Thursday, August 18, 2016

Social Determinants of Health - much more than bricks and mortar

These blog articles have often stated that better cities are not mainly a matter of brick and mortar but a matter of addressing people, a wisdom that has been first imparted in full clarity by Jane Jacobs when she engaged against brick-asphalt-and-concrete guru Robert Moses in New York when she wrote her seminal book about The Death and Life of the American City.
Sandtown: unfavorable conditions for health on many fronts
(Photo Washington Post)

This isn't something that architects and planners easily digest even though Jacob's insights have long been adopted in the profession. Deep down we are bricks and mortar people.

People stuff is somehow soft and metrics and measurable outcomes are hard to define. We can deal with livable, sustainable and resilient communities as long as this translates into building something. Lately the goal posts have been moved again towards healthy communities. ULI has added that target as part of the Advisory Services Program  in which experts are dispatched to cities to do a week-long planning session with stakeholders (I participated in the first one held in a series of three). The American Institute of Architects' national  Regional and Urban Design Committee, which a chaired until recently, will hold a regional conference in Tampa under addressing Health and Urban Design. but frequently architects and planners are at a loss what a healthy city really means.

That's where Social Determinants of Health (SDOH) come in. The approach of talking about health outcomes that follow from certain social and physical conditions (whereby the social ones usually determine the physical ones, and not the other way round) provides hard metrics. We know the sobering facts. For example life expectancy disparities: that life expectancy in Sandtown Winchester is like in Rwanda (65.3 years) and the one in Roland Park (83.1 years)is higher than anywhere else in the world, even Switzerland (82.7 years).
Diagram for  Social Determinants of Health

I learned a lot about SDOH on Wednesday this week when State Senator Shirley Nathan Pulliam, a trained nurse and representative of of the 44th District invited me to attend a retreat of her SDOH working group that has met throughout last year to define actions around the topic.

Pulliam's district is tortured as a result of redistricting due to Baltimore's population loss and due to gerrymandering. It includes large swaths of West Baltimore and County areas such as Woodlawn. The new district straddles the County and City line, a good thing,  if one considers that the City can only thrive as part of the region. Most County residents think that urban pathologies are a matter of the City alone, an assumption that is far from the truth even if the bias that the County is so much better off is promoted in the City as well.

The issue of segregated communities and increasing disparities doesn't stop at city lines. Ferguson outside of impoverished St Louis showed that and even Howard County's Columbia is not free of those problems anymore. This is why SDOH is a comprehensive approach that can work everywhere. It is an approach that forces specialists to come out of their silos and look at the many aspects that affect a pretty good indicator of our overall well being: Our health.
Senator Catherine Pugh, elected Democratic candidate for
Mayor addresses the SDOH work group (Photo: Philipsen)

The mission of Pulliam's  SDOH group reads like this:
Multi sectoral network of committed partners who are focused on improving social, material, economic and physical circumstances in which people live, work play and pray so that communities can have the thriving, high quality life that they deserve. 
To that end the group consisting of health professionals, educators, politicians, community leaders and researchers has formed committees for
  • Health and human services
  • Education
  • Housing
  • Social justice
  • Workforce Development
Health, a matter that was for long relegated to a small set of disciplines including doctors and nurses, has entered the main stage. Baltimore's Health Commissioner Leana Wen has gained more national popularity than the Mayor and Police Commissioner combined. Dr. Richard Jackson, a medical doctor, has for years taught planners and architects about healthy communities across the US and abroad.

The matter of health as an indicator of the well being of communities and a guide for broader policies has been adopted internationally not only by the World Health Organization (WHO), but has become a matter of broad research and policy studies for at least a decade.

As someone at the retreat explained, as we solve one set of problems after another, the tasks get more complex at each level and one has to dig deeper to understand them. That certainly applies to urban planning.

It is no longer sufficient to build affordable housing, for example. nor is it sufficient to build better schools. We can't build ourselves out of our problems, no more than traffic engineers can build cities and communities out of congestion. Brick and mortar won't do it if the people that those structures are supposed to serve are left behind.

This, more than anything is what Sandtown Winchester has taught us and all the attention and hand-winging that came in the wake of Freddie Gray's death has deepened the lesson.  Why couldn't $130 million transform Sandtown was the Washington Post's headline. They couldn't, because the efforts of rebuilding the neighborhood was done without truly empowering the community in it, several attempts of doing so, for example through the creation of an Empowerment Zone notwithstanding.
Senator Nathan Pulliam poses with Senator Pugh at the
SDOH group meeting Wednesday (Photo: Philipsen)

Andre Robinson, Executive Director of the Mount Royal Community Development Corporation, who represented as a co-founder the Innovation Village West Baltimore at the Senator's retreat, understands this. His and the Innovation Village founders' hope is to not only unleash the creative potential of the people in the community but create a stronger economic base as well. Mr. Robinson noted that 14,000 people live in the area defined as the Innovation Village, 9,000 live there and only 450 live and work there. Indeed, there seems to be room for improvement.

This isn't any longer just about housing or even social programs. it is about communities that can stand on their own feet.

Klaus Philipsen, FAIA