Public Health and Urban Planning

Photo courtesy of Free Stock photos by Vecteezy

The disciplines of public health and urban planning have a long tradition of working in symbiosis. Ancient Romans practiced sound public health when they built army barracks far from swamps to prevent insects from spreading diseases among the troops. During the medieval period in Europe, monasteries were models of cleanliness, built mostly on the outskirts of densely-packed towns or in the countryside. These structures “had fresh running water, ‘lavers’ (wash rooms), flush ‘reredorters’ (latrines) connected to sewers, clean towels and a compulsory bath four times a year.”

While much progress has been made in the years since, the infrastructure of cities and towns still plays a major role in people’s health outcomes. This realization has, in recent years, occasioned a resurgence in collaborations between public health practitioners and urban planning experts. According to Whitney Austin Gray, PhD, faculty member of the Urban & Regional Planning program and Executive Director of Research and Innovation at Georgetown University, in the U.S., the fields of public health and urban planning began drifting apart in the 1950s when the public health community “started focusing more on the individual, and in doing so, looked at pharmaceutical interventions” to fix public health problems. 

Only recently, Dr. Gray says, have experts in public health and urban planning rediscovered each other. In so doing, they have begun looking at chronic diseases on a population level which, in her words, “urban planners are the best suited to do.”

This reinvestment in city planning as a way to help solve public health issues is necessary in a country like the U.S., which is so heavily dependent on cars. Indeed, says Leslie Meehan, Deputy Commissioner for Population Health at the Tennessee Department of Health, “when you look outside of the the coastal areas, there’s not a lot of public transit and so what we are finding is that housing which is close to where people want to work, where the grocery stores are, where the parks are, where the schools are,” is getting more and more expensive.

Nowhere is this situation more true than in the Northern Virginia suburbs of Washington, DC. As in most affluent parts of the U.S., some residents of these suburbs live in comfortable conditions while others live in relative squalor. To highlight this dichotomy and the preconditions that often lead to it, I’d like to focus on the supply of adequate, affordable housing in Fairfax County, Virginia as an important cause of divergent health outcomes on a county level.

A Social Determinants Lens

Before we get into specific strategies for making housing more widely accessible in Fairfax County, Virginia, we should first set a foundation for how to look at these issues through a social determinants of health (SDOH) lens. As defined by the World Health Organization, SDOH are “the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”

From a public health perspective, healthcare providers are becoming more active in addressing the social drivers of negative health outcomes, including how to manage the housing needs of their patient populations. The author of an article called “Social Determinants of Health 101 for Health Care: Five plus Five,” asserts that accountable care organizations (ACOs) “are responding to nonmedical needs of patients such as transportation, housing, and food with the assumption that outcomes and cost will improve.” Adding to this, author and social epidemiologist Steven H. Woolf notes that “Good health requires access to high-quality housing and transportation, clean air and drinking water, and stores that sell healthy food.”

Photo courtesy of Free Stock photos by Vecteezy

Relatedly, in 2023, Medicaid section 1115 waivers have been approved in states like California, Arizona, and Arkansas to help people afford housing. Although Virginia does not appear to have any such active waivers (with the possible exception of the “VA Building Independence Waiver” which expires in June of 2023), an interesting past example of how the state attempted to address the SDOH of its Medicaid enrollees was in 2016 when Virginia’s Department of Medical Assistance Services (DMAS) submitted a §1115 waiver application for a program called the “Virginia Delivery System Transformation Section 1115 Demonstration.”

This proposed demonstration project sought authority to implement two initiatives: Medicaid Managed Long-term Services and Supports (MLTSS) and the Delivery System Reform Incentive Payment (DSRIP) programs. Alignment of these two programs aimed to “strengthen and integrate Virginia Medicaid’s community delivery structure and accelerate payment reforms toward value-based purchasing.”

The first phase of Virginia’s DSRIP proposal was meant to support the creation of high-performing, integrated partnerships known as Virginia Integration Partners (VIPs). The VIPs would partner with managed care organizations to improve care for high-cost enrollees, providing resources in the community to help “connect the VIP beneficiaries to housing, employment, and nutrition supports.” While it looks like this waiver never came to fruition, it marks one possible avenue of collaboration between, as the waiver application words it, “medical, behavioral health, and long-term services and support providers” that would be “anchored by strong care navigation and community supports.”

An Uneven Distribution of Resources

Access to safe, affordable housing varies widely depending on one’s zip code in Fairfax County, Virginia. To bring the challenge into sharper focus, it is helpful to examine a few relevant housing-related data points. Since one’s income often determines the level of access one has to safe housing, it will help to start there.

According to the U.S. Census Bureau, for the 2017-2021 reporting period the median household income in Fairfax County was $133,974. By contrast, the real median household income in the United States for the same period was $70,784. Relatedly, as of 2020, out of a population of 1,150,305 people, 72,584 Fairfax County residents lived in poverty. This equates to around a 6% poverty rate. Given that the median poverty rate of all counties in the U.S. was 12.8% in 2020, at first glance this would suggest that Fairfax is doing relatively well compared to most counties.

But when one looks closer, a different picture begins to emerge. Because housing affordability plays a major role in people’s ability to thrive in their day-to-day lives, this variable must also be taken into account when assessing the area’s standard of living. According to one report, “Fairfax County has a median home value of $569,100 and a median rent of $2,033 — about twice as high as the national averages of $244,900 and $1,163, respectively.”

