Healthier and More Equitable Communities

In 2014, the state of Michigan replaced the city of Flint’s safe water with improperly treated water from the Flint River, resulting in severe health problems for Flint residents — primarily disadvantaged families. It was one of the worst public health crises in the United States in recent history, according to Agustin Arbulu, director of the Michigan Department of Civil Rights. More than that, it brought to light the importance of social justice, health and community planning. “How do you design policies with equity in mind?,” says Arbulu.

According to a study by the Michigan Dept. of Civil Rights entitled, The Flint Water Crisis: Systemic Racism Through the Lens of Flint, “The people of Flint have been subjected to unprecedented harm and hardship, most of it caused by structural and systemic discrimination and racism that have corroded the city, its institutions and the water pipes.” According to Arbulu, “It was the legacy of racism that created these inequities — the implicit racial inequity — not explicit racism.” He notes that segregation practices of years past contributed to social inequity and the health crisis.

“While the governor has put into place a number of initiatives revising copper lead rules for safety and replacement of pipes and service lines, the problem you still have is that the community has been decimated, residents have been displaced and those remaining have lost trust in our government,” he says. “You have to engage the community from the beginning when it comes to community, and city planning.”

Tying Health, Housing, and Social Equity

Because of Flint and even before this health crisis, many federal agencies recognized the importance of public health, community planning and social equity. “In the past, the health department would assess the current state of health in populations living in a certain community, but, other than the hospitals, the built environment wasn’t considered. Transportation wasn’t linked to overall health, either,” says Anna Ricklin, former manager of the American Planning Association’s Planning and Community Health Center and now a Health in All Policies Manager for the Fairfax County, Virginia Health Department.

“The built environment has features that can help or hinder its residents when it comes to resources for healthy food, access to parks and other social determinants,” she adds. That’s why, she says, a 2017 initiative called the Joint Call to Action to Promote Healthy Communities was so important. “It shows a lot of promise for bringing fields together to be more holistic about how health and social equity are shaped,” she adds.

In 2017, eight national organizations agreed to collaborate with one another to create healthier, more equitable communities. Those eight organizations include American Institute of Architects, American Planning Association, American Public Health Association, American Society of Civil Engineers, American Society of Landscape Architects, National Recreation and Park Association, U.S. Green Building Council, and Urban Land Institute.

According to the American Society of Landscape Architects, The Joint Call to Action to Promote Healthy Communities brings together professionals who recognize that the built environment is a key determinant of health. Working together will create new momentum towards the common objective of creating and sustaining healthy buildings and spaces. Solutions may include multi-use pathways for walking and biking, Complete Streets policies, equitable and affordable transportation and transit-oriented communities, implementation of green infrastructure, more efficient land, water and resource use, expanded tree canopies, and access to buildings with health-promoting indoor environments.

“The partnership is all about helping our [the American Planning Association] members understand how folks in other sectors operate. The way to get to social equity is by having more inclusion every step of the way. If a landscape architect or civil engineer learns more about the planning process, rather than just their small piece of the project, then they have a better understanding of how to carry community engagement all the way through,” says Ricklin.

According to a Change Lab Solutions white paper, “A Roadmap for Healthier General Plans,” the process of updating a community’s general plan offers a critical opportunity to shape local development patterns for decades into the future, creating healthier and more sustainable neighborhoods for all residents. But planners often face competing needs and priorities: other issues that may take center stage include job growth, business interests, and local leaders’ platforms and passions. The Joint Call to Action is one way to ensure the right issues take center stage.

Avoiding Displacement

While community upgrades can also lead to gentrification and social inequity by forcing out current residents, if done correctly, it can improve social equity by making communities safer and healthier for the residents, not despite them. “There is an inequity in underprivileged communities when it comes to access to resources required to be healthy. Many of us take for granted that we have full-service grocery stores and access to fresh, healthy food,” says Ricklin. “Many inner cities are what we call food swamps; they have access only to unhealthy foods and, while many have parks, they are unsafe for residents,” she says. “These inequities often fall on the low-income, immigrant communities.”

As reported in a study called “Development without Displacement: Resisting Gentrification in the Bay Area,” between 1990 and 2011, the number of Latino households in the Mission district of San Francisco decreased by 1,400, while the number of White households increased by 2,900. In fact, says the report, gentrification is changing the population of Oakland and San Francisco as a whole. Between 1990 and 2011, Oakland’s African American population decreased from 43 percent to 26 percent of the population, the largest drop by far of any population group. During the same period, San Francisco’s Black population was cut in half from about 10 percent to only 5 percent of the population.

Gentrification affects housing quality and health and exacerbates inequalities. In Oakland, neighborhoods in the latest stages of gentrification have the greatest disparity between Black and White mortality rates. The report also found that rates of overcrowding increased in San Francisco neighborhoods between early and late stages of gentrification.

