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976
VOLUME 115 |NUMBER 6 |June 2007
•
Environmental Health Perspectives
Research
|
Mini-Monograph
Introduction
This article examines policy challenges faced
by federal and local governments in the
United States as they address the adverse
health consequences of substandard housing,
buildings, and other indoor environments.
Specific experiences at the U.S. Department
of Housing and Urban Development (HUD),
the U.S. Environmental Protection Agency
(EPA), and the Cuyahoga County Health
Department (near Cleveland, Ohio) are high-
lighted as examples of how multidisciplinary
approaches can yield important advances in
environmental health in an area in which both
scientific research and legal authorities remain
relatively underdeveloped compared with
existing building code, environmental law,
and public health practice.
There is renewed interest in the linkage
between substandard housing, poor indoor
environmental quality, and unsustainable pat-
terns of community development on the one
hand and the state of the public’s health on
the other (HUD 1999a; Sharfstein and
Sandel 1998). Sustainability, affordability,
and health are all highly related and depen-
dent on one another. At the most basic level,
substandard housing and buildings are
unhealthy, unsustainable, and unaffordable
(Jacobs 2005; Sandel et al. 2004).
Origins of the health and housing connec-
tion. Linking housing and health is not fun-
damentally a new idea. Florence Nightingale
said “The connection between health and the
dwelling of the population is one of the most
important that exists” (Lowry 1991). There is
little doubt that improvements in housing in
developed countries have greatly advanced
the public health. Early housing standards
provided for improved ventilation, sanitation,
reduced crowding, structural soundness,
lighting, and other habitability criteria, partly
as a response to the appearance of concen-
trated slum housing around factories and big
cities during the industrial revolution [Riis
1890; Centers for Disease Control and
Prevention (CDC) 1976]. The public health
movement and the housing movement have
common roots a century ago in the sanitation
movement that worked to clean up squalid
conditions in housing. For example, the pro-
vision of indoor plumbing, still lacking in
much of the developing world, had much to
do with improved sanitation and the control
of cholera and other similar diseases in the
developed world. Yet today housing, health,
and environment are all seen as separate and
unrelated disciplines (HUD 1999a; Krieger
and Higgins 2002; Lowry 1991).
In the developed world, housing deficien-
cies still exist, although the context and cer-
tain disease outcomes have changed (Matte
and Jacobs 2000). Inadequate ventilation and
crowding in housing contributed to the
tuberculosis epidemic a century ago in the
United States (Stein 1950) and remains a sig-
nificant problem in developing countries
today, causing 2 million deaths in 2002
[World Health Organization (WHO) 2004].
Although the tuberculosis problem seemed
insurmountable, improvements in lighting,
fresh air, and crowding in housing all helped
to reduce its prevalence. Today, inadequate
ventilation and moisture management in
housing still contributes to asthma, mold-
induced illnesses, carbon monoxide poison-
ing, and other diseases and injuries (Krieger
and Higgins 2002; Matte and Jacobs 2000).
Although the focus of this mini-mono-
graph is on housing conditions in Europe and
the United States, it is worth noting at the out-
set that substandard housing conditions are
truly a global problem. A recent United
Nations report shows that more than one-third
of all urban dwellers live in slums in develop-
ing countries (nearly 1 billion people), and the
percentage is increasing rapidly, with the num-
ber of slum dwellers expected to double by
2030 (United Nations 2003).
Some of the key policy impediments in
this field involve the tension between hous-
ing affordability and health, privacy issues,
lack of clarity in statutory authority, and
gaps in responsibility for the built and
indoor environments.
Indoor air pollution and the “shared
commons” problem. In the United States, the
Clean Air Act (1970) authorizes an intricate
system of regulation and oversight to support
outdoor air quality and a network of top-
down mandates that originates with national
legislation and standard setting and extends
to states, counties, and localities for execution
and monitoring. Generally, the system enjoys
broad national support for clean and healthy
outdoor air. Yet no such consensus has
formed to support the quality of air indoors,
where people do more of their breathing.
Indoor air pollution is one of the top four
environmental health risks identified by the
U.S. EPA and the Scientific Advisory Board
This article is part of the mini-monograph “Developing
Policies to Improve Indoor Environmental Quality.”
Address correspondence to D.E. Jacobs, National
Center for Healthy Housing, 10320 Little Patuxent
Parkway, Suite 500, Columbia, MD 21044 USA.
Telephone: (443) 539-4157. Fax: (443) 539-4150.
E-mail: djacobs@nchh.org
The findings and opinions expressed in this paper
are solely those of the authors, not of any govern-
ment agency.
The authors declare they have no competing finan-
cial interests.
Received 9 January 2006; accepted 19 April 2006.
Linking Public Health, Housing, and Indoor Environmental Policy: Successes
and Challenges at Local and Federal Agencies in the United States
David E. Jacobs,
1
Tom Kelly,
2
and John Sobolewski
3
1National Center for Healthy Housing, Columbia, Maryland, USA; 2U.S. Environmental Protection Agency, Washington, DC, USA;
3Cuyahoga County Board of Health, Cleveland, Ohio, USA
We describe the successes and challenges faced by federal and local government agencies in the
United States as they have attempted in recent years to connect public and environmental health,
housing, community development, and building design with environmental, housing, and building
laws, codes, and policies. These policies can either contribute to or adversely affect human physical
and mental health, with important implications for economic viability, research, policy develop-
ment, and overall social stability and progress. Policy impediments include tension between hous-
ing affordability and health investment that causes inefficient cost-shifting, privacy issues, unclear
statutory authority, and resulting gaps in responsibility for housing, indoor air, and the built envi-
ronment. We contrast this with other environmental frameworks such as ambient air and water
quality statutes where the concept of “shared commons” and the “polluter pays” is more robust.
The U.S. experiences in childhood lead poisoning prevention, indoor air, and mold provide useful
policy insights. Local programs can effectively build healthy homes capacity through local laws and
housing codes. The experience of coordinating remediation for mold, asthma triggers, weatheriza-
tion, and other healthy housing improvements in Cuyahoga County, Ohio, is highlighted. The
U.S. experience shows that policymakers should adopt a prevention-oriented, comprehensive multi-
disciplinary approach at all levels of government to prevent unhealthy buildings, houses, and com-
munities. Key words: built environment, healthy housing, housing, indoor air quality, indoor
environmental quality, policy, public health. Environ Health Perspect 115:976–982 (2007).
doi:10.1289/ehp.8990 available via http://dx.doi.org/ [Online 25 January 2007]
authorized by Congress to consult with the
U.S. EPA on technical matters (U.S. EPA
1990). On average, U.S. citizens spend about
90% of their time indoors, where indoor lev-
els of pollutants may be two to five times
higher than outside, and occasionally 100
times higher. Indoor pollution is estimated to
cause thousands of cancer deaths and hun-
dreds of thousands of respiratory health prob-
lems each year. Millions of children have
experienced elevated blood levels of contami-
nants resulting from their exposure to indoor
pollutants (U.S. EPA 1997). Other health
effects include irritation of the eyes, nose, and
throat, and more subtle neurotoxicologic and
behavioral and other adverse effects.
