5

Revitalizing Communities

Professionals in medicine and public health have a great deal of awareness and have taken significant action around the relationship between community revitalization and population health. Moderator Victor Rubin, vice president for research at PolicyLink, observed that there are also parallel efforts under way in the fields of urban design and redevelopment, city and regional planning, architecture, landscape architecture, and property development that focus on the social determinants of health. Community leaders have recognized the same connections between the social determinants of health and the overall well-being of their constituents, mostly low income and mostly people of color, he said. They are getting involved in issue-based neighborhood organizing, and taking action on policies and practices. Health impact assessments and other analyses have shown the impact of community advocacy and organizing. Various types of business enterprises are also beginning to focus on the social determinants of health. Real estate developers, for example, are creating communities that allow for a healthier lifestyle. Health insurers and hospitals are also taking opportunities to include a focus on the built environment. Highlights from this panel are found in Box 5-1.

Social determinants of health are just that; they are social, Rubin emphasized. They are less about individual behavior and more about how communities are constructed and operate, and how residents are more or less healthy depending on the broader factors of equity and access to economic opportunity. Creating access to fresh food or the chance to exercise is not merely a design task that can be separated from the broader mission

of creating a city that works for everyone, and that provides everyone the opportunity to work and prosper.¹

This is an era of revival for some failing American cities, Rubin observed. There are large new investments in development, research on populations, new forms of commerce, and widespread appreciation of the health and social benefits of compact, less auto-dependent development. It is important to remember, he stressed, that, for the health benefits of this urban revitalization to be realized, the revitalization needs to be equitable and inclusive. He noted that PolicyLink refers to this as building healthy communities of opportunity.

In this session, speakers provided examples of the community building and economic revitalization that are under way in two major cities, what these initiatives mean for health equity, and in particular, the role of business in this process. Anne Griffith, senior program director at Enterprise Community Partners, Inc., discussed HOPE SF, a revitalization project in San Francisco, California. Dan Kinkead, director of projects for

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¹ For more information on why place matters to building healthy communities, see, for example, http://www.policylink.org/sites/default/files/WHYPLACEMATTERS_FINAL.PDF (accessed October 12, 2015).

Detroit Future City, described the implementation of a strategic framework to stabilize and transform the city of Detroit.

San Francisco and Detroit are cities in very different circumstances, Rubin said. San Francisco is in the midst of a technology-driven growth boom. This has placed enormous pressures on the affordability of the city, and a rapid demographic change is under way that threatens the historic diversity and character of the city, he said. In contrast, Detroit is emerging from the end of an era of manufacturing employment that led to massive disinvestment, population loss, property abandonment, and physical stress. Despite the differences between these cities, there are similarities in the communities. For example, an isolated public housing development in San Francisco will present many of the same health, education, and safety challenges for children and youth as that same type of development does in Detroit. There are hipster coffee shops, and start-up business incubators for the creative class and the tech entrepreneurs in Detroit, just as there are in San Francisco, he said. In each city, there is a need to rebuild neighborhoods with health equity in the forefront of the plans, and create an inclusive strategy for both jobs and business development, Rubin said.

SAN FRANCISCO: HOPE SF

Enterprise Community Partners is a national, nonprofit organization that offers a range of financial products and programs to improve and increase the supply of affordable housing and to revitalize communities. Griffith discussed the HOPE SF revitalization project, of which Enterprise is a partner.² HOPE SF is a public–private partnership, led by the San Francisco Foundation, Enterprise, and the City of San Francisco. The HOPE SF project was launched in 2008 and is the nation’s first large-scale public housing revitalization project that was designed to focus on the residents who live there.

Two Sides of San Francisco

As mentioned by Rubin, San Francisco is experiencing a boom in economic prosperity. One in six San Franciscans have graduate degrees, Griffith said. Eighteen percent of all patents are generated in the San Francisco Bay Area. It is home to 56 of 300 of the wealthiest people in the world. Starting salaries for coders (i.e., computer programmers) are between $115,000 and $200,000. Twitter alone has created 1,600 millionaires, she said. The average monthly rent for a two-bedroom apartment is $4,780, which requires an income of $230,000 to be affordable, Griffith

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² See http://hope-sf.org/overview.php (accessed July 31, 2015).

added. Because of this wealth, there is increasing money coming into the city coffers, and the city itself is wealthy. San Francisco is also a service-rich city, offering a wide array of public services.

