As discussed by the first panel, the federal government provides policies, incentives, leadership, and tools for health, said session moderator James Knickman, President of the New York State Health Foundation, but “health is local.” In this session, panelists described innovative efforts at the state and local levels to advance community health. Ned Codd, Director of Project Oriented Planning for the Massachusetts Department of Transportation (MassDOT) provided a brief overview of state laws and policies supporting Massachusetts’ commitment to promoting healthy transportation. Freddy Collier, Assistant Director of the Cleveland Planning Commission, described his county’s involvement in Place Matters, a national initiative which seeks to improve the health of participating communities by addressing disparities in social, economic, and environmental conditions through policy and/or systems change. Rochelle Davis, President and CEO of Healthy Schools Campaign, described her work to develop cross-sector partnerships and incorporate health and wellness into education policy and practice. Kathleen Dickhut, Deputy Commissioner at the Chicago Department of Housing and Economic Development, discussed the land-use, planning, and economic development aspects of A Recipe for Healthy Places, a plan to address the intersection of food and obesity. An open discussion moderated by Knickman followed the panel presentations.
Massachusetts has been working to build a strong foundation for promoting healthy transportation, said Ned Codd, and he provided a brief overview of state laws and policies supporting this commitment. An “early win” in the area of healthy transportation, Codd said, was the Complete Streets Policy and Design Approach established in the State’s Project Development and Design Guide in 2006. The approach is to design roadways from the outside in, starting by accommodating the most vulnerable users first (pedestrians, bicyclists, and public transit riders getting on and off the roadway) and then the motorists.
In 2008, the state legislature passed the Global Warming Solutions Act, which called for economy-wide reductions in greenhouse gas emissions, 25 percent below 1990 levels by 2020, and 80 percent below 1990 levels by 2050. The result, Codd, said, was a focus on projects that enabled different transportation modes and minimized the use of automobiles.
That was followed in 2009 by a very broad-based transportation reform law that consolidated disparate transportation agencies into a single, multi-modal transportation agency under a strong secretary. The new focus was on customer service dedicated to moving people, and to promoting economic development, environmental sustainability, and quality of life. The approach was much more holistic, Codd explained, and enabled activities such as bringing the Registry of Motor Vehicles together with the Massachusetts Coalition for Biking to talk about including more information about bicycle safety in the driver’s manual and on the driver’s licensing examination.
Codd stated that the Massachusetts Transportation Reform Law also created the Healthy Transportation Compact, an interagency group co-chaired by the state secretary of transportation and the secretary of health and human services, to collaborate and focus on the health outcomes of transportation decision making. Efforts to promote health and transportation are supported by a number of different initiatives including, for example, the Mass in Motion Program (which promotes opportunities for active living), Municipal Wellness Grants, Leading by Example (which promotes green practices by state-owned and -operated facilities), and Safe Routes to School (which promotes healthy alternatives for children to travel to school).
The GreenDOT Policy is a broad-based, comprehensive policy that requires the state Department of Transportation (DOT) to consider the environment in all of its operations and policies. It is guided by three primary goals: reduce greenhouse gas emissions; promote healthy transportation modes of walking, biking, and public transit; and support smart growth development. Examples of GreenDOT initiatives highlighted by Codd included statewide bike weeks held in May since 2010; creation
of a 700+ mile statewide network of bicycle routes that will ultimately include about 500 miles of shared use paths; and a Mode Shift Goal to triple the amount of travel on foot, bicycle, and public transit between 2012 and 2030.
As required by the Transportation Reform Legislation, Massachusetts has also instituted health impact assessments (HIAs). A 2-day training session in HIAs was held for MassDOT, Health and Human Services, and consultant staff, Codd said, and a pilot HIA was conducted on a transportation study of an old, elevated highway in Somerville, Massachusetts. The transportation study has entailed reviewing a range of alternatives for removing the elevated highway and replacing it with a surface street; the companion HIA evaluated the health impacts of the different surface alternatives and found them all to be a significant public health improvement relative to the elevated highway.
