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. Thu, 17 Sep 2020 09:45:00 -0400 en-us Copyright 2000- 2020 RWJF (RWJF) <![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 Health Disparities Disease Prevention and Health Promotion 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[Connecting Systems to Build Health Equity During COVID-19]]>

COVID-19 has magnified vast racial inequities in health, underscoring an urgent need to improve alignment of medical, social and public health systems.  

Demonstration sign.

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. The fact that health outcomes vary by race and other indicators reflect systemic problems in the medical system. But it also reflects how disparate economic and social circumstances are accounted for. If health care is disconnected from social services or the public health system operates in a silo removed from them both, we’re not going to make enough progress.

It’s easy to see what this means on the ground. 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. 

In short, fragmented systems prevent us from treating the whole person. The research base we are building at Systems for Action helps us understand why we need to do better: coordinating the delivery and financing of medical care, social services, and public health saves lives. 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.

There are many tools to align systems—including integrated financing streams, joint governance bodies, inter-organizational agreements, pooled data, and shared workforce models. But we need to learn more about what works best and get that into wider practice.

At Systems for Action, we are supporting projects that test novel ways to repair pervasive fragmentation, including these:

  • In Chicago, the Comprehensive Care, Community, and Culture Program (C4P) pairs high-need patients with a single outpatient and inpatient medical provider. It provides systematic screening for unmet social service needs, access to a community health worker, and community-based arts and culture programming.

  • In Atlanta, Georgia State University researchers plan to test whether improving transportation for low-income patients with diabetes improves access to care while reducing health care costs. These improvements could include vouchers for public transit and ride-share apps, so they can more readily reach medical care and sources of fresh food. The research question: does enhanced mobility improve access to care, diabetes progression, and the use and costs of services? 

  • In Florida and Texas, hospitals and clinics are increasing screenings for social determinants of health so systems can work together to improve health outcomes more equitably. The screenings result in more referrals to nonprofits and other community-based organizations. It’s sometimes unclear the organizations’ capacity to absorb these increased referrals for services. New research sheds light on how to strengthen cross-system integration and expand effective partnerships.

COVID-19 Enters the Equation

These past few extraordinary months have 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. Early findings from that 16-year data set suggest that communities with strong multi-sector networks have fewer COVID-related deaths and lower infection rates. That information should certainly inspire action. 

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.

Some of our projects have pivoted to respond to the pandemic. The CCP project in Chicago, which is a sister program to C4P (described above), designed a communication campaign. It includes town hall meetings, videos and infographics, on how to care for oneself and help protect others during the pandemic. Researchers in Atlanta, as another example, recognize that public transportation may pose high risk for some. They are looking at other ways to meet the needs of diabetic patients. One possible approach is improving access to broadband technology and measuring to see whether it reduces social isolation and the associated health effects.  

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.

Find out how cross-sector collaboration can help communities improve health outcomes for their residents


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, 13 Jul 2020 10:00:00 -0400 Chris Lyttle Health Disparities Disease Prevention and Health Promotion <![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 Child and Family Well-Being Disease Prevention and Health Promotion 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 all drug, prostitution, and even public urination 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 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 Public and Community 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 more about the RWJF Award for Health Equity.


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 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.

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[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.

Note: This piece was originally published in February 2018.

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 communities across the nation that are striving to shape these new stories of hope.

One such story is unfolding in Louisville, Ky., where 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 some of Louisville’s most 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 Louisville’s 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.

Wed, 5 Feb 2020 16:00:00 -0500 Dwayne Proctor Health Disparities Social Determinants of Health <![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 Social Determinants of Health Child and Family Well-Being Health Disparities 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 <![CDATA[How Bitter Melon Improved Housing in Providence, Rhode Island]]>

Many housing projects focus exclusively on putting a roof over peoples’ heads. We sought a broader approach that integrates cultural values into kitchens, homes and neighborhoods.

Illustration of a neighborhood.

The literal translation of the word “sankofa,” from the Akan tribe in Ghana, means "go back and fetch it.” Figuratively, it captures an important belief in Akan culture: While the future brings new learning, knowledge from the past must not be forgotten.

This principle guided our efforts to transform 10 formerly blighted lots into a vibrant community of 50 modern “green” apartments in Providence, Rhode Island’s diverse West End community. The $13.5 million development is connected to 30,000 square feet of community garden space. Single fathers come with sons, pastors come with children and people sit under the garden’s pergola, which was built by local youth volunteers. It is, as one article put it, a “beehive of activity.”

A Holistic Approach to Health

We’ve come a long way from where we started nearly a decade ago. Then, residents of the West Elmwood Housing Development Corporation (WEHDC)—more than a third of whom are immigrants and refugees from Central America, West Africa and Southeast Asia—didn’t have much access to fresh, high quality, affordable food that both supported their overall well-being and allowed them to preserve their cultural values.

Food has a direct impact on health and is a critical component of cultural heritage within the diverse community. But WEHDC residents had trouble finding fresh produce native to their countries—places like Liberia, Nigeria, the Dominican Republic and Haiti. Instead, they relied on what canned goods they could find and resorted to high-fat, low-nutrition foods typical of the standard American diet, like hamburgers, pizza and so on, or traveled long distances to access foods native to their culture.

Neighborhood residents faced other systemic barriers to health and well-being: high crime rates, underperforming schools, large tracts of vacant lots and little access to green space, safe, walkable paths or community gathering spaces. The health of the community was in decline, with high rates of obesity, diabetes and other ills. Immigrants who arrived here in good health grew less healthy with each passing month.

Where you live matters to your health. RWJF President and CEO Rich Besser discusses how housing is linked to health and equity in America. Read the 2019 Annual Message

Community members raised concerns. We at the WEHDC listened—and began a coordinated effort to bring about structural change in housing, food access and the environment.

In 2011, we partnered with community leaders, scholars, nutrition and gardening experts and others to explore how to improve health and advance equity in the community. We conducted surveys, focus groups and interviews with members of the community—sometimes in their native languages—to learn how to best support health in the community, and we assessed offerings at local markets.

Most housing projects only emphasize housing—the more units the better. But we realized we needed to go beyond the number of apartments we build and pursue a broader approach to health and well-being—one that integrates people’s cultural values into their kitchens, homes and neighborhoods.

In addition to apartments, we imagined a housing development with community spaces where tenants could come together and build community ties; a community garden, with raised beds, a tree nursery and a greenhouse, where residents could grow food and enjoy nature; and a weekly market with affordable, culturally relevant foods that celebrated cultures around the world.

In our view, this initiative fit WEHDC’s motto and mission perfectly: We build homes, we build community, we build lives.

Still, it wasn’t an easy sell. We had to bring two separate and often siloed social movements together—those advocating for affordable housing and those advocating for urban green space. And we had to persuade funders to set aside a large swath of prime real estate to use as garden space rather than for more apartments.

With the help of partners in academia and the nonprofit sector, we convinced funders that a holistic project such as this would be greater than the sum of its parts: Not only would it improve public health and narrow health disparities, but it would expand economic opportunity and strengthen community ties.

Building Cultural Capital

In 2016, we completed the project. Housing units are now connected to community gardens, where tenants and other members of the neighborhood gather to grow crops, socialize and rest. They grow fruits and vegetables that are otherwise hard to find, like bitter melon, sweet potato greens, water spinach, amaranth, Asian corn and more.

