Introduction

The US is facing a severe affordable rental housing crisis that has only been exacerbated by the recent COVID 19 pandemic. In 2022, there was no state in this country where a full-time minimum wage job was sufficient to affordably rent a one-bedroom apartment [1]. In many areas, nearly two full time jobs were needed. Furthermore, rental subsidies such as vouchers and public housing are in short supply, with only 1 in 5 eligible households receiving assistance and waiting lists averaging more than two years nationally [2]. Without access to these subsidies, rental housing is out of reach to many low-income renters. This unmet need for housing has contributed to multiple forms of housing insecurity including rising rates of homelessness, crowded and poor quality housing conditions, unstable housing arrangements, and housing cost burdens.

In 2018, more than half a million Americans were unsheltered or staying in emergency homeless shelters and even more were living doubled-up with friends or family [3]. Many low-income renters who do find housing must contend with subpar housing conditions or housing in disadvantaged neighborhoods that contain few health promoting resources and multiple hazards. Others experience significant cost burdens. Among renters in the lowest income quintile, 71% spent more than half of their income on rent [1]. These high rent burdens have contributed to a growing eviction crisis. While evictions temporarily slowed during the pandemic due to state and federal moratoria, they have now surpassed pre-pandemic levels in many areas [4, 5]. These unmet housing needs are born unequally by communities of color, owing to an ongoing history of structurally racist housing policy and other manifestations of structural racism [6,7,8].

A considerable body of evidence finds that housing is an important determinant of health [7, 9,10,11]. However, the existing literature may fall short of conceptualizing and measuring the full impact of the current affordable rental housing crisis on population health equity. In this paper, we seek to expand the conceptualization of housing as a determinant of health by considering housing insecurity as a manifestation of structural racism that intersects with other manifestations and impacts of structural racism to affect the health of individuals, networks, and communities. First, we situate housing insecurity within larger systems of structural racism. Following prior discussions of housing and racial health equity [8, 12], we discuss how housing insecurity is determined by an ongoing history of structural racism reflected in policies and practices. We extend this prior work to also discuss the ways that the meanings and impacts of housing insecurity themselves may be shaped by racism when housing insecurity is exacerbated by other manifestations of structural racism or its impacts are shaped by racism. Second, we consider how the health impacts of housing insecurity, shaped by structural racism, can extend beyond individual households to affect networks and communities. While prior work has focused on how an individual’s own housing affects their health, housing insecurity may reverberate through networks when friends and family step in to address unmet housing needs or when housing insecurity shapes community health exposures and resources. Furthermore, the meaning and impacts of these community and network exposures may be shaped by the broader context of structural racism. We argue that consideration of these complex multilevel processes is critical to understanding how the inequitable distribution of housing insecurity contributes to population health and that this expanded framework can inform both research and policy.

Defining Housing Insecurity

In our paper, we consider the health impacts of “housing insecurity” a concept that encompasses multiple distinct, but related, forms of unmet housing needs. Prior research has described how multiple forms of housing insecurity individually operate to affect health and wellbeing [7, 13, 14]. Research has described, for example, the health impacts of high housing costs which can create stress and displace other expenses that are important for health, including food and medication [15, 16]. Research also documents how housing instability (including eviction and other forced moves) can disrupt social networks, health routines, and sense of place, and act as a source of trauma to produce numerous health outcomes [17,18,19,20,21]. Other work describes how housing quality can impact health through safety risks, exposure to pests, and environmental contaminants such as lead paint [9, 22, 23]. Relatedly, research has described how crowded housing conditions can contribute to interpersonal tension, psychosocial stress, disrupted sleep, and the spread of infectious disease [24, 25]. Literature on neighborhood effects describes how the location of housing shapes health, including through access to health promoting resources, exposure to environmental hazards and risks, and through social processes such as stigmatization [26]. Finally, a robust literature documents the health harms of homelessness [27, 28].

The broader term housing insecurity also encompasses other health-harming deficiencies in housing access that are less well-documented in the housing and health literature. For example, research has described how “housing autonomy” or control over one’s housing environment can affect health and health behaviors [29]. Relatedly, research describes how surveillance of housing environments can prevent the development of “ontological security” that is important for health [30]. For example, for individuals returning to the community from prisons and jails, housing options in half-way houses or with friends and family members often preclude ontological security or a sense of home [30].

