Rebuilding a healthier Main Street

by David Erickson, Federal Reserve Bank of San Francisco and James Marks, Robert Wood Johnson Foundation

We all have a vision of the “Main Street” we would like to live near – tree-lined, friendly and safe. But our “Main Streets” are in disrepair. Across the country, they lack sidewalks, parks, well-stocked grocery stores with fresh food, healthy homes and apartments, and convenient public transportation. And it turns out, these things add up to a lot more than just an unpleasant place to live – they can have a major impact on our health.

There has been much in the news about the costs of medical care and our current and future economic competitiveness because of those costs. But little has been done as a nation to see if we can reduce the amount of disease we have to treat.

On Main Street in America, a woman with diabetes – perhaps one who is newly insured under health reform – will see her doctor, who after telling her what medications and tests she needs, will tell her to improve her diet and be more physically active. But what if she returns home, to a neighborhood that makes following the doctor’s advice nearly impossible because there is no supermarket with fresh food like in Detroit, where there are only 5 grocery stores for a city of 139 sq. miles?

Or, what if her neighborhood is unsafe, rundown and a bad place to walk? Her diabetes will be less well controlled, complications will occur earlier, hospitalizations be more frequent. Her care will become more costly, all from factors outside the capability of medical care.

To show how important things like this can be, you only have to look at two communities a few miles apart. In Washington, D.C., residents of one inner-city neighborhood die nearly a decade younger than people who live just a few miles and 17 stops away at the end of the Metro line.

On the D.C. Metro’s Red Line, there’s a 9-year difference in life span between Union Station and Shady Grove in Montgomery County, Md. View full map.

Last month, our organizations, the Community Affairs Function at the Federal Reserve and the Robert Wood Johnson Foundation, formed a unique partnership with a common goal: to make the places we live healthier.

Together, we convened leaders in public health, finance, housing and community development to meet, share what’s working, learn from each other, and collaborate on the issues facing our neighborhoods and communities.

For many who walked into the room, it was the first conference where they did not know everyone already.

The Federal Reserve, which works to strengthen communities with better housing and increased economic opportunity, heard how its investments have important health effects that could increase with careful planning. The public health community gained a better understanding of how investments from outside the health sector can significantly contribute to better health. Real progress was made in connecting groups from across sectors, and having many diverse perspectives in the room was essential.

As U.S. Health and Human Services Assistant Secretary Howard Koh so aptly put it, “Health is too important to be left to the health sector alone.”

For banks and community developers, whose capital finances everything from small businesses and apartments to charter schools and day-care centers, this means thinking about themselves as long-term equity investors in both the human and physical capital of communities, not just as short-term lenders in a series of one-off projects. Community development finance is adept at taking innovative local ideas – like affordable housing with wrap-around health services for formerly homeless residents and mobile fresh produce carts – and finding ways to grow those efforts into full-scale solutions for improving our nation’s health. As the Berkeley epidemiologist Len Syme said, “those who design our living environments are some of the most important public health workers of our time.”

For foundations, this means scouting for innovations like the Fresh Food Financing Initiative to eliminate food deserts, testing and evaluating, and developing tools like Health Impact Assessments to help community developers make their targeted investments have the highest probability for success.

For the federal government, this means collaborating across agencies – HUD, HHS, EPA, Transportation, Energy, Labor – and using their power as a convener, funder and evaluator to find what’s working and bring it to scale.

The Federal Reserve will broaden its discussions on these topics and will hold its first regional health and community development conference at its branch in Los Angeles in September.

Beyond Health Care:New Directions to a Healthier America: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America.

For all of us gathered last month, including leaders from public health, community development and finance, the energy and sense of common purpose was exciting. And, it put in perspective what could happen with initiatives like Promise Neighborhoods, the First Lady’s Let’s Move campaign to combat obesity and the EPA/DOT/HUD partnership to promote livable communities.

Many described this meeting as “The Moment” – when community development, philanthropy, public health, and federal government are all understood that they had to work together to achieve their goals improve the livability, economic vigor and physical and fiscal health of our communities. For the Robert Wood Johnson Foundation, it was an inspiring outcome of our work on the Commission to Build a Healthier America, which called for exactly this type of collaboration in its recommendations last year.

So what’s next?

Those with the dollars – banks, government, philanthropy and other investors – most often ask in their own lingo, “Is this program proven to work based on evidence and data?” or “What’s the return on investment?” We have spent years asking these questions, and both the Robert Wood Johnson Foundation and the Federal Reserve have rigorous evaluation mechanisms in place.

But imperfect science should not be a barrier to action. There’s too much need right now to wait for the perfect evidence. As Ron Sims, deputy secretary of the U.S. Department of Housing and Urban Development, put it, “Good works if it saves lives; good works if it saves futures. Is it an experiment? It’s a wonderful experiment!”

With so much at stake, we need to learn along the way and measure and evaluate everything we can to strengthen our efforts and invest wisely.

But now is time to act, and what we’ve seen and heard tells us that we’re ready to move beyond talk to change. The way forward includes more intentional collaboration between community development, finance and public health to improve the places we live, learn, work and play. We can no longer allow some neighborhoods to win and some to lose.

It’s time to rebuild Main Street as a healthier place for us all to live.

For more on the event, read the recently published journal from the Federal Reserve Bank of San Francisco that was the impetus for this conference, visit The Health Care Blog (on which this posting originally appeared), or follow the discussion on Twitter at #FedHealth.

David J. Erickson, Ph.D., is Director of the Center for Community Development Investments at the Federal Reserve Bank of San Francisco.

Dr. James S. Marks, M.D., M.P.H., is Senior Vice President in charge of the Health Group at the Robert Wood Johnson Foundation.

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