May 2018 Housing and Health in New York City: Perspectives From Low-Income Communities A Report of Focus Group Findings New York City Population Health Improvement Program May 2018 Maya Scherer, MPH | Alexandra Kamler, MPH | Elisa Fisher, MPH MSW | Linda Weiss, PhD INSTITUTE FOR URBAN HEALTH FELLOWS LIBRARY 3INTRODUCTION Table of Contents 4BACKGROUND 5METHODS 12FINDINGS 13 Housing Quality and Maintenance 14 Housing Affordability 19 Landlord-Tenant Relationships 21 Housing Related Services and Resources 23 Resident Engagement 24 The Role of Health Care Providers 25 Safety and Violence 20 Participants’ Recommendations for Improvement 30LIMITATIONS 31CONCLUSION 33 APPENDIX 1: HOUSING ISSUES AMONG OLDER ADULTS 34 Multigenerational Housing 34 Accessibility 35 The Negative Impact of Dislocation on Older Adults 36 Impact of Violence and Crime on Older Adults 37 APPENDIX 2: LIVING IN PUBLIC HOUSING 40 Community Member Recommendations 40 Policy Perspectives 43 APPENDIX 3: IMPACT OF HURRICANE SANDY ON HOUSING 45 APPENDIX 4: FOCUS GROUP DATA COLLECTION INSTRUMENTS NYAM.org INTRODUCTION In January 2015, the New York City Population Health Improvement Program (NYC PHIP) was launched as a collaboration between the Fund for Public Health in New York, the New York City Department of Health and Mental Hygiene (NYCDOHMH), the United Hospital Fund (UHF), and The New York Academy of Medicine (the Academy). The NYC PHIP one of 11 such bodies around the state, is funded by the New York State , Department of Health. It is tasked with aligning various health reform activities to support population health, promoting the "Triple Aim" of better care, lower health care costs, and better health for New York City (NYC) residents, and supporting the City in achieving the health equity targets outlined in Take Care New York 2020 (TCNY2020)– the City's blueprint to address health equity. Each year, the Academy conducts focus groups on selected topics, gathering community perspectives to generate recommendations on how to best achieve health equity in NYC in order to inform the work of the NYC PHIP and its partners. In 2017, the focus group topic was housing, including the impact of housing on physical and mental health, as well as relevant barriers to and supports for healthy housing conditions. The report is intended to be used by the NYCDOHMH in its efforts to bridge the health and housing sectors in order to promote healthy housing in low income NYC neighborhoods and tailor programs and policies to meet the needs of specific communities and populations. It is being made publicly available to be of use to those working at the intersection of housing and health. Housing and Health in New York City: Perspectives From Low-Income Communities 3 BACKGROUND A large body of evidence documents the significant impact of housing on health. Living in poor quality or overcrowded housing, or experiencing unstable living conditions (e.g., temporary housing, living with the constant threat of eviction), increases risk for incidence and poor management of health conditions including depression, anxiety and other behavioral and mental health issues as well as asthma, communicable diseases, cardiovascular disease, and disability.i,ii,iii,iv,v,vi,vii These living conditions can also lead to premature mortality.vii Furthermore, high rent burdens limit resources available for other health necessities, such as health care and healthy food.ix Harvard University’s Joint Center for Housing Studies reports that severely rent-burdened households with children (those spending over 50 percent of their income on rent) spend 75 percent less on health care than those with lower rent burdens.x Housing has historically been and continues to be a public health challenge in NYC. Today, one in three New York City residents is severely rent burdened, and 56 percent of renters live in homes with at least one health hazard.xii Gentrification in NYC further contributes to housing challenges, as long-time community residents struggle to keep up with rising rents and are often displaced from neighborhoods where they have built social networks and support systems. These burdens fall disproportionately on people and communities of color, contributing to health inequities across NYC.xiii,xiv NYAM.org 4 METHODS Findings presented in this report are based on data from five focus groups. The focus groups were conducted in November and December 2017, in partnership with community based organizations (CBOs) located in five NYC neighborhoods of interest. In partnership with the NYCDOHMH, one neighborhood was selected in each borough, with the goal of representing diverse communities and neighborhoods. Some of the selected neighborhoods are undergoing gentrification or in a flood zone because these experiences were of particular interest to the NYCDOHMH. Specific details on the focus groups are provided in Table 1. Focus groups were facilitated by two Academy staff and lasted for approximately two hours. Four of the groups described in this report were conducted in English and one was conducted in Spanish by bilingual Academy staff members using professionally translated materials. A semi-structured guide was used to elicit participants’ views on connections between housing and health. Participants were also asked about their experiences with and perspectives on affordability and access to housing, gentrification, housing composition, the implications of high housing costs on meeting other basic needs, landlord-tenant relations, housing quality and maintenance, safety, resources and services that support healthy housing, and recommendations to improve housing. Participants also completed a brief questionnaire to gather basic sociodemographic and health and housing-related information (see Appendix 4 for the focus group guide and brief survey). Participants were informed that their involvement in the research was completely voluntary and confidential, and were asked to provide verbal consent. Each participant also received a $30 incentive. Focus groups were audio recorded and professionally transcribed. The Spanish language recording was professionally translated. Transcripts were managed and coded using NVivo, a software package for qualitative data analysis. A coding scheme (with definitions) was developed that included pre-identified and emergent themes. The project protocol and all instruments were reviewed under expedited procedures and approved by the Academy Institutional Review Board. Housing and Health in New York City: Perspectives From Low-Income Communities 5 Characteristics of Focus Group Participants The characteristics of focus group participants and their reported housing information are shown in Tables 2 and 3 respectively. As shown in Table 2, most participants were 50 years of age or older (68%) and approximately two-thirds (65%) were female. Over half (60%) identified as African American. Twenty-nine percent were Hispanic/Latino and four percent were White. One-fifth of participants were born outside of the United States. One quarter did not graduate from high school, and close to one fifth (18%) earned a college degree or higher. Thirty-five percent of participants were not working or unable to work and one-quarter were employed full-time. In the past year, three- quarters (76%) of participants were “always” or “sometimes” worried about paying for food and/or housing. The most commonly reported health issues were: difficulty sleeping (38%), depression and/or anxiety (35%), diabetes (35%), arthritis (29%), and chronic pain (22%). Table 3 shows participants’ housing information and experiences. Fifty-eight percent of participants currently live in NYC Housing Authority (NYCHA) developments. Just over half (53%) had lived in their current neighborhood for more than ten years. Forty- percent of participants reported living alone. Approximately one-fifth (22%) receive Section 8 vouchers (a housing subsidy for low income individuals). Almost two-thirds (60%) reported that half or more of their monthly income is spent on housing. Forty-percent of participants reported that they had not experienced any housing issues in the past five years. Of those who had issues, the most common were dangerous housing conditions (for example, broken elevator, poor lighting, unsafe construction, peeling paint) (35%), pests and rodents (29%) and severe mold or leaks (24%). When answering who they would ask for help with housing issues, approximately half indicated city agencies (55%) or their landlord, super or building manager (45%). Thirty-five percent indicated a ‘friend or family member’ and one- quarter indicated a community organization would be asked to assist. NYAM.org 6 TABLE 1: FOCUS GROUP SITES AND PARTICIPATION COMMUNITY- NUMBER OF BOROUGH NEIGHBORHOOD BASED PARTNER PARTICIPANTS Bronx Mott Haven Mitchell Resident 11 Association (NYCHA) Brooklyn Bedford- Northeast 10 Stuyvesant Brooklyn Housing Development Corporation Manhattan Washington Washington 8 Heights* Heights CORNER Project Queens Rockaway Rockaway Institute 13 for a Sustainable Environment Staten Island Stapleton Stapleton Senior 12 Center *Spanish language group Housing and Health in New York City: Perspectives From Low-Income Communities 7 TABLE 2: PARTICIPANT DEMOGRAPHIC CHARACTERISTICS (N=55) N (%) AGE 18-34 8 15% 35-49 9 16% 50-59 14 25% 60-74 21 38% 75 and older 3 5% GENDER Female 36 65% Male 17 31% Missing 2 4% RACE / ETHNICITY* Black / African American 33 60% Hispanic / Latino 16 29% Other 7 13% White 2 4% COUNTRY OF ORIGIN U.S. born (including U.S. territories) 41 75% Non-U.S. 11 20% Missing 3 5% EDUCATION Not HS graduate 14 25% HS graduate / VOC training 17 31% Some college, no degree 14 25% College degree or higher 10 18% (continued on page 9} NYAM.org 8 N (%) WORK STATUS* Employed full time 14 25% Employed part time 6 11% Not working/ Unable to work 19 35% Retired 15 27% Homemaker/Caregiver 3 5% Other 4 7% CONCERNED ABOUT MONEY FOR FOOD/HOUSING IN PAST YEAR Always/Sometimes 42 76% Rarely / Never 13 24% CURRENT HEALTH CONCERNS Difficulty Sleeping 21 38% Depression / Anxiety 19 35% Diabetes 19 35% Arthritis 16 29% Chronic Pain 12 22% Asthma / Breathing Issues 8 15% Severe Allergies 8 15% Overweight / Obesity 7 13% Experienced a fall 6 11% Heart Diesease 6 11% Mobility Issues 6 11% Other 6 11% Mental Health Challenge or Illness 4 7% Cancer 3 5% None 3 5% Missing 1 2% *Multiple Response Allowed Housing and Health in New York City: Perspectives From Low-Income Communities 9 TABLE 3: HOUSING INFORMATION (N=55) N (%) TYPE OF CURRENT HOUSING Public Housing 32 58% Private Housing (rent) 15 27% Private Housing (own) 4 7% Other 4 7% YEARS RESIDED IN CURRENT NEIGHBORHOOD Less than 1 year 2 4% 1-4 years 8 15% 5-10 years 16 29% More than 10 years 29 53% # OF PLACES LIVED IN PAST YEAR 1 46 84% 2 3 5% More than 2 5 9% Missing 1 2% I LIVE WITH * I live alone 22 40% Partner/Spouse 15 27% Children 12 22% Other Family Members 12 22% Other non-relatives 1 2% PORTION OF MONTHLY INCOME SPENT ON HOUSING Half or more 33 60% Less than half 20 36% Missing 2 4% (continued on page 11} 10 NYAM.org N (%) RECEIVE SECTION 8 VOUCHER TO PAY RENT No 43 78% Yes 12 22% HOUSING ISSUES EXPERIENCED IN PAST 5 YEARS None 22 40% Dangerous housing conditions 19 35% Mice, cockroaches or bedbugs 16 29% Severe mold or leaks 13 24% Harassment by landlord 10 18% Could not pay mortgage/rent on time 9 16% Wanted to move to larger space but unaffordable 8 15% Eviction 4 7% Moved to larger space because of growing family 3 5% Forced to move due to natural disaster 2 4% Forced to move because cannot afford costs 1 2% WHO WOULD YOU ASK FOR HELP WITH HOUSING ISSUES?