While the existing literature often considers the many dimensions of housing insecurity independently [14], they are undoubtedly interconnected. One form of housing insecurity may lead to another. For example, cost burdens often result in evictions, and evictions can constrain housing options, forcing renters into low-quality housing, disadvantaged neighborhoods, or homelessness [31]. Poor housing conditions can also lead to evictions when renters contest these conditions and experience reprisal from their landlords. Poor quality housing may also exacerbate cost burdens through increased utility expenses that are associated with inadequate insulation or outdated appliances [32]. Experiences and dimensions of housing insecurity are also related to tradeoffs that renters make in a context of constrained choices. For example, a renter may pay high rents to avoid low-quality housing or accept low-quality housing to avoid eviction. We consider these interconnected dimensions of housing as manifestations of the larger affordable rental housing crisis and the often racist and exploitative policies and practices that have produced it. This housing insecurity is also rooted in racist policies and practices in multiple other domains of US society, as we describe in the next section.

Structural Racism, Systematic Exclusion from Housing, and Population Health Equity

An Ongoing History of Discriminatory Housing Policy

Prior research has described how structurally racist housing policies and practices have shaped inequality in housing access, with implications for health equity [6,7,8, 33, 34]. Just as structural racism has produced inequities in housing insecurity, so has it also shaped the context in which housing access and insecurity are experienced [6]. We consider how the broader context of structural racism may shape the meaning of housing insecurity with implications for health. This review is not meant to be an exhaustive discussion of the countless ways that manifestations of structural racism impact housing insecurity and the ways that this housing insecurity impacts health. Instead, we seek to develop a framework for considering these complex intersections.

Multiple and intersecting domains of structural racism have, throughout history, systematically structured and given meaning to housing access such that housing insecurity disproportionately impacts non-white Americans and Black Americans in particular. Black and other non-white Americans are more likely than white Americans to be renters. Among renters, Black and other non-white Americans are more likely to experience cost-burdens and evictions [35].

An ongoing history of racist policies have created and maintained racially segregated neighborhoods that restrict opportunity for Black and other minoritized communities [36,37,38], perpetuate racist beliefs [39], and adversely affect health through exposure to environmental hazards, stigma, and police surveillance [40,41,42,43]. As just one example, in the New Deal era, the construction of segregated public housing projects transformed formerly integrated neighborhoods into segregated ones [6]. Existing patterns of segregation are also maintained by numerous historical and contemporary housing policies, including zoning restrictions and racial covenants [37].

The current affordable rental housing crisis is also shaped by racist housing policies that have supported homeownership and housing choice for white Americans, while limiting opportunities for others [8, 44]. As one notable, and often cited example, practices known as redlining excluded predominantly Black neighborhoods from federally backed home loans which in turn contributed to vast racial inequalities in homeownership [37, 44]. When locked out of the traditional lending market, Black homeowners were forced to rely on predatory lending practices such as contract buying [44]. Decades later, many previously redlined neighborhoods were targeted for predatory subprime lending in a newly deregulated market [45]. This predatory inclusion served as a vehicle of resource extraction from Black communities that supported the capital interests of real estate [38].

Redlining was part of an ecology of policies that restricted housing access for Black and other non-white Americans [8]. Made possible because of pronounced residential racial segregation, redlining also perpetuated this segregation and ongoing disinvestment in predominantly Black neighborhoods. Furthermore, disinvestment in and stigmatization of segregated neighborhoods paved the way for the appropriation of these spaces through processes of serial displacement [46, 47]. For example, urban renewal practices in the 1950s through 1970s uprooted Black communities to create public housing projects [48]. Decades later, the large-scale demolition of largely underfunded public housing, displaced residents, and paved the way for gentrification and further displacement [49, 50]. Indeed, the disinvestment and stigmatization of predominantly Black neighborhoods has played a critical role in gentrification processes, devaluing these spaces such that they can be acquired for the purpose of profitable development [46].