They can also buy such foods at the local weekly market and cook them in the local community kitchen. As a result, they’re able to get the ingredients they need to prepare the healthy meals they love, and they don’t have to travel far to get them. Nor do they have to pay an arm and a leg for bitter ball or some other “exotic” item at a boutique grocery.

The project has blossomed in other ways too. In addition to selling international foods, the weekly “world market” features live music, hand-made goods, cooking demonstrations and exercise activities that cater to different cultural backgrounds. Volunteers and staff at the community development corporation teach financial literacy and food preparation to young mothers and others and support local food and social impact entrepreneurs. And vendors at our microfarm grow and sell produce, bringing economic vitality into the low-income neighborhood.

Our next project is a café that will provide a much-needed space to gather and do business and, at the same time, create jobs in the community and draw dollars into the neighborhood. The café was suggested to us by a member who was frustrated that he had to leave his own neighborhood to network with potential clients. He saw it as a missed opportunity to circulate dollars within the community. A professional in the food industry volunteered to help put together a business plan. Two years later, with the backing of a national funding partner and the local municipality, the Sankofa Café site is now under environmental review, with  construction slated to begin soon.

The impact of the Sankofa initiative has been profound. Easy access to healthy, culturally appropriate food has made a big difference in the health of the community, where one third of residents live below the poverty line. It has also built cultural capital and created a sense of community pride. The neighborhood has turned into a cultural mecca, and demand for more housing is high. Residents lobby their elected officials to continue supporting our services. Once regarded as a pass-through, the West End is now a destination.

Learn about RWJF Award for Health Equity program and meet the 2018 awardees.

The project is also drawing wider attention. In 2017, it won the Smart Growth Award from GrowSmartRI, and we are so proud that the National Civic League nominated us for an RWJF Award for Health Equity, which we won in 2018. These awards helped us spread the word about our holistic approach and legitimized our dream. We believe it is a model not only for our city but for the nation: It shows how we can create spaces that cultivate health and well-being, civic engagement and community pride.

National Civic League President Doug Linkhart says Sankofa “truly embodies” the spirit of the Health Equity Award, which celebrates systems change at the local level. “By engaging local residents, the project attracts the active participation of people in the community to build both physical and mental health, as residents gain access to healthy food and a social environment that encourages communication.”

We couldn’t agree more. We named this project Sankofa because we wanted to pay homage to the cultural needs of the community and the importance of drawing on the past to make progress in the future. We chose this word because it underscores our belief that culture—reflected in housing, in food, in music and more—is an essential ingredient in creating a culture of health, both here in Providence and around the world.

Learn more about the RWJF Award for Health Equity


About the Authors

Sharon Conard-Wells is executive director of the West Elmwood Housing Development Corporation, a nonprofit community development corporation.

Angela Bannerman Ankoma, executive vice president at United Way of Rhode Island, is immediate past president of the WEHDC and sits on its board of directors.

Mon, 9 Dec 2019 09:45:00 -0500 Sharon Conard-Wells Built Environment and Health Health Disparities National Rhode Island (RI) NE <![CDATA[Disability Inclusion: Shedding Light on an Urgent Health Equity Issue]]>

We cannot achieve a Culture of Health until our nation is fully inclusive. Yet systemic factors prevent many people with disabilities from thriving.

Next year will mark 30 years since the Americans with Disabilities Act (ADA) became federal law—first of its kind legislation that outlawed discrimination against people living with physical or mental disabilities. It was a culmination of decades of challenging societal barriers that limited access and full participation of people with disabilities.

And yet in spite of the ADA’s passage, we still have a long way to go before society is fully inclusive of the 61 million people living in this country with some type of disability. Judy Heumann understands that while the ADA is important, in practice, “we’re not done yet." She is currently a leading advocate for disability inclusion and has been an advisor to institutions like the U.S. State Department, the World Bank, and the Ford Foundation. As a child, Judy was barred from going to school because she used a wheelchair. Years later, she was denied a teaching license for the same reason. These obstacles to education and employment are just two of many barriers that stand in the way of inclusion. Judy understood the need for strong advocacy in partnership with others experiencing continuous discrimination because of their disabilities. This discrimination is also often compounded by class, race, ethnicity, religion, gender, age, or sexual orientation among other characteristics.

I had the chance to personally meet Judy at the first convening of the Presidents’ Council on Disability Inclusion in Philanthropy this year. Darren Walker of the Ford Foundation and I are co-chairing this group of 13 other foundation executives to champion inclusion of people with disabilities in our own institutions and within philanthropy. We have a lot to learn from Judy and many others who have challenged systems and paved the way to making our nation more inclusive.

Here at RWJF, we know that we cannot achieve a Culture of Health until everyone, including those living with disabilities, has a fair and just opportunity to achieve their best health. Yet these opportunities are impeded by many systemic factors. In this post, we take a closer look at three examples of glaring inequities that undermine the health and well-being of people with disabilities before exploring some efforts underway to address them:

1.  Barriers in health care leave the needs of people with disabilities unmet.

As a group, people with disabilities fare far worse than their nondisabled counterparts across a broad range of health indicators and social determinants of health. For example:

  • Adults with disabilities are 4 times more likely to report their health to be less than optimal compared to those without disabilities.
  • The Centers for Disease Control and Prevention reports that one in three people ages 18 to 44 with disabilities did not have a usual health care provider and had a health care need that went unmet in the last year due to cost.

Even visiting a health care provider often poses a variety of hurdles. Exam tables and chairs are frequently not adjustable, and scales fail to accommodate wheelchairs or require a step up. Visually impaired people may not be able to access patient portals, and care after a medical visit may be hindered by materials that are not available in plain language.

These inequities and disparities are worsened by inadequate training among health care providers in ensuring that patients with disabilities receive appropriate and effective care. Furthermore, many have reported a lack of dignity or respect shown by staff during appointments which adds to a psychological toll of being treated as “other” by the medical system. Disability awareness and competency training of the health care workforce would improve overall care and services for those with disabilities.

2.  Having a disability means you’re twice as likely to live in poverty.

We know that poverty creates greater obstacles to achieving health. Having a disability means you’re twice as likely to live in poverty as someone without a disability. And that poverty can be persistent—lasting over 24 months.

Reasons for this include lack of fair access to education, jobs, and housing. Before the ADA, students with disabilities were excluded from many educational institutions and opportunities. Still today, many are placed in alternative diploma programs, limiting their options for higher education and employment. In 2015, just 17 percent of people with a disability had completed a bachelor’s degree, compared to 35 percent of those without a disability.

And while more education often leads to higher paying jobs, in 2018, the unemployment rate for persons with a disability was more than twice the rate for those with no disability that year, according to the U.S. Bureau of Labor Statistics.

3.  Representation matters but is lacking.

Health equity cannot be achieved without actual lived experiences informing and advancing policies, regulations, laws and initiatives that address disability rights, accessibility and inclusion. And yet people with disabilities face barriers that make voting, let alone running for office, challenging. Problems range from the misperception and misplaced stigma that they are incapable, to financial challenges, and even physical limitations. Public attitudes may be starting to change, however. At one time, President Franklin Roosevelt hid his wheelchair. Today, Texas Governor Greg Abbott highlights his.

