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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
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4

Achieving Equitable Healthy Environments

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

Equity is a major issue to address within the built environment, said Shiriki Kumanyika, emeritus professor of epidemiology at the University of Pennsylvania Perelman School of Medicine and research professor in the Department of Community Health and Prevention at Drexel University’s Dornsife School of Public Health. To take just one example, she cited a recent report from the CDC stating that non-Hispanic blacks and people with a high school education or less have the lowest prevalence of walking for transportation or leisure (Ussery et al., 2017). Differences in walking prevalence by education among men have widened over time, she noted, warning that inequities can increase even when the aim is to be inclusive. “Doing the right thing,” for both the built environment and health, “may not work well for all population groups,” she cautioned.

Specific and targeted actions are necessary to counter such inequities, Kumanyika asserted. She suggested, for example, that communities can implement walking programs tailored to the interests and abilities of specific population groups, and streets can be designed so that walking is safe and convenient for everyone. She emphasized that approaches that consider people with less social capital who historically have been underserved could help reduce disparities in communities with minority residents of low socioeconomic status. “We can achieve equitable communities if we are intentional, we know what the principles are, and we adhere to those principles,” she argued.

In the third session of the workshop, moderated by Kumanyika, four presenters described exemplars of equity-focused work in the built environment.

PROVIDING ALL CHILDREN WITH OPPORTUNITIES TO PLAY

The KaBOOM! organization focuses on transforming the built environment to make it as easy as possible for all children, particularly those growing up in poverty, to play, said the organization’s chief executive officer, James Siegal. He emphasized how play not only produces active minds and active bodies but also enables children to make friends, build strong bonds with caring adults, and develop creativity and cognitive skills. “Play benefits the whole child,” he stated.

KaBOOM! has been building playgrounds in partnership with underresourced communities for 22 years, Siegal noted. He explained that the organization was founded by Darrel Hammond after he read an article about two young children who died after becoming trapped in a hot car while looking for a place to play in Washington, DC. The article reported that there were no places for children to play in the neighborhood, and Hammond was motivated to create the first KaBOOM! playground in

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

1995. The work continues today, Siegal reported, and KaBOOM! recently completed its 3,000th playground.

Despite its importance, play is disappearing, Siegal continued. The current generation of children is playing less than any generation before them, he observed, “leaving kids unhealthy, unhappy, and falling behind academically.”

Parents are well aware of the importance of play in their children’s lives, Siegal stated, arguing that the problem is action. To better understand the roadblocks parents face in getting their kids to play, he explained, KaBOOM! worked with the nonprofit group ideas42, which uses behavioral science to address issues facing society. He reported that the first key insight from ideas42 was that parents can go through the whole day and not even think about their children’s play. Nutritional choices occur repeatedly throughout the day, he elaborated, but daily life does not have “natural moments” when parents are forced to think about play. Second, he reported, ideas42 found that even if parents do think about play, the hassles of making it happen can get in the way: Is there a safe way to get to a park? Do children have the right clothes? Does the park have a clean, publicly accessible bathroom? “All these little hassle factors add up,” he noted, and “make it too easy for parents or other caregivers to say, ‘Sorry, now is not the time to play.’”

According to Siegal, to overcome these roadblocks, ideas42 suggested that communities integrate play into the everyday spaces and daily routines of children and families. Cities can have great play destinations, such as parks and playgrounds, he elaborated, but they also need playable sidewalks, bus stops, grocery stores, health clinics, and “all the places that kids and families are already spending their time.” “Play can transform these moments into moments of joy,” he added.

Siegal went on to say that KaBOOM! saw that very few communities were working to integrate play into the daily routines of children and families. To address this, he explained, the organization collaborated with the Robert Wood Johnson Foundation, Target, the U.S. Department of Housing and Urban Development, the National Endowment for the Arts, and Playworld to solicit ideas for innovative, replicable ways of integrating play into the daily environment, a concept called “Play Everywhere.”

From the 1,000-plus contributions it received, Siegal continued, the collaboration identified 50 winning ideas for creating kid-friendly public spaces that are “wondrous, inviting, convenient, challenging for kids, unifying, and shared.” He described several examples: in the San Francisco Bay area, a lot sometimes used for parking was converted into a giant sandbox; 1,200 people turned out the day it was opened. In Lexington, Kentucky, the transit center was outfitted with a playable installation that drew children away from traffic. In Miami, dead end streets formerly used for dumping

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

and other illegal activities were converted into playgrounds that drew multiple generations out to play. In New Orleans, a group called Urban Conga transformed a bus stop in the lower 9th ward into a musical play area called the Hang Out, where children could play drums and otherwise play while waiting for the bus. As a final example, Siegal cited the city of Nashville, which transformed a shipping container into a play structure that could be loaded onto a truck and moved from one place to another. Siegal went on to observe that “These and dozens of other Play Everywhere Challenge ideas are coming now to life and hopefully will spur other communities to follow their lead.”

