4

Regional Perspectives from the Midwest

Panel 2 moderator Surili Patel offered opening remarks on the reality that not everyone is equally resilient to the health impacts of climate change. She encouraged workshop participants to keep this in mind as they discuss policies and strategies for responding to these impacts. Particularly vulnerable populations include children, the elderly, tribal communities, low-income communities, and communities of color. She reiterated a comment that keynote speaker Jonathan Patz made earlier about the importance of listening and encouraged “going into those communities” to gain an understanding of their cultures and histories.

The focus of this second panel was on strategies for responding to climate change that are being implemented by health agencies and organizations in the Midwest. First, Paul Biedrzycki from the City of Milwaukee Health Department emphasized the important role of local public health officials in responding to climate change and discussed how this role is playing out in the City of Milwaukee. Then, Jeff Thompson from Gundersen Health System in Wisconsin, described Gundersen’s goal to become 100 percent energy independent through conservation and the use of renewable energy. This chapter summarizes these two presentations. Key points made by each panelist are listed in Box 4-1.

In the open discussion with the audience at the end of the panel, topics addressed included framing climate change as a health challenge; climate change awareness among health professionals at the national and international levels; what is unique about Gundersen that has allowed it to “push the envelope” with its energy system work; and how health agencies and organizations working on climate change strategies can build trust with

communities. The discussions on each of these issues are summarized at the end of this chapter.

LOCAL PUBLIC HEALTH PERSPECTIVES: CLIMATE HEALTH PREPAREDNESS AND RESPONSE¹

Paul Biedrzycki provided a local health department’s perspective on climate health, including results from a 2014 National Association of County & City Health Officials (NACCHO) survey of local health officers (“Are We Ready? Report 2”), and four examples of climate health adaptation strategies from the City of Milwaukee. The survey results, he said,

___________________

¹ This section summarizes information presented by Paul Biedrzycki, director of disease control and environmental health, City of Milwaukee Health Department, Wisconsin.

characterize the capacity and capability of challenges faced by local health departments across the country.

Milwaukee

The City of Milwaukee has about 600,000 people. Its larger metropolitan area, which now encompasses five counties, totals about 2 million people. Biedrzycki described Milwaukee as a majority/minority and highly segregated community, with about a 40 percent African-American population centered mostly on the north side of the city. There is also a growing Latino population on the south side. Both of these populations, he said, are among the lower socioeconomic status populations in the city.

Being on Lake Michigan, Milwaukee markets itself as the “freshwater capital.” Sometimes the mayor also refers to it as the “freshwater city of the Great Lakes” or the “fresh coast city of the Great Lakes,” according to Biedrzycki. The city’s freshwater center occupies a growing presence in the city’s research, technology, and business.

The Role of Local Public Health

Biedrzycki listed several ways that local public health agencies are well positioned to deal with climate health issues and emphasized that it remains well positioned, even as its capacity and capability are extremely limited these days. First, community health assessment, assurance, and policy development are part of the mission of local public health. Local public health agencies also maintain a focus on health disparities. Biedrzycki referred to Patel’s opening remarks on health equity and added that climate change exacerbates existing health disparities and inequities.

Another factor contributing to the well-positioned role of local public health, in his opinion, is that public health agencies speak articulately on the economic, social, and political intersections related to public health, hence the public health-in-all-policies approach that is now being advocated at many levels.

Finally, Biedrzycki pointed to local public health’s prevention-oriented approach to health care, which, he said, is the most cost-effective approach and “fundamentally reasonable.”

Community Social Capital

In addition to the many other physical and mental health impacts of climate change that were previously identified by other workshop speakers, Biedrzycki underscored the importance of what he referred to as “community social capital.” Interpersonal aggression, violence and crime, and

social instability are often overlooked or underemphasized, he noted, with discussions on climate health issues tending to focus instead on some of the better known impacts on food, water, and air.

Are We Ready?

