Culture of Health Blog Our blog features perspectives from Robert Wood Johnson Foundation staff and guest authors about efforts to build a Culture of Health. Mon, 1 Mar 2021 00:00:00 -0500 en-us Copyright 2000- 2021 RWJF (RWJF) <![CDATA[Connecting Systems to Build Health Equity During COVID-19]]>

Learn about a new $2 million funding opportunity for researchers to study how improving alignment among systems can address racial inequities.

Demonstration sign.

Editor’s note: This piece was originally published in July 2020.

A Personal Journey

It's hard to describe water to a fish while it’s swimming in it. I was that fish, growing up in a working-class, majority Black community in southwest Ohio. For instance, it hadn’t occurred to me to question why my school had metal detectors and armed police officers at every entrance yet so few textbooks that students had no choice but to share. Or why we had to travel to find affordable fresh vegetables while unhealthy food nearby was as easily accessible as payday loans and other predatory financial products. Having unmet needs was normal in these waters.

I was in high school when I began wondering why there were so many of these unmet needs in my community. An invitation to a cancer research conference hosted at a neighboring public school was an eye-opening experience. The school was one of the top-ranked in the state, nestled in a wealthy neighborhood with a well-stocked grocery store and multiple banks within walking distance. 

These waters were different.

That sense of unfairness filtered into my own life from another angle. I attended a school with limited resources which meant that opportunities within the school were offered to only a few. Since my mother was a powerful advocate for my education, I had access to after-school activities and advanced placement classes while friends living on the same block did not. That bothered me too.

It was some years before I learned the language that explained the difference. Studying law gave me a framework to consider racial inequality by exposing me to structural barriers such as red lining, the school to prison pipeline, and Black exclusion from wealth building opportunities such as the GI Bill. I carried this framing into my later work advocating for health equity in public policy and health services research. My early experiences clarified for me what was already intuited. Race-based inequities aren’t the result of personal choices. They reflect societal decisions that give blackness second-class status and normalize their unmet needs.

This knowledge has been empowering for me because it informs the pathway to change.

Understanding Systems

A strong evidence base confirms what many of us recognize intuitively—multiple systems influence health and must be aligned to improve lives. For example, one significant study found that when systems collaborate, there are fewer premature deaths from cardiovascular disease, diabetes, and the flu.  

Conversely, fragmented systems prevent us from treating the whole person. Urging a diabetic to eat nutritious food doesn’t mean much if she lives in a food desert. Providing someone else with job training but taking away his subsidized medical care once he is employed is self-defeating. Policies that keep people who have been involved with the criminal justice system out of public housing break the link between a secure home and positive health outcomes.

COVID-19 Enters the Equation

The COVID-19 pandemic has heightened our sense of urgency. There’s a through-line from our ongoing work at Systems for Action across COVID-19 and the racial injustice that has sparked such an outpouring of protest. Black and Latino communities have borne the brunt of the pandemic—from the risk of infection and the severity of the illness to its economic reverberations. And the racist practices that have been so vividly documented in numerous locales have also sent a stark message about the need for system-wide change.

I’m not naïve enough to believe that if we could just align our systems, we would vanquish racial disparities but I am convinced the pressure we are seeing on communities of color foregrounds the power of better alignment. New data stemming from that same study I mentioned earlier about diabetes, heart disease, and the flu suggest that communities with strong multi-sector networks have fewer COVID-related deaths and lower infection rates. That information should certainly inspire action.

The Wrong-Pocket Problem

There are many tools to align systems—including shared decision making, budgets, or data spelled out in agreements. But we need to learn more about what works best and get that into wider practice.

Too often, cost-benefit imbalance can, in fact, destabilize cross-systems partnerships. A common pitfall is what’s referred to as the “wrong-pocket problem.” Wrong pocket problems arise when costs are taken from one pocket, while the benefits flow into another. 

For example, in many cities, police are called to address mental health issues stemming from homelessness or addiction. Many cities understand that expanding mental health services can reduce law enforcement involvement. Making this type of collaboration work is difficult due to costs and benefits flowing in and out of the wrong pockets. In Eugene, Ore., the city created a program that diverts 911 calls involving non-violent offenders to a team that can intervene with mental health services. The city created a successful model that puts money where resources are needed, and alleviates work for another sector that was not well suited for that work in the first place. We want to understand how others solve wrong-pocket problems. 

Who Should Apply

This funding opportunity is for research and practitioner teams to evaluate existing models. We welcome all types of cross-sector models, as long as they examine how one sector (like education, criminal justice, housing, urban design, etc.) works in collaboration with the health or public health sector. We also welcome non-academic groups such as community-based organizations, government programs, etc., to apply in coordination with a research team. The proposal must include detailed research methodology. Please read our funding announcement for more information

I encourage you to join my colleagues and me on March 17 for an informational webinar where we will describe this opportunity in greater detail and answer your questions.  

My personal and professional journeys have led me to much the same awareness—systems need to work together to advance health equity. Let’s join forces in gathering the evidence that will inform how cross-sector collaborations can effectively help communities improve health outcomes.

Researchers, Systems for Action seeks proposals to study collaborations across medical, social, and public health systems that allow organizations to share in the costs, benefits, and power fairly. Learn more and apply by June 9.


About the Author

Chris Lyttle, JD

Chris Lyttle is the deputy director of Systems for Action, where he provides strategic direction on cross-system collaborations that address the social determinants of health.  

Mon, 1 Mar 2021 00:00:00 -0500 Chris Lyttle Health Disparities Disease Prevention and Health Promotion <![CDATA[New Narratives of Hope This Black History Month–And Beyond ]]>

More than 50 years after the civil rights movement we still have a lot to do to reduce discrimination and increase health equity. Dwayne Proctor reflects on the role of stories in the search for solutions.

An older student plays around with a younger student in a school auditorium.

Author’s note, February 2021: My post below was first published in February 2018. Over the past harrowing year, the issues it explores have become even more urgent, as the murder of George Floyd triggered a racial reckoning during a global pandemic that has hit communities of color hardest. In the midst of it all, systemic racism continues to take a brutal toll. The death of Dr. Susan Moore, who called out the racism she was experiencing as a patient, is just one example. Moore’s death, and those of Clyde Murphy and Shalon Irving, which I wrote about in my blog, are painful reminders of the cost of letting such racism continue. In the words of RWJF Trustee Dr. David Williams: “The first thing we have to do is acknowledge that the everyday racial discrimination embedded in our culture is sickening and killing African-Americans, and make a new commitment to make America a healthier place for all.”

One of my earliest and most vivid childhood memories is watching from my bedroom window as my city burned in the riots that erupted after Dr. Martin Luther King Jr.’s assassination 50 years ago.  

The next afternoon, my mother brought me to the playground at my school in Southeast Washington, D.C., which somehow was untouched. As she pushed me in a swing, she asked if I understood what had happened the day before and who Dr. King was.

“Yes,” I said. “He was working to make things better for Negroes like you.”

My mother, whose skin is several tones darker than mine, stared at me in surprise. Somehow, even at 4 years old, I had learned to observe differences in complexion.

That is particularly interesting to me now, as I eventually came to believe that “race” is a social construct.

Of course racism and discrimination exist. They are deeply embedded in America’s history and culture—but so too is the struggle against them.

Over 50 Years After the Civil Rights Act, Discrimination Persists

We are now more than 50 years beyond the civil rights movement, yet change has been excruciatingly slow. For example, despite passage of the Fair Housing Act in 1968, housing discrimination persists. Forty-five percent of black people surveyed in a 2017 NPR/Harvard T.H. Chan School of Public Health/RWJF poll say they have faced discrimination when trying to rent a room or apartment or buy a house.

While racial discrimination in hospitals nominally ended in 1964 with the signing of the Civil Rights Act, racial health gaps not only continue; in some cases, they have gotten worse. As recently as 2015, black babies are more than twice as likely as white babies to die before their first birthdays. And death rates from breast cancer are 42 percent higher among black women than white women, even though the prevalence is about the same.

I see inequity wherever it exists, call it by name, and work to eliminate it. Shalon Irving (July 9, 1980–January 28, 2017)

The numbers themselves are startling. But they take on added meaning when you consider the stories—millions of them—of real people, who face discrimination every day of their lives.

Sharing Your Story With the World

I’m reminded of the words of Carter Woodson, the black historian and educator who established Negro History Week, the precursor of Black History Month, which we are in the midst of celebrating.  “You must give your own story to the world,” Woodson declared.

How true that is.

Through our stories we call attention to racism and discrimination and assert our fundamental human dignity.

And by telling our stories, we demand solutions.

I see storytelling as essential to building a Culture of Health, where everyone—no matter where they live, how much money they make, or who they are—has the opportunity to live the healthiest life possible. By acknowledging each other’s stories, we recognize that racism and discrimination are monumental barriers to our goal of achieving health equity. We simply can’t have a Culture of Health without health equity. Dr. King himself noted that “of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Everyday Discrimination Measurably Diminishes Health

Take the tragic story of Shalon Irving, a brilliant epidemiologist at the Centers for Disease Control and Prevention. Shalon was working to understand how structural inequality, trauma and violence made people sick. She asserted her commitment on her Twitter bio, noting “I see inequity wherever it exists, call it by name, and work to eliminate it.” In a tragic irony, Shalon’s life was abruptly cut short at the age of 36 when she collapsed and died three weeks after giving birth. In the weeks leading up to her death, Shalon’s futile attempts to bring attention to concerning postpartum symptoms were dismissed by medical professionals according to Shalon’s mother. Shalon’s socioeconomic advantages and expertise in health inequity could not protect her from the reality that black mothers in the United States die at 3 to 4 times the rate of white mothers.

Higher educational attainment—which can lead to higher incomes and the ability to live in healthier neighborhoods and to access high-quality health care—can’t protect African-Americans from the disparities leading to higher mortality rates. This was also the case for Clyde Murphy, a renowned civil-rights attorney who died of a blood clot in his lungs 41 years after graduating from Yale University. Soon after Clyde’s death, his African-American classmates Ron Norwood and Jeff Palmer each succumbed to cancer. In fact, it turned out that more than 10 percent of African-Americans in the Yale class of 1970 had died—a mortality more than 3 times higher than that of their white classmates.

Clyde and Shalon’s disturbing stories and the stories of too many others force us to confront the injustice of discrimination—how the toll of incessant stress and implicit bias within the health care system can progressively erode one’s health.

Love means acknowledging and respecting the pain of others. When people do that, they can focus on how to heal and move forward, together.

Research shows how discrimination influences and determines how long and healthy our lives are. Experiencing discrimination day after day creates physiological responses that lead to premature aging (meaning that people are biologically older than their chronological age), as well as poorer health compared to other groups, and even premature death.

Through the 2017 NPR/Harvard T.H. Chan School of Public Health/RWJF poll we sought to gain a deeper understanding of daily personal experiences with discrimination from members of different ethnic, racial, and LGBTQ groups. As Woodson has suggested, this can help us better understand the reality of everyday discrimination that people face when looking for housing, interacting with police, seeking medical care, and getting a job.

Specific findings from the survey include:

  • Half or more of African-Americans say they have personally been discriminated against because they are black when interacting with police (60%); when applying for jobs (56%); and when it comes to being paid equally or considered for promotion (57%).
  • Four in 10 African-Americans say people have acted afraid of them because of their race, and 42% have experienced racial violence.
  • African-Americans also report attempting to avoid potential discrimination or to minimize their interactions with police. Nearly a third (31%) say they have avoided calling the police, and 22% say they have avoided seeking medical care, even when in need, both for fear of discrimination.
  • Similarly, 27% of black Americans say they have avoided doing things they might do normally, like driving a car or going out socially, to avoid encounters with police.

These poll findings—along with stories of Clyde and Shalon—underscore an urgent need to join in working harder than ever to shape solutions—solutions that spawn new stories where everyone enjoys an equal opportunity to live longer, healthier, and happier lives without the constant fear of discrimination.

Shaping New Stories of Hope

Through our work to understand everyday discrimination and its impact on health, we’re also learning about efforts to shape these new stories of hope.

In one such story more than 60 community- and faith-based organizations are collaborating with the Campaign for Black Male Achievement to create better futures for young African-American men and boys. This coalition has created an initiative called “Zones of Hope” designed to restore a sense of place and connection for marginalized neighborhoods, families, and young people. The idea is to reduce violence among young black men and boys (ages 16–27 years old) by increasing high school graduation rates, improving access to after-school programs, and expanding job opportunities. As community leader Rashaad Abdur-Rahman noted at an RWJF-sponsored event examining discrimination’s effect on health, this project has transformed relationships; built new partnerships; and rallied the education, government, and justice systems—to invest in supporting boys and young men of color so they can achieve their full potential.    

This is the kind of comprehensive, community-based approach that fills me with hope for better, brighter stories in the future.

Not believing in race means believing in love—and love means acknowledging and respecting the pain of others. When people do that, they can focus on how to heal and move forward, together.

Take the time to listen to these stories of how communities are coming together to root out Discrimination in America.



Headshot of Dwayne Proctor

Dwayne Proctor, PhD, senior adviser to the President, believes that the Foundation’s vision for building a Culture of Health presents a unique opportunity to achieve health equity by advancing and promoting innovative systems changes related to the social determinants of health. Read his full bio.

Tue, 9 Feb 2021 00:00:00 -0500 Dwayne Proctor Health Disparities Social Determinants of Health <![CDATA[Community Health Workers: Walking In The Shoes of Those They Serve]]>

By harnessing trust, community health workers are becoming a powerful force for achieving health equity.

Woman wearing protective mask taking groceries from caring volunteer.

It didn’t take long last Spring for Dr. Shreya Kangovi to realize that the COVID-19 pandemic would create a tsunami of inequity where inequity already long existed. Then the murder of George Floyd led to a national racial reckoning, too. Kangovi knew that community health workers (CHWs)—a field she is helping to pioneer and advance—are first responders on all those fronts.

A recipient of a 2019 RWJF Award for Health Equity, Kangovi is a primary care doctor in Philadelphia, a health policy researcher, and a professor who works to improve health equity. Kangovi developed IMPaCT, a community health worker program that relies on trustworthy individuals to help their community members improve their health and well-being. In randomized controlled trials, IMPaCT has improved chronic disease control, primary care access, mental health, and quality of care while reducing hospital admissions. It is the nation’s most widely disseminated CHW program.

Kangovi shared insights about the ways CHWs advance equity and better health, and the role they can play as we cope with and recover from the coronavirus pandemic.

Who are community health workers and how do they advance health equity?

There is tremendous variation, but CHWs are trustworthy individuals who share life experiences with those they serve. They understand what it’s like to face injustice or be overlooked. They also have a personality type defined in sociology literature as “natural helpers.” So it’s a combination of demography and ideology.

CHWs are trained to navigate systems, such as health, housing, and legal support, and to link community and clinical services to help people in their own communities lead healthier lives. They meet people where they are, get to know them as human beings, learn their life stories, then ask them how they want to improve their life and health. They may need help connecting to food assistance, planting a community garden, battling an eviction notice, running an anti-racism training for police, or navigating other issues.

Dr. Kangovi discusses IMPaCT, a standardized, scalable community health worker program which has been proven in three randomized controlled trials to improve chronic disease, primary care access, mental health and quality of care while reducing hospital admissions.

If you haven’t been in the shoes of the person you are working with, you are more likely to be biased. Clinicians may believe we know what our patient needs, and screen and refer her. That’s neither effective nor trustworthy. CHWs change this dynamic.

In rural Tennessee, a CHW might work at a faith-based organization. He will meet somebody at a church, food pantry or local hospital. He’ll take an hour to get to know that person—to learn where he was born, what happened in his life, what challenges he faces, his successes, and how he wants to improve his life and health. There is some shared life experience. CHWs always reflect back to the person and ask: What do you want to do about that? Then they create a step-by-step plan together. It might include battling an eviction notice, organizing a virtual funeral for someone who died of COVID, or going together to a doctor's appointment.

What role are community health workers playing in the pandemic and what role should they be playing?

COVID disparities are a symptom of an underlying pandemic of injustice that has persisted through history. Headlines have shown that Black and Brown people are disproportionately dying of COVID. Millions of Americans are going hungry in a new Great Depression while others are getting rich. Ultimately this all stems from the same problem: the trajectory of health inequities.

That’s why CHWs are an incredibly valuable workforce. They don’t just address symptoms or disease; they go straight to the root and identify solutions. We had a pandemic of racial and economic injustice long before COVID. So we need more than a vaccine. The hardest thing is to address the full range of social determinants of health but it’s the only way to advance health equity.

Can community health workers help overcome reluctance or resistance to vaccination?

As a public health scientist myself, I want to help people get better and vaccination is critical. CHWs can help with access and information, but they are trusted because they are trustworthy. Being trustworthy means not having an agenda and just offering help. It’s incumbent on us in public health to communicate the good science we have done in a very accessible way so people can make their own decisions about whether or not they want to take the vaccine.

What gives you hope right now?

On the policy front, I think this is our moment. This work began as grassroots and it still is. CHWs are meeting people on their porches and at their bedsides, asking them how we should build this workforce. Community-engaged scientists are doing strong randomized trials that not only demonstrate that CHWs can be effective, but also how. We’re working with the National Committee for Quality Assurance (NCQA) to translate that science into standards for the CHW workforce. So I think we're ready for scale.

There are approximately 50,000 CHWs in the county. That’s not nearly enough. President Biden’s proposal to create jobs for 150,000 CHWs would get us a lot closer to where we need to be. We helped inform the Biden proposal. We worked with bipartisan lawmakers on proposals to pay CHWs for the full range of work they do. We’ve had great conversations with the Centers for Medicare & Medicaid Services (CMS) about allowing Medicaid to fund the full range of supports CHWs provide. That’s the most momentum we’ve seen in this field. That gives me great hope.

Learn about how another RWJF Award for Health Equity winner is leading efforts to support mental health in communities of color during the pandemic.


About the Author

Headshot of Dwayne Proctor

Dwayne Proctor, senior adviser to the president, believes that the Foundation’s vision for building a Culture of Health presents a unique opportunity to achieve health equity by advancing and promoting innovative systems changes related to the social determinants of health. 

Tue, 2 Feb 2021 10:30:00 -0500 Dwayne Proctor Public and Community Health National <![CDATA[Understanding Our Health Before the Pandemic Can Help Us Improve It Afterward]]>

Measuring health and the social and economic factors that influenced it before the pandemic helps us understand the kind of risks the nation faced previously. It can also inform how to move forward toward recovery. 

Man receives blood pressure test.

2020 was arguably one of the most difficult years in American history, challenging our resilience and surfacing enduring and systemic challenges to our collective health and well-being. As we continue to measure the pandemic’s impact on short- and long-term health, as well as other social and economic indicators, it is useful to note where we stood pre-pandemic. Understanding the conditions and trends that shaped our health before COVID-19 helps us assess whether the systems now being tested to respond to COVID-19 are robust. 

Last year, the Robert Wood Johnson Foundation (RWJF), along with the RAND Corporation, shared an update on the national set of measures that we have been using to track our journey toward a culture where every person has a fair and just opportunity to live the healthiest life possible. The goal of the Culture of Health measures is to offer signals of change with a focus on broader social and economic drivers of health, well-being, and equity, as well as the role all sectors play in influencing health outcomes. Developing a clearer picture of what is changing (or not) via the Culture of Health measures is useful for directing investments and identifying where, as a nation, we need to make progress. 

What was the nation’s health before the pandemic?

In 2019, when we updated the measures, we reported small, positive changes in appreciation for social determinants of health and the need for broader community health investments. However, we also found slow progress on education, housing and other systemic factors that influence health, well-being, and equity. Now, COVID-19 has added stress to many of those systems. 

In our 2020 update, we again had some notable improvements in areas likely susceptible to pandemic impacts (e.g., mental health, health care). Still, progress on social and economic drivers that influence health remained slow. Here is what we found.

  • Sectors that influence health are making some progress. To achieve a Culture of Health, sectors outside of health care and public health (e.g., media, business) must recognize and leverage their influence on health outcomes. For instance, youth exposure to advertising by the corporate food and beverage sector is associated with children asking parents to buy specific—and potentially unhealthy—foods. This challenge may have become more acute as families stayed home during the pandemic. In 2018, data from Nielsen Media Research indicated that young children viewed an average of 1.7 food product ads daily during children’s programming, which was down from 2.5 ads in 2015. Nearly 71% of the products advertised failed to meet federal guidelines for nutrition standards, down from 80% in 2015. While more improvement is needed, these pre-pandemic decreases indicate that the food and beverage sector is either making healthier products or reducing advertising of unhealthy products to children—which may improve equity in terms of healthy weight.
  • Progress on mental health and well-being is mixed. Adverse childhood experiences (ACEs) are linked to mental illness, chronic health conditions, and premature death. The physical, social, and economic environment in which children live can influence their exposure to ACEs. There may be signs of hope on this front. The National Survey of Children’s Health data showed that, in the most recent data (the 2017–2018 school year), 42% of children in the United States had one or more ACEs, such as family divorce, domestic violence, or drug or alcohol use problems in the household. That is a 3 percentage point reduction from what was reported in 2016–2017. While this finding is promising, it will be important to track whether the pandemic worsens and increases exposure to ACEs. In contrast, general well-being as measured by life satisfaction did not improve in the years prior to the pandemic, according to the OECD Better Life Index, which found no improvement in life satisfaction (reported at just 6.9 on a ten-point scale) among U.S. residents aged 15 years and older from 2014–2016 to 2015–2017. Now the pandemic is testing an already-low U.S. life satisfaction that likely is worsening due to COVID-19.
  • There are improvements in the health sector, but costs remain high and flexibility elusive.­
    • New payment and health care delivery models are intended to provide higher value care. Analysis by Leavitt Partners found that, as of the end of 2019, about 12% of the U.S. population had a health care provider who is part of a population-based alternative payment program, an increase of about 2% since 2018. This may mean that more people have better care at lower cost.
    • However, the news prior to the pandemic was not all rosy. According to Medicare beneficiaries’ data (Kapinos, 2020), in 2017 the average total health expenditures in the last year of life was $66,176. This number has gone up by an average of about $3,000 per year since 2013. The pandemic’s pending health care bills will only exacerbate rising health care costs.
    • Finally, removing scope of practice barriers for nurse practitioners can broaden their ability to provide diagnostic and treatment services, which can improve COVID response, particularly in medically underserved areas. But before the pandemic, there had been no increase in the number of states with full practice laws for these health care providers (holding at only 22 states since 2017).  
  • Progress to create healthier, more equitable communities remains slow. The community conditions that represent some of the most entrenched, systemic issues are usually not tracked with other health measures, even though they are key influences on health. There is no improvement in environmental protections such as the number of states with cross-sector climate action plans (in fact, Alaska rescinded its plan) or states with air quality protections in bars and restaurants. 2020’s reckoning on racial issues is occurring at a time when the nation still has significant racial residential segregation. And while there was no change in 2018 from prior years in the percentage of American households spending 50% or more of their income on housing (12%), there was some improvement since 2014 in the burden on communities of color (an average reduction of 3%). However, there remains a disproportionate housing cost burden on Black, Hispanic/Latinx, and American Indian/Alaskan Native households, which are communities being disproportionately affected by COVID-19.  

