How substandard housing affects children's health

October 1, 2000

Recognizing that a child?s substandard home may be the cause of his or her asthma attacks, lead poisoning, or injury is the first step toward bettering that child?s health. The second step is to help the family access available resources for improving the home environment.

 

How substandard housing affects children's health

Jump to:Choose article section...Table 1 HOMES housing screenThe housing crisis Table 2 What is substandard housing? Direct effects of inadequate housing Indirect effects of inadequate housing Options for affordable housing Some case histories

By Megan Sandel, MD, and Jean Zotter, JD

Recognizing that a child's substandard home may be the cause of his or her asthma attacks, lead poisoning, or injury is the first step toward bettering that child's health. The second step is to help the family access available resources for improving the home environment.

Every day pediatricians see the effects of inadequate housing on their patients' health. Although pediatricians generally ask parents about symptoms of asthma or lead poisoning or about how an injury occurred, they may fail to connect these conditions with the inadequate housing that is the underlying problem. The health of many children who are living in poor conditions can be affected in more than one way: A girl whose asthma is triggered by living in a rodent- and cockroach-infested building may also be on the verge of homelessness, for example, or a boy with lead poisoning because of exposure to old paint may be at high risk for injuries because of other unsafe conditions in his home. Children also can be affected by where they live in ways that are not obvious. The girl from a family whose rent leaves little money for food may suffer from iron-deficiency anemia. The boy whose family is "doubled up" (living among family or friends) or moving frequently to avoid homelessness may be doing poorly in school because of his unstable home life. By asking about housing (Table 1) and knowing how to advocate for families living in poor conditions, pediatricians can detect and treat such problems early or help to prevent them.

 

Table 1
HOMES housing screen

H
ODo you ever spend
MHave you noticed
EHave you
SHave you tested your

 

The housing crisis

Despite the economic prosperity this country has enjoyed during the last decade, more and more families in the United States are unable to find affordable and safe housing. According to a 1999 study by the US Department of Housing and Urban Development (HUD), more than 5.3 million households, some 12.5 million people, have "worst- case housing needs, more than double the number of households a decade ago."1,2 Families with worst- case housing needs either pay more than half of their available income on rent or live in substandard conditions, or both. It is estimated that almost one third of these people, or 4.5 million, are children. Unfortunately, many families must choose between safe housing and affordable housing. Substandard housing "lacks complete plumbing for exclusive use, having unvented room heaters as primary heating equipment, multiple upkeep problems such as water leakage, open cracks or holes, broken plaster, or signs of rats."3 According to the 1993 American Housing Survey, more than 1.2 million families live in substandard housing that is considered to have moderate to severe problems (Table 2).

 

Table 2
What is substandard housing?

Housing with severe problems

Lacks cold or hot water, flush toilet, or both a bathtub and a shower

Heating equipment has broken down, resulting in lack of heat for at least 24 hours

Has no electricity or has exposed wiring with no working outlet

Light in public staircases is not working, steps or railings are missing, and elevator does not work

Has five or more basic maintenance problems, such as water leaks, holes in floor peeling paint, broken plaster, or evidence of the presence of rats during the last 90 days

Housing with moderate problems

Toilet has broken three times in the last three months

Unvented gas, oil, or kerosene heaters are primary source of heat

Kitchen lacks a working sink, refrigerator, or oven

Has some problem with staircase or other basic maintenance problem

 

Some families, unable to find either safe or affordable housing, become homeless. According to conservative estimates, about 600,000 people are homeless on any given day, and 36% of them are families with children.4,5

Direct effects of inadequate housing

Inadequate housing results in asthma, lead poisoning, injuries, and other health problems.

Asthma. The most common chronic disease of children, asthma has nearly doubled in prevalence during the past 10 years, affecting an estimated 5.3 million children in the US alone.6,7 Although dust, rodents, and animal dander have long been associated with asthma attacks, in the past decade cockroach allergens and molds have also been identified as triggers. As homes have become more energy efficient, ventilation has decreased, increasing exposure to indoor allergens. This lack of ventilation can also cause increased moisture, leading to growth of mold and dust mites and fostering peeling of paint.

Too often asthma triggers are beyond families' control. The presence of cockroaches are not simply a measure of cleanliness. Many apartments are infested because of the building's structure, not individual families' habits. Removal becomes complicated unless the entire building is exterminated. Families who are doubled up often cannot complain about cigarette smoke, another common asthma trigger.