The problem of home affordability has grown to nearly unsustainable levels in recent years. Indeed, according to a needs assessment published by the Fairfax County Department of Management and Budget in 2022 (PDF version here), “the Washington-Arlington-Alexandria area saw inflation in housing-related costs of 5.4% from May 2021 to May 2022, and a rise of 23.5% over ten years.”

This trend has caused a rift among those who can afford housing in the county versus those who can’t, and is most pronounced among renters:

“While the proportion of Fairfax County homeowners who are cost burdened has steadily decreased over time, the proportion of cost burdened renters continues to rise. Cost burden occurs when 30% or more of household income is spent on housing costs. Additionally, when 50% of household income is spent on housing, this household is considered severely housing cost burdened.”

A County in Crisis

When looked at this way, it begins to make sense why some are saying that Fairfax County is in a “severe housing affordability crisis.” A number of factors often contribute to the relative lack of housing opportunities for lower socioeconomic residents, but one key one key consideration is the problem of racism. Despite past reports by entities like the Fairfax County Office of Human Rights and Equity Programs that detail discriminatory lending practices, my research shows that quantifying housing inequality on a county level remains a somewhat elusive goal.

That being said, we know that on a national level, housing inequality impacts people of color more acutely than it does their white counterparts (as I explored in a previous blog post). As defined by the foundational article “Levels of Racism: A Theoretic Framework and a Gardener’s Tale” by Camara Phyllis Jones, MD, MPH, PhD, racism can be thought of as taking one of three forms: institutionalized, personally mediated, or internalized racism. When looked at through this prism, although partaking of all three causes in one way or another, the housing crisis in Fairfax County most closely aligns with Dr. Jones’ definition of institutionalized racism:

“In this framework, institutionalized racism is defined as differential access to the goods, services, and opportunities of society by race. Institutionalized racism is normative, sometimes legalized, and often manifests as inherited disadvantage…With regard to material conditions, examples include differential access to quality education, sound housing, gainful employment, appropriate medical facilities, and a clean environment.”

Photo courtesy of Free Stock photos by Vecteezy

To put this challenge of institutionalized racism as it pertains to housing inequality into context (PDF version here), it is instructive to look at our example of Fairfax County, Virginia. In Fairfax, the split between those who can afford to own their own home breaks down along racial lines, since white homeowners outstrip their share of the population, whereas the reverse is true for all other races: “White residents own homes at a rate greater than their share of the population, while residents of all other races and Hispanic residents own homes at rates less than their share of the population.”

The report makes the point that because homeownership is a key element to wealth accumulation, the ability of racial and ethnic minorities in the county to improve their financial situation is limited. An important subset of this demographic is immigrants, who make up a substantial part of the population of Fairfax County – indeed, nearly 350,000 foreign born persons call the county home, which as of 2021 represented about 30% of the county’s population. For those immigrants who are considered undocumented, a number that is hard to know but which was estimated to be 269,000 state-wide in 2016, the prospect of attaining affordable, safe housing presents substantial challenges.

Statistics are one thing, however, and personal accounts are quite another. Participants in one study that aimed to understand the impact that the Deferred Action for Childhood Arrivals (DACA) program had on on “health access, status, and behaviors” of Asians and Pacific Islander (API) undocumented young adults, really brings this issue into focus. One study participant noted her frustration that even though DACA deferred her and her family’s deportation, which was a positive, it ignored other issues that contributed to her loved ones’ worsening health:

“People would always talk about the ‘American Dream.’ What is it? You have people living here in the United States but there’s no American dream for them. But I would kind of like lay awake there crying and wish like, ‘why can’t I have that house? Why can’t I have that white picket fence? Why can’t I have the green grass? Why can’t my family have that benefit of getting healthcare?'”

Solutions to the Home Affordability Issue

So what can be done to help people struggling to afford a home in Fairfax County, Virginia? Thankfully, positive steps are already being taken to alleviate the county’s housing dilemma. In 2019, for instance, the Fairfax County Board of Supervisors endorsed something called the Communitywide Housing Strategic Plan. This plan identified ways to develop affordable housing, and one of its goals was to build a minimum of 5,000 new affordable housing units within the next 15 years. Two years later the Board of Supervisors approved doubling that number to 10,000 net new units.

Further, as part of the 2023 Fairfax Countywide Strategic Report, it was noted that the Fairfax Board of Supervisors recently adopted something called Indicators of Community Success. These guidelines will help the county focus on improving not just access to “affordable and quality housing,” but on other residential issues such as “access to amenities that promote healthy neighborhoods; flexibility and adaptability of land use rules; and a mission to prevent and end homelessness.”

While all of this is definitely a step in the right direction, I would argue that efforts should be increased when it comes to building new housing. A recent exploration by U.S. News & World Report gave Fairfax County a substandard housing capacity rating, finding that only 4% of the county’s homes were vacant as compared to the national median of 16.3%. A new regional fair housing plan put together “by a team of representatives from eight localities, including Fairfax County, and a few partner groups” seems to be on the right track.

In part, the plan calls on the county to “change zoning and land use policies to expand access to fair housing,” along with  lowering income requirements for residents. The comment period for this plan recently closed, so it will be interesting to keep up with this story to see the direction affordable housing takes in Fairfax County.

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