* City Agencies 30 55% Landlord, super or building manager 25 45% Friend or family member 19 35% Community organizations 14 25% Other 6 11% Missing 3 5% *Multiple Response Allowed Housing and Health in New York City: Perspectives From Low-Income Communities 11 FINDINGS In the following sections, we describe participants’ perceptions of housing and its connection to health. Themes discussed include: 1. Housing quality and maintenance and its impact on health; 2. Housing affordability, including the impact of rising rents, dislocation, gentrification, crowding, and competing financial obligations on health; 3. Landlord-tenant relations in private and public housing; 4. Housing related services and resources available to participants and community members; 5. Resident engagement in addressing housing issues and advocating for change; 6. The role of health care providers; 7. Safety and violence; and 8. Recommendations regarding approaches to improved housing conditions for low-income NYC residents In appendices, we also describe findings on three special topics: Appendix 1: the experience of older adults; Appendix 2: the experiences of NYCHA residents, including their attitudes toward policies on smoking and on restrictions regarding residents with criminal records; and Appendix 3: the experience of individuals affected by Hurricane Sandy. In each section, we report themes from discussions and include quotes from focus group participants. The quotes represent the perspective of the participant and their assessment of their housing, health and the context in which they live. NYAM.org 12 Housing Quality and Maintenance Poor housing quality and maintenance were mentioned as persistent problems across focus groups. In both public and private housing, participants described living with peeling paint, mold, collapsed ceilings, leaks, bugs, rodents, asbestos, and lead paint. They explained that living under such deteriorated conditions exacerbated physical and mental health concerns. With the rodents and the mice and the mold and the place not being cared for properly, it affects your mental health, too. It’ll trigger—if you have somebody that suffers from depression, and you’re living in a place that’s mouse and rat- infested with roaches, that’ll trigger your depression in a minute, and you’re back in the hospital. (Bedford-Stuyvesant) My wall had mold and asbestos, the roof fell…Everything was a mess and all that dirt and everything, when I was inside then my eyes were red, my nose, once I had to clean my nose, that was black. I was breathing all that inside me, in my lungs. (Washington Heights) Your kid can go and have pneumonia, because they didn’t want to come fix that heat. And you keep calling. Then, they don’t want you to put on—they say that you can’t do your stove. You can’t put a pilot on because of carbon monoxide, but how you want us to sit there and keep our family warm, in the morning time they have to go to school. You’re afraid if you have any kids, to put the heaters in there, because you don’t want them to burn themselves. You don’t want nothing to get on fire. (Mott Haven) Disease management was also impacted by housing conditions. For example, a participant in Bedford-Stuyvesant was without power for three days, despite complaints to her landlord. During that time, she was unable to use prescribed medical equipment. In Staten Island, a couple—one with cancer—living in a NYCHA apartment, had difficulty replacing a broken stove and refrigerator making it challenging to prepare healthy meals. I sleep with the machine because I don’t get enough air to my brain. You know how it was not sleeping for three days because I had no machine? You know what the man told me on the phone? “I’m so sorry. That’s not our problem.” (Bedford-Stuyvesant) Housing and Health in New York City: Perspectives From Low-Income Communities 13 I had a little toy stove. I mean, a toy stove. It kept breaking down…My husband, he’s sick. He [has] stage 4 cancer. And I had to…I’ll go and buy a stove. Refrigerator kept breaking down. I had to go and buy my own refrigerator… When it come[s] down to my husband health, he [has] to eat special food… and you could smell the gas when they fix it. You not playing with my life. (Stapleton) Housing Affordability Participants frequently described challenges related to the high cost of housing in NYC, including challenges around rent, dislocation, and gentrification. They also discussed the consequences of these challenges, such as overcrowding and the inability to afford other basic necessities such as food, utilities, and health care. Rising Rents Participants in all groups described rising neighborhood rents and a lack of affordable housing, making it difficult to find a place to live and a challenge for residents to stay in their homes. Often, rents were described as too high relative to income, and sudden rent increases sometimes necessitated a move. Participants reported that landlords are seeking higher-income tenants, and that conflict with landlords over rent is a common experience. I’ve been in my place now for nine years. And my landlord just called me down, and I knew it was coming. And she said, “In order for me to keep my building… we’re gonna have to put the rent up to market.” And now I’m losing my apartment within–in the next two years…I wanna stay in Bed-Stuy, but I don’t see it feasible for me to stay here, because we’re being priced out. (Bedford- Stuyvesant) Students are moving in and they are renting the apartments because they don’t care if they have to pay $1,800 per month, because they have several rooms to rent. So, the landlord likes that and obviously, he would prefer to have 1,800 USD from the same space than giving it to an old person who pays 800 USD, because she or he has been living there for a long time. (Washington Heights) NYAM.org 14 Participants described how rising rents and related housing insecurity affected their physical and mental health. Many said they experienced stress and anxiety due to inability to pay rent and fear of eviction. I almost lost my mind, because I was so worried about the rent, and maybe they were going to evict me, and [I’d have to] live in the street. So, everything, so my rent was affecting my family too, because it wasn’t that I didn’t have my rent, but sometimes it was hard to pay for it on time. (Washington Heights) Dislocation Participants in almost all the focus groups said neighbors have been forced to move from their community due to rising rents, gentrification, and eviction. They described the health implications of forced moves. Some break down. Some dove into a state of depression to where they have to go to a psychiatrist or an analyst or something. [Having to move] puts a toll on you. (Stapleton) I couldn’t pay for rent by myself and had to move to a room in the Bronx and just stayed there for three months in the Bronx…I was very depressed and just stayed there for three months and moved to Manhattan [with my mother] again. (Washington Heights) I had to move. I lost 30 pounds when I got that [eviction] notice after being in that house for 21 years. I lost 30 pounds packing up the stuff and worrying about how was I gonna move…it cost me what little bit of savings. It took it all. It mentally—I got on my knees. I cried. Thank God, I didn’t end up crazy or whatever. Maybe I am, I don’t know. But it makes you sick! (Stapleton) Gentrification In some neighborhoods, rising rents were perceived to be the result of gentrification. Participants noted demographic changes, as well as an increase in construction of new, higher-income housing and new high-priced businesses that cater to the incoming residents. In the Bedford-Stuyvesant focus group, participants described tensions between old and new residents. Housing and Health in New York City: Perspectives From Low-Income Communities 15 People are selling their homes, selling their buildings. We got contractors— work constructors—we got contractors coming in, refurbishing them, and putting rents so high that people whose parents and grandparents live in this neighborhood—if you don’t own a home, you can’t really afford to live here anymore. (Bedford-Stuyvesant) They’re building the houses, little restaurants, pizza places, and stuff like that, but they’re not really giving the community what they really need. (Stapleton) I feel like the gentrification—like someone mentioned—the police harass you more. Where you grew up in this neighborhood, you’re now, like, a target....you are seen now as a lesser person. Because growing up, I heard about racism and things happening, but I never experienced it until a couple months ago. (Bedford-Stuyvesant) Participants described how neighborhood changes associated with gentrification had a range of negative impacts on health and the factors that affect it. Many reported feeling upset by the dislocations. Although food options were described as increasing, so were prices, necessitating more (and more time-intensive) comparison shopping. I buy my groceries like that, comparing prices in different places, I have to. It’s like that, because there are a lot of new businesses, and those new places are expensive. (Washington Heights) Household Composition and Crowding Participants noted that “doubling up” is common, as family members move into relatives’ apartments in response to high housing costs, shortages of affordable housing, and fear of homelessness. Commonly, the apartments were held by older adults, who may or may not welcome the company (see Appendix 1 for more information on housing issues specific to older adults). This is a senior building. It’s more children in this building than any place in the whole development. Those are one-bedroom apartments and studios. When you’ve got two or three families in a studio, come on. (Mott Haven) NYAM.org 16 Yes, now people do have to have their children—older children, and stuff like that. And maybe their grandchildren to be with them...People don’t want to go into a shelter today. It’s too dangerous. (Stapleton) Participants in multiple