Lead poisoning. Lead, whose effects have been known for more than 100 years, is considered the most common environmental hazard to children. After lead poisoning was recognized as a health threat in the US in the 1970s, the mean blood lead level in children from 1 to 5 years of age dropped from 15 µg/dL from 1976 to 1980 to 2.7 µg/dL from 1991 to 1994. Many credit the removal of lead from gasoline, paint, and food products (soldered cans) for the decline.8 However, 890,000 children from 1 to 5 years old are estimated to have a blood lead level greater than 10 µg/dL. Some children still are exposed to lead in old paint and in soil; poor children from minorities are at highest risk for lead poisoning.

Injuries are the leading cause of death among 1- to 14-year-olds in the US. Almost half of the injuries, such as burns, scaldings, falls, and drowning, occur at home. A study in Philadelphia shows that 98% of families do not know what water temperature is safe for children, and 34% do not have a working smoke detector.9 Common housing hazards associated with injuries include radiators without safety covers and windows without screens or guards.

Impaired mental and physical health often results from homelessness. Homeless children are at increased risk of infections; one study shows that homeless children have diarrhea five times as often as poor children who live in homes.10 Another study found that 45% of children in homeless shelters meet criteria for special education evaluation, but only 22% receive any special education testing or placement.11

Indirect effects of inadequate housing

Malnutrition, exposure to violence, and educational problems are the most prominent indirect effects of substandard housing.

Malnutrition. Children in families on waiting lists for housing are 50% more likely to have iron deficiency anemia and are six times more likely to have stunted growth than children in families that receive housing subsidies.12 Many poor families who live in cold climates often must choose whether to heat or eat during the winter months. One study of 11,000 inner-city children 6 months to 2 years of age showed that children's growth rate decreased in the three months after the coldest parts of the year.13

Exposure to violence. Because of the lack of affordable housing, many children are trapped in unsafe neighborhoods or living arrangements. A study conducted in Boston found that one in 10 poor children has witnessed a shooting or knifing by age 5, and more than half of these incidents were within their own homes.14 This exposure to violence can have long-term effects, including signs of posttraumatic stress disorder, psychotic episodes, and suicidal tendencies.15 Domestic violence, which may be exacerbated by the stresses of substandard housing, also exposes many children to violence.

Educational problems. Students who move frequently are significantly more likely to fail a grade and have behavior problems than other children.16 In many families living doubled up to avoid homelessness, the children are unable to attend school because they no longer have transportation to the school where they are registered.

Options for affordable housing

Families that are homeless or looking for affordable housing have only limited options, and sometimes none of them meets their needs.17-19

Shelters. State government should provide shelter assistance for families that are homeless, provided they meet the financial and categorical eligibility requirements to qualify for homeless assistance. Usually, families must be poor and fit into specified classes, for example being homeless because of a natural disaster. Families fleeing domestic violence usually fit this category and at times may be given priority. Unfortunately, in most states, shelter is not an entitlement, and waiting lists therefore are common. Funding from the Violence Against Women Act, the Stewart B. Mckinney Homeless Assistance Act, and block grants provided in the Transitional Aid to Needy Families legislation (which replaced the Aid to Dependent Families and Children and Emergency Assistance programs) allow states, localities, and private organizations to run shelter programs for families.

Public and subsidized housing is offered by all states. Public housing consists of housing developments run by the local public housing authorities. Subsidized housing is any type of housing managed, owned, and maintained by private or nonprofit agencies. Funding for these types of housing comes from the federal or state governments. Federal and state grants enable owners of public and subsidized housing to offer apartments below the fair-market value. The amount of rent that a family pays is often a percentage of its income. Eligibility for public and subsidized housing usually depends on the family's financial status and sometimes their tenant history. Since public and subsidized housing is not an entitlement, long waiting lists are common. In Boston, a family can expect to wait between a year and five years for a public housing unit to become available.

By taking government money, landlords often agree to maintain the apartments at set standards for health and safety. (More information about such standards is available at 800-HUDS-FHA.) In addition, states or municipalities often have laws on minimum codes for leased housing. Federal, state, and local laws provide for health and safety inspectors and have in place a process for a tenant to assert the right to safe and healthy housing. State and local laws on health and safety also apply to private housing, units that are not subsidized by the government and that are leased for the fair-market value. Since these apartments do not receive federal funding, they do not have to comply with the minimum codes set by HUD, however.

