The Body Economic

by Basu, Sanjay, Stuckler, David

  Mosquitoes had rarely caused problems in Bakersfield. Indeed, the last major outbreak of a mosquito-borne disease in Bakersfield was in 1952, when an astonishing 813 people died of Western equine encephalitis transferred by mosquitoes from infected horses. That episode led federal and state health departments to create a Mosquito-Borne Virus Surveillance and Response Plan. The CDC launched the California Encephalitis Project, a specialized lab dedicated to monitoring unexplained symptoms and deaths from around the state.

  According to the CDC’s data, this particular West Nile outbreak was unusual. The CDC team had found that hot weather usually reduced the chances of a West Nile outbreak, as the pools of water next to the Kern River, where mosquitoes normally bred, had disappeared. Western scrub jays and house finches, two bird species that carried the virus, had also been dying of thirst. The numbers of rural mosquitoes, Culex tarsalis, caught in traps by scientists were also below their 5-year averages. Given these conditions, 2007 should have been a very-low risk summer for West Nile.

  Yet by the end of August, nearly 140 new human cases of West Nile had been confirmed in and around Bakersfield, a 280 percent increase from the previous year’s 50 cases. Twenty-seven people had died. “Once we had one human case, it was almost like popcorn after that,” said Dr. Claudia Jonah, the county’s interim health officer. “In a year in which we should not have had any cases, we had the most in the nation.” 4

  California Governor Arnold Schwarzenegger declared a state of emergency in the county. He was in the midst of busily writing IOUs to cope with California’s major budget crisis. But in a desperate attempt to end the epidemic, he started a $6.2 million campaign to reduce the number of mosquitoes around Bakersfield.5

  Kern County Department of Health officials mass-mailed letters to Bakersfield homes and issued television warnings, urging all residents to stay indoors at dawn and dusk, when mosquitoes are most active. Even in the sweltering heat, Bakersfield’s children and the elderly now donned long sleeves and trousers to avoid bites. Then, at 8:30 pm on August 9, planes descended in military-style flyovers across the town, blanketing homes and businesses in thick gray clouds of pyrethrin insecticide, a chemical derived from chrysanthemums.6

  To discover the causes of the epidemic, the Kern Mosquito and Vector Control team deployed a rapid-response outfit of epidemiologists from the University of California, led by mosquito expert Dr. William Reisen. Many possible explanations were considered. “Perhaps the current drought was crowding birds into smaller watering holes,” hypothesized Reisen’s team, “where they were more likely to come into contact with mosquitoes?”7

  First the team requested an aerial scan of Bakersfield to probe for hot spots of dead birds and mosquito-breeding clusters. While airborne cameras provided no sign of dense watering holes where birds might be over-crowding, they did reveal an unexpected clue: clusters of rectangular green fuzz. On closer inspection, about one out of every six swimming pools, bird-baths and Jacuzzis in the town of Bakersfield had turned lime-green.

  Quickly, Reisen’s team set out to investigate, knocking on doors and ringing bells to find out if the pools and baths were sites of mosquito breeding. At each of the “green-fuzz residences,” they found no one home. Instead, they were greeted with “For Sale” and “Bank Owned Foreclosure” signs on nearly every lawn. The researchers had discovered the origins of the West Nile epidemic. Reisen’s study found more than 4,000 larvae of mosquitoes infected with West Nile strains in 31 neglected pools.

