Health Affairs

It has long been understood that many factors beyond health care actually influence health. Social and economic determinants of health include income, education, physical environment, social isolation, and concentration of poverty. Given this reality, there is a growing realization of the potential for synergies between work to revitalize low-income communities and the need to promote and improve health.

Community development encompasses a range of efforts to improve the physical, economic, and social environment by promoting affordable housing, small-business development, job creation, and social cohesion in low-income neighborhoods.

The field of community development is diverse. It includes real estate developers, financial institutions and other investors, community organizations, and local governments. These players have unique assets as well as a network of connections that can be used to address the root causes or "upstream factors" that affect health.

This policy brief describes the potential for the community development sector to work more closely with the public health and related health-focused sectors. It discusses the potential impact of their efforts on health outcomes, and the challenges they may face.

Health is determined by a range of factors, only one of which is access to health care. There is a wide body of evidence that underlying social and economic determinants are also important. These include the level of a person's income, education attainment, and characteristics of the physical environment in which he or she lives, such as the level of pollution or violence (Exhibit 1). For a discussion of the way these factors contribute to disparities in health, see the Health Policy Brief published on October 6, 2011.

Exhibit 1
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HOW ACTIONS SHAPE HEALTH: Many of these underlying determinants of health or illness can be shaped by effective public policies and private actions. Having full-service grocery stores offering a variety of nutritious foods in poor neighborhoods may help people make healthier choices in the foods they eat. Neighborhoods will be healthier if they are devoid of damaging agents such as lead, asbestos, and industrial waste. Better housing stock can provide healthier places to live and may reduce the prevalence of such conditions as childhood asthma.

Meanwhile, recent history shows that low-income communities can be made better places to live and work through so-called community development--building affordable housing, launching small businesses, and creating jobs. The nation's current community development sector grew out of the federal "War on Poverty" launched in the 1960s. Today it constitutes a broad network of real estate developers, financial institutions, community organizations, local governments, and others focused on the objectives of improving life in low-income communities.

Led by community development corporations and community development financial institutions (which essentially act as nonprofit banks working exclusively on behalf of low-income people), these diverse parties work to assemble numerous sources of capital, including government subsidies and foundation grants, bank loans and investments, and equity investments for tax credits, to revitalize neglected communities. Their successes include building millions of homes as well as financing development of child care centers, charter schools, and retail hubs.

Although these community development efforts already target many of the underlying social determinants of health, they are typically not connected as much as they could be to broader public health prevention or promotion activities. And even though public health and community development efforts frequently operate in the same neighborhoods, their respective efforts have not been well coordinated--at least until now.

Recently, the community development and health fields have begun to focus on ways they can work more effectively together. For example, in San Francisco, Mercy Housing California, a nonprofit development company, is working with for-profit Related Companies of California to redevelop Sunnydale, the city's largest public housing community. The community consists of about 1,700 residents living in 785 units on 50 acres characterized by poor housing conditions, extreme poverty, and violence. Their plans include replacing all of the existing housing and adding 900 subsidized or market-rate units, a life center with a fitness facility and family programming, a health clinic, an arts program, educational facilities, 6.5 acres of new green space, a farmers market, and 8,000 square feet of retail space.

The Sunnydale developers are working with researchers at the University of California in a "Learning Community" program to collect baseline data on social and physical needs of residents. The data will be used to assess and document the impact that the project has on the community over time. Similarly, IFF, a large community development financial institution based in Chicago and supported by Citibank, is investing significant private-sector capital in federally qualified health centers across several Midwestern states.

The community development and health sectors can also collaborate by training and finding secure employment for community residents in the fields of public health, environmental remediation and protection, and food service. These are sectors in which there is expected to be substantial job growth over the next decade.

Focusing on these fields for workforce development has a number of potential benefits. First, it would reinforce efforts to reduce government spending and improve health by addressing health problems at their roots. And second, it would help low-income residents move out of poverty by providing them with both skills and high-quality jobs, positions that include salaries above the minimum wage, employer-based health insurance, and career paths for upward mobility.