The southeast part of the city, however, is geographically isolated from the rest of the city, and lacks many of the retail and other services that exist elsewhere. In the Bay View and Hunters Point areas there are four public housing developments: Hunters View, Sunnydale, Alice Griffith, and Potrero Terrace and Annex. These are old, dilapidated, barracks-style public housing, originally designed and built as shipyard housing, Griffith said. They were built to last for 10 years, she added, but have existed for nearly 60. For the residents of these public housing developments, the average household income is less than $14,000, and the average household size is four people. San Francisco overall has a diabetes rate of less than 5 percent, but between 16 and 29 percent of residents of public housing report having diabetes. The chronic absenteeism rate in school is 8 percent for the city, but 53 percent in these four housing developments. There is considerably more violence in these developments. The unemployment rate among able-bodied adults is about 73 percent, and for young adults ages 18 to 24, it is 92 percent.

The HOPE SF Revitalization Project

In a typical revitalization project for public housing, the housing is torn down and residents are given vouchers and sent to find other housing, Griffith explained. After the new neighborhoods are built, the new residents are not necessarily the same type of people who had been living there before in poverty and isolated from opportunities that other more affluent and healthier residents can access. The new residents often have fewer barriers to employment and fewer overall challenges. The neighborhood itself is touted as a success, Griffith said, but that is not necessarily so for the residents who had lived there. For the HOPE SF revitalization project, San Francisco made a commitment to support the residents who already lived there. The original barracks-style units are being torn down and replaced with three times the density of public housing, additional affordable housing, and market rate housing. Griffith shared some of the lessons learned in three key areas: the impact of trauma; safe, healthy, well-managed affordable housing as a lever for change; and the catalytic role of private philanthropy.

Trauma-Informed Community Building

In 2006, the Human Services Agency conducted a study looking at usage rates of public services and found that 60 percent of the families in

crisis (e.g., those that had intersected with child welfare, food stamps, or the justice system) lived within walking distance of seven street corners in San Francisco. Four of those corners correlate with the four developments that are now part of HOPE SF.

HOPE SF began with a model that focused on community building, which is a widely respected form of engaging people in communities where they are isolated by the physical, economic, social, and service environments in which they live, Griffith said. It often involves gatherings and celebrations as ways to get people to know their neighbors. However, there was not the level of uptake in the typical activities that was expected. The next model tried was a service connection model, connecting people to the many existing services in the city. However, just making that connection did not necessarily lead people to actually participate in or take advantage of that service. People were also frustrated that the services did not always correlate to their needs. It was also found that the service providers at the sites were experiencing a great deal of burnout. The temptation is to ask what is wrong with the staff that they cannot stay and work at these sites, or with the residents that they will not use the services, she said. At this point, HOPE SF got a “crash course in brain science” that taught them about the impact of trauma, so they could begin to think about what was happening in the communities in a different way. Traumatic events, especially events that happened in childhood, can have continuing neurobiological effects on people. Traumatic events also impact health outcomes and behavioral issues. It also became clear that the staff were experiencing trauma vicariously from working with the families.

To better understand the impacts of trauma the residents had experienced throughout their lives, the adverse childhood experiences (ACEs) test was administered. Griffith summarized the 10 types of traumatic events that are measured as part of ACE assessment. There is screening for three types of abuse (physical, sexual, and verbal), two types of neglect (physical and emotional), and five family dysfunctions (mental illness, incarcerated relative, substance abuse, divorce, and mother treated violently). A person with four or more ACEs is 12.2 times more likely to attempt suicide, 10.3 times more likely to use injection drugs, 7.3 times more likely to be an alcoholic, 2.4 times more likely to have a stroke, 2.2 times more likely to have ischemic heart disease, 1.9 times more likely to have cancer, and 1.6 times more likely to have diabetes. Trauma also impacts the development of executive functioning skills in young people. Griffith noted that California is 1 of 25 states that has conducted a statewide study of trauma. The study found that 17 percent of Californians across the board have four or more ACEs.

