ExploreMoHealth: An Example of How One State is Taking Health Data to the Next Level

The traditional delivery of health care is moving beyond just treatment within the walls of hospitals and into managing the health of populations in the community. Health care providers are increasing their focus on upstream social determinants of health that often lead to poor health outcomes. This shift is being driven in part by new regulations that require hospitals to work with public health experts, such as local public health agencies, and to develop community health needs assessments and improvement plans. These factors are expediting the collaborative delivery of care across the continuum – integrating voices from public health, social service, and community action organizations. It is critical that these collaborative efforts are founded on insightful, firm data that identify areas of need within different populations and across geographic locations. That’s where ExploreMoHealth steps in.

ExploreMOHealth was created in partnership between Missouri Foundation for Health (MFH) and the MHA Health Institute, the not-for-profit corporation affiliated with the Missouri Hospital Association. By combining resources, MFH and MHA were able to create one of the most unique health-related datasets in the country. The Center for Applied Research and Engagement Systems (CARES) at the University of Missouri helped to bring the data alive and make it accessible across sectors.

Data is the key to diagnosing and addressing some of our region’s most pressing health issues, and by making robust and up-to-date information available to the public, ExploreMOHealth is helping to further the missions of MFH and MHA to improve health and the health care system while also supporting other health related initiatives across the state with data for better decision-making.

Building on the Missouri ZIP Health Rankings Project, a collaboration between researchers at the Washington University School of Medicine and the Hospital Industry Data Institute, ExploreMOHealth provides a unique approach to measuring community health at the ZIP code level, using hospital discharge and census-based data applied to the County Health Rankings model of population health.

The data provided by the project are designed to inform community health needs assessments at a granular geographic level to inform targeted resource allocations for community health improvement initiatives. Project findings have been presented at the annual meeting of the American Public Health Association and published in the Journal of Public Health Management and Practice.

The ExploreMoHealth platform was launched last week and while still in its infancy, it’s generating excitement and opportunity across the state.

Health & Equity in General Plans: California’s Giant Step

We believe in the power of storytelling and the importance of investing in the future by sharing those stories – whether they are stories of successful community ventures or lessons learned from stories of things you wish happened just a little bit differently. These are the stories of communities working together for the common good.  – Community Commons 

Tina Yuen – ChangeLab Solutions | This past fall, an unassuming California agency quietly took a big step forward for health, equity, and sustainability. The Office of Planning and Research (OPR) issued its new guidelines for general plans, the documents created by California cities and counties to guide their future development. The 2017 General Plan Guidelines represent the first time OPR has included specific recommendations for how general plans can address community health, equitable development, and public engagement.

Thanks to the new guidelines, communities across the state working to integrate health and equity concerns into their general plans will have a free, publicly available resource from a trusted source to guide that work. The guidelines provide best practices, data sources, model language, and case studies focused on community health, equity, climate change and resilience, and community engagement. The guidelines will undoubtedly help many jurisdictions zero in on the most appropriate strategies for integrating these concerns into their general plan updates.

California law requires every city and county to periodically update its general plan, sometimes referred to as its blueprint for the future. As a public agency with a statewide view, OPR has a unique role in supporting and guiding general plan updates. The guidelines serve as an information clearinghouse for local jurisdictions, to help make sure their plans not only pass legal muster but also incorporate best practices and policy tools that can help them achieve their goals.

General plans in California have to include certain major sections (called elements), like housing, transportation, and, as of 2016, environmental justice. Recently, some jurisdictions have also begun including elements that directly address health and equity. More jurisdictions around the state are likely to take up this trend as planning practice more broadly integrates these concerns.

OPR deserves much credit for including new and expanded health and equity sections in the general plan guidelines. The new recommendations in the guidelines also reflect the hard work of many health and equity advocacy organizations around the state, including ChangeLab Solutions and its partners.

One key partner in this work was the California Pan-Ethnic Health Network (CPEHN), whose executive director Sarah de Guia praised the new guidelines as “a monumental first step by a state agency to provide leadership and guidance on equity and community engagement.” CPEHN advocates for public policies and resources to address the health needs of communities of color around the state, and de Guia expects that the new guidelines will “provide important strategies and best practices for local jurisdictions as they plan for growth and development” that takes into account California’s changing demographics.

ChangeLab Solutions, CPEHN, and many other partners worked together to construct a detailed set of comments and responses to OPR’s draft guidelines. These comments called for, among other changes, the addition of more and better case studies, clearer definitions, and more inclusive language, as well as a stronger emphasis on the links between health, equity, and community engagement.

For example, ChangeLab Solutions and CPEHN suggested that the guidelines include a definition of health disparities as a key term for planners. More broadly, the two organizations recommended that the guidelines be amended to better reflect the perspectives and needs of California’s communities of color. Over two-thirds of the changes suggested by ChangeLab Solutions and its partners were fully or partially incorporated into the final guidelines.

Publication of the new general plan guidelines is a momentous step for healthy, equitable planning in California, but it is hardly the last one. ChangeLab Solutions will assist with the rollout of the new guidelines, helping jurisdictions as they undertake general plan updates, as part of their continuing work in healthy and equitable planning. (See, for example, ChangeLab Solutions’ toolkit on creating and implementing healthy general plans.)

Healthy and equitable planning happens in other states, too, of course. More and more communities around the country are incorporating health and equity into their general or comprehensive plans, often with help from ChangeLab Solutions and other partners. We hope the new OPR guidelines will inspire other states to follow suit by providing the same kind of well-crafted, forward-looking guidance to their own local jurisdictions.

Tina Yuen

Tina Yuen is a senior planner at ChangeLab Solutions, where she works at the intersection of health, planning, and the built environment.

Incorporating Health into Physical Needs Assessments

This article was written by Elizabeth Zeldin and Emily Blank. It was originally published on the Building Healthy Places blog on June 27, 2017.

In May, the New York City Department of Housing Preservation and Development (HPD) and New York State Homes and Community Renewal (HCR) launched a new Integrated Physical Needs Assessment tool to provide affordable housing owners with a comprehensive protocol to assess the range of options available to upgrade their buildings. The tool will allow owners to take advantage of incentives and opportunities to make their properties as sustainable and safe as possible. A key component of the Integrated Physical Needs Assessment is a new health overlay, providing guidance on health-focused upgrades as well as operations and maintenance protocol.

As readers of this blog are aware, the quality of our housing determines the quality of our health . But while most affordable housing slated for rehabilitation is reviewed by an engineer prior to the creation of a scope of work to determine needs and upgrade options, this process does not typically focus on factors related to tenant health. Recognizing that building rehabilitation provides an important opportunity to improve health conditions, Enterprise Community Partners (Enterprise), and the Local Initiatives Support Corporation (LISC), in partnership with New York City’s health and housing agencies and Tohn Environmental Strategies, created a health overlay for the standard physical needs assessment (PNA) that is required for most affordable housing preservation in New York State.

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The potential public health impact of healthier affordable housing rehabilitations is immense, particularly for vulnerable and low-income households. There is a clear link between the quality of housing and epidemics like childhood asthma and other respiratory ailments. People in low-income communities are more likely to live in housing that is inadequate, and low income families are more likely to live in substandard housing that has elevated risks of lead poisoning and asthma. A health-focused assessment tool has the potential to reduce some of the housing-related health issues that plague low-income communities.  Housing upgrades with a health lens have repeatedly been shown to improve resident health outcomes.

In 2015, HPD began to require all building owners receiving low-interest financing to perform a Green PNA to enhance energy efficiency.  The process of revisiting the PNA to incorporate green components sparked an interest in refining the tool even further to add a health focus. To make this happen, Enterprise and LISC spearheaded a unique collaboration among professionals in the health sector, building scientists, government agencies, and nonprofit affordable housing organizations.  The collaboration was critical in ensuring the effectiveness of this tool.

While many building owners would like to incorporate health-focused interventions, the affordable housing industry has only recently begun to create tools that help prioritize their many options. With the health overlay to the PNA, owners can better understand the balance between costs and health outcomes of various measures and structure maintenance practices for long term sustainability. As the evidence base for the connection between health and housing grows, this tool will be invaluable in ensuring that properties incorporate essential healthy housing practices.

Map of overcrowded housing units

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One of the biggest challenges in creating the health overlay was to keep the assessment protocol cost-effective and clear to a building scientist not necessarily well-versed in public health, while still laying out a comprehensive set of solutions. For example, air quality testing was considered but ultimately excluded due to the difficulties in assessing the results and subsequent interventions. Similarly, in-depth interviews with existing residents were also discussed but ultimately not included in the process.