Another challenge is the misconception that people living with disabilities are a burden, not an asset. Yet people with disabilities are doctors, attorneys, teachers, artists, and productive workers in multiple fields. Both the health care and philanthropic fields have much to learn from the disability rights community and we should be engaging them in conversations, research and equity initiatives.

Working Together to Explore and Advance Solutions

Solutions begin with ensuring that the places where we live, learn, work and play, do a better job of including people with disabilities. There are efforts throughout the nation that provide hope and inspiration:

Work is being done to make private spaces more accessible. Sarah Szanton, PhD, ANP, FAAN, whose career was boosted by an RWJF fellowship, directs the Community Aging in Place—Advancing Better Living for Elders (CAPABLE) program. CAPABLE combines handyman services with nursing and occupational therapy to find solutions that permit low-income seniors to age safely in their homes and neighborhoods. Preliminary findings show that 80 percent of program participants, many of whom live with chronic physical, cognitive, and other disabilities, experienced improved quality of life and health.

Efforts exist to end social exclusion and build accessible, healthy public spaces. Building inclusive playgrounds and parks designed for children of all abilities is on the rise. Inclusive playgrounds and parks encourage physical, social, and sensory play while creating connections among children of different abilities. For instance, in San Antonio, children with disabilities play alongside others in a water environment. The creator of the first fully accessible water park undertook the project when he couldn’t find an inclusive place where his autistic daughter felt welcomed and others felt comfortable interacting with her. He brought together parents, therapists, doctors, and both people with and without disabilities to help plan facilities that accommodate a range of needs. He views Morgan’s Wonderland and Inspiration Island as places of inclusion “where everyone can participate together.” Visitors have come from 67 countries and every state.

Steps are being taken to train health care providers. This is a critical step in addressing the health care inequities people with disabilities face. RWJF Community Health Leader award winner Deb Jastrebski created Practice Without Pressure to ease the stress of medical visits for patients with disabilities. Jastrebski’s son who has Down Syndrome feared doctors and dentists. To help, she created a model of care delivery that uses lectures, role-playing, and disability-specific information to help providers offer care in ways that eliminate the need for sedation and restraint for patients with disabilities. Healthy People 2020 also includes a health objective that calls for increasing the number of public health programs with a course on disability.

When it comes to representation we know we must do more. At RWJF, we acknowledge that philanthropy has fallen short in being fully inclusive which is unacceptable. That’s why the Presidents’ Council on Disability Inclusion in Philanthropy has created a fund to be used for disability inclusion over the next five years. Members of this group are at different stages of the journey toward true inclusion. But we are united in our commitment to learn together and make the changes needed to truly address systemic inequities in our communities. We believe philanthropy, in collaboration with movement leaders, can catalyze a cultural shift that goes beyond compliance and access, aiming squarely at true equity. And imagine the possibilities if our nation was fully accessible so that everyone has a chance to reach their greatest potential.

As a first step, we are listening because we have a lot to learn. We invite your ideas on what else philanthropy should be doing to improve access and inclusion for people with disabilities.


About the Author

Richard Besser, MD, staff photograph

Richard Besser, MD, is president and CEO of the Robert Wood Johnson Foundation, a position he assumed in April 2017. Besser is the former acting director for the Centers for Disease Control and Prevention, and ABC News’  former chief health and medical editor. Read his full bio.

Mon, 2 Dec 2019 11:00:00 -0500 Richard Besser Health Disparities National <![CDATA[Small Business, Big Impact: The Untapped Opportunity to Advance Health and Equity]]>

New report shows that small businesses create jobs and wealth and are imperative to healthy, thriving and equitable communities. Small businesses represent tremendous untapped potential to promote health equity and create opportunities for everyone to live healthier lives.

Four women laugh around a table in a coffee shop.

On a recent trip to Ferguson, Missouri, I visited a locally owned coffee shop that was filled with people working on laptops, visiting with friends, reading and studying. The walls were covered in fliers with community news and people were connected with neighbors. Sound familiar? It’s like thousands of other coffee shops. Across America, there are businesses like these where the owners and employees have their fingers on the pulse of what’s going on in the neighborhood.  

Small businesses of all types are in just about every community in the United States—in fact, companies with fewer than 100 employees make up 98 percent of all businesses in America and more than 43 percent are in low-income communities. They are helping to create healthy, equitable communities through the assets, income and jobs they create. People walk in their doors every day and share information or ask for advice—from barber shops and hair salons, to hardware stores and corner stores, to accounting firms and yoga studios.  

For those of us working to create a Culture of Health and advance equity, small businesses and their leaders could be ideal partners—so why don’t we engage them more often? 

Our team at Public Private Strategies spent a year interviewing almost 100 small business owners and their associations, along with leaders from philanthropy, community development, economic development, advocacy, and the public sector to explore this.

Growth Rate in Business Starts infographic.

What we found? Tremendous, untapped potential:

  1. Small businesses create jobs, build wealth and help close racial and gender wealth gaps, especially in communities where opportunities have been limited historically. Although the majority of business owners today are white, small business startup rates are highest among black and Latino business owners. And while more men own businesses than women, about one in four businesses is women-owned and the share is growing rapidly, especially among black and Latina women. Success stories from small business are inspiring millennials and other younger individuals to increasingly pursue entrepreneurial paths.
  2. Small businesses are the 2nd most trusted institution in America. In general, small business owners think deeply about community needs, have strong networks and are committed to the places they do business. Employees rely on them as trusted sources of information and many small business owners treat their employees like family, far surpassing the typical employer-employee relationship. Small businesses often provide employment for those who may otherwise struggle to secure good jobs: the formerly incarcerated, immigrants, seniors and others. And their leaders are already sharing knowledge on things like SNAP benefits, EITC, or tuition assistance. As one interviewee told us, “Small business owners can educate employees and help guide decision-making when laws are passed.”
  3. Small business owners can also play critical roles in advancing policy that’s good for business and for their employees. For example, in San Francisco, Los Angeles, and Washington, D.C., small businesses are working with community leaders to support innovative policies such as rent stabilization grants and other real estate financing so small businesses can stay in communities to ensure that jobs aren’t priced out of gentrifying neighborhoods.

Small business owners and employees represent a broad cross-section of American society who depend on and contribute directly and indirectly to health equity and healthy communities. Yet most calls for business to promote health improvements for employees, customers and communities focus on large business. Giving small businesses a seat at the table and asking them what their communities need to improve health and well-being offers a fresh perspective and new approach (yet it’s important to recognize that as entrepreneurs, they are often stretched thin and pressed for time).  

As partners to government, philanthropy, and community development, leaders of small businesses represent tremendous untapped potential to help promote healthy communities and health equity.

Read the full report to learn more about the power of small business and how you can help elevate this untapped partner to advance health, equity, and a more inclusive economy. 


Rhett Buttle is an expert working at the nexus of policy and market change. He is the founder of Public Private Strategies and NextGen Chamber of Commerce. Rhett previously served as a private sector advisor to the Secretary of Health and Human Services and The White House Business Council. He is a Senior Fellow at the Aspen Institute Financial Security Program.

Mon, 25 Nov 2019 10:00:00 -0500 Rhett Buttle Public and Community Health National <![CDATA[It’s Time to Connect Rural Health Equity with Community and Economic Development]]>

It’s time to think differently about investing in rural America and the way we approach health and equity across its diverse communities. New research and resources show the critical connection between health, rural community and economic development.

