Fluent Essays

Babies control and bring up their families as much as they are controlled by them; in fact the family brings up baby by being brought up by him. —Erik H. Erikson A growing body of evidence is linking adult chronic disease to processes and experiences occurring decades before these diseases manifest themselves. In some cases, intrauterine influences may be linked to long-term health outcomes. A major challenge in population health is determining how to influence early life to produce good health in later years. Some countries do a better job in reducing socioeconomic inequalities and other determinants of health or mitigating their impact on children’s health and development than others. The challenge for public health professionals is to promote a greater understanding of the circumstances of early life and to foster policies to benefit those whose health ultimately depends on family and society. Medical care in middle age can mitigate the consequences but cannot redress or change the impact of those early factors. Additionally, medical care when you are already ill is expensive, sometimes providing too much care too late to make a difference. As demonstrated this week, medical care is less important for producing good health outcomes later in life. For this Discussion, you examine how the use of concepts of the developmental origins of life and health can influence adult morbidity. Your Discussion also challenges you to propose ways to improve child health that will also provide a long-term benefit on population health. To prepare for this Discussion, complete the readings and view the media in your Learning Resources. Look online and in the Walden University Library for additional scholarly resources regarding the developmental origins of health and disease and the impact of childhood policies and programs on lifelong health to support your discussion post and replies. Post a brief reflection on how the commonly held sentiment “we are all born equal” may constrain how society thinks about early life. Comment on influences that this concept may overlook or mask. Then, explain two ways the use of concepts of the developmental origins of life and health can influence adult morbidity. Describe two challenges to addressing the upstream risk and protective determinants of health in current health policies and programs in the U.S. or in other countries. Also, explain why they are challenges. Finally, offer two suggestions for improving child health that can have a long-term benefit on population health for one chronic disease and explain why. Expand on your insights utilizing the Learning Resources. Neighborhood Adversity, Child Health, and the Role for Community Development abstract Despite medical advances, childhood health and well-being have not been broadly achieved due to rising chronic diseases and conditions related to child poverty. Family and neighborhood living conditions can have lasting consequences for health, with community adversity affect- ing health outcomes in significant part through stress response and increased allostatic load. Exposure to this “toxic stress” influences gene expression and brain development with direct and indirect neg- ative consequences for health. Ensuring healthy child development requires improving conditions in distressed, high-poverty neighbor- hoods by reducing children’s exposure to neighborhood stressors and supporting good family and caregiver functioning. The community development industry invests more than $200 billion annually in low- income neighborhoods, with the goal of improving living conditions for residents. The most impactful investments have transformed neighbor- hoods by integrating across sectors to address both the built environ- ment and the social and service environment. By addressing many facets of the social determinants of health at once, these efforts suggest substantial results for children, but health outcomes generally have not been considered or evaluated. Increased partnership between the health sector and community development can bring health outcomes explicitly into focus for community development investments, help opti- mize intervention strategies for health, and provide natural experiments to build the evidence base for holistic interventions for disadvantaged children. The problems and potential solutions are beyond the scope of practicing pediatricians, but the community development sector stands ready to engage in shared efforts to improve the health and develop- ment of our most at-risk children. Pediatrics 2015;135:S48–S57 AUTHORS: Douglas P. Jutte, MD, MPH,a,b,c Jennifer L. Miller, PhD,b,c and David J. Erickson, PhDd aUC Berkeley-UCSF Joint Medical Program, University of California, Berkeley, School of Public Health, Berkeley, California; bBuild Healthy Places Network, San Francisco, California; cPublic Health Institute, Oakland, California; and dFederal Reserve Bank of San Francisco, San Francisco, California KEY WORDS allostatic load, community, community development, intervention, neighborhood, public health, social determinants of health, toxic stress All authors conceptualized and designed the article, drafted and revised the manuscript, and approved the manuscript as submitted. The views expressed here are the authors’ and do not represent the Federal Reserve Bank. www.pediatrics.org/cgi/doi/10.1542/peds.2014-3549F doi:10.1542/peds.2014-3549F Accepted for publication Dec 19, 2014 Address correspondence to Douglas P. Jutte, MD, MPH, Build Healthy Places Network, 870 Market Street, Suite 1255, San Francisco, CA 94102. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2015 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Drs Jutte and Miller were supported by funding from the Robert Wood Johnson Foundation. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. S48 JUTTE et al by guest on August 31, 2021www.aappublications.org/newsDownloaded from mailto:[email protected] On many fronts, pediatrics has been successful in improving the health of children. Medical advances and public health measures have reduced the oc- currence of acute life-threatening dis- eases that were once the predominant cause of childhood mortality and mor- bidity. According to measures other than acute illness, however, children are not faring as well. Chronic and noncom- municable diseases are on the rise,1 and racial and socioeconomic disparities continue to widen, not only in standard measures of health but also across the range of life circumstances that contrib- ute to well-being such as education and employment. More than 1 in 5 US children live in poverty; among Latino and African- American children, it is ∼1 in 3.2 These social disparities have the same sort of impact on poor children as does bullying of the weak by the strong. So- cial inequality is the population equiv- alent of the social hierarchies that exist among schoolchildren on the play- ground. Pediatricians are uniquely po- sitioned to see the effects of these growing threats to child development and well-being. At the same time, we pediatriciansmay feelpoorlyequipped, inthecontextofourclinicalpractices,to address the biggest health challenges our patients face.3 What can pediatricians do to address the community-level social hierarchies so prevalent in our society? We know that the family and neighborhood living conditions that our patients face can have lifelong consequences for their health. Recent advances from across fields of science reveal that exposure to adversity (particularly the sustained, unmediated adversity producing “toxic stress”) becomes biologically embed- ded, influencing gene expression and brain development. It has both direct health consequences as well as indirect health effects due to the resultant lower educational attainment, lower economic status, and poorer health behaviors.4–7 The effect of these latter factors is mul- tiplied because they place children into higher risk environments as they move through adolescence and adulthood. The result is significant differences in life expectancy and health outcomes throughout the life span and multigen- erational disadvantage. Simply put, one’s body is the sum record of the challenges and opportunities faced throughout life. Too many neighborhoods have too few opportunitiesandtoomanychallenges. This fact is hurting the health of many Americans, and children bear the brunt because so many live in poverty. By un- derstanding the developmental mecha- nismsbywhichadversitygets“under the skin,”8,9 we are better able to design interventions to improve child develop- mental and health outcomes. Pedia- tricians witness the effects of these disparities. We are in a unique position, therefore, to advocate for change. To address health disparities, we can- not simply intervene with medical care, even medical care in early childhood.10 We will also not be successful in ame- liorating the effects of poverty by pro- viding single-focus interventions, such as pre-K education. Such interventions are extremely important but do not— in isolation—overcome the deeper effects of sustained adversity.11 In- stead, a critical strategy requires im- provement in the overall neighborhood conditions and life circumstances into which children are born and spend their early childhood years.12 The tools to improve neighborhood conditions are beyond the means or capabilitiesofmedicalcareprovidersor even public health practitioners. How- ever,thefieldofcommunitydevelopment has been building the expertise to allow us to transform neighborhoods in ways that will have a profound effect on children’s health, both during childhood and throughout life. The community development industry has a growing number of examples in which disordered, high-poverty neigh- borhoods have been transformed to profoundly improve the trajectories and life chances of the children living in them.13 These efforts have brought multiple elements together, often utiliz- ing many funding streams and facilitat- ing collaboration among partners from different sectors of society. For example, they unite affordable housing, better education, functional transportation, and reliable public safety. These suc- cessful efforts are a great public policy success story. It is a success story, however, that is not well known. Communitydevelopmentimproveschild health outcomes but, generally speak- ing, improving health has only rarely beenanexplicit goal ofthese projects. In fact, in most cases, there has been no research on health outcomes. These efforts may represent solutions to the