In the communities KaBOOM! serves, safety concerns such as unsafe traffic, illicit activity, and violence create additional barriers to play, said Siegal. The health community, he asserted, needs to acknowledge this reality and find solutions that create safe places for children to play. He cited the example of Baltimore, where KaBOOM! recently partnered with a public housing development that had no play spaces for children. To overcome safety concerns, he explained, the playground was placed in the development’s courtyard, surrounded by row houses on all four sides, creating a natural surveillance system. “As Jane Jacobs would say, the eyes on the street are critical to neighborhood safety,” he noted. “And now everyone looking out of their back windows has a line of sight to where those kids are playing, and hopefully that will create a safe environment for them.”

Siegal stressed that solutions cannot benefit a privileged few. “Everywhere means everywhere,” he stated. “It means integrating [play solutions] into everyday spaces in underresourced communities. . . . It means every public housing facility and every public elementary school and everywhere else kids who need it most live and learn.” Low-income children are particularly in need of these solutions, he argued, because according to research by ideas42, they spend more time than their more affluent peers doing chores and running errands with their parents and caregivers as there is no viable alternative for childcare (Tantia et al., 2015). Moreover, he observed, their schools are less likely to have adequate places to play. “It is shocking that in most major cities across the country,” he said, “most elementary schools in underresourced communities do not have adequate play opportunities. You take it for granted in most communities, but it is not the case where most kids live.”

To make play a part of the lives of children everywhere, Siegal asserted, a renewed sense of urgency is needed. “What we hear from the communities that we work with on the ground is that they have had decades of disinvestment and decades of empty promises,” he said. “There is a hopelessness that comes from [thinking] that change is not possible. We have to help overcome that hopelessness before any change is possible.” One approach, he observed, is to seek quick wins that can link to larger-scale change. For

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

KaBOOM!, he noted, the “special sauce” is in the process of developing play spaces, which engages community members in caring for children. The process starts with children, he explained, who design their dream playground, “and then we help bring it to life.” He added that several hundred volunteers come together to build a playground in 6 hours. “It is like a modern-day urban barn raising for kids,” he said. “It is a cathartic moment that makes people care about the changes that are happening in their community and gets them to think bigger about what is possible.”

These quick wins can drive larger-scale change, Siegal argued. He urged the health community to help create linkages between shorter-term outcomes, such as increases in social cohesion, community pride, and perceptions of neighborhood safety, and longer-term health outcomes. He suggested that researchers could investigate how these short- and intermediate-term outcomes link to the health outcomes that are desired.

Responding to a question about local regulations, Siegal noted that every playground faces the challenge of obtaining building permits. Generally, he explained, the communities get the permits, with KaBOOM! providing technical assistance with the process. The most successful projects with which he has been involved have had co-leadership between government and a nonprofit organization because government partners are adept at the permitting process, while nonprofits are good at community engagement. “A lot of good things are happening in communities,” Siegal observed. “We have a lot of momentum. If we roll up our sleeves and engage in the change process, we can get a lot done. As a result, kids are going to be happier and healthier.”

COMMUNITY ENGAGEMENT IN ALAMEDA COUNTY

Kimi Watkins-Tartt, deputy director of the Alameda County Public Health Department, defined health equity as achieving the highest level of health for everyone. “Health equity,” she elaborated, “entails focused societal efforts to address avoidable inequalities by equalizing the conditions for health for all groups, especially those who have experienced socioeconomic disadvantage or historical injustices such as racism.” She described the goal of the Alameda County Public Health Department as ensuring that all residents of the county, regardless of where they live, how much money they make, or the color of their skin, can lead a healthy, fulfilling, and productive life. “Unfortunately,” she said, “in our county, that is not the case. The projects that I am going to talk about work to address that.”

Watkins-Tartt explained that the department has approached its equity work by focusing on policy and systems change, institutional change, and community collaborations and partnerships that include residents. She offered three examples that incorporate this approach.

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

First was the Ashland and Cherryland Community Health and Wellness project, part of the Alameda County General Plan, which sets the policies for how the county uses and manages its physical, social, and economic resources. The General Plan is not just a land use plan, Watkins-Tartt emphasized, although land use is an integral part of it.

Watkins-Tartt explained that the Ashland and Cherryland Community Health and Wellness project is based on the principles of equity, accountability, collaboration, diverse resident partnerships, and the development of local assets. She added that the project used a website so that residents of the community could track the progress of the planning process, a wellness advisory council to hold planners accountable and to make sure residents’ voices were heard, workshops so that residents could participate in the process, outreach in community events so that people who could not participate in some of the more formal structures were able to see what was happening, a communitywide survey of every household to hear from people who were not able to participate in the other venues, and focus groups to obtain more detailed information on what the residents wanted. The objective, she said, was to ensure that the residents most often left out of the planning process were instead front and center.

