A slip of paper posted on a door can signal the beginning of a destructive process for children’s health. Each year, more than 2.3 million households receive eviction notices.1 Despite fair housing laws which ban discrimination against children and families, households with children are more likely to be evicted than childless households, even when controlling for family income and rent owed.2 The proportion of children in a neighborhood is a stronger predictor of eviction rates than neighborhood-level poverty, racial makeup, or proportion of single parent households.2 Nearly 1 in 7 children will experience eviction before their 15th birthday, including 1 in 4 children living in poverty.3
Eviction, like mass incarceration, police violence, or environmental contamination, disproportionately affects families of color and exacerbates health inequities. Because of generations of systemic racism, Black and Latinx households are more likely to be evicted than white households, with women of color especially impacted.4 Close to 20% of Black children will be evicted during childhood, compared with 11% of white children.3
The economic disruption of the coronavirus disease 2019 pandemic has compounded this long-standing eviction crisis. In spring 2021, 1 in 5 renters with children was behind on rent, compared with 1 in 10 childless households.5 The pandemic has reinforced disparities in evictions, with households of color more than twice as likely as white households to fall behind on rent.5 Emergency aid has been slow to reach families and a patchwork of state and federal eviction moratoria are soon to expire, potentially leading to a massive wave of evictions. Given the widespread impact on children, pediatricians have an important role in supporting families and advocating for policies that help children remain stably housed.
What Is Eviction?
Eviction is a legal process used by landlords to remove tenants, most often for nonpayment of rent. The process begins when a landlord notifies the tenant and files for eviction, leading to a court appearance and potentially a sheriff removing a tenant’s belongings from the home. This formal process is only the tip of the iceberg. Many tenants leave at the mere threat of an eviction. Other households are forced out through buyouts, utility shutoffs, or changed locks. These “informal” evictions may be twice as common as formal evictions, resulting in millions of forced moves annually.3
Families struggle to find stable and affordable housing after eviction. An eviction filing, even those that do not result in removal of the tenant, can remain on a tenant’s rental history for years, limiting future access to rental housing. Many tenants cannot pay 2 months of rent for a comparable unit in their neighborhood. As a consequence, families are forced into more disadvantaged neighborhoods with higher rates of poverty and crime.4 Others become homeless, whether doubling up with other households, staying in shelters, or living in unsheltered settings.
Evictions and Children’s Health
Eviction can damage a caregiver’s health through stress, toxic exposures, unhealthy coping mechanisms, and lost financial resources. Evicted adults experience higher levels of depression, suicide, and all-cause mortality.4 Mothers of young children report higher levels of stress, depression, and poor health in the year after eviction.4
Children’s health is also directly impacted by evictions. Women who experienced eviction during pregnancy have a greater risk of low birth weight or preterm birth.4 Childhood eviction has been associated with food insecurity and worse overall health.4 Students may miss instructional time or change schools after a forced move.4 Stress, uncertainty, and material hardship have measurable biological impacts on children’s health, so it is unsurprising that eviction leaves a mark at all developmental stages. These disruptions may be even more damaging for children with special health care needs.
Health Care’s Role in Mitigating the Eviction Crisis
Given their relationship with families and connections to community resources, pediatricians may be a strategic point of contact for families facing eviction (Table 1). Screening for social needs is increasing nationwide and should continue to expand. Clinicians can work with registration staff, social workers, and community health workers to build screening workflows and refer to community resources. Validated screening tools that address multiple domains of housing insecurity can help identify families at risk for future evictions.6 Clinicians should create a safe and welcoming environment so families can discuss housing concerns without fear of judgement. Because evictions disproportionately impact communities of color, validating families’ experiences of historical and current injustices is critical to building trust.
Interventions and Relevant Partnerships to Prevent Evictions Organized by Level of Intervention: Pediatricians and Clinics, Health Systems, and Policy
| Pediatricians and Clinics . | Health Systems . | Local, State, and National Policy . |
|---|---|---|
| Level of intervention | ||
| Screen for housing insecurity and other social needs Refer to community resources Establish medical–legal partnerships Manage chronic conditions to prevent costly ED visits and hospitalizations Help patients enroll in and maintain health insurance Ensure continuity of care with primary and specialty providers Connect with families through telehealth or home visiting | Direct community benefit spending toward housing Form partnerships with local governments, housing authorities, managed care organizations, and others to provide housing to high-risk families Work to incorporate broader community development and anchor institution strategies Test ways to reimburse providers for housing-related services | Implement “just cause” ordinances to limit the circumstances under which landlords can file for eviction Provide legal counsel for tenants facing eviction Expand tenants’ due process rights Provide financial resources to renters in crisis Expand the Housing Choice Voucher system Incentivize the construction of low-income housing by increasing tax credits or limiting exclusionary zoning |
| Relevant partnerships | ||
| Registration staff, community health workers, nursing staff, social workers, volunteers, medical schools, law schools, legal services organizations | Local housing authorities, managed care organizations, community organizations, Centers for Medicare and Medicaid Services | Tenant advocacy groups, legal services organizations, city councils, state and national professional organizations |
| Pediatricians and Clinics . | Health Systems . | Local, State, and National Policy . |
|---|---|---|
| Level of intervention | ||
| Screen for housing insecurity and other social needs Refer to community resources Establish medical–legal partnerships Manage chronic conditions to prevent costly ED visits and hospitalizations Help patients enroll in and maintain health insurance Ensure continuity of care with primary and specialty providers Connect with families through telehealth or home visiting | Direct community benefit spending toward housing Form partnerships with local governments, housing authorities, managed care organizations, and others to provide housing to high-risk families Work to incorporate broader community development and anchor institution strategies Test ways to reimburse providers for housing-related services | Implement “just cause” ordinances to limit the circumstances under which landlords can file for eviction Provide legal counsel for tenants facing eviction Expand tenants’ due process rights Provide financial resources to renters in crisis Expand the Housing Choice Voucher system Incentivize the construction of low-income housing by increasing tax credits or limiting exclusionary zoning |
| Relevant partnerships | ||
| Registration staff, community health workers, nursing staff, social workers, volunteers, medical schools, law schools, legal services organizations | Local housing authorities, managed care organizations, community organizations, Centers for Medicare and Medicaid Services | Tenant advocacy groups, legal services organizations, city councils, state and national professional organizations |
Pediatricians can refer to other resources such as Supplemental Nutrition Assistance Program, Supplemental Security Income, or utility assistance to ease financial strain for families struggling to pay rent. Medical–legal partnerships, programs in which lawyers work within health care settings to connect patients to legal resources, can support families experiencing housing challenges or barriers in accessing benefit programs.