What do these changes mean and where do we go, given the pandemic?

Measuring health and the social and economic factors that influence it before the pandemic gives us a picture of the kind of risks the nation was dealing with before the devastation 2020 brought. In sum, the nation was making slow progress in some areas but was not moving the needle nearly as rapidly as many would hope to improve key aspects of our health care system, our environment, and our economic conditions. Critical systemic changes needed for more transformative health improvements have been slow or stalled and, as a result, inequities remain pervasive.

As we look ahead and capture more detailed information on COVID-19’s effects, it will be important to track whether these Culture of Health measures worsen or appear resilient to further stress. Even if it is unlikely that we will observe improvements in many areas of health, social status, and the economy during the pandemic, continuing to track the choices and investments various sectors make to cultivate healthier communities can inform the choices we make and directions we take going forward. In fact, it may be key to the nation’s ability to recover from 2020.

A fuller description of these measures and the data underlying them can be found at Making progress on them is imperative if we are to become a healthier, more equitable country.



Carolyn E. Miller is a senior program officer in the Research-Evaluation-Learning unit of the Robert Wood Johnson Foundation.

Anita Chandra is vice president and director of RAND Social and Economic Well-Being and a senior policy researcher at the RAND Corporation.

Fri, 29 Jan 2021 10:45:00 -0500 Carolyn Miller Disease Prevention and Health Promotion Public and Community Health Social Determinants of Health National <![CDATA[In a Worldwide Health Crisis, Lessons From Resilient Communities]]>

No community has had it easy during COVID-19. Those with a consistent health equity focus before the pandemic have found advantages in facing the crisis. 

Men distribute food.

The RWJF Culture of Health Prize honors communities—urban, rural, tribal, large or small—that are beacons of hope and progress on creating places that enable health and well-being for all.

RWJF recognizes Culture of Health Prize winners for their broad definition of health and strong collaboration between community partners and residents, and across many sectors and levels of power. In a Culture of Health Prize community, those facing problems participate in shaping solutions. These communities commit to sustainable systems change and policy oriented long-term solutions. They create conditions that give everyone a fair and just opportunity to be as healthy as possible. They use data to measure and share progress and results.

Throughout 2020, winners used the strategies and networks they built to tackle the coronavirus and America’s reckoning with racial justice. We drew lessons and inspiration from these communities. In future posts we look forward to sharing how several Prize winners have put addressing systemic racism at the center of their work to promote health for all and how in other Prize communities, young people are forging networks, leading by example and finding new ways to advance health equity.

In this post, we highlight five examples of how Prize-winning communities—the Bronx, N.Y.; Lake County, Colo.; Santa Monica, Calif.; Shoalwater Bay Indian Tribe of Washington; and Spartanburg County, S.C.—are responding to COVID-19. They shared their experiences as part of a virtual panel session of the Culture of Health Prize learning event in October 2020.

Building Strong Relationships

In the Bronx, N.Y., long-established relationships with community members have positioned the local government and service organizations to offer social support when disaster strikes, said Fernando Tirado. Tirado is the director of new initiatives at Bureau of Bronx Neighborhood Center for Health Equity and Community Wellness, which provides health care, community space, and health and wellness classes.

Tirado said that the isolation that jeopardizes people at risk during a crisis like a heat wave would have been an even larger problem during the pandemic without the existing social supports. Informing people about how they can protect themselves and others, and enabling them to access the resources to do so, has been crucial. Thanks to their previous work, partners in the Bronx knew they could reach people without email or telephones by instead relaying messages at local food pantries, farmer’s markets, and senior events.

Rich Besser, RWJF’s CEO and former acting director at the CDC, hosted a town hall with Culture of Health Prize communities.

Before the pandemic, the 2015 Culture of Health Prize-winning community's “Be a Buddy” system sought to protect people from heat exhaustion by sending volunteers from local universities to check on, provide resources to, and build relationships with individuals who may distrust government programs. With strong relationships in place, once COVID-19 hit, the project morphed to assist people during the shutdowns.

“Resiliency takes practice,” said Tirado.

Finding Common Ground

Early in the pandemic, 2019 Culture of Health Prize-winning community Lake County, Colo., established a committee to address the needs of people who don’t qualify for government assistance, but still struggle with things like housing and utility bill payments. The committee funnels people in need to various service agencies, which review cases and offer financial support. The Unmet Needs Committee was on track to pay half a million dollars in housing and utility bills by the end of 2020, said Katie Baldassar, executive director of Lake County Build a Generation, which conducts research on social issues in the community, opens communication between stakeholders, and mobilizes funding for programs. The group has long-established partnerships with residents of the county’s manufactured housing communities who have organized for better health and safety where they live.

To be able to respond to the pandemic in an inclusive way, the county needed to bridge gaps between people and groups with varying political views. These groups included businesses, nonprofits, social service and other government agencies. For example, the owner of a manufactured housing community raised rents during the pandemic. In response, the committee asked elected officials to write a letter noting that it was not a time to raise rents, given how community members were struggling with lost wages or job uncertainty. Some officials initially didn’t believe the government should intervene in private business decisions. However, the committee persuaded policymakers to send the letter, based on a common desire to make the most of taxpayer dollars in the county’s rental assistance programs and to keep families housed.

“We realized we had really different ideas about how to solve these problems and different mental models about how the world works,” Baldassar said, “so we had to learn how to talk across those differences in a way that would deepen those relationships rather than breaking them. I think being able to do that has brought us closer as a community.”

Ensuring the Well-Being of a Community

Santa Monica, Calif., proved that developing health-equity tools in normal times can make operations move more smoothly during a crisis. Before the pandemic, the 2016 Culture of Health Prize-winning community designed a “Wellbeing Index” to measure how people are doing, from their sense of community to their opportunities for health and economic opportunity. For example, said Lisa Parson, special assistant for equity and community recovery, do they have frequent social contact? Can they afford medical services and housing?

Parson said the index, regularly used for long-term planning, also informed the city’s pandemic-response efforts. The data they had already gathered revealed where to direct aid and guidance. For example, in one neighborhood where residents had the lowest wellbeing rating in part due to food insecurity, the city started a food pantry. The city has also boosted communication with its local nonprofit and business partners. Together they’ve solved new problems that emerged during the pandemic, such as keeping restaurants open through open-air dining or offering food delivery to comply with pandemic guidelines.

Creating an Inclusive Response

At the onset of the pandemic, Shoalwater Bay Indian Tribe—a 2016 Culture of Health Prize-winning community—was already well-positioned to leverage the community’s strengths in order to respond in an inclusive way. The tribe’s location in the tsunami zone, an area of the Pacific coast that is at risk for tidal waves, has forced the tribe to focus on emergency preparedness and plan for most types of crises—including a pandemic.

In the early days of COVID-19, the tribe’s crisis planning enabled it to quickly open a food pantry so families could get food without leaving the reservation, amp up efforts at their community garden, and hire more kitchen staff to prepare and deliver meals to elders.

According to Shoalwater Bay Indian Tribe planner Jamie Judkins, another secret to the tribe’s success was quickly establishing communication. “Any communication is key—making sure you have opportunities for people to come in and share ideas and build good solid foundations for wellbeing,” Judkins said.

Addressing Economic Conditions

For about five years, Spartanburg County, S.C., a 2015 Culture of Health Prize-winning community, has emphasized race, equity and inclusion in its health and social services efforts, said Paige Stephenson, president and CEO of United Way of the Piedmont. So, when COVID-19 exacerbated existing inequalities in access to health care, education, and economic stability, she said, “We doubled down.”

The pandemic gave momentum to discussions that the community had long had, such as improving broadband infrastructure and access. “It’s become clear to our local leadership that that’s what we really need to hone in on,” Stephenson said.

Improving child care infrastructure has also gained new urgency for this community with a large workforce in manufacturing, which happens round the clock. Stephenson and others have consulted with other communities that have a track record providing reliable 24/7 child care.

“Child care is an invisible foundation for the workforce,” she said.

They show how important it is to provide not only immediate crisis relief, but to work toward long-term change by boosting access to affordable housing, good wages, food, child care, and broadband.

Inspiring Examples

Prize-winning communities shine a light on what’s possible when community leaders and residents unite to leverage community strengths and address the barriers to a fair and just opportunity for health for all. Their responses to COVID-19 demonstrate the importance of collaborating and taking data-informed and inclusive approaches. They show how important it is to provide not only immediate crisis relief, but to  work toward long-term change by boosting access to affordable housing, good wages, and food.

We are grateful that Prize-winning communities for sharing their stories with others who can learn with and from them. Since 2013, RWJF has worked with the University of Wisconsin Population Health Institute to carefully select places that meet our criteria for promoting better health for all. It’s a highlight of our year to showcase the winners, whose spirit of collaboration and commitment to change are truly inspiring. We love introducing these examples of how to build a Culture of Health to the rest of the nation.

This year, in light of the COVID-19 pandemic, we postponed awarding the 2020 Culture of Health Prize. Instead, we’ll choose them this year, alongside the 2021 winners.

Learn more about Prize-winning communities, visit We look forward to sharing more examples from Prize winners in future posts and hope you are inspired to take action in your community.


About the Author

Headshot of Katie Wehr / RWJF

Katie Wehr, senior program officer, focuses on discovering and investing in what works to promote and protect the nation’s health and to achieve the Foundation’s vision where we, as a nation, strive together to build a Culture of Health enabling all in our diverse society to lead healthy lives, now and for generations to come.

Fri, 22 Jan 2021 12:45:00 -0500 Katie Wehr Public and Community Health National <![CDATA[Five Experts Reflect on the Health Equity Implications of the Pandemic ]]>

As the novel coronavirus swept the globe, structural racism drove its disproportionate impact on communities of color in our nation. As we look ahead to a new year, experts weigh in with thoughts and hope for shaping a healthier, more equitable future.

Two people wearing masks facing each other.

When acclaimed Barbadian author Karen Lord envisioned life on a small island during a pandemic in her story The Plague Doctors, she never imagined that within weeks of its publication, “history would become present, and fiction real life.” Lord’s short story in the Robert Wood Johnson Foundation’s (RWJF) first-ever book of fiction, Take Us to a Better Place, was written months before coronavirus emerged. With chilling prescience, it imagines a deadly infectious disease besetting the globe and follows Dr. Audra Lee as she fights to save her 6-year-old niece. The heroine confronts not just the disease but also a society that serves the wealthy at the expense of others.

This latter point was especially relevant here in the United States where COVID-19 hit communities of color dramatically harder than others. Centuries of structural racism have created numerous barriers to health including difficult living conditions; limited educational opportunity; high-risk jobs; lack of access to paid leave and disparities in care. Historical trauma has also driven deeply rooted mistrust of the medical establishment. All of these interconnected factors have magnified risk for both exposure to COVID-19 and the worst possible outcomes from the virus.

Photo credit: Henry Söderlund, Wikimedia Commons [O]ften what looks like prophecy is merely the skill of reading the signs of the past to guess at the challenges—and solutions—of the future. —Karen Lord (Read her post)

A series of polls also highlighted the heavy financial impact of COVID-19—with more than 40 percent each of Latino, Black, and Native American households reporting serious financial problems during the coronavirus outbreak—including using all or most of their household savings.

As we reflect on the year and the ongoing pandemic, we share observations by a range of experts featured on RWJF’s Culture of Health Blog in 2020. They provide important perspectives on the health equity implications of COVID-19, and offer some hope for the future.

We must keep equity at the forefront through activism.

Yolo Akili Robinson is the founder and executive director of the Black Emotional and Mental Health (BEAM) Collective and recipient of the RWJF Award for Health Equity. In a Q&A with Dwayne Proctor, Robinson explores how the pandemic's disparate impact on communities of color have strained mental health. Taking note of data demonstrating higher COVID-19 death rates for Black Americans, Robinson says the numbers are distressing, but not surprising:

Y. Robinson We now have to use our voices, through art, media, and politics, to keep issues of equity at the forefront. —Yolo Akili Robinson (Read the post)

We have already been living in spaces zoned so that Black and Brown people aren’t healthy—in food deserts, or where the water isn’t safe to drink, for example. And we endure untreated chronic conditions that lead to poorer outcomes from COVID-19, while struggling to access health care. So, when COVID-19 began spreading, we were already in distress because of systemic and structural failings.... When people of color actually do manage to receive care, doctors are more likely to minimize their pain and dismiss their symptoms. We have a long way to go in dismantling all of the “isms” within the system....

Speaking weeks before George Floyd’s murder touched off a national soul-searching on race, Robinson said:

I think back to the early days of the HIV epidemic and am reminded of all the ways advocates had to push the government to respond, over a period of years. They advocated and protested until finally the government put its weight behind finding effective treatments. That also had a very real impact on the structure of health care and the way programs were designed to help people with HIV. We, too, have to force a discussion and remind ourselves what started and energized national conversations that led to change. It was Martin Luther King, the Black Panthers, Gloria Steinem, Angela Davis, Fannie Lou Hamer, Black Lives Matter, ACT-UP. They got in our faces, even antagonized, and they got us past the collective amnesia and wishful notion that racism or sexism or homophobia don’t exist. We now have to use our voices, through art, media, and politics, to keep issues of equity in the forefront.

Maintaining social connections while physical distancing alleviates the pandemic’s impact.

Yolanda Ogbolu writes about families’ pre-pandemic self-isolation driven by fear of violence in her childhood West Baltimore neighborhood. Now a nurse researcher, Ogbolu is working to understand the effects of that “situational isolation,” which she defines as self-isolating behavior driven by circumstances in the social setting and built environment that make it difficult to get out and about or develop friendships.

To ease this isolation while combatting COVID-19, the community has rallied in many important ways ranging from taking decisive action to protect elderly nursing home residents from the virus, engaging trusted voices in community outreach and more.  

Yolanda Ogbula The one lesson I hope we’ve learned from standing together with family, friends, and community is how feeling connected can help all of us to not only survive but thrive. —Yolanda Ogbolu (Read her post)

She writes:  

In Baltimore, food, housing, and electricity are considered basic needs and are being urgently addressed for many. The digital divide that has been a barrier to equitable education is narrowing slightly through gifting of electronic devices and free internet services to the most vulnerable. The state has halted prosecutions for drug, prostitution, and some other offenses to protect vulnerable citizens in prisons. Baltimore ministers have created virtual “freedom schools” and are delivering free food to community members. The city’s schools have served over 50,000 meals to children and their families in need.

Others in the community are working and providing essential services, including health professionals, grocery workers, truck drivers, and hospital environmental health service workers. Caregivers, mothers and fathers, like those in my study, are reporting through social media that for the first time they can spend quality time with their children, serving as teachers and health promoters. They are making collages of the best moments of their lives, having dance parties, and building relationships with family and neighbors in new ways.

She concludes, “The one lesson I hope we’ve learned from standing together with family, friends, and community is how feeling connected can help all of us to not only survive, but thrive.”

Health care, public health and social services must work together to overcome the racial inequities that COVID-19 has intensified.

Chris Lyttle, deputy director of Systems for Action (S4A), focuses on the social determinants of health and how the pandemic has exposed race-based gaps in the nation’s health system.

Chris Lyttle [S]ystems need to work together to advance health equity. Let’s all join forces to push that alignment forward. —Chris Lyttle (Read his post)

Lyttle points out a “through-line” between S4A’s work, the failed response to the pandemic, and “the racial injustice that has sparked such an outpouring of protest. Black and Latino communities have borne the brunt of the pandemic—from the risk of infection and the severity of the illness to its economic reverberations."

"[F]ragmented systems prevent us from treating the whole person," he writes, continuing,

Drawing on 16 years of data from hundreds of communities across the country, an RWJF-supported study found that deaths from cardiovascular disease, diabetes, and influenza fall significantly when collaborative mechanisms are in place to promote population health....

I’m not naïve enough to believe that if we could just align our systems, we would vanquish racial disparities, but I am convinced the pressure we are seeing on communities of color foregrounds the power of better alignment. Early findings from that 16-year data set suggest that communities with strong multisector networks have fewer COVID-related deaths and lower infection rates. That information should certainly inspire action.

He concludes, “My personal and professional journeys have led me to much the same awareness—systems need to work together to advance health equity. Let’s all join forces to push that alignment forward.”

Data drives meaningful action.

Ericka Burroughs-Girardi, an action learning coach at County Health Rankings & Roadmaps, provides strategic guidance to communities that want to use data for meaningful action to improve health and advance equity. This year, the County Health Rankings team spoke with leaders from Black, Latino and Native American communities.

Ericka Burroughs Girardi Equity-focused decision-making is key for a future ripe with opportunity for every person in America, no matter the color of their skin, how much money they make, or where they live. —Ericka Burroughs-Girardi (Read her post)

One key lesson emerged: Used strategically, disaggregated data (local-level data broken down by race, ethnicity, gender, and age) can help facilitate a faster response, making it easier to see where resources like new testing sites are needed most. Data also can guide community responses in a fraught environment where politics and public health collide, but its availability varies greatly from state to state and community to community.

She writes:

Local-level data broken down by race, ethnicity, gender, and age are critical for understanding community challenges, with COVID-19 being no exception. Since the arrival of the virus, quickly expanding access to disaggregated data has been paramount for evidence-informed decision-making.

As response and recovery efforts evolve, communities will continue requiring precise, accurate, and transparent data to make informed decisions about resident needs. However, it is also important to recognize that these data may not capture the full story in a community. Not every community has access to universal testing.

Additionally, many residents fear how their information may be used—or do not seek care due to lack of health insurance, immigration status concerns, and more. All of these factors impact the data collected and their availability.

Check back in 2021 to read more perspectives on supporting an equitable COVID-19 recovery. In the interim, explore the Robert Wood Johnson Foundation’s collection of resources and perspectives on COVID-19.


About the Author

Najaf Ahmad

Najaf Ahmad is managing editor of the Culture of Health Blog where she highlights perspectives about how the Foundation is advancing health equity in communities across the nation.


Tue, 1 Dec 2020 12:45:00 -0500 Najaf Ahmad Health Disparities Public and Community Health <![CDATA[Sesame Street Offers Support to Families Coping with Pandemic Stress]]>

Navigating the holidays amid a pandemic is stressful. Sesame Street in Communities is offering support to help families cope with both common and new challenges.

Sesame Street Photo Credit: Sesame Workshop / Zach Hyman

Both of us, like many in America, are feeling anxious and unsure about what the upcoming holidays will look like for families. It’s difficult to know how to prepare or talk about this, and really all that is going on, with the young children in our lives.

Throughout this year our kids have continuously faced several changes. Suddenly their routines and schedules are different. Many are not seeing friends, family, teachers, and classmates in person as often or at all. They miss what felt normal and comfortable and they have all sorts of questions about what is happening and why. They struggle with what to do with all the “big feelings” they are experiencing.

They can also sense increased stress that the adults in their lives are facing. Adults are juggling care for their children, often adding homeschool teacher or “videochat technical support wizard” to already increased workloads. Those who are teachers, work in health care, or have other “essential” positions face significant danger and stress in their jobs every day. Others have lost jobs or are trying to protect or care for aging parents during a pandemic. Through all of this uncertainty and loss, parents and caregivers need ways to care for themselves, and children need to know they are going to be safe.

Sesame Workshop Offers Support 

In addition to teaching kids numbers, letters and some of their favorite songs, Sesame Street and the lovable Muppets have a history of tackling tough topics with a compassionate, evidence-based and age-appropriate approach and this year is no exception. Not only were caregivers helping children cope with the effects of the pandemic, but they also had to respond to the many questions brought on by the nation’s reckoning around racial justice.

In June, Sesame Workshop teamed up with CNN for a Town Hall to help families answer children’s toughest questions about racism. And in October, a new TV special, “The Power of We,” sought to teach children that they are never too young to be ‘upstanders’ for themselves, one another, and their communities. Additional resources to support families will be available in the coming months.

Also this fall, the  Sesame Street in Communities (SSIC) initiative released a new video special funded by RWJF. It focuses on building young children’s coping skills and fostering nurturing connections between them and the caring adults in their lives—whether parents, caregivers, or community providers. The video special, “Little Children, Big Challenges,” offers caregivers tips on how to help children cope with uncertainty by building resilience.   

With some of our favorite friends from Sesame Street and insights from early childhood education specialists and community service providers—including partners in three new SSIC communities, Miami, Baltimore, and Maricopa County, Arizona—the special offers tools and tips to families as they face each day with courage, optimism and hope. Suggestions include things that almost all of us can try, like sticking to a routine, talking about our feelings, and reaching out to friends and family we miss even if we are not able to see them in person.

The special also addresses common stressors families were already dealing with that the pandemic has intensified. These include challenges such as parental addiction and trauma. SSIC has an array of free, bilingual resources on these and other topics to equip parents and caregivers with the tools to help children navigate these difficult issues and make sense of their experiences.

For example, during the special, one of the Sesame Street Muppets, Karli, shares about her mom’s addiction and says, “My mom was doing a lot better, but now she seems really worried and I’m scared she’ll get sick again. What do I do?”

The host of the special, Sesame Street’s Alan, counsels, “There are many kids like you Karli” and connects her with the head of Arizona Recovers, one of the lead SSIC partner organizations in Maricopa County, to hear about how kids can cope with these challenges.

Muppet Karli talks to Sesame Street’s Alan and Angie from Arizona Recovers about how to deal with worries about her mom’s addiction issues.

Sesame Street in Communities’ Partners “Localize” the Initiative

Like communities and organizations across the country, SSIC’s new community partner organizations will also be integrating the resources including videos, interactive activities and print materials into their programs to better serve families.

