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¹ This section summarizes information presented by panel session speakers. The statements made are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

² This section summarizes information presented by Laura Torchio from the Project for Public Spaces. The statements made are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

Vienna, Virginia, and New York City’s Central Park. Torchio followed by asking what makes these places meaningful and what types of activities people engaged in within these places. Answers included “people watching,” listening to music, public art, food, and even getting married. Continuing, Torchio asked the audience to consider to what extent the places they have enjoyed can be accessed and “enjoyed by all.” Considering factors including “race, gender, age, class, ability, and language,” audience members indicated that many places were “extremely inclusive” because the spaces were free, included access to those with differing abilities, and had access to transportation. Other responses were “somewhat inclusive” i.e., “somewhat,” due to poor maintenance and lack of transportation, but inclusive due to being multilingual.

Following these questions, Torchio spoke about the difference between a space and a place. She defined a space as “a description of a land, building, or street,” whereas a place is something you can associate a space with “an experience you had or if it has some kind of meaning or memory there.” A short video was shown depicting various images of spaces. Torchio returned to the audience and asked their impressions of the video. Sharon Roerty from the Robert Wood Johnson Foundation stated that the video “put people first” and that while the scenes were nice, the focus was on the people. Audience member Ysaura Toribio noted the open spaces, parks, and families shown, adding that the places shown seemed accessible and free. Franklin said the images were surprising since they showed communities and people coming together, whereas she typically enjoys places of solitude. This comment led Torchio to highlight her earlier point

that people experience spaces differently. Dora Hughes from The George Washington University pointed out the racial and ethnic diversity noticeable among the images, as well as variation in socioeconomic statuses that could be inferred from the images.

Torchio then asked the audience how places support equitable health and well-being and how they can be more supportive of health. Doug Jutte from the Build Healthy Places Network in California named Dolores Park as one of the images shown in the video and explained its design. He said that it was designed with the intent of encouraging various uses for the space by including playing fields and playgrounds. He said designers wanted it to appeal to “people of different abilities and different interests.” Hanh Cao Yu from The California Endowment added that the images suggested a “sense of belonging” and community ownership. Gabino Arredondo from the City of Richmond, California, said that when community members are helping to design, build, and operate spaces, they become invested in that space.

Torchio posed the question, “What makes a place inclusive?” Nina Burke from ReThink Health said prohibitive signage (e.g., “No walking on the grass”) makes spaces exclusionary. Meg Guerin-Calvert from FTI Consulting said that consistency of the activity offerings throughout the years helps to make a place inclusive. She gave the example of the Takoma Park Farmers Market, which has been operating for about 50 years every Sunday, and even though there are different vendors and visitors, its reliability welcomes the community, even newcomers. Phyllis Meadows from The Kresge Foundation discussed health equity and inclusion, stating that a space should promote the well-being of physical and mental health, and that location matters. Roerty said that a space that has a sense of belonging and is equitable should be adaptable in both mindset and design. Yu spoke about the intergenerational aspects of some spaces, that may speak of history and belonging. For example, if a space is designed to be utilized one way, it could showcase its adaptability and flexibility by allowing other uses. Joseph (Joe) Griffin from Pogo Park in Richmond, California, shared how places that promote health equity do so in part by being responsive to community needs. He said that the first park that was redeveloped in Richmond, Elm Playlot, is a certified provider of school lunches and this need was identified after talking to parents in the community. It was the act of being responsive to the community’s needs that made the place inclusive and equitable.

Milton Little from the United Way of Greater Atlanta reflected on his experience as a child growing up in New York City when streets would close and fire hydrants would be opened for summer play. As a child, he took for granted the public will to acquiesce to inconvenience (e.g., street closures) for a communal purpose, but as an adult, he recognized

that there was a shared willingness to create spaces and access. Torchio summarized this point by saying that flexibility needs to be built into the design of spaces to allow for different uses at different times.