Earlier in September 2013, the MassDOT Healthy Transportation Policy Directive was signed, requiring all MassDOT projects (roadway and transit) to serve all travel modes. All projects that are funded or designed should not just accommodate, but should actively promote the healthy modes of walking, biking, and public transit for on- and off-street facilities, and any projects that do not meet these standards require specific approval from the transportation secretary, Codd said.
Freddy Collier described the involvement of Cuyahoga County, Ohio, in Place Matters, a national initiative of the Joint Center for Economic and Political Studies Health Policy Institute. One of the challenges of influencing policy makers to approach their work through a health lens is how best to convey the message to local officials, he said. Place Matters was designed to improve the health of communities by addressing social conditions through policy and/or systems change. The Cuyahoga County Place Matters team engages policy makers and community members to use an overarching health and equity lens for the development of policies that create conditions for optimal health. There is a very deliberate focus on creating intersectoral collaborations, Collier said. The team includes local public health departments, land-use planners, academic institutions, developers, community residents, city and county governments, health care systems, and philanthropic organizations.
Locally, initiatives in Cuyahoga County such as the Connecting Cleveland 2020 Citywide Plan, which proposes creating a city that is a model for healthy living, began to go beyond bricks and mortar to consider social, economic, and environmental conditions as part of the City
FIGURE 4-1 System change framework.
SOURCE: Collier presentation (September 19, 2013).
of Cleveland’s Comprehensive Plan. Following the adoption of Connecting Cleveland in 2007, Cleveland Mayor Frank G. Jackson initiated the Healthy Cleveland Initiative to “create a culture and lifestyle of health.” The Place Matters team saw this as an opportunity to engage, Collier said, and started to frame out how to have the conversations about systems change. Collier shared a model that he said became a valuable tool for conveying information (see Figure 4-1). System change requires change at all levels of a hierarchy, he said.
What Makes Us Healthy?
The Place Matters team also began to raise awareness about what it is that makes us healthy, including both medical and socio-ecological aspects of health. Collier presented a framework for health equity that shows how upstream social factors (neighborhood conditions, institutional power, social inequities) and downstream health status factors
(risk factors and behaviors, disease and injury, mortality) play into health and health equity (see Figure 4-2). Health equity is the fair opportunity to obtain full health potential. No one should be at a disadvantage from achieving this potential if it can be avoided. We are responsible for creating the conditions for people to have optimal health, he said.
The team reached out to elected officials to help them understand fundamentally what is meant by population health, and the role of social determinants of health. Economic, environmental, and social conditions that influence health include, for example, poor ventilation, mold, rodents, abandoned property, crowding, hunger, dangerous streets, transportation hazards, worsening traffic conditions, poor quality food, no place to play, declining moderate-wage jobs, and limited access to jobs, health care, and a lack of social networks. Dealing with these conditions from a position of limited control can result in chronic stress on individuals, which is an underlying cause of many health conditions. From a land-use perspective, Collier said, many of these challenges can be managed.
The team also worked to inform policy makers that differences in well-being between and within communities are systematic, patterned, unfair, and can be changed. These differences are not random, as they are caused by past and current decisions, systems of power and privilege, policies, and the implementation of those policies. The choices people make are shaped by the choices that they have. For example, many people are inundated with poor food options; therefore, they make poor choices about what to eat.
Another approach used to convey the message to policy makers about health equity was the use of geographic race maps. Collier showed maps of Atlanta, Boston, Buffalo, Charlotte, Cincinnati, Cleveland, Columbus, Detroit, and the District of Columbia, which all showed evidence of place-based segregation. Utilizing geographic information systems (GISs) in Cuyahoga County, the Place Matters team identified one of the largest disparities of life expectancies nationwide, a 24-year difference in life expectancy between the communities of Hough and Lyndhurst. This significant disparity launched a dialogue among multiple sectors of Northeast Ohio, Collier said.
In conclusion, Collier said that conveying the message and framing the conversation are critical tasks for engaging decision makers outside the medical sector.
Healthy Schools Campaign is based on the very simple and common sense notion that healthy students are better learners, and that health and
FIGURE 4-2 A framework for health equity.