Pediatricians can play a role in mitigating unexpected medical costs for families. Optimizing care of chronic conditions may help prevent avoidable emergency department or hospital visits. Ensuring that eligible families are enrolled in Medicaid may also help, as state Medicaid expansion has been linked to decreases in eviction rates.7 Pediatricians should work to ensure continuity of care with primary and specialty providers if families miss appointments or change addresses during an eviction.
Health systems can direct community benefit spending toward housing. Creative partnerships between health systems, housing authorities, and managed care organizations that provide housing as a therapeutic intervention for families have been shown to improve both child and parent health.6
Policy Solutions to Prevent Evictions
Beyond the clinic, pediatricians can be powerful advocates for families at risk for eviction. Pediatricians can work in partnership with community organizations and professional societies to advocate for specific policy goals. State and local governments can institute “just cause” ordinances to limit evictions only to cases involving lease violations or nonpayment. Several jurisdictions have implemented right-to-counsel programs, which fund eviction defense for low-income tenants. Policymakers can also enact policies to expand tenants’ due process rights, providing them with sufficient time and information to defend themselves in court. Beyond legal reforms, communities can direct resources to renters in crisis, including tenant advocacy groups, financial counseling, and emergency rental assistance.
Crucially, pediatricians can advocate for primary prevention by addressing the shortage of affordable housing. The mismatch between rising housing costs and stagnant wages is the main driver of evictions. Only a small fraction of households eligible for federal housing assistance receive this benefit. Expanding the Housing Choice Voucher (formerly known as Section 8 Voucher) program, coupled with regulations to prevent landlords from discriminating against vouchers as a source of income, may reduce the threat of evictions. Tax incentives (eg the federal Low-Income Housing Tax Credit) and single-family zoning bans have the potential to increase the supply of affordable housing.
Any solution to the eviction crisis must work toward eliminating disparities by race or household structure. Policymakers must pay careful attention to equity in the dissemination and evaluation of these policies. However, reforms should aim to root out injustice in the eviction process and reduce the burden of evictions overall, not simply distribute its harms equally between groups. Advocates should partner directly with families to ensure that their voices are central in these efforts.
Evictions harm families, destabilize communities, generate health disparities, and prevent children from living healthy and productive lives. Pediatricians can help build stronger protections for families at risk for eviction.
Acknowledgments
The authors acknowledge Ms Eloise Lawrence for her insights on the eviction process. The authors also acknowledge Dr Graham Mooney, Dr Priyal Gandhi, and anonymous reviewers for their comments on earlier versions of this manuscript.
Ms Goplerud, Dr Leifheit, and Dr Pollack conceptualized the article, Ms Goplerud drafted the initial manuscript, Ms Goplerud, Dr Leifheit and Dr Pollack reviewed and revised the manuscript, and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: Ms Goplerud was supported by NIH NCATS Grant TL1 TR003100. Dr Pollack was supported by NICHD Grant 5R03HD098411-02. Dr Leifheit was supported by a postdoctoral fellowship from the Agency for Healthcare Research and Quality AHRQ 2T32HS000046. The funders had no role in study design, collection, analysis, and interpretation of data; writing this report; or the decision to submit the report for publication. Funded by the National Institutes of Health (NIH).
References
Competing Interests
POTENTIAL CONFLICT OF INTEREST: Dr Pollack reports stock ownership in Gilead Pharmaceuticals. The work detailed here does not evaluate any specific drug or intervention produced by Gilead. In September 2019, Johns Hopkins University entered into a contract with the Department of Housing and Urban Development for Dr Pollack to work part-time on a temporary assignment, assisting the department on housing and health issues. The findings and conclusions in this article are those of the authors and do not necessarily represent those of Housing and Urban Development or other government agencies. Dr Pollack was previously on the Health Advisory Council for Enterprise Community Partners and was a paid consultant to the Open Communities Alliance. Drs Pollack and Leifheit signed on as amici to several Amicus Curiae briefs in support of the Centers for Disease Control and Prevention’s national moratorium on eviction as a public health measure. Dr Leifheit has provided expert testimony to legislative bodies regarding potential public health effects of eviction. Ms Goplerud has no conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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