HOW ARE PLACEMAKERS AND PLACEKEEPERS THINKING ABOUT INCLUSION?³

Carol Naughton, president of Purpose Built Communities, a national nonprofit that “guides neighborhood revitalization by creating pathways out of poverty for the lowest-income residents, and building strong, economically diverse communities” (Purpose Built Communities, 2020). Naughton described her organization’s approach to combating racial and economic inequities created by governmental policies. The first step is to acknowledge the malintended and racist policies that have disproportionally harmed persons of color. The next step is to approach a neighborhood as the way in which “people experience their cities.” She explained that a neighborhood should serve its residents’ needs rather than the other way around. She then paraphrased Bryan Stevenson, a lawyer, social justice activist, professor, and founder and executive director of the Equal Justice Initiative (who called on members of society “to get proximate to people who are suffering, to get closer to people who are excluded, to go into the parts of the community that other people say you shouldn’t go to”⁴). Naughton said that people need to change the narratives of hopelessness, but that this calls on people (practitioners in the field) to allow themselves to be uncomfortable and inconvenienced, and to have challenging conversations. Because serendipity does not happen by accident, she added, quoting a speaker on the Project for Public Spaces website, people need to be intentional in creating the conditions for serendipity, and for neighborhoods that are great, healthy places that facilitate joyful experiences.

FIRESIDE CHAT WITH AUDIENCE DIALOGUE⁵

Naughton continued by introducing the panel members. The first panel member was The Honorable Shirley Franklin, former mayor of

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³ This section summarizes information presented by Carol Naughton from Purpose Built Communities and The Honorable Shirley Franklin, former mayor of Atlanta. The statements made are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

⁴ See https://hub.jhu.edu/2018/05/24/commencement-2018-stevenson (accessed April 8, 2021).

⁵ This section summarizes information presented by Othello Meadows III, the Honorable Shirley Franklin, and David Erickson. The statements made are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

Atlanta and executive chair of Purpose Built Communities. The next panel member was Othello Meadows III, who directs the Seventy Five North Revitalization Corporation in Omaha, Nebraska, which is an engine for community change. The last panel member was David Erickson, senior vice president at the Federal Reserve Bank of New York. Highlights from the panel are provided in Box 2-2.

Franklin noted that she was considered the “water and sewer mayor” of Atlanta for her interest in the durability and function of places, infrastructure, and materials. Franklin explained that infrastructure, materials, durability, and flexibility are important, as is thinking about spaces beyond just [ensuring availability of] “green spaces” and taking into consideration who is utilizing the spaces. Residents clearly need to be asked for their input on design elements but, she added, so do visitors or tourists and investors, and that may be more challenging. She said the most effective strategy for facilitating those dialogues is to include faith leaders, for their moral leadership, and business leaders, for their contributions to public coffers, at the table in early discussions, although not driving the discussions. Franklin used the case example of the Atlanta Olympics, for which new physical infrastructure was built that would be privately and publicly owned after the Olympics. She said it was necessary to determine who would be impacted by this, who would fund it, and who would be given authority. Those who were identified as key actors—business, faith community, government—were included in the discussions and planning. Consensus was difficult, Franklin stated, as such planning takes a signifi-

cant amount of time and designing such spaces should have a long-term view of 50–100 years in order to ensure the creation of spaces that are accessible and still utilized in the future. She concluded by suggesting that children and youth should be included in discussions as well since they are able to visualize long-term goals.

Meadows began his remarks by contrasting challenges that Omaha faces with those of larger and more metropolitan cities. His organization is consistently working to attract investors into the neighborhoods, and it has been a challenge to ensure that the benefits of increased investment accrue to all who live in a community. His organization has three focus areas for revitalizing Omaha. The first area is a mixed-income housing model, which he identified as being more challenging than he had expected. The second area is working to support infants and children from cradle to post-secondary education. The third area is community health and wellness, which includes all aspects of health including economic mobility, financial literacy, physical health, and housing. The site they first chose to implement revitalization efforts was a public housing project known as Pleasant View; however, its historical name was Highlander. He stated that the site and discussions surrounding it had been synonymous with “the projects” and changing that narrative was important to reframing how people saw the area, and to bringing “energy” to the neighborhood. Pleasant View consists of 23 acres of continuous land located one mile from downtown Omaha. Reflecting on an observation on early planning discussions by Franklin, Meadows recalled that coming to a consensus and making decisions took work because neighborhoods are not monolithic and must not be stereotyped—they include a range of viewpoints.

Naughton then asked Meadows to describe the Accelerator, which is a part of the Pleasant View revitalization project. When the public housing was demolished, this displaced about 2,000 people, Meadows stated, and to rebuild, his organization worked with the community to create a communal space located in the middle of the new housing development. He explained that this space included a community college satellite campus for Creighton University, a “food-based hub for entrepreneurs” and a coffee shop, an event space (created in response to the community’s request), and office space. He said the idea was to bring the neighborhood together, serve the people, and be welcoming to people from outside the neighborhood.