For example, in Arizona, our partners, including Arizona Recovers in addition to the Arizona Department of Health Services; Arizona Governor’s Office of Youth, Faith and Family; and First Things First, will be training staff and integrating resources into therapy, child care, home visiting and family recovery programs in addition to bringing the tools into the emergency department at Chandler Regional Hospital, where they connect with families in crisis.

Thriving Mind, our lead Miami-based partner, will incorporate the resources into local healthcare provider organizations that support families. Their services include multidisciplinary outpatient care (including in-home visits), outpatient therapy, residential care and prevention programs. And, SSIC trauma and parental addiction resources will be embedded into early childhood services across Miami-Dade County, including within schools, public safety, and court systems. In Baltimore, our lead community partner, the Family League of Baltimore, will embed SSIC in efforts to support families struggling with substance use and new parents enrolled in Baltimore’s home visiting network, an intervention designed to improve health and development outcomes for babies.

Bouncing Back Together

This kind of support is especially necessary as we head into a holiday season that will look different for many of us. For some families, that might mean some of their favorite familiar faces are not with them at the holiday dinner table this year. Maybe they won’t get to travel, gather in their religious community, or participate in other familiar holiday traditions. But for other families, it could mean they don’t have enough food for a meal.

There are no easy solutions to the problems families are facing right now. But, we do know that children are incredibly resilient. And the most important thing we can do for them is make sure they have caring adults in their lives who will give them the space to talk about what’s on their mind and suggest ways they can feel better and “bounce back” stronger. Together, we can help children build the resiliency they need to face and overcome challenges big and small.

Learn more from Sesame Street in Communities about how you can help young children build resilience this holiday season and all year long.


About the authors

Katie Wehr, senior program officer, focuses on discovering and investing in what works to promote and protect the nation’s health and to achieve the Foundation’s vision where we, as a nation, strive together to build a Culture of Health enabling all in our diverse society to lead healthy lives, now and for generations to come.

Dr. Jeanette Betancourt is the Senior Vice President for U.S. Social Impact at Sesame Workshop, the nonprofit organization behind Sesame Street. She directs the development and implementation of community and family engagement initiatives making a difference in the lives of vulnerable children and their families. 

Mon, 16 Nov 2020 10:45:00 -0500 Katie Wehr Early Childhood Child and Family Well-Being <![CDATA[Grandfamilies and COVID-19: Families of Unique Origins Face Unique Challenges]]>

Raising a child can be hard at any age. Doing so in one’s golden years during a global pandemic introduces an array of unique challenges.

Grandfather carries grandson on his shoulders.

Mel Hannah spent most of his life in service to others. He was the first African American member of the Flagstaff City Council and vice chairman of the NAACP Arizona State Conference. And, in service to his beloved family, Mel and his wife Shirley, now in their 80s, have been helping their daughter Ashley raise her three children these past years. Sadly, however, Ashley contracted and tragically died from COVID-19 in May. Ashley’s untimely death left the Hannahs as the sole caretakers for her young boys, ages 5, 4, and 1.

The Hannahs’ story exemplifies the heavy toll of the pandemic, and especially the unique and often overlooked impact it is having on “grandfamilies” or kinship families. These are families in which children live with and are being raised by grandparents, other extended family members, and adults with whom they have a close family-like relationship, such as godparents and close family friends. Astonishingly, about 7.8 million children across the country live in households headed by grandparents or other relatives. Of that number, 2.7 million do not have a parent living in the household.

Often these families come together because of serious circumstances—including death, trauma, deployment, incarceration or substance abuse, and since March, the death of parents due to COVID-19. Raising kids is hard at any age, but doing so in one's “golden years” like the Hannahs’—particularly during a global pandemic—comes with its own unique challenges.

A report from RWJF grantee Generations United sheds light on families like the Hannahs, including the particular challenges they are facing as the world grapples with the coronavirus. The report found:

  • Almost half of grandparent caregivers are age 60 and older and at heightened risk for COVID-19.
  • More grandparent caregivers have disabilities than parents and also are likely at heightened risk for COVID-19.
  • Children being raised in grandfamilies are more likely to be Black or Native American than white. These are the same populations that are much more likely to be impacted by the pandemic and die as a result.
Racial Overrepresentation in Grandfamilies Caregivers in grandfamilies are disproportionally Black or Native American. These are the same populations that are more likely to be impacted by COVID-19 and die as a result. Source: Facing a Pandemic: Families Living Together During COVID-19 and Thriving Beyond, Generations United 2020 State of Grandfamilies in America Annual Report, September 2020

Kin Caregiving Poses Unique Challenges

The report also features the first nationwide survey of grandfamilies during COVID-19, conducted in partnership with GrOW (Grandfamilies Outcome Workgroup) and Collaborative Solutions, which revealed heightened needs related to housing, food insecurity, and alternative care plans:

  • 38% are unable to pay or are worried about paying mortgage or rent
  • 43% fear leaving their home for food
  • 32% arrive at food pick up sites after they have run out of food
  • 30% have no caregiving plan for the children if the caregivers die or become disabled
COVID-19 Challenges Facing Grandfamilies Grandfamilies are being forced to reckon with unprecedented challenges and tough realities and oftentimes with limited support systems in place. Source: Facing a Pandemic: Families Living Together During COVID-19 and Thriving Beyond, Generations United 2020 State of Grandfamilies in America Annual Report, September 2020

We all have heard that older adults should keep their distance from children because of the heightened risk of infection from COVID-19. For grandfamilies, that distance is impossible.

Also, kin caregivers do not always have automatic legal authority to access support and services for the children in their care. That becomes especially problematic when it is time to enroll in school, access health care, or find another adult to care for the child if the caregiver dies. Obtaining legal authority has been complicated by the pandemic for many families as courthouses are often closed, lawyers are in high demand, and the need to establish alternative care plans is urgent because of unexpected deaths from COVID-19.

Finally, most kin caregivers did not plan to be raising children at this point in their lives. Often, their homes do not have extra room to accommodate children, and they live on fixed incomes so supporting children can be difficult.

Benefits of Kin Caregiving

Decades of research show that children raised by loving family members have much better outcomes than children raised by unrelated parents in foster care. Children living with relatives have more stable and safe childhoods with a greater likelihood of having a permanent home. These children have fewer school changes, experience better behavioral and mental health outcomes, and, perhaps most importantly, are more likely to report that they “always feel loved.” They keep better connections to their brothers and sisters, extended family, and cultural identity.

There are also significant savings to taxpayers—estimated to be $4 billion a year because grandfamilies are caring for children who would otherwise go into foster care.*

*Generations United calculated this figure based on the federal share of the 2011 national average minimum monthly foster care maintenance payment ($511) for 1.1 million children. The number of children is less than one-half of the children being raised in grandfamilies outside of the formal foster care system. We use this number in the calculation due to a conservative estimate that the others may already receive some type of governmental financial assistance, such as a Temporary Assistance for Needy Families (TANF) child-only grant. Generations United also knows that a number of children in grandfamilies have special needs that would warrant higher monthly foster care maintenance payments. The cost of 1.1 million children entering the system would represent all new financial outlays for taxpayers.

Policy and Practice Recommendations to Support Grandfamilies and Kin Caregiving

The report contains robust policy and practice recommendations that would provide better support to these families. A few that are especially important are to:

  • Increase funding for Temporary Assistance for Needy Families (TANF) and encourage states, tribes, and localities to increase the monthly child-only grant amount to mirror foster care maintenance payments in each jurisdiction.
  • Coordinate COVID-19 response efforts across systems—including aging, education, housing, and child welfare—to ensure that grandfamilies can obtain services and support such as legal assistance to make alternative care plans; child care and respite; hardware and technology support; financial and housing assistance; help with court orders and child welfare case plans mandating visitation with birth parents; and caregiver training and other support.
  • Improve access to TANF child-only grants through simplified applications and more community outreach so kin caregivers can meet the needs of the children they did not plan or expect to raise.
  • License more relatives as foster parents by responding to delays caused by the pandemic with innovative virtual and other known solutions.
  • Use inclusive language and images in outreach materials, such as “caregiver” or “family member.”

Grandfamilies Must be Included in an Equitable, COVID-19 Recovery   

The health of our nation depends upon the health and well-being of our children and families—all our families. All parents and caregivers strive to provide what’s best for their kids. But in today’s America, families do not have the same access to opportunity—and the COVID-19 pandemic is making those gaps even wider. Families are making impossible choices between putting food on the table, providing shelter, and getting quality health care when a child gets sick. A recent poll released by RWJF, NPR and the Harvard T.H. Chan School of Public Health reveals how households with children experienced widespread, serious financial and health problems since the start of the COVID-19 pandemic, including problems caring for children and paying bills.

These challenges are often exacerbated for grandfamilies. For example, when Mel and Shirely Hannah’s daughter Ashley was living with them, she worked and was able to help with household expenses. They have struggled financially since her death. They have a hard time covering their $400 a month energy bill and had to give up their internet connection, making it difficult for their five-year-old to participate in online classes.

It is important to understand stories like the Hannahs’ and others like them, which you can listen to on Every Family Forward, so we can better consider, discuss, and design equitable policies and systems that support all families, including grandfamilies, who have lived unnoticed and under-resourced for far too long.

Learn more about the unique challenges that grandfamilies like the Hannahs' are facing by reading Generations United’s 2020 State of Grandfamilies in America Annual Report, Facing a Pandemic: Families Living Together During COVID-19 and Thriving Beyond.


About the Author

Jennie Day-Burget

Jennie Day-Burget, an award-wining public relations and communications professional, joined RWJF in 2015. She provides communications support to RWJF initiatives aimed at strengthening vulnerable children and families and programs that help all children achieve a healthy weight.

Thu, 12 Nov 2020 10:45:00 -0500 Jennie Day-Burget Child and Family Well-Being <![CDATA[Help Us Learn How Public Policy Can Advance Racial Equity]]>

We’re announcing $2 million in grants for policy research. Send us your ideas for studying the impact of local, state, and national policies designed to promote racial equity.

Woman wearing face masks and holding hands.

When Harris County voters approved a $2.5 billion bond to pay for more than 500 local flood-control projects, it seemed like a sound response to Hurricane Harvey. In 2017, the storm dropped 50 inches of rain in the Houston region, flooding some 166,000 homes. Based on a traditional return-on-investment analysis, it might also have appeared reasonable to spend that bond money in neighborhoods with the most expensive properties.

But county officials understood what that would mean—little protection for communities living with the most inadequate social, physical, and economic resources—many of whom are communities of color. And so, they chose a different policy approach. They gave preference to projects that ranked higher on the Centers for Disease Control and Prevention’s Social Vulnerability Index, which uses socioeconomic status, racial and ethnic status, household composition, housing, access to transportation, and other metrics to uncover potential vulnerability. The result: funds for flood control prioritized towards low-income communities and communities of color, those least able to recover from disasters.

An Opportunity to Gather and Share Evidence

Actively confronting assumptions that allow public investments to favor wealthier and whiter communities can help dismantle the legacy of racism. In a new call for proposals, the Robert Wood Johnson Foundation (RWJF) and its Policies for Action (P4A) program are inviting researchers to study the impact of local, state, and federal policies intended to promote racial equity in Black, Indigenous, and People of Color (BIPOC) communities. You will be helping us gather and share evidence in support of racial justice.

The Urgent Need to Dismantle Racism

We already know a lot about the harm public policy can do. The legacy of housing discrimination is but one example. Early in the 20th century, the Federal Housing Administration redlined neighborhoods with majority Black populations, refusing to insure mortgages there. Fast forward a century and racial disparities in home ownership rates continue, diminishing the ability of families to build wealth across generations. Discriminatory housing practices and health-damaging segregation also persist, as RWJF CEO and President, Richard Besser, MD, highlighted in his 2019 annual message.

Less is understood about solutions that will root out racism, but many policy experiments are underway. California recently began requiring that levels of COVID-19 infection be reduced in the hardest-hit communities before allowing the entire county in which they are located to proceed with reopening. Elsewhere, bold policies advancing racial justice are being tested and implemented in early childhood education, housing, health care, and public health. Promising mechanisms to propel racial justice include Medicaid waivers, equity principles, and wealth-generating strategies.

Through this funding opportunity, RWJF will support impact studies in these and other areas to determine what works. These grants recognize that intentionally applying a racial equity lens can uncover structural barriers that might otherwise remain hidden. Whether it is expanding a transit system, developing affordable housing plans, or implementing a plan to distribute a new vaccine, analyzing the impact of policies on people of color can detect harms that a broader population-level approach might miss. To identify such consequences, some cities like Seattle require that a “racial equity audit” be conducted before any new policy is finalized.

Research Criteria to Keep in Mind

We expect that researchers gathering actionable evidence under this initiative will engage community representatives. We cannot do this without voices from communities of color and the organizations that represent them. Whether ideas are solicited from a housing justice group, an NAACP chapter, community organizers, or other advocates, explicit interactions and partnerships will reassure us that the questions you are asking matter to those who can benefit from the answers. We also want to know how your findings can be translated into messages that resonate with affected communities and shared with legislators and policymakers to inform policies that create equitable communities.

We are flexible about methodology. While randomized clinical trials are valuable, we honor the power of interviews, surveys, focus groups, and other qualitative methods that can also generate rigorous data. And just as researchers expect economic and professional rewards from their work, we think those who allow their data to be collected should be compensated in some way, and we’ll be looking for that commitment in your research design.

Attracting a new crop of investigators is important to understanding policy impacts. We encourage applications from young and early-career researchers, especially from communities of color because they bring fresh perspectives and innovative ways of thinking to the work.

In the wake of the COVID-19 pandemic and the inequities it has laid bare, coupled with the racial reckoning triggered by the murders of George Floyd, Breonna Taylor and so many others, the imperative of dismantling structural racism is clear. Until we act, the vision of a just society that offers everyone the opportunity to be healthy cannot be realized.

Learn more about what our Policies for Action research program has funded in the past.


About the Author

Headshot of Mona Shah

Mona Shah, a senior program officer in the Research-Evaluation-Learning unit, joined RWJF in 2014. Drawing on her expertise in research and policy, she is committed to making research more equity-focused and accessible to the public, advocates, and policymakers.

Wed, 28 Oct 2020 12:30:00 -0400 Mona Shah Health Disparities Public and Community Health National <![CDATA[Global Approaches to Well-Being: What We Are Learning]]>

What can we learn from other countries about advancing well-being—a notion of health that extends beyond the absence of disease? A new, free book will offer examples and actionable ideas. 

A father and mother hold their baby.

Since we originally published this post in July 2019, more cities and countries are exploring ways of centering decision-making on human and planetary well-being—from Iceland, which revealed a new well-being framework, to Canada, which is exploring budget indicators that encompass happiness and well-being. 

Meanwhile, the COVID-19 pandemic is a reminder of how interconnected we are and always have been across lives, livelihoods, and well-being of communities and societies everywhere. In the United States, its spread has sharply illuminated inequitable conditions and ongoing systemic racism. Rates of infection and complications from the virus are significantly higher in communities of color, Native communities and tribes, immigrant communities, and other groups that live with higher rates of air pollution, spotty health insurance coverage, persistent health inequities, and lack of paid leave or a financial safety net to follow “stay home” public health orders. As we recover, prepare for potential future outbreaks and rebuild, we must prioritize equitable well-being as the ultimate goal. We might take a lesson from New Zealand, which adopted a well-being budget last year, has made significant investments in vital services like mental health and education as well as environmental protections, and has had an exceptionally low mortality rate and relatively rapid recovery from COVID-19.

Blue Marble Quiz Blue Marble Quiz—How may the rest of the world shape your thoughts and behaviors? Take our quiz to find out!

Stepping back a bit, four years ago, it dawned on me that the concept of “well-being” might lead to a world of learning opportunities that could deepen and broaden the Robert Wood Johnson Foundation's (RWJF) work to build a Culture of Health. I was in Copenhagen, at the World Health Organization Regional Office for Europe, for a meeting about the United Nations Sustainable Development Goals and developing measures for well-being. As I listened, I realized that many of us in the United States who were working toward improved well-being were not considering what others around the globe were learning as they incorporated well-being into policy and practice.

We were missing out on insights, for example, from years of research and community engagement underpinning New Zealand’s well-being indicators and recently announced national well-being budget. Officially introduced in 2018, the country’s Living Standards Framework redefines the national government’s priorities and measures of progress. It expands beyond economics to also consider policy impacts on human and environmental well-being. (Of note: As of this writing, New Zealand has had few deaths from COVID-19. The New Zealand Treasury puts well-being on equal footing with economics in its response planning, noting on its website: “The Treasury is also taking a longer-term view, providing ongoing advice to the Government about how the evolving global situation might impact New Zealand’s economic resilience—and the intergenerational wellbeing of New Zealanders—and the options for recovery.”)

And just a week after the New Zealand budget made international news, the United Arab Emirates was in the headlines with its National Strategy for Wellbeing 2031, which aims to promote social cohesion and prosperity by improving quality of life.

The idea of well-being has been integral to RWJF’s vision for a Culture of Health from the outset. In the spirit of the World Health Organization’s 1948 definition of health as a “state of complete physical, mental and social well-being, not merely the absence of illness or infirmity,” we have used concepts of well-being to broaden mindsets and strategies to improve health.

For RWJF, well-being includes people’s physical, mental, and social health, and the opportunities they have to create meaningful futures. It considers basic needs, like food, housing, education, employment, and income. It includes social and emotional needs, like sense of purpose, safety, belonging and social connection, and life satisfaction. And it is tightly linked with the well-being of our communities, our environment, and our planet.

But my Copenhagen trip prompted my colleagues and me to dive even deeper into what well-being means around the globe. Knowing that good ideas have no borders, we sought to identify promising practices that could help advance well-being in our own country. We were especially interested in building equity, as well-being approaches require inclusive processes and corresponding shifts in power. Well-being is also an important framework for equity because it is not a finite resource. While economic prosperity for some is often related to growing poverty for others, higher levels of individual well-being tend to increase group well-being.

As we continue our learning journey, we are seeking to understand the impact of these approaches. What do they add to efforts focused on social determinants of health, like income and education levels?

Here are some early considerations to share.

A Holistic Vision

By laying out a wide range of indicators that cross disciplines, a well-being driven approach demands collaboration and yields more holistic, integrated strategies. Rather than focusing narrowly on economic and health outcomes, well-being helps us see a more comprehensive picture, including early warning signs of crises to come.

Think of the isolation, disconnection, and deep worry that preceded the opioid crisis here in the United States. While we focused on job losses and economic declines and time-lagged vital statistics, we overlooked early signs of despair. Had we been measuring indicators of well-being, we might have focused on mental health support and community connection in addition to job creation, which may have led to dramatically different outcomes.

Tailored Approaches

Though every well-being effort is multidisciplinary, formulas for success vary and are customized to account for geographic, cultural, and political context. In Singapore, for example, decades of economic growth resulted in a strictly financial definition of personal success. As people focused solely on building wealth, their health declined. Even the Ministry of Health couldn’t capture attention when it declared a “War on Diabetes.” Eventually, the Ministry of Health and two universities recognized that reversing health crises required a shift in mindsets. Their new “health and wealth” narrative initiative aims to cultivate a cohort of university graduates who embrace this value system, leading to different personal, organizational, and societal decisions.

In the radically different context of Occupied Palestine, most people have spent their entire lives in warlike conditions. There, Birzeit University and its cross-sector partners are using community-based pilot programs to address the trauma of war and its impact on collective well-being. By addressing trauma as a holistic, socio-political issue, rather than an individual “problem to be treated,” advocates are alleviating social isolation and stigma and developing new indicators related to suffering, such as humiliation, insecurity, and deprivation.

Subjective Experience

To truly promote thriving individuals and communities, well-being approaches incorporate insights from psychology, sociology, economics, public health, and other disciplines. Metrics used to assess well-being encompass not only objective factors like income, but also people’s self-reported life satisfaction. Looking beyond objective data is vital, because simply checking off data boxes does not mean that an individual will experience well-being.

For example, according to one recent study, what people most want from the U.S. Medicaid system is not different interventions or coverage; rather, they want to be treated with respect and dignity regardless of their income, ethnicity, or insurance status. Unfortunately, these lived experiences, which have an undeniable impact on well-being, are not always measured or prioritized.

To ensure that subjective experience is taken into account, an NGO in the United Kingdom—Happy City—combines an objective Thriving Places Index with a simple, five-minute online survey. The Happiness Pulse employs user-friendly technology to measure the emotional, behavioral, and social well-being of individuals, groups, organizations, and communities. This tool is used to map strengths and needs and to evaluate impacts across projects and places.


The idea of well-being draws our attention to the fact that that we are essentially all in this together, even when we do not recognize it. Well-being approaches—including their sensitivity to the profound impacts of issues such as social isolation and injustice—shift our attention and action toward our interconnectedness.

Policies grounded in well-being also draw our attention to interconnection between people and the larger natural world. In Bhutan, for example, since the 1970s, Gross National Happiness (GNH) has provided a more holistic definition of progress than Gross Domestic Product (GDP) can alone. A key component of GNH is the recognition that all beings in the natural world are interdependent, and that the well-being of non-human life on Earth has intrinsic value. Using well-being assessments to guide decision-making, Bhutan has developed innovative natural resource and tourism policies and become the world’s first carbon-negative country.

What RWJF is Doing

In 2018, one of RWJF’s first steps on our learning journey was to convene thought leaders from five continents and 19 countries at the Rockefeller Foundation’s Bellagio Conference Center. The examples I cited above are all based on the work of people we met there. Recently, we published a book, Well-Being: Expanding the Definition of Progress, detailing insights from that gathering in order to spark thinking about well-being approaches in the U.S.

The book, which is part of our Culture of Health series with Oxford University Press, explores how leaders, cities, and countries worldwide are centering decision-making on a well-being approach—that is, on human and planetary well-being as well as economic growth, through policy, budget, and practice change, and by recalibrating narratives about what matters most.

Through essays, case studies, and academic papers, the book is meant to inspire city leaders, policymakers, economists, researchers, reporters, and others with ideas and actionable suggestions for advancing well-being approaches.

We are continuing to observe, test ideas, and explore how to integrate these insights from around the world into how we build and measure a Culture of Health across the United States, from our most rural communities to our largest cities. In fact, well-being is now an ongoing focus area for our Global Ideas for U.S. Solutions team. We are continuing to research measurement, narratives, policy, and other applications of a well-being approach.