Research also highlights the way that predatory exclusion, predatory inclusion, segregation, and the devaluation and stigmatization of predominantly Black spaces have supported capital accumulation and profit. These urban practices are part of a larger project of racial capitalism, whereby racism supports capitalist interests and profits [46]. Thus, racist policies that have produced race inequities in access to housing have, in turn, produced race inequities in wealth. They not only have excluded Black people from homeownership—a major source of wealth accumulation in racial capitalism—but in so doing have also made possible the concentration of wealth and resources in the hands of white people.

Intersections of Structural Racism across Multiple Domains

Recent research has described the multi-dimensional nature of structural racism and the ways that it is maintained and reinforced by interconnections across multiple institutions and domains [51, 52]. Indeed, the impacts of racist housing policies and practices are exacerbated by structural racism in other domains. As one prominent example, a system of racialized mass incarceration intersects with this history of structural racism in housing, to further shape Black people’s access to housing and, subsequently, its consequences for their health [53,54,55]. A long history of structural racism in the criminal legal system, including via the “war on drugs,” has meant that Black people, and Black men especially, are disproportionately represented among those with criminal records that create multiple barriers to housing. Landlord background checks can exclude individuals with criminal records. And criminal records can create barriers to obtaining federal rental assistance and to using federally subsidized housing vouchers [56]. HUD guidelines automatically exclude individuals who have been evicted from public housing for drug related criminal activity from receiving HUD assistance, but also allow for individual housing authorities to set further restrictions related to criminal legal involvement [57]. Most housing authorities have admission criteria that are substantially more restrictive than required by law, including locations that exclude individuals with arrest records from receiving rental assistance, despite the fact that arrests are not an indication of guilt and that the probability of arrest is related to the disproportionate surveillance of Black people and Black communities [57, 58]. Criminal records also can indirectly affect housing access by creating barriers to employment [54].

Not only are Black people more likely to experience housing barriers related to criminal-legal involvement, these barriers themselves may be shaped by other aspects of racism. For example, some housing authority eligibility rules allow discretion on the part of administrators and some evidence suggests that this discretion may benefit white applicants more than Black ones [59]. One analysis of formerly incarcerated individuals found that Black participants were more likely to report that their criminal record impacted their future housing access than white participants [54].

This exclusion from housing also contributes to the risk of incarceration or reincarceration, given both policies that criminalize homelessness and the ways that housing instability creates vulnerability to recidivism and law enforcement surveillance [60,61,62]. Furthermore, this relationship between housing insecurity and incarceration is likely shaped by the surveillance and policing of racially segregated neighborhoods, and thus may disproportionately affect Black people.

Racism-Related Health Vulnerability

Not only does structural racism operate across multiple intersecting domains to constrain housing options for Black Americans, but the consequences of this exclusion may be exacerbated by other manifestations and impacts of racism. Though Black tenants may draw support from systems of mutual aid and community-based social ties that have, throughout history, provided collective resistance and resilience to the impacts of racist housing policies [63], racial inequities in wealth may mean that these networks have fewer material resources to draw upon when managing unaffordable housing or eviction risk [64]. Additionally, racism in the rental market may also add to the challenges posed by having an eviction record. Similar to having a criminal record, having an eviction on one’s record can make it very challenging to find subsequent housing due to landlord background checks [65]. It is possible that white prospective tenants are more likely to receive the benefit of the doubt in these situations, and Black tenants are thus likely to experience more post-eviction homelessness and instability.

Housing insecurity may also intersect with the impacts of racism on the body. For example, research finds that chronic stress associated with racism can exacerbate the health effects of lead exposure, a common housing hazard to which Black Americans are disproportionately exposed [66]. More broadly, housing challenges are likely to have particularly adverse consequences for individuals with underlying health vulnerabilities [67]. And, owing to the health impacts of cumulative exposure to multiple forms of racism across the life course, Black Americans are more likely to experience such vulnerabilities at earlier ages [68]. Indeed, research illustrates how cumulative exposure to racialized stressors contributes to premature cellular aging [69], earlier onset of age-related chronic health conditions [70], and increased allostatic load [68] (a measure of cumulative wear-and-tear on the body’s regulatory systems) through a process of weathering. Weathering may create unique susceptibility to the health impacts of housing insecurity. For example, housing insecurity can disrupt the management of chronic health conditions such as type 2 diabetes and heart failure [71, 72]. Housing insecurity can also disrupt social networks that have been shown to mitigate weathering [73].

