The Need to Invest in the Health and Wellbeing of our Communities.

Chris Kay IAIA. AICP. Healthcare Infrastructure Research Institute Sept. 2023

Abstract:

Creative private redevelopment solutions supported by public Investment IE: Public – Private Partnerships (PPP),?in disadvantaged communities are becoming an instrumental part in helping curve neighborhood decay by bringing economic opportunities, access to healthcare, safety, and prosperity to historically marginalized populations in our inner cities.

Inner cities are broadly characterized as distressed urban environments that sit outside of the economic mainstream with high concentrations of poverty, limited educational opportunities, poor health, and high levels of segregation. Inner cities also have the largest numbers of ?inter-generational poverty, limited educational opportunities, poor health, and high levels of segregation generally located in underserved communities that are separated by physical, economic, and social barriers.

Once synonymous with the term central city, these inner city neighborhoods have been described as some of the oldest parts of a Metropolitan Statistical Areas and are most often ?the hub of economic disparity and tend to include some of the most densely populated areas with highest unemployment rates and greatest need for infrastructure including but not limited to transportation systems, educational and job opportunities and ?access to healthy foods and quality -affordable healthcare services. These same areas were once booming centers of industry and ?economic prosperity. Yet through today there has been a systematic departure of many of the ?industries and good jobs once found in ?inner cities, which starting in the beginning of the 20th century have gradually moved to surrounding suburbs. This social economic demographic shift has resulted in deterioration in both ?economic and social conditions within many Inner-city neighborhoods including impoverishment and structural decay of these communities over time. The poverty that has become characteristic in many inner cities neighborhoods ?across the US has become widespread, and synonyms ?with unemployment, poor health, environmental concerns, crime, violence, drug use, poor nutrition, and ?a general state if poverty and community decay.

The health consequences that have resulted over ?decades of poverty and neglect of the lack of inner-city infrastructure investment has been aptly captured by, Andrulis (DP) who describes “deterioration of inner cities and their social conditions joining with poverty to create an urban health penalty that profoundly handicaps the well-being of communities.” (1*). This description led to efforts by the American College of Physicians to issue a position on the state of health care of inner cities which was ?first published back in 1997. Since that time several other extensive reports by individuals and government agencies including the NIH, have undertaken research examining the challenges that inner city populations experience across individual, communities, including their state of health and wellness.

The body of evidence that has been generated over the last decade is powerful and serves to demonstrate the longstanding, systemic challenges, and barriers that exist for inner-city populations through today – highlighted by a lack of infrastructure ?investment including correcting environmental, communication, transportation, healthcare education access to nutritional healthy foods and services in many underserved inner-city neighborhoods in towns and cities across the US. ??

1.?????? Reference info Credit: Andrulis DP. *The urban health penalty: new dimensions and directions in inner-city health care. In: Inner-City Health Care. Philadelphia: American College of Physicians; 1997. no 1. (Available from: American College of Physicians, Independence Mall West, Sixth Street at Race, Philadelphia, PA 19106).

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While inner-city populations have long been considered among the nation’s most vulnerable, the inter-generational transmission of poverty and poor health persists due to poor and inadequate access to care, further compounded by adverse social and environmental risk factors cause in part by a lack of Infrastructure investment in these communities. In this paper I have chosen to focus on describing the need for quality accessibly healthcare and wellness services including healthy food and education on the importance of good nutrition. In doing so I will also present a ?framework for improving health among inner-city populations using a multidisciplinary approach drawn from medicine, economics, and public – private redevelopment interventions including a case study from the city of Milwaukee, WI. where I lived and worked for several years, in what was once an underserved inner-city neighborhood that was successfully redeveloped starting with a significant investment in new infrastructure which created the framework for success and resulted in significant social and economic prosperity that has been a catalyst for redevelopment of adjacent neighborhoods throughput Milwaukee. ?I feel it’s also ?important to ??specify or define the use of the term inner city ?as it pertained to Milwaukee but is representative of most cities.

