Bringing Public Health into Urban Revitalization: Workshop Summary (2015)

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5 Cross-Cutting Issues That Face All Urban Environments In the workshop’s fourth session, a panel of three speakers discussed some cross-cutting issues that arise in efforts to improve community health in urban areas across the United States and, in particular, in the three cities that were the focus of the workshop: Washington, DC; Detroit, Michigan; and New York City, including surrounding areas in New Jersey and Connecticut. Session moderator Lynn Goldman, dean of the Milken Institute School of Public Health at George Washington University, opened the discussion by offering a few of her own observations. In listening to the day’s case studies, Goldman said, she was reminded of the problem that doctors face in the development of new and novel treatments. That is, although there is often a lot of support for the development of new therapies—from the National Institutes of Health, for example, or from various private companies—there is much less support for the necessary next step of seeing that new, effective treatments are adopted widely by the medical community. “Even when we find new therapies,” she said, “it is not easy to scale them out. It is not easy to spread them among different practitioners. This has wound up being a major challenge in medicine: improving the quality of medical care and bringing evidence- based medicine to the forefront in terms of how we perform as doctors.” There is a parallel between this situation and the situation faced by those trying to improve the health of communities, she said. “Today we have heard about several approaches that are very exciting and very novel, new approaches that have received quite a lot of support from many funders. . . . In thinking about this last session, one of the things that I would like us to think about is how we both scale up and spread some of these practices to other communities. It is very difficult to do this in the context of medicine, [and] when you are talking about communities, it is even a more complicated problem.” 55 

56 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION Several factors make the community health problem so complicated, Goldman said. One is the sheer number of people involved. Although doctors deal with individual patients, community health practitioners are dealing with thousands or millions of individuals who are going to be affected and who also need to be engaged and involved in the public health efforts. “One thing that we heard in common between all of these processes,” Goldman observed, “is that one way or another, they always have a tremendous amount of engagement and involvement of the communities.” A second complicating factor is that the environment in which public health efforts take place varies from community to community, so there will always be questions about just how applicable a particular approach is in a given community. What works well in one community may not work so well in another. A third issue is the level of evidence that exists to support the various community health efforts, Goldman said. “Where are the data that prove that public health benefits from these actions? We have models that indicate there may be a financial payoff or a public health payoff, but where are the actual data that prove that there is an actual benefit?” Finally, Goldman said, there is the issue of the framing and communication of these public health efforts. How does one get the word out to people outside of the region in which the successful efforts are taking place? “In medicine, we suffer from an assumption that if we have a better practice, it will just spread,” she said. “People will just learn about it. It will just spread. What we have learned is that that is not true. It doesn’t happen that way. In fact, there is not an automatic spread of better practices. Even if they are much, much better for patients, save a lot of money, any metric that you can use, they don’t spread automatically.” It seems likely that the same thing will prove to be true for community health, she continued. “One thing that we can think about at a later time, in terms of the Roundtable, is the role of an organization like the Institute of Medicine in helping to scale up and spread these kinds of efforts, whether it is through our own efforts and holding a workshop like this or perhaps in helping to form what in medicine we call ‘learning communities.’” Such learning communities, Goldman explained, bring people together to learn from each other’s experience. These can be city planners, transportation planners, community groups, or other groups interested in improving community health and willing to learn from each other about what has worked in different situations. The bottom line, she said, is that it will be a major challenge not only to identify best practices in community health 

CROSS-CUTTING ISSUES 57 but also to figure out how to spread those best practices so that they are taken up by as many communities as possible. DESIGNING FOR HEALTH The first panelist was Matthew Trowbridge, a physician and an associate professor in public health at the University of Virginia School of Medicine. In his research he has studied the impact of the built environment on public health and, in particular, how health-promoting design strategies can support active communities and reduce the incidence rates of childhood obesity. Trowbridge began his presentation by offering some details about his background and his perspective on the field of public health. “I was trained as a physician,” he said. “I am a pediatrician but also a preventive medicine physician—I have a master’s in public health.” Like pretty much everyone in his field, he said, he was trained “in the core ideas of environmental health in the old-school manner.” In particular, he said, doctors are trained to think of environmental health in a particular way that reflects the successes of the past: “Physicians sit in their offices, see a patient come in with a constellation of symptoms and think maybe there is an environmental toxin and go out, find the toxin, and remove it. Similarly, we have been doing it with things like lead paint—again, waiting in our offices, seeing a constellation of symptoms, going out, finding something, removing it.” However, he said, doctors are beginning to realize that some environmental health problems are really different. They are not so amenable to that old model. In response, physicians and public health practitioners are beginning to approach their tasks proactively and to look for ways to encourage individuals to engage in healthful activities, particularly through the design of buildings and public spaces. Interest in this approach is now growing among both health professionals and the general population. “We have to harness that,” he said. “Obviously, everybody in this room understands that. Again, how do we respond as people are asking for action, asking to move forward?” One of the most encouraging approaches, he said, is the collaboration between public health practitioners and designers, epitomized by the publication of Active Design Guidelines: Promoting Physical Activity and Health in Design by the New York City Departments of Design and Construction, Health and Mental Hygiene, Transportation, and City Planning (Lee, 2011). The ideas in the book are not just theoretical, 

