Publications

Spring 2004 Newsletter

Development Of Healthy Communities Is Enhanced by Placed-Based, Public Facility Investments

NSBN is pleased to present this interview with Drs. Neal and Fran Kaufman on the subject of place-making and school facility investments and its relevance in the public health domain. Dr. Neal Kaufman is the Co-Director, UCLA Center for Healthier Children, Families and Communities and is a Commissioner for First 5 L.A.. Dr. Fran Kaufman is a Professor of Pediatrics the Keck School of Medicine of USC and Head of the Center for Diabetes, Endocrinology and Metabolism Childrens Hospital Los Angeles.

Fran, as President of the American Diabetes Association and through your own patient practice at Children's Hospital, you've been deeply involved in responding to perhaps the largest epidemic in the Los Angeles basin- obesity and diabetes. Elaborate on this health risk and on the neighborhood conditions in L.A. County that contribute to the epidemic.

Francine Kaufman, MD
We are certainly seeing more children, young adults and adults become obese and develop the major health consequences of obesity--cardiovascular disease, Type II diabetes, certain kinds of cancers, orthopedic problems, and related psychological issues. As a result, there's a huge influx of people into the traditional medical system needing more and more care, some of which is very expensive. So there's a huge crunch to the medical system ongoing. This begs the question, "Where did this all this come from?"
How did we come to have a tripling of obesity rates and a doubling of rates of diabetes and cardiovascular disease occurring every few years? The answer is that we have markedly changed the way we live our lives. Our genes haven't changed much over a 40,000 year time period, but our environment has been drastically altered. The environment in which our genes were evolved to thrive has changed so much that it will be on a collision course with our genes and cause our ultimate demise if we don't look at this in a more holistic approach. The traditional medical system does not have the answer. We have the band-aids--we can put things back together and drag somebody's life on with terrible morbidity until eventual mortality--but we don't have the answer on how to prevent this.
So what is the cause of causes? The way we live our lives. Where is that based? It's based in our environment. So we have to look for environmental change to start reversing this pandemic and eventually to get us back to a point where we can live long and healthy lives.

Neal, through your pediatric work at Cedars Sinai and as a commissioner for First 5 L.A., you've also dedicated yourself to fostering healthy neighborhoods. What's the nexus between public health, your work and First 5's investments?

Neal Kaufman, MD, MPH
It comes back to a basic premise that a person is only as healthy as the family in which they live; a family is only as healthy as the community in which they exist; and, the community is only as healthy as the society which nurtures it.
To be able to look at people's health and well-being, you have to get well beyond the individual as if they're an island and you have to look at the context in which they live. This could be something as obvious as whether they were nurtured appropriately by the people who care for them as a child. Do they have friends? Do they have a social network? It could be as fundamental as the ability to get appropriate nutrition and exercise. When a family of any age is stressed, or has drug or alcohol issues, or just has everyday stress and strain, to be connected to communities that nurture and support them makes all the difference in the world in regard to their health and well-being. When you look at communities and how communities can be created that support those individuals and those families, you get down to a couple fundamental issues.
One is, what are the structures within that community? How are the buildings built? How are the roads set up? Is there encouragement for healthy behaviors and healthy activities? Is it safe? Do people feel comfortable?
A second fundamental is, are there good interpersonal relationships? Are there ways to help people not be socially isolated? And, for those who are socially isolated, is there a way to reach out to them?
Finally, do they have access to the services they need? As Fran was mentioning, some of those services are medical, but many of those services are not. They are services that relate to helping you identify what your needs are in your family, what your strengths are in your family, services that allow people to be more whole and more supported.

Fran, in California and with LAUSD, you have successfully advocated, as a doctor and President of the Diabetes Association, that junk foods now prevalent on school campuses throughout the state be removed. What was it like to advocating for education policy reform?

Fran Kaufman, MD
I was impressed with how much the school board, and other agencies, organizations and groups that are involved in this same kind of mission, rallied together and appreciated the science behind all this. It all sounds good--let's not eat a lot of junk food, let's not drink sodas, etc--but until you present this compelling evidence of this march towards catastrophe we're taking as a global community, it doesn't have the power for change. We presented the data individually to some of the school board members and collectively worked with the other groups, and there was tremendous enthusiasm about making the kind of changes that needed to be made. We've had a few real champions up in Sacramento who have helped carry this along, some of them realizing that a lot of this is also about health disparities--that this is truly affecting our most vulnerable populations from a socioeconomic standpoint, and predominantly affecting African Americans, Latinos and Native Americans.

Neal, you've been advocating, along with your colleagues on the First 5 L.A. Commission, that school facility, housing, library and park bond funds be invested to change the way school facilities are now designed and sited within neighborhoods. Elaborate on how your interest in placed-based investment strategies connects to Fran's public health work.