With this new understanding, HOPE SF responded by conducting

staff trauma training at each of the housing sites. Training and support were provided to resident leaders, and a peer health leadership program was developed, facilitating resident support of one another. There is a pilot of onsite, nonstigmatized mental health counseling. A new “trauma-informed” community-building model was also implemented (Weinstein et al., 2014). The Department of Public Health responded by creating a trauma-informed system, and has been trauma training their entire workforce. The Department of Public Health also developed a set of basic principles for a trauma-informed approach, addressing five main practice areas: understanding trauma and stress; compassion and dependability; safety and stability; cultural humility and responsiveness; and resilience and recovery.

Housing as a Lever for Change

Most people think of public housing and affordable housing as a federal or other public subsidy, and it generally is, Griffith said. In fact, one of the largest providers of resources for affordable housing is the private sector, through the tax credit investment process. The federal government allocates low-income housing tax credits to states. State housing agencies allocate those tax credits to developers for development of affordable housing for qualified residents. Corporate entities invest in the developer, and receive a tax credit for 10 years. This has been incredibly successful, Griffith said. Since 1986, $2.5 million has been spent to develop more than 100,000 affordable units every year. There is rigorous state oversight to ensure that units are affordable for at least 30 years (many permanently). The housing credit program is a win-win situation, she said. The private sector has a stake in ensuring that the apartments are well done in order to continue claiming the tax credit, and the health benefits for residents that move from a place that is filled with vermin to a place that is beautiful and well-built is significant.

The Role of Philanthropy

More than $11 million in private-sector finding has been committed to HOPE SF, including a substantial gift from Kaiser Permanente of $3 million. This has allowed the funding of human capital programs that foster leadership at each of the housing sites, including the Peer Health Leadership Program, the Onsite Project-Based Employment Program, and the Educational Engagement and School Attendance Program. Philanthropic resources also allow HOPE SF to fund research, strategy development, and evaluation to identify best practices, and to implement them in a way that engages the residents.

In addition, philanthropic resources have funded research on nonstigmatized mental health care and the impact of peer leadership programs. The outcome of this research led to the pairing of the Peer Leadership Program with an onsite wellness center. A nurse was installed in a vacant residential unit to administer blood pressure checks and other routine procedures, with the goal of navigating residents to a medical home. As they talk about why their blood pressure is high, residents begin to talk about the traumatic events in their lives. This provides the nurse with the opportunity to make a “warm hand-off” to the behavioral health specialist sitting in the next room. A conversation is started that leads either to individual treatment, or to groups that are created at the housing sites. This approach has allowed the public health system to begin to move city resources differently, in a place-based fashion, Griffith said. With the grant from Kaiser Permanente, the program will be expanded from one pilot site to all four sites, and institutionalized within the public health system.

DETROIT FUTURE CITY

The vision of Detroit Future City recognizes the need for both immediate impact to improve current circumstances for Detroiters, and structural changes that will take decades and generations, Kinkead said. The 50-year strategic framework is broken down into four implementation horizons: stabilize (first 5 years), improve (years 5-10), sustain (years 10-20), and transform (years 20-50).³ Detroit Future City launched in 2013, and is in the stabilization phase. Kinkead pointed out that several of the goals and activities related to achieving a stabilized population overall are tied to business and workforce. Currently, only 50 percent of the working age population in the city of Detroit is employed. The city has lost 60 percent of its peak population of 1.85 million, and is now home to about 700,000 residents. Targets for the stabilization and improvement phases are to establish a stabilized population; double the number of jobs available in the city; create an integrated regional transportation system; become a globally recognized leader in adaptive land reuse; and be enhanced and sustained by a broad-based and ongoing civic stewardship network. One of the most important and enduring pieces of Detroit Future City, he said, is that it is not just about physical space and place, but about people.

This moment in the city’s history is very critical, Kinkead said. There is new governance; regional cooperation emerging where it has not existed in the past; and a dynamic economy emerging from within the city, including a much more diversified distribution of innovation and

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³ See http://detroitfuturecity.com/wp-content/uploads/2014/12/DFC_Full_2nd.pdf (accessed July 31, 2015).

technology firms, health-related enterprises, light-scale manufacturing, and other industries. There is also new transportation investment in light rail in the city, innovative infrastructure and partnerships, and public land coordination of land assets. Detroit Future City seeks to leverage these changes to stabilize, sustain, and transform the city for the long term.