groups described apartments with large numbers of tenants, who worked (and slept) in shifts. An arrangement attributed primarily to immigrant groups, one participant emphasized the positive implications: specifically, that members of immigrant groups can support one another until such support is no longer needed. And that not only happens in our culture, but it also happens with all minorities, because I’ve lived next to Muslims, and they live like eight to ten of them in just one room. It’s part of every culture because we are minorities… Because we don’t have a lot of options like a white person or American, so minorities help each other; we do it through the community. We can be Muslims, Mexicans, Dominicans or Puerto Ricans, we help each other, and that’s why we go to the same place until people get a good job, and sometimes that takes time. (Washington Heights) Sikhs, yeah. And I know a few Haitians that rent in one apartment and they’re driving cabs and stuff. When one is sleeping, the other is [working]—because of the rent. So, it might be like seven guys in one apartment—maybe one bathroom with two bedrooms. (Bedford-Stuyvesant) Though large numbers of tenants within an apartment is clearly a common strategy to address shortages in affordable housing, participants noted that living in a crowded apartment can negatively impact one’s mental health. People get agitated. It affects mental health, because maybe you get anxious to the point where it gets physical. Or maybe they call the police and they come to see what is going on in your apartment…Problems with the bathrooms for example, because emotions are so high, you can’t walk without stepping on someone, and if someone is sleeping then he is snoring and you have to be in the living room so the other person can be with his girlfriend, there are things like that. People get frustrated. Why do I need to live like this? So that animosity is common, even when they are family. (Washington Heights) Housing and Health in New York City: Perspectives From Low-Income Communities 17 Competing Financial Obligations Participants reported having to choose between paying the rent and paying for other necessities, such as food. When describing these trade-offs, participants described prioritizing food for their children and then paying their rent late, or in part. I try not to trade-off on food because like I have a child, so, I can’t—I don’t have that option to trade-off on food. But like, it’s definitely like she eats first, and then I kinda like eat. We made do. I don’t like to eat that much anyway. (Bedford-Stuyvesant) After paying rent, other participants noted relying heavily on food pantries. The starting pay was $32,000. I was getting on my feet and everything like that, but I had gas, electric, water, and rent to pay. I was paying at least $1,000 for rent. Section 8 was paying $98 at that point. I had to go to the food pantry. I had to go to City Harvest to feed my family of four. (Stapleton) Participants also described how housing costs impacted health care, including insurance coverage, medication use, and site of care. My trade-off is medical insurance. Unfortunately, I fall between the cracks because I’m supposed to be the middle America, where I make too much to get Obamacare, but yet, I can’t afford my $600 a month insurance and pay rent. So, I don’t have insurance right now. And I have a medical condition. I suffer from Crohn’s…It means I have to go to the urgent care clinics to try to just get my medication. And I’ll explain to them I don’t have insurance. So, they’ll give me medication, because I have maintenance drugs I have to take for my intestines, and they’ll give it to me like for six months’ time, and I’ll have to just keep going back there at this point. (Bedford-Stuyvesant) I was in the hospital. The medication for my treatment was, my copayment was $1,000. Insurance didn’t cover it. You have your mortgage to pay. What do you do? What I would do for the medication was—which put me back in the hospital—I would skip months…You get sick because you need your medication. So, going back, rather than the insurance company working with me, I went back in the hospital. (Stapleton) 18 NYAM.org Landlord-Tenant Relationships Participants reported a range of experiences in their interactions with landlords or management, though most were negative. Perceived reasons for the poor treatment and neglect varied. Private Housing Many participants rented apartments from private landlords. Although a small number described good relationships, with responsible and responsive building management, most described adversarial relationships. They recognized that the landlord’s main priority was financial, and detailed experiences with landlords who were slow to respond to tenant needs and requests—specifically those related to housing maintenance and quality. Landlords as I said—are slumlords, a lot of them don’t listen at all. They live in Jersey. When it snows, the tenants are responsible for whatever happens. Shovel snow, but they can be very nasty and it’s all about money with them. (Stapleton) Participants felt that landlords delayed apartment repairs (e.g., persistent mold, leaks, lack of heat, etc.) for long-term residents and others with relatively low rent, so they will move out. Such practices were more common in the quickly gentrifying neighborhoods of Bedford-Stuyvesant and Washington Heights. The ceiling had also fallen as well, and I had mold in the apartment too, and the landlord uses those things to put pressure on you. He does not fix the apartment so that you feel uncomfortable, feel bad and leave to another place. (Washington Heights) Participants living in these gentrifying neighborhoods were offered incentives to vacate, and were sometimes threatened if they did not accept the offers, which were often described as inadequate. They harass [tenants] by not providing them services. And then they go and they say, “Oh, well, we’ll offer you—I’ve heard as much as $10,000—for your apartment. Which is like, okay, well people I guess they say, “Well, I’ll cut my losses. I’m not getting any services here.” Ten thousand dollars might sound like some money if you don’t have any, but it’s not enough to relocate you to some place. (Bedford-Stuyvesant) In a couple of groups, participants noted the power imbalance between landlords and tenants. The latter often lack the money to pay for lawyers if taken to court and may be unaware of their legal rights. They’re getting forced out, and there’s laws on the books that their landlord cannot do that, but you don’t know…You don’t have to leave. You can go down to RSAa. You can call 311, and they cannot force you out. (Bedford-Stuyvesant) If you don’t know the law in this country, but the landlord is aware of everything, the person from whom you are renting, he can take advantage of all that to take you out of your home or do a lot of things different from what should be done. (Washington Heights) Some participants also linked these negative experiences with landlords to poor mental health. I think it is like that, in the sense that if you have problems, you feel worried and have problems with rent, and let’s say the landlord takes you to court because you are one month late, that is bad for your mental health. (Washington Heights) Public Housing Participants living in public housing reported that NYCHA management and staff were negligent, rather than antagonistic. They described housing management that was simultaneously lazy and opportunistic—chronically slow to make repairs, but quick and efficient at raising rents. It’s just the things that we need to be done here, they’re not doing it for us, but you want us to give all our money. You want every dime we get, but we’re not getting none of yours. Give us some of the things that we need, and we would have no problem. (Mott Haven) a Rent Stabilization Association 20 NYAM.org Housing Related Services and Resources Participants described many housing services provided by community organizations, including supports to eliminate asthma triggers, legal representation for individuals facing eviction and/or to address maintenance issues, and financial assistance for payment of rent. Although some CBOs ostensibly assist people in finding affordable housing, such assistance was limited by the minimal number of available units. A participant who worked with one such organization noted: We have a wait list of over 2,000—a two-year wait list…A two-year wait list says you don’t have housing. (Bedford-Stuyvesant) There was also some distrust of housing-focused CBOs. Given that most could not provide housing, participants felt the organizations were primarily concerned with getting people “in the door,” to receive payment for contract deliverables. And the other thing is a lot of them are non-profit or subsidized by the city, so some of them are just doing that to get the money for the city, and they’re not doing what they’re supposed to do…just doing it to get one grant or whatever. (Bedford-Stuyvesant) Rather than engaging with CBOs on housing issues, focus group participants were more likely to report contacting their tenant associations, NYC’s 311 line, 911, legal services, elected officials, and the media. Specifically, they sought to pressure landlords to address needed repairs, pest infestations, inadequate heat, and other issues; they explained that these efforts often had limited success. They also reported that many tenants were hesitant to make complaints for fear of eviction or reprisal. [311] took the complaint. Gave me the complaint number. I had an email. I had to—they sent me proof for the email. Sometimes they send you the paperwork in the mail. I had to go to [my City Council representative]. I had to go to [the NYC Public Advocate]. Especially with this last landlord. It was horrendous with him. He just blatantly didn’t do anything. The more I complained, the less he did. Then he threatened me. (Stapleton) Housing and Health in New York City: Perspectives From Low-Income Communities 21 Engagement of legal services and outreach to the media were considered to have the most impact (though sometimes just in the short term) for both private housing and NYCHA. My aunt lives on the ninth floor. She has no legs. Elevator’s broke all the time in her building. We go the landlord—we go—and everybody’s like, “Well, we should call the news and have the news people come and blow it up.” After they do all that, they fix it for a few days, and then it goes right back to the same thing. Then you got somebody trapped in their home. (Bedford- Stuyvesant) NYCHA’s employees—for two months—NYCHA employees have said to me, “Contact Channel 7. Contact this person. Litigation. You’re going to have to go to court.” If you want them to move, if you want them to put change in, if you want them to address