biggest child developmental challenge we face today: entrenched, multigener- ational poverty and the impact of growing up in high-poverty neighbor- hoods. The present article proposes the next steps for taking this approach to scale and maps out the critical role that thehealthsectorcanplaytobringhealth outcomes more explicitly into focus in these projects, to optimize intervention strategies, and to use these natural experiments to build the evidence base for what works. EVIDENCE FOR NEIGHBORHOOD CONTEXT AND CHILD HEALTH Neighborhood Matters to Health Outcomes Relationships with parents and care- givers form an emotionally protective environment for early childhood de- velopment. Communities or neighbor- hoods, similarly, are an influential environment, positive or negative, for adolescents,14 adults, and families.15,16 Neighborhood disadvantage, therefore, harms young children in part through its impact on family functioning.17–19 SUPPLEMENT ARTICLE PEDIATRICS Volume 135, Supplement 2, March 2015 S49 by guest on August 31, 2021www.aappublications.org/newsDownloaded from Research into the mechanisms and the impact of neighborhood conditions on health has now been underway for .2 decades.20 Key neighborhood factors affecting individual and family well- being include social integration, per- ceived control, financial strain,21 social capital, residential stability, and safety or exposure to violence.20 Although a handful of studies have suggested caution regarding the nuance of these links,22–24 a substantial body of re- search now supports this connection: neighborhood conditions have an im- portant and independent impact on long-term health outcomes. Living in high-poverty, distressed neigh- borhoods, such as those that undermine social ties and threaten safety through conflict, abuse, or violence, negatively affects health status into middle and old age.12,25 Indeed,studieshavedrawnlinks between neighborhood disadvantage and cardiovascular disease,26–28 can- cer,28 obesity,20,26,27 depression,20,27,28 self-reported health status,21,27,29,30 and risk behaviors such as smoking,26,27 risky or early sex,27,31 and alcohol use.27,28 Disparities in life expectancy of up to 25 years between neighborhoods just a few miles apart have been highlighted in citiessuch as Oakland, California, and New Orleans, Louisiana.32,33 A child’s zip code is more important than his or her genetic code in determining future health and life chances.34 Mediators of Neighborhood Impact Neighborhoodadversityseemstoaffect health outcomes to some degree by affecting health behaviors26 and sig- nificantly through the impact of toxic stress and associated increases in “allostatic load” (eg, stress and fear in response to the perception of neigh- borhood danger).29 Gustafsson et al studied the relationship between neighborhood features and allostatic load. They determined allostatic loadbyusinganumberofmeasurements, including blood pressure, blood lipids and glucose, and cortisol levels at ages 16, 21, 30, and 43 years, studying the cumulative effects on subjects across ∼3 decades. Social and material adver- sity were determined and cumulative neighborhood adversity was calculated with indicators including the percentage of residents considered low-income, un- employed, living in single-parent house- holds, and with low occupational status or low educational attainment. Cumula- tive neighborhood disadvantage was sig- nificantly related to higher allostatic load, suggesting that biological dysregulation (or wear-and-tear) accrued over the life course as a result of neighborhood disadvantage.35 These recent findings are consistent with the few other stud- ies available examining the long-term impact of neighborhood exposure. For example, Vartanian and Houser30 used 38 years of longitudinal data from the PSID (Panel Study of Income Dynamics) and a sibling fixed effects model to show that living in more advantaged neigh- borhoods as a child was associated with improved self-report of health in adult- hood. Remarkably, the relative affluence of adult neighborhood residence had little or no effect. This finding suggests that intervention in residential condi- tions during childhood represents a critical period for effective impact. Using NHANES data, Theall et al36 reached similar conclusions. They, too, found that teenagers living in higher risk neigh- borhoods had abnormal biological mea- sures that have been associated with increased allostatic load. One of the biggest challenges in studies on the health impact of neighborhood disadvantage has been to disentangle and determine the effects of neighbor- hoodadversity,independentofindividual- level adversity. Ross and Mirowsky29 found that neighborhood adversity results in worse self-reported health, even when controlling for individual levels of poverty. Hurd et al14 found similar outcomes with regard to adoles- cent mental health. The research of Theallet al36 and Schulz et al37 demon- strated the impact of neighborhood pov- erty on allostatic load in teenagers and adults, respectively. Both accounted for individual and/or family poverty and found that neighborhood was an inde- pendent predictor. Similarly, Gustafsson et al35 linked cumulative neighborhood disadvantage through adolescence to higher allostatic