Book Review

Housing, fuel poverty and health: A Pan-European analysis

Jonathan Healy

ISBN: 0-7546-4218-6; 2004; 249 pages; Ashgate Publishing;

Sharon Friel
National Centre for Epidemiology and Population Health, Australian National University, ACT

This is a very important book. Housing is a basic human right, embedded in the Universal Declaration of Human Rights (UN 1948), and in major international human rights treaties such as the International Covenant on Economic, Social and Cultural Rights (UN 1966). More recently, the Ottawa Charter blueprint for health promotion identified the prerequisites for health as being peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity (WHO 1986). It is against this backdrop of international law and governance that the author tells the story of inequity in a basic necessity for health: adequate housing.

The book embraces primarily housing-related, structural, and material determinants of health, but contextualises the observations within cultural and social policy considerations; describing how these upstream conditions shape (beneficially or otherwise), housing related matters and subsequently, health. Specifically, using a comparative framework, it sets out to examine, for Europe, the relationship between domestic energy efficiency, fuel poverty and related health impacts. The Republic of Ireland is used as a specific country context case study on the premise that it has high rates of fuel poverty, excess winter mortality, energy inefficient housing, high domestic energy consumption, and greater environmental emissions. While the introductory chapter rationalises the approach taken throughout the book, no explicit working definition is given for fuel poverty. Just as food poverty encompasses a number of domains including nutritional, social and health connotations, it would have been useful to make clear, upfront, the constituents of fuel poverty. Following from this, the book would benefit from a conceptual framework at the beginning, providing a heuristic device from which to consider the various ways fuel poverty and related socio-environmental factors affect health.

The book makes excellent use of existing datasets from a diversity of sources to illustrate systematic inequalities in key components of housing related socio-environmental determinants of health, both between countries and within countries. Chapters Two to nine explore the empirical data, demonstrating marked gradients across Europe in housing conditions, levels of deprivation, affordability and general satisfaction with housing. The book highlights data limitations within the European countries, but is not unduly constrained by them. A key message from the book is the usefulness and necessity for harmonisation of public health related data and development of multilevel surveillance systems. In Chapter Three, a new approach to measuring fuel poverty (and hence its definition) provides the mechanism by which to quantify and demonstrate the severity of fuel poverty within Europe. In an economically rich country such as Ireland, a remarkable 17% of households were found to be fuel poor.

The final results chapter combines the various risk factors, explored until now in singular fashion, and assesses their impact on seasonal mortality, specifically excess winter mortality. It is hard to imagine that the inhabitants of Portugal - a country which provokes images of hot summers and unexceptional winters - experience the highest seasonal variation in mortality across the EU, with a winter increase of 28%. However, using a collection of datasets from 1988-97, Healy demonstrates that relative excess winter mortality is highest in southern Europe, Ireland and the UK. The ecological investigation reports a relationship between country winter environmental temperature and levels of excess winter mortality. The author suggests there is a differential in vulnerability to cold exposure between populations, with some populations better resourced and equipped to protect themselves from cold spells. Building upon earlier demonstrations of between country variation in economic and housing conditions, the book makes a plausible argument that excess winter mortality could be alleviated through macroeconomic policy and the enhancement of socio-economic circumstances through a focus on reducing fuel poverty.

Many problems highlighted in this book are amenable to policy intervention. The social distribution of fuel poverty and related socio-environmental factors highlights particular groups (such as single parents, low income households and low income tenants), which would benefit from targeted intervention. However, the underlying economic, structural and social factors must be addressed using a universal policy approach. The illustration of cumulative stressors, particularly in Southern Europe, should warrant multi-sectoral, whole-of-government action. A concerted health promotion approach which encompasses the various possible determining factors is one which aims to reduce macro-social inequality through adequate policy initiatives, infrastructures that facilitate affordable housing options, combined with informed, targeted education in various settings.

This book will be of interest to readers who care about the health of individuals and societies, and who want to broaden their understanding of the socio-environmental determinants of health. The collation of evidence from a wide range of sources provides a major resource for public health. The book is particularly relevant for policy makers and practitioners in Europe. This book contains many important lessons that need to be taken back to the Irish government. For the non-Irish reader however, the lack of clear distinction between pan-European analysis and discussion, and the Irish situation may be somewhat frustrating, especially given the sometimes laborious repetition of methods and results across chapters. Nevertheless, there are many key learnings in the book which are transferable internationally. The range of methodological techniques, further empirical evidence of the relationships between distal and proximate causes of ill health, and wider policy implications, will each be of considerable relevance to academic and policy audiences worldwide. This book makes a valuable contribution to an evidence base which demonstrates that investment in housing, and the factors which contribute to healthy housing, is much more than an investment in bricks and mortar. Rather, it is an investment in the health and well-being of society.

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