#169 Spring 2012 — Health

Author Roundtable

Shelterforce authors discuss the roles of place, mobility, and displacement on health and neighborhoods.

Photo by Flickr user Roadsidepictures, CC BY-NC-ND 2.0


Photo by Flickr user Roadsidepictures, CC BY-NC-ND 2.0

As a follow up to our very popular issue on the intersections between place and health, we hosted a conversation that got deeper into some of the topics covered. Participating were two of the authors in that issue, Philip Tegeler and Mindy Fullilove, and Sr. Lillian Murphy, who had weighed in on health and housing topics in our interview with her in the previous issue of Shelterforce. Tegeler is the executive director of the Poverty & Race Research Action Council. Fullilove is a professor of public health at the New York State Psychiatric Institute at Columbia University. Sister Lillian is the CEO of Mercy Housing.

The following is an edited version of the conversation with Shelterforce editor Miriam Axel-Lute and publisher Harold Simon.

The Zip Code Idea

Miriam Axel-Lute: I wanted to start with this idea that your zip code matters more than your genetic code in terms of your health and your life expectancy. Is this particular idea useful for your work?

Philip Tegeler: That your zip code in some way determines your health outcomes is an important frame for us, and it’s similar to the framing of zip code and location in terms of school quality and other neighborhood factors.

We take a slightly different approach than a lot of other groups in that, while of course we support comprehensive community development, we also believe in expanding housing choice and desegregation as a necessary complement to community development work.

We look at the data that shows the strong links between low economic mobility, low school performance numbers, and disparate health outcomes and we continue to ask the question, why does federal housing policy continue to steer the vast majority of housing opportunities for families receiving federal assistance to neighborhoods that are documented to lead to less positive outcomes for families and children? Why does that continue to be the default option for federal housing programs when we’ve essentially proven that these neighborhoods, in the short and long run, have detrimental consequences for children?

We strongly support comprehensive community development to improve neighborhoods that are harmful to children’s health and to improve the schools in those neighborhoods. But we also see the importance of developing a better balance in federal housing policy to move more family housing opportunities to healthier neighborhoods and communities with stronger schools.

It takes a while to improve neighborhood outcomes for children, and it takes quite a while to improve school performance across a district or across a set of poor neighborhoods. And if very low income children, particularly children who are at risk, have an opportunity to attend those higher performing schools in healthier neighborhoods, we should provide those opportunities in addition to targeting more resources toward those neighborhoods.

A Shelterforce ad seeking donations from readers. On the left there's a photo of a person wearing a red shirt that reads "Because the Rent Can't Wait."

Sister Lillian Murphy: I think that framing has been effective so far in helping the public health community understand how community development and public health can intersect more effectively. Our mission at Mercy is to create stable, vibrant, healthy communities, so we’ve always had a health component.

We’ve described healthy communities as places where there’s affordable housing and childcare available to everyone, where there are meaningful jobs at a living wage, where there’s quality education for both adults and children, where there is accessible, affordable medical care when needed, and a good business climate for both large and small business.

It’s only recently that using that frame with groups other than community development groups has attracted more attention, and hopefully some resources follow. There’s a book out called What Works: Investing in People and Places. It’s a compilation of essays from politicians, academics, practitioners, and policy people. And almost every one of the authors talks about this health and housing connection.

So the frame has been useful. I think we may need a different frame going forward, especially in this era of scarce resources. I think we’re going to have to frame the community development contribution to communities in more economic terms, because we do make a real economic contribution to the communities where we are active.

Mindy Fullilove: I take a slightly different perspective on this problem of “zip code determines your health,” because our work has looked so closely at this problem of serial displacement, meaning that there’s been upheaval, particularly of African-Americans, but also of other groups, repeatedly.

So in Chicago right now, with the demolition of public housing projects, people are getting moved out of Chicago into the suburbs, and that’s happening in many major American cities. Both the process of displacement and where people are getting moved to are going to have huge effects on their health. We think that it’s really fundamentally important to factor [the process of displacement] in. We certainly believe that open housing is fundamentally important, as is full community development. We would add to that a third task, which is we have to stop these programs that lead to this serial forced displacement.

While the other two problems have been on the agenda of many, many groups, the problem of serial forced displacement has not really been recognized. It’s a big problem that needs our attention.

Miriam Axel-Lute: Do you know of any research that has sorted out the health effects on people who are stable but in poorer zip codes, as opposed to those who are being displaced or more mobile?