Farmland and street sign.

Thursday, November 21, was National Rural Health Day. You might expect the paragraphs that follow to be about hospital closures or opioids, struggling dairy farmers and falling life expectancy among rural women. These phenomena are true, so we could do just that. However, we want to challenge conventional wisdom and prompt fresh thinking about rural America, the drivers of health, and the role of community and economic development in both. From what we are learning, this broader lens is central to realizing health equity and a better rural futures.

In our predominantly urban nation, the words “rural America” often conjure images of farm country, small towns and white people living in places that once boomed and have since busted. But the real rural America is far more diverse and complex. Dr. Veronica Womack, a political scientist, advocate for black farmers, and RWJF Interdisciplinary Research Leader, whose work has helped bring new research and investment to her rural region, is case-in-point. Womack grew up in Greenville, Alabama—population 8,000—which is part of the “Black Belt,” a largely rural region in the coastal low-land south where black folks outnumber white folks. Economic opportunity is hard to come by—and health suffers as a result—in this region where poverty, racist policies and discrimination along with systemic disinvestment persist.

All the same, Dr. Womak grew up with the idea that you give of what you have, to help those around you. No matter if what you have is not much. In Dr. Womak’s words: “If you’re not willing to share it and work for the betterment of the community, then you know, why even have it?” Womak’s experience growing up with her single mom, who worked as a nurse and spent her weekends bringing medicine and other care to elders around the community, didn’t jive with how the nation viewed her region and her people. Where others saw deficits, Womak could see assets—people willing to work hard and support each other, strong ties, and innovative ideas to get things done.

Dr. Womak was featured in the opening episode of The Homecomers, a new podcast from Sarah Smarsh, journalist and author of Heartland: A Memoir of Working Hard and Being Broke in the Richest Country on Earth. Smarsh fills her new podcast with voices of people “fighting for the place that feels like home.” If we better understand rural places and their diversity, complexity, strength, innovation, and resilience, perhaps we can be better equipped to invest in their future leveraging each community’s unique assets to realize health equity and create economic opportunity for more people for generations to come.

“Rural America” is Not a Monolith

Here are two more projects that reveal a truer picture of “rural America” and what’s top of mind for the people who live there.

  • The American Communities Project’s “A New Portrait of Rural America,” helps to shed light on the diversity of places we call “Rural America," which includes Native American Lands, the African American South, Aging Farmlands and more. History, geography, demographics, economy, and policies—good and bad—all play a role in the differences between these places. For example, the median income for rural counties analyzed in this report—$46,600—is lower than the national median of $57,600. But these disparities mask some deeper complexities of race, class and place. In St. Francis County, Arkansas, a part of the African American South in this report, the median household income for blacks is only about $28,300, while the figure for whites is more than $10,000 higher at $39,500. While some rural places are thriving, others have experienced radical economic transition or decades of disinvestment; all too often these places are also low-income communities and communities of color where discrimination and lack of economic opportunity are compounding factors that persist. 

  • The Life in Rural America polls, produced in partnership with the Harvard T.H. Chan School of Public Health and NPR, similarly revealed complex rural realities. The poll also provides disaggregated data by race and place—for example, while drug addiction or abuse is the biggest overall community problem cited by whites living in rural America (27%), economic concerns are the most cited problem by African Americans (24%) and Latinos (22%).

Responsibility for Improving Health and Healthy Equity is Broadly Shared

There is more to health than health care. Whether our towns are walkable, the water is clean, residents are connected to one another and the local economy works for everyone—all of this has an impact on our opportunity to be healthy. Since health outcomes are closely tied to social, economic and physical conditions where we live as well as to income, wealth and education, health disparities are numerous and often intertwined with race, class and place. This means architects, economic development directors, city planners, city managers, county commissioners, businesses and civic-sector organizations of all stripes all play a role in creating opportunities for health—in rural places and across the country.

The Role of Community and Economic Development in Realizing Health Equity

If we see rural places in all their diversity and complexity and we see responsibility for realizing positive health outcomes as shared, then rural community and economic development becomes central to realizing health equity. Health outcomes in rural places lag less because of challenges in health care or individual behaviors than because of transformation in technology and the structure of the economy, systemic disinvestment, racism, structural inequalities and an outdated approach to economic development.

Aerial image of a rural town.

There is an urgent need to modernize policy and spread best practices proven to create vibrant and sustainable communities that enable people to reach their full potential and live healthy lives. We see signs of hope in communities across the country where innovation is underway and two specific projects provide insight on what’s working:

  • Rural Development Hubs: Strengthening America’s Rural Innovation Infrastructure, by the Aspen Institute Community Strategies Group, looks at the role of a specific set of rural and regional intermediary organizations—Rural Development Hubs—and finds them to be both at the heart of positive community and economic development practice and also an essential entry point for those looking to work or invest in rural places. The report finds Hubs to be the main players “doing economic development differently.” In addition to helpful primers on rural America and rural history, the report explains the importance of these civic-sector actors, what they do that sets them apart and articulates some of the challenges that Hubs and other rural institutions face that can stymie success. The report includes a set of recommendations for improving rural development policy and practice and realizing a better rural America that range from rethinking ‘impact’ to overhauling outdated federal policies.
  • Partners for Rural Transformation is a group of six trail-blazing regional organizations (great examples of the Rural Development Hubs mentioned above) focused on eliminating persistent poverty and advancing prosperity. Their paper, Transforming Persistent Poverty in America: How Community Development Financial Institutions Drive Economic Opportunity, highlights the ways in which race, place, and persistent poverty are inextricably linked; and how community development is strengthening local economies, generating wealth that sticks, and building power among those living in some of the most disinvested parts of our country. The report calls for increased philanthropic, bank, and federal investments in rural persistent poverty regions across our nation.

This year, in honor of National Rural Health Day, question any preconceived notions you may have about rural America and whose responsibility it is to improve health in America. Then consider how rural community and economic development policy and practice are essential to realizing health equity. Ready for action? Dive into the projects and resources we’ve highlighted in this blog and hone in on their recommendations for public, private and civic sector actors. For more ideas and a truer picture of the range of place, culture, people and economy in rural America, try outlets like the Daily Yonder, America’s Rural Opportunity Series of talks, Indian Country Today, and rural stories from the Solutions Journalism Network, and RWJF’s rural health page.

We hope you’ll continue to follow our work as it evolves—and keep an eye on new learning and coordination efforts across those working nationally and regionally to advance social and economic conditions in rural communities, which ultimately lead to better health and well-being. Those efforts will be led by the Aspen Institute Community Strategies Group, working closely with RWJF and the University of Wisconsin Population Health Institute.


About the Authors

Katrina Badger, MPH, MSW, is a program officer with the Robert Wood Johnson Foundation focusing on efforts supporting work building healthy, equitable communities. 

Katharine Ferguson, MPA, is associate director of the Aspen Institute Community Strategies Group (CSG) and director of CSG’s Regional and Rural Development Initiatives.

Thu, 14 Nov 2019 14:00:00 -0500 Katrina Badger Public and Community Health National <![CDATA[Listening to Families and Communities to Address Childhood Obesity]]>

Renee Boynton-Jarrett, MD, ScD, believes that children’s health and well-being are intricately and inextricably connected to their family and community.