Families that are homeless, doubled up, or in a city that lacks affordable housing may hesitate to assert their rights to have their homes brought up to legally enforceable standards because they are more afraid of losing their housing than of the health consequences posed by their poor indoor environment. This is a genuine concern and should not be taken lightly. Other families own their homes and lack the resources to fix the problems.

Some case histories

In 1996, after becoming aware of the connection between poor housing and health problems, a group of pediatricians began to look at housing as a child-health issue. We created the Doc4kids project, which collects stories from across the country about how inadequate housing can affect children's health. We documented these stories, along with evidence from the medical literature, in a report.20 The following three cases are drawn from the project's files. We chose cases that illustrate the resources available to help families living in substandard housing and how pediatricians can advocate for these families and help them access such resources. We have changed names to protect the families' privacy.

The Smith family. Two of Mr. and Mrs. Smith's children, Sharon and Michael, suffered from chronic asthma. The family lived in public housing (Everytown Housing Authority). Both children took inhaled steroids to manage their asthma but still suffered life-threatening attacks. In 1995, Michael was hospitalized for severe respiratory distress. The hospital released him after five days. In addition to being hospitalized, Michael visited the emergency room seven times during six years of living at Everytown Housing Authority. Sharon also visited the emergency room frequently, a total of 10 times from 1989 to 1995; three of those visits led to hospitalizations. In 1996, the children's doctor referred the family to the Family Advocacy Program, a legal service program to help families with complicated problems, including housing.

Referral to the program led to a visit to the apartment by the local health department. Inspectors found many sanitary code violations such as chronic dampness, rodent infestation, and paint dust from peeling walls. Mold covered many of the apartment walls. Both Sharon and Michael tested allergic to roaches, mice, dust mites, and mold. The housing authority determined that the problem was too costly to fix. Instead, it offered the family an emergency transfer. In March 1997, the family was finally able to move out of the apartment and into subsidized housing. According to Mrs. Smith, both children are now feeling much better and have had few asthma attacks.

This case offers many lessons. First, it points out that every community has a local board of health or inspectional services department. These agencies are an important part of the solution to every housing problem because often they can inspect houses for both existing and potential housing hazards and enforce sanitary or health codes. These inspections carry legal weight if it is necessary to convince landlords to make changes in the home.

This case history also shows how intervention by the pediatrician can make a difference. In this instance, the doctor referred the family to a legal service program. He or she could also request an inspection by a public health board or inspectional service department, as can a nurse. Most important, the pediatrician can write a letter to a controlling authority (if the family lives in public or subsidized housing) or a landlord (if the family lives in private housing) pointing out the health problem, specifying what rule, law, or requirement applies to it, and requesting the necessary repairs (see "Advocating for the poorly housed: How to write an effective letter"). Many private housing units are in worse condition than public housing because standards are not enforced, and tenants fear reprisals from landlords. A letter from a doctor can go a long way toward convincing landlords to repair hazardous conditions.

 

Advocating for the poorly housed:
How to write an effective letter

A good letter to a housing agency or landlord addresses the following issues

The letter should be sent to the person in charge of the housing. When this is the landlord, but he or she is also the local housing authority, get the name of the manager of the development. The letter must discuss specifically the needs of the patient and what relief is being requested. Before sending a letter, discuss its contents with the patient or parent. If the letter is to include confidential information, such as medical information, make sure the patient or the parent of the patient consents to release of this information. Keep a copy of the letter in the patient’s file. It is imperative to follow up any letter with a phone call.

Here is a sample letter:

Dear xxx

I am writing to request that you fix the leaky radiator pipes in Alison Lung’s apartment. Alison, who is my patient, lives at 123 Moldy Housing Way. Alison has asthma. She was allergy tested and found to be sensitive to molds. A board of health inspection found molds in the kitchen and bedroom. The inspector found that the leaky radiators caused the mold.

Alison’s asthma is worsened by her allergy to mold. In fact, mold can cause significant restriction in her airways, which may lead to hospitalization or death.

