What happened to seeing homelessness as a "national obscenity"?

When Labor came to power in 2007, then Prime Minister Kevin Rudd put homelessness at the top of the agenda, labelling it our ''national obscenity'' and ordering his ministers to spend a night in a homeless shelter to see how many people were being turned away.

In the post below, Dr Lesley Russell looks at the failure of political leadership on housing insecurity since. She tracks its impact, particularly on health and wellbeing, and points to international models that are showing the way.

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Dr Lesley Russell writes:

Where we live is the very core of our daily lives and so has the potential to help or harm both our physical and mental health in very profound ways. Housing is not just about a physical dwelling, a roof over one’s head to shield from the elements and the environment, but about a home, a protective, safe, private refuge to which we have attachment and where we develop a sense of identity. The community in which that home is located and the quality of the surrounding environment are additional facts that impact on health and wellbeing.

Poor housing is a key social divide, even in rich, first-world countries like Australia, and the most disadvantaged are those who are homeless. Failure to see the role that the social determinants of health like housing and education play means a poor return on healthcare expenditure and guarantees that health disparities will never be eliminated.

Poor housing and indoor environments cause or contribute to many preventable injuries, infections and chronic diseases in a variety of ways. 

•   Poor design and construction of stairs, windows, balconies, and electrical and heating systems can cause injury and death; home is the most common place for accidents to occur and is second only to the road as the location of most accidental deaths in Australia.

 •   The use of improper building materials and construction can mean contamination with chemicals, asbestos or mould, leading to cancer, lead poisoning, allergies and respiratory problems.

 •   When there is no ability or no money to control temperatures this leads to risky behaviours with heating and the increased likelihood of injury or death from carbon monoxide poisoning and fire. The very young and the very old are especially vulnerable to extremes in temperatures which also lead to increased mortalities.

 •   Residential crowding is linked to illnesses like respiratory diseases, infectious diseases and psychological distress. In crowded conditions, stress factors like harmful alcohol and substance use and domestic violence are magnified. Even when factors such as education, income and employment are controlled, overcrowding still has a significant effect on health, especially for children.

In addition to housing, related issues like a supply of safe drinking water, electricity sewerage and rubbish collection, along with neighbourhood factors such as social cohesion, environmental quality, and access to services such as transport, schools, shops and healthcare are also necessary to ensure good health.

The threat of housing insecurity to health

The ability to provide adequate and stable housing is an important aspect of family life and contributes to a sense of control and self-worth. In Australia, home ownership is often seen as a rite of passage to adulthood. Home ownership does not appear to have a direct impact on health outcomes, but when high rental costs take a substantial proportion of income this reduces the ability to buy other essential goods and services. This is the situation for many Australians as housing costs have risen out of all proportion to income, even when controlled for inflation.

What is clear is that homelessness and the risk of homelessness is a very real threat to health.  The same people who are most at risk of homelessness - the poor, Indigenous Australians, those with a mental illness, prisoners and women and children who experience domestic violence - are also those with the least access to primary care. A vicious cycle is quickly established as poor health - leading to the loss of employment and income - is a major cause of homelessness. Individuals experiencing homelessness have higher rates of acute and chronic illness and many of these people have incredibly high rates of use of expensive healthcare service such as Emergency Departments and hospitals. Even if they get needed healthcare, without housing to return home to, their recovery and healing is compromised and delayed.

This is particularly true for those with mental illness. There is an intimate link between homelessness and mental health and too often there is a failure to recognise that a secure home is a fundamental basis for improving mental health and preventing mental illness. 

In 1995 Human Rights and Equal Opportunity Commissioner Brian Burdekin wrote:

“Living with a mental illness - or recovering from it - is difficult even in the best circumstances. Without a decent place to live it is virtually impossible.” 

Addressing this issue requires more than the ad hoc provision of shelters for those sleeping rough; if we fail to address this need, mental health care will continue to be mostly crisis (hospital) based, and people with mental health problems will continue to be discharged from hospital and prisons with no ability for the provision of their ongoing treatment and support, despite evidence of the benefits of community care.