Children and their parents participate in a school activity.

When a mother walked into my health clinic five years ago with her 13-year-old daughter, she wanted to know why her daughter had gained a significant amount of weight in a matter of months. She was concerned an underlying medical condition might have caused the sudden spike her daughter’s weight. I was concerned as well. Childhood obesity is an epidemic that affects far too many children and it is linked to other serious, chronic health conditions, including high blood pressure, type 2 diabetes, heart disease, and asthma.

I knew I would run tests and order blood work, but I also wanted to know what factors in her social world could have sparked the weight change. We sat down together to look at her daughter’s growth chart, see when the growth trajectory started to accelerate, and what could have been happening then. “Did anything change in your family? Do you recall anything that happened around that time?”

The mom suddenly realized that the changes started shortly after the girl’s father was incarcerated. That’s information I could not have gotten from a blood test. Nor if I had rattled off recommendations without first sitting down to listen.

Understanding Impacts of Adverse Early Life Experiences

I began my career as a primary care pediatrician. I also trained as an epidemiologist with a focus on social factors in community environments that can contribute to health and well-being. As a result, my perspective on what impacts health and strategies to improve it that go beyond clinical treatment and prescriptions; we must also consider the environments where children learn and play, and structural conditions that impact opportunities to achieve health. Through my work in public health and primary care, I know that children who are exposed daily to struggles like food insecurity, unstable housing, and violence in the home or community face long-term impacts on their health.

The experience of the young girl in Boston was not unlike countless of others’ experiences across the United States. Nationwide, 4.8 million young people ages 10 to 17 have obesity, according to data released by National Survey of Children’s Health and highlighted in the State of Childhood Obesity report.

Image of Renee Boynton-Jarrett. Dr. Renee Boynton-Jarrett at Boston Medical Center’s rooftop farm.

The national rate of obesity for young people ages 10 to 17 is 15.3 percent, a rate that has remained fairly steady for the past few years. Rates among black and Hispanic youth (22.2 percent and 19.0 percent, respectively) are significantly higher than for white and Asian youth (11.8 percent and 7.3 percent, respectively). These racial and ethnic disparities have persisted over time and are demonstrated by other major obesity surveys.

Helping children maintain a healthy weight from an early age is essential to preventing a wide range of health problems, particularly for communities of color. But obesity is complex. It can’t be solved reactively or prevented through health care interventions alone. My philosophy around keeping children and families healthy has changed from playing a traditional educator/practitioner role to more of a listener/facilitator role where I work collaboratively with patients and families. They have their own insights, are familiar with neighborhood conditions and resources, and know what goals and solutions are feasible for them.

Adverse childhood experiences and socially adverse neighborhood conditions are not one dimensional. Social adversities can impact biology, behavior, development, and health. For example, addressing food insecurity offers a significant opportunity to prevent obesity. The population of children who experience food insecurity is also the population of children most likely to experience obesity or a less than optimal weight or growth trajectory, but approaches to end hunger and approaches to prevent obesity operate independently of each other.

Boston’s Community-Based Approach to Address Adverse Neighborhood Conditions

In Boston, we work collaboratively to break down these silos and address issues like food insecurity more holistically and at the community level. For example, at Boston Medical Center in 2010, I founded the Vital Village Community Engagement Network, a grassroots network of residents and organizations committed to maximizing child, family, and community well-being, to build the capacity of communities to work collectively with caregivers and residents to promote well-being. The Vital Village Data Workgroup, a group of resident leaders, recently developed the concept and designed the Abundance app, which enables people in the Boston community to map the closest food resources. It’s a way of identifying food deserts as a first step in addressing food insecurity in that particular area.

I believe that we have to not only listen to our communities, but also engage them in shared decision-making, governance, and leadership in promoting well-being and health. We also have to think about integrating policies and collaborating across sectors—including education, health, crime, housing, and the built environment—to truly create an environment that supports healthy growth and development for kids.

Learn more about my perspective and how the city of Boston is helping to ensure that more children have consistent access to healthy foods from the earliest days of life to help them grow up at a healthy weight at


About the Author

Renee Boynton-Jarrett, MD, ScD, is a pediatrician and social epidemiologist. Her work focuses on the role of early-life adversities as life course social determinants of health.


Thu, 31 Oct 2019 14:00:00 -0400 Renee Boynton-Jarrett Childhood Obesity Early Childhood National <![CDATA[Researchers: How to Leverage Personal Data and Still Protect Privacy]]>

The popularity of app-based research studies has soared, although plunging public trust in commercial technology companies could dampen enthusiasm and upend science if researchers don’t act quickly. 

A patient goes over app-based data with her clinician.

Nefarious cases of data sharing and data breaches are in the headlines on an uncomfortably regular basis. One recent exposé found period tracking apps were sending extremely personal information about millions of women directly to Facebook without their knowledge. This comes in conjunction with all-too-frequent corporate hacks—from credit cards to electronic health records and more—that leave consumers vulnerable and scrambling to reset passwords and freeze accounts. 

It’s a constant drumbeat that is feeding a climate of concern around our data: who has it, how safe it is, what it is being used for. 

Against this tumultuous backdrop, researchers around the world are launching studies that rely on smart phone apps and other digital devices to collect data. The hope is that these digital tools—and the data we provide through them—will enable more people to participate in studies and help accelerate medical discovery. But if researchers don’t act quickly, this turmoil around data privacy could upend their work.

There’s an App for That

Smart phones and devices such as the Apple Watch are proving to be valuable data collection tools for researchers. They’re enabling easy collection of information from people as they go about their lives, offering insight far beyond what’s reported in the doctor’s office. And they do this data collection at a fraction of the cost of more traditional studies.

A great example of this is mPower, an app-based study of Parkinson’s disease which was built with Apple’s ResearchKit. People make use of the phone’s sensors to track their symptoms—from memory to speech to balance.

More than 16,000 people are enrolled in the app study, sharing millions of data points on the daily changes in symptoms and effects of medication for people with Parkinson’s. This staggering amount of data is a stark contrast to most Parkinson’s studies which typically rely on data from fewer than 100 people.

Excited by their potential to help us understand more about health and speed up progress toward better treatments and cures, RWJF funded a number of projects beginning in 2013 that enabled people to contribute their data to research efforts.

Privacy Concerns Could Prove to Be a Major Stumbling Block for Research

Judging by the thousands of people who have signed up to participate, app-based studies are particularly attractive, though current events are creating new challenges for this young field. 

In today’s environment, people may think twice or thrice before signing up for a study that uses an app on their phone to collect data from them. In fact, some researchers say that prospective research subjects have been “scared off” by all the recent data breaches and violations of privacy.

Even when researchers have successfully recruited people to contribute data, the portion who drop out has been staggering—as high as nine out of 10. This should not be a total surprise. Marketing research shows the longer people own activity trackers, the less they use them and fully one-third have stopped using them altogether by six months. Add to that the cloud of mistrust and repeated assaults on privacy, it’s easy to imagine why there’s so much drop off.

Three Things That Researchers Can Do Now

So what can researchers do?