The local board of health requires that all leased housing be free of chronic dampness. This apartment is not free of chronic dampness. According to Alison’s mother, the radiators leak every winter, and the bedroom walls are always covered in mold. Despite constant cleaning, the mold reappears. The mold in the apartment therefore violates the law against chronic dampness in addition to significantly worsening Alison’s health. I request that you immediately remedy this problem by fixing the leaky radiators.

Please feel free to contact me if you have any questions. Thank you for your time and consideration.

 

The Smith case also points to the existence of sanitary or health codes at the local, state, and federal levels. Such codes protect against molds, cockroaches, and other infestations. To find out specific local sanitary codes, call the local health board for their requirements and ask about codes for your state. Note that the pediatrician who gets in touch with an agency on the patient's behalf must know if that patient lives in federal, state, or private housing, so as to refer to the appropriate code and know whom to call for help. Federal codes are available through HUD at www.hud.gov or at 800-343-3442.

Unfortunately, remedies like emergency transfer, from which the Smiths benefited, are options only within public and subsidized housing and even when tenants' health problems are severe can take months to years to effect. Currently, few local housing authorities have a formal review process for medical cases. Many letters and much follow-up often are required to evoke a response.

The Jones family. Ms. Jones and her two boys, 2 and 4 years of age, saw their pediatrician at her private practice office. Routine blood work showed that both of the Jones boys were anemic. Ms. Jones seemed distraught at the news. She finally confessed that the family routinely skipped meals, something she was ashamed to admit during the initial visit when the pediatrician asked about the boys' diet. The family's landlord had recently raised the rent on their apartment, and though Ms. Jones had a job as a secretary, well over half her income went for rent and utilities. Every month she ran short of money for food. She was extremely worried about what she would do during the coming winter when her heating bill generally doubled.

In response to the pediatrician's questions about living conditions in the apartment, Ms. Jones revealed that the two boys slept in the one bedroom in a bed pushed up against the radiator. Ms. Jones slept on the couch. She wasn't sure if the radiators were covered or if the smoke detectors worked. She said the windows, which she often opened to let in fresh air in the cramped apartment, had no guards. She refused to let her sons play outside because the downtown area where the apartment was located was unsafe.

With some help from the pediatrician, Ms. Jones learned that despite her job, she was qualified for a Section 8 voucher, a rental subsidy that the federal government pays directly to the landlord on behalf of the tenant (through the local housing authority or nonprofit agency) for a private rental unit of the family's choice (see "Applying for public and subsidized housing"). After proving her eligibility for food stamps and a heating-oil subsidy (Table 3), Ms. Jones went through three interviews to determine eligibility for the voucher and waited eight months on a Section 8 waiting list. Her pediatrician wrote a letter explaining the boys' medical conditions, which gave the family priority status at the local housing authority. After looking for three months, Ms. Jones found a new apartment, obtained with the Section 8 voucher. It has separate bedrooms for the boys, who can play outside safely. Ms. Jones spends only 30% of her income on rent and says she feels she is providing her sons with a better home.

 

Applying for public and subsidized housing

To apply for public housing or Section 8 vouchers, the family must go to its local housing authority. Each housing authority administers both public housing developments and the federal Section 8 programs in its area for subsidized privately owned rental housing. Every housing authority has its own application system and is required to tell prospective tenants about it. Users of the Department of Housing and Urban Development (HUD) Web site at www.hud.gov/local.html can access phone numbers for each state and get information about what services are offered and how to obtain them, income limits, tenant rights and responsibilities, and other general information. HUD can also be reached at 800-343-3442.

To apply for federally subsidized housing, the family must visit each privately managed building. Listings of privately owned subsidized housing sites are available through local HUD offices.

 

Table 3
Finding help for needy families

Food stamps

Each state has an 800 number hotline that offers eligibility requirements and other information

www.fns.usda.gov/fsp

www.frac.org

Food banks

www.secondharvest.org

Homeless programs

www.hud.gov/hmlother.html

A complete listing of other agencies that aid the homeless. In addition the following sites offer specific information, as indicated

www.hud.gov/hmlsagen.html (state homeless assistance agencies)

www.hud.gov/december.html (agencies in specific local areas)

www.nhchc.org (health-care organizations for homeless families in various areas)

nch.ari.net/domestic.html (National Coalition for the Homeless)

www.nlchp.org (legal rights of homeless families)

