.... To remove the forms of ill health which are produced by housing conditions, we must, therefore, discover the specific cause of each house disease and remove that cause. This is not easy, because many of the suggested correlations are still under dispute, but pending final agreement on the part of specialists, we must act, as in all other matters of human policy, upon tentative conclusions which may be accepted as reasonable.

Our problem may first be considered with reference to the types of houses which have been or may be constructed. Men may live in detached houses, in semi-detached or row houses, or they may live in flats - detached, semi-detached or in rows - or in block dwellings, tenements, apartments, hotels or lodging houses. Of these types mentioned, unquestionably the worst, under usual conditions, is the multiple dwelling; and although these, if properly planned within and properly placed on the lot, can be rendered tolerably wholesome, they inevitably contain at best features which render them far from ideal as places of permanent residences.

1 Adapted from "Bad Housing and 111 Health," National Conference of Social Work Proceedings, 46th Annual Meeting, Atlantic City, 1919 (Chicago: The Conference, 1920), pp. 237-41.

Let us take for example the prevailing type of multiple dwelling as found in our American cities. This is a structure four, five or six stories high, and perhaps higher, built largely of wood, but with brick exterior, three or four rooms deep, sharing party walls with similar buildings to right and left, sharing with its neighbors a narrow court or shaft at the sides and an ugly yard at the rear filled with clothes lines and drying clothes, outbuildings and board fences, and probably ash, garbage and refuse cans, and sharing with its neighbors to the front an ugly, monotonous, treeless, dusty paved street. The picture above given, which describes the urban homes of the middle classes, does not describe the homes of our wage earners who constitute the major part of our urban population, for to it must be added the inevitable dark hallway, the common toilet, often located in hall, cellar or yard, the disrepair and the stench from unclean cellars, halls, yards, from cooking and washing, from unsanitary plumbing, and from years of careless usage.

Such dwellings as have just been described may contribute to ill health on the part of their occupants (even though these tenements or apartments are newly constructed) in the following ways:

1. Through improper location by building on wet and imperfectly drained land; the buildings, especially the lower stories, may be damp, and dampness tends to lower resistance to disease. Or by placing the building in a highly-exposed position, proper heating in winter season may be impossible for many rooms and such exposure may reduce resistance.

2. Through the characteristic use of wood for interior, if not exterior, construction, tenants are exposed to a continuous fire risk. Few tenements or apartment houses have more than one fireproof means of egress, if any is provided, so each family is continuously exposed by the carelessness of all the other families in the building. A tenement-house fire may mean not only the possibility of death from burning, but also the greater probability of suffocation or accident. Perhaps the form of ill health which is most lasting in its effects is occasioned by fright, which may cause sleeplessness or even permanent nervous impairment.

3. Through defective structure or bad repair there may be continuous danger to life and limb from accident. Winding stairs take their annual toll in broken limbs; rotten flooring, insecure railings of stairs and piazzas or fire escapes insecurely attached are causes of many of the diseases technically classified as traumatic.

4. Through defective orientation with reference both to the points of the compass and to neighboring buildings, tenants may be deprived of sunshine and even of adequate light. Many of our cities have planned, and continue to plan, streets running due east and west. If the apartments are built up to their side-lot lines, approximately half of their rooms are sunless. The absence of sunshine generally means dampness, cheerless-ness, and for those thousands of flats which have no sunlighted room a reduced resistance and an increased exposure to disease, for sunshine is an effective germicide as well as a promoter of improved metabolism. The sunless room or apartment facing the north or facing a narrow court or yard shadowed by neighboring buildings is, therefore, a favorable medium for the transmission of certain respiratory diseases.

5. Through excessive height, for high buildings may contribute to ill health, not only by increasing the fire risk and shutting out sunshine as above mentioned, but also by necessitating stair climbing, which is a hardship to the aged and a limitation to the play activities of the very young, and often a source of pain, if not positive danger, to women who are about to become mothers. Tenement houses have no elevators and, hence, persons in poor health living above the second floor, to avoid stair climbing, will do without out-of-door exercise which is essential to their health.

6. Through the crowding of many families in the same building, sharing the same halls and perhaps the same toilets, the chances of exposure to certain infectious and contagious diseases are increased. The common stair railing touched by all who go in or out is a fomes by which common colds or other diseases of the respiratory system may be transmitted via the hands of the infected person to the hands of the new victim. The unwashed hand may soon be carried to the mouth and the infection accomplished. Though this mode of transmission is perhaps less serious than the common hand towel or drinking glass, it is not negligible, especially where halls are dark, for the railing is more used in such halls and sunlight does not exercise its germicidal action.