Conversations with leading app-based scientists suggests three things researchers can do to ensure their studies are not thwarted by privacy concerns:

  1. Give back. Getting people comfortable with sharing their data requires more than a simple tech fix. The relationship between the researcher and the participant is important. Depending entirely upon app interactions to cement long-term engagement has its limits. One way to both get around this, and to build trust, is to give people back the knowledge that you’ve gleaned from their data. But this doesn’t mean send them the study results or an excel chart full of data points or wait months for a research study to be published before you share any feedback with them. When you’re running an app-based study, the terms of engagement with participants need to change. People have expectations based on their experiences with commercial apps, where feedback is instant. So should app-based studies. From the start, apps should be designed to collect and share data that’s meaningful to the participants as well as data that’s meaningful to researchers. These have to be first-order thoughts, not afterthoughts.
  2. Hand over control. Commercial health apps routinely share users’ personal data often without their knowledge. Yet, researchers are finding that if you simply ask, many people are willing to have their data shared with a third party, especially when they control who their data is shared with. Take the mPower app: participants are able to choose whether to share their data with researchers associated with mPower, or to share it with qualified researchers worldwide. So far, more than 75 percent of mPower participants have chosen to share their data broadly. Of course handing over control over data-sharing decisions means more work for researchers. But the trade-off for science is worth it.

    When crafting data-sharing options, be transparent about what these options really mean. Don’t cloak them in jargon, promising to “de-identify” and “anonymize,” or only use “aggregate data” without fully explaining all of the implications. We’ve heard of organizations who describe the mere removal of an individual’s name or email address as ‘de-identification,’ despite retaining other highly identifying elements such as birthdate, profile photo or personal biography; if that’s the data you’re planning to share, you must alert people and give them the option to say no.
  1. Security, security, security. Many researchers have simply relied on copying industry approaches to managing data, which could leave people vulnerable to security breaches and the risk of sensitive information about their health falling into unwanted hands. Getting it right isn’t easy, but it can be done: encryption, firewalls, multi-layered surveillance, and identity verification systems are all established methods to keep user information secure and prevent unauthorized use of data. Researchers sometimes lack the technical knowledge needed to build such protections into the architecture of smartphone apps and their corresponding research networks, and cost can certainly be a deterrent. But the investment must be made.

This is a new way of thinking for most researchers and they’ll need to develop some new muscles. CORE is a platform where researchers can learn from one another about what is working and what is not in this still-young world of digital research.

Finally, a word of advice for consumers: When signing up for an app-based study or downloading a health app, be aware of the privacy pitfalls. Pay close attention to what you’re giving the app access to; check reviews and ratings and seek alternatives if you have any cause for concern.

Read the report Reinventing Discovery to learn more about these challenges and how researchers are responding.  

And if you’re already exploring how to make data sharing more meaningful for consumers and research participants, share your thoughts below.


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.

Thu, 24 Oct 2019 14:00:00 -0400 Paul Tarini Health Care Quality and Value National <![CDATA[How Communities are Promoting Health and Responding to Climate Change]]>

Across the United States, people are recognizing that climate change is a major threat to any vision of a healthy future. They are responding by developing solutions to not only avoid the health harms from climate change, but also actively improve health and limit climate change.

A city park offers a walking path for the community.

In Austin, Texas, city officials have grown increasingly concerned about their residents enduring more days with extreme heat. In particular, they worry that extreme heat events prevent young people from getting physical activity and harm people’s overall well-being.  

Austin leaders decided to respond by increasing green space and tree shade around some of the city’s public schools, especially those that largely serve students of color or those in lower-income neighborhoods. More trees create cooler spaces for physical activity. They also help address climate change by decreasing the need for air conditioning, which use about 6 percent of all electricity produced in the United States. Trees are effective because green space and shade reduce temperatures over heat-storing concrete.

At first glance, planting some trees may seem like a limited and short-term approach in the face of a changing global climate. Trees, however, are an important climate solution because they remove carbon from the atmosphere. Increasing levels of carbon in the atmosphere causes climate change. We need more trees—lots more.

The effort in Austin is just one of the countless creative solutions that communities across the United States are implementing—from Portland to rural Alaska to parts of the Navajo nation.  

How We’re Learning from Solutions for Health and Climate Change in Communities

Through its Health and Climate Solutions program, the Robert Wood Johnson Foundation (RWJF) has funded seven grantees, including the City of Austin, in an effort to assess and learn from programs developed by innovative communities to address the health impacts of climate change while building a better, more equitable future. Each grantee seeks to achieve three goals: create opportunities for better health, advance health equity, and focus on climate adaptation or mitigation. We have a lot to learn from these communities because we know our rapidly warming planet is changing our air, water, food and weather, which is harming human health. We know that climate change is a major threat to any vision of a healthy future. 

Fundamentally, human health and the health of our planet are intertwined.

While every part of the United States is experiencing the health harms from climate change—including extreme heat, wildfires, more frequent and intense hurricanes, insect-borne diseases like Lyme disease or West Nile spreading to new regions, and toxic algal blooms—some people and communities are affected sooner and more directly. Where you live or work, your age, your pre-existing health conditions or chronic illnesses, as well as your race or income all influence what health harms from climate change you experience—and how strongly you feel them.  

For example, low income and communities of color are more likely to live near pollution producing power plants. People with pre-existing health conditions like asthma or heart disease face greater threats from air pollution and reduced air quality from hotter days. Climate change magnifies the inequities that prevent all people from having a fair and just opportunity to live a healthier life.  

Climate change doesn’t just harm our health, it deepens inequities. 

That is why we are looking for community-driven solutions to understand how people on the frontlines of climate harms are creating solutions that improve health and support their communities.  

Drawing on Local and Indigenous Knowledge for Health and Climate Solutions

Many Indigenous people, for example, have knowledge and experience to shape some of the most effective solutions. This is critical because Indigenous communities are also at greater risk for the health harms of climate change.  

For example, leaders in the Swinomish Indian Tribal Community are blending the CDC’s public health approach—the Building Resilience Against Climate Effects (BRACE) Framework—with traditional Indigenous values, understanding and practices. In Finland, Minnesota, and Navajo communities in New Mexico, farmers are using regenerative farming practices—a number of farming practices like crop rotation and different grazing practices—to improve the quality of crops, foster soil health, reduce the climate footprint of agriculture, and improve the ability of crops to withstand flooding, drought and heat.

The work in Austin, the Swinomish Indian Tribal Community, Minnesota and New Mexico are four of seven new grants to learn what is working on the ground. The other three projects are:

  • Buffalo, New York: People United for Sustainable Housing, Inc., (PUSH) Buffalo is helping weatherproof houses in cities to improve energy efficiency, community development and resilience and improve health, while boosting the local economy. 

  • Portland, Oregon: Friends of Trees is planting trees in low-income, ethnically-diverse neighborhoods to improve the health and well-being of local communities. 

  • Anchorage, Alaska: the Alaska Native Tribal Health Consortium (ANTHC) has developed an innovative, portable water sanitation system for homes in rural, Native Alaskan communities where climate change impacts on infrastructure and the environment makes it nearly impossible to access safe, clean water.

We can’t build a Culture of Health if we aren’t responding to both known and emerging threats to health—and taking steps to prepare for those that we know are coming.


about the authors

Michael Painter

Michael Painter, a senior program officer, is a physician, attorney and health policy advocate. His work includes identifying cutting edge ideas and investments that could help build a Culture of Health. 

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.