Section 8 program information

www.hud.gov/section8.html

General advice for tenants on landlords and the law

www.cses.com/rental/homepage.htm

http://sunsite.anu.edu.au/community/natshelter/welcome.html

www.nhlp.org

www.nhi.org

www.urban.org

www.nlihc.org

Local legal services

www.lsc.gov/gla/directory.html

 

Ms. Jones's experience shows the importance of the Section 8 program. Created in 1975, it has become the largest rental subsidy program in our nation's history. Section 8 assistance helps individuals and families in two ways. First, tenants can receive vouchers that subsidize their rent and can be used in "private market housing." Second, subsidies are tied to landlords and their properties so they can offer specific rental units at lower than fair-market value.21 Section 8 serves 3 million families, twice the number of families the public housing programs support. Waiting lists can be long, but local housing authorities and landlords have discretion in deciding whom to move to the top of their waiting lists. The Clinton Administration's last budget also provided for 60,000 new vouchers for families on the Welfare to Work program.

As the Jones family story shows, hunger is a hidden force in many families' lives. Uncovering the problem can be as simple as asking, "Do you and your family have enough food?" "Do you sometimes not have enough food?" "Do you often not have enough food?" If a family indicates that it sometimes or often does not have enough food, make a referral to a food bank or suggest applying for food stamps.

Many families, like the Joneses, live in a home that has no smoke detectors or is otherwise unsafe. Pediatricians can ask parents to fill out a "safe home" questionnaire (Table 4) and then urge them to remedy problems. Many of the supplies needed to make a home safe, such as smoke detectors and outlet covers, are inexpensive or even can be obtained free from local public health commissions. Local and state building and fire codes often require homes and apartments to have smoke detectors or fire escapes. Children who must stay indoors because they live in an unsafe neighborhood or who live in overcrowded conditions, as the Jones family did, are at increased risk for in-home injuries. These families should be especially vigilant about making their homes safe from injury.

 

Table 4
Checking for safety

 SafeUnsafe
Is the hot water set for between 110° F and 130° F?YesNo Not sure
Do windows have guards, secure screens, or window locks?YesNo Not sure
Are the children buckled up while riding in the car?YesNo Not sure
Does the house have two unobstructed exits in case of fire?YesNo Not sure
Are all electrical cords in safe condition?YesNo Not sure
Are stairs, protective walls, railings, porches, and balconies sturdy and in good condition?YesNo Not sure
Is lighting adequate in hall and stairway?YesNo Not sure
Does the house have any loose, chipping, or peeling paint?YesNo Not sure
Is there a working smoke detector, and is it properly placed?YesNo Not sure
Is the phone number for a poison center on or near the phone?YesNo Not sure
Do cabinets and drawers have safety latches or locks?YesNo Not sure
Do all exposed electrical outlets have outlet covers?YesNo Not sure
Do radiators have safety covers?YesNo Not sure
Is the neighborhood safe?YesNo Not sure

 

The White family. Mrs. White and her daughter, Judy, a 1-year-old, were living with Judy's grandmother when it was discovered that Judy's lead level was high. With no other options, Mrs. White moved with Judy into a homeless shelter to avoid lead exposure. While in the homeless shelter, Judy had three episodes of bronchiolitis, two of which required hospitalization.

Mrs. White was committed to having Judy continue to see her regular pediatrician. She had to travel 90 minutes each way from the shelter to the doctor's office. Judy's pediatrician wrote many letters to the local public housing authority and nonprofit agency that administer Section 8 vouchers (after calling each office to get the name of the manager who was in charge of waiting lists), carefully documenting Judy's lead poisoning and multiple respiratory infections. After months of waiting on housing lists, Mrs. White and Judy were placed in a public housing unit, where Judy's health improved and she was closer to her doctor's office.

Like the Whites, many families double up with other families before they become homeless. Other mothers and children become homeless after they are exposed to domestic violence. Women in this situation become economically and socially isolated, and homeless shelters are their only option. Although many families are afraid to talk about these dire situations, asking questions about their current living conditions can sometime avert homelessness.

Along with many other consequences, homelessness puts children at increased risk of infection. Many children in shelters have difficulty, as Mrs. White did, seeing their primary care doctor, or any doctor at all. Congress has passed numerous laws to protect people who are homeless and has funded many Health Care for the Homeless sites throughout the US.