Mindy Fullilove: We think that the problem is actually lived at the level of cities. If you’re bashing around neighborhoods in cities, it’s undermining the whole stability of the city. It’s more reasonable to look at it in the context of this disruption of a larger social network. Whatever health issues we’re seeing are in the context of displacement.

Sister Lillian Murphy: I’m going to give you an example of something that I think is a coming together of the community development field and the academic world and the public health world in San Francisco. We’ve done two properties there. We were trying to find a model that would be akin to assisted living for very low-income seniors. We did the first property, which was a 93-unit 202 [HUD Supportive Housing for the Elderly], and we actually were able to get HUD to agree that people coming in there had to be defined as frail elderly. And then we got a matching grant from the city and we built an adult day healthcare center as part of that whole complex, the North and South of Market Adult Day Health Center. In that case, both our residents [and seniors] in the community were able to find affordable, accessible care.

The second model was a little different in that it was a new tax credit development, 160-plus units. That building again had an adult day health center attached, run by a healthcare provider, because we are not healthcare providers. We took 40-plus residents from Laguna Honda Nursing Home in San Francisco, which has been condemned and is being torn down, and brought these people who didn’t necessarily need nursing care—they needed some supportive care but not necessarily hands-on nursing care—into this building. The Department of Public Health pays a portion of their rent every month.

And after about three years, we got a letter from the Department of Public Health saying that they had estimated that they were saving $1.5 million a year on these residents in Medicare and Medicaid claims. It was a great example of bringing public health dollars into the housing arena.

Phil Tegeler: Looking at cost savings on the health side is very important to justify both the community development investments and also expanding housing mobility programs. Right now we have very few housing mobility programs anywhere in the United States, and as you know, the much-touted Moving to Opportunity demonstration only really affected about 1,000 families at the end of the day. So we haven’t really tried it on a large scale outside of a few cities in this country. We’ve seen, in the MTO experimental data on health, improvements that can be tied to savings in the health system.

Also in Baltimore, where we have a very robust housing mobility program, by moving families out to very high-opportunity neighborhoods with Section 8 vouchers, we’ve seen anecdotally some very powerful health impacts, which we’d like to measure more, because we think there’s measurable cost savings there that potentially could outweigh the cost of the mobility services that are being offered. Doing those kinds of calculations is an important way politically for us to justify these investments.

Facing the Displacement Question

Miriam Axel-Lute: Housing policy clearly needs to include mobility programs, development programs, and programs that prevent forced displacement. What programs do we need to give more to, or do differently, or do better to have the appropriate balance of addressing all three of those tasks to really get a massive health effect for everyone?

Mindy Fullilove: Stopping [economic and racial] sorting is [about] stopping policies. If you’re not destroying a neighborhood, presumably you’re not spending money to destroy them.

At least in our models of the ecology of this, you can’t get anywhere on any of the other problems until you’ve stopped the sorting. So we think of it as the most macro [issue]. The other two are on slightly lower levels of scale, and the impact is dependent on whether or not we’re still doing these massive displacements of communities.

As long as we’re doing that, we’re just going to keep on having a mess and keep on making people sick. It really undermines, in our view, the whole social foundation of the nation. There’s just no way to overstate the harm that this is doing.

Miriam Axel-Lute: Which policies should we stop?

Mindy Fullilove: All of them. All of the displacing policies. We should stabilize neighborhoods the way they are.

And within that, let anybody move wherever they want. Individuals can move. There should be open housing. Individuals should be able to move—wherever I want to live, let me go live there—but do not displace communities.

And with that, also include community development so that every community is a decent place to live. The idea that you have to move to opportunity is just a completely egregious place to start.

Miriam Axel-Lute: When you say displacing policies, there’s a range of things that that could refer to.

Mindy Fullilove: We’re against all of them. Everything from redlining, which undermines the viability of neighborhoods, to urban renewal, planned shrinkage, gentrification, the foreclosure crisis, mass criminalization—all of these are displacing policies that tear at the social fabric and destroy the very foundation of health, and thus the ability of people to work together to make the civil institutions, the political institutions, and the religious institutions that form our democracy.

Miriam Axel-Lute: What would a federal housing policy look like that would encourage revitalization without displacement?

Phil Tegeler: Take the poster child for what Mindy’s talking about, the HOPE VI program—substantial displacement, a promise that was never kept that residents could return to their communities after revitalization, a net loss of public housing units, an elimination of the one-for-one replacement requirement for public housing, demolition, and another unkept promise to relocate families, if they so chose, to the opportunity, less segregated areas during the relocation process.