Questions to Expand Well-Being Thinking

We encourage you to consider how these insights apply to your work and place. How are you, your organization, your city, or your country defining and pursuing progress? Does that encompass well-being? Who is missing from decision-making about what we value as a society? How does what we measure and report shape our narrative about what matters?

Learn more about this work and sign up to request a free copy of the book Well-Being: Expanding the Definition of Progress, which offers instructive examples and actionable ideas from around the world for advancing well-being approaches in the U.S.


About the Author

Headshot of Alonzo Plough

Alonzo L. Plough, PhD, MPH, chief science officer and vice president, Research-Evaluation-Learning at the Robert Wood Johnson Foundation.

Tue, 13 Oct 2020 14:00:00 -0400 Alonzo L. Plough Public and Community Health International <![CDATA[Research Shows the Importance and Paradox of Early Childhood Care and Education]]>

Dependable child care is critical for healthy development—and for the nation to return to work. However, costs are often unaffordable even while many child-care workers are not making a living wage. Ultimately, the entire nation faces the consequences of a system in crisis.

Young girl coloring in a daycare facility.

While working from home and caring for our families as we wait out the COVID-19 pandemic hasn’t always been easy, it certainly is a privilege that we value during these unprecedented times. We’re fortunate that our organization recognizes the importance of families and caregiving. In addition, the nature of our jobs allows us to work remotely and have flexible schedules. This helps us support our families during a global pandemic. Unfortunately, the vast majority of working parents in America today, especially women of color, don’t have this choice.

Instead, as pressure mounts to reopen the country, many working parents face an impossible dilemma. Those without the option to telecommute are forced to return to work while struggling to find safe and affordable child care. Or they must stay at home to care for their children and face financial ruin. This burden falls disproportionately on women of color who are on the frontlines of many essential jobs. Many are also child-care providers who face the monumental feat of juggling their low wage, high risk jobs with caring for their families and themselves in the midst of a pandemic. Ultimately, the entire country faces the consequences of an inequitable childhood care system in deep crisis.

Our nation’s health depends on the health of our children and the early childhood care and education (ECCE) providers that nurture them.

As America recovers from the pandemic and reopens the economy, rebuilding our ECCE system in a way that prioritizes equity and well-being is critical. We cannot reopen and recover without a stable and affordable child care system.

Several new studies funded by the Robert Wood Johnson Foundation (RWJF) support this. They show that ECCE is a public good that requires sustained investment, equitable access, and compensation that reflects the value and risks faced by frontline ECCE providers.

High-Quality Care is Critical for Healthy Development Into Adulthood

We’ve known for a long time that health and education are closely linked, and that people with higher education live longer. But a new study reveals that ECCE interventions may improve health outcomes later in life. Researchers have been studying long-term economic and health outcomes among children who had access to preschool education in the 1940s compared to those who did not. They found that children with access to nursery school had better long-term education and economic outcomes.

Early Childhood Care and Education Providers Face a Deep Crisis

While we know that ECCE is critical to children’s health and well-being, fewer studies have shed light on the 2.2 million providers, many of whom are women of color who care for the 10 million children in early childhood care. These child-care providers are in a double bind. They are responsible for caring for their own children and the children of others. They are both producers of ECCE and also consumers of it. In spite of risks to themselves and their families, they show up to their jobs every day. Ultimately, the health and well-being of these providers is one of the most important factors in ensuring safe, nurturing and appropriate ECCE care for all children.

Studies have shown that healthy brain development during early childhood increases the likelihood of success later in life. Supportive and nurturing environments set children up for a lifetime of good health.

Yet, a new study highlights the deep crisis ECCE providers and teachers face and how low wages force many to the brink of poverty. Many lack access to health insurance or paid sick or family leave.

This research shows that early childhood providers experience disproportionate mental health well-being challenges and face remarkably high rates of food insecurity. The very people caring for our children don’t have enough food to feed themselves and their families.

Messaging Shapes Perception of the Problem

So why aren’t we doing more to support the people and the system that cares for and nurtures our children during their formative years? The evidence is so clear that early childhood care and education is a public good. Why aren’t we making the investments needed to create a more equitable and affordable system that helps working families, including single-parent families.

Part of the problem is how the issue is framed. Another recent study shows how strategic messaging can build public acceptance for policies to support affordable, accessible and appropriate child care. But ongoing challenges remain in generating support among a sizeable subgroup of elected officials who oppose public funding for early childhood education.

Narratives that are rooted in sound evidence on the links between affordable and safe ECCE and economic benefits could help. Evidence shows that child-care subsidies for low-income families provide double value by creating healthier outcomes for children and higher economic benefits for families. A recently published policy brief by RWJF argues that sufficiently funding the Child Care and Development Block Grant (CCDBG), the primary public child care program in the United States, can play a critical role in supporting the health and well-being of children and families.

New Resources Offer Data on Costs

While no single entity is responsible for collecting data on the inequities of ECCE two new resources make reliable data on the costs of ECCE more accessible for advocates and policymakers. Project Hope’s Selecting Indicators for Early Childhood Systems Change Projects, is a new reference guide. It is a compilation of data sets that can help identify where inequities exist in order to set goals and mark progress on ECCE policy.

And a new database released by Child Care Aware now provides the most up-to-date data on ECCE cost for researchers and policymakers. The interactive database creates a real time assessment and picture of child care access and affordability in all 50 states. The database examines different factors that influence affordability, such as cost of living by region, median income for different types of families and household size. 

One shocking fact: Even before the outbreak of COVID-19 and the associated closures of child-care programs, the supply of child care was decreasing. Between 2018 and 2019, 53% of states reported a decline in the number of child-care centers and 79% of states reported a decline in family child-care providers.

We have the data, now we need to change how we talk about the positive health outcomes of early childhood care and education. More importantly we need to change a system that perpetuates inequality and neglects the providers who deserve basic benefits like health insurance, paid sick leave and better wages that account for the risk and value of the services they provide.

ECCE Workers are Essential—They Deserve a Living Wage

COVID-19 has made it abundantly clear that ECCE providers are essential to our society's livelihood. They deserve to be treated as such. Safe, affordable, accessible and appropriate ECCE that values providers shouldn’t be a choice. It is critical to our country’s overall well-being and to our economic recovery. In order for businesses to reopen, parents need safe, affordable child care. At the same time, the child-care workforce needs additional resources to provide safe, developmentally appropriate, care. We are seeing in real time how the current system cannot meet the needs of families, communities or our nation’s economic recovery. Let’s not miss this opportunity to improve the system and ensure equitable access to child care and early childhood education for all.

Learn more about how we’re expanding the evidence needed to build a Culture of Health through Evidence for Action, a national program of the Robert Wood Johnson Foundation, and our commitment to Healthy Children and Families.


About the Authors

Tina Kauh

Tina Kauh is a senior program officer with the Research-Evaluation-Learning Unit at the Robert Wood Johnson Foundation where she focuses on supporting the health and well-being of children.

Krista Scott bio image.

Krista Scott is a senior program officer at the Robert Wood Johnson Foundation where she works at the forefront of child health policy, advocacy, and equity.

Thu, 8 Oct 2020 10:30:00 -0400 Tina Kauh Early Childhood National <![CDATA[COVID-19 Research at the Community Level]]>

What investments, priorities and values are shared by communities that are faring better in the COVID-19 pandemic?

Contact tracers. Contact tracers in Harris County, Texas, discuss a COVID-19 case. (AP Photo/David J. Phillip)

Fifteen years ago the Robert Wood Johnson Foundation (RWJF) confronted a puzzling question that still resonates today: Why can some communities rebound after disasters, while others are unable to recover? We first studied this in the aftermath of Hurricane Katrina. Some parts of the Gulf Coast were irreparably damaged, while others were able to recover. Researchers at the RAND Corporation, with RWJF support, sought to identify the qualities that resilient communities shared after a natural disaster, such as the strength of collaborations among government and non-governmental organizations pre-disaster and robust plans to support those most affected. The same team later built on that research by examining community well-being after other types of disasters, including economic downturns and community violence. The researchers partnered with local governments and—time and again—found that prioritizing equity and building collaborative networks bolstered communities under extreme stress.

Today, this team is studying how communities are faring during a global pandemic. The patterns that are starting to emerge align with earlier research findings: Communities that practice health equity principles before disasters fare better afterward.

How Research Supports and Promotes Healthier, More Equitable Communities

It has been several years since the Robert Wood Johnson Foundation made a commitment to build a Culture of Health in America—where every person has a fair and just opportunity to live the healthiest life possible, regardless of where they live, how much they are paid, or the color of their skin. As part of this work, RWJF introduced a Culture of Health Action Framework and measures to help track the nation’s progress toward becoming a country that values health everywhere, for everyone.

Our Action Framework includes 35 exemplary measures that, taken together, can create meaningful change and provide useful signals of progress for the nation. We invite communities to use the framework as a starting point for discussion and recognize that each community will find its own path to a Culture of Health depending on its unique situation and context. We have been working with the RAND Corporation to continuously refine and update these measures, which include access to health insurance, substance abuse treatment, family and medical leave, voting, public libraries, reducing incarceration rates, and more. We believe that highlighting these measures as examples of areas needing focused attention and action will help to catalyze health equity. RWJF and RAND are continuously updating the Culture of Health measures to reflect new realities and to place greater emphasis on reducing collective trauma and racism.

To inform and complement this work, RWJF is using the Sentinel Communities Surveillance Project, which we launched in 2015, to better understand how the Action Framework can propel health equity and well-being in 29 diverse communities across the country. We are studying each community through the lens of the Action Framework to examine whether and how different sectors, organizations and local leadership in each community are working together; how priorities, policies, and investments strengthen health equity; and how each community is engaged in these processes. This surveillance project turns research into concrete, meaningful evidence about what communities are doing to improve population health, well-being, and equity. 

The Urgent Imperative COVID-19 Created

Then, everything changed this year when the COVID-19 pandemic hit. It has been the ultimate stress test for our health care and public health systems, our communities, and our country. It has cost us dearly in lives diminished and lost, not just due to the pandemic, but also to health care system gaps and inequities we’ve failed to erase. The pandemic makes the work to promote health equity and build a Culture of Health even more crucial and the consequences of not doing so excruciatingly clear.

Faced with this new challenge, RWJF leaders realized that, with surveillance already underway, the Sentinel Communities Project could provide a window into the impact and consequences of pre-pandemic investments. It could yield valuable data about which responses to the pandemic mitigate its impact and which exacerbate the harm and the health inequities it causes. Given the likelihood that many health care and social service systems will be re-built, often with greater attention to racial justice, after the COVID-19 crisis ends, the insights gleaned from this study can help communities rebuild stronger than before. So RWJF decided to closely monitor nine of the 29 Sentinel communities as they try to mitigate and recover from the pandemic in order to share and compare real-time information about the impact of these communities’ responses.

A Closer Look at Community Response to COVID-19

This project will report findings every few months on the following nine Sentinel Communities: Finney County, Kan.; Harris County, Texas; Milwaukee; Mobile, Ala.; San Juan County, N.M.; Sanilac County, Mich.; Tacoma, Wash.; Tampa, Fla.; and White Plains, N.Y. The first report (July 2020), available on COVID-19 Community Response: Emerging Themes Across Sentinel Communities, covers activities from March through early June of this year.

It concludes that pre-pandemic investments in holistic approaches to health, cross-sector collaborations, investments in data systems, and actions to promote health equity are key. It identifies four themes that differentiate community response:

  • Value of a community’s interest and focus on health and well-being before COVID-19;
  • Role of cross-sector collaborations for health and well-being in responses to the pandemic;
  • Use of data and systems to effectively monitor and track the course of the disease; and
  • Role of a community’s perspective on and actions to address health equity and meet the needs of historically underserved populations.

In Milwaukee, city and county governments responded swiftly to COVID-19, directing support to vulnerable populations, the report finds, even though the city was forced to furlough some employees. Governments posted a crisis hotline, offered resources to prevent infection spread in dementia care, and offered free meals and Chromebooks to students in need. Milwaukee is one of the most racially segregated cities in the country, and it has long experienced significant income disparities based on race. Nonprofits addressing health and economic challenges before the pandemic were able to ramp up by providing housing guidance, information on teleconferencing options for some court appearances, and emergency funds for food, housing, and health during it. Strong neighborhood revitalization programs already in place pivoted to tracking COVID-19 cases and deaths by race/ethnicity, and members of the Black community mobilized to address differential access to health care. Still, there are gaps in community response and many in Milwaukee are struggling.

In San Juan County, environmental damage, poverty, and lack of medical care have long been pervasive, and County residents have high rates of diabetes, alcohol-related injuries, and mental health problems. The County’s population is largely American Indian and Hispanic; oppressive policies have long stoked tensions with the Navajo Nation and anti-immigrant sentiments with the Latino community. COVID-19 hit this County hard, with the Navajo Nation surpassing New York City’s infection rate in May. The County’s unemployment rate more than doubled. Even when the state lifted parts of its stay-at-home orders, San Juan County was excluded from the relief because it was designated a “hot spot.” The County consolidated COVID-19 information and resources on one website, and worked with assisted living centers, hospitals, schools, and detention centers to help control the virus. The San Juan Safe and Healthy Communities Initiative (SJSCI) and other nonprofits have shared resources with residents and businesses.

In Tampa, the report finds, the pandemic has taken a toll not just on residents’ physical health, but also on their economic well-being and mental health. The community is in a state that has become one of the country’s worst “hot spots” for COVID-19. Florida has not expanded its Medicaid program and has a high uninsured rate. Still, Tampa-area officials adopted several policies to provide relief to those affected by the pandemic, including blocking evictions and suspending mortgage payments, providing food and housing assistance, and assembling an Economic Relief Task Force to identify business relief efforts. Hospital and health care systems formed a new collaborative to give health care leaders access to real-time data and help patients find care, but whether this and other collaborations can be sustained is unclear. Although the county has made strides to advance health equity, this work is new and the leaders have not issued specific equity guidance during the pandemic.

COVID-19 Community Response provides many more details on the pandemic’s impact in these and six other communities and looks at how these communities are responding. The next report on these nine communities, Collaboration in Communities to Address COVID-19, will be posted later this month. In both of these reports, we examine how community collaborations that existed before the pandemic are being leveraged to meet emerging needs and describe how health and equity concerns in communities are catalyzing new partnerships and cross-sector collaborations. Over time, this information is designed to inform a stronger, healthier, and more equitable recovery from the pandemic within communities.


About the Authors

Headshot of Carolyn Miller

Carolyn E. Miller is a senior program officer in the Research-Evaluation-Learning unit of the Robert Wood Johnson Foundation.

Alonzo Plough Headshot

Alonzo L. Plough, PhD, MPH, is chief science officer and vice president, Research-Evaluation-Learning at the Robert Wood Johnson Foundation.

Tue, 6 Oct 2020 10:45:00 -0400 Carolyn Miller Public and Community Health National <![CDATA[Helping All New Jerseyans Live Their Healthiest Lives]]>

We're breaking down barriers to health equity in our home state of New Jersey by encouraging collaboration across sectors and communities.

Girls running after school with hands up.

New Jersey is ranked as one of the nation’s healthiest states—on average. But if you were to look more closely, you’d see the numbers mask significant differences in health across the state. For instance life expectancy in one Newark census tract is 75.6 years while just a few miles outside the city, it’s 87.7 years.

Race is a big factor contributing to this and other health disparities. For example, babies born into Black families in New Jersey are twice as likely to die before their first birthday in contrast to those born into white families.

Other factors contributing to health disparities include income, gender, and education. Some are less apparent, like the distance from people’s homes to parks and grocery stores or the availability of public transit. The point is that many things beyond what might immediately be thought of as health related do, in fact, play a major role in determining health. 

The COVID-19 pandemic has triggered a health and economic crisis that worsens health inequity and adds urgency to the effort to end disparities.

A Policy Roadmap for New Jersey

To close these gaps in life expectancy and address destructive health disparities, the Foundation is in the midst of an unprecedented effort within our home state. After extensive research and months of conversations with nearly 300 community residents, nonprofit and business leaders, and others from across the state, RWJF in April 2019 released a comprehensive set of policy recommendations in partnership with the Center for State Health Policy and the John J. Heldrich Center for Workforce Development, both at Rutgers University. The report, Building a Culture of Health: A Policy Roadmap to Help All New Jerseyans Live Their Healthiest Lives, identified 13 priorities for building a Culture of Health in New Jersey in three key areas:

  • Healthy children and families
  • Healthy communities
  • High-quality, equitable health and social service systems

The report underscored how health inequities often flow from generations of unjust, unfair policies and practices that create barriers to good health. To achieve health equity, these practices must be dismantled. Where policies are the problem, equity-promoting public policy reforms need to be the answer.

This report connected all the dots. The result is a roadmap across many sectors, including education, housing, nutrition, income, and health care, with a particular focus on health equity—the principle that everyone should have a fair and just opportunity to be as healthy as possible, regardless of race, place, gender, income or any other factor. What sets this policy roadmap report apart from previous work to build a Culture of Health in New Jersey is its sweep.

Recommendations include providing high-quality early education for all 3- and 4-year-olds; helping everyone fully benefit from the state’s expanded paid family leave benefit; creating and preserving affordable homes; and integrating mental health, addiction, and physical health services for Medicaid enrollees. Each recommendation addresses pressing needs, advances health equity and is supported by evidence.

To bring the report’s policy recommendations to life, RWJF recently awarded nearly $2.9 million in grants to nine nonprofits for work in New Jersey. The response to RWJF’s call for proposals reflected applicants’ deep energy, commitment and optimism for finding new ways to tackle significant problems that cause health disparities. While they acknowledge the work won’t be easy, they know it must be done.

Building a Culture of Health will require unprecedented collaboration across all sectors and all communities. It must assure that those who have been pushed to the margins have what they need to make healthy choices. It will require directing resources to communities that have suffered from generations of under-investment. It will require evidence-based, equity-producing policies and unique partnerships.

The grantees and the areas in which they will work are:

  • Camden Coalition of Health Care Providers – patient-centered coordination of health, behavioral health, and social services
  • Family Health Initiatives – maternal and infant health
  • Housing and Community Development Network of New Jersey – housing
  • Make the Road NJ (a program of Make the Road NY) – minimum wage, Earned Income Tax Credit
  • Monarch Housing Associates – housing
  • New Jersey Future – lead prevention
  • New Jersey Citizen Action – paid leave, and access to health care coverage options
  • New Jersey Together – housing

Making Gains Toward Health Equity

The report recognizes that only state-level policy cuts across all 565 New Jersey municipalities and has the potential to undo past wrongs. At the same time, though, action at the local level is needed to influence state leaders. RWJF will continue to be involved in health issues at all levels in New Jersey.

The grantee work soon to begin in New Jersey will address some of the state’s most intractable health gaps with the goal of making significant gains in health, particularly for people with the fewest opportunities to achieve optimal health and well-being.

All New Jerseyans will benefit from state progress toward improved health and well-being, but the most significant progress will come when health gaps are eliminated, and health equity is achieved. We urge policymakers and other leaders across the state to work with our grantees as they take up and advance the recommendations in this report. Together, let’s build a Culture of Health across New Jersey that serves as a model for the nation.

Learn more about efforts to support our home state of New Jersey.

About the Author

Sallie George

Sallie Anne George, MPH, is a program officer at RWJF where she works in several key areas to support the Foundation’s health and leadership efforts in communities nationwide.

Thu, 17 Sep 2020 09:45:00 -0400 Sallie George Health Disparities Child and Family Well-Being New Jersey (NJ) NJ <![CDATA[Energy, Water and Broadband: Three Services Crucial To Health Equity]]>

Imagine enduring the COVID-19 pandemic without running water, reliable internet or affordable gas and electricity. While many have faced this stark reality, communities around the nation are working to build health and equity into these services.

Power line at twilight.

As COVID-19 swept our nation this year, the important influence utility services have on our health became clearer than ever. Running water is essential for washing hands to prevent infection. Electricity keeps individuals and families comfortable while they follow recommendations to stay home. And internet access allows employees to work from home, children to learn remotely while schools remain closed, patients to access needed health check-ups, and all of us to stay connected.

Conveniently powering up our laptops, logging onto the internet and turning on the faucet are things many of us take for granted. But the COVID-19 pandemic has also revealed fault lines in America’s aging infrastructure. These inequities especially impact people of color, rural and tribal communities, and low-income households. For them, energy, water, and broadband are often unavailable, unaffordable, unreliable—and even unsafe.

For example, on the Navajo Nation in the Southwest, the absence of clean, running water has forced families to drive for hours to haul back barrels of water to meet their basic needs, risking their lives by leaving the safety of their homes. In North Carolina, people asked to work remotely connect to the Internet while parked in front of the local library.

These inequities stem from a long, painful legacy of discriminatory policies and structural racism. But we can correct them and ensure everyone has the basics to be as healthy as possible. Communities around the country are already leading the way by building health and equity into three of our essential utility services:


Today, race is the strongest predictor of poor water and sanitation access. And lower income communities are least likely to have access to safe and affordable running water. We can eliminate these inequities by changing policy and practice. Doing so should be a priority given that more than two million Americans live without running water and basic indoor plumbing; when there are more than six million lead service lines in residential properties and schools across America; and as concern grows about synthetic chemicals, such as PFAS, contaminating our drinking water. For instance, in the Central Valley of California, residents fill bottles at public taps because their water at home is not safe to drink. In New Orleans, residents who are already saddled with unaffordable water costs rely on bottled water due to concerns about toxins.

Cities like Washington, D.C. are taking a step in the right direction. The city discovered that low-income and African-American households were less likely to be able to afford having their lead pipes fully replaced, and partial replacements can cause a significant short-term spike in lead exposure. The city has created a new program that helps property owners pay for complete lead service line replacements.



People across the country are cut off from access to affordable high-speed Internet with 15% of households lacking any form of broadband internet service. Economically and racially segregated places experience much lower levels of broadband connection than white and wealthier neighborhoods due in large part to its high cost. States and communities can help close the digital divide by investing in affordable, accessible high-speed internet, which is crucial to ensuring that everyone—not just the most privileged among us—can be informed, connected to schools and jobs, and engaged civically. In Cleveland, the fourth worst internet-connected city in the nation, the nonprofit DigitalC serves as a homegrown, community-based high-speed broadband network called EmpowerCLE. Low-income residents pay less than $20 a month for internet service, which is notably less than the $45 to $70 per month providers charge on average. States can help close the digital divide by not pre-empting, and instead supporting localities in establishing municipal broadband utilities like EmpowerCLE.