Mon, 30 Sep 2019 13:00:00 -0400 Michael Painter Public and Community Health National Environment <![CDATA[Policy Should Never Put a Child’s Health at Risk]]>

Here's why the proposed cuts to SNAP really hit home for me.

Mother bottle feeding her young son.

When I was a full-time pediatrician, I worked at a practice in the City of Philadelphia whose primary patients were teenage mothers and their children. Most of their parents were low-income with little to no outside support. Their lives were hard. Very hard. Many of the parents (grandparents to the newborns) were forced to choose between paying rent some weeks and having enough food to feed their children and grandchildren.  

I remember in particular one mother and her infant son who came to see me after he was born. She was scared because the baby was having trouble gaining weight, due in large part to the family not being able to afford much food. His grandmother was worried; given all the research showing how critical nutrition is to developing brains, I was concerned as well. Fortunately, the practice I worked in was a collaborative one, meaning that not only did we doctors work side-by-side with nurse practitioners, but also closely with social workers. And one of our social workers immediately went to work to get this family, in which the grandmother—who was the head of the household—worked full-time, enrolled in the Supplemental Nutrition Assistance Program (SNAP).

These are the types of situations and circumstances where SNAP is an absolutely essential lifeline. SNAP is the largest nutrition assistance program in the United States, helping to feed some 36 million people each month. SNAP provides temporary but critical support to help people who are struggling to gain access to nutritious, affordable food; nearly two-thirds of SNAP participants are children, older adults, and people with disabilities. It has a proven track record of helping families avoid poverty and hunger during difficult times, such as after losing a job or suffering a major injury or illness, while helping families achieve self-sufficiency and reducing health disparities.

Unfortunately, our social worker faced one bureaucratic challenge after another to get this family the food assistance it so desperately needed. The administrative burdens were significant—even for someone who had helped enroll multiple families previously—and as a result, the family’s eligibility was delayed by several months. While our practice worked hard to connect the family to food resources in the community to fill the gap, the little boy continued to have an extremely difficult time. The situation became so dire that we were on the verge of having to bring in the child welfare authorities to have the child removed from the home.

Child Food Insecurity Rate

Then, finally, a breakthrough. A new policy in Pennsylvania, known as broad-based categorical eligibility (BBCE), allowed people, particularly working families, enrolled in the Temporary Assistance for Needy Families (TANF) program to automatically qualify for SNAP. As it turned out, the baby’s grandmother was enrolled in TANF, meaning that when she automatically qualified for SNAP as a result, the baby and his mother were immediately enrolled as well. As the family started receiving that crucial extra support to buy the food it needed, the baby’s weight and well-being improved markedly. And just as importantly, the family was able to stay together. 

There are millions of families just like this one who depend every day on the support SNAP provides. Yet, inexplicably, a proposed new rule could take that support away. 

Earlier this summer, the U.S. Department of Agriculture proposed a rule change to SNAP that would eliminate states’ ability to adopt or maintain BBCE policies. The effects of this rule would be completely devastating to families across the country. An RWJF-funded analysis from our partners at Mathematica found that the rule would cause approximately 1.9 million SNAP households—coming out to nearly 3.6 million people—to lose program eligibility.  

The Urban Institute followed with a closer look at who would be impacted, including:

In fact, some of the most significant anticipated consequences of this rule come straight  from USDA’s own regulatory impact analysis, which predicts potential increases in poverty and food insecurity; billions of dollars in increased administrative costs for both the federal and state governments to administer the program; and millions of dollars in increased administrative costs for current and new SNAP applicants. USDA also estimates that approximately 500,000 children will also lose automatic access to free school meals if this rule takes effect, further exacerbating food insecurity for vulnerable children and making it harder for them to succeed in school. 

Data released this month from the U.S. Census Bureau confirms just how effective SNAP is at turning participants’ lives around. SNAP cut the U.S. poverty rate from 14.3 percent to 13.2 percent between 2016 and 2018, lifting 3.1 million people out of poverty in 2018 alone.  

Yet the department’s own conclusions show that this rule is fundamentally at odds with the mission and purpose of SNAP. Rather than providing people with access to nutritious food, this rule would take it away. Rather than making it easier for people to sign up and enroll, this rule would make it far more complicated. Rather than making it simpler for federal and state agencies to administer the program, this rule would make it more difficult.  

I remember vividly the faces and stories of my patients. And since the day this rule was introduced, I have often thought of that young mother and her baby son, struggling mightily to get enough food to eat and make ends meet, until they were finally saved by a social worker with compassion and a state policy with heart.   

The first rule of being a doctor is to do no harm. The same principle should apply to public policy, yet this proposal clearly fails that test.

Learn how many people would be impacted by this rule in your state.


about the author

Headshot of Don Schwarz

Donald Schwarz, senior vice president, guides the Foundation’s strategies and works closely with colleagues, external partners, and community leaders to build a Culture of Health in America, enabling everyone to live their healthiest life possible. Read his full bio.

Thu, 26 Sep 2019 09:30:00 -0400 Donald F. Schwarz Child and Family Well-Being National <![CDATA[Expert Guidance on What Young Kids Should Drink and Avoid]]>

The nation’s leading health and nutrition organizations have issued evidence-based recommendations for parents, caregivers, health professionals and policymakers.

Young girl drinking from a cup.

“Should I be giving my toddler milk?”

“What’s the difference between fruit juice and a fruit-flavored drink?”

“I thought fat was good for my kids. Why should I switch my 2-year-old to low-fat milk?”

Every day, parents, caregivers, child-care providers and others struggle with questions like these about what kids should drink—and what they shouldn’t. They’re trying to do their best for kids’ health, but it’s not as easy as it may sound.

Ensuring that kids grow up healthy includes paying attention not only to what they eat, but also what they drink, especially during the early years when they are establishing their eating patterns. To do that, parents and caregivers need clear, consistent advice from health professionals about what drinks are healthiest for their kids. And policymakers need guidance so that they can create the strongest policies possible to help all children grow up healthy.

But, faced with an array of product choices and inconsistent messages about what’s healthy and what’s not, it can be challenging to know which beverages kids should drink, especially since recommendations seem to change every few months as kids get older.

Not only that, but until now there have been no healthy beverage guidelines for kids under age 2. The U.S. government’s Dietary Guidelines for Americans include recommendations for children ages 2 and older.

Coming Together for Kids’ Health

That’s why the Robert Wood Johnson Foundation funded Healthy Eating Research, a leading nutrition research organization, to bring together experts from four prominent health organizations—the American Academy of Pediatrics, the Academy of Nutrition and Dietetics, the American Heart Association, and the American Academy of Pediatric Dentistry—in an unprecedented collaboration to develop recommendations to help parents and caregivers choose what drinks are best for young kids.

It’s hard to imagine a group with better credibility on this subject—providing parents and caregivers with nutritional guidance they can trust. Just as important, we expect that this collaboration will improve the consistency of healthy beverage advice they receive from health professionals, like pediatricians and dentists, as well.