The first NACCHO “Are We Ready?” survey was conducted in 2008 (NACCHO, 2008), and the second in 2014 (NACCHO, 2014). The surveys measured perceptions of local health officers and departments on climate health, including its underlying causes, human health impacts, and the ability of local health officers and departments to respond to these impacts. The majority of NACCHO’s 2,300 members represent small to medium-sized health departments, Biedrzycki noted. Not surprisingly, in his opinion, the 2014 survey showed that nearly 8 out of every 10 local health directors recognized that climate change is occurring, regardless of underlying attribution, compared to 6 out of every 10 Americans.

Among other health-related scenarios that survey respondents were quizzed on, Biedrzycki pointed to one in particular that stood out to him: disruption of health services for people with chronic conditions. That people who are chronically ill are often impacted when power or other key infrastructure components are disrupted is often overlooked, Biedrzycki noted.

The take away from the survey, in Biedrzycki’s opinion, was that fewer than 5 percent of local health departments had programs to educate the public about climate change and potential impacts. Similarly, only 19 percent have ample expertise and 8.4 percent agree that they have sufficient resources to protect residents from health impacts associated with climate change. This lack of capacity or capability, Biedrzycki said, “pushes us to more innovative, cost-effective collaborations within the community.”

Local Climate Health Adaptation Strategies: Examples from Milwaukee

Biedrzycki discussed in detail four climate health adaptation strategies implemented by the City of Milwaukee that he thought had been particularly effective. The first was a community garden rainfall harvesting program funded by a small grant from the Public Health Institute. One of the program’s two community gardens serves the largest male homeless population in Milwaukee, known as the “Guest House,” while the other, “Alice’s Garden,” provides produce to local markets and restaurants. Both gardens are located in the low socioeconomic area of the north side of Milwaukee. The many co-benefits of rainfall harvesting at these gardens include not just food security, but also reduced runoff pollution, water conservation,

and increased visibility to climate change issues. Having climate conservation within the broader community and in these types of environments in particular is “incredibly important,” Biedrzycki said. Overall, he described the program as win–win, low cost, not a heavy lift, creative and innovative, and a way to bring visibility to the issue.

A second example involves Lyme disease reporting and response within the City of Milwaukee. Biedrzycki described Lyme disease as a very serious disease resulting in joint pain and a rash. It can be treated with antibiotics, but may cause significant cardiovascular and neurological effects later in life. Centers for Disease Control and Prevention (CDC) data show a marked increase over the past 25 years in Lyme disease reporting nationwide, particularly in the northeast and mid-Atlantic states. Biedrzycki stated that many experts believe that the multifold increase in Lyme disease incidence in both the Midwest and northeast is connected with climate change. The disease is transmitted by the black-legged tick, or deer tick, with white-footed mice serving as the reservoir and deer the transporter. As these animals’ ecosystems change, so does their geographic distribution, he explained. In Wisconsin, these ticks, once seen only in the northwest quadrant, are now distributed throughout the state. This geographic redistribution has required a change in both the reporting of Lyme disease and the risk messaging to health care providers and the public on prevention and treatment. For Biedrzycki, this change demonstrates “an adaptive technique associated with potential transmission of communicable disease in a jurisdiction.”

A third example of an innovative approach to climate change adaptation is the City of Milwaukee’s engagement with what Biedrzycki described as “corporate America in Milwaukee.” Milwaukee is the home of several large corporate entities, including MillerCoors, Harley Davidson, and Northwest Mutual Life Insurance Company. The city has been able to engage these companies in public health emergency planning in response to several threats, particularly the post-September 11 bioterrorism threat and the threat of pandemic influenza.

The focus of the city’s current engagement regarding climate health is on business continuity in the face of different climate change scenarios, such as a power outage during extreme heat or a prolonged heat event, a drinking water shortage, or a disease outbreak. Biedrzycki recalled that Milwaukee was the epicenter for the 1993 Cryptosporidium outbreak, which he noted was the largest outbreak ever recorded in North America. During that outbreak, boiled water advisories were in effect for multiple weeks, bringing to light the fact that while water appears to be plentiful in Milwaukee, there are climate-related scenarios that can impact the potable water supply. As another example, he mentioned a more recent toxic algae outbreak in Toledo. He expressed uncertainty regarding whether much of

corporate America nationwide is thinking about this dimension of climate change, even though these outbreaks affect the entire community, including the workforce. Bringing the Milwaukee businesses up to speed on these issues, particularly the risk of communicable disease in the face of a climate event, via a focus group, presentations, and surveys has, he said, “really attracted their attention.”