In addition to public health concerns,
indoor air pollution accounts for substantial
economic costs. Cost–benefit estimates by the
U.S. EPA (2001b) suggest that net avoidable
costs associated with indoor air pollution
amount to well over $100 billion annually,
and more likely between $150 billion and
200 billion (all dollar amounts in this article
are calculated in U.S. dollars). About 45% of
those costs are attributable to avoidable deaths
from radon and environmental tobacco
smoke, about 45% from lost productivity,
and about 10% from avoidable respiratory
diseases.
Indoor air pollution can be defined as
chemical, physical, or biological contaminants
in the breathable air inside a habitable struc-
ture or conveyance, including workplaces,
schools, offices, homes, and vehicles (the
indoor environment). Indoor air pollution
includes the following:
• combustion by-products;
• ozone;
• allergens (including mold spores);
• volatile organic compounds and particulate
matter;
• paints, finishes, furnishings, adhesives, caulks,
and pressed wood products found in building
materials;
• cleaning products, personal care products, air
fresheners, pesticides commonly used
indoors;
• tobacco smoking, hobbies, cooking, and
other occupant activities, including bringing
home dry-cleaned clothes;
• bioeffluents; and
• soil gas intrusion (e.g., radon).
To address indoor air quality problems in the
United States, national, state, and local legis-
latures have typically authorized public agen-
cies to conduct voluntary programs intended
to raise the public’s awareness about indoor
air problems and appropriate actions they can
take, alongside mandatory regulatory pro-
grams for ambient exterior pollution. The
impetus for such contrasting public policies
may be found in historical, attitudinal, and
technical considerations that may have helped
to inhibit the formation of a broad social and
political consensus for controls on indoor air
quality problems.
Historically, the legal structure for the
environmental movement in the United States
stands on two fundamental principles of
English common law: “Shared Commons” and
“The Polluter Pays” (Hardin 1968). Shared
Commons is derived from medieval practice
governing community use of a public resource.
Although everyone’s cattle may graze on the
common green, nobody’s cattle may overgraze
the resource and deprive others of its use. In its
current legal application, this principle means
the community may act to protect its interest if
private activity deprives the public of its right
and reliance on a shared resource, for example,
breathable exterior air. The Polluter Pays prin-
ciple holds that it is the originator of the pollu-
tion, not the injured public, who bears
responsibility for the cost of its control.
Against this intellectual and legal back-
drop, in the late 1960s, a number of historical
developments and emotionally charged
episodes fed growing public outrage against
the increasingly obvious outdoor pollution.
For instance, in 1969, the Cuyahoga River in
Cleveland, Ohio, burst into flames because of
the combustible waste it was carrying rou-
tinely. Although the fires were quickly
doused, the spectacle was dramatic enough to
generate national press coverage of exterior
environmental degradation in many other
sectors of American national life. With
respect to exterior air quality, around the
same time, private charities called “Fresh Air
Funds” were widely supported because of
their promise to send urban children to camp
for a week, allowing some to escape, if only
for a brief interlude, the increasing choke of
urban exterior air pollution.
With such incidents firing the revulsion of
common citizens to increasingly visible envi-
ronmental insults, the first Earth Day in 1970
brought millions into the streets to express
broad and deep public outrage over the prob-
lem. President Richard Nixon responded by
establishing the U.S. EPA by Executive Order
in December 1970 (Office of the President
1970). By that time, the U.S. Congress had
already passed the Clean Air Act (1970), which
it supplemented with the Clean Water Act
(1972), to authorize urgent measures to
address the exterior environment.
Contrast this scenario with the case of
indoor air and indoor environments gener-
ally. Here, there is not a perceived Shared
Common for which the public feels a com-
munal benefit and responsibility. Interior air,
whether clean or contaminated, sits within
the enclosed space of one’s own home or
another discrete building. Typically, a pol-
luter cannot be easily identified and tasked
with payment for remediation. If the ambient
exterior air is a shared common “owned” by
everyone, ownership of indoor air is a far
more ambiguous matter.
Consequently, for indoor air, we have had
no dramatic moment of recognition such as a
river on fire to galvanize public action despite a
series of well-publicized serious indoor issues,
such as childhood lead poisoning, radon,
asbestos, mold, and so on. Furthermore,
responsibility for buildings is diffuse, including
architects, maintenance personnel, designers,
employers, code and building inspectors, occu-
pants, and others. In the absence of a clear-cut
villain on whom the burden of correction can
be laid, there has been less public support to
demand mandates to control indoor pollution.
This is not to say there is neither outrage
nor perceived villainy when it comes to indoor
air. But in this context, the aggrieved are typi-
cally individuals acting for themselves or in
small groups rather than an inflamed public
acting through the political process. For these
reasons, owners of private residences or ten-
ants of buildings typically turn to the courts
for redress of specific injury rather than to the
legislature for the enactment of broad stan-
dards applicable across all occupied spaces.
Despite these obstacles, an increasing number
of local housing and health code enforcement
agencies are adopting local ordinances to
improve indoor air quality (Environmental
Law Institute 2003), and foundations have
increasingly championed “green” communities
(Enterprise Foundation 2004).
Indirectly, federal U.S. laws and regu-
lations do address indoor environmental qual-
ity. The U.S. EPA administers the Toxic
Substances Control Act (1976), the Federal
Insecticide, Fungicide, and Rodenticide Act
(1996), and the Safe Drinking Water Act
(1974), each of which limits the harmful qual-
ity of substances brought into the indoor envi-
ronment, though not indoor air itself. As far
back as 1937, the U.S. Housing Act (1937)
called for “decent, safe and sanitary housing,”
and Congress enacted the Lead-Based Paint
Poisoning Prevention Act (1971) and the
1992 Residential Lead Hazard Reduction Act
(Title X 1992). The Consumer Product Safety
Commission has established regulations pro-
hibiting the sale of lead-based paint and other
dangerous consumer products. Most local
jurisdictions have health or housing codes that
contain prohibitions against broadly defined
public health nuisances.