Healthy Beverage Consumption in Early Childhood: Recommendations from Key National Health and Nutrition Organizations is designed for children from birth through age 5 and should help inform:

  • Health professionals who help shape children’s diets, including pediatricians, family doctors, dietitians and nutritionists, nurses, dentists, and child-care providers
  • Food and nutrition programs that serve children, such as the federal Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), as well as the upcoming revision of the Dietary Guidelines for Americans
  • Parents and caregivers who make choices for children every day
  • Child-care centers and homes, schools, and afterschool programs that provide meals and snacks to children
  • Food banks that assist families with children
  • Restaurants and food companies, which can adjust their labeling, marketing, and serving sizes so that the beverages they offer children are healthier

The goal is to ensure that kids are served healthy beverages, whether at home, child care, school, or at a restaurant, and that parents and caregivers feel confident that they’re making the healthiest choices for their young kids.

The recommendations grew out of a 2017 workshop convened by the National Academy of Sciences to identify policy strategies for reducing consumption of sugar-sweetened beverages among young children.

During the workshop, we heard evidence that patterns of sugary drink consumption begin early in life—and disproportionately among black, Latinx, and American Indian children and those from families who have lower incomes. These families often have less access to consistent nutrition guidance as well as to affordable healthy food choices in the places where they live. Not coincidentally, children from these families are also at higher risk for developing obesity and tooth decay and, later in life, diabetes, than white children and those from families with higher incomes.

But the problem is across the board: Too many kids consume too many sugary drinks like fruit-flavored drinks, sodas, and other beverages with added sugars. The Feeding Infant and Toddler study found that, on any given day, nearly one in three (29 percent) children ages 12 to 23 months and nearly half (46 percent) of children 36 to 47 months have a sugary drink. Further, sugary drinks are the number one source of added sugar from all foods and beverages for children 12 to 47.9 months of age.

What the Recommendations Say

For most kids, the following guidelines can help set children on the path for healthy growth and development:

  • 0-6 months: Babies need only breast milk or infant formula.
  • 6-12 months: In addition to breast milk or infant formula, offer a small amount of drinking water once solid foods are introduced to help babies get familiar with the taste—just a few sips at meal times is all it takes.
  • 12-24 months: It’s time to add whole milk, which has many essential nutrients, along with some plain drinking water for better hydration. A small amount of juice is ok now, but make sure it’s 100% fruit juice to avoid added sugar. Better yet, serve small pieces of real fruit, which is even healthier.
  • 2-5 years: Milk and water are the go-to beverages. Look for milk with less fat than whole milk, like “skim” or “low-fat.” If you choose to serve 100% juice, stick to a small amount, and remember adding water can make a little go a long way!

We need to put our children on a path to drinking healthier beverages early, and these evidence-based recommendations are a perfect place to start. We are confident that these guidelines will supply parents, health care providers, child-care providers, and other caregivers with consistent information, messages, and tools for providing the right beverages for children at the right age and setting them up for optimal health. And they provide policymakers and industry leaders with the information they need to set policies and make products that better support children’s health.

Learn more about the recommendations and share with your networks.


about the authors

Mary Story, PhD, RD, is professor of Global Health and Community and Family Medicine, and associate director of Education and Training, Duke Global Health Institute at Duke University. She started this position in January 2014. Read her bio.

Tina Kauh, PhD, senior program officer, RWJF, develops new research and evaluation programs, supports the development of team strategy, evaluates the work of grantees, and disseminates key learnings. Read her bio.

Thu, 19 Sep 2019 10:00:00 -0400 Tina Kauh Childhood Obesity Early Childhood National <![CDATA[New Data on How We’re Measuring a Culture of Health]]>

Four years ago, we introduced a Culture of Health Action Framework and measures to help us track the nation’s progress toward becoming a country that values health everywhere, for everyone. Today we share progress to date.

RWJF - Allen County Kansas

It’s been four years since the Robert Wood Johnson Foundation (RWJF), along with the RAND Corporation, began using a set of national measures to help track our journey toward a culture where every person has a fair and just opportunity to live the healthiest life possible—regardless of where they live, how much they earn, or the color of their skin.

Our goals were to offer some catalytic signals of change with a focus on broader social and economic drivers of health, well-being, and equity. The initial set of measures were used to track how diverse stakeholders, including those outside the traditional health sector, were advancing health and well-being—and if and how health equity was improving.

Developing a clearer picture of what is changing via the Culture of Health measures can guide those who are working collaboratively to accelerate improvements. We offer a few highlights from recent updates to the measures (see also and share some data on our progress to date.

What Has Changed?

Since 2015, what do the data tell us about our progress in creating a Culture of Health in America?

We are seeing small but positive changes in the appreciation of the social determinants of health and the need for broader community health investments. However, there has been less movement in many of the structural and systems-level factors that critically influence health, well-being and equity.  

Here are just a few examples:

  • There is greater understanding that diverse factors influence health. A critical component of a Culture of Health is the shared understanding that we’re all in this together—that we recognize our health is interdependent with others around us. We measured these values and beliefs about health as part of National Survey of Health Attitudes. In 2018, 37 percent of surveyed adults (vs. 34% in 2015) believed that one’s surroundings (both other people’s behaviors—and factors like physical environment, social support, and community safety) strongly influence health and well-being.
  •  Consumer experience with health care is improving. According to the most recent Consumer Assessment of Healthcare Providers and Systems Survey, 18 states earned the highest consumer experience rating (five stars) in 2017. This reflects improved subjective consumer experience in care, including ease of navigation, transparency, and communication within and across health systems.
  •  Access to care is still a struggle for too many. On the other hand, we have seen little change with respect to access to care and services. There have been no improvements in access to dental care (about 39% continue to report receiving dental care in the past year). Treatment rates for mental illness and substance dependence or abuse also show no improvement, having held steady for the last four years with only 40 percent of those needing treatment having received it.
  •  Progress is stalled on key conditions that create healthier, more equitable communities. These 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 has been no change, for example, in the number of states with cross-sector climate action plans. At a local level, there has been little change in racial residential segregation in neighborhoods, which is linked to poorer health and economic outcomes. This degree of racial segregation is largely unchanged from 2015, with white residents in America still living in the least diverse neighborhoods.

What Do These Changes Mean?

To summarize, people are expanding their views of what influences health and there have been some targeted improvements in health care and public health access. A key objective of the newly updated Culture of Health measures is to catalyze more discussion and action across sectors. We welcome growing interest in areas that these measures represent—from a focus on community health amenities like public libraries—to the importance of managing the effects of toxic stress in childhood reflected in the appointment of the California surgeon general.

Yet, the critical systemic changes needed for more transformative health improvements have been slower to follow.

Looking Ahead

RWJF will continue to monitor changes in structural determinants of health because doing so is essential to truly understanding progress in health equity. We also will support further work to spur progress in health care and social, economic, and environmental drivers of health. A fuller description of these measures and the data underlying them can be found at Exploring them can illuminate trends and help to pinpoint areas where targeted efforts may pay dividends. For instance, our failure to make significant—or any—progress in addressing decreased life expectancy; continued challenges associated with high rates of chronic disease; and increasing rates of maternal mortality are gravely concerning and demand investigation.

RWJF and its partners are committed to building public will to change our culture into one that values health everywhere, for everyone. With so much at stake, this imperative should be widely recognized as a national priority.

Success is within reach, but it will take a real commitment to turning research into action, and vision into a reality where we can all live the healthiest lives possible.

Learn how to take action and be part of the solution at



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

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


Thu, 12 Sep 2019 10:00:00 -0400 Alonzo L. Plough Public and Community Health National