Furthermore, the health consequences of structural racism and weathering can in turn create barriers to housing access. The disproportionate burden of poor health that Black Americans face across the life-course, and particularly at younger and middle ages, can lead to income disruptions and medical expenses that contribute to housing insecurity [64]. Indeed, a number of studies document associations between new health problems and subsequent housing risks among renters [74,75,76]. These findings are supported by qualitative research illustrating how the early onset of age-related health problems can disrupt fragile household budgets, contributing to housing insecurity [64, 77].

This complex and dynamic relationship between racism-related housing insecurity and health vulnerability illustrates the connections of both housing and health to larger systems of inequality and the need for research that considers this complexity. Existing research clearly shows how racism has created unequal exposures to multiple forms of housing insecurity. Future research must consider the ways that racism shapes the meaning and impacts of these exposures, not just for individuals, but for entire communities.

Beyond the Individual: Access to Affordable Rental Housing and Community Health

The inequitable distribution of housing insecurity that is produced by multiple domains of structural racism, not only affects individual households, but also the networks and communities where these households are located. Housing is a community resource as well as an individual one. As such, it is important to consider how to represent housing access at the level of community, along with its consequences for the health of communities, households, and individuals. Conceptual models that consider how an individual’s housing affects their own health may underestimate, or misrepresent, the full impact of the affordable rental housing crisis on population health equity.

Informal Housing Provision

Limited access to affordable housing may affect health through the strain that it places on network members who provide housing to those who are otherwise locked out of housing opportunities. Most individuals who are unable to afford housing do not live in shelters or on the street, but rather with friends and family members who serve as an informal housing safety net in the context of limited state resources [78, 79]. While sharing housing can provide many benefits including social support, companionship and the pooling of resources, recent qualitative work also documents how providing housing to others, particularly in a context of scarce resources, heavy surveillance, and stringent lease requirements, can create stressors that likely have health implications. For example, research describes disruptions in health and sleep routines, increased caretaking burdens, and financial strain that are associated with providing housing to partners, friends, and relatives [80, 81]. Research also describes how providing housing to those who are locked out of housing opportunities due to criminal legal barriers can increase exposure to the criminal legal system and potential negative sequalae of this exposure [82]. Research also documents how providing housing to others can exacerbate or cause housing insecurity for housing providers when leases prohibit guests or when increased expenses and caretaking undermine the ability to maintain one’s housing. In particular, those who live in subsidized housing (e.g., voucher supported housing or public housing) may place these valuable rental subsidies at risk when they provide housing to others in need, and violate the terms of their lease in doing so [56].

As with housing in general, the burden of housing provision is shaped by racist policies and practices, falling disproportionately on communities of color. Housing providers are filling gaps in housing access that were systematically created by multiple forms of structural racism. Not only is the distribution of housing provision shaped by structural racism, so are the meaning and impacts of this exposure on health and well-being. For example, as further illustration of the intersections of housing and mass incarceration, housing authority regulations often prevent adding an individual with a criminal record to one’s lease, placing family members or friends in a difficult position of having to choose between providing support and risking their own housing, choices which both may have adverse health consequences [81]. The impacts on health and well-being of providing housing in these contexts, which are shaped by structural racism in multiple domains, are likely to be extensive.

Community-Based Social Resources

Another way the affordable rental housing crisis manifests at the community level is through its impacts on residential instability, which in turn can weaken community-based social ties and resources that are known to affect health and well-being [83, 84]. The massive demolition of public housing that occurred throughout the US in the late 1990s and 2000s provides an example of such community level displacement that can inform our understanding of residential instability at the community level. Qualitative work has documented the ways that public housing demolition disrupted social networks and social ties, contributing to experiences of social isolation, even among those who are not displaced themselves [50]. Beyond disrupting network relationships, research also describes how public housing demolition produced a loss of organizations such as tenants councils, shaping residents’ opportunities for civic engagement [85]. Relatedly, research on urban renewal programs in mid-twentieth century describes how this policy induced displacement shaped civic engagement, political engagement, and political power in ways that likely had implications for the community as a whole [48]. Evictions, which are often geographically clustered into neighborhoods, may create similar losses of local social ties and community structures. This loss of community resources may partially explain associations between area-level eviction rates and health outcomes in multiple studies [86, 87].