Strategic priorities for reaching the first horizon (stability) are to have a real and immediate impact on residents’ quality of life, and take substantial initial steps toward long-term fiscal sustainability. Kinkead noted that these two priorities can be diametrically opposed and balancing them is difficult; satisfying the former can undermine the latter, and vice versa. Finding a balance where both objectives are integrated and met is essential. Strategically, Detroit Future City will “pick low-hanging fruit” and will be bold and take risks, while advancing the more systemic changes necessary. There is a focus on fundamental policy reform, and on piloting innovation, as well as engaging people for action.

Detroit is beginning to turn the corner, Kinkead said. The international waterfront in Detroit is the site of a tremendous amount of reinvestment (tens of millions of dollars invested monthly, and tens of thousands of new jobs generated every quarter). There is also substantial growth in Detroit’s central business district, and rapid growth in the overall greater downtown. However, Detroit also has 23.4 square miles of completely vacant land. For comparison, that is slightly larger than the island of Manhattan, he said. This land is distributed across the city, and concentrated in a few key places. This is seen as a tremendous liability, and Detroit Future City is working to identify ways in which this land can become an asset for the city, such as green infrastructure for air quality and recreation, blue infrastructure for storm water management, and urban agriculture.

Elements of the Strategic Framework

The strategic framework is grounded in community feedback and participatory planning. Stakeholders are not only contributors to the plan, they are also fully equipped to help implement it. The implementation office of Detroit Future City is housed in a storefront, Kinkead said, functioning as an access point for anyone in the city who wants to engage and help turn the city around. The five main planning elements for Detroit Future City are land use, city systems, land and buildings assets, neighborhoods, and economic growth. The element of civic engagement supports all of these components.

Land Use

In spite of all of the available vacant land, of the top 20 cities in the United States, Detroit ranks the lowest for available recreational park spaces per resident, Kinkead said. There are overarching unmet needs around service delivery, and a mismatch in the housing products offered. Historically Detroit has been a low-density city (i.e., single-family construction), even at its peak population. This is arguably unsustainable, Kinkead said. Current market demand for new housing is for multifamily structures. As mentioned, Detroit has more than 20 square miles of vacant land. To reuse this land, the Detroit Future City land-use strategy will drive greater density in key parts of the city, and support an open-space network. Maps of demographics, housing conditions, and other factors were used in an evidence-based approach to balanced land-use development. The plan promotes mixed-use and multifamily land use in key areas, drives greater density, creates open space, and redefines neighborhoods.

City Systems

Over the past 65 years, Detroit has lost 60 percent of its public revenues to support public systems, and has struggled on the delivery side for water, power, waste, and other services, Kinkead said. Public transportation systems have been underused and poorly maintained (e.g., only 9 percent of Detroiters use public transportation; only 35,000 of 88,000 existing street lights are working). There are numerous environmental impacts of failing city systems (e.g., unaccounted-for water system capacity from leaks and hydrant use; extensive “combined sewer overflow” discharges into the Detroit River in each year; lead poisoning). Nearly 20 percent of the population does not have health insurance of any kind. Death rates from heart disease are 50 percent higher than the national average, and childhood asthma cases are three times the national average. Detroit Future City hopes to impact these areas with more strategic decision making, and innovative investment that is tied to business opportunities and employment growth in the city.

We need to think differently about how we provide services, Kinkead said. The issue is not about removing services, but about being innovative in how service is delivered. For example, five-times daily bus service through a low-occupancy area of mostly older residents who are not part of the active labor force is not cost effective. However, residents will need to travel to the store or the doctor several times per month. One alternative approach developed is a paratransit network to bring residents to the doctor. This is an on-call service run by the local church, with a subsidy from Detroit Future City to cover the insurance for the bus.

The city is also taking a much more thoughtful approach to managing bigger systems, such as storm water management. Detroit, like many other cities of its vintage, has a combined sewer overflow system. Sanitary waste from buildings and storm water waste from the street both go to treatment facilities by the Detroit River. More than half an inch of rain over the course of 1 hour or less can overwhelm the system, and the overflow is directly discharged into the Detroit River. A comprehensive, citywide “blue infrastructure” system could prevent this, Kinkead said.