Owners will also need to carefully weigh the costs and benefits to health-focused interventions. Although there are many low-cost health upgrades that owners should consider, certain upgrades can come at a high cost. For example, ventilation upgrades, which can greatly improve indoor air quality and minimize mold and moisture issues, are quite expensive and might not be feasible in projects with limited ability to take on debt.

In order for housing to serve as a platform for success, it must be both affordable and healthy. As the evidence base connecting health and housing grows, the health overlay to the PNA will be invaluable in ensuring that a building offers the healthiest living conditions for those who call it home.

New Data: County Health Rankings

Data and maps from the 2017 County Health Rankings are now available on Community Commons. Search the Map Room for the term “CHR 2017” to view the full list of County Health Rankings data.

What are County Health Rankings?

The County Health Rankings & Roadmaps program is a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute. These organizations work together to produce annual rankings for 30+ indicators. County Health Rankings provide “a snapshot of how health is influenced by where we live, learn, work and play. They provide a starting point for change in communities.”

The goals of the County Health Rankings & Roadmaps program are to:

  • Build awareness of the multiple factors that influence health;
  • Provide a reliable, sustainable source of local data and evidence to communities to help them identify opportunities to improve their health;
  • Engage and activate local leaders from many sectors in creating sustainable community change; and
  • Connect and empower community leaders working to improve health.

How are communities using County Health Rankings to support their work?

County Health Rankings Action Cycle

The County Health Rankings & Roadmaps site provides a host of tools and resources to support the use of the data to drive positive change in communities. A few of our favorite resources include:

Where can I find County Health Rankings data on Community Commons?

You can search the Map Room for “CHR 2017” to view the full list of County Health Rankings data available to map. The Commons also has historical County Health Rankings data from 2016 and 2014. Below are a few maps to help get you started in exploring the County Health Rankings data in our Map Room.

Map of County Health Rankings for Access to Mental Health Care Providers

Click the map to zoom to your area.

Map of the County Health Rankings Diabetes Screening data

Click the map to zoom to your area.

County Health Ranking map of violent crime

Click the map to zoom to your area.

How are you using County Health Rankings data in your community? Tell us about it in the comments or on Facebook and Twitter.

National Summit Showcases Health, Economic, and Social Justice Benefits of Walkable Communities

By Jay Walljasper

Many things leap to mind when someone mentions walking: fitness, fun, fresh air, relaxation, friends and maybe your most comfortable pair of shoes.  But a word that rarely arises is “power”.

That will begin to change after the 2017 National Walking Summit (held in St. Paul, Minnesota September 13-15), which is themed “Vital and Vibrant Communities—The Power of Walkability”.

Like earlier summits, this event brings together people of all backgrounds to strategize ways of making sure the advantages of walking can be shared by all, no matter what their income or where they live.

Walking advocates once focused primarily on physical health —spurred by mounting evidence that physical activity is key to preventing disease—but now are stepping up to promote social, economic and community health. Their ultimate goal is to transform towns and neighborhoods across America into better places for everyone to live.

“The power of walking is becoming more clear all the time,” declares Kate Kraft, executive director of America Walks. “Community connections, social equity, a sense of well-being, business opportunities, affordable housing, more choices for kids and older people, a cleaner environment—these are some of the benefits of walkable places.”

Walking Boosts Health & Happiness

Streams of medical studies now document the central role physical activity plays in fending off disease and disability. Chances of depression, dementia, colon cancer, heart disease, anxiety, diabetes and other conditions drop by at least 40 percent among people engaging in moderate exercise such as walking.

A landmark study issued last year found that sedentary habits are a bigger health threat than high blood pressure or cholesterol— about the only thing more dangerous than inactivity is smoking reported the New York Times.  This followed on the heels of a Cambridge University study showing that a lack of exercise increased your risk of death twice as much as obesity.

All the scientific data persuaded former Surgeon General Vivek H. Murthy to issue a landmark Call to Action to Promote Walking and Walkable Communities in 2015, which has been compared to the 1964 Surgeon General’s report on the dangers of smoking. “Walking helps people stay both physically and mentally healthy,” Murthy wrote, calling on us “to increase walking by working together to increase access to safe and convenient places to walk.”

Walking stands out among all other exercise because: 1) It is free; 2) It requires no special training or equipment; 3) It can be done almost anywhere at any time; and 4) It is already Americans’ #1 favorite physical activity.  The US Department Transportation reports that Americans reported walking 14 percent more in 2012 than in 2002 (latest figures available).

Walking Advances Social Justice

“The health benefits of walking are so overwhelming that to deny access to that is a violation of fundamental human rights,” declared sociologist Robert A. Bullard, founder of the environmental justice movement, at the 2015 Walking Summit. “All communities should have a right to a safe, sustainable, healthy, just, walkable community.”

Unfortunately, that’s not the case across America today. People walking in lower-income neighborhoods are twice as likely to be killed by traffic than those in more affluent areas. African-Americans on foot are 60 percent more likely to be killed by cars than whites, while Latinos are 43 percent more likely.

“If you have walkable communities, kids will do better in school…seniors will be healthier,” said Ron Simms—a neighborhood activist from the African-American community of Seattle who later became Deputy US Secretary of Housing and Urban Development, at the 2015 Summit.

Better walking conditions also help low-income families economically.  Surprising new research from the George Washington School of Business shows “the most walkable urban metros are also the most socially equitable. The reason for this is that low transportation costs and better access to employment offset the higher costs of housing.”

Click the map to create a Location Opportunity Footprint for your community.

This is backed up with Federal Highway Administration data finding that families living in auto dependent communities spent 57 percent of their income on housing and transportation, compared to 41 percent in walkable communities.

This refutes widespread rumors that making a street safe for walking is a luxury important only to well-off people. Actually, low-income residents benefit the most because they travel by foot the most, especially kids.  “The fact is that we have twice as many low-income children [nationally] who are walking or biking to school than those in affluent neighborhoods, even lacking the infrastructure to protect the children,” reports Keith Benjamin, Transportation Director in Charleston, South Carolina.

“A big thing we could do to help low-income families is to make it easier to live without a car,” says community consultant Gil Peñalosa.  “And it would help middle-class families to switch from two cars to one.” The American Automobile Association calculates the annual pricetag of owning one car at  $8,500 a year—which goes a long way toward easing household budgets.

Safe, convenient and comfortable places to walk are fundamental to the forgotten one-third of Americans who don’t drive— the young, the old, the disabled and those too poor to buy a car. These people live under a form of house arrest in many US communities, unable to do much of anything—buy groceries, see friends, go the doctor, engage in favorite activities—without begging someone to chauffeur them. Communities from San Francisco to Birmingham to rural Iowa are pulling together to eliminate the roadblocks that deter people of all ages, incomes and racial backgrounds from walking.

Walking Expands Economic Opportunities

People on the street mean business—literally.  Neighborhood and downtown business districts thrive on foot traffic.  West Palm Beach, Florida discovered this after making a major avenue more comfortable for pedestrians, and attracting $300 million in new business investment.  Albert Lea, Minnesota—a blue-collar rural town of 18,000—found the same thing when a walk-friendly makeover of its Main Street drew 15 new businesses in two years, with $2-5 million more in investment planned.

Even companies not dependent on local customers are eager to locate in walkable districts—especially firms in the booming tech and creative fields, who realize the young talent they depend on to stay competitive want to work within walking distance of cafes, parks and cultural attractions.  “We moved from the suburbs to downtown Minneapolis to allow our employees to take advantage of the area’s many trails and to put the office in a more convenient location for commuting by pedal or foot,” explained Christine Fruechte, CEO of large advertising firm Colle + McVoy, in a newspaper op-ed. “Our employees are healthier, happier and more productive. We are attracting some of the best talents in the industry.”

Many other companies find that walkable locations pay off in lower health insurance premiums. Thomas Schmid of the Centers for Disease Control and Prevention points to Volkswagen, which built a manufacturing plant in Chattanooga only after local officials agreed to extend a popular walking-biking trail to their door.

Walking Connects People & Strengthens Communities

Eighty five percent of Americans express the desire to live somewhere walkable, making it the #1 quality they want in  a home, according to  the National Association of Realtors’ Community & Transportation Preference Survey. This is even more true for Millennials, millions of whom will be looking to buy their first home over the next few years.

“What makes people walk is [also] what makes great places to live,” emphasizes Harriet Tregoning, until recently a director in the Office of Community Planning at the US Department of Housing and Urban Development (HUD). “Walkability is the secret sauce that improves the performance of many other things” in our communities.