  Bakersfield was not just the epicenter of a West Nile outbreak, but also an epicenter of the nation’s foreclosure crisis. Since the collapse of the US housing market in 2006, home foreclosures in the United States had jumped by 225 percent, leading to the repossession of more than 6 million American homes. Bakersfield’s situation was even worse; it was at the center of California’s mortgage lending bubble, and soon became the center of the foreclosure meltdown that followed. The city had experienced a 300 percent rise in mortgage delinquency as the national foreclosure crisis began, ranking eighth among the worst-affected American cities. Almost two percent of Bakersfield homeowners had filed for foreclosure; the town of about 300,000 people listed more than 5,000 abandoned homes as the recession began. When people’s homes were foreclosed and repossessed by bankers, their backyards were abandoned. Weeds overgrew, swimming pool water turned stagnant, and algae bloomed—creating the perfect breeding ground for mosquitoes.8

  But West Nile Virus was not the worst public health outcome of the foreclosure crisis. The gravest risks to public health came from the rise of homelessness. When people lose their homes and live on the streets or in substandard housing, their health deteriorates. The homeless experience constant stress, and are more likely to skip medications and visits to the doctor. In the worst cases, if they lose all forms of shelter, they face a heightened risk of assault, death from cold exposure, severe mental health problems, substance abuse, and of landing in jail, the hospital, or the morgue.9

  Public housing and housing benefits are the best medicine for counteracting the health risks of homelessness. But different governments responded in very different ways to the housing crisis brought on by recession, with dramatically different results for the health of their citizens. The United States and the United Kingdom both experienced political regime changes during the Great Recession. These transitions played a critical role in how the American and British governments responded to their foreclosure crises, with subsequently different outcomes for public health. With the American Recovery and Reinvestment Act of 2009, enacted by Congress and signed into law by President Obama, the US government began investing in social protection programs to stop foreclosures from leading to homelessness. Costly hospitalizations, premature deaths, and infectious disease rates related to homelessness were all significantly reduced in the subsequent months. By contrast, the Conservative government that came to power in 2010 in the UK, while not facing as severe a housing crisis as the US, began instituting radical measures, which included cuts to housing support budgets. Homelessness increased following these measures, bringing with it a surge in avoidable hospitalizations and disease outbreaks.

  It has long been known that housing is a precondition for good health. Homeless persons are among society’s most vulnerable groups. People without homes tend to die forty years earlier than those with a roof over their heads. They often suffer from a raft of health problems and lack adequate access to healthcare. In addition, the homeless are at high risk of contracting infectious diseases like TB, which can then spread to the rest of the population. Poor health and homelessness are so closely linked that it is difficult to ascertain which came first, but the public health outcome is the same: a huge increase in the risk of death and avoidable suffering.10

  While the relationship between homelessness and disease has long been common knowledge, the foreclosure crisis during the Great Recession taught us something new: the threat of foreclosure can contribute to illness even before anyone loses their home. As people struggled to pay their debts, the accompanying stress increased risks of suicide and depression, and many people were forgoing food and medicines to make their mortgage payments. A study of Americans over age fifty found that between 2006 and 2008, people who fell behind on their mortgage payments were about nine times more likely to develop depressive symptoms, 7.5 times more likely to experience “food insecurity” (meaning a lack of adequate nutrition and skipping meals), and nine times more likely to skip medicines, even after statistically controlling for pre-existing health conditions.11

  Because so many people couldn’t afford medicines, or were sacrificing healthcare to pay their debts, those facing the threat of foreclosure were more likely to experience disease complications that left them in emergency rooms. A large case-control study in Philadelphia compared hospitalization rates among people who had a home foreclosure notice (cases) with those matched for age, gender, sex, residential area, and health insurance status but who didn’t face for
eclosure (controls). The study found that between 2005 and 2008, people whose homes had a foreclosure notice were at a higher risk of ending up in a local hospital than the control group. Within the six to twenty-four months before the date of foreclosure, people who had a foreclosure notice were 50 percent more likely to visit the emergency room. The two main causes were high blood pressure and kidney failure related to diabetes, conditions that should not result in hospitalizations unless people were for-going medications.12