load later in life, in- dependent of individual social adversity or current neighborhood of residence. The longitudinal study of Johnson et al25 examined the long-term effects of neighborhood exposure in young adults (ages 20–30 years) followed up for 38 years. After accounting for in- dividual and family factors, living in low-income neighborhoods early in life was strongly associated with poor adult health. Their findings suggest that fully one-fourth of differences in health in mid- to late-life can be at- tributed to neighborhood differences during young adulthood. From Neighborhood Impact to Neighborhood Intervention Public health’s response to the role of neighborhood on health often assumes that the key mechanism of neighbor- hood impact is lack of access to ser- vices and resources. Examples include work on obesity prevention that fo- cuses on introducing grocery stores or farmers’ markets in “food deserts” or work to bring health services to commu- nities lacking clinics. Although these op- tions are important, access to healthier food and medical services is not enough. We must transform neighborhoods into cohesive, stable, and appealing envi- ronments for the well-being of families and the healthy development of chil- dren. It is good fortune that health has a partner in the field of community de- velopment, which has been doing pre- cisely that since its establishment in the 1960s. S50 JUTTE et al by guest on August 31, 2021www.aappublications.org/newsDownloaded from COMMUNITY DEVELOPMENT HISTORY AND SCALE The term “community development” de- scribes a largely nonprofit sector of the economy that provides interventions to improve low-income communities and the lives of the people who live in them. The interventions are primarily invest- ments allowing individuals and families to build wealth and help communities provide service-enriched affordable hous- ing, clinics, schools, grocery stores, and other facilities to make neighborhoods more viable. In addition, community de- velopment fosters small businesses as a means of developing local entrepre- neurs; more small businesses in low- income neighborhoods provide local jobs and can create a powerful, positive ripple effect that improves the local econ- omy for all. The dollars invested are substantial. The federal government has several in- vestment tax credit and block grant pro- grams that amount to nearly $16 billion annually.38 Those subsidy dollars, along with funds from state and local govern- ments and foundations, provide the seed capital that allows community develop- ment to attract additional market-rate capital from insurance companies, pen- sion funds, and especially banks. Banks are motivated by the anti-“redlining” Community Reinvestment Act of 1977 requiring banks to demonstrate invest- ment in low-income neighborhoods. To- tal funds invested as a result of this act are hard to measure, but according to 1 count from federal bank regulators, it was more than $200 billion in 2009 alone.39 The achievements of this community development investment have been substantial. Community developers have built .3 million homes housing some 10 million low-income individuals and families since the late 1980s, using the Low Income Housing Tax Credit. This housing is a far cry from the common image of government housing projects as instant slums.40 Instead, as we de- scribe later, community development dollars have ledtohigh-quality housing in vibrant communities. When high-quality housing is coupled with integrated so- cial services, it can serve as an anchor investment in neighborhoods that have experienced decades of disinvestment. People begin to care about neighbor- hoods they can be proud of, where they feel connected and involved. A Brief History of Community Development Perhaps the earliest efforts at commu- nity development occurred in the late 19th century when US cities grew ex- plosively, with new arrivals from rural areas or immigrants from other coun- tries. These newcomers crowded into cities looking for work. Competition for jobs pushed wages down, and compe- tition for shelter pushed rents up. As a result, the new urban working poor oftenfoundhomesinslums,ghettos,and barrios.Weseethispatternacrossmany cities and many times: in Chicago in the 1880s, Rio de Janeiro in the 1960s, and Shanghai in the 1990s. Erickson,38 in The Housing Policy Revolution: Networks and Neighborhoods, provides a history of community development. People living in these neighborhoods werepoorbuthadmanyintangibleassets, asenseofcommunity,andentrepreneurial spirit. Community development was born in that liminal space between great need and great opportunity. The settlement houses of the late 19th and early 20th centuries responded by providing com- prehensive education, job training, and skills. Immigrants took advantage of the opportunities and built a better life for themselves and their children. Modern community development has its roots in the War on Poverty initiative begun under the Johnson administra- tion in the 1960s. Federal programs sought “maximum feasible participa- tion” of low-income communitiesto help themselves. Part of that process required community organizations to create a strategy for improving community con- ditions, which were called community