these concerns that you’re having, call the news. Get your face on it. I guarantee you they’ll be contacting you. (Rockaway) Housing Assistance Participants knew of housing assistance programs, but each came with challenges. Participants in the Washington Heights focus groups were aware of the Living in Communities (LINC) Rental Assistance program, which helps families living in homeless shelters to access permanent housing. They reported that landlords in Washington Heights did not accept LINC vouchers, preferring to rent to higher income applicants. Participants were also familiar with Section 8 vouchers, but noted the long waiting list (one person reported waiting 10 years) and that landlords can choose whether to accept Section 8 vouchers, making those tenants even more hesitant to make complaints or demands. A petition, you need to sign, and it has to be in general, everybody has to sign. So, a lot of people don’t do it, because they have problems with landlords and they don’t want to put their name there because they can be affected, if the landlord is giving them an opportunity maybe he can stop giving that help. So, a lot of people are afraid of that, and sometimes landlords do that, they retaliate against those who sign a petition. (Washington Heights) 22 NYAM.org Resident Engagement Participants reported various communal activities focused on improving housing conditions including attendance at community rent stabilization association meetings and informal meetings with neighbors. A number of focus group participants were engaged with their tenant associations. Association meetings included discussions of unresolved building issues and strategies to address them. We have a monthly meeting to discuss—tenants come down to discuss whatever issues that they have, or whatever we can help them with. Sometimes we can help, other times we can’t. One time or another we brought in people from the outside that actually brought in TV stations and stuff like that and reported the issues that we are having here. (Mott Haven) Despite the regularity of tenant association meetings in NYCHA developments, the perceived strength of the association—and the changes participants felt the tenant associations could affect—varied by focus group, with the strongest support for them occurring in the Mott Haven group, which included the tenant association president and five board members. If we had—because we had a meeting one time and we brought in the person in charge of elevators, the person in charge of maintenance, the person that’s in charge of heat and hot and water. We advertised this to our development. We put signs on every floor. Every single—there’s 20 floors in this building. We put signs on every single floor in this whole development [about 5-7,000 residents]. We got 89, 90 people to come out. (Mott Haven) We used to have tenant meetings—then, after a while, people don’t see nothing happening, so one by one people stop coming to the meeting. (Stapleton) Outside of NYCHA, tenant associations faced challenges, including inconsistent engagement and fear of retribution. They had meetings on the first floor, but then the landlord established a law, where they can’t have meetings on the first floor, so can you imagine that? They had to do them outside…. And then the landlord said they couldn’t do that, and very easily because they were a lot of people and there was a fire risk. (Washington Heights) 23 Housing and Health in New York City: Perspectives From Low-Income Communities The Role of Health Care Providers As noted throughout this report, in all focus groups, participants were clear about the connection between poor housing conditions and poor health. However, few participants reported that their doctor asked about or had any knowledge of their housing situation—the exception being when they or a household member had asthma. In these instances, providers helped the participant to access resources to address home-based environmental triggers. When I go to see my doctor, he always asks me any issues about my apartment...He’ll ask for my landlord’s information and all that stuff. I gave it to him. He calls and he’ll let [the landlord] know. (Bedford-Stuyvesant) I have kids with asthma. So, my baby had an asthma attack in the bathroom and also there’s a lot of stuff in the apartment that trigger the asthma. Once she was on the hospital for a week and a half. After she was discharged, I had a nurse come to my house and she did an assessment. She started looking at the conditions in the apartment. They worked with a lawyer and they also communicated with her doctors and they let them know the conditions of the apartment. So, those lawyers get in contact with the assistant. We give them all the information and they call the doctor and they try to work with them to better the conditions of the apartment. (Mott Haven) Other participants reported that they would welcome questions about their housing, viewing it as an indicator of good quality care. They felt such information would help the provider better understand the factors that may be negatively impacting their health and develop a more responsive and effective treatment plan, ideally including advocacy on their behalf. It’s a vital part to whatever may be ailing you, whether it’s the community that you’re in, or the residence that you’re in, can be your trigger. If the doctor knows that, maybe he can tell you ways to get around it, or he might have to tell you that you need to just get the hell out. (Mott Haven) Another girl just got a doctor’s note to validate that because of the dust from the construction and the mold—like in my kitchen, also—the walls are protruding out from all the water condensation. It bubbles. Her son bursts one of the bubbles and something oozed out and it got on him and she believes that’s what made him sick like that. The doctor wrote a letter saying that’s what caused it, that’s why he’s sick. (Rockaway) Safety and Violence Although not a “brick and mortar” housing issue, concerns about safety and violence were mentioned in all but the Washington Heights focus group. In that neighborhood, participants reported that resident familiarity with one another reduced levels of violence. In other groups, participants attributed safety and violence concerns to high numbers of homeless shelters in particular neighborhoods, broken front doors and security cameras, and high crime rates in the surrounding community. They readily connected stress about consistent violence to physical and mental health issues. As far as how it affects health, everybody in this room knows it’s unhealthy not to get a certain amount of hours of sleep. So, at one or two in the morning when the arguments, the fights, the police siren, the gunshots that jump you out of your sleep, can’t go back to sleep when you got to hit the floor... So, it affects your health that way—not sleeping—because you’re worrying about your problems, the gunshots at night, police sirens every minute, crazy neighbors that’s on drugs—they’re keeping you up all night. I mean, these things affect your health. (Bedford-Stuyvesant) The crime affects your pressure because when you’re going out, you’re looking around. You don’t know who may shoot you. We’ve had plenty of shooting all this summer. So, it affects your health quite a bit. People have to change up their routines. There are some people that go in groups for shopping. (Stapleton) Homeless Shelters Although participants were sympathetic to those who were homeless, they felt that shelters were disproportionately located in their neighborhoods, and that there were insufficient supports available to shelter residents. Their presence, therefore, resulted in an increase in robberies, assaults and drug activity. There’s like a shelter across the street, and then on the next street there’s a shelter, and then like on the next street there’s another shelter. And at first, I felt a little bad because I’m like I want people to be off the street, but they 25 Housing and Health in New York City: Perspectives From Low-Income Communities allow these people—like they come out—they leave the shelter, they don’t have programs for them, so they’re just on the street and they’re panhandling. And sometimes they’re violent. Everyday there’s a police car, ambulance, or something happening and you have children, and it’s just not the environment where you can even like hang out in front of your home. I have to take my daughter to a park somewhere, we can’t even play in front of the house. (Bedford-Stuyvesant) It’s not that people are fighting against them coming. It’s because once they’re placed, they’re neglected. There’s no more monitoring. A lot of them would not be in—they don’t administer or follow-up with them with the medication they need…When you have somebody that’s just roaming around, anything can happen. They can be outside, but two hours ago they needed to take medication and now they don’t, so you don’t know how they’re functioning. Just a loud noise or a sudden touch can trigger them…It’s not the fact that they’re living here, it’s the fact that they’re specifically dumped. (Rockaway) Broken Doors and Security Cameras Participants in both NYCHA and private housing reported broken doors, locks and security cameras—and ineffective security personnel—that made them vulnerable to assault within their building. I’m in [public housing] and they always have a stick propped in the door, people standing outside to get in…They have security there. Half the time, they’re asleep or they’re not there…After a while, you feel like it’s a setup. (Rockaway) We had cameras in the building. The cameras up there—the super told me— he said, “The cameras are up there, but they’re not working. They’re just for show.” Oh wow, we really—our front door just got busted, so now you can’t even lock the door…We’ve done had two people get robbed in my building, gun pointed. They know about it. The new owner said, “Well, we had no idea what was going on.” “Okay, we’re letting you know. Are you going to fix the front door?” “It’s gonna take a couple of weeks. We have to get parts for the door.” Are you fricking for real? (Bedford-Stuyvesant) 26 NYAM.org When I get on the elevator, I have to look. Because they break the doors. NYCHA fixed the door, they break the doors. Anybody could come in. I don’t even think the cameras work. They have cameras in the elevator...If I see somebody strange, I do not get on the elevator with them. (Rockaway). Neighborhood Crime Specific issues of building security and homeless shelters were embedded in broader discussion of high crime levels. Older adults and children were considered particularly vulnerable to safety issues. I live in the projects right here. It can be dangerous at times. I’ve had people shot in my building. During the daytime. I ain’t even talking about