Poor quality, overcrowded housing and a lack of the usual amenities that go with housing like water and electricity to facilitate washing, laundry, and the safe storage of food, are major contributors to the disadvantage and health disparities experienced by Indigenous Australians, especially those who live in remote areas. This leads to a range of infectious diseases of the skin, eyes and ears, respiratory infections and rheumatic fever - some of these conditions are seen only in Indigenous people and they have a huge impact on the normal development and education of Indigenous children.

It is shocking that in a prosperous country like Australia that prides itself on a fair go for all that an estimated one million people live in substandard housing and one in every 200 people are homeless. A staggering one in eight Australians have been homeless at some point in their lives. Perhaps as many as one-third of Indigenous households live in dwellings with major structural problems (e.g. rising damp, major cracks in floors or walls, major electrical/ plumbing problems and roof defects) and in remote communities many Indigenous people live in temporary or improvised dwellings.

Obviously action is needed, but politicians seem more focused on first world problems like the housing bubble and the pros and cons of negative gearing rather than the third world problems that face many Australians who are living in unsafe housing or who are homeless.

Turning away from The Road Home

In 2008 the Rudd Government commissioned a White Paper on homelessness The Road Home: a national approach to reducing homelessness.  Prime Minister Rudd called homelessness a “national obscenity” and agreed to two headline goals: to halve homelessness and to offer supported accommodation to all people sleeping rough by 2020. The Council of Australian Governments committed over $800 million over four years (2009-12) to a National Partnership Agreement on Homelessness, a 55 percent increase in funding. A new agreement, providing $250 million over two years was commenced in July 2015.

But the opportunity to implement real change is now seen as wasted. The innovative, evidence-based ideas that underpinned the proposed reforms did not take hold, and today, as political leadership in this area has evaporated, the majority of funding is still directed towards transitional support linked to short- and medium-term emergency accommodation.

It’s no surprise then that the number of homeless people, including families with children, continues to grow.  There are large costs as a consequence.  A recent study that looked at ‘rough sleepers’ in inner Sydney found that their costs to government and non-government agencies was between $15,900 and $35,000 per person per year.

The cost of bringing substandard housing up to standard is unknown but intimidatingly large. However there is also the possibility of substantial savings if this is done well. In 2011 it was estimated that it would cost £10 billion ($16 billion) to improve all 3.5 million poor homes in England, but that this would save the National Health Service £1.4 billion pounds in treatment costs in the first year. On the health basis alone, such an investment would pay for itself in seven years, with benefits beyond that.

It is clear that efforts to Close the Gap on Indigenous disadvantage will not succeed without a coordinated effort to address housing problems. Efforts to tackle health issues like scabies, ear and eye health and rheumatic fever, education issues like school attendance and community safety issues like family violence all demand suitable housing.  Considerable funds have been spent in this regard, but too often without community consultation, and so have made little difference.  Last November Indigenous Affairs Minister Nigel Scullion acknowledged these failings and announced an Indigenous-led, independent review into remote Indigenous housing to “explore practical and innovative solutions to address the inadequate conditions and supply in remote Indigenous housing”.

Innovative approaches from overseas show that bold moves and substantial upfront investments are necessary to make a lasting difference to poor housing and homelessness. The American Housing First model, as implemented in Utah and Colorado, isn’t just cost-effective, it’s effective. Finland has a similar model that has seen it as the only European country to reduce homelessness. Housing costs are major contributor to poverty and substandard housing in Australia, and the community as a whole pays the price in poor health and education outcomes. 

Policy makers and bean counters at all levels of government need to examine the costs of poor housing and homelessness to their budgets - and add in alarge dash of compassion and forward vision. Then we might see some action on this blight to our society.

Dr Lesley Russell is an Adjunct Associate Professor at the Menzies Centre for Health Policy at the University of Sydney.