Will we ever see the end of poverty in the United States? An “Investing in What Works for America’s Communities” event held December 4 in Washington, D.C., looked at the evidence and leading examples toward doing just that. The event, sponsored by the Low Income Investment Fund, the Federal Reserve Bank of San Francisco, and The Citi Foundation, convened top community and economic development experts, analysts, financiers, researchers, philanthropists, and public policymakers from across the nation to share their findings and efforts for improving communities and discussing the next steps toward reversing record high rates of poverty. Reducing poverty, said participants, also goes hand in hand with making communities more sustainable and healthy places to live, learn, work, play, and grow.

The event was a showcase for the book, Investing in What Works for America’s Communities, in which essays from more than 40 experts in a variety of fields provide innovative ideas and concepts that are transforming community involvement and providing sustainable and healthy neighborhoods across the nation. More than 500 people from all backgrounds of public health to private sectors of the government were in attendance, either in person or through the live webcast.

Martin Fenstersheib, MD, MPH, director of the Santa Clara County Public Health Department in California led a session on safe outdoor activity for kids and adults at the 2012 Public Health Law Conference. NewPublicHealth spoke to Dr. Fenstersheib about what is keeping our communities from safely getting outside to play—violence, blight and communities built for cars—and solutions grounded in evidence-based public health law.

NewPublicHealth: You presented at a key session on making outdoor physical activity opportunities safer. What makes this an important issue for you?

Dr. Fentersheib: Often when we talk about physical activity, we hear people say that all we need to do is convince kids to go outdoors. A lot of us then say, “when we were kids, our parents let us out of the house in the morning and we came back at nighttime and all was well.” There wasn’t any problem with that. But, of course, we’ve all become aware of safety as a barrier to outdoor physical activity. And the issue has to do with not only criminal or violence safety, but safe streets generally. Do cars in an area make it less safe for example? And, is our environment built in a way that it is safe for kids to walk to school? My presentation will be an overview of the benefits of physical activity, and what some of the barriers are.

We’ll also look at the legal side of the issue, including a study on mixed use land zoning. I think the bottom line is that safer neighborhoods will have more of a mixed use flavor so that you don’t have to go far to get to work or play or to recreational areas. In such neighborhoods, there are stores and other places for you to go, and you’re closer to public transportation. The data to be presented will show that the crime rates in those areas are lower than in pure industrial areas or areas where there isn’t mixed use. Mixed use is helping to improve the built environment in the communities in which we live by having more eyes on the street, by having people basically looking out for one another and be more of a community.

NPH: What are examples in Santa Clara of new plans to create safer outdoor spaces for children and adults? 

Safe, vibrant neighborhoods are vital to health. The community development industry—a network of nonprofit service providers, real estate developers, financial institutions, foundations and government—brings together public and private funds and directs them into investments that transform impoverished neighborhoods into better-functioning communities.

Last week, Nancy O. Andrews, President and CEO of the Low Income Investment Fund, recently moderated a panel on “Healthy Communities” at the National Interagency Community Reinvestment Conference, a premier biannual conference for community development professionals. Andrews previously moderated several sessions on the intersection of community development and health at a series of “Healthy Communities” conferences co-sponsored by the Federal Reserve Bank of San Francisco, The Pew Charitable Trusts and the Robert Wood Johnson Foundation. [Watch an archived video of the “Capital Systems Change” session at the Healthy Communities Conference in November 2011 here.]

NewPublicHealth: What is the connection between community development and human development, particularly when it comes to health? Or, how does investment in a community actually improve the health of the people living there?

Nancy Andrews: Human development, community development and health are inseparable. There is a growing body of knowledge that makes it clear that the communities we live in can help us or hurt us in every conceivable way. The effects of living in poverty can be life-long and can affect one’s ability to be physically, mentally and emotionally healthy. Just in the last six months there have been new data from a 10-year study by the Department of Housing and Urban Development that demonstrates that living in quality housing in a good community reduces obesity and diabetes by as much as 20 percent – that’s an impact a great as a medical intervention! We also know medical interventions can solve only about 10 percent of our health issues. Much, much more of a person’s health outcomes are a result of our environment, our upbringing and our habits. It is almost impossible to overstate how important the environment is on our ability to lead healthy, quality lives.

NPH: You recently led the "Healthy Communities" panel at the National Interagency Community Reinvestment Conference. What did this session cover?

The first national meeting on Health Impact Assessment begins April 3 in Washington, D.C., and interest is so high that registration has been at capacity for weeks. The meeting capitalizes on the growing interest in health impact assessments (HIAs) and will convene policymakers, public health professionals, HIA practitioners and anyone with an interest in learning more about the value of health impact assessments.