In addition to businesses’ concerns about continuity of operations, Biedrzycki pointed to their strong interest in green marketing as well. He observed that the emerging millennial workforce has strong sentiments about working for corporations that are sensitive to sustainability and climate change in general.

The fourth and final example that Biedrzycki used to illustrate effective strategies being used in Milwaukee was the city’s development of a heat vulnerability index. When the index was developed in 2012–2013, Biedrzycki considered it a “groundbreaking” effort, given that Milwaukee was one of only five or six cities with one at the time. He explained that a heat vulnerability index overlays natural and built environmental, demographic, socioeconomic, and health behavior variables predictive of heat susceptibility. Milwaukee’s index, which has about 20 such variables, shows that the greatest risk for negative health impacts due to extreme heat is in the poor areas of the city. Biedrzycki remarked that the development of the index, which was funded by a Building Resiliency Against Climate Effects (BRACE) grant, allowed the city health department to “jumpstart” strategic decision making around heat health, for example, where to place cooling centers, how long to keep public swimming pools open, and where to target messaging to vulnerable populations.

Equitable Adaptation and Community Engagement

Biedrzycki concluded with some remarks on the importance of equitable adaptation and community engagement. First, he referred to a 2016 summit held at the Georgetown Climate Center in Washington, DC, on opportunities for equitable adaptation in cities. At the summit, some key tenets associated with equitable adaptation were identified. He stressed the importance of these tenets given what is known about how even small impacts of climate health exacerbate existing inequities. The tenets include, for example, building trust between government and the public and leveraging community-driven networks and resources to address climate health scenarios.

Finally, he mentioned a community engagement toolkit for Wisconsin, funded by the BRACE grant, that is now being integrated into local health department emergency planning, especially with respect to climate change scenarios (Wisconsin Climate and Health Program, 2016). Additionally,

NACCHO’s 12 steps to operationalize climate change,² which were meant to serve as guidance for local health departments, underscore community engagement for the development, implementation, and evaluation of climate adaptation strategies.

Moving Forward

In summary, Biedrzycki listed the steps that have been built into Milwaukee’s climate health planning and response:

• Build community awareness and inspire action, especially among local policy makers, such as the mayor’s office (i.e., making the economic argument compelling and convincing to policy makers);
• Leverage community networks and resources, particularly given that “the money just isn’t there right now,” according to Biedrzycki, and be creative about programs in environmental health, communicable disease, and emergency preparedness that are already on the ground;
• Incorporate climate adaptation into the economic sustainability and urban planning framework; and
• Advocate for climate equity.

PROTECTING THE HEALTH AND WELL-BEING OF COMMUNITIES IN A CHANGING WORLD³

Gunderson Health System is an integrated health care system with a number of hospitals and clinics across Iowa, Minnesota, and Wisconsin. Jeff Thompson provided an overview of Gundersen’s energy system work, including how and why they took on the climate change and sustainability issues that they did. One of the great leverages that Thompson and his colleagues used to initiate Gundersen’s energy system work and communicate not only with the board, but also community partners, was the purpose of the organization: “Our purpose is to bring health and well-being to our patients and communities.” They described “health and well-being” broadly to also include financial health, social health, and environmental health.

___________________

² The 12 steps are described at http://www.naccho.org/uploads/downloadable-resources/NA634PDF-12Steps.pdf (accessed May 9, 2017).

³ This section summarizes information presented by Jeff Thompson, executive advisor and chief executive officer emeritus, Gundersen Health System, La Crosse, Wisconsin.