Naughton then turned the discussion to Erickson by asking why the Federal Reserve, the central U.S. banking system, cares about health equity and public spaces. Erickson acknowledged that that juxtaposition may surprise some, such as the registration desk at a maternal and child health conference he once attended and where he was told he was the first person from the Federal Reserve to ever attend the conference. Erickson

gave a quick introduction to the two mandates of the Federal Reserve, which are to control inflation rates and maintain employment as high as possible. The Federal Reserve is a bank regulator and enforces the Community Reinvestment Act of 1977, which in part means an annual investment of approximately $400 billion in communities, including responsibility for promoting a positive environment to ensure the money is spent appropriately with the goal to improve communities.

Erickson discussed the first implementation of the Purpose Built Communities model, which was in East Lake, New York, and includes a public charter school education component that graduates more students with low socioeconomic status than have graduated from the Harlem Children’s Zone.⁶ He stated that this is a “model that is working.”

Erickson stressed the importance of geographical location as an indicator of health as documented decades ago by Michael Marmot, the well-known British epidemiologist who conducted research at the University of California (UC), Berkeley (Marmot et al., 1975). Erickson explained that Marmot found that there were significant differences in stress-related diseases between Japanese American populations in California and Japanese populations, with Japanese populations not experiencing any of those diseases. To further his research, Erickson said, Marmot looked at Japanese populations in Hawaii and the prevalence of stress-related diseases was half the rate of the California population. This helped illustrate the powerful connections between place and health.

The Federal Reserve has been conducting conferences to bring community developers together with people focused on health to address the overlapping nature of development issues such as overcrowding, unemployment, and poverty and health conditions such as diabetes and asthma. This has been highlighted again and again in “heat” maps highlighting development and health metrics. The last conference, Erickson noted, was at the Federal Reserve Bank of New York in December 2019, which was focused on how “neighborhoods are creating health.” So often, he added, these two sectors work side by side, but as UC Berkeley epidemiologist Leonard Syme has observed, the people who design, build, and finance cities are among the most important health workers. Erickson closed by asking the question, “How does one harness and capture the value?” He answered this by explaining that investing in and creating neighborhoods that promote health lowers health care costs, but it is difficult to measure the monetary value of this kind of work. He referenced a speech delivered by the president of the Federal Reserve, John

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⁶ Harlem Children’s Zone is a nonprofit organization with the aim of reducing generational poverty in Central Harlem by giving students support to go to and complete college (Harlem Children’s Zone, 2020).

Williams, a speech that took place immediately next to a talk given by the then president and CEO of the Robert Wood Johnson Foundation, Risa Lavizzo-Mourey, who spoke about community development. Williams said $3.5 trillion is spent on medical care and 85 percent of that is on chronic diseases. Erickson said, “most chronic disease that is avoidable is a by-product of living in low income, poverty, [and] low-opportunity places.” Erickson inferred that by investing in neighborhoods, this money could be saved. He asked whether another business model could capture this value more accurately, and shared how a colleague, Maggie Super Church, has mused about the need to find ways to invest in health-promoting places in the same way in which we invest in the development of new blood pressure medications.

DISCUSSION

Following Erickson’s talk, Naughton turned to the audience for questions. Lourdes Rodriguez from the Dell Medical School at The University of Texas at Austin initiated the discussion by describing a Federal Reserve meeting over 6 years ago that was attended by public health and clinical practitioners with developers. She said that while developers had the opportunity to build health, it was not the vision of people working on the health side since it did not include public spaces. She said the developers did not know how to monetize that as opposed to building clinics for which services could be billed. Rodriguez asked what the cost-benefit analysis is on creating spaces and inquired how it would be possible to convince investors when they are likely not to see a clear return. Erickson responded by saying that he used to think “medical care” when people said “health.” He suggested talking to those who own the downstream medical care cost risks. He gave the example of Kaiser Permanente in Maui, Hawaii. He said about half of Hawaii’s population are insured by Kaiser, and Kaiser operates all of the hospitals, so they have high risk. To help reduce the risk of medical costs later on, Erickson explained, Kaiser began to invest in preschools. Franklin also responded by saying that the question is whether the public sector is willing to be a financial partner. She shared the case of the Atlanta Beltline, which was a 30-year, tax-funded project, focused on investing in physical infrastructure to attract private investment and promote health. She said that attention should be on how the public sector can invest with existing dollars. Meadows added that partnerships can be developed to help alleviate some of the monetary risk. Moreover, he said that solutions to health problems may come from surprising areas and that by being too “rigid” or “prescriptive,” might mean “miss[ing] the opportunity or the understanding of how the built environment affects people’s health.”

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