night. (Stapleton) It’s too many shootings and kids can’t be around outside and you gotta be ducking. I’m done with it. (Bedford-Stuyvesant) We have a senior center. I leave the senior center at three o’clock. [Another person from the senior center] got robbed. She’s lucky because they just took her jewelry and her bag. And she had a walker. I’m just saying is that we open to a whole lot of things and you have to worry about it. (Mott Haven) Participants’ Recommendations for Improvement When asked about recommendations for addressing the negative consequences of housing challenges on health, participants had specific recommendations for NYCHA, including (1) increased staffing to address outstanding repairs and inspections, (2) enforcing the rules and regulations set forth in the NYCHA resident handbook, and (3) holding NYCHA accountable for neglect. Their staffing is not meeting our needs. You have so many buildings—Section 1, Section 2. And you don’t have at least four housing assistants… The housing assistant goes out and if they say something is broken, or something happened in the building, they have to go and inspect the building and then they have to go and send letters and go up each floor, back and forth all these flights. One person and you’re not supposed to go alone, so then you’ll have two housing assistants out in the field, when you have a whole host of people in the office trying to get assistance. (Mott Haven) 27 Housing and Health in New York City: Perspectives From Low-Income Communities They have a handbook of rules that gives you the rules and regulations but they do not enforce the rules and regulations and people don’t care… The quality of life is so low because they’re not enforcing their rules and regulations. (Rockaway) Nobody trusts NYCHA anymore. Their track record is damaged. It’s tainted. It’s nothing. The cherry on the cake was today. The city chair has been exposed for falsifying records, and this is a health issue. (Rockaway). Participants in all focus groups thought that health care providers should ask patients about their housing situation. Two participants in the Brooklyn focus group recommended having providers incorporate questions about their patient’s current housing situation into their visits, and use the responses to tailor the patient’s treatment plan. They’re not looking also further into—okay, yes—I’m adhering [to my medication], but also the stress of trying to live in a clean place—trying to find someplace—that should be in with your adherence as well. That should be in your medical plan so that you’re getting the help that you’re needing. (Bedford-Stuyvesant) I thought that before I got diagnosed with cancer, if they would have had somebody there—maybe they call in a social worker or consult just to talk to me. And maybe after I found out the news, just to talk me through, well, everything that you find out with your situation. How’s your living situation because you’re dealing with this cancer now? How’s your mental state? They didn’t do that. They just diagnosed and then scheduled you for surgery. So, it all relates. (Bedford-Stuyvesant) Lastly, participants recommended increasing availability of affordable housing and having community based organizations place greater emphasis on outreach so that community members are aware of and take advantage of the available resources. The organizations that’s out there, there’s not enough outreach. You just asked about the resources and services. Nobody in this room could probably name more than a couple because the outreach—you don’t know about them because they don’t do a lot of outreach. (Bedford-Stuyvesant) 28 NYAM.org How you have places that have land and stuff like that where there’s nothing there—old Bailey Seaton Hospital there. That’s an eye sore! Why not get someone and put housing up there so people can afford low-income housing. Do something about that! You’ve got land there that’s just wasting away. You need more housing, and affordable housing. (Stapleton) 29 Housing and Health in New York City: Perspectives From Low-Income Communities LIMITATIONS Focus group participants were not a representative sample of NYC residents and findings should not be generalized to the population at large. Instead, participants offer insight into their own experiences and provide recommendations to inform the development of future policies, programs or initiatives designed to address housing and health challenges in NYC. They offer an important community voice and perspective for such efforts. Notably, the findings detail many negative housing-related experiences and their repercussions, as viewed from community members’ perspectives. This may, in part, reflect self-selection of individuals concerned about housing. It may also reflect the framing of our questions, which focus more on housing challenges—and their health implications—than housing assets. These biases, as well as the limited sample, suggest that the findings may not fully represent the broad range of housing-related experiences of residents in low-income NYC neighborhoods. However, we note that they are consistent with multiple reports on housing availability and quality from other organizations and from the media.b, c 30 NYAM.org CONCLUSION It is widely recognized that, while the US spends more than any other country in the world on health care, our health outcomes are relatively poor. As a result, policymakers, public officials, health care administrators and others are beginning to acknowledge the value in investing in sectors outside of the health care system to improve health outcomes, reduce health care costs, and improve health equity. Housing is increasingly being recognized as one of the most consequential health determinants, especially in NYC, where the housing stock is limited and expensive. A large and growing evidence base suggests that the stability, affordability and quality of one’s home impact a wide range of physical, mental and behavioral health outcomes in children and adults, including heart disease, asthma, depression, and anxiety. The experiences described by participants in these focus groups are consistent with other studies that examine the impact of housing on health and wellbeing. d Participants not only reported experiencing a range of housing challenges, they also made strong connections between these challenges and their own health, and the health of their neighbors. Participants reported living with persistent leaks, mold, pests, and other maintenance issues and explained clear linkages to their mental and physical health, most commonly referring to anxiety, depression, asthma, and allergies. The rising cost of housing, gentrification and forced displacement, and the need to deal with negligent landlords and delayed repairs, also contributed to increased stress and anxiety, leading to poor mental health. Residents of public housing reported particularly difficult living conditions, especially around poor apartment maintenance and safety. They described a housing system that left them feeling unsafe, yet they lacked the autonomy to make needed changes and control their living environment. They linked these conditions to stress, anxiety and poor physical health. Across groups, participants conveyed a general sense that, while housing-related challenges are pervasive in their communities, there are few avenues to advocate for improved living conditions. They noted a power imbalance between landlords, management and tenants, and lack of responsiveness. They also reported feeling that there were few service providers who could provide tangible assistance. Although Housing and Health in New York City: Perspectives From Low-Income Communities 31 participants described a variety of methods used to compel landlords or management to address their housing issues such as calling 311 or seeking the support of community based organizations, they also explained that fears of eviction prevented them from engaging more actively in advocacy. Findings from these groups demonstrate the dire need for more affordable and better-quality housing, as well as better recourse for tenants living in sub-standard conditions. Effectively addressing inequities in housing and improving collaboration between health and housing sectors will be an essential step in achieving the City’s goals outlined in TCNY 2020 – giving everyone the chance to live a healthy life. b “How is affordable housing threatened in your neighborhood?” Association for Neighborhood and Housing Development. [n.d.]. Viewed Jan. 12, 2018. c Austensen, M. et. al. State of New York City’s Housing and Neighborhoods in 2016. New York: NYU Furman Center, 2016. Online. Viewed Jan. 12, 2018. d The New York Academy of Medicine. Designing A Strong and Healthy NYC: Housing Matters. Online. [n.d.] www.nyam.org/dash-nyc The views presented in this publication are those of the authors and not necessarily those of The New York Academy of Medicine, its Trustees, Officers, or Staff. 32 NYAM.org APPENDIX 1 33 Housing and Health in New York City: Perspectives From Low-Income Communities HOUSING ISSUES AMONG OLDER ADULTS All participants in the Stapleton focus group, which was held in a senior center, were older adults. Participants in this group were asked specific questions regarding housing issues in the context of aging. Relevant information regarding housing issues among older adults came up in other groups, as well, and are incorporated into the findings below. Multigenerational Housing Older adults are more likely than younger populations to have rent-controlled apartments. Participants in multiple groups spoke of older adults with stable and/or low-cost housing taking in other family members. Such, multigenerational housing was described in both positive and negative terms. Because of the rent, I live with my grandmother there. My grandmother is retired, and she used to work, she takes her social security, she is an old person, she is 85 years old, and she worked for 17 years in this country in a factory as a dressmaker. And she pays, her bills are paid with her monthly check, but I also help her, so there’s no problem because the rent is so low, but the reason for that is because she had lived there for fifty-five years in that apartment. (Washington Heights) I have an issue where I am accommodating my granddaughter. She’s 21. I give her space, so she can get her act together. She has a baby 2 years old, and I have a two-bedroom. Now, she’s 22, she’s coming back to me, and she’s telling me she’s pregnant again. So, that will be three – four people in my space, and it bothers me. Even though I want to be nice and help her out, it bothers me when I come home, and I want to relax and watch my TV, the 2-year-old tells me – she gets upset because I’m watching TV, and she tells me to go in my room. I don’t want to be in my room all