58 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION Trowbridge emphasized, as they have been put into practice in various New York City projects, such as the transformation of Broadway into a more pedestrian-friendly thoroughfare that encourages walking. Perhaps the most dramatic example is the development of the High Line, a former railroad spur through the Lower West Side of Manhattan that has been turned into a 1.45-mile-long linear park. “One of the things I love about the High Line,” he said, “is not just that it exists, which is amazing, but also, if you walk along it, every moment of it is highly designed and unique. This was not just a utilitarian park. The landscape architects really got to show what they can do.” One of the lessons of the High Line Park, he said, it that good design is critical to the success of such efforts. “The High Line compels you to walk along the entire thing because you keep getting surprised. It is contextually appropriate. It is exciting.” The question that remains, however, is how to bring that approach to scale and to deliver such an effect to everyone in a community. It is not just New York City that has been creating such health- friendly environments, he said. He mentioned Detroit and Nashville, Tennessee, as examples of the places all around the United States that are doing this sort of development. “And people are responding,” he said. “People are having an amazing time utilizing these amazing new spaces.” This is not happening by accident, Trowbridge emphasized. “People are trying to figure out how to do this,” he said. “There are people on the ground turning these places into reality.” As an example, he described the creation of a health center in Nashville. The city’s medical officer came across the idea of active design and decided to incorporate it prominently in the health center. Instead of hiding the stairs, for instance, he gave them a place of prominence in the design as a way of celebrating and encouraging physical activity. “As the users of the building got excited about the idea of active design,” Trowbridge said, “they started asking for more.” Because the designers had planned the building to take advantage of natural lighting, there were no offices along the outside, but instead there was a walkway along the outside that people were naturally drawn to. It was like a walking track, he said. “But the users came back to the architecture firm complaining, ‘You are giving us a semicircle. We need a full track.’” So the architects decided to do a bridge across the top of the lobby to complete the circle. Previously, they had assumed they would not have gotten approval for the bridge, but because it was now 

CROSS-CUTTING ISSUES 59 being presented in terms of active design, as a way to encourage people to walk around the outside of the building, they got their approval, and it was built. “Now, there are actually lunchtime walking meetings going on inside of a Nashville health clinic,” Trowbridge said. “The cool part is there was so much success for that [active design element] that they are going to be getting a bike-share station out here, which was not originally part of the plan.” A moment of opportunity for creating such things now exists, he said. “These places are starting to happen, there are tools that people can pick up and utilize, . . . but we have to keep making more of that.” It was this idea of a “moment of opportunity” that inspired Trowbridge to carry out his current work on childhood obesity, he said. Working through an interagency personnel agreement between the National Institutes of Health and the National Collaborative on Childhood Obesity Research, Trowbridge has been looking to develop design tools that can help in the fight against obesity. He began by asking, “Who else in this sphere is pretty good at taking concepts like health and making them matter in the market?” Although he knew nothing about green building, he recognized that the green building industry has been successful at this sort of thing, so he ended up leading a collaboration among the National Collaborative for Childhood Obesity Research, the U.S. Green Building Council’s Center for Green Schools, and the National Academy of Environmental Design. “We convened a workshop and a set of papers, all focused on merging the kind of market transformation capacity of green building with emerging evidence from public health,” he said. The idea that the green building industry might be able to help in creating healthy buildings and environments generated enough excitement that the Robert Wood Johnson Foundation provided funding to keep the work going. Thus, for the past 2 years Trowbridge has been working with the U.S. Green Building Council to lead the Green Health Partnership, which is seeking to use some of the marketing tools developed for the green building industry to encourage the design of buildings for health. The partnership has three objectives, Trowbridge said: (1) to provide thought leadership at the intersection of the green building industry and public health, (2) to develop prototype practical and scalable health metrics based on existing components of the LEED1 green building rating system, and (3) to demonstrate the integration of 1 LEED is a green building certification program developed by the U.S. Green Building Council. 