  Once people’s homes were actually foreclosed and people forced to leave, their risks of ending up in the ER jumped even higher. As people skipped necessary medicines during the recession in Arizona, California, Florida, and New Jersey, a strong correlation emerged between the rates of home foreclosures in communities and rates of emergency room visits. When we looked across all zip codes between 2005 and 2007, at the peak of the foreclosure crisis, but before unemployment rose, those zip codes with higher foreclosure filings had greater risks of emergency room visits, even after adjusting for housing prices, unemployment, migration, and historical trends in ER visits among those communities. On average, each additional 100 foreclosures were found to correspond to a 7.2 percent rise in emergency room visits and hospitalizations for high blood pressure, as well as an 8.1 percent jump in diabetes-related complications, mostly among people under age 50. Between 2007 and 2009, emergency rooms visits surged by 6 million people over and above the number expected during normal periods.13

  While it was clear that foreclosure posed a serious threat to Americans ending up in emergency rooms, the real danger to their health was if they had no place to live. Whether more people became homeless during the recession ultimately depended on how governments chose to respond.

  When President Obama came into office, the foreclosure crisis was escalating. Since the housing bubble collapsed, the nation’s foreclosed population nearly tripled from one in 476 house holds in 2007 to one in 135 in mid-2009.14

  This wave of foreclosures put enormous pressure on public housing systems, at a time when they were already overstretched. It’s often forgotten that US homelessness rates were already at record highs after Hurricanes Katrina and Rita in 2005, which had displaced thousands of families in New Orleans and on the coast of Texas.

  Even before the burst of new foreclosures, public housing services were unable to keep pace with Americans’ need for housing assistance. In 2007, a study of 23 large US cities found that half of the cities’ public housing programs had to turn people in need of shelter away due to a lack of capacity. While some people experiencing homelessness managed to find temporary housing arrangements—for example, with friends or relatives—others were not so lucky. Before the Great Recession hit, nearly 40 percent of homeless people were living on the street, in a car, or in another place not intended for human habitation. As Neil Donovan, executive director of the National Coalition for the Homeless, explained at the time, for these people, “the U.S. housing safety net isn’t just frayed, it’s missing.”15

  When foreclosures increased in the United States during the Great Recession, homelessness rose in step. Between 2008 and 2009, more than half a million additional houses were foreclosed. In turn, at least 20,000 additional people became homeless during the same period. In 2009, about 1.6 million people (about one in every 200 persons in the US) used an emergency shelter in at some point. But more than 250,000 homeless people were unsheltered—living in abandoned ware houses, parks, cars, and back alleys among other places not intended for human residence.16

  Children were among the most tragic victims of the foreclosure crisis. The number of children living without homes increased from 1.2 million in 2007 to about 1.6 million in 2010, or about one in every forty-five American children. Reporters found that in some towns plagued by foreclosure, school buses had to stray from their usual routes to stop in Wal-Mart parking lots, where parents had parked their vans and converted them into make-shift homes. Bedbugs and scabies were but a few of the health problems facing these homeless children.17

  Homelessness leaves a permanent mark on the health of people who experience it. In the worst of cases, it can be lethal. During the recession in the United States, the homeless were estimated to have been about thirty times more likely than the rest of the population to die from the effects of illegal drugs, 150 times more likely to be fatally assaulted, and thirty-five times more likely to kill themselves. On average, US homeless persons were experiencing a life expectancy on par with that of people in war-torn Sierra Leone and the Congo.18

  The city of San Francisco’s foreclosure crisis put the nation’s problems in perspective. Between 2007 and 2008, San Francisco’s housing programs couldn’t keep up with demand and had to expand wait-lists by 50 percent for families and individuals to access emergency shelters. An analysis of data from California estimated that approximately thirty-seven house holds entered the shelter system for every 1,000 foreclosure filings, even after adjusting for poverty rates—meaning that those pushed into homelessness by foreclosure weren’t simply those who were already likely to need assistance. More people were being turned away, and their health problems were putting a tremendous burden on the healthcare system.19

  Thomas, a man in his forties, was one such case. He had lost his home and become an alcoholic. Sanjay met Thomas at San Francisco’s Housing and Urban Health Clinic, treating his numerous injuries and a seizure problem caused by his drinking. He also landed on the city’s list of “high utilizers” of the emergency room, which is to say he cost the city an inordinate amount given the frequent injuries he suffered while drunk from getting into fights, being mugged, and even once falling down the stairs at a subway stop. Repeated attempts to persuade Thomas to stop drinking were unsuccessful.