Arguing for Energy Independence (Without Mentioning Climate Change)

Regarding why a health care organization would want to become involved in activities related to climate change and sustainability, the answer, Thompson said, is “the incongruity.” He explained that the mission of Gundersen is “We will distinguish ourselves through excellence in patient care, education, research, and improved health in the communities we serve.” Yet, he said, “we’re supposed to be keeping people healthy, but we’re killing them with our pollutants.”

According to the U.S. Department of Energy, hospitals are 2.5 times more energy intensive than schools and other commercial buildings. Given that the health care sector accounts for approximately a sixth of the economy, its energy impact is huge. Pharmaceuticals and hospital equipment have an even bigger carbon footprint, Thompson noted. To add to this, in 2008 when Thompson and his Gundersen colleagues began their efforts to change Gundersen’s energy use, they believed that energy prices would continue to rise. Although what Thompson described as the natural gas “glut” has flattened a bit, today they continue to believe that prices will eventually rise again. Finally, Thompson and partners also believed that reducing waste would result in greater savings.

Thompson clarified that he and his colleagues did not set out to “sell climate change” to the board. Even mentioning climate change, he said, especially back then, would have “been a fail.” He admitted, however, that if they were to have asked him about climate change, he would have told them that there is better evidence for climate change than for the majority of treatments Gundersen provides in its institutions. Nor was climate change the discussion back around 2008, Thompson explained. Rather, the discussion revolved around how to decrease pollution that is causing harm to people, how to do so while decreasing operating cost, and how to improve the local economy and stop sending money out of the state (e.g., importing coal from Wyoming for electricity and natural gas from Texas for heat). It was also believed that changing the energy system of Gundersen would help the organization to “truly live” its mission, as opposed to “just giving lip service.”

Finally, some of the inspiration for their efforts came from Natural Capitalism, which Thompson described as a book about ignoring conventional wisdom that one must choose between jobs or the environment (Hawken et al., 1999). In making their case to the board, Thompson and partners argued that their proposed energy plan would be the best use of Gundersen’s savings; that Gundersen would receive a good return on investment; it would be safer than the stock market (i.e., again, Thompson noted, this argument was put forward in 2008); that the local investment required of the plan would make for great public relations; that there were

available partners in the community (e.g., Thompson commented on the faith community in particular); and that Gundersen’s early conservation projects had been successful. Regarding the last point, Thompson noted that, by spending $2 million in the first 2 years of the program, Gundersen realized savings of $1.2 million in every following year.

Another argument that can be made when trying to build coalitions of people, Thompson said, is “to face the brutal facts.” In 2008, Gundersen was emitting 435,000 pounds of particulate matter, more than 70 million pounds of CO₂, and nearly 2.5 pounds of mercury every year. Regarding the mercury emissions, Thompson explained that one gram of mercury pollutes hundreds and hundreds of acres of water, so pounds pollute tens of thousands of acres. He noted that the reason pregnant women and children are advised not to eat fish from lakes in upstate New York is that the water is contaminated with coal debris from Wisconsin and elsewhere. “So this is truth,” he said, referring to these emission figures from 2008. “This is what we’re doing.”

Achieving Energy Independence: Gundersen’s Strategy

Gundersen set a goal in 2008 to be 100 percent energy independent by 2014, with a key component and the first step being to decrease energy use. Thompson emphasized that energy conservation does not require Congress passing a law or the generation of new energy. It means simply saying, “We are going to start conserving.” As a result of its initial conservation efforts, Gundersen Health expected to achieve in 2017 a 59 percent improvement in energy efficiency compared with 2008 (see Figure 4-1).

After its initial conservation phases, most of the next steps in Gundersen’s effort to gain energy independence have involved the generation and use of renewable energy, beginning with wind energy generation and a landfill bio-gas project (see Figure 4-2). Regarding the latter, the county installed a pipe from the county landfill to Gundersen’s northern clinic so that Gundersen could buy and use the gas from the landfill. Today, Gundersen uses the gas to heat, cool, and power an entire campus, while the county receives $250,000 per year. Prior to this landfill bio-gas pipe being built (i.e., by Gundersen), that gas, Thompson said, was “just being flared into the atmosphere.” The project, Thompson said, has been good for Gundersen by lowering the cost of care; good for the community by providing a source of income so that the county does not have to raise taxes; and good for the environment because it displaces other energies, namely coal, which is a major source of electricity in the upper Midwest.