Former Surgeon General Regina Benjamin emphasizes that taking a stroll “is good for the social fabric of our communities”—creating new opportunities to connect with friends and neighbors, which is not only good for your soul but also your health. That’s why Benjamin added a walking path to the grounds of the health clinic she founded in rural Alabama.

Walking Protects Our Environment

Walking more is an important step you can take to avert climate disruption, air pollution, urban sprawl and other environmental threats. More than half the suggestions in 50 Steps Toward Carbon-Free Transportation, released last year by the Frontier Group research organization, involve walking.

Walking in the Heartland

Drawing a crowd ranging from block club organizers and grassroots advocates to elected officials and medical experts, the 2017 Walking Summit features two-and-half days of workshops, major addresses, trainings, break-out discussions, success stories and on-the-ground exploration of solutions in Minnesota communities.

Among the more than seventy sessions are:  How to Build Safe Walking Networks; Walking in Rural Communities; Creating Walkable Communities Without Displacement; You Are Where You Live and Creative Walkable Interventions.

Keynote speaker Tamika Butler—director of the Los Angeles County Bicycle Coalition—will showcase how her organization broadened their mission from sustainable transportation to social justice. “We must talk about public health, gentrification, people of color, women who feel harassed on the streets, older people, black men who fear for their lives on the street, immigrants who fear deportation,” Butler says.  “Walking for many people has everything to do with living full lives and being able to get around.”

St. Paul Mayor Chris Coleman—who launched a first-of-its-kind $42 million Vitality Fund to promote walking and other community improvements—will also speak at the conference along with racial and social justice leader Glen Harris from the Center for Social Inclusion and George Halvorson of the Institute for InterGroup Understanding, who made strides in launching walking movement as CEO of the  Kaiser Permanente health care system.

Participants will find specific information and inspiration to take back home by following one or more of the Summit’s six “paths” of subject matter:

Healthy Communities: People’s zip codes are as accurate as their genetic code in predicting a healthy life. That’s why it’s essential to put in place policies, programs and resources to ensure everyone has an equal chance for a healthy life.

Safe, Well-Designed Communities: Too many communities are designed for the ease of motorists with little thought of people who get around other ways. The focus here is practical approaches to provide safe, convenient transportation and affordable housing for all.

Artistic and Innovative Communities:  Creativity flourishes in places where people regularly connect face-to-face on sidewalks and in public spaces.  Discover ideas about fostering foot-friendly settings that spark community engagement, cultural diversity and imaginative energy.

Productive and Thriving Communities: Walkability is closely linked with socially and economically successful places. Here’s where to start in creating vibrant neighborhoods, equitable development, affordable housing and strong downtowns or Main Streets.

Open and Collaborative Communities: Wide-ranging collaboration explains the difference between towns, suburbs or cities that blossom and those that wither. What’s the key in getting people together for authentic conversations and effective partnerships?

Engaged and Informed Communities: Access to information and decisionmakers are two powerful tools for transforming a community. These sessions offer a detailed look at new methods to gather data, engage communities, mobilize citizens and influence local government and businesses to catalyze walking.

This is the first Walking Summit held outside Washington, DC.  “We’re really excited to showcase some of the success we’re seeing, but also share the challenges we have in Minnesota,” says Jill Chamberlain, chair of the local host committee and a senior program manager in the Center for Prevention at Blue Cross and Blue Shield of Minnesota, a featured sponsor of the event.

The Twin Cities metropolitan area in many ways represents a microcosm of America when it comes to walking. Minneapolis and St. Paul both rank relatively high for the rate of pedestrian trips among US cities, but until recently autos were the centerpiece of all urban planning in the region. Many suburbs lack sidewalks and other basic infrastructure for pedestrians. Concentrated populations of low-income households and/or people of color are found in both suburbs and cities. But there is a growing awareness that walking is important to future prosperity and quality-of-life—and growing numbers of projects to get people back on their feet.

Mobile workshops on the first day of the conference will fan out across the  area to investigate local initiatives that illustrate the power of walking— from  a police department campaign for pedestrian safety to a residential neighborhood with a small town feel to an inner city community torn apart by a freeway, which is exploring plans to reconnect itself by building a land bridge over the road.

Jay Walljasper—author of the Great Neighborhood Book and America’s Walking Renaissance—writes, speaks and consults widely about creating healthy communities. 

In Rhode Island, a Model for Upending Health Inequity

This article was written by Julie Ryan. It was originally posted on March 2, 2017 in the Building Healthy Places Network blog.

Looking at a map of the places they call home, most people can easily point to notably affluent areas versus the ones that have dilapidated homes, under-resourced schools and unsafe sidewalks—places more likely to be cut through by a six-lane highway, or to host a polluting factory rather than a supermarket stacked with fresh food or a tree-shaded playground.

In the last decade, as public health experts have mapped these areas of social disparity, they have also begun plotting a new set of data points on health outcomes. Indeed, it probably doesn’t surprise anyone that healthier living environments give rise to healthier lives. And longer lives, too. For example, a baby born in the Lakeview area of New Orleans can expect to live to 80, whereas one born just a few miles away in Treme has a life expectancy of 55.

Click the map to zoom to your area.

Twenty five years. It’s hard to imagine a starker reflection of unequal opportunity. But this doesn’t have to be.

When government, community leaders and public health advocates collaborate, these disparities don’t have to be inevitable. In fact, this is how my organization, the Local Initiatives Support Corp. (LISC), approaches our work to help improve health in low-income places all across the country. We know we can begin to upend health inequities by focusing our combined efforts to support well-being in the neighborhoods that need it most.

That’s the idea behind a path-breaking initiative launched last year by the Rhode Island Department of Health to establish ten “health equity zones” (HEZ) across this small New England state.

Health-focused Cross-Sector Collaboration

Each health zone is a contiguous area—as small as a few city blocks or as large as a county—with higher-than-average health risks and burdens. And each is managed by a local “backbone” agency.

The variety of these lead agencies is part of the initiative’s novelty and strength. They include an extensive community health center with multiple sites and an organization that supports domestic-violence survivors as well as a municipality, an affordable housing developer, and a school district. LISC serves as backbone agency for Pawtucket and Central Falls, two small cities north of Providence.

To get the health zones we are leading up and running, these we have partnered with everyone from police departments to community health centers. We’ve also reached out to residents to gauge needs and priorities, and have developed and begun to implement multi-strategy action plans for community health.

Some strategies are targeting the physical environment, like promoting bike lanes and improving vacant properties. Others are focusing on behavioral change, disease prevention, and education. Still others are promoting access to nutritious food, health services, and even job training. In just the first year of implementation, we have filled six diabetes prevention classes and helped launch 76 community gardens on public housing land, as well as a community health fellowship program for residents.

Even before becoming the lead agency for a health zone, LISC was working to revitalize Pawtucket and Central Falls. We invested in safe and affordable housing there and worked with the police and other partners to get help for local sex workers at risk for addiction, violence, homelessness, and sexually transmitted disease. In many ways, the complex, cross-disciplinary crime reduction work we support dovetails perfectly with this approach to improving health.

Click the map to zoom to your area.

As part of the health zone, we’re continuing to use our comprehensive lens to better the lives of local residents by investing in groups working to develop community gardens and urban farms, for instance, and helping homeowners make necessary repairs, avoid foreclosure, and get rid of lead.

But what’s new isn’t the interventions themselves—established approaches with proven effectiveness—it’s the way they’re bundled for maximum impact in particular places, and the way they push the very concept of health promotion beyond the confines of the doctor’s office and  disease-specific efforts.

Guided by Community Input

In the Central Falls/Pawtucket HEZ, nearly a third of residents live in poverty and one out of three are recent immigrants. The area suffers high rates of teen pregnancy, early-childhood obesity, and infant mortality. Carrie Zaslow, my colleague in LISC’s Rhode Island office, says that during the agency’s “listening tour” of the area, investigators didn’t inquire a lot about resident’s physical health. The conversation was far more open-ended. What came up included concerns about income and jobs, access to healthy foods, and the need for better transportation.

One concern was voiced again and again: older people reported they had a hard time getting out, especially in winter, and faced a dearth of activities to help them stay connected—a double whammy of physical immobility and social isolation that could have a substantial impact on their health. The health zone partners created a community-service program in which teens help their elderly neighbors on snowy days by shoveling out their walks and drives. That’s just one of many practical solutions the collaborative came up with.

