informal education (25').Three provisions are of special concern to health:1. Security and emergency services to protect against bodilyharm, victimization and substancesharmful to health, as wellas fire, rescue and emergency medical services.The provisionof these services depends not only on social cooperation inorganizing and financing them, but may also depend on theplrysical configuration of the settlement: closely packeddwellings and nanow streets may make the older quarters ofsome cities inaccessible to service vehicles and personnel,


27/54

PART I: PRINCIPLESRELATEDTO HEALTH lEEDS

and traffic congestion may make timely response to emer-gencies impossible.2. Health and social services should be physically accessiblefor both preventive and curative purposes. The transportprovided in housing areas should enable residents to get notonly to their places of work, but also to these supportiveservices.3. Access to cultural and other amenities means accessnotonly to amenities in the neighbourhood and the largercommunity of which it forms part but also to printed matter,

radio broadcastsand television. The provision of facilities forplay and recreation in the neighbourhood and the encourage-ment of participation in communal activities promote a senseof belonging and of social support that contributes to personalhealth as well as to community well-being. The planting ofvegetation in housing areas-trees along the streets, patchesof greenery or woodlands-helps to improve climatic condi-tions in the community by absorbing dust, regulating humid-ity, reducing excessive exposure to sun and wind, andrecharging the ground-water, and adds a touch of beauty tothe environment.

If it is to be adequate, housing development must be based oneffective community housing standards and the means of enforcingthem. In the urban areas of many industrialized countries theinfrastructure this requires is largely provided under govern-ment auspices and results from a long evolution of institutionsset up to defend the people's interests in regard to housing. Inother situations, reliance may have to be placed on voluntaryefforts by the people themselves o develop institutions that canlay down and enforce standards.


28/54


PRINCIPLEMaking nformeduse of

Only if residentsmakeproper use of their housingcan itshealthpotentialbe realized o the full.As mentioned in regard to each of the preceding principles, thehealth impact of housing depends not only on physical factors,such as site, structure and social amenities, but also on the usesto which housing is put by human beings individually andcollectively.The most adequate of structures will not serve health purposes,if it is not maintained and if its defences against health hazardsare allowed to deteriorate. The provision of hygienic facilitieswill do little good unless they are properly used for personal anddomestic cleanliness, and the best of food preparation andstorage equipment will be ineffective if it is not properly used.The use of safe designs and materials in consumer products canonly go so far in preventing accidents, injuries, fires andpoisonings; to be fully safe, the products must be used with thenecessary caution and control. Likewise, no amount of land-useplanning and zoning can ensure the salubrity of a neigh-bourhood. if its residents allow it to become run-down andsqualid or if they fail to take action against environmentaldamage and disfigurement.Proper use of housing and the enhancement of its capacities forimproving individual and community well-being depend ulti-mately on the attitudes, aspirations and knowledge of house-holders. Experience in various countries indicates that positiveattitudes can be developed and integrated into the popularculture. In some cases the changes have been sponsored bysocial leadership and the media, occasionally with governmentparticipation; in other instances, they appear to have arisenspontaneously from the people, initially at the local level.Although the origins of changes in attitude are somewhatobscure, the need for public information and education could be

housing


29/54

PART I: PRINCIPLES ELATED O HEALTHNEEDS

met by systematic measures. It may also prove useful to examrnethe strength or weakness of householders' incentives to improvetheir dwellings and neighbourhoods. Some types of tenure andpersonal investment may strongly encourage the maintenanceand improvement of housing, while others may have no effect ormay even discourage such actions.The attainment of health and social objectives in relation tohousing, therefore, depends not only on technical and materialmeasures, but also on encouraging and helping people to makethe optimum use of the housing available, a process to whichgovernments can make a helpful contribution by stimulating,responding to, and cooperating with popular initiatives anddesires (26).


30/54


PRINGIPLEProtecting opulations tspecialriskHousingshould educe o a minimumhazards o the healthof groups at special risk from the conditions they live in,including

. wornnand children,. thosewho ive n substandard ousing,. displaced ndmobilepopulations, nd. the aged, he chronicallyll and he disabled.The inadequacies in housing that have been described posespecial health risks to certain groups. These risks may derivefrom unusual exposures,biological statesor social circumstances.Women and children are more likely than adult males to beexposed o health hazards in the domestic environment, mainlybecausethey spend more time in the home and their activitiesinvolve greater exposure to whatever safety deficiencies andhealth hazards are present. The frailty of infants and childrenand the impoverished conditions under which so many millionsare condemned to live, coupled with their lack of information,makes them especially susceptible (3); worse off still are themillions of abandoned "street children", who have no dwellingsat all.Inadequate provisions for water, domestic hygiene and foodpreparation increase women's labour and take their toll ofvitality and resistance to disease; the drain on their strengthmay be aggravated by additional work in the fields or in thehome to supplement the family's income (27). At the same time,the primacy of the home in the consciousnessof most womenmakes them potentially valuable as workers in community self-help programmes.Those who live in substandard housing are mainly the urbanpoor, whose numbers are rapidly increasing in developingcountries and who are exposed o special health risks from the


