The health promotion field should start paying attention to community development, and vice versa. In the November issue of Health Affairs several authors (including my friend and mentor David Erickson) make the argument for better collaboration between practitioners, advocates, and developers around the shared goals of revitalizing neighborhoods. One important contribution of this issue is that it provides an actionable, policy-oriented strategy for marshaling resources from both the health and development sectors, getting beyond the public health truisms that neighborhoods are important for health. As Susan Detzer says in her introduction: “new tools can help focus attention and frame decision making on the health-promoting potential of community investment measures,” including so-called “health impact assessments”).
Understanding the context of community development is important for health policy. David’s article with Nancy Andrews is essential reading, because it provides a short history of the major funding organizations that support subsidized housing and other amenities. Previous partnerships have been formed, but these have largely been to address specific diseases or populations, rather than to engage with the holistic health and wellbeing of a community. Braunstein and Lavizza-Mourey’s article provides the example of the Seattle King County Healthy Homes Project, which sponsored the remediation of structural lead and injury hazards in housing projects. Nationally, there have also been initiatives focused on reducing lead levels in low-income communities as well as allergens that cause asthma. More recent initiatives have also focused on promoting access to fresh fruits and vegetables in “food deserts,” areas that are not served by grocery stores. The next logical step is to form more place-based initiatives, a movement that is partially supported by funding in the Affordable Care Act.
The overall impression I was left with is that community housing-public health partnerships are being formed, but there are many logistical and financing challenges that still need to be resolved. As this field develops, I think new kinds of organizational structures that cut across public and private entities and different authorities will need to be formed. This is a challenge, but not an insurmountable one. I wanted to raise a few questions that I think will need to be answered in the coming years.
Does it matter if community development does not bend the cost curve?
It would be a slam-dunk to show that community development strategies reduced medical costs. If health insurers or employers discovered that improving poor neighborhoods reduced their medical spending, they might be willing to take action purely out of self-interest. This would be nice, but I’m skeptical. Consider that while most preventative care does improve health on average, it does not lower health care costs. We know less about the cost savings of public health interventions, but it is difficult to find many “low hanging fruit” – even when we make people much healthier, we usually have to spend more on the margin. The data from community development initiatives might disprove this assumption, but realistically it is important that community developers do not oversell the cost-savings potential of place-based interventions. I think it would be more important to emphasize that improved health matters for its own sake, especially in places where neighborhoods make people sick and less productive. Economic benefits matter—a point that David Williams and James Marks emphasize in their article – but they are not economic benefits that accrue in any measurable way to federal and state organizations.
What do joint health-community initiatives look like in “underwater” neighborhoods?
There are now major suburban areas in places like Las Vegas, Miami, and greater Los Angeles that have been ravaged by foreclosures and where many homeowners are “underwater” – unable to sell their homes because they are worth less than the outstanding mortgages. These are not necessarily the traditionally poor neighborhoods, and consequently they do not have the social services and community development resources in place to assist households. As I reviewed, Janet Currie and Erdal Tekin show that these areas are experiencing an acute health crisis. What can be done to help them? Part of the response extends to a complex banking infrastructure, which reaches beyond the limited resources of community development organizations. Once the initial crisis has been resolved, there will be a need for creative solutions to redefine these neighborhoods, luring back families and making use of the existing housing stock. An important challenge for public health-community development partnerships will be to devise ways to also increase access to health amenities in these areas.
How do we get cities and suburbs to work together?
One point that is emphasized in several of the papers (especially Arcaya and Briggs) is that using community development to promote health will require regional solutions. We are past the old paradigm of thinking about poor health and neighborhoods on the level of atomistic urban cores. Urban areas are integrated with suburbs, and low-income communities are now more dispersed than in the past. We might hope that authorities from cities and suburbs would sit down together to develop regional solutions, but there are real political obstacles. As the work of Katie Levine Einstein (a classmate) emphasizes, racially and economically fragmented communities are much less likely to forge regional collaborations to solve shared problems such as transportation. We need to know more about whether poor collaboration reflects something cultural (such as historical patterns of mistrust) or something economic (such as an inability of cities to kick in their share of the financial resources to develop infrastructure). The guiding assumption has been the latter, but we need to understand the cultural factors better.