Almost one-third of households report difficulty paying their energy bills or adequately heating and cooling their homes. And more than 20 percent—roughly 25 million households—report reducing or forgoing necessities such as food and medicine to pay an energy bill. African-American families and rural households are more likely than other groups to spend a high percentage of household income on energy. It’s time for states and communities to put policies in place that will improve energy affordability and access and advance energy equity.

On the Pine Ridge Indian Reservation in remote South Dakota, where many tribal residents live without electricity in their homes, community members are tackling this problem head on. Pine Ridge received its first transmission line in 2018, but the cost of installing lines and meters has been prohibitive for many households, given that more than half the reservation lives below the poverty line. In the late 1990s, community member and entrepreneur Henry Red Cloud partnered with the Colorado nonprofit Trees, Water & People, which had foundation funding to install portable solar heating systems in Pine Ridge at no cost to homeowners. As of November 2019, 500 homes had Red Cloud’s off-grid solar furnaces and they have reduced their heating costs by up to 30 percent.

In the face of COVID-19, municipalities, corporations and community organizations have stepped up to address inequities in utility services—from free internet access for K-12 and college students, to bans on water and energy shut offs for people unable to pay their bills. Yet many of these protections are set to expire on arbitrary dates even though the need for them will surely continue. While the imperative to make access to utility services more equitable became more urgent during the pandemic, the real challenge is making them affordable and accessible over the long term.

Energy Insecurity chart. Source: Synapse Energy Economics, Inc.

As the nation begins building toward an equitable and lasting recovery, we must ensure everyone’s basic needs for water, energy, and Internet are met, and that investments in infrastructure are advanced with an equity frame. Returning to the way things were is not acceptable.

To build healthier communities, we must advance equitable public infrastructure. Learn more about the connection between public infrastructure and health equity.


About the author

Pamela Russo

Pamela Russo, MD, MPH, senior program officer, joined the Foundation in 2000. The major area of her work is improving health at the community level, based on the understanding of health as the result of interactions between social, environmental, behavioral, health care and genetic determinants.

]]> Thu, 10 Sep 2020 10:00:00 -0400 Pamela Russo Built Environment and Health Health Disparities National <![CDATA[Lessons for an Equitable COVID-19 Response and Recovery]]>

COVID-19 has magnified deep-rooted barriers to health and opportunity—particularly in Black, Latino, and tribal communities. Leaders from these communities shed light on how we can shape an equitable and just recovery.

Sign at a shop for new coronavirus protocol.

In the almost seven months since the novel coronavirus national emergency was declared, we’ve witnessed how it has magnified centuries-long inequities that have created deep-rooted barriers to health and opportunity in communities of color and tribal communities.

At the County Health Rankings & Roadmaps, my colleagues and I know the first step to action is knowledge. We cannot address the disparities the coronavirus has brought to light without first understanding the data, challenges, and historical context at play.

Through conversations with six leaders from Black, Latino, and tribal communities, we examined the inequities the pandemic has exacerbated and explored strategies and solutions for where we can go from here. Three lessons emerged from these conversations that can inform an equitable response and recovery.

COVID-19 is Not Happening in a Vacuum

We know that where we live and our access to resources like an affordable home and living wage make a difference in how well and how long we live—and COVID-19 has made that even more apparent.

The coronavirus has exposed cracks and structural inequities caused by unjust and unfair policies and practices, shared Dr. Camara Jones, senior fellow and associate professor at Morehouse School of Medicine and former president of the American Public Health Association, and is a much-needed wake-up call to address them.

Access to child care, running water, and well-paying jobs that can be done remotely all contribute to our ability to stay safe during the pandemic. Dr. Patricia Nez Henderson of the Diné (Navajo) Tribe and Black Hills Center for American Indian Health noted how a lack of access to running water for about 30 percent of Navajo Nation makes it near impossible to follow public health guidelines.

COVID-19 has also created hurdles for people trying to care for their families, as access to child care becomes more limited and they return to work in-person, according to Cassandra Welchlin of the Mississippi Black Women’s Roundtable and Mississippi Women’s Economic Security Initiative. This is further exacerbated by the fact that communities of color are also overrepresented in essential jobs and services, limiting their options to work from home as they provide critical services. As UnidosUS’s Deputy Vice President of Health Rita Carreón pointed out, Latinos have the lowest percent of people who can work from home at 16.2 percent, compared to almost 30 percent of Whites.

Timely, Disaggregated Data are Critical

Local-level data broken down by race, ethnicity, gender, and age are critical for understanding community challenges, with COVID-19 being no exception. Since the arrival of the virus, quickly expanding access to disaggregated data has been paramount for evidence-informed decision-making.

In Chicago, for example, Esperanza Health Centers’ Chief Operations Officer Carmen Vergara shared how Esperanza’s timely data collection from their health centers laid the groundwork for a faster response in the city. As her team collected more data, they also were able to identify trends, making it easier to see where resources like new testing sites were most needed.

As response and recovery efforts evolve, communities will continue requiring precise, accurate, and transparent data to make informed decisions about resident needs. However, it is also important to recognize that these data may not capture the full story in a community. Not every community has access to universal testing. Additionally, many residents fear how their information may be used or do not seek care due to lack of health insurance, immigration status concerns, and more. All of these factors impact the data collected and their availability.

Opportunity to Reimagine What’s Possible

As we look to the future and how we rebuild from COVID-19, we know there is no single solution that will work for every community. But, these past seven months have presented us with an opportunity to reimagine what is possible. Maryland House Delegate Jheanelle Wilkins shared that “some of the issues that have been dead on arrival...are now issues that are truly at the table.”

We have the chance to rewrite the narrative on what housing, income equality, access to health care, and more, can look like. Equity-focused decision-making is key for a future ripe with opportunity for every person in America, no matter the color of their skin, how much money they make, or where they live.

As the nation recovers from one of the biggest health and economic impacts in a generation, learn more about these health equity principles to help guide COVID-19 reopening and recovery within communities.


About the author

Ericka Burroughs-Girardi

Ericka Burroughs-Girardi, M.A., M.P.H., is an action learning coach at County Health Rankings & Roadmaps, a collaboration of the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute (UWPHI), where she provides strategic guidance to communities who want to move with data to action to improve health and advance equity.

Mon, 31 Aug 2020 09:45:00 -0400 Ericka Burroughs-Girardi Health Disparities Disease Prevention and Health Promotion National <![CDATA[To Help Recover From COVID-19, We Need Universal Free School Meals]]>

As school officials face tough decisions about the 2020–2021 school year, the last thing they should be worrying about is determining who qualifies for free or reduced-price school lunches.

Empty school lunch room.

For tens of millions of children in the United States, school isn’t just a place to learn, but a place where they can depend on receiving healthy meals. In March 2020, according to the U.S. Department of Agriculture (USDA), more than 31 million children participated in the National School Lunch Program (NSLP) and more than 17 million participated in the School Breakfast Program (SBP); the vast majority of children receiving these school meals are from families with low incomes.

So when COVID-19 swept across the nation this spring and forced at least 124,000 schools in the United States serving 55 million students to close, a public health crisis quickly became an education crisis and a nutrition crisis.

School districts responded quickly, creatively, and heroically, implementing “Grab and Go” models allowing parents to pick up meals in school parking lots or other community hubs; loading up school buses with meals and dropping them off at stops along neighborhood routes; and delivering meals directly to students’ homes. USDA did its part by issuing a series of waivers granting more flexibility in how meals could be prepared, packaged, and served. Particularly for students living in poverty and areas where healthy foods are typically scarce, the heroism of school officials and volunteers was a lifeline.

Today, there are more questions than answers about the 2020–2021 school year, which may be unlike we’ve ever experienced. But the last thing school officials should be worrying about upon reopening is how to process meal applications and figuring out who qualifies for free or reduced-price categories; their mission of educating and feeding students as safely as possible should be their primary concern.

USDA recently announced that some of the meal flexibility waivers issued this spring would continue into 2021, which will help. But we need to act bigger and bolder. To that end, USDA should take the natural next step of allowing schools to serve free meals to every student during the coming school year (e.g., universal free school meals) and Congress should appropriate any necessary additional funding to cover the full cost of all meals served.

Universal free school meals will help accomplish three key goals.

More families—particularly families with low incomes—will have enough to eat.

Since March, more than 40 million people in the United States have filed new unemployment claims. The national unemployment rate has jumped to 11.1 percent, with even higher rates among Black and Latinx Americans. With more families losing their livelihoods and extra federal unemployment insurance benefits set to expire at the end of July, putting food on the table will be tougher. We’re already seeing this happening. The Institute for Policy Research estimates that food insecurity rates doubled overall and tripled for families with children between March and April 2020 due to spikes in unemployment and greater difficulty accessing school meals.

The Robert Wood Johnson Foundation has released a series of health equity principles to guide state and local reopening and recovery efforts to ensure that families that have been hardest hit by the pandemic and resulting downturn get the help they need to get back on their feet. One of the pillars of our framework is proactively identifying and addressing existing policy gaps—which includes the expansion of school meals programs to more children.

More children will receive healthy meals that help them grow, learn, and thrive.

Healthier school meal nutrition standards have worked exactly as intended since implementation began nearly a decade ago. USDA’s research shows that the nutrition content of school meals has increased significantly, and student participation in meal programs is highest in schools that serve the healthiest meals.

In fact, research published in Health Affairs just this week shows that the healthier school meals are associated with a significant decrease in the risk for obesity among children growing up in families with low incomes. The authors calculated that the obesity rate among these children in 2018 was 47 percent lower than it would have been without the healthier school meals standards, translating to roughly 500,000 fewer cases of obesity.

Healthier meals are good not only for students’ wellbeing, but can also help them succeed in the classroom. For instance, research shows that eating regular breakfast, including breakfast at school, has cognitive benefits, including a mainly positive effect on on-task behavior in the classroom and children’s academic performance.

Schools will be spared financial and administrative burdens.

Figuring out how to reopen schools during a pandemic is an incredibly difficult challenge. When should students return? How many should be in the building at one time? Can students even sit in the cafeteria? There is no set playbook to follow.

School districts are facing enormous logistical and operational challenges ahead of the 2020–2021 school year, and meal service is no exception. Per a recent School Nutrition Association survey, more than 860 school districts nationwide reported combined estimated financial losses from food service programs of more than $626 million due to the impacts of COVID-19. With the number of children who would otherwise qualify for free and reduced-price meals expected to jump significantly, the federal government should step in to ensure that every child is properly fed during the school day at no expense to schools or families.  

For more than 70 years, students have relied on national school meals programs to keep them healthy and help them learn, but their importance to our health and well-being has never been greater. Universal free school meals won’t solve every challenge associated with this pandemic, but it is a key component of a safe and equitable recovery.


About the Author

Jamie Bussell

Jamie Bussel is a senior program officer at the Robert Wood Johnson Foundation in Princeton, N.J. Follow her on Twitter: @JBussel

Thu, 9 Jul 2020 09:45:00 -0400 Jamie Bussel Early Childhood Child and Family Well-Being National <![CDATA[Reducing Childhood Obesity Now May Help in the Next Pandemic]]>

Research suggests that obesity leads to greater risk of becoming severely ill from diseases such as COVID-19. How can we address health disparities that contribute to obesity to better protect our children from future public health crises?

A woman and child pick fresh fruits and vegetables from a food cart.

Among the many lessons emerging from the COVID-19 pandemic is the impact of obesity. People with obesity and associated diseases tend to become sicker and are more likely to die when COVID-19 strikes.

We know childhood obesity is a powerful predictor of obesity in adulthood. It puts children at increased risk for developing numerous health problems later in life, including diabetes and heart disease. In addition to these chronic diseases, early research suggests that obesity may also increase their susceptibility as adults to serious illness like COVID-19.

COVID-19 and Obesity

Obesity amplifies the life-threatening effects of viral infections like H1N1 and now COVID-19. With a prevalence of 42 percent among U.S. adults and just over 18 percent in children and adolescents, obesity is a pandemic in its own right.

During the 2009 H1N1 pandemic, numerous reports identified obesity and severe obesity as risk factors for hospitalization. In one study, more than half of California adults with severe or fatal H1N1 had obesity; a quarter had severe obesity.

Similar trends are becoming apparent with COVID-19. In a study of more than 4,000 New York City COVID-19 patients, obesity emerged as a powerful predictor of hospitalization, second only to older age (over 65). Even among COVID-19 patients younger than 60, those with obesity were twice as likely to be hospitalized and 1.8 times more likely to need critical care.

Rates of obesity are higher among people of color, driven by structural racism that creates disparities such as poverty, economic disadvantage and lack of access to healthy food. In addition, many people of color experience higher rates of COVID-19 hospitalization and death than whites. Many are also essential workers along the food supply chain—including farm workers, workers in meat processing plants, grocery clerks, and food deliverers—which increases their vulnerability to infection. Unfortunately, the wages, benefits, and working conditions of these workers do not reflect their essential status. Combined with the impacts of COVID-19 on their daily lives, including disruption of the food supply and layoffs of family members, many are having a harder time than usual putting enough food on the table for themselves and their families—let alone healthful foods that can be more expensive than the alternatives. As a result, food insecurity has increased, and undernutrition may be just around the corner.

These factors add to family stress, including stress on children, who are already lacking normal support structures like schools. It’s important also to remember that going hungry is an Adverse Childhood Experience (ACE), a potentially traumatic event that impedes healthy development, contributes to chronic health problems in adulthood, and can negatively impact educational attainment and job opportunities.

In the short term, the disproportionate impact of COVID-19 on people of color and people with obesity should heighten awareness of the adverse effects of COVID-19 infections. It should also emphasize the need for increased prevention and aggressive care for those who are affected. Vaccine efficacy must be tested in an adequate sample of people of color and people with obesity. Furthermore, when we finally have an effective COVID-19 vaccine, we should prioritize its use to assure that people at highest risk for severe illness receive it first.

Strengthening the Food Supply Chain

We also need to ensure that children continue to have access to fresh, healthy foods, especially in light of projections that the pandemic will double out-of-school time for many, increasing the risk for weight gain often seen during summer vacation. This will require:

  • Strengthening the food support system: The most urgent need is to strengthen the food support system to ensure that all families have access to enough food to live healthy lives. The COVID-19 pandemic has underscored the importance of school nutrition programs, food banks, and food assistance programs like the Supplemental Nutrition Assistance Program (SNAP) to many vulnerable communities.
  • Expanding SNAP eligibility: Recently, the U.S. Department of Agriculture announced that the Families First Coronavirus Response Act is providing emergency allotments to SNAP recipients totaling $2 billion a month—a 40 percent increase. The emergency increase is a good start, but both the minimum and maximum benefit should be increased. Strong evidence shows that an increase in the level of the overall benefit could help stabilize the economy and reduce poverty and food insecurity. Because many more people currently need assistance, SNAP eligibility should be expanded and additional flexibilities added to allow for benefits to be used virtually.
  • Increasing funding for school foods: School meal programs will also need additional funding and continued flexibility to serve families across our communities. School districts have done a superb job of adapting their meal programs to meet the needs of children and their families during the COVID-19 crisis, but their resources are limited.
  • Sustaining the many positive changes in school meals mandated by the Healthy Hunger-Free Kids Act.

Addressing Factors Beyond Food Security

However, strengthening the food security system is only the first step. The COVID-19 pandemic has starkly illustrated the fragility of our food supply chain, from field to fork, and how easily disruptions can exacerbate the food environments that lead to obesity. The essential people on whom we depend for our food harvesting, processing, transport, and distribution are also those who are most vulnerable to COVID-19 and least protected from job loss. A critical step in repairing the food supply chain will require us to address the issues that make these workers vulnerable, like housing, immigration status, living wages, paid sick leave, and workplace protections against injury and illness.

The COVID-19 pandemic has laid bare stark health and social inequities in our country and underscores the urgent need to build healthy and equitable communities that can withstand future public health crises like the one we face today. We need to apply the lessons we are learning from the COVID-19 pandemic to generate the political will necessary to reduce obesity and health, achieve health equity, and establish a sustainable food system. Achieving these goals will help our children and the generations that follow grow up healthy, strong, and resilient.


about the author

Tue, 23 Jun 2020 10:45:00 -0400 William H. Dietz Childhood Obesity Disease Prevention and Health Promotion <![CDATA[In West Baltimore, Physical Distancing Was a Way of Life Before COVID-19 ]]>

Further physical distancing during COVID-19 has made us find creative and generous ways to strengthen connections.

Illustration of a family.

Imagine what it’s like to live on a block where elderly neighbors are bolted behind their front doors for fear of venturing out. Where parents worry daily about safety, so they resist letting children play in the neighborhood. Where more than half of the houses lie empty.

These images are not consequences of life under a pandemic. This was life pre-COVID-19 for the Baltimore neighborhood where I grew up and now work as a nurse researcher.  

For the past year, my research team at the University of Maryland, the Black Mental Health Alliance, the PATIENTS program, and B’more for Healthy Babies at Promise Heights, with support from the Robert Wood Johnson Foundation, has been listening to residents of two disadvantaged neighborhoods in West Baltimore. Residents told us they were “self-isolating” from family, neighbors and the community to cope with living in a neighborhood where they don’t feel supported, safe, or connected.

As one resident put it: “A lot of things scare makes us not want to allow our kids to go to the recs that open because we fear that a drive by [shooting] or...standing in the doorway you can get shot.”

Another told us: “I fear standing at the bus stop or going to the subway stations [because] I’ll be caught up in somebody else’s mess.”

Physical distancing during COVID-19 is intended to keep us safe at home and limit the spread of the virus. In much the same way, these families are self-isolating to protect themselves from the dangerous situation or environment in which they live. They fear being swept up by violence or toxic social groups so they avoid playing basketball on their neighborhood courts and don’t participate in community life. We coined the term “situational isolation” to describe this self-isolating behavior which is driven not by choice but by circumstances in the social setting and built environment that make it difficult to get out and about or develop friendships.

But these anxieties and isolating behaviors have serious consequences. When families weaken their social networks by isolating themselves, they are cut off from support and opportunities that affect health and well-being. Studies show that poor family support and limited involvement in community-life is associated with increased illness and premature death. One study found that social isolation is as damaging to one’s health as smoking 15 cigarettes a day.

These behaviors take on sharper meaning today given the disproportionate impact that the coronavirus is having on communities of color. In Maryland, blacks comprise about half of COVID-related deaths even though they make up 30 percent of the population.

We are formed, deformed, and transformed by our social relationships. While individuals and families in West Baltimore endure further social isolation during COVID-19, I’m moved by the kindness radiating across our community.

Physical distancing in the COVID-19 pandemic has forced many to look for creative and generous ways to strengthen connectedness for families and communities. We have reached a critical moment of deep understanding that if all of our neighbors have access to what they need to survive and thrive, we too have a better chance in life.

We are formed, deformed, and transformed by our social relationships.

In Baltimore, food, housing, and electricity are considered basic needs and are being urgently addressed for many. The digital divide that has been a barrier to equitable education is narrowing slightly through gifting of electronic devices and free internet services to the most vulnerable. The state has halted prosecutions for drug, prostitution and some other offenses to protect vulnerable citizens in prisons. Baltimore ministers have created virtual “freedom schools” and are delivering free food to community members. The city’s schools have served over 50,000 meals to children and their families in need.

Others in the community are working and providing essential services, including health professionals, grocery workers, truck drivers, and hospital environmental health service workers. Caregivers, mothers and fathers, like those in my study, are reporting through social media that for the first time they can spend quality time with their children, serving as teachers and health promoters. They are making collages of the best moments of their lives, having dance parties, and building relationships with family and neighbors in new ways.

This crisis has helped us realize the importance of social connections to our health and well-being. While observing physical distancing recommendations, I urge you to stay connected to your family, friends, and neighbors. Do not underestimate the impact of a 30-second smile or a simple wave. Look out for essential workers in your community and show appreciation while at the grocery store or a health care visit.

Physical distancing does not have to exacerbate the underlying social isolation in disadvantaged communities like Baltimore. When the pandemic is over (and it will end), we should strengthen these meaningful social connections we’re creating so they are sustained.

Crises have a way of bringing people closer together. I am reminded of the mantra for the African philosophy of Ubuntu: “I Am Because, We Are.” The one lesson I hope we’ve learned from standing together with family, friends, and community is how feeling connected can help all of us to not only survive but thrive.

Learn how communities in the United States and abroad are putting health and quality of life at the center of decision-making.


About the Author

Yolanda Ogbula

Yolanda Ogbolu, PhD, CRNP, FNAP, FAAN, is an assistant professor, neonatal nurse practitioner, and director of the Office of Global Health at the University of Maryland School of Nursing.

Mon, 1 Jun 2020 10:00:00 -0400 Yolanda Ogbolu Built Environment and Health Health Disparities Social Determinants of Health National <![CDATA[How the Future of Work May Impact Our Well-Being]]>

COVID-19 has rapidly compounded problems shift workers and gig economy contractors face, with implications for individual, family, and community health. What can we do to advance health equity in this new reality? Apply for funding to help us explore.

A man driving a car.

Editor's Note: The health impacts of our rapidly changing work environment are often overlooked. Since 2018, when this post was first published, we reported on the health equity implications of unstable incomes, unpredictable schedules, and lack of access to paid sick leave. In the wake of COVID-19, these questions about health equity are more important than ever. See what we’ve learned, and apply for funding to explore what the next five to 15 years may hold for workers.

When her regular job hours were cut, Lulu, who is in her 30s and lives in New York, couldn’t find a new full-time job. Instead she now has to contend with unsteady income and an erratic schedule juggling five jobs from different online apps to make ends meet. Cole, in his first week as a rideshare driver in Atlanta, had to learn how to contend with intoxicated and belligerent passengers threatening his safety. Diana signed up to help with what had been described as a “moving job” on an app that links workers with gigs. When she arrived, she had to decide whether it was safe for her to clean up what looked to her like medical waste.

Work is a powerful determinant of health. As these stories about taxi, care, and cleaning work from a 2018 report show, it is a central organizing feature of our lives, our families, our neighborhoods, and our cities. And work—its schedules, demands, benefits, and pay—all formally and informally shape our opportunities to be healthy.