(2) The use of the term inner city is often thought to be synonyms with poor health, crime, ?drugs, and poverty ?which ?also characterizes many social issues faced by many minority populations.

2. *Reference - Axel-Lute M 4 reasons to retire the phrase “inner city”. Shelter Force. 2017; Accessed from: https:// shelterforce.org/2017/05/23/4-reasons-to-retire-the-phrase-inner-city/. Accessed 2 Feb 2020.

Scholars suggest the validity of the term “inner city” is best defined by the term “urban community” defined as an integrated whole with subpopulations, diversity, major problems, urban renewal, and related initiatives all a part of a whole” (refer to 1. ). ?

My perspective of the term aligns closely with the ?definition above . However, as an Architect and Urban Planner ?I ?not only view the term ?“inner city” from the perspective of academic medicine and health disparities, but also recognize a more historic meaning; describing the state of economic, social, and environmental infrastructure deterioration due to the systematic removal ?or lack of investment of resources, followed by unconscious, or potentially, in some cases, intentional ?attempts to further isolate and segregate communities living on the margins of society.

Whether others embrace or agree with the use of the word inner city, the critical and salient point remains that inner-city environments continue to experience extreme levels of infrastructure decay, poverty, poor health outcomes, and generational cycles of deprivation underscored by a lack of investment. The current condition of infrastructure decay in many of our inner-city neighborhoods discourage and make it very difficult for upward mobility due to limited economic opportunity, and also measurably alter the upward wellness and health trajectories of these communities as a result of social, structural, and environmental deterioration. ?An example of ?this lack of wellness ?is ?the high mortality rate of ?infants who die in underserved communities as a result of ?poor access to pre, and post-natal care, lack of access to nutritious foods and ?a gap in relevant education for young women whom African American young women in particular have ?2.4X times the infant mortality rate as those white women living outside these under served communities.

The definition of an inner city should therefore ?include the ?historic events leading to the needs of our society’s most vulnerable who live in the underserved neighborhoods of the inner city. . For this reason, I have chosen to use the term inner city to emphasize the imperative of addressing the health and ??????????????“wellbeing” of these communities and their populations who, while sitting at the heart of many major cities across the US, now reside on the margins of society due in large part to a lack of public – private investment and a decaying infrastructure and the physical isolation of these communities as a result of poor urban planning ?which has unconsciously physically segregated these communities now looked at as being on the fringes of society.

CASE STUDY: ?THE CITY OF MILWAUKEE (5)*

(5)* Reference This project ( case study) was supported by grant from Advancing Healthier Wisconsin. PMC data base

The city of Milwaukee is the state of Wisconsin’s largest city with approximately 600,000 residents. Milwaukee is one of few cities in the United States that is a majority minority city and is also one of the most segregated cities in the nation. Milwaukee is the second poorest city in the US, second only to Detroit, for cities with greater than 500,000 residents. Preliminary work has shown that the health of inner-city Milwaukee is impacted by a number of factors that may be considered vulnerabilities. These include discrimination, poverty, segregation, and food insecurity.

As the first phase in a coordinated effort to address health disparities, high crime, high poverty, and racially segregated neighborhoods in inner city Milwaukee, a research team used qualitative methods to understand the impact of the built environment on stress and the negative effect it has on cardiovascular disease risk factors among African Americans. They conducted 29 focus groups, 40 key stakeholder interviews and 10 photovoice interviews with a total number of over 350 community participants and community leaders across 10 zip codes in inner city Milwaukee. Key stakeholders represented multidisciplinary backgrounds including healthcare, public education, public housing, churches, police departments, fire departments, community-based organizations, and civic agencies. The rationale behind qualitative methods was to foreground the lived experience and voice of the patients in their own words. Photovoice specifically is a well-established methodology used in participatory action research and allows participants to serve as co-researchers by collecting data through images that reflect their own perspectives of strengths, weaknesses, barriers, and facilitators within their community. Video conference interviews (photovoice’s) ??served as a powerful tool to generate dialogue and impact policy. All interviews and focus groups were led using a semi-structured interview guide and moderator guide to facilitate discussions around the role of poverty and health within inner cities. Stakeholders included representatives across government and community organizations including the Milwaukee Health Department, Milwaukee Fire Department, public officials including Aldermen, judges, and public defenders, representatives from the YMCA, YWCA, Boys and Girls Club, local food pantries, and local churches. Focus group participants included individuals with and without chronic disease and photovoice participants included individuals with chronic disease, all ranging in age from 19 through 70. Grounded theory approach was used with constant comparison to identify themes as they emerged through interviews and focus groups.