SOURCE: Collier presentation (September 19, 2013), citing figure adapted by the Alameda County Public Health Department from the Bay Area Regional Health Inequities Initiative, Summer 2008. http://www.acphd.org/social-and-health-equity.aspx (accessed November 26, 2013).
wellness should be incorporated into all aspects of the school experience, said Rochelle Davis. Based in Chicago, Healthy Schools Campaign is locally focused, working to make changes in schools, communities, and the broader school district in Chicago, and nationally minded, elevating the lessons learned to state and federal policy levels. A core part of the organization’s mission and vision is to work at the intersection of health and education and address the disparities that exist in both.
The primary focus in Chicago has been on changing the food and fitness environment. Healthy Schools Campaign supports Chicago schools in meeting the U.S. Department of Agriculture (USDA) HealthierUS School Challenge to improve nutrition, physical activity, and nutrition education. In the past 3 years, more than 200 schools (about 40 percent of Chicago elementary schools) have met the challenge, resulting in more than 90,000 students attending schools in which the environment was significantly more supportive of healthy eating and physical activity. Davis added that these changes at the school level have been followed by changes in district policy (e.g., higher nutrition standards that often exceed the HealthierUS School Challenge standards; an extensive local and sustainable procurement program; breakfast in the classroom; reinstatement of recess).
The work of Healthy School Campaign is framed to align with education goals, including improving student growth and development, and addressing the achievement gap. Davis cited the work of Charles Basch (2011) who documented the connection between health disparities and the achievement gap, and identified seven health conditions that have a strong impact on learning. If the education sector is going to address the achievement gap, they are going to have to address health disparities, Davis said, and there are proven best practices for school-based interventions in health.
In 2013, the Equity and Excellence Commission at the U.S. Department of Education released a report providing recommendations on addressing equity in education, and student health was identified as a critical focus area for schools (EEC, 2013). Healthy Schools Campaign is working to connect health and wellness to some of the key strategies the education sector is focusing on to achieve its excellence goals, specifically, data-based decision making, transparency, and professional development.
Data-Based Decision Making
The education sector is placing significant focus on developing data systems to better understand the factors that affect learning and to inform data-based education policy decisions. Given the impact that student health has on academic performance, Davis said, it is crucial to include
information about student health and about how schools support student health among the data collected and in the analysis of student success.
Davis highlighted Texas as one example of how health is being incorporated into data-based decision making. Texas mandates that states annually assess students in grades 3 through 12 on their physical fitness. That information is then compiled by school districts and analyzed to identify relationships between student academic achievement, attendance, obesity, disciplinary action, and school meal programs.
Healthy Schools Campaign has met with the U.S. Department of Education Office for Civil Rights to include health in their analyses. The Office for Civil Rights conducts surveys to document and address inequities in educational opportunities. Although it has one of the most comprehensive sets of data on schools, there is virtually no data on student health and well-being. Healthy Schools Campaign is recommending that data collected include information about facilities, food, fitness, and health services.
With regard to transparency, student performance (i.e., test scores) has long been used to measure a school’s performance, and to compare schools within a district or state. However, Davis noted, there is little information in school reports about anything connected to health and wellness.
Healthy Schools Campaign is working to integrate health and wellness into school progress reports at both the district and state levels. In Chicago, for example, school progress reports include whether or not the school has a Healthy Schools Certification from USDA. The impact of this addition to the report has been significant, Davis said, and is clearly one of the reasons that more than 200 schools across the district have sought to achieve this designation. At the state level, legislation was introduced to authorize the State Board of Education to update their school report card, and the Healthy Schools Campaign successfully advocated for this new report card to include a health and wellness metric.
The education sector is reevaluating how it prepares teachers, principals, and administrators to meet the needs of students today, explained Davis. Healthy Schools Campaign works to ensure that educators also have the knowledge and skills to support student health. In Chicago, Healthy Schools Campaign offers a program called Fit to Learn for teachers and principals on how to incorporate healthy eating and physical
activity into their classrooms and schools. The training provides participants with the research basis for linking health and learning, and focuses on strategies for incorporating nutrition education and physical activity into lesson plans as well as implementing health-promoting rewards and celebrations.