60 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION these health metrics within U.S. Green Building Council products and tools. “Basically, what we have realized,” Trowbridge said, “is what we are really all trying to do is to make healthy places investable. That is what the green building industry has done so well. They have made green something that the market can measure and, hence, can invest in. If we can use that as a frame, we can start getting somewhere with health as well, at least from the perspective of scale-up and using some existing partnerships like green building.” To learn more about the intersection between the green building industry and public health, Trowbridge had two graduate students study the LEED program in depth. “Our goal was to look at where health is referred to within LEED, how consistent the health language is within LEED, and how health-related strategies are currently used,” he said. What they discovered was that health concerns run throughout LEED. “We found health- and wellness-related credits and intents in every LEED credit category,” he said. However, LEED uses a wide range of terminologies to describe health-related issues, and much of that terminology is different from what is used in the public health field. Thus, people in the public health field may find it difficult at first to communicate effectively with people in the green building industry. More importantly, Trowbridge’s analysis of LEED-certified buildings showed that there is plenty of room for improvement in terms of meeting health-related goals. In particular, he and his colleagues examined how many of the various health-related credits used in LEED certification are now being achieved in LEED-certified buildings. He found wide variation, with some buildings receiving most or all of the health-related credits in their LEED scores and some receiving only one-quarter to one-third of the possible health-related credits. “The variance of whether the health-related credits are currently being used is wide open,” he said. “What does that mean? It means that we have a really powerful potential partner for scaling up health: the green building industry. There are some health-related credits waiting to be utilized, but currently they are not really being utilized in any sort of directed way.” Trowbridge cautioned that not everything in LEED makes a perfect health measure. “No, I think what we do have is a nice vision for how you could use a really powerful new set of partnership tools and a group that has a leadership position in the real estate market. They are very excited to engage with us.” 

CROSS-CUTTING ISSUES 61 He closed his presentation by saying that he is seeing a “swell of interest” in the topic of community development and public health. Indeed, the most recent issue of Health Affairs before the workshop focused on that very issue.2 Discussion Frank Loy opened the discussion session by asking Trowbridge to say some more about the health and wellness metrics that might be used by the real estate industry to put a value on various health- and wellness- related design elements. “Until we develop those, it is going to be hard to push them, to insist on them, to credit them, [and] to judge the effectiveness of them,” Loy said. Trowbridge answered that the development of those metrics is a task that still needs to be done. “No one is sitting off quietly with a secret set of the perfect health and wellness metrics for the real estate industry at this moment,” he said. “I am not claiming to have them either.” He indicated that in an article he wrote for the special issue of Health Affairs, he established a set of performance criteria that health and wellness metrics would need to satisfy to be useful for the real estate industry. “Some of the criteria are things like making sure that they are actionable,” he said. “We don’t always deliver metrics like that in public health. They also need to be mutable; that is, the actual developers or the architects have to have a chance or feel empowered that they could actually shift the metrics that you are handing to them.” Another criterion deals with the scale of the effect that one expects. “No developer wants to be on the hook for changing obesity rates at the county level with . . . one building,” Trowbridge said. “We have to figure out how to get them down to a scale that they can deal with.” The metrics also need to be practical. “The infrastructure [used] to gather data is expensive,” said Trowbridge. The gathering of data is also time-consuming and is not a core competency of many people in real estate, he suggested. Thus, it will be important to find new ways to gather data for the metrics. “I think there needs to be a new science—a lot of thinking on how to utilize the pros and cons of crowd-sourced data and things like that, but with a focus on making those data easier for a developer to gather.” Finally, he said, the metrics need to be valuable “in the sense of being relevant to the investors.” 2 See http://content.healthaffairs.org/content/33/11.toc (accessed August 4, 2015). 