Now, the new version of HOPE VI, the Choice Neighborhoods program, we’ve been told has learned from the mistakes of HOPE VI. The plan is that Choice Neighborhoods, which is now being implemented in five cities, is going to do one-for-one replacement of public housing units that are lost, is going to give any resident who wants to return to the revitalized community the opportunity to come back, and is also supposed to give families who want to make mobility moves to higher performing school districts, healthier neighborhoods, et cetera, the opportunity to do that.

We don’t know yet if those things are going to happen as promised, but that’s an example of a program that was much criticized by fair housing advocates that has now been reformed with this new program. We’re hopeful that HUD has learned some of the lessons of the mistakes of HOPE VI and is heading a little bit more on the right track here.

Mindy Fullilove: I think that the whole premise of supporting people to move to higher performing neighborhoods is a statement of a continued problem, which is that in the United States, there’s investment in some neighborhoods and not in others. This reverberates, so some places get money and some places get trashed.

How do you have a thorough undoing of that premise, that some neighborhoods are better than others, so that every neighborhood has a real chance at survival, at being a strong neighborhood? How do you make many, many places for people to live? How do we get out of the current housing famine and not have selective investment?

That’s what we think is the challenge. I wouldn’t object to some of these programs in any way other than that they’re just too small to make any kind of a dent. Harlem Children’s Zone gets on the order of = $30 million a year to help a very small part of the Harlem neighborhood. There are hundreds of neighborhoods in that kind of condition, or worse. Do we have $30 million a year for each of them?

When we do, things will really start to perk and pop and be exciting for everybody, and I think that’s the goal of democracy—as I understand democracy and as I want to live in a democracy: that everybody has a chance. And everybody can only have a chance if every neighborhood has a chance.

Sister Lillian Murphy: From the perspective of a practitioner who is committed to these lower income neighborhoods, we want to be there. We want to help. And we’ve had, I think, more than one experience where we’ve gone into a very troubled neighborhood, done a lot of community work ahead of time, getting the community involved in the vision for the community and the design for the buildings, et cetera, and bringing people back who had lived there—and this was HUD housing that was demolished—bringing people back, as many who wanted to come back.

But it is a struggle every single day in that neighborhood because of the violence. Our property managers are wearing bulletproof vests. The violence is just amazing. And we’ve reached out to the police, to the city, to anybody we can think of to help us figure out how to make some headway there, because the people are back in the neighborhood in much improved housing than what they had, but it’s still a very dangerous environment, and people are being shot at every day.

The dream of investment in all communities is laudable, and we should continue to dream that. But the reality is something different, and we’ve got to get the silos in the federal government and the state government together, because it’s not going to be just housing that solves this problem.

Federal policy could help here [by] somehow—and I know HUD and HHS and Energy and Education have tried to get together on some—getting some cross-fertilization going. It hasn’t yet happened. I don’t think we should give up on it, because I do think that finally is the answer to solving some of these issues. But it’s going to take a long time. Meanwhile, people are suffering, and we’ve got to find better ways to do what we’re doing.

Mindy Fullilove: Yes—investing in all neighborhoods is what we need. I think that we can only help the neighborhoods that are in trouble to get out of trouble by really being conscious of this commitment across the board.

For my research colleagues and me, it’s actually been very, very important for us to go to the National Archives and look at the redlining maps and look at the redlining rating forms, and really start to understand the history of how we came to be in the situation we’re in now. They’re really startling. Why not redo it? Why not send people out into the field to survey neighborhoods using some standards that aren’t about racism, that are about all neighborhoods being prosperous and being helped?

There are many ways to think about this that could help us really have novel solutions that we don’t have yet, if we start to open our minds to say it’s not choice—it’s not, like, go move to the better neighborhoods so you don’t have to live here, because somebody’s going to be living there. Every neighborhood has to be a place where kids can grow.

Phil Tegeler: The neighborhood you’re describing—which, if it ever existed, was destroyed by federal policy—is a racially and economically integrated neighborhood. The policies that artificially created these residential zones that were only for very poor families and schools, that were only for the poorest of the poor, those are the policies, especially in our older, larger cities, that we’re still dealing with a legacy of.

Part of restoring health to communities, whether they are so-called higher opportunity suburban communities, gentrifying neighborhoods, or poor neighborhoods that are in need of community development investment, part of the solution to making them healthy again is to remove the sense that this is a place only for poor people, or this is only a place for upper middle class people. We need to break down those barriers and restore communities to a more natural balance [like] before these government policies separated people and sorted them.