In advance of the meeting NewPublicHealth spoke with Arthur Wendel, MD, MPH, team lead for the Healthy Community Design Initiative at the Centers for Disease Control and Prevention. The Initiative is helping to plan the upcoming HIA conference.

NPH: What is the overarching goal of the Healthy Community Design Initiative?

A major theme at last week's New Partners for Smart Growth Conference was "co-benefits." Many sectors and interests were represented at the conference and each took a different tack on the benefits of smart growth, or building communities so that they are walkable, affordable, generate jobs and help people get to where they need to go, including to fresh food markets, to work and play and to green spaces. The co-benefits of this kind of growth include better health, a cleaner and more sustainable environment, and a stronger economy.

The benefits to the economy were the focus of a Friday session at the Smart Growth conference, led by Lee Sobel, Real Estate Development and Finance Analyst at the Office of Sustainable Communities for the U.S. Environmental Protection Agency.

Mitchell Silver, AICP, Planning Director of the City of Raleigh, NC and President of the American Planning Association quoted Chattanooga Mayor Littlefield with an important maxim for smart growth: "If you aren't a city where people want to live, you aren't a city where people want to invest."

Younger generations will demand a different lifestyle, said Silver, and separate office parks will play no part in it. More integrated, mixed land-use areas where people can walk or take public transit to work are becoming more and more attractive to employees—and, importantly, to employers.

While young people used to find a job and then a place to live nearby, more young people today start by finding a city or community they love and then looking for a job where they want to live, said Silver. That means employers want to be where people want to live.

Beyond attracting employers, dense growth means more tax revenue for cities. It would take 150 acres of 600 single-family homes to equal the tax value of Raleigh's Wells Fargo Capitol Center, which sits on 1.2 acre land, said Silver.

A report from Active Living Research, a national program of the Robert Wood Johnson Foundation with direction and technical assistance provided by San Diego State University, found that green spaces have economic pay-offs as well. The existence of a park within 1,500 feet of a home increased its sale price by between $845 and $2,262 (in 2000 dollars). Additionally, as parks increased in size, their impact on property value increased significantly, according to the report.

This builds on parallel research finding that preventive health efforts are sound business decisions:

• The Healthier Americans for a Healthier Economy report showcases several states and cities that have found that better health for their citizens can also improve their bottom line, in collaboration with local businesses. Read more on the report and a Q&A with Tom Mason, President of Alliance for a Healthier Minnesota, on the business perspective on prevention.
• An investment of $10 per person annually in proven, community-based public health programs could save the U.S. more than $16 billion within five years—a $5.60 return for every $1 invested. Read more on the report on the return on investment of prevention.
• Companies that sell "better-for-you" foods perform better financially. Read a Q&A with the report author.

>>Follow our coverage of the New Partners for Smart Growth Conference.

Collaboration between the community development and health sectors is critical and beginning to gain greater traction to improve lives—particularly in low-income neighborhoods—according to Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation (RWJF) and Sandra Braunstein, director of the Federal Reserve Board’s Division of Consumer and Community Affairs, writing in the November issue of Health Affairs. The journal issue, produced with support from RWJF, features several articles on emerging collaboration between these sectors to improve health. Access the articles here.

>>Recommended Reading: For an overview of the articles included in the Health Affairs issue, check out this post from the County Health Rankings blog.

Also this week, the Federal Reserve Bank of San Francisco, the Pew Charitable Trusts and RWJF hosted a day-long conference, “Building Healthy Communities,” to discuss next steps for these shared new efforts.

The conference builds on a series of regional meetings held in the last year and attended by experts in community development, finance, urban planning, housing, government, business, academic, philanthropy and health sectors to help lay the groundwork for innovative new ideas and public and private partnerships with shared goals—such as creating safe and accessible places to exercise, preventing chronic diseases, and building safe, affordable housing. View the webcast or participate in the discussion on Twitter at #FedHealth.

“Greater opportunities lie ahead,” writes David Erickson, PhD, Manager of the Center for Community Development Investments at the Federal Reserve Bank of San Francisco, who is both a co-author in the current Health Affairs issue and a coordinator of this week’s conference. “Many of those opportunities involve better coordination. Moving beyond coordination to integration will require the health sector to see community development as its partner in addressing the 'upstream' factors that influence health.”

NewPublicHealth spoke with David Erickson about the developments this week and next steps in the intersection between community development and health.

NewPublicHealth: How did this week’s conference build on past regional conferences?

David Erickson: Previous Healthy Communities conferences have focused on "consciousness raising”—making the case that health care and community development are both necessary prescriptions for better health. This conference attempted to not only surface new ideas and partnerships, but also to drill in on three specific areas of systems change—finance, data, and policy—necessary to fully integrate population health work and community development. As the day unfolded, a consensus emerged that a new business model is needed to incentivize collaboration and capture downstream health care cost savings resulting from strategic community investments.