62 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION A key point to keep in mind, Trowbridge added, is that decisions about which metrics to use will inevitably influence what one gets over the long run. People will design in ways that satisfy the health and wellness goals that are captured by the metrics but not necessarily other goals that are not represented in the metrics. “A big part of the success of green building has been in creating an opportunity for competitive differentiation projects,” he concluded. “Health and wellness [are] really rapidly emerging as the new potential competitive differentiation.” This is something that people interested in public health should leverage, he said, but it will be important to move fairly quickly, as the real estate industry is already moving in this direction. Richard Jackson of the University of California, Los Angeles, mentioned a report published in 2013 by researchers at the Massachusetts Institute of Technology in which the authors argued that there is no silver bullet for healthy communities.3 “Howie Frumkin and I were pretty upset with that,”4 he said. “There is a silver bullet. It is walking. It is the one thing. People need to walk, walk, walk, and then they need to walk some more.”5 He then introduced Sarah Hammerschmidt from the Urban Land Institute, noting that the institute has been looking at the business case for healthy communities.6 Hammerschmidt told the workshop audience that she and the institute have a new report coming out that was prepared in partnership with the Center for Active Design, which created Active Design Guidelines (Lee, 2011). The new report, Hammerschmidt said, offers a set of 21 strategies that developers can use in projects from individual buildings to community-scale developments, and all of these strategies have been shown to lead to improvements in health (Urban Land Institute, 2015). Trowbridge responded to Jackson’s comment by saying that he firmly agrees that walkability is an important metric to employ. Referring to a book by Jeff Speck, Walkable City, Trowbridge said that Speck comes to the same conclusion (Speck, 2012): “If you had to 3 See http://news.mit.edu/2013/3q-alan-berger-on-cities-and-health-1121 (access- ed September 15, 2015). 4 See http://www.scribd.com/doc/217720272/Report-on-the-State-of-Health-Urban ism-A-Critique (accessed September 15, 2015). 5 The U.S. Surgeon General recently released a report on this subject (HHS, 2015). 6 See, for example, Kramer et al., 2014. 

CROSS-CUTTING ISSUES 63 choose one metric, it would be walkability.” However, Trowbridge said, it will be important to figure out what the other big metrics should be, in addition to walkability. “I don’t know what they are perfectly yet, but we need to capture some of the other domains as well.” John Balbus of the National Institute of Environmental Health Sciences asked about health metrics on a macroscale. “As we think about the health metrics for the real estate industry at the building scale, is there a way to think about how these get aggregated up? Are there metrics connected to the kind of data that are available at the macroscale so that we can incorporate some of these ideas into very large scale economic development projects?” Trowbridge responded that this will certainly be important. One approach would be to work with an open data platform where the information on various health-related issues is collected in a rawer form. By working with raw data and processing them only as needed, it might be easier to collect and analyze data on a more macroscale. Al McGartland from EPA asked if behavioral health scientists are working with architects and health scientists to find designs that will encourage people to act in more healthful ways, such as taking stairs rather than an elevator or escalator. Trowbridge replied that, yes, people from a variety of areas are working with designers to come up with ways to encourage desired behaviors. He mentioned one workshop at the National Institutes of Health where he was able to include interior designers and graphic designers. “That was actually one of my most proud moments,” he said. By thinking carefully about things like interiors or signs, it should be possible to nudge people toward more healthful behavior. “That was actually one of the main points of the NIH [National Institutes of Health] workshop,” he said. “We chose a school and we basically said, ‘You are going to have to start thinking at multiple scales at the same moment. Everything from the graphic design of the signage up to site selection for that school is going to be relevant going forward.’” HEALTH EQUITY IN COMMUNITY DESIGN The next panelist was Nicholas Freudenberg, a professor of public health at Hunter College of the City University of New York. He discussed ways to take health equity into account when undertaking various community development initiatives. He structured his comments around three questions. 

64 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION First, he asked, what can be done to make sure that community development initiatives designed to improve health contribute to shrinking rather than widening the existing inequalities in health? “I know that is something that all of us who are working in this area worry about,” he said. Community amenities like parks, better housing, health food stores, improved transportation, and improved schools are known to contribute to increased property values, he said, but “how do we ensure that these increases in property values and amenities don’t push poor people out because they can no longer afford them? Or . . . how can we ensure that these improvements don’t create apartheid food, housing, and other kinds of markets with one system—Whole Foods [and] the farmers’ markets—serving the better off and the other—the bodegas and convenience stores—serving poor people, creating very different opportunities for health?” One solution, Freudenberg suggested, lies in the process used to plan community initiatives. “By making sure that all sectors of communities— including those who are sometimes disenfranchised—are involved in planning and making decisions, we can at least maximize the chances that the improvements will benefit everybody and not just the better off,” he said. A second approach is to develop interventions that focus on the poorest and most vulnerable sectors, an approach that is referred to as “privileging the poor” by people who study liberation theology.7 “For example,” Freudenberg said, “in East Harlem, epidemiological studies have shown that the population that has gained the least from the improvements in longevity and health in New York City are middle-aged adults living in New York City Housing Authority facilities.” Thus, a lot of the current equity-promoting efforts, both those that the faculty at the School of Public Health are involved in and those that the administration of Mayor Bill de Blasio are carrying out, are focused on populations such as those middle-aged residents of the Housing Authority facilities. The third approach to ensuring that benefits do not accrue only to the wealthy or the better off is to provide subsidies, Freudenberg said. As an example, he mentioned a program in New York City that supplements the food stamps from the Supplemental Nutrition Assistance Program (SNAP) to help poor people get more fruits and vegetables. A number of other cities have tried such programs as well, he said. “If you are able to 7 Liberation theology refers to an interpretation of Christian scripture that emphasizes Christ’s role as a liberator and one who was especially focused on raising up the voice of the poor and speaking on their behalf. 