the time! So, that’s bothering me. I need my space. But, how to put pressure on her for her to get her life together because she’s young and she can’t do it? (Rockaway) Accessibility Most participants in the older adult focus have not made home alterations to accommodate their changing needs. One of the few who did, covered the cost of the modifications on her own. Not surprisingly, most challenging to older adults are 34 NYAM.org stairs. One woman said she was looking to move out of her home and into a NYCHA development so she would have an elevator. Another said that she has not been to the second floor of her home in more than two years. In my house, I don’t go to the second level either because of the stairs since I came out of the hospital. But, I’m fortunate in that I have a bathroom downstairs and I moved the bed downstairs. So, what’s upstairs – I could have visitors upstairs. It’s what, two years now? (St. George and Stapleton) A few participants in the group lived in senior housing managed by a local non-profit organization. These participants said their housing was designed to accommodate the needs of older adults and was generally well maintained. [In senior housing], I get in the shower or something, you have the bar there. So, we can hold on to get out of the shower. You have the cord in the bathroom. You have a cord in the bedroom. God forbid if you would fall, there’s no one home. You ring that, and the super is able to see that. (Stapleton) The Negative Impact of Dislocation on Older Adults Several participants shared stories of older residents who were pressured to leave the homes they had lived in for years, in order to make way for new development. Participants said these moves have a negative impact on health, due to the disruption and the likelihood that new housing options are limited. The landlord was pressuring this old lady because she’s had that building for years, but she had no family. And they was doing everything to get this woman to move out of her house, because they wanted to buy it. And everybody knew it in the neighborhood. They made that woman so sick, she wind up in a nursing home. (Bedford-Stuyvesant) It started ten years ago when the landlords were moving seniors and people with disabilities out of their private home and forcing them to move into little spaces. And, it affected them mentally, physically. It bothered them. I started seeing that happen. (Stapleton) 35 Housing and Health in New York City: Perspectives From Low-Income Communities Impact of Violence and Crime on Older Adults In several groups participants mentioned that older adults are particularly fearful of crime and violence in the neighborhoods where they live, and that they themselves—or other older adults they know—had been victims. Participants in the older adult group described their fears, and the impact of fear on their well-being. Well, we’re scared. It’s a big problem. It’s a very big problem. It affects the health. It affects everything that you do. (Stapleton) Younger people don’t fear like the seniors do. Because [younger people] hear them. And, they see – they feel like they’re invincible, even though they are not… We’re cautious. (Stapleton) 36 NYAM.org APPENDIX 2 37 Housing and Health in New York City: Perspectives From Low-Income Communities LIVING IN PUBLIC HOUSING In two of the focus groups, Mott Haven and Rockaway, most or all participants were residents of New York City Housing Authority (NYCHA) developments. In both groups, participants detailed numerous challenges associated with living in public housing. They felt that NYCHA is expensive and that management is negligent. I work and yes, I have to sacrifice, in order to get my rent paid, yes. Because just like you said, no matter how much I make, it’s based on my rent, plus if my son has a part-time job, please, $2,000 for what? Project? Where I get no maintenance, I get no repairs on time. My wall has been busted. We have the same wall and it’s busted. They fixed, they repaired it, they plastered it – how many years ago? It’s still plastered, but not painted. (Mott Haven) There was a time when I didn’t have hot water. I didn’t have hot water in my house for five years. Five years. I went to the city council to testify. I went everywhere. Nothing was done. (Rockaway) A toilet – it takes them a month to come fix a toilet. In the meantime, what are we supposed to do without a toilet? Use a bucket. They’ve got nerve to tell you, you could go to somebody’s house. Really. (Mott Haven) Slow repairs were attributed to a flawed reporting and repair system and an understaffed and uncaring NYCHA workforce. These frustrations and the resulting physical decay of the buildings were stress inducing for residents, and described as impacting their mental health. I put tickets in until I was raw in my throat, because they would not come and put plaster on that damn ceiling, and I couldn’t take a shower. You know how it is, going without being able to take a shower? (Rockaway) [NYCHA staff have] gotten so comfortable that they’re clocking in and clocking out. All they’re worried about is time and attendance. They’re not worried about what they do in between. Their performance doesn’t matter anymore. (Rockaway) Housing affects some people’s health. Like elevators [if they’re broken]. If you live on the 20th floor, and you have to walk up that 20th floor for three, four, 38 NYAM.org five [times a] week, you’re going to get out of breath, you start losing weight, you get sick, you get lightheaded. You got to go back and forth, back and forth. You can’t go nowhere. That’s mental, because in your mental mind it’s like, “I have to walk down these flights of stairs. Now I get downstairs, I’ve got to walk back up the stairs.” (Mott Haven) Participants also described serious problems associated with poor upkeep of common spaces by their neighbors. They reported trash left in hallways, residents who fail to clean up after their pets—even inside hallways and elevators—and in one case, use of common spaces as a toilet. These actions by neighbors angered participants and contributed to high levels of stress and depression. When I see somebody leave their garbage in their hallway, I yell in the hallway, “Who did this? You are nasty! Don’t you leave your garbage here!” I do it every time I see them leave their garbage in the hallway, and it’s a couple doors down. Even if the building is old, if it’s kept clean, you can breathe clean air. You can prevent roaches, you can prevent mice—all of that stuff. (Rockaway) I live on the first floor. I can hardly open my window, because there’s…some stairs and they constantly take that as a bathroom. They’re always pissing down there. They’re taking dumps down there. I open my window, that smell comes in my window. I have asthma and I have COPD, too. My house gets all dusty, because I always have that damn window closed. I can’t get no air. (Mott Haven) Moving within the system to accommodate changing family size was also described as difficult, resulting in frustration and feelings of powerlessness. Meanwhile, pressure from NYCHA to downsize when family members moved out was described as persistent and upsetting, as evidenced in the exchange between Mott Haven participants below. Participant 1: You apply for it, and they’ll keep telling you, “You’re on the waiting list. You’re on the waiting list.” I’ve been here over 20, 30 years with my oldest kid and I’ve still got a young kid in the house. The kid is going on 12 years old. I’m still two bedrooms, so when am I going to get that third bedroom? Why should it take me 20 years to get a third bedroom? By the time I get that third bedroom, all my kids will be grown. 39 Housing and Health in New York City: Perspectives From Low-Income Communities Participant 2: Yet, when the kid moves out and they find out he moved out, they really gung-ho, overnight. You got to leave. Downsize. Real fast. Community Member Recommendations When asked about recommendations related to problematic housing, participants had specific recommendations for NYCHA, including (1) increased staffing to address outstanding repairs and inspections, (2) enforcing the rules and regulations set forth in the NYCHA resident handbook to ensure hygiene and proper disposal of trash, and (3) holding NYCHA accountable for neglect. Their staffing is not meeting our needs. You have so many buildings—Section 1, Section 2. And you don’t have at least four housing assistants…The housing assistant goes out and if they say something is broken, or something happened in the building, they have to go and inspect the building and then they have to go and send letters and go up each floor, back and forth all these flights. One person and you’re not supposed to go alone, so then you’ll have two housing assistants out in the field, when you have a whole host of people in the office trying to get assistance. (Mott Haven) They have a handbook of rules that gives you the rules and regulations but they do not enforce the rules and regulations and people don’t care… The quality of life is so low because they’re not enforcing their rules and regulations. (Rockaway) Nobody trusts NYCHA anymore. Their track record is damaged. It’s tainted. It’s nothing. The cherry on the cake was today. The city chair has been exposed for falsifying records, and this is a health issue. (Rockaway). Policy Perspectives Participants in the Rockaway and Mott Haven groups were also asked about two NYCHA policies: one barring people with a criminal record from moving into NYCHA apartments, and the other prohibiting smoking on NYCHA property beginning in 2018. The regulation to keep people with a criminal history out of the buildings was viewed as generally positive, though inconsistently enforced by NYCHA and unrealistic 40 NYAM.org given high rates of arrest and incarceration in low-income NYC communities. There was sensitivity to the type of crime, with less concern for non-violent offenders. A participant with a criminal record felt the ban was unfair, given that he had served time for his offense. Why do you want anybody that comes out of prison – we don’t know what they did. They could be rapists, whatever the case may be, and we’re just going to let in once they get out? It’s bad enough they got them living around us in these shelters and whatnot. (Mott Haven) Nowadays, it’s a little different from back in the day. You all got somebody that been in jail or had some kind of – it’s almost in every family, so you can’t stop everybody. The ones that you know, that are troublemakers or something like that, those are the ones who should not be able to just come in, especially not be on the lease. If they’re visiting or something – sometimes you can’t control everything. (Mott Haven) I spent my time in prison, I’ve been out, and I’ve been on the street. But I can’t put in a housing