Watkins-Tartt described the plan, which was approved by the board of supervisors in December 2015, as a success, and noted that it also produced some lessons for similar initiatives. First, she said, future plans can try to avoid being dependent on champions within organizations: “As we all know, as organizations change, people move on. If that is how this is getting done, then some of the work can stall or just come to a halt altogether.” A second lesson she shared is that a more formal structure could help ensure that the planning department uses the policy document consistently to maintain the vision of the community. “We are working on putting that structure in place now,” she added. She observed that one of the primary strengths of this effort was the deep engagement of the residents of Ashland and Cherryland and the community partners, who now have collective ownership of the values and the intentions of the project.

Watkins-Tartt then described a partnership with the East Oakland Building Healthy Communities group, which is funded by the California Endowment, to incorporate a health equity lens into the City of Oakland planning department’s reviews of new projects. A collaborative group created Healthy Development Guidelines as a tool to be used by the planning department and the general public to better understand the city’s requirements and expectations for health equity. Watkins-Tartt noted that the guidelines were intended to benefit the health of both new and existing residents, especially those who face the greatest exposures to cumulative health impacts or the effects of multiple environmental exposures. She added that the group worked diligently with community leaders to convene

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

a half-year process focused on developing the vision and priorities of the tool and then led follow-up meetings and events to share updates, determine ground truth for the various drafts, and obtain residents’ feedback. As one resident said, “[This has been] an opportunity to be true partners. I can see how these [guidelines] could have been made without residents at all. We have partnered because we have something to say. We have a lens that should always be there. We know how [development] will affect the people who live here.”

Watkins-Tartt described the role of the public health department as helping to convene a technical advisory group that included community-based organizations, the City of Oakland, public health staff, developers, and consultants, which met after the resident meetings to review their input and develop policy goals and standards. She added that city planners provided helpful feedback on existing policies and technical details to ensure that the new standards would be implementable. “It was a long and iterative process,” she observed, “and naturally issues of capacity and trust came up quickly.” She stressed the importance of trust and accountability, and of sustaining the vision of the residents in the process of creating the standards. She explained that informing residents helped involve and engage them authentically, and the public health department built on its own knowledge by gathering the perspectives of everyone at the table. She added that opportunities for transparency were created so that residents could see that their vision was not being lost. As an example of the changes made, she reported that the new guidelines include language about displacement and ensuring that people who live in Oakland are not forced out when development occurs.

“We consider the guidelines to be an interim step,” said Watkins-Tartt. “We are hoping that we will be able to participate in a more formal process of including objectives and health equity language into the city’s general plan at a future date.”

Finally, Watkins-Tartt described an effort to change the physical and social conditions of low-income neighborhoods by improving the food retail environment. She pointed to the Healthy Food Retail project, which is designed to achieve and sustain healthy food retail environments in the neighborhoods most burdened by chronic disease. She explained that the project included demonstrations in both east and west Oakland, research on local policy options to institutionalize promising practices, and identification of resources for a countywide effort. She noted that two community-based organizations—the Hope Collaborative and Mandela MarketPlace—implemented the project along with public health staff. Each of these organizations has a unique approach to its work, she elaborated, but they share the approach of engaging residents in the surrounding neighborhoods to inform the approach being taken. She added that the

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

two organizations worked with stores to increase the availability of healthy foods, reduce the shelf space allotted to such unhealthy products as tobacco and alcohol, reduce advertising for unhealthy products, and increase the visibility of the choices available in stores.

Watkins-Tartt described one success of this project as having much deeper relationships with store owners, which increases their investment and participation. She noted that the public health department has used its own resources to garner additional funding to support store changes. She explained that store owners are under economic pressure to replace lost profits from unhealthy products, to cover the high costs of making improvements in their stores, and to change negative perceptions of the stores among the neighborhood residents and law enforcement. “What we have learned,” she said, “is that asking store owners for layout changes is possible, but [it is] easier after there is a relationship. Once tobacco and alcohol ads were reduced, customers started to look at the store differently and see them as places to purchase healthy food.” She added that as the demographics of many Oakland neighborhoods change, the department is working with stores to strike a balance among the increasing demand for healthier products, the increasing ability of customers to pay higher prices, and the needs of long-term neighborhood residents. “Offering a variety of store interventions contributed to the success of this model,” she stated.

Watkins-Tartt noted that she has been with the public health department for more than 25 years, and asserted that a key ingredient in transforming practice is leadership. “For us,” she said, “it has been evolving over time to look at public health as being more than just about caring for sick people, though that is a lot of what we do.” She added that work on upstream factors and the built environment was not a part of the health department 25 years ago. “It has taken a constant commitment,” she noted.