CROSS-CUTTING ISSUES 65 bring a farmers’ market into a low-income community and the prices are somewhat higher, by providing some kind of subsidy, you can make it available to more sectors of the population,” he said. “Similarly, setting aside subsidized housing within new housing developments is a strategy that has been used to mix the benefits.” The second question Freudenberg asked was what role health professionals can play in finding an appropriate balance between the market forces in the public sector and efforts to improving community environments to promote health. “Many of the housing, food, health care, and employment problems that low-income communities face result from market failures and the inability of the market to provide all sectors with access to healthy goods. . . services, and products,” he said. “For example, the ubiquity of unhealthy food in poor neighborhoods is a market failure of our food system.” The classic solution for market failures—such as information asymmetries, externalities, and various inefficiencies—is government intervention, he noted. “In several sectors, such as food, housing, transportation, and education, the public sector and the market sector coexist, sometimes in partnership and sometimes in competition,” he said. But city governments and community development projects have rarely attempted to leverage the public sector to correct market failures. “I have been thinking about this a lot in terms of food,” he said. “There is a very robust public sector in food. . . . New York City serves 260 million meals a year in schools, hospitals, jails, and day care centers. That has the power to change food environments, particularly for vulnerable populations. And food benefits like SNAP and WIC [the Women, Infants, and Children Supplemental Nutrition Program] are an important part of the food retail environment. If we could encourage cities to think about the variety of tools they have in the public sector— all of the different ways that taxpayer dollars and city services touch food or, in other cases, touch transportation and touch housing—and then to use that public sector in a focused way to promote community development and to reduce inequalities in health, I think we might be able to achieve more systematic results than [those from] the kind of laissez faire approach . . . that we see today.” The third question that Freundenberg asked was how people can better integrate job creation, workforce development, and job training into community development initiatives. “The most urgent need for low- income communities is jobs,” he said, “especially jobs that have low entry barriers but that also provide a path into lasting jobs that pay a 

66 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION living wage, offer better benefits, and provide safe working conditions.” Finding jobs that satisfy both criteria—low entry barriers and a path into lasting good jobs—is a tall order, he said, because those two things are often in conflict with each other. “I think it may be possible to develop interventions that meet this need of job creation, or ‘upskilling,’ while also creating healthier communities,” he said. “The Affordable Care Act and the development of patient navigators, . . . chronic disease managers, and community health workers may offer a way to create new jobs within poor communities that also have other benefits to the community, like improving health,” he said. Another area in which such jobs might appear is green industry, he said. “I think the whole green jobs sector—and, particularly, brown field remediation, which led to asbestos abatement—creates entry-level jobs, which if done properly, can lead people into a sector where permanent jobs that are better paying are available.” Yet another possibility is what Freudenberg termed “good food jobs.” He said that “the food sector is particularly promising for offering entry-level jobs but not very good at providing living wages or good working conditions. By thinking about jobs that could increase the pay and working conditions and also contribute to making healthier food available, we offer the possibility of improving health. For example, I am working with some folks in the city health department at creating certificates for home health care workers in nutrition, . . . shopping, and food preparation that would, ideally, enable them to make more money but also to contribute to community health.” Discussion Jack Spengler of Harvard University noted that while the WIC program, with an annual budget of about $8 billion, specifies exactly which foods are reimbursable, SNAP, which supplies about $80 billion in food stamps each year, has no such limitations. With that in mind, he asked Freudenberg, “Can you elaborate more on your public influence in the marketplace that might drive populations to better choices?” “I think that rethinking how those billions of dollars that SNAP spends, much of which now goes into unhealthy food and subsidizes Pepsi, . . . Coke, and other unhealthy food makers, is a really important opportunity,” Freudenberg replied. “We are doing a little bit of work here in East Harlem, looking at stores that already accept SNAP—there 