As illustrated in Figure 4-2, in addition to conservation, wind energy, and the landfill bio-gas project, Gundersen has also invested in geothermal fuel, a high-tech biomass boiler, a dairy bio-gas project, and a variety of

other projects. Thompson noted that the financial returns for each of these projects vary, but emphasized that all of these forms are renewable energy. For example, a biomass boiler uses hardwood chips that otherwise would just rot into the ground, while dairy bio-gas not only generates electricity, but also prevents both methane from entering the atmosphere and phosphorous from entering lakes and triggering massive algae blooms.

Not all of Gundersen’s renewable energy efforts have been successful, Thompson acknowledged. Their brewery bio-gas attempt, for example, failed. The goal of that project was to generate electricity from beer gas. But the company they had partnered with switched to working on other projects. Plus, the company used a method that relied on sulfuric acid, which damaged the bio-gas engine.

Reduced Fossil Fuel Emissions

Again, the goal set back in 2008 was to become 100 percent energy independent, Thompson continued. He remarked that while 2016 saw only 90 days of energy independence, Gundersen’s fossil fuel emissions have been reduced by more than 90 percent. Specifically, in contrast to the 72 million pounds of CO₂ emitted in 2008, only 1.6 million were emitted in 2016, representing a 98 percent reduction; in contrast to the more than 435,000 pounds of particulate matter emitted in 2008, only 11,000 were emitted in 2016, representing a 97 percent reduction; and in contrast to the more than 2 pounds of mercury emitted in 2008, only 0.16 pounds were emitted in 2016, representing a 94 percent reduction.

Increased Return on Investment

Not only have fossil fuel emissions improved, but Gundersen has also made money on these efforts by changing its investment portfolio. Specifically, Thompson explained, by removing 5 percent of savings (i.e., from cash, treasury bills, bonds, and stocks) and reinvesting these funds into Gundersen’s energy infrastructure, their return has increased from 5–6 percent to 10–12 percent. Reinvesting what he described as “stranded assets that are sitting there that could be used for other things” is, he said, “a different level of thinking.”

As a result of these efforts, Gundersen’s energy expense remains below the 2008 spending level (i.e., $5,016,000 in 2015, compared to $5,348,264 in 2008) and well below what would have been spent if they had maintained “business as usual” (i.e., projected $7,688,000 in 2015).

The local economy has been boosted as well, Thompson noted. “So you can’t tell me it’s jobs versus the economy,” he said. He added that beyond improved health and savings for the health system, staff pride has

blossomed, Thompson continued. The environment and sustainability are part of the value set of college graduates today, and thus Gundersen has been attracting employees because of its energy program.

Concluding Thoughts

Thompson concluded by reiterating that Gundersen did not set out to “save the climate.” Rather, its pitch revolved around health and the economy. He encouraged workshop participants to visit Gundersen’s website (www.gundersenhealth.org) to learn more about the mechanics of what it has done and to read his book, Lead True, on value-based decision making (Thompson, 2017).

DISCUSSION

Following Thompson’s presentation, panel moderator Patel commented on the emphasis that both Thompson and Biedrzycki placed on partnerships. “Understanding climate change is such a big feat,” she said, “that we can’t do it on our own.” She referred to Biedrzycki’s statement that less than 5 percent of local health departments, who are on the front line, have the capacity to respond to climate change. That, she said, is why partnerships are so important. In addition, she appreciated Thompson’s emphasis on the reality that calling the challenge “climate change” does not matter. That is, regardless of the language used, she said, “the solutions are where we are going to benefit the most.” The two panelists then addressed several questions from the workshop audience.