Furthermore, these processes of displacement and their impacts on social structures are linked to the larger context of racial and class inequality. Fullilove and Wallace [88] describe urban renewal, public housing demolition, and gentrification as part of an ongoing history of serial displacement that repeatedly uprooted Black communities, hindering the development of geographically rooted political power and social ties. The meaning and impacts of displacement for a Black household today may be shaped by this ongoing history. Recent displacements compound the impacts of prior ones, and these experiences of displacement may be shaped by contemporary forms of racism. For example, recent research describes how the displacement of Black residents from gentrifying neighborhoods can contribute to social isolation among those who remain in these neighborhoods and experience racism from new neighbors [89]. Furthermore, the loss of social structures and social support related to displacement may have unique consequences for Black Americans who have relied on identity affirming networks of mutual aid and support, to resist racism and mitigate its impacts on health and well-being [73].

Housing Insecurity and Infectious Disease Risk

Housing insecurity, in multiple forms, may also contribute to the spread of infectious diseases, and unequal exposure to housing insecurity may contribute to racial inequalities in infectious disease risk. This is clearly evidenced by the recent COVID-19 pandemic when crowded housing conditions reduced individuals’ ability to engage in social distancing and contributed to viral spread within households [90, 91]. Additionally, evictions, forced moves, and unstable housing arrangements likely contributed to viral spread across households. Research finds that lifting COVID eviction moratoria (policies that reduced evictions) was associated with higher COVID incidence and mortality, even after controlling for other public health measures and area characteristics [92]. The impacts of these policies on disease transmission likely reflect both individual and community level pathways. Indeed, one simulation study found that reducing evictions would not only reduce COVID-19 risk for those who experienced eviction, but also for their surrounding communities [93].

The impact of housing on community disease transmission is not limited to the recent pandemic. As another example, research finds associations between county-level eviction rates and sexually transmitted infections [86]. Qualitative work also demonstrates how exclusion from housing can shape sexual networks and sexual risks, with implications for sexually transmitted infections [94].

And as with other examples above, the relationship between housing insecurity and community disease risk likely intersects with other forms of structural racism. For example, the impact of housing instability on COVID transmission was likely exacerbated by the ways that structural racism shaped occupational exposures to the virus. The relationship between housing instability and COVID risk was also likely exacerbated by the ways that prisons, jails, and the conditions within them, created COVID hot spots, and then transferred this risk to the surveilled and policed communities that have borne the brunt of mass incarceration.

Expanding conceptual models of housing and health to consider the ways that unmet housing needs can be represented beyond the individual level and have impacts that reverberate through networks and communities is important to conceptualizing the full impact of housing on health. Also, critical is conceptualizing and measuring the multiple ways that structural racism (in multiple domains) has shaped and gives meaning to these community exposures.

Discussion

In summary, the framework we have outlined above illustrates how structural racism across multiple domains, not only shapes exposure to housing insecurity in its multiple and intersecting forms, but also the meaning and health impacts of these exposures through multiple individual-level and community-level pathways. We show how a lack of affordable housing contributes to multiple intersecting forms of housing insecurity that not only affect the individuals who experience them, but also their families, networks, and entire communities in multiple ways, including by creating burdens associated with informal housing provision, through the loss of social structures and social support, and through infectious disease risk. These individual and community exposures and their impacts are also shaped by the larger context of structural racism that has created them in the first place. We discuss how racism creates vulnerabilities to the impacts of housing insecurity at the individual level, for example, when weathering contributes to disease risk that is exacerbated by (or exacerbates) housing insecurity. At the community level, racism shapes the impacts of housing insecurity, for example, when the loss of social ties due to eviction is compounded by a history of prior displacements, or when community transmission of COVID-19 or other infectious diseases are driven by intersecting risks related to housing, incarceration, and employment, all shaped by racism and racial capitalism.

Though our review focuses on intersections of racism and housing security, it is important to acknowledge the systems of gender and class oppression that intersect with structural racism and housing to affect health. For example, the gendered racism that shapes Black men’s exposure to criminal-legal systems may contribute to housing burden for Black women. Future research that takes an intersectional approach to examining housing and health inequalities is important.