Land and Building Assets

Available land area can be used to develop green and blue infrastructure. The current land vacancy is a real asset that could be transformed into, for example, recreation or agricultural production. Kinkead shared several examples of current projects. As part of the Great Lakes Restoration Initiative, $1 million received from the U.S. Environmental Protection Agency was matched with $1 million from local philanthropic donors for a green infrastructure project across the lower east side of Detroit. Detroit Future City is also working with the U.S. Department of Energy on renewable energy production in the city (e.g., biomass energy production from switchgrass anaerobic digestion, solar photovoltaic energy production with pumped-storage hydro).

Neighborhoods

In places where there is the highest vacancy, and the biggest disinvestment and depopulation, residents simply cannot get what they need in the city. In fact, $1.5 billion of Detroit resident expenditures are made outside the city each year, Kinkead emphasized. The people with the least are traveling the farthest to obtain groceries and other needs. What is required is a place-based strategy for providing retail amenities, linking people to retail through transit, and providing employment. The crime rate in these communities is high, particularly the violent crime rate, which is the second highest in the United States. As noted above, health statistics in these areas are poor.

Improving quality of life is a focus of Detroit Future City’s work with communities and neighborhoods. The city takes down about 240 homes per week in a blight elimination strategy that will remove 80,000 structures out of the 380,000-structure portfolio. As a result, there is more and more open land becoming available. Thinking differently about neighborhoods and available land use has led to a variety of programs, for example, community arts programs, or employing residents in the deconstruction efforts and selling salvaged materials for a profit.

Economic Growth

In Detroit, there is one private-sector job for every four Detroiters, Kinkead said, compared to a ratio of around 2.5 to 1 for most successful cities. Those in the city who are working face many types of challenges. The majority of employed Detroit residents (61 percent) are working outside the city, often in service-based jobs. Seventy percent of the jobs in the city are held by people who live outside the city. Opportunity is further limited by a poor mass transit system.

Again, this is about strategic land use, he said, locating businesses and new enterprises in the city, increasing job opportunities and the tax base, and reenergizing the economy. The place-based strategy supports four key economic pillars: industrial, education and medical, digital/creative, and small business. Local entrepreneurship and minority business participation are key, Kinkead said. There is also a need to improve skills and support education reform. The place-based strategy builds on existing assets and identifies those that previously have been underused, such as parcels of land in industrial areas. He noted that Detroit Future City was part of a team that helped to recruit the Goldman Sachs 10,000 Small Businesses Initiative to Detroit, which provides financial capital, tools, training, and professional support to new enterprises. Detroit Future City is also focusing on employment districts that have been overlooked in the past (i.e., areas outside of the greater downtown area), and working with schools to help with job preparedness.

In closing, Kinkead summarized what businesses need to do today to begin to have a positive impact on revitalizing their communities. Embrace strategic land use, make decisions, and evaluate development options with the entire city in mind, he said. Support an open-space network. Drive better employment and purchasing in the city, particularly at an institutional level. Foster supportive relationships with surrounding neighborhoods. Support small-firm development, including training and financing.

DISCUSSION

Rubin observed that San Francisco and Detroit are both working to redefine the public good, and the identity and vision of the city as a whole, and each is going about it in a different way. He noted that increasing wealth and growth overall do not solve the problem of pockets of isolation and poverty, and a growing city runs the risk of losing sight of its public responsibility. There are complex questions about how to maintain and grow a community that works for a given city. During the discussion, panelists provided further information on the structures and financing of their organizations, and discussed working with public health as a part-

ner, scaling up their organizations to create system change, and keeping partners and staff moving forward in the face of such challenges.

Organizational Structure and Financing

Paula Lantz of The George Washington University asked about the business and funding models for the organizations. Griffith responded that under the nonprofit parent organization of Enterprise Community Partners, there is an asset management arm and two financial arms (a nonprofit Community Development Financial Institution that makes loans and an investment subsidiary that brings in capital through activities such as low-income housing tax credits and new market tax credits). Enterprise also secures grants to support its work, including the U.S. Department of Housing and Urban Development (HUD) Section 4 grants that pass through the organization and are re-granted to community development corporations. She reiterated that HOPE SF is a phased development framework, with phases one and two under way. There are financing plans that are nearly finalized for the third and fourth phases. These include federal resources (e.g., a Choice Neighborhood Initiative grant of $30 million from HUD), and financial support from the city. Pulling together the capital for HOPE SF has been very challenging overall, she said.