That’s one of the factors that’s going to lead us to having communities in zip codes that are healthier for everyone, where we don’t have zones that either exclude or isolate folks.

Miriam Axel-Lute: We’ve mentioned gentrification a couple times, and when you mention displacement, that’s one of the things that comes to mind. What sort of things do you all see as promising approaches to allowing people to remain in a place that is improving?

Phil Tegeler: That’s a really important question, and we’re putting a lot of thought into that. Is it possible to have an inclusive gentrification process that’s managed and preserves the rights of existing residents to stay in place? We were fascinated by Lance Freeman’s work in New York—interview-based, looking at the ways people respond to gentrification in their neighborhoods.

It’s not all negative. There are a lot of positive things that come with gentrification, if only families could retain the foothold in the community and retain shared ownership of the schools and the neighborhoods, as well as the housing units. It’s a big question. Can we design policies that are going to make that possible in the future? We don’t have the answers here, but I hope there is an answer to that question. I hope it’s not inevitable that families will be displaced.

Mindy Fullilove: Nothing is inevitable. It’s a result of our policies—how we view the world, what we permit, what we don’t permit. I think there is a comprehensive set of policies that promote gentrification, and so the question is, can we have a comprehensive set of policies that prevent it?

And gentrification is about what we were mentioning earlier—neighborhoods that are only for poor. But at least in the redlining maps, it’s not just neighborhoods that are only for the poor, because the redlining maps are also actively about undesirable racial elements, so it’s also about no racial mixing. It’s about creating a more complete, more devastating kind of segregation than we had before.

To the extent that those are still problems, then as this more desirable element—it’s not quite as much stratified by race, but let’s just call it ethnic group—whenever this more desirable ethnic group moves in, it does trigger a kind of ethnic cleaning, which extrudes the other group that doesn’t fit. It’s that formula that we have to undo. How we make that a big part of many people’s thinking about how we make our cities is a question that is very urgent.

Sister Lillian Murphy: I think there has been some progress on this. I don’t want to leave us with thinking that nothing has worked, because some of it has. In Chicago, the previous policy was segregate, put everybody up in these 20-story towers on the waterfront there and ignore them, get them out of sight, out of mind.

But the HOPE VI renewal has had some real gains there. They’ve demolished the towers. They’ve brought some people back. We participated in joint ventures with folks there to be able to ensure that there is some affordable housing. They have required that the developers, the four property developers, also include some affordable housing in their work.

The city of Seattle has done a great job of gentrifying older neighborhoods and still keeping people there, but bringing in new people and new economic activity. In the Columbia City area of Seattle, the light rail goes right through there, and they have built up on both sides of that light rail mixed-income communities that are vibrant today.

So some of it has worked, and I think we ought to take lessons from what it is that made it work, that helped it to work, and see if we can duplicate that. The problem is, at least in our experience, it’s not just federal policy. It’s also state and local policy that affects what we do. And while the federal policy may say you have to do one thing, the state or the local group tells you to do something different. And you have to tread those lines and figure out what’s possible.

It’s not to scale, you’re absolutely right. And in order to do this stuff to scale, there’s got to be resources. And in today’s environment, with very constrained resources, it’s going to be even worse. I think we need to be very practical about what could happen now with the resources that we have that will get us to some of these goals that we’re after.

Talking About Scale

Miriam Axel-Lute: To some extent, you’re all talking about projects and programs and methods that are very fine-grained, not big, sweeping projects that knock down large areas and build up huge towers, or put a large development somewhere. How do we talk about scale, and at the same time focus our efforts on this kind of work that doesn’t barrel over things?

Sister Lillian Murphy: Well, if the community developers are going to get to scale, they need resources. To do an at-scale development would take a lot of dollars. The nonprofits that are doing this stuff don’t have that kind of capital. We have to piece it all together, whereas the for-profits who’ve got capital sitting aside waiting to be spent can move in and do that and don’t have to worry about some of these things that we do.

We’re one of the largest [nonprofit housing developers], but we’re not big enough. The need is enormous, and we’re only filling a little piece of it so far.

Mindy Fullilove: I think one of the ways that we think about this is that if you stop destroying, then you can accumulate more quickly. If you stop bulldozing neighborhoods, you stop tearing things down, you make them work, you sustain them, then everything that gets built adds, as opposed to destroying and then having to replace.

