It’s a common truth but one worth repeating: one’s health and life expectancy can be predicted by a zip code. In many cases there exist 10-year life expectancy gaps between people living just a few miles apart. And while many factors help shape this disparity, they often have little to do with medical care, but rather with an individual’s social, economic, and physical environment, genetics, or behavior. A lack of proper medical care accounts for just 10 percent of premature deaths.
Take asthma, for example. Roughly 40 percent of asthma cases are triggered in the home. Children, even those with insurance and health care, can come home from school to water leaks, poor ventilation, moldy carpets, and other conditions that increase allergens and exacerbate their condition.
Merging Health and Community Development
For decades the Robert Wood Johnson Foundation (RWJF), the country’s largest health philanthropy, has worked to improve health and health care in low-income neighborhoods, but only recently have we realized that while we work in the same places as the housing and community development sectors, we’re often working on separate, parallel tracks.
But this is changing. In 2009, the Federal Reserve Bank of San Francisco published an article in an issue of Community Development Investment Review about the work of RWJF’s Commission to Build a Healthier America, convened in 2008 to explore factors outside the health care system that affect health and make actionable recommendations for change. This article opened with the commission’s call to action: “Building a healthier nation will require substantial collaboration among leaders across all sectors, including some — for example leaders in child care, education, housing, urban planning and transportation — who may not fully comprehend their roles in improving health.”
Operating on the same track will benefit all of us and we’ve seen progress already as the housing, urban planning, community development, and finance sectors increasingly explore how their work can help people be healthier. From the recent New Partners for Smart Growth conference sponsored by the Local Government Commission to the Healthy Communities events hosted by regional Federal Reserve Banks, HUD’s national Healthy Homes conference, the Living Cities Integration Initiative, and countless other meetings, events, and projects, we have seen an explosion of interest in the intersection between housing, neighborhoods, and health.
Health Begins Where You Live,
Learn, Work, and Play
It’s easy to see how the presence of lead, radon, water leaks, poor ventilation, pollution, or mold are linked to poor health. Structural defects such as unsafe stairways, balconies or windows, and lack of smoke detectors are injuries waiting to happen. An estimated 4 million emergency room visits each year are related to home injuries.
Harder to detect is the link between neighborhood conditions and health, particularly for people living in circumstances that make healthy living nearly impossible. What’s more, when working in the community development world, we’ve had to learn to speak each other’s languages.
In the health world, “CDC” used to mean “Centers for Disease Control” not “community development corporation.” More importantly, measuring return on investment is very different than measuring health outcomes. And speaking of measurement, how do we measure the health effects of building healthier housing or LEED-certified buildings? How do we collaborate to develop and test new approaches? We are beginning to work together to explore common evaluation, research, and data collection metrics that will allow us to set common goals and collaborate more effectively.
We can start with housing affordability. Affordability shapes families’ choices about where they live. Lower-income housing is often situated in neighborhoods with higher rates of poverty and crime and fewer opportunities to play, exercise, or eat healthy food. Families with fewer financial resources are the most likely to experience unhealthy and unsafe housing and neighborhood conditions — and are typically the least able to overcome these barriers. What can be done to address these effects?
There is evidence that changing housing or neighborhood conditions can improve health and reduce costs. HUD’s Moving to Opportunity demonstration project (see page 31), intended to uncover the effects of neighborhoods on a range of measures, recently published findings in the New England Journal of Medicine showing that lower-income women who moved to safer, more affluent neighborhoods had lower rates of obesity, diabetes, psychological distress, and major depression than those who did not move. The authors suggested that interventions to change neighborhood conditions could help improve the health outcomes of vulnerable families.
Another example is Mercy Housing — a nonprofit affordable housing developer and pioneer in incorporating health services into housing projects — which has saved the city of San Francisco nearly $1.5 million a year by shifting seniors from a city-run nursing home to Mission Creek Apartments, which provides a healthier environment for residents, according to a 2011 study in the journal Health Affairs.
Health care providers also are seeing this connection: in a recent RWJF survey of physicians, 85 percent of primary care doctors said they believe it is as important to address patients’ social needs as their medical conditions — and most wished they had a greater ability to “prescribe” things like affordable housing, reliable transportation, or nutritious food.
This growing recognition of housing, neighborhoods, and factors such as income and education — the “social determinants of health” — has led the health sector, and increasingly the housing and community development sectors, to look beyond improving access to health care to address root causes to help people avoid getting sick in the first place.