Successes and Limitations
There are a few examples of successes of govern-
ment interventions in the indoor environment
that have led to dramatic improvements in
environmental health, although in each case the
improvements have also highlighted the fact
that far too many remain at risk and further
interventions are needed. Here, we consider the
Health, housing, and indoor environmental quality
Environmental Health Perspectives
•
VOLUME 115 |NUMBER 6 |June 2007
977
experiences with childhood lead poisoning,
radon, and mold.
Lessons from the lead poisoning prevention
experience in the United States. The policy
lessons from the lead paint experience provide
a framework for addressing other housing-
related health hazards. The need for primary
prevention (taking action before harm occurs);
validated and affordable exposure assessment
and hazard control techniques; surveillance;
targeted public investment; articulation of a
national plan; cost–benefit analyses; enforce-
ment; and policy-relevant scientific research
were all at work here.
In one of the clearest examples of the
linkage between health and housing, public
health officials warned over 100 years ago
(Gibson 1904; Turner 1897) against permit-
ting the use of lead paint in housing, a legacy
only recently addressed in the United States
(Jacobs 1995; Markowitz and Rosner 2002)
and in France (Fassin and Naude 2004).
Unfortunately, lead paint is still being used in
much of the developing world, constituting
an emerging housing problem (Alliance to
End Childhood Lead Poisoning and
Environmental Defense Fund 1994; Clark
et al. 2006). Many countries have not identi-
fied the prevalence of lead paint hazards in
housing (Howson et al. 1996).
Lead poisoning prevention in the United
States has emerged as a major public health
success story, although childhood lead poison-
ing still remains a major environmental dis-
ease. The number of lead-poisoned children
steadily declined in the United States after
government action was taken to remove lead
from new paint, gasoline, food canning, and
most recently from housing, where it presents
a hazard. In particular, the removal of lead
from gasoline and control of industrial emis-
sions greatly reduced the exposure problem
with airborne lead. As a result of these and
other measures, the percentage of children
1–6 years of age with blood lead levels
≤10 µg/dL declined from 88% in the 1980s
to approximately 1.6% (316,000 children) in
1999–2002 (Brody et al. 2005; Meyer et al.
2003). The number of houses with lead paint
in the United States has also fallen from
64 million in 1990 to 38 million in 2000
(Jacobs et al. 2002). Although this progress is
substantial, it should be tempered by the real-
ization that it took nearly a century to develop
the necessary infrastructure to begin to solve
the problem, and that far too many children
will be poisoned unnecessarily by lead in the
coming years unless additional action is taken.
Indeed, the United States did not achieve its
goal of eliminating childhood blood lead levels
> 25 µg/dL by 2000 (Meyer et al. 2003).
How did the progress in preventing lead
poisoning happen? What scientific and policy
advances made it possible? And what does that
experience mean for addressing other housing-
related health hazards?
After many years of paralysis, a political
consensus emerged in the early 1990s in the
United States that the dislocations in the
housing market caused by the added expense
of making homes lead safe are less important
and far less costly than the impact on chil-
dren’s health and on society. This resulted in
the unusual passage of public health and envi-
ronmental legislation through a housing law
(Title X 1992).
Exposure pathway studies revealed that
children were most commonly exposed to
deteriorated lead-based paint and the contam-
inated settled house dust and soil it generated
(Bornschein et al. 1987; Charney 1983;
Lanphear and Roghmann 1997; Lanphear
et al. 1998), although the very earliest studies
had also suggested the importance of contam-
inated dust and soil from paint (Gibson
1904). This led to the development of stan-
dardized dust-sampling procedures that were
significantly correlated with children’s blood
lead levels (Lanphear et al.1995). These pro-
cedures were subsequently incorporated into
health-based exposure standards for paint,
dust, and bare soil for housing undergoing
remediation, renovation, or repainting (U.S.
EPA 2001a).
Previously, the absence of such standards
had sometimes resulted in well-intentioned
abatement efforts that may have actually
increased blood lead levels in some children
(Amitai et al. 1987; Aschengrau et al. 1997).
The absence of such standard abatement
methods contributed to the policy paralysis
described earlier. After all, what policymaker
would want to implement a procedure, how-
ever well intentioned, that exacerbated the
problem? These standards also helped to solid-
ify the legal definition of exactly what condi-
tions constituted a lead-based paint hazard in
housing (U.S. EPA 2001a) and how they
could be controlled (National Center for
Healthy Housing 2004).
Congress required that state-of-the-art pro-
cedures be published and broadly implemented
in subsidized housing and local law (HUD
1995). The creation of standardized proce-
dures helped to create a viable, professional
inspectorate and remediation work force, pro-
moted private sector competition on a level
playing field, and thus drove down the average
cost of lead paint hazard control. These stan-
dardized procedures also provided for the pro-
hibition of dangerous forms of lead paint
removal, such as use of torches to burn lead
paint, abrasive blasting, and power sanding
(HUD 1995; Jacobs 1998), although the U.S.
EPA has recently proposed to permit such dan-
gerous practices (U.S. EPA 2006).
The data show that the cost of lead hazard
control is far less than the monetized benefits.
For example, in federally assisted (i.e., subsi-
dized) housing in the United States, the cost
of lead hazard control was estimated to be
$253 million, but the benefits were estimated
to be $1,143 million ($1.1 billion) in the first
year of implementing a new lead paint regula-
tion (HUD 1999b). For all high-risk U.S.
housing, the incremental cost of eliminating
lead-based paint hazards from 2000 to 2010 is
$2.3 billion, but the benefits are at least $11.2
billion (Jacobs et al. 2000). In addition, a ret-
rospective study quantified economic benefits
from improved worker productivity due to
childhood blood lead declines from 1976 to
1999. With discounted lifetime earnings of
$723,300 for each 2-year old expressed in year
2000 dollars, the estimated economic benefit
for each year’s cohort of 3.8 million 2-year old
children ranged from $110 billion to $319
billion (Grosse et al. 2002).
These cost–benefit analyses, together with
the development of a viable infrastructure and
compelling scientific research, enabled key fed-
eral U.S. agencies, including HUD, the CDC,
the U.S. EPA, the Department of Justice, and
others, to develop a 10-year plan covering
2000–2010 that defined what resources would
be needed to eliminate lead paint hazards in
houses and to protect children (Jacobs et al.
2000). The plan estimated how many children
would be poisoned over the 10-year period if
no action was taken and it estimated the costs
of not making homes lead safe. From 2000 to
2005, the plan called for a total of $1.15 bil-
lion in investment, but only $0.8 billion has
actually been appropriated through fiscal year
2005. Unless additional resources are obtained,
this deficit is likely to further delay the goal of
making housing safe for children by 2010.