We are hugely influenced by Jane Jacobs’s point that people will—if you leave them alone and you aren’t destroying the neighborhoods and they have some access to employment—invest their money and fix things up. And all of a sudden, you look around, and a place is better. You don’t necessarily know how it got better. It just got better.

Not to say that such things are easy or automatic, but we do believe that if you stop the wanton, horrific destruction of neighborhoods that have been so much a feature of American life, then everything that gets built is adding to as opposed to replacing.

Sister Lillian Murphy: Except that you may not be able to do anything with what’s there. We’re working in communities where the housing is so substandard that you couldn’t get enough money to rehab it.

Mindy Fullilove: That might be true in the communities where you’re working, but it’s not true all over the nation, and it certainly hasn’t been true all these past 70 years. So how do we get out of the mindset that what you’re supposed to do is destroy, and really start to preserve some of what we have?

Sister Lillian Murphy: I’m coming at it from a very practical practitioner viewpoint. When we’re working in San Francisco, for instance with a large public housing development, it’s one of the most dangerous places in the city. And the housing that was built there was built way back in the ’30s.

We’re working with a for-profit developer and the city, and hopefully with a federal grant from the [New] Communities program, to redevelop that into a mixed-income area in stages. So we would replace some of the housing in stages, and people could stay there and then move into the new housing.

We’re trying to get schools on that ground, because the schools in the neighborhood are just substandard. We’re trying to get grocery stores because they need that. We’re trying to do community gardens. It’s going to be at least a ten-year project to do that. And that will help maybe 2,000 people.

The practicality of making this stuff happen is very, very time-consuming. So getting to scale with a system that forces you to piece together the resources that you need to get this done is almost impossible. I’m not saying we should give up on trying to do it. We have to continually try to do what we’re doing and do it better and serve more people.

But I think the underlying problem for all the stuff that community developers do and social service people do is poverty in this country. If we had a living wage so that people could afford to support their families, we wouldn’t have to have all of these subsidy programs for housing and food stamps and everything else.

Mindy Fullilove: Except that it’s really important to keep in mind that poverty—not in any way to detract from the need to solve the problem of poverty—in America is not what it was 50 years ago or 70 years ago, for many reasons.

If we keep moving the threshold, moving what it’s going to take to get people out of poverty, if we send all the jobs away, if we put all the men in prison, if we break up the communities so we destroy anything that people might have used to get themselves out of poverty, then how do we ever get anybody out of poverty? Quite the opposite has been happening, which is that people now live in a poverty that’s much more hostile and much more difficult to escape. And all the data show that we’ve broken the social ladder, so people can’t escape from poverty. How do we create some stability so things can build, things can accumulate, and people can get out of trouble?

Harold Simon: I’ve been hearing we need to change policies that are destructive, and we need to change policies that limit resources. The question is, how do we do that? How do we get to those policies? How do we actually get to this shift in policy and a shift in mindset both about the resources and about the approach?

Mindy Fullilove: There are people like us in every neighborhood struggling with these issues and doing as great a job as they can. I always find that very reassuring. There are just so many people who are working on these issues.

The crucial thing is conversations like this one, where we bat around what the problems are, and we try to figure out a new direction. It’s not lack of awareness. People are aware. It’s not a lack of heart. People have heart. It’s just trying to stay on the same page and pushing the same direction.

The problem of sorting is that it tears people apart, so the process that’s going on undermines the solution that we need. It makes it very, very, very difficult to get ahead of the curve, but I think that’s what we’re trying to do.

Sister Lillian Murphy: I think so much of it is controlled politically. You have to give it to the Tea Partiers. They had a cause. They got organized, they elected people. They’ve been very effective. I happen to think they’re deluded, but I think they’ve been effective. And if you look at the Occupy movement, I think, thank God they were out there saying what they were saying, because I think they did raise consciousness. I think they really did raise consciousness. But they weren’t organized. They weren’t able to take the next steps of getting a coalition together and then moving forward. And that’s all community organizing work. The Tea Party used it also. They were much more effective at it.

Miriam Axel-Lute: They had good funding also.

Sister Lillian Murphy: Yes, the dollars are part of everything. Maybe we need to be looking at nontraditional partners in this stuff. Unfortunately, we lost many community organizers when ACORN was scrubbed away, and they played a really important role in some major social movements, like the Community Reinvestment Act. They’re not out there anymore in these communities organizing people, and that may be a first step that we’ve got to start thinking about.

Mindy Fullilove: Well, yes. Anything that supports more organizers doing more good work is going to be an important step in these situations.

Thank you so much.


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