CROSS-CUTTING ISSUES 67 are a lot that do—and that offer healthy, affordable food. We are calling those places food oases within the food swamp of unhealthy food or the food desert of no healthy food.” Freudenberg indicated that his group is developing community-driven marketing campaigns to encourage people—particularly those who live in public housing, where diet-related diseases are a particular problem—to patronize these food oases to help these businesses grow and to increase demand for the sorts of food that they provide. That is one approach, he said. A second is to provide incentives to SNAP recipients to use their vouchers for healthy food so that, for example, $5 of SNAP vouchers would be worth $10 if applied only to healthy food. “I am reluctant to limit SNAP to healthy food,” he said, “because that restricts things for poor people in a way that isn’t restricted for others. There has been a lot of debate about that. It really divides people. I am looking for incentives for people [who participate in] SNAP to use it for healthier food.” Spengler responded by describing what he had seen on a visit to Malmö, Sweden. “Throughout their public housing, on the sides of their buildings there must have been two-story-high pictures of people in the community—very ethnically diverse in this community—with the food of their native cultures. They created a cookbook and then created restaurants right within the complexes where they lived. They celebrated their ethnic diversity through their common culture of food. It was really well done. It might be an idea that you can think about.” Freudenberg replied that some Brazilian cities have subsidized restaurants that offer healthy food at a steep discount. These restaurants also serve as an economic development project for local farmers because they give the farmers a guaranteed market. “These quasipublic restaurants buy from local producers and then sell at a discount,” he said. Changing the subject, Balbus referred to Freudenberg’s suggestion of hiring community health workers as a way of providing accessible jobs with an upside. “Is the Affordable Care Act or anything else,” he asked, “providing enough of a market incentive to pay, . . . train, and have community health workers in these communities so that it is a sustainable field?” A lot of people who work in the health care sector are talking about this, Freudenberg replied. Provisions of the Affordable Care Act and Medicare provide reimbursement for patient navigators at a decent salary. These patient navigators mostly enroll people in health care, but actions are being taken at the state level to certify community health workers and 

68 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION make their work eligible for different kinds of reimbursement from insurance companies. With the development of health homes, he said, “I think there is a possibility that community health workers could take on some new roles not only in chronic disease management . . . but also [in] chronic disease prevention. That would be a huge potential cost saver. I think there is more evidence that needs to be accumulated to document the potential benefits of that and then to translate that into demonstration projects and then policy.” In response, Goldman said that in Washington, DC, people at George Washington University have a large Center for Medicare & Medicaid Innovation project—more than $20 million, actually—to create a kind of community-based health home for people with HIV/AIDS. “It remains to be seen if these things work. It is pretty exciting that they are at least trying to innovate,” she said. Goldman also said that people involved with a number of funded projects around the country are looking at these sorts of issues, but a certain amount of variability exists from state to state. “Some states aren’t actually establishing exchanges, nor are they expanding state Medicaid; therefore, they would not have the need to hire people in some of these roles,” she said. Freudenberg suggested that what is most possible at this point is to carry out demonstration projects “that raise the question of going to scale, not nationally, but within a region.” Over the next 5 to 8 years, by gathering evidence about whether it is possible to take these projects to a larger scale and determine what cost savings might be available, that evidence could be used over a longer time period to contribute to better policies. IMPROVING COMMUNITY HEALTH In the day’s final presentation, Hazel Edwards of The Catholic University of America discussed five broad issues that are key to improving community health in the context of urban revitalization. She began with a definition of health from the World Health Organization: “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Health, Edwards said, is not just a personal issue; it affects the entire community. Furthermore, with the health care costs and burdens that the individual places on the system, “those places where people live are where we should be fostering well-being.” 