At the Core: Community-Based Initiatives
Supporting partnerships between local community-based nonprofits, public health leaders, and community leaders is part of how RWJF is acting on the idea that housing doesn’t only represent place, but also stability — especially for people who are most vulnerable.
In New York City, RWJF funds housing integrated with medical and social services for high-risk families through the Corporation for Supportive Housing. Working with several city agencies and other nonprofits, for example, the Keeping Families Together initiative provides 29 units of permanent, affordable housing to homeless families, coupled with supportive services such as counseling; job, parenting, and life skills training; and mental health and substance abuse recovery support. KFT is showing a positive effect on housing stability, child welfare involvement, and school achievement among children — all of which, in turn, can be linked to better health.
Based on the success of this project, the U.S. Department of Health and Human Services’ Administration for Children and Families (ACF), RWJF, and three other foundations are supporting a $35 million initiative to demonstrate how supportive housing can stabilize highly vulnerable families and keep children out of the foster care system. ACF has released a public Notice of Funding Availability that will close on July 30, 2012, truly representing how
community-based organizations and housing authorities can work with the health field.
Another example is the Green House model: a new kind of nursing home composed of small 10-bedroom homes. By altering the facility size, interior design, staffing patterns, and methods of delivering services to residents, the approach is directly linked to better health outcomes. The 100th home opened last year in Baltimore, and the model continues to be replicated across the country.
New Community Partners
We’ve also been working closely with the Federal Reserve Bank of San Francisco, the Low Income Investment Fund, and others to support a series of “Healthy Communities” meetings that bring together the health, community development, and finance sectors to identify common goals, share information about cross-
cutting work, and forge new relationships.
At the same time, we’ve seen increasing media attention to the intersection of health, housing, and community development. A 2009 issue of the Community Development Investment Review focused on the intersection of community development and health. The widely read health policy journal Health Affairs focused its November 2011 issue on health and community development. And then HUD Assistant Secretary Raphael Bostic and RWJF President and CEO Risa Lavizzo-Mourey co-authored a December 2011 Roll Call op-ed titled Housing and Health Care Go Hand in Hand.
Using Data to Drive Policy Change
and Smarter Investments
We’re also investing in data collection and evaluation to help determine what’s working — and what’s not.
RWJF’s County Health Rankings & Roadmaps assess the health of every county in the United States and are based, in part, on environmental quality and neighborhood conditions, including access to healthy food and recreational facilities. Now in their third year, the rankings have been used to garner support among government agencies, health care providers, community organizations, business leaders, policymakers, and the public for local health improvement initiatives.
We also help fund the Health Impact Project, which promotes the use of health impact assessments (HIAs) (see page 20) to help decision makers identify and address the health impacts of a policy decision or project. In Oakland, for example, an assessment of Jack London Gateway Senior Housing explored potential respiratory illness, high blood pressure, and other health issues as part of the planning for a low-income senior housing project. The HIA resulted in a decision to install a central ventilation system with air filters inside housing units and common spaces and modification of the building design to orient the main entryway through a noise-buffered courtyard facing the existing community.
How can the community development and housing sectors get involved in this work? The first step is to get connected. There are hundreds of communities working to improve the lives of their residents using Community Commons, an interactive mapping and networking tool that helps users maximize their investments to build healthy, sustainable, and livable communities. The Commons, which was created by funders, government, community-based organizations and others, uses over 7,000 GIS data layers at the state, county, zip code, census tract, block group, and data point levels and helps people connect and work together to transform communities.
Also, the Federal Reserve Bank Healthy Communities regional events will continue this year and provide valuable opportunities to cultivate cross-sector partnerships. These meetings are typically focused on the health and community development needs of the local or regional community hosting the meeting and provide a tangible way for sectors to break down the walls between them.
Our goal is to bring multiple fields together — each with their own language, assumptions, and evaluation standards — and improve the health of neighborhoods. We can help engage the health sector — especially health departments and public health workers — to increase support for on-the-ground community improvements. We can also engage other philanthropies to serve as conveners and funders of innovation to lead to smarter investments and new evidence-based solutions.
Together, the health, housing, and community development sectors spend billions of dollars each year. Joining forces is not about spending more money, but about better targeting efforts; sharing tools, data, and what’s working; and replicating the best programs and investments.
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Paloma is senior policy adviser and senior program officer at the Robert Wood Johnson Foundation.