Neal Kaufman, MD, MPH
If you look at the opportunity that we have in California to build new schools, as well as new parks, libraries and low income housing, there is the potential to create schools that are centers of neighborhood vitality. You can have the preschool or school where individuals come not only for education for their children, but also for their own life long learning, and not only to provide nurturing for their children, but also for themselves. When these entities – schools, libraries, community centers, health care, and open space – are put together, you find that the entire neighborhood becomes more vital and that the families use that school for many resources and support.
The idea is to proactively show that the wise use of public funds to do all of the building and urban planning is best if it's not done with silo-like mentality, where the individual public entities think only of what they need to meet their goal. The question becomes, how can we have win-wins amongst many organizations so that each of those goals will be met? Working with New Schools-Better Neighborhoods and with a number of people throughout the county, First 5 L.A. has been at the forefront of trying to put some of those facts on the ground through the collaborative master planning of these joint-use facilities.
We, though the work of NSBN, have a number of schools in a range of planning modes. Some are going to take low income housing, primary centers, green space and preschools and put them into a site that was only going to have one of those services. To be able to add housing, rather than take it away when a school is built, especially in the densely populated urban areas where space is at such a premium and housing is so critical, is a terrific benefit to the community.

Fran, let's focus on lessons learned. You've been traveling the world with U.S. Secretary of Health Thompson speaking about diabetes. But so often, as Neal said, cures are presented in a silo-like fashion--as healthcare, as education reform, as transportation, land-use, or whatever solutions. How do we better connect the dots? Using public policy, how do we cross-tab needs with solutions to realize healthier neighborhoods and healthier communities in California and worldwide?

Fran Kaufman, MD
Partnerships are emerging around a collaboration between health care providers doing their research out in communities and public health professionals. Traditional medicine is coming out of their box and trying to link with people. The Secretary has certainly spent a long time in Congress trying to generate interest in these issues, and he's spent a lot of time trying to shore up support from groups to help with community change.
We just have to look at where we can come together and plan. Obviously, the place to do that is in the community itself. If we're going to do interventions, they have to be based on what an individual community may or may not have the ability, the resources and the desire to do.

Neal Kaufman, MD, MPH
For me, part of it is leadership. On the local level, this means identifying individuals from impacted communities and helping them to understand what the opportunities and possibilities are. If you look at some of the most exciting work around schools, you'll find that there's often a dynamic individual from the community who has a vision, learns how to do things in very creative ways, and is supported by others to make it happen.
At the governmental level--whether it's the city, county, state, school district, or any other of the large organizations--the key is identifying leadership both at the top of these organizations who will work to encourage collaboration, and then at lower levels identifying those who will help carry out the collaboration.
If we talk about the future, it's the academic pipeline. It's taking individuals who have been traditionally trained in single approaches--medicine, social work, psychology, urban planning or architecture--and helping them, as they're in their most formative phases, to learn from the varying perspectives about what makes this collaboration possible.
If we support the local leadership, support the organizational leadership, and get involved in training the rising stars in these various fields, that leads to a transformation in the way people think, which over time leads to these changes being institutionalized.

One last question for each of you. Fran, because of your achievements and reputation, many foundations have been attracted to your research an and practice. Because often it's philanthropy that advances reform of public systems, what do you suppose is attracting their attention and financial support?

Fran Kaufman, MD
If you look at everyone's top-three lists, obesity, diabetes and cardiovascular disease prevention are at the top for all of the major funding agencies. I think they are looking for a paradigm shift. This isn't about people coming to my medical center and being given a bunch of drugs. This is about me getting out of my center and looking at what we can do with the knowledge we have. These organizations are interested in what we can do to increase the availability of different foods. Then, once we've changed the environment, it's getting people to change their behavior and take advantage of the opportunity to lead healthier lifestyles.

Neal, the First 5 L.A. Commission, impressed with Rob Reiner's advocacy and the UPK Advisory Bd. findings which rest on the work of Karen Hill- Scott, has made a significant commitment of $600 million to Universal Pre-K in L.A. County. What's the nexus between that pledge and the place-based strategies for healthier neighborhoods that NSBN has been advancing?

Neal Kaufman, MD, MPH
If you look at the Commission's activities overall--whether they are universal preschool, universal health care, or child abuse prevention--a range of them all have one thing in common: we are seeking to improve outcomes for children by their fifth birthday throughout the county. Some of those strategies will be specifically targeted to areas where the need is the greatest.
Within universal preschool, for example, we have identified those neighborhoods where there are hundreds or thousands of children who should be in pre-K, and who are not able to because there is no space. This means that in the coming years, tens of thousands of preschool slots or spaces will need to be created. The creation of those spaces is very expensive, and requires collaboration between cities, businesses, urban planners, and government funding agencies. First 5 is going take a very central roll in helping make that happen. We do not have enough money, even if every dollar of tobacco tax went towards universal preschool, to pay for the construction of all of these sites. But we do have a commitment to the creation of a sustainable system to provide all children with a preschool experience.
We will be working with cities, with urban planning individuals, with New School-Better Neighborhoods, and with other organizations, in specific, targeted areas to identify the funding options, policies, and procedures that need to be modified for preschools to be created. Whether these facilities are connected to elementary schools, health facilities, birthing hospitals, or family resource centers, the idea of having those preschools linked very closely or co-located with other facilities that serve families really helps us to create strong communities and centers of neighborhood vitality.