CROSS-CUTTING ISSUES 69 So what should be done to foster health? One important issue is mobility, she said. “We know the impact that the 1949 Housing Act and federal funding had on our cities, in terms of cutting through and dividing our communities because of the federal funding for slum clearance,” Edwards said, showing an image of a city cut through with a number of multilane highways. “How do we, as planners and architects, stitch those neighborhoods back together so that we can connect people with the places that they go to and enjoy?” Part of the answer lies in the saying “When we make places for cars, we get places for cars; when we make places for people, we get people who are engaged and active in our community.” Edwards showed before- and-after images of a city street, the first of which was dominated by roads and parking lots, in other words, an area designed for cars. The second showed a cityscape with something for everyone: roads as well as widened sidewalks for pedestrians, bike lanes, a lane devoted to a streetcar, and plenty of trees to provide shade and beauty. “Places like these address the multiple modes of travel and address the varied mobility needs that are necessary,” she said. Edwards mentioned in particular the Capital BikeShare program in Washington, DC. “It is one of the programs in our region that is helping people to become more active [and] get out of their cars. . . . It connects these dead zones between Metro stations or places where people are going.” Other metropolitan areas have similar programs, she noted, including many of the jurisdictions surrounding Washington, for example, such as Arlington and Alexandria in Virginia and Rockville and College Park in Maryland, plus other cities around the country. “We can’t have BikeShare or more cyclists on the road without developing infrastructure that supports them and keeps them safe,” Edwards continued. Bike lanes, for instance, protect cyclists from automobiles and also from pedestrians. “We should look at other places, like Bogotá, Colombia, to see what they are doing,” she said. She spoke of Enrique Peñalosa, a former mayor of Bogotá, who focused on making the city convenient to move around in for everyone and not just those wealthy enough to own cars. Showing a photograph from Bogotá with streets, sidewalks, and bike lanes, she explained, “The promenade connects neighborhoods, particularly low- income neighborhoods, to goods and services. During [Peñalosa’s] tenure, he transformed the city’s landscape and democratized public spaces in Bogotá. He added hundreds of miles of sidewalks, . . . bike paths, and greenways as well as parks.” 

70 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION Sometimes, she said, improving mobility is as simple as making sidewalks safe for pedestrians by adding a setback from the street and pedestrian-scale lighting and planting strips with trees, leaving enough distance from the road that people feel safe and protected from the passing automobiles. A second key issue in improving community health is land use. Much of the 20th century was devoted to development that separated land uses, with large numbers of people moving outside of cities into suburbs, Edwards noted, but in recent decades there has been a return to the city and more mixed-use and transit-oriented development, along with the desire to create destinations so that people will have places to walk to. “Walkability is great,” Edwards said, “but you need a place to walk to and places [people] can access within a quarter mile.” Showing a photo of a vibrant neighborhood in the Columbia Heights section of Washington, DC, she said that one of the keys to the development of that neighborhood was the opening of a Target store and other major retailers. “Harriet Tregoning, the former director of the D.C. Office of Planning who now is at HUD [the U.S. Department of Housing and Urban Development], used to talk about how people didn’t think that Target would work here in the city or work in an urban setting,” Edwards said. “She said, ‘I have actually seen people carrying 50-inch flat-screen TVs from the store.’ As I drive around . . . I have seen Target bags a mile or two miles away. There has been a great need for this type of retail in the city.” A photo from downtown Silver Spring, Maryland, showed an open space, or plaza, that is a playground for children but also a place where merchants are set up. “It is a flea market, a farmer’s market, but a great space for the neighborhood,” Edwards said. She then showed a photo from South Orange, New Jersey, of a traditional train station to which a number of shops that cater to people that are commuting were added. “As you are going to catch the train to go into Manhattan, for instance, you can stop and get coffee or drop your clothes off at the cleaners,” she said. “These transformed a single-use development into a multiuse development that caters to the needs of the community.” All of these examples underscore the importance of land use to creating healthful spaces for communities. The third issue that Edwards described was food access. In many places across the country, particularly in the South, significant numbers of people have no car and no supermarket within a mile of where they live. In many cases where people—particularly minorities and low- and 

CROSS-CUTTING ISSUES 71 even moderate-income people—do have access to food, the food choices that they have are not healthy ones; for example, they are fast-food or convenience stores with few fresh foods. One way to improve food access is to set up community gardens and urban agriculture. This has benefits beyond the provision of healthy foods, Edwards said. “In addition to the quality produce, it is a way to get children engaged. It is a way to keep them from the ills of the city, having them right there, working with their parents or relatives. It is also a way to engage the older population.” She mentioned a documentary that described how a church in New York City had begun growing plants on a vacant parcel of land. “It was a teaching garden, but it was also a place where the older members of the church came together on certain days and they shared the stories of the community. These can become these great centers of the neighborhood.” Farmers’ markets provide a similar service, making healthy foods available but also engaging the community, she said. Some negatives may also be associated with improved food choices, she said. In particular, as better, healthier foods become available in an area, it can be a trigger for gentrification, and the lower-income people who had been in the area may not be the ultimate beneficiaries of the new stores. The fourth issue that Edwards offered was affordable housing. Affordable housing refers not only to affordability for residents but also to affordability for businesses, Edwards said, because as prices increase for residents, they also increase for businesses. “Affordable housing relates to a stable home environment for residents and access to quality schools,” she said. “It also means a decrease in transportation costs and burdens on low- and moderate-income families because they can live in town, as opposed to living farther out in areas that they can afford. It also means more investment in quality schools.” The final issue she described was community engagement. Referring to the earlier presentation by Dan Kinkead of the Detroit Future City Implementation Office, Edwards noted that he had spoken about the importance of not taking a top-down approach in urban revitalization efforts. “It really needs to engage people—hopefully, a cross-section of the community in terms of age, ethnicity and race, gender, and class. You really need to work through as many of the organizations that exist.” She also mentioned the Sustainable DC program, saying that it had been very good about setting up a community engagement process that brought a cross section of the city together. “There were the big meetings 