Watkins-Tartt also emphasized that community members in Alameda County expect to be involved. “If we do anything that they are not driving and they are not at the center of, they are very quick to say, ‘Wait. That is not how you guys do things. That is not how we do things here.’ That is where the accountability comes in,” she observed.

In closing, Watkins-Tartt said, “We know that, when we make changes in the environments that people live in, their health will improve. The challenge is to make sure that the people who we so often read about in the data are at the center of the conversation. They have to drive it. They have to shape it. And they have to own it.”

DEVELOPING HEALTHY COMMUNITIES

Sara Hammerschmidt, senior director for content at the Urban Land Institute (ULI), described it as an 80-year-old nonprofit organization dedi-

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

cated to promoting best practices in real estate development. She explained that it uses convenings, research, case studies, and other strategies to help its 40,000 members achieve its mission, which is to help create and sustain thriving communities worldwide.

In 2013, the Institute launched the Building Healthy Places Initiative, whose purpose Hammerschmidt characterized as engaging the Institute’s membership and networks in shaping places and projects in ways that improve the health of people and communities. “It was launched out of a recognition that many global health trends are pointing in the wrong direction,” she said. “We recognized that the real estate community needed to do more to be part of the solution to our global health problems.”

According to Hammerschmidt, the Institute’s theory of change is that its members (who represent development, design, financial services, the public sector, and other land use professionals) can promote health in three ways. First, in their own organizations, members can create and promote policies that boost the health of their employees. Second, in their investment and project decisions, they can promote healthy and thriving communities. And finally, in the influence they have on their own communities, they can increase opportunities for people to be active or enhance their access to healthy food. Hammerschmidt asserted that the private sector has a responsibility to create healthy places that do not exacerbate inequities.

At the same time, however, Hammerschmidt acknowledged that there are differences in understanding and terminology between real estate developers and public health professionals. For example, she observed, the word “equity” has two definitions. In the context of this workshop session, she noted, equity means “just and fair inclusion.” “An equitable society is one in which all can participate and prosper with a goal of creating conditions that allow us all to reach our full potential,” she elaborated. She cited as another definition that equity is the value of the shares issued by a company. “Equity, to a real estate developer, is more along the lines of the second definition,” she observed. “Equity in real estate relates to the component of development capital provided by investors who obtain the return mainly from project performance. These are very different definitions and very different meanings of the same word.” To overcome this barrier, Hammerschmidt continued, ULI is working to explain equity issues from a land use perspective and encourages its members to learn from and form new partnerships with other disciplines, including public health. “We know it is going to take coordinated effort to improve our built environments in ways that improve health for all,” she said.

Hammerschmidt then described how, as one way to improve the built environment, ULI issued a joint call to action with seven other built environment–focused membership organizations, including the American Institute of Architects, the American Public Health Association, and the

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

American Planning Association, that encouraged the more than 450,000 individual members of these organizations to promote healthier and more equitable communities.1 She added that members of the partnering organizations, which include architects, planners, engineers, public health officials, recreation and park administrators, and other professionals, are encouraged to build relationships, share expertise, establish health goals within their projects and plans, implement strategies and certification systems that improve health, and communicate with other professionals about the importance of health.

As an example of a specific project, Hammerschmidt described ULI’s Healthy Corridors work. Unhealthy, automobile-centric, commercial corridors exist in almost every community, she noted, adding that they make it challenging not only to walk and bike but also to access healthy foods, transit, jobs, and other services. Moreover, she observed that these corridors often cut through low-income neighborhoods, separating residents from each other and from the places they need to reach.

The Institute has done work on such corridors in the past, Hammerschmidt noted, but realized that less attention has been paid to the health issues that arise for those people who live, work, and travel along the corridors. She explained that to address this issue, ULI has been working closely with its local chapters on demonstration projects designed to show how a focus on health and equity can change the standard approach to urban and suburban arterials. She listed the key questions the project is seeking to answer: What is a healthy corridor? How can a focus on health and equity inspire community action? How can low-income people and people who live in lower-income neighborhoods be better served by these roads? What are the barriers to healthier corridors, and how can they be overcome? For each “demonstration corridor,” she explained, there is an interdisciplinary local group guiding the work that includes business owners, real estate developers, planners, elected officials, community representatives, public health professionals, and others. “We have been convening stakeholders and bringing in national experts to help each corridor address specific challenges and create actionable plans for change,” she said.

Hammerschmidt also mentioned several specific development projects that are working to improve health and provide more equitable access to housing and services. She described Aria, Denver, as a new community that was designed with an intentional focus on the health of not only its residents but also the surrounding communities. It sits on a 17-acre site that was formerly home to a convent. The development has a 1.25-acre production garden, a greenhouse, and other features to accommodate access to fresh produce. A pay-what-you-can farm stand allows residents of

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1 See www.planning.org/nationalcenters/health/calltoaction (accessed November 7, 2017).