But the world of work is rapidly changing. Job instability and unpredictable earnings are a fact of life for millions. Regular schedules are disappearing. With “predictive scheduling,” a retail worker today is essentially on call, making everything from booking child care to getting a haircut impossible until the work schedule arrives. Health and other fringe benefits are less often tied to the job. Nearly six in ten low-wage workers today have no paid sick leave. Two-thirds lack access to employer-based health care benefits.

And what is workplace safety when there is no workplace? In the gig economy, marketplace matching apps and others can create difficult trade-offs for workers who depend on the income. If a worker leaves a job undone because she feels unsafe in a male client’s presence, for example, or if she is asked to do a different job than she signed up for, the client can give her a one-star rating and the worker will have little recourse. When online platforms like these tie ratings to higher pay, the incentive for workers is to put the job before safety.

And more change is on the way. In the past 20 years, the growth of jobs in the gig economy—including self-employed freelancers and contractors—have far outpaced the growth of traditional firms. Some economists estimate this sector currently makes up roughly one-third of the U.S. workforce and may reach 43 percent of all U.S. jobs in the next two years.

Well-Being in the Future Workplace

All of this affects health and well-being. Our job at the Robert Wood Johnson Foundation (RWJF) is to look at emerging trends and their implications for health and health care. Through our efforts to elicit pioneering ideas around the future of work, we’ve been exploring interventions to improve well-being in the workplace.

We’ve been thinking about three areas in particular. First, we’ve been exploring how the nature and structure of work detract or contribute to our well-being. How, for example, do erratic schedules affect diet and sleep? The evidence is pretty clear that they both suffer. Long days, back-to-back shifts, and unpredictable work hours also make parenting harder and high-quality child care nearly impossible to secure. Financial instability creates chronic stress, which has a destabilizing effect on health. Not only do vacillating incomes make it difficult to afford a doctor, but the chronic financial worries have a cumulative effect on the body.

Second, our grantees have identified numerous examples where discrimination and bias, both intentional and unintentional, go unchecked in the gig economy, and traditional worker protections are absent, deepening vulnerabilities.

Takarah, for example, cleans homes in New York City by finding gigs on an app. The app company’s policy protects their cleaners against “no-show” clients by paying them a kill fee so long as they remain within 500 feet of the no-show client’s home for at least 30 minutes after the scheduled start time. The app tracks their location. But for some women like Takarah, waiting can get uncomfortable, particularly when she is working in wealthy, predominantly white neighborhoods like the Upper East Side.

"It’s uncomfortable because I am black and...I stand out” as she waits out her 30 minutes on the stoop or sidewalk near the home. “So I don’t like to be in that situation,” she told researchers of a study we funded called “Beyond Disruption.” She will sometimes opt to leave, and forfeit her kill fee for the client’s no-show. “Sometimes I don’t get paid for that and I don’t think that is fair.”

The app’s wait policy does not take into account the way racism shapes the kinds of scrutiny and risks that people of color may face in public space.

Finally, and on a more basic level, health insurance is increasingly the responsibility of the employee to secure, particularly in low-wage work and the gig economy. Policies such as the Affordable Care Act have taken steps to address this by allowing individuals to buy affordable health care on their own. Other innovations such as portable benefits uncouple health care from an employer. The construction industry, for example, allows workers to take their health care with them when switching jobs within the industry. In other fields, customer surcharges help pay benefits. Alia, a mobile platform created by Fair Care Labs, the innovation arm of the National Domestic Workers Alliance, collects money from clients to fund benefits for house cleaners such as sick leave, disability, and life insurance.

In our work, we’ve found that employers want to do the right thing but need help finding a clear path. Therefore, we supported the development of the Good Work Code, eight simple values that begin to codify a set of rights and obligations for both workers and employers. If you’re hiring a home-care worker, what’s a fair wage and how should you treat someone? And the flip side, what is good quality work? The code is a first step in promoting good standards and being clear about what those are.

People in the United States spend half their waking hours at work. We need both vibrant economies and jobs that enable people to live the healthiest lives they can. As RWJF works to build a national Culture of Health, we will continue to study the effects of work on health and health equity and find ways to ensure the changing world of work supports good health.

In the short-term, COVID-19 is rapidly compounding the problems shift workers and gig economy contractors face. In the long-term, it is imperative that our nation addresses the health and well being of all workers in an equitable way. Until we do, the health of our communities and the economy will remain in peril. 

RWJF is announcing a new funding opportunity to explore pioneering ideas about the future, including the future of work. We want to understand how changes to the nature and structure of work in the next five to 15 years may impact health, equity, and well-being.

Learn more and start your application today.


about the author

Headshot of Paul Tarini

Paul Tarini, senior program officer, focuses on exploration, discovery, learning, and emerging trends that are important to building a Culture of Health, as well as fostering connections between health and health care. Read his full bio.

Fri, 15 May 2020 09:45:00 -0400 Paul Tarini Public and Community Health Health Care Coverage and Access <![CDATA[Caring for Mental Health in Communities of Color During COVID-19]]>

Lack of access to testing, fear of being profiled while wearing face masks, and other issues are increasing toxic stress and straining mental health in communities of color. Learn what one leader is doing about it.

Man with hand on forehead.

One of the most troubling aspects of the COVID-19 pandemic is how it is exacerbating long-standing and deeply rooted inequities in communities of color. Health disparities stemming from structural racism have contributed to COVID-19’s devastating toll on blacks and Latinos in America. Often overlooked is how heightened stress from this heavy burden is impacting mental health.

Yolo Akili Robinson, a recipient of the RWJF Award for Health Equity, is swiftly responding to this new reality the pandemic has created. As the executive director and founder of Black Emotional and Mental Health Collective (BEAM), he leads his colleagues in training health care providers and community activists, as well as non-mental health professionals (family members, peers, etc.) to address mental health needs in communities of color. Robinson is witnessing firsthand how lack of access to testing and fear of profiling while wearing face masks, among other issues are increasing toxic stress and straining mental health.

In the following Q&A, Robinson shares insights about the impact and implications of COVID-19 on mental health within communities of color.

What are the unique mental health needs facing the communities of color you work with during this pandemic?

First, we must acknowledge the historic causes of mental health challenges: the legacy of racism, homophobia, transphobia, ableism, economic stressors, and systemic failures that contribute to our mental health struggles. Adding COVID-19 has greatly amplified this distress.

Data is showing that people of color are more likely to die from COVID-19. That’s not surprising. We have already been living in spaces zoned so that black and brown people aren’t healthy—in food deserts, or where the water isn’t safe to drink, for example. And we endure untreated chronic conditions that lead to poorer outcomes from COVID-19, while struggling to access health care. So when COVID-19 began spreading, we were already in distress because of systemic and structural failings.

When people of color actually do manage to receive care, doctors are more likely to minimize their pain and dismiss their symptoms. Serena Williams, a world famous athlete, experienced this. So imagine if you’re not a celebrity, but an elder in rural Alabama! Will you be heard? We have a long way to go in dismantling all of the “isms” within the system.

At BEAM we’re seeing these factors culminate in greater depressive symptoms and increased isolation within our communities. For instance, we are seeing that our folks who are living with diagnosed mental conditions like bipolar or anxiety disorders report higher distress.  

We also rely on our traditions to process grief. After a funeral, we usually return to the home and eat together, a repast. That’s part of our healing process and how we support one another. Mandated bans on traveling and gatherings have interrupted these traditions when we need them the most.


We must acknowledge the historic causes of mental health challenges: the legacy of racism, homophobia, transphobia, ableism, economic stressors, and systemic failures that contribute to our mental health struggles.


Our community partners such as domestic violence shelters are also witnessing a marked increase in calls related to intimate partner violence or hostile home environments. For instance, social distancing is forcing LGBTQ youth to stay at home with families who are hostile or abusive about their sexuality or gender.

Exacerbating all of this is that the words “mental health” are a trigger for communities of color. Someone seeking our services shared that when he hears the words “mental health,” he envisions a social worker taking away his cousin. And not too long ago, the American Psychological Association had to demand that Immigration and Customs Enforcement stop using confidential psychotherapy notes to justify deportations.

Finally, staff at community-based organizations are already overworked and under-resourced. This stress is now amplified as they face increased demands.

How is BEAM adapting its approach to new challenges stemming from COVID-19?

Our work is modeled on the idea that we cannot rely solely on psychiatrists, social workers, therapists, and other professionals to do all of the mental health and healing work within communities, especially now. Our goals have been to educate and equip peers and families with tools, resources and skills so they can support themselves and their friends, families and communities. For instance, we know through our work that young people need the consistent presence of someone who can listen, validate and support them. It’s not always a deep clinical intervention that’s needed, but rather someone who knows how to listen, hold space, be compassionate, witness and process things. And that’s work we need to know how to do wherever we are.


We now have to use our voices, through art, media, and politics, to keep issues of equity at the forefront.


We know our services need to be more accessible during this pandemic so we now have offerings on Instagram Live, Facebook drop-ins, and so on. Previously, much of our work was in person. While we’ve had virtual options in the past, we’re now ramping those up. We also acknowledge that many may not have access to the Internet. Not only does that make it harder for us to reach them, but it intensifies their sense of isolation. To address this, we are providing services by telephone and also training the people who can virtually access our platforms to support those within their own networks who are more isolated.

So this crisis has provided an opportunity to reimagine how we plan for accessible and innovative care delivery, how we run our organizations, and how we prioritize mental health and wellness for our staff.

What advice do you have for community health workers who may be feeling overwhelmed?

Many community workers do not prioritize self-care. They may tell themselves “I’m not doing enough and I should be doing more.” There is always work to be done. We must recognize that every dime we raise, every meal we drop off, every phone call we make, any information we share matters and is valuable.

This is a moment for us to concurrently attend to our own stress and anxiety because if we don’t, it will show up in our work. Seek out virtual support from other organizers. Find a practice that will ground you and center you as much as possible. If we don’t prioritize our own wellness, we will not be able to sustain supporting our communities and ourselves now and especially not beyond COVID-19.

Where do you see hope?  

I think back to the early days of the HIV epidemic and am reminded of all the ways advocates had to push the government to respond, over a period of years. They advocated and protested until finally the government put its weight behind finding effective treatments. That also had a very real impact on the structure of health care and the way programs were designed to help people with HIV.

We, too, have to force a discussion and remind ourselves what started and energized national conversations that led to change. It was Martin Luther King, the Black Panthers, Gloria Steinem, Angela Davis, Fannie Lou Hamer, Black Lives Matter, ACT-UP. They got in our faces, even antagonized, and they got us past the collective amnesia and wishful notion that racism or sexism or homophobia don’t exist. We now have to use our voices, through art, media, and politics, to keep issues of equity in the forefront.

Another hopeful sign is that a lot of community-based organizations are working together, providing aid to the community, training one another, collaborating. Together they’re trying to make sure that everybody gets groceries and medicine, and they’re checking in on the vulnerable and staying in touch to combat isolation. We hope those alliances continue.

Learn about how another RWJF Award for Health Equity winner is bringing visiblity to community health workers — trusted laypeople who share life experiences with those they serve in their local communities.


About the Author

Headshot of Dwayne Proctor

Dwayne Proctor, senior adviser to the president, believes that the Foundation’s vision for building a Culture of Health presents a unique opportunity to achieve health equity by advancing and promoting innovative systems changes related to the social determinants of health. Read his full bio.

Tue, 5 May 2020 09:45:00 -0400 Dwayne Proctor Health Disparities Public and Community Health National <![CDATA[The Plague Doctors: Imagining the Pandemics of the Future]]>

An acclaimed author reflects on the startling connections between her fictional story on a pandemic and our current reality.

Scientists in protective clothing holding test tubes in lab setting.

In the Robert Wood Johnson Foundation's (RWJF) first-ever book of fiction, Take Us to a Better Place, published earlier this year, Dr. Karen Lord and nine other writers use the power of fiction to help us imagine paths that may lead to a healthier, better place for all--and those that may lead us astray.  

In her short story The Plague Doctors, Dr. Lord envisioned what life on a small island during a pandemic might look like. Now, she reflects on foreseeing some of today’s challenges and solutions in her latest blog post.

Note: The following post originally appeared on the William Temple Foundation Blog and has been republished with permission. 

Last year, I was asked to write a story about the future of health. Speculating about the future is my job, but for something this specific and important, I asked Dr. Adrian Charles to be my advisor for all things medical. We chose that perennial favourite of history and fiction—a pandemic—never guessing that within weeks of the story’s publication, history would become present, and fiction real life.

Take Us To a Better Place, a collection of ten short stories from a diverse set of authors, was commissioned by the Robert Wood Johnson Foundation to help readers see how decisions we make today on a range of issues could influence our health tomorrow. The anthology was published on 21 January 2020 and is available free as an e-book in English and Spanish, and in audiobook format.

Roxane Gay provided the foreword. Science writer Pam Belluck, winner of the Pulitzer Prize for coverage of Ebola, wrote the introduction, which included this summary of my story:

“A different sort of dystopia, an uncomfortably realistic one, confronts us in Karen Lord’s “The Plague Doctors.” It is only 60 years from now, and the earth is being wracked by a deadly infectious disease, with bodies from the mainland washing up on an island where Dr. Audra Lee is desperate to find an answer in time to save her pox-exposed six-year-old niece. It’s the kind of global pandemic that should prompt all-hands-on-deck cooperation, but Dr. Lee finds herself working not only against a disease but against a veil of secrecy and selfishness erected by wealthy elites who want to prioritize a cure for themselves. Will she be tempted to cross the line of scientific ethics to relieve her own family’s suffering?”

That’s the story—but stories are icebergs, and below the surface a writer’s choices are complex.

Why, for example, did I choose a place called Pelican Island for the setting? Easy, because the quarantine station for Barbados used to be located on Pelican Island. Why a two-phase contagious disease? In 2015, Barbados experienced an outbreak of a disease new to the region, chikungunya. With no immunity in the population, the workforce was temporarily reduced and slowed by weeks of sick leave (first phase) and months of chronic pain (second phase). I personally experienced chicken pox (first phase) and hope to never experience shingles (second phase). Why a disease that was relatively easy on children but deadly to adults? Dr. Charles, my advisor, reminded me about mononucleosis, which can cause mild, short-term symptoms in infancy but result in a serious, debilitating disease for adults.

We assumed, with great optimism, that sixty years into the future our health systems would be so robust that it would take a combination of unknown factors for something as routine as an epidemic to cause worldwide disaster. We decided on a relatively ordinary, contact-transmission, low-mortality first phase to cause complacency; and an unanticipated, droplet-transmission, rapid and deadly second phase to cause panic.

We also added extra challenges, some expected, like political unrest and conspiracy theories, and some less expected, like the partial collapse, or rather sabotage, of telecommunications, leading to restricted access to and exchange of information.

So, how does Dr. Audra Lee fight a pandemic on limited resources? We added critical background details, like a second, smaller island for quarantine and a coast guard on constant patrol. Futuristic tech is available, such as advanced 3-D printers to manufacture on-island equipment that can no longer be imported, for example, bespoke parts of the personal protective equipment (PPE). We settled on a contemporary design for the PPE. The illustrator, Niv Bavarsky, produced an accurate image of suit, goggles, mask, and face shield, which is now all too commonly seen on the news.

To win our battle against COVID-19, we too will need broad-based support and many heroes.

Audra can also rely on the main hospital, but her best support is the island-wide network of community health teams to which she belongs—quasi-mobile units that include one or more doctors, nurse practitioners, caregivers, counsellors, nutritionists/herbalists, lab technicians and pharmacists. The health teams do not merely tend to the sick; they actively monitor the well and reduce the burden on the main hospital by preventing or mitigating illness before it gets to a critical stage. The community model is effective, but the teams’ actions are occasionally questionable, for example, when regulations and procedures are overlooked so that Audra can take care of her niece at home.

For Audra to win the war against the grey pox, it will take the further cooperation of similar community-oriented teams of practitioners and researchers in remote locations around the globe, the IT support of a guerrilla group of techs operating outside of the usual channels, and financing from a few billionaires who have ‘learned the hard way that a luxury bunker is too narrow a world at any price’.

To win our battle against COVID-19, we too will need broad-based support and many heroes. It’s never a comfortable feeling for a writer when fiction strays too close to prophecy, but often what looks like prophecy is merely the skill of reading the signs of the past to guess at the challenges—and solutions—of the future.

Listen to Karen Lord’s interview for BBC’s The Cultural Frontline, where she discusses how fiction can transform thinking and inspire solutions. And to read Karen Lord’s short story, download a free audio or eBook of Take Us to Better Place.


About the Author

Karen Lord is an award-winning author whose writing focuses on possible futures and alternate worlds.

Thu, 16 Apr 2020 09:45:00 -0400 Karen Lord Disease Prevention and Health Promotion Public and Community Health <![CDATA[The Impact of Changing SNAP and School Meals During COVID-19]]>

Emergency relief would shore up programs, but longer-term proposals would still reduce access to food stamps, make school meals less healthy.

A sign indicates that a school is closed.

The coronavirus pandemic has resulted in thousands of deaths in the United States and has upended daily life for millions of people across the country. Part of the emergency response at all levels of government has been to ensure that children and families continue to have access to healthy affordable foods.

The largest nutrition assistance program in the United States is the Supplemental Nutrition Assistance Program (SNAP)—sometimes known as food stamps—with the National School Lunch and School Breakfast Programs also among the largest. These programs have become even more critical during the current pandemic, but pending changes to those programs would fundamentally change how they are run and who has access to them.

I spoke with Giridhar Mallya, senior policy officer of the Robert Wood Johnson Foundation (RWJF), to better understand how recent coronavirus relief legislation impacts SNAP and school meals, as well as some of the longer-term proposals in both areas.

Why is SNAP important? Why has the Robert Wood Johnson Foundation invested in the success of the program?

SNAP is the Supplemental Nutrition Assistance Program. It's the program that was previously referred to as food stamps. As a foundation, we care a great deal about promoting health equity, which means giving everybody a fair shot at living out their full health potential. A program like SNAP is just essential to that mission. It provides individuals and families financial support to put food on the table. It serves about 40 million people in this country, in any one particular year. About half those people are kids, and two-thirds are kids, older adults, or people with disabilities. So, it really serves as a lifeline for those people.

How SNAP brings long-lasting benefits

What I really love about the program is that it not only meets its primary goal of reducing hunger—and it does that effectively, as has been shown by a whole body of research studies—it also reduces poverty among families. When you look at people who were served by SNAP as kids, if you then follow them over the course of their life, as adults, they have lower rates of things like diabetes and high blood pressure. And some people served by the program have better economic outcomes as adults. So, this program is really a home run in terms of people's physical, financial and social health.

What does it mean for a family to have access to SNAP, particularly during challenging times in their lives?

Most of the families with kids that are served by this program live in poverty. For a family of four, that means they're living on $26,200 or less per year, which really helps put this in perspective. The SNAP benefits—which could be a couple hundred dollars a month—really could mean the difference between a child having three meals per day versus maybe only two or one. Particularly for young kids, food is fuel for their development—their developing bodies, but also their developing minds. There are a number of studies that show that kids who don't go hungry—who are food secure—are both able to be more physically present at school, but also mentally present. So, it has both short and long-term impacts on their educational trajectory.

Congress has recently passed several pieces of legislation to address the coronavirus pandemic. Have any of those impacted SNAP?

Yes, those laws include a few broad changes to SNAP. For one, the work requirements and time limits on benefits that are normally in place have been effectively suspended. Secondly, it lets states request special waivers from the Secretary to provide temporary, emergency benefits to existing SNAP households up to the maximum monthly allotment. Finally, households with children who would normally be receiving school meals will receive emergency SNAP assistance to help cover the meals those children would have had at school. All of those are good changes that aim to make benefits more secure for more people during this emergency.

However, the legislation has not included an increase to the baseline SNAP benefit, which some advocates were calling for as the debates were happening. There was an increase in SNAP benefits during the Great Recession, for instance, that reduced hunger and financial distress.

Giridhar Mallya Giridhar Mallya, a public health physician and health policy expert note that USDA actions related to SNAP will make it harder for people and families to quality for the program.

Apart from that emergency response, what are the potential longer-term changes to SNAP currently on the table?

There’s a lot going on in terms of U.S. Department of Agriculture (USDA) actions as it relates to SNAP. In the aggregate, the longer-term changes USDA has proposed will make it harder for a number of people and families to qualify for the program. And for those that continue to qualify, many will see a reduction in benefits. So, I think that is kind of the big-picture impact of these proposals.

In terms of the particular proposals: First there is a proposal from USDA that basically would make it harder for states to waive the work requirements that are written into SNAP. The second is a rule change that would make it harder, again, for states to be more flexible in terms of their eligibility requirements as it relates to income thresholds and asset thresholds. And then the third rule change relates to how utility costs are accounted for in determining whether a person or family is eligible or not. And it basically, again, sets a federal standard, instead of having the state-by-state standards, even though the latter may better reflect what utility costs look like in that place.

What would these proposals mean to those families who are affected by these rules?

The big picture impact is that it would adversely affect eligibility and the amount of benefit that millions of families get. If you look at the impact of all three of these proposals together, 3.7 million people would lose eligibility for SNAP and around 4.5 million people or more would see a decrease in benefits.

We were talking specifically about children before: About a half-million households with children would see a loss of eligibility and over a million would see a decrease in the amount of benefit that they get. So, it’s really just a substantial and significant adverse impact if all three of these rule changes went into place together.

How would these changes to SNAP impact kids’ access to healthy meals at school?

There are going to be changes to broad-based categorical eligibility that don't just affect SNAP, but also school meals. What happens under broad-based categorical eligibility is that if a child or a family is receiving a certain type of cash benefit from the state, they can automatically qualify for SNAP, and then in turn they can automatically qualify for free or reduced-cost school meals.

With the proposed changes from USDA to broad-based categorical eligibility, almost a million kids would lose their direct eligibility for school meals. Some of them, with additional documentation, would be able to continue to get free or reduced-cost school meals, but some wouldn't. So, this proposed change would also affect kids’ access to healthy and nutritious meals in school. It's a double whammy in that way: It impacts food security in the home and also in school.

What impact do healthy school meals have on kids, in terms of their health and their learning?

I think what we've seen, particularly since the Healthy and Hunger-Free Kids Act, is that the nutritional quality of school meals, kids’ participation in school meals, and their satisfaction with the school meals have improved. So those are all great things.