31/54

PARTI:.PRINCIPLES ELATED O HEALTHNEEDS

run-down, overcrowded and ramshackle dwellings they live in.The main categories are those living in:urban slums, defined as run-down older properties, often inthe inner cities, in which the structures themselves, theavailable living space, urnishings, maintenance and sanitaryservices are deficient and whose occupants are often in-adequately protected tenants; andshanty-towns and squatter settlements, usually on thefrilrges of the cities in developing countries, in which thecogditions found in the slums are exacerbated by the flimsy,makeshift character of the structures (often little more thanhuts),r the uncertainties of tenure, the absence of anyprovision for sanitation and other health protection, severeovercrowding and a multitude of hazards to physical andmental health-in effect, a violation of all the principles ofhealthy housing. (This category also covers refugee settle-ments that have acquired a permanent character, even thoughofficially regarded as "temporary".)

Rooted in poverty, their environmental hazards aggravated bythe malnutrition and illiteracy of those who live in them, thesesettlerhentsnegate the very concept of public health and provemuch too much for the resourcesand energiesof the communityand the 'authorities. The problern is ofte; related to economicdevelopment-either its failure to provide sufficient and equi-tably distributed benefits, or its apparent success,which attractsthe rtual poor into circumstances no better than those theyleave and often more'hazardous to their health.Inadeciuateprovision for housing in socioeconomicdevelopmentschemiis exposes these people to overcrowding, filth andphysical' danger; the sources and vectors of disease areencouragedby the conditions in which they live-drinking andbathing in contaminated water, direct exposure to excreta andto the ,,insects and rodents that breed in rotting refuse andstanding water, eating spoiled. or undercooked food, andbreathing air polluted by the effluents of nearby industry anddomesiic cooking and heating. Risks to physital health grecompo'(indedby the psychological and social effect of beflngdefenceless and vulnerable, of struggling along on the edgq ofsurvival.Displaced and mobile populations may be exposed to thesesamehazards to an even greater extent. Refugees rom war andcivil disturbance, those uprooted by large-scale development


32/54


projects, and migrant labourers' families are groups of specialconcern. Many of their health problems may also be foundamong nomadic populations. The fact that these people. usuallydo not stay long in any one place means that they have nopolitical influence, and have no moral claims on communityresources; any services obtainable may not be continuously so.Their transiency may lead to economic and social victimizationand the perpetuation of poverty, ill health and lack of educationfrom generation to generation.The aged, chronically ill, and disabled, whether living inmarginal or affluent circumstances, have special needs forhealth protection, safety, access to services and the means ofpursuing as active and rewarding a life as possible. Generallylimited in their mobility, these groups have diverse needs thatmay have to be met through special arrangements for housing,equipment and appliances, care and supervision, employment,protection against physical hazards (fires, crime, naturaldisasters), and social activities.


33/54

23

PART IIPrinciples elated ohealthactionPrinciples -11dealwith heways nwhich hecommu-nity can respond o needs connectedwith the healthaspects f housing, nd are concerned ith:

7. Health dvocacy.8. Economic ndsocia lpol ic ies.9. Processes f development,lanning, nd man-agement.

10. Educat ionn regard o the provis ion nduseofhous ing.11. Communityooperat ionndsel f -help.


34/54

HEALTHPRINCIPLES F HOUSII{G

PRINCIPLEHealthadvocacyHealth advocacy, carried out by health authorities andbodies n related fields,should be an integralpart of publicand private decisions about housing.If the provision and use of housing are to contribute to betterhealth, health values must be advocated and supportinginformation provided vigorously and in all relevant quarters.Health advoeacy of this kind requires efforts by governrnentaland nongovernmental bodies in addition to the national healthauthorities, but the leadership of the health authorities isessential. These considerations are the basis for three sub-principles.Princ ip leNo.7.1Role of lhe health authoritieslmprovement of the health aspects of housing requires actlveleadership and Informed advocacy by heallh authorities at alllevels.In keeping with their mission and commitment to promoteimproved health in the community, health authorities should beaware and informed of the health aspects of the housingenvironment, should commit resourcesto this important area ofhealth intervention, and should be aetive advocates of preven-tive and remedial measures to ensure health protection andpromotion, whether through governmental decisions or privateactions. Health authorities should earcy out their advocacy roleby participating in policy and planning decisionsat al l levels ofcommunity action; by implementing educational programmesonhealth and housing hygiene; by monitoring and evaluating needsand responses;and by linking housing programmes with otherhealth programmes,particularly family-oriented primary healthcare.To carry out these functions health authorities should haveknowledge of the health aspects of the local housing situation.


