As a graduate student living in Boston's Dorchester neighborhood, Diana Hernandez was studying the health of families residing in substandard housing and how legal interventions might help.
But as she interviewed parents — mostly mothers — she discovered something pretty much all of them shared: It's what social scientists call "energy insecurity," or the inability to get basic energy needs met, whether it's air conditioning on sultry summer days, or heat in winter, or lights throughout the year.
So Hernandez further analyzed what these families faced: the dilemma of choosing to "heat or eat," or using the stove for household warmth, bundling kids up in added layers, living in darkness for as long as possible, or just plain suffering in extreme weather. In her new study, Hernandez reports that often, these kinds of energy woes are accompanied by health problems — chronic stress, exacerbated asthma, anxiety and depression.
About 16 million households in the U.S. face "energy insecurity," according to a report cited in the new study. This new analysis by Hernandez -- now an assistant professor at Columbia University's Mailman School of Public Health, and a JBP environmental health fellow at the Harvard T.H. Chan School of Public Health -- adds to a growing body of research that links basic social and environmental needs — food, energy, housing, transportation — to health outcomes. And it comes amid growing income inequality in Boston and the country.
Consider these quotes from a few of the study participants:
"In the wintertime it's more [of a problem] ‘cause [my child] gets sick more with asthma."
"Stress. It adds stress. It's silly sometimes, but I think like, 'Geez. My lights are gonna shut off.' "
"Every time I call I get nowhere, that's why I told my psychiatrist. Then I went into a depression, you know, 'cause I'm trying to show them my bill and everything and don't nobody ever have funds for me. So I told her I feel like I'm being targeted, which I know better, but I was just feeling low, you know …"
"My kids said, ‘Mommy, when they gonna put the gas back so we cook the fish?’ I finally got two checks and turned the lights back on. You gotta sacrifice."
Hernandez says energy insecurity is more of a "hidden hardship" compared to, say, lack of food. But access to reliable energy is "a source of anchoring that allows people to carry out a healthy life at home."
All this may seem pretty obvious, but researchers who study these co-called "social determinants of health" say the research is important because it strengthens the case that basic needs should be considered in a medical context and integrated as a key part of primary care.
Requests for "utility support," for instance, "routinely rank among the top concerns for patients who screen positive for unmet social needs in the health systems we serve,” said Rocco Perla, president of Health Leads, a Boston-based nonprofit working with health care organizations across the country to address patients’ unmet social needs.
“While this study is qualitative, it adds to mounting clinical evidence in support of interventions that connect patients to the basic resources they need to be healthy. More importantly, this study puts the actual voice of the population front and center so we can learn more about the realities of people’s lives who experience these needs on a regular basis."
Perla cites two recent studies conducted at Massachusetts General Hospital, showing that social needs are associated with nearly twice the rate of depression, 60 percent higher prevalence of diabetes, more than 50 percent higher prevalence of high cholesterol and more than twice the rates of emergency department use, for instance.
“We’re no longer debating the connection between unmet social needs and health; it’s well-researched that the inability to plug in a nebulizer if you have asthma, or refrigerate your medication, is going to impact your health,” Perla said in an email exchange. “What we’re seeing today is a groundswell of interest from health systems and policymakers who are increasingly realizing the value of addressing these needs as a standard part of quality medical care.”
For the new analysis -- published in the journal Social Science and Medicine, and part of a larger study by Boston Medical Center -- Hernandez interviewed 72 parents recruited from community health centers in the Boston area. All of the participants reported income well below the federal poverty level — the median was $30,000 annually — and the majority received housing subsidies.
The report details the kind of chronic, toxic stress related to poverty that is widely known. But it focuses on the impact of fuel and other utility bills, in particular.
From the report:
Participants described feeling worried about fuel bills and the deteriorated conditions of their home environments. The experience of energy insecurity also triggered mental health disorders such as anxiety and depression... The constant threat of service interruptions due to non-payment fueled parental fear and stigma. Parents felt judged by persistent surveillance on the part of child protective services and feared losing parenting privileges to the state with the concern that being unable to “keep the lights on” could be considered a marker of inadequate parenting. Some participants expressed feelings of shame and a disruption of family life when living through a utility service disconnection.
The report compared energy insecurity to food deprivation: "Food is generally considered indispensable whereas energy is often perceived as an amenity," it says. "Most ... people would cringe at the thought of hunger-prone families, few shudder at the notion of poor households living in the cold and in the dark, accruing debt to fulfill a basic need."
Hernandez adds that it's not only about access to basic needs, but also about quality. "We know and appreciate that people should eat, but we also know they should eat nutritious food. It's the same with energy — it should be affordable and high quality so people aren't using the stove for heating because the systems in the house are inadequate."
This study wasn't meant to determine whether families with energy insecurity are more likely to have health problems, or what those particular problems might be. But it further supports the notion that "poverty is multidimensional — it's not just about limited income, it's about what that money can't buy, and in this case it's that people can't afford basic energy." That, she says, can exacerbate existing health problems — like the child whose asthma gets worse in a cold, drafty apartment — or become a trigger for mental health issues for that child's single mom.
Hernandez said she was surprised by some of the ways these families coped. Some leveraged their medical conditions — citing kids asthma, or a frail older grandparent living in the home — to get "shutoff protection" so utilities wouldn't get turned off, she said. Others used their Earned Income Tax Credit — envisioned as a source of poverty alleviation and a way to save money — to pay down debt on utility bills.
Hernandez said she recalls arriving at an interview and stepping in to a pitch dark home. "I remember walking into this woman's house and it was so dark. And she was like, 'Yeah, we turn off all the lights and we only use [them] when we really need to.' "
The good news is that are fixes available. Housing interventions "that promote warmth and energy efficiency are among the most effective options to improve health outcomes," the study says.
Programs such as the federal Low Income Home Energy Assistance Program provide fuel assistance for families. And in Massachusetts (where about 200,000 families qualify for help under LIHEAP, according to a report by WBUR's Martha Bebinger) the group Action for Boston Community Development can also help people get the energy assistance they need.
"While this is often a hidden hardship," Hernandez said, "it's also an addressable one. There are interventions that can happen — these programs exist — they just need to be expanded."