72 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION with hundreds of people, down to the very small groups,” she said. “All of this was geared toward listening and getting people’s inputs and comments. It is these pieces of paper, these points of information that I think are critical. The community, they live there. We are the experts. We are the ones who bring the knowledge that will help to kind of synthesize their points of view, but listening to the residents—and not just the residents but all of the community stakeholders—is very important.” There are a variety of keys to effective community engagement, Edwards said. Residents and community members should be brought to the table early and often. There should be open dialogue with the various city agencies that affect quality of life and livability issues, such as planning, transportation, economic development, housing, and health and human services. Monitoring and mitigation tools should be developed for residential, business, and commercial properties to gauge the changes that occur. Social, economic, and physical conditions should be addressed together in a holistic way. Finally, she said, the aim should be for outcomes that promote a just and equitable society. “I will close with this quote,” Edwards said. “Communities and neighborhoods that ensure access to basic goods, that are socially cohesive, that are designed to promote good physical and psychological well-being, and that are protective of the natural environment are essential for health equity” (Marmot et al., 2008). It is vital, she said, that people from the architecture and planning communities reach out to the public health professionals and do a better job or work together to create healthy communities. Discussion Canice Nolan of the European Commission began the discussion period by noting that he had heard very little at the workshop about federal efforts to encourage urban regeneration. Goldman responded that HUD does have such a program. It is run by Harriet Tregoning, who had been invited to the workshop but was not able to attend. The hope is that she will be able to attend a later Roundtable meeting. In Europe, such encouragement of urban revitalization is not seen as the European Commission’s responsibility, Nolan said. Instead, it is the member states and cities themselves that are seen to be responsible. Also, the World Health Organization runs a network of healthy cities in Europe, noting that he had not heard anything at the workshop indicating 

CROSS-CUTTING ISSUES 73 that people in the United States are trying to create a healthy-living network that spanned a number of cities.8 “From our research side,” he said, “we can incentivize and try to stimulate the market. We, in fact, are proposing prizes for tools for smarter cities.” The European Commission is also involved in establishing networks of city procurement officers and developing common standards “so that people are not always reinventing the wheel or repeating old mistakes.” Another speaker asked about the approaching reauthorization of the transportation bill and what is likely to happen with investments in nonmotorized transportation. Goldman responded that the major issue is cost. “I don’t think it is a partisan issue, in terms of investing in alternative transportation,” she said. “I do think it is a very important issue to bring to the attention of Congress. That act does have an enormous amount of leverage.” Concerning the transportation bill, she suggested that instead of focusing on specific solutions, such as building sidewalks, it would be more useful to get policy makers to focus on outcomes such as walkability. “I think there has been a tendency with that kind of bill to focus on the product instead of the outcome,” she said, “and perhaps we health people need to get more involved with transportation policy than we have been.” REFERENCES HHS (U.S. Department of Health and Human Services). 2015. Step it up! The Surgeon General’s call to action to promote walking and walkable communities. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General. Kramer, A., T. Lassar, M. Federman, and S. Hammerschmidt. 2014. Building for wellness: The business case. Washington, DC: Urban Land Institute. Lee, K. K. 2011. Active design guidelines: Promoting physical activity and health in design. New York: New York City Active Design Guidelines Team. 8 Although it was not discussed at the workshop, the interested reader can access information about Advancing the Movement in the United States at http://advancingthemovement.org (accessed October 6, 2015). 

74 BRINGING PUBLIC HEALTH INTO URBAN REVITALIZATION Marmot, M, S. Friel, R. Bell, T. Houweling, and S. Taylor, on behalf of the Commission on Social Determinants of Health. 2008. Closing the gap in a generation: Health equity through action on the social determinants of health. Lancet (372):1662–1669. Speck, J. 2012. Walkable city: How downtown can save America, one step at a time. New York: Farrar, Straus and Giroux. Urban Land Institute. 2015. Building healthy places toolkit: Strategies for enhancing health in the built environment. Available at http://uli.org/wpcontent/uploads/ULI- Documents/Building-Healthy-Places-Toolkit.pdf (accessed September 16, 2015).