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Guest Blog: Health Equity and Housing Equity—Two Sides of the Same Coin

Health and housing are inextricably linked. Quality, affordable housing isn’t simply about shelter, it is also about the sense of community, opportunity, and security that comes with having a safe, stable place to live. Without access to such a home, achieving an optimal quality of life becomes impossible, making housing one of the leading social determinants of health. As defined by the World Health Organization, social determinants of health are those “conditions in which people are born, grow, live, work and age, which are shaped by the distribution of money, power and resources at global, national and local levels.”

Research suggests that in certain instances, affordable housing has contributed to a 12% reduction in the overall healthcare expenditures of Medicaid recipients, an 18% decrease in emergency department visits, and a 20% increase in use of primary care services.1 Investing in affordable housing has also been shown to have a significant and beneficial impact on the local economy.

Access to stable housing can have a powerful impact on health outcomes, and that impact only becomes more significant when that housing is safe, well-maintained, and located in a dynamic neighborhood. Health disparities associated with conditions in residential communities are often caused by a lack of consistent investment within and across neighborhoods. For example, environmental conditions such as mold, poor ventilation, and pests have been linked to poor health, with an especially strong association with high asthma rates.2 At a neighborhood level, safe street infrastructure, walkability, and access to affordable fruits and vegetables, parks, and public transportation are some of the ways the built environment is tied to health.3 any of these elements are not consistent across communities, with low-wealth areas experiencing less favorable conditions.4

Improving the quality of affordable housing is one step toward supporting healthy communities and promoting a country in which everyone can attain the highest level of health possible—a condition commonly referred to as health equity.

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Setting a Standard for Healthy Housing

Since its founding in 2012, the Center for Active Design (CfAD) has focused on developing practical, implementable design strategies that promote health and create equitable access to public and private spaces. This mission has expanded to explore how design and development practice can affect the civic health of communities by inspiring greater trust, participation, and stewardship.5

CfAD’s strategy for incentivizing inclusive, equitable mixed-income communities that are designed for health has two core components: (1) working with actors across the real estate industry to implement the Fitwel® Certification System as a framework for optimizing health within commercial and residential buildings and sites, and (2) a partnership with Fannie Mae to advance the Healthy Housing Rewards™ (HHR) financial incentive program. The two strands of work complement each other because certification systems like Fitwel provide the evidence-based foundation and guidance necessary for developers, building managers, and building owners to design housing that supports, rather than detracts from, resident health.

However, certification systems tend to primarily reach market-rate properties, as the desirable features can be used to garner rental premiums. In order to reduce inequitable health disparities, health-promoting strategies like those within Fitwel should be incorporated into housing for people of all income levels—a goal that HHR is designed to achieve.

Fitwel was developed in 2011 by the CDC and the General Services Administration to embed active design principles into standard practice. It is rooted in a strong evidence base, supported by more than 3,000 research studies, and based on input from experts in public health, design, and development. After thorough pilot testing, Fitwel was launched for public use in March 2017 by CfAD, which serves as the licensed operator of the certification program.

Fitwel for multifamily residential use encompasses over 70 evidence-based design and operational strategies, divided across 12 sections that promote health through enhancing buildings and communities. Interventions address features throughout a building and across the neighborhood, including but not limited to indoor air quality, walkability, public transit access, food environment, and emergency preparedness. Each strategy addresses one or more of the certification system’s seven health impact categories:

  1. Impacts surrounding community health
  2. Reduces morbidity
  3. Supports social equity for vulnerable populations
  4. Instills feelings of wellbeing
  5. Enhances access to healthy food
  6. Promotes occupant safety
  7. Increases physical activity

Through these categories of impact, Fitwel promotes physical, mental, and social wellbeing, treating health as an interconnected system.

Working Toward Market Transformation

Building on the success of the sustainability movement, the Fitwel certification system and Healthy Housing Rewards program have introduced incentives for designing and building health-promoting affordable housing. However, there is more work to be done, and in the face of rising chronic disease rates and intensifying economic disparities—deeply aggravated by the COVID-19 pandemic—this is a crucial time to prioritize health by designing and creating health-promoting, mixed-income communities.

Integrating healthy building standards like Fitwel into other federal programs, such as those managed by HUD, can accelerate the promotion of healthier affordable housing. HUD maintains a wide array of multifamily-oriented programs, ranging from mortgage insurance (for new construction, rehabilitation, acquisition, and refinancing) to grant programs that stimulate production and preservation of multifamily housing supply.

If HUD were to consider incentivizing the use of Fitwel in the same vein as environmental-related certifications such as LEED, ENERGY STAR, and National Green Building Standard, it would have a tremendous impact on how real estate market stakeholders view healthy housing.

In addition to HUD, many other governmental agencies—most notably HHS, EPA, USDA, and VA—can play an important role in improving the quality of affordable housing. The creation of the Federal Interagency Working Group on Healthy Homes is a recognition of this fact. Working together to implement evidence-based strategies within existing governmental programs has the power to positively impact resident health for generations to come.

Just as the sustainability movement transformed real estate development over the past few decades, the real estate industry is now on the brink of a full-fledged market transformation oriented toward promoting human health. In 2020, Fitwel alone saw an 190% increase in project registrations when compared with the previous year. Without financial and regulatory interventions, the affordable housing sector is at risk of being left behind. Through the continued dissemination and expansion of incentive-based programs, CfAD is committed to bringing healthier environments to all populations. By advancing a systematic approach to revolutionize how multifamily affordable housing is designed, constructed, and located, we can decrease the health disparities plaguing our nation and continue to work toward a healthier future for us all.

Alfonso Costa, Jr. is an Executive Vice President at the Falcone Group and previously served as Deputy Chief of Staff at HUD. He is a member of BPC’s Housing Council.

Sara Karerat is the Director of Applied Research at the Center for Active Design.

End Notes:

1 Center for Outcomes Research and Education, “Health in Housing: Exploring the Intersection between Housing and Health Care,” February 2016. Available at:
2 Adamkiewicz, G., et al, “Environmental Conditions in Low-Income Urban Housing: Clustering and Associations with Self-Reported Health,” August 2014, American Journal of Public Health, 104(9), 1650-1656. Available at:
3 Mary Northridge, Elliot D. Sclar, and Padmini Biswas, “Sorting Out the Connections Between the Built Environment and Health: A Conceptual Framework for Navigating Pathways and Planning Healthy Cities,” December 2003, Journal of Urban Health, 8(4), 556-568. Available at:
4 Gordon-Larsen, P., et al, “Inequality in the Built Environment Underlies Key Health Disparities in Physical Activity and Obesity,” February 2006, Pediatrics, 117(2), 417-424. Available at: Larson, N.I., Story, M.T., & Nelson, M.C., “Neighborhood Environments: Disparities in Access to Healthy Foods in the U.S.,” American Journal of Preventive Medicine, 36(1), 74-81.
5 See CfAD’s publication, “Assembly: Civic Design Guidelines,” 2018. Available at:

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