NPH: Can you give us a strong example of a recent community-building collaboration?

A movement to improve health at the community level has been gaining traction, including new efforts to improve not only access to health care but also access to resources that promote health, such as safe housing, farmers’ markets and recreational facilities.

A major force behind this effort is an emerging collaboration between the public health, health care, community development and economic development industries. The Federal Reserve System has been convening leaders from these industries to discuss collaboration to reduce health disparities and create healthier communities for all.

To date, the Federal Reserve Banks of Boston, New York and San Francisco have held regional meetings. On September 28, the Federal Reserve Bank of Dallas will host “Healthy Communities: the Intersection of Community Development and Health” at its Houston Branch. NewPublicHealth talked with Elizabeth Sobel Blum from the Federal Reserve Bank of Dallas to learn why the Dallas Fed is involved in this movement and to hear about her expectations for this conference.

NewPublicHealth: Why is the Federal Reserve Bank of Dallas interested in health?

Elizabeth Sobel Blum: At the Dallas Fed’s Community Development Office, our role is to support the Federal Reserve System’s economic growth objectives by promoting community and economic development and fair and impartial access to credit. Our constituents serve low- and moderate-income individuals, often by providing or facilitating affordable housing, personal financial products and services, small business development products and services and community facilities.

The individuals community developers reach are the same individuals who face major health disparities. While access to health care is one component that explains these disparities, the social determinants of health – where people work, live, learn and play – can play a strong role as well. The more opportunities individuals have to make healthy choices, the more likely they can live longer and healthier lives. These social determinants of health are the nexus of the community development and health sector’s joint interests. It is in this space that collaboration is imperative. And the health of our country and economy depend on it: in general, wealthier people are healthier and healthier people are more economically productive.

NewPublicHealth: Why are you focused on healthy communities now?

How can the billions of dollars that are spent each year on community development make the places where we live, learn, work and play healthier?

That question is among many debated today by leaders in urban planning, housing, government, business, philanthropy, public health, and health care, who are gathering at the New York Federal Reserve to share ideas about making communities healthier--together.

The meeting is supported by the Robert Wood Johnson Foundation, which is partnering with the Federal Reserve Banks of San Francisco and New York, the New York Academy of Medicine, and the Primary Care Development Corporation, to bring traditional and non-traditional partners together to find common ground on addressing the social and environmental factors that influence health. This is the fourth meeting like this that David Erickson, PhD, who manages the Center for Community Development Investments for the Federal Reserve Bank of San Francisco, has convened in the past year. He talked to NewPublicHealth.org about today’s Healthy Communities Conference and why community developers and public health advocates are natural partners.

NPH: You’ve said that health is too important to be left to the health sector alone. But how do you engage groups that don’t speak the same language to even sit at the same table and work on an issue that is relatively foreign to many of them? How do you help those in the transportation, housing, education and health sectors bridge their differences and roll up their sleeves and work together?

Erickson: It is much easier than you might think though there are challenges. We often confuse each other just in the language that we use. We say CDC and we mean community development corporation but for people in public health that acronym means something entirely different. But in terms of our work, there is a strong and immediate bond. We often start our meetings with a local health expert showing heat maps with red colors representing neighborhoods with the worst health outcomes. If you pick asthma, for example, you see which neighborhoods light up in red. We then have community development experts put up a similar map to look at things like overcrowded housing or high unemployment rates and you see maps that are practically identical. Instantly, everyone in the room realizes that we are working together to address problems for the same communities.

Those of us in community development work in the large financial world and banks are our biggest partners but we are not always understood by them. People who do community development have an immediate affinity and understanding for those in population health and vice versa. Where we do stumble is how we make it concrete. Those of us in community development know how to put grocery stores in food deserts or build, locate and finance small businesses. But we struggle with how to link more effectively to federally qualified health centers or connect housing with improving public health. We need to do better at taking approaches to community development that are geared toward attacking the root causes of bad health. That is a real challenge. What we are trying to do is find the best ideas and practices so we can create a playbook to show us how.

NPH: This is the fourth of several meetings you’ve had like this. What are your goals coming out of these meetings? How do you keep the conversation going and ultimately push it beyond just talk into action?