As Carrie Zaslow explained it to me, “A lot of how LISC has evaluated our work is through metrics like increases in income, decreases in unemployment, housing units built—how we’ve impacted the economic wellbeing of a neighborhood.” In this case, she added “we’re asking about health outcomes. Are more people who potentially have pre-diabetes in programs? Are we seeing people eating more vegetables, are they reporting that they’re exercising more? Are they able to access culturally sensitive behavioral health services?”


That the Rhode Island Department of Health has been able to channel millions of dollars to develop the HEZs is itself an object lesson in creative budget management. After all, it’s not as if there’s a big pot of money out there earmarked for attacking health disparities in a holistic, place-based way. Novais knows the challenge of getting taxpayer support for such work. She and her colleagues responded by pulling together federal monies targeting such areas as child and maternal health, chronic disease prevention, smoking cessation, and emergency preparedness—and focusing those resources on the work of the healthy equity zones.

A Long View of Change

Everyone involved in the health zones understood from the outset that a few years is not enough time to effect—let alone to persuasively document—changes in longevity. Instead there are two basic levels of evaluation. The most important is a fine-grained check on how well each HEZ has met the goals laid out in its own detailed action plan. So, for example, a health zone focusing on chronic disease might show how many people completed a diabetes prevention program, or the number of residents with diabetes who improved their blood-sugar control.

The second level of evaluation looks at the components of the HEZ and how well they’re run: Does the backbone agency have governance standards that are clearly spelled out? How diverse and active is the health zone’s collaborative? In addition, the health department will be studying statewide data to try to identify core indicators of success. A light switched on for me several years ago when I learned that medical care contributes only about ten percent to health and longevity—far less than the impact the environmental and social factors we experience in our homes and neighborhoods. So for all the money the United States spends on health care–and we spend more per capital than any other country—we have considerably higher rates of obesity, diabetes, and low birthweight, to name a few.

As a society, we can do better. Let’s imagine a different map, a different drive through our communities. On this one you won’t find a longevity gap; you won’t find food deserts or high rates of pediatric asthma. Everywhere you point should be a place where any one of us can live a healthy, productive life.

Growing Accessibility of Opioids in Rural Areas

A recent Kaiser Health News article shed light on one business that is thriving in some poorer, rural towns: pharmacies. Specifically, it highlights Manchester, KY, a town of 1,500 in Clay county. Despite dilapidated infrastructure and empty storefronts, drug stores continue to open. Three in the past four years gives the town a total of eleven drug stores. Their best sellers are prescription pain drugs.

To put it in perspective, in a 12-month period 2.2 million doses of hydrocodone and 617,000 doses of oxycodone prescriptions were filled. In a county of 21,000, that’s 150 doses for every man, woman, and child. In some areas, Clay county’s doses are 100 percent higher (sometimes more) than nearby counties of similar size. From 2009 to 2013 Clay county also had the third highest rate of hospitalizations for pharmaceutical opioid overdoses among Kentucky’s 120 counties.

Click image to zoom to specific area or to create a map of your own.
Note: The map highlights the counties of Breckinridge (north central KY), Allen County (south central), and Clay (east).

Adults with poor or fair health are more prevalent in Clay county than many counties of similar size, specifically Allen and Breckinridge. Obesity and diabetes in these areas are also higher than the state and national averages.

Areas like Clay county aren’t only disadvantaged in terms of health, but economically as well. The unemployment rate is above the national average at 8.4 percent, nearly half of the residents live below the poverty level, and 60 percent of residents are on Medicaid. Hardships like poverty, unemployment, and feeling isolated can make the use of substances, like opioids, more attractive. As the Kaiser article points out, one key predictor of prescription drug abuse is social ranking.

Click image to zoom to specific area or to create a map of your own.

The opioid epidemic that’s sweeping the country, especially rural America, has been well noted. And while there is a growth in legal ways to obtain prescription pain, in part due to the Medicaid expansion, Dr. Jeffrey Newswanger, an ER physician and chief medical officer at Manchester Memorial Hospital, believes that most people who abuse prescription drugs acquire them illegally. “We see a lot of overdoses and have a tremendous drug problem in the area,” he said.  “Whether there is any correlation between OD’s and the Medicaid expansion is hard to say. I think in general most abusers are getting their drugs from the street, not from prescriptions.”

A lot of focus is on Kentucky, but there are even more startling stories just across the border in Mingo county, West Virginia. In Kermit, a town of 392 residents, drug companies shipped 9 million hydrocodone and oxycodone pills to one pharmacy over a two-year period. And in a six-year period 780 million hydrocodone and oxycodone pills were distributed throughout the state- in the same period 1,728 West Virginians overdosed on those same drugs. Meanwhile the CEOs of the big three wholesalers that shipped the drugs to West Virginia were compensated a collective $450 million over four years. You can find additional reading, maps, and data on opioid prescriptions and use in West Virginia, here.

Click image to see specific area or to create your own map.

Many living in rural areas lack basic access to substance abuse treatment services. Nearly 82 percent lack access to detox services. Those who need more advanced services have to travel long distances to reach the specific services they need. That can be especially burdensome for disabled patients who do not drive or do not have access to public transportation. And in places like Manchester, KY, the closest inpatient drug treatment facility has a waiting list of 100 people. The waiting list has grown by 50 percent just within the past few years and has been at capacity for the past several.

Frontline health care employees in many rural areas do not have the resources or specialized training to treat the growing substance abuse epidemic- especially in the face of a growing number of pills that are acquired both legally and illegally.

A New Resource for Health: The Practical Playbook

Donning the slogan, “Helping public health and primary care work together to improve population health,” the Practical Playbook is a new resource focused on supporting collaboration and innovation in community health work.  Launched in mid-2016, the Playbook’s development was supported by de Beaumont Foundation and Duke University Community and Family Medicine. The online resource center is full of inspiration and guidance for communities implementing policy, system, and environmental change policies.

The Practical Playbook was designed recognizing and embracing the following six values:


  1. Strong public health and primary care are essential for an effective health system
  2. To achieve maximum impact on health, upstream factors that affect health must be addressed
  3. Community engagement is critical for success
  4. Multidisciplinary, multi-sector teams are most likely to drive improved health behaviors
  5. Evidence, data, and evaluation must drive prioritization of resources and efforts
  6. Collaboration is hard, takes energy and time, but is worth the effort

The “Fundamentals” portion of the site will help you better understand the basics of population health. More importantly, it also digs deep into the nature of partnerships and provides five principles of success that, “enable primary care and public health groups to work together.” These principles are based on research from the Institute of Medicine (IOM) and selected as best-practices of the longest standing health collaboratives in the nation:

  • Principle 1: A shared goal of population healthlogic-plan-the-practical-playbook
  • Principle 2: Community engagement
  • Principle 3: Aligned leadership
  • Principle 4: Sustainable systems
  • Principle 5: Shared and collaborative use of data and analysis

But the Playbook doesn’t stop there. In the “Building A Partnership” section, you can find everything from sample logic models and helpful videos to pitch checklists and data sharing agreements, the Playbook has resources to support you at every step along the way.

Finally, the last two sections of the site help bring us full circle. “Expert Insights” and “Success Stories” connect us to on-the-ground testimony and use cases – providing real-life advice and “what not to do” tutorials.

The Commons team has been exploring the Playbook over the past couple of months and continue to find new resources each week. We hope you will too!

Beyond the Pipeline: Standing Rock Sioux Tribe

Right now, thousands of protestors from all over the world are joining protests in Standing Rock Sioux Tribe Reservation in North Dakota. The protests are in response to the proposed Dakota Access Pipeline, a 1,172 mile pipeline that wants to connect the Bakken and Three Forks oil production areas.

What’s drawing the ire of protesters and folks around the country is where the pipeline is being routed. It would pass under the Missouri river, just half a mile upstream from the reservation’s boundary. An oil spill would not only be catastrophic to the water quality, but also to the already burdened economy and health of the reservation. Second, the pipeline would pass through culturally significant sacred sites and burial grounds. While not located on the reservation, they are sites that the federal government has sought to protect.

When we look at the Standing Rock Sioux Tribe we see a reservation, like many others around the country, already in dire straights in terms of health, education, employment and economic opportunities. Understanding their history sheds some much needed light on an often-overlooked culture.

Standing Rock Sioux Reservation History

Established in 1868 as part of the Treaty of Fort Laramie, Standing Rock Sioux Reservation was originally part of the Great Sioux Reservation that included the Black Hills and Missouri River. Under Article 12 of the treaty, no cession of land could be taken unless three-fourths of adult males on the reservation approved. But by 1877, gold was discovered in the Sacred Black Hills and the area was removed from the reservation by Congress- without the required three-fourths consent.