Lessons from the indoor air activities at
the U.S. EPA. In 1989 the U.S. EPA estab-
lished the Federal Interagency Committee on
Indoor Air Quality (CIAQ), under Title IV,
Section 403(c) of the Superfund Amendments
and Reauthorization Act (1986). The purpose
of the CIAQ is to coordinate the activities of
the federal government on issues relating to
indoor air quality. Since the late 1980s, the
U.S. EPA has used the statutory authority in
Section 103, Subsections (a) and (b) of the
Clean Air Act (1970) to establish a nonregula-
tory program for the indoor environment that
analyzes relevant research and communicates
indoor air quality risks and steps citizens can
take to protect themselves and their families.
The major indoor air quality priorities of
the U.S. EPA are the prevention of lung cancer
due to radon and the reduction of illness from
respiratory and related diseases, such as asthma,
in homes and in schools. Here are some high-
lights of progress to date.
Radon. Through 1996, an estimated
880,000 homes had implemented radon-reduc-
ing features. These accomplishments led to the
Jacobs et al.
978
VOLUME 115 |NUMBER 6 |June 2007
•
Environmental Health Perspectives
prevention of an estimated 285 future prema-
ture cancer deaths annually. By the end of
2003, an estimated 1.7 million homes had
radon-reducing features (515,000 active mitiga-
tions and 1.2 million homes with radon-resis-
tant new construction), preventing 470 future
premature cancer deaths annually. In 2004, the
number of annual mitigations increased to over
575,000, and the total number of future lives
saved increased to 520 annually.
Indoor triggers of asthma. Results of the
U.S. EPA 2003 National Survey on Environ-
mental Management of Asthma and Children’s
Exposure to Environmental Tobacco Smoke
(U.S. EPA 2003) indicate that approximately
30% of people with asthma took all the essen-
tial actions recommended by the U.S. EPA to
reduce exposure to indoor triggers.
Schools. U.S. EPA data (U.S. EPA 2005)
indicate that 22% of U.S. schools now have
an indoor air quality management plan that
meets the U.S. EPA standard for effectiveness.
Implementing a local healthy homes pro-
gram in Cuyahoga County, Ohio. The high
prevalence of poverty, density of children, and
substandard housing place children in the
Cleveland area at high risk for pediatric dis-
eases related to the home environment. The
area has the largest population (1.4 million)
and some of the oldest housing stock in Ohio,
with 42% of the housing units built before
1950 and nearly half the population classified
as very low, low, or moderate income persons
(U.S. Census Bureau 2000).
Idiopathic pulmonary hemosiderosis in
infants (IPHI) first arose as an issue in Greater
Cleveland. A geographic cluster of 10 cases was
identified in 1993–1994, and subsequent
analysis found an association between water-
damaged building materials, mold, and ventila-
tion systems and IPHI (Dearborn et al. 2002).
Between 1993 and 2005, 59 infants were diag-
nosed with IPHI in the Greater Cleveland area,
with 16 resultant deaths (Dearborn 2005).
The Pulmonary Hemosiderosis Prevention
Program (PHPP) was established by the local
public health community in 1996 and sup-
ported with funding through public health
agencies and local foundations. As a result,
2,874 inspections have been conducted by
PHPP over the past decade, and 37% of the
housing units were classified as at-risk and
requiring some remediation to mitigate water
infiltration and environmental cleanup of
mold and other potential asthma triggers in
the home environment.
Another significant risk factor was a spe-
cific forced-air furnace design in which all of
the supply air was drawn from the basement
space and none from the living space. This
resulted in the migration of significant volumes
of air from the basement space to occupied
areas of the housing unit. Asthma triggers, irri-
tants, pathogens, and other exposure risks that
collect in damp basement air were then
distributed into breathing air in living spaces.
A study of a Cleveland house containing
significant amounts of Stachybotrys chartarum
on drywall in the basement due to water infil-
tration and the furnace configuration described
above found that air samples collected in the
upstairs living areas contained 5-fold increases
in S. chartarum spores when the furnace and
blower were actively circulating in comparison
with quiescent conditions (Vesper et al. 2000).
Basements often have the highest incidence of
water infiltration, water damage, and mold
growth of any other room in the housing
structure.
A study of high-risk asthmatic pediatric
patients who were hospitalized or had recent
emergency department or doctor office visits
and had water damage/mold within the home
was undertaken to study the effects of simulta-
neously controlling asthma triggers, excess
moisture, and lead paint hazard control. The
average cost for the interventions (n= 104)
performed by trained and licensed lead abate-
ment contractors was $5,635, with 56% of the
costs being dedicated to mold and moisture
control. These interventions provided the
opportunity to combine healthy homes inter-
ventions and lead hazard control. The mean
maximum number of symptom days declined
significantly for the intervention group at
10 months (p< 0.0001) and 12 months
(p= 0.053). Emergency department visits and
hospitalizations also declined significantly;
11 of 33 subjects in the control group required
hospital care, compared with only 1 of 29 cases
in the remediation group (p= 0.003)
(Dearborn 2005).
Briefly, the Cleveland experience shows
that local governments can successfully
a) combine repairs for moisture problems and
lead hazard controls with existing housing
programs; b) integrate funding resources,
scientific evaluations, specifications, and reme-
diation; and c) achieve programmatic collabo-
ration between local health and housing
organizations.
The Cuyahoga County experience shows
that local public health programs can respond
to poorly understood pediatric diseases related
to housing. Although specific legislation is
desirable, it is also possible to use existing
housing codes and units of local government
to implement healthy housing strategies and
improve indoor environmental quality.
Integrating Emerging Science
with Policy
All these examples show that government pol-
icy development in this field requires a firm
scientific foundation. That foundation must
include data on specific adverse health effects
related to specific housing and building condi-
tions and on interventions that are practical,
effective, and do not inadvertently result in fur-
ther disinvestment in low-income, quality
housing, workplaces, schools, and other build-
ings. In the cases of lead and radon, the scien-
tific research demonstrating significant harm to
the public health was particularly compelling
and robust.