35/54

PART ll: PRINCIPLESRELATEDTO HEALTHACTION

Staff capable of undertaking technical and support duties inconnection with programmesare required, and should be able toprovide staff in other health programmes with information onthe health implications of housing and the range of feasibleinterventions, in order to encourage them to make effectiveinterprogramme linkages (25, 28).

Princ ip leNo.7.2Roleof relatedgroupslmprovedhealth n relation o housingcan be seryedby mobili.zingthe energiesandtalents ol all relatedagenciesahdgroups.As the resources of health authorities are finite, healthadvocacy must be enhanced by involving related governmentalagencies (planning, interior, sanitary services), communityorganizations (civic, religious, social), and professional andtrade groups (architects, builders, civil engineers); the lead-ership of political parties may also play a strategic role inefforts to improve housing.Not only should health leaders be,responsive o initiatives fromthe organizations interested, but steps should be taken to singleout potential collaborators and those in a position to affectwhat is done in regard to housing, to provide them withinformation, to suggestways in which they can collaborate, aadto maintain the contacts and communications neededto ensuretheir continuing cooperation. Inasmuch as a great deal ofhouse-building is undertaken by families themselves, mportantpotential collaborators are those who can transmit the healthmessage:schools, the mass media and community leaders.

Princ ip leNo.7.3Gommunicating ealth messagesHealth advocacy should work through a multiplicity of channelsand media.To be effective, health advocacy in respect of housing as inrespect of other facets of health, has to be ubiquitous-as arethe hazards to health and the action needed for improving it.Therefore, information on health problems and the actionsneeded o maintain and improve health should be communicated


36/54


to and through national and local decision-making bodies,planning and development agencies, the ministries in charge ofproduction activities and social services, professional and tradegroups, political and civic organizations, teaching agencies(civil and religious), the mass media, community leaders, andespecially those health services that come into direct contactwith individuals and families. Horizontal and oblique communi-cations are at least as important as formal vertical communi-cation lines, if not more so.


37/54

PART l: PRINCIPLES ELATED O HEALTHACTTON

PRINCIPLE o.8Economicand socialpoliciesEconomicandsocialpolicies hat atlect he stateol housingshould support the use of. and and housing resources tomaximizephysical,mentaland socialhealth.Key preventive and remedial measures often depend on themajor policies of governments and economic organizations. Theincorporation of health values in the policies that directly andindirectly affect the housing environment may be of greatstrategic use in the sense that it may influence the choices ofindividuals towards alternatives that support health objectives.Such policies may reduce the need for dispersed, intrusive andoften expensive remedial efforts. For example, a policy thatmakes it easier for people to own their homes may be moreeffective (and much more efficient) than information campaignsto persuade tenants of the advisability of properly maintainingtheir homes. Particularly relevant to the health aspects ofhousing are policies-often interrelated-that are concernedwith:

socioeconomic development priorities, which affect theallocation of investments and distribution of income andthereby have an impact on poverty and the extent to whichsocial considerations are incorporated into schemes ofeconomic development;priorities of governments (and international agencies) inregard to water supplies, sanitation, the upgrading ofhousing, health services and support for community ini-tiatives aimed at social development;increasing the supply and lowering the cost of componentsof housing, including sites, the establishment of the basicinfrastructure and the provision of easier credit;the affordability of measures aimed at improving thequantity and quality of housing, with the government actingas intermediary rather than provider;


38/54


. decentralization of the authority toresources and levy rates and taxes,can be tackled by local initiatives,priate to the different settings innizing and supporting community grass-roots efforts;

o encouraging the building industry to use local materials;. giving rights and protection to householders, particularlytenants;. family planning, which may affect the population density incommunities and the health prospects of mothers andchildren;. land and housing tenure, which affect accessibility to goodhousing, people'ssenseof security and their income and life-style, and the efficient use of land and building resources;. regulation of building and land use, which affect thequantity and quality of dwellings.

take decisions, allocateso that local problemsusing standards appro-the country and recog-


39/54

PART ll: PRINCIPLES RELATED TO HEALTH ACTION 29

PRINCIPLE O.9lntersectoral ction ordevelopment lanningandmanagementEconomic and social development, as it alfects humanshelter, shouldbe basedon appropriateprocessesof plan-ning, the formulationand implementation l public policyand the provision of services, with intersectoral collabor-ation in:

. development lanningandmanagement;. urbanand and-use lanning;. housing legislatlonand standardsand their enforce-ment;the designand constructionof housing;the provisionof communityservices;andmonitoringand surveillanceof the situation.