Framing Climate Change as a Health Issue

Linda Rudolph observed that both Jonathan Patz and Georges Benjamin had emphasized the importance of framing climate change as a health issue earlier in the morning, yet Thompson, in this panel, spoke about not leading with climate change. Additionally, she remarked that based on having perused many local health department websites, including Milwaukee’s, climate change is not prominent in any but a small number of local health department communications. She asked the panelists how they reconcile these different perspectives and what they think the responsibility of health leaders is with regard to raising the level of awareness among both policy makers and the public that climate change is one of the greatest health challenges today.

Thompson replied that in 2007–2008, he realized that what he wanted to do with Gundersen’s energy system would require millions of dollars of investment. If he had told the board he needed millions of dollars to

mitigate climate change, he said, “it would have been a non-starter . . . they would have just shut me down.” He had to identify where their values overlapped with his. Again, he said that if they had asked him about climate change, he would have been very clear about climate change and its devastating health effects. In fact, he has spoken out about climate change at a number of places in his community, as well as regionally and around the country. He mentioned, again, that there is better scientific evidence for climate change than for most medical treatments in the United States. But to move forward within his organization, he had to frame the problem in a different way.

Biedrzycki replied that while he had mentioned during his presentation that local public health departments were on the front line, it is actually the private health care providers who are on the front line. Private health care, in his opinion, has an essential role in broaching the climate conversation within the community. The reason climate change is not mentioned on Milwaukee’s health department website, or on any of the Wisconsin municipal websites, is because it is not politically popular at this time to even say “climate change” given the state’s current governor and some of the state’s municipal leaders, he said. He called for a way to navigate conversations with policy makers and other key community leaders and champions so that the impacts of climate change can be addressed in a manner that creates a win–win solution—in other words, one that results in cost-effective economic solutions that are good for both the community and business. “We recognize the challenge,” he said, but “have yet to come up with an easy solution.”

Climate Change Awareness Among Health Professionals at the National and International Levels

Jonathan Patz asked Biedrzycki about the pervasiveness of climate change awareness among members of NACCHO. He asked if climate change is “on the table” nationally. Additionally, he asked Thompson whether, based on Thompson’s recent international trips and audiences, climate change is gaining traction among health ministries.

Climate change is gaining traction at NACCHO, Biedrzycki replied, particularly among the emerging, younger workforce. For example, NACCHO now has a climate health workgroup. But most of the discussion has revolved around what is being done locally. He acknowledged that local case studies can be stimulating, particularly with respect to their demonstration of unique partnerships and collaborations with nontraditional stakeholders and of ways to shift the dialogue outside of what Biedrzycki called the “groupthink” around climate health issues. However, he called for a comprehensive strategic plan and for strong national leadership as

well. Currently, there is no cohesive, comprehensive strategic plan that links what local public health agencies are doing with what is being done by state and federal agencies. Noting that the intention was not to be overly critical of CDC and that he was aware that the American Public Health Association was a strong advocate and promoter, in his opinion, there is no strong national leader or champion. Until a national leader emerges, he said, “I think we are going to struggle with developing this comprehensive plan that interlinks us horizontally and vertically across our communities nationwide.”

Thompson added that the opportunity is not dissimilar to other times in history when governments “dragged their feet” for political, financial, or other reasons. He said there are many examples of middle-sized organizations, like Gundersen Health System, moving forward on their own to make a change. Additionally, he mentioned a group of mayors, some states, and a medical society group that are all moving forward despite the federal government’s stance. He also noted that internationally, even in China, most of the world recognizes the urgency of the challenge. He said, “I think the movement forward is to say, ‘The cause is so important that we will build coalitions of people with similar values . . . and a similar goal.’”

What Is Unique About Gundersen Health System?