action plans. Many of the plans morphed into institutions, called community action agencies, which evolved over time to be- come community development corpo- rations (CDCs). Senator Robert Kennedy championed the first CDC, the Bedford Stuyvesant Restoration Corporation in New York, in the mid-1960s. Today, there are .4600 CDCs across the country.41 CDCs are primarily real estate devel- opers. They are joined in the community development network by community de- velopment financial institutions (CDFIs) thatoperatelikenonprofitbankscreating tailored financial transactions for com- plexdeals.CDFIsstartedoutassmall-loan funds, many originating with the re- tirement savings of Catholic religious orders. Today, in the United States alone, there are .800 CDFIs with more than $30 billion under management, many of them large and sophisticated. The Low Income Investment Fund, for example, has deployed more than $1.5 billion benefitting 1.7 million low-income indi- viduals.42 CDCs and CDFIs also work with banks, for-profit real estate developers, state and local governments, and other nonprofits in true public–private part- nerships to improve neighborhoods. Health and Community Development Untilrecently,communitydevelopersdid not consider health to be among their responsibilities. More recently, com- munity developers and public health visionaries who recognize that zip code has more influence over health than one’s genetic code have realized that a partnership between industries con- cernedwithhealthand thoseconcerned with neighborhood development could be fruitful. Indeed, Risa Lavizzo-Mourey, president of the Robert Wood Johnson Foundation, the nation’s largest health SUPPLEMENT ARTICLE PEDIATRICS Volume 135, Supplement 2, March 2015 S51 by guest on August 31, 2021www.aappublications.org/newsDownloaded from foundation, wrote recently that “we are likely to look back at this time and wonder why community develop- ment and health were ever separate industries.”13 Examples of Community Development’s Impact on Children and Families The community development sector offerssignificantresourcesearmarked for addressing what the medical and public health fields consider the social determinants of health.43 The key ques- tion is whether neighborhoods can ac- tually be improved enough and in the right ways to make a difference in children’s lives. Can they be transformed to provide families the environments they need to support healthy child de- velopment and end the cycle of poverty? Over the past several years, the Federal ReserveSystem,inpartnershipwiththe Robert Wood Johnson Foundation, has led a series of meetings around the United States to explore how commu- nity development and the health sector can partner to create meaningful changes in disadvantaged neighborhoods, and to do so at scale.10 Although rigorous evaluation data on health outcomes have not yet been gathered, there are a number of neighborhood transfor- mation projects with results that are powerfully suggestive.10,40 The most successful projects tackle neighborhood distress and dysfunction on numerous fronts simultaneously, addressing mul- tiple social determinants of health (al- though those in community development would generally not have used that term). By addressing both place and people (ie, physical infrastructure and human capital/community processes), these projects achieve results that are more than just the additive benefit of separate component parts. Each project is also tailored to its community, in- volvingresidentsandutilizingtheunique assets of each neighborhood. There are commonalities across these projects, however, that could be replicated to “routinize the extraordinary.”40 A key common feature is that each project has had a “community quarterback,” usually a single organization often led by a dy- namic individual, that holds the vision for the project, convenes stakeholders and potential partners, coordinates partners’ activities across sectors and funding streams, provides staffing, and tracks results.44 Recognizing the impor- tance of community quarterbacks in catalyzing and coordinating transfor- mational change, the Citi Foundation through its Partners in Progress pro- gram recently awarded more than $3.25 million to 13 organizations across the United States to play such a role.45 The present article describes 3 such projects that have dramatically improved neighborhoods: East Lake in Atlanta, transformed by what subsequently be- came Purpose Built Communities; the Magnolia Community Initiative in Los Angeles, a multisector network in part- nership with residents; and Neighborhood CentersInc,responsiblefor transforming several neighborhoods in the greater Houston area. Purpose-Built Communities/ Eastlake In the early 1990s, the East Lake neigh- borhood of Atlanta grappled with ex- treme poverty, high crime rates and violent crime, poor educational attain- ment, and high unemployment. The neighborhood was called “Little Vietnam,” not because it was home to Vietnamese immigrants, but because it was like a war zone.46,47 Prompted by a study link- ing neighborhood to the likelihood of resident incarceration in the New York state prison system, Atlanta philanthro- pist Tom Cousins devoted the resources of his family foundation to transforming