Multi-Sector Resource Support
Davis highlighted several efforts to leverage money from other sectors to meet education goals. Because schools face many barriers in accessing resources from the health sector, Healthy Schools Campaign is advocating for relevant changes to the Medicaid reimbursement rules. Healthy Schools Campaign has also launched a program called Space to Grow, to redesign schoolyards to provide places of active play and outdoor education, and is partnering with the Metropolitan Water Reclamation District and the Chicago Department of Water Management to build these playgrounds to be green infrastructures that will also help to address storm water management issues. Davis also noted that they are encouraging the U.S. Department of Education to incorporate health and wellness into the School Improvement Grant Program, a $5 billion program to support the 5,000 lowest-performing schools.
In conclusion, Davis reiterated that Healthy Schools Campaign is also working to raise these broad issues (e.g., creating health promoting environments in schools) at a national policy level.
A Recipe for Healthy Places is a plan by City of Chicago to address the intersection of food and obesity. The “recipe” contains six community-based planning strategies: build healthier neighborhoods, grow food, expand healthy food enterprises, strengthen the food safety net, serve healthy food and beverages, and improve eating habits. Kathleen Dickhut discussed the first three strategies which all involve land-use, planning, and economic development.
Build Healthier Neighborhoods
Dickhut described three basic steps to building healthier neighborhoods: collect and analyze data on obesity-related health disparities, identify priority communities with elevated risk for obesity-related diseases, and then focus land-use planning on those communities to addresses the situation. Data compiled to identify priority communities included the presence of areas where residents of low-income communities had to
travel more than half a mile to reach a grocery store that is at least 2,500 square feet in size; high food insecurity rates; and high diabetes hospitalization rates.
The Southside of Chicago has several priority communities. The City of Chicago planning staff, with technical support from the Chicago Metropolitan Agency for Planning and grant funding from the U.S. Department of Housing and Urban Development (HUD) Sustainable Communities Initiative has undertaken planning activities under a land-use strategy called Green Healthy Neighborhood.
The second strategy with land-use implications is to grow food. There are many public open spaces in the city for recreation, but urban agriculture is limited. The goal was to create a system of public open spaces for large-scale growing of food, job training, and education. Dickhut described two agricultural sites that have been developed in partnership with the nonprofit organization Growing Home.
Expand Healthy Food Enterprises
The third planning strategy is to support the expansion of businesses involved in the production, processing, and distribution of healthy food, and expand the number and variety of healthy food retail options. Dickhut noted that urban agriculture was not defined in the zoning ordinance, so it was necessary to change the zoning in order to allow the expansion of food production. The new urban agriculture zoning defines urban farm, aquaponics, and hydroponics, and makes them permitted uses for business, commercial, and industrial zoning districts. Vacant city-owned land parcels have been identified for sale to individuals in the community to grow food for private enterprise, including people who have been trained at the nonprofit hubs such as the Growing Home farms.
Work is also ongoing to expand the number and variety of food retail options, including the sale of city-owned vacant parcels of land to develop a retail center with a Whole Foods store.
In the conversation that followed the presentations, the panelists, roundtable members, and other participants discussed how to begin reorienting American culture toward health (and not merely clinical medicine), aligning resources and creating partnerships, engaging young people, and identifying workforce training needs.
Shifting the Culture Toward Health
Moderator Knickman asked panelists their opinion on whether there is a cultural movement toward concern for livability, and whether they have experienced any pushback or heard concerns about such projects not being of value. Collier said that the mayor of Cleveland is very focused on human impact. Understanding the conditions on the ground from a human standpoint allows for a public health response from a land-use perspective. Previously, planners did not take these conditions into consideration when zoning and planning communities. He cautioned, however, about mistaking activity for success. Codd noted that there has been some criticism in Massachusetts, for example, about wasting money on projects for bicycles. But he said that the state feels that offering safe transportation options is essential, and people have repeatedly demonstrated that they want to have these choices. Davis pointed out that there is an enormous amount of activity happening in schools across the country to promote healthy eating and physical activity, and very strong reinforcement of this message from the White House. The concern, she said, is what happens if support from leadership or funding for programs diminishes. It is important that the relevant actors seize the moment and integrate health into the core of education, education metrics, accountability, and professional development. Dickhut agreed that it is important to seize upon the current interests of policy makers and encourage them to make this part of their legacy.