The awareness of the potential to marry community development with health concerns builds on a number of efforts under way at the federal level, as follows:

Healthy People 2020. The Obama administration's 10-year plan for improving the nation's health emphasizes social determinants of health and encourages the use of health impact assessments as a strategy to address them. Health impact assessments are systematic efforts to identify the ways in which a project or policy can affect health. For example, a health impact assessment for a major new housing construction project might assess whether there will be sufficient green space for residents to exercise or engage in other healthful leisure activities. Such assessments can highlight health-related issues that should be considered during project planning or implementation, identify new potential funding sources tied to improving health outcomes, and provide additional support for undertaking a project.

Although health impact assessments are still uncommon in the United States, their use is growing. The Health Impact Project, established by the Pew Charitable Trusts and the Robert Wood Johnson Foundation, encourages policy makers to make greater use of health impact assessments when considering new laws, regulations, projects, and programs.

Action Plan to Reduce Racial and Ethnic Health Disparities. Released in April 2011, the administration's action plan commits to adopting a "health in all policies" approach of considering the impact on health inequalities of policy and program decisions beyond the health sector. The underlying premise is that, for every key policy decision, policy makers should be asking, "What are the health consequences?" This approach is intended to encourage government agencies in sectors such as transportation, agriculture, and trade to support a healthier environment.

White House Office of Urban Affairs. The Obama administration created this new office to specify national goals for cities and metropolitan areas and develop policies that advance those goals. Its projects include the Neighborhood Revitalization Initiative, which strives to transform high-poverty communities by better aligning federal funds and recognizing interconnected problems and solutions. This effort engages staff in the White House and a wide range of federal government agencies, including the Departments of Health and Human Services, Housing and Urban Development, Education, Justice, and the Treasury in support of local solutions to revitalize neighborhoods.

Place-based policies. The administration has advised all federal departments and agencies to emphasize "place-based" policies--policies that consider the equity and livability of places--in developing their budgets. Agencies have been asked to identify programs for achieving place-based goals including community health improvements such as expansion of access to healthy food, support of environmental health, and healthy homes.

Healthy Food Financing. This initiative, jointly carried out by the Health and Human Services, Treasury, and Agriculture departments, seeks to expand the availability of nutritious food in low-income neighborhoods. The initiative includes developing and equipping grocery stores, small retailers, corner stores, and farmers markets to sell healthy food.

Choice Neighborhoods Initiative. This collaboration among the departments of Housing and Urban Development, Education, Justice, Health and Human Services, and the Treasury supports efforts by community leaders to attract private investment to transform distressed neighborhoods into sustainable ones by providing affordable housing, safe streets, and good schools. One of the primary goals of the program is to support positive outcomes for people living in the targeted neighborhoods, particularly outcomes related to residents' health, safety, employment, mobility, and education.

Community Transformation Grants. The Affordable Care Act of 2010 provides new funding for community projects to reduce chronic disease, violence, and injury and to improve mental health and equity. In September 2011, the Department of Health and Human Services awarded more than $100 million in Community Transformation Grants to 61 projects in 36 states. These projects focus on the root causes of chronic disease with an emphasis on reducing tobacco use, increasing healthy eating and physical activity, and providing preventive services. The lessons learned from these projects will be amplified by the National Dissemination and Support Initiative, which provides $4.2 million to seven networks of community-based organizations to disseminate information about successful strategies.

Although there is great potential for improved coordination between the health and community development sectors, the path forward is complicated. Each sector has its own processes and procedures for documenting needs, implementing projects, and evaluating results. The government agencies that oversee various projects are often unrelated and have different timelines and requirements.

Government budget processes and program administration also present barriers to collaboration. Federal funding for health, housing, economic development, and other community revitalization activities is administered by different agencies and overseen by different committees of Congress. Cost savings and program impact are almost always considered separately. For example, lower health costs associated with a program funded by the Department of Housing and Urban Development might not be identified as savings because those effects are seen in the jurisdiction of another agency or congressional committee.