East Lake.48 Using both community de- velopment and private funding, the East Lake Foundation built mixed-income hous- ing in place of the existing substandard public housing, built a charter school, and brought in shops and the YMCA.47 The effort of this public–private part- nership took ∼10 years, with a lead or- ganization dedicated solely to ensuring that all elements were properly se- quenced and coordinated (ie, a commu- nity quarterback), but the results are impressive. There was a 73% reduction in crime and a 90% reduction in violent crime. The estimated economic benefit of reduced crime (including reduced costs to victims and savings from esti- matedreducedlifetimecriminality ofthe student body) was $10 to $14 million in 2007 dollars.49 The employment rate rose from 13% to 70%. Although some of the original residents did not return to the reconstructed East Lake neighbor- hood, most did. The neighborhood also attracted many new middle-income neigh- bors. The new Drew Charter School is now 1 of the top-performing schools in thecity,whilestillservingpredominantly low-income children (80% of the students receive free and reduced-cost lunch). In- creased lifetime earnings as a result of higher educational attainment were pro- jected to be $14 million (in 2007 dollars) per graduating class of 85 students or nearly $165 000 per child over the course of his or her life. The project was successful because it used a coherent and integrated strat- egy.50,51 As the Robert Wood Johnson Commission to Build a Healthy America noted, “Instead of attacking poverty, urban blight, and failing schools piece- meal, a group of community activists and philanthropists in Atlanta took on all of these issues at once.”52 Inter- estingly, in the early stages of this effort, neither health nor health care was identifiedas key components, although a health-related focus has been incorpo- rated more recently. The approach used in the East Lake neighborhood has become the basis for multiple efforts across the country, including New Orleans, Indianapolis, and Omaha. S52 JUTTE et al by guest on August 31, 2021www.aappublications.org/newsDownloaded from Magnolia Community Initiative The Magnolia Community Initiative fo- cuses on a 5-square-mile area, com- prising 4 zip codes and 500 square blocks south of downtown Los Angeles; this neighborhood is home to 35 000 children. The Magnolia Community Ini- tiative was launched with the goal of reducing child abuse and neglect. In- stead of focusing on identifying in- dividual at-risk children and providing individual services, the initiative took a population-based approach, seeking to improve conditions within the neigh- borhood so as to provide robust improvements in conditions for all children. The initiative supports resi- dents within neighborhoods to take personal actions that improve the well- being of their own family and their neighbors. Moreover, the network of organizations that comprise the initia- tive set aspirational goals for itself: that the childrenliving inthe catchment area “will break all records of success in theireducation, healthand the qualityof nurturing care they receive from their families and communities.” Four goals that are recognized contributors to lifetime outcomes for children were identified: “educational success, good health, economic stability and safe and nurturing parenting.”53 The initiative established the Magnolia Place Family Center, a community hub offering colocated services related to all 4 of the core goals and bringing together agencies and service pro- viders offering medical care, parenting classes, legal services, access to af- fordable financial services at a bank, and mental health services. The state- of-the-art center, opened in 2008, also offers spaces for family activities and parent/child activities. More than 70 city,county,andnonprofitorganizations that comprise the network operate at the center and throughout the larger community.54 An explicit feature of the multisector partnership is that new partners (organizations or individuals) are asked to bring to the community the contributions that enable them to fulfill their goals. The initiative does not incentivize or compensate partners; instead, they participate in the initia- tive as part of fulfilling their own mis- sions. They focus on working together as a system using linkage, empathy, and holistic elicitation of client and resident assets and needs to support achieving the 4 core goals. The network utilizes the expertise in diverse service sectors on how to mitigate toxic stress and optimize well-being. Progress is rigorously tracked by using a commu- nity dashboard (Fig 1) that follows outcomes on a population basis.55 Neighborhood Centers Inc. The focus for Neighborhood Centers Inc (NCI), based in Houston, Texas, is smoothing the way for immigrants and other newcomers to succeed, thrive, and contribute as they integrate into life in Houston and other Texas communities.56 Using an asset-based approach,57 the goal of NCI, which operates 74 centers in 60 Texas counties, is to change lives. They start not from what is “broken” in com- munities, says CEO Angela Blanchard, but from what is working.58 This method involves facilitating residents and social service partners in the community …