Congress further reduced the size of the Great Sioux Reservation in 1889- dividing it into six reservations, including the Standing Rock Sioux Reservation, which has remained intact since then. This resulted in “checker-boarded” land ownership within the reservations, creating opportunities for non-Indian entities to come in and buy land for profit making ventures like casinos, liquor stores, etc – not the makings for healthy and vibrant communities.

The tribe has jurisdiction over right-of-ways, waterways, and streams that run through the land- which has lead to many ongoing disputes among the reservation, government, and private businesses- most notably the current dispute with the Dakota Access Pipeline.

In all the discussions about the pipeline, it’s important to also focus on Standing Rock Sioux Tribe as a community in need of support. There are historically rooted problems that persist to this day and will continue – with or without the pipeline- if these conditions are not acknowledged and addressed.

What are conditions like on Standing Rock?

Standing Rock, like many reservations around the country, are plagued by poverty and poor health outcomes. So why has poverty and associated conditions persisted on these lands?

  • Most jobs are only available in tribal governments- some reservations see 85 percent unemployment!
  • Persistent exploitative policies that allow garbage disposal and nuclear testing on or near reservation land
  • Geographic isolation from schools and health facilities
  • Poor access to banking and lending institutions

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Education and Employment

In recent years African American and Latino students have seen an increase in graduation rates- that’s not the case for Native Americans. Their graduation rates have been declining since 2008. In 2014, 67 percent of Native American students graduated from high school, compared to the national average of 80 percent. Much of the responsibility is ineffective relationships between the Indian Nations and the federal government, mostly due to mismanagement, poor leadership, and lack of collaboration among the Bureau of Indian Education, that oversees the Indiana reservation schools, and the Education Department, Department of the Interior, and Department of Housing and Urban Development. In other words, it’s a bureaucratic mess. And the students are suffering with not only poor education, but subpar learning environments as well. Many schools are rodent-infested school buildings that have electrical problems, broken water heaters, and rotting floors.

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It goes without saying that not graduating from high school or earning a GED severely limits employment opportunities. That’s what we see on Indian reservations- but it’s not the sole cause for the high unemployment rate. In many cases, there are simply no jobs. The tribal and federal government are the largest employers on Indian reservations, but those jobs are limited. And If they reside in a state with poor job creation it’s even harder to find employment- even off the reservation. Families pool their resources together and often times grandparents raise the kids as mom and/or dad seek employment opportunities elsewhere. It’s a heartbreaking reality for millions of people that reside on these reservations. However, we could see a turnaround. Over the summer President Obama made a historic visit to Standing Rock Sioux Tribe Reservation where he acknowledged the critical health and economic issues facing Native Americans. He pledged to begin the process of working to create more economic opportunities on reservations. Programs like “Made in Rural America” or Program for Investment in Micro-Entrepreneurs (PRIME) are good places to start, but we still need more deeply rooted change.


America in general is facing a housing crisis, mostly due to skyrocketing housing costs- but on reservations it’s a different story: families simply trying to find adequate housing that doesn’t pose health risks. Living conditions on some Indian reservations are frequently described as “third world”. Overcrowded housing, homes with no plumbing, electricity, or kitchen facilities are more common on these reservations than most other parts of the country.  Even though the Indian Housing Authority makes efforts to provide adequate housing– only so much can be done on a stretched budget. Currently 30 percent of Indian housing is overcrowded and roughly 40 percent of housing is considered inadequate.


Health Outcomes

Native Americans on reservations suffer from health issues, millions across the country suffer from. However, they feel the impact much more intensely and see more premature deaths because of it. They experience diabetes, obesity, heart disease, hypertension, influenza, pneumonia, tuberculosis, and death from cancer at substantially higher ratesThe severely underfunded Indian Health Service has taken on the colossal burden of managing health care on reservations. Not only are needed programs and interventions not implemented, the reservations remote locations make access to needed health and treatment facilities even more complicated.

Vast majority of Native Americans lead healthy productive lives on and off reservations- but alcohol’s role always weaves into the conversation. It’s important to understand that hard liquor (much more potent than their fermented beverages) was introduced to Native Americans by European colonists. During trading sessions the colonists would drink and provide it freely to the Native Americans or use it to trade for animal skins and furs. There was high demand with no laws to regulate it. Today we still see that impact in communities- and very little resources coming in to treat.

Perhaps most staggering is that the death rate from suicide is 50 percent higher in Native Americans than whites. Forty percent of the deaths by suicides are among 15 and 24 year olds- the highest rate of suicide among all ethnicities and higher than the general population.



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The health of Standing Rock Sioux Reservation is not an anomaly, many reservations, such as Pine Ridge in South Dakota, suffer even worse health outcomes. At the center of the issue is the lack of trust Native Americans have towards the federal government- and rightfully so, the relationship has been strained and dysfunctional from the start- and it’s the folks on the reservation that have paid the price.

When we look at the news we see a crisis- millions joining in protests to protect Native American waterways and lands from corporations. It’s a struggle that’s emblematic of the rooted tradition of devaluing Native American land and lives. The next administration should not only work to create functional, meaningful relationships with the Indian nations, but also work to harness the innovative ideas and ingenuity that are already ripe in the Native American community, especially among the youth. The passion to do better and be better for their community is there, but the opportunity isn’t. It’s a long process and hopefully the media attention from the protests in Standing Rock can bring these longstanding issues further into the mainstream. Keep talking about it- no matter what happens with the pipeline.

Catalyzing Health Care Investment in Healthier Food Systems

Health Care Without Harm is undertaking a national study of non-profit hospitals’ community benefit practices to improve healthy food access and reduce risk of diet-related disease. We’re excited to share information about the initiative below.

Recent changes under the ACA to IRS regulations governing the community benefit obligations of tax-exempt hospitals build on a movement by health industry leaders to promote greater community engagement and a population health orientation in community benefit practices. There is now a powerful new opportunity for non- profit hospitals to collaborate with other stakeholders to implement community health improvement plans that address social determinants of health such as housing, environmental and safety conditions, and the availability of quality, affordable food.

Health Care Survey

In this three-year project, funded by the Robert Wood Johnson Foundation, Health Care Without Harm is conducting a national study of non-profit hospitals’ community benefit practices targeted to strengthening food system resilience and sustainability, improving physical and economic access to healthy foods, and promoting healthier dietary patterns and healthy body weight. Through a national survey, in-depth interviews, and case studies, the study will identify best hospital community benefit practices as well as model programs promoting sustainable and healthy food systems.

Research Aims

  • Examine the extent to which hospital facilities are integrating food access, food insecurity, dietary patterns, obesity, and diet-related non-communicable disease (DR-NCD) in their Community Health Needs Assessments (CHNAs)
  • Analyze the kinds of Community Benefit (CB) investments that are taking place to strengthen food system resilience and sustainability, promote physical and economic access to healthy foods, improve dietary patterns, and reduce obesity and DR-NCD risk
  • Identify facilitators and obstacles to hospitals’ choosing to direct CB funds to obesity and food- related interventions
  • Identify best CB practices. These will include best practices in CHNAs; collaboration with public health agencies, community groups, and other stakeholders; implementation plans; and program evaluation based on criteria derived from a literature review and from the study
  • Identify model programs targeting food & nutrition-related community health impacts and improvements to food systems sustainability, which are currently or potentially could be supported by CB funds, based on criteria derived from a literature review and from the study

Desired Outcomes

  • Strengthen collaboration among stakeholders
  • Develop and disseminate tools for hospital facilities, the public health community, food security and environmental advocacy groups
  • Promote best practices

Survey invitations will be sent to a random sample of tax-exempt hospitals to learn about how hospitals include food insecurity, healthy food access, and diet-related health conditions in their community health needs assessments and implementation plans. If you receive an invitation to complete the brief survey, please do so! Your contribution is vital. Findings will be made available through various learning networks, including Community Commons.

Heath CHealth Care Without Harm Logoare Without Harm seeks to transform the health sector worldwide, without compromising patient safety or care, to become ecologically sustainable and a leading advocate for environmental health and justice. This project is being conducted by our Healthy Food in Health Care program. To learn more, please contact: Susan Bridle-Fitzpatrick, Senior Researcher, Healthy Food in Health Care Program, HCWH at, 1-888-264-7721 or visit

Data Viz of the Week: 3 Ways to Map Summer Food Programs

When school lets out for the summer, it’s a time for celebration and warmer weather. But for some kids, it can also become a season of hunger.

