International and Domestic Health Equity and Leadership (IDHEAL) UCLA Emergency Medicine

Social Emergency Medicine Teaching Modules
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Module 9
Dennis Hsieh, MD, JD


1. To understand how housing conditions can affect health.

2. To understand what a tenant’s rights are when it comes to substandard housing

3. To offer guidance for those patients facing substandard housing conditions.


A 65-year-old man, with a history of hypertension, type 2 diabetes mellitus and hyperlipidemia is brought in by ambulance because he is weak and short of breath. The patient has been feeling progressively unwell over the last week. Patient has also had nausea and vomiting. Paramedics note that his glucose read “HIGH.” Vitals are as follows: BP 180/100, HR 110, RR 30, T 98.6°F, O2 100% on 2L. The patient says that he has been out of his medications for one week because he didn’t have the money for his co-pay. Until this past week, he had not missed any medications for several years. The patient is on fixed Supplemental Security Income (SSI) each month and has not been able to cook at home because his stove is broken. He called his landlord, but his landlord refused to fix the stove. As a result, patient has had to eat out instead of cooking at home, and thus has not been able to afford to pay the co-pay on his medications. His heater broke a year ago, but he has some extra blankets so this has not been an issue. You call social work. The social worker recommends that the patient call Code Enforcement because as a tenant, he has a right to safe housing with functional heating. The social worker also provides a template demand letter to sign that the patient can provide to his landlord.

Discussion Questions

1. Why did this patient come to the ED?

2. How do you ask a patient about their housing conditions?

3. How did this patient's housing conditions affect his health?

4. How can you advocate for your client if you discover a poor housing condition?

5. What is a demand letter?

Teaching Points

1. Housing conditions can impact health in multiple ways. The impact can be direct i.e. mold/roaches on asthma, or indirect, as you see in this case – the patient had to make an economic tradeoff leading to a lack of medications, leading to diabetic ketoacidosis.

2. Local jurisdictions all have habitability laws where a landlord has a legal duty to the tenant/renter of keeping a rental unit livable (habitable). This usually includes working heat (but not AC), working appliances, and cleanliness (pests/mold/rodents, etc.).

3. A tenant can request a housing inspection to document poor conditions. Each jurisdiction has a different office for this, but often it is either through the housing department (code enforcement) or the department of public health (environmental health).

4. A tenant can write a “demand letter” to a landlord asking that conditions be improved.

5. A healthcare professional can often help a client’s case by documenting how housing conditions are poorly impacting health and writing a letter expressing their concern to the landlord.

Practical Questions

1. What are the local agencies responsible for housing inspections and code enforcement and what is their contact information?

2. What are landlords in your community obligated to provide/ensure about the units they rent?

3. Are there local resources available to help the client enforce their rights?

Recommended Screening Question(s)

1. Think about the place you live. Do you have problems with any of the following? (CHOOSE ALL THAT APPLY)

  • Pests such as bugs, ants, or mice
  • Mold
  • Lead paint or pipes
  • Lack of heat
  • Oven or stove not working
  • Smoke detectors missing or not working
  • Water leaks
  • Other; Specify: ______
  • Not applicable
  • Satisfactory conditions

Paired Reading

Oudin A, Richter JC, Taj T, Al-Nahar L, Jakobsson K. Poor housing conditions in association with child health in a disadvantaged immigrant population: a cross-sectional study in Rosengrd, Malm, Sweden. BMJ Open 2016; 6(1): e007979.

Discussion Points from the Reading

1. Child health is especially vulnerable to environmental exposures. Poor housing conditions impact children as they spend more time in the home, have higher respiratory rates and are closer to the floor and more likely to put objects in their mouths. Exposure to poor housing conditions therefore may impact children to a greater extent. Poor housing conditions may also be a factor in the association between income inequality and child health.

2. In this cross-sectional study of child health in a disadvantaged, immigrant population in Sweden, there was an association between dampness and asthma, mold and headache and cockroaches and a variety of poor health outcomes.

Additional Readings

1. Gibson M, Petticrew M, Bambra C, Sowden AJ, Wright KE, Whitehead M. Housing and health inequalities: a synthesis of systematic reviews of interventions aimed at different pathways linking housing and health. Health Place 2011; 17:175-84.