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

Aria and the surrounding communities to purchase produce grown in the garden at whatever cost they can afford. Pocket gardens allow residents to learn about permaculture, a system of sustainable gardening practices. Hammerschmidt explained that the onsite greenhouse, which is run by a local nonprofit organization and is tended by teenage employees, can produce up to 10,000 pounds of food annually, 75 percent of which is sold to local restaurants and a local university, while the other 25 percent is donated for affordable sale. She noted that the developers have built 72 affordable rental apartments and townhouses and have planned a total of 450 homes, with a grocery store slated for future development.

The developers of Aria participate in the Cultivate Health partnership, which provides health care services and nutrition education, Hammerschmidt continued, adding that the partnership, which is supported by the Colorado Health Foundation, also includes Regis University and surrounding neighborhood groups. She noted that an adjacent Regis neighborhood health clinic offers primary care services through providers who not only write traditional prescriptions but also offer prescriptions for fruits and vegetables. According to Hammerschmidt, the project “illustrates how innovative partnerships among real estate developers, nonprofit organizations, private philanthropy, and community institutions can produce a development with a set of shared priorities that are really focused on improving health and equity.”

Another example Hammerschmidt described is Arbor House, a 120,000-square-foot building with 124 units of affordable housing in the Bronx neighborhood of New York City. Located in a part of the city with disproportionately high rates of chronic diseases, such as diabetes and heart disease, the development includes features to promote healthy living, including a hydroponic rooftop farm that allows residents to buy healthy produce grown on the farm. Hammerschmidt explained that 40 percent of the produce is available to the surrounding neighborhood through school, hospital, and food market programs. She added that Arbor House includes features designed to promote physical activity, including indoor and outdoor fitness areas and playgrounds and prominently placed stairs. A living green wall in the lobby produces fresh oxygen, she observed, an air filtration system helps clean the air, and a 100 percent no-smoking policy is designed to improve air quality in and around the development.

Finally, Hammerschmidt described Silver Moon Lodge, a mixed-use development in Albuquerque with 154 studio and one-bedroom units built for renters who are seeking a car-optional lifestyle or who do not own a car. The project, she noted, is located adjacent to new bike lanes and designated cycling routes that provide easy access to the city’s 400 miles of trails. The location allows residents to get to work or the grocery store or to go out to eat on foot or by bicycle, she said, and the project is also located near a

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

transit stop and has an onsite car share service. The building is consistently nearly fully leased, Hammerschmidt reported.

In general, Hammerschmidt observed, social equity has typically not been something real estate developers have talked much about. She described a new effort by ULI to initiate a deliberate conversation about social equity. She explained that a consultant is helping the organization reflect on how it thinks about equity and is providing advice on opportunities to integrate social, economic, and health equity considerations into thinking about land use in a way that its members will relate to and use. “We know that equitable growth provides greater access to economic opportunities,” she said. “It is beneficial to a broad cross section of the population, and it can help prevent or minimize commercial and residential displacement in communities. This is very important to us as an organization.”

DEVELOPMENT STRATEGIES FOR EQUITY

Real estate development has many facets, observed Shai Lauros, national health program director at LISC (Local Initiatives Support Corporation) National, a community development intermediary that brings capital investment from banks, foundations, investors, the public sector, and other sources together with technical resources from community development corporations, community action agencies, community-based organizations, and real estate development organizations to build community assets and local capacity. She described how developers can be both for-profit and nonprofit, and how private developers can have nonprofit missions, while nonprofit developers can have profit-driven missions. She also noted that development entails many other forms of supplementary and complementary programming, initiatives, and policies, describing it as a comprehensive undertaking that involves the confluence of many issues, concerns, and opportunities.

In operation since 1980, LISC has local offices in 31 cities and works in 2,000 rural counties across 44 states. Its work has resulted in more than 365,000 affordable homes and apartments, 61 million square feet of retail and community space, and $17.3 billion in investments that have leveraged $52 billion in total development, Lauros reported. She explained that its goal is to drive investments to low-income communities to improve the quality of life for all residents.

According to Lauros, LISC has two financing affiliates to invest in affordable housing and mixed-use facility and institutional developments: New Markets Support Company and National Equity Fund. She noted that the organization approaches community development as a form of “transaction for transformation.” Its approach, she elaborated, is to bring local leaders together with residents to address the physical, social, and economic

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

needs of a neighborhood and facilitate cross-sector partnerships while also assembling public and private capital to do the work. She added that its investments are usually high-risk. “We all know that the market does not always provide what is needed by a neighborhood,” she said. She noted that LISC facilitates the development of public goods, which are often more difficult to pursue financially because of questions about whether there will be a return on investment.