application, because it’s just going to be kicked out because I have a criminal background. I paid my time. I did my time. I did a crime, I did the time, and now I’m out, and I can’t even get a hand up. It’s a messed-up thing. (Rockaway) The proposed smoking ban was extremely unpopular in the Mott Haven group—where, it seemed, many were smokers. Participants in that group felt it was unfair to be told how to behave in one’s own home, particularly when NYCHA does such a poor job of servicing and maintaining those homes. One participant also felt the ban would force people into the street to smoke and provoke negative, and potentially violent, interactions with the police. You want to tell me what to do in my home, but you don’t want to come and fix my home. Don’t tell me not to do anything. It’s my home. (Mott Haven) The other downside to that smoking part, that six months and no cigarettes, is we’re going to have a lot of people come downstairs in front of the boilers which is going to create havoc, because you have the police department saying, “You don’t belong in the street. What are you doing? Who are you?” Chaos. (Mott Haven) Housing and Health in New York City: Perspectives From Low-Income Communities 41 Participants in the Rockaway group were less critical of the smoking policy, though in both groups participants questioned how such a rule can be enforced, as demonstrated in the exchange from the Rockaway group below. Participant 1: How do you regulate that [smoking ban], though? Participant 2: Like they do everything else – snitching on each other. Notably, in the Mott Haven group, a couple of participants felt the ban was a tool NYCHA would use to force people to move out, so the units could be turned over to new residents paying higher rent. They’re doing it for a reason. They want people to say, “No, F this, I’m going.” That’s what they want people to do. They want you to say, “F this, I’m going.” Why? Because that’s their way of getting you out and bringing the other people in that’s going to pay more rent than you are and they don’t care. They’re doing things to provoke you to get out. They’re just making more restrictions and more stuff on you so you can just say, “I’m not dealing with this mess no more.” (Mott Haven) 42 NYAM.org APPENDIX 3 43 Housing and Health in New York City: Perspectives From Low-Income Communities IMPACT OF HURRICANE SANDY ON HOUSING The Rockaway Peninsula was severely impacted by Hurricane Sandy. In the Rockaways focus group, participants were asked about their experience. They described damage and dislocation, though the questions did not generate a great deal of discussion, possibly because Sandy occurred several years ago. And even when Sandy came through…We were out of electricity and our basic utilities for over a month. Sandy happened the end of October. It was after Thanksgiving before we got power. I had to actually live at my job for about two weeks, and I was lucky that I worked at a place where I could sleep, and do all that stuff, and stay there, and I didn’t have to come home. (Rockaway) I did receive money to fix the inside, but I had so much damage on the outside...And then I had pressure because I live in a condo and things have to be all the same with everybody. So, I was getting pressure from my neighbors—“You have to fix this, you have to fix that,” because they claimed it was an eyesore. I was very hurt, because I didn’t get reimbursed for a lot of things that happened on the outside. I had to take [out] loans, come up with money, and so it just left me in a financial burden and that’s kind of difficult to deal with. (Rockaway) One participant had a more positive perception of Sandy response. Mission extender—or something like that—where they come in, they color- code the apartment and they do the job of polishing the floors, cleaning the building from top to bottom. So, my building looks fairly neat. We still have Sandy work to do. They’re going to come and put protective doors and storm protectors—that work will be done later in the fall. So, there’s still work to be done, but they’re doing—they’re improving a little bit. (Rockaway) 44 NYAM.org APPENDIX 4 45 Housing and Health in New York City: Perspectives From Low-Income Communities FOCUS GROUP DATA COLLECTION INSTRUMENTS New York City Population Health Improvement Program (PHIP) Focus Group Participant Survey Please take a few minutes to answer the questions below. All answers will remain confidential. 1. What zip code do you live in? _______________ 2. What neighborhood do you live in? __________________ 3. How long have you lived there? L ess than 1 year 1 – 4 years 5 – 10 years More than 10 years 4. How many places have you lived in the last 12 months? 1 2 More than 2 46 NYAM.org 5. Who do you live with? (Check all that apply) I live alone Partner/Spouse Children (please specify): Number of children under age 5? _____ Number of children age 6-17? ____ Other family members Other non-relatives 6. How many people live in your home, including you? _______ 7. In what year were you born? __________________ 8. Where were you born? __________________ 9. What is your gender? _______________________ 10. What is your race or ethnicity? (Check all that apply) American Indian or Alaskan Native White Asian or Asian American, specify: ____________ Other, specify: _____________ Black or African American Hispanic/ Latino Native Hawaiian or other Pacific Islander 47 Housing and Health in New York City: Perspectives From Low-Income Communities 11. Which of the following describes your highest level of education to date?   (Please check only one) Primary or middle school Some high school, but did not graduate High school graduate or GED Technical or vocational training Some college but no degree Two year degree (i.e., Associate’s Degree) Bachelor’s Degree Master’s Degree or above Other (please specify)_______ 12. Which of the following describe(s) your current work?   (Check all that pply) Employed full-time Employed part-time Student Unemployed On disability Retired Homemaker/Care giver Other (please specify) __________ 48 NYAM.org 13. In the past year, how often did you worry about having enough money to   pay for food or housing? Always Sometimes Rarely Never 14. In the past year, which of the following health concerns did you face?   (Check all that apply) Arthritis Severe Allergies Asthma or other breathing issues Cancer Chronic pain Diabetes Overweight or obesity Difficulty sleeping Drug or alcohol problems Experienced a fall Heart disease Mobility issues Depression or anxiety Other mental health challenge or illness Other (specify) __________ None 49 Housing and Health in New York City: Perspectives From Low-Income Communities 15. What kind of housing do you currently live in? (Check only one) Public housing Private housing (own) Private housing (rent) Other, specify: ____________________ 16. Do you receive a Section 8 voucher (also known as a Housing Choice   Voucher) to pay for rent? Yes No 17. How much of your monthly income do you currently spend on housing (for   example: rent, mortgage)? Less than half (<50%) Half or more 18. Within the past five years, have you experienced any of the following?   (Check all that apply) Harassment by your landlord (for example, threatening notices or actions) Forced to move because you could no longer pay your housing costs Could not pay mortgage or rent on time Moved to larger space because of a growing family Wanted to move to larger space because of a growing family, but couldn’t due to cost Eviction Severe mold, or leaks, Mice, cockroaches, or bedbugs 50 NYAM.org Dangerous housing conditions (for example, broken elevator, poor lighting, unsafe construction, peeling paint, etc.) Forced to move because of damage due to natural disaster (e.g., hurricane, flooding, etc.) None 19. If there is a problem with your home, who would you be comfortable asking   for help? (Check all that apply) Landlord, super or building manager City agencies (for example, calling 3-1-1) Community organization Friend or family member Other (please specify) _____________________ END. Thank you Housing and Health in New York City: Perspectives From Low-Income Communities 51 Public Health Improvement Program (PHIP) Year 3 Housing and Health Focus Group Guide Welcome and thank you for participating in this focus group. We are from The New York Academy of Medicine and we are partnering with the New York City Department of Health and Mental Hygiene to conduct focus groups about New Yorkers’ experiences with housing and the relationship between housing and health. The Department of Health would like to get community input on ways to address the health impact of housing-related issues. Today, we would like to hear from you about the different housing-related challenges that you and people in this community face, and the ways in which those challenges might affect peoples’ physical and mental health. We hope to get as much detailed information as possible, so as you answer our questions please try to give specific examples, and also provide details about the context of your comments—like whether you are referring to NYCHA housing or private housing. This will help us better understand your experiences. This research will help the Department of Health to develop informed recommendations to support healthy housing. I also want to say, before we start, that some of the topics that we will discuss today may be difficult or upsetting. We welcome input from everyone and would like to hear about your own experiences, but please do not feel like you have to share beyond what’s comfortable. 1. To begin, we would like to hear from you briefly about how long you’ve lived in   this neighborhood and why you were interested in participating in the   discussion today? Now, I’d like to get a sense of housing-related experiences in this neighborhood and the impacts of housing on health. 2. Can you tell us a little about the housing in this neighborhood—in general,   and your own home? a. What do you like best about the place where you live or are staying right now? 52 NYAM.org 3. How easy or difficult is it to find a home in this neighborhood? b. What kind of housing is easy to find? What kind is difficult? 4. Do people face issues related to rising costs of housing? Can you describe   examples? a. How easy or hard is it to find housing that is affordable? b. Have there been any changes in the cost of housing recently? 5. In your view, how does your housing impact your health—we’re thinking   about both physical and mental health? a. What about your home, or the place where you are staying, promotes health and well-being? b. What about your home, or the place where you are staying, negatively affects health and well-being? 