Despite significant progress, there is still no
comprehensive system in the United States
that determines what substances and systems
should be permitted into buildings and houses
during construction, renovation, and mainte-
nance, and whether construction methods
effectively prevent naturally occurring toxic
substances such as radon from accumulating to
dangerous levels. Unfortunately, most efforts
to control building-related disease and injury
remain largely reactive not preventive. The
introduction of materials and construction
methods still is done with little regard for
adverse health outcomes. Lead paint was intro-
duced into housing with little thought about
the potential for lead poisoning. Urea
formaldehyde foam insulation, asbestos, and
other similar substances are also examples of
materials that cost far more to remove or con-
trol than they ever saved in reduced construc-
tion or maintenance costs or improved
durability. Improvements in weatherization
and energy conservation initially had similar
adverse moisture management consequences
due to sealing of building envelopes, with little
or no planning included for the interiors to dry
out or for proper ventilation (Engvall et al.
2003; Hirsch et al. 2000).
Furthermore, existing research methods
remain ill equipped to disentangle specific
housing characteristics from a host of con-
founding variables to discern their effect on
disease causation and exacerbation. In many
research studies, inadequate housing factors are
simply subsumed under “socioeconomic sta-
tus” and relegated to a covariate at best. We
need research that looks at the effect of specific
housing and building conditions together with
housing and community interventions if we
are to move to a more comprehensive, preven-
tive system that anticipates how changes in
housing and communities impact physical and
mental health. Former U.S. Surgeon General
Leroy Burney, best known for his statement
regarding the link between cigarette smoking
and lung cancer, said that in public health,
unlike the law, the suspect is guilty until
proven innocent.
A few examples of areas where this type of
research is needed are discussed below.
Asthma and other respiratory conditions,
mold, and moisture. In the United States,
asthma rates have increased by 73.9% from
1980 to 1996 (Mannino et al. 2002). More
evidence is accumulating that factors in the
home environment play an important role in
sensitizing children to asthma and triggering
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979
attacks. Chronic exposure to allergens in the
indoor environment from mold, pets, mice
and rats, cockroaches, and dust mites is associ-
ated with asthma (Breysse et al. 2004). For
example, recent exhaustive reviews found there
was sufficient evidence to establish a causal link
or association between a number of respiratory
conditions including asthma (or asthma exac-
erbation) and the presence of dust mites, cock-
roaches, fungi and mold, pet dander, tobacco
smoke and other substances [National
Academy of Sciences (NAS) 2000], and damp-
ness (NAS 2004).
There is also new evidence that housing
interventions are indeed effective in reducing
the onset and severity of asthma. A large ran-
domized controlled trial in seven U.S. cities
enrolled 937 children with atopic asthma.
The experimental group received remediation
of allergens in the home: provision of mattress
and pillow covers; use of a HEPA (high-effi-
ciency particulate air filter) vacuum cleaner;
use of a HEPA air purifier if environmental
tobacco smoke was present; and pest control
if needed. Follow-up showed that the inter-
vention group experienced fewer symptom
days for 2 years (p< 0.001), and there were
significant reductions in dust mite and cock-
roach allergens, also for 2 years (p< 0.001)
(Morgan et al. 2004). Another study showed
the rate of doctor-diagnosed asthma was 25%
in children residing in deteriorated public
housing compared with only 8% in other
housing (p< 0.01). This same trend also was
observed in self-reported health status
(Howell et al. 2005).
Many other studies have examined the link
between allergens in the home and asthma, but
the evidence of clinical significance and the
cost-effectiveness of home-based interventions
needs to be further substantiated (Morgan
et al. 2004; NAS 2000).
Unintentional injuries. Approximately
55% of unintentional deaths among U.S. chil-
dren 0–19 years of age occur in the home
(excluding motor vehicle accidents), and more
than 4 million injuries in the home (39%)
require a visit to an emergency department,
resulting in over 70,000 hospitalizations each
year (Nagaraja et al. 2005; Phalen et al. 2005).
Falls in the home were the most prevalent
mechanism of injury, and falls on stairs were
the most common, yet we have relied almost
entirely on educational efforts, with little com-
prehensive assessment of the effect of altering
the physical environment. The evidence that
does exist shows that reducing the temperature
of hot water heaters to prevent scalding,
installing window guards in high-rise build-
ings, installation and maintenance of smoke
alarms and carbon monoxide alarms, and
installation of cabinet locks and segregation
and locking away poisons all have beneficial
effects (Breysse et al. 2004).
Community design, obesity, poverty, and
income segregation. The ways in which our
communities are geographically arranged also
have important health implications that are
only now becoming clear. Rates of obesity and
diabetes have increased dramatically in the
United States (Mokdad et al. 2001). New
communities are rarely designed to encourage
walking, exercise, and recreation. Suburban
developments are more often optimized for
automobile transportation, not walking or
biking. Unplanned growth of communities
(sprawl) is unlikely to be sustainable and has
important health consequences, such as obe-
sity and diabetes, that are ripe for further
research (Dannenberg et al. 2003; Frumkin
et al. 2004).
In a randomized trial known as Moving to
Opportunity, families living in high-poverty
U.S. public and assisted housing in five cities
were given vouchers (subsidies) to move to pri-
vately owned housing in low-poverty areas (n=
4,248 households). Two control groups
included families that continued to live in pub-
lic or assisted housing in areas with poverty
rates exceeding 40%. From 1994 to 2002, the
study found significant improvements in adult
obesity and mental health (p< 0.05) in the
group that moved to low-poverty (i.e., mixed-
income) neighborhoods. Improvements in
asthma were also significant in one of the five
cities (HUD 2003). The study showed that
adverse health effects are associated with segre-
gating housing by income, and that policies
that promote mixed-income communities are
likely to have beneficial health outcomes. A
review of programs that increase housing choice
and promote mobility shows significant public
health benefits (Acevedo-Garcia et al. 2004).
Incremental versus comprehensive policy
change. Traditionally, building and housing
interventions for health have proceeded from a
categorical, substance-specific program design,
i.e., lead, radon, mold, and so on. But from a
building systems perspective, it is possible to
conduct housing interventions that are focused
on four major issues and that could be
expected to yield multiple health benefits
(HUD 1999a). These include moisture,
ventilation, settled dust and cleanable surfaces,
and education. For example, controlling mois-
ture can be expected to affect mold-induced ill-
nesses, asthma and other respiratory diseases,
lead poisoning (because moisture causes paint
deterioration), pests, and perhaps others.
Improved ventilation can be expected to help
control exposures from off-gassing of building
materials, combustion products, organic sub-
stances, excess moisture, radon, and so on.
Settled dust control will have an impact on
lead poisoning, pesticide- and asbestos-induced
illnesses, and so on.
In short, research and programs should be
designed so that the more common incremental,
reactive, trial-and-error substance-specific cate-
gorical strategies are incorporated into more
comprehensive systems that, if improved, will
address many individual toxic substances and
unhealthy housing factors simultaneously and
at lower incremental cost.