One goal of comprehensive community development is to strengthen communities by addressing the social determinants of health, Lauros explained, which involves working on housing, facilities, infrastructure, and other aspects of the built environment; on jobs, small businesses, financial literacy, and other features of economic vitality; on education, early-childhood workforce training, wellness education, and other components of human capital; and on engagement, organization, connectedness, and participation in building social capital. “We look at a place as a way to bring all of the elements together,” she said, “to not just work comprehensively but to leverage each other’s effects for sustainability.” Although she cautioned that no type of work can be continually subsidized, she asserted that the implementation of best practices can allow for sustainability, while revenue-generating opportunities can supplement and support community development beyond short-term interventions.

Lauros then described several examples that embody this approach. The first was LISC’s Healthy Futures Fund initiative, which brought together a variety of funders, including The Kresge Foundation, Morgan Stanley, and Dignity Health, to pool about $200 million for investment that was dispersed in targeted initiatives across the country. She also cited Low Income Housing Tax Credits, which enabled the development of affordable housing with on-site health care, and New Market Tax Credits, which funded federally qualified health centers that connect with housing and other local partners. She added that grants supported capacity building and collaboration across sectors. “The major thrust of this was about collocation,” she said. “We were trying to bring together initiatives that would have a greater health impact. . . . That means being able to articulate outcomes and impacts, tracking and evaluating them. You cannot set goals if you are not able to then determine whether or not you have achieved them.” She acknowledged that although causality can be difficult to determine, the organization is using techniques for evaluating outcomes: “We are evaluating, tracking, adjusting . . . evaluating, tracking, and adjusting.”

Lauros then described the new development of a grocery store in Brockton, Massachusetts, adjacent to a 13,600-square-foot health center on a long-vacant site, which featured an on-site test kitchen, collaboration between the grocer and the health center on nutrition education, cooking demonstrations, guided shopping, and a rewards program for healthy food

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

purchases. As another example of “health-intent housing,” she cited a clinic and affordable assisted living community in the rural village of Manito, Mason County, Illinois, in which the health department and housing authority are part owners of the development. She reported that as the result of work with the community to determine what they needed, the clinic built for the seniors as an assisted living facility also operates as a pediatric clinic.

Lauros next described the So Others Might Eat (SOME) Conway Center in Washington, DC, a 300,000-square-foot mixed-use development adjacent to a metro stop featuring 202 affordable apartments, a medical and dental clinic, a job training center, retail shops, and green space. She noted that the initiative also includes a focus on youth education and recreation through a partnership with the National Baseball Hall of Fame. Another project highlighted by Lauros was the Senior Residences development at Mercy Park in Chamblee, Georgia, which has 79 units and a 45,000-square-foot medical facility that includes 13 fixed and mobile primary care clinics, and which offers direct service, health education, and referrals on site to tenants. She also described the Neighborhood Health Association Clinic in Toledo, Ohio, a 42,000-square-foot health clinic that consolidated locations and expanded services to include family and adult medicine, urgent care, women’s health, dental health, specialized care for homeless persons, a credit union, a community garden, and a pharmacy providing heavily discounted medications.

LISC works to form partnerships between institutions and organizations on the ground for greater health impact, Lauros continued. In New York City, for example, LISC worked with the Tisch Foundation in the Communities for Healthy Food initiative, which integrates multiple healthy food strategies. Lauros noted that LISC is also working with the Robert Wood Johnson Foundation’s County Health Rankings Project to use existing data to improve programs. In Boston, Indianapolis, and Philadelphia, she added, it is creating new planning initiatives that are coordinating multiple nonprofits working on similar issues. “We brought them together,” she said, and “had them look at the data and figure out what were their next steps, using the data and using their partnerships to move forward for greater health impacts.”

Lauros then described the Home Preservation Initiative, which addressed deferred maintenance and pests, mold, and indoor air quality in small and low-rise multifamily homes in West Philadelphia, a largely low-income community of color. In surveys administered by local hospitals and health systems, she explained, lack of stable housing was the number one issue raised by patients in the neighborhood. She gave the example of a patient with hearing loss diagnosed during a medical appointment. “This is a critical issue,” she stressed. “You are losing your hearing. Yet for the patient, hearing is not the issue right now. They might not have a place to

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

go after they leave the appointment. How do you start talking about health issues if you do not have your basic foundation of a place to sleep each day?” She added that the project’s investment in home maintenance was intended not only to bring a renewed sense of dignity to the neighborhood but also to support housing stability.