If policies are to be effective and socially productive, theirformulation and implementation should be governed by suitableprocesses of planning and management. The processes used insocioeconomic development are of special interest, because somedevelopment projects aim directly at housing improvement,while housing issues are inextricably linked with manyeconomic development projects, either because the projectsdisplace communities, require temporary shelter to be providedfor project workers, or alter the physical and social environmentin the vicinity of established residential areas.Intersectoral collaboration is essential for the attainment ofhealth goals. Such collaboration is necessary in virtually all theprocesses listed above, if health and many other potentialbenefits of development and social well-being are to be realized(29). However, the characteristics of housing development makeintersectoral collaboration difficult as well as important.

o

o

a


40/54


Responsibilities and initiatives in housing are widely distribu-ted, and many nongovernmental agencies are involved. In somecountries, no single national body is responsible f,or housing.Even when such a body is established, however, it can be nomore than a focus for efforts to promote the collaborationneeded from other ministries. Activities by governmental andnongovernmental agencies may impinge on housing directly(financing agencies, building industry, trades unions, theproducers of materials) or indirectly (production ministries,development boards, local government officials, social serviceagencies). AIso, because in most countries it is the peoplethemselves who build, modify and acquire their housing, anyagencies able to influence personal or family decisions onhousing must collaborate in guiding popular choices towardsdesirable types of housing and housing use.

Princ ip leNo.9.1Development lanningand managementtncorporationof health and social criteria in the ptanning andmanagement f economicdevelopment an preventwastefulanddangeroushousingbeingbuilt.Principle 9.1 is concernedwith developmentactivities that areplanned by central or local authorities (often the case indeveloping countries) or where such authorities have the powerto permit or forbid private development schemes, which is usualin the industrialized market-economy countries.In such circumstances, the processes of project design andapproval should take into account the way in which eachdevelopment proposal may affect the health and safety ofdwellings and neighbourhoods. Adverse effects may result froma broad range of potential errors: siting industries in placeswhere they intrude in an unpleasant and hazardous way onhousing and the surrounding soil and water, routing publictransport in ways that disrupt established neighbourhoodsinstead of linking them, failing to prepare for the movement oflabour into the vidinity of newly established workplaces,displacing settlements and their populations, or making inad-equate (or no) provisions for the temporary accommodation offamilies while a development project is being implemented.In developing countries, the rapid and uncontrolled growth ofurban centres produces a pattern and density of housing for


41/54

PART ll : PRINCIPLES RELATED TO HEALTH ACTION

which it is very expensive to supply infrastructure and services.Public housing and squatter settlements are often built on steephillsides, floodplains, or other unsuitable sites. Official schemesmay overlook the dangers of landslides and erosion. Squattersmay choose risky sites, because only on such sites do they havea chance of avoiding eviction. Such patchwork patterns ofhabitation multiply many times the costs of providing pipedwater, storm drainage, roads and other essential infrastructureand household services.On the other hand, sound development pianning can maximizecommunity benefits, by such means as locating social and healthfacilities where they can be of use to the greatest numbers orthe most needy, encroaching as little as possible on productiveagricultural land, restricting damage to forest resources,encouraging the rehabilitation of valuable housing resourcesand developing the community's capacity for self-help-thisimplies, of course, obtaining community participation in theplanning and decision-making process.In many development planning situations formal "habitatimpact assessments", like environmental impact assessments,may not be technically or politically feasible, but the principlethat decisions must take into account the social consequences ofeconomic development may be served by informal and pragmaticmeans.For this to happen, health and social interests have to berepresented when development decisions are made, either directlythrough health authorities or indirectly through the healthawareness, knowledge and sympathy of development planners anddecision-makers. Moreover, since official and community partici-pants need good information on the health implications ofalternative decisions, health representatives, supported by thenecessary information resources, can play an active advisory role.