According to the USDA Food and Nutrition Service, over 31.6 million children received low-cost or free lunches throughout the 2012 school year. Without school lunch programs during the summer, many families have a harder time making ends meet. To fight hunger in their local communities, many organizations offer summer food programs when school is out of session.

Let’s look at three ways to visualize summer food programs in the US:

Visualization One: Summer Programs in Your Community

The Maproom in Community Commons hosts many publicly available data sets, including the locations of summer food programs. Below we can see all the summer food sites in St Louis, Missouri.

Click on the map to zoom to your area.

Click on the map to zoom to your area.

Visualization Two: Additional Context

The location of summer food programs may differ depending on the resources and needs of the community. By mapping the percent of population below 50% poverty, we can see which summer food sites are in more vulnerable areas. For a higher resolution of the community’s needs throughout the county, we can map the percent of children who qualify for free or reduced-price lunches at each school.

Click the map to zoom to your location.

Click the map to zoom to your location.

Visualization Three: Potential Partners

The USDA Food and Nutrition Service has developed a list of tips to help include local food and farmers’ markets into summer food programs. To see which farmers’ markets are close to summer food sites, we can layer this data on the map as well.

Click the map to zoom to your area and apply this data in your community.

For more information about farmers’ markets and summer food site partnerships, check out the USDA videos below.

How Are We Handling Mental Health Care in the U.S.?

There are many challenges to discussing mental health.  It’s an issue that touches millions of people, regardless of age, race, or socioeconomic status. It manifests itself in just about as many ways. Yet when it comes to caring for those who suffer from mental illness, the U.S. has serious ground to make up.

It’s estimated that 1 in 5 Americans suffer from some form of mental illness, yet 60 percent of adults and 50 percent of teens do not receive treatment. That’s just the tip of the iceberg. From depression to schizophrenia, not only are we seeing an uptick in mental illness nationally, especially among women and teens, suicides in the U.S. have gradually increased 24 percent from 1999 to 2014. It’s estimated that 90 percent of people who commit suicide have an underlying mental illness.

Furthermore, we are seeing a startling  increase in suicide among certain groups. Rural teens are two times more likely to commit suicide than their urban contemporaries even though the rates of mental illness are relatively similar when comparing the two. This “Silent Epidemic” is discussed in depth by Dr. Cynthia Fontanella, here.

The issue extends beyond teens to American Indians, middle-aged white women and even 10-14 year old girls. When we look to rural areas, especially those with tribal and native lands, we see that people report a higher number of poor mental health days (per month) compared to other parts of the country.

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So, what’s happening? Why are we seeing these steady increases in mental illness and suicide? Sociologists attribute economic stagnation, feeling hopeless, social changes (i.e. rising divorce rate), and social isolation as major factors. The effect is felt especially hard among American Indians and low income whites in rural America, where chronic disease, poor job prospects, no or limited health insurance, and split families are becoming more common. With these compounded problems, many view the “American Dream” as not only out of reach, but see any upward social mobility as a pipe dream . Additionally, the fear and stigma associated with mental illness keeps many from seeking treatment. Though with the inaccessibility and unaffordability of many effective treatment programs, it would be a major hurdle to overcome if treatment was sought. The result?  Self destructive behaviors like substance abuse become all too common.

What’s the problem with mental health treatment in America?

Massive cuts to mental health services have only amplified the problem, especially in rural communities. To put in perspective, from 2009 to 2012 states cut $5 billion in mental health services and eliminated 4,500 public psychiatric hospital beds (10 percent of the total supply).

Access to skilled mental health professionals in rural areas is much lower compared to other medical services. Poor physical access is one thing, but the cost barrier is another. Finding in-network mental health care providers, high deductibles, co-pays and expensive medications can be an exhausting challenge for those with insurance to overcome. Imagine it for those without insurance. Mental health care is now covered under the Affordable Care Act, but there are still huge state-by-state disparities that make coverage complicated. Still, 4 percent of all hospital visits are for behavioral health needs. In 2012, the U.S. spent $11.4 billion in payments  to medical centers that had patients unable to cover cost of care.

Click the map for a closer look at access to mental health and substance abuse treatment facilities

And while effective treatments exist, integrating them into our health care system is an ongoing challenge. This, coupled with many states paring down mental health services, has left millions of Americans to fall through the cracks of a broken system. In an article for USA Today, child psychologist and Representative Tim Murphy R-PA said,  “We have replaced the hospital bed with the jail cell, the homeless shelter and the coffin. How is that compassionate?” Essentially it comes down to health insurance companies’ and states’ political will to care for this country’s vulnerable populations. 

The current state of mental health treatment is a costly one, not just for individuals, but for the country. Mental illness costs the U.S. roughly $444 billion dollars annually due to disability payments, medical care, and lost productivity. That does not factor in the costly expense of cycling those with mental illness in and out of jail and homeless centers. The way we care for those with mental illness now, is far more costly (financially and socially) than it is to simply care.

For a closer look on the current system’s impact on families, check out The Guardian’s series, “America’s mental health care crisis: families left to fill the void of a broken system“.

To learn more about mental health, find support, or to learn how you can help raise awareness, visit National Alliance on Mental Health (NAMI)

America’s “Worst City for Walking” Gets Back on its Feet

The following was originally published at and written by Jay Walljasper. 

Oklahoma City improves life for people who walk– and reaps the benefits

The US gave up on walking in the mid-20th Century—at least planners and politicians did. People on foot were virtually banished from newly constructed neighborhoods.  Experts assured us that cars and buses (and eventually helicopters and jet packs) would efficiently take us everywhere we wanted to go.

Thankfully, most Americans refused to stop walking.  Today —even after seventy years of auto-centered transportation policies—more than 10 percent of all trips are on foot, according to Paul Herberling of the US Department of Transportation. That number rises to 28 percent for trips under one mile.

Indeed, we are in the midst of a walking renaissance as millions of people discover a daily stroll can prevent disease, boost energy, ease stress, connect us with our communities, and is just plain fun.  The number of us who regularly take a walk has risen six percent in the last decade, according to the US Centers for Disease Control and Prevention. According to a new study from the National Association of Realtors, 79 percent of Americans–even higher for those under 35 –want to live in a place that’s walkable.

Walking’s popularity is now reaching beyond older city neighborhoods into suburbs and the Sun Belt.

Even Oklahoma City—which was named as the “worst US walking city” in a 2008 study of 500 communities by Prevention magazine and the American Podiatric Medical Association—is embarking on big plans to become more walkable.

“Bleak” is how Jeff Speck, urban planner and author of Walkable City, describes walking in Oklahoma City seven years ago.  “Traffic sped too fast…for pedestrians to feel comfortable on the sidewalks…oversized traffic lanes encouraged highway speeds,” he wrote in Planning magazine. Oklahoma City also suffered from perhaps the worst sidewalk network in America.  Most other towns conscientiously built sidewalks until the 1950s, but Oklahoma City abandoned the effort as early as the 1930s in some neighborhoods.

Mick Cornett, the city’s Republican mayor since 2004, notes, “We had built an incredible quality of life, if you happened to be a car. But if you were a person, you were seemingly combating the car all day.”

“We probably were last in the country for walking,” Cornett admits.

Pedestrian Road Network Density, Road Miles per Sq. Mile by Block Group

Click on the interactive map to see what this data looks like for your own community or visit our Map Room to create your own maps.

This rock-bottom rating really stung in a community that had earlier been passed over by United Airlines as the site for a new maintenance facility because, despite the city’s generous financial incentives, the company’s CEO said he couldn’t imagine asking his managers to move to Oklahoma City.

Then, a year after the walk rankings, the city again found itself in the harsh glare of unwanted media attention.  This time Men’s Fitness magazine stigmatized Oklahoma City as the “#2 fattest city” in America. Among the country’s 100 largest cities, only Miami was more corpulent.

That’s all changing now. An ambitious $18-million sidewalk improvement fund was approved by voters as part of a tax increase that also included money for parks, transit, bike trails and senior wellness centers around town.  Four busy streets heading into downtown are now being narrowed, with new “smart intersections” that provide walkers more safety with “refuge island” medians in the middle of streets and clearly marked crosswalks.

So what’s driving all this pedestrian progress?

Mayor Cornett, a former sportscaster, bristled at his city being called fat and sedentary.  Yet he knew that he couldn’t credibly deny these charges since he’d gained enough extra pounds while in office to be labeled obese, thanks to endless rounds of breakfast and lunch meetings.