Erickson: We have multiple goals. Some are more achievable than others. One goal has been to just do some consciousness raising, which we have been successful with. People are more knowledgeable about these issues and more sophisticated about how to approach needs. The other goal is to just get people to meet each other. We have been successful in creating local partnerships. For example, a group of researchers from the University of California, Berkeley attended one of our meetings in Los Angeles and met a group of housing experts from Mercy Housing, a nonprofit Catholic affordable housing developer. The researchers are now teamed up with this group to do a health analysis for a 50-acre public housing site in San Francisco that wants to incorporate health into development. A community developer just doesn’t have time to pour over all the health literature. Now they have this built in advisory committee from Berkeley, who are leaders in the field of population and public health, who are helping them. Plus, they will have the data and analysis to figure out what the health effects are of remaking a community. We hope that during the process that not only will Berkeley researchers be able to feed back strategic information so developers can make adjustments in the best interest of their tenants but also realize what this means from a health perspective to radically improve a neighborhood. This is a partnership that emerged from a conversation begun at a reception we held during the meeting. We have similar stories coming out of Boston, where the Boston Community Foundation is working with the Boston Federal Reserve on a local housing project and Los Angeles, where researchers at UCLA are beginning discussions with Federal Reserve staff in Los Angeles.

NPH: So what is the take-away message from all of these encounters or opportunities?

Erickson: I have been doing community development for 20 years and frankly it gets kind of depressing. While there are plenty of wins out there - places that seemed hopeless are now thriving thanks to community development - if you look at the overall numbers, we are not winning the war against poverty and unhealthy communities. As a community developer, I find that when we start talking to health professionals, I find new allies. These are people who have new ideas, resources and energy to put into this effort. So it is very energizing.

NPH: The measures for success for the public health and financial sectors seem to be at opposite ends of the spectrum. Banks and community developers tend to see themselves as short-term lenders and want to see short-term wins. Investments in public health often take years if not decades to show promise. How do you convince your financial partners that the ROI for investing in improved health is worth it?

Erickson: Some look to childhood reading levels as an indicator of prison population eight years out. That is something we could be looking at – intermediate measures – such as childhood reading rates or high school graduation levels or unemployment levels – to assess whether health is improving. Community developers are increasingly on the hook to try to explain the benefits that come from community development interventions. Increasingly we are going to look to health as a partner in measuring the success or failure of those interventions. That will be an important part of the community development toolbox going forward.

NPH: What can community development and finance experts teach health experts and vice-versa? Have these meetings yielded some key lessons that others can learn from that are trying to do the same thing?

Erickson: One thing that community developers are very good at is being plugged into a local community and understanding their needs and connecting them to much bigger systems and resources at a much greater scale then they can source locally. They are on the side of the community but also can go to Wall Street and tap sources of capital as well as the federal government. They can bring in this whole symphony of players to work on a project. And that would be helpful to health. The community developer can play that coordinating role and bring the right players to the table that assemble and harmonize the right subsidy and market rates for capital. I think the two working together will be a powerful combination. Health can teach us a lot about measurement and being more methodical to make sure we stay with what is working and discontinue what doesn’t seem to be helping. It also helps community developers broaden their focus to improve the health of local people.

NPH: Do you believe then that we are moving to a new way of dealing with health at the community level?

Erickson: We know from studies that only about 10 percent of premature deaths are related to access to health care and environmental and social factors are much more significant. If we are going to keep the country healthier and make some improvements in the overall health of the people here, we really have to improve those areas so people don’t get sick in the first place. People understand that you can live a healthier life but I think what people don’t often understand is the gradient for improved health. It’s not just that poor people are sick and wealthy people are not. It’s that at every income bracket as your income rate rises, people tend to be a little healthier. If you have a sense of control over your life, you tend to live better and live longer. We are increasingly understanding that people in local communities feel like they have no control over their lives. We think we can intervene in those places and give them a sense of control and translate that into significant health improvements.

NPH: Do you feel like you’re having impact? Can you share a story of how you’ve affected change or gotten a non-health sector to think differently about improving the places we live, learn, work, and play?

Erickson: We still have a way to go but we are changing the conversation and that is an important step. I think it’s definitely changing how we in community development think about how we do our work. One small example is that the lead umbrella organization for community development finance – Opportunity Finance Network – has a conference every year that is attended by anyone who does community development finance work in the United States. Now they have a health track as part of the meeting. They never had that before. We do think we will see concrete changes soon. Housing and Urban Development is pushing for sustainable communities and focusing on the effects of place on health. We see this happening with transportation projects too. Agency heads in charge of health and city leaders are starting to work together and that has been unprecedented. This is still relatively new but it is pretty remarkable that at the highest levels, there is interest in bringing different components together to build healthier communities.

We recently held an equitable transit-oriented development conference here at the San Francisco Federal Reserve Bank and there was a discussion about building affordable housing units near a train stations. A train station in a community increases land value because it provides access to transportation. The developers not only looked at what it would do for the economy but they also factored in how it would affect health, and saw from studies that it would foster physical activity and reduce obesity rates. It was unusual to think about building a train station using the lens of public health but it shows that health is becoming part of the equation for community development.

Read previous NewPublicHealth.org Q&As with newsmakers and difference makers in public health.