Princ ip leNo.9.2Urbanand land-useplanningTakingsocial nformationand values nto account n urbanandland-useplanninghelps to ensure that housingwill promotebetterhealth.Taking health and social considerations into account shouldtemper the usual dominance of physical and economic criteria in


42/54


planning decisions on land use in urban and other areas, as wellas in decisions on siting structures and transport facilities incities. Claims to use available land, perhaps unutilized or notproperly utilized, to meet housing needs may have to berecognized and given competitive status with commercial andindustrial development claims.The capacity of the urban environment to meet human needs forwater, sanitation, clean air and transport should be taken intoaccount in decisions about residential development, industrialsiting and transport. To obtain the information required,research and pilot projects may be needed to find solutions thatbest fit local conditions.Princ ip leNo.9.3Housing egislation,standardsand enforcementHealth equirementsshouldbe incorporated nto legislationandstandards hatestablishnorms or the construction,maintenanceand useol dwellings andtheir surroundings.Suchnormsshouldbe clear, consistentand supportiveof affordable, ncrementallyremedial housing provisionsand made effective through ade-quate technicalsupportservices.Various legal instrumentsare usedto establishnorms for thatpart of the housing economy that is subject to governmentsupervision and regulation; in addition, guidelines and recom-mendations on good practice may be used to reinforce the normsand extend their influence to unregulated dwellings. Apart fromhousing codes, which la5r down the requirements for decenthuman habitations, housing norms are embodied in buildingcodes, plumbing codes, sanitary codes, nuisance laws, land-usezoning regulations, electrical codes, and statutes pertaining toowner-tenant relationships. It is important that health norms beincorporated in all such legal instruments to ensure that al lthose involved in providing and maintaining housing are awareof health issues and how they are to be resolved, are directed tokeep to the norms, and are held accountable for theirobservance. Further, these normative statements should beconsistent and up-to-date; to ensure this will require someinvestment of resources, particularly in the training andassignment of competent personnel.The criterion of consistency should be used in ways that supportrather than hamper the prospects for housing improvements.Impractical norms can neither be enforced nor complied with,


43/54

PART l: PRINCIPLES ELATED O HEALTHACTION

and no single set of norms is applicable to all countries, or to alldwellings in the same country. Setting inflexible norms that areunrealistically demanding may result in nothing being done;impractical standards discriminate most heavily against thepoor, who have the greatest need.If standards are not to be obstacles o action, they should aim atincremental improvement. The standards in force should rec-oncile abstract ideas of what is proper and ultimately desirablewith what can realistically be dbne at the moment lo improvethe health, safety, and comfort of a settlement or neigh-bourhood, bearing in mind the economic situation, environmentand cultural practices of the community concerned. This callsfor either local norm-setting or the formulation of a broad rangeof classified norms- not a single national standard, nor t[eenforcement of standards that may be obsolete or irrelevant topresent conditions. It further suggests that, especially indeveloping countries, the setting of legal and advisory normsshould be approached as a task to be performed progressively,not "once and for all", with standards rising as economic andsocial development increases the feasibility of achieving improve-ments in housing.In the process, the implementation of standards at any stageneeds to be supported with technical assistance, advice andguidance on how housing can be made more healthy at minimumcost.

Princ ip leNo.9.4Designand constructionof housingNorms for housingdesign and construction echnologyshouldembody appropriatemeans of ensuring safety and promotlnghealth.The improvement of health and safety features in dwellings mayalso be fostered by persuading those who design and constructhousing to incorporate such features in plans, the selection ofmaterials, and building techniques. In the case of some housingin urban and suburban areas, this approach means informingand influencing architects and professional builders; in the caseof other urban housing and virtually all rural housing, those tobe reabhed are the householders themselves.Spreading knowl-edgeof design and construction norms is a function of education(Principle 10).


44/54


As is the case with housing standards, no universal norms fordesign, materials and construction exist, nor should they.Differences in climate, the availability of materials, culturalpreferences and practices, and financial capacities mean thatdifferent standards, specific to each country, must be set.Housing conditions and possibilities need to be assessed o thatnorms can be established that fit the situation-or could bemade to fi t the situation when coupled with new ways ofsupplying low-cost materials not previously available to mostpeople,but which meet requirements for health and comfortableshelter.In deciding upon norms, the concept of "ecocultural regions"may be useful. Groups of people within a particular country orstraddling national boundaries have traditional social responsesto their environments that are intimately connected with theecology of the region and this meansthat their preferencesmustbe ascertained through consultation with them.

Princ ip le o.9.5Provisionof communityservicesSanitaryand relatedhealth servicesshould be organized n thecommunity.Community-based services should be organized' to support thesanitary use of housing, particularly for the disposal of excretaand solid wastes, the supply of clean water and the drainage ofstagnant waters. In urban areas, "community-based" has theconnotation that the services provided will be financed by taxesor the payment of fees. In rural communities, it may connoteorganizing cooperative efforts by the residents and determi-nation of what is expected from each householder. In the lattercase, it is incumbent on local leaders to initiate processes ofeducation and consensus-building to mobilize self-help efforts-one requirement for which is a heightened awareness of thehealth benefits resulting from improved sanitation in dwellingsand in the community.

Princ ip le o.9.6Monitoringand surveillanceAttainmentof housing mprovementgoals requires actiYemoni-toring and surveillance.