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Primary Findings

Major themes identified across interviews, focus groups, and photovoice sessions for barriers to managing health in the community included the role of stress, specifically resulting from constant experiences of violence, discrimination, racism, crime, residential segregation and incarceration. For example, participants stated:

“We wonder if when our kids walk out the door if they are going to make it home. I think that is the stress in my eyes that there is so much happening. My stress is coming from some of the, I don’t claim I am sick, but that is where a lot of the stress come from. Kids in school, kids getting shot. I was sitting in my house one night and a bullet came through my window. That is where stress comes from.”

“I served in Afghanistan. Living in inner city Milwaukee is like serving in Afghanistan. The difference is you do not get hazard pay.”

Additional themes included the impact of cycles of poverty on the community, and limited resources to care for health. Limited resources included lack of transportation to clinic visits, the high cost of healthy food and stable housing, and a lack of access to education and unemployment. For example:

“Stress is a very big factor. Other factors are the lack of community resources and the lack of family resources, high unemployment and general urban stress= crime, violence, anything that affects the health of individuals.”

“Access to health care and high cost of medication. With age comes illness, living on fixed income and paying for medication is very hard and you have to make choices of what you will pay for. Some people have very good benefits and that helps but when you don’t have it is very stressful. You ignore being sick because you know you cannot afford it.”

Participants also discussed substance abuse and a sense of hopelessness that resulted from the social factors dominating their lives. They regularly tied these experiences back to stress and trauma, which they believed resulted in poor health and disability.

“A lot of people do not expect good health for themselves, so they are willing to accept or ignore issues regarding their health. Because people feel they will not be treated seriously they avoid seeking treatment but also minimize, deny, and use substances so they don’t have to think about it. There is a lot of trauma which adds complexity to the health issues.”

“Stress plays a huge role. Trauma is a very destructive form of stress. Exposure to the stress is only part of it, the damaging part is that there is actual harm that is done to the brain. That kind of stress is very toxic and disables your sense of safety and security. It causes you to develop a narrow and comprised vision of what your life could be. Stress has so many organic effects on blood pressure, sleep, concentration, hormones. I think a lot of obesity is tied to stress and then it is complicated when living in food deserts.”

THE CHALLENGES

Human capital is a measure of knowledge, skills, health, resilience, and values that people obtain throughout their lives, positioning them to achieve self-actualization]. These intangible forms of capital have the ability to increase earnings and improve one’s health overtime, increasing their contribution to society. The World Bank maintains that health is a key component of human capital as people are more productive in society when they are healthier. The development of human capital, a central driver of sustainable growth and poverty reduction, can be used to bring an end to extreme poverty by investing in people through increasing access to and provision of adequate nutrition, health care, quality education and jobs. Even though human capital is a key aspect of economic growth, policy makers find it challenging to make the case for human capital investments due to the length of time necessary for the benefits of investing in people to materialize. Building roads and bridges can rapidly generate economic and political benefits, however, the human capital of young children will not deliver economic returns until those children become adults and join the workforce. Due to this slow return on investment, countries often underinvest in human capital and miss the opportunity to create a cycle of increased human capital and growth. In addition to healthcare, education and training also ?have been identified as important investments in human capital While it is known that higher education can increase one’s human capital and earning potential, racial and ethnic minorities face more barriers compared to their non-Hispanic White counterparts to graduating from high school and entering and finishing college.