Cornett launched an initiative to get the city back in shape. Over the past seven years, he notes, Oklahoma City has added hundreds of miles of new sidewalks, built eight miles of bike lanes on the streets (there were none in 2008), added 100 more miles to the recreational trail network, built new gyms at many public schools, created a public rowing center and started work on an whitewater kayak and rafting course on the Oklahoma River.  Low-income neighborhoods, where health and obesity issues are most severe, are the biggest focus of the city’s programs for healthy eating and active living.

Cornett also issued a successful Challenge for Oklahoma City residents to lose one million pounds. Over 47,000 people signed up, and lost on average 20 pounds.  Cornett himself shed 38.

One major thrust of this campaign was working with fast food restaurant to offer healthier menus. Cornett is proud of this partnership and during our interview slipped into his office closet to fetch a life-size cardboard cut-out of himself posing with Taco Bell’s low-fat options, which was displayed in the chain’s 40 Oklahoma City restaurants.

This all seems to be making a difference—the growth in Oklahoma City’s obesity rate has slowed significantly from six percent annually to one percent, with the stage set for reductions in the future.

Adult Obesity (BMI >=30), Rank by County

Click on the interactive map to see what this data looks like for your own community or visit our Map Room to create your own maps.

The mayor is quick to share credit. First and foremost, he applauds local citizens, who in 2010 voted to continue a one-cent addition to the sales tax for seven more years to pay for health initiatives.  Oklahoma, he points out, is a very conservative state—the only one where Obama did not carry a single county in either 2008 or 2012.  Yet Oklahomans are willing to support taxes when they know where their money is going. “They like projects where they can see the results,” he points out.  “And this is not debt and it’s not a permanent tax–it’s up for renewal every few years.”

Cornett views this spending as a smart business move, noting that the 2010 tax referendum, and two earlier ones under previous mayors focusing on downtown revitalization, public education and overall quality of life, amassed $2 billion in public investment which in turn spawned $6 billion more in private development.

“Ever since we decided to make this a great place for people to live, the jobs started coming here and young Millennials, who want to bike and walk, are arriving in numbers we’ve never seen before,” he says. “We are creating a city where your kids and grandkids will choose to stay.  They used to go to Dallas or Houston.”

“It turned out that one thing people—especially young people—wanted was better sidewalks,” Cornett explains.  That’s why the city now builds new sidewalks as part of most repaving projects and kicks in half the cost for any homeowner or neighborhood that wants them. Developers are now required to provide sidewalks in all new projects. As for the $18 million earmarked for sidewalks from sales tax revenue, “most of it goes where we know we need sidewalks, connecting schools and shopping centers with neighborhoods,” the mayor says.

While most people consider walking essential to a good neighborhood, there’s still a lot of opposition. “We hear from those who say, ‘We don’t need sidewalks, because no one walks here,’” Cornett says, noting that the absence of sidewalks is a big reason people don’t walk.

The city is in the early stages of initiating a Safe Routes to Schools program, making it possible for more school kids to walk or bike, and a Vision Zero campaign, aimed at eliminating all traffic fatalities in the city, says Dennis Blind of the city’s planning department.  The city also holds Open Streets events—festivals where a street is blocked off to vehicles so people of all ages can reclaim the streets (temporarily) as public space.

“We’ve come a long ways in a short time,” says Cristina Fernandez, who moved from Santa Monica—one of the most walkable communities in California—for an executive position at a local firm. “But we still have a long ways to go.”

Walkscore, which rates the walkability of any address in America, still ranks Oklahoma City in the lower 15 percent of cities over 200,000, which is nonetheless a big improvement over last place. The city’s low score can be partly explained by the fact that sprawling subdivisions, which would be classified as separate municipalities elsewhere, are inside the city limits here.

The epicenter of walking in Oklahoma City is downtown and nearby neighborhoods, which exhibit all the signs of urban vitality: sidewalk cafes, new loft apartments, refurbished old neighborhoods with local business districts, indie shops and restaurants, nightlife, sports and entertainment venues, well-populated parks, riverside bike trails, and sidewalks alive with people of all ages walking between all these spots.

An old warehouse district with a pedestrian promenade along a canal thrums with activity. A 70-acre central park is being developed that will connect downtown with a largely Latino neighborhood on the South Side via a new pedestrian bridge. A streetcar line debuts later this year that will loop through many of these neighborhoods. Protected bike lanes, which physically separate bicyclists and pedestrians from rushing traffic, will soon appear on major arteries coming in and out of downtown.

Oklahoma City’s mission now is to widen the walkable section of the city outward.  Local transit service has been improved (including new Sunday and evening buses), resulting in a sizable jump in ridership.  The Wheeler District, a new pedestrian-focused infill neighborhood south of downtown, breaks ground this year with plans to create 2000 homes.

North of downtown, things are already picking up.  “You have a lot of young people moving into the area because they can walk,” says Fernandez, who lives in the Crown Heights neighborhood.  Business districts scattered throughout this part of town, some of which once harbored crack houses and brothels, now flourish with restaurants and shops catering to local residents.

Fernandez, her husband and kids are still waiting for sidewalks on their street but already are walking more “because there are now more places to walk to.”  An attractive streetscape to improve the pedestrian ambience of the Western Avenue business district near their home makes walking more fun.

“When we go anywhere in the neighborhood now, we usually go on foot,” she says.

Jay Walljasper writes regularly about public health and healthy communities.  The former editor of Utne Reader, he is author of The Great Neighborhood Book. His website is

City As A Commons

The following was originally published at and written by Jay Walljasper. 

The disaster with Flint, Michigan’s drinking water, incited by political leaders more devoted to fiscal austerity than the common good, illuminates why it’s important to think of our cities as commons–human creations that belong to all residents, not just the wealthy and politically well-connected.

Drinking Water Safety, Percent of Population Potentially Exposed to Unsafe Water, Rate by County

Click on the interactive map to see what this data looks like for your own community or visit our Map Room to create your own maps.

The commons itself means all the many things we share together rather than own privately–a list that starts with air, water, parks and streets and expands to include more complex entities such as the Internet, civic organizations and entire communities.

Typically the commons evokes images of the countryside: sheep grazing on communally-tended pastures, people frolicking on a town green, untrammeled wilderness open to all. Even in the modern context, commons champion (and Nobel Prize winner) Elinor Ostrom is best known for research on the management of forests, fisheries and agricultural irrigation systems even though one of her important studies focused on police departments in metropolitan St. Louis.

Yet the recent resurgence of commons projects is happening in urban as well as rural areas, witnessed by the City as a Commons: Reconceiving Urban Space, Common Good and City Governance conference held last November in Bologna, Italy–a city taking big steps to integrate commons-based collaboration into its own policies and operations (more on this below).

The strong pastoral association with the commons makes sense from an historical perspective. Individualism and market economics were embraced first in urban areas as enlightenment philosophies and industrialization spread throughout Europe and eventually the whole planet. It was in rural communities where cooperative traditions endured and in some cases expanded, said Dutch historian Tine De Moor, president of the International Association for the Study of the Commons, one of the conference sponsors. Cooperatives, for instance, grew up the countryside of many nations during the 19th and 20th centuries because many rural communities’ needs could not be profitably met by private businesses.

In England, many villages once held Beating the Bounds parties in which folks hiked the boundaries of their local commons together, ripping out private encroachments on their collective land. US commons scholar David Bollier suggested urban and digital activists might update this custom to preserve commons of our own time.

The social alienation and crushing poverty associated with early industrial cities can be explained by the sudden loss of commons connections and resources by rural refugees forced off the land into factories, said Michel Bauwens, founder of the Foundation for Peer-to-Peer Alternatives, based in Thailand. Cities lacked the free common spaces where people could raise food, gather firewood or gather outside with their neighbors. These human necessities must all be purchased.

The Rise of Urban Commons

Urban commons like parks, sanitation systems, public schools, public transit, libraries, hospitals, labor unions, private and public social welfare agencies emerged throughout the 19th century in response to squalid urban conditions. And the commons movement today stands on the shoulders of people’s continuing efforts to improve urban life by addressing issues like racial and economic inequality, environmental problems, neighborhood vitality, community organizing, walkability and biking.

“The city as a commons is designed to be disruptive–to question who owns and controls the city,” explained Sheila Foster, Fordham University Law Professor at a post-conference conversation convened in a bustling Bologna park by magazine. “It’s a claim that the city is open to how we exchange goods and services. It’s not just elites who should have power.”