  Sanjay could do little to treat the health consequences of homelessness in patients like Thomas. As another doctor explained, when homeless patients come to the clinic, treating their medical symptoms is “like giving someone aspirin for cancer.” Homelessness makes it hard for people to take medicines consistently as required for high blood pressure and diabetes, as co-payments for those medicines are expensive. Homeless persons also face extreme depression and anxiety, so they often self-medicate with drugs and alcohol. To treat all of these conditions, a homeless person would need up to ten different medications, and even then it is unlikely that they would work as intended without the security of stable housing.

  The best medicine for people without homes is simple and obvious: put a roof over their heads. It is an approach known as “Housing First,” because it first seeks to address people’s immediate need for shelter, before dealing with their other concerns. Of course, this costs money up front, but the evidence shows that it saves money (and lives) in the long run if done correctly.

  That is precisely what the US government began to do soon after President Obama took office. On May 20, 2009, Obama implemented a massive stimulus package to help people like Thomas and boost the economy. The Congress passed a $1.5 billion Homelessness Prevention and Rapid Re-Housing Program bill, creating a program designed to prevent victims of foreclosure from becoming homeless and to help those already homeless regain housing. As part of the program, local governments identified these people and helped them to find and pay for new places to live. The US Department of Housing and Urban Development (HUD) also used the funds to increase the number of emergency shelters and units for long-term housing.20

  Homelessness prevention programs, like those supported by the stimulus, helped Thomas get his life back on track. At the clinic, nurses and doctors had tried everything they could to help Thomas, but it was only when the city of San Francisco found him an apartment through its longstanding, but oversubscribed, Direct Access to Housing program that his underlying depression substantially improved. Thomas joined Alcoholics Anonymous and eventually recovered from his drinking problem. He now works as a chef’s assistant at a local restaurant, paying his rent and taxes, as well as avoiding the emergency room at the hosp
ital.

  Over the long run, San Francisco saved money by putting a stable roof over Thomas’s head. It turned out to be cheaper for the city to provide Thomas a modest apartment than to pay for his stays in hospitals and jails. A statistical analysis of programs like San Francisco’s Direct Access to Housing found that they often saved money for cities and states by reducing healthcare (and often jail) expenditures.21

  With support from Obama’s stimulus package, mayors in New York City, Denver, San Diego, Chicago, and Philadelphia soon began expanding Housing First programs similar to San Francisco’s. In Philadelphia, each group of 100 people housed saved the city $421,893 per year, over and above the costs of running the program and covering housing bills.22

  Across the United States, despite an historic housing and economic downturn, homelessness actually decreased between 2009 and 2011 in tandem with the rollout of HUD’s homelessness prevention program. Even as another 1.9 million homes were foreclosed in 2010, the homeless population actually fell. In 2010, the stimulus-financed program helped 700,000 at-risk and homeless people find shelter, and by 2012 it had averted homelessness for 1.3 million Americans.23

  The United Kingdom presented a stark contrast to the US example during the Great Recession. In the UK, housing had long been recognized as a public health issue. Government housing programs were considered so integral to health that the UK Housing Department was under the control of the Department of Health until 1951 (when the Tories defeated Labour, at which point housing was separated, seen partly as a move to weaken the power of the National Health Service). Before the Great Recession, the British Department for Communities and Local Government operated a successful social housing program analogous to the Housing First programs in the United States. Britons who qualified could receive housing subsidies of up to several hundred pounds per month—not a huge sum, but enough to help people keep a roof over their heads. British housing support had managed to keep homelessness at about two-fifths of US prevalence rates (about 1 homeless person per 500 people in the UK versus about 1 per 200 in the US) and had helped bring about a roughly 50 percent reduction in homelessness rates between 2000 and 2007.24