The lead poisoning prevention experience is
instructive. The U.S. Congress passed the origi-
nal Lead-Based Paint Poisoning Prevention Act
(1971), but because the research, standards,
capacity, and other elements described above
were not yet adequately developed, it was not
until 1992 that the more comprehensive pri-
mary prevention approach embodied in Title X
was feasible to implement as a national policy.
The challenge of developing a comprehensive
healthy homes and indoor environment policy
remains the key to further progress.
Without an integrated research and policy
agenda, the “science of muddling through”
(Lindblom 1959) and tackling each issue one-
by-one is likely to preclude a comprehensive,
preventive, and integrated policy (Quade
1975). Both the comprehensive and incremen-
tal approaches are necessary to achieve mean-
ingful policy change, but the comprehensive
approach in this field remains largely untapped.
Conclusion
The key research and policy challenges in this
field include the following:
• Improved and lower-cost housing and
building hazard measurement techniques.
• Better understanding of the interactions
between specific housing and building
conditions with physical and mental health
outcomes.
• How interactions with confounding
variables in the residential setting can be
adequately controlled.
• Long-term assessment of the efficacy of
integrated housing- and community-based
interventions, in addition to assessment of
categorical interventions.
• Better understanding of optimum delivery
of integrated services and the construction
of improved local capacity to provide
comprehensive health-related improvements
in buildings through improved collabora-
tion between housing and health agencies at
all levels of government.
• Making scientific research findings more
accessible and more relevant to housing
finance, maintenance, and rehabilitation
and housing and community development
policies.
Relying solely on a substance-by-substance,
categorical, trial and error approach (i.e., the
incremental approach) is essentially a pes-
simistic view about the capabilities of citizens,
researchers, policymakers, and nations to
understand and ultimately make homes,
buildings, and communities safe and viable.
Moreover, relying solely on the incremental
Jacobs et al.
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•
Environmental Health Perspectives
approach creates barriers among the disci-
plines of public health, housing, environmen-
tal science, urban planning, transportation,
and others. Instead, we should work to build
a multidisciplinary approach to improve the
indoor environment.
By producing the science to identify and
control hazards, by building the consensus to
end the false tradeoff between affordability
and health, by accurately describing the costs
and hidden benefits, by implementing pri-
mary prevention in the indoor environment,
and by creating multidisciplinary capacity and
know-how at local and national governments,
nations can systematically create living envi-
ronments that will not harm, but actively pro-
mote the well-being of their citizens.
REFERENCES
Acevedo-Garcia D, Osypuk TL, Werbel, RE, Meara ER, Cutler DM,
Berkman LF. 2004. Does Housing Mobility Policy Improve
Health? Housing Policy Debate 15:49–98. Available: http://
www.fanniemaefoundation.org/programs/hpd/pdf/hpd_
1501_Acevedo.pdf [accessed 26 November 2004].
Alliance to End Childhood Lead Poisoning (now the Alliance for
Healthy Housing) and Environmental Defense Fund. 1994.
The Global Dimensions of Lead Poisoning. Available:
http://www.globalleadnet.org/publications/alliance_pubs/
globaldimensions.cfm [accessed 26 October 2004].
Amitai Y, Graef JW, Brown MJ, Gerstle RS. 1987. Hazards of
deleading homes of children with lead poisoning. Am J Dis
Child 141:758–760.
Aschengrau A, Beiser A, Bellinger D, Copenhafer D, Weitzman
M. 1997. Residential lead paint hazard remediation and soil
lead abatement: their impact among children with mildly ele-
vated blood lead levels. Am J Public Health 87:1698–1702.
Bornschein RL, Succop P, Krafft KM, Clark CS, Peace B,
Hammond PB. 1987. Exterior surface dust lead, interior
house dust and childhood lead exposure in an urban envi-
ronment. In: Proceedings of the Conference on Trace
Substances in Environmental Health, Columbia, Missouri.
Columbia, MS:University of Missouri, 322–332.
Breysse P, Farr N, Galke W, Lanphear BP, Morley R, Bergofsky
L. 2004. The relationship between housing and health: chil-
dren at risk. Environ Health Perspect 112:1583–1588.
Brody DJ, Brown MJ, Jones RL, Jacobs DE, Doa MJ, Ashley PJ,
et al. 2005. Blood lead levels—United States, 1999–2002.
MMWR Morb Mortal Wkly Rep 54:513–516.
CDC1976. Basic Housing Inspection. Centers for Disease
Control, Bureau of State Services, DHEW Publ no. 76-8315,
Atlanta:Centers for Disease Control and Prevention.
Charney E, Kessler B, Farfel M, Jackson D. 1983. A controlled
trial of the effect of dust-control measures on blood lead
levels. N Engl J Med 309:1089–1093.
Clark CS, Rampal KG, Thuppil V, Chen CK. 2006.The lead con-
tent of currently available new residential paint in several
Asian countries. Environ Res 102(1):9–12.
Clean Air Act. 1970. 42 U.S.C. 7401. Available: http://www.epa.gov/
region5/defs/html/caa.htm [accessed 12 May 2007].
Clean Water Act. 1972. 33 U.S.C. 1251. Available: http://www.epa.
gov/region5/water/cwa.htm [accessed 12 May 2007].
Dannenberg AL, Jackson RJ, Frumkin H, Schieber RA, Pratt M,
Kochtitzky C, et al. 2003. The impact of community design
and land-use choices on public health: a scientific
research agenda. Am J Public Health 93:1500–1508.
Dearborn DG. 2005. Cuyahoga County Urban Mold and Moisture
Program. In: Controlling and Preventing Household Moisture
Problems: A Report to Congress. U.S. Department of Housing
and Urban Development. Available: http://www.hud.gov/
utilities/intercept.cfm?/offices/lead/report040105.pdf
[accessed 26 November 2005].
Dearborn DG, Smith PG, Dahms BB, Allan TM, Sorenson WG,
Montana E, et al. 2002. Clinical profile of 30 infants with
acute pulmonary hemorrhage in Cleveland. Pediatrics
110:627–637.
Engvall K, Norrby C, Norback D. 2003. Ocular, nasal, dermal and
respiratory symptoms in relation to heating, ventilation,
energy conservation, and reconstruction of older multi-fam-
ily houses. Indoor Air 13:206–211. Available: http://www.ncbi.
nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&
dopt=Abstract&list_uids=12950582 [accessed 27 November
2004].
Enterprise Foundation. 2004. Green Communities Initiative. Avail-
able: http://www.enterprisefoundation.org/majorinitiatives/
green/index.asp [accessed 26 November 2004].