The framework presented in this paper is not a comprehensive account of the numerous intersections of racism, housing, and health equity. However, it can inform future research on housing and health in important ways. First, we indicate a need to consider both individual and community level exposures to housing insecurity. Measuring the impact of individual housing exposures is likely to underestimate the impact of unmet housing need when these impacts reverberate across communities. One approach to addressing this is to utilize natural experiments that can capture changes in housing security that affect entire communities. For example, variation in state-level eviction policy during the COVID-19 pandemic created exogenous variation in eviction exposure allowing researchers to examine health impacts of eviction on entire communities in the framework of a natural experiment [95]. These measured effects are likely comprised of both the impact of eviction on evicted households and of community level effects. Another approach to more fully capturing these multi-level effects is to use multi-level models that include both individual and community level exposures to housing insecurity and can begin to parse the contributions of each. Finally, qualitative research can be a valuable tool to unpack the multiple and nuanced manifestations of housing insecurity and the processes through which they shape health at the individual and community level.

Second, our framework suggests that research must consider the complex intersection of housing insecurity and racism across multiple domains. In addition to showing the unequal distribution of housing insecurity, there is a need to understand how the impacts of this housing insecurity may themselves be shaped by exposure to racism. This can include incorporating race interactions into statistical models and using qualitative and mixed methods to capture racialized experiences of housing insecurity. Such research may identify unique ways that racism vulnerability exacerbates the impacts of housing insecurity and also ways that racially marginalized communities have uniquely resisted and buffered the impacts of racist housing policies and practices. The framework presented in this paper can also inform how we interpret race interactions. For example, eviction may have a statistically larger impact of health for white renters than for Black renters, not because they are less harmful, but because for Black people, the impact of eviction is masked by other harmful impacts of structural racism or because for white renters there is more adverse selection into eviction because it is a less common occurrence. Finally, the more diverse the perspectives and experiences that we bring to our research—shaping the questions, identifying potential pathways, highlighting complexities, and interpreting findings—the better our understanding of the issues and the likelihood of developing effective solutions. Housing and health research that incorporates the voices of stakeholders—especially tenants themselves—is critical.

Though our framework does not suggest or prescribe particular policy solutions, it can provide some guidance for policy. For one, it suggests that attempts to address housing insecurity through policy solutions must consider the ways these policies intersect with historical and contemporary forms of structural racism across multiple domains. For example, the efficacy of voucher programs that reduce housing costs is likely undermined by discriminatory zoning restrictions that limit the creation of multi-family housing in affluent areas and by the absence of legislation (or its enforcement) that prohibits landlords from discriminating against voucher holders. Similarly, as we have discussed elsewhere [6], given our current racist systems of mass incarceration and policing, expansions of rental assistance programs (through vouchers and public housing) will have limited and racially unequal impacts that will reverberate across families, neighborhoods, and communities if they exclude or create barriers for individuals who have criminal records. In general, our framework suggests a need for policies that intentionally address the ways that racism has shaped housing insecurity and the contexts that in turn shape its meanings and subsequent implications for health equity. Race neutral or color blind policies that do not recognize the ways that structural racism—historically and contemporarily—differentially situates minoritized individuals and communities cannot be expected to promote health equity. Instead, policies must intentionally confront and challenge structural racism.

Given the complex intersections of housing and structural racism, approaches to addressing housing insecurity should include the voices and knowledge of those closest to these problems. Marginalized communities have long been supporting each other to mitigate housing insecurity and its impacts. For example, Black homeowners formed contract buyers leagues to resist exclusionary lending practices [44]. More recently, tenant organizations across the country have mobilized to resist evictions through cancel-the-rent movements and efforts to pass “right to counsel legislation” [63]. Communities have supported each other through informal housing provision, addressing critical gaps in the housing safety net to care for family, friends, and community members [81]. Policies should support or enhance, rather than undermine this work. Furthermore, just as the impacts of housing insecurity may reverberate to adversely affect communities, some research suggests that the work of tenant activism may reverberate to positively impact community well-being. In a recent qualitative study, Michener and Sorelle [63] describe how tenant activism can not only prevent an eviction, but it can also transform political life of a community. Ultimately, attention to the multiple and intersecting dimensions of housing security and the broader context through which they operate to affect individual and community health, underscores the importance for promoting health equity interventions intentionally focused on the root causes of housing insecurity, including structural racism.