It’s a very real challenge, says Saneta deVuono-powell, an attorney and program director for Change Labs Solutions, a social justice nonprofit focused on health issues. “We’ve been grappling with chronic disease prevention for the last several decades with limited success. That has elevated the attention to the social determinants of health, and housing is one of the areas where you can most clearly see the health effects of the issue,” she says. “In poor quality housing, you have air quality issues, lead poisoning, and there is strong evidence that when people live in poor quality housing, there is a plethora of disease. The United States’ investments in housing have been unevenly distributed along racial lines, drawing a clear connection to social inequity and health issues,” says deVuono-powell.

She notes that moving investments into communities to bring resources that improve health, such as sidewalks, parks, lighting, and encourage physical activity such as biking trails, are good for health. “They are also precursors to neighborhood destabilization or gentrification,” says deVuono-powell. “That’s why it’s so important to stabilize neighborhoods with the goal of helping residents.”

Neighborhood Stabilization

One community that has worked to stabilize, rather than gentrify, is Denver, Colo. “They created a city fund to support and grow the affordable housing pool. They are piloting a program of housing vouchers for moderate- income families and have a process for doing health assessments and integrating health into the framework,” says deVuono-powell.

In Portland, Ore., “they started a program a few years ago where, in their new housing development, they set aside a certain percentage of units where previously displaced residents could come back. They are also adopting an interesting mapping protocol that looks at what areas are vulnerable to displacement and targeting interventions before it gets to the point where tons of people have been pushed out,” says deVuono-powell.

A Model for Health and Social Equity

Another area that is hopeful to find success in tying social equity with health and planning is Trenton, N.J. When the city of Trenton was updating its comprehensive plan in 2016, it decided to take a collaborative approach and include a health and food systems element to the plan. Other cities have taken on this challenge with varying levels of success. What makes Trenton different is the collaboration with the residents of that city to improve social equity. “An important component for the partnership is collaboration with the people on the ground,” says Dr. Jennifer Senick, executive director of the Rutgers Center for Green Building and a facilitator of the Planning Healthy Communities Initiative. “Healthy changes must benefit the current population, not lead to gentrification and an exodus of those residents,” she says.

The Planning Healthy Communities Initiative (PHCI) promotes the integration of public health impacts into planning and decision-making about projects and policies. According to Senick, PHCI advances the practice of Health Impact Assessment (HIA) as a tool to improve planning and decision-making throughout the United States Northeast region.

Partnering for Success

“We partnered with the Trenton Health Team, which included 40 area nonprofits, including an area hospital. The innovative aspects of this project are that it didn’t just look at things through a planning lens but also took into account population health data and tools. It was a joint initiative of planning and public health,” she says. “The vast majority of those living in Trenton have health problems and are disadvantaged populations,” says Senick. “When people take on social inequity, they think one neighborhood. In Trenton, for the most part, the entire city is a disadvantaged community. With the planning we’ve done, it feels like what we’re doing is unlikely to lead to rapid gentrification.”

On a high level, in Trenton, the initiative worked on visioning aspects and goals. Some goals include increasing access to healthy foods and promoting healthy food outlets within walking distance (½ mile from city center). “You do that through zoning and partnerships to bring healthy food outlets to an area. We also partnered with the school system to promote healthy eating and nutrition,” says Senick.

Another goal was to increase physical activity. “There were a number of strategies related to making it easier and safer to walk and bike. We also wanted to improve access to parks and support school-based initiatives,” she says.

The third goal was to improve access to health care and health literacy, which included improving transit accessibility to health care and expanding and integrating substance abuse and mental health care. Finally, the fourth goal was to promote healthy housing conditions. “Among other things, we wanted to improve conditions at vacant and abandoned properties, which present health hazards as well as being an economic drag,” says Senick.

Each goal was motivated by a map that visually conveyed information on obesity and crime rates, respiratory disease and more. “Using the map, we found that opportunities for physical activity may be in high crime areas.

It’s not just the built environment that will encourage health and improve social equity. You must apply a Health in All Policies (HiAP) framework to figure out what’s working and what you can put in place to support the built environment,” says Senick.

Collaborative Approach

Health in All Policies is a collaborative approach to policymaking and improving the health of a community. By recognizing shared goals, collaborating, and coordinating their efforts, public agencies can work with the communities they serve to ensure public policies and public resources address local needs and improve health outcomes.

While it’s too soon to declare it a success, Senick says, “There’s an ongoing focus to realize these interventions that the plan provides. We know in the literature that these types of interventions will lead to positive health and social equity outcomes, but it’s difficult to claim direct success from the plan. There are multiple variate equations,” she says.

The good news is that many planners and other professionals recognize the importance of collaboration and introducing health variables into comprehensive plans. When done correctly, with the residents of the community involved and protected, social equity and health can improve in disadvantaged communities across America.