NOTE: Aboriginal and Torres Strait Islander readers are advised this story contains the names of deceased persons
One of the proven ways Australia can help close the gap for Indigenous health is to fix housing. And when housing is in bad repair it turns out tenants are not generally at fault.
That’s the evidence and data that’s emerged from around 40 years of practical Housing for Health projects delivered by Healthabitat in fixing more than 10,500 homes across Australia, improving the lives of more than 60,000 people.
According to director of Healthabitat, architect David Donald, his organisation has obtained an enormous amount of data on the repair work this organisation has carried out over four decades, as every tradesperson who works on one of the “survey and fix” projects contributes information on what the issues were, why they occurred, and what rectification was undertaken.
Only 7 per cent of issues with basic health infrastructure in the homes are due to tenant damage or misuse the data shows, he tells The Fifth Estate. A whopping 74 per cent of problems are due to lack of landlord or owner maintenance, and a further 19 per cent are due to faulty construction of the dwelling in the first place.
Less illness, less time in hospitals
The prevalence of issues with the basic health hardware of a home has had a major impact on the wellbeing of people, Donald stresses, and this insight comes from the organisation’s early foundations.
A key founder was Yankunytjatjara Elder the late Yami Lester who had been heading up the Anangu health service, when he realised that around 80 per cent of people were coming in with infectious diseases that could be traced back to the quality of housing.
The fundamental “health hardware” of housing
The organisation’s Housing for Health (HfH) program revolves around safety and nine health living practices including personal and environmental cleanliness.
A HfH visit involves tradespeople surveying and testing a list of around 250 essential health and safety items around the home and yard which are required for occupants to maintain a standard of living that meets the nine healthy living principles.
The most urgent items, such as problems with toilets, lack of running water in kitchens or bathrooms, or life-endangering matters are immediately attended to.
Other less critical yet still fundamental “health hardware” repairs or upgrades are scheduled in for prompt follow-up repairs, with project timeframes of between six to 12 months for the complete program of works.
In addition to the benefits to the occupants, the program also trains locals in basic home repairs and maintenance during the project.
Average cost of repairs has been just $11,000.
Donald points out that “we know from centuries of experience” that health will improve if people have access to the opportunity to have a proper wash once a day, prepare food in a safe and clean space, wash clothes and manage human waste and wastewater appropriately.
“As architects we tend to think of hardware in a home as things like door hardware. But health hardware is things like a tap, which needs to work, or a ceiling fan, to cool people in the heat.”
He notes that there are flow-on benefits also.
“If we can make a small improvement to someone’s life – fix the shower and toilet, for example – it frees up families who may be struggling to get the kids to school or go out and do a food shop.
“In many parts of Australia, people just give up (on the issues in their home). They go and shower next door, for example… this leads to an increase in crowding and increased disease risks.”
The data gathered over the years shows that in 39 per cent of homes attended by HfH tradies, the shower was not working. Yet with “just a little bit of money” the projects can get the proportion of working showers up to 100 per cent.
“When you walk into a house after a project, mostly you won’t notice anything has changed. But the idea is that everything in the house will now be working.”
Reframing what “good” looks like
Donald says his involvement has changed how he perceives his practice as an architect.
“Once you do one of these projects, you’re never going to see a bathroom in the same way. The focus isn’t on a finished surface, the focus is on all the parts behind the wall that now work.”
Given the high proportion of problems that can be traced back to defects in the original build, there is a clear lesson for the broader industry on the need to put more focus on quality of construction.
“Aboriginal community housing has for decades attracted people with you-beaut designs they want to try out on a remote community because there are government dollars available…. Everybody in the sector needs to be really vigilant.”
There are also risks from the political sphere, with ministers for Indigenous affairs largely focused on number of new homes. In the Northern Territory, for example, there is a pledged $4 billion over 10 years for building 2700 new houses, yet Donald observes that when announced there was no mention of pledges to fix up the existing 5500 older houses.
“The focus is on building houses and building them quickly.”
The issues of poor quality housing are much wider than with Indigenous people
He points out that issues around housing quality are not confined to Aboriginal housing. Healthabitat has also delivered projects in regional NSW for mainstream community housing providers and found similar issues.
“The commonality is poverty,” he says.
“If a community housing provider is pumping out houses and apartments, and they are not checking the quality, there is a risk to the longevity of the asset and a risk with health.”
In many cases, Donald says smaller community housing projects (CHPs) have an advantage, as the closer a CHP is to the community it serves, the better their accountability is to the people that matter, their tenants.
Another big takeaway for the mainstream property industry from all this is the importance of effective maintenance for rental housing. For private rentals, the onus is on landlords to provide a “safe and healthy place” for people to live.
“If you want to make the biggest improvement on the functioning of a house and the health of people, it’s your maintenance program. Having planned, cyclical maintenance in place is by far the biggest way to improve people’s health.”
The background
Healthabitat was formed as a not-for-profit organisation by the late Yankunytjatjara Elder Yami Lester when he recognised the role of the living environment in the health outcomes for Anangu and Pitjatjantjara people in the APY Lands of north-west South Australia. He and another APY leader, the late Kawaki Punch Thompson, worked with local Anangu people on a strategy for wellbeing, Uwankara Palyanku Kanyintjaku (stop people getting sick).
Known as the UPK Report, the strategy revolves around nine healthy living principles, and a program of works that follows the Dr Fred Hollows example of “no survey without a fix”.
The nine principles are:
- washing people
- washing clothes and bedding
- removing wastewater safely
- improving nutrition, the ability to cook and store food safely
- reduce the negative impacts of crowding
- reducing the negative effects of animals, insects and vermin
- reducing the health impacts of dust
- controlling the temperature of the living environment
- reducing hazards that cause trauma (such as electrocution risks)
In 1985, Lester assembled an initial team including Dr Paul Torzillo, the medical officer working at the Pukatja (Ernabella) health clinic for Nganampa Health Council; anthropologist-turned community development worker and fluent Pitjatjantjara speaker, Stephan Rainow; and architect, the late Paul Pholeros, who had been engaged by Nganampa Health Council to carry out additions to a health clinic in Fregon and had also worked on projects at Uluru and the Mutitjulu community in the Northern Territory.
In more recent times, the nine principles have been vindicated as a way to stop the root cause of this burden of illness.
HfH partner NSW Health undertook an evaluation of the program that found Aboriginal and Torres Strait Islander persons who had received a Housing for Health intervention in the 10 years between 1999 and 2008 had a rate of hospital separations due to infectious diseases more than 40 per cent lower than the state’s Aboriginal population as a whole.
Health interventions at scale
Since its inception Healthabitat has fixed more than 10,500 homes across Aboriginal housing and community housing in every Australian state and territory except the ACT and Tasmania. At an average cost of $11,000 per project, the lives of more than 60,000 people have been improved.
Funding has come from multiple sources including State and Territory housing agencies, state and territory health departments and independent community housing providers.
Healthabitat has also supported projects in Nepal, South Africa, India and in low-income communities in the US, and made its model and guidelines available for use by any organisation anywhere.