Environmental Law Institute. 2003. Improving Indoor Air Quality in
Rental Dwellings: A Review of Policies in Five U.S. Localities.
Available: http://www.elistore.org/reports_detail.asp?ID=
10881 [accessed 20 March 2006].
Fassin D, Naude AJ. 2004. Plumbism reinvented: childhood lead
poisoning in France. Am J Public Health 94:1854–1863.
Federal Insecticide, Fungicide, and Rodenticide Act. 1996.
7 U.S.C. 135. Available: http://www.epa.gov/region5/defs/
html/fifra.htm [accessed 12 May 2007].
Frumkin H, Frank L, Jackson R. 2004. Urban Sprawl and Public
Health: Designing, Planning and Building for Healthy
Communities. Washington DC:Island Press.
Gibson JL. 1904. A plea for painted railings and painted walls of
rooms as the source of lead poisoning amongst Queensland
children. Aust Med Gaz 23:149–153.
Grosse SD, Matte TD, Schwartz J, Jackson RL. 2002. Economic
gains resulting from the reduction in children’s exposure
to lead in the United States. Environ Health Perspect
110:563–569.
Hardin G. 1968. The tragedy of the commons. Science 162(3859):
1243–1248.
Hirsch T, Hering M, Burkner K, Hirsch D, Leupold W, Kerkmann
ML, et al. 2000. House-dust mite allergen concentrations and
mold spores in apartment bedrooms before and after instal-
lation of insulated windows and central heating systems.
Allergy 55:79–83. Available: http://www.ncbi.nlm.nih.gov/
entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=
Abstract&list_uids=10696861 [accessed 27 November 2004].
Howell E, Harris LE, Popkin SJ. 2005. The health status of Hope VI
public housing residents. J Health Care Poor Underserved
16:273–285.
Howson CP, Hernandez A, Rall D, eds. 1996. Lead in the Americas: A
Call to Action. Institute of Medicine and National Institute of
Public Health (Mexico). Washington, DC:National Academy
Press, National Academy of Sciences.
HUD. 1995. Guidelines for the Evaluation and Control of Lead
Paint Hazards in Housing. HUD-1547-LBP. Washington,
DC:U.S. Department of Housing and Urban Development.
Available: http://www.hud.gov/offices/lead/guidelines/
hudguidelines/index.cfm [accessed 26 October 2004].
HUD. 1999a. The Healthy Homes Initiative: A Preliminary Plan.
Washington, DC:U.S. Department of Housing and Urban
Development, Office of Lead Hazard Control. Available:
http://www.hud.gov/utilities/intercept.cfm?/offices/lead/
reports/HHIFull.pdf [accessed 20 October 2004].
HUD. 1999b. Economic Analysis of the Final Rule on Lead-Based
Paint. Washington, DC:ICF Consulting/U.S. Department of
Housing and Urban Development. Available: http://www.
hud.gov/utilities/intercept.cfm?/offices/lead/leadsaferule/
completeRIA1012.pdf [accessed 26 October 2004].
HUD. 2003. Moving to Opportunity: Interim Impacts Evaluation.
Washington, DC:U.S. Department of Housing and Urban
Development, Office of Policy Development and Research.
Available: http://www.huduser.org/publications/fairhsg/
mtoFinal.html [accessed 27 October 2004].
Jacobs DE. 1995. Lead paint as a major source of childhood lead
poisoning: a review of the evidence. In: Lead in Paint, Soil
and Dust: Health Risks, Exposure Studies, Control Measures
and Quality Assurance (Beard M, Iske AS, eds). ASTM
Special Technical Publication 1226. Philadelphia:American
Society for Testing and Materials, 175–187.
Jacobs DE. 1998. Occupational exposures to lead-based paint
in structural steel demolition and residential renovation.
Int J Environ Pollut 9:126–139.
Jacobs DE. 2005. Housing and health: challenges and opportuni-
ties. In: Proceedings of the 2nd WHO International Housing
and Health Symposium, 29 September 29–1 October 2004,
Vilnius, Lithuania. Bonn, Germany:World Health Organization
European Centre for Environment and Health, 35–50.
Jacobs DE, Clickner RP, Zhou JY, Viet SM, Marker DA, Rogers
JW, et al. 2002. The prevalence of lead-based paint hazards
in U.S. housing. Environ Health Perspect 110:A599–A606.
Jacobs DE, Matte TD, Moos L, Nilles B, Rodman J. 2000.
Eliminating Childhood Lead Poisoning: A Federal Strategy
Targeting Lead Paint Hazards. President’s Task Force on
Environmental Health Risks and Safety Risks to Children.
Washington, DC:U.S. Department of Housing and Urban
Development/U.S. Environmental Protection Agency.
Available: http://www.hud.gov/offices/lead/reports/
fedstrategy.cfm [accessed 26 October 2004].
Krieger J, Higgins DL. 2002. Housing and health: time again for
public health action. Am J Public Health 92:758–768.
Lanphear BP, Emond M, Jacobs DE, Weitzman M, Tanner M,
Winter N, et al. 1995. A side-by-side comparison of dust
collection methods for sampling lead-contaminated house
dust. Environ Res 68:114–123.
Lanphear BP, Matte TD, Rogers J, Clickner RP, Dietz B,
Bornschein RL, et al. 1998. The contribution of lead-conta-
minated house dust and residential soil to children’s blood
lead levels: a pooled analysis of 12 epidemiological stud-
ies. Environ Res 79:51–68.
Lanphear BP, Roghmann KJ. 1997. Pathways of lead exposure
in urban children. Environ Res 74:67–73.
Lead-Based Paint Poisoning Prevention Act. 1971. 42 U.S.C.
4801. Public Law 91-695. Available: http://www.fda.gov/
opacom/laws/leadact.htm [accessed 12 May 2007].
Lindblom CE 1959. The science of muddling through. Public
Adm Rev 19:79–88.
Lowry S. 1991. Housing. BMJ 303(6806):838–840.
Mannino DM, Homa DM, Akinbami LJ, Moorman JE, Gwynn C,
Redd SC. 2002. Surveillance for asthma—United States,
1980–1999. MMWR Surveill Summ 51:1–13.
Markowitz G, Rosner D. 2002. Deceit and Denial: The Deadly
Politics of Industrial Pollution. Berkeley/Los Angeles:
University of California Press.
Matte TD, Jacobs DE. 2000. Housing and health—current issues
and implications for research and programs. J Urban Health
77:7–25.