David Kindig asked Thompson what the state of acceptance is regarding Gundersen’s energy use and investment program and what is unique about Gundersen that has allowed it to “push the envelope” as it has. Thompson replied that the state of acceptance is “on a steady upward curve.” A few years ago, Thompson and colleagues developed the Healthy Hospital Initiative. In the course of just 3 years, membership grew from about a dozen organizations to about 1,400 hospitals and health systems across the country reporting on how they are doing with energy conservation, waste management, and water. There is escalating interest, he said, both with respect to the effects on health and the fact that this can be done in an economically viable way. However, he did not expect anyone to adopt the Gundersen model exactly, because different places have different environments and costs. For example, places that have more sun and lower photovoltaic costs would likely benefit more from solar energy than from diary digesters. He added that, in his opinion, while acceptance is happening, it is not happening quickly enough. He suspected that it will take a generational change in leadership to make doing what Gundersen has been doing “more natural.”

Regarding the uniqueness of Gundersen, Thompson remarked that one of the things that is appreciated at Gundersen is long-term thinking. There are no political cycles at Gundersen, he said, nor do they provide yearly

bonuses for executives. Thus, their tolerance for risk is a little higher than it might be otherwise. But most importantly, in his opinion, is that what they have done is consistent with a values-based approach, one that would not shift with every quarterly report. Initially, finance was treated as a tool, not a goal. This does not mean that they did not have to hit financial targets. They did, Thompson said. But treating those targets as a tool to accomplish a mission, rather than as a goal for either the organization or individuals within the organization, made it easier initially to engage government, nongovernmental organizations, business, and other partners.

Biedrzycki added that, in his opinion, what is missing in the current narrative is what success looks like from a climate-healthy business economy and how that success intersects with national security and economic goals. Until that narrative is written and that intersection is defined, which he said is something typically done by the citizenry, it will be difficult to establish a good strategic plan and predict a future trajectory.

Building Trust

Patel asked Biedrzycki to provide an example of the trust building that the City of Milwaukee has done with communities. Biedrzycki defined trust building as genuine and authentic relationship building. In his opinion, it is at the core of many public health programs. But it is difficult to achieve, he said. It takes time, face-to-face encounters, and development of win–win situations that are mutually consensual and agreeable. He referred to Milwaukee’s rainfall harvesting project, which he had described during his presentation, as an example of a win–win relationship on many fronts. For example, the garden that is located in a male homeless shelter represents a win for public health by engaging that part of the community and a win for the community by providing food security for what is a very vulnerable population. Additionally, Biedrzycki pointed out, the project has supported Milwaukee’s award-winning HOME GR/OWN initiative by repurposing vacant properties into community gardens. The project’s success required agreeing, beforehand, on what constitutes successful outcomes for each partner. Building the trust to do that requires time. “It’s not prescribed,” he said, “It’s developed.”

Sanne Magnan observed that the rainfall harvesting project appears to have built what Biedrzycki had referred to in his talk as “community social capital.” She asked whether it is a lack of such capital (i.e., decreased community cohesion, increased social instability) that affects the ability to work on climate change or if it is working on climate change that impacts this capital. Biedrzycki responded, “Both.” He reminded the workshop audience that Milwaukee is a highly segregated city with great racial divides. As they have done in many urban communities, these divides have

created tensions among the government—in Milwaukee’s case, the police department—and its citizenry. This tension, he said, can work against building trust. On the other hand, when meaningful seminal partnerships are formed, as they were with the rainfall harvesting project, then these tensions can be assuaged and trust can be built.

Also related to the issue of building trust, Pamela Russo of the Robert Wood Johnson Foundation commented on the clear win–win situation demonstrated by Gundersen’s investment in the community. She then asked first, whether any of the work that Thompson discussed was counted in the organization’s community reporting, and second, whether there were any issues or hindrances that made it difficult for Gundersen to move forward in any particular localities or states. Thompson was unsure which of their many community partnerships were reported. Regarding the second question, he referred to the “morass” of rules and regulations, which are different in every state, and the complexity this creates. Despite this challenge, he said they had good luck working with the state governments, and with the federal government as well. He said, “We’re almost always able to find people who are inspired enough to roll up their sleeves and say, ‘Let’s find a way,’ rather than just say, ‘No, you can’t do that.’”