Detroit Future City exists as an initiative nested within the nonprofit Detroit Economic Growth Association (DEGA), which is within the Detroit Economic Growth Corporation (DEGC), Kinkead said. DEGC is not part of the city government, but partners closely with it. The Detroit Future City Implementation Office has about 10 staff plus about 5 consultants. It is exclusively funded philanthropically, and is directed by a steering committee, with administrative and legal oversight from the DEGA board. Kinkead said he expected Detroit Future City to evolve into a 501(c)(3) nonprofit organization.

Rubin pointed out that these are examples of how private resources have led to systems change. In nearly every large city, and a number of small cities, there is a complex relationship (i.e., partnership) between place-based and citywide philanthropic initiatives, and the local government.

Public Health as Partner

Raymond Baxter of Kaiser Permanente emphasized that there is a great opportunity to promote health by design when revitalizing cities and building economic opportunity. He asked about the extent of the involvement of the professional public health community and local

universities in these initiatives. Griffith said the department of public health has been a very active participant in HOPE SF. As a public–private partnership and a Living Cities grantee, HOPE SF works with city departments and philanthropic organizations. In addition, one of the Master ’s of Public Health classes in the Health Equity Institute at San Francisco State University is conducting community-based participatory research at HOPE SF. There is also a HOPE SF Learning Center at San Francisco State University.

In Detroit, the public health implications are so obvious that a public health focus is ubiquitous, Kinkead said. However, there is no public health specificity in partnerships, policy, and approach. The health department was actually dismantled as the city went through bankruptcy proceedings, and was replaced by the private, nonprofit Institute for Public Health. Whether Detroit Future City is working with philanthropic partners or community-based partners, public health is the undergirding element, he said. Rubin added that the University of Michigan School of Public Health has the Detroit Urban Research Center, which partners with community-based organizations to do participatory research on a range of health issues.

Scaling to Change Systems

A participant observed that one of the frequent tensions in this work is the scale of intervention and the systems involved. To what extent can these initiatives change the broader systems in which they are embedded? A common critique is whether neighborhood, or even city-scale initiatives can really have an impact when the systems involved (e.g., educational, environmental) operate beyond the boundaries of that place.

Kinkead concurred, and noted that in issue-focused work, the power to effect policy can be orders of magnitude above the local initiative level. Detroit Future Health is very deliberate in moving among those levels, and bringing those working on the ground together with those in high-level policy-making positions. In cities that are recovering, it is important to constantly make those connections, he said.

Griffith said that, in the beginning, philanthropic money was used in small and innovative ways that bridged the gaps. For example, liaisons were created between the school district and the housing development sites because HOPE SF was not going to change the school system. Over time, HOPE SF has been able to show that the programs it pilots using philanthropic dollars are successful in the community, and the public education system has begun to think about adopting them. HOPE SF then moved to using private funding to help the public system work out how to adopt those programs.

One element now working in favor of HOPE SF, said Griffith, is the new administration. The mayor has appointed a high-level staff member to be the director of HOPE SF in the city. This director has the authority to call all of the city departments together, and require them to interact in a way that has not happened before, she said. HOPE SF is now in its second year of having a director at that level, and change is occurring.

Keeping the Momentum

Catherine Baase of The Dow Chemical Company noted the challenges of convening people effectively to address such overwhelming and daunting issues. How do initiatives generate the will among collaborators and partners, and how do staff stay motivated and committed in the face of such despair? Kinkead said that major challenges tend to galvanize people, including groups that might not otherwise agree on an issue. He observed that people have rallied around community revitalization. As the city went through the largest municipal bankruptcy in U.S. history and people were struggling, a new sense of community emerged. At the same time, however, the resurgence is happening more for some than for others. It is important to be mindful of that, and ensure that everyone has opportunity. On the personal level, he acknowledged that there are very difficult moments, but if you are committed to do this work a point comes where you have to step forward and do it.