Health disparities experienced by racial/ethnic minorities and individuals living in low socioeconomic status environments can thus be framed within the construct of human capital. Unemployment and underemployment are chronic factors limiting human capital despite programs initiated to support individuals with financial difficulty. Research on welfare to work programs show that half of welfare recipients do not have a high school degree or equivalent and while many recipients are able to find a job, a large proportion lose the job within the first year of employment. Employment has also been positively associated with perceived health, with non-working women reporting themselves as less healthy compared to those who were working. Women on welfare are at high risk of having mental health problems, and health problems account for about 10% of all job losses in government sponsored programs. Individuals whose government benefits are terminated due to noncompliance with the work component of the welfare-to-work program report serious personal or health issues as the primary reason for non-compliance. Finally, research shows that being in good health increases the likelihood of being in the workforce and keeping a job for both men and women. As racial/ethnic minorities are disproportionately impacted by chronic conditions like obesity, diabetes, high blood pressure, and stroke, potential economic and societal contributions are also missed largely due to missed workdays and loss wages. This limitation of human capital within specific groups adds a layer of complexity to the discussion of health disparities that is often overlooked.

Intervention Approach and Conceptual Model

The above case summary illustrates the historical challenges facing inner-cities, the patient perspective of how the inner city impacts health, and the current challenges and factors that converge, sealing health trajectories for those who live within an inner city. Private public partnership models that promote models that incorporate building economic sustainability at the individual and community level, aiming to foster wealth creation rather than simply meeting immediate economic or social needs through investing in infrastructure development are proving to? have a positive impact on the chronic state of inner-city health. Drawing on the public private partnership investment and ?interventions under the umbrella of ?Social economic redevelopment focused on improving the state of wellbeing through the built environment and increasing ?human capital over the long term.

Public private Real Estate development ?investments in inner city communities are well established and have been incorporated into many ?re-development models. The current approach to addressing the needs of inner-city environments has primarily focused on government sponsored ?relief programs such as income assistance, housing subsidies, and food assistance, that while all necessary, have proven to not be adequate in addressing the root cause of the disparity that currently exists with underserved ?inner-city neighborhoods. (3*) ?

(3*). Reference. Porter ME. The Competitive Advantage of the Inner City. In: Harvard Business Review. 1995. https://hbr.org/1995/05/the-competitive-advantage-of-the-inner-city. Accessed 5 Jan 2020.

This social framework, though necessary, does not encompass the full scope of needs that exist when reviewing ?inner city ?communities as a man-made disaster in need of a disaster response. Social relief programs focused on basic needs do not address the concurrent existing loss of capability or capacity of the community, or the lack of stability at both human and economic levels. Economic models would incorporate building economic sustainability at the individual and community level, focusing on providing adequate infrastructure, healthy lifestyle environments, and economic revitalization of an area through prover planning and redevelopment including Public private participation in the redevelopment of the built environment. ( IE; affordable housing, ?the creation of local business, and access to good Jobs, Healthcare, education ?located in safe and accessible neighborhoods which foster sustainable wealth creation rather than simply meeting the immediate social needs.

A key attribute of social and economic productivity along with physical capital such as buildings, is human capital, characterized as aggregate levels of education, training, and skills that exist in our ?populations.(4*)

(4*) Reference. Becker GS. Human capital. Chicago: University of Chicago Press; 1964. https://www.econlib.org/ library/Enc/HumanCapital.html. Accessed 15 Feb 2020.

A focus on economic redevelopment should include the revitalization of all infrastructure in underserved inner-city communities. The investment of infrastructure will spur further public- private social economic ?development incorporating healthcare, research and education which can play a significant role in attracting ?new high paying jobs while improving the health and wellbeing of the community these services are located in. Similar to low-income and middle-income countries, capital investments in inner city neighborhoods tends to not only meet the ?social needs of residents, but also serve to improve the economic and educational opportunities, while new physical infrastructure investments in healthcare facilities not only meet the health needs of citizens but also help ?improve human capital and economic productivity with new jobs and demand for services.