What's even more important, I think, from a public health perspective, is that we're finding that through improved nutritional quality of school meals, plus a number of other changes that are happening in school environments, that this can have a positive impact on a kids’ health. Additionally, we know that when kids are well-fed, they are much more prepared to learn in school, to meet the developmental and educational milestones they should be meeting, and that they perform better in school. So there are positive impacts on nutrition, health and educational outcomes that are put at risk if this rule goes through.

In January, the USDA proposed changes to the school meals programs that would make those meals less healthy. Can you talk about what impact that proposal would have?

The proposal from USDA would mean that schools would be allowed to serve less fruit, fewer whole grains, fewer varieties of vegetables, and more starchy vegetables. Foods like pizza and cheeseburgers could be served more often without being required to meet nutrition standards. This would have a real impact on the roughly 30 million students who rely on school meals.

An analysis from Healthy Eating Research examined the projected impact of the proposal and found that it would have negative impacts on kids’ health and academic achievement. The students who would be most impacted by these changes are those from low-income families attending majority black and Hispanic schools and in rural communities—kids who are often already at highest risk for obesity and related health conditions.

USDA has taken some positive steps to give schools flexibility in how they serve meals during the pandemic, as more than 54 million kids across the country face school closures. That flexibility is commendable, because we know how important healthy meals are to these kids. That’s exactly why these potential changes to school meal nutrition standards would be the wrong approach.

Has the coronavirus legislation impacted school meals too?

Yes. As I mentioned before, households with children who participate in the school meals programs should now receive a SNAP benefit instead, so that’s one way the legislation impacts these programs. Secondly, USDA has allowed states more flexibility in how they serve meals so that they can serve them outside of school settings.

In the bigger picture, what policy preferences does RWJF have when it comes to SNAP and school meals?

These programs, both SNAP and school meals, have health, educational, and economic benefits. So, I think the big question is: Do we want to make it easier or harder for people to access these effective programs? Our position is that any proposed policy changes to these programs should make it easier for people to qualify and reap the benefits. And when we look at the proposed changes, whether it's the three proposed changes to the SNAP program or this most recent proposed rollback to school meal standards, we don’t think those changes meet that principle.

Very specifically, in terms of SNAP, any proposed changes should be carefully considered in terms of what impact it will have on eligibility and utilization, and therefore on the health, educational, and economic outcomes we described. Second, SNAP should continue to invest in strategies that enable people to purchase healthier foods. And there are a few different models that SNAP has tested which have proven effective. We know that it can be more expensive to eat more healthfully, so we need to enable families to do that. Third, we believe these three proposed changes to SNAP should not move forward and that the program should be maintained in its current form.

As for the proposal on school meals, we think it’s misguided. As our president and CEO Richard Besser put it, “Weakening school nutrition standards does not solve problems; it creates them.”

The bottom line is that, while the coronavirus response legislation seems likely to help in the near term, the long-term changes still on the table would make SNAP harder to access for many people and would make school meals less healthy.

For more on how the coronavirus relief legislation impacted SNAP and other food programs, see resources from the Food Research & Action Center and Urban Institute.


About the author

Jennie Day-Burget

Jennie Day-Burget, an award-wining public relations and communications professional, joined RWJF in 2015. She provides communications support to RWJF initiatives aimed at strengthening vulnerable children and families and programs that help all children achieve a healthy weight. Read her full bio.

Fri, 3 Apr 2020 08:00:00 -0400 Jennie Day-Burget Early Childhood Child and Family Well-Being <![CDATA[Incarceration Rates: A Key Measure of Health in America]]>

Mass incarceration is a pervasive problem that undermines health and health equity for individuals, families and communities. That’s why we have included it in the 35 measures RWJF is using to track progress toward becoming a country that values and promotes health everywhere, for everyone.

American flag behind barbed wire fence.

As coronavirus sweeps our nation it has brought deep-seated health inequities, including those linked to incarceration, to the forefront. Overcrowding and poor sanitation are putting prisoners at risk now more than ever. Persistent, widespread reports that guards and prisoners are testing positive for COVID-19 are especially alarming, and a sobering reminder that quarantines are nearly impossible among incarcerated populations. To address this, many jurisdictions are releasing select prisoners.

The Robert Wood Johnson Foundation (RWJF) has long recognized how incarceration adversely affects health and health equity for prisoners as well as families and communities. With some 2.2 million adults and youth in juvenile detention facilities, prisons, and jails, the United States incarcerates many more people—and a higher percentage of our population—than any other nation in the world. There is widespread agreement that incarceration has adverse effects on health and health equity, not just for prisoners themselves but also for families and communities. That’s why, in 2018, RWJF included it among 35 illustrative measures we are using to track our progress toward building a Culture of Health in America—that is, becoming a country that values health everywhere, for everyone.

The measures linked to RWJF’s Action Framework are intended to be viewed together to identify priorities for investment and collaboration, and to understand progress being made toward realizing our vision. We are also considering the impact each individual measure has on efforts to build a Culture of Health. Because mass incarceration is a pervasive problem that undermines health and health equity, tracking it allows us to examine how it compounds the persistent challenges associated with achieving health equity nationwide and affects communities.

Exacerbating inequity, inflicting harm

There is a growing consensus that incarceration has been misused, grossly overused, and used inconsistently in the United States. Many of the more than 2 million people who are imprisoned are disadvantaged by poverty and/or discrimination, and were already unhealthy. Even before the coronavirus outbreak, it was clear that, while incarcerated, they often experience conditions that further harm their physical and mental health. These include: poor sanitation, overcrowding, inadequate nutrition, violence and sexual abuse, inadequate mental health care, and other exacerbating conditions.

And once prisoners are released and return to their communities, these unmet health needs increase their risk for homelessness, mental health issues, and other health problems. In fact, incarceration has profound and far-reaching effects on health and health equity, not only for prisoners themselves but also for their families and communities.

Discrimination and disparity increase incarceration rates

Those who are incarcerated in our country are among the people with the lowest incomes. In many cases they are behind bars, not because of being found guilty of a crime, but simply because they cannot afford to pay court-imposed fees or make bail.

Incarceration rate graphic.

Race-based policies such as “stop and frisk” also have resulted in racial/ethnic minorities being arrested and convicted in disproportionate numbers and sentenced more harshly than others. In fact, many discriminatory, punitive policies that contribute to mass incarceration were enacted and sustained even at times when crime rates were not increasing or were at historic lows. Among sentenced prisoners in 2016, the majority (57%) are black or Hispanic. In comparison, the proportion of black or Hispanic people in the 2016 U.S. population was approximately 30 percent. Given what we know about health among these populations, compounding these challenges with incarceration can cause profound, lasting harm to individual and community health and well-being.

That cumulative stress is not consistently tracked in health data systems or addressed in comprehensive community health plans. Health leaders, including philanthropy, need better data to understand the lifetime impacts of incarceration on prisoners who are released and the communities to which they return—in many cases, communities that are already stressed by poverty and discrimination.

Incarceration policy and community health are inextricably linked

Advocates and national leaders have come together to begin improving incarceration policy. One result is the enactment of the bipartisan First Step Act, which caused the U.S. Department of Justice to announce the release of 3,100 federal prisoners. As this is happening, much of the focus remains on the social and economic consequences of incarceration and recidivism, rather than the health consequences.

But the short- and long-term health impacts that stress health and community systems require attention too, as they will affect our country for years to come. Further, despite recent strides, progress in reducing incarceration is slow. And while decreasing incarceration lessens the health impact on imprisoned individuals, it potentially increases the health impact on communities as more formerly imprisoned individuals return to these places, often with unmet health needs. Considering how to address those health needs is critical for community health planning.

Next steps to reduce incarceration and improve health

The First Step Act does demonstrate that disparate groups can work together to address mass incarceration. How can we build on this momentum, and ensure that the health consequences of incarceration are more directly considered? Health philanthropy can play a role by working to build awareness of incarceration’s impact on the health and well-being of entire communities. In highlighting incarceration as one of the 35 Culture of Health measures, RWJF is contributing to that work.

Philanthropies and others can support data collection that provides greater context and helps those making policy choices understand how incarceration influences health and well-being. The lack of transparency about life in jails and prisons is a significant impediment to understanding incarceration’s impact on health. A recent issue of the American Journal of Public Health, supported by RWJF, sheds light on new research that broadens our understanding of how incarceration negatively influences possibilities of hope, happiness, sense of security, and other critical components of well-being.

Finally, another important step is to address the drivers of mass incarceration. That includes racial disparities in arrests and pre-trial detention, mandatory minimum sentencing laws, incarceration for inability to pay bail and court fees, and similar measures.

Taken together, taking these important steps can advance progress on reducing mass incarceration and, in doing so, help build healthier and more equitable communities.

RWJF will continue tracking incarceration rates, along with other measures that affect our progress in building a Culture of Health in America. We invite you to view a fuller description of our measures and the data underlying them.


About the Authors

Douglas Yeung is a behavioral scientist at the nonprofit, nonpartisan RAND Corporation and on the faculty of the Pardee RAND Graduate School.

Carolyn E. Miller is a senior program officer in the Research-Evaluation-Learning unit of the Robert Wood Johnson Foundation.

Thu, 2 Apr 2020 13:00:00 -0400 Carolyn Miller Health Disparities Public and Community Health National <![CDATA[Global Approaches to Curb the Health Impact of Climate Change]]>

Cities from around the world have a lot to teach us about improving our planet's health. Their efforts can inspire us to be resourceful, creative, and inclusive as we work to tackle climate change and its health impacts.

Global illustration.

In times of crisis, it becomes readily apparent how interconnected we are and that sharing learning around what works and what doesn’t is of utmost importance.

We are seeing this with COVID-19, as learning from Singapore, from Italy, from South Korea and from China is informing the efforts of other countries—including the U.S. response.

The same is true of climate change.

A recent survey found that the proportion of Americans who are concerned about climate change tripled over the last five years and is now at an all-time high. 

Whether it’s raging wildfires; stronger, bigger hurricanes and tornadoes; more extreme heat events; or worsening air pollution, people in cities across the United States and around the world are seeing, living and having to manage the impact.  

What’s worse is that damage caused by global climate change magnifies inequities, placing the most vulnerable communities and individuals at greatest risk. Historic and social factors, such as access to health care; where you live or work; your age; and your income can all impact how and how much climate change harms your health.

Blue Marble Quiz Blue Marble Quiz—How may the rest of the world shape your thoughts and behaviors? Take our quiz to find out!

With everything we know about climate change and its consequences for health and equity, it’s easy to feel anxious and even powerless. But take heart—we can find inspiration and practical solutions for U.S. cities from beyond our borders.

Learning From Abroad

Equitable and sustainable approaches that curb the health impacts of climate change are being tried and tested in cities around the world. Their efforts can inspire us all to be resourceful, creative and inclusive as we work to tackle climate change and its consequences for health and equity in our own communities. 

Here are just three approaches from cities abroad that show us what’s possible:    

  1. Cape Town, South Africa, is retrofitting ceilings in low-income communities. Cape Town’s climate can be moist and cold, making its residents susceptible to tuberculosis and other illnesses, especially in low-income neighborhoods where housing often lacks the proper insulation. The city realized that by focusing on retrofitting ceilings in low-income communities, they could improve the health of the community and the energy efficiency of the buildings--reducing the fuel used to heat homes by up to 74 percent in the winter. To date, the city has retrofitted more than 10,500 homes in the outskirts of Cape Town, in areas that are vulnerable to heavy rainstorms, and wet and cold conditions. It is estimated that the total impact of these retrofits will save approximately 7,400 tons of CO2 each year. Knowing that it is more cost-efficient to design and build homes with the insulation, than to retrofit existing homes, in 2015 the city’s subsidy regulations for new low-income housing were changed to include properly insulated ceilings. Residents who received a new insulated ceiling reported significant improvements in health and happiness, as well as reduced stress levels associated with financial burdens because upgrades led to significant reductions in energy and health care costs.
  2. Chennai, India, developed a framework to restore water bodies and flood-proof the city. A devastating flood in 2015 claimed the lives of over 300 people in Chennai, displaced nearly two million people and destroyed billions of dollars worth of property, including infrastructure for ponds and other water bodies that help prevent flooding by holding excess water. The event spurred the creation of the Chennai Water Restoration and Resilience Framework, a plan to recharge its aquifers and flood-proof the city for the future. Some of the ponds affected were used as dump sites, while others were located in the most vulnerable communities in the city, where people live in informal settlements. As a result of the framework, each pond now has a customized and comprehensive restoration plan drawing on technical expertise from researchers and engineers. Community volunteers also bring their local knowledge to the maintenance and monitoring of the project. To date, the city has restored 210 water bodies, which has led to increases in biodiversity, reduced emissions of CO2 and increased space for exercise and physical activity. The next phase of the city’s plan aims to increase the number of restored water bodies to 460, and subsequently 1200+ more upstream from the city. As extreme weather events increase with climate change, Chennai is adapting to become more resilient to these impacts.
  3. Paris, France, has an app to help residents find cooling stations during heatwaves. In the summer of 2019, temperatures in Paris soared to a record-high 108.6°F/42.6°C during heatwaves that killed approximately 1,500 people across France. In response, the city of Paris began mapping its network of “cool islands.” These were 800, generally free sites like shaded parks, trees, and fountains, as well as buildings like swimming pools, museums and malls that served as a refuge for residents during periods of extreme heat. The project resulted in the creation of the EXTREMA Paris app, which geolocates the user to suggest the closest cool spots from their location. More than 7,000 Parisians have been identified as vulnerable during extreme heat—mostly elderly people and young children. Heatwaves also dramatically affect economic productivity, sometimes reducing productivity by one-third. Through the Extrema project, the city of Paris was able to inform residents about how and where to cool off, while maintaining their health and economic productivity. Developing an app also ensured the information is widely available for free. Thanks to the app’s accessibility, the city recorded increased downloads before the July 2019 heat wave in Europe.

Taking Action in U.S. Cities

We’re excited to be supporting a number of  U.S. cities in bringing proven approaches, like those from Cape Town, Chennai, and Paris, to their community. Because, when it comes to health, we know that good ideas have no borders.

Big and small cities across the globe have so much to teach us about how to do this sustainable development work most effectively, and ensure that everyone has a fair and just opportunity to live the healthiest life possible. I hope you too find inspiration from the world, as you work  to improve the health of people and the planet.

See what else we’re learning from abroad

 About the Author

Sharon Roerty

Sharon Roerty, AICP/PP/MCRP, a senior program officer who joined the Robert Wood Johnson Foundation in 2011, is an urban alchemist who has spent a lot of time at the intersection of health and transportation. Read her full bio.

Mon, 23 Mar 2020 08:45:00 -0400 Sharon Roerty Built Environment and Health International <![CDATA[Handwashing to Slow the Coronavirus Pandemic]]>

Among several steps to prevent the spread of coronavirus is one we can act on several times a day: frequently and thoroughly washing our hands. But how frequent and how thorough? And what about those whose living conditions make handwashing anything but easy?

Young boy washes his hands at the bathroom sink.

The simple act of handwashing has always been an important factor in preventing the spread of disease. As the coronavirus gains traction, it’s all the more critical. But a quick splash of water and perfunctory spritz of soap is nowhere near sufficient to keep the virus at bay, if you’ve been exposed. Now is the time to be sure we’re washing often enough and doing it right.

With that in mind, we want to share some resources. First, the Centers for Disease Control and Prevention (CDC) offers very specific guidance as to how often. Experts there say we should wash our hands:

  • Before, during, and after preparing food
  • Before eating food
  • Before and after caring for someone at home who is sick with vomiting or diarrhea
  • Before and after treating a cut or wound
  • After using the toilet
  • After changing diapers or cleaning up a child who has used the toilet
  • After blowing your nose, coughing, or sneezing
  • After touching an animal, animal feed, or animal waste
  • After handling pet food or pet treats
  • After touching garbage

Moreover, technique matters and we all need to take the time to do it right. The CDC recommends 20 seconds of solid scrubbing. To help make sure we spend the time we should, CDC offers a little life hack: singing “Happy Birthday to You” twice while we scrub. If you find that the musical selection doesn’t suit your ear, the Los Angeles Times offers up a number of worthy alternatives for accompaniment. And if soap and water are not readily available, the CDC recommends rubbing your hands together for twenty seconds with hand sanitizer that contains at least 60% alcohol and fully covers your hands. Hand sanitzers will not work however if your hands are dirty or greasy (such as after gardening or playing outside).

This video from Johns Hopkins Hospital breaks handwashing down step-by-step.

Unfortunately, many of us may have developed bad habits that we’ll need to overcome. In 2012, long before COVID-19 was on the horizon, RWJF published a blog post noting that surveys had concluded that the great majority of us have observed people failing to wash their hands at all after using a public restroom, much less for the 20 seconds recommended by the CDC.

From his days as ABC News' Chief Health and Medical Editor, Rich Besser puts hand santizers and soaps to the test.

There are health equity considerations too. Not everybody has ready access to soap and water. A recent story in the LA Daily News describes the initial steps Los Angeles County is taking to make sure homeless people have access to soap and clean water, as well as sanitary restrooms and health care. Tacoma, Washington, undertook a similar effort a few years ago, well before COVID-19, with important benefits for health and local pollution, as well as the comfort and dignity of the homeless.

And U.S. Senator Kamala Harris (D-Calif.) is among those calling on the Federal Bureau of Prisons to protect people in its custody, who are especially at risk for community spread due to crowded living conditions, poor sanitation, and the constant churn as inmates come and go.

Read an op-ed in the Washington Post by RWJF President and CEO Richard Besser on how past public policy failures are affecting our country’s ability to cope with Coronavirus.

The Robert Wood Johnson Foundation is closely monitoring the Centers for Disease Control and Prevention's (CDC's) guidance on the Novel Coronavirus (COVID-19). For more information, please refer to the CDC and National Institutes of Health (NIH) resources that are regularly updated.

Thu, 12 Mar 2020 12:00:00 -0400 Culture of Health Blog Public and Community Health National <![CDATA[Bringing the Research Home]]>

RWJF is funding new research that evaluates housing policies. Long-standing and complex barriers keep safe and stable housing out of reach for too many. We are seeking research partners to investigate the impact of housing policies and broadly share lessons learned.

Boy plays at public park.

For millions of people in America, having a home is an obstacle and a financial burden. Too many live in residentially segregated neighborhoods isolated from opportunity, making it difficult to break out of poverty and overcome the adversity that comes with it. 

The Robert Wood Johnson Foundation (RWJF) is offering funding for policy research aimed at overcoming deeply rooted problems related to housing stability and equity. We invite researchers, partnering with small cities or community-based organizations, to evaluate housing policies in hopes of turning up actionable lessons for other communities.

We Need Far-Ranging Solutions to Deeply Rooted Problems

RWJF president and CEO Richard Besser, MD, explained how safe and affordable housing supports positive outcomes across the lifespan—and how unsafe and insecure housing can deepen inequity and undermine a Culture of Health. Where we live can make it easier or harder for us to access opportunities: to get a good education, to have transportation options to living-wage jobs, to afford and have access to nutritious food; and to enjoy active lifestyles.

Yet, too little is known about policies that promote stable, affordable housing that ultimately translates to lifelong opportunities. For this reason, RWJF is announcing research funding to evaluate existing housing policies for their effectiveness in promoting equity. Because current problems are tied to decades- and centuries-old discriminatory policies and practices, this funding opportunity aims to identify promising policy solutions. Research proposals should foremost address equity and stability in housing.

Let’s first look at what evidence has taught us—so new research can effectively build on, and not replicate, what’s already been done.

To build more equitable, healthier communities, we need to boost people’s ability to afford a good place to live. Housing in America is expensive, and is getting out of reach in too many places. While housing costs have risen, incomes have not. More than half of all American households spend over 50 percent of their incomes on rent or mortgage.

As a result, many live in substandard and crowded housing and/or in unsafe neighborhoods—especially among low-income families. As our colleague Amy Gillman, MA, explains, “When we’re spending too much of our income on rent or a mortgage, that leaves little to pay for transportation to work or the doctor or to put healthy food on the table for our kids.” 

A recent RWJF-funded national poll revealed that large proportions of people from marginalized communities have experienced discrimination when trying to rent an apartment or buy a house: 45 percent of African-Americans, 31 percent of Latinos, and 22 percent of people identifying as lesbian, gay, bisexual, transgender, or queer.

Discrimination is often built into policies and practices, explains Harvard professor David R. Williams, MPH, PhD. Nearly half of black people, for example, say they have experienced discrimination when trying to rent or buy a house, limiting access to one of the most foundational needs.

Deeply rooted in American history is the practice of denying whole sectors of the population from grasping opportunities and building generational wealth. The cycle of poverty persists and accumulates through time. This is why where we live—and the policies that shape them—matter. To buck this unjust trend, it’s important to identify and address policies that shape inequality in our communities.

Who Should Apply

Ultimately, through this grant we want to find how housing policies allow greater, more equitable access to opportunity. We are offering up to $250,000 in funding to researchers who will evaluate policy interventions that address housing affordability, stability, and/or ways to reduce exclusionary barriers. 

We are particularly interested in research teams who will:

  • study policies that are already in place at the state, county, or local levels. We are not looking to research emerging laws or practices.  

  • analyze the policy’s impact on small cities. Although we will review all proposals, we are particularly interested in proposals that look at small cities of approximately 50,000 to 500,000 people. There’s been a fair amount of policy research on big urban areas, but little is known about how urban policies translate to improvements in areas with smaller populations.  

  • have secured data—or have forged partnerships with those who have it. Establishing connections and gaining access to data can take a long time, and this grant’s duration is only two years. Researchers with access to data will have an advantage because they can spend more time analyzing data and constructing the evaluation.

Although RWJF’s mission is dedicated to health, grant proposals need not address direct health impacts or health outcomes for this funding opportunity. We want to understand policies that alleviate high costs or bias, and other barriers to opportunity. We believe that by addressing these fundamental problems, in time, better health and more equitable outcomes will follow.

To understand this funding opportunity, we invite you to connect with our Policies for Action (P4A) program. P4A is a signature research program of the Robert Wood Johnson Foundation, administered through the Urban Institute. Since 2015, P4A has funded research identifying policies, laws, and other levers that can support healthier, more equitable communities. 

Take part in an informational Policies for Action webinar for this grant opportunity on March 30, 2020 from 2:00 p.m. to 3:30 p.m. ET and start your application today.