A participant asked for examples of initiatives that might have the potential to be scaled up nationally. Codd suggested that one foundational element that works at the local, state, and federal levels is the Complete Streets approach to designing transportation systems. With this approach, the focus is on spending every dollar to promote access and safety in all modes, and to provide people with the transportation choices that they have shown they want.
Resources and Partnerships
A participant said that there are many tools available to communities for land use planning. The challenge is how to connect these grassroots community efforts toward changing the local infrastructure to the Patient Protection and Affordable Care Act (ACA) and disease prevention. Davis responded that schools can be very important components of community care (e.g., through screening, chronic disease management, prevention, health promotion), but there are barriers at federal and state levels that make it difficult for schools to access health sector resources. Codd suggested that, in the current fiscal environment, new money for initiatives is going to be small (e.g., limited in geographic scope or to pilot programs).
Another approach is to make smarter use of existing funding, for example in the transportation or education sectors.
A participant pointed out that the public sector has enormous purchasing power (not just as a purchaser of health benefits, but also of food and land), and an enormous impact on employment. These are levers that can be used to improve health, he said. With regard to the influence of large-scale purchasers, Collier noted that the Cleveland Clinic has taken some very aggressive steps toward ensuring that employees are healthier, but there has been some opposition. This approach has spilled over into the City of Cleveland, which has begun eliminating sugar-based drinks from all of its vending machines as a practical step toward better health for its more than 8,000 employees. He suggested that ongoing, persistent education and dialogue with local officials is essential for influencing the uptake and institutionalization of healthy community design. Dickhut added the importance of also talking to the constituents about proposed plans for their community. Codd reiterated that the Leading by Example Program of the Commonwealth of Massachusetts promotes environmentally sustainable and healthy purchasing decisions and travel decisions by state employees.
Individual panelists also discussed the role of the business community in building healthier communities, and the potential for partnerships. In Chicago, Davis said, there is a very strong sense that schools are not working the way they need to, and that that impacts business. For example, the corporate community clearly understands that Chicago needs a better education system in order to attract workers that want to live in the city. There is a civic and business advisory committee, and corporations want to come to the table and understand what they can do to improve the schools. Collier added that developers are operating what he considers a community business, and it is important that they view health and its improvement as a business opportunity. Codd said that in Massachusetts, many businesses want to be located in walkable communities with transportation choices.
Roundtable member Marthe Gold noted that school-aged children are a potential constituency, asked whether school systems are talking to students about the experience of being ill and the notion of the value of health for their education. Davis was not aware of such efforts, but responded that in Chicago there is a focus on the violence that children face, including helping children develop different ways of expressing themselves, and helping children who have been subject to bullying or violence. Codd said that Massachusetts does work with students to educate them on the
importance of healthy transportation, such as the statewide Safe Routes to School program. The program includes pedestrian and bicycle safety training, and education on the importance of walking and bicycling and other forms of exercise. Another program is focused on in-school assessments to identify infrastructure deficiencies and safety and access issues that prevent students from walking and biking to school.
A question was raised about the present and anticipated workforce issues (e.g., capacity, training, distribution) associated with applying a health lens to policy making in other sectors and in the implementation of HIAs. Dickhut noted the need for a team approach, because this is not work that one profession or one individual does. There are the planning experts, and the experts in other areas, such as health. Collier said this is not about building a new workforce around HIA. Rather, it is reexamining the existing workforce in these sectors and getting them to operate differently. HIA, for example, can be viewed as a new method of engagement for a planner. The question really is how to reframe the value proposition? Dickhut added that HIAs and efforts to consider health in all policy making are about adding substance, not about creating more work. Codd noted the importance of being willing to accept that things that were traditionally outside one’s particular area of specialization are no longer outside. In fact, he added, health may be at the heart of work in one’s own sector if one understands how the connections are made, and how actions taken affect the broader environment.