Partnerships with public health agencies, health systems, and hospitals also can have important health impacts, Lauros asserted, although this work is “still in its infancy.” She suggested that the health sector has mainly reached out to partners willing to work with it instead of seeking new partnerships across sectors. According to Lauros, “We are trying to bridge this divide and move forward and not just for the funding it potentially provides . . . but also for the new opportunities that it brings by tapping into essentially untapped resources.” She then described several examples of projects that bring together health and community development. In New York City, she reported, the health department worked with LISC to help owners of affordable housing with green and healthy retrofits, such as integrated pest management, smoking cessation programs, and active living supports. In Rhode Island, she continued, the health department initiated a Health Equity Zones initiative with extensive community planning. In both Richmond, Virginia, and Richmond, California, revitalization of a commercial corridor reflected the local health care system’s awareness of the importance of commercial corridors to a neighborhood. In the Twin Cities, Lauros observed, a grassroots initiative partnered with LISC to improve social connections, build health literacy, and help residents care for their own health with Citizen Health Action Teams.

These and other programs seek to “focus on place without too much of a focus on place,” Lauros explained. She stated that development involves both positive and negative externalities, including gentrification that can displace not only residents but also businesses. “There are opportunities to do things differently around [Hurricanes] Harvey and Irma and . . . things that did not happen during [Hurricane] Katrina, where there were conversations about sustainable redevelopment, that hopefully can happen now,” she suggested, adding that “communities need to start addressing gentrification 10 years before they think they are going to have to start working on it. I have had cities come to me [saying] that they do not need to worry about gentrification. They are just starting on their path. I said, ‘You will not be able to worry about it later. It will be too late. We have to be thinking about it very early.’”

Lauros closed by noting that conversations are ongoing around the country about racial and geographic divides. Equitable development can be part of these conversations, she argued: “We need to merge the conversations of equity in health and equity in development, workforce development, and social services.”

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

DISCUSSION

The discussion following this session’s presentations addressed accountability to communities, sustaining progress in equity-focused work, and evaluation.

Accountability to Communities

In response to a question from Kumanyika about accountability to people in the community, Watkins-Tartt responded that accountability means constantly considering whom an action is supposed to benefit, who is going to be disadvantaged, how the disadvantages can be mitigated, and how the benefits can be institutionalized. “We have to literally graft it onto the bones of our organizations and our systems,” she asserted. Another part of accountability, she argued, is embedding equitable practices so that they continue beyond the life span of a project. She explained that in her work, this means institutionalizing the practice of having community members drive, rather than inform, projects. People in communities, she said, “have to be at the table, because that is the only way accountability can occur.” If the work is not institutionalized, she warned, it can become an easily discarded side project.

Siegal agreed, adding that mission-driven organizations, whether nonprofit or governmental, often “set the bar way too low for community interaction.” Even when communities are asked for their input, he observed, the input is often at odds with the ultimate directions of the project. “The bar has to be at community ownership and community leadership,” he argued. “If we are not achieving that, then we are not going to be able to address the needs of the communities that we are purporting to serve.”

Hammerschmidt pointed out that real estate developers do not typically take the lead on community engagement strategies. Furthermore, she observed, challenges arise when what some see as one community to engage is actually many different communities, all with different needs. For example, she noted, some community members may be wary of change, thinking that a new grocery store or bike trail will drive gentrification. Successful and meaningful community engagement is difficult, she acknowledged, and ULI is working on strategies for its private-sector members to use to achieve it.

Another complication, Lauros observed, is that trust in government may be broken in some communities. Given a history of red lining2 or racist policies, she elaborated, community members may not trust what a

___________________

2 The illegal practice of refusing to offer credit or insurance in a particular community on a discriminatory basis (as because of the race or ethnicity of its residents) (Merriam-Webster Law Dictionary, available at https://www.merriam-webster.com/legal/redlining [accessed March 19, 2018]).

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

government official says; they may not even come to meetings because they do not see any value in providing input. She then described best practices around antidisplacement work. Ideally, she suggested, a community-based organization that has a long history and the trust of community residents can initiate a partnership with government, providing a broader voice for the community. The pressure that can be brought to bear on government through such a partnership can lead to major changes, she asserted. “I have seen significant investment by cities, and multiple millions of dollars for one neighborhood happen because of that pressure and because it is community-based,” she said.

Lauros added that when she first started doing this work more than two decades ago, she engaged in programming with children to design public spaces and play spaces. She characterized the children as “in many cases more innovative than the adults.” Instead of providing childcare at community planning events, she held planning activities with the children. “What do you want to see in the community? They are the same questions we were asking the adults, just asking a little differently. They have something to say and should be participating.”

Sustaining Progress in Equity-Focused Work

As the discussion turned to the sustainability of equity-focused work, Katie Adamson, senior director of health partnerships and policy, YMCA of the USA, pointed out that only a small proportion of health outcomes are due to clinical care, “yet all of our money goes to pay for the treatment.” She asked how hospitals and health systems can be involved in financing and sustaining work on healthy communities. Lauros observed that an increasing number of hospitals are acknowledging the costs they incur for dealing with issues in the community that are not being addressed, such as homelessness. She suggested that having someone on their staff—“ideally their chief financial officer”—sit on advisory councils and task forces in community development can build relationships through which to work on prevention rather than dealing with problems after they arise.