Lead laws vary from state to state. Although federal law mandates that Section 8 housing and all federally funded public housing be lead free, some Section 8 housing does indeed contain lead. Tenants can file complaints through HUD (800-685-8470 or www.hud.gov/hoybadl.html).

An opportunity to help

As pediatricians, we have many opportunities to intervene on our patients' behalf to treat and prevent disease. In the three case studies we have presented, pediatricians were able to improve their patient's housing, and therefore their health, through advocacy. By inquiring about housing, not just the child's medical condition, the pediatrician can recognize when the true problem is inadequate housing and address the situation.

Ask specific questions to determine the quality of the family's housing. Does the dwelling have cockroaches, mold, lead paint, or hazards that could lead to injury? What does the housing cost? Be prepared to refer patients to the appropriate housing or legal authorities and to follow up and track results.

Awareness is increasing that the health of children depends on the environment in which they live. Now we must start to create ways to detect and prevent housing hazards before they cause problems. Future research should evaluate cost-effective housing interventions that address multiple hazards. Only through partnerships among pediatricians, families, and housing communities can we guarantee that every child will live in a safe and healthy home.

REFERENCES

1. US Dept of Housing and Urban Development: Waiting in Vain: An Update on America's Rental Housing Crisis. Washington, DC, US Department of HUD, March 1999

2. US Department of Housing and Urban Development, Office of Policy Development and Research: Indicator 12. Housing Condition of Children, American Housing Survey (unpublished data). www.ed.gov/pubs/YouthIndicators/Demographics.html#12

3. www.childstats.gov/ac2000/econ3.htm

4. http://nch.ari.net/numbers.html

5. http://www.naeh.org/back/factsus.htm

6. Centers for Disease Control and Prevention: Forecasted state specific estimates of self-reported asthma prevalence-United States, 1998. MMWR 1998;47:1022

7. Taylor VM, Newacheck PW: Impact of childhood asthma on health. Pediatrics 1992;90:657

8. Juberg DR, Kleiman CF, Kwon SC, et al: Lead and Human Health. New York, NY, American Council on Sciences and Health, 1997

9. Shaw KN, McCormick MC, Kustra SL, et al: Correlates of reported smoke detector usage in an inner-city population: Participants in a smoke detector give-away program. Am J Public Health 1988;78(6):650

10. Wood DL, Valdez RB, Hayashi T, et al: Health of homeless children and housed poor children. Pediatrics 1990;86(6):858

11. Zima BT, Bussing R, Forness SR, et al: Sheltered homeless children: Their eligibility and unmet need for special education evaluations. Am J Public Health. 1997;87(2):236

12. Meyers A, Rubin D, Napoleone M, et al: Public housing subsidies may improve poor children's undernutrition. Am J Public Health 1993;83 (1):115

13. Frank DA, Roos N, Meyers A, et al: Seasonal variation in weight-for-age in a pediatric emergency room. Public Health Reports 1996;111:366

14. Taylor L, Zuckerman B, Harik V, et al: Witnessing violence by young children and their mothers. J Dev Behav Pediatr 1994;15 (2):120

15. Famularo R, Fenton T, Kinscherff R, et al: Psychiatric co-morbidity in childhood post traumatic stress disorder. Child Abuse & Neglect 1996;20:953

16. Wood D, Halfan N, Scarlata D, et al: Impact of family relocation on children's growth, development, school function, and behavior. JAMA 1993;270(11):1334

17. Housing boom closed doors to many. Boston Globe Oct. 3, 1999, A24

18. Jason DeParle: The year that housing died. New York Times Oct. 20, 1996

19. US Conference of Mayors: A Status Report on Hunger and Homelessness in American Cities, in There's No Place Like Home: How America's Housing Crisis Threatens our Children, San Francisco, CA, Housing America, 1999

20. Sharfstein J, Sandel M: Not Safe at Home: How America's Housing Crisis Threatens the Health of Its Children. Boston, MA, Boston Medical Center, 1998

21. http://www.hud.gov

DR. SANDEL is a Fellow in the Department of General Pediatrics, Boston Medical Center, Boston, MA
MS. ZOTTER is an Attorney and Director, Family Advocacy Program at the same institution.

 

Megan Sandel. How substandard housing affects children's health. Contemporary Pediatrics 2000;10:134.