?The Council of Underserved Communities (CUC) focuses on communities and populations that traditionally have faced barriers in accessing credit, capital, and the other tools they need to start and grow businesses. These communities include inner cities and rural areas and may include populations such as women, minorities, veterans, tribal groups, and others. This same approach can be taken by Local city governments to promote locally sponsored public – private partnerships in the redevelopment of physical infrastructure. Public Private partnerships focused on the redevelopment of inner-city communities, including mixed use development ?can ?be co-sponsored by SBA programs that include ongoing efforts to expand its reach into underserved communities including? affordable housing Healthcare and education to name only a few categories. While the nation’s economic recovery is moving forward, that recovery has been uneven, particularly for socially, economically, and geographically disadvantaged communities and many local small business owners who live and serve these communities. To help address the challenges facing underserved communities, the CUC partners with Private – public partnerships including Local private real-estate developers, non-profit health systems ?and local government agencies on developing new ways to increase access to capital, invest in infrastructure and promote healthy living, sustainability, growth, and job creation. Private real-estate developers, across the country are now participating in Public private partnerships, investing in community infrastructure, and dealing with equitable real estate that benefits the investor and helps uplift the economic and social conditions of the communities they invest in. ?Many REITS are now also committed to creating diverse teams to help manage select Public Private investments in Inner city under-served communities including but not limited to secure affordable housing and mixed-use healthy lifestyle building environments that bring access to? quality health and wellness services in new and innovative ways.

ABOUT THE AUTHOR AND THE HEALTHCARE INFRASTRUCTURE INSITITUTE RESEARCH INITIATIVE.

Chris Kay IAIA, AICP, ACHE, DBIA. is a healthcare facility planning, design, ?construction professional, and city planner with over 33 years of experience in delivering integrated healthcare planning and facilities design and construction projects across the US and MENA regions. Chris ?speaks ?regularly on public private partnerships with a focus on inner city ?redevelopment. Chris is an ?internationally accredited healthcare architect, (IAIA) Certified Urban Planner, (AICP), experienced real-estate development professional and a member of the National Institute of Building Sciences, (NIBS). He serves on the boards of KHJR Real-estate Advisors, Greenwood Walker Development, Collaborate Architects, and Planners and, The Guess Group a commercial real-estate company bridging the gap ?between public and private sector interests. Chris is the Executive Program Director of The Healthcare Infrastructure Research Initiative, a program supported in part by The University Research Institute. And The National Institute of building Sciences. HIR is a collaborative research program helping bring community leaders together with leading healthcare real-estate, hospital, and life sciences professionals to address ?social and economic ?challenges that the healthcare sector both faces and can support solutions for in underserved communities. HIR's mission is to present the latest thinking from nationally recognized experts, providing an arena that facilitates interaction and collaboration among healthcare real-estate, hospital, and research leaders, with a focus on creating actionable programs that help improve the delivery of cost effective, safe, sustainable, and operationally efficient healthcare and life science facilities using Public private partnerships in underserved communities across the US.

For additional information regarding our sponsors or to learn more about HIR's mission, contact Chris Kay @?[email protected]

?HIR WOULD LIKE TO THANK OUR SPONSORS.

Thank you to our corporate sponsors and partners;?KHJR Real Estate Advisors, Collaborate Architects and Planners, Oppenheimer Investments, Greenwood Walker Investments, The Guess Group A Commercial Real Estate Company, ?Kay Properties, ?and Investments, TIG Advisors, Raymond James Financial, The Mayo Clinic, Advent Health, Methodist Health, St Luke's Health, Stanford Health, Legends Landing Senior Housing, and Union Village - The first fully Integrated mixed-use health and wellness community of its kind in the US.

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