“The idea of the urban commons is still very much in development,” said Foster, who wrote a groundbreaking paper on the city as commons with her conference co-chair Christian Iaione.

Foster outlined four major tenets of the city as commons in conference’s closing session:

  1. The city is an open resource where all people can share public space and interact.
  1. The city exists for widespread collaboration and cooperation.
  1. The city is generative, producing for human nourishment and human need.
  1. The city is a partner in creating conditions where commons can flourish.

What Does the Future Look Like?

The form urban commons might take over the next 25 years was vividly sketched by Berlin activist Silke Helfrich. She described a convivial community living according to the African philosophy of ubuntu (“I am because you are”). Many people live in cooperative co-housing communities, and work at home or co-working spaces. The streets are alive with people on foot, bike, transit and in shared cars. Every neighborhood proudly sports community vegetable gardens, fruit orchards, flower patches, herb commons, sanctuaries for birds and bees, greenspaces, cafés, a cultural center, library, ballroom and open source hub.

“The space of the commons will expand, and the space of the market will shrink,” Helfrich envisions, because systems are designed to allow commons to happen. Commoning will be as easy to do then as shopping is today.

The conference’s workshops zeroed in lessons learned from local urban commons projects around the world, including US inner cities.

A struggling neighborhood on the west side of Buffalo, New York became a laboratory for applying Elinor Ostrom’s eight commons principles to community revitalization efforts. Ronald Oakerson, a political scientist at nearby Houghton College, and Jeremy Clifton, an AmeriCorps organizer, experimented with how to activate low-income renters in tackling crime and disinvestment problems on their blocks.

Rural vs. Urban Household Poverty

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“What doesn’t work is flyers and knocking on doors,” says Clifton, who is now studying psychology at the University of Pennsylvania. What worked is identifying the community’s natural leaders and helping them create block clubs. “People take action when they feel ownership, but not necessarily home ownership but ownership of the street where they live.”

In Brooklyn, local activist Paula Siegel discovered the borough harbored 596 acres of vacant land (more space than Brooklyn’s beloved Prospect Park). Under the banner of “this land is your land,” she launched 596 acres to explore how residents can claim it for public use as gardens, playgrounds and learning centers.

Barcelona is moving toward participatory democracy with new commons policies tapping citizen’s ideas “to create the conditions for social initiatives to flourish”, according to Miquel Ortega, the city’s Commissioner for Commerce, Consumer Affairs and Markets. Airbnb was recently banned in the city because it was jacking up rents in many residential neighborhoods and forcing families out in favor of tourists.

Hitting the Ground in Bologna

The City as Commons event, which attracted more than 200 commoners from around the world to a refurbished factory, closed with a panel featuring Bologna’s Deputy Mayor Matteo Lepore who outlined some of the more than 100 collaborative projects with citizen groups the city has undertaken in its pioneering plans to incorporate commons thinking and practice into municipal governance:

  • Neighborhood regeneration projects, which he emphasized, are “not on behalf of citizens but with citizens, who are a great source of energy, talent, resources, capabilities and ideas.”
  • An experiment where restaurants and bars work directly with neighbors to set rules for their businesses and cooperate on regenerating the community.
  • A program to draw upon parents’ ideas and skills in improving kindergartens.
  • A civic crowdfunding prototype to support projects that the city cannot wholly fund, such as restoration of Bologna’s 24 miles of arched porticoes over sidewalks.
  • An ambitious program of urban gardens.
  • Creation of digital platforms to support commons projects of all varieties.
  • A citywide conversation “about what is collaboration, and how the city government can work in new ways.

“Commons aren’t just something we protect, but also what we invent,” declared Lepore.

Bologna’s urban commons initiative began in May 2014, when the city council passed landmark legislation, Bologna Regulation for the Care and Regeneration of Urban Commons. “A new era was dawning where citizens are active co-managers of the resources they use in cities instead of passive recipients of services,” wrote Neal Gorenflo in Shareable after visiting Bologna at the first anniversary of the project.

The origins of the idea date back to 2011 when a group of local women contacted the city about donating benches to their neighborhood park, which lacked any place to sit. The women grew frustrated as their generous offer was bounced from one municipal department to another until finally they were told it was impossible. In fact, it was illegal for citizens to contribute improvements to their hometown.

As one of Italy’s most progressive cities, home to Europe’s oldest university and with a regional economy based on cooperative enterprises, this incident caused a stir around Bologna and spurred city officials to partner with the Rome-based organization LabGov (Laboratory for the Governance of the Commons) which applies the work of Elinor Ostrom to city life. Conference co-chair Christian Iaione, a legal scholar, was instrumental in bringing the project to life. Similar projects sprouted in the Italian cities of Palermo, Montova, Battipaglia and Rome. In North America, Toronto is looking at implementing Urban Commons policies and LabGov is partnering Fordham Urban Law Center to launch a project in New York City.

Jay Walljasper writes regularly about public health and healthy communities.  The former editor of Utne Reader, he is author of The Great Neighborhood Book. His website is

Data is Key for This School Nurse

This feature was previously published on the Healthy Schools Campaign blog.

When school nurse Kelly Grenham first started at Mapleton Public Schools outside of Denver, a serendipitous event put her office next to the tech department. “Tech people love teaching people about tech stuff,” she said. She started with a simple spreadsheet full of student health data, but that sheet morphed into a complex thing with lots of data and info, she says.

Kelly is a district school nurse consultant at Mapleton, which is contracted through the Children’s Hospital School Health Program. It’s through this program that she’s able to access research and resources and apply this information to benefit her students and their families.

And it’s data that Kelly used to spearhead some of her most successful interventions. She led an effort over four years to ensure that more students with asthma in her suburban district were able to receive the care they needed—and reduced their rate of absence at the same time. By working with the Regional Nurse Specialist Program through the Department of Education on a statewide level, Kelly made changes in her schools and across the state.

In her role as a Regional Nurse Specialist, she helped revise the standardized state asthma health care plan, which she presented to nurses in the metro area and in Northern Colorado. In the Mapleton district, she sent home an intake sheet and asthma care plan to all students with asthma. Prior to developing care plans, the school was only allowed to give two puffs of albuterol every three to four hours. The new plan allowed for up to eight puffs in an hour.
Asthma Map

The number of care plans for children with asthma increased from a handful to several hundred over a period of four years. By collecting data, Kelly found that the absentee rate of children with asthma was statistically down. Parents who may have kept their children home when they had concerns about asthma were more confident their child could be at school, and fewer children were sent home because their asthma was treated appropriately.

Kelly also used evidence and best practice research to change the district’s policy on head lice, another common reason children are absent from school. The district had a policy that involved sending the child home if there was evidence of nits, the eggs of head lice. Using information supplied by the Children’s Hospital of Colorado (School Health Program), National Association of School Nurses, American Academy of Pediatrics, the Colorado Department of Health and supported by Children’s Hospital, Kelly made the case that a child found to have head lice did not have to be excluded until the end of the school day and that child could return to school after treatment, even with evidence of nits. Kelly also helped change the previous practice of checking every child in the involved class for head lice, which has not been shown to be an effective practice.

In York International IB School, there is a Life Skills Program for students with developmental delays and Kelly is working on implementing a “Healthy Living” program for the students with special needs. Kelly is working with staff members at the school to identify programs that would educate students about making better lifestyle choices including food and physical activity. “We’re helping the kids to figure out how they can put their heights and weights into a CDC BMI calculator,” she says. “Then we show them the graph and say, ‘Here you are.’ We then tell them what that is saying and how it relates to their health.”

Youth Disability map

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The program is in the early stages, Kelly says, but the hope is that there will not only be a decrease in BMI but that the education will positively affect these students’ lives and how they think about their health.

Kelly has been instrumental in Mapleton Public Schools’ collaboration with the University of Colorado and Children’s Hospital to implement in January 2016 a 12-session course on “The Healthy Living Program” for families to improve their physical activity and nutrition.

Last May, HSC proudly announced the winners of our second annual School Nurse Leadership Award. It’s an award that acknowledges the tireless commitments that school nurses make, and is supported by School Health Corporation and MAICO Diagnostics. The five winners and five honorable mentions selected from across the country represent school nurses who are reimagining the role they play in school health and wellness, students’ academic success and the health of the larger community. Congrats to Kelly for being selected as a 2015 School Nurse Leadership Award winner! Thank you for the work you’ve done—and continue to do—to improve the health and wellness of your students and community. Read more 2015 School Nurse Leadership Award winner profiles.

feature photo credit: Neil Turner