45/54

PART l: PRINCIPLES ELATED O HEALTHACTION

Health improvements related to housing, like other healthimprovements, depend to a large extent on the quantity andquality of information that can be obtained and applied inidecisions about policies, norms, intervention strategies andservices. Just as health authorities need information abouthealth status, disease incidence and prevalence, the availabilityand utilization of services, and sources of environmentalpollution, those working to ensure housing hygiene require up-to-date information on housing conditions and practices. Suchinformation must be collected, processed, analysed and put togood use.In considering what information may need to be collected,health leaders should not overlook existing sources of informa-tion in other agencies (housing, census, agricultural extension),nor the possibilities of linking data collection on housing withexisting health services that are in contact with people in theirhomes (primary health care and other outreach programmes,sanitary inspections). As in the case of al l managementinformation systems, the development of a monitoring andsurveillance system for housing hygiene requires planning anddesign to determine what information is needed and for whatpurposes in policy formulation, programming and decisionsabout the provision of services.


46/54


PRINCIPLE o.10Education n healthyhousingEdueation-public and prolessional-should actively os-ter the provisionand use of housing o promotehealth.Because the construction and use of housing are inseparablefrom people's choices and behaviour, education is a key tool inbringing about improved health in the home. The targets ofeducational efforts are multiple:

Householders are the largest group to be educated and,because families often build their own dwellings and, bydefinition, are the users of housing, they arJ the rnosiimportant target for education. The educational objectiveshould be to increase their understanding of what is needed nthe home to foster the health of the family (so far as theirresourcespermit) and the personal and domestic practices ofhygiene, maintenance, hazard reduction and accident preven-tion that enable people to promote their health and well-being.Architects, builders, and the manufacturers and sup-pliers of materials require education in design and con-struction factors that promote health and reduce hazards.Health information should be integrated into professional andtechnical education curricula for those entering this work,and current practitioners should be reached through continu-ing education, in which professional and trade associationscan be effective collaborators.Health workersn ranging from community-basedphysiciansengineers and sanitarians to primary health care auxiliaries,should be educated to understand the health hazards ofhousing and to integrate educational and other remedialmeasures into their health service work. Workers in othersectors, such as those in agricultural extension, ruraldevelopment and social work, who are in a position toinfluence and assist in household efforts towards economicand social improvement, are a further target for education.


47/54

PART ll : PRINCIPLES RELATED TO HEALTH ACTION

Policy leaders, development planners and managers, andlocal officials should be helped to understand the healthimplications of housing, as it impinges in various ways ontheir responsibilities and the decisions they are in a positionto make that will affect health outcomes.

Mounting these educational efforts will be an extensiveenterprise, for it requires the establishment of a body ofknowledge that is relevant to national and local conditions andgoals, the development of educational materials and messagesthat are each relevant to these various targets, the selection andutilization of channels to carry the educational message,and thetraining of teachers and trainers. Effective health educationrequires competent leaders, able to train others to transmit thevarious messages o these diverse audiences. For, in addition toformal education, the effort requires the use of communitynetworks and the mass media, both for direct educationalpurposesand to create a climate of opinion favourable to healthobjectives.


48/54

HEALTH PRII{CIPLES OF HOUSING

PRINCIPLECommunity ooperation ndself-helpIn dealing with the needs and problems of the humanhabitat, ommunitynvolvement t all levelsshouldsupportthe processesof self-help,help betweenneighbours,andcommunalcooperativeactivities.While education is necessary to provide the cognitive basis forhouseholders to take action to improve housing conditions, itmay not be sufficient to induce the action itself-particularly ifefforts in regard to water supply, waste disposal and neigh-bourhood improvement require cooperation among families.Support from within and outside the local community may beneeded to convert knowledge into positive attitudes andeffective action.Women are not only primary victims of inadequate housing, butalso potentially powerful agents for positive change. As thebearers and rearers of children, the keepers of the domesticenvironment, the haulers of water from distant sources and thenurses of the sick, women have the most at stake in improvinginadequate housing. In many cultures, women are the mostactive and effective mobilizers and organizers of people informulating demands for improved health services and livingconditions and taking the practical steps involved.The strongest support for improved housing conditions comesfrom the community itself, from organized activities that areintegrated into the life of its people. The support may rangefrom collective ideals and attitudes, community-based serviceprogrammes, physical cooperation between neighbours andcommunal resource development. How such activities can beinitiated differs considerably in different social groups in aparticular country, and in different countries. Sometimes peopleneed only a clear opportunity to participate; in other situations,groups need reassurance and encouragement to voice theirneeds and state what help they want; in still others, cooperation


49/54

PART II: PRII.ICIPLES ELATEDTO HEALTH ACTION

has to be encouraged through sponsored and well-thought-outefforts by community organizations. Whatever means may berequired to bring about cooperation, most efforts will be moreeffective if information is available that increases awareness ofthe possibilities and crystallizes opinion, as a necessarybasis forlocal cooperation in formulating ideas and proposals, devisingways of implementing them and sharing costs in money orcontributed goods and labour.Where external assistance in developing these capabilities isneeded, it should be linked with other community self-helpefforts, such as primary health care, rural development andneighbourhood organization in urban and periurban areas. Thepotential of all such efforts is strongly enhancedby the fact thattheir essential objective is to help people improve their ownconditions in direct and tangible ways.