About the Authors

Headshot of Mona Shah

Mona Shah, a senior program officer in the Research-Evaluation-Learning unit, joined RWJF in 2014. Drawing on her expertise in research and policy, she is committed to making research more equity-focused and accessible to the public, advocates and policymakers. Read her full bio.

Priya Gandhi

Priya Gandhi, a research associate in the Research-Evaluation-Learning Unit, helps develop and manage research initiatives and evaluations that generate evidence around programs, policies, and practices that can lead to a Culture of Health.

Thu, 12 Mar 2020 11:00:00 -0400 Mona Shah Public and Community Health National <![CDATA[Why Neighborhoods—and the Policies that Shape Them—Matter]]>

The Child Opportunity Index 2.0 uses contemporary data to measure and map inequities in all 72,000 neighborhoods in the United States. The tool helps researchers, city planners, community leaders and others identify and address inequities in their metros.  

Boys and girls run and play in the park. Image credit: iStock

The Tale of Two Boys Growing Up in Cleveland

Let’s ask two hypothetical 9-year-old boys a question: What is it like to grow up in Cleveland? 

Each boy attends school, and enjoys riding his bike and playing with Legos. Both live in Cleveland. Beyond these similarities, their life experiences are—and will continue to be—starkly different based on multiple, complex factors that lie within their neighborhoods.

Neighborhood A 

The boy living in Neighborhood A faces a host of obstacles to opportunity and well-being. 

Economic adversity is the norm. One in four families struggle with poverty, and nearly 83 percent of his peers in school need free or reduced-price lunch.

The boy does not have many adults in his life who can serve as role models for educational attainment and employment. Less than 20 percent of adults in this neighborhood have earned a college degree. Also, less than 20 percent have a high-skill job. Low education and employment levels among adults in his neighborhood may instill low expectations of his own employment prospects, and he will have weaker networks of employed adults to help him find a good job when he grows up. 

This boy is growing up in a neighborhood with signs of distress. Nearly 25 percent of housing units are vacant, which increases the risk of fires, crime and drug use. It also signals that his neighborhood is in disrepair and has been neglected, which has negative effects on home values. As a result, his neighbors have limited household wealth, which makes families and the community even more economically vulnerable.

Neighborhood B

Another boy lives a few blocks away in Neighborhood B. He enjoys a community in which economic security is the norm. Only 2 percent of people live in poverty, and less than 20 percent of his peers are eligible for free or reduced-price lunch.

This boy has adults in his life that bolster his aspirations and confidence in the future. Almost two-thirds of adults in his neighborhood have a college degree, and two-thirds also have a high-skill job.

The physical conditions in his neighborhood signal to this child prosperity and safety. Only 2 percent of houses are vacant, and homeownership is almost universal (94 percent).

How do the boys’ neighborhoods support their healthy development? 

While the boys are hypothetical, the conditions described here are real.

Child Opportunity Level map.

The map above illustrates the differences in conditions favorable to healthy child development between very low- and very high-opportunity neighborhoods. As you can see, Neighborhood A’s opportunity level is very low, indicated as light blue, while Neighborhood B’s opportunity level is very high, indicated by dark blue.

This map was developed and analyzed using the Child Opportunity Index 2.0. Our team at Brandeis University created the first version of the Index in 2014. The map uses the updated and improved version of the Index, released on January 22, 2020. The new Index helps us understand how children are growing up today in every neighborhood in the United States.

The Child Opportunity Index 2.0 is a tool that quantifies, maps and compares neighborhood opportunity for children across the United States; unlike similar tools that are retrospective, this tool uses contemporary data to measure and map all 72,000 neighborhoods in the United States. Our first analysis of the Index looked at inequities in neighborhood opportunity within the 100 largest metros in the U.S.

Each U.S. neighborhood and each metro are assigned a Child Opportunity Score on a scale of 1 to 100, according to its percentile in the national child opportunity distribution. The Index ranks opportunity by looking at a wide range of neighborhood conditions—like the quality of schools, the number of adults with high-skill jobs, availability of green spaces, and air pollution levels—that shape kids’ health and development.

Cleveland has an overall Child Opportunity Score of 61. However, this measure masks wide inequities. For example, Neighborhood A above has a score of only 7 (one of the lowest in the country) and Neighborhood B has a score of 99 (nearly the very highest in the country).

The Index also allows users to see where children of different racial/ethnic groups live in each metro area in relation to neighborhood opportunity.

Who lives in Neighborhoods A and B?

Racial inequities are vast and pervasive in Cleveland and nationwide.

Map of Cleveland depicting opportunity levels by neighborhood.

The map above was developed using the Child Opportunity Index 2.0. It shows the racial/ethnic composition of Cleveland neighborhoods. The areas with yellow dots are neighborhoods where predominantly black children live. We can tell from the map that those tend to be lower opportunity neighborhoods (light blue). In contrast, areas with green dots, where predominantly white children live, tend to be higher opportunity neighborhoods. Of the 451 children living in Neighborhood A (very low opportunity), 78% are black, while of the 1,139 children in Neighborhood B (very high opportunity), 67% are white.  

Neighborhood A and B exemplify a stark pattern of inequity across Cleveland: the majority of black children (84%) are growing up in very-low and low-opportunity neighborhoods, like Neighborhood B. Cleveland has the third highest opportunity gap between white and black children among the 100 largest metros in the nation.

How long and how well will the boys live?

The simple fact that the boy in Neighborhood A lives in a low-opportunity neighborhood puts him—and the rest of his peers—at a lifelong disadvantage. His day-to-day life, and his life expectations and outcomes, are far more stark than the boy in Neighborhood B. Because Neighborhood A lacks neighborhood resources, it may negatively impact not only his childhood experiences but his long-term education and income opportunities, health, and more. 

Meanwhile, Neighborhood B conditions are favorable and well aligned for supporting the boy and his peers to grow up healthy and reach their potential. The boy in this neighborhood will not have to think much about his neighborhood but will simply enjoy the resources it offers. Eventually, having grown up in such a supportive environment may have a favorable influence on his education, health, economic prospects, and even life expectancy.

RWJF Life Expectancy Chart  in metro Cleveland. Sources: Child Opportunity Index 2.0 database, U.S. Small-area Life Expectancy Estimates Project (USALEEP), Centers for Disease Control and Prevention.

As you can see in the chart above, residents in Neighborhood B, a neighborhood of very high opportunity, have a life expectancy of 81.7 years, while residents in Neighborhood A, a neighborhood of very low opportunity, can expect to live to be 72.4 years old. 

How can the Child Opportunity Index inform policy reform? 

Cleveland is just one metro area the Child Opportunity Index has mapped and measured; there are many more U.S. metros like it. The vastly different neighborhood conditions children experience, even though they might live right beside each other, aren’t happenstance. There are policies and practices in Cleveland and other metros nationwide that limit opportunities for all children to grow up healthy.

Communities are not islands. Economic forces (e.g., regional housing and labor markets) and federal, state, and local policies (e.g., land use zoning, public school funding) shape infrastructure and resources. Investment or disinvestment in communities reflects deliberate public policy and private decisions. 

The Child Opportunity Index is a tool that can help us understand where—and to what extent—inequities exist, so we can address them. 

Since it was first released in 2014, researchers, city planners, city and community leaders, and other stakeholders have used the Child Opportunity Index to identify current inequities in their metros and—most importantly—take steps to address these inequities so that children have more equitable opportunities. 

These solutions are happening across the country. 

For example, the Child Opportunity Index found that Albany, N.Y. ranked worst among the 100 largest metros in terms of the concentration of black children in very low-opportunity neighborhoods, so the City of Albany developed a capital improvement plan to increase access to ADA-compliant and cerebrally challenging parks and playgrounds in neighborhoods that had been long neglected and where predominantly black children live. Read more about Albany's efforts and its impact and hear about it on an NPR segment that ran in December 2019

The City of Chicago used the Child Opportunity Index as a key tool that informed its five-year (2016-2020) strategic plan, Healthy Chicago 2.0: Partnering to Improve Health Equity. The Department and its partners across the city now more effectively create both prevention and intervention strategies to address child health inequities across Chicago’s 77 neighborhoods. For example, some of the city’s health care institutions host job fairs in West Side neighborhoods, where unemployment rates are high and opportunity is very low.

We must invest in improving public policies that address the inequities that the Child Opportunity Index so clearly shows us. 

You can start by understanding what opportunity looks like in your own backyard at


About the Author

Dolores Acevedo-Garcia is professor and director of the Institute for Child, Youth and Family Policy at the Heller School for Social Policy and Management, Brandeis University. Her research focuses on the social determinants of racial/ethnic inequities in health; the role of social policies in reducing those inequities; and the health and wellbeing of children with special needs and their families. Read her full bio


Thu, 23 Jan 2020 14:00:00 -0500 Dolores Acevedo-Garcia Built Environment and Health Health Disparities Social Determinants of Health National <![CDATA[Community Health Resolutions for a New Decade]]>

Five things your community can do to ensure healthier, more equitable 2020s for all.

Group dancing in the street.

Have you noticed that most New Year’s resolutions are about developing healthier lifestyles? Most people want to eat better, exercise more, and find time for themselves. These are all worthy pursuits. But a few weeks into our new decade, for many, these resolutions will start to fade.

At the Robert Wood Johnson Foundation, we believe that good health is significantly determined by forces outside of ourselves—our health is greatly influenced by the places where we live, learn, work, and play. Having opportunities to get a good education and stable employment is foundational to our well being. Access to affordable housing and healthy foods, and feeling safe in our neighborhoods all create opportunities to help us live our healthiest lives.

This made me wonder: why not adopt community-wide New Year resolutions? Because fostering healthier communities sets individuals up for success!

Here’s a look back at some of what research has taught us over the last few years on what works to create healthier, more equitable communities. Let’s set a collective resolution to do what works so that the next decade and the next generation, can be the healthiest possible.

1.   Let a shared vision guide the way forward

A good first step can be prioritizing community needs by inviting everyone in the community to map conditions, strengths, and resources. Question who’s often missing from the table, and why, and find ways to make sure they’re welcome and there are no barriers to them in sharing their voice. See how this happened in Atlantic City or the more rural Columbia River Gorge on the Washington-Oregon border. Use RWJF’s Culture of Health framework to understand what success looks like, and how to get there.

2.   Use big data locally

Local health data can serve as a rallying point to help residents, community leaders, policymakers, and advocates come together to set common goals for improvement and change. We’re seeing a big uptake in U.S. Census tract data that provides a snapshot of life expectancy gaps from one neighborhood to the next and the City Health Dashboard, which provides data on 37 measures of health and well-being for the 500 largest U.S. cities. And the Opportunity Atlas shows how childhood experiences have a big impact on mobility through life. Data like these can be combined with your own local data to give a more complete view of challenges and opportunities for better health—including where there are gaps in opportunity by race, income, and neighborhood. This collection of Better Data for Better Health resources can help.

3.   Practice resiliency

Over the past few years, our nation has witnessed catastrophic natural disasters, and it’s certain that more will hit. Some communities rebound quickly, while others struggle. The difference between them? The preparedness and social cohesion of a community before disaster strikes. Here are ways communities can collectively prepare, withstand, and recover from disasters.

4.   Foster radical collaboration

When sectors come together—even when they seemingly have nothing to do with one another—powerful things can happen. This is also the message from the U.S. Surgeon General when he visited RWJF. At the community level, here is a practical example of how collaborations foster safer spaces for kids. And when it comes to building healthy communities, it takes the power of partnerships and all people uniting to take on challenges and grasp the opportunities.

5.   Lift up marginalized communities

Cultivate equity, diversity, and inclusion by lifting the voices and the truths from marginalized community members. Collect culturally sensitive data. Read about what equity means from the very people who are often discriminated against. By building and sharing stories, perspectives, and data that lead to action, people from all walks of life will have a fairer chance at living safe, healthier, productive lives.

Has your community used these tactics? If so, please share your stories! We also encourage you to keep an eye on Robert Wood Johnson Foundation’s funding opportunities to learn how you can contribute to a growing evidence base on how communities can thrive.


About the Author

Headshot of Oktawai Wojcik

Oktawia Wójcik, senior program officer, joined the Foundation in 2014. A distinguished epidemiologist, Wójcik’s work at RWJF focuses on driving demand for healthy places and practices and building a Culture of Health through research that informs both grantmaking and broader health-related policy and practice. Read her full bio.

Tue, 21 Jan 2020 13:45:00 -0500 Oktawia Wojcik Public and Community Health <![CDATA[New Year, New Nutrition Facts Label]]>

The Nutrition Facts label just got its first big makeover in 20 years. Learn why the updates will be a game-changer for parents and families.

For many of us, January 1 brings New Year’s resolutions—and those resolutions often have something to do with a renewed commitment to better health. As we all know, of course, these resolutions can sometimes lose steam after a few months...or even weeks...or sometimes just days. Fortunately, for those of us who have made commitments to eat healthier in 2020, we’re all getting a hand to ensure those resolutions can stick for the long-term.

We’re all familiar with the Nutrition Facts label. This is the label that appears on billions of food and beverage products, giving us the lowdown on how healthy (or not so healthy) items are based on metrics like calories, fat, sugar, salt, carbohydrates, protein, and various vitamins and minerals. The label has been mandatory under a federal law enacted in 1990.

On January 1, an updated Nutrition Facts label took effect covering all food and beverage products from manufacturers with more than $10 million in sales (most manufacturers with less than $10 million in annual sales get an additional year to comply). This milestone is a long time coming—the previous label had been in effect for 20 years and it’s been six years since the U.S. Food and Drug Administration first proposed updates. RWJF submitted comments in support of the proposed changes, which will empower consumers and families to make healthier purchasing decisions.

Side-By-Side Nutrition Facts Label Comparison

You’ve probably seen the new label already—a number of companies have been using it voluntarily for some time now. But let’s take a closer look at some of the changes that are now mandatory and why they’re so important. The image below has the old label on the left and the new label on the right. Here’s what’s new:

  • New line for added sugars. Several studies have found that overconsumption of added sugars is associated with an increased risk of obesity and related conditions like Type 2 diabetes. As a parent of two young girls, it’s extremely helpful for me to know not only how much added sugar is in a product, but also the percent daily value. In other words, if one serving of a product provides 10 percent of what you should be consuming in a day (the daily value), that’s 10 percent of the maximum total amount of added sugars per day. Fortunately, the new label includes both pieces of information, which is a major help for families.
  • More realistic serving sizes. The Nutrition Facts label has always included serving sizes, and by law they must be based on how much people actually eat. Yet the serving size requirements hadn’t changed since 1993, even though the amount people eat—not to mention obesity rates in the United States—have increased dramatically since then. Serving sizes will now reflect how much people typically eat and drink today, instead of standards from more than 25 years ago. That change will help consumers be much better at estimating what they are actually taking in.
  • Taking care of the math. Under the previous label, people could sometimes mistakenly equate calories in a single serving for  total calories in a package (see this study); people could also incorrectly calculate percent daily value percentage of calories in a single serving (see this study). The updated Nutrition Facts label will help guard against ‘human error’ by literally doing the math for us. For instance, certain products that can be consumed in one or multiple servings—the FDA cites a 24-ounce beverage or a pint of ice cream as examples—will now feature “dual labels” that include the nutrition content of both a single serving as well as the entire package. The last thing busy parents need to do while they are shopping in the grocery store is math; with the updated labels, we will not have to!  
  • Refreshed presentation. Calories, servings per container, and serving size are among the most essential pieces of the Nutrition Facts label. Under the new design, they’re all featured in bigger and bolder font, making it much easier to see.

    The Nutrition Facts label has always been popular among consumers. More than three-quarters of U.S. adults report using the Nutrition Facts label to inform purchasing decisions, with half using it “always” or “most of the time,” while nearly 80 percent use it always or sometimes when purchasing a product for the first time. The new label is even more of a hit—a 2018 poll from the Center for Science in the Public Interest found that nearly 90 percent of Americans support implementation of the updated label. With all these important and helpful changes, it’s easy to see why. And when you consider that the new label will generate up to $78 billion in benefits to consumers over 20 years, according to the FDA, there’s simply no reason not to cheer that this day has come.

    Nutrition education, of course, is just one piece of the puzzle. To really turn the obesity epidemic around, we need all food and beverage manufacturers to commit to making and marketing healthier products, and ensuring those products are affordable and accessible to people in every community. But having information at our disposal to make the healthiest choices possible is also essential, and the Nutrition Facts label will help us do just that. For my family and millions more, this new label means a lot. And that gives us even more reason to celebrate the new year!

    Which of these changes matters most to you and will make the biggest difference for your family?


About the Author

Jamie Bussell

Jamie Bussel, a senior program officer who joined RWJF in 2002, is an inspiring, hands-on leader with extensive experience in developing programs and policies that promote the health of children and families. Read her full bio.

Thu, 9 Jan 2020 10:00:00 -0500 Jamie Bussel Childhood Obesity Public and Community Health National <![CDATA[A Holistic Approach to State Policymaking That Strengthens Families by Advancing Equity]]>

A multi-state laboratory explores the interconnectedness of programs and policies to find ways for all families to thrive.

Kids jumping on an interactive exhibit at a museum.

Families don’t live in silos—one silo for health care, one for child care support, and yet another for food assistance. They need all those things—and more—to build strong and healthy futures for their children.

That’s why at the Robert Wood Johnson Foundation (RWJF), we're supporting a multi-state laboratory for advancing policies that strengthen families across a range of issues. The Center on Budget and Policy Priorities (CBPP) is the hub for this initiative. We are administering $2.65 million in grants to state-based organizations working to ensure that children and families get the support and resources needed to raise healthy kids through policy and systems change.

That means instead of addressing one issue at a time—e.g., child care supports or family leave—an array of issues are being addressed simultaneously. These include child care and family leave and minimum wage and job training and other policies that can help families get ahead. These policy levers are interconnected, playing off each other, which is why a holistic approach is needed to make real progress in families’ lives.

With technical assistance and other support from CBPP, states are working both offense and defense—driving policy conversations on, for example, the need to improve cash supports for working families while defending core safety net programs like SNAP that are under attack in many states.

Working Within an Equity Frame

Equity is key to this work. Every project in the initiative seeks to reduce disparities and structural barriers to opportunity while promoting inclusion across race, ethnicity, gender, socio-economic status, and citizenship lines.

In Virginia, the work of The Commonwealth Institute (TCI) is a good example of a state grantee working to advance equity across multiple issues simultaneously, including paid family and medical leave, a state refundable earned income tax credit (EITC), and a minimum wage raise.

“Virginia has made major strides in recent years in terms of improving health care access through Medicaid expansion, but more needs to be done,” says Laura Goren, TCI’s research director. “We’re looking across the social determinants of health for ways to help stabilize families—such as EITC and other types of income supports, which have big effects on the health of families and children.”

TCI has committed to an explicit focus on equity—addressing race and disparities across all its policy work.

“In Virginia, the conversation is always about race, even if nobody’s saying the word,” Goren says. “If we do not engage openly in that conversation, then we allow it to be used as the silent dog whistle. We are better off if we engage honestly and explicitly on policy changes that we can make to increase opportunities for communities of color and on how that helps all everyday Virginians.”

For example, Virginia’s “upside-down” tax system places unfair burdens on low-income African-American and Latinx families, who wind up paying disproportionately high shares of their income in state and local taxes—a result of Virginia’s sales and excise taxes, property taxes, and relatively flat income tax.

Refundable tax credits for families with low and moderate incomes, like EITC and the Child Tax Credit (CTC) can help correct this unfairness. These credits not only increase incomes and reduce poverty but have been linked to improvements in birth outcomes, maternal health, and, for children’s school achievements.

But Virginia doesn’t have a refundable EITC. As a result, working families in Virginia—and particularly families of color—can’t fully access these benefits or the full value of what they’ve earned.

Family and medical leave is another example. Everyone should be able to care for themselves and their loved ones without risking their jobs or financial wellbeing. But in Virginia, 70 percent of Latinx workers and 60 percent of African-American workers either don’t qualify for unpaid family and medical leave or can’t afford to take it. A statewide paid family and medical leave program would give more families a chance at a healthier and more prosperous future—especially families headed by women of color, who tend to earn low wages while often facing significant caretaking responsibilities.

Context is Key to Understanding Challenges

Freddy Mejia, TCI’s health care policy analyst, says legislators need to understand not only that racial disparities exist but why they exist.

“As a policy organization, it’s easy to just point out the differences in outcomes, but it’s vitally important to explain why those outcomes look they way they do,” he says. “We have to let people know who we’re talking about and the historical and present-day barriers they’re fighting.”

Most of TCI’s work involves educating policymakers, businesses, and other influencers, using its own research and real-life stories of the challenges so many families face.

In addition, TCI is holding a series of listening sessions in communities of color to get a better understanding of their everyday challenges and of the policy changes that would benefit them most. The first session engaged teenagers and young adults in Petersburg, an older, predominantly African-American city that has suffered from disinvestment in recent decades. Health outcomes there are poor and the high school dropout rate is high.

These kinds of meetings help researchers and advocates make the connection between policy and “real life.”

 “That’s hard for us as policy wonks to get sometimes—how to make policy problems that hit close to home feel more relatable to people,” says Goren.

That kind of understanding is also critical to reshaping the narrative about what working families need to live with dignity and set their kids on paths toward healthy and productive lives.

Through the multi-state initiative, RWJF has invested $1.64 million in 21 “rapid response” grantees around the country with resources and intensive, tailored technical assistance on policy opportunities at the state level. In addition, the initiative’s Focus State Fund supports three states—Georgia, Kansas, and New Mexico—with more intensive investments to strengthen their policy, organizing, and advocacy capacity to develop and drive longer-term safety net agendas.

Each state is a different story, with a unique set of challenges and historical and contextual factors. While the overarching goal is to build a Culture of Health where all families can thrive, the strategy and tactics for achieving that goal may differ from state to state.

We hope that, through this initiative, family advocacy groups at the state level can learn from each other’s experiences and successes.

We invite you to share your ideas and lessons learned about how policy and advocacy can advance equity with us.


About the Author

Monica Hobbs Vinluan

Monica Hobbs Vinluan joined RWJF in 2015 as a senior program officer, and has been a passionate professional advocate for health promotion and a distinguished government relations professional on a variety of health and well-being issues for two decades. Read her full bio.

Mon, 16 Dec 2019 13:00:00 -0500 Monica Hobbs Vinluan Child and Family Well-Being Social Determinants of Health