Meyer PA, Pivetz T, Dignam TA, Homa DM, Schoonover J,
Brody D. 2003. Surveillance for elevated blood lead levels
among children—United States, 1997–2001. MMWR
Surveill Summ 52:1–21.
Mokdad AH, Bowman BA, Ford ES, Vinicor S, Marks JS, Koplan
JP. 2001. The continuing epidemics of obesity and diabetes
in the United States. J Am Med Assoc 286:1195–1200.
Morgan WJ, Crain EF, Gruchalla RS, O’Connor GT, Kattan M,
Evans R III, et al. 2004. Results of a home-based environmen-
tal intervention among urban children with asthma. N Engl J
Med 351:1068–1080.
Nagaraja J, Menkedick J, Phelen KJ, Ashley P, Zhang X,
Lanphear BP. 2005. Deaths from residential injuries in U.S.
children and adolescents, 1985-1997. Pediatrics 116:454–461.
NAS. 2000. Clearing the Air—Asthma and Indoor Air Exposures.
National Academy of Sciences/Institute of Medicine.
Washington, DC:National Academy Press.
NAS. 2004. Damp Indoor Spaces and Health. National Academy
of Sciences/Institute of Medicine. Washington, DC:National
Academy Press. Available: http://www.nap.edu/books/
0309091934/html [accessed 30 November 2004].
National Center for Healthy Housing. 2004. Evaluation of the HUD
Lead-Based Paint Hazard Control Grant Program. Final
Report. Columbia, MD:National Center for Healthy Housing/
University of Cincinnati. Available: http://www.hud.gov/
utilities/intercept.cfm?/offices/lead/EvaluationFinalReport.pdf
[accessed 26 October 2004].
Office of the President.1970. Reorganization Plan No. 3 of 1970, 9
July 1970. Available: http://www.epa.gov/history/org/origins/
reorg.htm [accessed 9 May 2007].
Phalen KJ, Khoury J, Kalkwarf H, Lanphear BP. 2005. Residential
injuries in U.S. children and adolescents. Public Health Rep
120:63–70.
Quade ES. 1975. Analysis for Public Decisions. New York:Elsevier
Science/North Holland.
Riis A. 1890. How the Other Half Lives: Studies among the
Tenements of New York. New York:Charles Scribner’s Sons.
Safe Drinking Water Act. 1974. 42 U.S.C. 300f. Available: http://
www.epa.gov/region5/defs/html/sdwa.htm [accessed 12
May 2007].
Sandel M, Phelan K, Wright R, Hynes HP, Lanphear BP. 2004.
The effects of housing interventions on child health.
Pediatr Ann 33:474–481.
Sharfstein J, Sandel M. 1998. Not Safe at Home: How
America’s Housing Crisis Threatens the Health of Its
Children. Boston:Boston University Medical Center.
Stein L. 1950. A study of respiratory tuberculosis in relation to
housing conditions in Edinburgh; the pre-war period. Br J
Soc Med 4:143–169.
Health, housing, and indoor environmental quality
Environmental Health Perspectives
•
VOLUME 115 |NUMBER 6 |June 2007
981
Superfund Amendments and Re-authorization Act. 1986. 42 U.S.C.
9601. Available: http://www.epa.gov/region5/defs/html/
sara.htm [accessed 12 May 2007].
Title X. 1992. The Residential Lead Hazard Reduction Act of 1992.
Title X of the 1992 Housing and Community Development
Act. Public Law 102-550.
Toxic Substances Control Act. 1972. 15 U.S.C. 2601. Available:
http://www.epa.gov/region5/defs/html/tsca.htm [accessed
12 May 2007].
Turner JA. 1897. Lead poisoning among Queensland children.
Aust Med Gaz 16:475–479.
United Nations. 2003. The Challenge of Slums: Global Report on
Human Settlements 2003. HS/726/04E. New York:UN-Habitat,
United Nations Human Settlements Programme.
U.S. Census Bureau. 2000. Cuyahoga County, Ohio, QuickFacts.
U.S. Census Bureau, Economics and Statistics Adminis-
tration, U.S. Department of Commerce. Available: http://
quickfacts.census.gov/qfd/states/39/39035.html [accessed
26 November 2005].
U.S. EPA. 1990. Reducing Risk: Setting Priorities and Strategies
for Environmental Protection. Washington, DC:U.S.
Environmental Protection Agency.
U.S. EPA. 1997. Report of the Presidential/Congressional
Commission on Risk Assessment and Risk Management.
Washington, DC:U.S. Environmental Protection Agency.
Available: http://www.riskworld.com/Nreports/1997/risk-rpt/
miscinfo/nr7mi003.htm [accessed 20 March 2006].
U.S. EPA. 2001a. Lead; Identification of Dangerous Levels of
Lead; Final Rule. 40 CFR Part 745, 5 January. Washington,
DC:U.S. Environmental Protection Agency. Available: http://
www.epa.gov/fedrgstr/EPA-TOX/2001/January/Day-05/
t84.pdf [accessed 21 May 2007].
U.S. EPA. 2001b. Healthy Buildings, Health People: A Vision for
the 21st Century. EPA 402-K-01-003. Washington, DC:U.S.
Environmental Protection Agency.
U.S. EPA. 2003. National Survey on Environmental Management
of Asthma and Children’s Exposure to Environmental
Tobacco Smoke. Washington, DC:U.S. Environmental
Protection Agency. Available: http://www.epa.gov/asthma/
pdfs/survey_fact_sheet.pdf [accessed 8 May 2007].
U.S. EPA 2005. Tools for Schools. EPA 402-F-05-2005. Available:
Washington, DC:U.S. Environmental Protection Agency.
Available: http://www.epa.gov/iaq/schools/actions_to_
improve_iaq.html [accessed 8 May 2007].
U.S. EPA (U.S. Environmental Protection Agency). 2006. Lead; ren-
ovation, repair, and painting program. Fed Reg 71:1487–1636.
U.S. Housing Act of 1937. 1937. 42 U.S.C. 1437. Available: http://
www.hud.gov/offices/ogc/usha1937.pdf [accessed 8 May
2007].
Vesper SJ, Dearborn DG, Yike I, Allan T, Sobolewski J, Hinkley
SF, et al. 2000. Evaluation of
Stachybotrys chartarum
in the
house of an infant with pulmonary hemorrhage: quantitative
assessment before, during and after remediation. J Urban
Health 77:68–85.
WHO. 2004. Tuberculosis Fact Sheet. World Health Organization.
Available: http://www.who.int/mediacentre/factsheets/
fs104/en/ [accessed 20 October 2004].
Jacobs et al.
982
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