50/54


References

1. Kasl, S. V. The effects of the residential environment on health andbehavior: a review. In: Hinkle, L. E. & Loring, W. C., The effectof the man-made enuironmenton health and behauior.Atlanta. GA. Center for DiseaseControl, 1977.

2. American Public Health Association. APHA-CDC recornrnendedninimumhousing standards. Washington, DC, 1986.3. Hardoy, J. Poverty kills children. World health, July 1986.4. Stephens, B. et al. Health and low-cost housing. World health forum,6:5$-62(1985).5. *International drinking water supply and sanitation decade: mid.-decad.eprogress reuiew. Unpublished WHO document, 439/11, 1986.6. *Benefits to health of safe and adequate drinhing-water and sanitarydisposal of human wastes.Unpublished WHO document, EHE/82.32,1982.7. World Bank. Appropriate technology for water supply and sanitation.Washington, DC, 1980.8. *Maximizing benefits o health-an appraisal rnethodologyor water supplyand sanitation projects. Unpublished WHO document, ETS/83.8, 1983.9. Mara, D. & Cairqcross, S. Guid.elines or the safe use of wastewaterandexcreta n agriculture and aquacultureinxedsuresor public healthprotection,Geneva, World Health Organization, 1989.

10. Suess, M. J. , ed. Solid uaste managementiselected opics. Copenhagen,WHO Regional Office for Europe, 1985.11" McKeown, T. The role of medicine: dream, mirage, or nemesis?Princeton,NJ, Princeton University Press, 1979.12. WHO Technical Report Series, No. 705, 1984(The role of food safety inhealth and deuelopment:eport of a Joint FAO/WHO Expert Committee onFood Safety).13. Goromosov,M. S. Thephysiological basisof health standardsfor dwellings.Geneva, World Health Organization, 1968(Public Health Papers No. 33).14. Martin, A. E. & Oeter, D. Enuironmental health aspects of humansetthmcnts. WHO Regional Office for Europe, unpublished document,Ie P/BSM/0O2, 7e78.

* A limited number of copies of this document are available from: Division ofEnvironmental Health, World Health Organization, 1211Geneva 27, Switzerland.


51/54

REFERENCES

15. Public health aspects of climate in cities. WHO Chronicle, 25:L6l (1971).16. The effects of indoor housing climate on the health of the elderly. WHORegional Office for Europe, unpublished document, ICP/BSM/002(3),1982.17. Methods of monitoring and eualuating airborne man-mademineral fibres.Report on a WHO Consultation. Copenhagen,WHO Regional Office forEurope, 1981(EURO Reports and Studies, No. 48).18. de KoninC, H. W. et al. Biomass uel combustion and health. Bulletin of theWorld Health Organization, 63:ll-26 (1985).19. Indoor air pollutantsi etcposureand health effects. Report on a WHOMeeting. Copenhagen, WHO Regional Office for Europe, 1983 (EUROReports and Studies, No. 78).20. Health aspects elated to indoor ai r quality. Report on a WHO WorkingGroup. Copenhagen,WHO Regional Office for Europe, 1979 EURO Reportsand Studies, No. 21).21. Gove, W. R. et al. Overcrowding in the home: an empirical investigation ofits possible pathological consequences. American sociological reuiew,44:59-80 (1979).22. Lambo, T. et al . Effeets of population density and crowding on the functionand tolerance of communities for disabled people.Ekistics,49(296):399-400(1982).23. Duckitt, J. Household crowding and psychological well-being in a SouthAfrican coloured community. Journal of social psychology, L2l:231-238

(1982).24. Lee, R. P. High-density effects n urban areas: What do we know and whatshould we do? In: King, Y. C. & Rance, P. L., ed., Social life anddeuelopment n Hong Kong, Hong Kong, The Chinese University, 1981.25. WHO Technical Report Series, No. 225, 196l (Public health aspects ofhousing: first report of the Expert Committee).26. Improuing enuironmental health conditions in low-income settlements:acornmunity-based approach to identifying needs and priorities. Geneva,World Health Organization, 1987(WHO Offset Publication, No. 100).27. Women,health and deuelopntent.Geneva,World Health Organization, 1985(WHO Offset Publication, No. 90).28. WHO Technical Report Series, No. 297, 1965(Enuironmental health a.spectsof metropolitan planning and developrnent: report of a WHO ExpertCommittee).29. Schaefer, M. Intersectoral coordination and health in enuironmentalm,anagement:n exarnination of national experience.Geneva,World HealthOrganization, 1981(Public Health Papers, No. 74).