Lauros suggested further that the key to sustainability is volunteerism. Programs continue, she argued, when they represent an investment by individual community members who work to keep them going.

Siegal cautioned that “hoping for large-scale policy change, whether at the federal level or even at the state level, is a really tough road.” Policy tends to be a lagging indicator, he observed: “There is proof of success, and then the policy codifies it.” The current opportunity, he argued, is to identify existing sources of funds that are not being used for health outcomes. “It is incumbent on people interested in health outcomes to look at those aligned fields where there are resources available and figure out how to tilt

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

the ship without having to argue for additional resources from some new pot of money.”

Watkins-Tartt made a similar point, noting that resources are going into systems that affect people’s diets, physical activity, and levels of education. But, she suggested, those systems could “use the resources they [already have] to ensure that everyone is actually benefiting from [them]. . . . That is why our focus has been on trying to reframe how we look at the communities where people are living.”

Hammerschmidt described an example of integrating health care within communities. She pointed to the Henry Ford Hospital in Detroit, which has been considering how best to use the land around the hospital. The hospital would like to develop the land in ways that reflect not just what patients need but what the community needs, she explained. “If more hospitals took that type of approach,” she argued, “we could get somewhere.”

Bill Purcell noted that all of the panelists represented organizations with fairly long histories. “What keeps organizations like these growing, transforming, and responding to various needs?” he asked. Watkins-Tartt, Lauros, and Hammerschmidt all emphasized the importance of leadership in transforming their organizations. In Alameda county, Watkins-Tartt observed, a new health director came in with the mission to “put the public back in public health.” He created a foundation of community engagement on which each successive director has built, she explained. Lauros echoed Watkins-Tartt’s comments, noting that senior-level leaders at LISC have an understanding of the relationship between income and health. Similarly, at ULI, Hammerschmidt noted, board members became aware of the evidence showing a relationship between health and the built environment, “and understood that land use professionals really do have a significant role to play in improving health outcomes.”

Referring to the work of ideas42, Siegal explained that KaBOOM!’s focus has shifted in light of research that “suggested a path forward that we had not seen before.” He noted that other aspects of the work have been driven by lived experience in the community. For example, he said, when Freddie Gray was killed in Baltimore and the city was in turmoil, KaBOOM! reached out to the 18 community organizations with which it had built playgrounds, as well as connections within the Baltimore government and philanthropy community. He explained that KaBOOM! learned that a new area of focus for the city was engaging youth aged 16 to 24, so the organization created a path forward for engaging young adults as apprentices. “It is finding those multiple objectives based on real community need to mobilize a broader group of stakeholders to drive larger-scale change,” he said.

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

Evaluation

Finally, as the discussion turned to evaluation, Hammerschmidt acknowledged that obtaining measurements and hard data is difficult. She noted that the Healthy Corridors project has created an audit tool that collects baseline information about corridors, such as demographics, aspects of the physical environment, and health metrics for people who live and work along the corridor. She explained that follow-ups then show where progress is being made, where demographics are changing, and whether different strategies could be considered. At the same time, she observed, people like to hear about specific case studies in terms of communicating successes and failures.

According to Hammerschmidt, her organization is constantly examining research so it can inform its members about trends that are taking place. She noted that the Building Healthy Places toolkit offers 21 recommendations that are based on research. She added that the organization is also learning from its members, who are collecting their own measurements and learning what works in practice.

Siegal added that at the time of the workshop, KaBOOM! was about to publish a playbook that synthesizes lessons learned from the national challenge in a way that is useful for a variety of stakeholders, including urban planners. He noted that the attention to livability and urban planning has not yet trickled down to a focus on children and families in the way that it could. “That is where I see our work going forward,” he said.

Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×

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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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Suggested Citation:"4 Achieving Equitable Healthy Environments." National Academies of Sciences, Engineering, and Medicine. 2018. Advancing Obesity Solutions Through Investments in the Built Environment: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25074.
×
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The built environment—the physical world made up of the homes, buildings, streets, and infrastructure within which people live, work, and play—underwent changes during the 20th and 21st centuries that contributed to a sharp decline in physical activity and affected access to healthy foods. Those developments contributed in turn to the weight gain observed among Americans in recent decades. Many believe, therefore, that policies and practices that affect the built environment could affect obesity rates in the United States and improve the health of Americans.

The National Academies of Sciences, Engineering, and Medicine convened a workshop in September 2017 to improve understanding of the roles played by the built environment in the prevention and treatment of obesity and to identify promising strategies in multiple sectors that can be scaled up to create more healthful and equitable environments. This publication summarizes the presentations and discussions from the workshop.

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