6. Have you ever had to make trade-offs in order to pay your housing costs, for example, spending less money on health care, healthy food, etc. so you could afford to pay rent? a. Can you tell us more about that? What has been the impact of those   trade-offs? 53 Housing and Health in New York City: Perspectives From Low-Income Communities 7. Do you know people who moved recently—either in or out of the   neighborhood? a. Some people move because they have to. If you know of people who   have moved in or out of the neighborhood because they had to, what   are some of the reasons people moved? b. Can you talk about how moving has impacted people, for better or   worse—including work, school, access to health care, access to   other services? c. Do you think peoples’ health can be impacted by having to move?   Can you give examples? 8. How common is crowding in the home in this neighborhood? (for example,   two families sharing an apartment, renting out rooms, letting someone   sleep on your couch) a. Do you know of people who live in crowded living situations? Can you   tell me about that? b. How does crowding affect you or people you know? c. What kind of health—including emotional— challenges come with   sharing a home with a lot of people? 9. How well is the housing in your neighborhood maintained? Do you or your neighbors ever have problems with lead, mold, leaks, bugs, or mice; broken elevators, unsafe construction, etc.? Can you give examples? a. If you’ve had those problems, what did you do to address them?   [if not mentioned: did you report them? To who?] b. How quickly and well do landlords/supers—or building   management—respond to maintenance issues? c. Have you ever called 311 or another city agency about a building   problem? If you have, can you describe the response? d. If you did not report the problems, why not? 54 NYAM.org 10. Do tenants in your buildings ever get together to talk about maintenance problems they are experiencing? 11. Do you feel that housing quality and maintenance issues impact health? If so, how? 12. What differences, if any, have you noticed in the quality and maintenance of housing depending on the type (e.g., private apartments versus NYCHA)? 13. Is safety in and around your home a concern to you? Can you explain your concerns? a. How do you think concerns about safety impact your health and   well-being? (if needed: for example, are you hesitant to go out at   certain times) b. How do people deal with safety concerns? 14. Can you tell me a little bit about the relationships people in this community    have with their landlords or building managers – are they generally positive?   Negative? a. How big of a concern is eviction? b. What about other negative behavior by a landlord or building   manager (e.g., threatening notices or words, failure to make repairs,   etc.)? c. What kind of impact do these situations have on people’s health and   well-being? Can you give any examples? 55 Housing and Health in New York City: Perspectives From Low-Income Communities 15. Would you say gentrification is affecting your neighborhood? If so, how?   How is it affecting people personally? [note: clarify that everyone is familiar   with the term gentrification] a. In what ways (if any) is it making the community better—or worse? b. Do you feel that gentrification is impacting health – either positively   or negatively? Can you provide some examples? c. [If needed] Has gentrification caused or relieved any stress people   experience in this community? d. [If needed] Has gentrification affected the quality of housing for   long-time residents in this community? How so? e. [If needed] Has gentrification changed anything about the availability of things like food and exercise in the neighborhood? We’ve already talked quite a bit about health issues that are related to housing. 16. Other than what we’ve already discussed, are there specific ways in which   you think health (physical or mental health) is affected by housing? Do you   have examples? GROUP-SPECIFIC QUESTIONS: 17. [ROCKAWAYS] Did you experience any housing problems because of Sandy?   What happened as a result? a. Who did you reach out to for help? b. How long did it take for the problem/s to be resolved? c. Does something like this have any impact on people’s health and   well-being? If so, can you give any examples? d. If something similar happened again, how prepared are you? Are you    better prepared? Do you feel the community is better prepared? 56 NYAM.org 18. [OLDER ADULTS] Have you made any changes to your home to make    it easier to live there as you age, for example changes to reduce the risk of   falling (e.g. installing grab bars, improving lighting, etc.)? If so, what kind of    changes are they? a. How easy or hard was it to make these changes? 19. [OLDER ADULTS] What are some of the barriers older adults in this   neighborhood face to staying in their homes as they get older? (e.g., cost   of needed modifications, buildings with stairs, etc.) a. Do you know of older people who have had to move because their   homes were not practical for them? b. Do you know of supports in this community to help older people stay    in their homes? 20. [NYCHA] Are you familiar with policies related to persons with criminal    justice involvement residing at NYCHA? a. How do you feel about these policies? Do you think they’re good?   Bad? Why? b. Have you or people you know ever been impacted by these policies?   Can you describe how? 21. [NYCHA] Have you heard that NYCHA will be going smoke-free in July 2018    as a result of a government mandate? a. What are your thoughts about smoke-free public housing? b. What, if any, concerns do you have about this new rule? 57 Housing and Health in New York City: Perspectives From Low-Income Communities To end, we’d like to talk about resources. 22. What services are available in this community to help people with housing    problems? For example, resources that provide financial assistance for    housing, legal assistance, tenant organizing, housing referrals, etc.? a. Have you used any of these services? If so, which ones? b. How accessible were they? How helpful? c. What could they do better? 23. In general, how would you describe the level of knowledge your doctor has    about housing and housing issues? 24. Do you think it’s important that health care providers have an    understanding of where you live—or does that not matter? a. How would you feel about your health care provider asking you about   some of the challenges we discussed today, such as whether your   home has mold or whether you have difficulties paying your rent? b. Do people have experiences where health care has been better (or   worse) when your doctor knew about your housing? 25. Is there anything else we didn’t ask about housing and related health issues in your community that you’d like to share with us before we close? 26. Do you have any questions for us? 58 NYAM.org i Gaumer, E., Jacobawitz, A., Brooks-Gunn, J. (2016). Panel Paper: The Impact of Affordable Housing on Well-being of Low-Income Households: Early Findings from the NYC Housing and Neighborhood Study. 38th Annual Fall Research Conference: The Role of Research in Making Government More Effective. Retrieved from: https://appam.confex.com/appam/2016/webprogram/Paper17208.html Joint Center for Housing Studies of Harvard University. (2017). The State of the Nation’s Housing. ii Boston, MA. Retrieved from: http://jchs.harvard.edu/research/state_nations_housing. Desmond, M., & Kimbro, R. T. (2015). Eviction's fallout: housing, hardship, and health. Social Forces, iii 94(1), 295-324. Braveman, P., Dekker, M., Egerter, S., Sadegh-Nobari, T, & Pollack, C. (2011). Housing and Health. iv Robert Wood Johnson Foundation. Retrieved from: https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf70451 v Solari, C. D., & Mare, R. D. (2012). Housing crowding effects on children’s wellbeing. Social Science Research, 41(2), 464-476. Cutts, D. B., Meyers, A. F., Black, M. M., Casey, P. H., Chilton, M., Cook, J. T., ... & Rose-Jacobs, R. (2011). vi US housing insecurity and the health of very young children. American Journal of Public Health, 101(8), 1508-1514. Newman, S. J. (2008). Does housing matter for poor families? A critical summary of research and vii issues still to be resolved. Journal of Policy Analysis and Management, 27(4), 895-925. Braveman, P., Dekker, M., Egerter, S., Sadegh-Nobari, T, & Pollack, C. (2011). Housing and Health. viii Robert Wood Johnson Foundation. Retrieved from: https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf70451 Maqbool, N., Viveiros, J., & Ault, M. (2015). The Impacts of Affordable Housing on Health: A research ix summary. Center for Housing Policy. Retrieved from: https://www.rupco.org/wp-content/uploads/pdfs/The-Impacts-of-Affordable-Housing-on-Health- CenterforHousingPolicy-Maqbool.etal.pdf/. x Joint Center for Housing Studies of Harvard University. (2017). The State of the Nation’s Housing. Boston, MA. Retrieved from: http://jchs.harvard.edu/research/state_nations_housing. xi Shaw, M. (2004). Housing and public health. Annu. Rev. Public Health, 25, 397-418. Health hazards include: breakdown in heating equipment; additional heating required; rodent xii infestation; open cracks/holes in interior walls or ceiling, or holes in floor; broken plaster or peeling paint; toilet breakdown; and water leaks. Maqbool, N., Viveiros, J., & Ault, M. (2015). The Impacts of Affordable Housing on Health: A research xiv summary. Center for Housing Policy. Retrieved from: https://www.rupco.org/wp-content/uploads/pdfs/The-Impacts-of-Affordable-Housing-on-Health- CenterforHousingPolicy-Maqbool.etal.pdf/. Keene, D. E., & Geronimus, A. T. (2011). “Weathering” HOPE VI: The importance of evaluating the xiv population health impact of public housing demolition and displacement. Journal of Urban Health, 88(3), 417-435. 59 Housing and Health in New York City: Perspectives From Low-Income Communities About the Academy The New York Academy of Medicine advances solutions that promote the health and well-being of people in cities worldwide. Established in 1847, The New York Academy of Medicine continues to address the health challenges facing New York City and the world’s rapidly growing urban populations. We accomplish this through our Institute for Urban Health, home of interdisciplinary research, evaluation, policy and program initiatives; our world class historical medical library and its public programming in history, the humanities and the arts; and our Fellows program, a network of more than 2,000 experts elected by their peers from across the professions affecting health. Our current priorities are INSTITUTE FOR URBAN HEALTH healthy aging, disease prevention, and eliminating health disparities. FELLOWS LIBRARY The New York Academy of Medicine 1216 Fifth Avenue | New York, NY 10029 212.822.7200 NYAM.org © 2018 The New York Academy of Medicine. All rights reserved. NYAM.org