7. Through crowding of population within the tenement, block, or district, for, whether among rich or poor, density of population further adds to ill health by the nervous wear and tear which it entails. It is difficult to secure relief from the noises made by your neighbor, who insists upon moving around his furniture late at night, or walks the floor with his crying baby, or plays his pianola, victrola or cornet during the hours when you wish to concentrate upon your work or to sleep. Moreover, where there is large population there must be considerable traffic of persons returning home or delivering goods or making visits, and such traffic means noise, which in turn means nervous fatigue and sleeplessness. As sleep is essential to the repair of the body after the fatigue and wear and tear of the day's activities, the sleeplessness entailed by crowded living must be considered one of the most serious of the sources of reduced resistance or ill health on the part of the tenement dweller.

8. Through crowding of rooms. Crowding may be caused by shortage of housing, poverty, or ignorant racial habit. It almost inevitably means increased opportunities for a communication of disease, either by direct contact, fomites or droplet infection. Where there is crowding of lodgers in the same apartment with the family there are reduced opportunities for privacy and perhaps for the accepted decencies of life, which may be an occasion in conjunction with other causes for immorality with its train of sexual diseases, or for excessive sexual stimulation, especially on the part of the adolescent, resulting in perversions or neurasthenic tendencies.

9. Through inadequate plumbing or the use of undesirable or defective fixtures which may mean reduced cleanliness and in various ways increased opportunity for transmission of diseases. Lack of water supply within an apartment makes personal cleanliness and house cleaning difficult. Broken or imperfectly trapped fixtures mean that occupants must continually breathe sewer gas. Though sewer gas has been determined to be free of bacteria, its presence in an apartment leads to discomfort, reduced appetite and imperfect nutrition, and in extreme cases to nausea. Where fixtures must be shared by several families there is danger of transmission of venereal diseases and of body parasites.

10. Through poor ventilation. The habitual use of windowless rooms, of rooms on narrow closed courts, or even of rooms having only one window, where, for reasons of privacy the door must be kept closed, means at least discomfort from hot, humid, stale air and probably reduced resistance to disease.

11. Through poor lighting. Dark rooms cause ill health in a variety of ways. In the first place, a room which is dark is likely to be dirty, because the dirt cannot be seen. Such dirt may contain disease germs, and may contaminate hands or throat and lungs. Families living and working in imperfectly lighted rooms are likely also to suffer from eyestrain. When members of the family do housework, sew or read in such rooms for long periods, there may result permanent impairment of the vision, of which chronic headaches are the usual symptom. Careful experiments by the Boston Board of Health have demonstrated that the germs of tuberculosis can retain their virulence in such rooms for a period of more than two months. As a great many deaths in America are from tuberculosis and as there are a number of living cases in our population for each death, and as also the tenement-house population changes residence frequently, the chances of transmission of this disease from one family to another should not be considered negligible, though other methods of transmission of this disease are more common. If, as is frequently the case, all of the rooms of a tenement are gloomy, the resistance of those members of the family who are forced to pass their days in the home is almost certain to be reduced, for human beings, like plants, need sunshine for vigorous growth. Experiments seem to indicate that living in gloomy quarters, especially where accompanied by lack of exercise, results in a reduction of the phagocytic power of the blood; that is the power to destroy germ organisms, and an anemic condition also may result.

12. Through improper equipment. Defective or imperfect equipment may injure health in a variety of ways. A sink which is set too low means back strain for the housekeeper. A leaky stove may endanger the lives of the tenants from carbon monoxide. Defective gas fixtures may cause poisoning and defective electric wiring may cause danger to life from fire or shock. Careless insertion of plumbing or heating fixtures may make it possible for vermin and insect pests which are disease carriers to pass from the apartments of careless tenants to those of careful housekeepers. Lack of screens or defective screening may expose to mosquitoes, which are bearers of malaria, or to flies, which may be carriers of typhoid fever in cities where modern plumbing is not universal, or of the intestinal infections of infants.

13. Finally, the proximity of the tenement to the factory may mean poisoning of the air by chemical gases, mineral dust or soot, causing throat irritation and reduced resistance to respiratory diseases, as well as increased work for the overburdened housewife in keeping her curtains clean and her home free from dust.

The effects of the discomfort of an uncongenial environment are cumulative. Continuous living in such quarters tends to produce irritability, anemia and lassitude, or what is popularly called the "Slum Disease."

Some of the undesirable features in house construction which have been mentioned are actually reducing resistance or causing disease to the vast majority of the persons now living in multiple dwellings and are inherent in that type of dwelling. In comparison with the multiple dwelling the detached house is far more conducive to high resistance and good health. With a little attention to planning, it can be made structurally safe and every room can be well lighted, well ventilated and equipped for the comfort and convenience of its occupants. For families with children it is the ideal place of residence, as it makes possible not only good health, but opportunities for protection from undesirable associates. It also makes possible supervised play activities and through the household garden offers the children opportunity for familiarity with plants and flowers - an essential part of every child's education.