In addition, it will be critical to build a base of evidence demonstrating which interventions truly improve health outcomes. And building that evidence will itself be a challenge. It isn't possible to conduct classic randomized controlled experiments that assign one group of people to live in a "healthy" housing complex and another to live in an "unhealthy" one, and then follow both groups over the next 75 years. Researchers can, however, use what is called a quasi-experimental approach that relies on data from naturally occurring events. To use the same example of groups living in different housing projects, researchers could follow two comparably situated groups in housing projects that differ in aspects of particular interest, such as exposure to pollution, and determine much from what happens to them over time.

Working together, the community development and health sectors have the potential to marshal their respective resources to create healthy, vibrant, self-sustaining communities. To be sure, concerns about the federal deficit and prospective cuts in government spending could threaten existing programs or limit investment in new opportunities in both health and community development. Both sectors will need to collaborate and coordinate to make the best case for the overall value of their policies and to make a coherent case that they can accomplish more in tandem than they could working apart.

Arcaya, Mariana and Xavier de Souza Briggs, "Despite Obstacles, Considerable Potential Exists for More Robust Federal Policy on Community Development and Health," Health Affairs 30, no. 11 (2011): 2064-71.

Braunstein, Sandra and Risa Lavizzo-Mourey, "How the Health and Community Development Sectors Are Combining Forces to Improve Health and Well-Being," Health Affairs 30, no. 11 (2011): 2042-51.

Erickson, David and Nancy Andrews, "Partnerships among Community Development, Public Health, and Health Care Could Improve the Well-Being of Low-Income People," Health Affairs 30, no. 11 (2011): 2056-63.

Freudenberg, Nicholas and Emma Tsui, "Training New Community Health, Food Service, and Environmental Protection Workers Could Boost Health, Jobs, and Growth," Health Affairs 30, no. 11 (2011): 2098-106.

Jutte, Douglas P., Kaja Z. LeWinn, Malo A. Hutson, Ramie Dare, and Janet Falk, "Bringing Researchers and Community Developers Together to Revitalize a Public Housing Project and Improve Health," Health Affairs 30, no. 11 (2011): 2072-8.

Kotelchuck, Ronda, Daniel Lowenstein, and Jonathan N. Tobin, "Community Health Centers and Community Development Financial Institutions: Joining Forces to Address Determinants of Health," Health Affairs 30, no. 11 (2011): 2090-7.

LaVeist, Thomas, Keshia Pollack, Roland Thorpe Jr., Ruth Fesahazion, and Darrell Gaskin, "Place, Not Race: Disparities Dissipate in Southwest Baltimore When Blacks and Whites Live under Similar Conditions," Health Affairs 30, no. 10 (2011): 1880-7.

Syme, S. Leonard and Miranda L. Ritterman, "The Importance of Community Development for Health and Well-Being," Community Development Investment Review, Federal Reserve Bank of San Francisco, Volume 5, no. 3 (2009).

Williams, David R. and James Marks, "Community Development Efforts Offer a Major Opportunity to Advance Americans' Health," Health Affairs 30, no. 11 (2011): 2052-5.

Written by
Amanda Cassidy
Principal
Meitheal Health Policy
(Cassidy previously worked for the Centers for Medicare and Medicaid Services, in the Office of Legislation and the Center for Medicare Management.)

Editorial review by
David J. Erickson
Director
Center for Community Development Investments
Federal Reserve Bank of San Francisco

S. Leonard Syme
Professor Emeritus
University of California, Berkeley

Ted Agres
Senior Editor for Special Content
Health Affairs

Anne Schwartz
Deputy Editor
Health Affairs

Susan Dentzer
Editor-in-Chief
Health Affairs

Health Policy Briefs are produced under a partnership of Health Affairs and the Robert Wood Johnson Foundation.

Cite as:
"Health Policy Brief: Community Development and Health," Health Affairs, November 10, 2011.

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