52/54

HEALTHPRINCIPLESOF HOUSING

Annex 1WHOConsultation n Housing-the lmplicationsfor HealthGeneva,9-15 June 1987Parlicipants*Professor A. P. Barnabas, Consultant, Social Science Division,Indira Gandhi National Open University, New Delhi, IndiaDr S. Boyden, Head, Human Ecology Programme, Centre forResources and Environmental Studies, Australian NationalUniversity, Canberra, Australia (Rapporteur)Dr J. Bugnicourt, Executive Secretary, Environmental Devel-opment Action in the Third World, Dakar, SenegalMr L. Costa Leite, Municipal Secretariat of Public Works andPublic Services, Rio de Janeiro, Brazil (Chairman)Mr T. Deelstra, Associate Professor, Department of Housing,Physical Planning and Environmental Management, Delft Uni-versity of Technology, Delft, NetherlandsMr D. Djoekardi, Director of Housing, Directorate-General ofHuman Settlements, Ministry of Public Works, Jakarta, In-donesiaMr Y. Hassan, Director, Public Health Engineering, Ministry ofConstruction, Housing and Public Utilities, Khartoum, SudanDr F. K. Kloutse, Deputy Director, National Sanitation Service,Sanitati'on/Health, Lom6, Togo (Vice-Chairman)Professor A. Krtilova, Head, Department of Hygiene of Con-struction and Housing, Institute of Hygiene arrd Epidemiology,Prague, CzechoslovakiaDr K. Meguro, Director-General, Department of EnvironmentalHealth, Environment Agency, Tokyo, JapanDr J. Michelsen, Bogot6, Colombia* Invited butEngineering unable to attend: Mr. H.Department, Government of M. Aslamn Chief Engineer, Public HealthPunjab, Lahore, Pakistan.


53/54

ANNEX 1

Mr N. D. Peiris, Additional Secretary (Technical), Ministry ofLocal Government, Housing and Construction, Colombo, SriLankaRepresentativesof other organizationsUnited Nations Centre for Human Settlements (Habitat)Dr G. S. Sinnatamby, Human Settlements Offi.cer, Nairobi,Kenya

United Nations Children's FundDr t. T. Bisharat, UNICEF Regional Advisor, Middle East andNorth Africa, Amman, JordanUnited Nations Development ProgrammeMr A. H. Rotival, UNDP/WHO Coordinator of the InternationalDrinking Water Supply and Sanitation Decade, Geneva,Switzer-land.United Nations Environment ProgrammeMr A. Renlund, UNEP Regional Office for Europe, Palais desNations, Geneva, Switzerlandlnternationat Institute or Environment and DevelopmentMr D. E. Satterthwaite, Senior Research Associate, IIED,London, Englandlnternational Labour OrganisationMr D. Fillinger, Construction Industry Specialist, ILO, Geneva,SwitzerlandDr M. Pigott, Consultant, ILO, Geneva, SwitzerlandUnited Sfafes Agency for lnternational DevetopmentMr M. J. Lippe, Regional Director-West Africa, Housing andUrban Development, USAID, Abidjan, C6te d'Ivoire


54/54


WHOSecretariatMr B. Appleton, Prenton, Birkenhead, Merseyside, England(Consultant)Mr R. Bahar, Division of Vector Biology and Control, WHO,Geneva. SwitzerlandMr R. Novick, Responsible Officer, Environmental Health inRural and Urban Development and Housing, WHO, Geneva'Switzerland (Secretary)Mr G. Ozolins, Manager, Prevention of Environmental Pollu-tion, WHO, Geneva,SwitzerlandProfessorM. schaefer, Professorof Health Policy and Adminis-tration, School of Public Health, University of North Carolinaat Chapel Hill, NC, USA (Consultant)Ms J. Sims, Technical Assistant, Prevention of EnvironmentalPollution, WHO, Geneva, SwitzerlandMr M. Suleiman, Community Water Supply and Sanitation,WHO, Geneva, SwitzerlandDr J. Woodall, Division of Epidemiological surveillance andHealth Situation and Trend Assessment,WHO, Geneva,Switzer-land

health housing who

Documents