First, I’d like to take this opportunity to recognize the tireless work my much more accomplished co-authors engage in every day. Health disparities researchers face an increasingly maddening paradox – the simplest and probably most effective solutions to preventing unnecessary death are going to be the most difficult to implement. Additionally, I’m grateful for the invitation to write a corresponding blog post to our paper because the recommendations within I felt warrant some discussion about the lack of affordable housing in the US.

Researching this paper topic was of interest to the co-authors and myself because housing is a basic need and providing evidence that people’s health is negatively impacted when their housing is not stable is a prerequisite for advocating for change at a policy level in modern society. Our study findings added some new insights to the evidence base; we found those who reported housing insecurity had a lower likelihood of several self-reported diabetes processes of care and self-care behaviors, and this relationship was moderated by both employment and race/ethnicity in some interesting ways.

We highlighted prior research indicating individuals with diabetes who are housing insecure need to invest more resources and personal energy into getting around barriers to managing their diabetes, and clinicians find maintaining regular standards of care challenging for these patients (Henry et al, 2020). It’s not hard to imagine how the stress of potentially losing your home can be all consuming, leaving one with very little capacity to deal with a chronic disease like diabetes that requires so much daily effort from the individual affected to keep it in check.

With or without diabetes, human health is inextricable from basic needs for healthy food, clean water, and safe shelter – who would disagree? However, even in high-income economies like the U.S., basic needs are heavily regulated, unevenly allocated, and incessantly debated. In modern societies, accessing basic needs is not something an individual can do without engaging in the infrastructure and economies we’ve built around basic needs. An unhoused person in the U.S. cannot just build a house for themself to live in, they must seek out someone appointed with housing resources who can find the appropriate housing for their situation, and the appointed person has a dual obligation to ensure the unhoused person meets the criteria and follows the rules for living in that house/apartment/room/sleeping pod. Our basic needs are subject to conditions, and the worse off you are, likely the more conditions.

While many diabetes interventions at the individual, organizational, or provider level have the evidence behind them to be successful, they are not equipped to address gaps in basic needs for vulnerable people; providers cannot connect patients with material needs when they are unobtainable. This may be a reason why, as noted in our paper, only 2% of nationally representative sample of adults with diabetes who were unstably housed reported receiving help with housing in a clinical setting (Berkowitz et al, 2018). I recognize this poses a challenge to our paper’s concluding recommendation:

“To minimize the impact of housing insecurity on diabetes outcomes, housing insecurity questions should be included in standardized assessments used within the clinical setting to further tailor diabetes care interventions to patients and connect those facing housing insecurity to a social service provider with housing resources.”

The recommendation is valid. However, it is dependent on an individual who has access to a resource that must be readily available to the patient. This is exactly the point where individual and organizational level interventions fall short, where there exists a chasm between the basic needs of the patient and the capacity of their environment to meet those needs. In other words, it’s difficult to put these types of recommendations into practice in places that need community level interventions that directly target community level determinants of health.

Consider the current housing crisis in the City of Milwaukee where our team conducts research on diabetes interventions. For context, Milwaukee is one of the most segregated cities in the U.S. and most Black residents are concentrated in the central city where, not surprising, there is a lack of affordable and safe housing. Milwaukee County has a diabetes prevalence rate of 11%, however, 29% of Black residents participating in a national survey in the City of Milwaukee reported having diabetes (Ryff et al, 2018).

Wisconsin state statutes require municipalities to produce yearly housing affordability reports. The 2022 report from the City of Milwaukee states that there are 38,900 households that earn less than $20,000 per year and pay more than half of their income on housing, and they expect this number of severely cost burdened households to grow. In total, 95,900 Milwaukee households report cost burdens (42% of all households). Households of lower income and of persons of color tend to be disproportionately affected by housing cost burden and are subject to housing insecurity associated with lower home ownership rates, greater risk of foreclosure, and higher eviction rates. Most severely cost burdened households are renting, indicating there are very few rental units available that are appropriately priced. Despite the lack of affordable units, the city reports having a more than adequate supply of housing units. To remedy the issue, housing policy experts recommend providing housing assistance in the form of public housing, subsidized housing, or a housing voucher. The report acknowledges that the number of resources required to meet the needs of severely cost burdened households alone is far beyond the scope of local government to do at a meaningful scale in Milwaukee.

Now, I bet it’s not hard to figure out what a community level intervention for affordable housing in Milwaukee might look like with this knowledge. Simple solutions, right? Well, not quite – but I hope the health disparities researchers are taking note. People are in dire need of community level interventions to adequately address health disparities and the time to do them is now.